Episode transcript
Time stamps
01:01: Prevalence of respiratory allergies in athletes
03:37: Discussing asthma in athletes
05:08: Exercise-induced bronchoconstriction
07:16: Other factors contributing to allergies in athletes
08:03: Importance of addressing allergies in athletes
09:23: Prevalence of food allergies in athletes
10:08: Food-dependent exercise-induced anaphylaxis
12:19: Underdiagnosis and undertreatment of asthma in athletes
14:12: Addressing gaps in standardized care
14:41: Importance of specific IgE testing in asthma management
16:18: Dispelling the impact of asthma and allergies on athletic performance
Announcer [0:00 - 0:07]: ImmunoCAST is brought to you by Thermo Fisher Scientific creators of ImmunoCAP™ Specific IgE diagnostics and Phadia™ Laboratory Systems.
Gary Falcetano [0:13 - 0:19]: I'm Gary Falciteno, a licensed and board certified PA with over twelve years experience in allergy and immunology.
Luke Lemons [0:19 - 1:01]: And I'm Luke Lemons, with over six years experience writing for healthcare providers and educating on allergies. You're listening to immunocast, your source for medically and scientifically backed allergy insights. So the Olympics are coming up soon, and there's no better time to talk about sports and allergies than right now. So Gary and I have a special episode for you today around allergies and athletes and what it means for them. And we have two papers that we're going to be really outlining most of what we're talking about today. One from the European Academy of Allergy and Clinical Immunology, and the other from a panel of european allergy experts that actually looks directly at Olympians.
Gary Falcetano [1:01 - 1:23]: It's interesting the way these two papers both complement each other, but also speak to two different types of athletes. Right, elite performance athletes or Olympians, and then our weekend warriors or recreational athletes. And I think what we're going to be discussing today really applies to both. And there's some pretty interesting stuff here, Luke.
Luke Lemons [1:23 - 1:40]: Yeah. And EAACI won the European Academy of Allergy and Clinical Immunology. It's called diagnosis and management of allergy and respiratory disorder in sports. And it's a task force. And so it includes a multidisciplinary panel of experts, including allergists, pulmonologists, sports physicians, etcetera.
Gary Falcetano [1:40 - 1:54]: And the other paper that we're going to be discussing today is actually asthma, allergy and the Olympics. And it's a twelve year survey in elite athletes. It's from a panel of experts in Europe, but it specifically discusses the italian Olympic team.
Luke Lemons [1:55 - 2:26]: And when it comes to allergies and athletes, the Iaauke paper really sums it up well in that understanding this sort of subject matter, the purpose of it, is to help reduce the barriers to exercise and physical activity within a wider population. And this shouldn't be overlooked because people who do have asthma and do have respiratory allergies, for example, may find it difficult to start exercising. And so understanding these topics is important, especially in a primary care setting, when you might have kids who are just starting to do the mile at school or somebody who's trying to live a healthier life.
Gary Falcetano [2:26 - 2:34]: Yeah, exactly. We really need to encourage our patients to really control their disease and not have their disease control theme.
Luke Lemons [2:34 - 2:39]: And so why don't we start with the prevalence, Gary, and why athletes might have allergies in general?
Gary Falcetano [2:40 - 3:05]: Yeah, so there were some really surprising statistics that were in actually both of these papers. But I think one of the first statistics that really stuck out to me was that one out of every three athletes suffers from one or more allergic diseases. So over 30% of athletes, both high performance elite athletes and just generally athletic people in general, suffer from one or more allergic diseases.
Luke Lemons [3:05 - 3:20]: Yes. And looking at respiratory specifically, we see that about 40% of young athletic individuals have an allergy. And when it comes to allergic rhinitis, athletic individuals in general, that range goes up to 56%.
Gary Falcetano [3:20 - 3:36]: So I think it's incumbent upon anyone who cares for, whether they be elite athletes or recreational athletes, to really address the allergy and how it's impacting their potential performance and activity, and really help to guide them to the best possible management.
Luke Lemons [3:37 - 3:51]: And it's not just allergy, it's asthma as well. In athletes, we see that the range for a high prevalence of asthma in athletes, ranging up to about 55%. In this prevalence, it's increasing as well.
Gary Falcetano [3:51 - 4:18]: Yeah, exactly. So the Olympic paper actually looked at two separate Olympic teams, one from Australia and one from the US. What they noted was there was a doubling of prevalence of asthma in these elite athletes in a 20 year period from 1976 to 1996. That was for the Olympic, the Australian Olympic team and for the US team. They actually saw about a 7% increase over pretty much that same period of time.
