GI Flashcards
What does “DIGIN” stand for?
Digestion/absorption Intestinal permeability Gut microbiota/dysbiosis Inflammation/immune modulation Nervous system
(key functional roles and aspects of the gut)
What pathophysiological processes contribute to impairments in digestion & absorption?
Inadequate mastication Hypochlorhydria Pancreatic insufficiency Bile insufficiency Brush Border injury
What are triggers for increased intestinal permeability?
Poor diet, stress, infection, dysbiosis, inflammation, systemic disease, impaired digestion (low stomach acid), toxins, nutritional insufficiencies, medications, food reactions, malnutrition, increased uptake of toxins and lipopolysaccharides
What are the 5-Rs?
Remove - foods, pathogens, stressors, toxins
Replace - digestive factors, HCl, pancreatic enzymes, bile, fiber
Reinoculate - pre-, pro-, & synbiotics; eg. inulin, FOS, soluble fibers, Bifidobacteria, Lactobacillus, S boulardii,
Repair - Gln, Arg, vitamins A/D/C/E/B5, carotenoids, Zn, phosphatidylcholine, etc
Rebalance - relaxation, mindfulness, HRV/biofeedback, etc
What nutrients/nutraceuticals may be used for GI repair?
Nutrients for GI repair & healing: glutamine, arginine, vitamins A, D, C & E, pantothenic acid, carotenoids, Zn
Mucosal lining support - phosphatidylcholine
Mucosal secretion protectants - phosphatidylcholine, plantain, polysaccharides
GALT support - lactoferrin, lactoperoxidase, whey immunoglobulins
Antioxidants - catechins
Anti-inflammatories - curcumin, EPA/DHA
What conditions are causes of conjugated bile acid deficiency?
What nutrients become malabsorbed?
Liver disease, biliary obstruction, SIBO, ileal disease, CCK deficiency
Leads to malabsorption of fat, fat-soluble vitamins, calcium, magnesium
What condition are causes of pancreatic insufficiency?
What nutrients become malabsorbed?
Congenital, chronic pancreatitis, pancreatic tumors, hyperacidity (deactivates pancreatic enzymes)
Leads to malabsorption of fat, protein, CHO, fat-soluble vitamins, B12
What conditions are causes of reduced mucosal digestion?
What nutrients become malabsorbed?
Mucosal disease (ie Crohn’s, celiac), brush border enzyme deficiency (eg. lactase)
Leads to malabsorption of CHO, proteins
What are causes of dysfunctional intraluminal consumption of nutrients?
What nutrients become malabsorbed?
SIBO, parasites
Leads to malabsorption of B12, macronutrients
What conditions are causes of reduced mucosal absorption?
What nutrients become malabsorbed?
Mucosal disease (eg Crohn’s, celiac), intestinal surgery, infections, malignancies
Leads to malabsorption of fat, CHO, protein, vitamins, minerals
What conditions are causes of reduced GI transport?
What nutrients become malabsorbed?
Lymphatic disease, venous stasis (ie CHF)
Leads to poor fat, protein absorption
What conditions can reduce gastric acid and IF production?
What nutrient becomes malabsorbed?
Atrophic gastritis, pernicious anemia, gastric resection
Leads to B12 malabsorption
What conditions can increase gastric emptying and reduce gastric mixing?
What nutrients become malabsorbed?
Gastroparesis, prior surgery, autonomic dysfunction
Leads to malabsorption of fat, protein
What pathogenic mechanisms are likely responsible for non-celiac wheat sensitivity?
FODMAP reactions (intestinal sx only) non-celiac gluten sensitivity Amylase-trypsin inhibitors (ATIs) Wheat germ agglutinin (a lectin) Other identified protein antigens/epitopes
What genetic SNPs are responsible for predisposition to celiac disease?
HLA-DQ2 & HLA-DQ8 - give rise to proteins which display gluten fragments to immune cells
Which are the IFM advanced therapeutic interventions? (4)
Detox, GI-specific, Mito & ReNew
Which are the “first step” IFM dietary interventions
Cardiometabolic, Elimination
then transition to advanced plans, if needed
What are some types of elimination diets?
Comprehensive
Six food - wheat, eggs, dairy, legumes/peanuts, soy, seafood/fish
Four food - wheat, eggs, dairy, legumes/peanuts
Simplified (Caveman) elimination - lamb, rice, pear, sweet potato
Single food group elimination - gluten, egg, dairy
Sugar
FODMAP (low prebiotic, lactose, fructans, galactans, polyols)
Paleo
What are some proposed causes of dysbiosis?
