‘Uncomfortable and Embarrassed’: The Stigma of Gastrointestinal Symptoms as a Barrier to Accessing Care and Support for Collegiate Athletes

Abstract

This study aimed to explore the occurrence of exercise-associated gastrointestinal symptoms (ExGIS) in collegiate athletes and identify related self-management practices. A sequential mixed methods design was used, consisting of an online survey followed by semi-structured interviews. Data were analyzed with descriptive statistics (survey) and thematic analysis (interviews). Survey respondents (n = 96) represented various individual and team sports but were primarily female (76%). ExGIS prevented or interrupted training and/or competition in 32%. Female athletes experienced gastrointestinal symptoms (GIS) more frequently at rest (60%) and during training (37%), compared to males (22% and 9%, respectively; p < 0.01). Only 12% sought health care for ExGIS. Four (13%) female runners with ExGIS agreed to an interview. Response rates and interview data provided evidence of stigma in discussing GIS. Self-imposed food restriction was a common self-management strategy. In summary, female collegiate athletes may experience a greater burden of GIS and ExGIS than males. The stigmatized topic of ExGIS is a potential barrier to seeking health care and support. Access to a sport dietitian could help to address barriers to ExGIS care and support self-management practices in these athletes.

1. Introduction

Collegiate athletes participate in rigorous training and exercise programmes to compete in a range of athletic events from recreational to national competitions. Participants of intense physical activity (generally ≥2 h at 60% VO₂ max, regardless of training status) [1] report a range of exercise-associated gastrointestinal symptoms (ExGIS) of varying severity. Such symptoms may include both upper (e.g., regurgitation, belching, heartburn) and lower (bloating, abdominal pain, diarrhea) gastrointestinal impacts. ExGIS are particularly common in endurance athletes, with estimates ranging from 25 to 70% of athletes affected, but reported to occur in less than 10% of strength- or power-based athletes and some team sport athletes [2,3]. Females consistently report a higher occurrence of gastrointestinal symptoms (GIS) than males at rest and the frequency of occurrence increases during menstruation [4]. However, evidence for sex differences in GIS during exercise has been mixed. For example, a lab-based study using a two-week gut challenge trial with 18 athletes (8 female) reported that throughout the trial female participants had greater gut discomfort, greater total GIS, and more reports of upper GIS compared to males [5]. In contrast, controlling for training history in observational studies appears to diminish reported sex differences in ExGIS [4]. Thus, further research is required to elucidate biological sex differences in ExGIS.

The phenomenon of ExGIS applies to otherwise healthy individuals and is different, but often indistinguishable, from conditions with similar symptoms (e.g., irritable bowel syndrome (IBS), undiagnosed food allergies, or intolerances). ExGIS is inconvenient and uncomfortable for most, but in extreme cases may lead to adverse conditions such as hemorrhagic gastritis, hematochezia, and ischemic colitis [6]. There is also concern that repetitive bouts of ExGIS may adversely affect gastrointestinal (GI) health in those prone to gut-related disorders. For athletes with a history of GI distress related to medical conditions (e.g., IBS, celiac disease, food intolerance), strenuous exercise may aggravate symptoms, which suggests some degree of predisposition [1,7]. For athletes without a medically diagnosed GI condition, a variety of mechanisms may be contributing to the development of gut distress either during or after exercise such as splanchnic hypoperfusion and sympathetic nervous system activation [1,8,9]. Primary factors that appear to initiate or contribute to ExGIS include food (e.g., concentrated carbohydrate, hyperhydration, hypohydration, intake of poorly absorbed and rapidly fermented carbohydrates known as fermentable oligo-di-monosaccharides and polyols (FODMAPs)) [1,6,10,11,12], mechanical and postural factors [1,6] (e.g., forward bending on a bicycle), psychological stress and anxiety, and an increase in intestinal permeability [13,14,15]. Finally, emerging evidence suggests that intense, prolonged exercise may be associated with gut microbial dysbiosis, setting the stage for ExGIS [16].

