The Journey of an Ultra Marathoner and Dietitian: An Interview with Renee McGregor

While it is probably possible for a week to maintain that the issue will be the longer term consequences of that and the potential negative implications to that individual, both psychological and physical health.

In this episode we're joined by the amazing Renee McGregor, a leading sports dietitian, ultra runner and expert in eating disorders, particularly particularly in athletes. Renia has spent years bridging the gap between nutrition and endurance sports, working with Olympians and amateur athletes alike to help them fuel their bodies for peak performance. We'll dive into her journey, how she became a dietitian, the lessons she's learned from her own running experiences, and how she helps others avoid common pitfalls in nutrition and the dangers of relative energy deficiency in sport, which is known as reds. We'll also explore how to balance proper nutrition with the high demands of endurance training. Her thoughts on personalized nutrition through tech like the Zoe app, which is very outspoken on and why mental health plays such a crucial role in an athlete's well being. Whether you're an endurance athlete or just somebody looking to optimize your health, this episode will provide you with actionable insights on longevity, performance and finding balance. So I know you are going to love this episode with Renee McGregor Foreign. Welcome to the Business of Endurance podcast. I'm really looking forward to the conversation between you and Claire because obviously you both have very similar backgrounds, so this is going to be interest. I feel like I might be the the person in the middle of this conversation, but I'm sure it's going to lead to some really, really interesting discussion, but I always like to start with the stories. I really wanted to know how you got into running and how you got into being a dietitian and nutritionist. So give us those stories. Where did both start?

Yeah, thanks Charlie and thanks Claire for having me. Running started 20 odd years ago. I had just had my second daughter and I say just she was 11 months old and we lived on a boat as you do in Bass, with two small children, two small babies and my younger daughter had this tendency to get up like really early, have a feed and then she'd quite happily go back to sleep. But I found it really difficult to go back to sleep. So I decided just on a whim one November morning I was like oh do you know what, I'm just gonna go outside, I'm just gonna go and get some fresh air and go for a run. So yeah, I don't even think I had any proper care. I just and some old trainers who used to use in the gym, I think I put my ex Husband's running shorts on or like some sort of shorts, I don't even remember. And I just went off and I just ran along the tow path for like 10 minutes and then ran back again. But it was so nice to just have that time away from the girls. And I love my kids, but it was just nice to have that time to myself. Like it was the only bit of time I ever got to myself. And so it started to build up a little bit over the course of the following year. Like, I was never mad. I just would go two or three times a week. I got a little bit further and a little bit further and I've slowly built up to about an hour. And I was quite happy with that, to be honest, for quite a while. And then, I don't know, I just started. I was running more regularly. I entered this local 5k race. I just didn't know anything about it. Just, oh, I'll just go along. It's. It was two quid to enter. I thought, why not? And I won it. I didn't expect to win it at all. Had no concept of whether I was fast or good or anything. I just really enjoyed being out running. And it was after that, really, that then the race director who'd put that race on, she was also a big member of the local running club and then they invited me to join and then I started doing more and more running and obviously it's built from there and my running has changed over the years. It's interesting actually. I've just been writing about my running in my next book and yeah, it is interesting to see the journey over 20 years, but it has been 20 years. Like I would say I'm a pretty experienced runner, having run in lots of different terrains and scenarios and yeah, distances. So, yeah, that's where my running started anyway.

And sticking with the running for a minute. It's amazing how people that get to a very high level of whether it's running triathlon, whatever it is, often it's just starting on a weirman, it building and building from there. So you had some great successes in ultramarathons. What do you think is the highlight? What's the pinnacle of your running been so far? Because I'm sure there's more to come. But what's the highlight so far?

Three big moments, I'd say, in my running. The first one is probably the most recent, which was the Lakeland 50, which I did a month ago. And I think that felt really important and poignant because it was my first race in my hometown and I had no idea how I would do but I was really happy with the fact that I finished in the first 10%. It's a pretty tough race you can imagine in the lakes. So 50 miles up and down the Lakeland terrain. Yeah, I was really happy with that and it did feel really special to me, especially that you run through Ambleside in the Lakeland 50. And not saying I know everybody because I don't, but it has that same environment as UTMB in the sense of just the crowds. It is like the UTMB of the Lake district, the Lakeland 15, Lakeland 100. And the crowds are phenomenal and I genuinely felt a bit like a superhero. Like I felt like one of my professional athletes that I work with because the crowd was so amazing and just really cheering you on. You're like 30 miles in by this point so you're like, you really need that lift and that was really special. And then I guess the race that really stands out for me is probably the Summer spine sprint in 2022 because again I never turn up to a race with any expectation. I just do like running. I think it's the journey and I, I just go with the journey. I had a day where everything came together and I finished in third, third lady and ninth overall. I was the only person of colour at that race. Similarly with Lakeland 50 I was pretty much one of the only people of colour at the race. So it feels important to be able to represent and it's a big reason why I run. It's about representation and I know that you can't be what you don't see. And again as a role model to two, you know, mixed raced daughters, I want them to be able to feel like they can do whatever they want and never feel the barriers that I felt growing up. So that was a really important one. And I guess the other one was one of my many trips to Nepal. But probably the first time I raced in Nepal that was really special. It was the first time I'd done a multi day event. Second time I'd been at such high altitude. The first time in a racing environment and again that's just a very special place. Nepal is a very special place and I've been back twice since and planning to go again.

Charlie and I have got an ever growing list of races that we want to do. So when you mentioned the spine sprint, what I know of the spine is very long. So what does sprint actually mean?

The sprint is 72 km.

It is a sprint.

Somebody was Having some fun when they named that, weren't they?

I'd love to come back and touch into the pool and nutrition strategies in a second, but what I really wanted to dive into is you've talked about how you sort of got into running, but with the background of being a registered dietitian and a sports dietitian as well. How did you get into becoming a dietitian? Because perhaps if you could explain, like, how that happened, but also, you know, the training that you had to go through as well to get there.

