The Athlete’s Gut: Why Things Go Wrong and What to Do About It [transcript]

Written by Christopher Kelly

April 17, 2020

[0:00:00]

Christopher:    Megan, how are you doing this morning? Are you staying inside and safe away from the coronavirus?

Megan:    Yes, as much as possible. It's hard here in Colorado because the weather just turned really nice and most of the trails have actually been closed. They're fining people for being out on the trails. Unless you can walk from your house to a trail, you can't go out to a trailhead and start hiking.

Christopher:    Yeah. That's more aggressive than here in Santa Cruz. I've not been with anyone. I've stopped riding bikes with friends. I've been on my own and I've seen a huge uptick in the number of people out on the trail compared to normal, but I don't think they've been that aggressive about -- I can still drive the car. I guess if I parked in the car park, maybe they would give me trouble. I don't know. It sucks. We're the same. The sun's coming out. Everybody wants to go outdoors and do fun stuff and you can't.

Megan:    I know.

Christopher:    Well, I'm super happy to have you on the podcast today because a couple of weeks ago, I interviewed a microbiome researcher and clinician now, Lucy Mailing, about her 12 Microbiome Myths and Misconceptions talk. For those of you who are familiar with Dunning-Kruger effect, I found myself slipping backwards on the slope of enlightenment and into the valley of despair. During the interview, I kept thinking, "I wonder what Megan would think." She steeped in the scientific literature and she's working with athletes on their wonky gut, so I'm delighted to have you on to talk about the latest science and the clinical practice for the athlete's gut. Thank you so much, Megan.

Megan:    Thank you, Chris. I'm looking forward to this conversation and I look forward to hearing Lucy's podcast as well.

Christopher:    Oh yeah, of course. You haven't heard it yet, but you've seen the talk, right? You saw her slides and you've seen the talk.

Megan:    Yeah.

Christopher:    Okay. That's good. Well, maybe we should start at the beginning and talk about the importance of gut health.

Megan:    Sure. Yeah. This is a topic that I talk about with a lot of our NBT athletes regardless if they come to us with preexisting gut symptoms. A lot of them definitely do, but even if they don't, it's really good to keep gut health in mind for both performance and longevity and general health, I think. I thought we'd start by, like you said, talking about the importance of gut health and then we can transition into why athletes are a population that often struggles with gut health, and then we can talk about some practical things like what to do if you're an athlete who has GI symptoms either away from or during training and racing, and then we can end with some troubleshooting tips that often come up when working with our clients at NBT. 

    As far as the importance of gut health goes, definitely the gut plays a large role in digestion and absorption of nutrients. A large portion of the immune system is within the gut, so a healthy gut is often related to a healthy immune system. The gut could also be a potential source of systemic inflammation or local inflammation in the gut. We'll talk more about that in a little bit when we talk about endotoxin. Also, the gut produces a lot of neurotransmitters. That's something that some people don't know. They think of neurotransmitters as produced in the brain, but actually, a lot of them are produced in the gut. Gut microbes also play a large role in cardiovascular disease, neurodegenerative disease, diabetes and overall glucose regulation, autoimmune conditions and also some cancers, so they're really important for a lot of these chronic diseases that we see in the modern world. We've done a ton of Nourish Balance Thrive podcasts in the past on gut health including episodes with Lucy Mailing, like you've mentioned, Michael Ruscio, Jason Hawrelak, Lauren Petersen and others, so I'd definitely encourage people to check those out for more, and I'm sure Elaine will link to those in the show notes.

Christopher:    Yeah, it's a good time to point out that Elaine does a fantastic job of tracking down all of the references. Whenever Megan mentions a scientific paper, that will be linked in the show notes that you can find. If you poke around inside of your podcast app, you'll find the notes.

Megan:    Yeah, for sure. When you mentioned scientific paper, for people who are interested in the gut and its relation to glucose regulation because that's something that we've talked a lot about before on the podcast, there's a really good recent review called "The Interplay Between Gut Microbiota and Gastrointestinal Peptides: Potential Outcomes on the Regulation of Glucose Control". We won't go into details on glucose control now, but if people are interested in that, that's definitely something to look at. 

    We also know that exercise and gut health have this bidirectional relationship and that a gut-muscle axis exist just like the gut brain axis or the gut skin axis. Exercise can positively and negatively affect gut health, and then vice versa, the gut health can also affect positively or negatively exercise performance.

Christopher:    Well, that's interesting. I've never heard of that one before. I've heard of lots of axes. What's the power of axis? Axes, isn't it?

Megan:    Axes, I think, yeah. 

Christopher:    Yeah, but I've never heard of the gut-muscle axis. Can you talk a bit more about that?

Megan:    Sure. When we're talking about gut health and nutrition for athletes, the gut microbiota may be a mediator of the effects in nutrition and muscle cells. There's a really great article we'll have Elaine link to called "Aging Gut Microbiota at the Cross-Road Between Nutrition, Physical Frailty, and Sarcopenia: Is There Gut-Muscle Axis?"

[0:05:01]

    Basically, to summarize, the gut microbiota uses dietary fibers, protein and bile acids that we input or that are created to create metabolites like short-chain fatty acids which then affects signaling molecules like PGC-1 alpha, AMP kinase and CrT1, which then go on to have a downstream effect in muscle cells. It's pretty interesting. It's pretty complicated. We're learning a lot more about it, but there's definitely this -- just like gut-brain axis, there's definitely this gut-muscle axis.

Christopher:    So if you care about muscle, you care about the gut, which is everybody listening?

Megan:    Yeah, exactly, and every athlete cares about muscle, right?

Christopher:    Right.

Megan:    Okay. Now, we'll talk a little bit about why athletes often struggle with gut health and there are a few good reviews and articles that we'll link to in the show notes. A lot of the gastrointestinal effects of exercise can be part of normal physiology to some extent just because of what you're putting the gut and the body through during exercise, but that doesn't mean that exercise should be avoided. It just means that the athletes often need to pay special attention to how to support gut health. Diarrhea is often a common symptom amongst athletes. These symptoms whether they're diarrhea, constipation, gas, bloating can occur both during and away from training and racing. Typically, we see the worst exercise-induced symptoms in people who already have symptoms away from training in their everyday lives. A lot of our clients come to us complaining about just day-to-day gas, bloating issues and then that's exacerbated during racing.

Christopher:    Quite often -- and this was my experience, too -- was you go to the doctor, even a specialist, and they'll blow you off saying, "Well, this is just what happens to athletes. You need to stop what you're doing and then your symptoms will resolve" and of course, we know that's not true.

Megan:    Yeah, absolutely. There's a really great article called "Runner's diarrhea: What is it, what causes it, and how can it be prevented?" that talks about the main reasons behind why diarrhea occurs in a lot of runners and I'll kind of summarize that here. Typically, looser stools occur more in runners versus cyclists just because of the amount of jostling and pounding the pavement that they're doing, but exercise-induced loose stools, as well as just general GI pathologies, are largely intensity and duration-dependent, but heat can also exacerbate symptoms. 

    The three main causes of exercise-induced loose stools or diarrhea are ischemia. During exercise, blood flow is diverted from the visceral organs to the working tissues like the skeletal muscles, the brain, and the heart. The amount of reduced blood flow depends on the intensity, but just to give people an idea, at 70% VO2 max, there is an 80% loss of blood flow to the visceral organs and this reduction in blood flow to the abdominal organs can cause gastrointestinal ischemia and subsequent hypoxia. To put it in another way, that's the loss of blood flow to the gut which results in an oxygen shortage and ATP depletion, and nobody wants ATP depletion.