Genetic mutations (NOD2, IL23R, ATG16L, IGRM), diet, stress, poor early colonization (hospital births, altered exposure to microbes), vaccinations, antibiotics, hygiene, T-cell imbalances (low Treg, high Th1, Th2 & Th17)
What are non-immune mediated food reactions?
Toxic Non-toxic: Enzymatic - deficiencies (eg lactase), conversion (eg. scombroid) Pharmacological (eg vasoactive amines) Other - e.g., additive intolerances
What are immune mediated food reactions?
IgE - immediate & late phase allergies
IgA mediated
IgG immune complexes (food sensitivities)
T-cell mediated
What supplements may be useful for:
prevention of food reactions
symptomatic
Prevention: maternal fish oil during breast-feeding, prebiotics, probiotics, breast feeding
Symptomatic herbals: quercetin, stinging nettle
What are possible mechanisms of action for probiotics?
Neutralization of dietary carcinogens, immune stimulation, antioxidant, survival & adhesion competition w/pathogenic bacteria, bacteriocin, bioactive peptides, SCFAs, cholesterol assimilation, oligosaccharides, B-galactosidase activity, organic acids, free amino acids
What type of fiber is useful for microbiome restoration? Give examples
Soluble fiber
Eg. modified citrus pectin, oat bran, barley, nuts, seeds beans, lentils, citrus, apples, strawberries, many vegetables
Note: increases SCFAs
What is the approach to SIBO?
Dx w/breath test or empirically
symptom improvement w/low FODMAP x4-6wks
Antimicrobials and/or probiotics for 2-4 weeks; slow introduction of pre- & probiotic foods
Always treat methane-positive w/antimicrobials
Address root causes
Must restore gut balance to prevent recurrence
What tests are used for assessing GI function?
Stool analysis & PCR gene analysis, OAT, amino acids, fatty acids, mineral analysis, oxidative stress, food reactions, candida immune activity
What are markers for gut immunology?
calprotectin lactoferrin secretory IgA lysozyme eosinophilic protein X
Through what biochemical does the gut microbiota modulate the function and anatomy of the enteric nervous system?
Release of 5-HT and activation of the 5-HT receptor
How does the nervous system effect GI function?
Alters GI motility, increases visceral perception, changes GI secretion, increases intestinal permeability, negative effects on GI mucosal regeneration and intestinal microbiota, portal of entry of pathogens into the CNS
What are the ranges of function for stool pancreatic elastase?
> 350ug/g - Normal
200-350 declining function, consider supplementation
100-200 moderate pancreatic insufficiency; supplement with broad spectrum enzymes
<100 severe insufficiency, supplement with broad array of enzymes
(not impacted by enzyme supplementation)
Note: this works if stool is formed; less reliable with unformed stools due to low levels
What can cause exocrine pancreatic insufficiency?
Chronic pancreatitis, DM, celiac, IBD, CF, alcohol, gallstone disease and other obstructions of pancreatic duct, gastric ulcers, anemia, Crohn’s, Zollinger-Ellison syndrome, bone loss, neurological problems
What are the ranges of function for stool calprotectin?
<50ug/g - no inflammation
50-120 - some inflammation
>129 - significant inflammation; refer for pathology
>250 - active disease present; predicts imminent relapse in treated patients
What are some stool markers of inflammation?
Calprotection
Lactoferrin
Eosinophilic protein X
What are benefits of butyrate?
Intestinal health, immune-balance, anti-inflammatory, CA suppression, neuronal health, longevity, weight control & satiety, insulin sensitivity, dietary balance, reversal of damage of alcohol, microbiome balance, gut motility, bone health
Note SCFAs= butyrate, propionate, acetate; impt energy source for colonocytes, liver cells, skeletal muscle
What can elevate stool beta-glucoronidase?
Tobacco, toxins & carcinogens, red meat, Abx
What does elevated stool beta-glucoronidase a marker for?
Increased risk of hormone-dependent cancers (esp of breast and prostate)
What is the risk of secondary bile acids (SBAs) ? Where do they come from?
