The Ultrarunner's Gut with Patrick Wilson PhD RD⎮KoopCast Episode 17

what's going on folks welcome to another edition of the KoopCast i am your host as always Jason Koop and today's edition is going to be all about the ultra runners gut if you've been around the sport of ultra running for long enough you know that this is an issue that completely plagues ultra runners of all different calibers during racing and also during training and so i brought on the show today patrick wilson who is an assistant professor of exercise science and directs the human performance laboratory at old dominion university and he also is a registered dietitian which is a pretty powerful one-two punch out there in the world of sports nutrition and sports science i used some recent travel that i had out to the canary islands to the trans grand canaria race and i parlayed that into going and visiting him at old dominion university and sitting down and talking about a new book that he wrote that i just happened to get an advanced copy of called the athlete's gut and i have to tell you i think the book is extremely well uh laid out it's going to end up being a fantastic resource not only for ultra runners but for all different uh uh types of athletes uh so we took this conversation and we really kind of focused on three big things is first

off why the athlete's gut is important it's more than just a delivery system for the food stuff that you that you eat we then spent uh a bit uh a good chunk of time pretty much the majority of the interview talking about how to train the gut and what we know and what we don't know about training the gut and its implications uh for training and for racing and then we also took we talked about how psychology plays into this complex interaction of nausea and or uh vomiting that that ends up occurring not only during racing but also during training i think it's i think this episode is really chock full of a lot of practical tidbits that you can get and you can really readily implement tomorrow on your training run or if you're actually listening to this while you're training you're probably going to end up eating a whole lot more to be quite frank with you um so sit back kick back get your popcorn ready that would be a very appropriate thing to do for a nutrition talk get some popcorn ready and uh settle in for this conversation that i had with uh patrick wilson on the ultra runners gut i was uh thinking on the way down here about what the title is going to be and i was gonna you know where i'm going with this i think um and so i was gonna riff off of the the title of a book and just call it the ultra runners gut but i i thought to myself that when

i put that title out there ultra runners are probably going to think of like two different things they're gonna they're either going to think of like the abdominal adiposity right that they have like actually having like a big gut because you know ultra runners are you know like the beer gut yeah they have a beer gut or something like that or they're going to be so narrowly focused on like how many tater tots that they can consume at the next aid station or something like that so i don't know actually what the call what they call in advance but i do think it's a good like parlay into the fact that the gut and especially in the context of an athlete is more important than just a vehicle to consume and digest food right yeah i mean the gut obviously the main job is going to be breaking down and absorbing what you eat i mean that inherently is its main function however it's got other critical things that are going to be important in terms of an athlete being able to perform or do well it's a site of immune defense it's a extension of your nervous system so undoubtedly the way that your gut is functioning is going to have an impact well beyond the local gut itself i mean it's going to affect your mood it's going to affect the way you feel and it's potentially going to affect your risk of things like infections so it's not just on its own it only digests and absorbs the nutrients that you consume and has a set of functions that are going to be critical for an athlete including ultra runners

and the other thing is that when it comes to performance if you don't feel well whether that be gastrointestinal distress or some other source of pain or discomfort you're not going to be able to perform well so just beyond you know the digestion and absorption aspect of the gut how you feel and the way you perceive about the way your gut is feeling is going to have a huge impact particularly endurance sports and ultra sports with respect to how you're going to perform and that shows up clearly in the research is that the number one reason why ultra racers drop out of races is because of gut distress and primarily it's nausea so even if you kind of focus and drill down for a lot of ultra runners that seems to be the most critical symptom in terms of causing problems at least problems in your severe enough for them to actually quit a race yeah and i think that's one of the reasons why ultra runners specifically when they start when they start talking about their gut or their gi system they're going to have this like fairly narrow focus on the nausea that emanates from an ultra marathon race specifically because it is so prevalent in that sport but as you were pointing out it has all of these other aspects and all these other functions that are not only critical for performance but also important for just general health yeah absolutely yeah so why don't we start to like set the table there and let's go over specifically how like the athlete's gut is

different and how it needs to function within the body and then try to translate that into ultra marathon specifically i mean in terms of differences with the average person i mean i think structurally there isn't necessarily a huge difference it is the demands that especially an ultra athlete can place on their gut is going to be very different from the average person though and that can be day-to-day training and the amount of food that an athlete is going to have to ingest to supply the energy for that training can be quite large especially during heavy training periods or during a race and then obviously being able to eat during exercise is not a natural thing i mean that's not necessarily something that's natural to humans i think it's a challenge for most people to consume digest and absorb food when they're exercising particularly for prolonged periods of time so an athlete's gut is going to have to be trained in a way they have to accustom their guts to being able to handle eating especially in larger amounts during exercise which really isn't it's a not a natural i think thing for most people for most humans you don't have this inclination to eat in most cases during exercise at least the type of exercise that most people are doing yeah and you mentioned it's a big factor i mean we've in in your book the athletes guide mentions a study by marty hoffman that i actually mentioned in in my book as well where they

surveyed athletes after the western states 100 i think it was rio del lago as well just to get a bigger like sample size and the number one issue that they all encountered was nausea and or vomiting but to to relate to the point that you made earlier about trainability what i actually found more fascinating about that survey and just to set the survey up a little bit for the people that are that are listening to this they pulled people after they completed either one of these races and they asked them what you know what affected your race performance what affected your race performance and you had this menu of things to choose from and you could choose one or all of them and of course nausea and or vomiting rose to the top of the list and but in the middle of the list was inadequately trained and when i put my coaching hat on and i look at that i go wait a minute if you're suffering from anything in an ultra marathon you're inadequately trained for that particular stress and what i what one of the things that i took away from that is there's this big discrepancy between how athletes think about nausea and or vomiting which is the category that the hoffman group was was uh was giving that particular ailment and it's trainability and we're going to come back to that in a second because that's a fascinating area and one that i don't think we have really clear answers on but i think

needless to say i don't think a lot still a lot of athletes have this they just have this gap between what is trainable and what is not particularly when it has to do with digestive systems and food stuff so why don't we take it out of an athletic context for a little bit and talk a little bit more about competitive eaters which i think is a fascinating area as well but it demonstrates how malleable the system is right yeah yeah i mean it's it's something i talk about a little bit in the book because i think it's an interesting um population that obviously their goal is to consume large quantities of food in a very short amount of time now obviously athletes ultra runners that's not their goal but you can maybe start to think about how at least some of that stuff could translate uh in a situation where you do have to consume more food than what you're used to or maybe you want to naturally uh in a prolonged endurance event but yeah i mean there's you know obviously people like joey chestnuts kobayashi i mean they're eating i think the world record if i remember right is about 74 hot dogs in 10 minutes and that's with the buns so that's about 20 000 calories so about you know seven to ten days worth of food in a single sitting essentially and they weren't born with that let's be clear no i mean there's no way that you are born with that uh entirely with that uh capacity to consume that amount of food i mean they they will talk about in interviews progressively increasing the amount of food or water or fluid they consume over you know the weeks

and months before these competitions it's classic progressive overload it is like when you when you actually i'm glad that you mentioned the interview because i took the same thing away from some of those interviews when i see them on espn or whatever i'm like oh that's progressive overload training i don't know if they periodize or if it's a block scheme or what they're doing but yeah they're definitely progressing it to the point where in the competition they feel like they're at their peak to be able to you know consume a large amount of foodstuffs in a short amount of time you know the adaptations i think physiologically are not well understood in that population because there really aren't actually many studies with competitive eaters there's one where uh they had a guy who's a competitive eater um basically eat as many hot dogs as he could in that amount of time and then they compared him to a control and they said the control had a hearty appetite was their description of of what the comparison was they wanted somebody to compare this guy to and they basically did an x-ray type movie analysis when he uh downed these hot dogs for this study and you could just see the pictures in the journal article i mean it looks like there was a fireball explosion inside of his gut i mean it's a massive amount of food so what you see is that they're able to accommodate really large amounts of food um through maybe a greater relaxation of the stomach but to a large extent it seems like it's just tolerance like they're able to tolerate that same volume way better than anybody else could the stomach actually doesn't quick and hollow fast it empties in that situation it's just largely it seems

