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Nutrition two > Assesment And Diagnostics > Flashcards

Assesment And Diagnostics Flashcards

1
Q

What is a pathobiont? Give examples

A

Microbes that live with us without causing us problems , they only become pathogenic when there is an opportunity (change in terrain)- it is important to compare an abundance of them in relation to the commensal bacteria
- klebsella spp.
-prevotella copri
- staphylococcus aureus

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2
Q

What are commensal bacteria? Give examples and what can impact these negatively ?

A

Microbes that live in harmony with the host and provide benefit to us. Diversity of these is a major indicator of health in the human microbiota.
We want good levels of:
- bifidobacterium (taking up more space than E-coli- when higher predisposes the microbiome to IBS)
- lactobacilli
- Short chain fatty acid producers
Diets lacking diversity, antibiotic use and chronic conditions can impact commensal levels negatively

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3
Q

What is a pathogen? Give examples

A

Microbes that invade our micro biome to their advantage, and at a cost to our health . Given the choice we would rather not carry them at all, they will cause disease processes
- clostridium difficile
- shigella
- giardia spp.
- entomoeba histolytica

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4
Q

Are parasites always harmful? Give an example

A

Not always, many of us will carry parasites and amoebas that get picked up on tests but it may not be pathogenic , rather a sign of healthy diversity.
Eg. Blastocystis homini May cause IBS in some but May also be a sign of a healthy micro biome

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5
Q

In a stool test, which markers of inflammation may be tested?

A

1) calprotectin - a protein made by leukocytes when active in cell wall , triggered by damage to the epithelial lining eg IBD, ulcers, NSAIDS, cancer . NHS use marker to differentiate IBD from IBS

over 50 ug/g is flagged as high, 50-175 is ‘mid range inflammation ‘ over 175 with no diagnosis= retest, if raised on second test= referral

2) eosinophil protein X- can be raised due to a histamine response , colitis and food allergies
normal <1.1 mcg/g, high > 4.6mcg/g

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6
Q

Which digestion markers may be used in a stool test ?

A

1) faecal fats - elevated levels suggest fat malabsorption , pancreatic insufficiency, SIBO and low HCL
2)Pancreatic elastase PE1 - normal range 200-500 ug/g, optimal 500, < 100 severe insufficiency. if low lipase and amylase will be too. Stress and SIBO can deconjugate and make low on a test

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7
Q

Which bacteria strains may degrade mucin?

A

1) Akkermansia muciniphila is a mucin degrading bacteria but also plays a protective role to the mucosal barrier and absent levels increase the risk of metabolic toxemia . We want some but not in high amounts

2) Ruminococcus gnavus or Ruminococcus torques . High amounts of these with a low diversity can indicate autoimmunity

3) An absence of diversity in Bacteroides can cause bacteria to become more mucin degrading

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8
Q

Which immune markers may be used on a stool test?

A

1) Secretory IGA- secreted by mucosal tissue, first line of defence in GI.
-An elevated level can indicate an acute GI infection at time of testing
- A low level can correlate with chronicity and a higher risk of susceptibility to GI infections, immune system is struggling

2) Beta defensin 2- Antimicrobial peptides are produced by the GI wall when breached eg microbes or GI inflammation (colitis) High is >62ng/g

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9
Q

What are three things to remember when interpreting a stool test?

A

1) Look for correlations of symptoms with microbes and host markers- never take a marker in isolation, only in context with other microbes. Especially look at GIT symptoms and dietary patterns

2) Reference ranges in the microbiome are hard to ascertain as there is a large range of normal- look at the whole pattern

3) Different dietary models will impact the microbiota in different ways, so know your clients diet.

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10
Q

Which methods can be used to identify microbes in a stool test?

