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Episode 011 - On Food Intolerances and Athletic Performance

Episode 011 - On Food Intolerances and Athletic Performance

Dr. Pastore speaks to a group of NHL strength and conditioning coaches on food intolerances and their effects on athletic performance. In this conversation, he discusses why athletes are at greater risk of food intolerances and different types of reactions.

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Lexie: Welcome back to another episode of The Modus Movement. Today's podcast content is actually from a webinar that we recently hosted for strength and conditioning coaches, working within professional hockey. We at Modus are very, very grateful and fortunate to have developed some relationships with NHL an AHL teams, and we wanted to provide them with additional educational resources so that they could keep their multi-million dollar athletes in the best physical shape possible so that they can have the long and healthy careers in sport that they aspire towards.

Dr. Pastore is going to cover food intolerances and their effects on athletic performance, because, of course, if you've listened to any of our previous episodes, you will know that Modus' number one recommendation for athletes and non-athletes alike is eating foods that you are not intolerant to.

This content was created for certified strength and conditioning coaches who have years of education within the field, so there is some high level scientific information, and there were also slides on the screen for the webinar, so it's totally okay if you're a little lost or don't understand some of the concepts that Dr. Pastore's going to talk about. We will be releasing Food Intolerances Part Two, not next week, but the week after, where Dr. Pastore and I are going to sit down and discuss the topic in a more generally understandable way.

Dr. Pastore: Hey, everyone, thanks so much for joining me today. As Andrew stated, today's topic is on food intolerance and athletic performance, and I'm super excited to talk to you all about this topic, because it's near and dear to my heart, and it's something that I practiced clinically for well over a decade.

Just a quick outline, I want to introduce myself for those of you that don't know me, and then I'd like to define two different things, food allergy and how it differentiates from food intolerance, and then unique risks in athletes that perhaps all of you are not aware of, and then that impact on athletic performance.

Let's discuss food allergies and exactly what it is. Food allergies, in a simple way, are negative immunological reaction to a normally innocuous substance in the diet. It's when someone's eating something that should normally be harmless, but yet they're having a powerful immunological negative reaction to it. This adverse immune response should be reproduced upon consumption of the offending food, and one of the easiest examples is Johnny ate the peanuts, Johnny can't breathe, his throat is closing up, that's an anaphylactic reaction.

An adverse response that must be distinct from other reactions that are not food allergies is another defining characteristic of a food allergy, and what I mean by that is, if there's an intolerance. If someone says, "I was diagnosed as genetically being lactose intolerant," they're not allergic to milk or dairy products, they have an intolerance due to lacking an enzyme of digesting lactose, and I'll get into that more in depth.

A foodborne illness, if you eat shrimp that is bad and it actually is infected with a various species of protozoan, and you get food poisoning, as it's called, that's not an allergy. That's just a really bad experience that you had.

Then, pharmacological reactions. Believe it or not, there's been some reports in the clinical literature of various chemicals being introduced to food. We see it on TV all the time of substances being found in various meats or dairy products, and there's a recall. Well, people that consume those things and have negative reaction, you want to be able to differentiate that right away.

Going back one step more to foodborne illness in the states, we have major reports about an E.coli outbreak in romaine lettuce. Obviously, people that ate romaine lettuce and got sick were not allergic to romaine, but you'd be surprised how many people do not make that connection, and it's why it's so important in public health instances to figure out exactly what's causing the negative response in these individuals.

Also, and this is so huge, because this is changing over time, especially when I was first educated, food allergies are no longer considered a single antibody response. Back in the early days, medicine and medical science on food allergies, food allergies were just known as an immunoglobulin, IgE, meaning an immediate antibody response reaction. Now, we know that they are IgE and non-IgE mediated reactions that must be considered in food allergy diagnosis.

Food allergy reactions and comorbidities that are classic in the medical literature are what I mentioned with the Johnny ate the peanut scenario, that's classic food related anaphylaxis. There's various different types of symptoms, and I'll go through these quickly, but the reason I want to do this is you'd be surprised how many athletes I've seen that have had some of these problems, but never in their life were worked up to see if they had a food allergy, a true food allergy to something that they were eating.

There's laryngeal edema, there's Heiner Syndrome, which is better known as pulmonary hemosiderosis, there's asthma. I can't even tell you guys how many times I've seen professional athletes with asthma that were only told to keep adjusting their inhaler, particularly in baseball when they were playing at different altitudes, like when they were playing the Colorado Rockies, and they're an East Coast team, and doctors never in a million years thought, could a food be contributing to this? Yet, it's in all the various medical textbooks when you're looking at food allergy associated medical conditions and comorbidities.

Then, there's food-associated, exercise-induced syndromes. We're gonna talk about how athletes are at a greater risk for food reactions. Hopefully, that will keep you staying tuned.

Then, there's conditions and diseases, like colitis. There's eosinophilic esophagitis and gastroenteritis. There's cow's milk allergy syndrome, and while that may happen more frequently in pediatric cases, I have seen this in adults and in the professional athlete population.

