The Impact of Lifestyle Factors on Glucose Levels

How to Succeed With Continuous Glucose Monitoring with Dr. Ronesh Sinha

Health technology tools such as the Continuous Glucose Monitoring Device can help you improve your metabolic health by providing a picture of how your lifestyle factors – including diet, exercise, alcohol consumption, and sleep – affect your blood glucose levels. 

However, these tools are only as good as the user’s mindset and basic understanding of the science behind the numbers. 

Dr. Ronesh Sinha explains how to regard the CGM as an opportunity to learn about your body rather than getting stressed about single data points, and how to cultivate healthy glucose levels through a balanced lifestyle.

In This Episode

Episode Intro … 00:00:45
The Big Picture on Glucose Spikes … 00:09:59
Blood Sugar Spikes & Alcohol … 00:13:05
Mitigating Glucose Spikes – Exercise & Food Sequencing … 00:17:01
Mitochondrial Fitness & Properly Dosing Exercise … 00:25:14
Caffeine & Walking … 00:37:10
Daily Routines for Energy & Cognitive Focus … 00:38:29
The Dawn Effect … 00:43:47
Deep Ketosis & Sleep … 00:48:31
Breath Ketone Monitoring … 00:54:04
Episode Wrap-Up … 00:57:44

The Impact of Lifestyle Factors on Glucose Levels - Podcast338b RoneshSinha

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Hello, everyone. Today I have back on the podcast Dr. Ron Sinha, and we went a little bit deeper into CGM (or continuous glucose monitoring.) Wrapped in that conversation, we went over a few strategies to help buffer the effects of alcohol and bad and/or high sugar/high carb foods. So I think that’s timely with the holiday season around the corner here so I want to make sure to flag that. And again, a more expansive narrative and conversation on CGMs and how to use them. We also discuss the dawn effect, which is observed in those who eat moderate to lower carb, where there is this healthy and normal, slight elevation of fasting glucose in the morning. We talked briefly about keto and some tips for troubleshooting keto. It’s just really a great call, chock full of practical things that one could do to keep their metabolism healthy, buffer the effects of bad food and drinking, which we’re all going to be confronted with here in the holidays. A few more tips on CGM nuance use and some tips for keto. And with that, we will now go to the show and the interview with Ron.

And remember, if you need an all-in-one place resource for improving your gut health – Healthy Gut, Healthy You – my book took me about three years to put together in attempts to arm you with everything you need so you had a very linear book protocol that you could read through and was adaptable and able to be personalized to the individual. I hope you will give Healthy Gut, Healthy You a check, which is also available now in audio (if you like) and if you’re in need of help. With that, we will now go to the interview.

➕ Full Podcast Transcript

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:

Hello, everyone. Today I have back on the podcast Dr. Ron Sinha, and we went a little bit deeper into CGM (or continuous glucose monitoring.) Wrapped in that conversation, we went over a few strategies to help buffer the effects of alcohol and bad and/or high sugar/high carb foods. So I think that’s timely with the holiday season around the corner here so I want to make sure to flag that. And again, a more expansive narrative and conversation on CGMs and how to use them. We also discuss the dawn effect, which is observed in those who eat moderate to lower carb, where there is this healthy and normal, slight elevation of fasting glucose in the morning. We talked briefly about keto and some tips for troubleshooting keto. It’s just really a great call, chock full of practical things that one could do to keep their metabolism healthy, buffer the effects of bad food and drinking, which we’re all going to be confronted with here in the holidays. A few more tips on CGM nuance use and some tips for keto. And with that, we will now go to the show and the interview with Ron. And remember, if you need an all-in-one place resource for improving your gut health – Healthy Gut, Healthy You – my book took me about three years to put together in attempts to arm you with everything you need so you had a very linear book protocol that you could read through and was adaptable and able to be personalized to the individual. I hope you will give Healthy Gut, Healthy You a check, which is also available now in audio (if you like) and if you’re in need of help. With that, we will now go to the interview.

DrMR:

Hey everyone. This is Dr. Ruscio. Welcome back to Dr. Ruscio Radio. I have back again, Dr. Ron Sinha, and today we’ll be doing part two on our prior conversation. We talked a lot about glucose monitoring with continuous glucose monitoring devices, and we’ll get into some details on that and maybe end up touching on insulin resistance in mitochondria. Maybe a sprinkling of Covid, just a whole smorgasbord of health and metabolism related topics that we can jump in on today. Ron – it’s great to have you back.

DrRoneshSinha:

It’s a pleasure to be here again.

DrMR:

Tell us a little bit about your new podcast. I think that might be exciting just to loop people in on. You just launched one and congratulations by the way. Welcome to the podcast brotherhood, I suppose.

DrRS:

I suppose that’s the right word because I’d been sort of nudged into this like a year and a half ago, but I had a lot of inner resistance to doing it, but I’m like – everyone’s doing it, I gotta do it. So I launched recently. It’s called The Meta Health Show. I was like – if I’m going to put a podcast out in the podcast universe, it’s got to be unique in some way. So, one thing I love to do is teach. I teach medical students. I teach a lot of clinicians and obviously patients and my effort with this podcast was to use storytelling and a lot of imaginative mnemonics to teach people about really, really deep molecular concepts. So, then when they’re really out listening to really detailed podcasts, or when they’re reviewing science, they actually have that vocabulary in place so they can really understand the science being presented to them, which you do quite a bit, too. You’re so evidence based, I think both of us share that passion of making our listeners as knowledgeable as possible so they can make informed decisions. So, that’s been exciting.

DrMR:

That’s exactly it. I think if you can offer people information that allows them to make better decisions, rather than just having a specious argument that sounds really alluring, but it doesn’t lead people to make a good choice, that’s obviously suboptimal. If you can arm them with the machinery and the thought processes and education needed to make more effective decisions for their healthcare, that’s just the center of the bullseye, for sure.

DrRS:

Totally, totally.

DrMR:

One of the things that people may be confronting when trying to make those decisions is continuous glucose monitoring. And we talked about this a little bit last time, but I thought maybe we could reflect and use some of my personal experience from recently doing a trial with NutriSense. I had one of their devices on for two weeks and did my fourth round over the past, maybe a year or so, doing the CGM.

DrMR:

And what was interesting is that I’m coming into a two week period where I decided to up my carbs and see if I’d get better performance from doing so. And this was not a perfect experiment, sometimes things in your life change when you’re trying to isolate variables, but you can only control the world around you so much. And so, I didn’t get cleanest read. I have to run the experiment one more time, but I do think I had more vigor in the gym. For our audience, the reason why I’m being careful here is I just try not to fall on a confirmation bias. And it’s so easy to say – authority and exercise nutrition told me to up my carbs, therefore I’m going into this experiment pre-placebo and ready to just have a little flicker of “Ooh, that was a good lift. Yeah, it’s the carbs.” Right? And then you start really ingraining yourself into this confirmation bias and this placebo effect. I try to really be objective and look for a substantial signal before I say yes or no. So, maybe – the jury is still out. The one thing I did find insightful was I was thinking – if I have a cup of rice with my meal in the morning a couple hours before my workout, as I’m doing this higher carb thing, I’m expecting to see a real spike of my blood sugar. Coming from a place of more of a paleo/lower carb background, that’s some of the concern that’s rattling around in my brain, but I can’t really say I noticed a spike at all; higher than the week following that where I tried a keto experiment, but still within range.

