REPLAY: Continuous Glucose Monitoring with Dr. Michelle Woolhouse and Jessica Turton

REPLAY: Continuous Glucose Monitoring with Dr. Michelle Woolhouse and Jessica Turton

Jessica Turton, Accredited Practising Dietitian, joins Dr. Michelle Woolhouse to discuss the use of continuous glucose monitors (CGM) to identify blood glucose dysregulation in non-diabetic patients in our latest podcast.

Together, they discuss the role of the CGM in obtaining key, patient-specific information in terms of the blood glucose regulation of the individual, allowing for greater analysis of dietary, environmental and lifestyle influences on blood glucose regulation for the individual.

Jessica and Michelle discuss the role stress, sleep and inflammation play in blood glucose regulation and share clinically practical advice on the role of magnesium deficiency in patients with blood glucose imbalances.

Discussing the impact of certain exercises and alcohol, Jessica answers some of the many often-asked questions around how to best manage blood glucose levels for the non-diabetic patient.

Covered in this episode

[00:31] Welcoming Jessica Turton
[01:53] What is continuous glucose monitoring (CGM)?
[03:40] Using data from CGM to measure inflammation and blood glucose dysregulation
[09:11] Optimal blood sugar targets throughout the day
[13:45] The effects of high impact workouts on blood glucose
[18:20] Hypoglycaemia vs reactive hypoglycaemia
[24:30] Glucose metabolism, sleep apnea and magnesium wastage
[28:06] Stress, exercise and glucose metabolism
[32:34] Alcohol’s effects on blood sugar
[36:29] Patients’ views on CGM
[49:56] Thanking Jessica and final remarks

Key takeaways

Continuous glucose monitoring (CGM) involves the use of a monitor that is painlessly and gently inserted under the skin that records blood glucose data every 5-15 minutes for 5-7 days that are uploaded to your phone for review.
CGMs provide insight into the fluctuations of blood glucose levels throughout the day. The data provided by a CGM allows for the assessment of diet, lifestyle and environmental influences on blood glucose control.
The body is required to maintain control of blood glucose levels to support cellular, organ and brain function.
Chronic disease is associated with inflammation and blood glucose dysregulation. Interestingly, blood glucose dysregulation can itself cause inflammation.
Stress can negatively influence blood glucose management as stress hormones increase the production of glucose. Exercise can temporarily increase blood glucose levels as the body produces glucose in response to the increased energy requirement.
Low blood glucose levels influence adrenaline and cortisol production, increasing the risk of inflammation.
Targets for blood glucose control is 5, within a range of 3.5-6.5.
Sleep apnoea can be identified through CGM use due to blood glucose dysregulation overnight, resulting in a poor night's sleep and the individual waking unrefreshed.
CGM results can provide patients with the quantitative data to support behaviour change.

Resources and Further Reading

CGMs and Physical Activity

Research: ‘Using Continuous Glucose Monitoring to Motivate Physical Activity in Overweight and Obese Adults: A Pilot Study’, Cancer Epidemiol Biomarkers Prev, 2020

CGM Videos

Video: What is Continuous Glucose Monitoring (CGM)?

Video: ‘Sweat-based glucose sensing and transdermal drug delivery’, Ted

Transcript

Michelle: Welcome to FX Medicine, bringing you the latest in evidence-based, integrative, functional, and complementary medicine. I'm Dr Michelle Woolhouse. FX Medicine acknowledges the traditional custodians of country throughout Australia where we live and work, and their connections to land, sea, and community. We pay our respects to the elders, past and present, and extend this respect to all Aboriginal and Torres Strait Islander people today.

Today, we're going to explore the role and use of personalised digital technology, in particular, continuous glucose monitoring, also known as CGM. I want to explore how we use this technology in non-diabetic patients as a way of supporting behaviour and lifestyle medicine changes in issues such as weight management, metabolic syndrome, and polycystic ovarian syndrome.

So, joining us today is Jessica Turton. Jessica is an accredited practising dietician. She's the director of Ellipse Health in Sydney. And is soon to finish her PhD at the University of Sydney, where she's looking at the evidence for low carbohydrate diets and ketosis in the treatment of diabetes and obesity. Welcome to FX Medicine, Jessica. Thanks for being with us today.

Jessica: Hi, thank you for having me. It's great to be here.

Michelle: Pleasure. So, I'm going to start off really simply, and just ask and tell our listeners what is CGM?

