GI Issues in Ultrarunning. Problems and Solutions with Jamie Pugh PhD | Koopcast Episode 91

trail and ultra runners what is going on what's happening welcome to another episode of the KoopCast as always i am your humble host coach Jason Koop and this week i'm out on the road again i'm recording this out of my hotel room i brought on the podcast this week somebody who i have a tremendous amount of respect for in the research and the coaching community and that is jamie hugh PhD who is a researcher at john moore's university he is also an athlete and he's also a fantastic coach and he just happens to have a specialty in gi function and gi distress and i don't need to tell you athletes out there that that is one of the most prevalent problems in all of endurance sports and in particular with the rigors of ultra marathon running it's something that everybody experiences jamie was recently a co-author on the paper on a paper that was titled gastrointestinal pathophysiology during endurance exercise endocrine microbiome and nutritional influences and if you can't tell from the title of that paper we need to think about gi distress as this multifactorial problem that has different answers that you can use to reduce the severity and the symptoms of gi distress

we go through a whole host of those during the course of this podcast as well as some practical implementations that you can use during training and during races i really appreciate jamie coming on the podcast and as an extra special treat for the listeners we're going to have the lead author kyle smith uh of this paper come on next week in a special two-part series so i'm going to get right out of the way here's my conversation with jamie pew you're doing this you're doing the study at kona and you reached out to me to see if we had any athletes there how how has that generally been going for you guys are you guys going to get it up and running you're going to have a good subject pool it looks yeah we i think we've got just over 40 now i think in the last like maybe i think maybe the last 10 days of recruitment i think we'll get another 10 more at least so it's been it's been amazing like we don't win the study isn't directly in conjunction with iron man or anything that we're not officially affiliated with the race so that's always make things more difficult because you're trying to indirectly contact potential participants so we knew it was gonna be challenged but yeah it's good to me because you know ultra endurance athletes are amazing this sort of thing and they're more than happy to get involved and they're interested in data they're interested in themselves they're inquisitive so when you put the study to them our hit rate has been really good like most people that hear about it have said yes but um but it's just that challenge in the first place but it's going

amazing the biggest challenge now is getting me into hawaii for the study comes in place here in the uk what what i might have to do is go and spend two weeks in south america somewhere first somewhere that is letting the brits in go stay there for two weeks and then fly directly from there to hawaii oh my god i didn't think about that wow how i mean it just makes everything more complicated is there anybody else on the research team that needs to come from outside the u.s no no so everyone else is big basically it means that we've been hit on them slightly as well because i know so many brits and so many europeans who've got their place who've got their slot they've maybe entered or they've maybe booked their flights and their credit card but while they don't know what's going to happen with the restrictions it's like well i don't even know if i'm going to race event but i don't know if i can get there which is crazy that we're only i want six six and a weeks away seven weeks away yeah wow unbelievable good good good luck with it even what we've got now it's going to be an unbelievable study but something that something that shows the power of things like this because it all um happened from a podcast like greg and matt were um on uh another podcast i don't know if i should say the podcast because obviously it's another ultra endurance one that's totally fine you can say it's totally fine no they're only in shaman podcast discussing research and discussing discussing gi issues and then out of the blue uh one of them just goes oh there was this really cool study

from the uk and liverpool and i was just running listening to it and so i reached out to them and that was the start of this this whole study so it shows even from an academic side of things the the usefulness of conversations like this and the reach it can have yeah i mean it's interesting one of things that covet is kind of done is it's forced us to network differently right and part of that different in network is getting on podcasts and having conference calls and doing these like kind of seminars and stuff like that and it's kind of it's fostered some different ways of thinking in my in my perspective 100 100 that makes it some for the better some maybe not for the better if we can try um blend the two because it's still nice to meet people face to face and chat but maybe just cut some of the unnecessary ones with yeah i've definitely been on my on my fair share of unnecessary flights um okay well good luck good luck to you in that study i hope it comes back we'll bring you back on the podcast to discuss the results how does that sound definitely i think the results would be amazing said greg has already done um um a case study with one of the guys who ran western states a few years ago and if we see something similar in a large group of athletes then it'll be an amazing data set yeah perfect okay so what we're going to discuss is another paper though and to to cue the listeners up the title of it first off it's in the european

journal of applied physiology and the title is gastrointestinal pathophysiology during endurance exercise endocrine microbiome and nutritional influences and whenever i see a title like this i'm kind of laughing i feel that the i feel that the research team and in particular the lead author and the second and the second authors that have kind of like brought this to light whenever i see a title like this the only thing i can think is okay there's this big issue out there and they're just trying to figure all this shit out they're just trying to figure it out with the rest of us using the existing research because it's such a big comprehensive topic so let's take the broadest look possible at all of the existing research and try to distill it down into some into some common themes so am i correct to that assertion that you and kyle who's the lead author are kind of looking at this and going okay let's see if we can figure some of this stuff out 100 like you said we all start with that basic idea of that there's so much research now when i started my PhD about six years ago and i think that some of this stuff is starting to be public i think maybe going back to 2010 and around that sort of time papers are starting to gather in this area of endurance exercise or ultra endurance exercise and gastrointestinal issues and it just snowballs every year and so kyle and michael um who's a corresponding author on the paper approached myself and then graham close who's um my line manager at local john uh local john moore's university and because we published some papers in

