A Metabolic Approach to Tendon Issues

By Cynthia Monteleone,

MAM Metabolic Analytics Practitioner, World Champion

A major limitation for an athlete in optimizing their athletic performance occurs when they are presented with an obstacle in their training due to injury and illness. As part of my job as a metabolic practitioner, I seek to pioneer approaches in enhancing their ability to optimize athletic performance through choices in food and supplement consumption.

As I work with both elite and masters athletes in several different sports, I am presented with overuse injuries such as tendinopathies like tendonitis, bursitis and tears, in different body locations according to sport. For example: wrestlers and surfers that come to me tend to have shoulder problems, runners and ballet dancers usually have achilles problems. Through my own experience as an athlete and through my experience as a practitioner working with athletes, I hypothesize that a metabolic approach can be beneficial to healing tendon overuse injuries with a special focus in this paper on Achilles tendonitis.

Story:

A while back I was listening to my mentor, Charles Poliquin, lecture on joint ailments. He was stating that he believed all non-traumatic joint pain results from bacteria living in the joint. He suggested that he had great results from identifying which bacteria were living in the joint and treating that bacteria. He said the bacteria varied from place to place and for example: the bacteria in shoulder pain was not necessarily the same as bacteria as identified in knee pain. One of the bacteria he named in elbow pain, for instance, was blastocystis hominious. Blastocystis is a parasite that inhabits the gastrointestinal tract of humans. [1]This is an important because I hypothesize in this paper that beyond osteopathic methods, one can manage tendon ailments by managing gut bacteria through food and supplement choices. [2]

Let’s get into the bacteria first: The two most common organisms in joint bacteria and “septic arthritis” are Staphylococcus aureus (S.aureus) and Escherichia coli (E. coli). These pathogens arrive in the joint via direct inoculation or as carried through the blood (hematogenously). [3] [4]

This led me to start researching bacteria in tissues, joints and tendons- particularly Achilles tendons, bursitis and plantar tendons-since this seems to plague over 50 percent of runners at some point during their lifetime.[5]Sure enough, there is an interesting study in which tissue taken from patients that had suffered spontaneous Achilles ruptures tested positive for Staphylococcus genus bacteria. In healthy tendons, in the same individuals, this bacteria was not found. [6]

How do we get Staphylococcus (Staph) in our body? Staphylococcus aureus (S. aureus) is the most common Staph infection worldwide. We all have different types of Staph living on our skin, nostrils and in our gastrointestinal tract. However, more often than we think, S. auereus invades our soft tissues internally. It has been suggested that the recent outbreaks of MRSA or methicillin-resistant S. aureus is linked to the overuse of antibiotics by the medical community over the past few decades. [7] [8]I will go one step further and point out that it has also been speculated that the overuse of antibiotics and antifungals in past decades in our food has made for the production of more “supergerms” or resistant bacteria.. [9]Not only factory produced and processed meat is affected. Grains are treated with anti-fungals. Raw fruit and vegetables are the most frequent carriers of S. aureus and E. coli amongst other pathogens. [10] It is important to note here that “alternatively raised” organic and pasture raised meats are shown to have additives of pre-biotics and probiotics instead of antibiotics. This is providing new information on the beneficial impact of this method on human gut flora.[11]Stay with me while I connect the dots…

So we have bacteria- in fact we have trillions of bacteria in the human gut microbiome. Not all bacteria is bad. The good types of bacteria living within us preform necessary functions like making vitamins! There are some types of bacteria (prototrophs and auxotrophic species) that actually create B vitamins to feed… wait for it…not us, but each other and themselves! [12]A recent study by neurologist Stasha Gominak says that when we sleep long and well, we need more B vitamins to repair our bodies during the sleep process and one of them- B5 or pantothenic acid in its most absorbable form can only come from our gut bacteria! She further found that in her patients, Vitamin D deficiency led to a breakdown in this beneficial B feeding bacteria. This compromised the immune system since they were unable to feed each other.[13]Fascinating! Sometimes I feel as though we ARE just bacteria and our body is merely the puppet. Our bacteria controls everything from our genetic expression to our brain function via the gut-brain axis, as well as how many nutrients get to our muscles for that maximum athletic performance. A friend of mine in the probiotic business once said, “The battle of good and evil is fought daily… in our bacteria!”[14]

After continuing to research connections and experimenting with my athletes in various sports, I found that by fostering good microbiota in the body and eliminating inflammatory foods, my athletes had a positive result in their tendon health and overall athletic performance.

