International Journal of Sport Nutrition and Exercise Metabolism, 2019, 29, 236-245
https://doi.org/10.1123/ijsnem.2018-0309© 2019 Human Kinetics, Inc.

SCHOLARLY REVIEW

Dietary Practices Adopted by Track-and-Field Athletes:
Gluten-Free, Low FODMAP, Vegetarian, and Fasting
Dana M. Lis
University of California, Davis

Daniel Kings
Aspetar Qatar Orthopaedic and Sports Medicine Hospital

D. Enette Larson-Meyer
University of Wyoming
Some track-and-ﬁeld athletes implement special diets aiming to improve health and/or performance. An evidence-based
approach to any diet is recommended to minimize the risks associated with unnecessary dietary restriction, which may potentially
do more harm than good. Four prevalent diets are reviewed in this study: (a) gluten-free; (b) low fermentable oligosaccharides,
disaccharides, monosaccharides, and polyols (FODMAP); (c) vegetarian; and (d) fasting diets. Recently, gluten-free diets andlow FODMAP diets have emerged as novel regimes thought to improve gastrointestinal health and reduce the risk of exerciseassociated gastrointestinal symptoms. No direct beneﬁcial outcomes have been associated with avoiding gluten for clinically
healthy athletes. Indirectly, a gluten-free diet is associated with other dietary changes, particularly FODMAP reduction, which
may improve adverse gastrointestinal symptoms. Vegetarian diets can optimally support athletic demands. However, attention isrequired to ensure adequate energy and intake of speciﬁc nutrients that are less abundant or less well absorbed from plant sources.
Finally, fasting is a long-standing concept that is undertaken on a voluntary and obligatory basis. Despite limited supporting
research, voluntary fasting is a popular alternative to conventional diets perceptually offering health and body composition
beneﬁts. Strict obligatory fasting guidelines likely require the implementation of tailored nutrition strategies to help athletes copewith athletic demands. Overall, a multitude of factors inﬂuence adherence to special diets. Even when adherence to a special dietis a necessity, education and advice from an accredited dietitian/nutritionist are recommended for track-and-ﬁeld athletes tooptimize nutrition for health and performance.
Keywords: diet, performance, special, sport
A variety of special diets are adopted by track-and-ﬁeld
athletes for a multitude of reasons. Gluten-free (GFD), vegetarian,and fasting diets are among the more prevalent diets adopted for
health, ethical, religious, and performance purposes. A low fermentable oligosaccharides, disaccharides, monosaccharides, andpolyols (FODMAP) diet is also gaining popularity as a beneﬁcial
strategy to reduce commonly occurring exercise-associated gastrointestinal symptoms (Costa et al., 2017). Due to the risks
associated with unnecessary dietary restriction, special diets or
dietary restraint should be carefully evaluated (Mountjoy et al.,2018). The following review will discuss the current state ofknowledge, potential implications of select special diets, andpractical considerations for implementation of these for trackand-ﬁeld athletes aiming to optimize nutrition for health andperformance.

Lis is with the Dept. of Neurobiology, Physiology, and Behavior, University ofCalifornia, Davis, Davis, CA. Kings is with Aspetar Qatar Orthopaedic and Sports
Medicine Hospital, Doha, Qatar. Larson-Meyer is with the Dept. of Family andConsumer Sciences, University of Wyoming, Laramie, WY. Address author
correspondence to Dana M. Lis at dmlis@ucdavis.edu.

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Food Intolerances
Track-and-ﬁeld athletes with diagnosed food allergies or intolerances will require specialized dietary modiﬁcations to eliminate
exposure to allergens or food that trigger symptoms. A foundational appreciation of these conditions is important to assess thenecessity for adherence to a special diet and to sift throughcommonly reported coexisting food intolerances. Gluten intolerance has become one of the most popular self-reported reasons for a
special diet, and therefore, attention will be focused on GFDs and
FODMAP restriction in the following section.

Food Allergies and Intolerances
Adverse reactions to food are self-reported to occur in one ﬁfth ofthe population; however, the origin of the reaction may differ(Turnbull et al., 2015). Variability in methodologies also challenges accurate evaluation of true allergy prevalence. Across the
U.S. population, objective measures indicate food allergy prevalence rates to range between ∼2.5% and 3% (Rona et al., 2007;
Turnbull et al., 2015). Observations from work in the ﬁeld withathletes suggest that food intolerance appears to be escalating
among athletes, yet numerous factors such as the use ofSpecial Diets for Athletes

nonvalidated food intolerance testing and self-reported incidence
challenge accurate estimates of genuine intolerance (KosticVucicevic et al., 2016). Types of reactions to food can be classiﬁed
into four primary categories: (a) immune mediated (e.g., egg, ﬁsh,nuts), (b) nonimmune mediated (common food triggers as immune
mediated with different systemic response and subsequent symptoms), (c) exposure to toxin, and (d) genetic. A food allergy isdeﬁned as an adverse immune-mediated response, which occurs
reproducibly upon exposure to a given food and absent when thefood is avoided (Schafer et al., 2001). Other types of reactions
are labeled intolerances, which are nonallergic food reactions(e.g., lactose deﬁciency) and thus do not involve the immune
system (Schafer et al., 2001; Turnbull et al., 2015). Reactions tofood can also transpire from toxin exposure or excess histamine infoods (e.g., spoiled ﬁsh) or from inborn metabolic errors such as inphenylketonuria (Turnbull et al., 2015). Finally, malabsorptive
problems, such as fructose malabsorption or a disease condition,and functional gastrointestinal disorders may also be linked tofood-related reactions.

