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Presented by Terry Pollock, MS Clinical Educator Nutrition Specialist Slide 2 (The real me, at work last week) Big hello to all of the Nutrition Geeks folks! Slide 3 GI Health What Is It? Absence of GI symptoms or illness Normal/stable intestinal microbiota Effective digestion and absorption of foods Effective immune status Daily, Type 4 or 5 bowel movements (TAP) General feeling of well-being Bischoff, S. Gut Health a new objective in medicine? BMC Medicine 2011, 9:24 IBDQ, BDQ, IBSQofLQ most suitable assessment tool Slide 4 GI Health Two Major Determinants Infectious diarrhea IBD Celiac disease IBS Bischoff, S. BMC 2011, 9:24 1-The GI Barrier Allergic disease Autoimmune disease Obesity, FLD/NASH Sepsis ICU pts Malnutrition Slide 5 GI Health Two Major Determinants IBD Celiac disease IBS Allergy Arthritis Obesity Bischoff, S. BMC 2011, 9:24 2 GI Microbiome Slide 6 Testing the GI Barrier Lactulose/mannitol - urine Hydrogen breath testing IgG4 serum or bloodspot Histology (villus, crypt, etc) LPS cell membrane antigen in G-bacteria Lactoferrin - stool Immunity CBC, cytokines, sIgA Slide 7 Testing the GI Microbiome Cell cultures, chemotaxis, phagocytosis Bacterial/fungal cultures and toxins measurements Metametrix: PCR DNA-based identification/quantitation via GIfx test Metabonomics metabolites of gut bacteria via Organix Dysbiosis test Slide 8 It Is Usually Not One or the Other! The GI Barrier and the GI Microbiome Are Interrelated significantly more variation in the gut microbiota of healthy volunteers than that of IBS patients Codling C, et al, Dig Dis Sci, 2010 Feb;55(2):392 Slide 9 Gut Microflora Genes, receptors Age Diet Components Non-digestible CH2O, prebiotics Probiotics Antibiotics, drugs Infant environment Maternal flora Mode of birth The GI Barrier and the GI Microbiome Are Interrelated Host pathology Slide 10 Autoimmune Diseases Associated with Overgrowth of Specific Bacteria GI microbes linking to autoimmune pathology: Klebsiella: Ankylosing Spondylitis Citrobacter & Klebsiella: Rheumatoid Arthritis Yersinia: Graves & Hashimotos Disease, Ulcerative Colitis Slide 11 Irritable Bowel Syndrome (IBS) Symptoms abdominal pain or tenderness, bloating, change in bowel habits; no other known organic cause Risk of developing IBS increases 6 fold after acute GI infection The disease entity closest to the borderline between gut health and disease - Bischoff Slide 12 Irritable Bowel Syndrome IBS-like symptoms are associated with three intestinal protozoan parasites: Blastocystis hominis prevalence averages 30% in IBS patients. Prevalence in non-IBS patients ~7% Giardia lamblia exposed group IBS 46% versus controls IBS 14% (Wensaas, Epub, Sept 2011) Dientamoeba fragilis not as much data available Blastocystis hominis Slide 13 Irritable Bowel Syndrome IBS incidence in Chronic Fatigue Syndrome patients is 51% Psychiatric disorders are found in 94% of IBS patients Whitehead WE et al, Gastroenterology 2002, p. 1140 Probiotics (VSL #3, L. rhamnosus, B. breve) improve IBS flatulence, distension and pain Collado MC et al. Current Drug Metabolism 2009, p 68 Slide 14 GI Health What We Often See Bloating Flatulence GERD Nausea Vomiting Heartburn Constipation Diarrhea Food sensitivities Incontinence Abdominal pain Loss of appetite Weight loss/gain Blood in stools May not all originate in gut, but seem to be remediated by optimizing gut function and support! Slide 15 Overview Ulcerative Colitis, Crohns Selected Tests Case/Therapies Slide 16 The Importance of Mucosal Immunity The dominating part of the immune defense, even if flora is excluded, is localized in the gutno less than 75% of the immune cells of the body are suggested to be found in the GI tract. Bengmark S. Acute and "chronic" phase reaction--a