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SPORTS NUTRITION EDUCATION: Key for Success for Post-Bariatric Athletes

Mulvaney, Allison M.S.; Bader, Allison M.S., D.T.R.; Herbold, Nancie Ed.D., R.D.; Clark, Nancy M.S., R.D., C.S.S.D., FACSM

ACSM’s Health & Fitness Journal: May/June 2013 - Volume 17 - Issue 3 - p 20–23
doi: 10.1249/FIT.0b013e31828cb4d1
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LEARNING OBJECTIVE To educate health care professionals about the hydration and fueling needs of physically active clients after bariatric surgery and examine the need for individualized sports nutrition recommendations for this emerging population of endurance exercisers.

A growing number of recreational exercisers have had bariatric (weight loss) surgery. Because of the greatly reduced size of their stomach pouch, this population can only eat and drink small portions at one time without facing gastrointestinal distress. This makes hydrating and fueling for athletic events both challenging and a source of confusion. This article provides sports nutrition suggestions for working with this emerging population of exercisers.

Allison Mulvaney, M.S., has her Master’s in Nutrition and Health Promotion from Simmons College in Boston, MA. She currently is completing her dietetic internship in the Boston area to fulfill the requirements of becoming a registered dietitian.

Allison Bader, M.S., D.T.R., has her B.S. in Nutrition and Dietetic from the University of Rhode Island and her M.S. in Nutrition and Health Promotion from Simmons College. She currently works as a nutritionist for the Chester County Hospital and Health System and writes a bimonthly nutrition article for the West Chester Dish.

Nancie Herbold, Ed.D., R.D., is a Ruby Winslow Linn professor, chair of the Department of Nutrition, Simmons College, and codirector for the Center of Hygiene and Health in Home and Community. Her research focuses on sports nutrition and supplement use by athletes and active individuals.

Nancy Clark, M.S., R.D., C.S.S.D., FACSM author of Nancy Clark’s Sports Nutrition Guidebook, has a private practice in the Boston area. She counsels all levels of athletes and has a special interest in helping bariatric exercisers/athletes reach their weight and exercise goals.

Disclosure: The authors declare no conflicts of interest and do not have any financial disclosures.

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INTRODUCTION

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Along with the global rise of obesity during the past decades, there has been a coinciding rise in the prevalence of bariatric surgery. Close to 350,000 bariatric procedures were performed worldwide in 2008 alone, with the number continuing to grow (3). The primary objective of such surgical procedures is to achieve substantial weight loss to improve the health and quality of life of the individual. To enhance weight loss, bariatric patients are highly encouraged to exercise (5). Those who do engage in exercise programs may find themselves confronted by physical, nutritional, and hydration challenges.

Presently, there is very little research available to practitioners and the public on how to counsel people who have had weight loss surgery and now aspire to run a marathon, complete an Ironman triathlon, or accomplish any type of endurance challenge. These individuals are learning through trial and error how to manage their nutrition and hydration needs (6). Those who compete in endurance events, such as marathons and triathlons, are potentially at increased risk for experiencing poor performance, if not medical issues caused by dehydration or underfueling. Proper nutrition and training advice from coaches, personal trainers, nutrition professionals, and medical practitioners can help alleviate some of these concerns. Hence, the goal of this article is to educate health care providers about current hydration and dietary best practices of highly active individuals who have had bariatric surgery. Sharing this information will theoretically allow health professionals to offer more tailored sports nutrition education when helping this population reach its exercise goals.

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SPORTS NUTRITION PRACTICES OF PHYSICALLY ACTIVE INDIVIDUALS AFTER BARIATRIC SURGERY

As defined in Sidebar I (1,2), physically active people who have had bariatric surgery have different hydration and fueling needs than the typical exerciser. Because weight loss surgery changes the actual volume that the stomach can hold, highly active bariatric patients can only eat and drink limited amounts at one time. Consequently, adequate fuel and fluids before, during, and after prolonged exercise can be challenging. Food and drink have to be carefully managed to prevent gastrointestinal distress, specifically “dumping syndrome,” in which stomach contents rapidly empty.