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Common Food Allergies
Immune-mediated food reactions can range in severity from minor
abdominal discomfort to hives and to the most severe, anaphylaxis.
Reactions generally develop within minutes of exposure. Investigation of allergen food reactions is less reviewed in adults than inadolescents; however, the most common food allergy triggers areshellﬁsh, peanut, tree nuts, and ﬁsh, with some geographicalvariance (de Silva et al., 2014; Schafer et al., 2001). Cow’s
milk, egg, wheat, soy, peanut, tree nuts, ﬁsh, and shellﬁsh allergies
constitute the majority of food allergy reactions in younger populations (Rona et al., 2007). Determination of IgE-mediated reactions to food requires appropriate diagnosis beginning with adetailed medical/nutrition history to guide appropriate testingprocedures (Platt & Wulu, 2017). These veriﬁed diagnostic methods include skin prick, measuring food-speciﬁc IgE antibody
levels, or the gold standard of double-blind placebo-controlled
food challenges (Turnbull et al., 2015). Some inherent risks,
confounding factors affecting results, arduous nature, and highcosts are associated with these tests (Shtessel & Tversky, 2018;
Tapke et al., 2018). Subsequently, several alternative food intolerance tests appeal to athletes (e.g., microbiome testing, vega testing/electrodermal, hair testing, applied kinesiology, serum-speciﬁc
IgG, lymphocyte stimulation, facial thermography, gastric juice
analysis, endoscopic allergen provocation, cytotoxicity assays, andthe Mediator Release Test). Validation is lacking, and therefore,
these alternative testing methods are not currently recommended.
For track-and-ﬁeld athletes, food avoidance based on dubious test
results may introduce unnecessary food restriction and associatedrisks, which are discussed throughout this review. Established foodallergy testing should be guided by a licensed medical specialist(e.g., allergist, immunologist), and indiscriminate testing for large
batteries of allergens should be avoided (Turnbull et al., 2015).

237

intolerances (Fedewa & Rao, 2014; Levitt et al., 2013; Turnbull
et al., 2015). Other food intolerances are less clear. Symptoms may
appear hours to days after exposure (Turnbull et al., 2015) andrange from gastrointestinal (e.g., abdominal bloating, loose stool,
abdominal pain) to extraintestinal symptoms including fatigue,headaches, and cognitive difﬁculties. Several of these symptoms
overlap with those characterizing irritable bowel syndrome, functional gastrointestinal disorders, or exercise-induced gastrointestinal syndrome (Costa et al., 2017; Turnbull et al., 2015). Emerging
work in this area questions the potential for repeated stress on thegut and associated physiological alterations associated with exercise-induced gastrointestinal syndrome to increase susceptibility todietary triggers or the development of chronic gastrointestinal
disease (Colbey et al., 2018; Costa et al., 2017).

Gluten-Free Diets
GFD Adherence
Adherence to a GFD has exploded in popularity among athletes.
Forty-one percent of nonceliac athletes report adhering to a GFD atleast half of the time with ∼60% self-reporting “gluten intolerance”(Lis et al., 2015b). A strict GFD eliminates all sources of gluten, astorage protein composite, with the alcohol-soluble gliadinsdeﬁned as prolamins and the alcohol-insoluble glutenins as glutelins. Gliadin is incompletely digested, excreted, and does not
trigger an immunological response in individuals without celiac
disease. It is well established that a GFD is essential in managing
health and symptoms in individuals with clinical conditions such as
celiac disease, wheat allergy, and genuine nonceliac gluten/wheat
sensitivity. Nonetheless, the number of athletes reported to follow a
GFD appears to be four-fold higher than those of the general
population who are estimated to clinically require gluten elimination (Sapone et al., 2012). A primary reason for adherence to a GFD
in athletes is the widespread conviction that gluten elicits universal
gastrointestinal injury/symptoms and triggers inﬂammation. A GFD
is further touted as overall healthier and suggested to provide anergogenic advantage (Lis et al., 2015b). Only one study has examined the effects of a GFD in nonceliac endurance athletes (Lis et al.,2015a). In this tightly controlled randomized, crossover, doubleblind study, athletes followed a short-term gluten-containing dietversus GFD. Diet and exercise were replicated in both trials,
but no differences in measures of gastrointestinal injury, gastrointestinal symptoms, systemic inﬂammatory responses, perceptual
well-being, or exercise performance were observed between thediets. Only anecdotal-type substantiation supports the efﬁcacy of a
GFD for clinically healthy athletes. Nonetheless, it is important tounderstand the unique stress placed on the gut in some track-andﬁeld athletes and the likely higher incidence of exercise-induced
gastrointestinal syndrome (Costa et al., 2017; van Wijck et al.,2012). Potential exists for compromised gastrointestinal integrity
and function to increase the incidence or magnitude of gastrointestinal-related food symptoms or gastrointestinal disorders (Costa
et al., 2017).