A

1) PCR- a reaction happens with the DNA of a microbe

2) Culture with MALDI-TOF. A lot of bacteria doesn’t like to culture in an aerobic environment

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11
Q

What are the two main types of markers in a stool test? Give 4 examples of each

A

1) Microbial markers
- Commensal and pathogenic bacteria
- parasites
- pathobiont microbes
- Mycology
- Worms

2) Host markers
- Immune
- Digestive
- Intestinal permeability (Zonulin peptide)
- Inflammation ( Secretory IGa, calprotectin)
- Occult blood

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12
Q

In a stool test, what is the main marker of intestinal permeability , and why might it be raised?

A

-Zonulin family peptide- produced by the epithelial cells when the GI tight junctions are open. They are upregulated by gluten. >100ug/g is considered high.
- May be raised in severe intestinal permeability (poor nutrition, heavy metals, drugs, coeliac)

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13
Q

What is metabolic endotoxaemia?

A

Poor GI barrier integrity can lead to too many gram negative bacteria with an outer wall rich in LPS. An increased level of circulating endotoxins (LPS) creates an immune response that becomes a sub- clinical persistent low grade inflammation, linked with many chronic diseases including diabetes, chronic fatigue syndrome, autoimmunity, insulin resistance.

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14
Q

What is an OAT test?

A

-An organic acid test. Organic acids are normal by products (metabolites) created from the functioning of many enzymatic pathways in the body.
-These pathways need certain nutrients as co-factors , so organic acids are a window into the functioning of these pathways.
- It can be an indirect, functional assessment of nutrient status

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15
Q

Name 3 negatives aspects of an OAT test

A

1) Can be expensive, and hard to interpret purchased as a standalone test or as part of other nutritional panels
2) It is just a snapshot in time- tests like this need context to interpret ie what was happening on that day- diet can really impact?
3) Not measuring the vitamin directly, so you are making an assumption based on function

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16
Q

5 groups of people that may benefit from an oat test?

A

1) Chronic fatigue- persistent low energy, is the mitochondria not using enough nutrients? Krebs cycle metabolites may show this
2) Suspected nutritional deficiencies
3) Autism- neurotransmitter/ bacterial/ detoxification metabolites
4) Mood disorders- neurotransmitter/ bacterial metabolites
5) Hyperactivity
6) Suspected mitochondrial dysfunction

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17
Q

What preparation is needed for an OAT test and how is it measured?

A

Foods which raise metabolites such as grapes, raisins, pears, reishi, echinacea and all supplements need to be avoided for 3 days before.
Measured by urinalysis (looks for metabolic waste in urine)

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18
Q

What marker is used for candida in an OAT test and what issues may this cause?

A

Arabinose marker is elevated , which is linked to mucosal invasion.
Candida can cause issues with brain function, memory, attention and focus

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19
Q

Name 5 markers included in an OAT test

A

1) Oxidative stress markers - lipid and peroxide markers and 8-OHdG
2) Vitamin markers- specific analytes used to assess functional levels of vitamin cofactors- B6, B5, C, CoQ10, NAC (precursor for glutathione)
3) Neurotransmitter metabolites- downstream byproducts of epinephrine, norepinephrine, serotonin and dopamine. Relationships between these are critical for mood, focussing, calmness, attention
4) Malabsorption and dysbiosis markers- metabolites produced by the GI microbiome
5) Dietary peptide related markers- can indicate incomplete protein breakdown - leading to gut permeability
6) Cellular energy and mitochondrial markers- biomarkers of carbohydrate and fatty acid metabolism and krebs cycle- glycolysis metabolism

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20
Q

Describe the preparation diet for a SIBO breath test

A

A strict preparation diet must be put in place 24 hours before a breath test to ensure an accurate baseline.
- only steamed white rice, eggs, meat, poultry, fish, fats, oils, bone broth may be eaten
- Supplements must be stopped
- 12 hour fast
- no teeth cleaning in the morning

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21
Q

What is SIBO?

