Hitching a Ride on the Blood Sugar Roller Coaster - Part 1

We have all heard that eating too much sugar could eventually result in a diagnosis of Type 2 Diabetes. However, just because you have not been diagnosed with diabetes, does not mean your body is tolerating the amount of sugar in your diet.

In 2017, Outside Magazine published an article titled Are Endurance Athletes More Susceptible to Diabetes? In it, the author introduced an endurance runner who also happened to be an intern at the University of Canterbury Center for Bioengineering, which was researching the clinical potential of continuous glucose monitors (CGM).

After a hard bonk in her last ultra endurance event, she wondered if she could use a CGM to help her better understand her blood sugar levels during a long run, see when her levels started to drop and prevent the bonk all together by using exogenous glucose (aka- a gel). After some self experimentation and seeing some potential for future research, she soon found herself in a PhD program studying the potential uses of glucose monitoring in athletes.

​In 2016 her first initial pilot study on ten runners and cyclists was published in the Journal of Diabetes Science and Technology and the findings were quite a shock. 

“Instead of bonk-inducing blood sugar lows, the more common problem in her subjects, who typically averaged at least six hours of training a week, was high blood sugar throughout the day—an outcome that pointed to an elevated risk of Type 2 Diabetes in these seemingly super-fit athletes. ‘I was incredibly surprised to see the results,’ Thomas says. ‘It seemed contrary to almost everything else in the field.’”

Her initial findings were that 3 out of 10 athletes in the study had fasting blood glucose levels that were by the ADA definition, in the pre-diabetes range. Although the current numbers don’t support the claim that endurance athletes are more susceptible to diabetes, there is certainly a very large range of pre-diabetes that many of us sit in. ​

We Eat a LOT of Sugar
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Today, more than 1/3 of Americans over the age of 18 have pre-diabetes. That means that if the initial data from the study mentioned above actually correlates out when a larger study is completed, slightly less than ⅓ of athletes are also pre-diabetic. That’s frightening!  

Pre-diabetes is a condition in which blood glucose levels are higher than normal, but not high enough for a diagnosis of diabetes. If lifestyle and dietary intervention is not done, pre-diabetes can easily develop into Type 2 Diabetes. 

One of the most challenging aspects of pre-diabetes and Type 2 Diabetes is they are often accompanied by NO symptoms. Occasionally, people complain of increased thirst, frequent urination, extreme hunger, fatigue and irritability.  I don’t know about you, but those are things I can feel quite regularly during a block of hard training and easily brush it off as such.

You Don't Have to be Overweight to Develop Diabetes
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Many people believe that pre-diabetes and Type 2 Diabetes are diseases that only affect people that are overweight or lack a regular movement routine. Additionally, many athletes and medical professionals believe that if someone workouts all the time and are generally lean, that they cannot become pre-diabetic or Type 2 Diabetic.

Finally, after years of these false beliefs, we are starting to see (even in medical literature) that pre-diabetes and Type 2 Diabetes can affect athletes and sedentary people alike.  

Dr. Timothy Noakes, a South African researcher and author of The Lore of Running is an advocate for a blood sugar controlled diet for athletes after years as an endurance runner, he himself developed pre-diabetes.

A similar story exists for Dr. Peter Attia. Cardiologist, founder of the Nutrition Science Initiative and endurance athlete, Dr. Attia discovered in 2009 that he too had developed insulin resistance. Both doctors believe that a diet high in refined carbohydrates is to blame for their (and many other endurance athletes) blood sugar conditions.

For these reasons, the constant conversations I have with my athlete clients regarding energy levels, and my own personal experience with blood sugar regulation, I’m dedicating this month to providing more education on blood glucose.

​Of course this education is great for EVERYBODY, but I am particularly interested in helping athletes better understand how to manage their energy levels without developing a disease like Type 2 Diabetes!

This is a HUGE topic and in order to make it digestible, I’ll be dividing it up over the next few weeks. So stay with me as we get started with understanding the basic physiology of blood sugar regulation and why you should be monitoring yours!

Basic Physiology
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The body prioritizes blood sugar regulation over other bodily functions to ensure that the brain and other organs have the necessary energy to operate. Our body was designed to use a variety of macronutrients (protein, carbohydrates and fat) for energy sources.

Each human body has its own specific formula for how much of each of these macronutrients it needs to maintain optimal health and wellness. If the specific formula is off, you become susceptible to disease. There are many factors that play a role in your own specific nutrition formula, such as genetics, stress and activity levels.

