Can Continuous Glucose Monitoring Support Your Health Goals?

Episode Intro:

Welcome to Dr. Ruscio Radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now, let’s head to the show.

DrMichaelRuscio:

Hey, everyone. Today I speak with Kara Collier. She is the co-founder of NutriSense, which is a continuous glucose monitoring company. This is something I’ve experimented with myself. I’ve experienced some insights and some points of confusion, which seem to be fairly common points of confusion. So, I was happy today to be able to connect with her and kind of unpack what this new device is – the CGM (Continuous Glucose Monitor). How can it help people? And perhaps equally as importantly, what are some of the pitfalls to be wary of? Just as two quick examples – exercise and sauna can spike your blood sugar. Is that a problem? Is that good? Is that bad? We also take on a few other questions during this episode. We have all this data – continuous 24/7 glucose monitoring and that’s a lot of information. What should you be looking at? What are the guidelines for interpretation of all that extremely important data?

DrMR:

I can say that for myself – using this as a consumer – I was quite confused by some of the information. Thankfully, I have quite a bit of background in health and data management, so I was able to navigate this fairly effectively. However, for someone who doesn’t, but is enthusiastic, this is where that enthusiasm (if not properly channeled) can be deleterious. So, I was really appreciative of the conversation and also of her approach. It seemed to be very level headed in terms of using data and (very importantly) context in addition to just data to interpret. With that, we’ll go to the conversation here with Kara. Just as a reminder, if you have not left us a review yet, it’s really so valuable and helpful. This allows us to continue to reach new people and be a bigger show so we can have larger guests on the program to share their thoughts with you. With that, we will go to the show.

DrMR:

Hey, everyone. Welcome back to another episode of Dr. Ruscio Radio. This is Dr. Ruscio today here with Kara Collier. We are going to be talking about NutriSense and how we can use continuous glucose monitoring to try to clarify what we should eat, what we shouldn’t eat and get a better sense of what we should be putting in our bodies. Kara – I’m really excited to pick your brain. Like I was saying off air, I’ve done some tracking – some things were insightful, some were confusing. So, I’m looking forward to getting a better understanding today during our discussion.

KaraCollier:

Yeah, absolutely. I’m excited to be here.

DrMR:

Tell us a little bit about your background before we jump in and get into all the nitty-gritty.

The Start of NutriSense

KC:

Sure. I’m a registered dietician by trade and I started my career in the traditional nutrition world. I was working in hospitals – primarily ICU – working with pretty sick individuals. Most people coming into the ICU were not what you might expect, like gunshot wounds or car trauma. What we were seeing over and over were complications of lifestyle related chronic conditions. Individuals needed urgent hemodialysis… an amputation due to uncontrolled diabetes… all kinds of complications that were very frustrating. I felt we could have helped these people if we would have intervened so much earlier. So, those experiences as a dietician really led me to thinking about how to solve this problem in a more realistic way. I got a little bit frustrated in the traditional system and felt I couldn’t make the difference that I was looking for.

KC:

Fast forward a couple years and I helped start the company NutriSense. We’re taking continuous glucose monitoring technology, and we’re pairing that with human expertise – registered dietician coaching – in order to help people understand their unique bio-individuality and their metabolic health; to hopefully catch people before we lead to those complications of those most common chronic diseases. Our goal is really to help anyone have access to this data that is really trying to be proactive and be an advocate for their health.

DrMR:

Yeah. It seems a lot of people have that same gripe with conventional medicine, as great as it is. It can’t do everything for all people and all scenarios. If you’re trying to get a little more upstream, you’re a part of a large growing cohort who are looking for something different to offer people. That obviously comes through diet, and so much can be prevented with the right diet. That’s easier said than done. There is a lot to unpack with what “eat healthy” means because for some people that’s a high vegetable paleo diet, and for other people that wrecks their gut and they need to pivot in more of a low FODMAP direction. Of course, there are all these nuances regarding higher carb/lower carb. There is some argumentation between keto and higher carb communities.

DrMR:

My perspective has always been that there’s evidence to support different positions for many things. It’s more about helping the individual determine where they fall – what data point would they fall in a keto study. Would they be one of the adverse event people? Or would they be one of the better energy/better anthropomorphic measures? That’s what I think CGM’s – continuous glucose monitoring – can help people to determine, but there are also some things that are confusing to me. I want to try to get this ledger sheet in our heads and figure out: What are the pros? What are the cons? How do we use this tool effectively? That is one of the things we have to be careful about with any measurement device. There are certain things it can tell you, and then there are some red herring dead ends that can pull you down. It’s about trying to understand how to use these tools to the most benefit for the user. Before we go into some of the more nuanced questions – If people haven’t heard of continuous glucose monitoring, give people the breakdown. I’m sure most people have heard of a fasting blood glucose test, but tell us a little more about the device and what it does for people.