So I was a bit clueless when I was a teenager. I did know what I wanted to do, but I come from quite a strict Punjabi Sikh family background where it was predetermined that science was the way forward, even if that wasn't really what you want to do. I actually wanted to do English A level and I wanted to become a journalist and get into writing, but I was persuaded, shall we say, to stick with science. And I did science and thankfully I'm not too bad at science. So I left school with biology, chemistry, maths, A level, as most people who do science do, and had no idea what to do. I just knew I didn't want to be a doctor, even though that was what was expected of me. I didn't want to be a doctor, I didn't want to be a dentist and I literally. I didn't want to be a pharmacist. I literally had no idea what I wanted to be. But those are the three careers that my parents had gone. Those are the three careers you should try and go for. So I ended up doing a degree in biochemistry because I do find the human body really fascinating. And as a teenager I had suffered my own history of eating issues and had quite severe eating disorder for years, I'd say. And I was definitely interested in understanding what goes on at a cellular level, not just what happens in what we learn from a physiological level, but I was really quite interested in the cellular level type stuff. So, yeah, I did biochemistry and absolutely loved the course. If I'm honest, I thought it was the best thing ever. I'm a bit of a nerd. I found it really interesting. Again, at that point when I was getting to the third year, I was like, what do I do now? I don't really want to be in a lab doing research. It's not my bag. And so I had a really good mentor at uni and he suggested dietetics to me. I'd never really heard of it before. I never knew what it was, had no idea and I was like, okay, I'll look into it. So he set me up with some experience at the local hospital. I went and had a chat with a dietitian and saw what they did and thought this could be interesting, seeing how I can support somebody with a clinical problem from a nutritional point of view, again using that biochemical background as well. So I then applied to do the postgrad course at Glasgow. Back then you did a year studying and then you did a full year of placement in a hospital setting. So you basically were again, a bit like an apprentice in our second year. So I went and did my apprenticeship or my placement year at guy's of St. Thomas's so I got a really, really good grounding in all sorts of specialties and then got my first job a few months after qualifying on the diploma. And I say diploma, I was a postgraduate and I got my first job at St George's in Tooting. So basically worked my way up for the next, you know, nine, ten years. So during that time I'd spent the first two years doing pretty much everything, because that's what you do, a bit like a junior doctor. And then we had rotations, so then I moved into 18 month rotations in different specialties from like renal to gastroenterology to pediatrics. And then from that point onwards I did specialise in pediatrics. So I did an extra qualification in pediatric dietetics and then moved into adolescent eating disorders. So that was my last job in the NHS was working in adolescent eating disorders. And I guess at that point my girls were 2 and 4 and I was really struggling with being a mum and dealing with these really sick individuals that were coming into clinic and also just feeling a little bit frustrated with the eating disorder services and how it works in the nhs. It was very fixed, it was very constrained. There was no room for innovative thinking or different ways of trying to engage and get through to these individuals and I felt that wasn't really supportive of their care. So I decided to leave the NHS at that point and I did a little bit of private work to keep a little bit of cash flow coming in and also did my post grad in applied sports nutrition at the same time and also qualified as a personal trainer. So did all of those things in the same year with two children under the age of five. Because why not? Why not just throw it all in there in the mix? That's how I moved into sports nutrition and I've worked in sports nutrition ever since. My career has changed a lot. 2011 was when I started working with the rhythmic gymnastic team that went to London and then I moved into wheelchair fencing and wheelchair basketball and went out to Rio with them. And then since then have kind of had my own consultancy and now work with a number of different contracts including England National Ballet, Scottish Ballet, Oxford University Rowing and various other NGBs as well, just to provide support. But a lot of the work I do now is very much consultancy in trying to support governing bodies and individuals with reds and female athlete health and, and that kind of area.

I think with that context of what it took to get to where you are now, and I know Clare and I have chatted about this extensively in the past. For those people that aren't aware, both of you that are clinically trained, what is the difference between a nutritionist and a dietitian?

I think the biggest difference is obviously that the term dietitian is protected. So you have to have done a minimum of dietetic undergrad course in order to be a dietitian, be called a dietitian. Whereas obviously with a nutritionist the term is not protected. So anybody can call themselves nutritionist. Now there are registered nutritionists who do have a degree in nutrition and clinical nutrition and they have a different skill set to dietitians. I think dietitians very much we do learn about clinical conditions and how to apply our knowledge to those clinical conditions to support health. Whereas technically nutritionists do tend to work more in the area of well being and health and well being. So they're not technically allowed to work in clinical conditions. It doesn't stop some of them, but they're not supposed to. And I think the biggest problem is that the term is not protected. So you're getting individuals who've maybe done a little bit of nutrition on a PT course calling themselves a nutritionist, or you're getting people who are doing six week online courses and then they call themselves a nutritionist. And that's the problem, because as you've seen, it is a journey. I get asked a lot, like, how have you ended up being where you are and how do I get there? And I often just turn around and say to people, it's a lot of work I have really grafted for the last 25 years. It's not like I was handed all these opportunities. I do take opportunities when they come along, but I have worked incredibly hard and I've done roles that I haven't particularly enjoyed. But you do it because you gain experience. I'll never ever take for granted my clinical training, like my clinical training really helps me in my day to day sports, nutrition practice and work. And I think a lot of dietitians now, particularly younger, newly qualified dietitians, are skipping, going in and working in the nhs. They're setting themselves up as private practitioners because we have social media platforms then they're very good at creating content and they can make things look exciting and pretty. But I will always say you really do learn the most when you are working with people, because humans are not textbook. Regardless of how much you can read, regardless of how much theory you can regurgitate, it's not the same as living and breathing and responding to what's in front of you. And I guess that's quite an important aspect, I think. And when I'm recruiting individuals for my clinic, like if I'm recruiting a new person to join my team, experience is really important. Like, I will not take anybody who hasn't worked hands on in the field in some capacity.

Thank you for explaining about dietitian versus nutritionist. It's an ongoing conversation that we have, isn't it? Over and over again. And we haven't touched on nutritional therapy and everything else as well. But you mentioned really about reds. Over the number of interviews, we've talked about relative energy deficiency in sport quite a number of times actually, with another dietitian and a couple of people that have been athletes that have been through that themselves. It's an ever expanding area, isn't it, of reds. And now the question whether it does exist or whether it doesn't exist as well, but I just wondered if you could firstly just tell us a little bit more about reds and what that means, but also why that's so important that somebody who is clinically trained is working with somebody with relative energy deficiency. Because the reason that I asked that question is I think there's many athletes that you come across that are on that continuum. And what I mean by that is, do they have an eating disorder? Do they have relative energy deficiency? Is it normalized eating? And I think that's really difficult in the world of sport because some of these sports, as you know, working in gymnastics, there's an aesthetics part to this, an efficiency part to it as well. So I wonder if you could just tell us about reds, your thoughts and why it's important to be a trained.

