The relationship of inflammation and perfusion on MSK pain is real and modifiable.

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Stephan Esser MD
Feeding the Fire: Nutrition Considerations for
the Recreational Athlete

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Disclosure
No Disclosures

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Consideration and Perspective
• Rapidly Aging Population
• Generational shift to staying active despite age
• Most Obese, Chronically Ill Population
• >70% OO, 1:3 HTN, 1:6 HLD, 1:9 T2D
• Nutrition: Universal, Ubiquitous, Uniquely Modifiable

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Nutrition and the Recreational Athlete
• Caloric Intake
• Hydration Status
• Macromolecule consumption
• Supplementation
• Inflammation/Perfusion and Joint Health and Performance

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Nutrition and the Recreational Athlete
• Reduce / Prevent / Manage Pain or Injury
• Facilitate Healing
• Enhance Performance
• Maximize general health
Inflammation and Perfusion

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Reduce / Prevent Pain
– Anatomic
• eg: Fracture, Ligament tears, Tumors, Large Disc bulges
– Biomechanical
• eg: Body Weight, Weak hips/Glutes, Tight Hip flexors, Weak Shoulder muscles,
Sarcopenia
– Physiologic
• Biochemical/Cellular or Neurophysiologic

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Body Weight
• Weight:
• Lower Extremity Joints
• 1lb above the waist = 3-10 below
• Upper Extremity Joints
• Inc. Weight = Inc. work for RTC, neck muscles
• Alters Spinal Mechanics
• Inc. Lumbar Lordosis and “facet based pain”

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Obesity
• Obesity is a primary risk factor for disease onset, and mechanical factors increased the risk for
disease progression. Moreover, inflammatory mediators, in particular, adipose tissue‐derived cytokines (better
known as adipokines) play a critical role linking obesity and osteoarthritis Biomechanics,
obesity, and osteoarthritis. The role of adipokines: When the levee breaks Journal of Orthopedic Research, 2017
• Obesity enhances the cross-talk between chondrocytes and synovial fibroblasts via raised levels of the pro-
inflammatory adipokine leptin, leading to greater production of IL-6 in OA patients. IL-6 secretion in osteoarthritis
patients is mediated by chondrocyte-synovial fibroblast cross-talk and is enhanced by obesity Scientific Reports
2017
• Higher body mass index was associated with an increased risk of hip replacement due to osteoarthritis (P for
trend = 0.0001). Compared with women in the lowest category of body mass index (<22 kg/m2), those in the highest
category of body mass index (≥35 kg/m2) had a twofold increased risk (95% confidence interval [CI]: 1.4
to 2.8), whereas those in the highest category of body mass index at age 18 years had more than a
fivefold increased risk (95% CI: 2.5 to 10.7). Total hip replacement due to osteoarthritis: the importance of age,
obesity, and other modifiable risk factors The American Journal of Medicine 2003
• Increased weight = increased risk of OA and resultant need for THA and TKA. Role of Obesity on the Risk for
Total Hip or Knee Arthroplasty Clinical orthopedics and Research, 2007
• This underscores the immediate need for greater use of clinical and public health interventions, especially those
that address weight loss and self‐management, to reduce the impact of having knee OA. Lifetime risk of
symptomatic knee osteoarthritis Arthritis Care and Research 2008

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• “Don’t leave the “snow” on the roof too long”

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Weight
• Adipokines / Cytokines
Marks R. Adipokines and Osteoarthritis. International Journal of Orthopaedics 2014; 1(3): 85-92
Tu, Caho, An Extensive review regarding the adipokines in the pathogenesis and progression of osteoarthritis Cytokine 2019
Xie, Chenxi. Adipokines: New Therapeutic Target for Osteoarthritis? Current Rheumatology Reports 2019

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Adipokines / Cytokines
Macdonald, Iona, Associations between Adipokines in Arthritic Disease and Implications for Obesity Int. J. Mol. Sc. 2019

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Weight and Joints
• Reduce Biomechanical Load
• Reduce Pain and degeneration thru reducing cytokine and adipokine production

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Weight Loss
• Caloric Reduction
• Volume Control
• Amount, Timing, Frequency
• Calorie Density Model
• Alter Food Sources