The NutriSense Continuous Glucose Monitor

KC:

Sure. So, a continuous glucose monitor (CGM) is a small medical device that you can put on at home. There are a few different companies that make these. Most commonly, you’re going to either put it on the back of your arm or your abdomen. This is in contrast to what many people are probably familiar to – either a glucometer… or the finger stick meter you might have at home to prick your finger… or if you go to the doctor’s office/get labs, you might get a fasting glucose or a hemoglobin A1C. Those are snapshots in time that give you some insight into what’s happening in your glucose in that moment, whereas a continuous glucose monitor is continuously measuring glucose. It’s exactly what it sounds like – this device picks up glucose measurements every 5 to 15 minutes, and then you can scan the device with your phone and see a smooth curve of your glucose values.

KC:

Instead of having a snapshot of a random fasting glucose value here or there – or pricking your finger once or twice a day – we’re instead for the first time seeing this movie of glucose play out. The device itself is technically a medical device, so it does need a medical prescription in the United States. This is part of what we take care of. at NutriSense – taking care of that backend legwork to get this data. However, once you have it, you just put it on at home and it’s totally painless… really easy to insert… no pricking of the finger. It’s water resistant. You can shower and exercise and all of that with it on, and then it stays on for 14 days. So, it’s a little bit of a contrast to other wearable devices. It’s not like a Fitbit or an Apple Watch where you can take it on and off. It does stay on the back of the arm for the full 14 days.

KC:

During those two weeks, you get that full 24/7 graph of your glucose. As you’re mentioning, there are many different benefits to being able to see that movie versus a snapshot. One is we’re realizing this one-size-fits-all approach to nutrition and lifestyle advice in general is just not working. I think a lot of people are realizing that and feeling that frustration. There’s a lot of noise in the nutrition world. There is conflicting advice. There are the outliers in research studies, as you’re mentioning. Not everything is going to work the same exact way for every individual. What works for your sister might not work for you… what works for your neighbor might not work for you. Having that real time data can help cut through some of that noise and help identify how you are responding. People might experiment with keto versus a higher carbohydrate diet. We can get into all the different ways you can test different strategies in order to optimize your glucose values. One of the key insights is that we all respond differently. There really is that no one-size-fits-all. By having that movie version of the glucose data, we can pinpoint better what’s working for you versus what might not be working so well for you.

DrMR:

It’s certainly much easier than pricking your finger. For a while, I had one of those at home finger pricks that would do both glucose (and you could swap out the stick) and do ketones. That gets old really, really fast. I’m pretty motivated, and it’s not like it’s that painful, but it’s certainly not pleasant – getting poked and eliciting blood from your finger, especially if you’re trying to do it after every meal… and then 60 minutes and 120 minutes after every meal. You feel like a pin cushion really fast. That was definitely way more convenient, which is one of the reasons why I’m so excited about this.

NutriSense: Interpreting Glucose Value Data

DrMR:

So, what are the best time points to look at? This is something that confuses people – should I be standardizing for looking during the meal? 60 minutes? 90 minutes? 120 minutes? I think a lot of people are trying to know what windows to look at. If we zoom way out, there can be these obvious spikes or dips. However, are there high level guidelines that you recommend people use to take all that data and give them a few benchmarks to look within?

KC:

Yeah, absolutely. So, as you mentioned, you’re going to have this whole new movie of data. It comes with a lot of information, and sometimes too much data/too much information can be overwhelming or confusing. How we recommend customers to go through this process is to think about both what’s happening in a 24 hour day/a longer timeframe, and then also what’s happening in a meal. If we’re thinking about just looking at the daily values, we really want to pay attention to average glucose. It’s relatively simple. What is the average value from that 24 hour window? I think that helps ground people when they have maybe a small variability in their data or a small spike, but it comes back down quickly. We see that average glucose is really good – we want to aim for 105 or lower for that average glucose.

KC:

That helps people understand that maybe I had a little bit of a spike, but my average is still really good. So, that’s one thing we want to look at. The second thing we want to look at is what we use in our app’s standard deviation, and that’s a metric of glycemic variability (or those swings in your glucose.) Again, your glucose doesn’t have to be a complete flatline in order to be healthy. Some variability is completely normal. It’s physiologically normal for glucose to go up, especially if you have carbohydrates, but we want minor swings and we want it to recover. So, standard deviation in our app is what helps capture that amount of swinging. We’re looking for 14 or less, and then you can zoom in and look at per meal.