There's gastrointestinal hypersensitivities. I've actually saw an athlete that had this chronic vomiting syndrome that was associated with a white potato allergy. Never was diagnosed until she was finally in my office. There's skin conditions like contact dermatitis, eczema, atopic dermatitis, and while there can be some skin conditions that can develop in hockey just through perspiration, again, you'd be shocked how many people don't realize you could expedite the healing of that if you would identify the food that was behind that problem.

There's generalized flushing that can transpire when someone has a histamine release through a true allergy that causes a reddening of the skin, oral allergy syndrome, rhinitis, rhino-conjunctivitis, urticaria, and angio-edema, but what I really want to touch upon today is food intolerance, because this is actually something that I believe is more prevalent.

The American Academy of Allergy, Asthma, and Immunology believes food intolerance only impacts the gastrointestinal center, and then on the flip side, you have the Australasian Society of Clinical Immunology believes food intolerance can also cause headaches and mouth ulcers, but I really will tell you and show you through examples through this seminar today, that it's bigger than that. It's much bigger than those two small areas of the body, and, also, this type of reaction, of food intolerance, not a food allergy, is classically missed by routine food allergy testing.

It can also result from a lack of an enzyme, and I talked about lactose intolerance where you're missing the enzyme to digest the milk sugar, lactose, so you actually have this intolerance and that's not repairable. Yes, you can take an enzyme, but doesn't always 100% ameliorate those symptoms. Yes, you can consume products that are free of that milk sugar. Again, doesn't always with 100% certainty, address all of those symptoms. Of course, there's heredity fructose intolerance, where there's a hereditary inability to fully digest the sugar that's typically found that's found in fruit known as fructose.

These are more difficult to identify than a true food allergy. Prevalence is around 65% for lactose intolerance in the general population according to the National Institutes of Health and around 20% for food intolerance, which is identified by the American Academy of Allergy, Asthma, and Immunology. Some physicians claim that that number is actually more realistically 60%. I am absolutely, without a doubt, in that side of the spectrum. I have seen so many athletes with food-mediated reactions, not all of them, but many of them, and definitely more than half that have come into my clinical practice over the years.

In my clinical experience, a food intolerance can cause anything, decreased performance due to fatigue, aches and pains, increased injury risk, truncated nutrient absorption, which, of course, can lead to those other problems, and reduced healing time.

Food intolerances in athletes are unique. They're a very unique animal. It's more challenging in my experience to identify a food intolerance in an athlete because they're typically individuals that are tough, they're trained to walk it off. Also, many athletes that have come into my office, either just finishing a major course of antiinflammatory medications, or are on them on and off throughout the season, and that can mask symptoms, but you know what? We also have an innate homeostatic mechanism, which I call the masking phenomenon, to address consuming a substance that we are intolerant of, but we are not allergic to.

A perfect example of this that I've seen throughout my entire life is cigarette smoking. When an individual first smokes their very first cigarette, they will cough like crazy because they're putting such a toxic chemical in their body, but then it seems like almost magic, by the time they've finished their first pack, and they start on their path to addiction, they're no longer coughing like crazy. Why is that?

Well, that's known as the homeostatic mechanisms where our body secretes various chemicals to help us deal with this toxic onslaught of substances. We are really amazing, adapting species, and that's just part of who we are living in a polluted environment. Our body will do that until the whole system breaks down and then the person ends up coughing all over again, and then they're on the path of disease with regard to the aforementioned cigarette smoking analogy, but we do this on a food-based scale, and that has always fascinated me.

I have athletes that have had chronic pain syndromes, have an allergen or an intolerance to a specific food, feel chronic pain but blame their sport, and the pain is not that bad, but then if they stop that food, maybe they're on a vacation, maybe they were visiting relatives for an extended period of time, maybe they were in the off-season and not consuming the substance that they consumed more of that was in the locker room, they then go, "Wow, you know, I feel pretty good, but I'm gonna just chalk that up to I'm not playing right now. I'm not at that intensity level." Then the first consumption of that intolerance again, I swear to you, it's like they got knocked over. They're completely blown out. They're ringing up my office saying, "Oh my God, Doc, I'm in so much pain. What did I do?" They're in their physical therapist's office saying, "My hamstring's just aching, my back is so tight," or, more specifically, "I hurt all over." That's just, again, a classic masking phenomenon.

Rarely was there any analysis in professional athlete's when I first started practicing. I'm happy to see that there's more of an intention to it, but dare I say it? I'd like to say people are doing it wrong, and I'm hoping, today, I can at least open up your mind as to how we should be looking at the identification of a food intolerance in athletes, because here's why.

If it's not identified and corrected, and I say this with absolute certainty, careers will be cut short, and I will be giving specific examples.

Food intolerance and performance really first started hitting the medical literature only recently when we were looking at athletes. Kostic and Vucicevic and colleagues, they did this, published this amazing paper in the British Journal of Sports Medicine, only in 2016, it's really not that long ago, where they had had an identification of food intolerance elimination after identification. Check this out. It improved heart rate. It improved flexibility. It improved body composition. It improved gastrointestinal health in athletes. Can you imagine how much better it is if you have flexibility and you're trying to do physical therapy, actually work and rehab an injured athlete, or prevent an injury in an athlete? How about heart rate and the ability to perform, or, of course, body composition? Dropping a little bit of weight is dramatic at reducing pressure on the joints.