I have achieved this through the following methods:

I. Elimination of Inflammatory foods focusing on sugars.

II. Gut healing/support through food and supplements.

III. Inclusion of Polyphenol rich foods and supplements.

I. For the purpose of this article, I will provide which foods specifically triggered negative responses in my athletes. These are: Sugar, grains, soy, and legumes. (Legumes include all beans and peanuts). I will focus on sugar because the sugar is what most defined symptoms in my athletes more than the others. For instance, if an athlete ate repeated “cheat meals” or celebrated all week with birthday cake, increased daily fruit intake via smoothies or was “eating off season” sugary foods, their tendon pain returned. When they went back on the prescribed MAM protocol, I gave them, the tendon pain disappeared. [15] Sugars include both refined sugars such as those found in soda, sports drinks and baked goods (put the donut down!) as well as most fructose found in fruits. The only time I include fruits in my clients’ diet is if I feel that the polyphenol component outweighs the potentially harmful effect of the fructose content. More on polyphenols in section III. Linking back to the gut, excessive fructose intake is linked to Inflammatory bowel disease (IBS) and in studies have been shown to produce the expression of inflammatory markers such as interleukin (IL)-6 and IL-1beta .[16]The expression of tight junction protein was also decreased. Tight junctions are the parts of your gut lining that need to be kept in tact to keep things from happening like: bad bacteria from escaping into your bloodstream through the paracellular pathway. Remember, it is this bacteria that settles in the joints. High fructose diets were shown to lead to the “deterioration of intestinal barrier function”. [17]Other studies have found that Fructo-oligosaccarhides, (FOS) such as found in bananas, are associated with mucosal inflammation and gut permeability.[18]In healthy guts, FOS can feed good bifidiobacterium, but when gut balance is off and permeability is in question, FOS enchances bad bacterias like E. coli. [19] [20] [21]I only introduce FOS foods when after gut integrity has been approached. Bananas, however, still tend to cause a negative reaction in my own athlete case studies. In addition, high dietary fructose has been found to deplete beneficial gut bacteria. [22]

Keeping the glucose levels down is also a must! In a rat model, a high glucose diet hindered the healing of Achilles tendons. [23]In diabetics, achilles tendons are found to be thicker with increased stiffness. Another study links high glucose, high Body Mass Index (BMI) and high blood pressure to weakened achilles tendons. [24]

Other than sugar consumption and excessive fructose intake, blood sugar levels can be elevated by stress. I have my athletes practice meditation and keep grateful logs as ways to cope with stress. We need cortisol during exercise but chronic stress (ruminating or worrying all of the time) leads degraded immune system response and to chronic inflammation. This has been a deemed as a “characteristic potentially regulated by the gut microbiota”. [25][26]

In recent work by Dr. Elizabeth Blackburn and Dr. Elissa Eppel, they suggest that when the adrenal glands release cortisol as a response to a perceived threat, it results in the shortening of our telomeres. Telomeres are caps on the ends of our chromosomes in our DNA. They are a biomarker of healthy aging and protect us from the effects of aging- including the aging of the cells in our collagen/tendons. [27]In the chapter “Shorter Telomeres, More Inflammation” they outline the processes of inflammation through aging CD8 cells that produce pro-inflammatory cytokines. Regarding sugar, they further go on to state plainly: “We all used to think …a calorie is a calorie- this is wrong. Simply by reducing sugars, even if you eat the same number of calories can lead to metabolic improvements. Simple carbs wreak havoc on our metabolism…cutting back on sugar may be the single most beneficial change you can make to your diet.”[28]They also offer many ways to cope with perceived stress/ cortisol release. Notice I say “perceived”. Fear is only in our minds if we allow it. I teach my athletes to change perspective on ideas that cause them stress. It is important to be excited about their competition, for instance, which is an example of eustress, but rumination over every detail of execution to the point of worry only increases their systematic inflammation. In days prior to competition it causes poor sleep when sleep is so desperately necessary for optimal performance.[29]Through the process of good sleep, our immune system is strengthened. [30]In training months, I encourage my athletes to limit screen time and practice new perspectives on anything that might cause cortisol release/stress or disrupted sleep.

II: How about gut healing? When I first start working with an athlete, I help them to repair their gut microbiome balance. In addition to complete metabolic assessment, I approach this through an assessment of dietary protein. I adjust my athletes’ levels to optimal amounts of this important macronutrient. Dr. Gabrielle Lyon points out that muscle is the largest organ and our “organ of longevity” regulating metabolic and hormonal pathways in the body. In order to promote the proper muscle protein synthesis, we must be ingesting our optimal levels of protein.[31]As a practitioner, I recommend animal proteins like grass fed beef and grass fed whey, especially when tendinopathies are presented. These animal proteins are higher in the amino acids glutamine and glycine.[32] [33]There exists a plethora of research on the beneficial effects of glutamine on the mucosal lining of the gut. Glutamine is shown to heal and support the crucial epithelial cells.[34] [35] [36] [37] [38]In one study, beneficial gut microbiota was associated with higher glutamine/glutamate levels which indicated ‘processing speed and mental flexibility.” [39]In addition, decreased levels of glutamine and glycine have been found to lead to depression-like behavior due to chronic stress. [40]All of the elements are tying together! For athletes, glutamine is especially important because excessive training –(including high level activity like sprinting, as well as long-term exercise) causes impairment of immune function associated with low plasma glutamine levels. [41] Glycine also fosters collagen production and is linked to increased tendon repair .[42]In a recent study, certain pathogenic bacteria like H.pylori were actually DRAWN to the bleach we create through our T cells during inflammation. Our immune system normally sends out these attack cells to build a pool of bleach and hydrogen peroxide to kill bad bacteria. Now it has just been discovered that these “bad” bacteria swim towards this toxic pool and live comfortably in it instead of being killed by it. It was only in repairing the inflamed tissue, with glutamine, that the bacteria were kept in check.[43] [44] [45]