Christopher:    That's not pathology. That's just normal physiology and it makes perfect sense when you think about it. If you're being chased by a tiger then the last thing you want to do is invest in long-term building projects like digestion.

Megan:    Yeah, absolutely. Then to make matters worse, the GI reperfusion with blood post exercise can further exacerbate damage by increasing inflammation and also reactive oxygen species in the gut. The mucosal injury from this reperfusion can then cause intestinal permeability of the gut barrier and endotoxin translocation from the gut into the bloodstream.

Christopher:    Give us a sense of how hard 70% of VO2 max is. I have a feeling that's not that hard. I think I could sustain that for several hours.

Megan:    Yeah, you should be able to. It's going to be depending on how used to intensity athletes are versus somebody who's not an athlete. Seventy percent to an athlete probably won't feel very hard, and yes, you should be able to sustain that for a while versus --

Christopher:    But generally, the problems are going to be a function of time and intensity. You can go not very hard for a long time or very hard for a shorter period of time and you might see the same outcome.

Megan:    Yeah, absolutely. The other thing is heat and non-steroidal anti-inflammatories can absolutely exacerbate --

Christopher:    Oh yeah, don't do that. I've been through a period of that as well. I would take Tylenol or something before going for a ride because it made me feel better, but yeah, I'm not sure that's a great idea for your gut.

Megan:    Yeah, for sure. Again, talking about that mucosal injury that happens from the reperfusion of blood back into the gut when there has been a lack of blood, both of the intestinal permeability and the endotoxin translocation that can result from the reperfusion, those things can result in diarrhea, and then like I just mentioned, the NSAIDs and heat stress can also exacerbate those things. That's one reason for loose stools in athletes and runners particularly.

[0:10:00]

    There's also mechanical, so mechanical factors, again, especially during running can also contribute to exercise-induced loose stools. Much of this is speculation, but there are a few interesting theories about how this can happen, the mechanical damage and how that can result in loose tools. One is just the vibration of the abdominal wall and jostling of the abdominal organs, those things can cause GI distress. Motility can also be impaired. There's an interesting but controversial suggestion that running can delay small intestine transit time perhaps leading to something like small intestinal bacterial overgrowth (SIBO) or SIFO. Well, it also accelerates colonic transit time leading to diarrhea. The studies on transit time do have some mixed conclusions. However, the theory of the slowing of the small intestinal transit time -- well, the increasing of the large intestinal transit time does go well with what I see in a lot of our athletes, so the SIBO-like symptoms plus loose stools is not uncommon.

Christopher:    Right, yeah, I recognize that all too well.

Megan:    Finally, nutritional factors can play a role in exercise-induced loose stools and diarrhea. This is probably obvious, but certain types of foods or supplements taken around or during exercise can also cause gut issues. These things include high fiber intake especially the FODMAP fibers -- we'll talk a little bit more about that in a second -- fats, concentrated sources of glucose or fructose alone, caffeine, and then also bicarbonate. Being dehydrated can also paradoxically make loose stools worse, which then is a vicious cycle because the diarrhea also could cause dehydration. Maybe "paradox" isn't the right word, but it's kind of ironic. Because of that vicious cycle, the dehydration can cause loose stools and then the loose stools obviously cause more dehydration.

    As far as carbohydrates go, we know that carbs are ergogenic aids regardless of whatever anybody tells you. Most people do perform better when they have some carbohydrates in their diet. However, too many of the wrong types of carbs at the wrong time can contribute to exercise-induced GI distress and diarrhea. Taking in any food during exercise especially in the heat can cause intestinal permeability and translocation of endotoxins across the gut wall, but carbs in general can be really problematic, in particular, large concentrated boluses of carbs. You could think of traditional things that athletes use like gels and goos and carbohydrate drinks. Those things during exercise can delay gastric emptying which can then cause fluid shifts in the gut and result in diarrhea.

    That said, you can train the gut which involves obviously eating a lot of carbohydrates during training, so training the gut and then choosing the right combination of glucose and fructose. A common combination would probably be something like using a maltodextrin or other glucose source along with fructose. If you train the gut and then you use the right combination, you can typically take in and absorb more carbohydrates during exercise, and then the combination of glucose and fructose typically works better than one alone just because you can absorb more carbs without gastrointestinal distress using multiple transporters, so you use SGLT1 for glucose and then GLUT5 for fructose.

Christopher:    Okay, and you don't worry about maltodextrin being a cause of dysbiosis to begin with. I'm pretty sure I could find some evidence that maltodextrin is pretty bad for the gut microbiome.

Megan:    It would not be my first recommendation. I would try to use something like a UCAN SuperStarch, but I just use that example because that's a lot of what many athletes tend to use.

Christopher:    Right, and I can remember that UCAN was life-changing for me at one point. It's horrendous, chalky stuff, but it fixed my GI symptoms, so I didn't care how chalky it was.

Megan:    We'll talk about this in a little bit more detail later, but also, to reduce the risk of gastrointestinal distress and loose stools with traditional, concentrated carbohydrate sources. Even if they are glucose-fructose mixtures, training the body to be more reliant on the fat as a fuel at a given intensity can be really helpful as well.

Christopher:    That's the Holy Grail right there. You don't need the carbs in the first place and that's where I'm at now. I can ride my bike all day and not need any food whatsoever. The only thing that you have to be careful of -- and I'm sure you encounter this on a daily basis, Megan -- is that then you go to a race where you want some ergogenic effect of carbohydrates and you haven't used any in a bike ride for weeks or maybe months or years and that tends not to go well in the race.

Megan:    Yeah. You absolutely need to, if you're trying to be fat-adapted, use a lower carbohydrate approach during training, and then as you're building up to your race, really focusing on what carbohydrate sources are going to be beneficial and good for your gut during the race so that your gut isn't surprised like, "Oh, I haven't seen any carbohydrate sources in months" and now we're throwing the carbohydrate source at it plus the intense exercise and that's not good.

Christopher:    Yeah, it's a skill like any other and part of it is just getting the stuff down the hatch whilst you're on a bicycle is a skill that's acquired and lost in my experience.

Megan:    Yeah, absolutely.

[0:15:00]

    One of the other nutritional factors that can be problematic are FODMAP fibers. FODMAP fibers -- Chris, I think you like to say anything that looks like an onion. Is that right?

Christopher:    You're right. That's right, yeah. That's a good way of putting it. 

Megan:    These are great fibers for nourishing the gut microbiota especially in people who already have really good gut health with no significant microbial overgrowths. However, FODMAPs can increase gas, bloating, and also cause diarrhea in some people. Gut pathologies like SIBO can often cause issues with FODMAP fibers. There's been at least one preliminary case study that has looked at a low FODMAP diet in athletes and found a reduction in GI symptoms, and we'll link to that review in the show notes. There are a few hypotheses as to why athletes in particular might be really susceptible to the negative reactions of FODMAP fibers. These include just being more susceptible to microbial overgrowth like SIBO, which again, like we talked about before, could be due to decreased transit time in the small intestine. Also just general dysbiosis, pathogens, even repetitive physical stress on the gut can also cause people to be more susceptible to some of these fibers as far as symptoms go. 