like it's a tolerance thing and a distension of the stomach in a combination uh so that's that's one example of you know speed eaters how that translates to athletes obviously that's a bit of a stretch but it shows you that the gut is adaptable what you put into it um is going to have an impact on how it functions so that naturally is going to have some sort of implication for what an athlete might do during an event during their training to make sure that what they're putting into their gut they're ready for and they've experienced before it's not the first time they've done it yeah and although ultra runners are quite renowned for trying to eat copious quantities of food at aid station they are not going to compare to a joy chestnut or any of the other competitive eaters i mean that's on a totally kind of on a totally another level okay let's kind of bring it back to ultra though i like the i like the analogy though because it shows that some aspects at least some maybe not all of them of training the gut can be analogous to just like any sort of other physical training where your heart you know your heart changes with physical training your muscles change with physical training your ligaments change with physical training and things like that the gut is an organ right and with the gut like the gi system it's all it's all an organ and it can adapt depending upon what it's exposed to essentially yeah i mean i agree some of the adaptations are probably nutrient specific meaning if you put in uh to the diet a lot of carbohydrate or glucose the changes in terms of like how quickly

those things empty from the stomach will be specific to glucose or to carbohydrate some of the other adaptations my guess is that they're just more generalized so volume if you put a lot of stuff into the stomach in a short amount of time i think the perceptual changes you get with that the greater tolerance to a large degree has to do with just volume it's not necessarily a nutrient specific adaptation so yeah there's some that are maybe just volume then there's nutrient specific and then there's just things perceptually that change once you become accustomed to eating things either at a greater rate or in specific situations like exercise yeah it's the honest truth is we don't have a lot of data on the trainability of the gut specific to exercise most of this stuff is in other populations and there's a pretty limited amount of research specific to athletes how do you train the gut and does that impact performance let's not go too far down that rabbit hole yet let's continue to kind of like set the table because there are different issues that athletes and that ultra marathon runners are going to kind of encounter that are specific to their gi system and we what my opinion on this is is we tend to oversimplify or trivialize them all underneath this umbrella of gi distress yeah exactly and they can be several different very specific things and the reason that that that is important is depending upon what flavor of gi distress you have or what type of gi distress you have the pathway out of it or even the trainability to make it better can be different so what why don't

you take some time and let's go over all of those different like types yeah and why they might be specific or not specific to ultra marathon running yeah i mean that's a a great question and and thought in terms of if you read articles whether they be scientific articles or publications on you know the internet or wherever else usually they just kind of say gut distress right and as you're saying they're not the same phenomena they're sometimes different now there are things that will commonly make all symptoms worse like if you are super dehydrated or if you are somebody who is just overly sensitive to things in your environments sort of hypersensitivity is what we call it there are things that make most symptoms worse but a lot of these symptoms there are maybe specific causes so that if you're looking to fix nausea for example remedies that fix abdominal cramping may not apply and that's part of the book you know the athletes got to go through and um in chapter two and go through basically every symptom you could probably imagine and talk through what are the specific causes for each of those symptoms sometimes they're similar and sometimes they're not i think nausea and this is more related to the ultra endurance community is probably the most complex in terms of what can cause it you can have um physical stimuli you can have chemical stimuli i think for ultra runners a lot of times what you see happen is that over the course of a race as you get into the latter half especially like a hundred mile

race the amount of things in your blood that are likely to provoke nausea in the brain go up so you've got adrenaline you've got uh glucagon you've got arginine vasopressin that's a water conservation hormone you've got muscle breakdown products you've got endotoxins which are things that have come from the environment or now in your blood because your gut has become leaky so it's just this stew of stuff that builds up in your blood that particularly as the race gets into the you know 50 to 70 to 100 mile territory that's why you see rates of nausea as high as 60 percent in 100 mile races the other 40 percent are lying and the other 40 either they don't know what nausea is because sometimes you ask people in a study like are you nauseous yeah it's still perceptive right and they're like what does that mean again sometimes people don't know and then sometimes people don't want to say yes when they really are but it's it's the bulk of people in an ultra race have nausea so i think that one is probably the most complex and can be honestly one of the most difficult ones to really pick out what's the cause in any given situation because you have to evaluate all those possibilities that's just a short list of stuff i mean there are other things going on nutritionally health-wise that can cause that problem so then you go down kind of if you go down the chain you've got reflux regurgitation burping for most athletes unless it's really severe it generally probably isn't going to impact

performance burping and flatulence gas are the two most common symptoms that athletes report but they're usually not severe enough for them to quit a race no those are badges of pride right in ultra yeah for sure so those are common very common but not for the most part uh overly concerning for most athletes stomach discomforts fullness bloating is another one that is really common i think behind behind nausea bloating was um the next most kind of severe symptom in those studies that marty hoffman did that athletes indicated were problematic for them and then from there you go more maybe into the lower gut you've got abdominal cramping loose stools urge to go number two uh bloody diarrhea bloody stool gas flatulence um so it kind of runs the gamut and the point is that there are potentially different causes for each of those symptoms you know it would be impossible to go through all those in a short interview and kind of talk about what are the causes i think maybe it's helpful to focus on like the nausea for example to a large degree because that's the one that is most problematic for most ultra racers ultra racers would be my thought okay so we'll we'll stick on that for the most part but needless to say there's this whole host of other things that you know the prevalence in an ultra marathon run that could be high could be low i mean even if you look at things like side stitches and as you mentioned diarrhea is a big you know can be a big issue but it takes a like it's complicated to unwind all of that

yeah but i think for the kind of the remainder of this interview the the focal point is going to be specifically this this like big umbrella underneath the bigger umbrella of nausea yeah and it's incredibly complicated and as you mentioned there's a there's probably a chemical basis for it there's a psychological basis for it there is uh exercise basis for it both in terms of time and intensity what other things are playing into this whole nausea concoction that ends up rearing its head during an ultra i mean i think you hit on a few of those things you have especially with prolonged exercise you're kind of struggling to supply blood to your gut and that can act as a trigger for most symptoms not only nausea but for the other symptoms that elicit that's one of those features that uh one of those things that generally makes most symptoms worse and there's good studies to show that as you get you know from 10 to 20 to 60 minutes of exercise the amount of blood flow in the gut tends to decline and that's in a even in a hydrated state so if you take an athlete who is dehydrated it's even a smaller amount of blood that they have available to supply uh to their gut so under hydration certainly can play a role um if someone is well below where they probably should be in terms of their hydration status now interestingly at the same time over hydration can actually do the same thing if you've got fluid overload you're hyponatremic that extra fluid in your vascular space can kind of migrate into

your brain cause swelling that triggers nausea so that's another known symptom of hyponatremia is nausea it's kind of interesting that both dehydration and fluid overload from over hydrating can kind of do the same thing now there's other distinguishing features you can use to determine whether someone's hyponatremic versus dehydrated uh but just based on symptoms alone sometimes it can be problematic super tricky i mean they've tried to do that in the field for years right try to determine if somebody is hyponatremic over hydrated dehydrated or what you know combination of all those can actually be and it's it's very hard to do from the list of symptoms as you as you mentioned in terms of the other sources you know if you're going hypoglycemic potentially if you really have under eaten i mean the body's pretty good at regulating blood glucose during exercise but you might see 10-15 percent athletes or something like that if they're under eating develop hypoglycemia and that's going to trigger a further stress hormone response your catecholamines adrenaline noradrenaline and those hormones probably play a role in triggering nausea they get it into the an area of the brain that they bind to these receptors and those receptors communicate with another part of your brain called the vomiting center and it's not very imaginative but that's what they kind of came up with the name that basically tells you okay we may need to eject something from the body here as a way to protect it from you know various toxins or or substances that might be harmful so yeah if you think about

