515 International Journal of Sport Nutrition and Exercise Metabolism, 2011, 21, 515 -519 �� 2011 Human Kinetics, Inc. Case Study: Nutrition Challenges of a Marathon Runner With a Gastric Bypass Nancy Clark A new type of athlete is appearing in the offices of sports dietitians: formerly obese people who have undergone gastric bypass surgery and now aspire to be marathoners, triathletes, and other types of endurance athletes. The standard nutrition advice offered to bypass patients is contrary to the standard sports advice given to athletes. Bypass athletes need to limit carbohydrates, fluids, and energy intake and consume a protein-based diet. This case study describes the sport nutrition concerns of a woman who, after having gastric bypass surgery, trained to run a marathon (42 km). Because of her limited ability to consume food and fluids, she experienced dif- ficulty preventing fatigue and dehydration during her long training runs and the marathon itself. She learned through trial and error how to survive the nutritional challenges and complete the marathon. Health profes- sionals need to be aware of the potential medical risks associated with endurance exercise in gastric bypass patients. Research is needed to determine the best sports nutrition practices for bypass patients. Only then can sport dietitians better educate this small but growing contingent of endurance athletes so the athletes can meet their training and performance goals and reduce their risk of experiencing serious health consequences. Keywords: bariatric athlete, endurance exercise, Roux-n-Y, medical issues of marathon runners, dehydration The author is with Sports Nutrition Services, Healthworks, Chestnut Hill, MA. A new type of athlete is appearing in the offices of sports dietitians: formerly obese people who have undergone gastric bypass surgery and now aspire to be marathoners, triathletes, and other types of endurance athletes. According to research (King et al., 2008), an estimated 6% of gastric bypass patients become highly active (as defined by taking more than 12,500 steps/day). Assuming that an estimated 220,000 people underwent bypass surgery in 2008 (American Society for Metabolic and Bariatric Surgery) and applying the estimate of 6% who may become highly active, an estimated 12,000 of these individuals may need sport nutrition advice. This number will likely increase each year as the prevalence of bypass surgery increases. I have observed that gastric bypass athletes who have had minimal prior experience with exercise or sports lack knowledge about nutritional preparation for their exercise programs. They express concerns about hydra- tion, protein, carbohydrates, and what to consume before and during exercise. A few bypass patients (including the client in this case study) do have a sports history and knowledge about standard sport nutrition practices, but after surgery they are not able to consume and metabo- lize food and fluid as they had done previously. This can negatively affect training and performance. The following points of standard nutrition advice offered to gastric bypass patients (Allied Health Sci- ences Section ad hoc Nutrition Committee et al., 2008) is contrary to the sports advice given to healthy athletes (Rodriguez et al., 2009): ��� Consume high-protein meals and snacks, targeting 60���80 g of protein per day. According to the American Dietetic Association���s (ADA) position stand on nutrition and athletic performance (Rodriguez et al., 2009), protein needs for endurance- and strength-trained athletes range from 1.2 to 1.7 g/ kg (0.5���0.8 g/lb) body weight per day. Hence, a 100-kg (220-lb) reduced-obese gastric bypass athlete would require 120���170 g protein per day, or double the standard recommendation. Adequate protein intake is important to support tissue healing after surgery, limit lean-tissue breakdown (that occurs secondary to a severe calorie deficit), and repair muscle damage that can occur during exercise. Most gastric bypass patients are told to first consume protein and next consume other food groups as room permits in their stomach pouch (about the size of an egg). But by focusing on protein, bypass athletes may select a diet that lacks the carbohydrates needed to adequately replenish the depleted liver and muscle glycogen stores that occur with endurance exercise. Although novice bypass athletes exercise at a low intensity that spares muscle glycogen, more experienced bypass athletes work at a higher intensity and have higher carbohydrate needs. ��� Avoid concentrated sweets to avoid ���dumping syn- drome.��� The ADA���s position stand on nutrition and athletic per- formance (Rodriguez et al., 2009) recommends 30���60 g case studies