A
  • Small intestinal bacterial overgrowth with a bacterial count in the SI of over 105 CFU/mL
  • fermentation of carbohydrates in the small intestine result in raised hydrogen or methane
  • Chronic and postprandial pain after every single meal
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22
Q

What is SIBO frequently associated with?

A
  • Poor migrating motor complex- this is the dishwasher of foods, cleans everything out
  • Low HCL and low pancreatic juice
  • Poor ileocaecal valve
  • Low IgA
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23
Q

What does a SIBO breath test do and what indicates a positive result?

A
  • A SIBO breath test looks for the gases made by fermenting bacteria (hydrogen or methane) at set points in time, after the patient has ingested a substrate that the bacteria eats
  • Breath samples are taken every 20/ 30 minutes
  • Positive raised hydrogen= rise of 20ppm before 90 minutes
  • positive raised methane= rise of 12ppm before 90 minutes
  • Positive both = combined rise of 15ppm before 90 minutes
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24
Q

Which 3 substrates may be used for a SIBO breath test?

A

1) Lactulose- popular, isn’t digested well by us so can go further into the tract. May speed up transit time
2) Glucose- less false positives but absorbs quickly so might not pick up positives in the distal part of the SI
3) Fructose- not commonly used, can be used to test fructose intolerance though

25
Q

What test would you consider doing alongside a SIBO breath test?

A

A stool test- SIBO is rarely present in isolation, usually part of a bigger eco-system disorder

26
Q

What is the difference between a reference range and an optimal range?

A

-Reference ranges are obtained from the mean and standard deviation parameters of a sample population- what is normal for most people in that group. There will be variations due to age, gender, ethnicity etc. they are diagnostic.
-Optimal ranges indicate a need for support to maintain homeostasis

27
Q

3 benefits and downsides of functional testing?

A

Benefits:
- Can make a plan more targeted and effective
- Can uncover a deeper understanding of imbalances to inform a naturopathic plan
- Allows to quantitively measure a clients progress which can be a great motivator to change
Downsides:
- Provided privately, so can be expensive- are they likely to change the outcome?
- Sometimes challenging to read and interpret
- Are not diagnostic so can be difficult to communicate results to doctors- GPs aren’t looking for functions, only diagnostics
- They are only a snapshot in time so you need the context

28
Q

How would you apply the rule of 3 in the context of using functional testing for SIBO?

A

1) clinical symptoms eg bloating after eating, flatulence, constipation
2) Stool test microbial findings eg high methanobrevibacter bacteria
3) Other stool test findings for poor digestion eg raised faecal fats

29
Q

What is a microbiome?

A

Complex microbial ecosystems that occur within different areas of the body (Oral, vaginal, skin, urinary) .
- Microbiome balance can play a role in health and disease and is key in relation to the concept of ‘the terrain’ It is dependent on cultural, dietary, environmental and familial aspects
Diversity= healthy

30
Q

Define gram negative bacteria and LPS

A

Gram negative bacteria are bacteria which possess and outer cell wall, normally rich in lipopolysaccharides (LPS)
LPS are the major component of gram negative bacteria which have the ability to induce inflammation and immune responses. High loads= chronic diseases

31
Q

What is a stool test useful for?

A

It is a good way of getting a comprehensive snapshot of digestive function and the GI microbiome at any given time. Can be helpful when working with GI complaints or chronic systemic illnesses in which poor GI function might be relevant, including metabolic endotoxemia

32
Q

What is beta glucuronidase and what can elevated beta-glucuronidase mean in a stool test?

A

beta-glucuronidase is an enzyme made by some intestinal bacteria including E-Coli. it de conjugates molecules such as hormones (eg. oestrogen)
Elevated levels are often due to dysbiosis and a diet high in red meat and animal protein. This can interfere with oestrogen excretion and lead to higher circulating levels

33
Q

Give an example of a parasite that may be a sign of healthy diversity?