Menstruation is known to be accompanied by GIS such as nausea, bloating, and abdominal cramping [4,17]. Over 30% of the respondents in a global survey (n = 6812) of naturally menstruating women who exercise reported having “stomach cramps” and “bloating/increased gas” at the time of menstruation [18]. Healthy women on oral contraceptives (n = 78) also reported a higher frequency of bowel symptoms on the first day of menstruation, demonstrating menstrual cycle differences even with hormonal contraceptive use [19]. In a survey of healthy, menstruating women (n = 128), 34% reported avoiding physical activity during menstruation [20]. Follow-up interviews revealed a continuum of behaviours from avoidance of exercise environments to adaptations in type, amount or intensity of activity performed while managing menstrual symptoms. Similarly, interviews with elite female athletes identified “gastrointestinal disturbance” as a physical symptom of menstruation, which, overall, negatively impacted on training and competition [21]. Finally, one-third of healthy, asymptomatic women report experiencing GIS during menstruation and almost half of women with a functional bowel disorder report more GIS at the time of menstruation [22]. Thus, there is a well-established link between the menstrual cycle and GIS with and without exercise.

An athlete’s training and/or performance may be negatively affected by ExGIS or cease entirely, leading to slower recovery, delayed progress, and performance detriments over time [7]. Effective self-management behaviours may therefore increase an athlete’s capacity for training and ultimately maximize performance. Broadly, self-management refers to the ability to purposely engage in healthy, learned behaviours, to improve or maintain a satisfactory quality of life [23]. Individuals with effective self-management skills are able to identify their own needs, solve problems, make decisions, partner with health care providers, and ultimately take action to improve their health [24]. Self-management depends on an individual’s current beliefs, past experiences, knowledge and skills, level of self-efficacy, physical and social environment, and their access to resources, as well as broader factors including socioeconomic status, culture, quality of relationships and communication with health care providers [24]. Self-management may require individuals to make changes to their lifestyle by creating new routines, controlling their environments, or reorganizing their daily lives to minimize the disruptions that may be caused by a condition. The adaptive and maladaptive self-management behaviours among collegiate athletes are likely influenced by their unique roles and responsibilities including limited time, nutrition knowledge, budget, frequent travel, and exposure to large amounts of nutrition information and misinformation in society [25]. However, consideration should also be given to the broader context in which student athletes live their lives. For example, collegiate athletes commonly report obtaining nutrition information most frequently from their coaches, websites, training staff, and friends and family [25,26,27,28]. Sport dietitians or nutritionists have not been frequently cited, although this may be due to access barriers, at least at the time of the aforementioned studies.

While ExGIS research has focused on symptom occurrence in endurance-based athletic events and the multifactorial underlying causes, little is known of the experiences of ExGIS in developing, collegiate athletes. Thus, this project aimed to explore the occurrence of ExGIS in a collegiate athletic population and identify the self-management practices, knowledge, beliefs, and challenges of those experiencing ExGIS.

2. Materials and Methods

This study used a mixed methods sequential, explanatory approach [29] to explore the occurrence of ExGIS and related self-management practices in an athletic population. In this process, quantitative survey data were first evaluated to determine results needing further explanation. Then, qualitative data were collected and analyzed to explain key quantitative findings. The study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Board of St. Francis Xavier University (protocol codes #24356 (8 April 2020) and #24769 (10 June 2020). Informed consent was obtained from all participants involved in the study.

2.1. Participants and Recruitment

A convenience sample of collegiate athletes was recruited through the local student email listserv, social media advertising, and flyers across campus in 2020–2021. All participants who self-declared being 18 years of age or older, a current member of university varsity or club sport, and not presently experiencing a medically diagnosed stomach or gut-related health disease or disorder were invited to participate in the study. The university had 12 varsity and 12 club teams at the time of recruitment. Varsity athletes at this university compete in regional and national competitions; thus, they can be considered up to Tier 3: highly trained/national level [30]. Club sports athletes would vary from Tier 1: recreationally active to Tier 2: trained/developmental but some (e.g., rowers) may compete at the regional or national level (Tier 3). Purposive sampling for follow-up interviews was employed, targeting athletes who reported that GIS disrupted their training or competition sometimes, often, or always. This approach was used to maximize the opportunity to gain insight from those athletes most significantly affected by ExGIS. Four athletes were excluded after indicating they did not wish to be contacted again after completing the survey, leaving an interview participant pool of 27. Three email invitations were sent to each potential interviewee.