I hypothesize that by keeping the gut lining intact by decreasing inflammatory foods like sugar, and increasing animal protein and healing supplements, less disruptive bacteria like S. aureus or E. coli, are able to escape into the bloodstream and settle in the joints and tendons. Other science backs this up. In a study of primates, arthritis was correlated with poor diversity in the gut microbiome. [46]

When promoting a healthy gut, I also include probiotics and pre-biotic fiber.[47]The timing and amount of these is important to fostering good gut bacteria. One exception is the carnivore diet. The elimination of fruits and vegetables completely lowers inflammation and makes the probiotics and fiber unnecessary.

III: What fruits do I allow my athletes to eat? I have found some really great results from including polyphenol rich foods in my athletes’ diets (as long as they are getting enough vitamin C and iron because polyphenols can counteract these). In particular, studies show that some polyphenols, a type of anti-oxidant , reverse the negative effects of fructose. [48]My favorite type is resveratrol . This comes naturally from blueberries and grapes. Red wine contains resveratrol, however I do not recommend alcohol as alcohol has a negative effect on sleep and athletic performance. I have also recommended to my athletes a resveratrol supplement. In a mouse study on diabetic rats, resveratrol was shown to have a positive impact on the healing of tendons. [49]Another study found that the active component in resveratrol inhibited pro-inflammatory interleukin (IL) and interleukin 1 –beta in tendon overuse and tendinitis injuries. [50]Is it a coincidence that resveratrol was also found to reduce the presence of both E. coli and S. aureus bacteria, the top two bacteria mentioned above? [51] [52] [53] [54]I think not!

The other fruits I allow are lemons and limes… for many reasons, including their low sugar content, beneficial effects on the gut, and anti-oxidant and anti-inflammatory properties[55].I do not include oranges. Vitamin C, as found in the limes and lemons, is beneficial to tendons, by sparing our internal immune powerhouse- glutathione, however the high amounts needed for this, in relation to sugar content of oranges, is not optimal for my athletes. [56] [57] [58]If one is one a carnivore diet, high levels of animal products stimulate glutathione production without external antioxidants. If anyone is going for a Vitamin C punch, however, I have them add peppers (capsaicin) like bell peppers which have 2-3 times the amount of vitamin C as oranges and in addition contain antioxidants and anit-inflammatory components linked to enhanced gut microbiota.[59] [60]I eliminate bananas (see above). I find that athletes have an especially high banana content in their diet as they were previously taught that they needed bananas to replace the potassium lost during exercise. There are many other foods higher in potassium than bananas, like sweet potatoes for instance, or even lemons and limes, but they tend to rely on bananas as a frequent snack. I have had good results in athletic performance and recovery by eliminating bananas and introducing more proteins and fats.

Another polyphenol I include as a supplement is Curcumin, which has demonstrated pro-gut and anti-inflammatory effects, including on tendons in animal models.[61] Curcumin also fosters the growth of collagen fibers. [62]

One more interesting correlation to note is that of a substance called monolaurin derived from Lauric Acid (Glycerol Monolaurate). Monolaurin has been shown to inhibit both S. aureus and E. coli bacterias. Lauric acid is only found in coconut meat and oil, laurel oil (found in bay leaves), palm kernel (not to be confused with palm oil) and breastmilk. Since breastmilk is not usually readily available, I make sure that coconut milk or unrefined coconut oil is included in my athletes’ protocol either in cooking or in straight supplementation if their tendonitis starts acting up. [63] [64] [65] [66] [67]