    As a quick aside, while some people definitely have an overt inflammatory reaction to gluten, if you are getting gas and bloating from eating wheat-derived products, you might want to look at FODMAPs. There is some speculation that non-celiac gluten sensitivity, maybe FODMAP sensitivity in some people just because wheat contains fructans, so certainly, gluten could be a problem. Also, if it is, you might explore FODMAPs in general. We talked about FODMAPs. Fat is another thing that can be problematic. Too much fat during or before exercise can also be an issue for some people because it slows digestion. Also, the wrong types of fat particularly if we're talking about the concentrated sources of saturated fat can worsen intestinal permeability and the endotoxin translocation across the gut wall. This typically depends on the gut health of the individual including the balance of microbes in their guts. Overgrowths of certain gram-negative bacteria can also make excessive fat intake particularly inflammatory for some people.

Christopher:    You just told me that you remove 80% of the blood supply. It's not surprising that shoving anything down the hatch is going to be problematic.

Megan:    Yeah, for sure, which again is why that fat adaptation can really be a useful tool. Okay. We already talked a little bit about the endotoxemia and ischemic injuries, but just to reiterate, we know that fat definitely can cause inflammation due to intestinal permeability and endotoxemia, but it's not just that. Exercise itself definitely causes endotoxemia due to the prolonged hypoxic state in the gut, which is a lack of oxygen, which is then followed by that blood reperfusion. LPS or lipopolysaccharide doesn't just locally affect inflammation in the gut, but in the bloodstream, when it gets in the bloodstream, it can also wreak systemic havoc on many of the tissues including the heart, which for an athlete or for anybody, we don't want cardiovascular inflammation. We don't want any kind of issues with the heart.

Christopher:    Yeah. To tie it back to the Malcolm Kendrick podcast, we decided that blood levels of cholesterol had no effect on cardiovascular disease. The question then becomes what does, and Malcolm made this analogy that I very much enjoy. It's like asking what scratched the paint on your car. It could be a lot of things. It could be a shopping trolley. It could be a stone chip. It could be somebody else with a car key. Well, this gut problem that we're talking about could be a potential source of the endothelial damage that ultimately leads to cardiovascular disease.

Megan:    We already mentioned that the amount of intestinal permeability, endotoxemia, gut distress in general do depend on the intensity and duration of exercise, and then exertion and heat also makes things worse. The exact mechanism by which heat exertion makes gut issues worse isn't really understood quite yet, but we do know that heat definitely further impairs gut permeability beyond what just exercise we do alone.

    Just a couple of thoughts here on nutrition and the immune system in athletes especially during this time of COVID-19 and everything, a large majority of the immune system resides in the gut and there is some controversy in the literature around whether intense exercise in athletes causes a downregulation, an impairment of the immune system. Well, it's probably true that an extraordinary amount of excessive exercise to the point where somebody is overreaching or overtraining will tank the immune system. In general, if we have two athletes, let's say, doing the same amount of volume and intensity, but one has very few outside stressors, have a really good diet, great gut health, and the other has a lot of outside stressors, so relationship, work, et cetera, a poor diet and a slew of GI symptoms then it's the former who will be able to tolerate the high volume and intensity work from an immune system standpoint and the latter might find himself or herself catching more colds and flus simply given the amount of outside stress and poor gut health.

Christopher:    Right.

Megan:    Okay. Should we talk about some symptoms that we see?

[0:20:03]

Christopher:    Yeah, absolutely.

Megan:    Okay. These aren't just in athletes, but oftentimes in athletes, we see gas. We see bloating. We see abnormal bowel movements. That can be on any end of the spectrum, constipation, diarrhea or a mixture of the two at different times. Abdominal pain is one. General fatigue, so during training, away from training, low libido, mood disturbances like anxiety and also problems sleeping. Anything else that you see, Chris, that I missed there?

Christopher:    I think maybe an inability to feel pleasure, almost like a depression, but I feel like it's something specific to feeling ill. You know how you feel when you've got the flu? You don't really feel like phoning a friend and going out that night, right? You just want to stay inside and stay away from people even if you can get out of bed. I feel like that's definitely something that I had going on and occasionally have going on from time to time now as well when I've got gut problems.

Megan:    I have seen that actually now that you point that out. That's definitely one.

Christopher:    Then not so much anxiety, which is something you've got written here, but of course, your mileage will vary. I'm sure there's tremendous individual variability.

Megan:    Yeah. For some people, it might cause that feeling of not being able to feel pleasurable things or for some people, it might be anxiety. For some people, it might be depression, but definitely just general mood disturbances, the ups and downs, not being at a steady state mood, I've definitely seen in relation to gut issues.

Christopher:    Neuroticism is another way of putting it. It's this instability.

Megan:    Nutrient deficiencies are often common in athletes with gastrointestinal symptoms. Ironically, a lot of the common nutrient deficiencies in athletes are nutrients that also help with athletic performance, and of course, gut health. A couple of those nutrients, zinc and magnesium are both lost in sweat. Zinc will come from mostly shellfish especially oysters, and then magnesium is going to come from mostly plant foods. Iron is a big one that we talk about a lot. I know, Chris, you've talked a lot about the negative effects of iron overload in the past on the podcast, but we can talk a little bit about iron overload versus deficiency in athletes and how that might pertain to gut health. 

    I don't want to go into too much detail, but to summarize, we see a lot of iron overload in our male endurance athletes who are conscious of nutrient density and regularly eating a lot of red meat, which is very high in bioavailable heme iron. We know that too much iron in the body can cause inflammation and oxidative stress. However, a recent study in rats which we'll link to called "Chronic Iron Overload Restrains the Benefits of Aerobic Exercise to the Vasculature", this study -- again, which we'll link to -- the researchers showed that rats who had iron overload, that iron overload may be directly detrimental to the benefits of exercise. They showed the usual cardiovascular benefits of exercise in these rats and then they iron overloaded rats and showed that those who aren't iron overloaded, the benefits were not observed. In particular, the vascular reactivity and antioxidant defenses that we usually see improved with aerobic exercise training, those did happen with the exercise. However, the iron overloaded rats who exercised did not see these improvements in vascular health, so just one more reason to donate blood if you're an athlete who knows that they tend to be more iron overloaded.

Christopher:    I've experienced both actually. I was iron deficient and I've been in a hospital and had iron infused into me. It cost me a lot of money. I remember the PPO insurance not really paying for it and it cost me thousands of dollars to infuse iron with an IV because the supplements weren't working. Eventually, I ended up with iron overload after I fixed my gut, so yeah, I've experienced both ends of the spectrum.

Megan:    Yeah, and it's important -- you don't have to be crazy with blood work, but really to monitor blood work a couple of times a year, I think, just to make sure that you're not swinging again from one end of the spectrum to the other. 

Christopher:    Right, and the same with zinc and magnesium. With magnesium, you can almost guarantee that you're deficient and you should be supplementing with it, but certainly with zinc, as you just mentioned, the conventional advice for athletes is to eat a bunch of the things that block the absorption of zinc and then you're not really eating a lot of the foods that contain zinc. The end result is a zinc deficiency, really common in athletes. We used to joke that we would just hose everyone down with zinc and magnesium as they walked in the door. We even made a white label to supplement and called it "The Missing Zinc" because it was just so common, so yeah, definitely. I don't usually take the supplement anyway, but certainly, measuring plasma zinc from time to time is, I think, a good idea.

