Endurance sports are increasing in popularity and athletes at all levels are looking for ways to optimize their performance by training and nutrition. Although high muscle glycogen concentrations at the start may be beneficial for endurance exercise, this does not necessarily have to be achieved by the traditional supercompensation protocol.

An individualized nutritional strategy can be developed that aims to deliver carbohydrate to the working muscle at a rate that is dependent on the absolute exercise intensity as well as the duration of the event. Gastrointestinal problems occur frequently, especially in long-distance races.

Problems seem to be highly individual and perhaps genetically determined but may also be related to the intake of highly concentrated carbohydrate solutions, hyperosmotic drinks, as well as the intake of fibre, fat, and protein.

Vitamin and mineral considerations are crucial when participating in and training for ultra-endurance activities. When it comes to athletic performance, these micronutrients are particularly important for energy production, hemoglobin synthesis, maintenance of bone health, adequate immune function, and protection of the body against oxidative damage.

They also assist in important physiological processes related to synthesis, recovery, and adaptation to exercise. Because of this, exercise may increase the turnover and loss of these nutrients resulting in greater dietary intakes being required. Some vitamins and minerals that athletes need to pay particular attention to are calcium, vitamins D, C, E, and the B vitamins, iron, zinc, magnesium, as well as, beta carotene and selenium for their antioxidant properties.

Calcium and vitamin D play important roles in growth, maintenance, and repair of bone tissue as well as regulation of nerve conduction, and development and homeostasis in skeletal muscle.

A deficiency in both or either calcium and vitamin D increases the risk of low bone-mineral density and stress fractures [ ].

Calcium can be obtained from food; however, vitamin D is mainly synthesized through sunlight. In those with suboptimal levels stated in Table 2 , supplementation may be necessary. Current vitamin D supplement recommendations suggest — IU per day for athletes [ ].

B vitamins play a role in energy production and the building and repair of muscle tissue. There is some data suggesting that to obtain optimal health and performance, highly active athletes may need to double the current recommended amounts of these B vitamins though it is likely that these needs are being met with increased energy intakes [ ].

Of particular consideration, however, are vitamin B12 and folate. A deficiency in either of these nutrients results in anemia which can greatly reduce time to fatigue and therefore endurance performance [ ]. Because vitamin B12 is obtained through animal products, such as meat and dairy, athletes such as vegetarians or vegans may need to consume supplements with this vitamin.

Iron deficiency will also result in anemia, reducing the ability of red blood cells to transport oxygen. A deficiency in iron is common among those engaged in prolonged activity due to up-regulation of the hormone hepcidin. Because of this, ultra-endurance athletes should pay particular attention to their iron consumption and obtain regular blood tests to check their ferritin status.

Iron absorption can be improved by consuming heme iron found in meat products with non-heme iron found in plant products and vitamin C with sources of iron [ , ]. Zinc plays a role in muscle repair, energy metabolism, and immune status. A deficiency in zinc can result in disrupted thyroid hormone levels, affecting metabolic rate and performance [ ].

It can also reduce cardiorespiratory function, muscle strength, and endurance [ ]. Athletes are at high risk of inadequate zinc levels [ ] and should therefore strive to achieve adequate zinc intake through zinc-rich foods.

Zinc-rich foods include shellfish, green leafy vegetables, and seeds. If supplementation is required, athletes should receive guidance from their health care provider.

Magnesium supports the proper functioning of the nervous and musculoskeletal systems [ ]. Deficiency can cause multiple symptoms resulting in decreased performance as it is linked to many pathological conditions of the cardiovascular, skeletal, and nervous systems [ ].

Ultra-endurance athletes are at increased risk of this deficiency due to increased urinary and sweat losses induced by magnesium redistribution within the body during prolonged intense activity [ ]. Ultra-endurance athletes should have their blood levels of magnesium tested regularly and self-monitor for common symptoms of hypomagnesaemia such as muscle cramps.

Supplementation with magnesium is recommended if necessary and dosage should be determined under the discretion of their healthcare provider to avoid toxicity. Exercise can induce a release of free radicals or reactive oxygen species which have the ability to modify lipids, proteins, carbohydrates, and nucleic acids in the body [ ].