Sidebar I

Sidebar I

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The authors recently surveyed 113 highly active individuals who have undergone bariatric surgery. The goal of the survey was to learn more about how these exceedingly motivated and dedicated exercisers fuel themselves during prolonged exercise. Approximately 8% of those surveyed reported that they were novice exercisers and had not engaged in endurance activity before having had bariatric surgery (7).

When asked about what they most commonly eat and drink during the exercise period, we learned that (7):

  • Water was the most frequently consumed beverage.
  • 19% of participants reported not drinking any fluids during exercise.
  • Over time (i.e., 2 years vs. 6 months after surgery), athletes were able to tolerate higher volumes of fluid intake.
  • No participants reported drinking carbonated beverages before, during, or after exercise.
  • 46% of participants reported eating within 1 hour of exercise, 19% eat during exercise, and 59% eat within 1 hour after exercise.
  • Bars (such as protein bars) and energy gels were the most frequently reported food consumed during exercise. Specific brands that settled well without causing intestinal distress in several of the participants included Hammer Gel® and Hammer Perpetuem Solids®, GU Energy Gel®, Jelly Belly Sports Beans®, and Clif Shot Bloks®.

In addition, a subgroup of 40 endurance athletes who had bariatric surgery was asked about common problems encountered during exercise lasting more than 1 hour. Responses related to suboptimal nutritional practices included shakiness, light-headedness, dizziness (54%); extreme fatigue, “hitting the wall” (38%); dehydration (38%); muscle cramps (29%); and intestinal distress/urge to defecate (17%). Musculoskeletal problems related to knees, feet, back, or shins were reported by 36% of the participants (unpublished data). Eighteen percent reported that they had ended up at a medical tent during an organized athletic event because of shakiness/light-headedness/dizziness, dehydration, and muscle cramps. One athlete reported getting dizzy, tripping, and breaking a wrist. Another reported having to stop the medical personnel from making him consume a sports drink plus an orange, a carbohydrate load that could have provoked dumping syndrome. Clearly, both physically active individuals who have had bariatric surgery and health professionals alike are in need of sports nutrition education pertaining to how to manage nutritional needs during extended exercise.

The following are some of the common questions posed by participants in the survey:

“I have questions concerning actual caloric needs and questions about race fueling.” — 44-year-old man

“How many grams of protein should I be eating daily?” — 39-year-old woman

“How reliable is the resting metabolic rate formula? What are the best macronutrient percentages for weight maintenance?” — 49-year-old woman

“Will core workouts cause me to injure myself?” — 47-year-old man

“What are the minimal nutrition requirements for a bariatric patient per hour to run a marathon?” — 57-year-old man training for a half marathon and 25K trail race

“What is the best way for me to maintain muscle mass while losing large amounts of weight very quickly?” — 30-year-old woman training for a 5K and half marathon

As evidenced by the above examples, these physically active individuals have many questions about sports nutrition and training programs. Although their questions may be similar to those posed by physically active people who have not had bariatric surgery, the answers remain unclear for post-bariatric surgery exercisers. Because body weight, food tolerance, exercise capacity, and time since surgery vary among individuals, there is no one-size-fits-all response that answers the above queries. The questions underscore the emerging need for establishing guidelines for post-bariatric surgery exercisers.

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DISCUSSION

Health professionals who are likely to offer nutrition advice to a physically active person who has had weight loss surgery might find the following suggestions to be helpful:

  • 1. Find out when the surgery took place. The more recent the surgery, the less fluid and food the client will be able to tolerate. The client who had surgery within 6 months may not even feel hunger, in which case you could suggest liquid meals, such as a protein shake, to help reduce muscle loss. By 2 years after surgery, some individuals report that they are able to “eat normally.”
  • 2. Encourage the client to exercise with fluids readily available (i.e., carry a water bottle, use a CamelBak®) and take small sips throughout the exercise period. For exercise that lasts less than 1 hour, promote water and discourage carbonated beverages (to avoid gas formation in small stomach pouch). For individuals who sweat heavily, learning their sweat rate could offer helpful information. By weighing themselves with minimal clothing before and after exercise, they can calculate sweat loss and should try to replace as best they can. Dehydration should not exceed 2% of total body weight (4).
  • 3. During moderate- to high-intensity exercise that lasts longer than an hour, the athlete should experiment with consuming some type of carbohydrate to help maintain a normal blood glucose level. For some, the carbohydrate might be a jelly bean every 20 minutes; for others, it might be tiny tastes of a gel every few minutes or sips on a sports drink. Because of individual variation and lack of research, each athlete will need to learn through trial and error the foods or fluids that work best without causing gastrointestinal distress. Suggest experimenting with small amounts of solid or liquid carbohydrates if the client thinks he or she may be able to tolerate the fuel without experiencing dumping syndrome.
  • 4. On a daily basis, the client should enjoy small meals that provide adequate protein (minimum of 65 to 75 g per day) (8), along with carbohydrates as tolerated.
  • 5. Advise the client to increase the exercise period gradually. Beware of conditions such as high ambient temperatures that can increase sweat losses and adjust the planned exercise accordingly.
  • 6. Recommend that the client takes a daily multivitamin to offset deficiencies that could occur from the combination of malabsorption from the bypass and loss of nutrients from perspiration during exercise.
  • 7. When in doubt, refer. Bariatric surgery and its long-term effects on nutritional needs can be complicated. Use the resources you have available and collaborate with sports dietitians and the client’s medical team. The client’s safety is the number one priority.
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In summary, physical activity is routinely advised for individuals who have had bariatric surgery, yet there are no sports nutrition guidelines for these athletes. Individuals who become highly active after having bariatric surgery often have no history of sport-specific physical activity before surgery. After surgery, they become eager for sports nutrition education particularly how to optimally fuel for daily training and specific athletic events. More research is needed before health care providers can provide evidence-based recommendations that will improve the athlete’s exercise and competition experience as well as alleviate some of the confusion around diet and exercise after weight loss surgery.

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CONDENSED VERSION & BOTTOM LINE

After weight reduction surgery, physically active individuals who have had bariatric surgery need to carefully hydrate and fuel to perform well, prevent medical complications during training and events, and enhance enjoyment of their exercise program. To help ensure safe and successful workouts, these individuals should 1) eat small frequent meals/snacks that include tolerated carbohydrates both before and during exercise lasting longer than 1 hour; 2) avoid unfamiliar carbohydrates, such as gels and sports drinks, during organized sporting events unless they have first tested them during training; and 3) continuously sip on fluids before, during, and after exercise. With experience and sports nutrition knowledge, this growing population of exercisers will be able to safely enjoy, and excel at, endurance activities.

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References

1. Aills L, Blankenship J, Buffington C, Furtado M, Parrott J. American Society for Metabolic and Bariatric Surgery allied health nutritional guidelines for the surgical weight loss patient. Surg Obes Relat Dis. 2008; 4: S73–198.
2. American Dietetic Association, Dietitians of Canada, and the American College of Sports Medicine. Position statement: nutrition and athletic performance. J Am Diet Assoc. 2009; 109: 509–26.
3. Buchwald H, Oien D. Metabolic/bariatric surgery worldwide 2008. Obes Surg. 2009; 19 (12): 1605–11.
4. IOC consensus statement on sports nutrition 2010. J Sports Sci. 2011; 29 (Suppl 1): S3–4.
5. King W, Belle S, Eid G, et al.. Physical activity levels of patients undergoing bariatric surgery in the Longitudinal Assessment of Bariatric Surgery study. Surg Obes Relat Dis. 2008; 4 (6): 721–8.
6. Kulick D, Hark L, Deen D. The bariatric surgery patient: a growing role for registered dietitians. J Am Diet Assoc. 2010; 110 (4): 593–9.
7. Mulvaney A, Bader A, Clark N, Herbold N. Bariatric surgery and excercise: a descriptive survey of dietary intake. Top Clin Nutr. In press.
8. University of California, San Francisco Medical Center. Dietary Guidelines After Bariatric Surgery. UCSF Medical Center. Available from: www.ucsfhealth.org (Accessed November 27, 2012).
Keywords:

Weight Loss Surgery; Athletic Performance; Fitness Trends; Gastric Bypass; Special Populations; Sports Nutrition

© 2013 American College of Sports Medicine