2.2. Data Collection

2.2.1. Questionnaire

Participants completed a self-administered, 65-item online questionnaire to assess general demographic, health, training-related variables, and experience with GIS during exercise training and competition (Qualtrics, Provo, UT, USA, Copyright ©2016). Data on gender was collected through a choice format with multiple options (female, male, other, prefer not to answer). Questions were obtained (with permission) from the Birmingham Nutrition Questionnaire for endurance athletes [31] (n = 29) and the Endurance Athlete Questionnaire for symptom management [32] (n = 15) and included single response, multiple selection, and open-ended responses. Minor adaptations in language were made to reflect the Canadian food system and a wider variety of sport activities. Additional demographic and university-specific questions were developed and pre-tested for readability, relevance, and clarity of questions by five recent student athletes (see Supplemental Materials: Survey Questionnaire). Pre-testing data were not included in the final sample. A total of 113 athletes responded to the survey, 17 blank responses were excluded, resulting in 96 partial or complete responses.

2.2.2. Interviews

Preliminary survey responses were used to inform the development of a semi-structured interview guide for the qualitative component of the study. The guide comprised a series of open-ended questions and sub-questions aimed to gain insight into athletes’ experiences, beliefs, and current self-management behaviours related to ExGIS (see Supplemental Materials: Interview Guide). It was pre-tested with three recent student athletes to ensure clarity, flow, and to provide training for the interviewer prior to data collection. Pre-testing data were not included in the final sample. Interviews were conducted virtually (Microsoft Teams™), using audio only, as video recording may have deterred participation given the potential sensitivity of the topic. Interviews were audio-recorded using a handheld recorder and lasted approximately 25–40 min in duration. Interview questions were used flexibly depending on the content and depth of information provided by the participant and pre-selected probes were used to encourage further exploration of topics and for clarification. Participants were asked to describe their beliefs, understandings, and coping strategies concerning specific instances of ExGIS. Experiences of seeking support from health care professionals or other services, and the obstacles or enablers participants had experienced in doing so, were explored. To gain insight into how athletes were interpreting and making sense of their experiences, they were asked to describe their feelings about occurrences of ExGIS and their perceived abilities to manage ExGIS in the future. To conclude, athletes were asked if they had advice for other athletes experiencing ExGIS and were given an opportunity to share or comment further regarding any of the aforementioned questions. Audio recordings were transcribed verbatim and distributed to participants upon their request. Field notes were made immediately after each interview to assist in data analysis and as a means of critical self-reflection and improvement.

2.3. Data Analysis

Survey data were analyzed using descriptive statistics in STATA/SE 14.2 (StataCorp, 2015; College Station, TX, USA). Differences in participant characteristics by sex were compared with χ2 tests, or Kruskal–Wallis analysis of variance for non-normal data, as appropriate, with the level of significance set as p < 0.05. Thirteen upper and lower GIS were evaluated as experienced during exercise: never (1), rarely (2), occasionally (3), sometimes (4), quite often (5), fairly frequently (6), almost always (7), or always (8), and median scores were compared by sex (K–Wallis test).

Using NVivo Software 12.6.0, transcriptions were coded and analyzed using thematic analysis. Here, we report select quotes and summarize descriptions that add context and deeper understanding to the survey findings. Themes and overall findings from interviews will be reported separately.

3. Results

3.1. Survey Findings

Participant characteristics are described in

Table 1. Characteristics of surveyed collegiate athletes (n = 96).

Variable	All Participants (n = 96)	Females (n = 73)	Males (n = 23)	p-Value
Age in years, mean (SD)	19.1 (3.9)	19.0 (3.9)	19.2 (3.7)	0.96
Body mass index, mean (SD)	20.7 (3.0)	20.3 * (2.9)	22.1 (2.7)	0.004
Primary sport, n (%)
Varsity	52 (53)	39 (54)	12 (52)	0.22
Club	44 (46)	33 (46)	11(48)
Perceived health, n (%)
Excellent or very good	68 (71)	50 (69)	18 (78)	0.68
Good	24 (25)	20 (27)	4 (18)
Fair or poor	4 (4)	3 (4)	1 (4)
Perceived food allergy, n (%)	3 (3)	1 (1)	2 (9)	0.14
Perceived food intolerance, n (%)	21 (22)	20 * (27)	1 (5)	0.02

* p < 0.05 assessed by Kruskal–Wallis analysis of variance (for means) or chi-square test (for proportions).

. All respondents self-identified as either female (n = 73) or male (n = 23). On average, athletes were 19.1 years of age, had a body mass index of 20.7, and 96% perceived their health to be good, very good, or excellent. In pre-season, most athletes (60%) trained 10 h per week or less. In competition season, most athletes reported training more than 10 h per week (52%). Female athletes reported a lower mean body mass index (p = 0.004) and higher frequency of food intolerance than males (p = 0.02). There were no sex differences in other demographic, health, or training variables.