These modifications are collectively known as oxidative damage or oxidative stress and have been linked to negative health outcomes such as insulin resistance, atherosclerosis, cardiac dysfunction, and injury [ ]. Antioxidant vitamins and minerals, such as vitamins C and E, beta carotene, and selenium can be used to mitigate these effects.

These nutrients act in different ways to either remove oxidative species or prevent their reactions from happening [ ]. However, because oxidative species also have some beneficial effects on the body, their function is not to completely eliminate these processes, but to keep them at homeostatic, and thus optimal, levels.

Therefore, there is a threshold to which antioxidants can provide benefits for performance, health, and recovery. Research on ultra-endurance athletes has demonstrated that their need to prevent oxidative damage is higher given their extraordinary exercise volume [ ].

Although more research is needed to examine the effects of these antioxidant supplements during and immediately prior to an event, current evidence suggests little to no benefit [ , ]. It is important to note that although ultra-endurance athletes may benefit from ample intakes of antioxidant vitamins and minerals that exceed the current recommendations for the general population, they should be cautioned not to consume these nutrients at levels above the ULs.

High doses above the UL can also result in pro-oxidative effects, causing risks of decreased performance, recovery and health [ ].

Other antioxidants which have recently been investigated for their effects on endurance performance include polyphenols with the most popularly researched being quercetin, catechins, and resveratrol.

These polyphenols are organic chemical compounds mainly found in plants that have strong antioxidant properties [ ]. They have also been shown to have anti-inflammatory, cardioprotection, and anti-carcinogenic properties in clinical populations [ ].

However, few studies have investigated the effects of these polyphenols on performance, particularly in an ultra-endurance population.

Catechins are commonly found in plants such as green tea and cacao. Some human studies have shown positive effects for endurance including V02 max [ ], fat oxidation, and insulin sensitivity [ ] in an untrained population; however, studies on trained subjects are yet to show benefits [ — ].

It is unlikely that supplemental catechins would be beneficial to ultra-endurance performance. Resveratrol is present in concentrated quantities in grapes. With one exception, studies to date have only been performed on rodents, and the effects on performance range from extremely beneficial to extremely detrimental [ — ].

Taken together, these studies would suggest that resveratrol benefits trained rodents and is potentially harmful in untrained rodents. The only human study was performed in untrained elderly participants and the effect demonstrated that supplementation was also potentially harmful through blunting of cardiovascular training adaptations to endurance exercise [ ].

Further research is needed before supplemental resveratrol should be taken by ultra-endurance athletes. Quercetin is found in foods such as red onion, dill, apples and capers and has been studied more extensively than other polyphenols.

It provides many health benefits in humans [ ] and has shown to encourage mitochondrial growth in rodents [ ]. Although quercetin supplementation shows potential endurance performance benefits in cell culture and in vivo animal studies [ , ], research on its use as a supplement in humans are less clear.

Some studies have reported increased endurance exercise capacity and performance in humans following supplementation with quercetin [ — ]; however, many have failed to find benefits [ — ]. Of the 2 studies [ , ] on ultra-endurance trained subjects, both have shown no significant benefit.

Nieman et al. No improvements in performance or attenuation of markers of muscle damage, inflammation, increases in plasma cytokines, and alterations in muscle cytokine mRNA expression were found [ ]. Quindry et al. The supplement did not fortify plasma antioxidant levels against ultramarathon-induced oxidative stress in blood plasma or improve performance.

This being said, a meta analysis by Kressler et al. Based on data showing favorable outcomes for supplemental quercetin [ — ], a daily dosage of mg could have small potential benefits and is unlikely to be detrimental for ultra-endurance trained populations. However, the amounts needed in excess of those recommended for the general population are likely dependent on multiple factors including individual variability, training intensity, and training duration.

To determine if ultra-endurance athletes are consuming adequate amounts of vitamins and minerals, they should obtain regular blood tests to ensure blood levels are being maintained at levels that are not only acceptable for general health but are optimal for performance see Table 2.