To conclude, the metabolic systems of each individual is different. What I advise to my clients, along with their own physician approval, is dependent on each individual case. This article serves to offer discussion on metabolic approaches to support tendon repair and to share what has worked well for me personally as an athlete, and my client athletes. My mentor always taught us to pioneer our own paths in regards to research. Research already done by scientists is there as a potential tool for the discerning eye. He also taught us not to wait for scientific evidence if something is working well for our athletes. He was giving high doses of omega 3- fish oil to his athletes (40 g/day) back in the 1980’s with much criticism from the medical and strength training community. Finally in the 2000’s the evidence backed him up with doses up to 60g/day! He said if he had waited all of that time for scientific research to back him up, he would have missed his athletes attending and medaling in all of those summer and winter Olympic games. I know I, myself, and my athletes don’t want to miss a moment of training or competition! I am not proposing metabolic approaches are a cure-all, however, I am suggesting that when recurring tendon issues arise-like tendonitis and bursitis (which share the same fluid and bacteria)[68] [69]that there is something more one can personally do about it in addition to osteopathic care. I have managed to reverse Achilles tendonitis in athletes in as little as one week through only metabolic care, with no alteration to exercise or osteopathic protocols. After checking with their physician and metabolic practitioner, one can take steps to manage tendon issues with diet and supplementation.

[1]Lepcynska, M. et al, “Blastocystis: how do specific diets and human gut microbiota affect its development and pathogenicity?” Eur J Clin Microbiol Infect Dis 2017

[2]Blastocystis Hominous can be treated homeopathically with garlic and ginger.

[3]Mohamed, M, et al. “Retrospective Analysis of Septic Arthritis caused by Intra-Articular Viscosupplementation and Steroid injections in a single outpatient center.”

Journal of Medicine, Jersey Shore University Medical Center, 2019.

[4]Lotz, H. et al, “Septic Arthritis due to stepococci and enterococci in native joints: a 13 year retrospective study. “ Infection. 2019.

[5] [5]Maughan, Karen L., et al “Achilles tendinopathy and tendon rupture”, UptoDate Aug 2019

[6]Rolf, CG, et al, “Prescence of Bacteria in Spontaneous Achilles Tendon Ruptures”Am J Sports Med. 2017

[7]Thomer, Schneewind, Missiakas, “Pathogenisis of Staphylococcus aureus Bloodstream Infections”, Annu Rev Pahol, 2016 11: 343-364

[8]Peschel, Otto. “Phenol-soluble modulins and staphylococcal infection.” Nat Rev Microbiol. 2013. Oct 11 910) 667-673

[9]Pyzik, E. et al, “Detection of Antibiotic Resistance and Classical Enterotoxin Genes in Coagulase-negative Sthylococci Isolated from Poultry in Poland. , J Vet Res, 2019.

[10]Estrada, Alcaraz, Velazquez, “Presence of Enterotoxigenic Staphylococcus aureus in artisan fruit salads in the city of San Luis, Argentina, Brazil J Microbiol. 2013.

[11]Park, S. H. , et al, “Modifying the gastrointestinal ecology in alternatively raised pultry and the potential for molecular and mtabolomic assessment.” Poultry Science, Volume 92, Issue 2 Feb 2013 546-561

[12]Rodionov, DA, et al. “Micronutrient Requirements and Sharing Capabilities of the Human Gut Microbiome” Front Microbiol. 2019

[13]Gominack, SC, “Vitamin D deficiency changes the intestinal microbiome reducing B vitamin production in the gut. The resulting lack of pantothenic acid adversely affects the immune system, producing a “pro-inflammatory” state associated with atherosclerosis and autoimmunity. Med Hypotheses. 2016

[14]Charles Tang proprietor of “ CheeHu KimChee”

[15]Case studies of elite and masters athletes by CM Monteleone

[16]Jaiswal, N. et al. “High fructose-induced metabolic changes enhance inflammation in human dendritic cells” Immunol. 2019.

[17]Kawabata, K. et al. “A high fructose diet induces epithelial barrier dysfunction and exacerbates the severity of dextran sulfate sodium-induced colitis” . Int J Ol Med. 2019.

[18]Genda, T. et al, “Fructo-oligosaccharide-induced transient increases in cecal immunoglobulin A concentrations in Rats are associated eieth mucosal inflammation in response to gut permeability. “ J Nur. 2017.

[19]Johnson, Jon, “Are fructooligosaccaharides safe?” Medical News Today Jan 2018.

[20]Genda, T, et al, “The Impact of Fructo-Oligosaccharides on Gut Permeabilityand Inflammatory Responses in the Cecal Mucosa Quite Differs between Rats Fed Semi-Purified and Non-Purified Diets, J Nutr Sci Vitaminol (Tokyo) 2018.

[21]Bingyong Mao, Jiayu Gu… and Wei Chen, “ Effects of Different Doses of Fructooligosaccharides on the composition of Mice Fecal Micorbiota, Especially the Bifidobaceterium Composition.” Nutrients 2018 Aug 10 (8): 1105

[22]Jones, RB , et al. “High intake of dietary fructose in overweight/obese teenagers associated with depletion of Eubacterium and Steptococcus in gut microbiome.” Gut Microbes. 2019.

