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Episode 06 - Nutritional Diversity for Endurance and Ultra-Marathon Athletes

Episode 06 - Nutritional Diversity for Endurance and Ultra-Marathon Athletes

Dr. Pastore chats with Angie Dye and Bob Seebohar, two sports dieticians who work extensively with endurance athletes. In this conversation, they talk about different diets, including paleo, keto, vegan, etc and the importance of nutritional diversity.

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Lexie: Hello, everyone, and welcome to Nutritional Diversity for Endurance and Ultra-Marathon Athletes. Thank you so much for tuning in and taking some time out of your evening tonight. Today, we are joined by Angie Dye, Bob Seebohar, and Dr. Robert Pastore.

Angie, if you'd like to start with introducing yourself, and then we'll go along with the other guys.

Angie: Sure. I'm Angie Dye. I am a registered dietitian in private practice in Hershey, Pennsylvania. I am a certified specialist in sports dietetics and a certified intuitive eating counselor. I'm also an age-group triathlete and really passionate about endurance athletes and nutrition. I'm really happy to be here tonight.

Bob: Fantastic. My name is Bob Seebohar. Thank you and welcome. I am also a registered dietitian focusing on sport nutrition and do own a private practice here in Littleton, Colorado, 20 plus years been working with all sorts of athletes.

I specialize in endurance athletes, and I am one of those endurance ultra-crazies also, so I'm really looking forward to tonight's conversation.

Dr. Pastore: Hey, everyone, I'm Dr. Robert Pastore. I practiced for 18 years. I'm a certified nutrition specialist. I have a master's degree in human nutrition from Eastern Michigan University and a PhD in biomedical informatics, nanomedicine, and clinical informatics. I'm so excited to join all of you tonight. Thanks so much for hanging out with us.

Lexie: To get this conversation started, Robert, in your clinical experience with professional athletes, what sort of nutritional trends did you see amongst your endurance athletes?

Dr. Pastore: What was interesting is I treated my endurance athletes the same way I treated my pro athletes, so my athletes that were either Major League Baseball players, NHL players, football players. That was really, especially in the last eight years of my 18-year career, that was really the meat and bones of my practice.

I always started off with a very aggressive analysis of that individual's nutritional chemistry. My role was very different from a lot of other doctors that were working in the field. I worked with a group of doctors, and my job and the way I saw it was to carve out this unique niche of finding how these athletes ticked.

I would run organic acid analysis, measuring how they actually get their fat into the part of the cell where it burns the fuel source. There's some organic acid markers that are very well studied in that area. [inaudible 00:03:04] adipate, ethylmalonate are just a few of those markers that could be measured.

I love to have a really solid clinical workup to know my individual athlete's relationship with their glucose metabolism. I think that that was something that was also neglected.

Case in point, I met an ultra-marathon runner that actually had two heart attacks and was borderline type 2 diabetic. One of the main problems was the doctor just looked at him and said, "You're so fit," and got to his exercise physiology that he never bothered running a hemoglobin A1C or a fasting glucose.

He would just blow off, "Oh, your glucose is 157. Did you have breakfast today?" "No, I didn't." "You're just too fit to have a problem." I think my colleagues would agree with me, it's not just, you can't just judge a book by its cover.

Then, I would even move that into how athletes were actually metabolizing what they were consuming. Were they appropriating the proper nutrients? Working with Major League Baseball players and endurance athletes, I really was concerned about collagen synthesis.

I didn't just want to guess that they were doing it right. I was measuring actual levels of hydroxyproline, hydroxylysine, building blocks of collagen as part of my amino acid analysis, and full cell levels of various nutrients while also factoring in for polymorphisms.

I would look for individuals that might have issues with folate, methylenetetrahydrofolate reductase, polymorphism, folate trap, also, counter that against an organic acid marker known as formiminoglutamate, abbreviated, FIGLU, to see if there's actually the utilization of folic acid, which is involved in so many different processes.

I would to that for as many nutrients as I possibly could, so I really had a very unique and odd type of practice. I recall colleagues calling me it was more of applied biochemistry and organic chemistry. That would be my basis, and then I would build from that looking at hydration, macronutrient profile, the food reactions, what's the immunological reaction an individual could have with food.

But, at the end of the day with all that complexity, it was individualizing the nutrition for the patient. They had to really love it and want to and believe in the diet they were going to be consuming.

I had to make sure they were journaling like crazy. I'm militant about that, because even if you think about a true diagnosed food allergy reaction, at the best level, let's say an American Medical Association reaction to a food, not just anaphylaxis like shellfish or something, but something where a doctor confirms this patient's allergic. They will even say to the face of the patient while this is great testing and data to have, it still cannot trump a trial and an experience. You actually consuming this in the office, and us seeing how you feel. If it's non-anaphylactic, you consuming this after an elimination period and then reintroduction.

If anyone listened to the podcast I did with one of my dear friends and retired All-Star baseball player, Raul Ibanez, we talked a lot about that, and his personal relationship, not only what I identified chemically and clinically, but, also, how he felt not being able to run 40 yards at the age of 33, and then I identified that he had an immunological reaction to dairy. We removed that strictly, and he was able to run 100 and went on to have all these records well into his mid-40s and retired at the top of his game where he's still considered an expert, and he works for the Los Angeles Dodgers.

Yeah, for me, it was always the specificity for the individual. That's really the basis of what my practice was.

Lexie: Awesome. Bob, now in your experience, when you were determining an athlete that came to you, their personal health and their athletic performance related goals, what sort of strategies did you use?

Bob: Yeah, I think similar to Dr. Pastore, I look at each individual athlete's, and, just to qualify this, in my mind, if someone's gaining fitness, they don't have to be a competitive athlete to be an athlete. If you're active, you're an athlete, so we could qualify that.

I like to what I call pop the hood. I like to look in depth and from blood work analysis all the way into my specialty is looking at their nutrition periodization. Basically, aligning their training cycle or their training focus be it beginning, intermediate, advanced exerciser or during different times of the year. Maybe they're in a preparatory phase or a competition phase or off-season phase.