mother of disease, Clin Nutr, Vol. 23, No. 6, pp. 1256-1266, December 2004 Slide 17 Fasano A. Surprises from Celiac Disease. Scientific American, August 2009 Slide 18 Investigating the GI Barrier Lactulose/mannitol - urine Hydrogen breath testing IgG4 serum or bloodspot Histology (villus, crypt, etc) LPS cell membrane antigen in Gram-bacteria Lactoferrin - stool Immunity CBC, cytokines, sIgA Slide 19 Hyperpermeable GI Barrier Slide 20 Lactulose/Mannitol Urine test for Leaky Gut Lactulose molecule is larger and should not pass through to show up in urine. Mannitol should. Leaky Gut both L and M are elevated in urine Malabsorption both L and M are low in urine Slide 21 Hyperpermeable GI Barrier Since the mucosal immune system is a central component of host defense, as a whole, any dysregulation and inflammatory reaction in the GI tissue results in intestinal barrier dysfunction and the entry of undigested dietary proteins into the circulation. The entry of dietary proteins in the circulation results in systemic immune response and the production of very high levels of IgG and IgA against dietary proteins and peptides. This systemic immune reaction against dietary proteins and peptides depends on the antigenic structure protein antigen, particulate antigens, polysaccharides, lipoproteins or enzymes and their molecular sizes, and of course, the genetic makeup of exposed individuals. One may produce IgG antibodies against dietary proteins, while others may produce IgA antibodies, or IgG and IgA antibodies against different dietary proteins and peptides. Aristo Vojdani, PhD, immunologist, researcher Italics mine (TAP) Slide 22 IBD - Ulcerative Colitis Characteristics Any part of colon Diarrhea ~4X/d Mildly tender abdomen Fatigue Weight loss if severe case Increased oxidative stress Impaired colonic mucosal barrier - lesions very permeable Colon biopsy shows low copper/zinc Slide 23 IBD - Ulcerative Colitis Helpful Tests and Potential Findings GIfx stool analysis H lactoferrin, H absorption markers Fatty acids H arachidonic acid? OR mostly low fatty acids? 8OH-2DG, lipid peroxides H in oxidative stress Inflammation markers H crp, fibrinogen Lactulose/mannitol or IgG4 for permeability RBC elements L zinc and copper Slide 24 IBD - Crohns Disease Characteristics: Lower ileum usually, may occur at any locus Diarrhea ~4X/d (often twice as many) LRQ pain Bloody stool Fatigue Weight loss/anorexia Slide 25 IBD - Crohns Disease Helpful Tests and Potential Findings GIfx stool analysis H lactoferrin, malabsorption Organix Dysbiosis urine test H bacterial markers Fatty acids all L/L normal - malabsorption Fat-soluble vitamins most L 8OH-2DG, lipid peroxides (oxid stress) - elevated Ferritin low or sometimes very high! CBC Low rbcs, macrocytic cells, anemia Slide 26 Russ - 48 yo m Crohns History Remicade Rx d/c was not working 10 + bowel movements/d Hypothryroidism - on thyroid med Endoscopy showed Crohns-like inflammation Several antibiotics courses earlier Slide 27 Russ - 48 yo m Crohns Labs - H lactoferrin, H calprotectin, H leukocytes (original testing) Candida albicans neg Food sensitivities IgG + buckwheat IgG4 mod/severe + to casein, milk Slide 28 Russ - 48 yo m Crohns disease Supplements: DGL caps L-glutamine powder OTC Probiotics Slide 29 Russ - 48 yo m Crohns Borderline low anaerobes across the board. Borderline low probiotics even though taking them. GIfx can show successful probiotics therapy Slide 30 Russ - 48 yo m Crohns Low total SCFAs! Always look at number, not just at marker on the graph. Lactoferrin no longer H, but not where we see in non-IBD patients (1 st Q), so pt is in remission or quiescence Slide 31 Russ - 48 yo m Crohns Slide 32 Clear SIBO! Moral of story stool samples cant offer much about small bowel bacterial overgrowth! Slide 33 Russ - 48 yo m Crohns Bacterial action on polyphenols, tyrosine, unabsorbed phenylalanine HPA intestinal pathology Still no sign of Candida Slide 34 Russ Crohns follow-up 4 months later follow-up: Mainly 3- 4 bms per day. Feels not well, but much better Added in interim: Red yeast rice, vit D, vit C, milk thistle, Vit E, zinc carnosine, professional probiotic Needs to support colonic bacteria: I further recommended Biotagen, Therbiotic Complete, curcumin, anti-infl diet changes, no dairy! Slide 35 Overview Testing Microbial Therapy Slide 36 It is today generally accepted that intestinal flora [are] deeply involved In the pathogenesis of human inflammatory bowel diseases (IBDs). Although the exact presence of unwanted or lack of specific crucial bacteria are not yet known. Westerners lack, to a large extent, important immunomodulatory and fibre-fermenting lactic acid bacteria (LAB), bacteria which are present in all with a more primitive rural lifestyle. Bengmark S. Bioecological control of inflammatory bowel disease. Clin Nutr, 26, 2007, p. 169-181 Bifidobacter in colon Slide 37 Gut Microbiome Factoids There are ~1000 species of microbes in the human intestinal tract - totaling over 4 lbs There are 10 times the number of microbial cells as human cells in the body (90% of DNA in our body is bacterial!!) Metabolic activity of our gut bugs rivals that of the liver Slide 38 Colonization Resistance Normal GI microbiota: provides a natural defense mechanism against invading pathogens prevents overgrowth of opportunistic microorganisms provides colonization resistance in a variety of ways, including: occupying adhesion sites producing antimicrobial agents Slide 39 Testing the GI Microbiome Cell cultures, chemotaxis, phagocytosis Bacterial/fungal cultures and toxins measurements Metametrix: PCR DNA-based identification/quantitation via GIfx test Metabonomics metabolites of gut bacteria via Organix Dysbiosis test Slide 40 Obese mice on the same diet as lean mice demonstrate higher increase in body fat, indicating the microbial community seems to affect the amount of energy extracted from the diet. Germ-free mice inoculated with microbiota from obese mice increased in adiposity over germ- free mice inoculated from lean mice while on the same diet. Ley R, Turnbaugh P, Klein S, Gordon J, Human Gut Microbes, Nature, V444, December 21/28, 2006 Slide 41 Mechanism of Fat Bugs Effect CHO-Degrading Enzymes Increased blood lipids Fasting-Induced Adipose Factor Increased adipocyte storage AMP-Activated Protein Kinase Reduced energy for muscular activity Slide 42 Sacchromyces boulardii as Therapy Antibiotic-Associated Diarrhea: N = 466 children, 1-15 yrs of age Azithromycin alone11.4% diarrhea + S. boulardii5.5% diarrhea Sulfactam-ampicillin25.6% diarrhea + S. boulardii5.7% diarrhea Erdeve O, J Trop Pediatr 2004, p 234 Slide 43 Lactobacillus in Antibiotic- Associated Diarrhea 10 studies total of 1862 patients, 6 studies were patients >18 yrs (a meta- analysis) Risk ratio of developing AAD was significantly lower when Lactobacillus was given, compared to placebo Kale-Pradham PB. Pharmacotherapy, 2010, p. 119. Slide 44 SHEILA - 33 yo f - constipation Constipation Belching, gas Mild depression Fatigue History: B12 deficient Vitamin D deficient Iron deficient On GF diet for ~ 1 year Antibiotics 2 months for tooth infection Slide 45 SHEILA - 33 yr old female On antibiotics 2 months earlier for tooth infection Lowest value is for Fusobacteria; this genus is often found in infections of mouth (abx tx?) Slide 46 SHEILA - 33 yo f Fungal overgrowths are common after antibiotic treatments +4 is our highest rating Observation anti- fungal botanicals usually bring TU fungi down Slide 47 SHEILA - 33 yo f VERY LOW Short Chain Fatty Acids are consistent with constipation (and often