Assessment and Diagnostics Flashcards
What is Homocysteine a functional biomarker for?
Low B9 and B12 levels
What does low vaginal pH indicate?
High levels of lactic acid and an abundance of Lactobacillus
What would you consider using to help push oestrogen down the 2-OH pathway, upregulating CYP1A1?
I3C and broccoli sprouts
What type of test method is used for an Organic Acid Test (OAT)?
Urine test
What does an Organic Acid Test test for?
Some neurotransmitter metabolites
Nutritional function markers
Ketone and fatty acid oxidation metabolites
Low levels of T3, accompanied by high levels of TSH and thyroid antibodies suggests what?
Hashimoto’s thyroiditis
What is the optimal range for vitamin D levels?
75-125 nmol/L
Calprotectin is a protein made by what cell?
What is it an indicator of?
What would be a high result?
- Leukocytes (when they have migrated to and are active in the gut wall
- inflammation
- Over 50mcg/g (50-175 mcg/g = ‘mid range infammation)
Who said “All disease starts in the gut”?
Hippocrates
List the substrates used when testing for Small Intestinal Bacterial Overgrowth (SIBO)
Lactulose
Fructose
Glucose
- Definition of functional testing
- Definition of diagnostic testing
- Focuses on how the body systems are functioning
- Looks for markers to diagnose disease
What is the difference between a ‘reference range’ and an ‘optimal range’ on a test?
Reference ranges are diagnostic
Optimal ranges indicate a need for support to maintain homeostasis
- How are reference ranges produced?
- What variabilities are included in references ranges?
- Reference ranges are obtained by measuring a sample of the population and then setting the mean and standard deviation parameters of what is viewed as ‘normal’
- Age, gender, ethnicity
- Give three functional testing companies
- Two ‘direct-to-patient’ tests
- invivo, Genova Diagnostics, Regenerus
- Thriva, Medichecks
- What are the different areas where microbiomes exisit in the body called?
- Give 5 examples
- Niches
- GI, vaginal, oral, skin, urinary
Give 3 types of microbes with definitions
- Commensal: live in harmony with host/provide benefit
- Pathogenic: invade our microbiome and cause harm to health
- Pathobiont: opportunistic - generally don’t post a threat unless there is a clear opportunity (candida)
What is a gram negative bacteria?
Bacteria that have an outer cell wall - high in LPS
What are LPS? Why are they harmful to health?
Lipopolysaccharides - fragments of gram-negative bacteria
Can induce inflammation and immune responses
Define ‘metabolic endotoxaemia’
Caused by dysbiosis and intestinal permeability.
High levels of mucin degrading bacteria and gram negative bacteria - that produce LPS which translocate into the bloodstream via intestinal permeability and cause inflammation and immune reactivity.
- What is a CDSA?
- What markers do CDSAs evaluate
- Comprehensive Digestive Stool Analysis (stool test)
- Microbial markers and host markers
When interpreting a CDSA, what should you look for?
Correlations between
- symptoms
- Microbes
- host markers
- take a full case history first*
How do different diets afftect the microbiome?
- Vegetarian/vegan
- Gluten free
- Keto
- Low FODMAP
- Western
- Mediterranean
Best diet for diversity?
- Vegetarian/vegan:
low bifidobacteria - Gluten free
High bifidobacteria
High e.coli - Keto
Low bifido bacteria
high e.coli
high desulphovibrio - Low FODMAP
Low bifidobacteria - Western diet
Low bifidobacteria
High E.coli - Mediterranean
High bifidobacteria
Low E.coli
Mediterranean diet offers best diversity
What might calprotection of over 175mcg/g indicate?
IBD, ulcers, cancer
2 markers of inflammation on a CDSA
- Calprotectin
- Eosinophil Protein X
Enzyme that de-conjugates molecules such as hormones in the gut
beta-glucuronidase
Nutrients for intestinal barrier support
Vit A
Vit D
Zinc
Omega oils
Glutamine
Slippery elm / marshmallow (soothe)
Eosinophil Protein X
- Normal range
- High range
- Causes of raised marker
NORMAL: 1.1.mcg/g
HIGH: > 4.6mcg/g
Raised with intestinal inflammation, food allergies, parasites, colitis
- What is the main metabolic marker on a CDSA.
- How is it made?
- Causes of elevated levels?
- What can be a complication of this?
- Beta glucuronidase
- enzyme is made by some intestinal bacteria
- Dysbiosis / Western diet high in red meat and animal protein.
- Oestrogen metabolites can be absorbed/recirculated
2 immune markers found on a CDSA
Explain what each is
- Secretory IgA
- secretion from mucosal tissue (1st line of defence in the GI mucosa)
- Beta-defensin 2
- antimicrobial peptides produced in the GI wall when breached
SIgA
- what is considered LOW
- What is considered HIGH
LOW: <100mcg/g (suscepibility to GI infections (chronic stress?)