KC:

There are a couple different things you want to look at when you’re consuming a meal. One is – How high did your glucose go, at any point in time? That would be the peak glucose value – your maximum glucose value. For most intents and purposes, we want to stay below 140 most of the time, and this is particularly for non-diabetics. If you have diabetes and you have a glucose values that are consistently higher, we might aim for something around 180 and then work our way down to 140. For most people, that upper ceiling of 140 is what we’re aiming for. This is about repetition. I always remind people that if your glucose goes to 150 or 160, that doesn’t mean you have diabetes. That doesn’t mean your system is going to break and shatter.

KC:

It just means we should do some experimenting to maybe improve that glucose response. If it’s something you’re eating every day, we want to aim for something below 140. The second major thing we’re looking at is how quickly it returns to normal – or back down to what your glucose was before you started eating that meal. So, we’re really aiming to see glucose recover within two to three hours of eating. In our app, when you log a meal, it’s capturing that peak value, the recovery and also what we call ‘area under the curve.’ That’s just how much glucose exposure you had during that meal. Based on those metrics, it gives you a score of 1 to 10. This helps people break down all these different metrics and simplify it into one number; to be able to better compare meals to each other and understand if glucose went up, but it was still within normal limits. You can get a 10 and still have a glucose bump. It’s just about how high and how quickly it recovers. Those are really the main things we want to look for. Sometimes we also see what would be called ‘reactive hypoglycemia.’ Sometimes a person’s glucose goes up and then it dips down after they eat, and that’s usually associated with hypoglycemic symptoms – feeling dizzy, shaky, ‘hangry’… or maybe all of a sudden getting hungry again, even though you just ate. That’s another kind of nuance of a meal to look for. Usually, that means we might want to adjust what is in that meal to help prevent that dip.

DrMR:

Regarding what floor people should be staying above – Are you looking at 80 as being a good floor? Or what are you suggesting to keep your minimal at?

KC:

Typically, we recommend 70. As long as we’re between 70 and 140, that’s a pretty healthy range for most individuals. There are some people who are following a ketogenic diet or they’re doing a lot of fasting and their glucose will go in the 60’s and they don’t have any sort of hypoglycemic symptoms. What we know from the research of non-diabetics specifically, is that as long as there aren’t symptoms when you’re in the 60’s and you’re having other energy sources (so ketones are elevated) then it’s really nothing to be concerned about. We use 70 as a baseline threshold for the floor, and then we also just monitor for symptoms of the hypoglycemia.

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Management of Glucose Spikes

DrMR:

One of the questions I think you answered with the speed of return was a follow up I was going to pose – How do we assess if someone has not had a spike because they haven’t had a lot of refined carbohydrates with nothing else, but they’ve just eaten too much in general? How do we assess spikes versus total caloric intake? I’m assuming – but, I don’t want to assume too much – that you won’t see a return to normal within that 2-3 hour window if they’ve gone significantly over their caloric intake mark. Is that a fair posit?

KC:

That’s exactly right. When we see those really large meals – especially if it’s really high in both carbohydrates and fat (for example, creamy pastas, breaded and fried foods, sandwiches…), we’ll often not see a huge glucose spike (it’s blunted), but we will see a long return to normal. It’s taking a really long time for your body to process all that energy and regain back to homeostasis.

DrMR:

One of the other things I was wondering was regarding this post-workout spike that oftentimes is considered to be beneficial. There is some data showing a modest benefit from getting that post-workout spike with a protein source. As I was thinking about this, it seemed that as long as that excursion wasn’t prolonged (like you were saying before), that could be a beneficial response in some people. We certainly wouldn’t want to be doing that with someone who is already overweight, but with someone who had acceptable body composition and was trying to increase performance or muscle mass, that wouldn’t be a problem. Agree? Disagree? Would you modify?

KC:

There are two things to consider with exercise. One is what’s happening to your glucose while you’re exercising, regardless of what you’re eating. The other is that post-exercise meal that might spike it a little bit. One thing that might happen is you might actually have a glucose spike while you’re exercising, even if you haven’t eaten anything. We get this question a lot – “Is this a bad thing?” “Why is this happening?” You can think about glucose responses during exercise as a supply and demand type of equation. So, if you’re doing something really high intensity – sprints, interval training, heavy weightlifting – usually the energy demand from that exercise might be more than what’s currently in the blood circulation – the supply. Usually, your liver might flood with a quick burst of glucose and that leads to that glucose spike, but that’s fueling the exercise.