Looking at that periodization of their physical training, aligning their nutrition to support that, and looking at any deficiencies from a blood work analysis but, also, for metabolic efficiency. Metabolic efficiency training is a concept that I termed that I found in early 2000s, and it's really looking at the ... It's very basic exercise physiology.

As a trained physiologist, I was trained in VO2 max testing, lactate threshold testing, substrate oxidation, so I took this and reformulated physiology a little bit to look at the impact of food on a person's ability to use both fat and carbohydrates. When I refer to popping the hood, it's really looking at during exercise and during rest how an individual's diet, current and then, obviously, prescribed diet after doing some testing, how that is impacted on their metabolic status.

We've all heard, or basic consumers have heard of this whole fat-burning, sugar-burning. That's my specialty is putting them under the microscope, so to speak, and looking at their efficiency rate. That's what metabolic efficiency is all about, looking at how efficient their body is at utilizing the stores, the internal stores of both fat and carbohydrates.

I always approach it with that, will love to get some blood work on individuals and, usually, end up sending them to their physician to get that certain blood work and start tying those together, so use the traditional medical model of blood work, maybe adding on a few more things, such as, vitamin D, iron, different biomarkers, maybe even genomic, genetic testing and, then, really feeding in the old school turned new school metabolic efficiency testing with exercise physiology equipment.

At the end of the day, it's looking at where are we starting and let me craft a specific daily nutrition and training nutrition plan to that individual's physiology. That's what's really important is individuality, and we've heard that a lot. But, we don't know until we do testing.

That's, one of my sayings is, "Test don't guess." If you're just trying to throw out a diet, be it keto, low-carb, high-fat, high-carb, low-fat, whatever it is, vegan, vegetarian, you don't really know if that's going to work for you until you pop the hood.

That's my focus. That's my specialty, and that's how I relate and align my nutritional goals and even exercise goals to the endurance athletes and ultra-crazies, I call them that I work with.

Lexie: Angie, what about yourself? I know you specialize in intuitive eating, and that's a little different than what the guys do. If you could [inaudible 00:10:08] on that, and how you work with endurance athletes.

Angie: Absolutely. It was so fun hearing both of you talk about what you do, just really fascinating all the testing that you've done and continue to do.

My practice is a little different. [inaudible 00:10:23] and intuitive eating, I think the first thing working with any athlete and really all of my patients is trying to find something that's going to be really maintainable and sustainable in terms of an eating plan that fuels their activity and their daily life, and it's something that they can stick to and really enjoy.

A lot of people I work with might travel quite a bit, so finding ways to make their nutrition plan work for them while they're traveling, making sure they're enjoying ... A lot of people I work with have families, so making sure that what they're eating is also what they're family can enjoy.

Also, I don't have as much ability to do testing, but I talked a lot to my athletes about how they're feeling, how they're performing, what their performance goals are for the season. What, again, like Bob was saying, what time of the season are they in, are they in a building phase, a recovery phase, are they in their really peak training phase and adjusting their nutrition plans to that.

Lexie: If we can dive straight into some of the nutritional styles of eating, and the first one that I'd like to discuss is high-carb, low-fat so thoughts on that for endurance athletes.

Dr. Pastore: For me, it really is, it's hard to, and I'm going to have this similar answer for every one of these, so please don't throw anything at your screen. For me, it really depends on the individual. I can't say something is wrong, obviously, if it works for that individual, and I don't have any personal agenda. It's what's right for that individual.

What I would love to do, if it's okay is share some anecdotes, and Bob and Angie and I call them Ns of 1, of subjects that are extremely valuable. They're even equal to or if not greater than a peer-reviewed published study, because it's the patient you're working on who's right in front of you.

Just to share that story that was a negative implication on a high-carb, low-fat diet, I had an individual that was an ultra-distance cyclist, definitely, Bob's definition of ultra-crazy and was a former engineer and trained as an engineer. I don't even think I have to continue any further for his meticulous nature of himself.

But, he had a really fascinating problem. He came to see me referred by a physician, because his right quadriceps would ache deep, just absolutely deep, during intense mileage and putting out higher levels of watts. Then, he came into me to try to figure out what the problem was there. Had an ultrasound, they looked for peripheral artery disease, nothing turned up. Multiple cardiology visits, rapid CAT scans, you name it, this poor guy had it.

When I was working with him, I, of course, went over his full nutritional history. Love that saying, Bob, looked under the hood, so jealous I never used that for 18 years, how dumb could I be. I always learn something from Bob. Look under the hood.

Bob and I identified that he had an interesting marker that is an independent cardiovascular disease risk factor marker, that's typically overlooked. It's known as asymmetric dimethylarginine, ADMA. It's run by just a classic lab like Quest Diagnostics, Lab Corp, and it's fascinating.

I found that he had a score that was really off the charts and, immediately, called the cardiologist. I said, "Look, I have an idea. I think his diet may not be working for him based on some data that I have. Hemoglobin A1C's creeping up a little bit for his level of activity and his fitness, don't like his fasting glucose and glucose tolerance test," he had poor performance with what mimicked insulin resistance. He interestingly had borderline fasting, high fasting insulin, again, for someone who's that physically fit.

I referred him to the Cleveland clinic where what we did was actually put him on a bike and, God bless this tech, get an ultrasound of his blood flow during maximum watt output. What we identified, which was perfect when he was at rest, was basically about a 99% occlusion within one of his arteries.

Sure enough, he had bypass of that one leg vein, his artery, pardon, you taking a vein from his calf and doing what you would do cardiovascular-wise if someone had clogged arteries. Miraculously, and I'm so grateful that solved the problem, and it was typically a needle in a haystack.

But, I tell that story, because it really amplified all the warning signs I was seeing for metabolic insufficiency for a high-carbohydrate, low-fat diet, and I got him to flip more towards a balance.

Definitely not a rejection of carbohydrates, oh, goodness, no, he would hit the wall in no time. His glycogen stores were incredibly low. He was very, very slim. Your classic, "I'm going to pedal," my saying, Bob, was, "Pedal 'til I'm dead." I said that. That's basically what he did for a living.

Sure enough, flipping him over to a more logical carbohydrate diet, changing that in the off-season, and, of course, the surgery was the solution to his problem.