[23]Korntner, S, et al. “A high glucose diet affects Achilles tendon in healing rats” Sci Rep. 2017

[24]Fakoya AOJ, et al, “Correlation of some predisposing intrinsic conditions with the morphological integrity of the Achilles tendon. “ Ann Afr Med 2018 Apr-Jun.

[25]Rudak, PT , et al. “ Stress-elicited glucocorticoid receptor signaling upregulates TIGIT in innate-like invariant T lymphocytes.” Brain Behav Immun, 2019.

[26]Michels, N. et al. “Gut microbiome patterns depending on children’s psychosocial stress. Reports vs. biomarkers”. Brain Behav Immun. 2019.

[27]Blackburn, Eppel, “The Telomere Effect, pages 105, 296116,124,142,158,241,261,302,387,407,

[28]Blackburn, Eppel, “Telomere Effect,” page 131.

[29]Walker, Matthew, “Why We Sleep” pages 128-129.

[30]Walker, Matthew, Why We Sleep” pages 181-189.

[31]Dr. Gabrielle Lyon, “High Quality Protein is Essential for Healthier Muscles” Ariafoodsingredients.com

[32]Kapoor, Anatika, “8 Glutamine Rich Foods and How They Can Boost Muscle Strength: Jan 23 , 2017, Food.ndtv.com

[33]Reid, Faye, ‘Top 14 Sources of Glutamine in Foods” Myprotein.com

[34]Rapin, JR, et al. “Possible links between intestinal permeability and food processing: A potential therapeutic niche for glutamine”

[35]Barekatain, R. et al, “Performance, intestinal permeability, and gene expression of selected tight junction proteins in broiler chickens fed reduced protein diets supplememnted with arginine, glutamine, and glycine subjected to a leaky gut model.” Poult Sci 2019.

[36]Wishmeyer, PE. “Glutamine and Burn Injury” Nutr Clin Pract 2019.

[37]L’Huillier, C. et al. “Glutamine but not BCAA Restores Intestinal Barrier Function during Activity Based Anorexia” . Nutrients. 2019.

[38]Fukatsu, K. ann. “Role of nutrition in gastroenterological surgery”. Gastroenerol Surg. 2019.

[39]Palomo-Buitrago, ME, “ Glutamate interactions with obesity, insulin resistance, cognition, and gut microbiota composition”. Acta Diabetol. 2019.

[40]Yang, X. et al. “Effects of chronic stress on intestinal amino acid pathways”. Physiol Behav 2019.

[41]Parry-Billings, M. et al. “Plasma amino acid concentrations in the overtraining syndrome: possible effects on the immune system”. Med Sci Sports Exerc. 1992.

[42]Vierea, CP et al, “Glycine improves the remodeling process of tenocytes in vitro.” Cell Biol 2018.

[43]Perkins, Arden, et al, “Helicobacter Pylori senses bleach as a cheoatractant using a cytosolic chemoreptor.” University of Oregon , PLOS Biology 2019.

[44]Lan, A, et al, “Mucosal healing in inflammatory bowel diseases, is there a place for nutritional supplementation?” Inflamm Bowel Dis, 2015.

[45]De Bruyne E, et al, “Oral glutathione supplementation drastically reduced Helicobacer induced gastric pathologies.” Sci Rep 2016

[46]Rothschild, BM “Intestinal Flora Modification o A rthritis Pattern in Spondyloarhropathy, J Clin Rhematol. 2015.

[47]My favorite sources of Probiotics are ATP Probio7 and ATP PrebioFib

[48]Andrade, N. et al. “Effect of chrysin on changes in the intestinal environment and microbiome induced by fructose feeding in rats”. Food Funct. 2019.

[49]Zeytin, K. et al. “The effecrs of resveratrol on tendon healing of diabetic rats”. Acta Orthop Traumatol Turc. 2014.

[50]Busch, F, et al. “Sirt-1 is required for the inhibition of apoptosis and inflammatory responses in human tenocytes”. J Biol Chem. 2012.

[51]Hwang D, et al. “Resveratrol controls Escherichia coli growth by inhibiting the AcrAB-TolC efflux pump, FEMS Mirobiol Lett. 2019.

[52]Zakova, T., et al, “The relationship between structure and in virto staphylococcal effect of plant derived stillbenes”, Acta Microbiol Immunol Hung. 2018.

[53]Duan, J. et al, “Subinhibitory concentrations of resveratrol reduce alpha-hemolysin production in Staphylococcus aureus isolates by downregulating saeRS”, Emerg Microbes Infect 2018.

[54]Nohr-Meldgaard K, et al, “ Resveratrol enhances the efficacy of aminoglycosides against Staphylococcus aureus.” Int J Antimicrob Agents, 2018.