What's interesting about this study is what is the reality in all of our lives, as practitioners. As you can imagine, professional athletes in the pro-leagues, NHL, NFL, MAB, MBA, FIFA, etc., they don't line up to be part of public studies, these published studies, publicly. They don't do that. They're typically an N-of-1 basis. Practitioners out there listening to this identified them on their own, hopefully, or, in my office, I would identify them, and then it would just grow throughout teams and by word of mouth, but this isn't published study stuff, mostly because we're protecting the security of our athletes, publicity and keeping that quiet. They don't want that public. Totally understand that. You want the athlete to go public if they feel it's something so profound to them and they want to share that with the world and the media, that's great, but for all intents and purposes, no one is lining up, and there's not a group of a team that's publishing data that are pros on food intolerance identification and how well they got healed.

It's critical for those of us in the field practicing and desires to get our athletes at the top of their game on and off the field or ice to identify food-based reactions.

Why are athletes at risk? Here's the shocker that I'm hoping many of you know, but then part of me is hoping you don't know so that I'm stimulating a different type of understanding to the gastrointestinal makeup of your pros. Hard training negatively impacts the intestinal cell tight junctions, which is the gateway to gastrointestinal permeability. I dislike the term "leaky gut". I think the more appropriate term is "tight junction dysfunction", and that can signal the immune system to engage and result in symptoms inside and outside the gastrointestinal tract.

What happens? Well, when there's tight junction dysfunction, we have these cells that are all stacked up tight together, like deck of cards, playing cards, laid out, really tight next to each other on a table or a flat surface. When they start to separate, we have a serious problem, so oxidative damage during intense exercise disrupts the normal epithelial tight junction cells of the gastrointestinal tract where the bulk of the immune system resides, resulting in permeability, and luminal endotoxins, intestinals within the gastrointestinal tract, move into the bloodstream, leading to a systemic immune system response. Partially undigested protein fragments in the dye can then move to a location, signaling the immune system, resulting in a food reaction over time. If I had this massive, intense exercise, I maybe have a predisposition somehow genetically for a food intolerance, I'm eating this food like crazy, I don't know, I'm drinking whey protein shakes left and right because it's just part of the dogma within my team, and I'm separating this intestinal tight junction cells, poor digestion, protein fragments getting into a location they don't belong absolutely signals an immune system alarm and reaction. This has been studied clinically, and I'm going to discuss it.

Prolonged, high-intensity exercise can result in increase in KaiC phosphorylation enzymes, and those two are known as occludin and claudins that result in tight junction dysfunction.

How do we identify food reactions in our athletes? What do we do to see if there's any type of reaction? The first thing we need to do, and I know a lot of you may think this is just crazy, but I feel it's one of the most important things we could do because all the academies of allergy globally from different world associations say you have to journal what you're eating, you have to have a specialist examine that and see how frequently the individual is eating foods in their diet, and one of my favorite tools for that is a Food Frequency Questionnaire. There are many that are by many major groups. I'm a member of Professional Nutrition Organizations, as I mentioned. We have Food Frequency Questionnaires. Those are a great tool. I can't even tell you how many people have looked back, and pro-athletes in my office have looked back, too, a seven-day chart of the Food Frequency Questionnaire where you're just checking off boxes of how often you eat specific foods in food categories, and then they say, "Wow, I didn't even know how much shellfish I eat," or, "My goodness, that's a lot of cashews," and it's just that type of knowledge we can all get.

In baseball, there's some guys, you could imagine, they were just crushing sunflower seeds, and in some cases, I've found sunflower seeds to be the food that broke the whole case wide open. One person's food could truly be another person's poison. You can't just pick the main allergic responses. Trust me on that one.

From a academic perspective and a clinical perspective, I think multiple analysis is required, and that's why I teased and I said, "I think people are doing it wrong." I've met some ball clubs and sport clubs where they said to me, "Oh, Dr. Pastore, we're on that. We run this one test through this lab," and I say, "Really? Because that's not all the reactions an athlete would typically see," so I try to get the best of everything I possibly can find in the clinical sciences to identify food reactions.

From blood testing, you could look at immunoglobulin IgE tests, but you should also be looking at non-IgE tests, and I'll talk about one that I really like in a moment, known as immunoglobulin IgG4 or sub-class immunoglobulin 4. I like a lot of the new published literature on the more modern form of ALCAT, which I'll also show in a moment.

During an all-inclusive diet, let me just repeat that sentence because this is so important, and give you my reasoning why, you want to run multiple clinical analyses on your athlete to identify food allergies and food intolerances while they're eating everything they normally would eat, not while they're avoiding something that they believe is bothering them. If an athlete says to their trainer, their therapist, "You know, I really think soy is bothering me, and I know soy is in a lot of stuff. My wife's cooking more with soy because she saw that it's healthy, and I'm eating a lot of that, and I think it's bothering me, so I avoided it. Can you test me to see if it bothers me," the first question you should ask is, "How often ... How long has soy been out of your diet?" If it's been out of the diet for a period of time, several, two weeks, several weeks, it's completely illogical to then test for soy. It's something they should be consuming.