this area they published some papers in sarah so okay what let's bring together some of the current information so we didn't really start with all of those different topics in mind but as i said what naturally happens is you think well we can't really only talk about this while ignoring another huge factor that could play into it because you either make yourself look stupid or you know you're ignoring something blatant and then part of the reason we want to bring so many is to make our review a little bit different is to include include some of those topics even though there's no research in them with the hope that okay if we just start to bring this to light and we start the conversation then rather than rehash the same studies over and over again which is i think is definitely what has happened in the last couple of years i see so many papers that measure the same blood marker or the same two blood markers and we're not i think we've hit a stalling point in our knowledge so it's okay what about all of these other things that no one has started to study yet and that's some of those things i'm sure would answer and so the gist of the whole thing is is it's multifactorial right we tend to try to in in the ultra endurance in the endurance space we tend to try to look at gastrointestinal distress which is a big deal it's always been a big deal and it continues to be a big deal and i think that this in in in injuries are probably the front runners in terms of the things that we have not figured out very well as endurance athletes and one of the things i've kind of like come to appreciate

with actually both of those topics now that i'm thinking about it is that there are always a multitude of factors that are going into it and what i felt that you guys were trying to do is almost kind of rank order it a little bit like here are the things here are the heavy hitters that are that are the most important that are causing the issue and here are the heavy hitters that you can focus on to try to to try to alleviate it so we'll take the first topic first right the heavy hitters that are actually causing this issue so when you go and you look at the landscape of things what are the major contributing factors to all this gi distress and i think that this order is important because the solutions have to fit the problems right and i think a lot of that a lot of that linkage kind of came out throughout the paper so why don't you set that table for us really quick no and that's a really good way of thinking about it because it's that and even there's even almost a differentiation between the the causes that you've been acting upon and maybe some of the underlying physiology mechanisms which are sort of neat and interesting but like you said for a coach or an athlete it's sort of i don't really care what what more defiable action can i take in the building to my next race or in my next race and and that's where probably it all starts with the the diet and so i think one of the first one said in there is that if one of the if not the primary function of the gastrointestinal tract is to digest and absorb nutrients from our diet and we know that it passes through and eventually will come out of the other side and what we're trying to avoid is either unwanted movement unwanted

symptoms from movement um irregular movement or malabsorption of any of those foods all of which can start to manifest in symptoms even what we put into our stomach so when we look at some of the symptoms like nausea or vomiting this can happen if we put in too much of the wrong things in at the wrong time and then if it can't go down it's ultimately got to come back up at some point and i think you're right one of the it's so much more prevalent in running first of all than any other sport running is running events are one of the few sports where you have regular non-finish non-finishes non-completions or postponements due to gastrointestinal symptoms you rarely see it on a football pitch or in team sport or even in cycling it's so much rarer than it is in running at most distances and then as you go up in the distances it's more and more common i think we it's probably n-shaped i think there's probably a distance or a duration where we have the the highest incidence so i don't know if that's maybe at around the 100 mile 24 hour mark and i think potentially because that's the limit of the the we're still really running at a fast pace especially at that elite end they are running seriously fast so it's a huge physiological challenge they also then need to try and fuel that and they also probably don't want any unexpected bathroom breaks during it so i think

that's why then if you have one that is a major um drawback against performance if you're doing something longer than 24 hours you probably plan to go to the toilet at some point or other you probably plan to have a bowel movement so you can factor it in and it's less of a psychological stress so i think that as i said there's no great data it's difficult to collect data obviously from from a lot of these but from what i've seen that 100 mile 24 hour plus they're always running these amazing but hot places there's often an altitude challenge to some of the the big major races as well um so that you add that stress on top of it and all of a sudden the diet the digestive tract probably can't handle the huge amounts of food to try to get into fuel that performance and so when we we look at gastrointestinal distress through that like multifactorial lens and then specific for ultra runners can we rack and stack what the root causes are meaning or is it even possible meaning you talked about earlier modality matters right we see this in running a lot more than we see it in cycling or in other endurance sports the sheer volume of food that you're taking in matters a lot the amount of timing of that food as well yeah so instead it can it probably starts eight to ten weeks out your risk is going to be changing that whole way through because if you're if you're not eating the types of foods that you're going to eat in the race if you're not training the gut

if then in the 24 to 48 hours you're eating foods that are more likely to sit in the large intestines so your fatty foods your high fiber foods that's going to cause an osmotic challenge then right the way through to the race if you're eating the wrong sources of say carbohydrates or the wrong types of foods that you're you haven't trained the guts to eat so it is well that whole way through and i think that's what as you said what makes it so difficult because then when you get a study with 20 runners and you try and isolate one variable but you haven't been able to factor all of these other variables so even if you just look up you can look at the averages certainly and you can start to say well on average these are the ones that mostly affect athletes or have some impact on our athletes but you delve into it further you see that at an individual level none of them are great predictors you probably do need an appreciation of all of it to try and isolate the one that's that's impacting you or your athlete yeah so i think the better way to frame it up is to understand that there are all of these factors and then as you're going through training and the racing process to kind of like solve this problem pick the things that might actually have an impact across those factors versus just randomly kind of throwing throwing stuff throwing stuff across the across the wall right no definitely like you can start to think even within like i said the ultra endurance races

how how long is it will maybe even start to factor in will you consider solid foods or will you take almost an entire liquid or gel form of carbohydrate intake do you need foods other than high carbohydrate foods if it's that long you might want a hot meal you might want something um we know that the longer the duration the more our taste preferences flip a little bit and we go we start desiring savory type foods and all of that needs to go into the planning like you said it's such a one of the reasons i think it's still quite prevalent is because it's almost such a big task and when you're trying to think about your training load and your travel arrangements and all of those other parts that come to to race performance to add that extra one in is is difficult and maybe it's the one that most people bring in at the final stage if they've got that time or mental capacity to consider it otherwise it's all right well these are the general things that i know that i've heard about fueling i'll just stick with some of these general guidelines without thinking about you you just touched on a really important topic because most of the most athletes are trying to solve these gi issues in real time but the fact of the matter is is it's more likely that if you take a comprehensive approach throughout the training process those things don't show up in your paper identified three or four different things that can happen dirt both both