Common Food Intolerances/Malabsorption
Given the ambiguous nature of food intolerances or malabsorption,
there is a tendency for athletes to self-diagnose intolerances andsubsequently restrict foods or food groups (Kostic-Vucicevic et al.,2016; Lis et al., 2015b). Lactose and fructose malabsorption, which
result from insufﬁcient enzyme and functional capability of transporter(s), respectively, are the most commonly reported food

Gluten to FODMAPs Link
Adverse reactions, particularly gastrointestinal symptoms, areassociated with consumption of gluten-containing foods in individuals without a clinical condition requiring gluten elimination(Biesiekierski & Iven, 2015). Amid subjective reports of a GFD
improving gastrointestinal symptoms, an interesting connection

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Lis, Kings, and Larson-Meyer

exists between reduced FODMAP intake (e.g., fructans) andavoidance of gluten-containing grains (Gibson & Muir, 2013;
Gibson et al., 2015; Skodje et al., 2018). A reduction in FODMAPs
has been recognized as a modulating factor for symptom improvement with a GFD and not gluten itself (Skodje et al., 2018). Wheatbased food products such as breads and cereals not only containgluten but are also rich in fructans, which are within the FODMAPs
family and poorly digested (Biesiekierski & Iven, 2015; Fedewa &Rao, 2014). This concept is strongly supported by a handful ofclinical studies and scientiﬁc editorials detailing that the subsequent reduction in FODMAP intake is accountable for improvements in gastrointestinal symptoms and that fructans rather thangluten are associated with gastrointestinal symptom improvementin the majority of individuals with self-reported nonceliac gluten
sensitivity (Biesiekierski & Iven, 2015).

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FODMAP Mechanisms
FODMAPs are a family of fermentable short-chain carbohydrates
found in a wide assortment of foods/food constituents (Staudacher
et al., 2017). Select high FODMAP foods common in an athlete’s diet are categorized in Table 1 alongside low FODMAP
exchanges (Lis et al., 2016b). Brieﬂy, a low FODMAP diet is anindividualized nutrition strategy with three phases (i. low FODMAP,
ii. rechallenge, and iii. personalization phases) to tailor reduced
intake of speciﬁc short-chain carbohydrates that can elicit symptoms.
This diet has emerged as a frontline treatment for symptoms ofirritable bowel syndrome with a 70% success rate (Staudacher et al.,2017). Within a healthy general population, some FODMAPs arepoorly digested, but the resulting gastrointestinal symptoms arenonexistent or trivial (Ong et al., 2010). Conversely, in athletes
undertaking strenuous exercise with a subsequent impairment ofgastrointestinal function and integrity (i.e., transporters), undigested
food molecules may increase the osmotic load in the small intestineand contribute to increased osmotic water translocation, volume,and physiological consequences such as loose stool or diarrhea(Staudacher et al., 2014; van Wijck et al., 2012). Upon transit to
the lower intestine, these malabsorbed and highly fermentablecarbohydrates reach the colon and are subject to bacterial fermentation (breakdown) and result in physiological consequences such asincreased luminal volume and pressure (e.g., hydrogen, methane,hydrogen sulﬁde). In addition, FODMAP intake could augment
gastrointestinal symptoms (e.g., abdominal bloating and discomfort,
excessive ﬂatulence, urge to defecate, alterations in bowel movements) initiated by the osmotic effects of high carbohydrate
Table 1

consumption necessary to support fueling demands (Pfeiffer
et al., 2012).
FODMAP research has predominantly concentrated on lower
gastrointestinal symptoms (e.g., abdominal bloating, ﬂatulence,
abdominal pain, cramping, diarrhea/loose stool). However, FODMAPs also inﬂuence upper gastrointestinal symptoms, such as
feeling of fullness, as demonstrated in a clinical feeding study thatadministered doses of fructose and glucose via gastric infusion(Masuy et al., 2018). Costa et al. (2017) has further summarizedthat upper gastrointestinal symptoms may be linked to the ileal
break feedback mechanism, inhibitory or not. Upper and lower
gastrointestinal symptoms may be affected by FODMAPs, butthese nonspeciﬁc symptoms also congruently manifest frommechanical, physiological, and other nutritional factors (Costa
et al., 2017). FODMAPs may not be an exclusive gastrointestinal
symptom trigger but amplify symptoms initiated by other factors.

Low FODMAP Strategies for Track-and-Field
Athletes
Athlete-speciﬁc data support the concept of FODMAPs affecting
exercise-associated gastrointestinal symptoms (Lis et al., 2016a,
2017). Many athletes already self-eliminate foods high in FODMAPs but may not distinguish that these foods are in the FODMAP
family (Lis et al., 2016b). Lactose-containing foods are the mostfrequently eliminated, followed by fructose in excess of glucose,galacto-oligosaccharides, polyols, and fructans. Two case study
reports and one published intervention study further encourage theuse of a low FODMAP diet compared with habitual diet (typicallyhigh in FODMAPs) to reduce the severity gastrointestinal symptoms during and also outside of exercise (Gaskell & Costa, 2018;
Lis et al., 2016a, 2017). Importantly, gastrointestinal symptoms
may transpire after a strenuous training session/race potentiallyaffecting refueling for subsequent events. This is of concern insome track-and-ﬁeld events where competition is carried overmultiple days and/or multiple times per day. Assessment of
FODMAP intake may be required before, during, and after exercise
to optimize gastrointestinal contentment and refueling.