Elevated SBAs (hydrophobic) can cause intestinal cell membrane damage, increase inflammatory cytokines, and increase risk of colorectal CA
Formed from bacterial metabolism of bile acids and increased primarily by red meat and saturated fats
When should Blastocystis hominis be treated?
If patient is symptomatic, or if one of the more virulent subtypes are detected by PCR.
Symptoms: IBS, cutaneous (urticaria, pruritis, intense palmoplantar itching; from mast cell degranulation)
Sub-type 3 has strong correlation with disease. Also 1,2,4 and 6 have been associated with symptomatic patients
Note: short-term exacerbation with die off can occur
What protozoans have been associated with intestinal permeability?
Blastocystis, Giardia
What are some Rx treatments for parasites?
Nitozoxanide, metronidazole, tinidazole, iodoquinol, paramomycin
What are some botanical treatments for parasites?
Black walnut hulls, wormwood/Artemisia, bitterwood/Quassia, garlic, goldenseal, oil of oregano, olive leaf extract, citrus seed extract, thyme
x4-6 wks
What are some Rx & duration used for dysbiosis?
Cipro/norflox, co-trimoxazle, rifaximin (DOC for SIBO)
x 7-10days
What are some herbals used for dysbiosis, and duration of treatment?
Garlic, goldenseal, all berberine, wormwood/Artemisia, clove, curcumin, echinacea, Glycyrrhiza, grapefruit seed extract, oregano oil, sage thyme, uva ursi, usnea
x 4-12 weeks
What are signs and symptoms of hypochlorhydria?
Bloating or belching immediately after a meal, Sense of fullness after eating, Rectal itching Weak, peeling or cracked fingernails Post-adolescent acne Undigested food in stool Dilated capillaries in the face Iron deficiency Chronic intestinal infections Multiple food allergies Morning diarrhea/diarrhea after big meals Constipation N/V/GERD flatulence Symptoms worse after eating meat or protein, Or NO symptoms
What are signs and symptoms of pancreatic enzyme insufficiency?
Indigestion/fullness 2-4 hours after meal
Bloating or flatulence 2-4 hours after meal
Undigested food in stool
How can you support gastric acidity?
Betaine HCl w/protein-containing meal Umeboshi plums Digestive enzymes with acid pH range Bitters (gentian, ginger, wormwood, Angelica, cinnamon, rhubarb, myrrh, orange peel, fennel, dandelion root, artichoke) - usually 30-60 drops before meals Gentian root Vinegar Decrease stress: increase vagal tone, HRV Acupuncture
What are some pancreatic enzymes and how long are these used?
Pancreatin (mix of lipase, proteases & amylases), porcine or bovine derived: 500-2500U/kg/meal
Bromelain, papain
Also, lactase, gluten support enzymes,
Used long-term
What are cholagoges/choleretics that may be used and the duration? Food cholagogues?
Dandelion root 2-4g w/food, taurine, limonene Bile salts (ox bile) 500-1000mg w/food - Treatment time is variable
Foods which act as cholagogues: coffee, radishes, dandelion, chicory & other bitter greens, artichoke
What are the 3 criteria necessary for prebiotic food?
- Must be non-digestible
- Must be fermented in the GIT tract by endogenous anaerobic colonic bacteria
- Must be selective in the stimulation of intestinal flora/metabolic activity
Fruit-oligosaccharides and galactic-oligosaccharides are the two most important groups of probiotics
Examples:
FOS, inulin, larch, modified citrus pectin
Jerusalem artichokes, onions, garlic, chicory, bananas, asparagus, peas, legumes, eggplant, honey, green tea, yogurt
What conditions can probiotics be beneficial for?
What is the treatment duration?
allergic rhinitis, atopic dermatitis, depression (L helventicus, B longum, L casei), GI conditions/IBD/IBS, recurrent UTIs, bacterial vaginosis, systemic inflammation, dental caries, constipation, CV risk reduction, RA, radiation-induced diarrhea, H pylori
Treatment duration is indefinite or until fundamental diet change for 3 months
What interventions have been shown to change the microflora of the gut?
Dietary changes and stool transplants
What are some GI immune enhancers (ie support IgA production)?
Whey protein with concentrated immunoglobulins 15-30g/day
Saccharomyces boulardii 500mg-3g/day
Glutamine 5-10g QD-TID
Larch 2-10g TID
What is a foundational anti-inflammatory protocol?
5 components
Elimination Diet Probiotics Vitamin D Omega-3 fatty acids L-glutamine
What are weight-based dosing ranges for vitamin D?
