Nutrition For Runners, Continuous Glucose Monitoring (CGM) & Optimizing Health | Kara Collier

I like to describe it as there are kind of 4 pillars of glucose control, and it's like 4 legs of a chair. So they're equally important. Cut one leg off, it's not going to stand up straight, right? The first is nutrition. A lot of evening your glucose levels out comes from those meal spikes. The other leg is physical activity. And so for a general person out there, probably not an athlete, it's usually how do we increase your physical fitness to have better glucose control? How do we add more lean body mass? How do we increase the amount of physical activity that you're having, amount of movement. For athletes, sometimes it's how do we make sure you're not overexercising and overstressing, you know, getting good recovery. And then we have stress. So that could be psychological stress, physical stressors, so injury, not getting enough recovery can be in that category. And then that fourth leg is sleep. And so stress and sleep, a lot of people want to kind of push to the side and not prioritize as much as exercise and diet. Uh, but they're of equal importance if we really want to think about overall improving our glucose values.

Welcome to Extra Mileage Show number 53 with Kara Collier. This is a fascinating conversation where we take a deep dive in all things nutrition and blood glucose levels for health and performance. I'll also be sharing several of my own test results and observations. For example, at the recent Chicago Marathon, I was actually wearing a continuous blood glucose meter over here on my arm, and I was actually able to measure my blood sugar levels during, but also before and after the marathon. So I'll be sharing some more about that, the things I learned there. Cara is the co-founder and director of nutrition at Nutrisense, a leading personalized nutrition company that uses new technology to monitor the body and create personalized diets and optimized fitness routines. And this really has been super eye-opening for me. She oversees the health team and product development, so she's at the cutting edge of using technology to make health advice based on real data from our bodies. Cara is also a leading authority on the use of continuous glucose meters, or the CGM technology, particularly in non-diabetics for the purpose of health optimization, disease prevention, and reversing metabolic dysfunction. This episode is brought to you by PATH Projects, and this is my favorite apparel for running and daily wear. More info can be found at @pathprojects.com. Also, if you would like to improve your running or run a personal best, check out my running coaching program at pbprogram.com. I hope you enjoy my conversation with Kara Collier. Welcome, Kara. Thank you so much for being here. I'm, I'm really excited for this call.

Yeah, absolutely. I'm excited to chat.

Definitely. There's so many different directions that we can take this conversation about nutrition, about blood sugar levels, about CGM, the continuous blood glucose meter. Um, in our audience of the Extra Mileless Podcast, there's many listeners that are endurance athletes, so cyclists, uh, swimmers, and a lot of runners as well. So I would like to focus our conversation about the nutritional side of things and then really optimizing your blood sugar levels for performance and for long-term health. Uh, I think it would be good to start with the basics here. Can you explain what is a CGM and what are the benefits?

Yeah, absolutely. So CGM stands for continuous glucose monitor. We'll stick with CGM moving forward. It's a lot easier. Um, but it is a small device and it goes on either the back of your arm or sometimes your abdomen, depending on the manufacturer. And you put it on at home. It is a medical device in the United States. So it does require a medical prescription, um, which is why companies like ourselves and Nutrisense, we're kind of taking care of all of that headache and legwork for you so you can get the data that you want, but I— people always want to know, does it hurt? How do you put it on? And so I describe it as like an easy button. It comes in this applicator, you do it at home, and you just push the button and it's on. And then the device stays for 24/7 for 2 full weeks. So a little bit different than like an Oura Ring or an Apple Watch, you know, you don't take it on and off, you keep it on for those full 2 weeks. And now suddenly you have that opportunity to see your glucose values in real time, 24/7, for that 2-week window at a time. So you would just use your phone to scan over the device and then you get an updated view of your data. And really what that allows us to do is see again, real time, what's coming from you, pull back the layer, pull back the window to see how your metabolic health is running, how that fuel system is running. I'm sure as many people in this world are familiar with, glucose is essentially our primary energy source. So when we can see in real time, not an hour later or a month later or a year later, we can see in real time how our fuel is adjusting based on, you know, what we're doing, what we're eating, how we're sleeping. We can dial in things much quicker and get that feedback loop much faster. That's the power of real-time data. I'm sure anybody who's done heart rate tracking, HRV tracking, can attest to the difference it makes when you get something real time and that close You know, closed loop feedback loop. And now we're doing that for the first time and something that represents our fuel status and our metabolic health, which is kind of that glucose value.

It is so incredibly eye-opening. Um, like we had a little chat beforehand and yes, I've been experimenting with CGMs myself and I used your CGM. I use the app and just that part of putting food in your body. Having a certain sensation and realizing what is actually happening in your body and whether that is like an energy spike or an energy dip or like, yeah, all of these different things and the small modifications, like the small changes you can make that have a direct impact right away. And there's like, we're gonna take a deep dive into all of this. So this is really exciting. But one thing that I noticed, for example, is Right away that stood out to me is I thought I was eating reasonably healthy, and then I started tracking throughout the app, for example, and ah, we had a team lunch with, with some of our colleagues and we went out and I went to eat a curry and it had probably a full, a full cup of white rice in it. Just seeing that my blood sugar levels spiked to 200 and came down crashing hard and sure enough having that tiredness feeling after that, but then directly seeing that with the data was, was very eye-opening right there.