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Weight and Plants
• Vegetarian diets are associated with reduced body weight, lower incidence of certain chronic disease,
and lower medical costs compared with non-vegetarian diets Vegetarian Diets and Weight Status Nutrition
Reviews 2006.
• Self-identified semivegetarian, lactovegetarian, and vegan women have a lower risk of overweight and
obesity than do omnivorous women. The advice to consume more plant foods and less animal products
may help individuals control their weight. Risk of overweight and obesity among semivegetarian,
lactovegetarian, and vegan women American Journal of Clinical Nutrition 2005
• The 5-unit BMI difference between vegans and nonvegetarians indicates a substantial potential of
vegetarianism to protect against obesity. Increased conformity to vegetarian diets protected against risk of
type 2 diabetes after lifestyle characteristics and BMI were taken into account. Pesco- and semi-vegetarian
diets afforded intermediate protection. Type of Vegetarian Diet, Body Weight, and Prevalence of Type 2
Diabetes Diabetes Care 2009

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Weight and the Recreational Athlete
• We MUST address weight for all recreational athletes
• Nutritional modification is foundational (enhanced with exercise)
• Increased consumption of minimally processed plant based foods should be
encouraged due to multimodal benefits
• Weight reduction/maintenance
• CV Risk
• Inflammation reduction/Enhanced Perfusion

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Perfusion
• Blood is “king”
• Perfusion enhances growth, healing and performance
• Arteries/Veins are the Highways and Byways
• Perfusion can be altered through nutritional modification

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Perfusion
• High Total Fat, High Saturated Fat, High Refined sugar meals inhibit blood flow and arterial
dilatation
– Effect of a Single High-Fat Meal on Endothelial Function in Healthy Subjects single high-fat meal transiently impairs endothelial function by up to
50% at 4 hrs after the meal American Journal of Cardiology 1997
– Acute Effect of High Fat Meal on Endothelial Function on Moderately Dyslipidemic Subjects. Arteriosclerosis, Thrombosis, and Vascular Biology.
2005;25:406–410
• Minimally Processed, Plant-Based Foods have vasodilatory effect
• Inhibition of Endothelial Dysfunction by Dietary Flavonoids and Preventive Effects Against Cardiovascular Disease. J Cardiovasc Pharmacol. 2020
Jan;75(1):1-9.
• The role of inorganic nitrate and nitrite in cardiovascular disease risk factors: a systematic review and meta-analysis of human evidence. Nutr Rev. 2018
May 1;76(5):348-371.
– Flavonoid-rich apples and nitrate-rich spinach augment nitric oxide status and improve endothelial function in healthy men and women: a randomized
controlled trial Free Radical Biology and Medicine 2012
– An increase in F&Vs, regardless of flavonoid content in the groups as a whole, mitigated increases in vascular stiffness measured by PWA (P = 0.0065)
and reductions in NO (P = 0.0299) in the control group Flavonoid-rich fruit and vegetables improve microvascular reactivity and inflammatory status in
men at risk of cardiovascular disease—FLAVURS: a randomized controlled trial AJCR 2014
– In healthy overweight and slightly obese men a single dose of beetroot juice attenuates the postprandial impairment of FMD following a mixed meal,
possibly through increases in plasma NO concentrations. Beetroot juice improves in overweight and slightly obese men postprandial endothelial function
after consumption of a mixed meal Athersclerosis 2013

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Perfusion
• Blood Flow is essential for
• performance, healing, function, prevention
• High Fat/High Cholesterol meals
• Impair vascular dilation
• Produce Fatty streaks, CVD precursors
• Impair blood flow to MSK tissues
• Reduce O2 and micronutrient delivery
• Alter regional pH
• Increase risk of death

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Atherosclerosis
• Enos et al: 1955:
• Korean War: Mean age 22, Gross CAD in 77% of subjects
• Vietnam studies confirm these findings
• Holman 1961, Stron and Mcgill 1962, Stary 1989
• Aortic fatty streaks present in childhood, coronary fatty streaks by adolescence,
fibrous plaques by 20’s
• Bogalasu Heart Study/PDAY Study: 80% Cor. Art. Surface area have FS by 18
• Angina below the belt 30% by 30 ? : Erectile dysfunction in fit and healthy young men: psychological or
pathological? Transl Androl Urol. 2017 Feb; 6(1): 79–90.