during well a little bit during the race but mainly during the training process that could help alleviate GI symptoms and let's start to run through those because this is going to be the solutions part of the part of the podcast here we'll just we'll just say the problem super complicated here the solutions we'll skip we'll skip the first part so the things that you identified are low FODMAP diet training the gut which is kind of becoming a little bit controversial if these things can be controversial right can you actually achieve that adaptation and probiotics so let's run through those in in why they actually might be efficacious in terms of creating a better GI scenario for for race day yeah yeah so the low FODMAP diet living so anybody who hasn't maybe go across it or if those haven't it's about giving it too much of an in-depth run down we're looking at typically undigestible fibers or carbohydrates that will pass through the small intestine and then make their way through to the large intestine and then then fermented by the bacteria in our guts which for most of us is something that's actually beneficial we want in a lot of circumstances depending on the type of fiber or it's something that can have prebiotic effects so they could be good for our gut health the research has started to translate over because it's been found in IBS patients it can be an effective treatment for symptoms because what you're essentially doing if you're taking away the food from that fiber the food for that gut bacteria when they consume

that they're giving off gas and so that's going to cause an internal pressure in the abdomen or the intestines they can also have an osmotic effect so if the those molecules are in the large intestine they might be drawing water again into the intestines causing a like a hydro pressure if you like so that's where the idea has come from and then the researchers have translated to that to say okay does this have an effect for those who suffer from symptoms during exercise the the efficacy of it is is mixed I think it's again if you look at the so Dan Liz and Trent Stenemworth published an amazing paper a couple of years ago looking at symptomology in athletes the problem that they found and that I certainly found in some of my research is that athletes do have symptoms from time to time but in their general training it's it is still it's rare enough that it's difficult to measure so in that paper they have a really nice graph that shows that okay on a week if we ask all these athletes to rate their symptoms on a visual scale you have this huge range in their participants so some of them have a really small amount of symptoms that week which is sort of to be expected isn't it but we're not we if if all of us were always suffering from these symptoms we would have given up the sport a long time ago we wouldn't go out the door running if we were always guaranteed a symptom um so in that paper they found that on average the low FODMAPs reduced gastrointestinal symptoms the magnitude of response though was was really varied some

had no response whatsoever some people reported worse symptoms on the low FODMAP so it's one of those that exactly we started off saying that it's not then just as simple as saying oh should we just go low FODMAP because they're beneficial to health in other ways or certain high FODMAP foods to then unnecessarily restrict could have a negative impact especially if it's something that you bring into the race thing but without having trialed it before um so it's become one of those rich it's almost not quite but it's similar to what it's the new low gluten diet or gluten-free diet i think in a lot of endurance sport it's become this really like popular thing and of course in some people it can reduce their symptoms but while it's most of these foods if they're high carbohydrate foods they're going to be um lots of fruits lots of vegetables lots of foods that we'd otherwise want to consume um so it's that's the first i think so i think for some athletes it's it's certainly worth a conversation it's certainly worth a food diary before a race or before a key training run and then you can start to track the symptoms because like i said there's been a few case studies that has been really effective with some athletes who consistently suffer with symptoms during races it's so the dialogue that you just mentioned mirrors my professional experience with this because i have had athletes on both sides of the

efficacy fence where we introduce a low FODMAP diet and it literally is miraculous like i mean it's just it's just like that it is you're exactly right it is just like the low gluten or gluten-free diet was you know seven or eight years ago where people were going on this and they were just like you know kind of blown away with or some some people were just blown away with what the what the difference was and then i've had other athletes that we try to incorporate it for whatever reason and it's just like a big nothing burger you know like there's i was gonna say and that's why not that it's dangerous and dangerous may be the wrong word but the gluten diet is a gluten-free diet is is restricted a low FODMAP diet is really restricted right because there's so many meats vegetables dairy that you need to take out and if you're going to do it for an ibs patient who had gone on a low FODMAP diet you would go you would undergo this months-long process of eliminating all of them then bringing one of them back in each time to try and because it's likely that you're only one type of fermentable carbohydrate is the issue you could probably digest all of the others but one might give you the issue so it might be lactose for example it might be blues or whatever it's going to be so you that's the process you would undergo if you were diet so just completely restrict it before your races and if you're somebody who races three four five times a year you could be doing this every every couple of months every few months well and another one of the big issues with trying to figure it out that way

is just the total amount of energy availability that you're intaking typically goes down because you're taking your normal diet and you're restricting something or some things from it and most people have a challenging time replacing those calories one for one and when the training load is really high or even if the training load is not very high you can come it's very easy to come up with an energy mismatch so it's not the way that i view the way that i've always viewed trying to incorporate or try to try to test out a low fodmap diet is not simply by elimination but by substitution because if you get that substitution piece in your head you can kind of get the calories right because here you can very easily just substitute one problem for another right you substitute the gi issue maybe and maybe you find some alleviation or some sort of fix for that but on the other end of the spectrum now you have an energy intake problem which is you know you could argue is even more problematic from a especially from a long-term perspective and that comes back to something that i mentioned earlier on in saying that when we talk about gastrointestinal symptoms one of the problems has become and i sit and experience this with with athletes i've consulted for is that any symptom is a problem and the reality is it's not is it like so we could run and have a little bit of gap it's uncomfortable but so is running an ultra marathon like it's uncomfortable on your feet it's uncomfortable on your joints and so they said