Clinician working with them. Yeah, of course. So reds, as you said, stands for relative energy deficiency in sport. But I just tend to now call it relative energy deficiency because I actually think it covers a wider aspect than just sport. If I'm Honest. And as you pointed out, there's intentional and unintentional. So unintentional reds is where perhaps the athlete doesn't appreciate just how much fuel and how much energy they require in order to support biological processes within the body as well as their training load. And this is where it can become a little bit imbalanced. And the body has this tendency to prioritize energy for movement. So if there's not enough energy chronically left over for biological function, then the body will start to down regulate that biological function. So this is where they may present with hormonal changes or recurrent injuries or digestive issues. Because the human body is so complicated and we are like a series of chemical reactions and there's so many different systems within our body. And I think people just take their bodies for granted and don't fully appreciate what's going on. I think that's where my biochemical knowledge really comes into play because it's understanding how all these reactions interact with each other. And I know that even now in clinic, I'll often pick up interactions that even sports medic hasn't picked up because I'm. I'm aware of how they interact. And then you have what we call intentional reds, which is very much a conscious decision to restrict your energy intake and or over train. So it's definitely associated with an aspect of disordered eating and the worst case an eating disorder. And I think this is where it gets very muddled because we're definitely finding a lot of people with very well known diagnosed anorexia are coming into our clinic saying they have reds. And I think it's because people, there's a big stigma, isn't there, attached to having an eating disorder? Whereas there's not for some reason, there's no stigma attached to having reds. And yet they're actually very similar. Because if you think about what is going on is you're just not providing your body with enough energy to do the work that it needs to do. And I think before the 2016 IOC consensus statement came out, I was seeing so many athletes with low energy availability. And the reason I was picking up on it was because of my clinical experience in anorexia and eating disorders. And I could, I was seeing the similar sorts of biochemical interactions and the biomarkers and your blood testing that you pick up in, in people who have severe eating disorders. They were also the same as we were seeing in athletes. The only difference was that often athletes weren't always a very low weight. That was the key difference and that was really interesting. Again, from a metabolic point of view, understanding what's going on there. Why are they not losing weight in the same way as we see it in say, eating disorders? So I think like reds is hugely complicated. Even the people on the consensus group, the IOC are quite confused often and not always clear about what they're working with because it is a multi system problem. And again, we're seeing a lot of athletes coming forward and talking about their experiences. But most of them do have the very common symptoms we associate with reds and low energy availability, which is particularly in female athletes, and menstrual dysfunction and bone stress injuries. But also in males as well. We see hormonal dysfunction, low testosterone levels, subsequent bone injuries, digestive problems. But we're also seeing more and more athletes coming through with a much wider range of symptoms, including cardiac problems, including autoimmune conditions. And I think this is what I'm finding fascinating, is that reds is so much bigger. Whether we want to call it reds, we want to call it low energy availability, whatever we want to call it, basically when you're not giving your body enough energy and rest, I really want to add that in there because again, I think that's often missed. And again, a lot of athletes will say, well, I'll just eat a lot more and that will sort it out. Actually, it's really important to include the rest and the recovery. So if you're under recovered and you're under fueling, that's where we're looking at these really complex problems. Starting from my point of view and again, the research I have done, it all seems to be related to the threat and the stress we're putting on our nervous systems. And so again, this is why it's also very different, right? Like why it's so individual. Some people will cope with a lot more, other people will not cope with quite as much. And it's also, I think, why we're seeing so much of it even in the recreational athlete world, because we've got individuals who are trying to basically be pro athletes and have a full time job and be parents. And it's too much, there's too many layers. I will always say it's a very complex problem. It's definitely not something that I don't believe a newly qualified person will have enough experience in. I don't even think it's enough to say somebody who has personally experienced, has got enough knowledge to be able to offer support to somebody else. Because what I do see with athletes that are talking about their own experience. Very few of them are able to take the responsibility they've had in it. So what I mean by that is that they're often blaming the culture, they're often blaming the sporting environment, but they haven't done enough work psychologically to understand they also have a part to play because they have to appreciate that their own personality types has quite a big role to play in it. And you know, as humans, we're not very good at taking responsibility, are we? We're very good at blaming other things because it's uncomfortable to sit there and go, oh yeah, that's me. I mean, I'm very good at saying I'm a perfectionist and it is problematic a lot of the time. I'm not saying it's comfortable, but I'm very good at saying it. And I think that's another big problem is I've heard this narrative again and again. I'm not saying sport is not problematic. I have worked in high performance sport and it is brutal and absolutely the culture needs to shift. But I also think athletes need to appreciate that they are a particular type of individual that is more susceptible to developing dysfunctional behaviors.

You're absolutely right. And some of what you described, they might have been taking that as, oh, hang on, I'm over training and under fueling. That just mean I'm going to get better. What are the long term impacts of reds? You talked about some shorter term impacts, but what's the long term downside of suffering from reds for long periods? And it might even be, you want to add in the context of that to different categories, teenagers, ladies going through menopause and some other categories that you see.