So yeah, absolutely. And if you're taking kind of a wide view look at how you can utilize this data, there's really in the beginning, there's a discovery piece where you're learning all of this information. You're learning how you uniquely respond. You know, I'm sure we can dig into it more, but you will not have the same exact response to that meal as the other people you were eating with. Or if I were to eat it, even if we look similarly or we're of same, um, like physical shape, we're gonna respond differently. There's a whole host of factors, genetics, genetics, age, you know, muscle mass that determine our unique responses to food. So part of that is discovering how you as a unique individual respond. And then the other is kind of finding some of those hidden factors or maybe some surprising information or learning that maybe your go-to meals are really great choice. And that reinforces that those are good decisions. So a lot of it in the beginning is kind of that information gathering. And then the other component that really becomes more of the primary focus over time, after you've experimented, you've learned, is that behavior change component where now I know if I go out to eat and I eat, you know, the restaurant food that has probably some sugar in it and larger portions than I might eat, I know what's going to happen. And so I can compensate by maybe I do my workout beforehand or I eat half of the rice or, you know, you can learn these different tools and it's about implementation. And it's also about enhancing that mind-body connection. Like you mentioned, a lot of people will be like, oh, so when I feel really tired after my meal and I feel the, you know, absolute urge to take a nap, it's because my glucose is plummeting. You know, putting those things together really enhances that mind-body connection. And then that's information and tools in your toolbox you have for life. Cause now, you know what that feels like, you know, what strategies work and, you know, in response to that. And so that's really that long-term benefit that I don't think a lot of people think about at first when they're first trying it out and experimenting and learning. There's this whole behavior change component that's super important as well.

Yeah. So well said. And I 100% can see that part that different people respond differently and probably indeed gender and age and microbiome. There's a lot of different impacts there. But what is high level, like a range that is normal that we should be aiming to be in the majority of the time?

Yeah, so for non-diabetics specifically, we're aiming for a general range of 70 to 140, you know, 95 to 100% of the time. So if we're looking at it from a daily view, and we have, um, daily glucose scores in our app to kind of simplify some of these nitty-gritty details into a 1 to 10 score, which is helpful, um, and then we also have much more layer of information for the, the data nerds out there. But we want to see in an average day that we're not exceeding that 140 threshold too often. And it can be contextual, especially for athletes. So we'll get into that a little bit more. Sometimes you're going to have higher levels when you're really, you know, pushing your body to the max. And that can be okay depending on, you know, if the circumstance makes sense. There's sometimes where you're not doing anything too intense and you're seeing that big glucose spike that might be a little bit different. Um, and we also want to see the average glucose. So not just how high it goes, how low it goes, but we want to see the average around 105 or lower. So we're taking into account the swings, the maximum glucose, and then kind of what it evens out to overall. And sometimes we'll zoom in and really dial in per meal, because that is typically when we see our biggest fluctuations. But again, with athletes, especially endurance athletes, sometimes those big fluctuations are when you're training. So that might be when you're really dialing in to try to kind of stabilize or optimize. Um, but that 140 threshold is the upper limit we aim for most of the time.

It's, it's interesting to hear you talk about different measurements to be looking at. The one, like, yeah, there's the certain points of like the resting glucose or the morning fasted sugar levels, but then indeed the, the fat, the average one. Sometimes that's a fascinating one because we do a lot of low heart rate training or like just heart rate training in general. Sometimes people come to me and they say like, yeah, I ran at an average heart rate of 140. Is that good? Then I'm like, well, if you ran for an hour and the first half an hour you ran at 100 heart rate and the second half you ran at whatever, 180 or 200, yes, it's going to average out to a rather low heart rate., but like you were still anaerobic for a big part of it. You were running really low intensity for another. So, so average averages, as much as it is good to look at, sometimes can be kind of a misinformation from that perspective as well.

Absolutely. And that's where kind of the, um, traditional ways to measure glucose really fall short. So if you think about the most common ways before CGM that you can see what's happening with your glucose values, the first one is your hemoglobin A1C, which people might be familiar with. C, and that is essentially capturing your average glucose. So it's a lab value that gives you an estimate for the past 3 months. What was your glucose on average? So again, it's helpful. It's not meaningless. You know, we still want to know if you have a really high average glucose, that's an indicator of metabolic dysfunction, diabetes, et cetera. But you could have a good average and be going up and down all day long and it's evening out. To a normal average. And so it's only telling a small part of the story. Um, so we're really— what we see is a lot of people will come in with a normal A1C and they'll try the CGM, and then we're seeing these huge glucose spikes at maybe their breakfast meal every morning, and then it plummets, and then maybe it's even the rest of the day. So you don't know that information when you're only looking at an average. And then the other thing that people might be familiar with is a fasting glucose level. Which again is useful because it tells us how your body is responding in a fasted state, which kind of gives us information of when we're not eating, like when your body is just trying to maintain homeostasis, trying to do its thing, how is it doing? So it's useful, but again, doesn't tell the whole story, doesn't tell how you're responding to meals, exercise, um, what those day-to-day oscillations are looking like. So that's where, you know, this data you really get such a bigger picture and you can pinpoint kind of where you might want to focus your attention and where things are going well, not so well, just speeds up that learning curve.

It is so fascinating, like the, the part of indeed directly what you eat and the behavior you do around that, how that impacts your energy levels. So when you're looking at your glucose levels and your energy levels, how are they correlated with each other?

Yeah, they're tightly correlated, which a lot of people, you know, once you start looking at the data, as I'm sure you've experienced, you can really start to tie those things together. And so especially when glucose is just swinging a lot, so a lot of ups and downs and ups and downs throughout the day, that usually results in people just feeling kind of drained or fatigued overall. So the more we can kind of even that out, the better typically you'll feel. Um, and a lot of times what is called reactive hypoglycemia could happen in people. It's much more common than is documented in the literature. You know, what's documented shows that it's very rare for non-diabetics to experience hypoglycemia, but then when we work with real people every day, we see that it's happening a lot and people are associating it with symptoms. Um, so reactive hypoglycemia specifically is when you eat something, you have a big glucose spike, and then it comes crashing down. And you have those feelings of hypoglycemia afterwards, which typically feel like, you know, fatigue. That's that post-meal slump, nap urge that some people might get. Uh, and a lot of that is really just related to the fact that now your body feels like it's low in energy. And so you feel low in energy and you might actually get hungry and have cravings and then eat more, which starts this roller coaster. Cause your brain is like, I'm low on glucose. You need to eat again. So that can be a really vicious cycle for people.

So what can we do? And this is a very broad question, but I think it would be good to tie into or like to take a bit of a deeper dive into these different things that we can do to stabilize our blood sugar levels, or at least to minimize these, these big swings.