so definitely had athletes and you asked them oh you know did you did it cause you to not finish the race and you have to drop out and they sit around and say oh no it was just i'd rather not have it or you that's the impression that you get and so if that's the level you're starting to try and alleviate and like you said you could be throwing a much bigger problem on by a low energy availability or a restricted diet um it's obviously not worth it so that was one of the things i wanted to say from the start as well is that even the severity of symptoms needs to be considered because a lot of the research you see these big numbers from that 90 of athletes um surveyed at western states had a symptom you go through the data and you find that look 60 of that 90 just just farted essentially that was it on a scale of one to ten they reported one for flatulence so it's not that 90 had symptoms it's just that loads of people had a bit of gas which we all do we all do during the day anyway at some point probably so that's where i think that needs considering as well is that look we want to avoid anything if possible of course we all want that perfect race that everything goes well there were no issues with injuries or fatigue but the reality that i think if some athletes go in with the mindset of i could experience this as a mild problem and you go in almost expecting it that would i think in some cases help as well a little bit oh that's so brilliant this so the analogy that i've got in my head right now is is from a training perspective there's always a gap

right there's always a gap between the amount of training you can do during any training phase no matter how perfect it is and the physical resources that you need during the race and what we try to do with smart training is we try to get that gap as narrow as possible but there's always a gap and so you and so that gap manifests in the difficulty of the race right there is some struggle right during the course of a race sometimes it's late sometimes it's early sometimes it's middle sometimes it's the whole thing but there is some sort of struggle which is representative of that gap it's the same thing on the gi perspective like expect there to be a little bit of a gap between how well you can be prepared and what the race is actually going to demand of you come come race day and so when you do have the symptoms of one out of ten it's not so surprising you're like yeah this is part of the deal this is part of the job right yeah we we also want to avoid the ones that make us pull out and the gi symptoms are often the leading or the second leading cause for non-finishing or underperformance but yeah i think going in with the expectation of something is probably going to happen they said it's i've definitely had athletes running 100 milers and be surprised that at some point they needed to go to the toilet and so well you're pretty much out all day yeah you go to the toilet every day normally so why did you not think that there was going to be something special about this day that you just weren't going to go and i think if if you like you said expect it minimize the risk of something more severe

something worse then that's a good place to go for a lot of people that that you need to you need to edit the paper and submit something uh submit something after the fact and that's just athlete expectations right i'll take i'll take credit for that if you do get that submission okay so so we so we talked a little bit about the low fodmap diet it's miraculous for some it's a nothing burger for others and it can it can be problematic to to to implement but something certainly worth doing and i would i would recommend the athletes that are out there that are considering this as a as a long more of a long-term intervention to work with the registered dietitian or nutritionist with this because they can help guide that energy balance process and a lot of things that we can do often then really they're not simple but they're much simpler compared to the fodmap so let's say if we want to and what we're going to take a probiotic it's okay i take this pill or i don't if you change your carbohydrate strategy during a race it's okay i'm just fine tuning the amounts and the volume that i'm taking with a low-fat diet like you said all of a sudden you're looking at a complete upheaval of your diet potentially so that's something that needs a good sit down a good conversation and lots of deep planning okay so we started out with the most complex one we're going to kind of go from complex to simple maybe it's simple so it's the next one is the next one is the next one is gut training and um to set this up a little bit there's this great uh i don't know if it's great anymore but

there's this uh subheader in the book that i wrote and it just says your stomach is made of muscle too and the the point that i was trying to make with that is is most people think of muscle as skeletal muscle and they go and they do a bicep curl their biceps get bigger right because it's skeletal muscle and skeletal muscle adapts and so by presenting the stomach as a muscle too what i was what the argument that i was trying to set up is that it can adapt to stress in a similar way not the exact same way but in a similar way to skeletal muscle and this is kind of gone this is an area that's gone back and forth in in in in the research as well um we tend to trivialize it from uh coaching and a training perspective to say i'll just practice your race day nutrition but now there's some research out there that says well you know based on uh an overload principle you may be able to get superior adaptations with with overloading the system just in a way that you would do training right you overload and then you in the new or in a similar way as you would do training so you covered this in in in the paper and there's definitely you know it's probably going to end up being just as ambiguous as the low fond map diet so jamie why don't you why don't you take us through what what you guys found out when reviewing the research is because again it's one of those that a lot of cultures and athletes discuss this we know this we we have conversations about it we go to the literature and there's there's one study that is really looked at this that there's there's another one i can talk

about and in that study it's it's a really great methodological study it's a really good proof of principle what they got the athletes to do was run for an hour every day consuming 90 grams an hour of carbohydrates during every single run so it's 10 runs over two weeks which i'll leave it up to other people but i don't know how practical that is how many people are going to do that whereas a more traditional approach might be okay i do my long runs or i do my back-to-back runs on the weekend we'll start there and at some point we might add a couple more training sessions in a week so that that paper was good in that the proof of principle of showing that your your intestines can adapt so that you said you need transport proteins to take that carbohydrate from the the lumen of the intestine and almost let it come across into circulation though the number of those transport proteins aren't fixed and where they are in the cell aren't fixed so we can get more transporters and we can have more of them at the surface where they're needed so that paper was really good and it showed a reduction in malabsorption of the the carbohydrates but to translate that now to your athlete as you said is is difficult and if we start higher up in the stomach there's a really nice paper that again showed that over this time only over five days if you consume a huge amount of water i think it's close to two liters an hour you can very very like by a small amount increase the rate of gastric emptying which for when