stress other things that provoke a larger catecholamine or epinephrine or epinephrine adrenaline response you tend to see more nausea in those situations so it could be a contributing factor if an athlete is under eating carbohydrates and they're somewhat hypoglycemic theoretically that could be playing a role i so one of the confounding things here is we know what causes a lot of these nausea symptoms in the actual race it's either over this or under that over consumption of this under consumption of that over drinking fluid undertaking blah blah blah blah blah but in reality what athletes have been trying to do is they've been trying to train themselves to combat all of those over under types of scenarios and they do that in in kind of two you have to excuse the the the food pun here they kind of do it that's going to be a lot of there's a lot of puns in the book so i mean there are a lot of references to the office too there is so if you don't like the office maybe it's not the book or you could brush up on the on your office you can watch it beforehand yeah yeah but anyway there's kind of like two flavors that athletes have or two two tracks we'll use that analogy i mean two tracks that athletes have have used to kind of combat this because they know it's going to be an issue the first one is to do something in advance of the event itself i'm going to train in some way to be able to combat all this nausea during the race and we're going to take that issue first the second one are more of kind of the

oh shit things that happen during the race i'm going to take you know the supplement i'm going to take ginger i'm going to try you know this i'm going to do this type of you know acid you know acid reducer you know in the days uh leading up to the event and things like that but let's talk about the training aspect first so what started to emerge in the ultra marathon world that i want to get your take on are these two somewhat but not completely divergent strategies one of them is training the gut where you're practicing your nutrition program and even something that might be above and beyond from a caloric or from a volume standpoint more than what you're actually doing in the race that's one strategy actually training the gut like you would train your skeletal muscles essentially the other one is to train your body to utilize more fat so that you are less reliant on exogenous foodstuffs whether it be a gel or a pizza or kind of whatever so that you don't have to deal with as much right food and drink and things like that kind of going through the system let's talk about the first one first the first one i talked about first that makes sense right training the gut what do we know about that so there's you know in terms of the exercise world there's been a couple of studies in the last maybe 10 years that show if you repeatedly ask people to consume extra carbohydrate in their diet either over two weeks or a month what you see happen is in up regulation or an increase in their ability to utilize that exogenous carbohydrate

for fuel so if you supplement for example uh an athlete's diet with an extra you know 100 200 grams of glucose per day let's say uh that's going to result in a better ability for them to absorb that glucose and then burn it for energy now why does that happen it seems like it's kind of a increase in these transporters that are in the intestine that help you take the glucose from the lumen the hollow space across the cell membrane into your intestinal cells and then into the blood so if you can better absorb that glucose it means a couple things number one you can use it which is great carbohydrates generally more efficient fuel than fat and number two it means it's not sitting in the gut and if it's not sitting in the gut it's less likely to cause symptoms because when you have glucose sitting in the gut what happens is you have water that's pulled out into the lumen that carbohydrate can get fermented later on in the colon that equals loose stools diarrhea gas bloating generally things that are not favorable for performance so there are at least two studies that have shown that if you supplement runners or cyclists with more carbohydrates that they are able to better burn exogenous fuel now the question is does that automatically translate to better performance and that's a more debatable question the studies were generally pretty short term so you know i don't know that there's a clear scientific answer on that i think if you are going to try and consume a lot

of carb during a race then it makes total sense to train that way uh and to practice it and to implement that in your diet yeah and let's before we get too far in the weeds here let's kind of back up and and go over what that actually might look like like you you you know you mentioned 100 to 200 grams of carbohydrate in addition but there's also studies the one that we threw out uh in advance of this podcast that cost the study yeah where they're consumed what was the rate on that 90 grams basically 90 grams per hour for two hours two hours for two weeks something like that yes it was two week protocol i think they did it four or five times over two weeks something like that and what i'm trying to get at is if an athlete wants to train the gut they need to know some sort of dosage to train it with it in terms of amount just like we do with physical training yeah we know we need to train 10 hours a week for four weeks or eight weeks or whatever it is i know that the research hasn't like completely flushed this out but what would be a reasonable strategy if an athlete says okay i know i'm gonna have to eat in training like i'm going to do in the race and i want and i want essentially train the gut to absorb more food stuff what would be a reasonable strategy for that athlete to undertake i guess i would probably start by telling them to take a look at what they're doing now and then gradually increase that over time but the upper limit in terms of what you probably would try is between you know 60 and 90 grams maybe 100 grams per hour during your training uh so that

can be and what does that end up being three or four gels on the high end uh so that's kind of max the max would would theoretically make sense once you start to go above you know 100 grams per hour the studies generally show that you don't further oxidize that carbohydrate and it basically just stays in the gut which is bad which is bad you don't want you don't want generally carbohydrates staying in the gut because it causes those gastrointestinal problems the question is you know how often do you have to do this for how long i think it's you know scientifically it's not clear i would say at least a few times prior to your race you're going to want to practice that rate for probably at least a couple hours ideally in the environment that you're going to exercise it in terms of maybe the humidity uh the the pace and try and mimic those same things as best as you can uh that you're going to experience during the race if you can i always have kind of viewed this as kind of a no duh solution like you know let's just say an athlete decides i need to take in 250 calories an hour during the race they've gone through their planning that's how much they need for whatever rationale they need to either train at that level or greater in order to be able to tolerate that stress during the race absolutely and i once again i make the physical analogy like if i had an athlete that i knew needed to average 10 minute pace for 50 miles i would sure as heck be be able i would sure i would make sure that they

could handle 10 minute pace for whatever their training distance actually looked like i wouldn't ask them to run eight minute pace during the race because it's something their body clearly can't handle yeah i mean i think if you just think you're going to go out for 60 minutes and practice it once or twice before a hundred mile race and feel like oh i practiced this it's going to be good to go especially when you look at nausea tends to be worse in the latter half of an ultra and you know people can get confused and other things can happen that can make it difficult to stick to your plan so if you haven't practiced that i mean that's obviously going to be a recipe for some athletes to have really bad experiences in terms of the their feeding regimen so yeah i would agree with that you want to at a minimum practice it at the intensity that you're going to be working at it's hard to probably mimic a full hundred mile race in training so i you know that's probably unrealistic to think that you're going to do exactly that during training is what you do in a race but um at least go periods of maybe multiple hours at that rate that you're eating to see how you're going to handle it yeah but still even at that it's this is kind of a logical guess from the extension of the research the research demonstrates that it's plausible that we can get some sort of adaptation if we stress the gi system in some way in his in this way it's over overfeeding essentially it's reasonable say okay if we did that and did it in a repeated fashion for weeks or maybe months leading up to the event that some sort of positive adaptation would occur yeah i mean i think the research is good enough to say that