[55]Bianchi, F. et al. “In vitro modulation of human gut microbiota composition and metabolites by Bifidobacterium longum BB-46 and a citric pectin.”

[56]Villa-Ruano N. “ 1 H-NMR Based Metabolomics Profiling of Citrus Juices Produced in Veracruz, Mexico”. Chem Biodivers. 2019.

[57]Hagele, FA. Et al. “High orange juice consumption with or in-between three meals a day differently affects energy balance in healthy subjects.” Nutr Diabetes. 2018.

[58]Dincel YM, et al. “Effects of High Dose Vitamin C and Hyaluronic Acid on Tendon Healing. Acta Ortop Bras. 2018. Mar-Apr

[59]Kang, C. et al, “Gut Microbiota Mediates the Protective Effects of Dietary Capsaicin against Chronic Low Grade Inflammation and Associated Obesity Induced by High Fat Diet,” MBio 2017.

[60]Patcharatrakul, T. et al, “Chili Peppers, Curcumins and Prebiotics in Gastointestinal Health and Disease” Curr Gastoenterol Rep. 2016.

[61]Chen, Y, et al, “Controlled-release curcumin attenuates progression of tendon ectopic calcification by regulating the differentiation of tendon stem/progenitor cells. Mater Sci Eng C Mater Biol Appl. 2019.

[62]Barchitta, M. et al, “Nutrition and Wound Healing: An Overview Focusing on the beneficial effects of Curcumin,” Int J Mol Sci 2019.

[63]Hess, DJ, et al. “ Antibacterial synergy of glycerol monolaurate and aminoglycosides in Staphylococcus aureus biofilms.” Antimicrob Agents Chemother. 2014.

[64]McCarty, Mark F and DiNicolantonio, James J, “Lauric acid rich medium chain triglycerides can substitiute for other oils in cooking applications and may have limited pathogenicity.” Open Heart, 2016

[65]Leonard, Jayne, “Monolaurin: What you need to know.” Medical News Today 2 Oct 2017

[66]Merghni A, et al “Antibacterial and antibiofilm activities of Laurus nobilis L. essential oil against Staphylococcus aureus strains associated with oral infections.” Pahol Biol Paris, 2015.

[67] Fortuoso BF, et al. “Glycerol Monolaurate in the diet of broiler chickens replacing conventional antimicrobials: Impact on health, performance and meat quality.” Mirob Pathog. 2019.

[68]Suzuki, T, et al, “Retrocalcaneal Bursitis Precedes or Acompanies Achilles Tendon Enthesitis in the Early Phase of Rheumatoid Arthritis”. Clin Med Insights Arthritis Musculoskelet Disord. 2018.

[69]Pekala, PA, et. Al, “ The Achilles tendon and the retroclcaneal bursa; An anatomical and radiological study”, Bone Joint Res 2017.

[1]Lepcynska, M. et al, “Blastocystis: how do specific diets and human gut microbiota affect its development and pathogenicity?” Eur J Clin Microbiol Infect Dis 2017

[1]Blastocystis Hominous can be treated homeopathically with garlic and ginger.

[1]Mohamed, M, et al. “Retrospective Analysis of Septic Arthritis caused by Intra-Articular Viscosupplementation and Steroid injections in a single outpatient center.”

Journal of Medicine, Jersey Shore University Medical Center, 2019.

[1] Lotz, H. et al, “Septic Arthritis due to stepococci and enterococci in native joints: a 13 year retrospective study. “ Infection. 2019.

[1] [1]Maughan, Karen L., et al “Achilles tendinopathy and tendon rupture”, UptoDate Aug 2019

[1] Rolf, CG, et al, “Prescence of Bacteria in Spontaneous Achilles Tendon Ruptures”Am J Sports Med. 2017

[1]Thomer, Schneewind, Missiakas, “Pathogenisis of Staphylococcus aureus Bloodstream Infections”, Annu Rev Pahol, 2016 11: 343-364

[1]Peschel, Otto. “Phenol-soluble modulins and staphylococcal infection.” Nat Rev Microbiol. 2013. Oct 11 910) 667-673

[1] Pyzik, E. et al, “Detection of Antibiotic Resistance and Classical Enterotoxin Genes in Coagulase-negative Sthylococci Isolated from Poultry in Poland. , J Vet Res, 2019.

[1]Estrada, Alcaraz, Velazquez, “Presence of Enterotoxigenic Staphylococcus aureus in artisan fruit salads in the city of San Luis, Argentina, Brazil J Microbiol. 2013.

