If this is a patient, coming to you for your professional opinion, don't forget the basics:

• History
  • preexisting symptoms?
  • review training program
  • review diet - both between and during the activity; diet supplements
• and the physical exam
  • especially stool hemoccults
  • iron status

1. Adequate training - As the athlete often has had a rapid incrase in his/her training rpogram as the etiology, decreasing the intensity of workouts followed by a gradual return (10% increase per week) to previous levels after symptoms resolve can be a successful strategy.

2. Consider changing the type of exercise or cross training if possible - for example more cycling which is less jarring than running.

3. Attention to hydration - Drink while exercising to minimize dehydration which has a major effect on multiple GI symptoms. But limit intake to 600 - 1000 ml/hr. This is a balancing act as we know that symptoms are increased with dehydration, and we also know that symptoms can be increased with any oral intake. Recommendations will depends on length of the event, level of intensity, ambient temperatures, and so on. Small volumes are frequently better than larger, less often.

4. Avoid hypertonic solutions - Preferably no more than 500 mosm, 6 to 8% simple CHO; consider complex carbs solutions with lower osmotic activity to minimize gastric distention, aggravate reflux, and help maintain oral fluid and Caloric replacement.

5. Addition of NaCl to fluids for palatability (no effect on absorption)

6. Consider the addition of CHO to oral fluids during exercise
   • may theoretically increase fluid absorption in SB
   • may blunt decreases in visceral blood flow based on experimental studies
   • does provide Calories for competition lasting > 2 hours

7. Avoid dramatic diet changes from a pre competition training diet.

8. Don't eat a large meal of any type within 3 to 4 hours of exercising.

9. Focus on a CHO rich diet pre exercise. Limit fat and protein pre competition because of GI intolerance.

10. Avoid a high fiber diet 3 days pre exercise because of it's impact on lower GI symptoms.

11. Avoid caffeine, vitamin C, and dubious ergogenic aids - all of which have been associated with an increase in GI symptoms.

12. Minimize the use of anti inflammatories.

13. Consider a GI evaluation if there are recurrent symptoms in the non exercising state.

14. Prophylactic Medications - antimotility agents for diarrhea; H2 antagonist or omeprazole if reflux or gastritis symptoms (especially for marathon and ultramarathon level events).