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Perfusion
• Spinal Degeneration and Impaired Perfusion
• Aortic Calcifications as a risk for back pain
• Advanced aortic atherosclerosis, presenting as calcific deposits in the posterior wall of the aorta, increases a
person's risk for development of disc degeneration and is associated with the occurrence of back pain. Disc
Degeneration/Back Pain and Calcification of the Abdominal Aorta: A 25-Year Follow-Up Study in Framingham Spine
1997
• A significant association is indicated between atheromatous lesions in the abdominal aorta and low back pain.
Association of Atherosclerosis with Low Back Pain and the Degree of Disc Degeneration Spine 1999
• Aortic atherosclerosis and stenosis of the feeding arteries of the lumbar spine were associated with DD and LBP.
Atherosclerosis and Disc Degeneration/Low-Back Pain – A Systematic Review EJVES 2009
• High serum lipids predicted incident radiating LBP, consistent with the atherosclerosis-LBP hypothesis. Serum Lipids and
Low Back Pain: An Association?: A Follow-up Study of a Working Population Sample Spine 2006

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Osteoporosis and Perfusion
• In conclusion, older women with more marked AAC are at higher risk of fracture, not completely captured by bone
structural predictors. Association Between Abdominal Aortic Calcification, Bone Mineral Density, and Fracture in Older Women
Lewis, J. JBPMR 2019
• In our study, vBMD was inversely associated with AAC among men independent of age and shared risk factors. However, the
association was not significant among women. Relationship of volumetric bone mineral density by quantitative computed
tomography with abdominal aortic calcification Li, Sedong et al, Bone, 2020
• Exploring the Links Between Common Diseases of Ageing—Osteoporosis, Sarcopenia and Vascular Calcification Rodriguez,
A Clinical Reviews in Bone and Mineral Metabolism volume 17, pages1–23(2019)
• Bone mineral density and coronary calcification are inversely related in both men and postmenopausal women, supporting the
hypothesis that a direct relation between bone loss and development of atherosclerosis exists irrespective of gender. The
relationship between volumetric thoracic bone mineral density and coronary calcification in men and women – results from the
Copenhagen General Population Study Wiegandt, Y et al Bone 2019

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Perfusion/Increased Cholesterol
• Serum Lipids and risk of Rotator Cuff Tear
• Impaired micro-perfusion
• Increased risk of injury
• Increased risk of re-tear and slowed healing
• Patients with rotator cuff tears were more likely to have hypercholesterolemia when compared with the control
group. The Effect of Hypercholesterolemia on Rotator Cuff Disease Clinical Orthopedics and Related Research
2010
• Dyslipidemia may decrease the improvement of patient-reported outcomes in
patients undergoing treatment for RCTs; high triglycerides and low HDL may have
the most impact.The effect of lipid levels on patient-reported outcomes in patients
with rotator cuff tears JSES Open Access 2017
• The present study found a significant
association between moderate and high perioperative total cholesterol and LDL
levels and the rate of revision surgery after primary arthros copic rotator cuff
repair. Perioperative Serum Lipid Status and Statin Use Affect the Revision Surgery
Rate After Arthroscopic Rotator Cuff Repair AJSM 2017

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Perfusion/Increased Cholesterol
• Achilles Tendon Rupture
• Impaired healing
• Increased risk of tear/re-tear
• Total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) concentrations of the patients with ATR were
higher (p<0.001), and their high-density lipoprotein cholesterol (HDL-C) was lower than the control group (p<0.05).
Moreover, the concentrations of triglyceride (TG) and very low-density lipoprotein cholesterol (VLDL-C) were
significantly higher than controls (p<0.05). Is high concentration of serum lipids a risk factor for Achilles
tendon rupture?
• People with altered tendon structure or tendon pain had significantly higher total cholesterol, low-density lipoprotein
cholesterol and triglycerides, as well as lower high-density lipoprotein cholesterol. Is higher serum cholesterol
associated with altered tendon structure or tendon pain? A systematic review BJSM 2015
• One intrinsic factor that appears to have an association with tendinopathy is body composition; more specifically
central adiposity Adiposity and tendinopathy Disability and Rehabilitation 2008

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Perfusion
• Impaired Perfusion = Increased risk of Soft Tissue and Bony Dysfunction
• Enhancing Perfusion should be a goal in the Recreational Athlete

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Nutrition / Perfusion Goals
• Increase the consumption of Natural Nitrates, Anthocyano Pigment Rich Foods
• Arugula, Beet Juice, Rhubarb, Cilantro, Lettuce, Swiss Chard, Beets etc
• Greens, Berries, Minimally processed fresh, plants
• Reduce/Eliminate the consumption of Animal Based foods and Heavily Processed
Foods