I'm going to come back to that in just two seconds because I think there's a really, there's a study that's just come out that explains some of this as well. Just to try and tie it together. There's a new study that's come out in the cycling world and basically they've done a case study of a Tour de France femme cyclist and they wanted to prove that you can still get good performance output even when the individual is in low energy availability and the energy is like less than 25 calories per kg of fat free mass. And I was asked to comment on this study a few weeks ago and I said, while it is probably possible for a week to maintain that, the issue will be the longer term consequences of that and the potential negative implications to that individual, both psychological and physical health. So what we know is that it doesn't take too long before we start to notice these implications. It's usually like three weeks or more is when you start to see problems. And problems can be, as I said, endocrine issues. So female athletes start getting changes to their menstrual cycle. Maybe they just become a bit lighter, maybe they become less frequent, or they become more frequent, or they disappear completely. And again, it is quite common for endurance athletes, and specifically female injuries athletes, to lose their menstrual cycle. It's not acceptable, but it is quite common for them to. And again, if they miss 1, 2, maybe don't panic quite so much. But any more than that, actually that's going to have a significant negative effect on their bone health. And this is where it becomes problematic from an injury risk point of view, is that you get these individuals with very compromised bones that are not just weak in one place. That's the thing that I think people forget with stress fractures. It's not just about the place where the fracture is occurring. If you have a clean break, if you have somebody who has a fracture, that's very different to having a stress fracture. So stress fracture is where the bone has, over time, become very weakened due to poor recovery, poor nutrition, and poor hormonal status. And so the stress fracture occurs in that weakened spot due to overuse, basically. And what we find is often individuals, particularly those that have got reds and low energy availability, they'll go back to their training way too quickly, and that hasn't had enough time for that bone to heal properly. Like, it takes a long time for bone to recover. We know that it takes a minimum of six consecutive menstrual cycles for the bone activity to start up again. And then on top of that, you need to make sure you're having enough energy, you're getting enough calcium, you're having enough vitamin K. You know, like, it's a big matrix of different things. So what was interesting about this study was, and she won't mind me saying, because she has said she's happy for me to share it, the cyclist that was used in the case study came to work with me a few weeks ago because she basically said, I'm not doing okay. I haven't been doing okay for a long time. I wasn't really happy about being part of this study, but they wanted to prove something. So it's interesting, isn't it, that science was trying to prove a point, but actually hasn't taken into consideration that this poor athlete, this poor cyclist is now suffering the effects of that study. And I think the reason I'm making this point is because obviously Claire and I come from this very sort of academic background with dietetics, and obviously everything does have to be evidence based. But I think it's also really important to understand that not all studies are equal. And actually often studies are trying to prove a hypothesis or prove something without taking into consideration all the other things that are going on. Even when we look at studies around weight loss, for example, you may well get an outcome of weight loss, but nobody's looking at what effect is that then happening on the thyroid gland, or what effect is then happening on leptin levels. And that's the problem with looking at just one paper and just one angle. I think we're definitely not nuanced enough to be able to look after people properly. And I think that's something that I feel very passionate about. So, sorry, Charlie, to go back to your original question, in terms of the long term problems is that with teenagers the issue will often be the bone health issue. Because if they've got very low energy availability, it might mean either menstruation, particularly in girls, starts and then stops or doesn't start at all. And the same with boys that actually the testosterone levels don't get as high as they need to, so the bone doesn't reach its peak mass in what it could do. So even if they do recover from their low energy availability, maybe into their late teens or whatever, potentially if they then become professional in their early 20s, this is when we still see the effects of the fact that they've had these very low bone densities from a very young age. And the other thing is often that if they have had success as a younger athlete, especially based on being a low body weight, and again, their bone density hasn't been strengthened alongside as they become more professional or as they get older and their body is developing in the way that it should do, and they are the weight that they should be, often again, those bones and the pelvic region in particular, it can't support that volume of training. So this is where it can be. An issue is that often juniors really struggle to become successful seniors because of the mismanagement. At a junior level, which is problematic, it is possible to recover from reds. I don't want to be all doom and gloom like you can absolutely recover from it, and I have seen that. But I think people don't understand how long it takes. And again, if you listen to the athletes who share their experience, you'd think that you recover in three months, but that's not true. Like, we know that it takes a minimum of 18 months if recovery is linear, and that's for like metabolic health to fully get back to normal. And that's minimal. So I think I really want to stress that point because I think a lot of people assume that if they stop their activity for three months and they eat a little bit more and maybe their hormonal health returns back to normal, that's it, they're fixed. It's a lot more complicated than that. And particularly if it does have a psychological association with it, that also needs to be dealt with. That ability to manage your expectations, to manage your personality, is also a big part of it.

I mean, you gave a fantastic explanation of the long term and short term consequences of reds. And I think the thing with redds is the fact that we, as you mentioned, we still don't know enough about it. Do we actually really know what it is? Because we don't have so many studies to support that. And I think it's watched the space, isn't it? As it always is with science ever moving forward? You mentioned about high performing environments. I know you've worked within high performance for a number of years and you mentioned gymnastics and a number of other.

National governing bodies as well.

Thinking about social media and the environment that social media has created in terms of the way that we think about food, the fads, the trends, the diets that we might hop on and off. This is one of Charlie's big loves when we're thinking about AI technology here, but I'm just thinking of everything that's out there on social media. And the latest thing now is all these different fantastic technologies that are out there that can support us. But what do you see as potential risk when we're looking at very high performing athletes or busy professionals who actually are those kind of people that love data, they like to follow things. So whether that's a ring, a whoop, a Garmin watch, a glucose monitor, where do you see the risk lies with some of these devices? And where do you see the benefits within sport? Where can it actually help, do you think?

I'm not sure it can help. If I'm being brutally honest, I actually think it is problematic. I suppose the only way, the only place I'd see it helping is if you're literally using your watch maybe as a stopwatch. You know, it tells you you've done your 30 seconds or your two minute intervals or whatever you've got to do, and you've done it at the pace that you've been set. That's probably the only piece of tech that personally I think is useful. I think everything else is just causing more noise and complication and stopping. Whether we're athletes or whether we're just mere mortals, it's stopping us from listening to our internal monitoring. The human body knows what it's doing, we do not need to control it. And yet here we are all trying to control it. We're monitoring our glucose levels, we're trying to measure the microbiome by sending off stool samples, we're looking at our heart rate variability on whoop bands or whatever. And I think although that might provide some indication of how you're feeling, it can't be ultimate overriding decision. The human body has evolved to know how to survive. That's why we're all still here. And it knows what it's doing. You think about it, when the time is right, girls have periods. When we, when we are pregnant, our body knows how to have a baby. Like we know what to do. When we're cold, our body tells us and we put a jumper on like we know what to do. And yet the more and more we let tech decide and make decisions for us, the further and further away we get from just listening to our own bodies which probably have the answers for us. I think I do use HRV with certain individuals because it does help them to be more accountable. Like these are the individuals that are more likely to over train. And so I think HRV gives them an indicator of maybe when their body's not going to respond to training as well. So perhaps it's better to not train as hard that day. But I always say it's a crude value. It's not. Ultimately I'm not sure anything can measure really what's going on inside our bodies at all. So I personally find it all very difficult. The glucose monitoring thing. I'm sure if you have followed me or read anything about me or heard me talk about it, I have real problems with it because it suggests that the only thing that controls your glucose is food. And that is not true. As may you all know, as a dietitian, there are so many factors that influence our blood glucose, from stress to dehydration to illness to menstrual function, the list goes on. And even how you respond to food at different times, depending on what you're eating it with or what you're not eating it with or what you've been doing activity wise, all of these things have an influence. So to monitor your glucose and then decide that you shouldn't eat a certain food because it causes you to have a spike. And who's to say that spike's a problem? Because it's not actually in certain situations. We want glucose. Yeah, I have real problems with. Feels quite difficult in clinic because you are fundamentally, as always, up against the trends. And soon as you've got a celebrity or some sort of influencer who is promoting a trend that's got a much bigger following than you, is much more popular than you, you're onto a bit of a losing baffle. But all you can do is make sure you're there to pick up the pieces because ultimately you'll have to. And that's what I see time and time again.