30-75lbs = up to 1000 IU/day 76-125lbs = up to 2-3000IU/day >125lbs = up to 4-5000IU/day
Acute protocol 50,000IU once/twice per week for 8 weeks - check levels in 8 weeks
What are weight-based dosing ranges for omega-3?
30-75lbs = at least 1g/day
76-125 lbs = at least 2g/day
>125lbs = 3+g/day
(for CV and cognitive fun, dosages of 3-20g/day have been used; caution re hypocoagulability)
What is the dosing range for L-glutamine?
Depends on clinical situation
2-4g/day in divided doses for wound healing and general intestinal support
10-40g/day in divided doses for critically ill and advanced disease
What conditions are classified as non-IgE, allergies heterogeneous group?
Celiac disease, eosinophilic esophagitis, eosinophilic gastroenteritis
(Type 4, cell-mediated food reactions)
What food sensitivities are non-immune mediated food reactions? and their mechanism
Lactose intolerance (lactase deficiency) Tyramine, histamine intolerance (monoamines) MSG, aspartame, sulfites Salicylates (eicosanoid metabolism) Lectins (indirect immune stimulation)
What are the 4 classifications of immune-mediated food reactions? (Gell and Coombs classification)
Type 1: IgE-mediated (mast cell degranulation)
Type 2: Cytotoxic (IgG, IgM, complement)
Type 3: Delayed hypersensitivity (IgG mediated, complement)
Type 4: Cell mediated - activated macrophages (e.g. celiac, EOE)
What are ATMs associated with food allergies?
Genetics, epidermal permeability, medications, environmental toxins, nutrient deficiencies, hypochlorhydria, microbiota, stress, intestinal permeability
What are markers for testing for celiac disease?
Total IgA, tissue transglutaminase antibody IgA/IgG, deaminated antigliadin antibody IgA/IgG, antiendomysial antibodies IgA HLA DQ2 (more common), DQ8 Antigliadin IgG to expand beyond celiac
What are some botanicals for reducing food reactions?
Bronchodilation: magnesium chelate, caffeine
Anthihistamine: stinging nettles
Antileukotriene: quercetin
Prostaglandin balancing & anti-inflammatory: omega-3
What foods are eliminated in the 6-food elimination diet?
Dairy, wheat, eggs, tree nuts/peanuts, soy, seafood
useful for EOE
What are potential reactions to elimination diet? And how to treat?
Herxheimer (die off) - activated charcoal 4 capsules BID-TID & buffered C TID-QID
Withdrawal (detox overload) - Alka Seltzer Gold
Changes to GI fxn - fiber, chamomile/peppermint tea, peppermint capsules, magnesium citrate + buffered C for constipation
Hypoglycemia - frequent protein and fats
Coffee/simple sugar - buffered C
What to use for relief of loose stools in IBS-D, Constipation in IBS-C and distention/bloating/pain in IBS-M?
IBS-D: bulking agents like soluble fiber, probiotics, probiotics
IBS-C: optimal hydration, motility agents (insoluble fiber, magnesium oxide/citrate
IBS-M: carminative agents (eg. peppermint, fennel, ginger)
What are signs of pancreatic exocrine insufficiency?
Steatorrhea, diarrhea, gas & bloating, stomach pain, weight loss; fatigue, glucose intolerance, malnutrition, bulky stool
What factors contribute to pancreatic enzyme deficiency?
Damaged microvilli, toxicity, stress, nutritional insufficiency, imbalanced pH, inhibitors in food, free radical oxidation, alcohol abuse
What are some foods which help to stimulate digestive enzyme production?
Pancreatic amylase: ginger, curcumin
Lipase: curcumin
Disaccharidases (sucrase, lactase, maltase): coriander, onion; at least one - ginger, ajowan, fennel, cumin, asafetida, curcumin, capsaicin, piperine
Bile, lipase, amylase: mint & fennel
What increases the risk of hypochlorhydria?
Surgery, autoimmune gastritis, aging, stress, fasting, H pylori, PPIs/H2 blockers/antacid abuse, severe iron deficiency, viral or bacterial infection (fever), any debilitating chronic condition (as it takes 600-800 Cal/day to concentrate enough H+ ions)
How can you test for hypochlorhydria?