KC:

It’s a lot different than a glucose spike that might come from eating candy or drinking a soda, and then sitting on the couch. You’re flooding the system with energy, but you’re not really using it. That glucose spike during exercise is going towards fueling the workout. Any type of exercise – whether it’s more high-intensity or steady state (which usually results in steady glucose or a slight dip in glucose) are going to be beneficial for glucose regulation overall. It’s going to improve our insulin sensitivity, clear some of that glycogen storage space, make more room for glucose to come up, reduce adipose fat cell size and improve our mitochondria. We can go on and on about the benefits of exercise. So, that is not anything to be concerned about. A lot of people get worried that maybe they shouldn’t be doing intense exercise. Another strategy that people do – especially athletes or body builders – is they might have a big meal right afterwards. This spikes their glucose and stimulates an insulin response, which could help with building muscle and that anabolic response. There is not a lot of research on this. If your goal is putting on muscle or mass, or recovering quickly, that it probably won’t hurt – especially if it’s a glucose spike within normal levels. I don’t think if it’s below 140 that you’re adding too much inflammation or stress on the system, but it is a strategy that some people use in order to maximize that gain window, so to speak.

DrMR:

I’m glad you made the point about not being concerned about exercise spiking your blood sugar because that was one of the first things that I was like, “Oh. My goodness… look at this.” I’m also glad you clarified the supply and demand piece. We had another physician on who – to paraphrase and maybe I’m not recalling some of the nuance of his comment – essentially was saying if you exercise too hard, then you’re going to see a blood glucose spike. When I thought about that afterward, it didn’t really make much sense to me. Your response makes much more sense – if I’m doing zone 1 or 2 cardio (meaning my beats per minute isn’t going much above 150 or even 130, a low level steady state) as compared to doing deadlifts until I think I’m going to fall over, then doing pull-ups and then recovering for two minutes, just barely able to breathe normally again, and then going back to dead lifting… some of those workouts are just very intense – or playing a sport where you’re really pushing yourself to the max of your ability. It would seem that the glucose response would be vastly different for those. I have a hard time thinking that we should bridle people and say, “Well, if you went above 140, that’s too much for your system.” I only see that fueling this neuroticism regarding exercise, especially because of the excellent points you made of all these benefits that we know are associated with exercise. So, I’m really glad you made that point.

KC:

Yeah, absolutely. I don’t want that glucose spike to deter anyone from doing this type of workout, especially heavy strength training. The benefits of adding on lean body mass for overall glucose regulation and insulin sensitivity are enormous. We want to make sure we’re building our muscle and working out. Actually, a lot of this research indicates that some of that glucose spike that happens increases glucose uptake without the increase in insulin. So, a lot of this is non-insulin mediated glucose uptake. A lot of people get worried that if they’re fasting and they have a glucose spike when they’re working out, it’s breaking their fast because it’s stimulating insulin. It’s a rabbit hole that I wouldn’t recommend. It’s good, it’s healthy and I actually think it’s a very beautiful example of how impressive our bodies are. We don’t necessarily need food to provide the energy for that workout because we have all these systems in place to give the body what it needs. It’s much more beneficial for our system to overshoot glucose a little bit and make sure you have the fuel you need, than to undershoot it and go hypoglycemic during a workout. It’s totally physiologically normal and nothing to be concerned about.

DrMR:

Great point. For anyone who has had hypoglycemia, it’s not a great feeling. I think I’ve experienced it a couple of times from fasted exercise that was too intense + sauna + cold tank. I just had this sweating for no reason, and being deathly hungry and quite tired, which I didn’t document. I didn’t have any device on at the time, but I can only assume that was a legitimate bout of hypoglycemia where it felt like I was almost having an internal panic attack because I was sweating when I shouldn’t have been. This was way after the workout and everything else. I was so hungry – I felt like I could have eaten the calendar. You just generally feel jittery and unwell. I would like to never feel that way because it’s a pretty crappy feeling.

KC:

Absolutely. It’s an awful feeling. If you think about it, those symptoms are your body trying to tell you that you need to eat and you need energy. It’s signaling we feel awful – you need to do something. I think the body has done a pretty good job at that.

DrMR:

That’s the signal that definitely gets your attention. So, you’re not giving anyone that this is an acceptable peak. You’re just saying, “Don’t sweat it.” The amount of demand is going to be reflected by the amount of supply?

KC:

Yeah. With exercise, we usually start to look into it a little bit if we’re seeing those exercise spikes go above 180 or 200. I typically only see this with really elite athletes that are doing some pretty intense workouts, or training for CrossFit games. We often see this. Usually, we can fix this by making sure that you’re hydrated enough because dehydration can also lead to increased glucose response… or maybe fueling a little bit before the workout to have a little bit more energy in the system. That’s not that common to see it go that high.

DrMR:

Gotcha. What about caffeine? Is this something that you’re seeing an appreciable ability to cause a glucose spike?

KC:

Yeah. Caffeine is one of those really interesting things where it’s quite variable from person to person. For a lot of people, we see no response at all. For myself, when I drink coffee, my glucose doesn’t budge up or down. For some people, we see a little glucose spike – not usually something super dramatic, but a small increase in glucose. The research behind that is that it might be initiating a small stress response for some people, increasing cortisol and adrenaline, which can then stimulate the production and release of glucose. It varies person to person, and I’m sure there’s a component of genetics to that. We know some people are more sensitive to caffeine than others. I think it usually matches the symptoms. The people who tend to have caffeine and feel jittery, anxious and their heart is racing usually are the people that see that glucose increase.