GIS was reportedly experienced never (34%), some of the time (46%) and most or all of the time (20%) during training by participants. Respondents associated ExGIS during training with running activities, high-intensity training, stressful situations, specific foods, under- and over-fueling, dehydration, and a lack of fitness. During competition, GIS was reported never (51%), some of the time (30%) and most or all of the time (19%), and it was associated with running activities, pre-competition caffeine use, nervous emotions, and improper fueling. There were no sex differences in the frequency of reported GIS during training or competition. GIS was rated significant enough to interrupt or prevent exercise in 30% of participants during training but only 17% in competition (Figure 1).

Three-fold more females than males participated in the survey, and a majority (94%) of respondents reporting frequent ExGIS interruption of training or competition were female. Female athletes reported a higher prevalence of GIS interrupting exercise during training (p = 0.009) and more GIS at rest than males (p = 0.002; Figure 1). Female athletes also reported a higher frequency of specific upper GIS (abdominal pain, bloating, nausea) and lower GIS (cramping, right and left abdominal pain) than males during exercise (Figure 2). In descending order, ExGIS significant enough to interrupt or prevent exercise was reported in runners (26%), rugby (19%), ice hockey (10%), swimming (10%), cheerleading (10%), field hockey (7%), rowing (7%), soccer (6%), basketball (3%), and dance (3%). Overall, 12% reported that they had consulted a medical professional about their ExGIS. Participants most frequently consulted no one (n = 37), a family member (n = 36), or a friend (n = 27) for their ExGIS and few consulted a nutritionist (n = 5), a trainer (n = 5), or a coach (n = 2) for guidance. The most frequently cited sources of nutrition information were nutritionist/dietitian (n = 51), coaches (n = 49), the internet (n = 41), print media (n = 22) and advertisements (n = 15).

Most survey participants reported following no specific diet (76%). Other diet patterns included plant-based (13%), other (7%), and carbohydrate cycling (4%). Participants reported avoiding “junk foods”, dairy, high-fibre or grain-based foods during exercise. Overall, 16% suspected that sport nutrition products (bars, gels, beverages) contributed to their ExGIS. Amongst these products, energy or protein bars (n = 12) were cited most frequently as contributing to ExGIS. Overall, supplements reported to be used regularly were vitamin/mineral (n = 27), protein (n = 23) supplements, and creatine (n = 5).

3.2. Interview Findings

3.2.1. GIS and ExGIS in Female Runners

All interviewees were female and runners from the varsity cross-country running and/or track and field teams. Interviewees described ExGIS as part of the identity of the sport of running. For example, one respondent said “…you feel like everyone’s going through the same thing [ExGIS], so this must be normal…”.

3.2.2. The Stigma of ExGIS

Despite inviting all 31 participants reporting frequent ExGIS interruption of training or competition for an interview on three occasions, only four agreed to participate. When asked to describe their emotional response to an ExGIS incident in the past, one runner felt “Embarrassed and uncomfortable”. Another revealed feeling “uncomfortable, I guess would be the first word that comes to mind. Just… I guess uncomfortable in my own body, and also uncomfortable at the thought of talking about it as well”. Interviewees discussed having conversations about ExGIS only amongst teammates, family members, or close friends. The following quote demonstrates some communication challenges with ExGIS: “Well sometimes on a run people will just talk about how their stomach’s uncomfortable and they have to go to the bathroom, or sometimes people will say ‘I just had coffee right before this’. They more talk about it indirect and you know what they mean, you know what they are getting at, but they won’t specifically say”. Another interviewee noted some comfort in discussing ExGIS with teammates but varying degrees of comfort with coaches: “with teammates I feel like I can talk to them more casually about it but also serious if I need to. And then coaches, on the other hand I feel like I don’t know them as well and maybe they aren’t as comfortable talking to them about it especially this year where we don’t have a female coach or have a female coach who is always there, so I don’t feel as comfortable talking with a male coach per seper se. Especially when I have known him for years”. Finally, one runner relayed the positive experience of having a female coach address the topic of amenorrhea openly in a team meeting and suggested that a similar approach to ExGIS could help athletes feel more comfortable seeking supports.