On the flip side, I'm sure there's many great stories about a high-carbohydrate, low-fat diet, but I just wanted to single that out. That in N of 1, we're all biochemically unique, figure out what your issues are, because there definitely is a solution, just don't stop if you're having problems.

Do you guys have any opinions directly on high-carb, low-fat?

Bob: Ooh, ooh, I do.

Dr. Pastore: Okay, please, Bob.

Bob: Of course, I do. I love what you said Dr. Pastore. I think as the listeners will attribute, and they'll hear it quite often, one of my favorite sayings is, "It depends," because, like you said, everybody is so different. We're made up different.

I've had ultra-endurance and endurance athletes from Olympians and professionals all the way down to recreational who are what I call freaks of nature. They can put in a super high-carb content and load and low-fat and moderate low-protein, and they're fine. Blood work is fine. Metabolic efficiency is fine. Everything is fine. But, those are definitely the half a percent outside the bell-shaped curve.

My story is a little more personal. I love these N of 1s, because I used to, from 2002 to 2012, I used to be completely a vegetarian. Not vegan, but, I still consumed eggs that was my protein source from an animal-based protein.

It was nothing moral. It wasn't moral. It wasn't ethical. I love sharing this story. I just wanted to learn more about it. What a better way to do it than just turn vegetarian?

 hat I did for, and this is in my peak Iron Man racing days, so I'm ... This was the mantra, you've got to dump a whole bunch of carbs in your body to be successful. You've got to have GI distress. You've got to be throwing up, visiting every porta-potty. I'm like, "Okay, rite of passage."

It wasn't until 2012 where I actually started to use my brain a little bit and thought, "Wow, maybe I should do some testing?" That's another important factor to remember is popping the hood is so important.

What I did was a four-week experiment. I went from high-carb, low-fat, and I did blood work, and I did a metabolic efficiency test on me. Not truly comprehensive blood work, but just basic blood lipids, that's it just to get the process started. I did a metabolic efficiency test on myself to see how efficient I was at using fat and carbohydrate.

Then, I said, "Okay, I've got this data for four weeks, I'm going to go animal protein, full-on, just whatever happens, happens." Not low-carb, high-fat, of which there really isn't a technical definition, but I was, as you can imagine, lower carb, higher fat just because of the diversity and change.

Then, I repeated the same blood test and same metabolic efficiency test four weeks later saw a little bit of body weight changes. This was in my off-season, so I could play around a little bit, saw a little bit of body change, smidgen [inaudible 00:18:30] change, but that wasn't the purpose.

For me, it was more from a genetic standpoint, so family history, cardiovascular disease, diabetes. I don't know if I'm going to dodge the bullet, so I'm thinking, "Well, let's see what happens. In four weeks, I'm going to decide basically on blood work only, not necessarily my ability to burn carb and ability to burn fat, but I'm going to decide on my blood work which dietary pattern I'm going to do."

Suffice to say, I have been eating animal protein since 2012, because, for me, my not only genetic makeup, but by the way my body processes nutrients, I am not sufficient at utilizing a high-carb, low-fat diet, because and I'm sure a lot of people out there listening to this are in the same boat. You don't know what you don't know. Get tested, at least basic blood work, just to at least get a framework.

I had high blood sugar. I had high triglycerides. Cholesterol was high, but particle size was a little bit off. That was before.

After following more of an animal protein, moderate-carb, higher-fat, moderate protein, all the bad reversed, all the good obviously reversed also, so I was actually more, I hate to use this word, but healthy from a metabolic standpoint, and that's what really made up my mind.

That's in my practice I am very non-biased. I don't recommend a specific diet. We try to get testing on these athletes from all different angles, and then we decide which dietary strategy is right for them, health before performance. That's one thing I really want people to latch onto is, you can't perform if you're not healthy.

That is why we work with individuals and endurance athletes. That's why we always ask you about your health. That's why we always ask you, have you had blood work or any testing done. That's my little N of 1 share that I think has some golden nuggets for the listeners out there.

Dr. Pastore: Yeah, that's a great one. Thank you for sharing your personal story, Bob. That was awesome. I am fascinated by that type of metabolic shift, and, particularly, with regard to how we're producing lipids.

Our body really does know what it should do. If you do some testing and try to determine exactly what's going on, and what could be going wrong, the solution doesn't have to be ...

Because, you know what I feared when I heard your story, your N of 1, I'm thinking of the individual that doesn't have your knowledge and maybe ran right out and was prescribed a statin and maybe Tricor to also address the triglycerides. At the same time, they're addressing that, and we both know, well, three of us, obviously, all know what can transpire.

I'm not pointing blame at statins, but if you can be like Bob and, actually, get the data and figure out a better path, look how healthy the guy is. But, I can tell you this, there's been over 50,000 ... Back when I published in 2015 in the journal, Nutrition Research, there was over 53,000 published reports of statin-induced muscle pain and damage. That does not equal an endurance-crazy lifestyle. You will lose your ability to do what you love.

I love, health above sport, Bob, that was actually a mantra in my practice as well. I had some of the best athletes in the world come to me and say and, actually, agree to it, particularly, the older people, "Look, I want to be around for my kids. My family's from this demographic and this food lifestyle, and there's a predisposition to diabetes."

It's really remarkable to me how many people who are incredibly fit, are incredibly fit, actually have something going on underneath the seams.

Bob: Totally.

Dr. Pastore: I can't say enough, you can't just judge a book by its cover. Some of the most fit people with the unbelievable Michelangelo chiseled abs are actually sick inside and do have some problems they're trying to address, which is so remarkable.

From various autoimmune diseases we see, and professional athletes who become poster people for those diseases to bring awareness. To my disease, I have celiac disease. I think you both know, and that was just a life-changing event for me to even go back to my family history and see, my father died at 50 from this horrible disease.

It's, yeah, what we are consuming, and how it affects our body is tremendous. We really need to do some testing to look at those things.

Angie, have you had any experiences in extremes or anything with your practice in Ns of 1?

Angie: Yeah, just, similar story to Bob. I never did as much testing as he did, but I think we were both trained in the early '90s when that was very popular, high-carb, low-fat. I think a lot of dietitians coming out when we graduated were very drawn to that, oh, fat is really bad, carbs are really great.