DrMR:

That makes sense. Along those same lines – this is a bit nuanced and maybe an outlier question – but, does going in the sauna make the device go a little bit wacky for getting yourself up to 180 degrees… 200 degrees? Or is there a physiological response (like with exercise) in sauna that you’re seeing with any kind of regularity?

KC:

Yeah. So, with sauna, we almost always see a glucose spike and there’s probably a twofold explanation going on here. One is that we know glucose actually does increase during the sauna. There is research when they’re testing actual blood glucose values, so we know it’s not just the CGM. A lot of this is probably related to just the body’s blood flow redistributing. It usually redistributes from the core to the skin to facilitate sweating. You also get a little bit dehydrated if you’re sweating a lot, and all of this can lead to a temporary rise in glucose values. We also know that the CGM’s have a certain temperature range that they function best in. So, there’s an added factor where there tends to be a little bit of an additional artificial glucose spike that comes along with the sauna from the CGM interfering with temperatures it’s not optimally working for. With that being said, there’s also a lot of research linking sauna use to lowered fasting and average glucose values over time. So similar to exercise, intense exercise might give you a spike in the moment as your body’s under a little bit of stress, but it’s going to help improve that glucose regulation over time. Sauna is really working in similar mechanisms.

Glucose Responses: Food & Alcohol

DrMR:

Sure. I’m asking all the questions I’m personally interested in and hopefully our audience is also. A few of my reflections… There’s this great seafood restaurant here in Austin and I went out to dinner with a few friends. It was a “We’re going to eat whatever we want because pretty much everything this restaurant makes is phenomenal.” We had oysters, lobster rolls, French fries, tuna tartare, wine… just bring it all on. Paradoxically, my blood sugar looked great. The next day, I was fasting in the morning and saying, “Hey, I want to get a little something in my system.” So, I drank about four ounces of this red juice that had beets, carrots, orange. It was 4 ounces juiced. That’s going to be high glycemic because I had just that alone, but that launched me to 140-ish (maybe a touch higher), whereas that big dinner led to… I don’t think I got above 110. Now, I wasn’t really looking for the time to return so much. It could have been that dinner spiked me for a while, but man, that just seems like such a disparity. Is that 4 ounces of juice that detrimental? I’m assuming part of your response is going to be it depends on how quickly you return to normal after that, but I’m also assuming I’m not the only one who has noticed something like this. How do you account for that?

KC:

Yeah, certainly. So, you’re not the only one and this is where I think it’s important to recognize that the CGM can tell us a lot. It can tell us a lot about what’s happening with our glucose and our metabolic health, but it’s not the only metric that’s important for health. We remind our customers of this, and this is why we include the dietician support, too. We want to be able to answer some of these questions and make sure people aren’t walking away with misinformation. So, it tells you a lot about your glucose and that’s real data/real facts, but it’s not necessarily telling you what’s happening in your lipids afterwards or your inflammatory state. It’s not giving you every piece of information about your body. With that being said, we often see the highest glucose responses when you have carbohydrates on their own, especially if they’re easy to digest carbohydrates (like juice) on an empty stomach. The more empty your stomach is, the less things there are to blunt that glucose response.

KC:

This is why one of our top tips we give for mitigating these glucose spikes, is to always eat a little protein before your carbohydrate. Let’s say you do the juice every morning. Eating some scrambled eggs or some type of protein first, and then having the juice, can almost guarantee that’s going to blunt that glucose response. That’s what we see sometimes with these bigger meals. Often, you might be blunting some of the effects because you’re eating a lot of food. Those really high caloric meals usually don’t have the biggest spike, but tend to have quite a lingering effect as your body digests it and works through it for many hours to come.

KC:

Another thing that’s of interest to note – that may or may not have been a factor for you – is the impact of alcohol. Alcohol can have very interesting effects on our glucose. Of course, if we’re having a carbohydrate containing alcoholic beverage (like a heavy beer or a sugary cocktail), we’re probably going to see a glucose spike. With something that’s a bit more on the drier side (like a dry wine or liquor without the sugary mixer), we usually see either no immediate effect on glucose or it can actually have a glucose lowering effect in the moment. A lot of times, people will go out to eat and they’ll start the meal with wine or liquor. This interferes with the body’s normal glucose processes and homeostasis, so the body is essentially prioritizing breaking down that alcohol over all other things.

