Cecilia M. Kitic

Systematic review: exercise‐induced gastrointestinal syndrome—implications for health and intestinal disease

“Exercise‐induced gastrointestinal syndrome” refers to disturbances of gastrointestinal integrity and function that are common features of strenuous exercise.

No Effects of a Short-Term Gluten-free Diet on Performance in Nonceliac Athletes.

PURPOSE Implementation of gluten-free diets among nonceliac athletes has rapidly increased in recent years because of perceived ergogenic and health benefits. The aim of this study was to investigate the effects of a gluten-free diet (GFD) on exercise performance, gastrointestinal (GI) symptoms, perceived well-being, intestinal injury, and inflammatory responses in nonceliac athletes. METHODS Thirteen competitive endurance cyclists (8 males, 5 females) with no positive clinical screening for celiac disease or history of irritable bowel syndrome (mean ± SD; age, 32 ± 7 yr; weight, 71.1 ± 13.4 kg; height, 177.0 ± 11.8 cm, VO2max 59.1 ± 8.0 mL·kg⁻¹·min⁻¹) were allocated to a 7-d gluten-containing diet (GCD) or GFD separated by a 10-d washout in a controlled, randomized, double-blind, crossover study. Cyclists ate a GFD alongside either gluten-containing or gluten-free food bars (16 g wheat gluten per day) while habitual training and nutrition behaviors were controlled. During each diet, cyclists completed the Daily Analysis of Life Demand for Athletes (DALDA) and GI questionnaires (postexercise and daily). On day 7, cyclists completed a submaximal steady-state (SS) 45-min ride at 70% Wmax followed by a 15-min time trial (TT). Blood samples were taken preexercise, post-SS, and post-TT to determine intestinal fatty acid binding protein (IFABP) and inflammatory markers (cytokine responses: interleukin [IL] 1β, IL-6, IL-8, IL-10, IL-15, tumor necrosis factor α). Mixed effects logistic regression was used to analyze data. RESULTS TT performance was not significantly different (P = 0.37) between the GCD (245.4 ± 53.4 kJ) and GFD (245.0 ± 54.6 kJ). GI symptoms during exercise, daily, and DALDA responses were similar for each diet (P > 0.11). There were no significant differences in IFABP (P = 0.69) or cytokine (P > 0.13) responses. CONCLUSIONS A short-term GFD had no overall effect on performance, GI symptoms, well-being, and a select indicator of intestinal injury or inflammatory markers in nonceliac endurance athletes.

Carbohydrate and protein intake during exertional-heat stress ameliorates intestinal epithelial injury and small intestine permeability

Exertional heat stress (EHS) disturbs the integrity of the gastrointestinal tract leading to endotoxaemia and cytokinaemia, which have symptomatic and health implications. This study aimed to determine the effects of carbohydrate and protein intake during EHS on gastrointestinal integrity, symptoms, and systemic responses. Eleven (male, n = 6; female, n = 5) endurance runners completed 2 h of running at 60% maximal oxygen uptake in 35 °C ambient temperature on 3 occasions in randomised order, consuming water (WATER), 15 g glucose (GLUC), or energy-matched whey protein hydrolysate (WPH) before and every 20 min during EHS. Rectal temperature and gastrointestinal symptoms were recorded every 10 min during EHS. Blood was collected pre- and post-EHS, and during recovery to determine plasma concentrations of intestinal fatty-acid binding protein (I-FABP) as a marker of intestinal epithelial injury, cortisol, endotoxin, and inflammatory cytokines. Urinary lactulose/l-rhamnose ratio was used to measure small intestine permeability. Compared with WATER, GLUC, and WPH ameliorated EHS associated intestinal epithelial injury (I-FABP: 897 ± 478 pg·mL-1 vs. 123 ± 197 pg·mL-1 and 82 ± 156 pg·mL-1, respectively, p < 0.001) and small intestine permeability (lactulose/l-rhamnose ratio: 0.034 ± 0.014 vs. 0.017 ± 0.005 and 0.008 ± 0.002, respectively, p = 0.001). Endotoxaemia was observed post-EHS in all trials (10.2 pg·mL-1, p = 0.001). Post-EHS anti-endotoxin antibodies were higher (p < 0.01) and cortisol and interleukin-6 lower (p < 0.05) on GLUC than WATER only. Total and upper gastrointestinal symptoms were greater on WPH, compared with GLUC and WATER (p < 0.05), in response to EHS. In conclusion, carbohydrate and protein intake during EHS ameliorates intestinal injury and permeability. Carbohydrate also supports endotoxin clearance and reduces stress markers, while protein appears to increase gastrointestinal symptoms, suggesting that carbohydrate is a more appropriate option.