A

Blastocystis hominis can cause IBS symptoms in a small number of the population but can be a sign of a healthy diverse microbiomes with no symptoms in lots of people

34
Q

What are SCFAs and what can cause low levels?

A

Short chain fatty acids are by products of the fermentation of fibre. The most common ones are butyrate, acetate and propionate.
The epithelial cells (colonocytes) use butyrate as their main food source to maintain the intestinal lining- good example of microbe and host working together. SCFAs can also affect appetite and modulate inflammation.
Low levels caused by antibiotic use, low fibre diets and diarrhoea

35
Q

What is low mucosal integrity associated with?

A
  • Local symptoms such as ulcers, IBD and gastritis
  • also associated with too much cross-talk between the gut microbiota coming through the thin mucosal barrier and the immune system resulting in low grade inflammation (metabolic endotoxemia)
36
Q

How would metabolic endotoxemia be reflected in the microbiome?

A
  • High levels of mucin-degrading bacteria
  • low diversity of commensal bacteria
  • high gram negative bacteria
    (in conjunction with client symptoms)
37
Q

Name two gas producing bacteria?

A

1) Methanobrevibacter smithii- associated with methane gas producing
2) Desulfovibrio spp. and bilophila wadsworthia are associated with hydrogen sulphide gas

38
Q

Is Helicobacter Pylori considered a commensal or pathogenic bacteria?

A

H pylori can be part of a healthy ecosystem in small amounts, and many people carry commensal strains
Other more pathogenic strains of HP can carry virulence factors allowing them to damage the gastric mucosa eg stomach ulcers
- The presence of H pylori doesn’t always equal disease and must be taken in context with symptoms and other markers

39
Q

What are the two methods of testing for helicobacter pylori?

A

1) Faecal antigen testing- negative or positive
2) Faecal PCR tests - there will always be an amount of HP- look for a higher amount or virulence factors

40
Q

Why is it important to have a healthy vaginal microbiome?

A

The VBM plays a crucial role in vaginal, reproductive and maternal health.
Imbalances can lead to bacterial vaginosis (BV) , recurrent thrush, infertility, miscarriages, endometriosis. A test can provide an insight into vaginal ecology and its interaction with host immunity

41
Q

What are the three main vaginal testing markers and what do they indicate?

A

1) pH: a healthy vagina of a reproductive age woman has an acidic pH of 3.8-4.5 to prevent pathogenic microbes from growing and lactobacilli play a major role in maintaining the pH.
-Low pH= high levels of lactic acid= healthy vaginal microbiota
- High pH= (>4.5) indicative of overgrowth of BV associated bacteria and a dysbiosis

2) Interleukin beta-1: inflammatory marker made when epithelial cells break apart (infection) Healthy= <220pg/ml

3) Lactobacilli: vaginal health is associated with low community diversity, but lactobacilli dominance- 80-90%. Lactobacilli produce lactic acid, creating an inhospitable acidic environment to potential vaginal pathogens

42
Q

What should you avoid to support the VMB?

A
  • soap in the vagina (water only)
  • antibiotics
  • copper coil (increases BV- associated bacteria)
    -common lubricants (opt for jojoba oil instead)
  • alcohol and smoking ( byproducts are secreted into the vagina)
  • Vaginal douching
43
Q

What should you include to support the VMB?

A
  • Vaginal probiotics, with lactobacilli
  • optimise the oral and GI microbiomes which can impact the vaginal flora
  • Menopausal oestrogen support (flaxseeds, black cohosh)
44
Q

What can a dysbiosis of the oral microbiome lead to?

A
  • Can be associated with tooth decay, periodontitis and even oral cancer
  • some bacteria can also be associated with cardiovascular disease, autoimmune conditions and alzheimer’s disease as the more pathogenic ones can release endotoxins (LPS) into the bloodstream
45
Q

How can you support the oral microbiome?