This may be particularly important during times when their training or nutrition changes. It is important to emphasize that regular adequate intake of vitamins and minerals is required for optimal performance and that consuming extra vitamins and minerals through supplementation immediately before or during an ultra-endurance event has not shown to provide any performance, health or recovery benefits [ , ].

During ultra-endurance activities and corresponding training exercises, food and fluid must be consumed while being active to minimize the energy deficit.

Because of this, it is no surprise that GIS are a common issue for these athletes [ ]. Endeavoring to prevent GIS is important as it is one of the most common cited reasons for inadequate intake during events [ , ] and is positively correlated with increasing duration [ ].

Running in particular appears to result in more pronounced GIS than other activities [ ] as well as a dehydrated state compared with a euhydrated state [ ]. There also seems to be an individual predisposition for GI distress during exercise as Pfieffer et al. have determined a positive relationship between GIS during races and history of GI issues both associated with and away from exercise [ , ].

Another common issue in ultra-endurance athletes is reduced appetite, which is closely related to GIS as both are subsequent results of splanchnic ischemia.

If the event has no enforced breaks, whole foods may not be an option as they may be too difficult to chew and swallow and could result in GIS. In this case, intake from fluids is a viable option as not only does it provide the energy but also hydration. With gels, it has been shown that high doses of CHO 1.

Against this background, it may be best to determine strategies, such as use of different types of nutritional sources and frequency of consumption to find which methods work best to maximize carbohydrate intake during an event without causing GI distress.

One of the possible ways that this could be done is through coingestion of glucose and fructose as a carbohydrate source rather than one or the other. Research suggests that this can increase carbohydrate oxidation from an average of 1—1.

With the use of gels as a source of carbohydrates, Pfeiffer et al. However, some individuals showed more symptoms with one or the other gel.

It should, therefore, be advised that individual athletes, especially those who experience GI problems frequently, test their tolerance during intense training sessions, ideally under conditions similar to those of the races they aim to compete in.

The intake of the nutrients fat, fiber, and protein, have all been linked to GIS during exercise [ ]. However, as the duration of ultra-endurance races increases, these food and drink choices have become less tolerable and appealing [ , ]. Although the evidence of this is mainly anecdotal, intestinal carbohydrate transporters can indeed be up-regulated [ , ] and gastric emptying rates can be enhanced with training [ ].

GIS occur less frequently after adequate training or when relative exercise intensity is reduced [ , ]. Although more research in this area is needed, experimentation with this strategy during training is likely to present little risk and athletes should dedicate at least some time to gut training.

Endurance training itself appears to enhance gastric transit time [ ], and higher energy intakes during training further enhance this rate [ ]. Cox et al. The higher rates were attributed to improved absorption, which provides evidence that the gut is indeed adaptable and that this could be used as a practical method to increase exogenous carbohydrate oxidation.

This could lead to improvements in performance through greater fuel availability as discussed in preceding sections.

There is a paucity of agreed-on and concrete nutrition best practices for ultraendurance runners and even less demarcating such by event type. From a macronutrients perspective, ultra-endurance athletes need to ensure adequate intake.

However, the practicality of such recommendations needs to be considered on an individual basis and the importance of rehearsal of an individualized nutrition strategy prior to competition cannot be overemphasized.

As far as is necessary, and in keeping with advice from healthcare providers, ultra-endurance athletes may use supplements to support training and events performance and aid in recovery.

While some recommendations presented are prescriptive in nature based on the findings of various studies, ultra-endurance athletes are encouraged to apply them within the context of their particular training regiment, body mass composition, and corresponding physiological needs.

All the literature reviewed indicate that ultra-endurance athletes must take great care in attending to their nutritional needs to maintain good health, promote optimal performance, and reduce the likelihood of injuries.

Proper nutrition will result in decreased energy depletion, better performance, and accelerated recovery. With the growing international appeal of ultra-endurance events, significant research is needed to promote the health and wellbeing of athletes.

More longitudinal studies are needed to ascertain the precise nutritional and environmental conditions under which athletes perform most optimally based on age, gender, type of event, body type, and other physiological factors.

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