Nutritional Considerations for GFD and Low
FODMAP Diet
Any dietary treatment should be guided by appropriate diagnosis
and dietary/medical management to minimize the risks associatedwith overlooking the underlying cause(s) and the risks associatedHigh FODMAP Foods Commonly Consumed in an Athlete’s Diet

FODMAP categories

High FODMAP foods

Low FODMAP food exchanges

High lactose
Excess fructose

Yogurt, cow’s milkApples, ﬁgs, watermelon, cherries, agave, honey, many
fruit juices (e.g., apple, orange), and beetrootHigh fructans/GOS

Dates, dried apricots, cashews/pistachio nuts, breads/
bagels, onions, wheat-based energy bars, and ripebananaDried apricots, protein bars and powders, some electrolyte tablets, and sugar-free gum/candies

Lactose-free milk, and soy milk (from soy protein)
Oranges, berries, banana, grapes, kiwi fruit, cantaloupe,
strawberry, blueberries, raspberries, fruit juicesa madefrom the above low FODMAP fruits, blended vegetablejuice with tomato base, and canned or pickled beets
Gluten-free, spelt, special sourdough spelt breads, ricecakes, corn tortillas, wheat and/or gluten-free energy
bars, and unripe banana
Protein bars with alternative sweeteners, limit intake ofsugar-free gum/candies, or choose sugar-containing brands

High polyols

Note. Check cereals, bars, sports foods, mixed beverages, and mixed meals for high FODMAP ingredients. FODMAP = fermentable oligosaccharides, disaccharides,monosaccharides, and polyols; GOS, galacto-oligosaccharides.
a
Depending on the types and blend, fruit juices can be high in excess fructose and therefore problematic for some athletes (especially when ingested in high amounts).
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with unnecessary food restriction (Cialdella-Kam et al., 2016; Hillet al., 2017; Shepherd & Gibson, 2013). Numerous beneﬁts are
publicized with GFD and low FODMAP diets, yet these special
diets are also associated with perturbations in healthy gut microbiota, short-chain fatty acid production, possible increased arsenic
intake (Bulka et al., 2017; Halmos et al., 2015), orthorexia nervosaand disordered eating, increased psychosocial anxiety, and compromised energy/nutrient intake (Hill et al., 2017; Staudacher et al.,2017). Historically, a GFD has also been associated with suboptimal intake of iron, B vitamins, and protein and higher intake ofsugar and fat. With signiﬁcant improvements in commerciallyavailable gluten-free foods, this issue is less concerning (in Westernized countries). Although the exponential growth in the glutenfree market seems to be tapering, market reports suggest the low
FODMAP diet to be the next popular special diet for athletes.
Keeping this in mind, the primary goals of implementing a GFD or
low FODMAP diet to manage gastrointestinal symptoms should beto establish underlying mechanisms and to minimize unnecessary
food restriction and the associated psychosocial/nutritional risks. A
registered dietitian specializing in sports nutrition and certiﬁed in
low FODMAP diet teaching (Hill et al., 2017) should be consulted.
Overall, to address the multifactorial nature of gastrointestinal
symptoms, emerging evidence undoubtedly supports a beneﬁcialrole of FODMAP reduction as part of a treatment plan for someathletes with exercise-induced gastrointestinal syndrome (Costa
et al., 2017; Lis et al., 2017).

Vegetarian and Vegan Eating
Track-and-ﬁeld athletes adopt vegetarian and vegan diets forhealth, ethical, environmental, religious/spiritual, and aesthetic
reasons (Table 2). Although interest in plant-based diets among
athletes is not new, their popularity, particularly for vegan diets andsemivegetarian or ﬂexitarian diets, seems to be increasing withconsiderable variability by country, sport, and current public trends(Meyer & Reguant-Closa, 2017). Prevalence rates of vegetarianism
among athletes are not well established but are assumed to be
similar to that of the general population. Recent statistics suggestthat ∼22% of the world population is vegetarian (Leahy et al.,2010). The only published study in elite athletes indicated that 8%of international athletes followed a vegetarian diet—1% beingvegan (Pelly & Burkhart, 2014).
Although concern exists about the adequacy of vegetarian
diets for track-and-ﬁeld athletes, it is well established that vegetarian diets can be nutritionally adequate to support training demands
provided a variety of plant foods and source of vitamin B12(Agnoli et al., 2017) are sufﬁciently consumed. Hence, appropriate
nutrition education is encouraged for track-and-ﬁeld athletes.