A

1) Optimise levels of prebiotic fibres and polyphenols, and probiotic foods (kombucha, kefir etc)
2) Minimise processed carbohydrates and transfats
3) Avoid snacking - it does not allow time for the oral pH to recover between meals
4) Avoid mercury fillings
5) Use biofilm disruptors such as NAC where appropriate
6) Use a probiotic mouthwash, avoid smoking and antibiotics

46
Q

How can serum testing for deficiencies prove challenging?

A

Blood (serum) doesn’t always tell you how the tissue is utilising a vitamin or mineral as many are under homeostatic control. Blood levels stay stable until an extreme is reached

47
Q

What are the testing options for vitamin B12 and folate?

A
  • Testing for ‘active form’ of B12- holotranscobalamin
  • Homocysteine is a functional biomarker for low B9 and B12
  • Methylmalonic acid (MMA) is a more sensitive index of B12 status compared to serum B12. tested in urine or serum. Raised MMA in urine= B12 deficiency
48
Q

Why is serum ferritin more accurate than testing serum iron?

A

Serum iron moves quickly in the blood, ferritin tests the iron storage capacity which is a more accurate marker

49
Q

What would need to be considered when testing serum calcium?

A

This is generally only for kidney/ hormonal problems as it is under tight homeostatic control and only drops out of reference ranges in the extreme. RBC nutrients or OAT might be useful

50
Q

What are CRP and hsCRP markers for?

A
  • C-reactive protein can help to identify levels of low grade- extreme inflammation in the body. Normal range is <5 mg/L but below 1 is ideal
  • High sensitivity C- reactive protein (hsCRP) is a better measurement to look for low grade inflammation (2-5) used by some specialist labs for example in CVD and metabolic syndrome. Normal = 0.2-3 mg/L
51
Q

What is a red blood cell nutrient test and why might it be useful?

A
  • looks at the amount of minerals that have been taken up inside the red blood cell, which is more indicative of ‘tissue levels’ of minerals
  • helpful for more nuanced minerals and toxic minerals and for essential fatty acid testing
52
Q

What does a hair mineral and toxic element analysis provide?

A

An indication of mineral status and toxic metal accumulation, over a 2-3 month period
However, RBC levels of minerals and urine clearance for toxic metals are now preferred methods

53
Q

What is the difference between a standard thyroid test and a full thyroid panel?

A

-Standard thyroid only tests for TSH and T4
- Expanded panels will include TSH, Free T3, T4, reverse T3, thyroid antibodies (Anti TPO and anti thyroglobulin)

54
Q

What could indicate subclinical hypothyroidism?

A

High TSH and normal T4and symptoms of poor thyroid function- people may have come back with ‘normal’ readings

55
Q

What is the best way to test adrenal hormones and why?

A
  • Serum testing is only good for picking up extreme abnormalities of function
  • salivary or urine testing of adrenal metabolites is less invasive and can give a more nuanced view to adrenal function
  • Salivary adrenal tests are four point testing throughout the day to give an overview of daily curve- cortisol and DHEA are main metabolites tested
56
Q

What are the three main types of oestrogen metaboilised down 3 phase 1 pathways?

A

1) E1- Estrone
E2- Estradiol
E3- Estriol

57
Q

What are the 3 main phase 1 pathways for oestrogen?

A

1) 2-OH pathway: safest, due to anti cancer properties of 2-OH metabolites
2) 4-OH pathway: Most genotoxic as metabolites can create reactive quinones and damage DNA
3) 16-OH pathway creates most oestrogenic metabolite

58
Q

What does DUTCH stand for and when might you use one?

A

Dried urine test for comprehensive hormones. Used for reproductive imbalances such as low libido, PMS and irregular/ painful periods

59
Q

What markers are used in DUTCH

A

1) Metabolites of major hormones- oestrogen, testosterone, cortisol and progesterone
2) Specific nutritional markers
3) Adrenal markers

Nutrition two (10 decks)

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