I was just telling my son that our snack at college, we thought this was a healthy sorority snack, we would get bread sticks, no fat.

Dr. Pastore: No.

Angie: Midnight breadsticks, those help with the freshman fifteen, but that was the mentality at the time.

Not to belabor the point, but I think any time you latch onto an eating style that makes one thing so fabulous and makes the other thing so bad, it's really hard to have balance.

I see that now with some of these other types of eating styles we're going to talk about. That when one thing is really good and one thing is really bad, it's just, you're not really eating in any kind of balanced way that's sane or healthy or sustainable.

Dr. Pastore: Yeah, you know what I worry about, I don't know if you guys have seen this, but what I have seen is people actually suffering for the cause. They'll latch onto a specific cause and, then, maybe not get the best data or report from their physician, go to another physician to just verify that.

Then say, "Well, I'm just going to deal, I'm going to post this on an internet website, because they're going to have better knowledge than these doctors." Just stay with a program that's obviously hurting them.

I think that's where what you do, Angie, is so great, because you're listening to people, getting them to listen to what is sustainable, but, and then, also, what is logical for them. I want to get into that more that concept of suffering for the cause without pointing blame on any specific pathway.

Like all you guys, I don't have any enemies in this situation. I just think there's an enormous amount of misinformation. There's a new diet book out, is it monthly, guys? There's always-

Bob: Sure.

Dr. Pastore: ... always something new.

Angie: Yeah.

Dr. Pastore: But, it never is specifically for that individual. Yeah, sure you can take great components of basically anything.

I love veganism for the vegetable content. But, then, I've also met vegans that are basically pastatarians. That defeats the purpose in my mind.

I'm omnivorous, and I used to say to a vegan, "If I'm eating more vegetables at breakfast than you do all day long, you are not a vegan." You're doing everything wrong, everything wrong, no test needed, get out.

Lexie: Now, let's make the jump from high-carb, low-fat to the opposite of more high-fat, low-carb keto. For the audience that is listening that doesn't know what keto is, can one of you fill us in on the nutritional aspects of it, what it does, what ketosis is?

Dr. Pastore: Ketosis basically got its start in true, real academic medicine. It really was at Hopkins. To the best of my knowledge, it was used in treating seizure disorders that could not be treated successfully with medication on some specific pediatric cases.

What they found in the clinical literature after using this is it would switch the brain over from using glucose as a primary source of fuel to predominantly using ketone bodies which are completely different from the type of ketone bodies and danger you can get into ketoacidosis if you were uncontrolled diabetic. I want to make that clear. They found that it could actually help reset some of the communication between hemispheres, and it was this very interesting thing.

Studies got picked up and went pretty far. You're consuming an extremely low carbohydrate diet to the point of your individual body utilizing fat as a fuel source, burning in fragments of fat known as ketones, and you can actually measure them in the urine.

That's just a real basic laymen terms, please, anyone add-on to that more scientifically, if you want.

I've watched over the years this become progressively a movement, a movement of people using a keto diet to, some frightening dialogue like, "I'm going to use this for cancer." Frightening in the aspect of we don't know if that's right for that individual. But, there are some research in brain tumors I'm aware of where being in ketosis could actually starve that tumor entity of consuming glucose which it does in enormous amount.

But, there's also on the flip side some interesting data on cancer cells consuming ketone bodies. That's something that people should look up on PubMed, because it does indeed exist.

What I have seen is just more of an awareness in the internet, in the lay public of utilizing a ketogenic diet and adapting to a ketogenic diet for everyday living.

This is definitely where, guys, I would want to hear from Angie, because, I personally will tell you, if I could share an N of 1 story, I'm a big Jeff Volek fan. I just always like the guy. He's an RD. He's a PhD. He's someone I really respect. He lectures on ketogenic diets and keto adaptation for various curricula that is accredited.

I want to make very clear, this guy is the real deal. He's given some interesting examples of professionals in the endurance athlete space that have actually adopted it. It sounds counterintuitive when you hear all the stories about the way we were all trained in mega carbohydrates and pasta loading and the health of breadsticks at a sorority.

But, he actually shows examples of Tour de France winners, I think it was back in 2016 or 2015, where the first-place and second-place winners were actually low-carb keto people. Three ultra-endurance athletes that actually hold records, Tim Olson, Zach Bittner, I think it is, and Mike Morton. If, guys, please, anyone, correct me in a chat box if I'm wrong, but I have a pretty decent memory.

I respect that completely. Here's my N of 1. Just wanted to give it a whirl, wanted to see what would happen, I said, "I'm doing this for 45 days." I thought I was going to die by day 33.

I just want to make that clear, never got past any of the just awful ... I'm going to throw an old school reference, because I'm old, Atkins flu. I felt sick every day for 33 days straight. I had a blinding migraine for at least 25 of those 30 days.

Before anyone throws stones in the keto world which, again, I'm not attacking keto, I'm trying to share a Bob-type N of 1 story and be brave and share my emotions and feelings with all of you. It doesn't work for my metabolism.

I'm sure as heck not going to say, "Well, then it can't work for Mike Morton," who's holding a record in endurance. Of course, it can. We are all biochemically unique. It just makes me feel so sick it's not funny.

I never got any of the benefits. It's the whey protein studies, guys, I see the data, I am violently allergic to whey by a medical doctor at Columbia since I'm five years old. Columbia Presbyterian not the country. I can't consume the product to get those benefits.

Clearly, I'm not their demographic for a ketogenic diet. To feel that sick I threw in the towel and felt like a million bucks with my first half of sweet potato and my grass-fed steak, grass-finished as well, and my mound of green leafy veggies with olive and lemon. I wanted to run through a wall, and I was like, "Where have you been the last 30 days?"

That's just painting that picture. Listening, and not only having the data and the crazy testing that practitioners like Bob and I would do, but, listening to your body and saying, "Is this really right for me?" Then, when you are not doing that, how good it feels.

Angie, that's really where I'd love to hear from you with regard to your practice and intuitive eating and sustainability in a nutritional protocol that you would prescribe to a patient I think is critical, right?