HIGH >750 mcg/g (acute infection?)
2 host markers relating to digestion found on a CDSA and what they measure
- Pancreatic elastase (pancreatic digestive enzyme sufficiency/insufficieny
- Faecal fats (fat digestion capacity)
What would be a high result for beta-defensin 2?
Why might this be?
High is >62 mcg/g
Sign of the immune system responding to a breach by microbes or possibly GI inflammation caused by U.C.
Pancreatic elastase
- normal range
- pancreatic insufficiency range
- severe insufficiency range
- normal: 200-500 mcg/g
- insufficiency <200 mcg/g
- Severe insufficiency <100 mcg/g
Why might a client have increased levels of faecal fats in a CDSA?
- pancreatic insufficiency
- SIBO
- hypochlorhydria
Why might a client show low levels of faecal fats on a CDSA?
Because they are on a low fat diet
What is the marker for intestinal permeability on a CDSA?
What would constitute a high result?
Zonulin
- produced when tight junctions are open
> 100 mcg/g
4 causes of Intestinal Permeability
- Poor nutrition
- heavy metals
- alcohol
- dysbiosis
- Coeliac disease
What should you check for when looking a commensal markers of the microbiota?
- Diversity
- SCFA-producers
- Good Bifidobacterium levels
- Bifido taking up more space that E-coli
5.Lactobacilli
What can cause dysbiosis?
- lack of varied diet
- Antibiotic use
- FODMAP diet
- Over-eating
3 most common SCFAs
3 causes of low SCFAs
- butyrate
- proprionate
- acetate
- Antibiotic use
- Low fibre diet
- Diarrhoea
What can be signs of low mucosal integrity on a CDSA
- High mucin-degrading bacteria
- Low diversity of commensal bacteria
- High gram-negative bacteria
3 symptoms of poor mucosal integrity
- Ulcers
- IBD
- Gastritis
Bacteria strain associated with mucosal degredation
Akkermansia muciniphila
2 bacteria strains associated with autoimmunity
- Ruminococcus gnavis
- Ruminococcus torques
A species of bacteria that can become mucin degrading when there is an absence of diversity in the species
Bacteriodes
2 types of gas-producing bacteria (what gas do they produce)?
- Methanobrevibacteria smithii (methane)
- Desulfovibrio spp. (hydrogen sulphide)
- Bilophila wadsworthia (hydrogen sulphide)
2 bacteria species where raised levels are associated with SIBO
- methanobrevibacteria smithii
- Desulfovibrio
- Definition of a pathobiont
- E.g.
- bacteria that only become pathogenic where there is opportunity (changes in terrain)
- Staphylococcus aureus
2 testing options for H.pylori and what they look for
- Faecal antigen testing (positive or negative)
- Faecal PCR tests (looking for higher than expected amount or specific virulent factors)
3 e.g.s of pathogens
- Giardia spp
- Clostridium difficile
- Shigella
E.g. of a shamed parasite
blastocystis hominis
Key points to analysing a stool test
Pattern and context
- are there signs/symptoms that match the microbe?
- are host markers abnormal?
- is there gut inflammation?
- Is there high /low immune function?
- Lack of diversity?
- pathogenic strains?
2 potential causes of low pancreatic elastase
- chronic stress
- low Hcl
SIBO: definition
How is testing carried out?
Bacterial count in the small intestine of over 105 CFU/ml
Causing fermentation of carboyhydrates.
Subsrates are used for the breath test (lactulose, glucose, fructose)
After the substrate is taken, breath samples are collected every 20 or 30 minutes.
4 causes of SIBO
- Poor MMC
- Low stomach acid
- Low pancreatic juice
- poor ileocaecal valve functioning
Discuss the breath test preparation diet.
24 hours before the test (for an accurate baseline) clients should
- Avoid microbiota-feeding foods
- Foods allowed:
meat, fish, poultry (not cured or brined)
Plain steamed white rice
Eggs
Clear meat broth
Fats/oils
Salt/pepper
What would be a positive result when analysing hydrogen on a SIBO test?
A rise of 20ppm before 90 minutes
What would be a positive result when analysing methane on a SIBO test?
A rise of 12 ppm before 90 minutes
NB constipation - a rise of as little as 3ppm
What would be a positive result when analysing hydrogen and methane combined on a SIBO test?
Combined rise of 15ppm before 90 minutes
What causes bacterial vaginosis?
An imbalance of lactobacilli dominant vaginal composition
Why might you test the vaginal microbiome?
- Bacterial vaginosis
- Recurrent thrush
- infertility
- miscarriages
- endometriosis
- Healthy vaginal pH of a woman of reproductive age
- What does a pH of >4.5 indicate?
- 3.8-4.5
- overgrowth of BV-associated bacteria / dysbiosis
- Aside from pH, what is another vaginal testing marker?