you think you're taking on two nearly two liters an hour isn't great isn't it wasn't a huge finding but what they also found is that people could just tolerate it better so the perception of fullness actually reduced a little bit during that study so those are the like the two main studies in this area everything else is just experience and hearsay essentially which as you like you said it makes things difficult where do you go from that and where you put that in your season where you put that in your training phase um is is difficult there's this fear at this cell culture models and we know these sorts of things that we know this adaptation can happen but the science behind how best to do this is is pretty low the the other place there's good research is showing that just in general if you ask people in studies do you take do you consume carbohydrates during training usually and then when you compare the at the end of the race who had symptoms and who didn't those who consume carbohydrates in their training tend to have so that's it's nice evidence that some of what we do in the real world works but maybe doesn't mean it's perfect how we do it yeah and it i'm kind of laughing here because we it's almost cliche that we that we say these things like oh you need to try your race day nutrition program and like you said a lot of this is just the experience that we know that we shouldn't be incorporating new things on race day and we should have some degree of familiarity with our nutrition

program on race day but when i when when i come back to this i kind of like my coaching background is heavily rooted in interval training and when we talk about interval training one of the things that we try to get the one of the things that we try to get the best fix on is what is the dose that is necessary to achieve the right response so you want a vo2 max bump right we know with a reasonable degree of certainty that you need a certain amount of time at a certain intensity exposure to bump up vo2 max and you can go up and down the intensity spectrum and you can kind of get good fixes on this you need you know 10 minutes at 90 of your vo2 max or an hour at 85 of your vo2 max or whatever i look at this nutrition thing through the same lens and i can't come up with that precise of an answer no because like i said that if that australian study is the sort of okay we know this works if we hammer the system if we do this nearly every day for two weeks but that's that's almost unrealistic for athletes and like i said that's without even taking into account any dental issues that might come along we just consume that much but which is like you said we have to put the the whole athlete health even the cost of it the cost of doing that when you look at some of the the new hydrogel mixes and all these things that they're not cheap if you want to go and run and consume 90 grams an hour it's a 20 run all of a sudden it's a 20 run

like so that's the start point great here's our proof of principle like exactly what you said now if we try and think well what's the dose if we start so and again i can only speak from from my experience and what we've used to survive our athletes and it's it means that we start really early in the process so we might be off season do what you like you know you enjoy your runs if you're thirsty if it's hot have a drink but once we're in a specific training phase okay we're going to now just like your training load might increase we'll increase your nutrition load during some of those runs and i said it might start out that weeks one to three we only do this on your your sunday with your weekend long runs and it might be 30 grams an hour in a given volume of fluid weeks four to eight that increases every single week and we're also going to throw that into a midweek mid long run if you've got that in your program then two weeks out okay we're going to do it almost just to try and mimic some of what we see in that paper we do at least one of the interval sessions because that's often the one that might mimic some race pace or mimic some of the harder intensities that you'll no doubt get during a race so whether that be because you're hill climbing or this is the surgeon pace and we'll still also then do it in your uh mid longer and your long runs on the weekend but that's like i said that's that's a

all of a sudden that's a really complicated detailed program to include it it's costly and that's assuming that at no point during it does the athlete decide do you know what this this particular brand or this particular ratio of carbohydrates or particular food intake doesn't suit me anymore i want to experiment you all here's so you mentioned one thing that i think is really interesting is these adaptations are sure surely have some sort of transient nature to them right they come and they go and we don't know what that rate is and if i use my interval training analogy we know d training rates pretty well like you remove training stimulus and we can plot out on a curve what happens to vo2 max what happens to lactate threshold what happens to muscular strength and we like i said there's been enough experimentation there that we can get a realistic fix on this we don't know this in this area here's here's how i've honestly like alchemized it and it's very similar to what you do with your athletes is eight weeks before the race twice a week you have you're doing your race day nutrition program period and i just i just keep it that simple yeah and i always try and include as well you either have your your b races throughout that time where you're not going to do your in race but you need to practice exactly what you think you're going to eat the day before because it's no good thinking i'll care about my nutrition down but you you didn't even think about the food you're going to

eat the day before so it's almost okay we need that entire routine even if the volumes aren't exactly the same because of course you're going to load up much more to do your your 50 mile or your 100 mile wherever it's going to be but if you've got a big weekend at least one of those weekends two of those weekends you now need to think about and replicate and get that plan write it down make comments afterwards what felt good what didn't feel good exactly as you said you would do with your just your your the actual run training yeah yeah i i agree with that run a show thing whether you're using a long run or a b race or whatever but but i've i've just found through experience that eight weeks twice a week full race day program i feel yeah i hate scientists hate these statements but i feel that that get that that is the right dose for some reasonable gi response in addition to that it's enough frequency that the athlete just gets used to hey this is the stuff i'm going to take in on race day and the final thing is is it allows enough time and enough frequency just to get into the routine and take the thinking out of what is my race day routine going to be so like all like the physiology the practical the psychology side all kind of align up with that one frequency is three days a week you know better or is it nine weeks versus that you know who knows i'm not going to split that hair that finally but i think that's right like roughly enough enough dose and enough frequency to create a reasonable

response and then you line it up with all the other practical elements i i just think it's a you know it's it's in the i'm not going to say i'm right but it's at least in the ballpark well the one thing you know is that if you're not doing if you're not experimenting with something that is less well studied so if you're not thinking of taking i don't know ketone esters or medium chain for glycerides or amino acid if you're not thinking of taking these things and your your fueling is mostly carbohydrate which i'll leave to you to discuss and you're somewhere you're on the show but that's what your strategy is you can adapt the carbohydrate transport is just through your normal diet yeah so you have a higher carbohydrate diet like you said that's like the your residual training that's going on in the background so if you if you don't restrict that in your habitual diet it's like you're going to have that constant load added and these um training runs where you're adding them the exercise stuff can be exactly you said as much about the adaptation of the gut as it is the psychological side of things the practice the repetition all of those other things that is beyond just training the gut yeah you know i don't think you touched on this in this paper but i talked about this in a previous podcast with uh patrick wilson that a lot of this become a lot of the gi issues happen with people who have had previous gi issues and there's a physiological component to that absolutely but there's also a psychological component to that too if they've experienced