Angie: Yeah, yeah, absolutely. I would say that the biggest trend probably that I've seen this year of, it's old, but it's new again in some ways. A lot of people have come in this year, "I read about keto. My friend lost weight on keto, I really, really want to do keto."

My intuitive eating nature comes in, and I say, "Well, do you really like heavy cream? Do you really enjoy bacon? Are these the foods that make you tick and get really excited? Then, maybe keto is something we could try, and I would be happy to help support you in that effort."

If pasta is your favorite food, and you want to learn how to live peacefully with pasta and enjoy it in a balanced manner, I don't think keto is for you. That really what I would do in my practice, and a lot of people that have tried keto end up in a bag of candy. I do live in Hershey, so it's abundant here.

Just my small practice, that's what I see is it doesn't seem really sustainable for a lot of people. I'm really interested in that, in finding something for health, for their whole life that they can really enjoy and stick with.

Dr. Pastore: Yeah, because wouldn't you say, Angie, that if it's not sustainable, and they're going directly from keto to a bag of candy that couldn't we define that in a way of being yo-yo dieting, and we all know how-

Angie: Absolutely.

Dr. Pastore: ... deleterious that is on one's metabolism.

Angie: Yes, and even just on your mental health of feeling that you've somehow failed something. But, you set yourself up for such a difficult endeavor if that's not really something that you could see yourself doing for a long time.

Dr. Pastore: I'm so glad my mental outlook was, "It failed me." I'll rant to my sweet potato, and we're living happily ever after in a carotenoid bliss, if I may add.

Angie: Good to hear.

Dr. Pastore: Bob, do you have any interesting stories regarding, good, bad, or ugly regarding keto?

Bob: Yes, I don't even know where to start. In my practice, it must be about 90% of the individuals, be it competitive athletes or recreational just fitness enthusiasts, I think they fall in two categories, either one, they're coming to me saying, "You're going to put me on keto."

For one reason, let's just be honest. In my personal professional opinion, I believe people are romanticized with keto because of weight loss. That is 90% of the people that come to me, "I want to lose weight." Therefore, they think they need to go keto.

Then, the other 10%, they come to me, they say, "You're not going to put me on keto, are you?" They're kind of scared with that.

I think it's our responsibility, as we've been saying this whole time, is let's pop the hood, let's see what we've got going on. Because, I've actually taken some athletes who were on keto and made them a little bit more what I like to say low-carb, high-fat, which is actually adding in a little bit of carbohydrates, look at blood work, look at some efficiency rates, substrate oxidation, and they're healthier.

I think people are either scared of keto, or they're embracing keto. But, like you two were saying, I have met very few individuals who can actually sustain that lifestyle, because it's very difficult.

I've got another saying, we're throwing out all these things today, "Simple is sustainable." If it's not simple, it is not sustainable for individuals. Keto being very restrictive is not simple.

Like you, Robert, it works, it works for some athletes. But, I'm going to argue based on the level of competitiveness, or maybe I can get into the level of intensity that keto may or may not be the right aspect. That's why I like to periodize macronutrients, so periodize carbs, protein, and fat based on the intensity and the duration in activity.

If we get an ultra-marathoner, we know that typically, not the Zach Bittners of the world who are just going for broke, but, typically, the age-grouper, it's lower intensity. They're probably oxidizing a little bit more fat anyway, maybe they can pull off keto.

But, what if that person is going to drop in for a fast 5K or 10K or half-marathon, utilizing a little bit more of the anaerobic energy system, a little bit more burst of carbohydrate, there's no way keto will work. That's what I see in the testing. Up to a certain point, they can utilize fat very well, but if we get over that tipping point, that carbohydrate tipping point, they don't have that extra gear or the extra velocity.

I believe a lifestyle like that can definitely favor our lower aerobic-based, lower intensity individuals or maybe just the fitness enthusiast. But, I got to tell you, I don't ever put somebody on a diet. It's always periodizing macronutrients to fit into their health and performance. I've seen a lot of bad things with keto though, and I have not seen the sustainability.

That's what worries me is people jumping on this craze, this trend, whatever you want to call it. It's here to stay, let's be honest. It is not going anywhere anytime soon.

I just wish that people would maybe approach it psychologically a little bit more from a positive standpoint and maybe not go full-on elimination and full-on restrictive but maybe start to step-wise their carbohydrate down. Because, I believe everybody has what I call a carbohydrate threshold. You can do a little bit of metabolic efficiency testing and other testing to determine where that threshold is, high and low. That's what I try to help individuals with is decide what's too low and what's too high based on health markers, bio markers and then, also, based on some metabolic and performance data.

That's my take, not individual story. I've never tried keto. I've been a little bit scared. I've gone low-carb, high-fat, and part of me felt great, dropped some weight, dropped some fat, but I could not train at high intensities, and that was driving me crazy. That's my take on the keto side of the dietary influences.

Dr. Pastore: If I could add another point to that, and it's again a conversation I just had with, I'm sorry I keep going back to Raul Ibanez, but it was just the most very recent conversation, he was such an excellent athlete and did some incredible things. I love the aging athlete and longevity and athleticism, but you're maintaining your health status.

The young guys would say to me, "I want to age like Raul," from a point that how come he's the one not hurting in the locker room, and he's 42, and the 29-year-old is just rubbing his elbows and his shoulders and his knees. But, of course, he has Eggo waffles drowned in artificial syrup for ... You get the whole ...

The one point I wanted to share is, Raul was interested in reducing his carbohydrates even though he was just incredibly fit and already had a low body fat. I remember him calling me from the ballpark, and it's a story that he shared with me that's out there on the internet, and he said that I immediately said to him just go get a sweet potato, get a big sweet potato.

Just something that simple, it worked so well for him, I think it became almost like wearing a certain pair of socks if you're a pro. You think you're going to jinx, so he just started having that type of complex carbohydrate added before every game and to quote him, he said, "It was a game changer," something that simple.

If your athlete is bonking, and they're just not doing so well, and they're hitting the wall, and they just don't have that output, or like me, no one could say I did it wrong, because I'm well credentialed to know I did it right, but it just doesn't work for me. It was just something that I was not, quoting ... Just moving on to Angie's point, it was just impossible to be sustainable. I'm so glad I didn't jump into a bag of Hershey's candy, but it still was something it just didn't work for me.