Luke Lemons [4:18 - 4:41]: And I know that you usually have the fun facts, Gary, but I've got a fun fact for you today. Yeah. Interestingly enough, in 2002, the World Anti Doping Agency banned beta two atoms, so, like albuterol, from athletes if they wanted to compete, which is wild to think that if you were an athlete and had asthma, you couldn't use your inhaler when doing rigorous activity.
Gary Falcetano [4:41 - 4:43]: They literally banned their rescue medication.
Luke Lemons [4:43 - 5:04]: Yeah, but in 2010, luckily, they reversed that and they took albuterol off the prohibited list. There was suspicion that, oh, an athlete who uses albuterol might have an advantage over an athlete who doesn't. They found out that's not the case. If you don't have asthma, albuterol is not gonna make you run faster or breathe better. But very interesting.
Gary Falcetano [5:04 - 5:08]: I'm glad cooler heads prevailed and they actually came to their senses.
Luke Lemons [5:08 - 5:23]: And we see asthma common when it comes to exercise. So there's exercise induced bronchoconstriction, EIB, or exercise induced asthma, and primary care providers out there probably have patients who have this and they've seen this before.
Gary Falcetano [5:24 - 5:54]: Yeah. I think the old term for this was, as you mentioned, exercise induced asthma. Right. And I think the mechanism is still not completely understood where hyperpnea or heavy breathing causes irritation in the lungs, which causes a release of some of the allergic mediators like leukotrienes and histamines. And this is fairly common among athletes for sure. But I also. Look, you had noted this, I think, when we were doing some of the research for this. It's also a key indicator for children.
Luke Lemons [5:55 - 6:10]: Yeah. So this condition is a key indicator of uncontrolled asthma. And it's often one of the first signs of asthma in children. A child who does have trouble breathing when they're running the mile for the first time, it's an indicator that they might have uncontrolled asthma.
Gary Falcetano [6:10 - 6:26]: It presents as a distinct entity, especially in older children or adults, where it truly is not asthma. Right. But an exercise induced bronchoconstriction. But I found that really interesting, that especially in younger children, it can be a first sign of asthma.
Luke Lemons [6:26 - 6:48]: And outside of asthma, these papers also mention something very interesting when we were just talking about the prevalence of allergies in athletes. And why is that? Why do athletes have a higher prevalence of allergy? And it turns out that these high performance athletes, like Olympians, they actually stress their immune system and end up causing something called a TH2 shift.
Gary Falcetano [6:48 - 7:16]: Yeah. Again, it's not completely understood, but it seems like when the immune system is stressed, it really changes from a more TH1 prevalence to a TH2. And TH2 is an allergic, more allergic phenotype. Right. So it allows them to begin developing allergic sensitizations and following that actual allergy. But there's some other reasons, too, that they suspect that athletes may be more prone to asthma and allergic disease.
Luke Lemons [7:16 - 7:39]: Yeah. And that includes a chronic sustained exercise hypopnea and repeated exposure to noxious environmental pollutants or irritants, such as chlorine. For an athlete that maybe is an olympian swimmer, being exposed to these outside irritants can cause a inflammation and lead to symptoms like allergies. And even in winter sports, too, being outside all the time, if you're a downhill skier and breathing in that cold air.
Gary Falcetano [7:40 - 7:47]: Yeah, exactly. Or even an increased exposure to aero allergens. Right. If you're active in any outdoor, spring, summer or fall sports.
Luke Lemons [7:47 - 7:59]: And that includes pollution if you're a runner and you run in the city. And we actually had a great episode on climate change and allergy. So I recommend listening to that if you get a chance, because it's a very interesting connection.
Gary Falcetano [7:59 - 8:03]: So why are we talking about this? Why is this an important thing to address?
Luke Lemons [8:03 - 8:28]: So with all this information around allergies and asthma, one of the papers calls out that allergy is considered to be a major risk factor for asthma in the specific population of athletes. In fact, the risk of asthma has increased 25 fold in atopic speed and power athletes, 42 fold in atopic long distance runners, and surprisingly, 97 fold in atopic swimmers.
Gary Falcetano [8:28 - 8:56]: Those are some pretty dramatic numbers. We know that allergy itself in non athletes is certainly associated with asthma. And we know that up to 60% of adults with asthma have allergies, up to 90% of children. But this type of predictor, if you're an allergic athlete, especially if you're an allergic atopic swimmer, so you're an allergic swimmer, you have a 97 fold chance of having asthma. That's pretty dramatic.