Look, I have a genetic disease to gluten known as celiac disease. Biopsy-proven celiac disease is what I have. I had blood tests that could prove I had that and a biopsy that clinically proved I had it, but guess what? On a strict gluten-free diet that I follow due to my disease, which I have to for the rest of my life, I am completely negative, as I should be, on a blood test for gluten reaction. That's because I'm not consuming the foods, so I'm not having an immunological reaction.

It's just critical that the athlete is consuming everything that they think might be a problem, have a [inaudible 00:19:37] diet, or not doing some type of diet that they read in a book, they're not all of a sudden, "I'm ketogenic right now. I'm X. I'm Z. I'm intermittent fasting." No. I know it's not always applicable. My career will tell you that, and I have a lot of stories, but what I mean is off-season. God, it's the best time to test someone this way because you want an all-inclusive diet, all in, typically when our athletes gain weight. Am I right? Eating everything, "Just crushing food," as my guys would say, that's when I want to test them, and then I can really see what's going on.

Moving on to the next bullet point, genetic testing is particularly important in some cases. [inaudible 00:20:15] lactose intolerance. There's genetic tests for that. Yes, you want an athlete to journal. The athlete might say, "I have all the symptoms of lactose intolerance." Guess what? You also have all the symptoms of a food allergy. You have all the symptoms of a food intolerance. You have all of the symptoms of a non-IgE or immunoglobulin-mediated food reaction. What is it? That's where genetic testing can typically get us out of that.

There's been times where I've had an athlete that was 100% avoiding gluten. We're going into the playoffs. We have a strong shot at the World Series, and they're like, "Doc, I don't wanna change anything. I'm dying. I'm on a lot of medications prescribed by the team doctors, but I think gluten's a problem. I'm not eating it, but I'm on these drugs that are helping me right now. How can I test during the season and not disrupt me?" I say, "Well, we can't fully, but we could do a genetic test to see if you're even on the scale, to see if you have any type of risks, so let's do a genetic test to see how high your risk could be for gluten-mediated reaction or even potentially my disease," which, by the way, I've identified it in professional athletes. I have personally found celiac disease in some of the top pros where we're talking 100 million contracts, and they had no clue.

Athletes are just amazing, and I say this in a loving way, freaks of nature with phenomenal genetic abilities, and they can get by with deficits, and I know as people who train athletes, and you guys will be like, "Yeah, I've had athletes that had a complete problem with a weakness of a shoulder, and they'll overcompensate, a problem with a hip or a hamstring or a glute, and they'll overcompensate." Yes, they're at risk for an injury down the line, and when we improve that, their performance improves, but it didn't stop them from getting a hat trick the other night, and I'm actually giving you examples of reality of what I've seen in clinical practice, top hockey guys performing at the absolute highest ability, suffering inside, walking it off, suffering in silence, and then we identify what the real problem is in the off-season, and then notice a dramatic improvement in their career.

Another thing that is a great dead giveaway to these guys who are in the season and you don't want to change anything is repeat consumption should result in a same reaction. I know that's challenging, especially when you have a delayed food-mediated reaction, like immunoglobulin IgG4, which can cause problems over a period of time, and I'll talk a little bit more about immunoglobulins in a second, but this is a real important point. Those immunoglobulins can build up over time, and there can be a delayed response. Repeat consumption, if someone's ... Let's blame shellfish again. Someone's eating shellfish and goes, "Oh my God, my gut was bothering me, and that elbow injury I had just really was a little bit more magnified." Listen to your athlete. Journal that. Record that for them.

One of the things I started doing was journaling what my athletes were saying and just taking notes as I was talking to them about what they were eating as we were talking about how often they eat this. What'd you eat yesterday? What'd you have then? As many questions leading that I could, leading questions rather, to get them to spill the beans on what they were nourishing themselves with. So critical. Then, showing them this could be a problem, and then, at the right time, multiple analyses combined with journaling to identify what a problem food is.

Next thing I want to say before I move on to a bullet point is not one path is 100% definitive. There is no test ... I wish there was. There's no test on the planet that, "Yup, that's it. I'm only gonna do that. Oh, what'd you say, athlete guy? You said, 'Eggs,' that you really are sure they're hurting your back. When you eat them, just notice it, and when you went egg-free for a period of time, your back pain felt less and your back felt less tight? Well, your test says, 'Your completely fine with eggs.'" No, we're absolutely adding that to the list, and we'll either eliminate eggs in addition to whatever else we identify, and then slowly rotate that back in.

There can be cross-reactions. There can be, and I guess I should save this for when I show the slide of an actual test result, but there can be this tight junction dysfunction that causes all these secondary reactions when there is a primary immunoglobulin allergy, and IgE, that was really causing the problem, and when I eliminate everything and focus on that key main one, and then I slowly put back in the other guys over time, particularly again in the off-season, the athlete goes, "Ha, that's funny. Yeah, those eggs don't bother me, Doc. I'm so glad you identified what it really was on the blood test." Those are important things to identify.