Jessica: Well, CGM stands for continuous blood glucose monitoring. And it's basically a little device that you wear on your body, and it's monitoring your blood glucose levels without you having to think about it. There's a little tag that's inserted just under the skin. It's completely painless. It sounds a little bit invasive when you're first explaining it to someone, but it's painless, and you're just wearing this technology, and it's taking your blood glucose readings. And then what you need to do is you need to upload those readings onto some sort of cloud system, or your phone, or whatever it may be so you can actually view them.

And what you get to see is a picture of your blood glucose readings over the course of the day. So, it might be while you're asleep, in between meals, after you've had something to eat, during after exercise, I mean, during work meetings, there's so many different factors that impact your blood sugar levels. And so it's really, really useful to actually wear one of these monitors and learn more about how food and non-food factors impact your individual blood glucose levels.

And we all have sugar in our blood. That's very, very important. Our body needs to, I guess, maintain quite a tight range of sugar in our blood or glucose in our blood in order for all our cells to function properly, and for our brain to function properly, and our organs, and so on. And, yeah, there's lots of different reasons why you might use one of these devices.

Michelle: We're going to go into how we can use them differently. Because, currently, really they're used, and they've been a game changer for the management of insulin-dependent diabetes. And so in your clinic, you are starting to use CGM as a way of looking at other aspects. So, not so much about insulin-dependent diabetics, but maybe, yes, if you've got that condition, but also broadening the use of CGM. Tell us about that.

Jessica: Yeah. So, I guess I'm doing both. So, for my PhD, my PhD is focused in type 1 diabetes, so very much using these glucose monitors for people with type 1, taking insulin. And yes, it's an absolute game changer for people taking insulin because we know that insulin can change your blood sugars very, very drastically. So, it's very important to see and monitor what they're doing if you're going to take a medication like insulin. But outside of my PhD, in my clinical practice, in my day-to-day work, I don't have a huge amount of patients with type 1 diabetes, more so, just because type 1 diabetes isn't super prevalent. And I do see people with type 2 diabetes, or people who are just trying to lose weight, or people with the metabolic syndrome, people with PCOS, and we work with Dr. Pran Yoganathan at the Centre for Gastrointestinal Health. So, a lot of our patients have chronic gut issues as well. And, yeah, we use CGMs in many cases for those people too, because what we know is that most chronic diseases are associated with inflammation in one way or another. And your blood glucose levels are also associated with inflammation.

So, yeah, we know that if your blood sugars are too high for too long, that literally causes inflammation. And we also know that if your blood sugars are rapidly changing, that is another thing that can cause inflammation. But you can also see the impact of inflammation on your blood sugar levels too. So, it's kind of a chicken or egg situation. Let's say somebody has a really stressful meeting, or they have really bad sleep because they're in chronic pain, their body will make more stress hormones, and that will actually cause an increase in blood glucose. So, you get to see a cause and effect of inflammation and stress.

Michelle: That's so brilliant. And I want to go into the nitty-gritty and the details of that because I'm super interested in that. But because in clinic, previous to something like using a CGM, we used to use things like haemoglobin A1c or fasting glucose, maybe cholesterol, maybe uric acid to look at glucose metabolism as a whole. And there's so many limitations to those tests because they're really just a snapshot. So, as I was preparing for this chat, there was a research paper discussing three different patients all with the same haemoglobin A1c, but they all had three different types of glucose curves. One with super high regular highs and regular lows, which, therefore, the averaged out the haemoglobin A1c was normal, minimum variation. So, obviously, that's the optimal. And then intermittent excursions, so slow rises, slow declines. So, this is the kind of variation that CGMs can pick up, am I right?

Jessica: Yeah, definitely because the CGMs, depending on which one you're using, they're either taking a measurement every five minutes, or they're taking a measurement every 15 minutes. So, you get to see the curves of the blood glucose across the day within... Like, within an hour, you get so much data within one hour. Whereas, yes, the HbA1c, what that is, is measuring how much sugar has kind of stepped to your red blood cells, and we sort of call it a three-month average of your blood sugars. So, it absolutely can't capture day-to-day variation.

Michelle: That's right. And so, tell us a little bit about glucose dysregulation. Because, in clinical practice, that's actually quite a new way of expressing glucose dysregulation, so the variability. So, I know that in the research, they're sort of saying when the blood sugars are too low, that actually creates an adrenaline surge, which then increases your cortisol and then sets off the inflammation cascade. What's happening with these high readings and too low readings?