3.2.3. Sport and Exercise Experiences of ExGIS

Only varsity runners agreed to participate in a follow-up interview, despite many team sport athletes perceiving their training or competition to be interrupted by ExGIS. Interviewees described ExGIS occurring with long duration running (e.g., 10 km or more), with shorter bouts of high intensity speed running, and in response to pre-competition nervousness. These experiences could not only be uncomfortable and/or embarrassing but also disrupted training and performance.

“when you are running for a longer period of time and you do feel like you have to like immediately go to the bathroom sometimes that’s like in the middle of a workout, so then it’s like not only like embarrassing was also frustrating because you feel like you have to stop in the middle of your workout and then it like completely ruins…not necessarily completely ruins it but you feel like it’s affecting your workout because you didn’t get to complete it or there was like a large break in the middle of your workout. So, then you feel like your inhibiting your training”.

“I tried to just tell myself that even though I felt gross that it (ExGIS) wouldn’t actually affect my fitness level, but it was, I found it still affected my race even after telling myself that”.

3.2.4. ExGIS Contributing Factors

ExGIS were often described as unpredictable. Two of the interviewees had identified some effective strategies to self-manage these episodes, while the other two had experimented with multiple dietary and hydration practices but were unsuccessful. One respondent described their confidence in self-management as follows: “As much as I would like to say yes, I would say no just because I don’t know how to change my diet to help me as well with that or if it is a change in my diet that needs to be made or maybe like ways to reduce my stress that will affect GI related symptoms or what, I just haven’t been able to identify myself what affects it and when so I would definitely be interested in finding out more about that”. Diet was identified by all athletes as having an impact on symptoms, and all athletes had indicated having made one or more dietary changes to avoid or alleviate symptoms once they had occurred. Strategies included continuous dietary adjustments and the elimination of foods perceived to trigger symptoms. As evident in the following quote, strategies required “trial and error, and trying to wean off different foods and trying other foods”.

3.2.5. Seeking Support for ExGIS

Interviewees were most comfortable in seeking support from teammates or family members but were unsure of how to access additional expert guidance. This is demonstrated by the following quote: “[my teammates] don’t really know where to get support, yeah, they don’t know who would be the best resource for that”. And when asked what obstacles they may face to find more support: “I guess probably just who to go to, and also who to go to that I know would be able to help or understand. And then what resources there are, [what] information there is, that can help or support as well, that sort of thing”.

Table 2. Joint display of quantitative and qualitative findings for mixed methods study of collegiate athletes.

Quantitative Survey Results (n = 96)	Qualitative Follow-Up Explaining Quantitative Results (n = 4)	Integration
Female athletes had higher occurrence of GIS at rest (60%) and during training (37%) than males (22%, 9%, respectively; p < 0.01) and were more likely to report food intolerance. Female athletes also perceived higher occurrence of specific upper and lower GIS during exercise than males (p < 0.05). GIS interruptions to exercise were most commonly by runners and team sport athletes (e.g., rugby, hockey).	Those interviewed were female runners despite an active and long period of recruitment across 11 different sports.	Female runners accept ExGIS as a normal and/or expected part of running culture, possibly limiting their perceptions of seeing it as a problem. The stigma of ExGIS may hinder interview recruitment and openness to seek support. Sex differences in ExGIS require further research.
Type of exercise, dietary factors, and stress or anxiety were implicated in ExGIS. A total of 15.6% of athletes reported that sport nutrition products (mainly nutrition bars) contributed to ExGIS, while 36.5% were unsure of a possible link with these products.	Events of long duration, high intensity, and/or pre-event anxiety contributed to ExGIS. Athletes indicated using “trial and error” with diet (restriction) and hydration to manage unpredictable symptoms.	Athletes continually managed ExGIS through dietary modification with inconsistent results. University-tier athletes may lack awareness of and/or access to sport medicine and sport dietetic professionals to diagnose and manage ExGIS effectively.
Top sources of nutrition information cited were dietitians and coaches. Sources of information used most frequently for ExGIS included family, friends or none. Only 12.6% of respondents sought medical guidance for ExGIS.	Athletes indicated that resources specific to ExGIS were unavailable, that they were unsure where to go for support, or that ExGIS was a normal occurrence for runners. Athletes had not sought advice from a medical professional outside of their family. Athletes used family, friends, teammates, the internet for support, though most felt the strategies they found were unhelpful.	Limited understanding of ExGIS in combination with uncertainty in finding accessible and effective resources may have led to less support seeking behaviours. Athletes with GIS at rest, in particular, should be referred for medical evaluation.

provides a joint display of integrated quantitative and qualitative findings of the study.

