Another IM, another day with extreme nausea

Triathlon Forum
1

I was active in IM distance races about 10 years ago, and despite trying everything, always ran into nausea issues coming off the bike and during the run. While I was able to finish the distance, it was with a lot of walking and inability to eat or drink anything in the later hours due to extreme nausea and vomiting. After a 10 year break and a diagnosis of fibromyalgia which has been pretty limiting in my fitness, I decided last fall to give another IM a go. I had no lofty goals and the plan was to take it extremely easy and just enjoy the day. This past Sunday, that’s exactly what I attempted to do, and until mile 8 of the run, it was going great.

Swim 1:18 at (for me) a really slow / warm up pace. HR never topped 125 despite dealing with some insane swimmers who seemed to be in flight or flight mode swimming for their lives.

Bike 7:30 at 124 watt average. I trained with Trainer Road and was riding to a FTP of 199 or 2.91w/kg. So again, SUPER easy ride with HR never above 120 the whole ride. Did the hills under 210 watts the whole day.

Food was a mix of solids and gels I trained and had zero issues with, and gatorade on the course. I took in about 80g carbs per hour in addition with 24oz of liquid and a salt tab. The weather was mid 70’s with little wind. I never felt I was too hot or sweating excessively.

Around mile 100, I started to feel nausea coming on and by mile 2 of the run, I was unable to keep anything down. I ran until mile 8 at a 10:00/mile pace walking each aid station and forcing myself to drink 2 cups of gatorade or coke. It immediately came back up. I walked another 5 miles to the point I felt lightheaded, chilled, and my HR spiked to the 150’s.

I had nothing to prove having finished this race before, and as the sole earner for our family / small business owner, I didn’t feel the need to push on for another 3 hours of walking with no nutrition and risk some health issue that would jeopardize the safety of my family stability. As such, I called it a day. The nausea lasted until about 4am that morning, and by the following day I was feeling 90% normal. No muscle pain or fatigue. Felt like I could do an hour run no with no issue.

All this to ask: what else can I try? The swim and bike efforts were laughably easy, and the first few miles of the run felt just like a normal easy day run. But when you can’t take in nutrition, the day comes to an end real quick. I don’t necessarily want to run IM again, but I have interest in running longer or doing some endurance swims and really want to figure this out. And insight or suggestions would be helpful and appreciated.

2

What was your training like? You seem to have a very long day at a very easy pace, comparably to hiking. Is this what you trained for?

3

I took in about 80g carbs per hour in addition with 24oz of liquid and a salt tab.

This sounds like way way too much to me. You said your power average was 124W, which means you are probably only burning 400-500kCal per hour cycling. At that intensity level a lot of that is going to come from fat. You don’t need 320kCal of carbs/hr at this output, you very likely aren’t even burning that much. Similarly, 24oz/hr might be high if it was not hot and you are not exerting yourself very much. Eventually your stomach is just going to say ‘No Mas’. I’d try just ingesting less, consider drinking to thirst, consider less very sweet things like gatorade and gels.

4

What drink mix do you train with?

If not the same as the on course nutrition, maybe that is the culprit. I feel like I’ve read accounts here of people having issues with Gatorade Endurance because of the type (or mix) of sugar(s) present.

5

Thanks for the replies. To answer questions:

Training was a 6 month IM specific plan, so a mix of lengths and intensities. Usually worked out to be about 10-14 hour weeks. Long rides were 3-4 hours on the trainer with long runs of about 2.5-3 hours.

I don’t think it was too much food. The first time I puked nothing came up. It was a lot of dry heaving and the only thing that did come up was immediately after I tried drink. I peed every few hours and it was light yellow the whole day. I’ve experimented with past races going down to 50-60g carbs and had the same issues in similar conditions.

I trained with all the same food and drink including the gatorade endurance. Zero issues.

6

when i have athletes that have long history of nutritional issue in races, the first thing i do is simplify everything and bring them to the absolute basic nutrition

-all liquid, maltodextrin as the main fuel source,
-nail down the amount of liquid needed per hour
-nail down electorlythe needs.

we go with this and in 20 years of coaching…i never seen it fail with the worst of the worst athletes as long as they stick to the plan.

solid food can bring a lot of issue, mixing different sugar can also be a tricky element if you dont do it right. Long ride of 3-4h on the trainer might not be enough unfortunutly for your kind of ironman duration. real world experience of testing nutrition execution is needed…so 5-6h…outside if possible.

7

This has happened to me as well in my last 4 ironman races. I have tried everything, had endoscope, blood lactate tests, worked with two nutritionists and tried a multitude of race and nutrition scenarios. I have been leaning toward the fact I might be suffering from motion sickness. I may try wearing a patch during my next attempt but not even sure I want to attempt it again. I have also raced IM races consistently starting way back in 1983 so it’s not like this is something new to me. The nausea started for me at age 57.