You also should rule out gluten intolerance because I really do see this as a big problem. I'm seeing this vogue gluten elimination when there's no known reason, there's no known serology, there's no known genetics or DNA behind it, but it's more vogue, and that scares me because, then, I think an athlete or an individual will be more lax doing it, like, for example, me, being biopsy-positive celiac disease, there's nothing you could do, there's no environment I could be in that would tempt me to put something in my body that, honest to God, based on clinical literature, could give me cancer down the line. That's a fact, by the way. Small bowel cancer in celiacs does absolutely occur if a celiac disease person is not following the diet, which, by the way, is slightly under 50% of people with my disease just don't follow it.

Now, imagine someone just reading a magazine or meeting an athlete and going, "Oh, he went gluten-free? I'm gonna go gluten-free, too," and then they're at a big family gathering over the holidays, and they just go, "Eh, this wouldn't harm me." Well, if we have evidence that, yes, it would, we shouldn't be doing it. The athlete should know that, and it seems to be one of the most omnipresent, food-mediated reactions that I have seen and also one of the most misunderstood and the most dramatic when you identify it and remove it, dramatic, and I will give actual examples with real top athletes.

One of the things I recommend to identify a gluten-type intolerance is seeing if there is, number one, a secretory immunoglobulin IgA deficit, which is 15 times greater in the true gluten celiac disease intolerance group of patients. That's number one. Let's say a doctor on the team, you guys heard my lecture, and you go back to the doc, and the doc goes, "Ah, I ran a tissue transglutaminase and immunoglobulin IgA. Athlete X, who thinks he has this problem after he talked to the other athlete on the other team, doesn't have the problem." You can respond and say, "What was his SIgA? What? Well, what was his SIgA? Was that normal? Was that suboptimal, because according to the Mayo Clinic, there's actually a testing algorithm that's critical." If you are SIgA deficient, you would never test anyone with a tissue transglutaminase IgA to measure a gluten reaction. That's mental. You should find nothing. You should find nothing. 

If there is that type of reaction, you would divert, but, again, there should be multiple testing there. ALCAT has a separate, newly identified and proven in clinical literature, gluten sensitivity test to find if someone's intolerant, but the aforementioned tissue transglutaminase IgA, that's the first step to actually identifying my path of celiac disease, based on the Mayo Clinic testing algorithm.

Please, I would like to state for the record, I am an authority in this field. I did doctoral research in this realm. I've done work with the Mayo Clinic in this realm. I've had 22 institutions identify a computer program algorithm artificial intelligence that I developed specifically to walk a physician through this problem. So, please, heed my words on this.

Then, when you find these types of reactions, it's critical to identify any nutritional inadequacies. We don't want to guess. We should be looking, again, through academic testing and the right ones. What about vitamins, water-soluble, fat-soluble? What about minerals, full, trace? What about amino acids, conditionally, non-conditionally, essential? All those should be measured because that's what builds our athletes and makes them work. Those can all be impacted by something as simple as a food intolerance, something as simple as a food intolerance. Lactose intolerance could lead to anemia. Iron is critical for transporting oxygen. You want your player on the ice to be breathing less oxygen than their peer who doesn't have the problem? I've seen a lot of suboptimal levels of iron and ferritin in athletes that had a food-mediated reaction, but no one going out there and trying to identify if those were problems.

If there's any questions, since this is more about food intolerances than these other tests, you can always reach out to my team or even now, and we'd be more than happy to answer testing that I've used in my path that have given me blockbuster contract careers with professional athletes.

Then, lastly, in many circumstances, I've been a big fan of an DNA stool analysis that actually measures the microbiome, that actually gets in there and measures the intestinal tight junction cell markers that I mentioned, the occludin and claudins and pancreatica insufficiencies and how well the athlete's digesting. Sometimes, this is a real critical component, and I'm blessed to have one of my alma maters as one of the largest microbiome research facilities in the United States, and I'm referring to Rutgers. I've been really lucky to have so much of a profound education in that field with the microbiome, and we can never forget that the bulk of the human immune system, the gut-associated lymphoid tissue, resides in the gastrointestinal tract, and it's critical to make these identifications, and if we have to get really deep, this is one of the best noninvasive ways to do so.

Here's just two examples of some testing that I mentioned in the last slide up early on. On the right-hand side of the screen, you should be seeing an example of a test that I used in clinical practice when I was looking at an IgE food antibody assessment, and this is known as a classic food allergy reaction, as I discussed at the top of this lecture, and, here, if we just start looking at the results, we could see a really high reaction to corn, we can see a high reaction to wheat, we could see a really high reaction to peanuts, which would be considered very high by this scale. Specifically, in the seafood realm, we could see blue mussel, codfish, and shrimp, specifically. This would be a very enlightening case. I could tell you this is extremely rare. An example like this that I have seen in practice is maybe less than 10% of my professional athletes to be this severe, but I've had this type of test completely transform athletes in an off-season. I can't make that clear enough, and then explain, and then explain a test result on the left-hand side.