Jessica: Yeah. Well, I think the first thing I sort of thought about when I started using these CGMs is, “Far out, we actually don't know what normal blood sugars look like because CGMs were, or they've always been used in people with type 2 diabetes or insulin-dependent diabetes, type 1 diabetes.” So, we started off using these devices in people with severe blood glucose dysregulation.

Michelle: Yeah, that's right.

Jessica: Yeah. And it's only, I guess, more recently that people are accessing them for other reasons. And even the research, looking at people without diabetes and using glucose monitors, that's also more recent too. It used to be like, "Well, if I don't have diabetes, why would I test my blood sugar?"

Michelle: That's right.

Jessica: Even the word blood glucose, the first thing people think of is diabetes. But we all have glucose in our blood, and it's important for all of us, right?

Michelle: Absolutely. So, what do we know about normal? I was reading the research, and we say sugar is high as 11 postprandially is okay. Is that okay? Or should we be trying to gain tighter control? What's your experience in practice?

Jessica: Yeah. So, most of the blood glucose targets are usually the targets for fasting blood sugars, and after meals are usually 3.9 to 10. And if you're measuring it directly after a meal, as you just said, oftentimes it goes up to 12. But in my opinion, they are for people with diabetes. So, those broad ranges, those management targets that you usually find online, or you even find on your glucose monitor, they are generally for people who already have established diabetes, and we are just trying to prevent their diabetes from getting worse. That's what those targets do. Because you can have somebody with type 2 diabetes, for example, who is within the range of 3.9 to 10 a 100% of the time, but their blood sugars are all over the place. They're feeling terrible, their Hb1Ac might be 8 or 9, and they're on tons of medications to try and control their blood sugars. So, those ranges definitely aren't what we would call ideal.

What we do know is that a blood sugar around 5 is where our body does function at its best. And, of course, there's going to be deviations sort of above and below that. So, in our clinic, we tend to recommend a range of 3.5 to 6.5 as where we want our blood sugars to be for the majority of the time. But even with that range, we still want to, I guess, wear a glucose monitor and actually see where the blood sugar's sitting and for how long because we do have some patients that always sit between 3.5 and 6.5, which is pretty tight blood sugar control. But there'll be some days where their blood sugars are just hanging out at 6 all day. And we are like, "Well, hang on a second, why is your blood sugar sitting too high at 6 on this day and then all the other days it's at 5?" We know because we have the glucose monitor, we can collect all this data that that 6 is abnormal for that person. Whereas another person, their blood sugar sitting at 6 could be normal for them.

So, yeah, there's individual variation, and we don't have the exact answer. But these glucose monitors allow practitioners to learn from their patients. And, yeah, you collect so much data, you ask the patient how they're feeling, and things like that, and you can kind of figure out what their ideal blood sugar range is.

Michelle: Yeah. And I think it's just fascinating, too, if they kind of... You know, you mentioned the chicken or the egg kind of factor, because it could be they might be at 6 because they've had a really poor night's sleep, or there's something bothering them. So, I always love looking at, I guess, that internal stress response. Some people cope with stress so beautifully, but somewhere in them, there is still stress, even though they might be coping really well with it, or it could be the sleep, or the alcohol the night before, etc., etc. So, it's a great way of exploring what actually is going on for that individual person.

Jessica: We have picked up so many cases of sleep apnea by putting glucose monitors on people.

Michelle: Yeah. That's fascinating, isn't it?

Jessica: Yeah. Really fascinating. I mean, I thought GPs were doing quite regular testing for sleep apnea, and perhaps they are, and perhaps the patient just doesn't want to go off and do that sleep study because I imagine that's pretty uncomfortable. But, yeah, you're exactly right. If their blood sugars are sitting too high overnight, and in some cases, we see people's blood sugars swing wildly up and down through the night, and we're like, "Did you get up and have something to eat?" And they're like, "No, I was asleep this whole time." And then we say, "Well, how did you feel when you woke up in the morning?" "Terrible. I felt like I hadn't slept, or I'd been hit by a truck." And it's like, "Okay, you need to go and investigate that because that is definitely not normal."

Michelle: Yeah. Well, sleep apnea is so prevalent, really. They're sort of saying 10% to 15% of the population. And the sleep study places are so full, sleep physicians, the wait is three to six months. So, that's often some of the issues that GPs are facing as well.

Jessica: True.

Michelle: But apart from dietary choices, let's talk about these other factors that impact glucose modulation. So, we mentioned sleep, and sleep apnea is a big one, but also anxiety, for example, affects glucose modulation and exercise. Let's talk about what other impacts that you've seen using CGM apart from their dietary choices.