it before and they know it's at a certain mile marker at a certain temperature or kind of whatever that anxiety that is already enhanced throughout the process just because of doing a race that anxiety that oh shit literally i'm at this you know i'm at mile 50 of 100 and i always have these gi issues above 80 degrees or at mile 50 or whatever that creates another like compounding factor that that that can fuel a lot of this gi distress and that maybe leads on one of the things that we one of the things that we threw in the paper that we we had there's no exercise evidence therefore was this link between the gut and the brain and some of the neurotransmitters some of the the hormones that can play a role because we know from other other models of clinical models that all of these things can even affect the the visceral sensation of pain so as you said so then and this is why you might then see differences between athletes because you could have two athletes with the same diet the same training the same the same everything out of prep but if one of them is stressed and that leads to some underlying physiological or neurological change that might just mean that so not to say that it's all in that it's not something that is all in their head but their physiology is physically making that stress more painful to them than another athlete and that's so we put that in the paper even though it's really short and there's no great stuff to do before that just because we want to stimulate this conversation and

make people aware of these things and see how can we we study this in future well and go back going back to my you know twice a week for eight weeks a lot of times what i'll do when i uh start that process with athletes who who have like this routine uh or they show a pattern of gi distress during really specific parts we try to work through those really specific parts as much as you can or much as you can have an equivalent during the training process so that they get some reasonable degree of confidence that they can get there and it might not be zero but it's at least you know maybe one as opposed to four or five or six which they were experiencing earlier that's yeah that is something that with all the people up and sort of what i is almost something you i say to everyone at baseline don't expect this to completely alleviate your symptoms right let's just look for improvement if you look for improvement then the wrong you know you're on to when your performances will be better i love that i love that okay so we're going to go on to the third one in terms of simplicity of implementation i just came up with that and then i think that these are the things that people are naturally really interested in because it's the easiest solution to implement and everybody wants potions and pills to you know solve solve problems but there can be some you know reasonable degree of improvement that we can expect from this last category which you guys touch on a lot in the paper i think there's a lot of verbiage that's taken up with just with this last category and that is probiotics this is another one of those hot areas it

seemed like it was hotter like two or three years ago and now it's starting to die down where every thing that's going to take over definitely the fermented foods is one that the the army is coming definitely the fermented foods so you took a lot of time you took a lot of time with the paper to describe how probiotics might actually help the situation let's let's run through that part now i don't know i hope this isn't because of my bias in that i think two of my papers are excited it's like you said it's the simplest to implement in that you take a pill you don't take a pill there's there's maybe a decision to be made about finding the one that you might use and that's when this category the complexity and the difficulty comes in because like you said let's face it there are loads there are so many it's a multi-billion pound um industry now worldwide when you look at it and it's it's still it's been growing for the last 10 plus years and it's still growing this year uh as a consumer there when you're facing all this choice and you're also like screened at about how it's strain specific every probiotic is different and so you can sit there you go how do i know which one to choose because there's no great resource that says this is the one that reduces symptoms for athletes or this is the one that reduces traveler's diarrhea or this is the one that's really good for immune function you just left your own devices and i feel so guilty this is something that because of

my research i've been invited on podcasts or given webinars on so many times and i feel guilty because i can't give a much better thing than that better advice than that like other than okay well you need to do a little bit of research or if one doesn't work maybe it's because not all products are useless but maybe that one just didn't have the the ability to do what you wanted um so yeah so there's in in this area there's a little bit more research some of it has found no benefits whatsoever and and i i approached that so i went back to some of that literature and i started to have a look and not totally criticize it but in some of those papers the probiotics were almost destined to fail because exactly i've said with my athletes to have been beneficial they needed to like completely eliminate symptoms so the authors and some papers have found how many athletes had symptoms for example and there were there no difference between probiotics and placebo but that's the level at which they research not okay these athletes had an average severity of this much did it even get better slightly so some of those papers i think we touched on part of the paper were destined to fail because you're if someone has gi issues they have a long history of gi issues like you see it in ibs patients you're often looking for improvement not complete elimination um some of the others then that moves upon which i tried to based the design of some of my studies then did start to look at things like okay let's have a look

how many days a week for example in a given month how many times does does a runner or an athlete experience problems or experience a symptom what does that severity look like how many times do they have a moderate or severe symptom and papers that have tended to look at those type of measures have found differences in a few different probiotics so the the the the scientist in me definitely says that all of them are different but a lot of them can still do the same thing so a lot of them can change your mind make some small change to the microbiome a lot of them can block pathogens in or compete with pathogens in the intestine so yeah the the efficacy of them could be different but in general it's not a bad place to start if you want to be super detailed there are ones that have got a little bit more research than others um so in in two of our papers now that we've shown that with our marathon runners they tend to report about one or two days a week where they have a a series of a moderate or a serious gi issue during a run um it tends to be about one every 10 days and we found a about a halving of that incidence and then the number of moderate symptoms was about halved as well and we've we've replicated that and so we did it with our track marathon study where we was all really tightly controlled and we've replicated that in a bigger mass participation race as well very similar findings and we know no difference in the placebo