4. Discussion

To our knowledge, this is the first study to use a mixed methods approach to explore the occurrence and self-management practices of ExGIS in an athletic population. While the sample size was limited in this exploratory project, several key areas for further research were identified. In this study, 32% of collegiate athletes from a wide variety of sport disciplines and training calibres reported experiencing ExGIS interrupt their training or competition at least some of the time, with the greatest frequencies within the running and rugby teams. Endurance sports, running in particular, have a clear and consistent association with ExGIS [1,2,3]. ExGIS is likely less frequent in team sports than endurance, but it has also been shown to negatively impact sport performance, particularly in females [33]. A key finding from this study was the stigma evident in discussing GIS for these athletes. This stigma likely contributed to the difficulties experienced in recruiting interviewees to participate. Interviews revealed strong feelings of embarrassment and discomfort in recalling incidents of ExGIS, as well as discomfort with talking about symptoms in the past. Interviewees provided evidence of the stigma around ExGIS through discussions of how symptoms were kept private and only discussed indirectly or superficially amongst the team. The language used by interviewees themselves, was also indirect and neutral (e.g., ‘using the bathroom’ in place of an urgent need to defecate or diarrhea). Stigma is a well-recognized barrier in seeking health care and can cause additional emotional distress and exacerbate symptoms [34]. For example, stigma associated with IBS has been found to result in increased health care use, psychological distress, and lower quality of life [35]. Despite the common occurrence of disruptive ExGIS in this study, relatively few athletes consulted a health professional for guidance. Thus, the extent to which stigma is a barrier to seeking health care and/or performance advice for collegiate athletes should be further investigated. Stigma-reduction strategies for ExGIS in athletes should also be developed. Such interventions could include: (a) public campaigns to raise awareness on the occurrence of ExGIS in athletes and the local supports available; (b) team-specific training sessions on ExGIS for athletes and coaches, led by appropriate health professionals; (c) peer support groups organized for athletes with ExGIS.

4.1. Sex Differences in ExGIS

Female athletes in the present study reported 2.7-fold higher prevalence of GIS at rest and 4-fold higher prevalence of ExGIS during training than male athletes. A higher occurrence of GIS at rest in females has been previously observed and may be explained by sex differences in gastric motility as well as the nausea, bloating, and abdominal cramping associated with menstruation [4,33]. Indeed, these symptoms were more frequently reported by female than male athletes during exercise in the present survey and aligned with similar findings from a recent survey of team sport athletes of various calibres [33]. Alternatively, these symptoms could be indicative of an underlying, undiagnosed GI condition (e.g., IBS, celiac disease), of which females have a higher incidence than males [36,37]. Wilson et al. (2023) posited that sex differences in GIS could be explained by an enhanced episodic memory and greater openness to recount pain and discomfort in females than males [33]. This theory is supported by the response rate of the present study, in which only 24% of the survey respondents were male, only two males met the criteria for an interview, to which none agreed. However, females were over-represented in the survey, and it is possible that those who experience less severe or less frequent ExGIS are less likely to participate. Nonetheless, the predisposition for females to experience more GIS at rest, and potentially during exercise, requires further investigation. Notably, future studies should account for impacts of the menstrual cycle and menstrual status on GIS and ExGIS as well as control for potential confounders including nutritional status and medical history.

4.2. ExGIS Contributors

Type of exercise (e.g., long duration running, high-intensity training), dietary factors (e.g., dairy, fibre, grains, nutrition bars, hydration status), and psychological stress were identified as potential contributors to ExGIS in both the survey and interview findings. These findings align with the literature [1,14,38] and demonstrate the complex and multi-factorial nature of ExGIS. Strategies to emphasize easily digestible (e.g., low-fat, low-fibre, low FODMAP) pre-exercise meals, with adequate time for digestion and absorption may be useful in this context, as well as effective stress management strategies and adequate hydration. However, interviewees also expressed varying levels of uncertainty and unpredictability about when and why symptoms may occur. Food restriction and dietary “trial and error” strategies were used to manage ExGIS, a finding affirmed in the literature [11]. Yet, these athletes were very aware of the need to appropriately fuel before exercise. The use of ineffective dietary strategies perpetuated the need for continual adjustments to mealtime routines. This meant that athletes were hyper-conscious about the timing of meals and snacks prior to exercise to prevent ExGIS. Anxious thoughts related to preventing ExGIS, may have worsened symptoms for some hypervigilant athletes [39] and reinforced the belief that ongoing diet modification was necessary to prevent ExGIS. Such restrictions, without dietetic or medical consultation, could subsequently perpetuate symptoms, hinder optimal fueling, and have implications for long-term health. Evidence-based nutrition and stress management education are therefore critical for athlete development and performance. A recent intervention in adolescent female endurance athletes demonstrated that the group receiving a series of nutrition education sessions improved their energy availability and nutrition knowledge, along with favourable changes in energy intake and body composition, in comparison to a control group of athletes not receiving such education [40]. Professional, evidence-based nutrition guidance is especially critical for developing athletes in today’s world of internet influencers, social media, and heavy marketing of loosely regulated supplements.