Potential Beneﬁts of Vegetarian Diets
Plant-based diets may offer health advantages over the typicalWestern diet. Vegetarian and vegan diets are associated with areduced risk for chronic diseases in nonathletic populations(Melina et al., 2016). Less is known about the ability of thesediets to enhance athletic performance (Craddock et al., 2016).
A recent review of observational and short-term intervention
studies found no beneﬁt or detriment to strength/power, aerobic
or anaerobic performance parameters as a result of consuming avegetarian rather than a nonvegetarian diet for up to 12 weeks(Craddock et al., 2016). Due to the naturally high carbohydratecontent, a vegetarian diet may be advantageous for fueling

Table 2

239

Types of Vegetarian Diets

Vegan (strict vegetarian)
Vegetarian
Lacto-vegetarianOvo-vegetarian
Lacto-ovo-vegetarian

Excludes all animal products including
dairy and eggs and honey
Avoids all ﬂesh foods; may or may notconsume eggs or dairy products
Includes milk or other dairy products
but not eggs or other animal foods
Includes eggs but not dairy products
Includes eggs and dairy products

Note. Athletes who periodically eat small amounts of ﬁsh (pesco-vegetarian) andchicken (pollo-vegetarian), who typically eat a meatless diet but occasionally
include meat or ﬁsh (ﬂexitarian), or who try to limit red and other meats(semivegetarian) are often included in vegetarian classiﬁcations.

(Craddock et al., 2016). In addition, antioxidant and phytochemicals (Trapp et al., 2010) and the possibility of slight serum
alkalinity may be advantageous; however, this has yet to be shown
to augment athletic performance (Applegate et al., 2017; Trappet al., 2010).

Vegetarian Nutrient Considerations andRecommendations
To ensure optimal health and performance, track-and-ﬁeld athletes
following vegetarian diets should select a wide variety of minimally processed vegetables, fruits, grains, nuts, seeds, legumes,
and soy products and ensure adequate energy intake (Melina et al.,2016). Adopting a vegetarian diet may result in a reduction ofenergy intake or of speciﬁc nutrients including omega-3 fatty acids,
iron, zinc, calcium, vitamin D, iodine, and vitamin B12. Thesenutrients are less abundant in plant foods or are less well absorbed
from plant compared with animal sources.

Energy in Vegetarian Track-and-Field Athletes
Meeting but not exceeding energy needs is a foundation of sports
nutrition. Difﬁculty in meeting energy requirements on a vegetarian
diet may be due to food choices that are excessively high in ﬁber orof low energy density some track-and-ﬁeld athletes are poorly
prepared to make healthy vegetarian choices at work, school,
training, and when traveling. This can result in undereating or theselection of less nutrient-dense food. Aiming for ﬁve to eight meals/
snacks per day and adequate planning may help athletes meet energy
needs. As appropriate, track-and-ﬁeld athletes can increase energy
intake by selecting energy-dense foods and by reducing ﬁber-richfoods. It is also important to note that a vegetarian diet may be usedby some track-and-ﬁeld athletes to mask restrictive eating or aneating disorder (Cialdella-Kam et al., 2016).

Macronutrients: Protein, Carbohydrate, and Fat
A common misconception is that vegetarian track-and-ﬁeld athletes will not consume adequate protein. Meeting even the higher
protein requirements of athletes and additional need for adolescentathletes is not typically a concern provided adequate energy and avariety of high-protein foods are consumed (Castell et al., 2018;
Melina et al., 2016) (Table 3). As previously believed, it isunnecessary to combine plant foods in the same meal but instead
eat a variety of protein-containing foods throughout the day (Marshet al., 2013). Protein requirements in a diet consisting exclusively

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Table 3

Vegetarian Sources of Key NutrientsProteinHealthy fats
Omega-3 fatty acids
Irona

Zinca
Calcium

Vitamin D
IodineVitamin B12Beans, peas, lentils, soy products, nuts and nut
butters, dairy products, and most soy/plant-based“milks”
Nuts, seeds, nut butters, avocado, and olive oil
Walnuts, ﬂax, chia, camelina, and hemp seeds
and oils
Beans, peas, lentils, edamame, nuts, seeds,
many grain products, fortiﬁed bread, andbreakfast cereals
Beans, peas, lentils, edamame, nuts, and seeds
Excellent bioavailability (>50%): Chinese cabbages, kale, texturized vegetable proteins;average bioavailability (∼30%): dairy products
and calcium-set tofu; lower bioavailability:
fortiﬁed soymilk, most nuts, seeds, and beans
Fatty ﬁsh, vitamin D-fortiﬁed cereals, margarine, and plant-based “milks”
Iodized salt, seaweed, dairy products, and eggs
Nutritional yeast, soymilk and plant-based“milks,” fortiﬁed meat analogs, and Shiitake
mushrooms

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aAbsorption enhanced by organic acids, including vitamin C (see Melina et al.,2016 and Otten et al., 2006, for additional food sources).