Absolutely. So when you think about optimizing glucose values, again, if we're going to take kind of just a bigger picture view of it, I like to describe it as there are kind of 4 pillars of glucose control and it's like 4 legs of a chair. So they're equally important. If you cut one leg off, it's not gonna stand up straight, right? So they're all of importance. The first is nutrition, which we can dive into. It's a big, uh, category, very broad, but a lot of evening your glucose levels out comes from those meal spikes and trying to kind of tweak things, experiment. So we can talk about some kind of universal truths with nutrition. Uh, but the other leg is physical activity. And so for a general person out there, probably not an athlete, it's usually how do we increase your physical fitness to have better glucose control? How do we add more lean body mass? How do we increase the amount of physical activity that you're having, amount of movement? For athletes, sometimes it's how do we make sure you're not overexercising and overstressing, you know, getting good recovery. But that's one important component. And then we have stress. So that could be psychological stress, physical stressors. So injury, um, you know, not getting enough recovery can be in that category. And then that fourth leg is sleep. And so stress and sleep, a lot of people want to kind of push to the side and not prioritize as much as exercise and diet. Uh, but they're of equal importance if we really want to think about overall improving our glucose values.

Those are all 4 indeed. I can, I can see how you're saying like they all go hand in hand with each other because all of them play an important role. It's just how do you optimize them in each area? And so let's start with the first one, nutrition. Like what are some of your learnings over there? Because even that part for me, the order in what type of foods to be eating, that was one of my key takeaways from the CGM when Naturally, I know my body responds well to proteins and fats, and, but once I actually take that and then take the carbs a little bit later instead of at the same time, it already was a difference in blood sugar spikes, whereas it spiked a lot less when I started with some protein and then the carbs versus the other way around. So what are some of the things, some of your learnings, high level nutrition-wise?

Yeah. And that's one of the biggest ones that we always recommend to everyone. You know, we simplify it as no naked carbs. So try not to eat your carbohydrates completely alone. Of course, there's some nuance to that. If you're actually, you know, training and competing, you might be having some carbohydrates by yourself, but we're talking about meal times. Uh, we really want to prioritize starting that meal with protein especially, but also some fat before you're consuming any of those carbohydrates. That's a big one. I'll preface again with saying that nutrition is that category where there's the most variability from person to person. So that's an insight in and of itself, is that whatever, again, is your big takeaways or somebody else's big takeaways is going to differ person to person. And that's why we really recommend when you're wearing the CGM for the first time, take those first 2 weeks, that first sensor, to really just do your normal routine to see how you are responding to the things that you're doing most often. And then you can kind of enter experimentation mode where you might see that every morning when I have that smoothie for breakfast, I'm having a really good, really big glucose spike and a crash. So I'm going to experiment with swapping some ingredients around there. I'm kind of finding what's working best for you, but some more universal truths besides, uh, the order of your macronutrients. The big one also is carbohydrate processing. Uh, so this might seem obvious, but it's really quite a pronounced effect of the level of processing that the carbohydrates have gone through is going to have an impact on how dramatic of a glucose response you have. So think about the difference between steel-cut oats versus, uh, rolled oats versus instant oats. We see a significant difference in glucose response between each of that level of processing. Once we've gotten to instant oats, it's essentially like your body's already digested the oats a little bit and now you're eating it. So it's predigested essentially, which means it's going to be a quick glucose spike. And sometimes you want that. If you need quick energy, you want to think about those quick sources. But we don't always need that if it's just our recovery meal or if it's a meal in our normal off day. Uh, so really thinking about carbohydrate processing, um, and that goes for liquid form versus solid form as well. You know, being mindful of kind of the form of which you're taking your food in is a big one. There are lots of other, uh, nutrition takeaways that we could go through, but Some of them as well is focusing on real food as much as possible. So that's the same with processing, but really thinking about the source of the food and timing of your meals can play a big difference as well. We see a lot of people who have higher glucose response to the same exact meal if it's later in the day versus if it's earlier in the day. Um, so this is something to just think about if you're eating and you're seeing really high responses to your evening meal, it could be just that you need to bump it up a little earlier if possible. So kind of tweaking timing as well and thinking about, um, when you're having the most carbohydrates and how that is both time of day and in comparison to your kind of exercise plan.

Does that also have to do with the higher levels of melatonin, uh, at night in the evening hours?

Yeah, absolutely. So melatonin and insulin work kind of in opposing forces. So as our melatonin rises overnight, that makes us naturally less insulin sensitive, which is what helps us process the glucose and the energy coming in. Um, and this is just from an evolutionary perspective, because normally when we're eating, we're in the kind of rest and repair, or when we're sleeping, we're in the rest and repair state, not necessarily in the digest and metabolize state. So those work in kind of opposite direction. Um, a lot of people don't realize that we have a circadian rhythm to our metabolism as well. And so that's essentially kind of what's going on there is that we tend to have our best metabolic health at like around noon, middle of the day, peak hours. And then we have our worst responses in the middle of the night. And we see this really exacerbated with, um, like our shift workers. So nurses, physicians who are working those late night shifts, um, they'll eat, you know, maybe their regular go-to meal that they'll have on an off day, they'll eat it at 3:00 AM while they're working and they'll see 3, 4 times the glucose response than they normally see. So, uh, it's pretty pronounced. And so of course that's a whole nother separate topic of how to kind of work around that, but just being mindful of timing.

Yeah. What about, um, intermittent fasting, fasting, or snacking throughout the day, all day long? Like what— for like, I think we can look through two different lenses. One is for optimal health, longevity, and one is for performance, because sometimes I feel endurance athletes might risk not eating enough calories if they have to shove it in too short of a window. So just curious to hear your thoughts here.