Carbohydrates are the fastest burning of the 3 macronutrients. When properly digested, all carbohydrates turn into sugar in the body. Once these sugars are absorbed into the bloodstream, a healthy body will release insulin (a hormone) into the blood to help store these sugars away in the liver and muscles.

The liver and muscles have limited storage for these sugars. If the consumption of carbohydrate (or sugar) is higher than our body’s storage in the liver and muscles, the body will convert the excess sugar into fat and store it in fat cells, in which we have an unlimited storage.  

Since carbohydrates burn faster than fat and protein, a diet that is high in carbohydrates will require frequent consumption of carbohydrate to keep energy levels up. If this cycle of frequent consumption of carbohydrates is repeated day after day, month after month, year after year, the body can become less effective at producing and/or using insulin to store away digested carbohydrates.

Once this process begins, we see levels of sugar in the blood begin to rise. This is the very early stages of Type 2 Diabetes (pre-diabetes) and typically there are little to no symptoms associated with the early stages of pre-diabetes and the rise in blood sugar levels. 

For athletes, we obtain most of our energy from sugar (either exogenously from the foods we eat during training or endogenously from our stored sugar in the muscles and liver). We can obtain some energy from fat, but this can be a slow conversion and is a system that needs to be trained.

The major benefit to undergoing this adaptation process is that it is well known the body can only absorb so much energy per hour. Most endurance athletes are burning much more than they can comfortably consume in the gut and will inevitably hit the notorious “wall” and bonk at some point.

​If you train your body to be able to obtain energy from your own stored body fat in a more efficient way, you can conserve your limited glucose supply for later in your training or race or when you really need it. 

If you’ve never gone through the process of training your body to burn more fat for energy, it’s something to consider. I have a 6 week program specifically for this called the Keto Reset and you can learn more about it by clicking HERE. ​

How Blood Sugar SHOULD Work
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When you wake up in the morning after a 12 hour fast, your blood sugar should be at a healthy level, around 85 mg/dL.

After consuming a well-balanced meal, the body digests the macronutrients from your meal and they are absorbed into your bloodstream. This causes a healthy rise in blood sugar over the next 2 hours (to around 115 mg/dL) and a signal to the body to release the hormone insulin from the pancreas.

Insulin’s job is to remove any excess sugar from the blood and store it in the liver and/or muscles for later use.

After a few hours without a meal, the blood sugar levels begin to drop back toward the fasting levels (85 mg/dL) and the brain sends a signal to the pancreas to release the hormone glucagon.

Glucagon's job is to release stored glucose from the liver back into the bloodstream to be used as energy until the next meal is consumed.

NORMAL BLOOD SUGAR LEVELS should be between 80-99mg/dL fasting and should range between 85-115 mg/dL throughout the day.

How Blood Sugar Can GO WRONG
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When you wake up in the morning after an 8-12 hour fast, your blood sugar should be at a healthy level, around 85 mg/dL. However, if the hormones that regulate blood sugar overnight cannot function properly, it is not uncommon to see blood sugar levels drop below 79 mg/dL. This often causes people to crave carbs, sweets and/or caffeine.

If a standard American breakfast of cereal, sweetened yogurt, oatmeal, pancakes with syrup, fruit juice, sweetened coffee creamers, etc are consumed, the body digests the macronutrients from your higher sugar/carb meal, absorbs into your bloodstream quickly, and causes a rapid rise in blood sugar levels.

 In a standard American breakfast, it is not uncommon to see upwards of 30g of sugar in that single meal. Take for example a yogurt parfait. A single serving of Chobani black cherry flavored greek yogurt has 17g of carbohydrate (which includes 15g of sugar). Top that with 1/2 cup of organic Love Crunch granola, and you've added an additional 40g of carbohydrate (which includes 12g of sugar). That's a 400 calorie breakfast that includes 57g of carbohydrates and 27g of sugar!!!! WHOA!

Your hormones are fighting to keep approximately 5g (that's 1 tsp) of sugar in your blood stream at any given time. That means that your "healthy" greek yogurt parfait just created a crisis in your body because you now have over 5x the amount of sugar in your blood stream. This causes the body to rapidly release the hormone insulin from the pancreas in response to the high levels of sugars in the blood.