Here's an example of an ALCAT. This ALCAT is the most modern version of the ALCAT, which has an enormous amount of clinical research behind it. You'll see references at the end of my slides, the data ... Probably some of the best data comes out of Yale. Very modern studies, the most recent one being two days ago, 2018, if you're listening in 2018, so really relevant literature on identifying food-mediated reactions that would not be the traditional allergies that I'm trying to help you guys identify.

Let's just look at this side. If you look at this, and I chose this for a specific reason, this athlete's a train wreck. I know what you're thinking. We have some severe reactions to foods. We have some moderate reactions to foods and some milds, and the lists are pretty long, and, no, I would not be asking my athlete to avoid every single one of these foods. I would be making an amalgam of these two lists, and I'd be focusing on the severes and the IgEs as my critical list, and then I'd be rotating everything that was mild. In a specific case, I would make my decision case-by-case basis regarding moderates, and I also want to say this is a really extreme case, but the reproducibility of this is 92 to 96% three times over, according to Yale. You guys get that? Blind samples, double-blind randomized placebo control, blood tests done have identified the same results with a reproducibility times three with a 92 to 96% accuracy. You know how remarkable that is in an athlete that you're saying, "My goodness, just their sport puts them at risk for food-mediated reactions."

This is probably one of my favorite tests that I've used in my career because this is the one where I would also see all of my athletes in some way that came in with complaints, not the athletes who go, "Everything feels good, Doc. I just want you to pop the hood," to quote one of my friends, "and see what's going on, see if I have any suboptimal amino acids or have any deficiencies. Do I need anything in my diet?" Other than those limited people, this one would always light up for me, and do so in just a few foods.

Here's a great example of an athlete that I saw that had just two reactions. A Class 4, which is pretty darn high. The highest you can get is a 5, and that's not something you would see on an everyday basis, but here's a Class 4 to milk and here's a Class 4 to corn, and you can see that's on a 90-food test result. This is an IgG4 immunoglobulin food antibody response.

Why is that so important? Well, I'm not a fan of just IgG testing, just loosely like that. I've only used IgG4 sub-classes. IgG1 antibodies tend to be more sticky, and they combined more selectively to antigens, leading to a greater chance of cross-reactivity, and, thus, false positives. We don't want our athletes doing anything they don't need to do. We want them to focus on just the actual results for optimal recovery, repair, performance, done.

For example, cross-reactivities, you guys know that watermelon and ragweed are cross-reactive, so if you've got an athlete that's actually got a ragweed allergy, they can react to watermelon in their diet, but on a test that's just IgG and they're ragweed people, they're going to be told watermelon is one of the worst things in their diet that they could ever consume, and it may not be the worst thing in the world. It may be something they just have to moderate over ragweed season, and there's much more deeper false positives than that, but I just thought that was an interesting thing to throw out there.

Also, measuring both IgG1 and IgG4 together could cause many unnecessary food eliminations. Again, not what we want to do. We want a result like I showed you on the screen because that's going to help us pinpoint, like what you guys do when you're trying to figure out what hurts, what's the right training mechanism, we want to pinpoint what the problem is, how we can remove it, identify it, repair, move on. Therefore, the IgG4 antibody is just more clinically of a relevant marker for me, and it was in my practice for many years to identify these food-immune reactions and possibly be another link to intestinal permeability. IgG4 measurements are less likely to produce false positives in in vitro testing.

In a similar fashion, IgGs alone, and I've seen a lot of labs out there, guys, just avoid those if you can, that are just doing IgGs because they tend to produce a high rate of false positive reactions.

How can I say that? Well, I've had literature that has said that, and I've seen it myself. I've seen it myself in my clinical work. Just be really wise.

I want to add, I know there was some lab names that were on there, and I noticed I didn't mention any of the lab names themselves except for the ALCAT because that's the name of the test, like IgG and IgG4, but no brands associated with it. I am not paid for, sponsored by, get money from any lab. It's just when you're a practitioner, you know what works. When you see something that's been bogus and that you were able to disprove and then see it benefiting your athlete, again, you know what works, but I also want you guys to know there's other pathomechanisms of non-immunoglobulins that are really quite interesting, and some of them are like the DNA supernatants that DNAs actually released from the nucleus in a cell that's being injured by a food, and there's Yale research on foods actually stimulating that release. That's not good.

Then, there's neutrophil elastase, which is associated with just an inflammatory-type of process, an increased intestinal permeability. There's protein kinase C, known as PKC, and that's associated with chronic diseases associated with metabolic syndrome, autoimmunity, irritable bowel syndrome. There's innate immune system responses, like eosinophils and neutrophils that can stimulate inflammation in the athlete, and then there's the two cytokines. Tumor necrosis alpha, interleukin-1 beta are those two cytokines that are the real trouble makers, and if we single them out, tumor necrosis factor alpha has been implicated in allergy asthma, it's implicated in joint damage as a cytokine, but interleukin-1 beta has this really nasty reputation as a joint killer. I've seen it increase in fractures in my athletes. These are substances that are released from cells that tell the immune system to cause all wreak and havoc and hell in your athlete by just something they're eating that's not "killing them". It's not Johnny ate the peanuts and Johnny can't breathe, anaphylactic, get the epinephrin pen and save the kid. This is the athlete's getting slowly beaten down over time due to these chemical releases that are causing the problems.