DrMR:

My blood sugar was maybe between 80 to 90, a lot of time when I was attempting to do keto. And maybe between 90 to 100, maybe one 110, highest 120, when I was doing the experiment with the carbs. So maybe an average delta difference of 20 points. But I didn’t notice the carbs sent me off the charts unless it was something like a juice, even a greens juice that only had 13 grams of carbs; greens, juice, red juice, if I had some whey protein in there, it still wouldn’t matter. And of course, whey protein is known to be fast absorbing. But if I got some food stuff in with the shake, like a piece of bread or an apple, then those glucose spikes were pretty much wiped off the chart. Maybe we can start there. What are your thoughts? And how people may want to use some of my reflections on dialing in their carb intake?

DrRS:

Totally. Great points. I love the fact when you started off, you said that when you put the CGM on it wasn’t necessarily a perfect experiment. And that’s what I like about it, because like you said, our life is not perfect, right? Because when my patients get their blood tests done, often when they know their fasting blood test is coming up, either consciously or unconsciously, sometimes their lifestyle changes a little bit. Sometimes they might fast a bit extra before they get that blood test done. And all of a sudden you’ve got a single data point which may not actually reflect their average metabolic health. That’s really the beauty of these sensors – they actually get you to behave better, but they also get you to behave like your true self, which is really a good thing to do because otherwise you are following health recommendations from other individuals who have completely disparate metabolic effects from eating carbs.

DrRS:

And that’s been my struggle before the sensors back in the day, several years ago. I would try to reflect my own experience in what I’ve seen from the literature on different individuals. And I would see such different effects. So really these CGMs have been a game changer from that standpoint. So, that’s the plus side.You get personal feedback on all of the different lifestyle interventions from diet to stress to sleep and what it’s doing literally minute by minute to your glucose level. So, that’s the plus. The second thing, and this is something I had to struggle with and every now and then I go down this rabbit hole, is every glucose spike you see (and I’ve seen this with my patients), it can cause a lot of anxiety. You see a single glucose spike from eating something that’s a little bit more high glycemic, and all of a sudden you’re like, “Oh my God, I should not eat that food.”

DrRS:

It can cause a lot of stress. I think the first thing is if anybody’s considering putting the sensor on, just really have the right intent in mind. Don’t let this thing stress you out, be excited about it. This is like a toy that’s going to teach you a lot about your body and play around with different experiments to see how you respond to that. For example, you mentioned different circumstances – sometimes you’re between 80 to 90 and other situations, 90 to 100. And maybe if you’re going a little bit higher, 110 to 120. We know your average range throughout that if we looked at your average glucose, so you might know that number. It looks like you probably hover around 100 or maybe less. Is that correct to say? Like your average.

DrMR:

Essentially. I’m trying to run the reports right now in the NutriSense app, but that seems to be pretty approximate.

The Big Picture on Glucose Spikes

DrRS:

And that really is pretty optimal metabolic health. If you’re thinking about the A1C test, which a lot of people are familiar with, which is the average glucose for the last three months, it comes as a percent value. When you’ve got a 5.6% value, which is considered to be on the normal side, that’s about 114. The few limited studies that are out there look like people in optimal metabolic health are closer to 100. And again, to clarify, this is average sugar, not fasting blood sugar. So this includes post meal, all that effect. So average sugar there is a really good number to aim towards. But what I first do with individuals that wear this sensor, I tell them go through your normal life. Improve your life a little bit if you can, and let’s see where your baseline number is and work from there.

DrRS:

I’m actually running corporate programs right now in Silicon Valley using these glucose sensors. And I’ve seen a variety of different emotional responses to this. Some individuals are very fit. They’re metabolically healthy, they’re sharing numbers that are like yours or better. Others are already Type 2 diabetic. They didn’t even know about it. They all of a sudden think that they have to do drastic fasting and interventions to get to that normal point right away. And that can lead to some side effects and consequences. If you’re over fasting, all of a sudden subjecting yourself to nutrient deprivation and nutrient deficiencies, I tell people just be very gradual, go from your baseline and sort of work methodically from there. And don’t deprive yourself of essential nutrients because that could be a big problem. So, again, with the sensors, you have to look at the big picture and not just react to every glucose spike there is, and really understand metabolism in a way that you can predict when those glucose spikes happen; what to do to mitigate those spikes and then what do you do to rebound as quickly as possible. That’s the big picture on that.

DrMR:

Thank you for bringing it to big picture. Going through it myself, I’m observing my psychology and my reactions to some of these things and whenever there’s a spike, it’s like, “Ooh, a spike!” But after a day or two, you realize when I eat, there is going to be a spike. This should happen, but I think a part of you just wants to see that line stay perfectly level and never go up. Obviously that’s unreasonable. I will say from a behavior perspective, it did get me to rethink the post workout shake I’ve been doing and maybe I can rethink that. You could make an argument either way that perhaps that post workout insulin spike in an athlete – someone who is trying to optimize for muscle mass performance – wouldn’t be a bad thing, but that aside, it did get me to see some of these other things. The twofold were the pernicious impact of alcohol in that it doesn’t lead to an acute spike, which surprised me at first, but you will see an elevation of your blood sugar hours later that stays maintained for a decent amount of time.

Blood Sugar Spikes & Alcohol

DrMR:

And I’m assuming that for people who are drinking, this may be helpful to get them to better appreciate some of the metabolic effects of alcohol. It was for me. At first, I was like, “Oh, yay. I’m having this big dinner out with friends and nothing’s really happening to my blood sugar.” In a conversation I had with Kara Collier (who is one of the founders of NutriSense), she said, “We’ve been seeing a real consistent delay of the peak, and then a prolongation of that peak.” This is exactly what I saw. I’d be sleeping and my blood sugar would be maybe 130. Now, given this is metabolically the most imperfect situation. I think this was around Halloween. So, I’m out drinking alcohol, some candy spackled in there. I didn’t think any of this stuff was too much of a problem at 11:00 PM, but at 2:00 AM in the morning, my glucose is 130 and it’s staying 130 until 6:00 AM. That was an insight. Is that something I’m assuming you’ve also seen?