Heidelberg capsule and smart pill
Products of protein breakdown/Putrefactive SCFAs (valerate, iso-valerate, iso-butyrate) from fermentation of amino acids
Betaine HCl self test: take 1 tablet (350-750mg) with protein-containing meal; if any negative sx (tingling, GERD, diarrhea, neck ache), STOP
- if no change or improvement, continue x 2 days, then increase to 2 tablets; continue increasing up to 2500mg with meals and stop or reduce if any discomfort.
Baking soda and water self test: put 1/4 tsp into 4oz of water and drink on an empty stomach. Should be burping within 5 minutes
What are signs of bile salt insufficiency?
Incomplete digestion/absorption of fats Steatorrhea, diarrhea Bitter taste in mouth after meals N/V Queasy after fatty meal Constant feeling of fullness Deferred pain to head, abdomen, under shoulder blade, etc
How to test for fat malabsorption/maldigestion?
72-hr fecal fat test (100g of fat/day over 3 days)
Fecal fat stain
Fecal fat testing (TGs, LCFAs, cholesterol, phospholipids)
How to test for GI transit time?
Use a marker (charcoal tabs 1.5-3g, a large beet) - see how long it takes until you see the color in stool:
<12hrs - reduced absorption of food
12-24hrs - optimal
>24hrs - slow bowel transit
>48-72 hrs - waste is sitting too long; will be reabsorbing water, hormones, wastes; may also negatively affect SCFA and distal colonic pH
What can be done to support GI motility?
increase fiber, hydration Probiotic rich foods, fermented foods Psyllium husk, pectin, flax seeds Cod liver oil Natural laxatives: aloe vera, senna, buckthorn, rhubarb *caution with anthracyclines) Rx: metoclopramide, LDN, erythromycin
Natural pro kinetics: Iberogast, ginger root, tryptophan, magnesium citrate, vitamin C, vitamin D (5000IU/day), Swedish bitters, limonene, triphala, acupuncture, acupressure, deep breathing, stress reduction, exercise
What are potential signs and symptoms of dysbiosis?
Recurrent gas or bloating Cramping, urgency, mucus in stools Brain fog, depression, anxiety Food sensitivities Chronic bad breath Loose stool, diarrhea, and/or constipation IBS Carb intolerance Fatigue Micronutrient deficiencies
How can we test for dysbiosis?
Stool testing: microscopy, enzyme immunoassay (EIA) antigen testing, culture/PCR, metagenomics (16s PCR) - future, metabolomics (SCFAs, metabolites)
OAT (experimental): DHPPA, 3-OHphenylacetic acid. 4-OHphenylacetic acid, benzoic acid, hippuric acid for bacterial dysbiosis; d-arabinose, citramalic acid and tartaric acid for yeast/fungal dysbiosis)
Small intestinal breath testing
What is the difference between metagenomics and metabolomics?
Metagenomics = composition of the gut flora Metabolomics = the metabolic activity of the microbiota
What are symptoms of yeast dysbiosis?
Fatigue, poor memory, spacey, insomnia or hypersomnia, anxiety, mood swings, muscle and joint aches, alcohol intolerance, pruritis
How to treat intestinal yeast?
Dietary: eliminate all sugar (juice, white flour, refined grains), eat higher protein, lower carb, high fiber diet, avoid fermented foods and alcohol
Probiotics & biofilm treatments for yeast: S. boulardii 250mg BID, probiotics (Lactobacillus, bifidobacter), enzymes (amylase, peptidase, lipase)
Botanical Treatments: oregano oil, thyme, garlic, goldenseal
Tx: Nystatin, fluconazole, ampho B, etc
4-8 weeks of treatment
What probiotic may be used for treatment of difficult C. diff?
S. boulaardi 250mg BID x2-4 wks; + Rx treatment
What are some diets used for microbiome restoration?
Soluble fiber (modified citrus pectin, vegetable fibers)
Fermented foods
Specific carbohydrate diet (undigested carbs feed)
Low FODMAP
What are environmental risk factors for IBD?
Smoking, urban living, appendectomy, tonsillectomy, Abx, OCP, soft drink consumption, vitamin D deficiency, non-H pylori-like enterohepatic Helicobacter species
What are 7 factors which reduce risk of IBD?
Physical activity, breast feeding, bed sharing, tea consumption, high levels of folate, high levels of vitamin D, H.pylori infection
What dietary components can decrease IBD risk?
fiber (in CD, but not UC), fruit, vegetables, high n-3 FA
What dietary components can increase IBD risk?