of less well-digested plant sources, such as whole legumes andunprocessed grains versus well-digested sources including soy,dairy, or egg protein, may be slightly elevated to account for the
lower amino acid digestibility (Otten et al., 2006). Finally, it issuggested that resting creatine and carnitine concentrations, which
are predominately present in meat, may be lower in vegetarians andsupplementation may be warranted (Larson-Meyer, 2018).
Carbohydrates are an important fuel source and should makeup the bulk of most athletes diets. However, the challenge for many
track-and-ﬁeld athletes, vegetarian or not, is obtaining carbohydrates from high-quality whole food sources, such as whole grains,quinoa, and starchy vegetables, rather than from overly processedcarbohydrates and simple sugars.
Fat is also an integral component to the athlete’s diet. It is
speciﬁcally important to ensure adequate intake of plant-basedsources of omega-3 fatty acids through selection of omega-3-richfoods (Table 3) and replacing omega-6-rich oils (Jeromson et al.,2015). Omega-3 fatty acids may aid in the inﬂammatory modulation, whereas maintaining a low ratio of omega-6 (e.g., nuts, seedoils soy, sunﬂower, safﬂower) to omega-3 fatty acids allows forbetter elongation of plant-based omega-3 fatty acids (eicosapentaenoic acid and docosahexaenoic acid). In additionally, docosahexaenoic acid–rich microalgae supplements may be of interest tovegetarian athletes (Melina et al., 2016).

Micronutrients
A well-balanced vegetarian diet provides an abundance of nutrients
including vitamins A, C, E, and K; folate; potassium; and magnesium (Melina et al., 2016). Depending on food choices, however,meeting daily requirements for iron, zinc, calcium, and vitamin
B12 may be challenging. Iron and zinc are important for optimal
performance and growth. Compromised iron status has been foundin semivegetarian athletes and lacto-ovo vegetarian athletes compared with omnivorous controls (Castell et al., 2018). This is aparticular concern for distance and endurance athlete (marathon
and race walking) who may be more vulnerable. Although vegetarian track-and-ﬁeld athletes can achieve adequate iron and zincstatus by selecting foods rich in these nutrients (Table 3), knowledge about iron- and zinc-rich food inclusion and the factors thatenhance/impair absorption is essential (Gilani et al., 2005; Melina
et al., 2016). High-dose supplementation of both minerals can
impair immune function and the absorption of other minerals, andtherefore, high-dose supplementation is not recommended unlessdeﬁciency is present (Maughan et al., 2018).
Calcium, integral for bone health, is a concern for vegan trackand-ﬁeld athletes and vegetarians who consume little to no dairy orvegetarian milks not fortiﬁed in dietary calcium. Opting for
nondairy, well-absorbed calcium-containing foods (listed inTable 3) is preferred over calcium supplements (Melina et al.,2016). The calcium bioavailability of most of these plant foods is asequivalent to cow’s milk. Calcium from spinach, chard, beetgreens, and rhubarb, however, is of low bioavailability (<5%)
due to high oxalate content. Fortiﬁed foods, calcium-rich mineralwater, or calcium supplements if necessary are also options.
Vitamin D, which aids in calcium absorption, may also be deﬁcientdue to reduced intake of fatty ﬁsh, vitamin-D-fortiﬁed dairy
products, and limited sun exposure (particularly during indoor
training seasons). Requirements can be met by spending 5–30 min (depending on fair or dark skin) outside, at close to solar
noon several times per week during the summer (Table 3; Owens
et al., 2018). Vitamin D3, derived from lichen, or D2, produced
from irradiation of ergosterol from yeast, are vegan sources, butvitamin D3 may be more effective at increasing vitamin D status.
Iodine is a red ﬂag mineral for many vegans and vegetarians
who avoid table salt (typically fortiﬁed with iodine), limit cow’s
milk consumption, or consume plant foods grown in iodinepoor soil (e.g., parts of the United Kingdom, United States, and
New Zealand; Krajcovicova-Kudlackova et al., 2003). Althoughmany plant foods such as cruciferous vegetables, sweet potatoes,
and soybeans naturally contain “goitrogens,” which impair the synthesis of thyroid hormone, their consumption does not decrease
thyroid sufﬁciency unless iodine status is also compromised(Messina & Redmond, 2006). Finally, vitamin B12 is a concern
for vegan and semivegan athletes because it is found exclusively inanimal products. Vegan track-and-ﬁeld athletes should consume
vitamin B12-fortiﬁed foods daily or take a vitamin B12-containing
supplement or multivitamin. Vegetarian track-and-ﬁeld athletesshould consider taking a supplemental source if their intake of dairy
products and/or eggs is limited. Athletes should also be aware thatsome dietary supplements may come from animal sources including gelatin, collagen, omega-3 fatty acids, and vitamin D3.
Overall, vegetarian and vegan diets that contain a variety ofwhole grains, vegetables, fruits, legumes, nuts, and seeds canprovide the protein, carbohydrate, fat, vitamins, and minerals
required for track-and-ﬁeld athletes. Depending on dietary choice,emphasis of foods high in protein, iron, zinc, calcium, and vitamin
B12 (e.g., yeast extract products) will ensure adequate nutrient
status. Although research strongly suggests that a plant-based dietmay offer some health beneﬁts, there is little evidence that vegetarian diets are superior to omnivorous diets for improving athletic
training, health, or performance.