Jessica: So, these non-diet factors are more clear in people that do have some level of insulin resistance, like the metabolic syndrome, or prediabetes, or type 2 diabetes, polycystic ovarian syndrome because the process is still happening for people without diabetes, but you just don't see it as clearly on the glucose monitor. And again, depending which glucose monitor you've chosen, it might be really quite sensitive, it might not be that sensitive.

So, for example, if you are doing some exercise, and let's say you are doing exercise that requires glucose. So, if you're doing a high-intensity interval training session or something like that, even if you haven't eaten any carbohydrate, your body still needs glucose for that activity. So, your body will make glucose for the activity. And you will generally see, within a sort of 15-minute period, your blood sugar rise because of that, because your body has made the sugar. And then what tends to happen is because your muscles are pumping and working really hard, the muscles will just suck up that glucose without your body needing to produce insulin. So, you can see that on a blood glucose monitor, as I said, you can see it more on people who are a bit insulin resistant because their muscles are a bit insulin resistant. But you can still see it. If you've got an athlete who's training really hard, then they're making lots of glucose, you can see that.

Michelle: And when you say, showing lots of glucose, are we talking kind of up around the 7 or 8, 10 or 11? What are the numbers that you kind of see when you see someone that is just doing a high-intensity workout?

Jessica: It depends where the blood sugar levels start. So, let's say they're doing a fasted activity and they haven't eaten anything for 12 hours, so their blood sugars might be just hanging out on the lower end, maybe around 4, 4.5. Then if they do a high-intensity interval session, their blood sugars might go up to like 6.5, or something like that. They're not going to go super, super high. But the other thing as well is it depends on which blood sugar monitor you're using. If you're using a blood sugar monitor that's taking a reading every five minutes, you might actually pick up that it goes even higher. If you're only using one that takes a measurement every 15 minutes, you might miss a data point that goes even higher than that. So, you might not actually see how high it goes, but it's still a good indication of how your blood sugar is changing.

And it's not a bad thing. You know, like, patients will come in, and they'll be like, "Oh my God, exercise is terrible for me." And they'll show me all their spikes from exercise. And when I say spikes, again, it's relative to the individual. So, they might be really, really setting out to have these stable blood sugars. So, if they see a little spike like that, it's something that alerts them. And we just have to understand that it's different for exercise, high-intensity interval training because your muscles are sucking up the glucose. So, you're not producing insulin in those situations.

Whereas stress is different because stress, we are producing all these stress hormones, which increase our blood glucose levels in expectation that we are going to need that glucose. But usually, you know, modern-day stress, we're sitting at a computer screen wondering why our emails aren't working or something like that.

Michelle: Yeah, that's right. IT stress.

Jessica: Yeah, exactly. So, we don't tend to actually use that glucose that our body made, and it kind of just sits in the bloodstream and then our body has to put it away. And the way our body puts it away is by producing insulin, and then that helps the blood sugar go into the cells. And if you're doing that a lot, if your body's always producing insulin throughout the day because you've got a lot of stress going on, that can lead to weight gain, insulin resistance, progress you towards diabetes, and high blood pressure, and things like that.

Michelle: Yeah. Amazing. So, what about hypoglycaemia? So, sometimes when I've used the CGM in my clinical practice, there's people that actually have hypoglycaemic events. They don't actually know that they're having that, like, they don't actually feel hypoglycaemic, but it's something that is commonly picked up, maybe twice a day, maybe once a day, etc. What's going on there?

Jessica: People without diabetes?

Michelle: Yeah, people without diabetes. People, maybe they've got some insulin resistance. We're not quite sure, we're sort of just at that early stages.

Jessica: It depends what it's following. So, if you have someone who maybe they haven't eaten for four hours or five hours, or they wake up in the morning and they skip breakfast or something like that. So, they don't actually have food in their system, then it's probably just that their blood sugar levels are at the lower end of normal. Because when you say hypoglycaemic, what numbers are you talking about?

Michelle: 3.4 sort of thing. Not in the 2s, but just in the low 3s. So, I guess the question is also, like, you know, it's the same with blood pressure. We have these arbitrary cutoffs, like, anything below 150s, low blood pressure. But some people walk around with 90 on 50, but it's normal for them. So, I guess that's the thing is we've got this 3.5 to 6.5 is normal. Is some people normal at 3.4, 3.3?