group and and in those what was the specific intervention or supplementation parameters i guess that you were using in those cohorts so we used one that is again it's similar to a lot of other ones that you'll see so it was 25 billion colony forming units which is in the sort of ballpark for most capsule based probiotics with four different strains two of them are lactobacillus two of them with bifidobacterium again something that's not too uncommon what we haven't done and what many of us haven't done and i've written and almost criticized is that we didn't compare this one to another one and because it's difficult the more arms you add to a study the lowest statistical power the lower chances you have of finding anything so i think we are getting to that point where more funding is needed because it's no longer good enough to say okay is a probiotic better than nothing we know that if we design the study well enough there are some improvements in again some athletes it's not cure all by no i don't want to come across this and say okay you get everything that we just said all of those are really complicated just throw a probiotic at it it's not because even in our cohort of athletes in both studies you still have athletes on a probiotic and they still have a lot of symptoms a lot of moderate symptoms or a lot of severe symptoms so it's not a cure all you can't just throw a tablet at it and make it go away well not only is it not a cure all but and that kind of fits

the theme that we were talking about earlier right we're not looking to eliminate all symptoms we're just trying to move down the incident scale or the perceived exertion scale you know so to speak uh with it with any of these things is there though when we're talking about when we talk about any type of supplementation usually there's a minimum effective dose associated with that we talk about that with caffeine a lot uh and and a whole host of supplements that that athletes use is that still do you think this might be a i think statement again do you think that that is going to be the case on the probiotic side as well i think so and i think that's why fermented foods are going to be seem to be beneficial i'm almost sure of it there is enough potential there for how they can improve our old health what i don't think they'll be able to do is substitute for some of the times we want to use a probiotic like these specific circumstances because probiotics are in the tens of billions of bacteria fermented foods can be in the millions or hundreds of millions so you're talking at between 10 and 100 factor difference so i do think there's going to be this minimal dose and it probably is in that billions range where then what the difference might be i always present this slide that shows the the one end you have the fermented yogurt drinks that people will know the really popular one that when people know that i do probiotic research they think that there's only

this one that they all get that's the sort of so everyone knows that and that's normally so they they sell a range that's about nine billion on the very opposite end you can get ones that are sometimes pharmacologically prescribed but they are commercially available that have got 450 billion so even within commercial products you've got a 50 a 50 factor difference between the lowest and the highest that you can buy the number of species again is different and like i said the the yakults and things you often have one strain one species some products have 15 i've seen ones with 25 different species i don't know if a lot of that is just for marketing because it's okay if some is good more must be better but we often don't know okay which one of those might be the one that works which will be beneficial for this type of thing um so that comes back to what i said at the start for a consumer then you're sat there and you go okay this is this is my a race i want to get everything right is it enough to just buy the the the simple capsule that james used in his study or the fermented yogurt this is like super mega dox should i invest all my money and just like cover all bases and just just go on this one here 450 billion a day and no one knows if that is going to be any better to this at all or it could it could even be worse so what's the reasonable starting point there we presented this whole landscape of you know this many billion colony forming units to 50x that like where's the reason like somebody's looking at

this going okay i understand that it's not going to be a night and day difference this is an intervention that i want to try because these gi issues are hindering my performance in some way i think that using a probiotic supplementation is a you know reasonable thing for me it's you know relatively cost effective it's easy to implement like where's the starting point for people in terms of the types of products that they can use and then the duration that they need to experience that product with before they can see some sort of reasonable improvement let's take the science out of this yeah yeah yeah it's because i'm from a scientist but yeah from a practical point of view something that is in that region of 20 to 30 billion colony forming units has multiple strains or species again between three to five is probably the most that you want because then it means each of those individual species will be in them in enough because they said if you had more but only one of them is effective it means that yes you've got 10 strains but the one that you really need is is really low in in total amount so there are the good thing is there are lots of those different types of products i think as a very minimum you need to try and give it two weeks we've never seen this in any of our studies but there are a small number that show an increase in symptoms in the first two weeks so maybe that's just

if there's maybe some small change in the microbiome maybe it's that now you've got a slight increase in some of the bacterias that can ferment foods a little bit so like i said we've never seen it and lots of other studies don't report it but i do think you need to give it at least two weeks because you may may may may see a small increase in symptoms and that's the point that if you've got a history of symptoms you would go oh no that why this isn't for me right so some people that there is an adaptive period so if you go at least two weeks and like i said all of our studies we we found differences in just four weeks so in our marathon paper we found that even after two weeks there was a beginning of reduction in symptoms when we gave athletes when we gave marathon runners a probiotic four weeks before a marathon race and again we replicated this in a in a big city marathon um the runners who had taken the probiotic also had lower severity symptoms during the race itself so during the marathon race in our track marathon because we could obviously ask them almost every other lap every like of the 105 and a bit laps that they ran around the athletics track it was specifically in that final third of the race that the marathon runners symptoms were less severe so this increased a little bit but once they got into that final third it was just stabilized so exactly what we said the point you want to be might be mildly uncomfortable but the pace doesn't drop they can live with it whereas in our placebo group we had a couple of athletes

really start to slow down it was some really bad stomach cramping i i like we can put a pin in it there because we've got these three interventions and we've got practical recommendations for all of them let's kind of run through them and kind of recap it for the audience here so the first so the broad umbrella is with any of these interventions it's reasonable to expect some degree of relief but getting to zero meaning no issues especially in an ultra marathon situation it's probably unlikely so i'd say to even start out with make sure that your expectations are adjusted accordingly that's a big part out of all this right huge definitely okay so the first one is low fodmap diet and when when athletes are interested in this i almost almost immediately kick it over to the registered diet dietitians to try to do this this that's a long-term proposition there's some there's some evidence that this could work there's a lot of anecdotal tales of it was miraculous for me or i had some sort of you know mild symptom reductions and things like that but that's the complicated scenario because you're you're kind of turning over your entire diet you're like upheaving your entire diet correct 100 and like i said without going down and never rabbit hole into a complete other topic i'd say a simpler starting point for most athletes is to just look at the the diet so not from a fodmap point of view but from just there are other practical