Animal protein, heme iron, sulfur, refined sugars high-fat (trans)
Emulsifiers, maltodextrin promote dysbiosis and IBD (adherent invasive E coli, biofilms, increased cytokines)
Probiotics & prebiotics may not be effective for CD or UC?
CD - probiotics and prebiotics are not recommended
UC - could be considered as an adjuncts to Rx
For what condition has SCFA enemas shown to be beneficial for?
Refractory distal ulcerative colitis
What interventions could be considered for “Repair” in IBD?
Omega-3 FAs, immunoglobulins (whey protein or serum bovine-derived), vitamin D, l-glutamine, larch, bioflavonoids (quercetin, rutin, wheatgrass, ginger, turmeric, green tea, boswellia)
What herbals have best evidence for UC and CD?
UC: plantago ovata and curcumin for maintenance
CD: wormwood
What are risk factors for diverticular disease?
Men; more virulent if <50yo, but incidence increases w/age
Low-fiber diet
Obesity
Low physical activity
Industrialized nations
Chronic NSAID use, opioids & corticosteroids increase risk of perforation (note CCBs reduce risk of perforation)
How to reduce risk for diverticulitis by 75%?
BMI 18-25, red meat <4/wk, >23g fiber/day, exercise 2hrs/week, no smoking
How to treat diverticulitis?
Antibiotics (cipro/metro), anti-inflammatory medical food or low-residue diet, organic kefir, mesalamine 2.4g daily, exercise, stress reduction
What are modifiable factors that influence the microbiome?
Diet, circadian rhythm, timing of meals, stress, movement, chemical exposure, antibiotic usage, drugs;
Also vaginal or C-section birth, breast or bottle fed, pets & farm animals, # of siblings, age, culture, geographic location, genetics, health status
How does plant protein impact the microbiome, as compared to animal protein?
Plant protein (whey, pea, etc): increases Bifidobacterium, Lactobacillus & decreases Bacteroides, Clostridium perfringens; increased SCFAS, Tregs, gut barrier function and decreases inflammation
Animal protein: Increases Bacteroides, Allistipes, Biloohila, Ruminococcus & decreases bifodobacterium, decreased SCFAs (leading to IBD) and increases TMAO (leading to CVD)
What are some of the functions of the vagus nerve in the GIT?
Upregulates mechanical breakdown of solid foods
Stimulates release of digestive enzymes and bile
Allows for accommodation of food in stomach
Slows gastric emptying
Coordinates motility of the intestines
Decreases inflammation and intestinal permeability
Enhances satiety
What are some ways to enhance vagus nerve function?
B. longum probiotics, deep breathing & mind-body techniques, acupuncture Singing loudly, chanting, music Enhance serotonin Gargle vigorously several times a day Gag Strength training Coffee enemas
What diets would be considered for dysbiosis? (ie restriction of prebiotics and carbs)
Low FODMAP (use for IBS)
Specific carbohydrate diet (IBD)
Anti-fungal diet (for fungal overgrowth)
Elemental Nutrition diet (IBD)
What diets would be considered for immune/inflammation/increased permeability? (ie low antigenic diet)
Gluten free/casein free/egg free Comprehensive elimination diet Celiac disease: gluten free Low histamine diet Renew/Paleo Immune
What diet has been shown to be helpful for EOE or gastritis?
6-Food Elimination diet (cows milk [most common antigen], soy, wheat, egg, peanut/tree nuts, shellfish)
Note - food allergy testing not predictive of food triggers
What are indications for Specific Carbohydrate Diet?
Failed elimination diets
Pediatric IBD
Empiric (ie foods on diet are ones they feel well on)
Carb intolerance
Disaccharidase deficiency (ie lactase, sucrase, maltase)
Dysbiosis (SIBO, candida/fungal overgrowth)
What are allowed foods in the Specific Carbohydrate Diet?
Non-starchy veg Honey, fruit, juice Dairy - homemade yogurt, hard cheese, dry-curd cottage cheese Meat - fish, poultry, beef, bison, lamb Legumes - string beans, lima beans Nuts, seeds, nut butters Oils: avocado, coconut, olive, ghee Broths
What are components of an autoimmune diet for IBD?
