3. ASSESSMENT & DIAGNOSTICS Flashcards
THIS MODULE COVERS: • Functional vs. conventional testing. • Stool and SIBO testing. • Vaginal and oral microbiome testing. • Organic acid testing. • Nutritional testing. • Thyroid testing. • Adrenal testing. • DUTCH testing.
What is the ‘rule of 3’ used to inform the naturopathic nutritional plan?
As a naturopathically-trained nutritional therapist, you have a variety of evaluation tools including tongue, nail and facial diagnoses to help you better understand a client’s problems.
It is important to have three pieces of evidence (ie. Symptoms, tongue observation, test results) to confirm any hypothesis.
How is functional testing different from diagnostic testing?
Functional testing focuses on how body systems are functioning while diagnostic testing looks for markers to diagnose an illness.
What is the difference between ‘reference ranges’ and ‘optimal ranges’?
‘Reference ranges’ are diagnostic, whilst ‘optimal ranges’ indicate a need for support to maintain homeostasis.
In terms of Vitamin D, what is the
a) Reference range (diagnostic testing)
b) Optimal range (functional testing)
a) Conventional medicine considers levels over 50 nmol / L sufficient.
b) The optimal range is approx. 75-125 nmol / L.
List two benefits of functional testing
- Helps to uncover a deeper understanding of imbalances to help inform a naturopathic plan.
- Can make a plan more targeted and effective.
- Allows to quantitatively measure a client’s progress, which benefits the client as they can clearly see improvements.
List two downsides to functional testing
- Functional tests are provided privately, and so can be expensive. Always ask yourself: is the test likely to change the outcome / the plan you create?
- They can sometimes be challenging to read and interpret.
- As they are not diagnostic, it can be difficult to communicate results to medical doctors.
What contextual considerations are to be kept in mind when interpreting functional test results?
- What were the symptoms at time of testing? Do they correlate with the results?
- What is the dietary pattern this person adheres to? Can this impact the results in a predictable way?
- Is there any activity at the test time that could affect the results?
Define the following terms as they relate to the microbiota:
* Commensal
* Pathogenic
* Pathobiont
* Gram negative bacteria
* Lipopolysaccharides (LPS)
- Commensal — microbes that live in harmony with the host (us) and provide a benefit to us.
- Pathogenic — microbes that possess certain evolutionary advantages to invade our microbiome at a cost to our health.
- Pathobiont — microbes that live with us and normally don’t pose a problem unless there is clear opportunity.
- Gram negative bacteria — bacteria that possess an outer cell wall, normally rich in lipopolysaccharides (LPS).
- LPS — the major component of gram-negative bacteria which have the ability to induce inflammation and immune responses.
Why might you consider a ‘CDSA’ for a client with GI complaints or for more chronic systemic illnesses in
which poor GI function might be relevant?
CDSA = ‘comprehensive digestive stool analysis’
Stool testing is a good way of getting a comprehensive snapshot of digestive function and the GI microbiome at a given time. This can help you to identify underlying root causes and guide or confirm your nutritional plan.
What is Metabolic Endotoxaemia?
An immune response that becomes a sub-clinical, persistent, low-grade inflammation because of increased circulating endotoxins (LPS).
Why is knowing the client’s diet important to be able to read a stool test accurately?
Different dietary models are well known for impacting the microbiota in different ways
Which two broad types of markers can be evaluated by comprehensive stool tests?
- Microbial markers such as commensal bacteria, pathogenic bacteria, parasites, pathobiont microbes, mycology, sometimes worms (these are often best seen visibly in the stool).
- Host markers — markers made by the human host such as immune, digestive, inflammation, intestinal permeability and occult blood.
What is calprotectin and what can raised levels be indicative of?
Calprotectin is a protein made by leukocytes when they have migrated to and are active in the GI wall.
It is a marker of inflammation and is flagged as high over 50 μg / g. Between 50-175 is ‘mid-range inflammation’. The elevation is triggered by damage to the epithelial lining - in worst case scenarios IBD, ulcers, cancer, but in most scenarios, relates to pathogens or NSAIDS.
What is Eosinophil Protein X and what conditions might a raised level indicate?
Eosinophil Protein X is a marker of eosinophil-driven inflammation and can be raised with intestinal inflammation and in cases of food allergies, parasites, colitis.
Which elevated metabolic host marker can point to issues with oestrogen excretion?