things they can look at first in terms of what they're eating and when they're eating around the race so if that's your starting point looking at that pre-race diet sort of 24 to 48 hours before there are probably other things that will immediately stand out but if you just change that rather than let you say completely change the entire diet um but certainly if that's then the reason what go down the low fodmap registered dietitian good um solid well researched advice and support as well because i think this is it's such a big thing it's probably too big of an issue to just tackle on your own and keep yourself honest and accountable with it 100 so then there's gut training and i think the the recommendations we kind of batted or i'm laughing because it's just we're just making stuff up it's it they're reasonable reasonably educated guesses but at the end of the day that's about as good as you can get a few days a week for several weeks you're doing your race day nutrition plan i think that that's reasonable it's practically implementable and from a science perspective there's reasonable evidence to suggest that that has a degree of efficacy to it as and even if like you said even if we we said we could find a study that eventually said well the minimum dose showed that you maybe only needed to do this in your last long run for the race why would you leave it until then why would you not start thinking about this eight weeks out so even if you don't need eight weeks from a adaptation and

a like sort of training point of view you want as much time as possible to figure things out and get things wrong change your mind you might abandon a run halfway through because you do need to run to the toilet so for beyond just the physiological point of view you should be starting with a reasonable amount of time before okay so that's the gut training piece of it a few days a week several weeks several weeks beforehand and maybe a super gut trial to test like tolerance limits or some sort of new food or things like that those are one-off situations and then the last thing on the probiotics and you're gonna have to you're the expert here so you're gonna have to correct my dose and timing on this if i if i've misremembered it but it's in the tens of of billions of colony forming units that you're taking a supplement of which you have three to five strands for four weeks leading up to the race yeah at least and it is one of those things they said it's probiotics can be almost one of those lifestyle supplements so people will maybe take them over the winter period and it seems that they are um transient and if you start taking them within a few weeks all of those bacteria that you were putting in seem to disappear so it's not that you have to take them every day but like so it's not something you can think okay well i'll take it six months out for a few months before the race and it doesn't matter if i stop beforehand so as a minimum dose yeah four weeks before a race

um and i always it's the same thing as it then is your budget affords and where that ranks on your priority list of what you want to spend your money on leading to a race and i don't want to tell people to spend their money on that rather than coaching or physio or massage or anything else because i said that unless you're a sponsor athlete all these things come across and i think you need to think is is that the best avenue for my for my money for i mean that's a good that's actually the best point to leave it on if i put my coaching hat on which is the hat that i wear almost all the time i start with two which is the gut training make sure you know your race day routine and then i go to the probiotic side and then i go to low fodmap diet that's the way that i would kind of rank order those interventions as a genuinely exactly genuinely now exactly the same from from all of my experience and i found that 90s and 95 percent of athletes i only need to look at that yeah i yep i i'm with you there it's the but it's the five percent that it makes me pull my hair out and those are the athletes that pull their own hair out right i mean you have you have enough experience working with athletes that there is a it's a small cohort maybe it's five percent maybe it's ten percent or whatever there's a small cohort that you just have to throw all the interventions out and you just you're just trying to completely problem solve to get them from a nine or a ten on that one to ten scale down to

something that's manageable which might which might be four and i mean that becomes the performance limiter for those athletes for sure absolutely and it's again i think it's something we touched on early in the paper it's for me it's the realization that sometimes that if the more recreational athletes we work with just by chance the more that we will work with someone who has undiagnosed ibs somebody who has an undiagnosed i thought they're like you said that five percent is it's way more difficult than i said and could even i've had two scenarios where it's eventually even needed clinical follow-up because it's just they could live with it it was almost that that extra size physical challenge that started to reveal what was underlying pathology yep and sometimes that i mean just like training sometimes you need advanced interventions to create the adaptation it's the same thing here yeah definitely all right that's a brilliant place to leave it do you have any do you have any final thoughts on this incredibly complex issue and i do i do think i can't promise this right here right now but i do think that in sequence the next podcast uh that is going to be releases with your colleague kyle who's the lead author of this paper so it's going to be another it's going to be another follow-up we'll make sure to hit on sit on different angles of this for sure i'm sure because of obviously we came together because we all had different like different interests and angles so i'm sure that'll be bringing something completely different as well and a new approach to this and um now this is this has been awesome this has almost been like a bit of a dream for the

last few months so thank you so much for coming up to let me come on uh to come on podcast that you actually listen to is pretty cool well thank you for coming on it's a great it's uh always good to to weave in uh people who are in the scientific community that also directly work with athletes on a consistent basis like you do because you bring the practical element of all of the science and you can say well i studied all this stuff and i knew all about this but here's how we like you know throw most of it out the window and take the one sliver of what i do know you do that brilliant jame jamie and that's why that's one of the reasons i appreciate you out in the field good luck at kona that's going to be fun good luck getting into the us i appreciate it a lot man all right folks there you have it there you go much thanks to jamie for coming on the podcast today next week we are going to have jamie's colleague and the lead author of the paper that we were discussing kyle smith to come on the podcast as a follow-up to this conversation i cannot wait for that expect more practical insights and a little bit more of a deep science dive into why we experience these gi uh issues and how and what are the different pathways out of there i appreciate the heck out of each and

every one of the listeners out there as you all know there are no sponsors or no endorsers of this podcast the best thing that you can do to help the podcast out is just to spread the love and spread the word to your friends i really appreciate it when i see people sharing this podcast out there on social media it just makes my heart line up so i appreciate the heck out of each and every one of you and as always we will see you out on the trails