Low FODMAP: A Preliminary Strategy to Reduce Gastrointestinal Distress in Athletes

Introduction Gastrointestinal (GI) distress in endurance athletes is prevalent and detrimental to performance. Adverse GI symptomatology can be analogous with irritable bowel syndrome, where fermentable oligosaccharide, disaccharide, monosaccharide, and polyols (FODMAP) reduction has demonstrated efficacy. This study investigated the effects of low FODMAP (LFOD) diet on GI distress parameters in runners with a history of nonclinical exercise-associated GI symptoms. Methods Eleven recreationally competitive runners (five men, six women; 5-km personal best 23:00 ± 4:02 min:s) participated in the study. Runners were allocated to a randomized 6-d LFOD or high FODMAP (HFOD) diet separated by a 1-d wash-out in a controlled, single-blinded cross-over study. In each period participants completed two strenuous running sessions consisting of 5 × 1000 m and a 7-km threshold run. GI symptoms (during-exercise and daily) and the Daily Analysis of Life Demand for Athletes questionnaires were completed. Area under the curve was calculated for daily GI symptoms across each dietary period and analysis was conducted using multilevel mixed-effects linear regression for comparison between the two diets. Results A significantly smaller area under the curve for daily GI symptoms 6 d during the LFOD compared with HFOD (mean difference, −13.4; 95% confidence interval, −22 to −4.60; P = 0.003) was observed. The daily GI symptoms that were significantly lower during LFOD were flatulence (P < 0.001), urge to defecate (P = 0.04), loose stool (P = 0.03), and diarrhea (P = 0.004). No significant differences in during exercise symptoms or Daily Analysis of Life Demand for Athletes responses were observed between diets (P > 0.05). Conclusions Preliminary findings suggest that short-term FODMAP reduction may be a beneficial intervention to minimize daily GI symptoms in runners with exercise-related GI distress.

Validity of Power Settings of the Wahoo KICKR Power Trainer.

PURPOSE To assess the validity of power output settings of the Wahoo KICKR Power Trainer (KICKR) using a dynamic calibration rig (CALRIG) over a range of power outputs and cadences. METHODS Using the KICKR to set power outputs, powers of 100-999 W were assessed at cadences (controlled by the CALRIG) of 80, 90, 100, 110, and 120 rpm. RESULTS The KICKR displayed accurate measurements of power of 250-700 W at cadences of 80-120 rpm with a bias of -1.1% (95% limits of agreement [LoA] -3.6% to 1.4%). A larger mean bias in power was observed across the full range of power tested, 100-999 W (4.2%, 95% LoA -20.1% to 28.6%), due to larger biases of 100-200 and 750-999 W (4.5%, 95% LoA -2.3% to 11.3%, and 13.0%, 95% LoA -24.4% to 50.3%), respectively. CONCLUSIONS Compared with a CALRIG, the KICKR has acceptable accuracy reporting a small mean bias and narrow LoA in the measurement of power output of 250-700 W at cadences of 80-120 rpm. Caution should be applied by coaches and sports scientists when using the KICKR at power outputs of <200 W and >750 W due to the greater variability in recorded power.

Time of day and short-duration high-intensity exercise influences on coagulation and fibrinolysis

Abstract Exercise has been demonstrated to have considerable effects upon haemostasis, with activation dependent upon the duration and intensity of the exercise bout. In addition, markers of coagulation and fibrinolysis have been shown to possess circadian rhythms, peaking within the morning (0600–1200 h). Therefore, the time of day in which exercise is performed may influence the activation of the coagulation and fibrinolytic systems. This study aimed to examine coagulation and fibrinolytic responses to short-duration high-intensity exercise when completed at different times of the day. Fifteen male cyclists (VO2max: 60.3 ± 8.1 ml kg−1 min−1) completed a 4-km cycling time trial (TT) on five separate occasions at 0830, 1130, 1430, 1730 and 2030. Venous blood samples were obtained pre- and immediately post-exercise, and analysed for tissue factor (TF), tissue factor pathway inhibitor (TFPI), thrombin–anti-thrombin complexes (TAT) and D-Dimer. Exercise significantly increased plasma concentrations of TF (p < .0005), TFPI (p < .0006), TAT complexes (p < .0012) and D-Dimer (p < .0003). There was a time-of-day effect in pre-exercise TF (p = .004) and TFPI (p = .031), with 0830 greater than 1730 (p  .001), while 1730 was less than 2030 h (p = .008), respectively. There was no significant effect of time of day for TAT (p = .364) and D-Dimer (p = .228). Power output, TT time and heart rate were not significantly different between TTs (p > .05); however, percentage VO2max was greater at 1730 when compared to 2030 (p = .04). Due to a time-of-day effect present within TF, peaking at 0830, caution should be applied when prescribing short-duration high-intensity exercise bout within the morning in populations predisposed to hypercoagulability.

