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Copyright © 2015 All rights reserved.

Neither this document nor any part of it may be reproduced or transmitted in any form or

by any means including photocopying, email, fax, etc. without prior written

permission of the author.

Advanced Clinical Focus: Digestion and GI Health

presented by Josh Gitalis

Advanced Clinical Focus:Digestion and GI HealthDigestion

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ADVANCED CLINICAL FOCUS

What you will learn...

• The digestive process

• The 5 R’s of digestive healing

• Leaky gut syndrome

• Autoimmune disease

• Allergies

• IBD

• IBS

• Digestive healing diets

• Therapeutic foods

Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved


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What you will not learn...

• Protocols

• One-size-fits-all


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GI Facts

• Largest surface area that interacts with the environment

• Site where the needs of nutrient absorption and host defences collide


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GI Facts


The Digestive Process


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The Digestive Process


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Complex Ecological Network

• Proper pH

• Smooth muscle tone

• Stomach acid

• Pancreatic enzymes

• Bile

• GI Mucosa

• Microbiome

• Lifestyle



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Components

• Digestion: break down of foodstuff in progressively smaller units

• Absorption: food across membrane

• Assimilation: converting food into cells

• Elimination: removing metabolic waste and byproducts


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Digestive Regulation

Digestion

Nervous System

Autonomic Nervous System

24+ Hormones

SNS PNS



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Soil, Air, Water, Sun Into You


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Soil Into You


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The Cephalic Phase

• Conditioned reflex

• 20%-50% of gastric secretion and hormones



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There Are No Teeth in Your Stomach

• Release of plant enzymes

• Salivary amylase

• Salivary lipase

• Nitrate-reducing bacteria


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Importance of Oral Flora

• Gastroprotective and blood pressure lowering effect of nitrates.

Bacteria in the mouth convert nitrates into nitrite then bioactive circulating nitric oxide.

“Excessive use of antiseptic mouthwashes may attenuate the bioactivity of dietary nitrate.”


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Importance of Oral Flora



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Oral Microbiota and KissingRESEARCH Open Access

Shaping the oral microbiota through intimatekissingRemco Kort1,2,3*, Martien Caspers1, Astrid van de Graaf2, Wim van Egmond2, Bart Keijser1 and Guus Roeselers1

Abstract

Background: The variation of microbial communities associated with the human body can be the cause of manyfactors, including the human genetic makeup, diet, age, surroundings, and sexual behavior. In this study, we investigatedthe effects of intimate kissing on the oral microbiota of 21 couples by self-administered questionnaires about their pastkissing behavior and by the evaluation of tongue and salivary microbiota samples in a controlled kissing experiment. Inaddition, we quantified the number of bacteria exchanged during intimate kissing by the use of marker bacteriaintroduced through the intake of a probiotic yoghurt drink by one of the partners prior to a second intimate kiss.

Results: Similarity indices of microbial communities show that average partners have a more similar oralmicrobiota composition compared to unrelated individuals, with by far most pronounced similarity for communitiesassociated with the tongue surface. An intimate kiss did not lead to a significant additional increase of the averagesimilarity of the oral microbiota between partners. However, clear correlations were observed between the similarityindices of the salivary microbiota of couples and self-reported kiss frequencies, and the reported time passed after thelatest kiss. In control experiments for bacterial transfer, we identified the probiotic Lactobacillus and Bifidobacteriummarker bacteria in most kiss receivers, corresponding to an average total bacterial transfer of 80 million bacteria perintimate kiss of 10 s.

Conclusions: This study indicates that a shared salivary microbiota requires a frequent and recent bacterial exchangeand is therefore most pronounced in couples with relatively high intimate kiss frequencies. The microbiota on thedorsal surface of the tongue is more similar among partners than unrelated individuals, but its similarity does notclearly correlate to kissing behavior, suggesting an important role for specific selection mechanisms resulting from ashared lifestyle, environment, or genetic factors from the host. Furthermore, our findings imply that some of thecollective bacteria among partners are only transiently present, while others have found a true niche on the tongue’ssurface allowing long-term colonization.

Keywords: Intimate kiss, Oral microbiota, Tongue, Saliva, Next generation sequencing, Streptococcus, Lactobacillus

BackgroundMouth-to-mouth contact has been observed in a widevariety of animals, including fish, birds, and primatesand serves a range of functions, including the assess-ment of physical abilities and the acquirement of food.However, intimate kissing involving full tongue contactand saliva exchange appears to be an adaptive courtshipbehavior unique to humankind and is common in over

90% of known cultures, as reported in [1] and referencesherein. Interestingly, the current explanations for thefunction of intimate kissing in humans include an im-portant role for the microbiota and viruses present inthe oral cavity, although to our knowledge, the effects ofintimate kissing on the oral microbiota have never beenstudied to date.A recent study on the importance of kissing in human

mating situations proposes that the first kiss serves as auseful mate-assessment function and the following formediation of feelings of attachment in long term rela-tionships, rather than the facilitation of sexual arousal[1]. Kissing may contribute in mate assessment andbonding via sampling of chemical taste cues in the saliva

* Correspondence: [email protected] Microbiology and Systems Biology, Utrechtseweg 48, 3704 HE Zeist,The Netherlands2Micropia, Natura Artis Magistra, Plantage Kerklaan 38-40, 1018 CZAmsterdam, The NetherlandsFull list of author information is available at the end of the article

© 2014 Kort et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.