As mentioned earlier, it is insulin’s job is to remove any excess sugar from the blood and store it in the liver and/or muscles for later use. However, we only have a limited amount of storage in our body for sugar. So that excess sugar that doesn't have a place for storage, guess what happens to it?

It turns into FAT.

Because lucky for us, we have an unlimited storage for fat. But that fat topic is for another day...let's get back to what's happening to your blood sugar...

So that rapid spike in blood sugar, creates a rapid release of insulin, which rapidly drops your blood sugar and easily creates a another low blood sugar situation. This creates more cravings for carbs, sweets and caffeine, and the vicious cycle starts over again a few hours after your breakfast.

If this cycle isn't addressed with more balanced meals (less carbs and more protein and/or fat), the body will eventually become less capable of creating the amount of insulin need to drop your blood sugar levels into the normal range. This is what is known as insulin resistance.

Insulin resistance creates higher than normal levels of blood sugar throughout the day. If using a blood sugar meter, you will see levels ranging between 100-199 mg/dL regularly. If this condition is not reversed with lifestyle and dietary interventions, your blood sugar levels will continue to rise.

Once a persons fasting blood glucose level goes above 200 mg/dL, they will typically be diagnosed with type 2 diabetes.

Fasting PRE-DIABETIC SUGAR LEVELS are between 100-199 mg/dL.
Fasting DIABETIC SUGAR LEVELS are above 200 mg/dL.

Complications from Blood Sugar Dysregulation
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Blood sugar dysregulation disrupts all aspects of human physiology, including:

• energy
• the integrity of the tissues of every organ and blood vessel
• hormonal balance
• brain health

People can begin to experience anxiety, agitation, depression, fatigue or high levels of stress when blood sugar is out of normal ranges (either too high or too low). This is because the hormones regulating fuel distribution affect your mood.

Diabetic nerve damage (neuropathy) can also occur and affects approximately 60-70 percent of patients with diabetes. The longer a person has diabetes and the greater the degree of severity, the greater the risk of neuropathy. Neuropathy affects the nerves in the lower extremities first: the feet, hands and also the arms. Symptoms include tingling, numbness, burning and pain. The constant pain of diabetic neuropathy can be debilitating and worse for some people at night.

Heart attacks are a known complication of diabetes. When the blood vessels supplying the heart are damaged, the body responds by depositing plaques of fatty material, known as cholesterol, within the inner walls of the blood vessels. As the body works to repair the damage, the blood vessels narrow and harden with this plaque. The blood is not able to supply oxygen through the narrowed vessels, resulting in the death of part of the heart muscle. 68% of diabetics aged sixty-five or older will die of heart disease, and a further 16% will die of stroke.

Identifying Sugar
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When many people think of sugar, they think of foods like cookies, cakes or cereal.

Yet sugar is hidden in over 80% of other foods like catsup, relish, mayonnaise, crackers, bread, canned fruit and even low-fat yogurt!

Food manufactures have different names for sugar, making it very confusing for people to identify sugar as an ingredient.

​Some of the other names listed for sugar are: dextrose, barley malt, disaccharides, fruit juice concentrate, lactose, malt and sucrose, to name a few.

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​Types of sweeteners (from best to worst…):

• NATURAL SUGARS such as unrefined raw honey, raw cane sugar, and fruit, that when unprocessed, maintain some nutrient value to the body.
  
• NATURAL SWEETENERS such as stevia. Usually an herb. It tastes sweet but is not sugar. The more they are processed, the less healthy they are.
  
• REFINED SUGARS such as white cane sugar, processed honey, agave and corn syrup. Natural in origin, but the refining process generally makes them unhealthy.
  
• SUGAR ALCOHOLS such as xylitol, erythritol, sorbitol and mannitol. Real food but highly processed. These sugar alcohols are incompletely structured and are likely to cause digestive upset.
  
• ARTIFICIAL SWEETENERS such as splenda and aspartame. These are man made chemicals that are made to taste sweet. Artificial sweeteners, such as aspartame, Nutrisweet and Equal, which carry no caloric value,  have been shown to increase your risk of a metabolic syndrome by more than 34%. Additionally, there is a 43% increase of a vascular event (such as stroke and heart attacks) in those that consume artificial sweeteners regularly.

Since athletes need to consume carbohydrates to fuel longer workouts, finding the right sugars in the right balance is key! Stay with me as we explore exactly how to do this over the next few weeks.​

Reading Labels
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The American Diabetic Association recommends a daily sugar consumption below 20g for women, 36g for men, and less than 12g for children. The average American consumes 71.14g of sugar every day, well over the recommended amount. One of the simplest ways to reduce the intake of added sugar is by learning to read food labels.