KC:

We usually see that dip in glucose while the body is working its way through the alcohol, but it’s very common to see both higher fasting glucose values the next day, and also higher glucose responses to meals the next day. Some people have different thresholds. Some people had just one glass and they see that effect, where some people it’s two or three – probably genetics… all types of things going on there. Really what the research is suggesting here – and we’ve seen this working with clients – is it’s most likely impairing those normal functions in the liver and it might be lingering to the next day (depending on how much you drank.) This is just another interesting factor to consider. It would be worth experimenting – trying the juice on a different day or trying it in different situations, as well.

DrMR:

Both of those points are interesting. You reminded me of the follow up conversation I had with Morgan – the health coach on our team. She sent me a paper that was essentially reporting that wine may have this glucose spike blunting effect, but you make an excellent point. It might be just kicking the can down the road metabolically, so to speak, and you don’t see it that day, but you maybe see these impaired or heightened spikes the next day. That’s a really interesting insight.

KC:

Absolutely. You nailed it in the explanation.

NutriSense CGM: Proper Data Interpretation

DrMR:

So, what do you feel would be the best way for people to use this device? I know that’s a broad question. Let me pepper in one or two examples of how – as I’m looking back here retrospectively – may not be the best way to use this. I’ve heard some people say, “Well, I learned that rice is bad for me, but ice cream is okay.” Maybe that rice was a quick up/quick down, but what may have been missed was the ice cream may have had not as much of a spike, but an elevation that was much more prolonged. Maybe this all comes out in the wash by looking at your average? Is it looking predominantly at average and the amount of variants? How do you recommend people look at this? Again, my concern is that people are looking at these little interesting snippets, like, “Oh, I’m not going to do sauna… I’m exercising too intensely… More rice is bad and ice cream is good.” Maybe they’re missing the bigger picture way to read this data more on a macro level.

KC:

That’s a great question. I always recommend first starting with eating your normal routine and seeing how your day to day habits are affecting your glucose. When you’re looking to see how it’s affecting and reading that data, I would look again at that 24 hour value. Again, we have a daily score – it’s 1 to 10, just like the meal score. See how your average glucose looks… how is the standard deviation… how are the swings in glucose overall, and then also look at that per meal. What is the score? That will take into account that maximum value, but also the recovery value, and put that into one score to help you keep track of the different moving variables here. With that being said, I think it’s important to recognize there are some golden rules of good, healthy habits that apply to everyone, and then there are variants within that.

KC:

I always say that there are four pillars of good glucose control, and they’re really like the legs of a chair. If you take any of those off, the chair is going to tip over. They are nutrition, exercise/physical activity, stress and sleep. I would pay attention to all four of those factors while you’re looking at this data and discovering different things. There are universal truths in all of those, right? Especially nutrition – we want to focus on whole foods as much as possible… nutrient density. If we’re just thinking about rice versus ice cream, that universal truth is going to say that rice is most likely better for most people than ice cream, but then both of them might not work for you. So, within the foundations of healthy living – not even just nutrition, but lifestyle in general – we want to see where is the variability from person to person.

KC:

Maybe I have a go to lunch I eat every day. I make a salad and I put in some sweet potatoes, vegetables and protein, and I have a pretty big glucose spike. I want to see those daily meals and how they respond. A glucose spike to that restaurant meal you were talking about… If you do it once a month with friends, you’re enjoying it and having social interaction, that’s not a big deal. Even if your glucose did go high in that moment, you probably wouldn’t have really cared. If it’s your everyday routine (the meal you eat the majority of the time for lunch) and you have a glucose spike/poor glucose response, that’s when we want to dig more and do some experimenting. So, I always recommend starting with just eating your regular routine, doing your regular habits and seeing how those respond. From there, then enter an experimentation phase for your favorite meals or your go to different meals you have on a regular basis and tweak anything that might be suboptimal. You can then fit in the things that work within those good, healthy frameworks, but work also for your body. Everyone really is unique at the end of the day.

KC:

I always give the example of the glycemic index, and that it isn’t really a great predictor of your unique response. In general, the glycemic index is a prediction of – on a population level – how high your glucose will go to an individual food. We know that bananas have a much higher glycemic index than berries or apples, but for me as an individual, and this is actually true, I’ve tried just about every fruit out there. I actually have my lowest glucose response to bananas. So, for whatever reason, my body tolerates bananas really well, and it’s not the same as somebody else. A lot of people do have higher glucose spikes to bananas, but for some reason I do fine with them. It’s just learning about how you as an individual respond and making sure the things that you’re eating on a regular basis fit into both those good foundational rules, but also are following what we would expect to be good, healthy glucose responses.

DrMR:

Is this like glycemic index versus glycemic load? Maybe a few steps further, but is that what this is a remnant of?