Beta-glucuronidase
What would be your interpretation of Pancreatic elastase (PE-1) result of < 200 μg/g?
It shows exocrine (digestive) pancreatic insufficiency and there is need for digestive support. Below 100 μg/g is considered severe insufficiency.
How might you increase PE-1?
PE-1 = Pancreatic elastase
Naturopathic approach to pancreatic insufficiency:
* Don’t overeat, chew adequately, avoid snacking between meals.
* Correct stomach acid levels.
* Stimulate the Vagus nerve to activate the parasympathetic nervous system:
‒ Deep (diaphragmatic) breathing before meals.
‒ Gargle, hum or sing.
‒ Laughter and social enrichment.
‒ Using bitters such as gentian, artichoke and dandelion.
* Pancreatic enzyme replacement therapy (PERT).
What is sIgA (secretory IgA)?
SIgA is secreted by mucosal tissue and provides the first line of immune defence in the GI mucosa.
Upon reviewing a client’s stool test, you see that sIgA is low. What could this correlate with?
Low sIgA (<100 μg / g) correlates with chronicity. ↑ susceptibility to GI infections. Always identify why (e.g. chronic stress).
What could a high sIgA result signify?
High sIgA (>750 μg / g) signifies an upregulated immune response (e.g., acute GIT infection) at the time of testing.
What is Beta–defensin 2 and why might it be high?
High >62ng / g - might be a sign of the immune system responding to a breach by microbes, or due to GI inflammation e.g., UC.
What nutraceuticals might you suggest for a client experiencing chronic stress to help with low sIgA levels?
Saccharomyces boulardii and medicinal mushrooms can elevate IgA when levels are low
What is zonulin?
A peptide produced by epithelial cells when the GI tight junctions are open.
What might zonulin levels of > 100 μg / g indicate?
Zonulin may be raised in severe intestinal permeability (e.g., due to poor nutrition, heavy metals, drugs, alcohol, dysbiosis) and coeliac disease.
What nutrients can be taken to support the intestinal barrier?
Support the intestinal epithelial barrier with:
- Glutamine — supplemented or from food e.g., cabbage juice, spirulina, asparagus.
- Zinc carnosine, vitamin A and N-acetyl glucosamine.
- Bone broth (rich in glycine).
When assessing the levels of commensal microbiota, what would you be looking for as indicators of health?
In the commensal markers, check for:
- Plenty of diversity (check that all bacteria are accounted for).
- Good levels of short-chain fatty acid producers.
- Good levels of Bifidobacterium (check that it is taking up more space than E. coli) and Lactobacilli.
Which dietary and lifestyle factors are likely to adversely affect the levels of commensal microbiota?
Diets lacking diversity (e.g., junk food diet, FODMAP diet), over-eating, antibiotic usage and chronic conditions can impact these levels in an adverse way.
List three of the most common short chain fatty acids (SCFAs). What are they and why are important for health?
Butyrate, propionate and acetate.
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- SCFAs are by-products of bacterial fermentation of fibre.
- The epithelial cells of the colon use butyrate as their main fuel source — maintaining the intestinal lining.
- SCFAs can also affect appetite and modulate inflammation.
What is ‘mucin’?
Mucin = a glycoprotein constituent of mucus
What symptoms can be indicative of low GI mucosal integrity or too much cross-talk between the gut microbiota and immune system?
Symptoms such as ulcers, IBD and gastritis
What underlying mechanism would you suspect in a client with gastritis and test results revealing high levels of mucin-degrading bacteria (ie. Akkermansia, R. gnavus, R. torques), low diversity of commensal bacteria and high gram-negative bacteria?
Low mucosal integrity
or metabolic endotoxemia
Which important mucin-degrading bacteria, when absent, has been shown as a risk factor for metabolic endotoxemia patterns of disease (obesity, insulin resistance, autoimmunity)?
Akkermansia muciniphila
Which of the following bacteria are well known for their ability to cause gas, and can sometimes be implicated in ‘gassy’ symptoms or SIBO:
a) Akkermansia muciniphila
b) Bilophila wadsworthia
c) Desulfovibrio spp.
d) Hafnia alvei
e) Methanobrevibacter smithii
b) Bilophila wadsworthia
c) Desulfovibrio spp.
e) Methanobrevibacter smithii
Which bacteria are associated with methane gas production?