DrRS:

Yeah. Again, this is another key point, too. Just like I said for folks to not overreact if you have occasional glucose spikes here, when you see a number that looks really good, that doesn’t necessarily mean that a particular thing you’re consuming is metabolically healthy for you. We’re just looking at one parameter – glucose. With alcohol, it’s true. A lot of individuals are like, “Yes, I can have my scotch or I can have my wine or beer and my glucose looks fine.” I’m not here to take that away from them, but I want them to understand over the long term that alcohol does inhibit lipolysis – your body’s ability to actually release body fat. It can actually ruin REM sleep. We see that when you wear an Oura Ring or do a sleep study – it destroys it. And that’s why some people might have nocturnal hyperglycemia and obviously the mood issues just from getting less of that rapid eye movement sleep. Obviously, the alcohol impact for a lot of my individuals that are already insulin resistant – they already have a little bit of a fatty liver because they’ve got elevated fat stored inside that liver.

DrRS:

And those individuals are more susceptible to even a few drinks a week. So, they’re increasing fat production in the liver on top of what’s already from no alcohol. The problem with that over time is that can actually cause increased hyperglycemia. Short-term, that drink didn’t raise your sugar, but you’re actually changing the metabolism of the liver over time and causing your body to become more insulin resistant. So, this is where again, big picture makes sense. Obviously I’m not telling people to stop alcohol all together. It’s encouraging to know that the short term spikes aren’t happening, but I also worry that some people might be drinking more than necessary because they think that all of a sudden their metabolism is bulletproofed against alcohol.

DrMR:

Right. It’s a great point. I didn’t have time to run this experiment, nor was I super motivated to run a bunch of alcohol-based experiments with this, but it got me wondering. Maybe if I was more discerning to be lower carb the day of drinking, could that help buffer some of this? I’m not sure, Ron, if you run this experiment or if you had anyone try lower carb to offset that? Or if there are any strategies that you have? Again, not that we’re trying to give people license, but if someone’s saying, “Yeah, I’m gonna be drinking tonight. What can I do proactively?” Any thoughts you have there?

DrRS:

Yeah. So, I’m going to actually broaden that approach. Let’s say you just want to enjoy yourself – alcohol + or -. You want to have a normal meal and not worry about carbs. I actually do prep my body for that. This Saturday night, we do have a big dinner coming up. So, this has become unconscious for me. But if we recall from the last episode, what we really talked about is one of the issues with insulin resistance in hyperglycemia is when we overfill our muscle. When we overfill the muscle stores with glucose and it’s stored as a glycogen, you think of that as being a parking lot. Whenever we overfill that lot, that’s really when trouble happens because the muscle says, “Sorry, I have no space for glucose. I’m going to send you to fat that gets stored as adipose tissue in the fat cells, or I’m going to send you to the liver to produce triglycerides.”

Mitigating Glucose Spikes – Exercise & Food Sequencing

DrRS:

The way I teach this is – you literally have a bank balance every day. And when you used a CGM or do your own personal experiments, you might know that my body on a sedentary day can handle about a 100 grams.When I exercise because I’m metabolically healthy, I can handle about 150 to 200 grams. So, you’re right that if you already know in the evening you want to enjoy yourself, that’s a morning where I’ll probably be doing my usual intermittent fasting. If I’m hungry, my earlier meals are going to be lower on the carb side and heavier on the protein, vegetable, and fat side. So, by the time I enter that meal, whether that’s alcohol + or – whatever my body’s got, my muscles have space. And if I exercised on that day – the closer I can exercise to that evening episode, the more of that traffic is going to go towards muscle basically.

DrRS:

So, that can help with alcohol, but it can definitely help with overall carbohydrates in general, too. The other thing is if you are going to be ending up having a meal or even alcohol at night and you want to really mitigate the spike from that meal, food sequencing is big. These studies have been out for a few years now. How do you actually eat the food? What order you eat that in can have a big impact. We find that when you’re actually having vegetables before the carbohydrates, if you’re having protein and fat before the carbs, or at least mixing the carbs with protein and fat, you can significantly dampen that spike. That’s a hack I use all the time, Michael. When I’m in restaurants, I may get a side of veggies before or I might have the salad before. If you add a vinegar-based dressing (preferably not balsamic, which is sweet), but any sort of vinaigrette with that, that will dampen the ensuing spike from that glucose, as well.

DrRS:

Lately I like to do bowl-style eating – like Buddha bowls, for example. So you’ve got a bowl and you literally put the brown rice (or if you’re having starches) at the bottom of the bowl and then you can layer fish on that, meat on that, and put vegetables on the top. So, I’m sequencing that bowl in a way where the carbs are at the bottom. My body is already digesting vegetables, protein and fat before I hit the carbs at the bottom. And these seem like really subtle things, but over time that can drop your glucose spike from a carbohydrate meal by a significant amount. I’ve seen it have an impact when I’ve done comparisons in myself: 10, 15, 20 milligrams per deciliter, which is pretty significant. Those are some strategies I use for inevitable social eating. I’m glad you brought this up because we’ve got Thanksgiving coming up… we’ve got holidays. There are a lot of opportunities to run these experiments.

DrMR:

Great advice for people. I’m going to start implementing more of these as I venture into the food and drinking that’s a plenty for the holidays. The day after Halloween (and I think another celebratory day of a bit of overeating), I wanted to test that a 10 minute walk can be really powerful for lowering blood sugar. I had the CGM on so we could easily test this. It did work. Now, it did take probably 10 or 20 minutes after ending the 10 minute walk to see a 10, maybe 20 point drop in the glucose. But a nice leisurely walk was enough to really attenuate some of that. Activity in some simple things seem to really get us pretty far.

DrRS:

Yeah. And the key words you said were “nice and leisurely.” That’s the beauty. You can see some of the best glucose lowering effects from a non-sweat inducing walk. It’s funny because I think I might be wired a little bit like you, but my tendency always in the past has been to work out much harder than be in the moderate zone. There was one time where the night before I’d binge ate. I got up and I was already having glycemic spikes in the morning. My tendency was to go out and do a high intensity workout – go run in the hills and just go crazy. But then I got invited by a couple of buddies (who are actually not in very good shape) to go for a hike.

DrRS:

So, we went for a hike, which was more in the mild to moderate heart rate zone – far lower than what I would’ve done. And my glucose dropped so dramatically. So that sweet spot – that middle zone for aerobic – that’s the spot that can have the most impact on glucose lowering, believe it or not. I don’t know if you run the experiment with high intensity, but high intensity can actually accentuate glucose spikes quite a bit. One of the folks in my corporate programs – he was doing super high intensity sprinting. He’s over 60 years old and he shared his data with me. He had some glucose numbers that were far beyond 200. Now, coming back to my point about not necessarily overreacting to that single glucose spike. Yes, that’s scary to see that number. I did have to work with him to sort of moderate the intensity of his workouts. Over the long term, if he’s doing workouts like that five days a week, that’s not something healthy that I want to see, but obviously high intensity workouts might spike glucose a little bit.