Kort et al. Microbiome 2014, 2:41http://www.microbiomejournal.com/content/2/1/41

Kort et al. Microbiome 2014, 2:41


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Swallow Food

• Stomach expands

• Release of HCl (parietal)

• Release of intrinsic factor (parietal)

• Pepsinogen → pepsin (chief)

• Predigestion

• pH decreases



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Predigestion

60% of Carbohydrates30% of Protein10% of Fat


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With Sufficient HCl

• Enzymes deactivated

• Tissues softened

• Microorganisms sterilized

• Food in stomach 30min - 2 hours



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The Triad of Stomach Protection

1. Mucous

2. Bicarbonate

3. Blood


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pH Decreases to 1.5-3

• Minerals ionized

• Pyloric sphincter relaxes

• Chyme into duodenum


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Minerals Ionized

KCl Ionized



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Minerals Ionized

KCl K+ + Cl-


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Minerals Ionized

KCl K+ + Cl-Stomach

Acid


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pH Decreases to 1.5-3

• GB squirts bile into duodenum

• Pancreas secretes enzymes and bicarbonate

• Bicarbonate and bile neutralize chyme



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Gallbladder

• Bile:

• Bile salts

• Pigments (bilirubin)

• Cholesterol

• Phospholipids

• Thick greenish-yellow

• Formed by hepatocytes

• Emulsifies

• Stimulated by fat


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Pancreas

• Bicarbonate

• Amylases

• Lipases

• Proteases


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Small Intestine

• 15-20 feet

• 3-6 hour journey

• Almost all absorption

• GALT (A.K.A. MALT)



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Small Intestine

• Pancreatic enzymes

• Brush border enzymes

• Bile re-absorbed


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Small Intestine: Absorbed into Blood

• Minerals

• Water-soluble vitamins

• Amino acids

• SCFA


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Small Intestine: Absorbed into Lymph

• MCFA

• LCFA

• Fat-soluble vitamins



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Colon• 3-5 feet long, 2.5 inches thick

• No microvilli

• Goblet cells

• Fecal matter:

• Bacteria

• Fibre

• Intestinal secretions

• Cellular debris

• Bile salts


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Colon

• Bacteria make vitamin K and some B-vitamins

• “Bad” bacteria metabolize end products

• With fibre and water, wastes eliminated

• Food particles

• Metabolic waste

• Bacteria

• Water absorbed


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Lipski. Digestive Wellness: 4th Edition. 2012. pp. 19



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Transit Time

• Ideal = 18-24 hours

• Avg. = 72 hours


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FibreEast Africans • 100 g of Fibre • 18-24 hours

transit time

North Americans • 25 g of Fibre • 72 hours transit time

Jensen, Bernard. Dr. Jensen’s Guide to Better Bowel Care. Avery: 1999.

The “5 R’s”



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Digestive Healing


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Diet Functional Foods

SupplementsLifestyle


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Factors to Consider

• Symptom control

• Modified diet

• Heal the gut

• Reintroduce and rebalance





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1. Remove

2. Replace

3. Reinoculate

4. Repair

5. Rebalance

The 5 R’s of Digestive Healing


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Remove: What?

• Pathogens

• Allergens/sensitivities

• Irritants/toxins


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Remove: How?

• Antimicrobials:

• Pharmaceuticals

• Neutraceuticals

• pH

• Starve

• Crowd out


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Remove: Antimicrobials

• Garlic

• Oregano oil

• Grapefruit seed extract

• Olive leaf

• Berberine (goldenseal, oregon grape)

• Black Walnut Hull

• Plant oils (thyme, oregano, peppermint)


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• Oregano oil caps, 200mg TID

• Thyme, standardized thymol, 100-200 mg TID

• Goldenseal, standardized berberine, 200-400 mg TID

• Artemisia/Chinese Wormwood 1-3 g TID



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Alkaline Diet• Meat, eggs

• Coffee

• Grains

• Nuts

• Dairy

• Oils

• Sugar

• Alcohol

• Drugs and chemicals

• Fruit/veg, sea salt

• Organic chicken breast

• Organic eggs

• Herbal tea

• Millet

• Sprouted nuts, seeds

• Organic yoghurt

• Apple cider vin.