I knew that you weren't a fan of Zoe, and obviously we can pick up on the fact that that's one of the things that you're referring to there. It must be really difficult for both of you because there's a couple of times where you said that where you're just like, there just isn't the research. Particularly in female athlete. There's just not the research. And yet companies like Zoe have more data on the general population than probably anyone's ever had before. And so it must be really difficult for you guys to be almost fighting against the companies that have more data than perhaps even you've had access to through the research that you get. How do you see it evolving to the point where it is a benefit, or is AI always going to be detrimental in the area of nutrition?

I think it would help if Zoe knew how to actually put the data forward in an actual manner that's not flawed. That would probably help quite a lot.

Could you just tell us what is flawed by the Zoe data? Because I'm really intrigued by it.

Firstly, with the Zoe data, there's a massive conflict of interest that the lead authors are invested in the company. So that's a big no when you're looking at any sort of study. But the other thing is that their most recent study that they claimed proved it wasn't comparable. The two groups, they had the control. They didn't have a control group. The two groups they had were given completely different advice. So, yes, the people on Zoe apparently did better, but the group they were comparing it to had not been given any advice. So you can't compare that because that's not how studies work. That's like saying, I'm going to eat a bar of chocolate and Claire's going to eat an apple and then we're going to Compare whose blood sugars are better. Like, you can't do that. So I think that's some of the very basic stuff. My biggest concern is that they make a number of claims, but they don't actually have the data to make those claims. So, for example, when I had a conversation with them, we were like, you're not taking into consideration the changes in glucose control in women. You're not asking women about their menstrual cycle. There was no questions about their menstrual cycle. There was no question about whether these women were perimenopausal or menopausal or even lactating or pregnant. Like, no questions. How can you give out information if you don't even know basic information about a client? So I do have big problems with it. And I'm not just on a massive vendetta against them. That's not what I'm here for. I am here because I fundamentally will always advocate for the vulnerable. Always. I would always advocate for people who don't feel able to say, this is not working for me. And I'm too scared now to go up against a big company because they're making huge amounts of money and it's incredibly clear that they don't care about people. They care about making money. That's what they care about. Because if they cared about people, then they wouldn't charge so much. Like their latest thing is this ridiculous high fiber seed mix that is. I don't like £10 or £15. I. And it literally blows my mind that this is allowed. That's what throws me is that this is allowed. Yeah. We could talk all day about Zoe, but I won't get anywhere because they'll never. I did have a conversation with them, but I'll be brutally honest, it was probably lip service on their part because nothing has changed and that upsets me. But at least I gave it a go. I will keep supporting people and I will keep calling them out if I have to. Especially something like Zoe, which apparently has people from professional backgrounds working in it. I think that's the bit that I find the hardest. Other brands that don't have any academics or nutritionists or scientists involved, I'm not saying it's okay, but you can go, okay. They don't have the knowledge, but when you have the knowledge, I personally don't know how they sleep at night. They just don't know how they sleep at night.

Really, it's fantastic to hear your passion, even though, you know, with what's happening in the world of nutrition And I think, as Charlie mentioned, it is and does feel like, you know, I've been qualified for 22 years, like a constant battle against even more. So now I won't even mention that when I was first at university, it was when mobile phones first came out and we certainly didn't have the Internet on them. But now it's even more of a battle and I think it's an interesting landscape and environment, but one that we have to also help people navigate as well. And I think that's really important to help people understand why and how to do that as well. But fantastic that you're out there flying the flag as well. Eating disorders and mental health. We talk quite a bit actually about mental health and have done in this, in the last episode actually. And lockdown was obviously a huge time when eating disorders and mental health really suffered. And certainly I saw a lot of people, there was increases in eating disorders coming out of everywhere and certainly within young people. Where do you think the landscape is at the moment in terms of eating disorders? Have you seen from your practice that actually things have settled down a little bit? Have eating disorders continued to increase over that time? And why do you think Covid was such a time where we saw that as well?

