Nutrition for the Bariatric Athlete: Part 1- Endurance Training
As a registered dietitian I specialize in sports nutrition, but I have the unique opportunity to work with bariatric patients as well. In fact, I work with bariatric patients both pre- and post- surgery. Many people may assume that these are two very different areas of expertise, but there are a growing number of bariatric athletes in which the two different specialties are combined. Some of these individuals were always active and some of them start being active after surgery. Some of these patients are exercising beyond the recommended 150 minutes of physical activity per week and are competing in long duration endurance events such as marathons, ultra distance events, and ironman triathlons. Training for some of these events can include hours of training per day. They might be getting the 150 minutes of exercise in one training session.
Calorie recommendations post-bariatric surgery are usually very low at around 1,000-1,400 calories per day and focus on protein foods at each meal. Patients are advised to eat 5-6 small meals per day. Weight loss surgery changes the actual volume that the stomach can hold. The typical stomach can hold between 1,000-3,000 mg of food and fluid. After surgery this is reduced to 100-300 ml. Bariatric patients are advised to limit or completely eliminate sugary foods and beverages as there is an increased risk for “dumping syndrome,” in which a high concentration of sugar can cause a rush of fluid into the small stomach and results in a rapid emptying of stomach contents. This is most common in patients who have had the gastric bypass surgery or roux en y. Bariatric patients are also advised to take supplements such as a multivitamin, vitamin D, iron, Vitamin B12, and calcium and will likely need to be taking supplements the rest of their life to prevent vitamin and mineral deficiencies.
There is minimal research available to practitioners on how to counsel bariatric athletes. Because of the unique challenges that bariatric athletes face, they are increased risk of experiencing poor performance and having medical issues caused by dehydration or under-fueling. These patients face a challenge to get adequate fuel and fluids before, during, and after prolonged exercise. Food and fluids have to be carefully managed to prevent gastrointestinal distress including “dumping syndrome.”
Patient who have had bariatric surgery are told to follow a low fat, low sugar diet. Patients are told to focus on protein and limit fat and sugar in the diet. This makes sense for weight loss, but once these individuals start increasing activity this can often cause a patient to feel conflicted because many sports nutrition guidelines encourage higher amounts of carbohydrates and an increased intake of fats to support training. Patients often avoid consuming food during a workout and may not realize how much energy they require to fuel their body for their sport. This often leads to frustration, poor performance, injury, and increased risk for disordered eating.
When I work with bariatric athletes I spend time explaining their unique situation and counseling them on the nutritional requirements for training. This often involves reassuring them that eating to support training, if done properly, will not lead to weight re-gain. This is also why it is critical for athletes who have had a bariatric surgery to find a sports dietitian that has an in depth knowledge and understanding of the different bariatric surgeries and the potential nutrition and dietary challenges these individuals face.
General recommendations for bariatric athletes:
Liquids meals/snacks: Because there is limited space in the stomach after surgery an individual is limited by the amount of solid foods they can consume at one time. A meal may consist of 2-3 ounces of meat and ¼ cup of vegetables. For the bariatric athlete this can make it difficult to get adequate energy to fuel exercise. I often recommend liquid snacks or meals such as protein shakes or smoothies 1-2 times per day. Shakes are easy to sip and are easy to digest so the nutrients are absorbed more rapidly than a solid meal allowing for more energy to be consumed.
Fluids: I advise the bariatric athlete to always have fluids readily available, small sips spread throughout the exercise duration. The bariatric athlete is going to have to be more diligent about carrying water even during shorter duration exercise because the limited space in their stomach makes it difficult to chug or swallow large amounts of fluids at one time. This also makes it more difficult for them to rehydrate adequately after a workout.
Frequent meals and snacks: Most bariatric patients are already advised to consume 3 meals and 2-3 snacks per day. This recommendation is especially critical for the bariatric athlete. As stated above, some of these meals may need to be liquid. These athletes need to continue to focus on protein, but added fats and carbohydrates are also advised, especially during hard training cycles.
Post workout nutrient timing very important: Getting a meal or snack in within 60 minutes post exercise is very important for the bariatric athlete. This meal should contain both carbohydrate and protein.
Try products with chia seeds or maltodextrin: These products are digested slower than other forms of carbohydrate and may help prevent dumping syndrome. Maltodextrin is a polysaccharide making it more complex than products with fructose, glucose, or dextrose and thus digested and absorbed at a slightly slower rate. Chia might be a good option because chia seeds can slow digestion. After being soaked in fluid they form a gel-like consistency and this helps slow the conversion of carbohydrates into sugar. Another option is to try sports gummies, waffles, and beans and consuming only a few bites at a time throughout the training session to avoid an overload of concentrated sugar that leads to dumping.
Hydration and electrolytes are critical: Low sugar electrolyte drinks should be a must for long duration exercise or for individuals that lose a lot of salt during exercise. Some bariatric athletes may also need to consider salt tabs or electrolyte tabs.
Keep an eating schedule: The bariatric athlete will need to stick to an eating schedule to make sure they are getting enough fuel, but they also need to identify when they are satisfied. This includes mindfulness at meals and identifying hunger and fullness signals.
Nutrient deficiencies: Nutrient deficiencies are common for bariatric patients and with the increased nutrient demand of exercise there is an increased risk of deficiencies in the bariatric athlete. Getting routine blood testing is very important. The bariatric athlete needs to be diligent about taking their supplements and may even have an increased need for certain vitamin and mineral supplements including iron or B12.
Getting your nutrition dialed in may take a bit of trial and error. It is important to try different fueling and hydration strategies during workouts to see what works best.