Methanobrevibacter smithii
In the context of healthy and diverse microbiome, which of these at any level could pose concern?
a) Klebsiella spp.
b) Giardia spp.
c) Entamoeba histolytica.
d) Prevotella copri
b) Giardia spp.
c) Entamoeba histolytica.
These microbes are purely pathogenic in nature, and we would rather not carry them at all if possible. It is worth checking symptoms to make sure it correlates with your case, and also check the levels.
List three pathobionts of which high levels are of concern in the context of low commensals.
Prevotella copri, Klebsiella spp., Staphylococcus aureus.
Always read them within the context of the host markers, symptoms and the health of commensals.
When H. pylori levels test higher than expected, which other two markers can be used to confirm an overgrowth that needs to be tested?
Calprotectin and FIT.
FIT = faecal immunochemical test (detects minute amounts of blood in faeces).
List four natural antimicrobials that could be used to eliminate pathogens such as Giardia spp., Clostridium difficile., Entamoeba histolytica & Shigella.
- oregano oil
- garlic (allicin)
- barberry bark (and berberine)
- thyme
- clove
- sage
Do parasites such as blastocystis hominis always need to be eradicated?
Many of us carry some weird and wonderful sounding amoebas and parasites that might be picked up with extensive testing.
In a small number of the population, it
may cause IBS-like symptoms. But it can be found in a high level of healthy population groups, and may also be a sign of health and a diverse microbiome.
A stool test shows A.muciniphila is absent. What might this indicate and what can you recommend to increase this marker?
Low levels of Akkermansia indicate possible GI mucosal damage. Increase polyphenols such as grape extract and pomegranate.
Which three species of commensals should always be abundant and in roughly the same number (in individuals consuming a western diet)?
Bacteroides spp.
Faecalibacterium prausnitzii
Ruminococcus bromii
Which three gram negative bacteria are typically present on stool tests?
Bilophila wadsworthia
Hafnia alvei
Veillonella spp.
Name the microbe:
High levels of this gram negative bacteria indicates a need for liver support to help remove excess LPS through the biliary system (e.g., dandelion root, burdock root, artichoke).
Veillonella spp.
Methanobrevibacter along with which other two microbes is suggestive of SIBO?
Bilophila and Desulfovibrio
What is a reading of 12.8 of R. gnavus suggestive of?
Ruminococcus gnavus is often present and is normal up to about 8 — beyond this it is associated with mucosal degradation.
Define: Small intestinal bacterial overgrowth (SIBO)
SIBO = a bacterial count in the small intestine of over 105 CFU / ml.
CFU = colony forming units
Explain in detail how the SIBO breath test works. Include details of the possible substrates and preparation to be done before the test.
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- In SIBO, fermentation of carbohydrates in the small intestine results in raised hydrogen or methane.
- Breath-testing is a non-invasive test that is looking for the gases made by fermenting bacteria (hydrogen or methane) after set points in time in which the patient has ingested a substrate that the bacteria eats.
- After the substrate is taken, breath samples are collected every 20 or 30 minutes.
-
Types of substrates (bacterial food) used for the breath test:
‒ Lactulose: Very popular and preferred by a lot of practitioners — may give false positives as it is known to speed up transit time, making it hard to read.
‒ Glucose: Most substantiated and used by NHS. There are less false positives, but absorbs quickly so might not pick up distal positives.
‒ Fructose: Less commonly used; gives you the bonus of seeing if there is fructose intolerance. - A strict preparation diet should be done 24 hours before to get an accurate baseline, where microbiota-feeding foods need avoiding.
The only foods allowed are:
Any meat / poultry / fish / seafood that is not cured or brined; Plain, steamed white rice (not brown); Eggs; Clear meat broth (made only from the meat, no bone / cartilage or vegetables); Fats / oils (coconut / olive / vegetable oils, butter, or lard); Salt and pepper (no other herbs / spices).
In SIBO breath testing, what is interpreted as a positive result?
- Increase in hydrogen: A rise of 20 ppm before 90 minutes.
- Increase in methane: A rise of 12 ppm before 90 minutes (or in severe constipation, a rise as little as 3 ppm might indicate a problem).
- Increase in combined methane / hydrogen: A combined rise of 15 ppm before 90 minutes.
Why is the cut-off for reading SIBO breath tests usually at 90 minutes?
The substrate transitions to the large intestine at around 90 mins