Yeah, absolutely. And just as you mentioned, it kind of depends on your end goal and of course the context of the individual. Um, as a general rule of thumb, we have some best practices when it comes to just, I wouldn't even call it fasting. It's more thinking about how you eat throughout the day where try to have some hours of fasting. 12 to 14 hours is just kind of like a healthy baseline where you're going without food at least throughout the night and, you know, a couple extra hours. And then as another general rule of thumb, people tend to respond best if we're avoiding food at least 3 hours before bed. That tends to help people with those overnight values, tends to help with that aligning with our circadian rhythm. And then as a general rule of thumb, again, we really try to avoid grazing. So kind of the constant eating, the snack here and there, Because for most people that results in glucose, not necessarily having large glucose spikes, but kind of these minor peaks all day, which then you never get down to those lower baseline values, which can raise your overall average. Um, and a lot of people, if you're trying to lose weight, tend to actually eat more if they're doing those small frequent meals grazing, because you're never feeling totally satiated. And if we compare just like total intake, people tend to eat more when they're having that pattern. So again, kind of depends on your goal, but I will say through the perspective of athletes, especially those who are performing at high levels, doing a lot of training, usually I would say 9 times out of 10, I feel like people are undereating, um, underfueling. So it depends on the goal. So if we're identifying you're underfueling, you're undereating, and the best way for you to get in everything you need to get in is 4 to 6 meals, that's a preferable solution than getting too hyper-focused on intermittent fasting. So it is contextual. And that's where, um, at least with Nutrisense, we also pair you with a dietitian so that you can hopefully kind of take some of that into context because there's no one-size-fits-all approach. Um, because we can also go the other extreme where if somebody's showing a lot of signs of insulin resistance, metabolic dysfunction, Maybe you actually have a diagnosis of prediabetes or diabetes, maybe not yet. For those individuals, leaning more heavily on fasting can actually be an extremely effective tool. So going even further between meals, maybe doing some longer 24-hour fasts, um, that can really help bring that glucose homeostasis kind of back into normal. But then I wouldn't recommend that for somebody who has a high energy demand, who is showing good signs of metabolic flexibility. And that tends to be the people who do do more fasting. So the people who should do it usually aren't, and the people who don't need to do it typically are overdoing it. So it's really thinking about kind of your general health and your goals and your fueling needs.

I'm so glad you brought that part up about the underfueling, because we have a running coaching program, the Personal Best Program, and we have athletes all around the world. And one topic that comes up frequently is about nutrition and also One thing we identify often is indeed athletes not taking in enough calories once they start increasing training volume. And even myself, who have been running and training for many years, and I feel I'm pretty in tune with my body. Once I started working with your app and truly tracking all of my activities and realizing like, oh yeah, I just ran 2 hours and I totally skipped lunch because it was too busy. And I realized I ate way too little for what my actual energy output was. And then sure enough, the next day my energy levels might be off, or I might actually— I've had a few times that I wake up early in the morning at like 3 or 4 AM. And when I spoke with one of your nutritionists about it through the app, that, that was one of the things that we had talked about, like increase your overall calorie intake. And sure enough, that early morning wake-up disappeared. So like those quick identifications and then seeing the real data, like my blood sugar level went below 60 it was 59. And I saw that it was out of the range where it should be. And then talking with her about it, all of a sudden, like, yeah, let's make some modifications here.

So yeah, it's, it's really incredible that feedback loop again of being able to pinpoint like, ooh, my glucose went out of range and I felt poorly, you know, let's try XYZ, which let's see which thing, um, you know, is the solution. And sometimes we don't always know the answer, but it might be like, here are the 3 most common things that might improve this response and let's experiment with it. And usually within a couple couple days, you can test those out, see the result, and then you know right then and there, oh, the solution that works best is that I actually need to be eating more, or, you know, I need to increase my protein or my carbohydrates or swap this ingredient around. And now you have that information that you can run with and really become part of your plan. And that's where it starts with kind of the baseline information that most people can use, the starting ground, um, you know, generic information that is useful, but then you have to use that and be willing to kind of tweak, experiment, be mindful of the data. And then you can find that different version, different iteration of that core information that works for you specifically. But that underfueling, undereating, um, especially not getting enough protein is something that we see really often. And I think it's completely understandable. It can be hard to get in enough food. You know, sometimes the caloric needs are pretty high. And people don't often feel that hungry if they're doing a lot of training as well. We are all busy. We have lives, you know, real life gets in the way too. And that's where just tracking or being mindful of it with information can be helpful too. Sometimes it's just an awareness thing. Like, you know, maybe you need to be eating more, but it's easy to kind of ignore it if you're not actually tracking it. So really kind of that awareness, the tracking is the first step to really dialing it in and kind of making those those fine-tuning differences that can actually really move the needle.

For sure. Because of you guys, I started doing meal prep now, seriously, in the weekends, all of a sudden, like starting to make more food, getting it ready for in the week. So it's easier accessible to, uh, to take that throughout the week. So yeah, that was really good. Yeah.

Having, having things available, make, make your life as easy as you can, you know, meal prep if possible. Um, add in extra ways to like get quick calories, you know, more calorically dense foods that are still healthy or within your goals, trying to prepare is, is always the way to go. Because if you don't have anything available, you know, nothing's around, it can get really easy to just not stick to it.

Yeah, for sure. Let's move on to the second pillar, the second chair leg, which was movement. So tell us a little bit more about some of your findings there.