[1] Park, S. H. , et al, “Modifying the gastrointestinal ecology in alternatively raised pultry and the potential for molecular and mtabolomic assessment.” Poultry Science, Volume 92, Issue 2 Feb 2013 546-561

[1]Rodionov, DA, et al. “Micronutrient Requirements and Sharing Capabilities of the Human Gut Microbiome” Front Microbiol. 2019

[1]Gominack, SC, “Vitamin D deficiency changes the intestinal microbiome reducing B vitamin production in the gut. The resulting lack of pantothenic acid adversely affects the immune system, producing a “pro-inflammatory” state associated with atherosclerosis and autoimmunity. Med Hypotheses. 2016

[1]Charles Tang proprietor of “ CheeHu KimChee”

[1] Case studies of elite and masters athletes by CM Monteleone

[1]Jaiswal, N. et al. “High fructose-induced metabolic changes enhance inflammation in human dendritic cells” Immunol. 2019.

[1] Kawabata, K. et al. “A high fructose diet induces epithelial barrier dysfunction and exacerbates the severity of dextran sulfate sodium-induced colitis” . Int J Ol Med. 2019.

[1] Genda, T. et al, “Fructo-oligosaccharide-induced transient increases in cecal immunoglobulin A concentrations in Rats are associated eieth mucosal inflammation in response to gut permeability. “ J Nur. 2017.

[1]Johnson, Jon, “Are fructooligosaccaharides safe?” Medical News Today Jan 2018.

[1] Genda, T, et al, “The Impact of Fructo-Oligosaccharides on Gut Permeabilityand Inflammatory Responses in the Cecal Mucosa Quite Differs between Rats Fed Semi-Purified and Non-Purified Diets, J Nutr Sci Vitaminol (Tokyo) 2018.

[1]Bingyong Mao, Jiayu Gu… and Wei Chen, “ Effects of Different Doses of Fructooligosaccharides on the composition of Mice Fecal Micorbiota, Especially the Bifidobaceterium Composition.” Nutrients 2018 Aug 10 (8): 1105

[1] Jones, RB , et al. “High intake of dietary fructose in overweight/obese teenagers associated with depletion of Eubacterium and Steptococcus in gut microbiome.” Gut Microbes. 2019.

[1]Korntner, S, et al. “A high glucose diet affects Achilles tendon in healing rats” Sci Rep. 2017

[1] Fakoya AOJ, et al, “Correlation of some predisposing intrinsic conditions with the morphological integrity of the Achilles tendon. “ Ann Afr Med 2018 Apr-Jun.

[1] Rudak, PT , et al. “ Stress-elicited glucocorticoid receptor signaling upregulates TIGIT in innate-like invariant T lymphocytes.” Brain Behav Immun, 2019.

[1]Michels, N. et al. “Gut microbiome patterns depending on children’s psychosocial stress. Reports vs. biomarkers”. Brain Behav Immun. 2019.

[1]Blackburn, Eppel, “The Telomere Effect, pages 105, 296116,124,142,158,241,261,302,387,407,

[1]Blackburn, Eppel, “Telomere Effect,” page 131.

[1]Walker, Matthew, “Why We Sleep” pages 128-129.

[1]Walker, Matthew, Why We Sleep” pages 181-189.

[1] Dr. Gabrielle Lyon, “High Quality Protein is Essential for Healthier Muscles” Ariafoodsingredients.com

[1]Kapoor, Anatika, “8 Glutamine Rich Foods and How They Can Boost Muscle Strength: Jan 23 , 2017, Food.ndtv.com

[1] Reid, Faye, ‘Top 14 Sources of Glutamine in Foods” Myprotein.com

[1] Rapin, JR, et al. “Possible links between intestinal permeability and food processing: A potential therapeutic niche for glutamine”

[1]Barekatain, R. et al, “Performance, intestinal permeability, and gene expression of selected tight junction proteins in broiler chickens fed reduced protein diets supplememnted with arginine, glutamine, and glycine subjected to a leaky gut model.” Poult Sci 2019.

[1]Wishmeyer, PE. “Glutamine and Burn Injury” Nutr Clin Pract 2019.

[1]L’Huillier, C. et al. “Glutamine but not BCAA Restores Intestinal Barrier Function during Activity Based Anorexia” . Nutrients. 2019.

[1]Fukatsu, K. ann. “Role of nutrition in gastroenterological surgery”. Gastroenerol Surg. 2019.

[1]Palomo-Buitrago, ME, “ Glutamate interactions with obesity, insulin resistance, cognition, and gut microbiota composition”. Acta Diabetol. 2019.

[1] Yang, X. et al. “Effects of chronic stress on intestinal amino acid pathways”. Physiol Behav 2019.

[1]Parry-Billings, M. et al. “Plasma amino acid concentrations in the overtraining syndrome: possible effects on the immune system”. Med Sci Sports Exerc. 1992.

[1]Vierea, CP et al, “Glycine improves the remodeling process of tenocytes in vitro.” Cell Biol 2018.