I love what you guys are saying. We're all 100% in sync as I knew we would be. We're not in the realm of prescribing diets, we're trying to recommend health, and what is the right way to nourish an individual at any different time.

Changing that, and I did the same thing, Bob, I absolutely did. We called the Major League Baseball season, especially, if you got a post-season, you got 162 games. That's the grind. These guys are crushing it, and there's loss of sleep. My guys are, some guys are losing weight by the end of the season.

By the way, guys, what I did is I just had all the meals made by my specifications by a chef sent to every one of my players no matter where they played they showed up in a FedEx truck. That way I knew exactly what ... I was nuts. That was type of ultra-marathoning. Sadly, it was just at a desk all day long working on all this stuff.

But, that was the way I could get it done, and that goes back to Bob's point, if it was simple enough, it was sustainable.

Lexie: Let's transition now into diet I guess that each of you somewhat agree on. Angie I know that you said that this style resonates really well with your clients, and that is Paleo. If you can just educate the listeners on what Paleo is, and why you find it works well with your clients.

Angie: I think Paleo appeals to a lot of people. This idea of going back and eating what our primal ancestors ate, so really focusing more on whole foods, things that are found in nature, much less processed foods that I think is just really appealing to people.

What oftentimes happens, whether it's weight loss or feeling better performance-wise, I think a lot of times it's just attributable to eating more plant foods in general. When a lot of processed foods are cut out, you are really taken back to these more natural foods.

But, sometimes, I do have people that even find with Paleo, it's not sustainable because, again, of that exclusive nature that they might not be able to go to a wedding and have what's on the menu. Again, I'm always looking at sustainability, if that's something that the person really wants to stick with forever.

A lot of times I get Paleo dropouts as new clients. They liked a lot of things about Paleo, but they didn't want to stick with it entirely. I try to work with them on the things that really enjoyed about it and finding ways to keep that in their eating, looking at the things that really worked well, but maybe having a little bit more flexibility around it for the long-term.

Dr. Pastore: Very interesting, Bob, do you have any comments there?

Bob: I do if I can share another really interesting tidbit with you guys and the world. Dr. Paleo or Dr. Loren Cordain who is the movement of this, so I did all my studies at Colorado State University, Fort Collins, Colorado, undergrad and two master's degrees. My undergrad was in exercise science, exercise phys.

Dr. Loren Cordain was one of my exercise physiology instructors back in the day.

Dr. Pastore: Wow.

Bob: Back in the day before Paleo ever existed, so-

Dr. Pastore: Wow.

Bob: ... kind of cool for me to see that evolution, one. But, two, so, aside from that, I've got some personal interest in that, because he was one of my professors.

But, what's interesting is that I personally don't believe that there really is a Paleo diet anymore. I remember when Paleo first came out. Obviously, I work with a ton of endurance athletes, and then, shortly thereafter, a really well-known endurance coach, Joe Friel, triathlon coach, one of my colleagues and friends, came out with the Paleo diet for endurance athletes.

I was kind of scratching my head thinking, "Well, wait a second, you're taking a Paleo diet, then you're matching it to endurance athletes." You read it through, and you're like, "Oh, so you're basically just including a lot of sport nutrition products," traditional ones, the gels and everything. I said, "That's not Paleo anymore."

To Angie's point, I love the concept of Paleo, but I don't believe it actually exists anymore, because there are so many spokes that have taken off from this. Again, love the concept, love the teachings, but I think it's just completely expounded now to where people don't know what Paleo means.

Dr. Pastore: Bob, I didn't even know you and I go this far back. If you right now were to google Loren Cordain, Dr. Pastore, you would find Loren Cordain answering the questions of Dr. Pastore's interns on the Paleo diet. I go way-

Bob: I love it.

Dr. Pastore: ... back with Loren.

The paper that influenced me was a little known paper out of Colorado State known as Cereal Grains: Humanity's Double-Edged Sword published in 1999. Here I was a celiac disease individual, so I was so excited about reading this, befriended Loren, phone calls, emails, really just a couple of public ... I'm jealous, because he's a really lovely human being.

Bob: Yeah.

Dr. Pastore: He's a great guy, super smart. I was also the guy who invited him to his award-winning lecture for the American College for Advancement in Medicine in 2004 where I spent an enormous amount of time with him.

I do have to agree with you. I'm actually trying to get him on my podcast out of retirement, because I want to talk to him about what he believes the landscape of Paleolithic nutrition has become, how does he feel about that, how does he feel about the talking heads of Paleolithic nutrition.

I would like to state, if I may, just two more points on this, because like both of you I do have just ...

I think deep down it resonates with me, the hunter-gatherer concept of consuming the least amount of processed things as possible. I really love the utilization of qualities of our meat sources, quality of our fish, quality of all the foods we are consuming. The abundance of vegetables I just think are ... It's just such important messages that are wrapped within Paleolithic nutrition.

For me, it's always been the term hunter-gatherer. But, that also has dramatic diversification. One of the things I would do if I like a researcher is I would read their paper, and then I would read every one of the citations.

Now, Bob, you had Loren as a professor, Loren loved like 99 citations-

Bob: Oh, yeah.

Dr. Pastore: ... so it took me a long time to comb all the way through that. But, I started reading up on all his 216 hunter-gatherer societies that he researched.

I personally researched those and found just a dramatic difference with regard to macronutrient profiles and ratios of hunter-gatherer societies, from an enormous amount of fructose differential to an enormous amount of saturated fats when you get more into what we could call the beginning of the Eskimo civilization, et cetera, aborigines, the !Kung.

I could go on and on and on about the differentiation of macronutrient profiles. I agree with you. I don't think there's this one entity.

Now, what I did, because I love challenging things, you guys know my keto N of 1, I thought it would be really fun to get an IRB at my alma mater, one of my alma maters, Eastern Michigan University, and I published a study, it was a year, it was a brutal battle. What did I do?

I got 20 volunteers, I put 10 through the, I put all 20 through the American Heart Association and all through Paleolithic nutrition protocols.