DrRS:

The long-term benefit of that is if your body is handling that and you’re getting aerobically fit, then on a daily basis, you’re still going to be metabolizing glucose much better. I don’t overreact to transient spikes in glucose from my high intensity workouts, but if that’s a repeated pattern, that’s your body sending a signal that you’re having chronic cortisol releases from those intensity workouts. Coming back to your point, I love the fact that literally after Thanksgiving, etc, you can go for a 15 or 20 minute walk at a mild to moderate pace without having to change into your gym clothes. And I do this between meetings sometimes. It can really have a significant effect on that glucose spike.

DrMR:

Thank you for underscoring that. It doesn’t have to be super high intensity. If we paint this as such, then people who just ate a big meal may be less likely to actually follow the advice and go for a vigorous walk because they’re saying “I’m really full.” Like it was good advice, but it’s too much for me. So yeah, it can be a really leisurely walk.

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DrMR:

And just to push back a little bit on one concept – or maybe to try to give people a little bit more of a guardrail – my thinking is if someone’s doing high intensity exercise, but you’re seeing no other signs of metabolic problems (high triglycerides, high fasting insulin, poor body composition, poor recovery), they’re probably okay to keep doing that. And maybe that’s me being a little bit persnickety, but I just see so many people get so caught up in the numbers that they stop listening to their body and looking at practical metrics. They lose the practicality for the novelty. Do you have any reason why someone who was seeming to have other surrounding parameters of health be where they should be, should have to pull back on intense exercise? Let’s say, if they are doing it four or five days per week?

DrRS:

This is a really good point. First of all, the key thing is you’re right. A lot of us get very hung up on the numbers. I had to detach from that, too – where they’re obsessed with all the metrics, the sensors, the heart rate, etc. And like you said, a lot of us are losing that ability to just intuitively know when too much is too much and just react to our body’s natural signals. Now having said that, I’m a little bit biased because in my clinic I see a lot of sedentary, really metabolically unhealthy folks that have not really even been athletic even in their youth. I can tell you already that that power structure in their cells called the mitochondria doesn’t have a very enhanced capability of actually burning energy, fat, and carbohydrates.

Mitochondrial Fitness & Properly Dosing Exercise

DrRS:

In those situations, when they are doing high intensity workouts over long periods of time, it actually isn’t doing their mitochondria much benefit. You are definitely getting some threshold benefit from that. The last time we talked about a simple equation that I use – the Maffetone heart rate zone – which is literally 180 minus your age. And that’s really a pace where you’re breathing a little bit heavy, but you’re not huffing and puffing. When you’re in that zone two moderate range, especially in somebody who’s not metabolically healthy, over time you’re going to build up the mitochondria more aggressively than doing high intensity. And even if you don’t buy into that concept, one way I challenge that is when people that do high intensity (especially if they’re not fit and their muscles are not conditioned to do that) they can’t go as long, right?

DrRS:

They go for 15… 20 minutes and that’s about all they can do. But when they’re in that middle zone, they can go for 30… 45 minutes… an hour… and now they’re really building exceptional mitochondrial fitness. And then when they get to that zone, they can start interspersing in high intensity in little doses here and there. Now, on the other side of the spectrum, I have some patients that are professional elite level athletes and they’ve got plenty of “mitochondrial horsepowers” (as I put it.) And in that case, they can definitely mix in high intensity here and there. And in addition to all the parameters that you said that are subjective, if their numbers are still improving, their strength and endurance is getting better, they can probably handle that high intensity.

DrRS:

Phil Maffetone – I’d definitely have your readers look him up because he’s done a lot of research in this area and he basically has trained some of the most elite endurance athletes in the world. When he actually takes on clients who are world class triathletes, runners, etc, even in these folks he has to dial their exercise intensity down to build a really strong aerobic base. And these individuals initially are very resistant. They’re like, “What the heck? Why are you having me literally walk or lightly jog at this pace?” But over four, six, nine months, they build such a wide base of aerobic fitness that now all of a sudden they’re breaking records. Their high intensity now is at a different zone altogether. I think it depends where people are in terms of their baseline fitness. And then just being aware of what intensity is going to be right for them. Keep in mind – for sedentary folks, high intensity for them is actually jogging. For most of my patients that have never run before, when they jog their heart rate is 160, 180 so there’s no point for them training for a half marathon or a 5k. They need to just fast walk for now until they get fit enough to actually start interspersing jogging with walking. You can tell I’m pretty methodical about this, but I’ve seen the health impacts and some of my high risk patients doing too much high intensity and I’ve actually had people develop cardiovascular complications from that. I might be a bit biased in terms of being very sensitive to the impacts of excessive high intensity in folks that actually can’t handle that.

DrMR:

This is a great point. Even though I try to factor out my bias as much as possible, sometimes you live in the world in a certain way. For me – as a former college athlete and someone who has always been pretty fit – high intensity (as you beautifully said) is not that far of a reach from my relative level of baseline fitness. But for other people, it’s a great point that it may be a further stretch. And this is why I appreciate the conversation we had with Mike Nelson, which talks a lot about this same thing that you are with the Zone 2 training. He gave a few parameters for doing something like a Cooper’s 12-minute run test and easy access to this normative database where you could cross reference to see if you had poor up through good cardiovascular fitness health.

DrMR:

And if not, you may want to balance out your routine a little bit so you’re not always going high intensity. You do make a good point. I have a feeling, Ron that you’re not too far off from me either – always going as hard as you can, hard as you can, hard as you can. And that can be hard to recover from. And this is one of the areas where throttling back my cardio for a while was helpful. And in fact, we just recorded a patient conversation with a young gentleman. One of the keys for him improving from his brain fog, was getting a few days per week in of this Zone 2 cardio because he was always high intensity. He felt that once he developed some of this cardiovascular base, that was one of two or three things that were really pivotal on him recovering from his brain fog.

DrRS:

Oh my gosh, that’s fantastic. I love hearing stories like that. Coming back to the physiology of how this works, when we’re in that anaerobic threshold, our body is definitely burning glucose and fat, but we’re burning a higher proportion of glucose. That might sound really good and we definitely want to clear some of those glucose stores. However, when we overdo that, we can deplete some of that glycogen store and that can lead to some hypoglycemia. And I’ve seen that when I do a lot of high intensity… my glucose variability. So, that’s another metric that’s really powerful when you wear a CGM. You can’t get that from a standard blood test. You can look at the graphical waves of how your glucose is undulating throughout the day.