What do we do post-identification? Dr. Pastore, I nailed it. I got my journal, and I worked it out with my athlete and talking to them, and I see ... We potentially think these are problems. I ran the aforementioned tests you said, narrowed it down and got these three, four, two, one, whatever things. We think that's the problem. What do we do?

Well, there should be a strict elimination from all major food reactions, the severes, the highs, those IgEs, those immunoglobulin IgG4s that I showed you with the corn and the milk. Yank those out of the diet. Just completely pull them. At the same time, I hope you guys are identifying what food-mediated reactions caused from a nutrient standpoint deficiencies, suboptimals, fix those things all at the same time. These guys, they depend on their bodies. It's so critical that we get them back out there and playing, recovery, and they're going to recover so much slower if they have any type of deficiency or immunological response. Rotate lesser reaction foods. If you see a tiny reaction, but your athlete had a massive reaction to one of those shrimp or something like that or peanuts or corn, and then you see avocado is on that mild list, just don't have guacamole every day. Let's do that once every seven days, depending, of course, it's case-by-case basis, but just don't completely remove it and wreck your athlete's life, and, again, case-by-case, but rotate those in the diet, and I can't say this enough, you really want to address any gastrointestinal issues in GI health.

The aforementioned food tests should do that. There's double-blind randomized placebo-controlled trials that have been done on the food tests that I showed you that prove performance in gastrointestinal health, but you know what? These are top athletes, and sometimes you got to use some little help. There's been some substances out there that I have found to be just phenomenal. Zinc L-carnosine is remarkable in this aspect. It's been shown to actually help with that tight junction dysfunction. Glutamine, specific probiotics for gut health, amazing. There's a lot of new research on bone morphogenetic protein-4, BMP-4, and helping to heal those tight junctions in the intestinal cells. Those may be great tools, but that's a case-by-case basis and something that the doctor would work on with the athlete, you guys would discuss, and work as a team. It takes a village to keep our athletes healthy. That's something you want to do, and that's all in addition to repleting nutritional inadequacies, which I cannot say enough because that's another side, guys. I've had athletes come to me from another doctor's office identifying, completely identifying, that they had a food reaction, and I verified it and proved it, and the athlete proved it in the off-season, ingesting and go, "Yup, yup. That's a problem. I don't wanna go there." Let's blame eggs again. "It was eggs. I had scrambled eggs, Doc, and, oh, my God, my knees lit up. I'm done. I'm out."

Well, guess what? I've had an athlete come to my office and no one looked to see were they deficient in any key nutrients that are critical for performance. Vitamin D deficiency is in this one case I'm thinking of. That's associated with a lack of performance, increase in injury, bone problems, everything you don't want in an athlete that's in a collision sport. It would be crazy.

There's even genetic testing where you could say, "Wow, this athlete's at risk for ... They have a genetic polymorphism, a single nuclear-type polymorphism, to be at risk for not fully absorbing all the vitamin D in their diet. Then imagine adding that genetic risk to a food intolerance, and let's say that food intolerance is dairy that contains vitamin D. Wow. Then you have a whole world of problems. You want to remove the food, replete. Sorry, guys, I keep repeating this, but, ideally, this all happens in the off-season, but, sometimes, it must transpire whenever the opportunity arises, and we do the best we can. We recon to get through that.

Post-identification examples, I know this is a lot of heavy text. I'm just going to read this. This is just a direct dialog from a dear friend of mine and former patient, Raul Ibanez, in my humble opinion, one of the nicest guys in professional sports. Sports Illustrated voted him the second Nicest Guy, which I debate. He's number one in the history of Major League Baseball, and he has some phenomenal records that I think are going to stand my entire life, like the oldest player to ever do a walk-off home run in the 12th inning of the New York Yankees at 42 years old.

Raul says, in 2009, after winning the World Series with the Philadelphia Phillies, he's on all these anti-inflammatories; second half of the year, he's having surgery. He could barely walk. The guy's 37 years old, guys, and he can't walk down the stairs, and he's on pure adrenaline. He's pumping up anti-inflammatories, as I mentioned. He goes and he has surgery. He comes out, does the rehab. Director of the rehab says, "Well, you should be good by now." Physical therapist says, "Well, you should be good by now." Can't run 40 yards. Right around the 40-yard mark, starts sprinting, pain gets so intense, barely keeps going. Through a mutual friend, he finds out about me. We do a bunch of blood work, as I showed you, and then all of a sudden, I call him and I go, "Raul, oh, my God, you got the worst reaction to gluten and dairy I've seen in a long time. You need to stop." This is a dramatic case, as I mentioned, because he had the real biological markers. Within five days, the guy was running 100-yard sprint.

Then, we look to Michael Morris. Mike was just a beast to look at, man, 6/5, 245, solid. When the guy hits a home run, it was really something beautiful to see, and I got to do that right behind home plate for many years, but Mike was falling apart, not even 30 years old, and everything hurt. In the middle of the night, the guy couldn't even walk to the bathroom, and this is from Forbes, and he remembers he was just aching, so he came to see me, and it was just a huge, dramatic change, and I talked to you guys about showing you how gluten can just be so bad. I wanted to pick out some gluten cases if someone's really reacting, but I've seen these same reactions to potatoes, soy, corn, eggs, sunflower seeds. One person's food could truly be another person's poison.