I'll answer that one first because I think that's probably easier if we think about what an eating disorder is, regards of how it presents. And also there are several different types. But basically an eating disorder is the way of trying to cope. It's a method of avoidance. It's a method of trying to contain yourself when life feels chaotic and messy. Sometimes it's all you've got. You know, if I think about some of the clients I have, their eating disorders are developed in the midst of really difficult scenarios going on for them. Whether it's familial relationships or trauma, or could say Covid was a very special circumstance for all of us. We have never had so much uncertainty in our lives from all aspects. And also there was this constant threat. Like those first few months. Nobody knew enough about COVID and we still don't. But if you think back to that time, I remember being terrified of touching a gate in case someone had Covid. And it's ridiculous to think about it now, but when you don't know enough. And I remember one of my friends ringing me when we were first allowed out and she said, I've come home and I've washed my clothes, had two showers because there was so much fear associated with it. So we created and generated this huge amount of Fear. And of course, we're not very good at coping with fear. Like I said earlier, humans are biologically hardwired to avoid threat and they don't want to experience it. And understandably, they find means and ways. Think about whether you're restricting your intake or whether you're fixating on what you're eating or avoiding certain foods. It's not about that, but that just gives you a way of avoiding what's really going on. And similarly, with exercise, you numb your feelings for a temporary amount of time. So all these things give you a temporary relief, but they're not long standing. But of course, if you never learn how to deal with all that uncertainty and threat, then you just keep going back to the same behavior because it gives you this temporary relief from it. So I think that's probably why Covid was a platform. I think I can't remember the exact stat, but it was something like, wasn't it over 200% increase in people developing an eating disorder. And I think probably a lot of people already had functional disordered eating, which then just became full blown because they lost their routine and they lost their security. And so it was the one thing that they had. It was something that they could manage. But I think also we all spent way too much time on social media, so all you did was compare yourself all day long to everybody else. And some people appeared to be thriving in Covid and had these wonderful lovely family scenarios going on and people making banana bread and all sorts, whereas others of us, we were not thriving at all. And all you then did was sit there watching all these people. And it just kept fulfilling that sense of, I'm falling short, there's something wrong with me, I'm not good enough. So again, you go in search of a way of trying to avoid feeling that way. So I think Covid definitely had a really negative impact on our mental health. In terms of your question around, has it settled? It's a good question. I think people are still affected by it. So I think those individuals where it became heightened in Covid, they are still suffering the consequences of that very acute time. So I don't know if we've got more cases, but I would definitely say there are still a high number of people who can't get the support they need and are really struggling with eating disorders. And again, I don't think social media helps. I think social media just validates. Sometimes it validates your behaviors, sometimes it influences your behaviors. And it fundamentally, there's no filter, is there? Like, you have to be the filter. And if you haven't developed that ability to filter content that is harmful to you or causing you discomfort, then it's gonna, it's going to contribute to how you think and then your behaviors.

Unfortunately, the algorithm is designed to give you put you into an echo chamber. So if you're responding to something that's going to make you feel upset, then it's going to feed you more of that. But it must be a massively challenging area for both of you guys. I want to bring it back to running and let's talk about some running nutrition stuff. I'd like to ask you for some top tips around how you go into your ultramarathons, maybe in the lead up to, during and afterwards. But I'd also like to throw into that question. Have you had a nutritional calamity in one of your races and what did you learn from that and what have you done as a result?

I have had a nutritional calamity.

I'm human after all. In 2019, I did the Monterosa 4 Day Stage event. And the Monterosa is basically a loop around the Monterosa and you go up to some very high altitudes. You go up as high as 3,800 meters. And I really underestimated my sodium losses. I hadn't appreciated how much sodium I lost in terms of when I'm running through my sweat. And I remember on the second day, climbed up to this big refuge, it was like, I think we'd got 2,900 meters and it was a really tough climb. It was really hot and it was through a forest, it was very humid as well and I was actually absolutely dripping with sweat. Got to the top and felt pretty awful, but did manage to eat some real food at that point and thought, okay, cool, that'll get me going. But was really thirsty and so kept drinking water, but hadn't really appreciated that the bread and cheese I'd just eaten probably wasn't quite enough salt for what I needed. It started running down and then was like, oh my God, this is not good. Like my stomach was churning proper, like washing machine situations going on. And I knew what the problem was. I knew I needed salt. And weirdly, the day before I had helped someone out who had the same problem and had been stuck on an aid station. And even the medics didn't know what was going on with him. And I said, how much salt have you had? And he said, not anything. I said, well, here you go, I have two salt tablets and make sure you keep taking them. And you'll be fine. And I remember that the day in the day one, he bought me a beer because he's, you saved my race. I said, it's all right, it's my job, it's not a problem. Anyway, obviously giving him my salt tablets meant that I didn't have any in my back. And so I was like, oh, this is terrible. I don't know if I can continue because I felt so unwell and I just sat on a rock and thought, okay, I'll just sit here and hope that someone passes and they might have some salt tablets. And funnily enough, the same guy that I'd helped the day before passed me by and he's, are you all right? I was like, no, not really. I need salt tablets because, oh, I've got loads today.

And so he gave me some and then I was able to continue and.

I managed to get on and finish the day. It was good karma. God, I still make mistakes. I was thinking about this at the weekend and I was talking to my partner about it. Sometimes people get very locked into what has worked for them before and think, okay, I'll just do that again. And not necessarily realize that the conditions might be different, the terrain might be different, particularly if you're a female, your hormone levels may be different, and all of these things are going to have an effect on whether that same strategy is going to work for you. And sometimes we just have a really shit day and that's it. And it doesn't matter what you do, it's just a big, really bad day and I think it's really interesting. So, yeah, I definitely don't get it right all the time. You know, Lakeland 50, I didn't get it too wrong, but there were points in Lakeland 50 where I did struggle to eat because, again, I was drinking loads. I had loads of electrolytes and everything, but when I tried to eat solid food, my mouth was so dry I really struggle to swallow anything. And so, as someone who's not, I always keep gels as an emergency, but I don't tend to use them very often in ultras because I like to be able to eat proper food. I was actually surviving on gels because it was the only thing I could actually swallow without being too dry. So I think what I have learned is always have a contingency, and that is something I always teach the people I work with, is that you can practice and practice. You can know exactly what's going to work for you, but always have a bit of a Backup, just in case, because you never quite know how the day is going to pan out and how your body's going to react and.

Respond as part of that backup, are there any particular food groups or particular things that you go, right, we've got to have some of them in there and we've got to have some of that in there because there's a good chance I may need that in the future. And I think Claire and I are speaking from experience in terms of ultra running and suddenly needing peanut salted peanuts or salt, vinegar, crisps or whatever it is. So what are your backup foods and what do you have in the pack?

So in my pack, I will always have a mixture of sports nutrition and real food, because I do think there's a place for sports nutrition. I don't always want to use it the entire time, but I definitely think there's a place for it. I'm a big fan of active root, so I use a lot of active root from a drinking point of view, just because I really like the ginger and it helps with nausea. And I do tend to get a lot of my energy through drinks because again, a lot of the races I do, I'm using poles. And so if you're relying on trying to eat, sometimes that can be problematic. So I do use a lot of liquid energy. I always have a Snickers bar because I always look forward to that. I usually have some salted peanuts in there or some like mini cheddar or something like that, because again, salt is something you definitely look forward to depending on the race. Like for the Spine Sprint, I had a bagel with Marmite and cheese, which I did eat in small amounts because also the Spine Sprint, you have to carry everything. There's no checkpoints, so you can't stock up. So you just had to have it all with you. Whereas with the Lakeland 50, there were checkpoints so you could grab sandwiches and crisps and whatever else they had going. Cheese toasties. That was a good one. So, yeah, I guess my pack tends to have a range and I'll always have some gels and probably some sweets in there as well, like board sweets have got me out of a jam quite a few times when I haven't been able to eat anything. But if I suck a bald sweet, it just helps to again keep the saliva being produced and the sugar going into the brain. That's always got me out of a pickle at times. So they're my kind of go to. But that's not to say that's what everybody else should do, because that's what I've found works for me. Over the course of however many years I've been doing ultra running, but when I did marathons and half marathons, it was always gels because you're going fast and so you can't really. I can't chomp and I go if they can't chew and run fast at the same time. So it's always a gel. Usually when I'm doing anything faster.