diarrhea too). More about SCFAs just up GF diets effectively lower AGA sIgA. Slide 48 SHEILA 33 yo f Trend persists: H nml trigs plus H nml Absorption markers LCFAs, Total fat and cholesterol This trend correlates with gluten sensitivity Slide 49 SHEILA 33 yo f Treatments Suggested: Prebiotic supplements Anti-fungal diet Sacchromyces boulardii - 150 mg/cap = 3 billion CFUs - 1 bid with meals Increase water intake Added psyllium on her own after 5 weeks has better BMs and less gas! Follow-up: Slide 50 Short Chain Fatty Acids Derived from microbial fermentation of undigested carbohydrate (fiber) that reaches the colon Act as physiological ligands of FFA receptors 2 and 3, which are expressed in immune, endocrine and fat cells, to name a few Increase colonic and hepatic blood flow Increase solubility of Ca++ Increase absorption in the small intestine Slide 51 Short Chain Fatty Acids Major SCFAs studied are acetate, butyrate and propionate Low SCFAs on stool testing mean more prebiotic soluble fiber is neededand more bacteria to process them are needed also! Bacteroides species, etc can change SCFA profile (MacFarlane, 1996). Slide 52 Short Chain Fatty Acids Food sources of soluble fiber: Legumes Oats, rye, barley, chia Broccoli, carrots, asparagus, Jerusalem artichoke Sweet potatoes, onions, leeks Prunes/plums, bananas, apple/pear flesh, berries Psyllium husks Slide 53 HENRY - 60 year old male, hx chronic GI problems, no GERD, big tummy (loves beer) H serum anti-gliadin antibodies Several other IgA-mediated markers H 4 of 6 autoimmune markers positive (Cyrex Labs, Phoenix, AZ) Labs: (non-MMX) Slide 54 HENRY - 60 yo male Lower levels of predominant bacteria Higher Bifidobacter associated with less weight gain Slide 55 HENRY - 60 yo male, hx chronic GI problems No GERD, but is this level of Hp a problem? This +2 Sacch may be brewers yeast Observation chronic Blastocystis is concurrent with IBS symptoms in some people Slide 56 HENRY 60 yo male, hx chronic GI problems When LOW sIgA, anti-gliadin sIgA may be false negative; Nml lactoferrin, rather than >3 rd Q, is a good finding! If lactoferrin H, IBD likely Henrys blood tests showed H AGA, so he has gluten sensitivity Slide 57 HENRY - 60 yo m, hx chronic GI problems Digestion issues H Putrefactive SCFAs (protein) Malabsorption of LCFAs (VH marker) Observation pattern of H or H nml trigs with one or more Absorption markers H often is associated with gluten sensitivity. Persists long after GF diet is started. Slide 58 HENRY - 60 yo m, hx chronic GI problems GF diet, learn to like GF beer Digestive enzymes with trial of HCl Pre- and probiotics daily Experiment with new foods providing prebiotic substrate (replacing gluten foods) Slide 59 General Gut-Healing Go Tos Biotagen prebiotic powder containing inulin, oligofructose, beta-glucan and Larch arabinogalactan Ther-Biotic Complete probiotic (7 Lactobacilli, 4 Bifidobacteria and Streptococcus thermophilus) Theralac (5 Lactobacilli with two prebiotics) Zinc carnosine 50 mg bid L-glutamine 1-35 g/d Curcumin 50 mg (Meriva) 2-6/d DGL 300-1500 mg/d powder Slide 60 Addenda Slide 61 An Ecological Perspective The effects of the GI microflora are not mediated by a single species but rather by relationships among many. Therefore, characterization of the global composition is critical to understanding the effects of the microbiota on the host. Slide 62 Many clinicians consider Types 4 and 5 to be in the normal or ideal range Intestinal Transit Time Slide 63 GI Complications in Eating D/O Esophageal spasm/tearing Gastric dilation Acute pancreatitis Motility issues Nutritional deficiencies esp. Zn, Mg, Bs, EFAs, calories, protein, vitamin K Low serotonin in bulimia/anorexia available tryptophan prioritized to make vital protein! Slide 64 Urine Organix Toxicity Markers