Megan:    For sure. You mentioned that athletes tend to eat a lot of the things that block zinc absorption, so that's going to be largely phytates. It's funny because conventionally, higher carb-eating athletes may eat a lot of whole grains that are high in phytates. Legumes are high in phytates, and then when they switch to something like a Paleo diet, they're eating a ton of nuts that are high in phytates. You really have to be conscious of getting your zinc levels right.

Christopher:    Yeah. Almost everything works against you when it comes to those minerals.

[0:25:02]

Megan:    Yeah, for sure. One other study to highlight on iron, we'll talk about deficiency this time. I always appreciate when there's a new study that brings something to light that I previously thought maybe wasn't true. Previously, I was under the impression that it was mostly endurance exercises that cause an increase in this hormone called hepcidin, which regulates iron absorption, so higher hepcidin levels lead to lower iron absorption. We've known for a long time that hepcidin is increased with endurance exercise, especially running, which is why a lot of endurance athletes are at risk for iron deficiency anemia particularly women who are still cycling, and then also vegans and vegetarians, but some new research came out recently that showed resistance exercise actually caused a greater increase in hepcidin than endurance exercise, so strength athletes also need to be aware of an increased risk for iron deficiency. That study we'll link to in the show notes was called "Resistance exercise causes greater serum hepcidin elevation than endurance (cycling) exercise".

Christopher:    Was there any clue given as to how that all nets out? I read the abstract, but not the entire paper.

Megan:    No.

Christopher:    Because obviously, it's not got that if duration and intensity is important. Most people are not doing four-hour sessions in the gym lifting weights, right? So maybe your overall gut health is better than the average endurance athlete, and so even though you've got greater increase in hepcidin, your iron status is still superior to the average endurance athlete.

Megan:    Sure, yeah, it's possible that could be the end result. I think that a lot of the literature on hepcidin shows that. It would be interesting if they looked at running versus cycling on this because one of the theories is that hepcidin increases more when there is more pounding of the pavement and more stress to the bones and the musculature in general. Typically, we see a higher increase in hepcidin with running versus cycling. If you think about resistance exercise, you are adding a lot of weight to bones and the skeleton, so the reasoning behind that could potentially be due to just the amount of stress on the skeletal musculature.

Christopher:    But who are we kidding? We should just not inspect anything in particular and just do the blood test and find out for yourself exactly what your level is because I don't think anyone can really predict that with true accuracy.

Megan:    Yeah, absolutely. Ultimately, when it comes to nutrient deficiencies, I like to point people to a really nutrient-dense diet first, and then if deficiency symptoms persist or if test results continue to show signs of deficiency then I would at that point consider supplementation, or if they're not willing to eat something like --

Christopher:    Oysters?

Megan:    Yeah.

Christopher:    Liver. 

Megan:    Yeah. It's funny. Liver and oysters are the two --

Christopher:    Yeah, Top Trumps [0:27:44] [Phonetic].

Megan:    -- best sources of zinc and copper.

Christopher:    It's the T-Rex of Top Trumps.

Megan:    It's hard to get people to eat them.

Christopher:    Yeah.

Megan:    Okay. Let's talk about what to do. You know you have these symptoms of gastrointestinal distress either in general or around exercise. You know you might be a little bit nutrient-deficient, so what do we do from there? The first thing I would always recommend, and again, going back to Josh's Four Quadrant Model, starting with quadrants one and two and then branching out into testing in quadrants three and four when needed, so dietary tweaks and modifications. I always recommend more whole foods, so stopping the reliance on so many gels, drinks, and goos, also eating more colorful plants and more variety as well to support the gut microbiome.

    Some athletes really do end up doing really well on the autoimmune Paleo diet where they remove potential immune system triggers like eggs, nightshades, nuts and seeds from a Paleo diet. It may be especially important to avoid these foods that are potential immune system triggers around exercise if you tend to be sensitive. For example, eating eggs an hour before a hard training session may not be a great idea just given the fact that both eggs, if you are sensitive, and then exercise can cause intestinal permeability. The intestinal permeability from exercise could exacerbate the reaction to egg proteins. On the other hand, you may be able to eat something like eggs away from exercise just fine and not have symptoms, so timing of certain foods also becomes important. 

    Gluten and dairy at the very least, I would consider potentially removing them if you suspect you might have an issue and especially if you have gut symptoms, and then in general, just focusing on nutrient density, whole foods diet. Chris, I know you and Julie did a lot of work on your gut health initially. Anything that I missed? Any tips that you have that really worked well for you?

Christopher:    That was the main thing was I had huge improvement in my gas and bloating, diarrhea, depression, as I mentioned, low libido, insomnia. You name it, I've pretty much had it apart from constipation. I've never had constipation, which is nice.

[0:29:54]

    The transition from a high gluten, high dairy diet to a more Paleo-type diet of the type that I read about in Loren Cordain's "The Paleo Diet for Athletes" was very helpful, but it really took Julie and her expertise to construct a better Paleo diet that consisted of something more than just eggs and nuts, so I just went out the frying pan and into the fire. Having somebody construct a proper diet, I think, was really, really helpful. Then all the other things you talked about too, getting off the gels, I think, was really, really important and it was a gradual process. I wasn't able to do it overnight. It was going from I can't do more than 45 minutes without taking a gel to now I can go an hour, now I can go an hour and 15 minutes, and the whole time, I'm replacing it with the UCAN. Eventually, you realize that -- sometimes what would happen is I forget to take the UCAN like I wouldn't really like it anyway because it tasted like chalk. I know they've probably improved the formula and they have flavors and all this kind of stuff now, but I stuck to the chalky stuff because I didn't really want to replace it entirely with the gels. Eventually, I found myself just forgetting to take it either during the ride or I just leave the house without it and then I'll go, "Oh, I guess I don't need that anymore." It was a very gradual process. It wasn't like I rip the Band Aid off quickly.

    Also, you mentioned the autoimmune Paleo diet for athletes and I think that is an important intervention. We've had great results with many, many clients with that now, but you do have to be careful, and this is true. I think anytime you restrict food choices that calories tend to spontaneously go down, which can be disastrous for athletes especially if you're the type of athlete that needs an additional 5000 calories on top of what you would normally need if you just sat on the couch, so be really careful of that. The solution is probably going to vary from individual, but you probably know more about that than I do, Megan.

Megan:    Yeah, absolutely. We'll talk a little bit more about low energy availability and just getting enough calories and a little bit here. In general, especially with autoimmune Paleo protocol, you really need to make sure that you do it for a period of time and then after that, you start adding foods back in. Some people get stuck in this AIP diet. They're afraid to go branch out, and oftentimes, there are only a couple of things. Maybe it's tomatoes and almonds that really wreck your diet whereas you can have eggs, and eggs are super nutrient-dense. Maybe you can even branch out of the Paleo sphere and have something like white rice, which can be really helpful for getting more carbohydrates in. Definitely do the elimination, but then don't forget the reintroduction.

Christopher:    It can be helpful for getting more arsenic in.

Megan:    Well, you have to choose rice from the right place.

Christopher:    What is the right place? Have you found a right place?

Megan:    Yeah. Lundberg rice tends to test their rice for arsenic. They're a California-based company.

Christopher:    Okay. That's good information.

Megan:    White rice, I believe, tends to be better as far as arsenic profile goes than something like brown rice, just the way that it's processed.

Christopher:    Okay. I'm glad I asked.