Luke Lemons [8:57 - 9:22]: It's wild to think about that. And I don't think the papers that they don't go necessarily into why it is swimmers, but I would speculate it might have to do also with that exposure to chlorine and all these pool chemicals, as well as breathing consistently in that water, in air. So we've talked a lot about respiratory allergies, but that's only one side of the coin when it comes to allergies in athletes. There's also food allergies.
Gary Falcetano [9:23 - 9:41]: Yeah, we see a pretty significant prevalence of food allergy among athletes and even elite athletes. Up to 7% of the subjects studied in this one paper actually present it with food allergy, and most of it was associated with anaphylaxis. So pretty severe food allergy.
Luke Lemons [9:41 - 10:08]: Gary, this is something that is not uncommon. We call it actually food dependent exercise induced anaphylaxis, which means that somebody might eat a food that normally they want to have a reaction. Let's say wheat, they eat pasta for dinner and they go sit down on the couch to watch their tv show and they're fine, they don't have any sort of reaction. But now they eat pasta and they decide to go for a run. And when they go for that run, they end up having a reaction. It's dependent on that exercise.
Gary Falcetano [10:08 - 10:48]: Yeah, exactly. We've talked about this before, right? It's cofactor dependent allergy, where if you're allergic to something, you're not exposed to any cofactors. You may not express symptoms, but with that same allergy, you have a cofactor. And in this case, because we're talking about athletes, talking about exercise, it actually causes the person to develop allergic symptoms. So you mentioned food dependent, exercise induced, and you said specifically wheat. We have another name for that. It's called wheat dependent exercise induced anaphylaxis, or WDEIA. And there's actually an assay for that. So there's a diagnostic specific Ige assay called omega five gliadin, or Tri 19 that really helps to diagnose that wheat dependent exercise induced anaphylaxis.
Luke Lemons [10:48 - 11:03]: So if a patient does have elevated levels of this cause, it's an allergen component. Correct. Tri a 19. If they have elevated levels to this specific allergen component, they may be at risk for this wheat dependent, exercise induced anaphylaxis.
Gary Falcetano [11:04 - 11:13]: Exactly. And like other components, it also helps to diagnose standard wheat allergy as well, especially in children. But it's especially associated with this widia syndrome.
Luke Lemons [11:13 - 11:32]: Yeah, in the paper that looked at the Olympic athletes, they actually made a call out to the component resolved diagnostics. So they say component resolved diagnosis of specific or cross reacting allergens may be very helpful in polysensitized athletes for diagnosing food allergy and preventing severe asthma and anaphylaxis.
Gary Falcetano [11:32 - 11:42]: Yeah, for sure. We've had previous episodes where we discussed the food allergy components pretty in depth. I would definitely refer our listeners to those to take a deeper dive into their significance.
Luke Lemons [11:42 - 12:10]: And they had mentioned in that quote, too, severe asthma. And we know food allergy and asthma, they go hand in hand. People with food allergy are at a higher risk of severe asthma exacerbations, and people with asthma have a higher risk of severe reactions when exposed to food. And so when we're looking at athletes whose life is exercise, especially Olympians, and that exercise could lead to anaphylaxis due to their food allergy, and they're also at a higher risk of asthma. There's a lot of risk factors going on there.
Gary Falcetano [12:10 - 12:19]: Yeah, we've seen the majority of deaths that occur from food allergy anaphylaxis are actually in people with coexisting asthma diagnosis.
Luke Lemons [12:19 - 12:42]: And it leads to probably the most shocking bit of information out of the study that looked at Olympians, which they found that these conditions are extremely under diagnosed. So looking at the Olympians who had asthma, they found that 40% of these athletes, they didn't have a diagnosis. So this study in itself exposed that they have asthma and they were never diagnosed.
Gary Falcetano [12:42 - 12:57]: Exactly. And we're not talking about our everyday weekend warrior athletes. We're talking about elite, high performance Olympians, 40% of them that were diagnosed with asthma during this study did not have a previous diagnosis of that. That's crazy to me.
Luke Lemons [12:57 - 13:05]: It's crazy. And also, they were undertreated, too. 18% of the athletes had uncontrolled asthma, and only half of those were receiving treatment for their asthma.
Gary Falcetano [13:05 - 13:13]: You know, I think that speaks to the underdiagnosis, right. If you're not getting the diagnosis correct, how are you going to get the treatment correct? They go hand in hand as well.