Jessica: Yeah, definitely. So, people who are... If their body can use fat efficiently as a fuel source, then the blood sugars will sort of drop because their body doesn't need the glucose. So, as I was saying, if you haven't eaten for a while, if your insulin levels are low, so there's nothing stopping you from burning fat, your body starts breaking down fat, whether it's stored body fat or fat from the diet and using that for energy, your brain will suck up that fat, your heart will suck up that fat, everything in your body will be happily using fat. And glucose's role is to provide us with energy. So, if your cells are already taken care of, and they're using fat, they don't need as much glucose.

So, your body will naturally produce less glucose, but it's never going to just stop producing glucose. Like, if you don't eat carbohydrates for 48 hours, your body is still going to make the glucose you need. It's never just randomly...like, your blood sugars aren't just randomly going to fall to one, or anything like that. Some people get a bit alarmed if they see their blood sugars going low, it just means your body doesn't need as much glucose at that time.

Now, that's for someone who's not symptomatic. If you're actually symptomatic and you are feeling symptoms of low blood sugar, so you are shaky, or anxious, or hungry, or irritable, usually, in someone without diabetes, that usually follows a meal, and it might be one to two hours after a meal. And what it means is that...it's something called reactive hypoglycaemia, where it’s a form of carbohydrate intolerance, where your body actually over-predicts how much insulin you need. So, when your blood sugars start rising because you've eaten some carbohydrates, like, let's say you've had a meal with mashed potato, or you've had some bread or something like that…

Michelle: Mashed potato is terrible, isn't it? It's really like a bowl of skittles.

Jessica: Well, look, any carbohydrate is going to lead your blood sugars to rise, whether it's good carbohydrate, not good carbohydrate. I mean, carbohydrate breaks down to sugar. So, it has to cause an increase in your blood sugars. But, yeah, with some people, their body really doesn't like their blood sugar changing. And so when the blood sugar starts to rise, their body will release large amounts of insulin, probably more insulin than they actually needed, which can cause a consequent drop in their blood sugars. And because their blood sugars are dropping too low for their needs, what happens is they tend to feel symptomatic, they run out of energy, they get brain fog, shaky, irritable and so on.

But eventually, what will happen is their stress hormones kick in, like you were alluding to before, and they'll start making glucose again. So, it's not a life-threatening situation for people without diabetes, but it's certainly something that can make people feel uncomfortable, can increase anxiety, can make it very, very difficult to "eat healthfully." These people do need quite a specific diet, where the carbohydrates are controlled. They have a lot of protein, good healthy fats, and that basically stabilises the blood sugar.

Michelle: Yeah. Because it's interesting when I was doing some reading up on that. And because one of the issues with hypoglycaemia and the way that the body responds, you know, you mentioned the release of stress hormones, but that release of stress hormones also actually activates cytokine release and increases platelet activation and neutrophil production, which can then also microscopically lead to this subacute inflammation that we all talk about in terms of one of the drivers of chronic diseases. So, I think it's one of those things that if this is a big issue, this is the sort of stuff that CGM is a game changer for, this is one of the things that we can kind of look out for. Would you agree?

Jessica: Oh, yeah, definitely. For sure. And I always recommend patients when they're using a CGM to keep as many notes as possible, the CGM usually stays on for 7 to 14 days, depending on the brand that you get. And, yeah, usually, it pairs with an app on your phone. And every time you scan your phone against the sensor, it gives you an opportunity to write a note. So, yeah, I would always recommend take down notes about how you're feeling, so, any symptoms that are slightly unusual, headaches, irritability, anxiety, any stressful events, any physical activity, and then, of course, food as well.

Michelle: And you mentioned sleep apnea before and kind of diagnosing sleep apnea. Is there other aspects of glucose dysregulation that actually affects insomnia? So, for example, a lot of people, they may not have sleep apnea and they actually feel like they do sleep. But we know a lot of people, I think it's up to 33% of the population, suffer some level of insomnia. In your experiences, has glucose metabolism or dysregulation play a role in that?

Jessica: Yeah. I would probably say there's quite a few mechanisms for why it would. But one thing that I'm just thinking for people who...oh, I guess, I mean, this would be people with diabetes and without. But a big issue that we see for people with insomnia is magnesium deficiency. And we know that when your blood sugars are high, what happens is... I don't want to get this wrong, but it's either your glucose and magnesium compete to get into the cell. So, if your blood sugar's high, glucose will preferentially get into the cell over magnesium. And then also when your body is excreting glucose from the body. So, if your blood sugars are high and you have excess blood sugars, your body tries to get rid of that, to bring it back down to normal. So, you'll lose glucose in the urine, for example. But to get that glucose out of the body, it does take magnesium with it.