Yeah, absolutely. So kind of just again, as first a general rule of thumb, Uh, for most people, just getting enough general physical activity is going to really, really, really improve, improve their glucose control. So we think about it through 3 components. One is endurance activity. So making sure you're really training that system. Second is getting enough lean body mass. And so our muscles are actually the largest sink for our glucose. And so having more muscle mass usually makes you a little bit more flexible and, um, prepared for potential meals. So the more muscle mass you have, the more if you go off script or eat something that you wouldn't normally eat, the more your body's kind of prepared to handle that and be more metabolically flexible. Then the third component is just movement throughout the day. And so if you have a large meal, let's say you went out to a restaurant and you had things that you wouldn't normally have, that's totally okay. But going on a gentle, even 10 to 15 minute walk afterwards can really help blunt that glucose response, minimize some of those spikes, and get you back to a more even state. So that gentle movement, using walking as your best friend, uh, can be really helpful for people. And then of course, with this audience, if you're doing a lot of exercise, it's also being mindful of that refueling component, uh, trying not to overshoot carbohydrates afterwards where you're going to get a big glucose spike and that might cause inflammation. And make it a little bit more difficult to really truly recover, but then also not underdoing it where you're seeing those glucose dips. And so it's kind of fine-tuning the combination of your training plan with your eating plan to, to figure out what's working best for you. And I'm sure we'll get into that more, but as that general leg, really what we try to emphasize to people is, is being mindful of those three components. A lot of people will want to do their workout, their training, their gym session, and then they're sedentary all day. And I think what is really powerful for a lot of people is realizing how effective simple movement is. You know, I have a desk job, I'm an entrepreneur, so I'm very busy. I'm sure you can relate to that. Sometimes you're, you know, back to back all day and you're not actually getting out. And, you know, I try to do a walk throughout the day. Sometimes I miss it. So really simple things that I've learned personally is in between meetings, if I have 30 seconds, do 30 seconds of bodyweight squats or, you know, quick movement. Those types of activity actually make a difference. So a lot of people think it's silly or unnecessary, but it really can, can help.

Yeah. Wow. So much to unpack over here because even, even like taking phone call meeting from time to time or sometimes I'm replying to social media or to emails or whatever, and I just do it while walking outside. Instead of necessarily always being stuck behind a desk in a sitting or standing position. The other part, I think you hit it on the head, the nail on the head right there when you said athletes might work out and then be sitting on their butts all day. And that, that you have to be careful and aware of that because there's been some studies that actually shown where they compared different movement Throughout the day, uh, and, and only a few minutes, even 3 minutes of movement, or like, like you said, 30 seconds here or there, a minute that already makes a difference versus sitting still all day.

So yeah, absolutely. Yeah. Really being mindful kind of that move movement throughout the day. And I think I know that the study you're referencing where they compared like an hour stretch workout versus like 20-minute blocks throughout the day and the blocks were actually more effective for overall health and wellbeing. So especially if we're thinking about this through the lens of balancing sometimes performance goals with longevity and healthspan and overall health is being mindful of some of those little things that can actually make a difference.

Yeah. Eating a breakfast and walking my kids to school versus eating a breakfast and right away working made a difference of, I think, 20 or 30, um, how would you say it? What is it?

Millimole? Yeah. It's, it's milligram per deciliter, but we always just say points.

Even 30 points. Like it was a significant difference. It just didn't end up spiking as much.

So yeah. Yeah, absolutely. And similarly for me, like I typically do kind of a, a weight training sessions in the morning, um, before I kind of jump into work and then I'll have a breakfast afterwards and I'll have a higher carbohydrate breakfast if I do that. But if I have a really busy day and I'm gonna I'm going to skip that workout or I'm not going to make it until maybe the end of the day, I'll have that same breakfast and it's 40, 50 points higher because I haven't kind of used my body yet. And so just being mindful of like, oh, I know if I have to move my workout to the evening instead of the morning, I'm going to do a different breakfast than if I was going to make my morning workout. So kind of those little things that you can adjust, uh, based off of circumstance, you know, real life, whether this is happening or that is happening, then you can kind of know those tools that help adjust depending on the circumstance.

We'll talk through like marathon running and nutrition in a little bit, but I, I wanna briefly touch on pillar number 3 and 4. So you said stress management and sleep. Any high-level thoughts on those there?

Yeah. Um, both of them are, are easier said than done. Try not to be too stressed, get good sleep are the high-level takeaways. Yeah. But it's really impactful. Um, I think that we all know that, but both of those are factors that are maybe more subjective or harder to quantify for a lot of people, especially stress. Um, and so when you're able to kind of, again, quantify it with data or see the true impact, it helps it become more apparent for people. Um, when it comes to stress, we can think about it as both acute stressors and chronic stressors. So with acute stressors, we get that flood of glucose as our body kind of goes into flight or flight, and we have that cortisol, the adrenaline, and that breaks down our glucose stores, but also produces more glucose. To give our body the energy to deal with an acute stressor. And so that is evolutionarily beneficial, except now a lot of times our acute stressors don't actually require energy from us. So stressful email, stressful phone call, traffic jam, you know, a fight with your friend or partner— we don't usually actually need that big glucose spike that comes with that, but that is the way our body responds. And so often we'll have people who come to us and say, the highest spike of my whole entire day isn't coming from meals. It's not coming from exercise. It's coming from my 9:00 AM meeting with my boss. You know? Wow. Yeah. A lot of times we'll see these huge glucose responses from these acute stressors. So then it becomes, you know, more of how do we manage that stress? How do we go into that in a little bit more of a relaxed state or kind of find some alternatives? Then the flip side to that is chronic stress, which I think we all know, uh, we're kind of living in a time where we are relatively stressed, uh, society. And that's more of a constant hum of glucose that can happen. We'll typically see this if somebody has really high morning fasting glucose values, that's a good warning sign of maybe there's a lot of chronic stress going on. Um, because it's more of that baseline elevated glucose levels that's being driven from a constantly elevated cortisol level. And so if we're fasted, we haven't eaten anything, and our meal the night before was good, our sleep was good, and we're seeing those values be pretty high in the morning, we can usually kind of drill down on stressors and see what might be going on there.

So then the digestive system is really compromised by that stress, correct?

Yeah, absolutely. And then it can be this whole, you know, spiral effect that comes from that. So then we're more likely to have higher glucose responses to our meals throughout that day because we're in that compromised state and our body's sort of in that more, um, stressed response. You know, a lot of that then dealing with that, or a technique that helps a lot of people, is that parasympathetic breathing. So getting those deep breaths in, especially before a meal. We'll see this often, people will eat Again, same exact lunch on a weekend where maybe they're relaxed, they're spending time with their family, and then they'll eat that lunch during the week in front of their desk while they're multitasking and they're, you know, distracted. And they'll see a much higher glucose response when they're in that distracted state. So it's putting away the screens for just a couple minutes while you eat your meal, taking a couple of those deep breaths before your eat, before you eat and putting your body into that more parasympathetic state can actually really make a big difference. It helps with digestion, helps with that stress response, and it helps with your glucose levels. So again, little things that, um, people become more aware of and become more meaningful to somebody when they see the data. You can tell people that and they may or may not do it, but usually when they see it and they try it and it works, that's when it becomes really sticky habit.