Look for foods with 5g of sugar or less per serving!

Keep in mind that:

• As of July 2018, added sugars are listed separately on food labels in America, but not in all countries.
• Naturally occurring sugars from whole foods are not considered added sugars.
• Lactose is the naturally occurring sugar from dairy. The amount of sugar from dairy can vary from product to product. Generally speaking, there is approximately 5g of sugar per 100g of dairy with no added sweeteners.

Check the ingredient list for any added sugars!

There are currently 61 different names for added sugar in the US, which makes them challenging to identify. 

The main things to keep in mind are:

• Words ending in “-ose” are added sugars.
• Words ending in “-tol” are added sugars.
• Words such as “syrup,” “juice,” “concentrate,” and “crystals” are sugars.

Just because the label lists “zero” sugar, does not mean that there are no added sugars in the ingredients. You must check both!

Monitoring Your Blood Sugar
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One of the best ways to prevent (or reverse) pre-diabetes or Type 2 Diabetes and discover exactly how your specific body tolerates different types of carbohydrates/sugars (the type, load and frequency) is to monitor your own blood sugar levels.

This can be easily done with an at home blood glucose monitor. These monitors are sold over the counter at many drug stores and range from $20-$50. If there is one single thing you can do to discover your own personalized diet and monitor your own health over time, it is to use a blood sugar meter regularly.

To test, always start with your FASTING blood sugar in the morning before you do anything like eat, drink, or brush your teeth. Follow the instructions included with your specific kit to get an accurate test result.

Healthy fasting blood sugar readings should be around 85mg/dL. Consistent fasted readings below 80mg/dL may indicate hypoglycemia, and consistent fasted readings above 99mg/dL may indicate pre-diabetes. Keep in mind that there are other factors that can affect your blood sugar, such as sleep and stress (more on this coming up!)

The most important part of blood sugar testing is to be consistent. Timing is everything. It is highly advised that you set an alarm to make sure you stay consistent with testing for 7 days. This will allow you to start seeing a pattern. It is important to note that there is a degree of error with all blood sugar meters.

The goal is not to become fixated on each and every number, but to see all the numbers together and the pattern they create. To get the most out of testing, you should also be keeping a food and lifestyle journal and be noting things that affect your blood sugar, like: sleep, stress, exercise, macronutrients, and hormone cycles.

Coming Up Next
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Understanding blood sugar and learning how to balance it takes a bit of time.  That is why, rather than inundating you with information, I have decided to dedicate the entire month of September to teaching you the ins and outs of blood sugar and how balancing it can be crucial to your athletic performance and overall health.

Coming up next, we continue to talk about blood sugar, with a stronger focus on how to find a better balance between carbs, fats and proteins so you can fuel your workouts appropriately and not put yourself at risk for developing disease.

If you have any questions about blood sugar, you can email me!  And, if you’re ready to take the next step by becoming a fat burning machine rather than an exhausted sugar burner, then sign up for the Keto RESET Program waitlist!  This 6 week course is dedicated to teaching you how to transition your body so that it can efficiently burn fat for fuel allowing you to experience vitality and great health.

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REFERENCES:

1. National Institute of Diabetes and Digestive and Kidney Diseases. Nerve damage (diabetic neuropathies) 2013 Nov. Available from: http://www.niddk.nih.gov/health-information/health-topics/Diabetes/diabetic-neuropathies-nerve-damage-diabetes/Pages/diabetic-neuropathies-nerve-damage.aspx Accessed 2017 Jun 6.
2. American Heart Association. Cardiovascular disease & diabetes. 2015 Aug. Available from: http//www.heart.org/HEARTORG/Conditions/More/Diabetes/WhyDiabetesMatters/Cardiovascular-Disease-Diabetes_UCM_313865_Article.jsp/#.WZYRWK3MXE4 Accessed 2017 Jun6.
   
3. Lutsey PL, Steffen LM, Stevens J Dietary intake and the development of the metabolic syndrome: the Atherosclerosis Risk in Communities Study. Circulation. 2008 Feb 12; 117(6): 754-61.
   
4. 2016, March. 2015-2016 Dietary Guidelines for Americans, Eighth Edition. Cut down on added sugars.​