Michelle: So, it's like a magnesium wasting? Yeah, waste down magnesium.

Jessica: Yeah. Exactly. So we know that people with glucose dysregulation and insulin resistance, they have a higher requirement for magnesium. So, they're more likely to become magnesium deficient. And if you are magnesium deficient, then your cells, including your muscles, your nerves, they're not getting the magnesium they need, and they need magnesium to switch off and relax. So, a lot of the times people are going to bed and they're wired, you know, that wired but tired feeling. And it's like whatever they try to do, they can't switch off, they can't relax. They don't even yawn because their body just can't get into that state of relaxation.

Michelle: It's such a good...

Jessica: And they need magnesium.

Michelle: Yeah. It's such a good way to understand it too because I've often spoken about magnesium. When you do have a high carbohydrate diet, or if you have a lot of coffee, or if you have a lot of alcohol, or if you have a lot of stress, you waste that magnesium away. And so it's just a really nice, simple way for people to understand, why do I need so much magnesium, which to kind of calm myself down.

Jessica: I know.

Michelle: It's that trying to block up the holes, it's trying to block up the loss of the magnesium, which is really common in our day-to-day lives.

Jessica: Exactly. And my patients will always say to me, "What did they do? What did humans do 10,000 years ago when we didn't have all these supplements?" And I'm like, "Well, they certainly weren't experiencing this chronic stress like we are today."

Michelle: I know.

Jessica: "So, their requirements for these nutrients weren't as high." And then the other thing about magnesium which you've probably talked about before is that the magnesium in the soils in Australia is so deplete. So, the foods that we used to think were rich in magnesium, like berries, and nuts, and seeds, and things like that, they no longer contain sufficient levels of magnesium. So, our food isn't a reliable source. So, most people are going to need a supplement, even just to meet their basic requirements, let alone people who are under significant stress, which is most people they're definitely going to need a level of supplementation.

Michelle: Brilliant. I 100% concur. But I wanted to explore a little bit because you mentioned high-intensity exercise, which is obviously the latest and thought to be really fantastic for weight management and for many people in exercise of choice. But what about different choices of exercise? Like, do you know, or do we know about things like long walks? Hippocrates always talks about walking is man's best medicine, like that kind of 10,000 steps a day. Or do we know the impact of something like yoga on glucose metabolism? Do we know a little bit about what particular exercise and how it changes in terms of glucose metabolism?

Jessica: Well, I can tell you what I know from my patients. I would say to my patients, coming from what we were speaking about before about stress, is choose the exercise that lowers your stress the most. Because, generally, what happens is you've got people who want to lose weight, right? So, you've got people who are desperately trying to lose weight, they're on all these crazy diets, they're fasting, they're working 10 hours a day, and then they're going to the gym for like two hours, doing everything they can. There's a lot of patients that fit into that camp that are just desperately trying to do everything. And for those people, if you've got this heightened level of stress, you'll probably find in your glucose data that your blood sugars are just sitting a little bit too high all day. So, when you come along to that exercise, if you're then doing something like high-intensity interval training, it can actually cause more harm than good in some situations because exercise is a stressor. It's a positive stressor, but it is still a stressor.

And so I like to think of our stressors all going in the same bucket. It doesn't matter whether it's positive or negative. So, if you are got all this negative stress going on and then you're trying to be healthy, and one of those things is adding lots of exercise, especially that high-intensity interval training, which is probably one of the more stressful forms of training for your body, then it actually may not be the right thing for you. And you may notice in your blood sugars, they sit a little bit higher, or they don't come down as quickly as you'd like after exercise or something like that. And for those people, maybe doing a half an hour walk would be better. And we might work on the stress in the body. So, we might increase their magnesium, increase their Omega 3, we might change the structure of their diet to stabilise their blood sugars. And once we've done all that and their body's under less stress, then they can go and do the hit training because their body is able to deal with the stresses better because they don't have all this stress overflowing their stress bucket.

Michelle: Yeah. That's such a good way to look at it so that people can actually start to choose, and see, and witness, you know, let's get that biofeedback from their own choices. Amazing.