Used the title to get published, because it was still pretty hot at the time. That was actually my colleague who said, "You should really, don't use hunter-gatherer, don't use historical. Nope, nope, you're going to get rejected right away. Please use Paleolithic nutrition." I went with that advice, and, sure enough, it was published in the Journal of Nutrition Research.

Why did I do it? I love questioning. I played with the macronutrient ratios. You had to have some type of understanding. I kept it quasi as loose as I could. It definitely I don't think would hit Loren Cordain's true diagnostic values of what a Paleo diet was.

For example, I had no more than half a cup of white potato. I'm trying to get people in Michigan to do something here. No more than one ounce of dried fruit, and you couldn't have any more than four ounces of wine. Everything was this just list of really healthy, if it's not grass-fed, grass-finished, you couldn't have it.

I really tried to be militant to that. I had calories, macronutrients, everything calculated. It's all in that full published paper, you could pull up on PubMed.

The outcome was not surprising to the three of us, people were in the middle range. When I ran the macronutrient ratios, the average consumption of carbohydrates did not exceed 30% of their diet, on average. They were having more of a fat intake and more of a, protein was hovering around 37 to 42%, and that could also be interchanged with fat depending on the individuals.

I just wanted them to feel it out intuitively, Angie. I never said, "You have to have this many ounces. You have to have this many ... " Just, "This is all you're allowed to eat, figure it out, and we'll let the testing determine what transpired."

Well, sure, I criticized my own study, and I'm really a horrible critic on myself, but I ripped my own paper apart in the discussion section.

I thought that it didn't have enough diversity of the population. I feel that it could have been in a better way. I was only looking at just total lipid profiles, and to be honest, because the IRB wouldn't support doing fractionation, believe it or not, it's still on the fringe, Bob, which is mental.

They didn't care about buoyancies. They didn't care about Lp(a), so I said, "Okay, let's just go after what the American Heart Association preaches." This more hunter-gatherer, intuitive eating lifestyle across the board had better lipid profile outcome than the American Heart Association which I was militant to, no more than less than 7% total saturated fat.

That was actually, you know, Angie, that was the hardest part of it. To have the subjects of the trial follow that massive dogma was so hard. It was so hard.

Yes, before you ask, I did make sure we had the proper statistic analysis to make sure weight change did not have anything in the lipid profile, really ripped it apart. I actually had four pages of mathematics on it that were rejected, and they wanted me to simplify it, but that's just me.

That's really my Paleo stories. I lean towards more of a historical, hunter-gatherer diet. I think it should be individualized.

I don't think it makes sense for a 90-pound Asian woman to follow a ketosis diet just as much as someone who might walk into Angie's office and say, "I loathe fish and chicken," and Angie would say, "Well, you need to be a pesco-vegetarian."

That's not going to-

Lexie: That is a great transition, just because we are running really short on time here. We will go over. Holly, your question will be answered, don't worry.

But, if we can jump more into the vegetarian, plant-based, and vegan diets and your thoughts on that for endurance athletes.

Dr. Pastore: Please, you guys, I talk too much.

Bob: Angie, you want to start?

Angie: Oh, sure. I think along with keto with a lot of endurance athletes that I work with that's probably the next really biggest or even bigger than keto actually trend that I'm seeing with my endurance athletes. I can't count the times I've heard, "Well, I read Rich Roll's book, and I really want to try this vegan thing."

I ask a lot of the same questions that I do if someone wants to go keto. Do you love all plant foods? Is that the thing that you really, really want to do? Can you see living without eggs ever? Would your family support this? Do you travel? Will you be able to get vegan meals when you're on the road? Finding whether that is going to work with their lifestyle or not.

I also like to remind people that a lot of times like you were saying, Dr. Pastore, that you get a lot of the benefits of eating a lot of plants without signing up for the vegan card. Sometimes, you feel like you have to go all the way to get all those benefits of eating a high-plant diet.

A lot of times I like to work with people on where they're at with what they're eating now and transitioning to more plants, because there's just loads and loads of data on the benefits of all of that. That's a little bit of my experience, Bob, you-

Bob: Well, let's just-

Angie: ... [inaudible 00:52:19] I'm guessing.

Bob: ... just remember one thing, I am 45 minutes south of Boulder, Colorado. I think that probably says everything.

No, as I said earlier, I was a practicing vegetarian, not vegan, for 10 years. Absolutely, loved the flexibility of eating different grains and different veggies and how to combine different things together just to make a great taste profile.

Back to my example, I think vegetarianism is very useful for some individuals. Veganism is useful for other individuals. It simply does not fit, not their lifestyle, but their genetic biochemical makeup. That is the most important thing.

It's nothing against vegetarianism or veganism. I'm a huge supporter of that, but I believe also vegetarian, kind of like Paleo diet, vegetarianism to me doesn't really, it doesn't really exist, because I call it more flexitarian.

If someone's vegetarian, oh, well, they eat cheese, and they eat chicken, and they eat fish, but, they just don't do eggs, or one of the things. I'm like, "Well, that's not really vegetarian. That's flex."

I'm a huge believer in the concepts that it teaches. But, in the same aspect, I think we need to take a step back and determine, is that the right approach for individuals. That's my summary among all these "diets" out there.

Dr. Pastore: Yeah, absolutely, and if I could pepper in my opinion there at the end, one thing that I always found fascinating going back to my statement on suffering for the cause is individuals that would come into my office clearly sick, on any one of these programs. I want to make it clear that I'm not attacking anything. We just happened to hit the wheel of fortune on the last topic of veganism/vegetarianism.

Just clearly not feeling well, and even I, Bob, I've even had, and Angie, I've had someone come in office that couldn't even properly grow fingernails. They just were not able to utilize their proteins properly.

How did I get them, just off the street? No, a medical doctor ran an analysis and said, "This individual is deficient in many of the key amino acids for the amino acid pool for the building blocks of life." That was a pretty intense conversation that this is clearly you are in the category of suffering for the cause.

I love the cause. I understand what you're saying, and you believe in. But, this dogmatic approach in the absence of understanding your own unique biochemistry and physiology just doesn't work.

If we go back on topic to our endurance athletes, and if I could add in professional athletes, which was really my bread and butter in at least the last eight years of my clinical practice, it was all about just getting that athlete as healthy as possible for their sport and, more important to me, outside their sport and for longevity.