Breathwork is so powerful, how quickly you see that response from feeling tense to relaxing in a matter of seconds, minutes, really. One other one that somewhat goes hand in hand with breathwork that I've noticed to be very beneficial is cold exposure. Like, I've been doing that for years. I have an ice bath here, and that one I've noticed, like, makes me much less stressed. It makes me feel more under control and directly impacts sleep as well. Indirectly also impacts your glucose levels, I've noticed.

Yeah, actually cold therapy can, can really drop glucose levels. I don't know if you saw a dip in glucose. Absolutely. Yeah, it's super interesting. Um, the cold therapy itself is kind of activating some of that brown fat that we have, which is more metabolically active. And so we get to activate that when we're having that cold exposure, which can help drive glucose levels down. Both in the moment, but really overall it's also a pretty effective metabolic tool. So that's a cool one to, to keep in mind as well.

Yeah, for sure. And so there's the cold exposure, and then on the opposite, the heat exposure as well with sauna. Yeah, sauna use and whatnot.

Yeah, both of those are powerful tools. Um, and with the sauna, you might see a glucose spike in the moment because it's a little bit more of— it's almost like your body is working out. You're kind of raising your heart rate a little bit, so There's sometimes a component of dehydration, but then we'll see people have more even glucose responses afterwards. And there are long-term studies on it as well that show frequent sauna use helps lower fasting glucose and fasting insulin levels. So, um, both of those pretty, pretty powerful tools.

It's all connected there. And then we move over, all connected. And then we move over to the fourth one, sleep. So that one is also, once again, connected. Tell us a little bit more about sleep and glucose levels.

Yeah, it's really powerful. So sleep and glucose levels are kind of a bidirectional relationship where if we get a poor night of sleep, we're going to have higher glucose levels the next day. And then the other flip side to that is if we have really high glucose levels going into the night, it tends to affect our ability to have good high-quality sleep. Um, so the poor sleep can come in the form of both disrupted sleep, you know, maybe you're waking up throughout the night, you're not getting those high-quality sleep cycles, or can come from just like not enough sleep. You know, maybe it's pretty high quality, but it's shortened, and both of those will result in putting your body in kind of a temporary state of insulin resistance the next day. There's research that's been shown on this. Of course, we also see it anecdotally with our customers, but that can put your glucose levels sometimes up to 30 to 40% higher the next day if you're kind of having that continually poor sleep over and over. And it can be fixed rather quickly. It's different than, um, the physiological changes that come with diabetes that take more time to correct. If you get better sleep, you can see improvements almost immediately, but it is something where, you know, you're putting yourself in a totally different physiological state the next day, even if you're a non-diabetic, even if you know, don't have any metabolic dysfunction at baseline. Uh, so that's something that I don't think people are aware of until you start to see it. You get a bad night of sleep, you have your normal breakfast, and suddenly you're having a way higher glucose response than normal. And everyone's like, what is going on? I'm not doing anything differently. And then usually the first question we'll ask is, well, how did your sleep look like last night? You know, what was, what was different? Um, and then just the other side, the other direction of that is if we have that really big evening meal, and we have a higher glucose response and we're going into the night with those higher levels, that can also impede our ability to get those deep— that deep sleep we want, just because, as we talked about, sort of opposing factors. If our body is trying to metabolize and bring glucose levels back down to normal, it's not getting to put— funnel as much energy into that restful state. So we tend to see that with those high glucose levels, um, we're not able to get as much deep sleep specifically in that night.

I've noticed that. I use the Oura Ring to track sleep and just looking at the quality of the sleep, but also the heart rate variability. And one of those things, not only that you notice more poor sleep at those moments when you've had a late meal, but even if you have had a poor night's sleep or less sleep, sometimes in the morning, my stomach is growling and I'm having like cravings that I normally wouldn't have. And so that, that's kind of a fascinating one too.

Yeah, definitely. And a lot of people will wear an Oura Ring or some type of sleep tracker and, and always notice that there's tightly correlated— if one thing is off, the glucose is usually following. So connecting those data pieces can be really powerful for sure.

Let's talk a bit more about running, in particular marathon running and endurance running, and actual glucose levels. So it is really cool to see that even some of the world's greatest athletes like Eliud Kipchoge are now running with a blood, uh, or with a CGM and are tracking it to optimize health and performance, really dial in the nutrition and training and on race day. What, what is it like? What happens throughout a workout? And I think we can talk about two different workouts, one an aerobic workout, workout, so at a low intensity and one at like a higher intensity, because there are different fuel sources to some extent. At a lower intensity, you might use more body fat for fuel source, whereas at a higher intensity, most of your energy will probably come from glycogen. Um, so what do you see typically happening with blood sugar levels throughout a workout?