Jessica: Exactly, exactly. And I don't know, I mean, that's probably more something you'll see in people's symptoms rather than using a blood glucose monitor per se. Because if you talk to a patient and you hear they're doing all this exercise, they might be doing one, one and a half hours a day and they're trying to lose weight. So, you're kind of thinking, "Oh, good for them. That's great." But then you dive a little bit deeper and find out that they're not recovering after exercise. So, they're sore for like seven days instead of just the next day. And when they finish a session, they feel more fatigued, not more energetic. If you are noticing things like this, they're getting a lot of muscle cramps, muscle pain, things like that, then it probably means that the exercise is too inflammatory for them. So, they need to change the type of exercise or reduce the duration.

Michelle: And what about things like alcohol, smoking, some of the more illicit drug-related activities? What do you notice with that? Is there research on things like smoking and glucose?

Jessica: I don't know about smoking, in particular, but I do know about alcohol. And alcohol is a good one to talk about because alcohol can actually lower your blood glucose. And so a lot of the times, especially people with diabetes, if their blood sugars are sitting a little bit high and they have a couple of glasses of wine, or they have some spirits or something like that, and they see their blood sugars come down, and they're like, "Oh, this is the best thing ever. I should just drink every single night."

Michelle: Great.

Jessica: It's a good one to talk about. And then in your people who maybe don't have high blood sugars or even people with type 1 diabetes, then having alcohol can actually make your blood sugars go too low. So, again, it's something to be aware of. And the reason that this happens… and I'm talking about pure alcohol, like dry wine or spirits that don't have any carbohydrates or sugars in them.

Michelle: Sure.

Jessica: So, what happens is if we think about the different fuel sources for the body, we've got fats, we've got carbohydrates, and we also have alcohol, and your body can only use one source of fuel at a time. It cannot metabolise two at once. So, your body will always prioritise the most toxic fuel first. So, usually, that's glucose. Your body will always burn glucose before fat. If you eat a sandwich or something like that, like a cheese sandwich, your body will always deal with the glucose first. The fat usually just goes and sits on the sideline. Usually, it never gets burned for most people because the body's always dealing with the glucose.

Michelle: Right.

Jessica: And that's really important because if your body didn't prioritise the most toxic fuel first, then that glucose would just sit in your blood and start damaging things because it is toxic. It is a toxin.
But alcohol is more toxic than glucose. So, again, your body needs to prioritise the alcohol first, which means glucose needs to sit on the sideline. And so your body's in a tricky situation there because glucose is also toxic. So, what your body does is it stops producing glucose. So, your liver's production of glucose, which is always going 24/7 in the background, it just shuts off. So, what that does then is it causes the blood glucose levels to kind of dip lower. And they tend not to just, like... I mean, they definitely don't just drop to nothing. Your body still maintains a safe level of blood sugar control if you don't have type 1 diabetes, but they do drop significantly.

So, as I said, people with type 2 that are used to having blood sugars of 10 all day, they might have some alcohol and their blood sugars drop to 8. And they're in the green zone, and they're like, "This is cool. I need to drink my alcohol." Usually...

Michelle: Yeah, that's really fascinating. I mean, there goes...that's why fatty liver and alcohol-related fatty liver is the two sources of metabolic syndrome within the liver.

Jessica: Yes. Yeah, exactly. And I think if people are having one or two drinks and the drinks aren't associated with extra sugars or extra carbohydrate, and it's part of a healthy diet, then I don't really see any detrimental impact on that. I mean, if you already have established fatty liver or something like that, then you might want to reconsider. But for people who don't, it's usually not detrimental. However, what tends to happen when people drink is they make poorer choices. So, they either drink more, they're like, "Oh, I'll just have one or two," but then it leads to three, four, or five, or they choose foods that are less ideal for them because they've got less awareness and less worries, I guess. So, it's kind of…

Michelle: Less frontal lobe, less inhibitions.

Jessica: Less decision-making capacity, yes. So, I usually try to figure that out with my patients too. Like, if they're having one or two drinks, and that's not leading to any consequences, then that's no problem at all. But if one or two drinks leads to a whole path of other issues that can then negatively impact their blood sugars and their health, then it's something you need to look at.

Michelle: Yeah. It's just brilliant. I mean, it's such a great way to explore metabolism, lifestyle, stresses. What is the feedback that you're getting from patients? Yeah, what are they saying about using a CGM? Are they finding it helpful? What are they saying?

Jessica: It's a good question because nowadays, that is the main reason we use it, just so the patient can see what's going on. Because we've used so many. I have so much CGM data that I can, in many cases, predict what someone's blood sugars are going to be doing based on everything else they've said. I almost don't need to do the CGM for a lot of people anymore, unless it's like a troubleshooting exercise, where we've done everything else we can and we really just want to check the blood sugars are all good.