Fasting Diets
Fasting is characterized by the absence of energy intake forsustained period of time ranging from several hours to days

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Special Diets for Athletes(Maughan et al., 2010). It is not a new concept, but an age-old
practice prescribed by many religions (Trepanowski & Bloomer,2010). Apart from religious obligation, fasting also holds appeal forweight loss, chronic disease management, and to increase longevity(Horne et al., 2008). However, the impacts of fasting, particularly
for track-and-ﬁeld athletes, are inconclusive and challenging totranslate into practice due to methodological variances, study
design limitations, animal-based concepts, and diverse clinicalpopulations.
Recently, fasting has received an upsurge of attention. Someforms of fasting are promoted as a strategy to offer health andperformance beneﬁts. This has prompted an increase in contemporary fasting publications and renewed academic focus, which hasprovided some insight into the possible effects of fasting on athletic
performance. In particular, investigation of the use of fasting toenhance substrate utilization and mitochondrial adaptation toenhance exercise metabolism and performance (Aird et al.,2018). Any improvements in lipid proﬁle, inﬂammatory markers,
glucose metabolism, or cardiovascular function are short-lived andare not clinically signiﬁcant (Barkia et al., 2011; Memari et al.,2011; Stockman et al., 2018). These ﬁndings prevent using nonobligatory fasting practices within standard practice evidencebased recommendations.

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Types of Fasting Practices
Several types of fasting exist. Intermittent fasting (IF) and caloric
restriction are the most predominate. IF is conducted intermittently
with fast and refeed periods each 24-hour day. Caloric restriction isa chronic reduction in calories for a prolonged period of time where
ad libitum water is permitted. Most applicable literature has
focused on IF, and therefore, the following discussion will focus
on this type of fasting. IF is subdivided into three categories:
alternate day fasting, whole-day or periodic fasting, and timerestricted fasting (TRF). In all cases, a primary concern for trackand-ﬁeld athletes is the loss of lean mass during a period of fastingor caloric restriction (Heilbronn et al., 2005).
Time-restricted fasting has received the most attention within
the fasting literature. This form of fasting theoretically offers
metabolic and body composition beneﬁts for athletes (Morton
et al., 2018). It involves 16–20 hr of fasting with a 4- to 8-hr
feeding window. Several commercial variations of this diet havebeen developed. To date, only one study in recreationally active
and resistance-trained athletes has been conducted. Findings
indicate TRF does not support favorable changes in lean and fat
mass compared with a normal diet (Tinsley et al., 2017). Theseobservations may be attributed to unmatched macronutrient intake,speciﬁcally protein, between the normal diet group (1.4 g/kg)
compared with the TRF group (1.0 g/kg). A follow-up study
matching protein intakes (1.9 g/kg in both groups) demonstrated
that TRF may be more effective in reducing fat mass while
maintaining lean mass compared with normal diet controls(Moro et al., 2016). However, these results could be inﬂuenced
by the more favorable feeding period around the training period for
the TRF group.

Ramadan IF
Ramadan is a holy month during which Muslims refrain fromeating and drinking between sunrise and sunset for 30 days. It is themost widely studied form of TRF and probably the most relevant
for many elite athletes. Depending on the seasonal and241

geographical conditions, Ramadan falls on different dates every
year and fasting varies from 11 to 18 hours daily (Azizi, 2002);
patterns that can indirectly affect performance and alertness (Rokyet al., 2004). Ramadan is also associated with more rapid onset of
fatigue, lethargy, and noncontact athlete injury (Chtourou et al.,2011; Tian et al., 2011). Therefore, much research has focused on
the factors negatively affecting performance and tools to mitigate
these potential detriments (Tables 4 and 5).

Nutrition and Ramadan
Daily eating routines are characterized by two meals: one before
sunrise (Sahur) and one after sunset (Iftar). Variation in Ramadan
food volume and eating patterns as well as fundamental nutrition
Table 4 Factors Involved in Detrimental Effects on
Physical Performance During Ramadan• Training time of day• Geographical location (and if the environment is controlled)• Levels of athlete education and fasting experience• Circadian rhythms• Changes in sleep pattern (architecture and duration)• Physiological, metabolic, and hormonal changes• Blood glucose level reduction• Reduced daytime ﬂuid intake• Decrease in body temperature• Alteration in psychomotor functioning (deterioration across the day)
• More rapid onset of fatigue• Possible increase risk of injury and the effect on training load
Note. Adapted from Farooq (2016).

Table 5 Select Strategies to Cope With Ramadan
Fasting for Track-and-Field Athletes
Focus
Training

Strategy description

a. Shift training to morning and evening to maintaineffective training loadb. Monitor “well-being” (e.g., pre- and postsession fatigue,
hydration status) and adjust training load appropriately
c. Promote rest (i.e., naps) after morning training
d. Music may counteract negative effects
e. Sports psychology support to address anxiety issues
regarding ability to maintain performance
Education a. Prior education on key areas (e.g., behavioral adaptation
to minimize ﬂuid loss)b. Advice on portion size control (for the Iftar meal)c. Query beliefs and individualize nutrition plans to copewith Ramadan
Nutrition a. Focus on protein quality and intake amount to maintainlean massb. Encourage carbohydrate at mealsc. Electrolyte/oral rehydration solutions as needed tomaintain hydration status
d. Carbohydrate mouth rinsing as appropriate to maintainperformancee. Individualized ﬂuid/nutrition strategies adapted for unique logistical considerations
f. Quick communication technologies useful to guide/
monitor dietary intake
g. Dietary supplements (e.g., creatine, beta alanine) for
performance-focused interventions
h. Promote good oral health care across the refeed window