Yeah, it's exactly as you mentioned, it kind of depends on what type of workout is happening and how much demand for energy the body is requiring for that workout.. So you can really think about it as a supply and demand type of equation. So if we're doing that lower state cardio, you know, zone 2 steady state, then we would expect glucose to be fairly steady throughout and maybe go down a little bit because the energy that is available within the system, we're able to fuel the body for the demands that we're asking of it. Um, of course, if it's much longer, then we might eventually run out of our own fuel for that and kind of have have to keep topping off. But for general purposes, that study states we're going to expect to see glucose to be pretty even. Whereas as we start to get into higher intensity, we're going to see glucose rise during that exercise. So again, supply and demand type of thought process. If it's high intensity, our body's saying we need energy now to fuel this movement. And so this could be sprints, this could be higher intensity, um, aerobic activity. It could also be heavy weightlifting. It could be something like HIIT exercise, a variety of activities. And what we'll typically see is a glucose spike during that. And it's different than a glucose spike from, you know, if you're eating candy on your couch or if you're stressed with your boss. And so they are totally different physiological responses. You know, we always try to educate people and remind them that that glucose spike during intense exercise is a a totally normal physiological response. Your body is producing glucose really quickly to fuel that exercise, you know, either breaking down your own glucose stores, or we can make glucose from the liver gluconeogenesis, and then it's getting fueled and utilized immediately by the exercise. So that's different than, you know, a glucose spike of the same magnitude from a meal where it may or may not be utilized. Uh, maybe you didn't need that energy right then. Um, but with the exercise, we're using that energy right away, and then we would expect to see it normalize afterwards. And so it's really about making sure still that you're not going too high during that intense exercise. As a general rule of thumb, we recommend staying below 180 during intense exercise. If it's going a lot above that, it might be, again, contextual. If you're going If you're having a really intense, uh, you know, maybe it's performance day or competition. I know we'll talk about your data as well, which is a little bit different than if every single day when you're training you're getting above 180. And the other thing can be tweaking fueling. So sometimes if we're underfueled going into it and just a regular higher intensity exercise, your body might kind of overcompensate a little bit and have that higher glucose response. So a lot of times we can see that spike get closer to 180 or a little bit below if we just tweak some fueling and also hydration. Uh, so just kind of paying attention to how high that is going. And again, experimenting.

How far in advance before, let's say, a marathon would you recommend eating?

Yeah. And this is something where I think it's going to depend person to person, uh, especially related to kind of GI tolerance. Um, and this is where experimenting to see how you are responding to different things to know beforehand what's working best for you.

Highly recommend. Practice, practice in the long run, not on race day.

I like your style. Yeah, exactly. Uh, but what we tend to see work best for people for like longer endurance events in general is having one of those like larger meals. It's more protein and carbohydrates 3 to 4 hours before. And then if you're going to have something before, make it more of the simple carbohydrates. Smaller meal closer to only like 30 minutes before. Again, there's gonna be some people who are gonna be outside of the general recommendation, but that's what we have found to work best for most people.

The only tricky part with that, and I'm just throwing it out there, is that, for example, I just ran the Chicago Marathon, started at 7:30 in the morning. So you would, if you do 3 to 4 hours, you would be waking up and really minimizing the amount of sleep. As much as you can go to bed early the night before, you can only eat so So it's this fine line. And I think so, like you were saying, everyone is different. Some people can get away with eating a meal closer to their race, whereas others really need that full time. But then there's other elements as well. You want to have enough time to somewhat be able to use the bathroom before you go to the race. And there's a lot of different factors involved here.

Yeah, absolutely. It's a very good point. And if you know, you know what time it's going to be, trying that out and say, maybe I'm going to have this much protein and carbs an hour before, and I'm going to test it out on a non-race day and see how it works. And then, you know, maybe that works fine, or maybe you need to decrease the total portion size a little bit, change the composition, but certainly would not recommend, um, having your sleep take a hit in order to kind of fit some of these more general recommendations.

I'd like to do a quick screen share over here and show you my data from the Chicago Marathon. I just want to get high level a few thoughts from your perspective because I think it's, it's kind of eye-opening to actually have the direct data here. If we're looking at the time differences integrated over here, so actually I woke up, um, 3— it looked like 3:30 over here that I had my meal, but it was actually 5:30 in the morning. So a few different things I consumed electrolyte drink with 0 calories, 3 eggs with half a cup of black beans. So that's 300 calories, 24 grams protein, 16 gram carbs, and 13 grams of fat. And then I had a coffee with some heavy cream. And then just before the race, and this was 2 hours before the race started, and then 15 minutes before the gun went off, I actually took 1 energy gel with 30 gram of carbs and 120 calories. Then I raced for close to 3 hours, 2 hours 52, and you start seeing the, the glucose levels go up. So over here at the blue dot, um, and for those listening, basically my, um, blood sugar levels are at about 125. And from there on, it starts rising as I take a gel every 25 minutes at the beginning and then every 20 minutes after that. So realistically, I'm taking in, if we're looking at it on an hourly basis, 72 grams of carbs per hour, close to 29 grams of sugar per hour, and 240 calories at the beginning. And then later it increases a little bit higher over here. But yeah, then we see the line gradually go up, or like it shoots rather quickly up just above 160. It stays relative between 160 and 180. And then at the end, as I'm increasing my intensity, it goes up to about 200 over here. So I'm just high-level curious if you have any thoughts on what you're seeing over here, Kara.

Yeah. And the first question we would always ask athletes in this situation, and I know we kind of chatted a little bit, but the first question is always, how did you feel? Uh, cause that's important context. And I know You said you felt pretty good.

Yeah, I felt good. It has been in some of these previous races where I sometimes felt at the end of a race I was somewhat low on energy, and that was also when I spaced my gels a little bit further out that I almost felt the need to increase my gel intake because it's this fine line, I think, between eating enough calories but not overdoing it and getting stomach discomfort in a race. Those, those two, right? And so, yeah, I felt, I felt really good energy-wise and I didn't feel any discomfort on the stomach either.

Yeah. And that's super important. So it's always, again, contextual of how did you feel? That's the, the first place to start. And you know, as we talked about, we want to in general stay below 180, but when it comes to race day, I don't think it's as important to be focused on the 180 versus the 200 number and what is really good and about your, your glucose information that we're looking at is that slow and steady rise, as we talked about. Um, so it's much different than if you were having big, you know, jumps up and down. If you're seeing your glucose start to plummet and then you're compensating by bringing it up, and then it's kind of going up and down and up and down, that's when we would really want to rethink that fueling strategy. And usually that comes with probably not feeling as good. And so an important component of your glucose chart is that kind of steady, even levels over time. That's really what we want to achieve is that stability. Um, small things that like you could experiment with if you wanted to try it differently next time was maybe trying a different amount of carbohydrates right at the beginning, because you can see it starts to rise before you start. And so it can be, you know, I don't know if you've experimented with this personally, of not having that first gel just to see what happens, um, in comparison to kind of then starting it right at the beginning. It's not like a, you know, deal breaker, but that's like in a first experiment I would think about. Another thing that we haven't necessarily talked about is just kind of hydration overall, cuz that can help that even glucose level is experimenting with. Did you feel like you were hydrated throughout? Um, I know you had some electrolytes beforehand, which can be really helpful and we typically recommend.