if you take someone who's not accustomed to eating 90 grams of carbohydrate an hour have them do that and then have them train for a couple weeks and do that their symptoms will go down pretty dramatically so they do tolerate that more aggressive approach much better than when they first started and that's what the costa study showed was that gi symptoms were really actually bad the first baseline test they did it was like right 50 of people who had severe symptoms on this uh 90 gram per hour rate and then over the course of the study by the end those symptoms went down pretty um pretty significantly so yeah if you're if you're gonna try the very aggressive carbohydrate intake approach which isn't necessarily whatever athlete needs to do but if you're gonna try it then yeah i mean makes logical sense that you're gonna practice that in training and do it multiple times before your race we we've thrown out this like 60 to 90 gram of carbohydrate per hour recommendation a few times i want to back up a little bit for the for the listeners because this is a common recommendation that sports scientists nutrition scientists throw out for events that are that last beyond two to two to four hours and there's this really interesting divergence in the ultramarathon world where i think well i i know as a practitioner that that's a common recommendation and i would i would make the guess that many athletes have heard that recommendation as well yet and all of the research teases this out which you're very well well aware of

that is practiced by very few athletes in an ultramarathon setting and and it's not even close when they take surveys of ultra runners after races they're in the 30 to 40 grams per hour yeah which would be on the order of like one and a half gels or something like that so just to calibrate everybody 60 to 90 grams per hour would be two and a half to three gels would be 75 grams per hour so almost three and a half gels per hour for the entirety of an ultra there are very very very few people that actually can pull that off during a race and it leads me to one of two conclusions either the athletes are getting it wrong or the research recommendations are wrong in some way because the practice is very divergent from the recommendations i want to know what your thoughts are on that yeah i mean that's that's an excellent question i mean i've seen in the research to that and it's not only for ultra marathons but for other athletic endeavors if you look at even team-based sports or regular marathons the amount of carbohydrate that people consume is oftentimes lower than what the recommendations are i guess a couple points is one that a lot of these recommendations were based on higher level athletes and as endurance sports have gotten more popular you have more people participating who honestly probably don't need to consume 90 grams of carbohydrate per hour now that's what i look at it as it's maybe a little bit different because you self-select to people who

are going to be better who are going to be probably more uh not your weekend warrior type athletes so i think it's maybe a little bit more surprising that the intakes are sometimes lower with ultra runners but yeah i mean not every athlete needs to consume 80 grams of an hour of carbohydrate i mean that even ultra runners if you're mostly concerned with finishing and you're not simply worried about your best time ever then i don't know that it's is critical uh to have to consume that high level of carbohydrate the reason why you see those high recommendations to some extent is to see maximally how much carbohydrate can we oxidize because it's a more efficient fuel for than fat so if you're looking especially like a world record setting marathoner kipchoge uh to be able to run a two-hour marathon you basically have to completely rely on carbohydrate to do that right and you don't know enough glycogen stores to do that so if you want to maintain carbohydrate burning through that entire race you really have to consume a pretty large amount of carbohydrate and he does i mean he consumes 90 grams an hour of carbohydrate from the reports that i've seen so for an event like the regular marathon where the intensity is higher and the natural rate of carbohydrate burning is higher um and you're an elite athlete it makes a lot of sense to me to go high for a middle of the road ultra runner i don't know i mean it's it's up to them it kind of depends on their experience i don't think it's necessarily an absolute that they have to consume that much yeah i've just always when that research gets translated

down to the everyday ultra runner i just think that it gets misconstrued just from simple math because their caloric burn rate if you just take you know average mid-pack hundred mile finisher their caloric burn rate is going to be baby 700 calories an hour maybe at the most yeah at the very most and they're probably at a 50 50 split carbohydrate versus uh fat that they're burning so that means they only need to replace if they want to keep everything even 350 calories an hour and they've got a tank to deal with so i kind of like look at the math and i'm like wait a minute hold on 90 grams like like they're going to be in a surplus if they're 90 grams for a lot i mean just based on that math no i agree yeah if you look at energy expenditures it's hard for ultra races because you know you could have like a portable metabolic unit which a i think a couple of case studies have done you might see the energy expenditures on the winters you know if it's maybe a 50 to 100 mile i want to say it's that's where you start to dip below a thousand calories an hour it gets into the 700 to 900 for a good runner and then the middle of the road is probably 500 or 600 depending on who it is yeah you know logically it doesn't make sense to me that they would have to consume 70 80 90 grams an hour and the risk of gi distress does go up with that even if you train your gut there's probably some extra risk with that so middle of the pack ultra runner who's not super concerned about setting records or the prs and they're not going that fast to begin with you know practice what you think you're going to use and make individual adjustments based on your experience would be my recommendation this

is my last tangent on the 60 to 90 grams per hour yeah uh question i mean because once again i've seen it time and time again i've written about a lot and i sometimes i just kind of shake my head because of the specificity of that recommendation towards elite athletes and i still think that that we don't quite know some things as the distance gets longer but what's your opinion on how time dependent that is meaning can you actually can we know we know that the body can tolerate that rate 90 grams per hour if you have the right carbohydrate mix but i don't know and i don't think that it is actually known how long in theory or in practice that could actually be tolerated for because the studies on those are from an ultra perspective actually pretty short four hours yeah i think the longest is like four or five hours you know i don't know i mean the other thing was as you go farther out in distance the natural intensity of those events gets lower so the reliance on carbohydrate is probably less to begin with so my thought is the 60 to 90 grams per hour is probably most relevant for athletes who are doing things at an elite level from maybe two hours to four hours once you start getting into the ultra stuff does it or does it not help to go higher we really don't know to be honest if you're really pushing the boundaries if you are trying to set records then there is some maybe some theoretical justification for going high but for most ultra runners i don't know that it really is

that solid in terms of translating what the research says to what practically makes sense for an average athlete yeah i like that i i appreciate that yeah okay that's enough down that rabbit hole so we're talking about the ways that ultra runners kind of cope with nausea and these two kind of divergent strategies one of them is training the gut and just to summarize that you're essentially having to take in the count the calorie count that you would have taken in during the race for in training sessions for a few to several weeks before the race in order to get any sort of adaptation that's an extension of the research that's out there it's not known but it's a reasonable extension of that research there's this other strategy that's it's almost in a polar opposite direction because one of them is i'm going to train things to tolerate more and the other the other strategy is i'm going to train things so that i don't need as much of it um and that is training your body to utilize more fat now i want to kind of stick with their theme here of the athlete's gut yeah so when an athlete takes on any of the fat adaptation strategies whether it's a day-to-day nutritional intervention or a fasted run or back-to-back runs why don't you walk the listeners through what are the changes that happen to the gi system whenever an athlete undertakes those so yeah you've got basically macronutrient specific adaptations that happens in the gut and some of those happen at the stomach some of those happen in the

small intestine probably a little bit less known about what happens in the large intestine but with the stomach generally it's kind of it tends to be nutrient specific so if you eat a lot of fat in your diet over the course of a few days to a couple weeks the emptying of that fat tends to be accelerated compared to a baseline if you eat a high carbohydrate diet the emptying of that carbohydrate if you give someone a test meal that's high in carbohydrate after a few days to a couple weeks the emptying of that accelerates so your gut seems to respond to what you put in it and what's probably happening is the tissue in your small intestine right outside of the stomach maybe gets desensitized to that nutrient over time because usually what happens is if you eat a lot of fat or you get a huge amount of glucose in one sitting once that gets into the small intestine it activates tissue that talks back to the stomach and says slow down we are putting too much into the small intestine right now we can't handle that level of nutrient but it seems like over time that the stomach adapts to empty faster when you habitually eat something in the diet in high amounts so i mean can i can i pause you right there does it also maladapt that's a good question so and and what i mean what just to just to clarify this for the listeners when you're taking a high carbohydrate diet does it maladapt to the other macros protein and or fat or if you take a high fat approach does it maladapt to the carbohydrate