Megan:    Yeah. Okay. Chris, you mentioned a little bit about training fuel. I usually encourage the athletes I work with to transition away from the mentality that they can only use carbs for fuel during exercise. It often works well from a gut standpoint to fuel using all sources of energy versus just carbohydrates. That could look like something like UCAN, like you mentioned, Chris, or another carbohydrate source. I would determine fast versus slow burning depending on the athlete and the race, and then maybe some essential amino acids and even some MCT powder if tolerated. Some people might even consider adding an exogenous Ketone ester to that mix if they want to as well, so transitioning away from carbs, carbs-carbs to using all of the macronutrients to work for you.

Christopher:    There might be a mechanistic explanation for that, which is, those things use different transporters, so if you take all the available channels, you'll get more energy in. You can almost guarantee that whatever type of activity you're doing, you're going to be exceeding the amount of energy that you can get in, and so using every available channel is helpful.

Megan:    Absolutely. That is the same story for the glucose and fructose. You're using two different channels to get those in.

Christopher:    Right. My experience more recently with all these different types of things is they're all kind of fine actually compared to -- even when I know SIBO myself. I'm in a race or something and I've run out or something's happened. I lost a bottle of whatnot and you've got to take whatever they've got at the feed station. My experience of that has been actually fine. You expect a disaster and it's been fine. I think what you do every day is way more important than what you do in training for a race or in the race.

Megan:    Yeah, for sure. Some people, some athletes I work with end up not wanting to do the UCAN and amino acids and MCT powder concoction. They eat really well 99.8% of the time and then when they're racing, that's when they tap into some of the goos and the gels and that works for them and that's fine, but if you work on fat adaptation, you might not have to use as many of those goos and gels during the race. Chris, I would imagine, correct me if I'm wrong, but when you do -- you mentioned sometimes forgetting the UCAN and being totally fine. I'm sure you don't rely so much on exogenous fuel source now than you did before.

[0:35:11]

Christopher:    Absolutely, and part of that has been changing my sport to suit my gut. Recently, I've been doing a lot more cyclocross, and then also, the shorter distance mountain bike events where if it's less than two hours, I'm probably not going to need anything at all. I'm pretty sure less than two hours, I wouldn't take anything. Is it really going to make that much difference to you if you do two-hour mountain bike races or two-hour whatever type of event it is rather than a four or a five or a six-hour one? I think that can make a huge difference.

Megan:    Yeah, I'm certain it can, and I found the same with a lot of our athletes as well. Just to talk briefly about fat adaptation, it's beneficial because the ability to tap into your own body fat stores could ultimately decrease, like we just said, the need to take on more exogenous calories during training and racing.

Christopher:    You've got the fuel onboard already. You don't need to stuff it in while you're riding.

Megan:    Yeah. Even the leanest person can definitely tap into their body fat stores. They have way more body fat stores and they have glycogen stores to draw upon for fuel. A lot of people are talking about the Ketogenic diet these days. We've talked about it multiple times on the podcast. It can be appropriate for athletes in some contexts. Low carb or Ketogenic diets are going to be better for endurance athletes although the literature on Ketogenic diets for strength and power athletes doesn't really suggest much, if any, of a decrease in performance given sufficient adaptation. That said, a lot of athletes, strength and power in particular, but also endurance, do feel better with a little bit more carbohydrates. That doesn't mean you have to have 600 g of carbs a day, but that means you can oftentimes get away with 100 g to 200 g of good, high quality carbs. It's also worth noting that many Ketogenic and low carb athletes can get away with a reasonable amount of carbs, so let's say 100 g to 150 g and still be in a "fat burning state" just because of the amount of volume that they put in.

Christopher:    Right, and there are some really good studies on this now, I think. Well, not studies, but data, I should say. In fact, Ryan Baxter, who's been great on the forum recently, linked one study that shows some tremendous amount of carbohydrates that ultra runners would take and still be in Ketosis, so it's very much a relative term.

Megan:    Absolutely, and then that just comes back to, well, there are different ways to get into Ketosis. Something else that can be helpful is fasting. It's not always appropriate, but sometimes it is. Fasting itself, just stepping away from exercise for a second, can be really beneficial for the gut. Training in a fasted or glycogen-depleted state can also help with mitochondrial adaptations to exercise as well as help train the body to more able to tap into its own fat stores.

Christopher:    I forget who is the original person that introduced me to this. It's one of the guys the coaches from Team Sky who was talking about this forever ago. Maybe I'll find the name and I'll put it in the show notes. If you're looking to push the fat adaptation process, say you're where I was in 2008 and you're on one gel every 45 minutes and you want to get to the point where you can do a five-hour ride without anything then the fastest state workouts are the fastest way to fast track that process, if that makes sense.

Megan:    Yeah, absolutely. You can do fancy things like doing more of -- it's called sleep low, train low where you do a glycogen-depleted exercise or training session in the evening then you have a low carb dinner. You sleep on that low carb dinner and then in the morning, you go out and do a fasted, more low intensity style exercise session. That helps with mitochondrial adaptations and training your body to be more fat adapted as well. Obviously, those fasted exercise sessions absolutely have a time in place, but you don't always want to train fasted because you will probably -- some people perform a little bit better when they have some fuel onboard from a previous meal, so use it when appropriate, but it's not always the right tool in the toolbox.

    Food timing, really quick, I usually recommend avoiding eating any kind of large meal two to three hours before a hard training session, and then also trying to wait at least a half hour to 45 minutes after exercise to eat just to let the dust settle before adding food into a gut that hasn't seen a lot of blood due to it being diverted to the working tissues. Most people typically aren't super hungry right after they work out unless of course they have this carbohydrate-burning metabolism.

Christopher:    You clearly haven't been to a bike race and seen the line at the burrito truck.

Megan:    All the carb-burning athletes are lining up, but I'm sure you weren't, Chris. 

Christopher:    Quite often, I find that the guy that won the race has already finished his first burrito and he's on his second beer by the time I get on the finish line. He's doing something right. 

Megan:    That's funny. Okay. Fiber is another thing that you can think about, the type and the timing of fiber. You don't want to have a huge bolus of fiber right before you go work out or you go train.

[0:40:05]

    Also, if fiber is a problem, we'll talk a little bit more about the types of fiber in a little bit, but digging deeper into what's causing the GI distress. If fiber is a problem, that can be a red flag for something like dysbiosis. Probiotics can potentially be helpful. Also, some supplements in the literature have some decent evidence behind their efficacy for exercise-induced gastrointestinal symptoms. Those would include zinc carnosine, glutamine, colostrum, or you can use something like SBI, Serum-derived Bovine Immunoglobulin, if you are sensitive to dairy and you don't want to do colostrum.

Christopher:    Okay. I think I'm sensitive to both. I've tried that supplement so many times because everybody's talking about it, and like 700,000 other things, it just gives me diarrhea.

Megan:    Interesting. Well, I've never tried it myself, but I've had some decent results with it with clients.

Christopher:    Right.

Megan:    Testing, I want to talk a little bit about testing. If all else fails and you've tried everything that we just talked about from a quadrant one and two standpoint, I would think about doing something like a simple blood chemistry, a stool test, maybe an organic acid test, look at yeast and bacterial overgrowth, and maybe even SIBO. There are some issues with SIBO breath test, and all of these little tests aren't necessarily perfect, but digging deeper into tests of what could be going on under the hood can be beneficial again if you've tried all those basic diet and lifestyle things.

    Chris, let me ask you. I know you've worked a lot on your gut as far as doing tests and protocols. As far as testing the protocols versus the diet and lifestyle stuff -- and I don't want this to be a leading question -- what was the most beneficial or impactful?

Christopher:    It's not necessarily an either/or, is it really? There's no dichotomy here. You can do both, but yeah, no question, you don't need to do a ton of testing to figure. I really like this carpenter and the gardener analogy because the gut really is like a garden. You do need to keep the weeds out. There are certain things that when they're there, they're very, very bad and they'll outweigh all of the other good things. If you're currently walking around with an Entamoeba histolytica infection, you're not going to be able to lifestyle your way out of that. You've got to get rid of it, and not even the herbals are going to do anything for that. That's a particularly rare one we don't see very much, but it does exist.

    Certainly, I think the testing has really helped me, the stool testing, the organic acid testing. I've never done a SIBO breath test and I don't think anyone should actually. After the conversations I've had with Lucy Mailing, I just don't think it's meaningful data and you probably shouldn't bother. Even the people that were heavily promoting it are now saying that they're not doing serial testing, and the reason they don't do serial testing is because the test is spurious. It's not repeatable. So when you do serial testing, it's confusing because it just tells you something that you weren't expecting that doesn't accurately portray your life experience and that's not helpful.

Megan:    Yeah, for sure. I think you can get a lot of good data without testing just based off of history and symptoms.

Christopher:    Yeah, absolutely.

Megan:    I briefly want to go over blood chemistry just because blood chemistry can give you -- it's not very expensive and it can give you a ton of good information if you know what you're looking at not just for the gut, but for health in general. We'll talk about a few of these markers and when they're out of range, what it could mean for the gut of an athlete, but I would caution people and tell them to keep in mind that there are plenty of other reasons that these markers can be out of range. If you see a combination of symptoms and when these markers are elevated or decreased then you might start thinking about working on gut health. 

    Bicarbonate or CO2 on a blood chemistry, that could be decreased with dehydration, and that dehydration could be lack of appropriate fluid intake or sweat loss or just due to something like diarrhea, which of course would clue you into gut issues, but you could also look at symptoms as well. Chloride can be elevated with dehydration and diarrhea. Albumin can be high with dehydration and it can also be decreased with infection or inflammation. Triglycerides, I often see them low with either just people not eating enough calories, low energy availability, or low due to malabsorption. If they are eating enough supposedly and they still look low, it could just be due to malabsorption of calories and nutrients.

    White blood cells are typically decreased with a chronically suppressed immune system which could be due to something like a chronic gut infection, protein malnutrition or nutrient deficiencies like copper. If you do suspect copper, if somebody is not eating a lot of liver then I would check neutrophils as well. Those tend to be low with low copper status. MCV, which is mean corpuscular volume, also tends to be higher in athletes. The jury is out as to whether that's actually pathological or not. I would really like to see some more literature on that because I have a ton of athletes, including myself actually, that we do everything. We eat a ton of B12, a ton of folate, which are typically the nutrients where deficiencies cause MCV to be higher. Nutritionally, they look fine, but their MCV still is at a high range, so there may be something pathological to that or potentially not with athletes. 

[0:45:04]

Christopher:    If you shifted it -- so this is optimal reference range meaning you can predict health outcomes using this reference range, and I agree with you. We see it almost at the top end of that range, or if not, elevated. Mine is the same, but I have been able to shift it in the right direction, and with that came improved hemoglobin levels and I think sports performance too. Are you not seeing that with other athletes? Okay, you can't get into that optimal range, but you can shift it in the right direction.

Megan:    Maybe at first. It's a very small shift if they are not eating enough B12 or folate, but typically, it's a very small shift, if anything. I don't often see it actually coincide with increases in hemoglobin and hematocrit, but I'm not surprised that that happened to you.

Christopher:    Yeah, it's one of these things. Everything you've heard Megan talk about is just a hypothesis, right? You really have to go out there and explore that for yourself. Sometimes it would seem like you found the thing and you do the corrective thing and nothing happens. Well, probably it wasn't that thing, right? You just have to give up and move on.

Megan:    Yeah, for sure. HDL cholesterol is another one that's not uncommon to see high levels in low carb endurance athletes or just endurance athletes in general. It may be non-pathological especially if there are no symptoms or signs of inflammation or gut infection, but if there are abnormally high levels, so abnormally high would probably be greater than 100 mg/dL in females and greater than 85 mg/dL in males then I usually like to rule out something like infection or inflammation.

    We talked about iron a little bit, so looking at an iron panel, which would include a combination of serum iron, ferritin, TBIC and transferrin saturation. Those could all give you a really good indication of iron status along with red blood cells, hemoglobin, and hematocrit. I would also consider looking at sex hormones, maybe a full thyroid panel if this person is having thyroid symptoms. There's definitely a gut-thyroid connection and gut-sex hormone connection, looking at hs-CRP for inflammation, looking at homocysteine, and then also nutrients like copper and zinc. All of these that I just mentioned can provide a better picture into malabsorption and malnutrition due to something like higher needs in athletes due to nutrient deficiencies because they're just not eating enough or enough of the right types of foods, or inflammation or infection, which could cause malabsorption and thus poor nutrient status.

    As far as other testing is concerned, digging deeper into the gut microbiome, so looking at dysbiosis, which are the imbalance of beneficial and pathogenic bacteria in the gut. Pathogens can also play a role in gastrointestinal symptoms especially in athletes who travel overseas a lot. Overgrowths like yeast and bacteria can also cause symptoms as well. Also, before I choose which test to run, if we need to go that route, I always try to look at is this more of a small intestine thing or a large intestine thing, and I tease that out. I like to look at if they're having bloating, where is it located. Is it above or below the bellybutton? Also, what other symptoms are present? That can clue me in sometimes too whether I want to run a stool test or an organic acid test or maybe just do an empirical protocol without testing.

Christopher:    How are you getting on with the Onegevity test?

Megan:    It seems okay. It takes a long time to come back and that's been an issue for a lot of people. They just don't want to wait especially if they're having bad gut symptoms, but otherwise, I think it's pretty good.

Christopher:    Okay. Good.

Megan:    Yeah. I'd like to see it more in comparison with the GI-MAP just to see -- they look at a lot of the same thing, so I would like to see --

Christopher:    Side by side, yeah.

Megan:    -- side by side how that looks, but so far, so good with the Onegevity. Then as far as treatment, if you do find some kind of gut pathology, I would look at herbal antimicrobials. I would look at using a short-term, low FODMAP diet, sometimes even maybe a carnivore diet if you need to completely remove fiber. Pro and prebiotics can be helpful. Probiotics, you're often shooting in the dark, which often isn't helpful. I would try to be as targeted as possible, if you can. I know you talked to Jason Hawrelak about this on the podcast and he has a great probiotic advisor resource that you can use for that.

Christopher:    Yeah, that database is great.

Megan:    Nutrient density, always taking a food first approach and then supplementing if needed, and then also balancing life stressors. This is often overlooked especially with athletes who are trying to be a CEO and trying to be a mother or a father and trying to be an Ironman triathlete, but we often feel stress in our guts and stress often manifests in gut symptoms. If we think about public speaking or gut symptoms just before a big race, definitely looking at the stressors in your life and trying to balance those and change your perception of how they're affecting you can be helpful as well.

Christopher:    Simon did a really good podcast on this and it's better than anything else I've heard about. Most people are taking one specific coping strategy and using that and only that whereas what Simon gave us in the "How to Manage Stress" episode was a framework, and within the framework, there were two categories of coping strategies.