DrRS:

A lot of my patients are doing a lot of high intensity. They’re seeing those swings. We talked about the high intensity that can cause that glycemic response and then all of a sudden, they can crash. But long story short, the reason I think that’s relevant is – Number 1 – that can cause a lot of intense hunger. And that was my issue, too. When I was doing high intensity before, by the time mid-afternoon came around, I had a really hard time moderating my food intake. So, when I really balanced out my workout intensity, my diet is much easier to control. The other thing that I’ve come to realize more recently is, morning is usually my favorite window to work out. My tendency to do really high intensity long workouts – although they felt good – would lead to me crashing cognitively more throughout the day.

DrRS:

And that’s a big problem because I’m doing a lot of creative work, I’m doing a lot of presentations, writing, podcasting, as well. And I really felt like my crash was much more significant. Now my high intensity doses are lower, especially if I have a day where I know I’ve got a lot of cognitive work to do. I really moderate that dose and that keeps my glucose variability much more in check. You don’t see all these waves throughout the day and I can function so much better. Those are two other elements of why we want to really be careful with the way we dose our exercise.

DrMR:

And also the timing. I’m glad you brought that up. Not necessarily that I’m connecting this to blood glucose, but I did and I do notice that my high intensity exercise is normally the best if I do it midday. And I think this is because it helps keep me as cognitively sharp as much of the day as possible. And that’s really what we’re both (and so many people) are trying to optimize for. If I would work out at the end of the day, I could do it, but I came into the end of the day a little bit more burnt out and fried. My exercise wasn’t that good, and I also have some suspicion that it wasn’t great for my sleep. If I work for a few hours and then get this reset in the middle of the day, that seems to be great. On the back end of that, I got another three hours or so of really high functioning cognitive work. And I can do the lower intensity cardio at 6:00 PM or so and that seems to be fine. I share your interest in trying to find the ideal timing for exercise in the day to keep you in that power curve for as long as you can.

DrRS:

Roughly what time do you work out? When is your midday workout typically?

DrMR:

Usually about 1:00 PM to 2:00 PM.

DrRS:

That’s one of my to-do’s. I’d like to add on a few sessions at that time. My meeting schedule just always destroys my plans to do so. We want healthy living to fit into people’s lives, wherever they’re at. But if you have the option, there are some additional benefits from doing midday training. With the testosterone-cortisol balance, it looks like people do have better strength gains. So when you look at studies, people who do midday workouts do find that they can lift better than when they first wake up in the morning. That’s one big plus. The second is when it comes to fat loss. There are some studies that show that there’s probably an increased lipolytic or fat loss effect from doing workouts more in the midday.

DrRS:

The interesting thing about that study does show that if you actually consume caffeine in the morning before workouts, then it’s kind of a wash. It looks like it’s a little bit more equivalent, but it looks like there are some subtle hormonal advantages. When my boys are back from school, sometimes I’ll hit the gym with them and we’ll lift together. And I’ve definitely seemed like I lift so much better. My max and everything is much better during that time than it is in the morning. But in terms of my schedule, I just have not been able to do that as regularly.

DrMR:

Gotcha. It took me a while to get that orchestrated and I’m happy that I was able to because I do notice I’m way better on so many parameters. Just a reminder for our audience to listen to your body. Experiment. When I started working out midday, I said, “Wow!” I come back to the second half of the day and I just feel so much better. I also have that killer instinct level intensity you don’t always get when you’re lifting weights and you feel like you could lift them through the floor and throw them through the ceiling. Sometimes you have it, sometimes you don’t, but I have that more often midday and definitely not at the end of the day. That was one of my main motivations. My days, as I’m sure you and many people can appreciate, are pretty full. I’m not sitting around chatting with coworkers. It’s like constant engagement, problem solving, deep thinking. And so come 6:00 PM or 7:00 PM oftentimes, I’ll go to the gym, but it’s moreso I’ll do some dead lifts, I’ll do some pull ups, but I just don’t feel like I’m on fire.

DrRS:

The thing I struggle with is morning actually cognitively is a great time for me to do work. So, sometimes when I do a long workout, I feel like I missed that optimal window. So, I think it’s great you actually do that in the morning. A lot of us are working from home now where we’re spending a lot of hours seated in front of a screen. When we’re back in our corporations, sometimes we’d get outdoors… maybe eat lunch… visit a colleague down the hall. I am finding people are spending a lot more sedentary time. The morning is still a really golden opportunity to even take a 10, 15, or 20 minute walk. One way I teach people about health and mitochondrial function is you think of that mitochondria as being an engine. You want to at least start that engine running a little bit in the morning because then whatever you consume or even when you’re at rest, your body is going to burn through more glucose, fats, and nutrients.

DrRS:

So for me often, if I don’t have time to do that prolonged workout, I will get out there and get in a vigorous walk, maybe a light jog. I’ve got an exercise bike. I just want to get that engine running. And a lot of my patients, they will roll out of bed and they’re in there for a Zoom meeting already and they haven’t done anything before that. So, I encourage them to do that. And the way I think about the mid-afternoon is sort of the morning – if I can keep myself revved up. And even when I’m in meetings, I’m often off video or I’m doing some mini squats below the desk level. I’m keeping my body warmed up. And the nice thing about that is when that midday time comes, when I want to do a harder workout, I’m totally primed and ready to go.

DrRS:

It’s not like I’m going cold from sitting all day. Your body’s revved up and you can go and just lift. You don’t need to even stretch and warm up because you’ve been doing that in the morning. So, that’s a trick and really we find when you distribute activity throughout the day, that is just great for glucose control. I do have patients that do such an intense workout in the morning that they cannot move for the rest of the day. They’re just seated all the time and psychologically, they feel like, “You know what? I spent 90 minutes in the gym. I did my workout. I’m good for the rest of the day.” You are going to get some after benefits from that workout, but if you’re really so tired that you’re just sitting all day or even standing without moving, you are missing out on some opportunities to really lower inflammation, glucose, all the different spikes that you see from prolonged sedentary activity.

Caffeine & Walking

DrMR:

Not to get to into the weeds, but does the timing of caffeine related to that morning walk seem to matter?

DrRS:

You mean in terms of getting that fat burning effect from it?

DrMR:

Yeah. Like if you have your morning coffee and then walk? Or wait to have your coffee until you get back from your walk?

DrRS:

If you’re doing any workout in the morning or even in the afternoon, having a dose of caffeine before that does seem to enhance lipolytic effect in terms of the fat burning. But if it’s a walk, I think it’s perfectly fine to do the walk and come back. If it’s a short walk, you’re not burning a whole lot of fat anyway. I don’t think it makes a difference whether you have the caffeine before or after. There is an effect though, in terms of energy. For example, if you want to sustain energy and cognitive function throughout the day, there are some studies that show that if you do the morning walk first and then you come back and have the caffeine, you’ll probably have more of a sustained benefit from that. Because when we wake up in the morning, we’re already getting a natural cortisol spike so we want to benefit from that. You don’t need to necessarily add caffeine on top of that the minute you jump out of bed. If you get a walk from that, you’re also getting the additional energy enhancing effects from that. And now when you come back and you sit down and you want to have your coffee then, that’s perfectly fine to do it that way, as well.