KC:

Yeah. In glycemic index and glycemic load, I think glycemic load is a little bit better because it at least takes into account a normal portion size you might eat of something. Both of those are done on a population level. Let’s say we sample 100 people. We gave them all 100 grams of bananas and we average that glucose response, but it’s going to be the average. This means there was a bunch of people who had a lower response and a bunch of people that had a higher response. What we’re seeing when we put CGM’s on unique individuals – and not average at a population – we’re seeing those individuals who have the lower and the higher and then right in the middle, where you would expect. We’re seeing that spectrum of responses. Actually, what has been researched, is that a lot of this individuality between people is possibly mapped back to just microbiome in general.

KC:

There was a research study that was done that studied close to 1,000 people and mapped their glucose responses with CGM’s. They found that high interpersonal variability. They looked at a variety of factors that could influence this, and they were able to eventually accurately predict someone’s postprandial glucose response after a meal based off of their microbiome testing. There’s a very clear link there, and we think that might be a reason we have these differing responses to food. I’m sure there’s also a genetic component – probably some epigenetics going on – but there is certainly a tie to the microbiome.

DrMR:

Yeah. We were using the DayTwo testing in the clinic for a little while, and unfortunately it just did not seem to have a lot of relevance. It’s a super interesting concept, which you pose, and we discussed that on the podcast before. I would rather see someone do a CGM than doing the DayTwo testing because I don’t think they’ve refined their interface with how they are vectoring that data. From the patients who we slotted to use that, they came back more confused than they did with any clarity, unfortunately.

KC:

Yeah. I think it’s interesting from a research concept. I don’t know if the application is there yet. I liken it to some of the genetic testing. They do a similar thing where they maybe take the very specific recommendations a little too far. There’s a lot of research behind some of these genetic tests, but I don’t know if that means I can tell you exactly what to eat. I don’t think we’ve nailed it that far. So, I would liken it to something similar.

Dr Ruscio Resources:

Hi everyone. This is Dr. Ruscio. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to DrRuscio.com/resources, you will see a few links you can click through for more. There is the clinic, of which I’m immensely proud of the fact that we deliver cost-effective, simple, but highly efficacious functional medicine. There’s also my book – Healthy Gut, Healthy You – which has been proven to allow those who have been unable to improve their health (even after seeing numerous doctors) to be able to help them finally feel better. There’s our store where there’s a number of products like our Elemental Heal line, our probiotic line and other gut supportive and health supportive supplements. We now offer health coaching, so if you’ve read the book or listen to a podcast like this one or are reading about a product and you need some help with how or when to use it/how to integrate with diet, we now offer health coaching to help you along your way. Finally, if you’re a clinician, there is our clinician’s newsletter – The Future of Functional Medicine Review. I’m very proud to say that we’ve now had doctors who’ve read that newsletter, found challenging cases in their practices, applied what we taught in the newsletter and have been able to help these patients who were otherwise considered challenging cases. Everything for these resources can be accessed through DrRuscio.com/resources. Alrighty – back to the show.

The Logistics & Usability of CGM

DrMR:

If people are wondering what the logistics look like, can you walk people through where they go, what they do and help them turn this into a couple actionables if they wanted to get started?

KC:

Absolutely. If you’re interested in trying a CGM – seeing what your glucose response looks like – you would just sign up on our website: nutrisense.io. We make it super simple. You just fill out a quick health questionnaire and we take care of the rest. So, we’ll get the prescription for you, we’ll get the devices for you and we’ll ship them to your house. We have varying options. There’s a subscription model and you can either month to month with no commitment, or you can commit all the way up to 12 months. So, that’s our longest package, and it gets cheaper the longer you commit. You get 2 CGM’s per month, so they each last those 14 days. The minimum you would be doing is one month – or 2 CGM’s.

KC:

You then just put them on at home. As I mentioned, it’s really painless. Some people are intimidated the first time they put on the CGM, but I promise it doesn’t hurt. It’s not scary. Once it’s on, you just use our app to both chat with your dietician, but also see your glucose values and log your meals. As I explained, I really recommend taking those first 2 weeks to just get your baseline values. So, eat your regular meals, do your regular exercise and then your dietician will help you interpret it. There’s also education in the app. Of course, there are also the scores I mentioned to break down how that’s looking, and then using that second 2 weeks to experiment a little bit. Maybe you have a meal you really want to see a better response to… or maybe you want to try incorporating some more exercise or walking to see how that responds. I would take that time.

KC:

If you have something more concrete to work on – maybe you just got a pre-diabetes diagnosis or a diabetes diagnosis… or you’re experiencing those hypoglycemic symptoms… or you really want to test different diets (for example, trying keto for a while and then trying something else), I would recommend at least 3 months if you have a lot of experimenting to do or a big goal to tackle. With that, your dietician will help prompt ideas and things to tweak, but I recommend certainly swapping around different carbohydrate sources. If you’re having a glucose spike or prolonged response in a meal, maybe sweet potatoes aren’t your ideal starchy vegetable, but white potatoes might actually work better for you. It’s just swapping things around.