Eliminate grains, legumes, nightshades, dairy, eggs, coffee, alcohol, nuts, seeds, refined sugars, oils, food additives
Eat fresh foods, bone broth, fermented foods
What are allowed foods in the Paleo Immune diet?
Protein - animal, eggs, protein powder, beans, hemp
All non-starchy veg
Fruits - berries, cranberries, cherries, kiwi, pomegranate
All nuts and seeds
Oils & fats - avocado, coconut, ghee, butter, olive, sesame
Dairy alternatives - coconut or nut/seed milk
Beverages - broth, seltzer, decaf teas, coconut water kefir, freshly made veggie juice, water
Herbs and spices
Condiments - coconut aminos, lime/lemon juice, miso, stone ground mustard, tamari, vinegars
What is the ReNew food plan?
A whole systems reboot for autoimmune, GI, neuro and other chronic health conditions.
Reduces inflammatory foods, eliminates potentially addictive and harmful foods, support for detox
Short term for 2-3 weeks
Removes all sweeteners, processed foods, dairy, gluten, grains, alcohol, caffeine, saturated animal fats, most legumes, shellfish/tuna, soy
What is the Restoration Diet?
For debilitated, frail or people who can only digest limited amount of foods
Includes:
Medical foods, bone broths, pureed foods, smoothies, soups, slow-cooked animal proteins, congee, juiced or well-cooked veggies, really ripe, cooked or pureed fruits, healthy fats, fermented foods (non-dairy kefir, kraut juice, sauerkraut, umeboshi plums)
What is the Elemental diet?
For people with malabsorption to support healing and decreases intestinal permeability
Hypoallergenic, predigested, easily absorbed, non-solid x 2weeks, tastes terrible
Contains free amino acids, MCT, glucose or maltodextrin, vitamins, minerals
Absorbed high in GI tract before fermentation can occur
eg. EOE, IBD, refractory celiac, pancreatitis, SIBO, pouchitis, radiation-induced mucosal damage; also RA; Tx for dysbiosis - starves microbes
* Caution w/dialysis or diabetes, weight loss
Gradual reintroduction of foods, starting with meats, eggs, white rice and lactose-free dairy
What js a low FODMAP diet?
Eliminates food that are fermentable and high in olig0-, di-, and mono-saccharides and polyols
For IBS, gas, bloating, diarrhea
Lasts for at least 2-6 weeks, with additional 5 weeks of reintroducing each sub-group
What is the anti-fungal diet?
Eliminates all sweeteners, processed meats, peas, some nuts, high sugar fruits, grains, yeasted breads, starchy veggies, mushrooms, fermented foods, caffeine.
For people with hx of chronic antibiotic use, immune suppression, history of fungal infections, sugar cravings
Usually for 1-6 months or until symptoms improve
What are possible causes of intestinal permeability?
Nutritional - tight junction downregulation, histone deacetylase inhibitors, enteric nervous system modulators
Infections & toxins
Hygiene hypothesis
Lifestyle - impaired function and diversity of microbiome
Endogenous factors - hypoperfusion of intestines, chronic inflammation and auto-immunity
SIBO, protozoal infections
Chronic alcoholism
IBS, AD, PD, metabolic disease, etc
Strenous exercise
Increasing age
Nutritional depletions
What is the role of toll-like receptors?
Act as gates for controlling the immune system
Can react to gut flora and bacterial DNA, recognizing them as normal or foreign
Defects can increase inflammation (e.g. NOD2 portions of TLR defect in Crohn’s)
How does the microbiome modulate the immune system?
Increase sIgA, cytokine modulation, decrease epithelial permeability, maturation of dendritic cells, increase Treg activation
Which probiotic species has been shown to inhibit pathogenic biofilms?
Lactobacillus
How can lactulose & mannitol test be interpreted?
Lactulose/mannitol test - non metabolizable sugars; mannitol passes intestinal mucosa via transcellular uptake, lactulose diffused paracellularly and usually held back by tight junctions
L/M index high w/permeability
Normal/high mannitol, high lactulose = increased permeability
Low mannitol and lactulose = malabsorption
Low mannitol and high lactulose = increased permeability + malabsorption
What are tests for intestinal permeability?