and or protein in that fashion as well yeah i'm not as entirely sure on that my guess is that um i don't think it's going to maladapt the one exception would be is if you shifted from eating something that's for example really high carb to extremely low carb and bump up the fat extremely so i think it's proportional to probably the amount of change in the diet in terms of the um how aggressive that change is i mean most of the studies that are looking at more rapid emptying of the stomach for more carbohydrate for example are using a pretty hefty dose i mean it's maybe a couple hundred extra grams of glucose per day supplemented on top of what these people are already eating so to me these adaptations would seem to occur more readily when you're making big shifts so that would apply to an athlete who's going keto or super low carb um in an attempt if for example they're trying to deal with some of their gut issues then during a race if they decide that they're going to rely on carbohydrates for whatever reason they may have some more issues in comparison to an athlete that habitually consumes um a high carb diet that's all theoretical there aren't specifically studies in an exercise setting showing athletes that are fat adapted if you give them lots of carb they have more GI symptoms those studies as far as i'm aware don't exist yeah i mean the the exception that i'll that that i'll bring to the table there is out of the supernova group louise berks group out of the australian institute for sport where they took the race walkers through a ketogenic and a high fat

protocol and they all and this is a research that or this is a piece of research that you cited in your book as well and the high fat group underperformed compared to the periodized carb group and the race walking test and the the the the biochemical rationale for that was is they weren't able to uptake as or they weren't able to utilize glycogen at the same rate as the periodized group yeah trent stellingworth who did his PhD maybe 10 15 years ago did a really intricate study need study where they tried to look at the mechanism of that right and you see that when you go on a high fat low carb diet even if you restore glycogen levels if you put somebody on a high fat diet for a couple weeks but then a day or two before the exercise even if you give them more carb they still are not able to turn the jets on and the mechanism or one of them is a reduction in pyruvate dehydrogenase which is an enzyme that's involved in metabolizing carbohydrate so these athletes if they want to kick it into an extra gear especially for prolonged periods they just the biochemistry it doesn't seem to allow them to do that more relevant for certain sports where that's more important right where you are kicking it into a higher gear if it's a race that lasts 24 hours it may or may not matter but for certain sports anywhere from a half marathon to a full marathon eating a high fat diet probably isn't going to be real good in terms of your performance if you're not elite level yeah or training right i

mean because a lot of ultra marathon training is a can be depending upon the athlete a lot of athletes just go on run but some ultra marathon athletes they do intervals and things like that that are not dissimilar from you know high caliber marathoners would actually do and i would say that there's training implication there as well so can you have the best of both worlds that's that's like the sixty four thousand dollar question right i know the high fat uh debate high carb debate for ultra running is a big issue right now it's just really hard because those studies are almost impossible to do at the distances that those events are done at what i would say theoretically it starts to make some plausibility when you get past you know maybe 50 miles to 100 miles in that range where if you look at the energy expenditure of those events and you look at the faster study um uh from jeff folic and you see if you take the energy expenditure from fat oxidation in those studies they start to line up with what you could potentially achieve in maybe a 50 plus mile race now that is just solely looking at the bioenergetics and not considering how do you feel when you don't ingest carbohydrate for or very small amounts of carbohydrate for 100 miles so in theory i think maybe there's some sense um or for some athletes there's maybe some benefits you go from maybe 50 mile plus i think there is some speculation that it could be helpful now with the gi symptoms i mean i don't know that's another one that's hard to figure out um scientifically whether or not there's more or less gi symptoms for an athlete that's switched to

a high fat approach but from the bioenergetics in performance you know that's kind of the threshold i think about is maybe a 50 mile race plus or theoretically there could be some where it's plausible where the energetics are plausible enough that you can that you can liberate fat at the rate that you need it while you're exercising i think the in that study the highest fat oxidizer this was during their view to max test not during the submaximal um was 1.75 grams per minute and if you know that extrapolates out to maybe 900 or so calories maybe a little bit more um i mean in a full regular marathon i mean you you're working at a higher rate than that so those athletes doesn't make sense bioenergetically to go low low uh carb and just to give the the listeners a little bit of a relevant point there so 1.5 1.75 grams of fat oxidized per minute is fairly high what would you see you had a college kid we went through your lab earlier today you brought a college kid that you know is playing basketball you know right right over here to our uh right hand side and you put them and yeah and had them do an incremental exercise test what's their fat max going to be um if you put them so it depends on their diet but you know i'd have to go back and look at the specific numbers i want to it's usually less than one yeah yeah that's what i wanted to get at is that in in the what that volick study has become more renowned for is not the fact that the low carb and the ketogenic group burned more fat that's kind of a no shit statement right it's the rate right that rate

that they were actually yeah absolute rate that they're actually able to get up to where they're like oh wow that that actually is but i can tell you from our lab and we have a lot of high caliber athletes that come through our lab are in colorado springs and so some of the olympic athletes will come there from time to time as well as our own elite athletes it's like it's not that far off and we don't manipulate their diet beforehand yeah it's really like i i kind of look at it from a sports science perspective and this is another tangent i kind of look at those rates of fat oxidation from a sports science perspective and go well you know we got to lead athletes that are kind of in the ballpark of that yeah and it's the other thing is these bioenergetic changes don't necessarily translate to differences in performance you don't always want to assume that if you burn more fat or even if you burn more carb that that always going to lead to better performance i think on the whole if you switch people to a high fat diet they do burn more fat at a moderate exercise intensity the question becomes are there impairments to that when they try and do things that are higher intensity and then there are other issues that really we don't understand about its effects on the central nervous system or other things beyond just how much atp are you producing so we've gone through these two different strategies as well as kind of an overlay of what causes nausea i'm going to put you on the spot a little bit let's say i'm an athlete that comes to you you're the expert and i and i'm saying you know what every time i go into a 50 mile or 100 mile race

at point x 75 through the race or whatever i start to experience nausea to the extent that it affects my performance what steps would you take me through and then what would be the outcomes of those steps in order to get some relief from it i mean i would probably start with the things that are more easily modifiable so looking at your rate of fluid ingestion uh looking at your rate of carbohydrate ingestion to see if you're either under or potentially over consuming either of those because both as we've talked about uh can be contributors now how do you figure out if you're under over consuming you might do a field test where you compare you know this athlete naturally decides that they're going to drink at 500 milliliters per hour regardless of the weather conditions let's say that leads to a seven percent loss in body mass you could field test to see if you put them at a higher rate of fluid ingestion does that have any impact on nausea so that's one step practically speaking you could take to take a look at is that one of the contributing factors in that environment to do a sweat test and see if something higher than the sweat test triggers it i mean sweat test is something that's i've written about it a few times common field tests a lot of athletes do you go you run an hour you see how much weight you lose that's how much you're sweating out you're saying go and do another trial where you're consuming fluid over that loss correct i mean most most runners seem to be pretty good about self-regulating based on thirst and things like that however i have an issue

sometimes when people will say that thirst is the option that works best for everybody in every environment because it you see in some studies there's a percent of people a minority who really if you look at their either weight loss or their changes in plasma volume they're pretty significant it would seem like they're under consuming fluid so even if the average in some of these studies seems to be fine you see for example huge variations in plasma volume changes at the end of a ultra race the difference may be on average nothing but the variation is is sometimes huge so that would indicate to me that there are some athletes yes who could benefit from a sweat testing protocol see where they're at maybe try replacing a little bit higher percentage of their losses i wouldn't recommend trying to place all of it in most cases right but maybe a higher percentage but you're trying to figure out if that's a trigger yeah right if the amount of fluid is a trigger yeah and kind of taking a step-by-step approach starting with one thing and trying to isolate it because when you get into an environment where you're manipulating multiple things at once it becomes really problematic sometimes to figure out which of these is really the the culprit so to me fluid carbohydrate intake other food intake sodium intake looking at what the athlete is doing to see if those are easy fixes to start off with okay and then let's just say that it's food intake i'm just taking in too much food over the course of time this gets back to the do i train myself to consume more or do i train myself to to be able to rely on