But, yeah, most of the time, we are using the CGM for their benefits. So, they can see, on a day-to-day basis, how different foods and different activities impacting them. Because in our education session, we might say, "Okay, these foods that are high in carbohydrates are going to increase your blood sugar, and that's going to cause release of insulin, and that's going to potentially stop you from losing weight." And it's one thing to hear that, but then it's another thing to actually see it firsthand in your own blood glucose, and especially for patients who are a little bit resistant to change.

So, we have some patients who come in because their doctor told them to, and they're not really that keen on changing their diet. They think everything they're doing is right. Maybe they've been following standard conventional healthy eating advice, but they've got type 2 diabetes, or they've got high blood pressure, or the metabolic syndrome. And we try to give them this new education, and we try to tell them, "Well, hang on a second, what you've been doing isn't working for you." They may not actually believe what we say. But then taking a blood sugar monitor and testing their blood sugars, we might give them a target to aim for, and they're seeing that every time they eat a meal, they're constantly out of target. And then they're coming back for their second session, and now they're engaged, and now they're really keen to learn because seeing it firsthand in your own body is amazing. I mean, it's the best way to learn.

Michelle: Totally.

Jessica: And it's the best way to troubleshoot for yourself. Oftentimes, you don't need to give patients all the information, just give them a glucose monitor.

Michelle: That's right.

Jessica: And oftentimes, they can figure it out for themselves.

Michelle: Yeah, it's potentially game-changing, I think, this kind of personalised insight-based data. I mean, the internet, as we know, the last 15 years has just flooded us with knowledge, and the knowledge isn't enough to get us motivated in many ways. Obviously, for some, sure it is, you know, but for other people, it's like, "I just need to know what's right for me." And I think the CGM monitoring is actually like, "Okay, well, let's show you what's right for you. And let's see it, let's witness it, let's look at your choices, and let's see whether we can ascertain how you're actually doing and how you want to do in the future." So, I just think from a behaviour change perspective, those daily insights, 15 minutes or 5 minutes, whatever the increments are, is just such a powerful way for people to actually investigate their own choices...

Jessica: Agreed.

Michelle: ...and do what they need to kind of do.

Jessica: Yeah. Yeah.

Michelle: Jessica, thank you so much for being with us today to discuss this new technology, and particularly, how it can be utilised in clinic. I just love that in-depth understanding of the highs and lows. It's like being on a seesaw of glucose, food choices, exercise as well. And metabolic health optimisation is probably one of the most critical aspects of world health today. And the work that you are doing in a PhD is so vital to understand metabolic dysfunction and what we actually need to do as clinicians to change this very, very scary trajectory of human health. So, I'm excited to watch this space with you.

Jessica: Yeah. Thank you for having me. No, it's a pleasure to be here. And maybe next time we can talk about glucose data for people with type 2 diabetes and with type 1 diabetes because that's a whole other conversation to have. That's still very, very important.

Michelle: Yeah, let's do that. That's a date. We'll pop it in the diary.

Jessica: Let's lock it in. Sounds good. Well, thank you so much for having me.

Michelle: Thank you everyone for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the FX Medicine website. I'm Dr. Michelle Woolhouse, and thanks for joining us. We'll see you next time.

About Jessica Turton

Jessica is an Accredited Practising Dietitian (APD) with postgraduate qualifications in Nutrition & Dietetics and full membership with the Dietitians Association of Australia. She is interested in developing, evaluating and improving dietetic strategies for the management of diabetes and is currently undertaking her Research Doctorate (Ph.D) at the University of Sydney under the supervision of A/Prof Kieron Rooney and Prof Grant Brinkworth (CSIRO). Jessica successfully completed her Masters in Nutrition and Dietetics at the University of Sydney in 2017 and was awarded the Faculty of Health Sciences Dean’s Scholar Award for her double degree. Her Masters Research Project was to conduct a systematic review of all low-carbohydrate diets in the management of type 1 diabetes. This was published in the scientific journal, PLOS ONE, in March 2018 (read it here). Jessica also published "An Evidence-based Approach to Developing Low-carbohydrate Diets in Type 2 Diabetes: A Systematic Review" in Diabetes, Obesity and Metabolism (read it here). Jessica was invited to speak at the American Diabetes Associated Conference in June 2020 to present the evidence for low-carbohydrate diets and nutritional ketosis in the treatment of diabetes and obesity.

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