516 Clark carbohydrate per hour of endurance exercise. Endurance athletes commonly consume per hour 500���1,000 ml of sports drinks (24���48 g carbohydrate) and/or one or two gels (25���50 g carbohydrate). Gastric bypass athletes need to learn how to consume carbohydrates in doses small enough to prevent dumping but high enough to maintain normal blood glucose levels. They commonly report limiting carbohydrate intake to less than 10 g per ���dose.��� ��� Sip fluids, targeting 240���360 ml (8���12 oz) per waking hour (~3 L/day). The ADA���s position stand on nutrition and athletic perfor- mance (Rodriguez et al., 2009) recommends consuming 450���675 ml (16���24 oz) of fluid for every 0.5 kg (1 lb) of body weight (sweat) lost during exercise. This could require a fluid intake of 950���1,400 ml (32���48 oz) in an hour, 3���6 times higher than what is recommended for gastric bypass patients. ��� Do not consume fluids during meals or for 60 min after having eaten. This may compromise fluid intake and delay recovery from dehydrating workouts. ��� Maintain weight by consuming 1,200���1,600 kcal/ day. Gastric bypass athletes who exercise for an hour or two each day may expend 500���1,000 kcal on exercise alone. A 1,200- to 1,600-kcal intake would likely result in muscle wasting, depleted muscle glycogen, needless fatigue, and reduced performance. Clearly, the recommendations for healthy endur- ance athletes contradict the recommendations for gastric bypass athletes. This raises questions and concerns about the appropriateness and dangers of endurance training among bypass clients who cannot consume adequate food and fluid to fuel their exercise. Presentation of the Athlete PK, a disciplined, dedicated, and successful graduate student and businesswoman and mother of two children first sought nutrition counseling from me in 2006. At 132 cm (62 in.) and 136 kg (300 lb), she was frustrated with her weight. She reported, ���I���ve been up and down with my weight all my life. I lose weight only to regain it. My parents are also obese.��� PK routinely met with me from August 2006 through March 2007. The counseling focused on creating a sus- tainable eating pattern that would contribute to fat loss. PK made appropriate dietary and lifestyle changes that initially contributed to loss of 17.2 kg (38 lb) in 3 months. By 7 months, she had regained 5 kg. She acknowledged ���I���m back to where I started. . . . I���m overstressed with school and work.��� In an effort to reduce ���stress eating,��� I referred PK to a therapist. Counseling proved to be helpful, and that is when PK chose to focus her time with the therapist (as opposed to continue nutrition counseling). Unlike many obese individuals, PK enjoyed exercise. In high school and college, she had not participated in school sports, but after college, she started exercis- ing regularly (aerobics, strength training). By the time she came to see me, she was participating in sprint triathlons. In 2007, PK decided to undergo gastric bypass sur- gery. She perceived that her body was not losing weight despite her hard work. She had pondered the costs and benefits of bypass surgery for several years and finally decided the benefits were higher than the costs. PK���s medical team recommended the Roux-n-Y bypass procedure. It was performed at a top-ranked bar- iatric surgery facility in December of 2007. PK entered into surgery being physically fit, with serum cholesterol and blood pressure values within normal limits. The surgery was uneventful and her body healed quickly. On the first day postsurgery, PK walked 2 miles up and down the corridors. PK has read this case study and has given written permission for it to be published. This case study con- forms to the principle that has been approved by the ethics committee of the Australian Institute of Sport. Athlete Assessment Within the first 6 months postsurgery (December 2007 through June 2008), PK���s weight dropped from 145 kg (319 lb) to 104.5 kg (230 lb), a loss of 58% of excess body weight.. By spring of 2008, she was participating in 5K and 10K road races. She completed her first half- marathon in July 2008 (7 months postsurgery 100 kg [220 lb]). The Marine Corps Marathon in October 2009 seemed a fitting way to celebrate her 40th birthday. Despite the bariatric center���s solid reputation, the facility did not have experience working with the spe- cific nutritional needs of a bypass athlete training for a marathon. It did not occur to PK that her previous sport dietitian could help her, a bypass patient. Feeling des- perate for guidance, she found some information on the Internet (www.obesityhelp.com). Through considerable trial and error, PK managed to fuel her training sessions the best she could. Overview of Nutrition Plan With all bypass clients, dietary patterns evolve through trial and error as each individual learns which foods are well tolerated and which are not. This progression may take up to 1 or 2 years before stabilizing at a new ���norm.��� The first 7 months after bypass surgery, PK���s food intake progressed from a blended diet (pureed/liquid food) to semiblended and then to regular food. Her protein-based bypass diet included minimal fruits, veg- etables, and grains (see Table 1). PK reported she had to force herself to eat during the first year. She ���felt great��� and did not experience hunger or fatigue, despite her limited daily intake of less than