endogenous fat more how would you go about getting that answer i don't really know to be honest i don't know if there's an answer because i get this man i'm trying to like this is a little bit for my i'm trying to think through you know maybe if the person is already um if they've already had experience saying that they've practiced this they've tried it and it just doesn't seem to work for them for whatever reason they've got a sensitive gut no matter how much they practice then yeah i would probably go the approach of okay let's maybe see if we can switch your diet overall so that you have to rely less on exogenous fuel i mean it's probably going to be a trial and error approach um and i don't think there's really any easy answers that's what everybody hates is the trial and error approach to it you know they want like simple answers like just tell me the you know red pill or blue pill like tell me which one to take if it was simple 60 percent of ultra runners wouldn't have nausea i mean it's you know good point so i it's multifactorial so in most cases doing one thing oftentimes will not completely alleviate the problem it may make it better but it probably in a lot of cases is not enough on its own to completely resolve it but you would let me let me kind of cast in a let me kind of cast an overview of the recommendations that you would make for a runner that continually has nausea in an ultra marathon you would first start to isolate the big variables food fluid volume and then figure out which one of those is the trigger through trial and error and then once you figure out which one of the more of the trigger i guess right which one of those is more of the trigger and then based off of that you're going to adjust within that one specific thing to get more to the ideal

yeah i mean you would have uh maybe some sort of field setting where you test the athlete before and after your sort of little case study intervention to see how much of a benefit you get and trying to maybe just change one thing at a time so as opposed to okay now i'm going to consume more fluid now i'm going to consume more carb at the same time it you know it can be a little bit more problematic to figure out which of those issues is really more of a factor for you so yeah i mean i would start with kind of easily easily modifiable things or more easily modifiable things and then from there if those don't solve the problem then you maybe have to start looking at um other potential things whether it be a gastrointestinal condition whether it be you know looking at someone's osmolality before and after a run looking at the increase in things like urea or creatine kinase for how much muscle damage they have i mean it gets really advanced interventions at that point and at that point you're kind of grasping at straws trying to figure out what the heck is going on um or you could try the intervention approach like medication or supplements to hope that even if you have an underlying issue maybe that would help dampen the severity of the nausea let's move on to the medication supplements piece because i know there are a lot of athletes that are looking at that from as simple as hey i'm going to take a course of prilosec you know seven days before a race too i'm going to have this elaborate supplementation program with all these probiotics and they're going to get shipped to me

every month and that area is like really hot right now i'm going to drink kombucha every day and all this stuff let's try let's can you kind of like summarize those the the the supplement and the medication interventions and then we can kind of drill down into a couple of those and why they may or may not work yeah i mean in terms of the medication for ultras you know you you look at sort of anti-medics or anti-nausea medications um zofran or andonstron i think is the one that is um probably the most often kept on hand at ultra races so as far as i'm aware they're not actually like randomized double blind studies in that environment that the show that show that that medication works however anecdotally it seems like athletes get relief from it whether it's a placebo effect or something else it's a commonly prescribed anti-nause medicine it's not like it's they're just pulling out no just grasping at a random straw and that's going to be you know a little bit more uh challenging sometimes to to access that obviously i mean it's generally something that a race director might be giving you or prescribing it's not going to be something you buy off the shelf and take on your own supplement wise you know it's probiotics would be the one that as you mentioned is really popular that oftentimes athletes will turn to ginger is one that in other situations has been fairly effective at alleviating nausea now in exercise there's not really any data with that but pregnancy morning sickness chemotherapy motion sickness spinning people in a chair seems to work decently for at least

moderately reducing nausea i think maybe the difficulty of using that during an ultra is it can also provoke heartburn stomach irritation if you take it in large dosages so if you're going to use that what i would say is probably take it an hour or two before the race because the effects seem to maybe last a while um so maybe that would be something that uh delays the development of nausea as you progress into the race i mean that's all based on just speculation i had an athlete that would use raw ginger during a race how much like a little just like a look you guys can't this is a failure of audio i'm i'm showing patrick how big it was is maybe like one centimeter squared okay which is i mean that's not a trivial amount of raw ginger to just eat yeah on the side of a trail right but he's sore by it yeah i mean it's if you're having problems figuring out where your nausea is coming from and it's you know medical things have been ruled out i mean it's a relatively safe thing you can try that may have some benefit for some people uh implementation wise i think the issue would be not taking too much at once during the race because it you know can lead to other gi issues so maybe taking something an hour or two before the race starts um and then theoretically maybe taking something a little bit later on so long as it's not a huge dose most studies are using like a gram or two right right in one sitting how much validity is there to improving your gut flora i know this is going to be a loaded question for you the microbiota yeah the microbiota man it's hot

right now how much validity is there to improving that to reduce nausea during an ultra marathon race through whatever mechanism whether it's diet or supplementation or whatever nausea specifically very little to none so the studies and athletes who have that have used probiotics have been mixed some have shown modest benefit some have been neutral at least one has shown uh greater um incidence of mild gi upset it's kind of across the board but really none of them as far as i'm aware have really isolated nausea specifically and most of the exercise durations they were working with were fairly short so it's probably fairly low risk to try but i don't know how much benefit there really is specifically with the type of nausea that arises at the end of a ultra race i mean if it's not you know necessarily something that um you have a a good idea about what's causing it you know it's kind of throwing stuff against the wall and hoping that it'll do something for you which maybe it will but the evidence doesn't necessarily support that it's going to be the most efficacious thing but you're not you're not only throwing it against the wall from that it's also strain specific right the the efficacy of any of the probiotics is extremely specific to the strain of that of of that's that's actually in the that's actually in the supplement that you're taking and most people almost everybody have no idea

what that strain specificity is because the words on the back of the label have like you know 30 different letters and i'm gonna like wait what is this again what am i looking for yeah that's a excellent point i mean the the thing with probiotics and this applies to not only athletes but uh irritable bowel syndrome other gut disorders where you know the evidence is very mixed probably in large part because the species and strains of bacteria that have been used vary a lot from study to study the dosages vary a lot from study to study so in terms of practical implementation it makes it pretty challenging to give any sort of individual prescription about what you should do as an athlete i would say that most of the studies that are are using probiotics that show some sort of benefit whether it be athlete or non-athlete uh use lactobacillus and bifidobacteria species so if you buy a supplement that has a variety of those types of of bacteria in them that's probably a safe bet but again it's it's not a for sure thing and it's kind of throwing something against the wall hoping that maybe it'll do something for you but here's my thing with that you just mentioned a very specific strain right yeah nobody's going to be able to remember that after just hearing this pipe with all due respect to with all due respect to you they're going to they're going what what did that mean and they're going to go try to find it and they're going to have to listen to this podcast again and it's it's just it's so complicated for a lay person to actually unwind and understand yeah i mean i agree uh the so the the bifidobacteria and the lactobacilli those are kind of the

genuses the the broader categories of bacteria that you have strains and species within that so the long name where there's three things a part of it the first part of it the lactobacilli or the bifidobacteria those are kind of broad classifications that a lot of probiotics contain but you're right i mean beyond that when you get deeply into the different species and the strains you know it gets pretty convoluted and as a regular everyday athlete i mean it's it's really hard to come up with a regimen that's science-based i mean honestly it just is yeah it's just a big area right now a lot of people making money off it's very it's very hot right now as you know if that's a zoolander quote there i don't know if you drop a lot of zoolander quotes no we can't we'll we'll drop some zoolander quotes on this okay maybe a few years past it's uh it's uh yeah you know i i remember it very fondly um but needless to say i mean you wouldn't like if you going back to my analogy earlier you had an athlete coming into you hey i'm always having nausea you would still take uh what are you taking during the event what are you taking day-to-day approach first yeah before moving on to any of the medical or you know supplemental types of interventions yeah i mean unless someone has other symptoms where it seems clear that maybe they have a gastrointestinal medical condition going on if it's just isolated nausea and a few other things that seem to appear the latter half of an ultra race yeah start with the nutrition stuff um you know carbohydrate fluid sodium potentially other supplements or things you're consuming that could be provoking the gut start with that and then