Lactulose/mannitol index (significant false negatives due to small size compared to antigens) Zonulin testing (increased w/permeability) Antibody testing (antibodies against zonulin, occludin, lipopolysaccharides, actomyosin network) - presence suggests tight junction breakdown (experimental)
Note: single measures of zonulin not recommended due to its fluctuation; antibodies preferred
What conditions can increase calprotectin and lactoferrin? (released by activated neutrophils)
IBD, post-infectious IBS, GIT CA, GI infections, NSAID enteropathy, food allergy, chronic pancreatitis
Note - fecal more accurate than serum, though not specific for IBD; can still be useful for differentiating inflammatory disease from functional bowel disorders
What can lower sIgA production in the gut?
Dietary restriction (lowers thyroid function and slow autonomic functions), excessive alcohol intake, body mass loss, negative mood, anxiety
Note - sIgA may be good marker of overall nutrition status, overtraining in athletes and of infection in the gut
What is lysozyme and what is its significance in lab testing?
An antimicrobial peptide which attacks bacterial cells walls (innate protection).
Found to be unregulated in various inflammatory GI diseases and therefore useful for determining colonic inflammatory activity.
Fecal lysozyme >2000 suggests IBD
How is SIBO defined? What are symptoms?
SIBO refers to abnormally large numbers (>10,000 per mL of aspirate) of bacteria the small intestine AND decreased biodiversity (usually colonic gram-neg organisms)
Symptoms: gas, bloating, abdomen discomfort, diarrhea, steatorrhea (bacteria deconjugate bile salts, damage mucosa), weight loss, symptoms from micronutrient deficiencies (vitamin B12, A,D, E, K, iron, thiamine, niacin)
What conditions has SIBO been associated with?
IBS (78% of patients test positive), fibromyalgia, chronic fatigue
SI dysbiosis can damage intestinal villi
What are causes of SIBO?
Medications (PPI, narcotics), hypochlorhydria (old age), enzyme deficiencies, anatomical disturbances, hypothyroidism, motility issues, ileocecal valve issues, abnormal salivary IgA, duodenal bile, low hemoglobin, IBS-D, celiac, cirrhosis, chronic pancreatitis
Results from carb maldigestion and malabsorption, leading to SIBO -> bacterial enzymes and toxins cause mucosal damage and inflammation
What malnutrition conditions can result from SIBO?
Unabsorbed fatty acids form soaps with calcium and magnesium -> osteomalacia, bone disease
Vitamin B12 deficiency (bacteria use B12 and detach it from intrinsic factor)
Hypoproteinemia
Iron deficiency anemia (rare)
Note: also can cause elevated serum folate and vitamin K from bacterial production
What tests can be used to diagnose SIBO?
Direct: quantitative culture
Indirect: 14C d-xylose, hydrogen breath tests after ingestion of lactulose or glucose (>20ppm after 90minutes)
- methane gas also produced
- hydrogen sulfide gas (usefully H & CH4 flat-lines)
Also urinary and serum tests
imaging to determine mechanical causes of SIBO
Which methanogens feed on hydrogen?
Archaea, a primitive bug;
Certain clostridium and bactericides also produce methane
What types of SIBO are associated with diarrhea vs constipation?
Hydrogen-dominent SIBO - diarrhea
Methane-dominant SIBO - constipation (b/c methane delays intestinal transit and possibly a neuromuscular transmitter)
What are SIBO subtypes and their severities?
Hydrogen - mild; easily corrected w/diet or one course antimicrobial
Methane - moderate; needs diet and antimicrobials for extended period
Hydrogen + Methane: recurrent - returns after 4wks of Rx
Hydrogen sulfide: refractory - fails multiple rounds of therapy
What are the general treatment options for SIBO?
Diet (low FODMAP) Antibiotic Tx Prokinetics Herbs for weeding (berberine, oregano oil, wormwood) Probiotics Serum bovine-derived immunoglobulines Enzymes/HCl
What is an herbal approach to SIBO?
Candibactin-AR, Candibactin-BR
FC-Cidal, Dysbiocide
What are lectins? What foods contain lectins and how can they be minimized?
Lectins are proteins which bind sugars. Can bind to glycoproteins on the intestinal lining leading to barrier damage. May induce DAMP-associated inflammasome activation.
Found in most foods, but especially in grains, dairy, legumes and nightshades.
Cooking, soaking and fermenting will reduce lectin content
What is the duration of botanical antimicrobials for dysbiosis?
6-12 weeks + diet + pre/probiotics for bacteria
4-8 weeks for fungal/yeast
6-12 weeks for parasites (usually Rx better)