[0:50:07]

    What Simon nearly always finds when working with clients is there's a gross imbalance between the two classes. Most people are heavily dependent on either a task-based strategy that is like something that cuts off the stress at its source or something that's more emotional-based that addresses the stress at its target. The important thing to remember is that they're two-strengths ninja. They have both. They have both classes of tools in their toolbox and that's what we're not seeing with the athletes that we work with or anyone else for that matter. Listen to that episode with Simon because it's super good.

Megan:    Yeah, absolutely. That was a great one. I think he calls it a stress audit. Is that right?

Christopher:    Yeah, that's right. It's because of the stress audit, yeah, exactly. That's where you start, is the stress audit.

Megan:    Okay. I want to briefly just talk about some troubleshooting that I talk about a lot with our clients. The first thing is fat causing intestinal permeability, so if you're trying to do a higher fat diet to promote fat adaptation whether that's low carb or Keto, there are different ways to construct a Ketogenic diet. The first way would be the butter, bacon, and fat bombs way. Fat bombs, I've never made one or had one, but I think they're typically made with cream cheese or coconut products and some kind of low carb sweetener, lots of calories, lots of fat, but not super nutrient-dense. The second way would be a wide variety of low carb, non-starchy, colorful plants and some quality animal protein, beef, chicken, lamb, pork, eggs, seafood. The latter will definitely foster a good microbiome as well as provide the nutrients necessary for optimal training and performance and recovery whereas the former can absolutely cause gut issues increases and endotoxemia, stuff like that. 

Christopher:    Do you think it's the fat per se that increases endotoxemia or do you think the leaky gut comes first? I think Lucy Mailing has again been pretty good on this and she wrote a whole article about it. "About Keto" specifically, I think, is the name of the title. We can link to that again in the show notes. I thought that was some really great insight that perhaps the leaky gut preceded the endotoxemia, not the saturated fat causing it.

Megan:    Yeah, absolutely. I don't think saturated fat is inherently a problem. I think it's typically if there is intestinal permeability at play, absolutely. 

Christopher:    Right, which probably everybody has. It's like what Malcolm Kendrick said about the endothelium. It's almost a moot point because everybody's got shitty endothelial function.

Megan:    Yeah. Then something else to look out with higher fat or Ketogenic diets while you're trying to promote gut health is looking at polyphenols, so the compounds that give plants their really rich, vibrant colors, as well as pro and prebiotics. Those have been shown to be effective at fostering the growth of beneficial bacteria as well as decreasing endotoxins. You can also look at timing your fat intake, so large boluses of fat especially saturated fat right before a hard training session might not be a good thing. Something like bulletproof coffee with a lot of MCT oil and butter on an empty stomach in the morning right before you go out for a ride or a run, typically not something that I recommend.

Christopher:    I'm laughing because I love that stuff. I still keep drinking it even when it gives me diarrhea. It's so good.

Megan:    I've never had it. I'm afraid of what it would do to my gut.

Christopher:    Oh, right. Yeah, I know. It's pretty addictive. I can see why people drink it. It's good.

Megan:    Yeah. Fat also slows down digestion, so you don't want to be still digesting that salad and burping up sardines two hours later on a run. I typically recommend people to not go crazy with fat in the meal before they train unless they feel okay doing so. MCT oil, it can be helpful in that it's easily converted to ketones. It's a source of calories. It can cause loose stools, so definitely increasing your intake is advised. It is a type of saturated fat although the jury's out as to whether MCT oils promote endotoxemia. Probably not. Even though they are a concentrated source of saturated fat, they seem to be the least problematic of the saturated fat sources when it comes to endotoxemia in the literature.

    There is a time and a place for a lower fat diet. Sometimes too much fat can cause digestive issues. It can also lead to some inflammation if you do have certain gram-negative bacteria in your gut that are present in large numbers. If a person just reports that they simply feel better gut-wise without a lot of added fat then those are signs that maybe some work needs to be done on the gut front. Like you said, Chris, looking at intestinal permeability, looking at pathogens, looking at dysbiosis to really figure out why that fat isn't serving that person in a healthy way.

    Getting enough calories from food, we kind of alluded to this before with AIP diet, but I see a ton of this low energy availability status in our athletes. It's a common occurrence that's written about in the literature. I would just look up "Relative Energy Deficiency in Sports" or RED-S in PubMed. Nicky Keay was on the podcast awhile back talking about RED-S with Tommy, so I would recommend people listen to that episode as well.

[0:55:08]

    There are a couple of really good studies that we'll link to in the show notes that look at the detrimental effects of within-day energy deficiency on hormonal and metabolic status in athletes and these studies basically compare the same amount of athletes across the day, but they're timed differently. This idea of within-day energy deficiency could look like not eating enough around exercise or backloading all of your calories regardless of the overall intake of calories over 24 hours. Those studies are called "Within-day Energy Deficiency and Metabolic Perturbation in Male Endurance Athletes" and then "Within-Day Energy Deficiency and Reproductive Function in Female Endurance Athletes".

    Another common problem I see with respect to this is just getting enough calories around exercise while keeping gastrointestinal symptoms at bay. Also in general, with a normal amount of exercise, energy intake and hunger is typically increased in proportion to the amount of extra energy expended during exercise. This is one of the reasons why exercise alone typically isn't a really good plan for weight loss without also a dietary component. However, as a quick side note, it is typically a crucial factor for keeping weight off after it has been lost. Returning to athletes, it seems that with increased exercise frequency and duration, the amount of extra calories consumed may not make up for that which is lost during exercise. A recent study came out of the UK that showed that daily running for a week cause an energy intake compensation of only about 60% of exercise-induced energy expenditure, so this suggests that negative energy availability would probably occur with time in people doing a lot of exercise unless they're really consciously trying to keep calories up. That can be hard in a whole foods diet. We see this all the time in the athletes we work with on NBT, but it's always nice to have a study that shows that there's some truth to some clinical experience.

Christopher:    It makes sense from an ancestral health perspective as well. If you look at even modern hunter-gatherers like the Hadza, they're not running a two-hour marathon every day. Sure, they may run for two hours on any particular day, but after they've done that, they're going to sit around under a tree for a week. This is not the same thing. It makes sense when you look at the physiology. It's really just not well designed to cope with that continual daily stress, but of course, that is what us athletes like to do. I'm still doing it now out on my bike most days.

Megan:    Yeah. There's just the need for more calories, and also, excessive time-restricted eating. Excessive time-restricted eating is really popular right now. Widening the eating window just by a few hours can help. Most athletes can't afford -- at least the athletes that I've worked with -- to eat in a 16-8 or 18-6 window and also get enough food for fueling and recovery to keep themselves out of that low energy availability state, so switching that, let's say, 18-6 window to a 14-10 can sometimes make or break the threshold of energy availability for an athlete.

Christopher:    14-10? You better explain these numbers. I'm trying to work this out in my head as you said it. Can you explain?

Megan:    Yeah, so 16-8 would be 16 hours fasting, 8-hour eating window.

Christopher:    I was thinking about the time of day, which was not the right thing to do.