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Joint Pain and Cardiovascular Risk: BOGO
• Increased Fruit and Vegetable Consumption is related to reduced joint pain and less
OA
• Relationship between Total Fruit and Vegetable Intake and Self-Reported Knee Pain in Older Adults. J Nutr Health Aging. 2017;21(7):750-758. NRS
scores of knee pain decreased significantly with increasing fruit and vegetable intake quartiles
• Association Between Dietary Intake of Antioxidants and Prevalence of Femoral Head Cartilage Defects and Bone Marrow Lesions in Community-
based Adults. J Rheumatol. 2016 Oct;43(10):1885-1890.
• Exclusively “Plant Based” Nutrient Interventions are the ONLY intervention shown to
reverse Heart Disease
• Can lifestyle changes reverse coronary heart disease?: The Lifestyle Heart Trial
Ornish, D. et al Lancet, 1990
• Intensive Lifestyle Changes for Reversal of Coronary Heart Disease Ornish, D et al, JAMA 1998
•
• Updating a 12-year experience with arrest and reversal therapy for coronary heart disease (an overdue requiem for palliative cardiology) CB
Esselstyn, American Journal of Cardiology 1999
• A plant-based diet and coronary artery disease: a mandate for effective therapy CB Esselestyn Journal of Geriatirc Cardiology, 2017
• Is the present therapy for coronary artery disease the radical mastectomy of the twenty-first century? American Journal of Cardiology 2010

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•BOGO
• Identify strongest motivator and guide change

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Reviewed
• A “Healthy BMI” is essential for joint health
• Enhanced perfusion enhances joint and soft tissue health
• Increased consumption of phytonutrient rich foods may reduce joint pain and enhance
perfusion
• Other Theoretical Relationships of Nutrition and Inflammation/Pain

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Physiologic
– Arachidonic Acid and Prostaglandins
– Inflammatory Joint Problems: Gout, Rheumatologic disease

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Arachidonic Acid

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Intake of arachidonic acid-containing lipids in adult humans: dietary surveys and clinical trials Lipids
in Health and Disease volume 18, Article number: 101 (2019)

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Intake of arachidonic acid-containing lipids in adult humans: dietary surveys and clinical trials Lipids
in Health and Disease volume 18, Article number: 101 (2019)

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Arachidonic Acid
• A diet low in arachidonic acid ameliorates clinical signs of inflammation in patients with
RA and augments the beneficial effect of fish oil supplementation.Anti-inflammatory
effects of a low arachidonic acid diet and fish oil in patients with rheumatoid arthritis
Adam, O et al Rheumatology International volume 23, pages27–36(2003)
• Study results suggest that a whole-foods, plant-based diet significantly improves self-
assessed measures of functional status among osteoarthritis patients. Whole-Foods,
Plant-Based Diet Alleviates the Symptoms of Osteoarthritis Chelsea, C, Arthritis 2015
• Fruit and Vegetable Intake reduce levels of Pro-Inflammatory Cytokines Root, M et al.
Combined Fruit and Vegetable Intake Is Correlated with Improved Inflammatory and Oxidant Status
from a Cross-Sectional Study in a Community Setting Nutrients 2012, 4(1), 29-41

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Review
• Arachidonic Acid is Essential for Human Health
• Consumption of AA in Animal Based foods increases circulating AA
• AA is a precursor to PG’s and the conversion is inhibited by NSAIDs etc
• Reduction of AA consumption anecdotally reduces MSK pain however conclusive
scientific evidence is lacking
• Theoretically reducing AA should reduce the volume of available precursor for
transition to PG’s
• In addition, studies suggest lipid perodixation and other pathways may alter AA
inflammatory nature

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Inflammatory Processes
• Rheumatologic Disease
• Gout