These people are doing very unnatural things with their body. You want to have the most optimal nutrition for them. Of course, that's stands for every human being.

But, if you're doing Death Valley, I had a professor that would see me every year to prep for, a Princeton professor every year would say, "I'm doing Death Valley." The prep for that was incredible. The amount of work we had to do, the training program that he was on was intense. Then, of course, we would change all of that after in the down time.

There is no way I would say, "You have to follow this dogmatic approach to this one pathway, and we can't go outside that." No, it was, "This is exactly how your body's working for this year of your life. This is the type of fuel you need. Here's how we can do it," case closed. That's really what I needed in my office to get people to the next level.

Lexie: We are almost at the hour mark here. Holly, thank you for being so patient. Holly asked, can you all address relative energy deficiency in sports, and how easy it might be for endurance athletes to have chronic RED-S or under-fueling? Do you have any tips to manage energy availability?

Angie: That's a great question. Bob, you may see it more often. In my practice, I'm seeing this mostly with young, collegiate runners. How I see that, a lot of times for women, they're in college, they may not be on a meal plan. They may be responsible for preparing their own food. They're training 70 miles a week running. They're also full-time in college, and it gets pretty easy to fall into this category with that perfect storm of everything going on.

Tips on how to manage it, I do think food journaling can help if they have time for that. Really looking at how many calories they're getting in, how much protein, how often they're eating, are their guts able to tolerate all this with all the running that they're doing.

But, journaling those feelings of hunger, fullness, gut symptoms, recovery can help. But, it's sometimes a job, really big job to eat enough to support that kind of activity.

Dr. Pastore: If I could add in as well, Angie, this is amazing how we have such similar experiences. The first time I identified this was in the graduate students that were runners. They were predominantly female.

What I was identifying was female athlete triad without a disordered eating pattern that was cognizant. It was just really like you said, eating at the kitchen, maybe not liking what they had, moving major sources of macronutrients off their plate and under-eating subconsciously, or, I should say, unconsciously, and then performing at such an enormously high level.

What frightened me, because we were doing DEXA scans and different things like that is I was seeing full-on evidence of osteopenia at such a young age. The three of us are aware that female athlete triad is a very serious situation and could end up in life-long negative applications and implications from metabolic to bone issues to full-blown osteoporosis before the young woman is even in her mid-30s.

For me, it was really just being militant about them understanding what they needed to consume for their sport. We spent, I spent, as you guys did too, we spent a ton of time in graduate school with just calculations, macronutrient ratios and what that visually looks like.

I actually had in these cases, did you guys ever work with those rubber foods and the fake foods, and what a portion actually looks like? Sorry for the nightmares.

Angie: I promised I wouldn't buy those in my private practice, so I don't have the rubber food.

Dr. Pastore: [inaudible 00:59:10].

Angie: I know exactly what they are.

Dr. Pastore: Of course, you're traumatized. They were forced upon me. The dangers of graduate school.

Angie: Yeah.

Dr. Pastore: You too can get into graduate debt with rubber food.

Angie: Yeah.

Dr. Pastore: But, really I got to tell you where it was an asset is in these types of cases. People go, "Oh, so you're telling me I need this many grams per kilogram of body weight of protein, and that's what it looks like in a day?" Yes, and they're eating a third of that. I had those type of frightening experiences.

I'm happy to report in private practice, I stopped seeing that completely. These were people that were very in tune with their body. Unlike Bob and Angie, they have way more experience than I have in endurance, though I did work with Iron Men competitions which I think they should change that name, Iron Brethren. Come on, man, let's not be sexist.

A lot of long-distance cyclists, but a lot with the pros in the major sports that we all watch and enjoy, in those scenarios, I was blessed that people were coming in, and, believe it or not, my problem was more over consuming calories in the down season. That was more of what I saw.

Bob: Yeah. I think just to summarize, I don't see that too much anymore. I used to work more in the collegiate setting and the younger population. I do a couple of youth, junior athletes. But, as the aging population comes into more of the sport and nutrition focus, I don't really see a lot of this concern as much as I saw in the younger population.

You guys were paving a path there that we're really seeing that more in the younger population. For whatever reason, either they're learning at a young age, and then they're coming into themselves with more knowledge as they get older or not.

I see more of that type A OCD personality where if we identify some clinical symptoms of that, we can address it pretty quickly. They'll fix it, because they're adults, and this endurance ultra-athlete mindset is very, "Tell me what to do, and I will do it," just not at the younger age.

Dr. Pastore: Thanks, Holly.

Lexie: I know we are going over time here, so just if each of you could give a couple takeaways to wrap this up for endurance athletes and how to fuel your body for optimal performance.

Dr. Pastore: I think Bob and I are going to have a similar takeaway. For me, it's the way it worked for me. Just, we're all individual practitioners, test is best.

I really needed to know what was going on with my individual athletes. I do believe in journaling deeply, and that was always a part of my practice. But, I really needed to see that data even if it was to confirm a suspicion or to push someone in the right way and be able to show them what they were doing was deleterious to their body like some of the aforementioned patients that I shared this evening.

Angie: I love the little adage that nutrition is the fourth leg of triathlon. If there's anything could take away from me would be that that nutrition should really be enjoyable and support you. Whatever pathway you decide, it should be something that really makes you feel good, that is really sustainable and is really supportive in that fourth leg of endurance sports.

Bob: Yeah, mine's really simple, two phrases, test don't guess, periodize your nutrition, simple.

Dr. Pastore: Love it, Bob.

Bob: Yup.

Lexie: That does conclude an hour for the webinar. Thank you guys so much for tuning in, giving some of your time tonight. It does mean a lot to all of us.

If you do want to check out either Angie, Bob, or Dr. Robert Pastore, there will be links in the description below. Angie can be found online at Bob has two websites. His personal one and, and energy is E-N-R-G. Of course, if you questions about Modus Nutrition or Dr. Robert Pastore, you can check out

Thanks so much and have a great night.

Bob: Bye, everybody.

Dr. Pastore: Take care everybody, thanks so much. Thanks.

Angie: Bye, thank you.