8

Sounds like what I have been going through. After the first time I vomit it is generally dry heaves because I can’t keep anything down. I am usually nauseous for a good 12 hours after I first start getting sick. Typically all night after the race and breakfast is still tough the next morning. I would compare it to motion sickness or morning sickness. I have not had either of those but even anti nausea meds through an IV didn’t help in the med tent. All my blood work came back normal in the med tent as did body temp and dehydration was not a factor.

9

Thanks for the replies. To answer questions:

Training was a 6 month IM specific plan, so a mix of lengths and intensities. Usually worked out to be about 10-14 hour weeks. Long rides were 3-4 hours on the trainer with long runs of about 2.5-3 hours.

I don’t think it was too much food. The first time I puked nothing came up. It was a lot of dry heaving and the only thing that did come up was immediately after I tried drink. I peed every few hours and it was light yellow the whole day. I’ve experimented with past races going down to 50-60g carbs and had the same issues in similar conditions.

I trained with all the same food and drink including the gatorade endurance. Zero issues.

So here is your answer. 3-4 hour indoor trainer rides will not prepare you for the demands of your race. You need to simulate the stress of your races in training, do a 1 hour continuous swim, a 6 hour continuous outddor ride and a one hour run in training and see, if you can replicate and then fix the problem.

10

Just swim and run. Triathlon requires a lot of bike volume and time. You are a good swimmer and there are loads of iconic swims all around the world. And just a little running to keep the weight down. If you are really motivated to do a good ironman then thats a different subject.

11

For me the best solution is to take something with ginger in it: Ginger thee, tablet…

Tried all different fuel strategies, nothing worked.

It is mainly nausea caused by the swim for me.

12

I don’t think that is the reason. He/she has done Ironman races in the past so I don’t think the training and prep is the problem. Something is happening physiologically in the midst of racing. Possibly stress related to racing. Maybe a form of heat stroke/exhaustion. Not sure but there are many IM finishers that “finish” and are far less prepared. Nausea can be relentless and once it starts it is a slippery slope. What triggers it in a long race is the primary question but unfortunately it is very individual and unique to each person who suffers from it. It is impossible to recreate the stimulus/stress of racing in a training session. I raced successfully at the IM distance for years with no nausea and have been well prepared for all my races. Something is just happening that I have very little control over and it is incredibly frustrating. Trial and error and being a human guinea pig is how the question gets answered. I will let you know how that goes;)

13

He wrote, he “always” runs into this issue. And he trains 1/4-1/3 of the race time at max.

I would NEVER attempt an 10 hour race, without having at least a few sessions > 6 hrs under my belt in the 8 weeks before the taper. 3-4 hours on the bike is a half ironman preparation at best.

14

You might want to give the folks at Infinit nutrition a call. They can work with you on a mix that will be very easy on your stomach. I don’t buy the fact that your training is the reason for your issues; I think it’s either something you’re doing nutrition-wise. Their consultations are free, and they’ve helped others who have come to them with similar issues in the past.

15

Thanks for all the replies. Just to clarify, I had a few long runs of around 20 miles and one 100 mile ride before the race. Sorry if I wasn’t clear in my original post. Most of my long weekend rides were structured Trainer Road workouts on the trainer where I’d ride for 3-4 hrs straight with less than :30 seconds of costing or rest. I actually felt way stronger on the bike vs pst years I’ve run the race.

Another reason I don’t feel it’s fitness related - when the nausea finally broke early Monday morning and I was able to eat, I felt 95% by the end of the day. TUE I went on a 45 easy and felt totally normal. Rode an hour on WED and again felt fine. Zero fatigue or soreness. If I was undertrained, shouldn’t I be shot after 13 hours and nearly 130 miles?

This has always been an issue. In years I worked with a coach, years I’ve tried all liquid nutrition, years it’s been hot, and years it’s been cool. I just don’t seem to find any fixes.

16

I was active in IM distance races about 10 years ago, and despite trying everything, always ran into nausea issues coming off the bike and during the run. While I was able to finish the distance, it was with a lot of walking and inability to eat or drink anything in the later hours due to extreme nausea and vomiting. After a 10 year break and a diagnosis of fibromyalgia which has been pretty limiting in my fitness, I decided last fall to give another IM a go. I had no lofty goals and the plan was to take it extremely easy and just enjoy the day. This past Sunday, that’s exactly what I attempted to do, and until mile 8 of the run, it was going great.

Swim 1:18 at (for me) a really slow / warm up pace. HR never topped 125 despite dealing with some insane swimmers who seemed to be in flight or flight mode swimming for their lives.