Luke Lemons [13:13 - 13:28]: And like you had mentioned, these are olympic athletes, that every part of their physical body is being monitored, whether it's how much oxygen goes into their blood and how fast they can run, or their muscle development. But to know that these Olympians were undiagnosed and then under treated, it's just wild to wrap your brain around something.
Gary Falcetano [13:28 - 13:55]: Else that we see often. And we've talked about this in multiple episodes, how important it is, especially when you have asthma. Right. To phenotype that asthma, determine if it's atopic or not, allergic or not, and then if it is allergic, really identify triggers. And this study also had some pretty dramatic numbers when it came to nothing, testing these elite athletes for their suspected allergic triggers. Yeah.
Luke Lemons [13:55 - 14:12]: As you know, allergy is a major risk factor for asthma. They found with these athletes and present in 85% of those asthmatic athletes they were looking at allergy diagnostics, was not a part of their routine medical examination, which is shocking.
Gary Falcetano [14:12 - 14:41]: So one of the reasons we're doing this podcast, Luke. Right. Is to really address these major gaps in evidence based, standardized care that can really help people better manage their disease process, and especially do it in a complementary manner with medications to help make medications more efficacious. Once we identify those allergies, do some exposure reduction, it can generally improve their whole clinical course. So I think closing that gap is so important.
Luke Lemons [14:41 - 15:07]: Yeah. And even though we are zeroing in on athletes right now, this goes for anybody who has asthma. If they haven't been tested for potential allergens, it's something that should almost always be done. Primary care is in a position to easily address these gaps, especially when primary care who maybe see, like pediatric patients, who are just, again, starting to get into exercising and maybe playing little league. But patients need to be tested for their suspected allergies if they are showing symptoms of asthma.
Gary Falcetano [15:08 - 15:36]: Yeah, and I think there's really a silver lining to all this information we've been talking about, and that's despite their asthma and their allergy diagnoses. Both of these papers really address the fact, that should not be a limitation. And we're talking about Olympians here, you know, in the one paper. So these people have been either diagnosed or not diagnosed with asthma, but they have asthma and allergy, and they're competing at some of the highest levels. So what's the take home? Luke, from the Olympic paper?
Luke Lemons [15:36 - 16:18]: I'm glad you mentioned the silver lining, Gary, because the takeaway is that, interestingly enough, suffering from asthma and allergy did not affect the quality of performances and the chances of qualifying for the Olympics or winning a medal. That's a direct quote from that paper that looked at twelve years of Olympians. And it's so impactful when you think of how some people may not want to start exercising or don't think that they can win a race or go swimming because they have asthma or some sort of respiratory allergies, and they're saying no. Some of the most well trained and athletes in the world, even though they had these diseases, asthma and allergies, it did not affect the way in which they performed as an athlete.
Gary Falcetano [16:18 - 16:45]: Exactly. And with all the hype around the Olympics now, I think it's a great time to really address this with patients and say, you don't have to be an Olympian, but you can get out there, you can do whatever exercise you enjoy. There's a strong correlation between lack of exercise and a lot of chronic diseases. We really need to encourage our patients, especially those with asthma and allergy, but, of course, all of our patients, to get the regular exercise that they really need.
Luke Lemons [16:45 - 16:54]: Whether you're seeing elite athletes, weakened warriors, or patients who aren't very active, appropriately diagnosing and managing their allergies and asthma symptoms can help them live their best life.
Gary Falcetano [16:54 - 17:18]: And for those patients presenting with allergy like symptoms or asthma, it's so important to assess their allergic triggers, find out if they're atopic or not to begin with, and if they are atopic, what are those allergic triggers? And really empower them with the advice that they need, with the management advice that they need to really address those triggers, improve their quality of life, and get them out there exercising as often as possible.
Luke Lemons [17:18 - 17:26]: Couldn't have said it better. Hopefully, everybody has a good time watching the Olympics and is breathing easy this summer. Thanks for listening.
Gary Falcetano [17:26 - 17:27]: Thanks. We'll see you next time.
Announcer [17:33 - 18:12]: ImmunoCAST is brought to you by Thermo Fisher Scientific, creators of ImmunoCAP Specific IgE Diagnostics and Phadia laboratory systems. For more information on allergies and specific IgE testing, please visit thermofisher.com/immunocast. Specific IgE testing is an aid to healthcare providers in the diagnosis of allergy and cannot alone diagnose a clinical allergy. Clinical history alongside specific IgE testing is needed to diagnose a clinical allergy. The content of this podcast is not intended to be and should not be interpreted as or substitute professional medical advice, diagnosis or treatment. Any medical questions pertaining to one's own health should be discussed with a healthcare provider.