The Impact of Mild Heat Stress During Prolonged Running On Gastrointestinal Integrity, Gastrointestinal Symptoms, Systemic Endotoxin and Cytokine Profiles

The study aimed to determine the effects of mild exertional heat stress on intestinal injury, permeability, gastrointestinal symptoms, and systemic endotoxin and cytokine responses. Ten endurance runners completed 2 h of running at 60% V̇O2max in warm (WARM: 30°C) and temperate (TEMP: 22°C) ambient conditions. Rectal temperature (Tre) and gastrointestinal symptoms were recorded every 10 min during exercise. Blood samples were collected pre- and post-exercise, and during recovery to determine plasma intestinal fatty acid-binding protein (I-FABP) and cortisol concentrations, and systemic endotoxin and inflammatory cytokine profiles. Urinary lactulose:L-rhamnose ratio (L/R) was used to measure small intestine permeability. Compared with TEMP, WARM significantly increased Tre from 50 min onwards (38.1±0.3°C vs. 38.4±0.5°C, respectively; p<0.01), gastrointestinal symptoms (p=0.017), post-exercise plasma cortisol (26% vs. 59%, respectively; p<0.001) and I-FABP (127% vs. 184%, respectively; p<0.001) concentrations. Circulatory anti-endotoxin antibodies increased post-exercise (p<0.001) on WARM (20%) and TEMP (28%). No differences were observed for plasma endotoxin concentration (6% vs. 5% increase, respectively) or small intestine permeability (L/R 0.026±0.010 and 0.025±0.015, respectively). Both pro- and anti-inflammatory cytokines increased post-exercise, with inflammatory response cytokines TNF-α (p=0.015) and IL-8 (p=0.044), and compensatory anti-inflammatory cytokines IL-10 (p=0.065), and IL-1ra higher on WARM than TEMP. Findings suggest that exposure to warm ambient conditions during prolonged submaximal running induces transient intestinal epithelial injury, increases gastrointestinal symptoms, and promotes greater perturbations to the systemic cytokine profile compared to running in temperate conditions.

Does Short-Duration Heat Exposure at a Matched Cardiovascular Intensity Improve Intermittent-Running Performance in a Cool Environment?

PURPOSE To investigate whether a 5-d cycling training block in the heat (35°C) in Australian Rules footballers was superior to exercising at the same relative intensity in cool conditions (15°C) for improving intermittent-running performance in a cool environment (<18°C). METHODS Using a parallel-group design, 12 semiprofessional football players performed 5 d of cycling exercise (70% heart-rate reserve [HRR] for 45 min [5 × 50-min sessions in total]) in a hot (HEAT, 35°C ± 1°C, 56% ± 9% RH) or cool environment (COOL, 15°C ± 3°C, 81% ± 10% RH). A 30-15 Intermittent Fitness Test to assess intermittent running performance (VIFT) was conducted in a cool environment (17°C ± 2°C, 58 ± 5% RH) before and twice after (1 and 3 d) the intervention. RESULTS There was a likely small increase in VIFT in each group (HEAT, 0.5 ± 0.3 km/h, 1.5 ± 0.8 × smallest worthwhile change [SWC]; COOL, 0.4 ± 0.4 km/h, 1.6 ± 1.2 × SWC) 3 d postintervention, with no difference in change between the groups (0.5% ± 1.9%, 0.4 ± 1.4 × SWC). Cycle power output during the intervention was almost certainly lower in the HEAT group (HEAT 1.8 ± 0.2 W/kg vs COOL 2.5 ± 0.3 W/kg, -21.7 ± 3.2 × SWC, 100/0/0). CONCLUSIONS When cardiovascularexercise intensity is matched (ie, 70% HRR) between environmental conditions, there is no additional performance benefit from short-duration moderate-intensity heat exposure (5 × 50 min) for semiprofessional footballers exercising in cool conditions. However, the similar positive adaptations may occur in HEAT with 30% lower mechanical load, which may be of interest for load management during intense training or rehabilitation phases.