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Rheumatologic Disease
• Nutrition Interventions in Rheumatoid Arthritis: The Potential Use of Plant-Based Diets. A Review Alwarith, J et al. Front. Nutr., 10 September 2019
• A systematic review and meta‐analysis of nutrition interventions for chronic noncancer pain Brain, K et al, Pain Management 2018
• 27 patients were allocated to a four-week stay at a health farm. After an initial 7-10 day subtotal fast, they were put on an individually adjusted gluten-free
vegan diet for 3·5 months. improvement in number of tender joints, Ritchie's articular index, number of swollen joints, pain score, duration of morning stiffness,
grip strength, erythrocyte sedimentation rate, C-reactive protein, white blood cell count, and a health assessment questionnaire score Controlled trial of fasting
and one-year vegetarian diet in rheumatoid arthritis Lancet 1991
• A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction in antibodies to food
antigens Rheumatology 2001
• 4-week, very low-fat (~10%), vegan diet on 24 free-living subjects with RA, average age, 56 ± 11 years old. All measures of RA symptomatology decreased
significantly (p < 0.05), except for duration of morning stiffness (p > 0.05). Weight also decreased significantly (p < 0.001). At 4 weeks, C-reactive protein
decreased 16% (ns, p > 0.05), RA factor decreased 10% (ns, p > 0.05), while erythrocyte sedimentation rate was unchanged (p > 0.05). Effects of a Very Low-
Fat, Vegan Diet in Subjects with Rheumatoid Arthritis The Journal of Alternative and Complementary Medicine 2004
• Intake frequency of vegetables or seafoods negatively correlates with disease activity of rheumatoid arthritis Murakami, I. PLOS One 2020
• 27 patients were allocated to a four-week stay at a health farm. After an initial 7-10 day subtotal fast, they were put on an individually adjusted gluten-free
vegan diet for 3·5 months. improvement in number of tender joints, Ritchie's articular index, number of swollen joints, pain score, duration of morning stiffness,
grip strength, erythrocyte sedimentation rate, C-reactive protein, white blood cell count, and a health assessment questionnaire score Controlled trial of fasting
and one-year vegetarian diet in rheumatoid arthritis Lancet 1991
• A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction in antibodies to food
antigens Rheumatology 2001
• 4-week, very low-fat (~10%), vegan diet on 24 free-living subjects with RA, average age, 56 ± 11 years old. All measures of RA symptomatology decreased
significantly (p < 0.05), except for duration of morning stiffness (p > 0.05). Weight also decreased significantly (p < 0.001). At 4 weeks, C-reactive protein
decreased 16% (ns, p > 0.05), RA factor decreased 10% (ns, p > 0.05), while erythrocyte sedimentation rate was unchanged (p > 0.05). Effects of a Very Low-
Fat, Vegan Diet in Subjects with Rheumatoid Arthritis The Journal of Alternative and Complementary Medicine 2004

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Gout
• The results of our study suggest that serum and urine uric acid reflects synovial inflammation based on MSUS and
radiographic progression and then is associated with the pathogenesis of knee OA. Clinical Usefulness of Uric Acid
as a Biomarker for Knee Osteoarthritis: A Comparative Analysis With Plain Radiography and Musculoskeletal
Ultrasound Kim, SK, J Rheum Dis. 2020 Jan;27(1):51-60.
• The association between serum uric acid level and changes of MRI findings in knee osteoarthritis Xiao, L Medicine
2019
• The association between asymptomatic hyperuricemia and knee osteoarthritis: data from the third National Health
and Nutrition Examination Survey Wang, S. Osteoarthritis and Cartilage 2019
• Uric acid is a danger signal of increasing risk for osteoarthritis through inflammasome activation Denoble, F. PNAS 2011
• Exploring the Link between Uric Acid and Osteoarthritis Anna, MA. Frontiers in Medicine 2017
• Serum uric acid as a predisposing factor of clinico- radiological severity of osteoarthritis knee Srivastava, RA,
Osteoarthritis and Cartilage 2014

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Performance
• Beet Juice
• reduced time to exhaustion and improved performance ( V02Max) Cermak et al Sports Nutrition and
Exercise Metabolism 2012
• improves submaximal aerobic endurance and blood pressure Eggebeen et al JACC 2016
• Improved time trial performance in cyclists and kayak racers Peeling et al SNEM 2015
• Pomegranate Juice
• Improves running time to exhaustion Trexler et al 2015
• Blueberries
• Effect of New Zealand blueberry consumption on recovery from eccentric exercise-induced muscle damage Mcleay, J. JISSM 2012
• Effect of blueberry ingestion on natural killer cell counts, oxidative stress, and inflammation prior to and after 2.5 h of running
MCanulty, L Applied Physiology, Nutrition, and Metabolism, 2011, 36(6): 976-984

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Conclusion
• Weight Matters
• Lifestyle Measures are the Primary cause and answer
• Increased consumption of Anti-inflammatory minimally processed plant based foods
with a focus on nitrate rich greens, roots, berries etc
• Reduces Caloric Load and average BMI
• Improves Perfusion
• Reduces atherogenesis
• Enhances Nitric oxide production
• Reduces Inflammation
• Improves pain related to uric acid and rheumatologic dysfunction
• Cumulative positive affect on joint health and pain

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Nutrition and the Recreational Athlete Take Homes
• Think beyond macronutrients
• Look for BOGO’s
• Evaluate need, personal goals and readiness for change
• Offer tangible and science based recommendations
• Re-evaluate regularly and modify accordingly
"Eat food, not too much,
mostly plants” M. Pollan."

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