I remember hearing you on a podcast talk about the power of Peanut M M's. I was like, yeah, that's a great idea.

I had those.

Did you? Sounds like a good addition.

I tried something new, which maybe everybody might. I actually made my own trail mix up, but my trail mix was salted cashew nuts, Peanut M&MS. Haribos and Mini cheddar's.

Wowzers. That sounds very good.

Yeah, it was a good mix. I have to admit, like, every time I put my hand in, I was like, oh, yeah, this is quite cool. Yeah, I did eat quite a lot of their registration because I didn't realize that registration was going to take quite so long. So then I had to repack my bag. It's all fun and games.

Brilliant. Now, you are the author of quite a few books and we always ask on this podcast for books that have helped you on your journey. So what books would you do you find yourself other than your own recommending to your patients or what books helped you?

So I really like reading books about human behavior because I think if you understand human behavior, you can definitely help your clients a lot more. So I do read quite a lot of psychology textbooks and things like that. But I think the two books that I do recommend quite a lot is Radical Acceptance by Tara Brack, which if you don't know who Tara Brack is, look her up. She's absolutely phenomenal. She's a psychologist that has brought Eastern and western practices together and it's a little bit how I like to practice myself. So I actually did my mindfulness training through her organization. And so I definitely bring mindfulness into my practice because I think there's a lot there that can help individuals. And then the other book that I do recommend quite often is the book by Kimberly Wilson, how to have a Healthy Brain, which I think is fantastic. It's a really well written book. She'd be a good person for your podcast as well. But yeah, it's a very well written book in that it's very simple to use. You think of the brain is A very complex organ. And I just love the way in which she has helped you to understand how the brain works, but also the psychology of the brain as well. So I think it's a very good book.

Brilliant. Those are two books that have not been mentioned before. And I love the sound. I've just actually finished reading Headstrong by Dave Asprey, which is also about biohacking the brain and boosting your mitochondria and all that sort of stuff. So that. That sounds brilliant. I'm definitely going to check both of those out. Thank you for that. We also have a tradition on the podcast where we get the last guest to ask the next guest a question without knowing who that is. So our last guest was Dean Carnassis. So you're getting a question from a very renowned runner and I think Claire's.

Got Dean's question, so this one's going to be an exciting one to answer. How important is innovation to you and how do you innovate?

I think innovation is really important when you're thinking about how to get a client to engage. You know, it's not all just, here's a nutrition plan and off you go. Like, you have to really get to understand that person. You've got to think about the best way to get them engaged with you. So I find it a really important aspect of practice. How do I innovate? I'm quite good at thinking outside the box. Like, when I left the nhs, I got told I'll be really good at my own practice because I think outside the box too much. And I've taken that as a compliment and moved forward with it. So I spend a lot of time in my head. Even my partner says that I spend a lot of time in my head thinking about ways in which I can make the world a slightly more bearable place for most people. I don't know if I can think of an exact technique that I use, but, yeah, I definitely look for different ways, I suppose, more about how to maybe describe things. So, for example, I had a young lady I worked with a few years ago who had very severe autism, and she was really struggling with understanding the importance of fueling her body and really just struggled with it. And I sort of said. I said, well, if you think about your body as a garden, you need to tend to your garden, you have to water it, you have to feed it, otherwise it's going to go to pot. And she said she found that really helpful way of being able to visualize looking after herself and actually fueling herself and feeding herself in a better way. So I guess that's the kind of thing that I would try and come up with.

That's absolutely fantastic. And the beauty of having ultra running as your sport is that you've got plenty of time to think and mull over this stuff and process it, haven't you? And in fact, actually that's one of the conversations we have with Dean Carnassis was this wonderful gift of thinking time, whether it's listening to books or whether it's processing and innovating around that. So really this has been absolutely brilliant. There is so much there. I've written loads of notes, lots of really great advice for those people that are listening that are maybe thinking they need help with some of the stuff that you're talking about, whether it's eating disorders, reds or whether it's just wanting to know more about you and your running. Where's the best place for them to find you?

So do have a website which is Rene mcgregor.com, which tells you more about what we do from a clinic point of view. And then the best place to really know more about me is my Instagram, which is rmcgregor, which is definitely more of a educational platform. Like I definitely don't divulge deep dark secrets of my life on there. It's not that kind of account.

That's fantastic, really. It's also been really interesting to hear you and Claire discuss things. It sounds like you're both preaching to the choir. So fantastic. Thank you very much and thank you for the work that you've done.

Thank you so much for having me. It's been a real pleasure.

What did you make of the conversation with Renewal?

It was fantastic. It's good to catch up with somebody within my own field as well. So aligned within my own field. So it's really good to hear some of her comments around eating disorders. We talked a lot and we over Covid how that had increased. What about your thoughts? You're in a different profession. What did you take away from it?

There was loads of really interesting stuff in there. For me, the bit I was going to ask you about was the Zoe piece really interested me because I get why Zoe is clearly having a personalized approach to nutrition is better than an AI app is going to deliver. And let's be honest, if we take tried off the AI coaching platform, if you're a professional and you're going to be paying a coach to truly bespoke if you're Kristen Blumenfeld, are you going to Get a better program built by a professional coach. Yes, you are. But for 99% of people, they're not going to be paying £1,000amonth for a top professional coach. Therefore, the AI does a better job. So I'm just really. I was just really intrigued by that Zoe conversation. If Zoe helps people eat a more diverse diet and it gives them more awareness of how they react to different foods, that to me, seems like a positive. But equally, I'm appreciative of the fact that sometimes those apps can drive people to exclude foods they should be eating. So that, to me, really intrigued me. And I suppose I'd ask, as a professional dietitian and nutritionist, what do you think of the Zoe app and Reni's.