Daily Routines for Energy & Cognitive Focus

DrMR:

Just to share for our audience… The way I’ve set up my day now (and this seems to really allow me to get as much done as possible in the day and avoid those energy lulls, those challenges with focus), I’ll wake up and do my morning routine of brushing my teeth, showering, etc. I’ll then have an espresso, go for a walk, come back and meditate, do three to four hours of work, go to the gym around 1:00 PM or 2:00 PM, do another ~ three hours of work; if I’m going to do a second session, oftentimes it’s this lower intensity cardio or this knee stability plan called ‘Knees Over Toes.’ It’s nothing too intense, but it’s just some stability and mobility work. And I’ll get one of those in maybe starting at 6:00 PM or 6:30 PM for about 20 minutes, hop in the sauna, hop in the cold tank, and then have my dinner. And that seems to be an excellent rhythm. And as you had said, Ron – it really helps spread that activity out throughout the day. I can’t imagine doing all of that in one sitting. If you’ve ever played Excitebike on Nintendo, there are those little channels where you get a burst of speed. It’s like you have a little burst in the morning, a little burst in the midday, and a little burst at the end of the day. And that really helps keep you from just getting into those fatigue patches or those lulls cognitively.

DrRS:

I love that. I think a lot of us think of an eight hour or 10 hour work day that’s continuous, but you can really break it up. If you’re playing sports, you break it up into quarters or halves. So, you’ve got a three hour window here. If you’re setting up your schedule, really think about… “Okay, this is my three hour window of deep cognitive work.” And just like you talked about… “here’s my break,” which might be meditation, an exercise session, etc. I think breaking the day into chunks and doing that approach is really much better. Otherwise, people feel like it’s a continuous, continuous drive. I feel like we have so much in common because I’m a huge fan of ‘Knees Over Toes.’ I actually met Ben Patrick when he did his first live seminar in Sacramento. Unbelievable guy.

DrRS:

For those of you that don’t know about ‘Knees Over Toes,’ look up his work. It’s game changing and life changing. I’ve referred a lot of my patients to his program, but I do a lot of the ‘Knees Over Toes’ stuff even while I’m working. I’m often standing on a slant board or I might be doing some of those simple exercises. I’m constantly keeping the body mobile while I’m working. And that really has a huge benefit. Studies have even shown that if the thought of doing 50 squats at one time is hard – if you do five here, 10 there, if you cumulatively get 50 to 70 squats throughout the day, you can still have pretty incredible strength gains if you’re doing that on a regular basis and without depleting that muscle all at one time. So, lots of creative options out there, but I love the layout of your day. That sounds awesome.

DrMR:

I love that you know Knees Over Toes. I was thinking about bringing this onto the podcast. I wanted to get a little further in my experiment before I announced it broadly, but that’s great to hear you’ve done it and you’ve referred people to it. From doing it for a few weeks, intuitively it feels like it really hits some of the points that I need to work on. So far I’ve been a pretty big fan.

DrRS:

Yep. Good stuff.

DrMR:

Cool. Another interesting observation regarding glucose — Obviously exercise and sauna can spike it, but I wasn’t expecting to see when I got in my cold tank (that’s at about 37 degrees), that that would lead to a fairly precipitous drop in my blood sugar. I’m wondering if you have any information on the effects of the cold tank on blood sugar?

DrRS:

That’s a neat one, actually. I’ve seen the effects of the sauna in terms of causing more of a glucose spike. But I haven’t heard about the cold tank. I’d have to look that up. My head’s like spinning with different physiological mechanisms, but I don’t want to propose one without actually looking it up. That’s a fascinating one. I’ll have to get back to you on that. But on that note, there is one point I wanted to bring up. When you put these sensors on, another big revelation that I’ve seen in myself and a lot of my hard driving patients who were working really hard, is that they’re having a lot of hypoglycemic events, low blood sugar events, that they weren’t aware of before.

DrRS:

And this is why the sensor is so important. Many of my patients before I was using sensors, when they got their standard blood tests done, their fasting blood sugar looked great. Their A1C looked really good, which is their average score. But what you realize from using the sensor, is a lot of times their numbers look really good because their lows, their hypoglycemic values, are bringing down the total number. If you’re consistently in the sixties and seventies and you’re seeing these sorts of swings, you might look like you’re metabolically healthy based on your A1C, but we don’t want to see that sort of variation. And that’s a perfect example. For example, if you’re eating high glycemic foods, you’re under a lot of chronic stress, you are going to start seeing those low glucose events during the day. And those can actually get mirrored into the nighttime as well, too. Again, for my patients that are showing no signs of diabetes, sometimes just uncovering the low glucose episodes and then really trying to regulate the diet, the activity, the stress levels and sleep, to keep that variability much less significant can have a huge impact on cognitive function and overall health. And there are studies that show that glucose variability, even if your average numbers are normal, significant swings in glucose can be a big metabolic stress. It can increase inflammatory cytokines. It can actually raise a risk of heart disease downstream. And that’s something obviously you can’t check for from a normal blood test.

The Dawn Effect

DrMR:

One of the things regarding a paradoxical elevation that I wanted to get your thoughts on… I think we may have touched on this the last time we spoke… is the dawn effect – this mildly elevated glucose in the morning that seems to occur in those who are eating a moderate to lower carb diet. This is definitely something that I’ve seen. It wigged me out the first couple times. This is years and years and years ago when I was getting my blood drawn down at the local LabCorp. And I had a fasting glucose of 102. Everything else looks great, and I’m saying, “Geez, am I that stressed in the morning?” Finally, I learned about this dawn effect. So to my understanding, I haven’t directly fact checked this, but it’s been verified or at least acknowledged to be a normal observation for many in the camp of moderate to lower carb. This slightly elevated glucose in the morning is okay. Do you agree with that? The reason why I just want to echo this again is because a number of patients in the clinic have come in and said they’re diabetic or pre-diabetic based upon this one point of 103 or 104, 105 in the morning, even though everything else is fine. So, if it’s not something to be concerned about, I just want to make sure that people understand that and better understand what the dawn effect is.

DrRS:

So, this runs back to one of our central themes of single data points, right? The reason we call this pre-diabetes is because of population health studies. This is back before the days of CGM and ketogenic diets and all the things we’re doing right now. In general, if you would see somebody that had an average blood sugar above 100, 105, 110… that sort of a population… typically you would unmask a high risk of diabetes downstream. But now when you’re taking individuals on ketogenic diets, low carb diets, who are doing a lot of fasting, and they’re waking up with a 102, 104, 105 – that’s a completely different mechanism. And just to explain it real quickly is when you are on a low carbohydrate type plan or a ketogenic diet, all of a sudden your tissues, particularly your muscle is like a hybrid engine now instead of just using glucose for energy. It’s really good at using fat, as well.