Bike 7:30 at 124 watt average. I trained with Trainer Road and was riding to a FTP of 199 or 2.91w/kg. So again, SUPER easy ride with HR never above 120 the whole ride. Did the hills under 210 watts the whole day.

Food was a mix of solids and gels I trained and had zero issues with, and gatorade on the course. I took in about 80g carbs per hour in addition with 24oz of liquid and a salt tab. The weather was mid 70’s with little wind. I never felt I was too hot or sweating excessively.

Around mile 100, I started to feel nausea coming on and by mile 2 of the run, I was unable to keep anything down. I ran until mile 8 at a 10:00/mile pace walking each aid station and forcing myself to drink 2 cups of gatorade or coke. It immediately came back up. I walked another 5 miles to the point I felt lightheaded, chilled, and my HR spiked to the 150’s.

I had nothing to prove having finished this race before, and as the sole earner for our family / small business owner, I didn’t feel the need to push on for another 3 hours of walking with no nutrition and risk some health issue that would jeopardize the safety of my family stability. As such, I called it a day. The nausea lasted until about 4am that morning, and by the following day I was feeling 90% normal. No muscle pain or fatigue. Felt like I could do an hour run no with no issue.

All this to ask: what else can I try? The swim and bike efforts were laughably easy, and the first few miles of the run felt just like a normal easy day run. But when you can’t take in nutrition, the day comes to an end real quick. I don’t necessarily want to run IM again, but I have interest in running longer or doing some endurance swims and really want to figure this out. And insight or suggestions would be helpful and appreciated.

Salt water or fresh water swim?

17

Fresh with fairly calm water.

18

I can’t answer why this might be happening to you, although like others have suggested the volume of what you are taking in does seem comparatively high. Your stomach does not empty super well when the body is under stress at any time and you often need to “train” your stomach to be able to take in the volumes that you might need for an Ironman. You also need to have a sports nutritionist familiar with the demands of Ironman and not just a general nutritionist.
Disclaimer-MD here and I work in a field of medicine where preventing and treating nausea and vomiting is a key part of my day to day work.
Have you ever tried, or consider trying, medication for nausea as part of your race strategy?
The chemoreceptors trigger zone in your brain has a variety of different receptors that can contribute to vomiting, which can be blocked by different classes of anti-emetics.
Ondansetron is one of the most common agents that we use in anaesthesiology and works on the serotonin receptors. Metoclopramide is not used as much these days, it works on the dopamine receptors and also promotes gastric emptying, which can be useful when you have more volume in your stomach. The other major class of medicines we use are anti-histamines, although the ones which are effective for nausea and vomiting tend to be in the sedating class and so not ideal for racing!
Ondansetron is nice as it comes in an oral dissolvable tablet that you can just pop under your tongue and go from there. Metoclopramide is low risk as well. Both likely require a prescription in the USA, ondansetron used to be expensive but not as much these days as it is generally off patent.
These agents on not on the WADA list of prohibited substances as there is no performance benefit to using them.
My advice if you wanted to try this approach would be to have them with you on the bike and take them in the later portions of your bike so that their peak effect will kick in in the first part of the run. With the maximal allowable doses etc you should be able to take a further dose during the run.

None of these drugs are treating the actual cause of your nausea and vomiting, in anaesthesia we try and avoid the triggering agents as such (like opioid medications) to decrease the baseline risk, but there are things we cannot avoid (like the type of surgery or need for strong medications for pain) and therefore we use these agents both in a prophylactic sense (ie to prevent nausea) and for treatment.

Just putting it out there as an option to try, if you ever get the motivation to do IM again!

19

I appreciate this and have definitely thought of it. I’m prescribed Zoltan for nausea related to migraines and it works really well for it. I did take one about an hour after the race, but it didn’t seem to work as well as I was still nauseous for a few hours afterwards. Still with a try for sure!

20

I appreciate this and have definitely thought of it. I’m prescribed Zoltan for nausea related to migraines and it works really well for it. I did take one about an hour after the race, but it didn’t seem to work as well as I was still nauseous for a few hours afterwards. Still with a try for sure!

We always talk about prophylaxis being better than treatment in post operative nausea…so my advice would be to hit yourself hard with them in the later portions of the bike. Ondansetron you can load with 8mg easily later in the bike and then take another 2 as you need them during the marathon. Same with metoclopramide. You can start with 10mg towards the end of the bike and another 10mg about 30-60 mins into the run…or take 20 before the end of the bike and reserve another 10mg for during the run.

Using them in combination will be better as they both work on different receptor pathways and hence are treating the nausea and vomiting differently.

I will put the usual disclaimer in here-you need to talk to your own family doctor about getting the prescriptions, in part to double check you have no absolute contra-indications to either of them and then to also source them legally.