KC:

Also, keep thinking about that whole food concept – the more processed something is, the higher glucose response we’re usually going to have. So, think steel cut oatmeal over instant oatmeal… a whole fruit versus juice. Have those basic concepts in your mind. Also, movement and exercise – If you’re seeing a higher response, try to time that meal so it’s after your workout. Or go on a quick walk after you eat. Even a 10 minute walk can make a really big difference in our glucose responses. So, be incorporating a little bit more movement. Finally, I would just recommend thinking about stress and sleep. Those two are harder to tackle, and I know that it’s easier said than done, but those are two of the core pillars of glucose management. A lot of times, we’ll see glucose spikes when someone is in a stressful situation, or we’ll just see really elevated glucose values throughout the day if people are having a lot of stress or they’re not sleeping well. Those are 2 factors to keep in your mind as you’re looking at the data and thinking about how to tackle it.

DrMR:

Those are great points, especially if someone’s not sleeping well. They then put on one of these devices and they get even more stressed out because I know if you don’t sleep well, that can be stressful in and of itself. I think some of those contextual points are really important just to prevent people from not using these things in a self-destructive way, which can happen, right? When you see a score that doesn’t look good, it can be easy just to only read that as bad, and not understand that context matters. I was scared, as was Dr. Joe from our office. He said, “Michael, are you thinking about no longer using the sauna because I noticed my blood sugar spiked.” I said, “Well, we’ll be doing an interview and I’ll have a chance to pick someone’s brain on this, but my thinking, Joe, is we know there’s all these health benefits associated with sauna. Those are well-established, and if those positive things are happening with people – less neurocognitive decline, less heart disease, improved mood – then whatever’s happening mechanistically probably doesn’t matter because it leads to a healthier end point.” That’s exactly what you said, but I just tie that together so people don’t use this stuff in a way that can make them scared or lead them to stop engaging in healthy behaviors, but rather use it to help inform and fine tune their diet.

KC:

Yeah, absolutely. Actually, we’re working on a way in our app to omit both exercise spikes and sauna spikes from that daily score because those are positive behaviors and we don’t want people to walk away thinking that they shouldn’t be doing that, as you mentioned. All those beneficial reasons can actually lower glucose values overall. It’s just a little bit harder to visualize that if you’re not used to looking at it, but you want to take into account the whole picture. This is part of the reason that we included a dietician in with our support. We want a real human there to help you if you’re confused about something or if you’re not really sure how to make this data actionable. There’s also education in our app if you want to make it more self-led. However, for a lot of people, too much data can be stressful, and we’re aware of that. This is why we designed the program this way so that there is a human there if you are confused or not really sure what to make of it. So, I always encourage people to utilize that. It comes with the program, so definitely take advantage of that person on the other side.

Episode Wrap-Up

DrMR:

I could not agree with that more. The amount of patients that we’ve saved from fretting over a lab result that was meaningless, but they fretted over it for a few weeks, is pretty high. I would fully agree with you and encourage people to plug in to get some advice rather than just Googling stuff. A lot of the Google results probably won’t be calibrated to CGM’s and you might be getting the Medline super conventional reading on a glucose spike, but you’re not getting the context of that in a CGM paradigm. That’s well said. Cool. Well, will you remind people one more time where to go if they wanted to plug in, and if you have any closing thoughts you want to leave people with? I think we did a pretty good job already, but if there’s anything else you want to tack on, please.

KC:

Certainly. Yeah. To sign up for the program or just to learn more, you would go to our website: nutrisense.io. We also have a blog and a newsletter on there if you’re just curious to learn some more information about glucose monitoring or nutrition in general. You can also follow us on social media, of course: @nutrisenseio. We’re posting different screenshots of things we’re experimenting with, or things we’re learning and thinking about.

KC:

My closing thoughts – I always recommend people to test, don’t guess. I get a lot of questions like “Is this food better for me than this one? Or will this give me a glucose spike?” It’s really just easiest for each individual to test it out and see how they respond. With that being said, as we mentioned, enter things with a state of curiosity. It’s not – I’m bad or I’m good. It’s “I’m curious how this will respond… Okay, I was kind of higher. Let’s try this swap and see how that responds.” It’s all about learning and making incremental improvements over time.

DrMR:

Well said. Kara – thank you. You helped me better understand some of the things that were a bit paradoxical and I’m actually looking forward to you slapping on another sensor – again, for our audience, it does not hurt at all – and trying to see if I can weed out anything that I’m doing dietarily that’s not serving me. So, thank you. You legitimately helped me clarify a few of those things, and I’m looking forward to round 3 with a sensor.

KC:

Absolutely – happy to have helped.

DrMR:

Yeah, definitely. Thank you, again.

Outro:

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