- What causes this marker to be high?
- What is an elevated range?
- Interleukin beta-1 (IL-b1)
- it’s an inflammatory marker made when epithelial cells break apart = infection
- Healthy <220 pg/ml
Elevated >220 pg/ml - BV/candida
Define vaginal health in terms of microbiome
Low diversity and high lactobacilli that create lactic acid. Lactobacilli need to be taking up the most space.
7 ways to support the vaginal microbiome
- Avoid soap
- Avoid antibiotics/copper coil
- avoid lubricants - opt for natural
- Reduce simple carbs, alcohol and stop smoking
- Indlude vaginal probiotics
- Menopause oestrogen support
- Diet full of pre and probiotics
- 2 conditions that oral microbiome dysbiosis is associated with
- 2 serious health conditions associated with oral pathogenic bacteria and the reason for this
- Tooth decay, peridontitis
- CVD, autoimmune disease, Alzheimer’s - due to endotoxin release
7 ways to support the oral microbiome
- Pre and probiotics in the diet
- Minimise carbohydrates
- Avoid snacking so oral pH can recover between meals
- Avoid mercury fillings/removal
5.Oil pull - Probiotic mouthwash
- Use biofilm disruptors (NAC)
Specific health concerns where OAT analysis may be beneficial
CFS
Nutritional deficiencies
Mitochondrial dysfunction
Mood disorders
Labs where OAT can be carried out
Biolab
Genova
Regenerus
What can be given to boost sIgA secretion by mucosal tissue?
Sacharomyces boulardii
Medicinal mushrooms
What is the normal range of pancreatic elastase (PE-1)?
200-500 µg/g
3 benefits and 3 cons of OAT testing
Benefits
1. Good overview of metabolic function
2. Shows need for extra nutrients
3. Helps guide naturopathic care plan into areas for further investigation
Cons
1. hard to interpret
2. Diet imacts markers/changes results
3. not measuring the vitamin directly
5 OAT metabolite groups
- Krebs cycle metabolites
- NT metabolites
- Glycolysis metabolites
- Ketone and fatty acid oxidation metabolites
- Amino acid metabolites
- Bacterial metabolites
- Mould metabolites
OAT interpretation - key points
- outcome if displayed by shpwing how far a client’s result is from the mean
2.Look for anything that’s ‘out of range’ - Use the interpretive guide
- Only a snapshot in time - requires context, case history
Best method for testing B12 and D3
Serum testing
Best testing method to give an indication of ‘tissue levels’
RBC testing - can show minerals and toxic elements taken up into RBCs
Why is serum testing not always reliable for testing for deficiencies?
Because in the blood, many minerals are kepts under homeostatic control, sometimes at the expense of bone/other tissues, therefore blood lvels can be quite stable
- What is a more sensitive index of B12 status compared to serum B12?
- How can it best tested?
Methylmalonic acid
Via serum and urine
- Give a more accurate option for iron tests than serum iron.
- What would be an optimal range?
- Serum ferritin (iron storage capacity)
- 30-100 mcg/l
How might you accurately test for magnesium?
Test cellular levels - test for RBC mg
Best test options for Calcium
OAT testing or possibly serum RBC but not serum calcium as Ca is under strict homeostatic control
What is a key marker of inflammation that is tested by he NHS?
What is the normal range?
CRP
NORMAL: <5mg/L
- What is a better measurment of inflammation than CRP testing?
- What would be the normal range?
- Above what level might be considered low grade inflammation?
- hsCRP - high senstivity
- Normal range 0.2-3mg
- Anything over 2mg/L
Nutrient testing is not easy, what might be the best approach?
Choose a lab that carried out mixed methodology testing
Thyroid testing
- What does standard testing measure?
- What might an expanded panel/functional test measure?
- THS and T4
- TSH, Free T3 or T4 or both, reverse T3 and thryroid antibodies
2 thyroid antibodies tested?
- anti-TPO
- anti-thyroglobulin
What could suggest sub-clinical hypothyroidism on a test?
High TSH and normal T4
What would low THS and high FT4 indicate?
Hyperthyroidism
What is the marker for Grave’s disease?
TPO
Adrenal testing
- What is the best testing option?
- Main approach with this option?
- Main metabolites tested?
- Saliva or urine testing
- 4 point testing - 4 samples throughout the day
- Cortisol and DHEA
DUTCH test
- When might you choose this test?
- When testing female clients, what additional info will you require?
- For reproductive hormone imbalances (low libido, PMS, irregular periods etc.
- Menstrual history and stage
- What are the 3 main oesstrogens?
- What are the three main phase I detoxification pathways for oestrogen?
- E1 (estrone); E2 (Estradiol); E3 Estriol
- 2-OH (safest); 4-OH (most toxic); 16-OH (most oestrogenic)