[1]Perkins, Arden, et al, “Helicobacter Pylori senses bleach as a cheoatractant using a cytosolic chemoreptor.” University of Oregon , PLOS Biology 2019.

[1] Lan, A, et al, “Mucosal healing in inflammatory bowel diseases, is there a place for nutritional supplementation?” Inflamm Bowel Dis, 2015.

[1] De Bruyne E, et al, “Oral glutathione supplementation drastically reduced Helicobacer induced gastric pathologies.” Sci Rep 2016

[1]Rothschild, BM “Intestinal Flora Modification o A rthritis Pattern in Spondyloarhropathy, J Clin Rhematol. 2015.

[1] My favorite sources of Probiotics are ATP Probio7 and ATP PrebioFib

[1]Andrade, N. et al. “Effect of chrysin on changes in the intestinal environment and microbiome induced by fructose feeding in rats”. Food Funct. 2019.

[1]Zeytin, K. et al. “The effecrs of resveratrol on tendon healing of diabetic rats”. Acta Orthop Traumatol Turc. 2014.

[1] Busch, F, et al. “Sirt-1 is required for the inhibition of apoptosis and inflammatory responses in human tenocytes”. J Biol Chem. 2012.

[1] Hwang D, et al. “Resveratrol controls Escherichia coli growth by inhibiting the AcrAB-TolC efflux pump, FEMS Mirobiol Lett. 2019.

[1]Zakova, T., et al, “The relationship between structure and in virto staphylococcal effect of plant derived stillbenes”, Acta Microbiol Immunol Hung. 2018.

[1] Duan, J. et al, “Subinhibitory concentrations of resveratrol reduce alpha-hemolysin production in Staphylococcus aureus isolates by downregulating saeRS”, Emerg Microbes Infect 2018.

[1]Nohr-Meldgaard K, et al, “ Resveratrol enhances the efficacy of aminoglycosides against Staphylococcus aureus.” Int J Antimicrob Agents, 2018.

[1]Bianchi, F. et al. “In vitro modulation of human gut microbiota composition and metabolites by Bifidobacterium longum BB-46 and a citric pectin.”

[1]Villa-Ruano N. “ 1 H-NMR Based Metabolomics Profiling of Citrus Juices Produced in Veracruz, Mexico”. Chem Biodivers. 2019.

[1]Hagele, FA. Et al. “High orange juice consumption with or in-between three meals a day differently affects energy balance in healthy subjects.” Nutr Diabetes. 2018.

[1] Dincel YM, et al. “Effects of High Dose Vitamin C and Hyaluronic Acid on Tendon Healing. Acta Ortop Bras. 2018. Mar-Apr

[1] Kang, C. et al, “Gut Microbiota Mediates the Protective Effects of Dietary Capsaicin against Chronic Low Grade Inflammation and Associated Obesity Induced by High Fat Diet,” MBio 2017.

[1]Patcharatrakul, T. et al, “Chili Peppers, Curcumins and Prebiotics in Gastointestinal Health and Disease” Curr Gastoenterol Rep. 2016.

[1] Chen, Y, et al, “Controlled-release curcumin attenuates progression of tendon ectopic calcification by regulating the differentiation of tendon stem/progenitor cells. Mater Sci Eng C Mater Biol Appl. 2019.

[1] Barchitta, M. et al, “Nutrition and Wound Healing: An Overview Focusing on the beneficial effects of Curcumin,” Int J Mol Sci 2019.

[1] Hess, DJ, et al. “ Antibacterial synergy of glycerol monolaurate and aminoglycosides in Staphylococcus aureus biofilms.” Antimicrob Agents Chemother. 2014.

[1]McCarty, Mark F and DiNicolantonio, James J, “Lauric acid rich medium chain triglycerides can substitiute for other oils in cooking applications and may have limited pathogenicity.” Open Heart, 2016

[1]Leonard, Jayne, “Monolaurin: What you need to know.” Medical News Today 2 Oct 2017

[1]Merghni A, et al “Antibacterial and antibiofilm activities of Laurus nobilis L. essential oil against Staphylococcus aureus strains associated with oral infections.” Pahol Biol Paris, 2015.

[1] Fortuoso BF, et al. “Glycerol Monolaurate in the diet of broiler chickens replacing conventional antimicrobials: Impact on health, performance and meat quality.” Mirob Pathog. 2019.

[1]Suzuki, T, et al, “Retrocalcaneal Bursitis Precedes or Acompanies Achilles Tendon Enthesitis in the Early Phase of Rheumatoid Arthritis”. Clin Med Insights Arthritis Musculoskelet Disord. 2018.

[1] Pekala, PA, et. Al, “ The Achilles tendon and the retroclcaneal bursa; An anatomical and radiological study”, Bone Joint Res 2017.