DrRS:

So it is often not uncommon that, especially when you wake up, that the muscle is really saying, “Listen, I’ve got enough fuel here already. I don’t really need carbs and glucose for energy.” You will have some of that physiological insulin resistance, where you just get a little bit of a glucose spike in the morning. That number used to really bug me after seeing a lot of pre-diabetics for many years, but now in the whole context of things, it doesn’t bug me at all. And when I actually am tracking ketones, often I’m in significant ketosis and I’ll still have these mild spikes. And that just verifies for me even more that my muscles are really good at burning fat.

DrRS:

But yes, in the mornings when I get up, I do have these subtle spikes. Now, in my case, I have found that those spikes can sometimes be exaggerated and that’s a pure cortisol effect. Some people just have a very sensitive liver and I’m one of those people. If I go to bed too later or if I’ve got a lot of thoughts in my head, I will see the impacts of that on my sugar. Other people may not have as much of a stress sensitive liver and their fasting glucoses are okay. But I’ve seen in my case, some combination of two can often lead to those isolated spikes in the morning.

DrMR:

Gotcha. Now you mentioned keto. So, this is the other experiment that I wanted to loop into our conversation while I’m picking your brain here. So, I was nice enough to get one of these Biosense breath ketone meters to run some experiments with, and after two weeks with the CGM and going higher carb, I was jazzed to try keto. To get myself kicked off on a Sunday before I would start this, I did a one meal per day fast. I kept that meal pretty darn low carb – just a ribeye and vegetables – and the next day it was fully keto with some MCT.

DrMR:

This was Monday – probably total carb intake was 30 grams and that was okay. But then on Tuesday, I could not sleep for the life of me. I’ve had this happen before where I’ve noticed if I’m too low carb or if I don’t eat enough, I cannot sleep. I’ll try melatonin. That’ll fail. I’ll try Unisom, where the active ingredient is diphenhydramine. And when Unisom doesn’t work, I know I need to get some calories into the system or I’m not going to sleep. And after two hours of fiddling around with melatonin and then Unisom and trying to sleep and not getting anywhere, I have a meal with a decent bowl of carbs and I’m back to sleep in 20 minutes.

Deep Ketosis & Sleep

DrMR:

I’ve compared notes with some colleagues on this. The consensus seems to be that if people are under a lot of stress and/or do a decent amount of training, some people just have a very hard time sleeping if they try to go keto. Would you agree? And is it as simple as some people, depending on the level of training and level of demand, are just going to have a hard time with keto? Or is there something else? I did make sure to get adequate electrolytes. It’s possible I needed a whopping dose, but I had done three of the LMNT electrolyte packs in a day, which seems to be a decent dose, but, curious how you would interpret that and how you might troubleshoot that if I may selfishly ask.

DrRS:

No, totally. And I will tell you I’m in the same boat. When I actually am in too deep into ketosis, it can have a negative impact on my sleep. The first thing we have to think about is when we think of ketogenic diets as we know now that we’ve been doing this for many years, there’s a lot of different flavors of the ketogenic diet. People that are very hypocaloric on the ketogenic diet (they’re still eating that one meal a day that’s very low carb and not a sufficient amounts of calories), they can see significant impacts on sleep. It can actually affect their performance in training, too. The one meal a day is something I have had some patients definitely take up, but if they’re training at more of a moderate to high level, I am concerned that they’re not getting the adequate nutrients they need to really keep that up.

DrRS:

And that can really cause a major stress in the body that can affect sleep and even cognitive function. If I have a person on a CGM, I want to see what’s happening with their glucose, but I’ll tell you from experience that even my patients that are doing one meal a day and they’re being really restrictive and training on top of that, even if their CGM values are good, it is having other impacts on their health. So I’ve seen some people with increased inflammatory markers. When we’re talking about performance in terms of strength and endurance, sometimes we see that drop off. I definitely have some patients that are thriving on it. They look like they’re doing well, but I’d say that’s a minority, especially if your workouts are glycolytic (i.e. a lot of sprints and heavy lifts, etc.) In my experience, most patients will not do well on a hypocaloric, ketogenic, one meal a day type diet. But if they have a ketogenic diet that’s got some healthier starches and maybe they’re having two or three meals over a little bit of a wider window, that looks like that works pretty well.

DrMR:

Just to clarify, the one meal per day was only on one day just to kick me off. And then I was doing two or three meals from there and trying to be good about eating fairly liberally. I was trying to prevent exactly what you said. I noticed that same thing where even if I’m eating moderate to higher carb, but one day I just under ate, it can sometimes perturb my sleep. So, I tried to be pretty generous with the caloric intake. What if someone was keeping their caloric intake at a decent level and not doing too much fasting? Do you have any tricks up your sleeve on how to help someone who may have a hard time sleeping if they’re in ketosis?

DrRS:

Basically, I’ve actually found that one of the key things is that last meal. So, having some starches with dinner – whether it’s potatoes or rice – and I’ve had some patients do resistance starches, too and that’s kept their glucose pretty stable during the night. And they’ve done really well, in general. For me personally and in most of my patients, I recommend what’s called carb ramping where you’re much more restricted with those earlier meals, but in the evening most of my patients tend to do well when they do have a little bit of the extra carb load on the end part of the day in terms of sleep. I think that’s the thing that I’d definitely keep track of the most. So many patients, even independent of their carb levels, there are so many other reasons they’re not sleeping well. The other thing is the timing of the dinner – some people are just finishing their dinner too early. If they’re finishing at 4:00 PM or 5:00 PM, I do encourage them to maybe push that dinner out by an hour or so… maybe they can finish dinner at 6:00 PM or 7:00 PM or even up to 8:00 PM and include some starches with that to see if they actually sleep better. In most people, that can make a difference.

DrMR:

The carb back loading makes sense. Part of the reason why I had historically eaten dinner a little bit later, was I came from a lower carb history and I was noticing that if I ate too early, I wouldn’t be able to sleep. I think I fumbled my way into your comment there about pushing the meal back a little bit if sleep is challenging.

Dr Ruscio Resources:

Hi, everyone. If you are in need of help, we have a number of resources for you. Healthy Gut, Healthy You – my book and your complete self-help guide to healing your gut. If you’re not a do-it-yourselfer, there is the clinic – The Ruscio Institute for Functional Medicine – and our growing clinical and supporting research team will be happy to help you. We do offer monthly support calls for our patients where I answer questions and help them along their path. Health coaching support calls every other week. We also offer health coaching independent of the clinic, for those perhaps reading the book and/or looking for guidance with diet, supplementation, etc. There’s also the store that has our elemental diet line, our probiotics, and other gut health and health supportive supplements. And for clinicians, there is our FFMR – The Future of Functional Medicine Review database – which contains case studies from our clinic, research reviews, and practice guidelines. Visit drruscio.com/resources to learn more.