Approach to it from a clinical perspective as a dietitian and working in eating disorders? I see where Renee's coming from, and I think there were two parts, really, to what Renee was saying there. I think firstly that she was questioning some of the studies that were coming out. They're collecting huge amounts of data. In science, it's really difficult to get people to do trials. I think it's amazing how they've actually managed to get people to pay to collect their data. Actually, in the world of science, maybe this is moving into whole new realms of actually we can do better clinical collection of data because people are paying for things. I haven't read all the trials inside out, so I can't comment on that without reading it. But I think she's right to question when this isn't telling the whole story. So I think that's really good that we should always be questioning the data that we're reading. And that's something I always talk about, actually, where does it come from? Is there any invested interest in the trials, etc. But I do think here, like I say, I think it gives scope to more data. As long as that data is the trials that are coming out is something we can do with. It's interesting because when you collect data, if you're thinking of eating disorders, it.

Doesn'T have to be eating disorders.

Whether it's a watch, a band, a ring, we look at the data. And actually, sometimes it does drive you to think, I need more sleep rather than listening to your body. Sometimes it does drive you to do something because it's almost telling you that you need to have more sleep or you need to rest or whatever without actually thinking, do I feel okay? Blood glucose monitors, I think, are a way of finding out a little bit more about yourself. But you're absolutely right. I think for some people, truly it would really help them nudge them in the right direction, that they need to be making some changes, that potentially they're kind of new. So let's take it as an example of somebody maybe who is rushing around, they were grabbing things on the go and they knew they needed to do something about it. But actually having the data in front of them nudges them in the right direction. And then they see by introducing more plant based foods or different types of carbohydrates that actually, wow, I can see a change. So I think for some people, generally on a general level, I think nudging them towards health, I see the flip side. I see the flip side in terms of when you generalize something and you put something out to sell to the population, you can't give individualized advice.

You just can't.

And whilst they have nutritionists working for them, that gives them an idea from the data they're seeing. You can't go into the nitty gritty details. The problem is some people may not see the full story. So for example, poor sleep and the effect that has on our stress cortisol levels that may increase blood glucose. But you may not necessarily know that because it's generalized data. I think in the world of AI, I know this is your area, Charlie, like in the world of AI, but I think in the world of health it's about reducing risk for certain more vulnerable groups, for example with eating disorders. But it's also, how can we use it to our best advantage to help us as dietitians, as nutritionists be able to actually provide better support to people. I can absolutely see how if you had an eating disorder, if you went and did a run, like a fasted run as an example, when you finish, you're likely to see your blood glucose really rise. If you were then about to have breakfast or about to have lunch, but you thought, oh well, it's too high, I can't eat because it's high. That's just a physiological response. Your blood is still pumping out glucose from a fasted run. It doesn't mean you can't eat. But that could be taken as with somebody with an eating disorder, I shouldn't eat because my blood glucose is too high. So I think if you teach someone properly, that sits in a good place. But also any devices, somebody with an eating disorder looks at the number of steps they do. One day it's 12,000 and now 12,000 is where they have to be. Next day it's 14,000, 15,000. So I think it's really challenging in an environment now with so many ways to track things. We're not going to get away from that. But I see where really is coming from in terms of potential risk especially for people more vulnerable with an eating disorder.

It's interesting, isn't it? Different people do different things with it. Both my daughters are at school diligent and hard working and so when teachers in their wisdom say look, you've only got this number of months between now and doing your A levels or GCSE they get stressed out. They would have done the work anyway and they've just been put under more pressure than they needed to be. For the boys like I was at school that are lazy, that do the bare minimum, they need the kick up the ass to go, come on, you've only got this number of months till your exam because otherwise I do nothing. One approach for everyone doesn't work. Bespoke nutrition advice is always better, isn't it? But I suppose for some people Zoe is going to help them. For some people Zoe's not going to help them but probably for the majority it's going to put them a step in the right direction going back to try not for obsessive compulsive like a typical ironman athlete would be often actually reduces their training because actually a lot of ironman athletes over train and it often the training program is lighter than it would have been if you'd bought an off the shelf cookie cutter type one or through a traditional coach and in some ways AI is reining you in. Another interesting thing we talked about red S and eating disorders. You asked about what calamity have you had with your own race? Nutrition, the salts, the electrolytes piece. If your stomach's upset that could be your electrolyte and if there's other things going wrong that can well be electrolytes and it's thinking about am I getting the electrolyte right? If you're feeling low in a race, have you eaten enough? That was interesting and good advice. When training or racing, if you're not feeling like I'm loving this then the first questions to ask are is my nutrition right? And is my electrolyte balance right? That's the first thing to fix. Was there any other quick takeaways that you got from the conversation?

Her biochemistry background is really interesting. That is extremely helpful when looking at blood biomarkers from a training perspective. She explained that well recovering from relative energy deficiency can take a year and a half and I think it's really interesting to listen to her talk about actually it's not as quick as you see on the surface sometimes that actually there's so much recovery that needs to be done. So that for me, I thought she put that across extremely well. And it does take a long time. Actually on the flip side of that, there's a period of time that it takes for you to get in that position as well. So it is, it makes sense. It takes a long time to get back to that full level of fitness.

And I think that ties. I think also it's very. With nutrition in particular, it's very easy to get caught up with short term stuff, isn't it? Particularly Zoe app is encouraging you to think about your blood sugar today. Whereas actually the long term impact of doing this wrong and suffering from red s for longer periods was interesting part of the conversation. I think people do need to think about making sure that their nutrition is right. Not just for the short term, but the long term impacts are so great. There was loads of great takeaways, great advice and really interesting to hear you guys talking about your professional subject together. Lots of takeaways for everyone at home and keep on training. If you want us to keep getting amazing guests onto the business of Endurance podcast, we don't ask for you to pay for us. We don't ask for patrons patronage. All we ask for is that you subscribe to the podcast, ideally on Apple, give us a five star rating because it shows us you care and if you've got time, leave us a comment. One word is fine, something like inspiring or amazing or something like that, but we really do appreciate it and it will help us to continue to deliver amazing guests on what we hope you find to be an amazing podcast. Thanks very much.