Megan:    Yeah. 14-10 will be 14 hours fasting, 10 hours of eating. Sometimes getting enough fuel for performance and recovery in a condensed eating window, if you do decide that you want to do a 16-8, let's say, might mean that you need to eat foods that are higher in calories, maybe a little bit more processed and less nutrient-dense, something like white rice comes to mind, arsenic-free white rice, of course, but if an athlete really wants to push the volume, push the performance and also condense that eating window, often eating becomes a second job and you just need to eat as much as you can in that condensed window or consider just widening it by a couple hours. It doesn't mean that you need to be eating 14 hours of the day. You can still fast for 14 hours and eat in a 10-hour window, but just a couple of hours can really help people get in a couple hundred more calories.

Christopher:    Right. I think the timing is important as well in terms of eating breakfast like a king. I think it's really important too. It really messes with my sleep if I end up eating too many calories later on in the day, but again, it's hard because you go out for your ride or whatever in the afternoon, or at least I do, and then you're super hungry after that, so it's really common to want all your calories at that time of the day. Yeah, you just have to force yourself to eat a bigger breakfast if you're going to go out.

Megan:    Yeah, for sure. Those studies that I linked to about the within-day energy availability, they did show that eating around exercise is really important, but also eating throughout the day versus totally backloading all of your calories and having them at dinner like most people do in the United States is also really important. I absolutely encourage our athletes to frontload their calories versus backload their calories.

[1:00:11]

    I want to briefly talk about fiber. The timing of fiber is important for keeping GI symptoms at bay, so avoiding large fibrous meals two to three hours before exercise. I typically, like I mentioned before, recommend avoiding eating altogether two to three hours before training especially if it's intense. The type of fiber is also really important. We talked about FODMAPs before. While they're great for fostering the growth of beneficial bacteria, they can also feed overgrowths of bacteria and cause significant GI distress, so I would definitely eat them although probably not around exercise if you can. If you do get symptoms when you eat FODMAP fibers then it's time to dig a little bit deeper into what might be going on under the hood. 

    One other thing that I find in our athletes is an imbalance of soluble and insoluble fiber. It's a little bit funny because a lot of conventional, higher carb-eating athletes, they have a lot of soluble fiber in their diets, but not a lot of insoluble fiber. Then when somebody switches to either being a low carb athlete or even eating a Paleo diet, they often find themselves eating a ton of insoluble fiber. Insoluble fiber is plant roughage like in above ground vegetables and not a ton of the soluble fiber. Most plants do contain a small amount of each type of fiber although they usually have predominantly one kind. The soluble fiber will be found in whole grains and starchy roots and tubers. If you think about cooking a bowl of oatmeal and leaving some of it in the pot and it gets kind of sticky and gooey and it's a pain to clean, that's the soluble fiber. A lot of people I've worked with who have loose stools, for them, adding in more soluble fiber can be really helpful because it slows transit time. It also almost acts like a sponge which absorbs water and helps to form stools. Too much insoluble fiber, on the other hand -- remember that's the roughage from plants -- can often worsen loose stools in athletes or people in general. The moral of the story here is just to get a variety of fibers in your diet. If you're having either diarrhea or constipation, just look at the balance of the fibers that you're consuming.

    Last thing I just wanted to touch on briefly is this idea of orthorexia. We do see some people come to us and they don't want to eat carbs because they heard that carbs cause insulin and insulin is the bane of everyone's existence.

Christopher:    As well as fat. 

Megan:    Yeah. They don't want to eat fat because they have this phobia fat from years and years ago during the low fat era. They don't want to eat protein because they hear that it stimulates mTOR. They're afraid of eating too many calories because they don't want to put on weight. They're afraid of plant compounds like oxalates and lectins because they listen to everybody in the carnivore community now. What's left is ice and you can't really survive on ice, right? Sometimes this fear of different foods is a cultural fear that's coming from the media and diet zealots. Other times, it's actually a fear that's stemming from how they feel when they eat certain foods just in general or around exercise. Then it's me and the client talking about do we need to schedule a talk with Simon? Do we need to dig more into the psychology of this and/or do we need to run a stool test and see what might be going on?

Christopher:    Again, it's a dichotomy. Can you do both?

Megan:    Yeah, for sure, and often both works. I always encourage people to talk to Simon just because he has a ton of really good insight. In general, if we're talking about carbs, avoiding carbs is probably not good for performance or gut health. Like I mentioned before, carbohydrates are definitely ergogenic and while there is a time and a place for eating low carb, most athletes don't need to be very low carb forever or even at all. Low carb and Keto athletes or Keto-adapted athletes can often benefit from an increased amount of healthy whole food carbohydrates in their diet from both the performance longevity and health standpoint.

Christopher:    Yeah. This term, orthorexia, I don't know what to make of it.

Megan:    It's a little bit controversial for sure.

Christopher:    It is controversial. I suppose you need to know who you're talking to before you get into this. If you're talking to an athlete that's already eating a Paleo-type diet and doing all of the quadrant one and quadrant two stuff then yeah, maybe there's a conversation to be had there, but the moment you wander outside of that very tiny niche, I think most people need to be a lot more orthorexic. The definition I heard on a podcast recently was an obsession with eating clean and healthy foods. I think you do need to be obsessed with eating clean and healthy foods. Walk into Safeway and see how many of the foods are fit for human consumption in there. It's not that much.

[1:04:56]

    I can cite a study in the show notes that suggested that with objective measures from the NHANES data, so none of this food recall nonsense, but objective things like blood levels of fasting glucose and triglycerides and waist circumference, only 12% of Americans have good metabolic health, which makes sense when you look at what's available in the supermarket at Safeway. There's something pretty bad going on here and perhaps we do need to be obsessing over clean and healthy foods.

Megan:    Yeah, absolutely. That is quite the statistic. I think that definitely orthorexia is probably not an issue in the general population, but I've seen it more than a handful of times in health-conscious athletes or more health-conscious people in general, and that might look like -- going back to the white rice thing, maybe they really are struggling with adding more carbohydrates in their diet. They're eating more of a Paleo type diet and it's really hard to get enough carbs from root vegetables and potatoes if you're expending a ton of calories. They're so afraid of white rice because it's "nutrient devoid" that they won't add it in. It can be a problem, but I agree that in the general population, it's definitely not something that most people need to be concerned about.

Christopher:    It's a problem with podcasts in general, right? You never know who you're talking to. I frequently hear experts mixing up a message that's suitable for insulin-resistant, type two diabetics, and then in the next breath, they're talking about athletes and it's not that clear that they've made that shift. Here for sure, we're talking specifically to people who are proficient in moving their body regardless of the sport.

Megan:    Yeah, absolutely. Anything else, Chris, that you think we missed that you want to touch on? I would definitely encourage people, if you're having issues with gut health, come to the forum. If you want to ask questions in office hours, I'm happy to dig into more personalized questions, but anything else that we missed, Chris?

Christopher:    No. I was just going to say exactly the same thing. That's what people should do next, is come support us on Patreon and then join us on the forum. If you want to speak to Megan in person, you can do that if you show up on her Zoom at a specific time. I'll also link this really lovely outline for this interview that you've put together, Megan, together with all the scientific references so people can use that as a checklist of sorts, or maybe a framework is perhaps a better way of putting it. This is a really valuable resource, and so I'll link that from the forum as well. If people are having problems then perhaps they could discuss it over on that thread too. 

Megan:    Yeah, that sounds great.

Christopher:    Excellent! Well, thank you so much for your time, Megan. I really appreciate you. Thank you.

Megan:    You're welcome. Take care, Chris.

Christopher:    Cheers!

[1:07:30]    End of Audio

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