After a month of eating better, he lost five pounds, woke up without aching. His results showed on the field, as well. Get this. He had the best year of his career. In 2011, he was batting 303, 31 home runs, 95 runs, appeared in 146 games when this guy was benched left, right, and center. Even the pain he experienced that he was able to communicate to his team, to you guys, he was able to pinpoint it, where, before, he was just like, "I don't know. I hurt all over." How hard is that to rehab a guy when they can't say, "It's exactly in this spot." Removing that immunological storm and inflammatory markers really helped us identify, pinpointing exactly where he was having a problem for rehabbing with his training staff.

I've seen this with teams. I'm just giving you two examples. This is a short lecture. I could just do athletes for four hours and not run out of gas.

Let's go to hockey. We have the Toronto Maple Leaf. He's retired. This is Colin Greening, as you guys may know. Let me just use a quote. This is through food journaling. He was told, after journaling, "'Why don't you stop dairy for 30 days,' and the difference I had in terms of how much I recovered and how I felt, and how I slept, it was huge," and then this practitioner says, "After you've done that, why don't you try some?" He drinks some milk. "See how you feel." He said he felt lethargic and bloated and tired. See, that's that repeat. That's cause and effect. That's through journaling. He just felt really lousy, and he says, "It may not cause an allergic reaction," where his throat swells up or anything like that, but just felt so much pain and inflammation over time, and then going back to the quote, Colin feels it's really important, and he thinks all athletes should know.

I think, if I could have seen a guy like Colin early on in his career, it's a completely different story because I have stories where guys were really young. Mike's a decent example, but I've had guys younger, and I completely work them as part of their rehab, and then, oh, my God, they go on from two million dollar career to signing in the hundreds of millions of dollars contract, and I've seen that multiple times in my years.

My concluding thoughts, I've never not had this question, gang. My first athlete sits across from me. I go, in my head, I wonder what this athlete's immunological relationship is with the food that they use, they're consuming, for optimal nourishment. What is their immunological relationship to what they are consuming, because everything is a suspect for me. I was like a detective with these athletes, and nobody's innocent. It's not the healthy, amazing avocado. It's not the grass-fed beef. Every single food was on my hit list of what could be a problem, so I needed to know the specifics.

Next, check off the box. If there's a negative relationship, what are those ramifications? I want to identify them. I then want to tell the athlete I want to remove them, like Raul, but what we're not talking about there with Raul is, what would the suboptimal nutritional values, essential nutrients, key components of muscle, connective tissue, building blocks of all that. I would do tons of testing to identify what was problematic. Were there faulty enzyme reactions? In clinical practice, I'd love looking at organic acid analysis, seeing the use of a nutrient, as opposed to just I don't care what's in the blood at that minute. I'm not going to look at magnesium just in a serum. You'd have to have projectile vomiting to have deficient magnesium just in your serum. Your body will take it out of another system, organ, tissue, bone to normalize it. We have [inaudible 00:47:13]. I look at red blood cell magnesium, but I also look at the utilization of a nutrient. Methylmalonic acid, formiminoglutamate, when I'm looking at B12 and folic acid, shows me the utilization from an organic acid analysis. So critical. Of course, a full serology, amino acids, vitamins, all the way down the line, including the aforementioned DNA stool analysis, is warranted.

Then, we have all that information, all that data, and you're on the repair track. Adjust the training and rehabilitation accordingly. It's kind of in vogue now. If your athlete doesn't sleep well, you guys change the way you're rehabbing them, training them, repairing them, getting them back out on the ice.

Same thing when you identify this. Think of your athlete ... Pardon me. I said the joke in my head and laughed before I said it out loud, but think of your athlete just being hit by a freight train. It's like, "Oh, my God." That's how bad these immunological reactions can be. I know I'm being dramatic, but, guys, seriously, when you look at the clinical literature, there's such a pumping of pro-inflammatory cytokines, interleukins, chemicals that are causing such profound inflammation all over the athlete's body that we want to rehab them really as if they were injured, and then as soon as they get past this period and they have this quiescence, which takes typically around ... Well, you saw Raul's case. We want everyone to be like that, but, typically, it can take around two weeks, 30 days, in my guys, and athletes are really, really fit people, so two weeks in, they're going to say to you, "Man, I feel so much better," and you're going to be able to push them further from a training perspective and have an easier time rehabbing them, and then, God forbid, they are injured or, God forbid, something does hurt, they're going to be able to zone in and tell you exactly where that is, and you're going to be able to use your magic wizard techniques to actually get them quicker to back on the ice and repaired.

I just want to thank you all so much for taking the time to listen to me and what I had to share with you guys today. Can't even tell you ... I hope you can feel my passion. These are some of the references to the clinical trials that gave me the information and the content for this, so please feel free to reach out to us if you need a copy of these, but thank you guys so much.