Commercial hype versus reality: our current scientific understanding of gluten and athletic performance

Recent explosion in the prevalence of gluten-free athletes, exacerbated by unsubstantiated commercial health claims, has led to some professional athletes touting gluten-free diet as the secret to their success. Forty-one percent of athletes report adhering to a gluten-free diet (GFD), which is four-fold higher than the population-based clinical requirements. Many nonceliac athletes believe that gluten avoidance improves gastrointestinal well-being, reduces inflammation, and provides an ergogenic edge, despite the fact that limited data yet exist to support any of these benefits. There are several plausible associations between endurance-based exercise and gastrointestinal permeability whereby a GFD may be beneficial. However, the implications of confounding factors, including the risks of unnecessary dietary restriction, financial burden, food availability, psychosocial implications, alterations in short-chain carbohydrates (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), and other wheat constituents emphasize the need for further evaluation.

Comment on: “Association Between Exercise-Induced Hyperthermia and Intestinal Permeability: A Systematic Review”

We read with great interest the systematic review of Pires and colleagues [1] entitled “Association Between Exercise-Induced Hyperthermia and Intestinal Permeability: A Systematic Review”, and commend the authors on a comprehensive review. The authors conclude that there is a relationship between exercise-induced hyperthermia and intestinal permeability; however, we raise two concerns with the systematic review that would influence the strength of the relationship reported by the authors. These issues are (1) the exclusion of an eligible study and (2) the incorporation of resting measures to investigate a relationship between exercise-induced hyperthermia and intestinal permeability. The authors have incorrectly excluded the data from Shing et al. [2] in their analysis, despite the study meeting their inclusion criteria. They state that “Shing et al. [42] ...only measured the urinary excretion of lactulose.” and they have therefore not included these data in their regression of core temperature and the urinary lactulose-to-rhamnose ratio. The paper by Shing et al. [2] clearly states that they measured the urinary lactulose-to-rhamnose ratio (as reported in the abstract: “There was a small to moderate reduction (d = 0.35) in urine lactulose:rhamnose”), they describe the procedure in their methods, and they present the change in urinary lactulose:rhamnose in their results, with a figure dedicated to this outcome variable (Fig. 3 Lactulose-to-rhamnose ratio post-run to fatigue). Inclusion of the data from Shing et al. [2] would weaken the strength of the relationship between intestinal permeability and core temperature reported by the authors. Inclusion of resting core temperatures and resting lactuloseto-rhamnose ratio measures in their correlation analysis also limits the conclusions that the authors may draw about ‘exercise-induced’ hyperthermia and intestinal permeability. The authors conclude “The magnitude of exercise-induced hyperthermia is directly associated with the increase in intestinal permeability” as a result of a significant correlation between core body temperature and intestinal permeability assessed with the urinary lactulose-to-rhamnose ratio. The authors have included resting measures in this correlation and as such their statement that the relationship between intestinal permeability and exercise-induced core temperature “is supported by the positive and strong correlation between TCore levels attained during exercise and the lactulose-to-rhamnose ratio, which is a marker of intestinal permeability (Fig. 3)” is not correct. When data for only end-exercise core temperature and intestinal permeability are correlated, a strong relationship between exercise-induced hyperthermia and intestinal permeability is not evident. This is illustrated by Shing et al. [2], who report an end-exercise core temperature of 39.4 °C with a lactuloseto-rhamnose ratio of 0.020, while Zuhl et al. [3] report an endexercise core temperature of 39.55 °C and a lactulose-to-rhamnose ratio of 0.055, a ratio that is approximately half that of Pals et al.’s [4] reported ratio of 0.108, despite a similar end-exercise core temperature (39.6 °C). Findings of similar increases in end-exercise core temperature, yet significant differences in intestinal permeability (measured using the lactulose-to-rhamnose ratio) [5], provide further support for the hypothesis that the magnitude of exercise-induced intestinal damage is not strongly related to core temperature. In conclusion, the exclusion of an eligible study and the inclusion of resting measures in the correlation between core body temperature and intestinal permeability assessed with the urinary lactulose-to-rhamnose ratio affect the strength of relationship proposed, and therefore affect the conclusions that the authors have drawn in relation to exercise-induced hyperthermia and intestinal permeability.