Yeah. I actually took one salt pill. Per hour and I hydrated at most of the stations. The temperatures were relatively cool, so I felt, felt well hydrated throughout the race, but typically I would still lose a few pounds at the end of a race like this.

Definitely. Yeah. Yeah. So overall, I think that your data looks really good and it's kind of what we're expecting of those slower, more steady rise and increases and wouldn't get, go crazy over the fact that it went one over, over 180 on race day. Especially if we look at the context of the rest of your 2 weeks of data, which you never came close to that level in other trainings, which is important context too. You know, if somebody was hitting 220 every single day at every training session, then that's when we would want to do a little bit more digging as well.

The other part that was interesting is how quickly it came down as soon as I went across the finish line. And I know you have that window that you kind of want to start refueling just for a recovery process. So as soon as I got across the finish line, they start handing out bananas and, and other things. So I put a banana in me and like a muscle milk and some of these other things. And yeah, how, how long is that window that you, that you can typically eat after like a workout that it's still somewhat elevated?

Yeah, we, you'll see it elevated. Usually it depends on, uh, the intensity, you know, something like a marathon, it's gonna be a little bit higher that we might You might see it elevated. 2-ish hours is a general rule of thumb. Some of the shorter ones, we kind of want to get that recovery in within the first hour or so, try to refuel a little bit just for optimal glycogen, uh, resynthesis, but 2 hours as a general rule of thumb. And that's when, you know, it's also important to think about not just what you're doing before race and during race, but then after kind of getting some of those quick carbohydrates in right afterwards is really helpful. But then also making sure, as we've been talking about, you're getting enough adequate refueling in afterwards, especially because a bigger event like that is stressful on the system. So making sure you're recovering properly with lots of anti-inflammatory foods, lots of protein, enough carbohydrates, um, and kind of monitoring what your glucose levels look like the next day. Because sometimes, as you've mentioned, they can plummet pretty quickly within 24 to 48 hours after a bigger event.

Absolutely. I want to be respectful of your time over here. I have two last questions before we dive in. Like, what— where can people find more about Nutrisense and about you?

So the best place to find out more is our website, which is just nutrisense.io. That's where you can sign up for our programs, test out a CGM for yourself. But we also have a really awesome newsletter and blog if you just want to kind of learn more and explore the content. And then we're putting out a lot of information and stories and, uh, research that we're finding in our social medias as well. So anywhere social media, Instagram, Twitter, Facebook is Nutrisense.io as well. Um, you can follow me, Kara Collier, one at also social media, all handles out there. Uh, but a lot of the research I'm finding or the customer stories trends we're seeing, I'm putting out through the Nutrisense platform.

Absolutely. And I will make sure to link to that as well in the show notes. Um, what do you feel would be good nutrition for athletes on actual workouts? And at what point should they start taking some calories in? Uh, obviously once again, very different per athlete, but if we're talking about you going on a 1-hour run, a 2-hour run, a 3-hour run, at what point would you start adding in some calories here?

Yeah, I think as a general rule of thumb, if it's an hour or less activity, you typically don't need to add anything during extra. Usually kind of any sort of pre-exercise meal or the stores that you already have should be enough to get you through an hour workout. As we start to get longer and longer activities, especially something that's a little bit more high intensity like a marathon or even ultra endurance, activities, then a general rule of thumb, start fueling at regular intervals. What we have people start with is every 30 to 45 minutes, and then continue every 30 to 60 minutes, um, and vary anywhere from 30 to 75 grams of carbohydrates per hour to start with. So again, that's a kind of baseline of what we recommend and what we see work as a starting board, but then that's where the beauty of the data helps you to kind of fine-tune, experiment, and see what works best for you, because As we've talked about, and it's kind of the take-home lesson here, is that everybody is different. Um, and that's the fun part about data is really figuring out your unique situation.

It's definitely one puzzle that is continuously changing and that we're trying to solve here. Last question is, do you have any closing thoughts as far as for advice for recreational runners to become a stronger, healthier, and happier athlete?

Yeah, I think as we mentioned, one of the biggest things that I see is the underfueling. Uh, so if I was going to kind of emphasize a big take-home point is track, monitor, you know, correlate that with your subjective experience too. How do you feel? Like, how are you performing? Really track these things to build awareness and then pay attention to your calorie intake and your protein intake and make sure you're actually giving your body what it needs to perform at its best.

So well said. And that's the beauty of the app that you can actually scan labels from products. And so you can just put in like, ah, 1 portion of this, 1 cup of this, 1 like, and it makes it really easy to get a good idea of like how many calories are in there, how much carbs and everything.

So yeah, absolutely. Yeah. We have a built-in food tracker to try to make it as easy as possible to kind of monitor all the different things that are important.

For sure. Kara, thank you so much. And I wish you all the best with your company in the future years here.

Yeah, absolutely.

It was a pleasure chatting. Definitely. By now, thank you for listening. A few closing thoughts here. What was your favorite lesson, takeaway, or quote from this episode? Please let me know below in the comments. Also, Nutrisense was kind enough to offer the Extramile listeners a discount if you want to try out Nutrisense, the continuous blood glucose meter. The code EXTREMILE25 will give you $25 $10 off your first month, and you can check it out at nutrisense.io. If you would like to improve your running and really hit that personal best time, reach that potential that you have in training and racing, check out thepbprogram.com. And this is my own running coaching program with runners from all around the world. More info is available at pbprogram.com. Thanks so much for listening. And have fun out there on your runs.

Bye now!