move on to the things that become a little bit more complicated i mean you want to rule out the easier stuff first before you start to get real fancy with what you're uh trying to figure out well and speaking of fancy i don't know where you put this in the list how does psychology play into all of this because this is a big part of your book as well yeah i mean it's a third well by volume it's you know there's three parts of the book it's basically the intro nutrition is the biggest the middle section and then there's a third part on psychology i love how you have to talk about it by volume just like we talk about you know fluid and yeah exactly i should say parts it's not it's not a three volume set it's reasonably it's 300 pages so it's not going to come in a you know 10 pound box i just like the fact that you know by volume by word i do the same thing this is okay okay so we're talking we're talking about psychology and the gut how much does that play an impact i mean i think it definitely plays a pretty large role for a subset of athletes so this is surprisingly from the research side something that is not well studied i mean every athlete has an experience an anecdote where they were nervous before a race before a game or even outside of athletics you're nervous before an interview before a presentation and you know your gut does not seem to be functioning well so it's not like it's groundbreaking research to show that people who have more anxiety with competition have more gastrointestinal problems but surprisingly there are really few studies that have done that i mean i've done a couple in the last few years that seem to confirm that people who

have more stress and anxiety do seem to be more predisposed to gastrointestinal problems during training and also during competition so i think it does play a role in a subset of athletes who struggle with anxiety who struggle with managing stress so it's not a primary culprit in every athlete by any means but it certainly is something to take a look at especially if you have one of those athletes that seems to have trouble managing their race day nerves you know they just can't get on top of it so yeah that's definitely one to look at do you want to hear one of my theories on that why it starts to rear its ugly head during our especially in an ultra is for almost everybody there is one there's like one mile marker or one section of the race that contains in an ordinate amount of unknown because you don't go and run 100 mile or 50 miles in training in order to do those races and so they're always extending whatever their normal training run would be especially for athletes that are inexperienced at the distance they have that psychological block of oh my god i've only run 30 miles or whatever it is and now i'm doing this 100 mile race when they get to mile 35 even though it's really no big deal they've they're so pent up about what's going to happen what's going to happen i haven't done this in training i've never experienced this before that that just adds one more toxic element to this soup that eventually that eventually unfolds into nausea yeah i mean that makes sense to me in that

you see studies that look at what are the predictors of gi symptoms during endurance races during competition and repeatedly experience is one of those things that does correlate with a lower rate so if you're more experienced the more times you've done done something it's not a super strong correlation but it is measurable it is sizable enough to say that it seems like if you practice something over time or you've done something over time it makes sense that you're going to be probably less stressed about it less anxious about it so i mean that makes sense to me in terms of that would be a contributing factor in an athlete who's super new to the sport or to that race they don't know what to expect as you said it's impossible to completely go through that race without doing it the whole time uh or doing it the first time yourself so there's going to be more unknowns you know i think if you couple that with an athlete who gets a lot of pre-competition anxiety you know that's the recipe of where uh it's much more likely to have problems yeah yeah it's like i've seen it time and time again like going to races and when i say see it i mean that literally like you can see you can see the anxiety like unfold on their face and when you see them at an aid station you i mean it's a it's a it's it's literally a look and a vibe that you get and it almost always is coupled with at that immediate point in time or maybe at the next aid station five miles down the road or whatever sure enough they'll come in oh my stomach's in knots i you know this doesn't sound good that doesn't sound good i puked you know back there whatever it is it's it's it's so predictable yeah so i mean i think that

it's something to take a look at for sure you know the studies that i've done on it there was one where we took 150 runners for a month they basically tracked every one of the runs they reported after each run what their gastrointestinal symptoms were during that run and at the end of the month they rated their anxiety and stress on validated questionnaires and we just simply kind of looked at you know what's the association there are people who are reporting more anxiety more stress more predisposed to having issues and of anything in the study was one that was correlated with with more symptoms maybe a little bit more particularly upper gi symptoms but there were still correlations with the lower gi symptoms now the the associations are not super strong but none of these studies where you look at correlations are they ever strong right because there's multiple factors that play a role and you should never expect one single factor to completely explain why people are experiencing problems well and that's one of the fascinating things about your area research is it's always multi-factor i mean very very very rarely can you look at a can you look at a case study or a scenario and go oh that's it right there like just you know as long as you switch this from this to that like you're going to be you know free and clear it's it's a lot of you know educated guessing and deductive logic and things like that to try to like pinpoint actually what's going on yeah i mean in your own experience i mean when you have athletes who have had these problems i mean what kind of approach have you taken to try and figure out what's going on i mean what's as a practitioner the

way that you deal with it because from my side i'm more of a researcher i mean i'm more study the problem try and figure it out give some practical recommendations but i'm not a you know endurance coach it's the exact same thing i mean we look at the inventory in terms of what's going on and then i compare that to what have they done so if it's it's one of my athletes already know that right because we've gone through the whole thing in training what did you do what types of things are you taking in during your long runs and things like that and then we try to match it up during the during the race or the or the training activity that caused the distress and try to figure out where the mismatches are okay it's too much fluid not enough fluid too much sodium not enough sodium and a lot of times you'll find those mismatches and that's just that's just kind of coaching but even when we go through that and you try to you try to massage the situation to get as good as we can and this is why this is one of those areas it's just so fascinating still on race day because the race is usually so much harder and so much longer and so much more stressful than anything that you could ever recreate in training you can still have those issues crop up and to your point it is it is an experience thing so then you take the inventory of the race experience which is harder longer more stressful than what they've done in training you compare it to what they were doing in training what they should have done during the race and you try to find those mismatches and then correct them and i've always taken uh train the gut approach first and then do a dietary intervention second and that is there's a whole host of reasons

why i do that mainly mainly it's just training related because i think that that impacts training less because you're still training an athlete yeah at the end of the day and whenever you take an overall nutrition intervention you have to manage it with the training load and the training stress appropriately so that that's what i do is i take a training the gut approach for our inventory training the gut and then if needed the dietary intervention go kind of goes last the dietary intervention being that like uh we're gonna burn more we're gonna teach you how to burn more fat yeah okay yeah i mean that makes sense yeah cool yeah so let's wrap it up a little bit let's go over just some like key incredibly practical recommendations for athletes for ultra marathon athletes that have gi distress which that's everybody that's listening by the way it's not six out of ten or seven out of ten it's i guarantee at some point it's a hundred percent yeah at some points you're at that's a that point is well taken at some point during the entirety of their ultra marathon career it will be them yeah so it's everybody listening all five people but everybody listening is going to experience every every ultra runner out there is going to experience gi distress in some form or fashion at some point during their ultra marathon career and if they don't they're freaking unicorn and come talk to me afterwards but what are the maybe top three or five like super practical things that that any ultra runner can kind of walk away with and either work on or learn about to not have a magic bullet to fix it