Breath Ketone Monitoring

DrMR:

Are you doing much with the breath ketone monitoring? Or any ketone monitoring, in general?

DrRS:

Only with my patients and myself personally, I’ve done blood ketone monitoring. Next on my checklist is to try the breath ketone monitoring. I’d love to hear about your feedback and experience. Obviously, there is a great practical and compliance factor with using breath related ketone devices. You probably miss out on a certain level of precision, but would love to get your feedback on how that experience has been.

DrMR:

I don’t profess to have a super deep working knowledge of keto dieting. It’s not something we often recommend at the clinic, so I don’t really have a lot of tools for that. I was assuming that I could get myself into ketosis in a couple days. And I was able to, but not as high as I would’ve thought. The breath ketone meter goes from zero to 10 – it’s this unit called ACEs which is somehow calibrated to the BHB in the blood. After the low carb/no carb OMAD on Sunday, and then 30 grams of carbs on Monday, I was thinking Tuesday afternoon I was going to be deep in ketosis. And I was still at a paltry one or two. I’m not sure if getting deeper in takes longer? Is that something you’ve noticed? Does it take days or weeks to get someone into ketosis?

DrRS:

That’s a good point. I’m definitely not going to say that I’m a keto master here, too. Actually, most of my patients could not even handle doing the ketogenic diet for very long. Sometimes I have to have them dip into ketosis or do it intermittently, but many of them will just not be on a ketogenic diet. But one thing that we do know, and I think this might be your case in particular too, because you’re somebody who I can tell is very metabolically healthy. You’ve dabbled in low carb for a long time. I think your muscles are probably really good at using fats and ketones for energy already. So, part of this is utilization. A lot of really fit, healthy people that have been low carb, or they’ve done fasting for a while and they decide to go on a ketogenic diet… Well, guess what?

DrRS:

They were probably on somewhat of a ketogenic diet already because if they’re doing 16:8, 18:6 type fasting, they’re spending some part of that day in ketosis. They’re already keto adapted. And what that literally means is when the liver is actually producing ketones, the muscle is soaking that up for energy. The brain’s taking that on for energy. The level that you read on a meter doesn’t necessarily correlate with you being in a higher level of ketosis necessarily. I guess it does if it’s blood ketones – you’ve technically got more ketones in the blood, but when you’ve got metabolically active muscles just from being really healthy, they’re soaking up those ketones. The brain is using it, as well. You may not necessarily see a large number. For my newbies – my patients that are actually not metabolically healthy – it takes them longer to get into ketosis because their muscles have not been in the habit of using fats. This is like a new condition for their body. And interestingly, when they finally hit ketosis, after a few days, their levels come back super high, but it’s not like they’re in a higher degree of fat burning. It’s just the fact that their muscles are sort of getting used to taking the ketones, but a lot of it is still hanging out in the blood, if that makes sense.

DrMR:

Yeah. Interesting. That makes a lot of sense to me because I was a bit at a loss. I can’t be this unable to burn ketones, as someone who has done low carb for a while and haven’t been high carb. I’ve done a few stents, but certainly I’d say skew more in the other direction — fairly low body fat.

Episode Wrap-Up

DrRS:

I guarantee you were a partial ketogenic person already without even knowing it before measuring this. This is a key point, Michael, because a lot of people are in that boat. I often see patients that are not familiar with this that when their ketones aren’t going high, they start fasting even longer and harder and they’re dieting even harder. Okay – now you’re just starving yourself. I think this is a good public health message – that more is not better when it comes to necessarily developing ketones. I think that’s a key thing.

DrMR:

And listen to your body over these devices, in a lot of cases. We’re still trying to figure out the nuances of these… the accuracy of some of these devices. You’ll get this in the literature with the Biosense device, but brushing your teeth will affect your ketones falsely… even having a little bit of vinegar with your dinner because it measures acetone rather than actually breath ketones. So, the user error on these can be fairly high and which is why we just have to make sure to step back. And if these devices are causing any sort of fear or neuroticism, take a step away. If they’re helping you inform your behaviors in a better way, use them, but it can be a slippery slope with using these the correct way.

DrRS:

That’s such a good point. Absolutely. With the generation of CGMs, especially the more accessible ones, there can be quite a wide band of error. You definitely want to be aware of that and make sure you’re not making the wrong decisions or having psychological issues as a result of using these devices. I’m glad you brought that up because it can be a big problem.

DrMR:

I noticed that. I notice that with how high or low on the tricep I position mine, I seem to get readings that make sense. And then there’s been, I would say, two of four seem to really not make much sense. And then one of four really made sense. And then the other moderately made sense. And part of that could have been my user error in terms of where I mounted it. But just as a point, it seems that the positioning may skew the numbers. So, as you’re saying, Ron, don’t get too worked up if things don’t seem to be adding up when you’re looking at your CGM.

DrRS:

Even at its best sometimes. Just explain to folks – these sensors are not measuring your blood glucose. That’s a bit of a misconception. They’re measuring the glucose in the interstitial fluid, which is a layer above the blood. And those things are not 100% identical and different situations can cause more of a disparity between both. It’s like using a body fat scale where the scale is not necessarily accurate, but the deltas and the fluctuations that you see or the progress over time, you’re looking for that improvement over that percent change — that can be accurate. The other thing is when you first put these sensors on – because I’m sure this episode is going to probably motivate at least some folks to go out and get a sensor – there is an adaptation period. For some of my patients, it’s 48 to 72 hours where the glucose is running rampant all over the place.

DrRS:

I think it’s a good idea to have a background glucose monitor. I’ve had some patients that have lows all the time and they can’t figure it out, but when they check the finger stick glucose, their value is completely normal. You mention the arm – For people that wear it too close to the side of the arm, when you lie on your side/sleep on your side, it’s going to compress the sensor. There are all these issues that you have to be aware of when you use these, otherwise you’re going to be looking at incorrect readings.

DrMR:

All great points. I think it’s important for people to have a healthy respect for some of these sensors and not look at them as being infallible – so as to not lead you too far astray. Ron, man, I feel like we could talk for another hour easily, but I want to be respectful of your time. Anything you want to point people to? A website, a clinic, maybe remind them also of your new podcast?

DrRS:

Oh yeah, sure. I mean the best resource for a lot of my writings and my free e-books is my blog and that’s at culturalhealthsolutions.com. I have been spending a little bit more time (more than I’d like) on social media – on Instagram – I am @RoneshSinhaMD there. The main place to really go to learn about this stuff in depth, if you’re into this stuff, is my Meta Health podcast where I really dig deeper into these issues. So, those would be some good places to start.

DrMR:

Sweet, Ron. Well, thank you for talking shop here. It’s always fun connecting. Until the next time.

DrRS:

Alright, sounds great. Take care. Thanks, Mike.

Outro:

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