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challenges have been previously characterized (Reilly &Waterhouse, 2007). The two main challenges are that foods offeredtend to be higher in fat and sugar compared with habitual diets andthat meal quality is less under an athlete’s full control due to thesocial nature of the eating occasion. It is commonly believed thatRamadan fasting results in a signiﬁcant calorie deﬁcit. However,studies have demonstrated that energy intake is similar to nonfasting periods but that eating times are later/earlier and within alimited time frame (Maughan et al., 2010). Amid eating challenges,
the primary goal for track-and-ﬁeld athletes should be to maintainbody composition as well as minimize decrements in performance.
Due to the variances in food availability, there is potential toovereat at fewer meal times, and it can be difﬁcult for some athletes
to maintain a stable body composition. Conversely, for someathletes, food choices during Ramadan may become better planned,
and subsequently, the quality of food is improved compared withintake during the rest of the nonfasting year. Demonstrating this,unexpected improvements in lean mass and fat mass have evenbeen measured, which may be attributed to improved food choices
during Ramadan (Fahrial Syam et al., 2016; Norouzy et al., 2013).
Particularly, during the ﬁrst week of fasting, body composition
measures may be inadvertently skewed by increased total body
water loss, decreased gastrointestinal volume, and glycogen stores.
These factors should be considered with athlete monitoring during
this fasting period.

Unique Sport Nutrition Challenges
Ramadan is an opportunity to offer education opportunities totrack-and-ﬁeld athletes during a period when an athletes’ receptiveness may be enhanced with a renewed interest in well-being or
to maintain physical capacity throughout fasting. For the sports
nutrition practitioner, several well-documented challenges before,
during, and after exercise exist. Rehydration, posttraining recovery,
fatigue management, portion control, and maintaining optimal
body composition are the most common nutrition challenges(Table 4; Norouzy et al., 2013). These challenges are magniﬁed
when Ramadan occurs across major sporting events (e.g., theOlympics, the FIFA World Cup). Competing in a non-Muslim
country and requirements of weight-making sports present further
complications (Aloui et al., 2016). Muslim track-and-ﬁeld athletes
undertaking obligatory fasting are also at a potential disadvantage
compared with voluntary fasting as they are less able to modify
their feeding periods around training. Some athletes will obtainspecial permission to observe their fast after an important event. In
addition, valuable nutrition strategies such as carbohydrate mouthrinsing may be not permitted due to the interpretation of fasting law
by Islamic scholars. Overall, many challenges are associated with
Ramadan fasting, and individualized strategies are required forsuccessful management to avoid a possible detraining effect(Table 5; Aloui et al., 2016; Maughan et al., 2012).

Knowledge and Beliefs
A solid understanding of the knowledge and beliefs pertaining toRamadan is important for practitioners counseling Muslim trackand-ﬁeld athletes as much contradictory evidence exists on theeffects of Ramadan fasting on health. Personalized knowledge andbeliefs can often translate into attitudes and practices. Longstanding experiences established in early years, advice from peers,knowledge level, and how well the environment is controlledappear to be signiﬁcant factors of Ramadan impacting performance(Chamari et al., 2016). It is commonly trusted that Ramadan fastingnegatively affects physical performance (Chamari et al., 2016).
However, evidence continues to advocate that only a few aspects ofphysical ﬁtness are negatively affected by Ramadan (Alkandari
et al., 2012; Chamari et al., 2016). Cognitive performance(e.g., psychomotor function, vigilance, executive function) anddecision making are negatively impacted, which may moderately
compromise skill execution and reaction time in some sports(Kirkendall et al., 2012; Meckel et al., 2008). Overall, maintenanceof daily energy and macronutrient intakes, body composition,
training load, and sleep duration similar to the rest of the year
will minimize impairments of physical performance during
Ramadan.
Evidence is lacking to support any beneﬁt of fasting comparedwith conventional techniques for improving body composition or
metabolic parameters in track-and-ﬁeld athletes. Nutrition strategies should be planned in advance to avoid possible performancedecrements during obligatory fasting.

Conclusions
Special diets may be appropriate for some track-and-ﬁeld athletes,but each of these should be carefully evaluated as well as
the rationale for choosing a diet. Ad hoc adherence to a special
diet is associated with several risks, which should be carefully
evaluated and monitored. Even in cases where a special diet isnecessary, proper education is essential as dietary restriction
may do more harm than good. To optimize nutrition for elite
performance guidance from an accredited dietitian/nutritionist,
together with advice from appropriate medical and sport science
personnel, should be sought before adherence to a special
diet.
Acknowledgments
D. M. Lis, E. Larson-Meyer, and D. Kings wrote initial draft of respective
sections. D. M. Lis compiled, edited, formatted, and revised the manuscript. All authors approved the ﬁnal version of the paper. The authors haveno conﬂicts of interests to report.

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