but just to reduce the likelihood and the severity of the symptoms yeah i mean i would probably say that uh the biggest thing for a lot of athletes is we've already hit on this is going to be practice what you're doing in the environment as best you can to match the demands of the race with the realization that you're not ever going to be able to completely in most cases match those demands in terms of nutrition i would say take a close look at whether you're under hydrating or over hydrating because they both can contribute to nausea it's relative to the conditions yeah relative to the conditions in hot environments uh the under hydration is probably more plausible the other thing i would say is if it is a hot environment human environment we haven't talked about this but maybe using some cooling strategies i mean that seems like an obvious thing for performance but it probably plays a role in gi symptoms too consistently see when you put athletes at the same exercise intensity in a hot lab versus a temperate lab gi symptoms go up so acclimatize to your environment uh practice cooling strategies employ cooling strategies if it's a hot day make sure your hydration's on point as best you can you need to go out to bad water and just watch that race unfold you would find have you ever been out there before no no you'd find it fascinating because everybody has a slightly different strategy they're all trying to cool off but everybody has a slightly different nutrition strategy which ranges

from all liquid like literally all liquid which you're familiar with that's a that's a strategy that a lot of uh ultra endurance athletes do not just ultra runners but ultra endurance athletes do to real food and water and everything else in between yeah and very few of them actually get it right it's because it's so hard the race is so hard that's what that's what makes it such a cool cool pun intended such a cool playground because the race is so hard because of the heat yeah it's you know i come from sort of a mix of endurance background team sport background so i was more of a basketball tennis distance running until my uh knee and hip decided it wasn't real good to continue on with long distances so i mean i've got a mixture of stuff but the ultra stuff has never been what i've been able to handle but for you i guarantee i mean i love to use a researcher like just go out there and watch people first you'll be like what are these idiots doing like it's like the it is the most bizarre ultra marathon ever but in terms of having a playground that stresses athletes out to their maximum and especially in your area of expertise it's absolutely fascinating oh yeah i mean i've done some field-based studies with like a half fireman triathlon but that's a whole different environment in terms way different yeah way very triathletes they don't they don't they don't hopefully they don't hold the candle to us okay so keep going so so test it out especially at hot and cooling strategies potentially uh i would look at you know if you are the type of person that struggles with competition anxiety stress uh considering not only maybe just pre-competition

but from day to day trying some interventions that you know we see in other populations help reduce the severity of of gi issues that could be deep breathing meditation mindfulness they seem to work pretty well at making people less sensitive um in terms of how their gut feels to certain stimuli so whether that's doing it right before the race like if you're going to do deep breathing a half hour beforehand or just do it on a day-to-day basis if you're kind of a wired athlete who's high strong who struggles with that stuff i think it is of anything um is one of the more low risk potentially high benefit things you could try um you know beyond that it gets a little complicated but one other simple thing you can do is avoid taking lots of nsads non-steroidal anti-inflammatory drugs i know a lot of runners have minor aches and pains and things that they use those medications for um but at least in high dosages during uh ultra you know they're likely to contribute to gi issues i throw if i have an athlete that has that in a drop bag i throw it away good seriously because sometimes they won't tell me yeah like that's probably bad coaching on my part but if i if i find it and somebody's like somebody's crew has it or they pack it in a drop bag i just throw it away i mean to some extent if you can't make it through a race without taking a high dose and said maybe you shouldn't just do the race um or find other ways to to help manage that pain because they're really i mean not only on the gi system but they're they're problematic for athletes for a lot of different reasons um may increase the risk of hypernatremia you could die you could die you could

have severe gastrointestinal bleeding in some cases die that's all you should be able to say and they increase the risk of of cardiovascular events in the population so did you see iron man signed a partnership with the leave no oh my gosh i i i did law i i wrote an op-ed in uh triathlete magazine which i very rarely do because it's not the sport group that i typically work with but i i i lost it and they contacted me and they were like will you write an op-ed for this i'm like absolutely i'll write an op-ed for it like and the the summary was is this is a terrible partnership because somebody's gonna die i mean the taking a uh ibuprofen here and there is not a big deal but if you're using it like chronically in high dose especially it's problematic during a race yeah that's okay so don't take ns yeah so in terms of the gastrointestinal system system that's a bad choice is to take high dose ns before or during you know beyond that i mean it gets into some more nuanced things that um probably don't have you know an infinite amount of time to to go through the list of that's why you wrote the book that's why i wrote the books check out the book you can plug the book it's cool yeah yeah but by the way in an effort of full disclosure we have the same publisher fellow press which is now pocket outdoor media i always have a hard time remembering that that they change their name and that's how patrick and i got introduced but it's his book it's a great book i read an advanced copy of it i think it's a fantastic resource for athletes so why don't you tell them a little bit about the book and when it's going to come out yeah so it's basically a

a book 300 pages or so that like i mentioned before is divided into sections on understanding the gut the physiology why symptoms happen and then a third on nutrition carbohydrate fat protein sodium fluid training the gut and then the last third's on psychology based stuff so and then there's appendices where you look at medications um and then gastrointestinal disorders so there's kind of something for everybody hopefully that deals with those issues should be coming out uh late april early may um you know i'm selling it on my website velipress uh it's other places as well where you can get it but yeah i mean i'm looking forward to coming out i think it's a pretty needed resource so i hope that you know athletes who struggle with those issues get some benefit out of taking a look uh i i appreciated how well referenced it was and as a practitioner in the field where i don't deal a lot with the like the journals and the you know writing articles and things like that and have to blend both both worlds on a day-to-day basis 600 references about 700 now some of them are listed in multiple chapters so it's probably a little bit less than 700 still though it's a lot you you gave your indexer a work over yeah i don't know if they were happy with me with the number of references that i had can we cut back on the reference just a little bit i mean that's a lot of pages to print that's to every page yeah i mean it's basically book it's a lot of pages to print for them and i'm like yeah but we can cut back a little bit no i i see in all seriousness i appreciate how well researched it was i appreciate that yeah good job on that so yeah i mean it's it's very science-based but i try and

make it you know entertaining enough to read for the person who you know doesn't live and die in science you know if you're not the type of person who needs to have a scientific explanation for everything hopefully there'll still be some good practical stuff practical stuff all right where can people find you on social if you want people to find oh god you're gonna ask me to remember my social media handle it's uh sports rd PhD i think something of that effect just google it people just google it yeah uh athletes dot athletes gut dot com the athletes gut dot com uh you can check out the reviews you can buy the book there learn a little bit about my research and it's going to come out when so i think you can it starts shipping from velopress in late april and then uh a lot of the other places you'd find it it says may 12th i think is the release date cool patrick thank you for your time really appreciate it yeah cool it's great to be here yeah to be on the podcast awesome man thanks all right trail runners what did you think i thought that was a really interesting conversation full of a lot of practical knowledge that you can kind of take out on the trails and into your training sessions this week maybe even uh later on this month uh really appreciate uh patrick for coming on the podcast uh with us today uh he uh the book i got to tell you guys the book that he wrote is just going to end up being a really valuable resource for a whole lot of athletes like i said on the onset um it's laid out really well in a completely practical uh way that even if you have no nutrition

background you're gonna really understand what's going on uh so thanks to patrick thanks to our mutual publishers velopress aka pocket outdoor media which is what they're known as now for uh connecting us and getting me an advanced copy of the book i enjoyed it i enjoyed it very much thank you guys for listening if you have not had the opportunity to do so go ahead and give this podcast a rating on itunes it helps the show out a lot coming up i am going to be out at lake sonoma in about a month's time i'll be taking your questions from the mobile recording studio so be sure to stop by check it out say hi uh get a question entered that i can uh bring up in a future edition of the podcast i've already got a ton of those already loaded up and i'm trying to compile them into some kind of reasonably uh flowing uh discussions that uh that have some common uh threads of of knowledge that we can disperse uh amongst the audience here so thank you guys for listening i hope to see you guys on the trail soon and yeah we'll see you on the trails people you you