4.3. ExGIS Resources and Self-Management

Despite most survey respondents citing nutritionists or dietitians as the most frequent source of nutrition information, most reported consulting no one, a family member, or a friend (n = 100 responses) for their ExGIS rather than a dietitian (n = 5 responses). Consistent with this and previous findings [41], interviewed runners seldom consulted health care professionals but rather turned to parents and/or teammates for nutrition advice. Interviewees either stated that resources specific to ExGIS were unavailable or reiterated the idea that ExGIS was an unmodifiable or normal occurrence for runners. Others found that symptoms were not severe enough to warrant the time and financial logistics that may be necessary to pursue these resources. Importantly, athletes were unsure of which resources to turn to for support and how these resources would be able to help them. Taken together, these findings suggest several barriers for collegiate athletes to access appropriate medical evaluation. Consequently, access to a sport dietitian for collegiate athletes could address these barriers. Appropriate guidance with dietary choices to fuel and manage ExGIS may reduce symptoms during exercise as well as anxiety for these athletes. At the time of this study, no sport dietitian was associated with the university athletics programme. Historically, sport dietitian access has been limited to elite athletes in Canada [42,43], though current data are lacking. Our survey findings of frequent GIS occurrence when not exercising suggest that some athletes may also benefit from a comprehensive nutrition assessment that could lead to a specialist referral when appropriate. Including a sport dietitian on the coaching and medical staff team could also potentially help to change the culture around stigmatized topics such as GIS.

4.4. Limitations and Future Research

This study provides novel insights on the occurrence and self-management behaviours of ExGIS in a developing collegiate athletic population, using a mixed methods approach. A key limitation of the survey component is the use of convenience sampling, which may have attracted more athletes with GIS to participate and limits the generalizability of findings to other collegiate athletes. The sample was also skewed toward females, which may be related to biological sex differences in ExGIS and/or social (gender) differences in the willingness to discuss a stigmatized topic. Future research should seek to determine the extent of any biological sex differences in ExGIS in well-controlled laboratory studies (e.g., menstrual and hormonal status, training history). Follow-up interviews explored a unique topic, and participants shared openly their often uncomfortable or taboo experiences. The inclusion of qualitative data provided rich data; however, this small, purposive sample of interviewees focused on the experiences of a self-selected sample of female runners, who may have experienced symptoms of ExGIS more acutely due to runners’ repetitive and high-impact, jostling movements. Further, it is unclear why males and athletes other than runners were unwilling to participate in a one-on-one interview. Thus, future qualitative studies should explore the barriers and enablers to discussing GIS in athletic populations (including the role of coaches and team cultures), self-management practices in higher-calibre athletic populations with access to more resources, and the potential role of sport dietitians (and other health care professionals) in managing ExGIS at various athletic calibres.

5. Conclusions

Exploratory findings in this study identified that ExGIS was disruptive for 32% of respondents, particularly for runners and female collegiate athletes. There was evidence of stigma associated with the topic of GIS and ExGIS, which may be a barrier to seeking health care. The complexity of exercise, diet, and psychological factors that contribute to ExGIS may also make it challenging for athletes to self-manage and to know where to go for support. Food restriction was a common strategy to self-manage ExGIS, suggesting potential benefit for a sport dietitian for collegiate athletes. Several areas for future research emerged, including mechanistic studies on the impact of female sex in ExGIS; a deeper understanding of the impact of GIS-related stigma on athletes seeking health care and support; and the evaluation of the impact of a sport dietitian on GIS and ExGIS management in athletes of various calibres.