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Remove: Starve

• Eliminate sugar and alcohol

• Eliminate grains

• Eliminate monosaccharides,disaccharides, polysaccharides

• Eliminate FODMAPs



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Replace

• Digestive factors:

• Water

• Hydrochloric acid

• Enzymes

• Bile

• Fibre


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Replace: Water

• Symptoms:

• Dry skin, lips

• Thirst

• Constipation

• Yellow pee

• 1 oz. per Kg of body weight


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Hydrochloric Acid

• Beginning of the digestive cascade

• Ionizes minerals

• Activates pepsin

• Sterilizes (immune)

• 50% over 60

• 85% over 80



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Hypochlorhydria

• Protein putrefaction

• Carbohydrate fermentation

• Formation of Sulfur compounds


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Hypochlorhydria: Clinical Cues

• Bloating, burping, burning and flatulence immediately after meals

• Fullness

• Feeling as though food sits for hours

• Indigestion, diarrhea, or constipation

• Food allergies

• Nausea after taking supplements

• Itching around rectum

• Weak nails

• Dilated blood vessels in cheeks

Indigestion, Antacids, Achlorhydria and H. Pylori. American Journal of Natural Medicine. (Jan-Feb 1997): 11-16


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Hypochlorhydria: Clinical Cues

• Acne

• Iron deficiency

• Chronic parasite/infection

• Undigested food in stool

• Chronic candida

• Upper GI gas

Indigestion, Antacids, Achlorhydria and H. Pylori. American Journal of Natural Medicine. (Jan-Feb 1997): 11-16



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Misdiagnosis?

But that sounds like too much

stomach acid?!


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Hypochlorhydria: Disease Assoc.

• Addison’s

• Asthma

• Celiac

• Autoimmune

• Hives

• Dermatitis

• Diabetes

• Eczema

• Gallbladder disease

• Graves

• Hepatitis

• Thyroid issues

• Lupus

• Myasthenia gravis

• Osteoporosis

• Pernicious anemia

• Psoriasis

• Rheumatoid arthritis

• Rosacea

• Sjogren’s syndrome

• Thyrotoxicosis

• VitiligoIndigestion, Antacids, Achlorhydria and H. Pylori. American Journal of Natural Medicine. (Jan-Feb 1997): 11-16


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Heidelberg pH Capsule Test

Normal Heidelberg gastrogram Achlorhydric gastrogram



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Replace: HCl

• Stomach makes 60-70 grains of HCl per meal

• 1 grain = 60mg

• 1 capsule = ~10 grains


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Replace: HCl

• Rest and Digest

• Stomach acid repletion protocol

• Bitters


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Decrease HCl Requirement

• Lemon juice or ACV

• Smaller meals

• Limit mealtime fluid



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Replace: Enzymes1413121110987654321

pH Scale Alkaline

Acid

Pancreatic enzymes

Mouth pH and resting stomach

HCl and pepsin

Food Enzymes


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Digestive Stimulation from SpicesPancreatic Amylases

Lipase Activity Disaccharides At least one

disaccharaseAlkaline

phosphatase•Ginger •Curcumin

•Curcumin •Coriander (nearly 300%) •Onion

•Ginger •Fennel •Cumin •Curcumin •Capsaicin (cayenne) •Piperine (black pepper)

Increased: •Onion •White coriander

Decreased: •Coriander •Fenugreek •Mint •Mustard •Adapted from Platel & Srinivasan, 2004; Indian J Med Res, 119, 167-179. Review Article: Digestive stimulant

action of spices: A myth or reality?


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Digestive Stimulation from Herbs

• Globe artichoke

• Dandelion root

• Gentian

• Chamomile

• Turmeric

• Ginger

Ailment Pharmacol Ther 18 (2003): 1099-105.

Fitoterapia 75.7–8 (2004): 760–3.

Current Therapeutic Research 1981;29:525-536.

Mol Med Report. 2010 Nov 1;3(6):895-901.

J Altern Complement Med 10.6 (2004): 1015–18.

Dig Dis Sci 50.10 (2005): 1889–97.



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Replace: Bile Salts

• Secretes 700ml/day

• Functions:

• Emulsifies fat

• Cholesterol removal

• Toxin removal


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• Cholestasis

• “Sludgy” bile

• Removal of gallbladder

Replace: Bile Salts


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Replace: Bile Salts

• Insufficiency Signs:

• Incomplete digestion/absorption of fats

• Steatorrhea

• Diarrhea



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Replace: Bile Salts

• Cholagogues/Choleretics → agents that promote the flow of bile from the gallbladder or production of bile from the liver

• Bile salts

• Dandelion root

• Globe artichoke

• Taurine

• Wormwood


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Reinoculate

• Probiotics

• Prebiotics


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Microbial Individuality

The composition of the microbiota can shape a healthy immune response or predispose to disease.



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Microbial Individuality

“The mammalian gut microbiota interact extensively with the host through metabolic exchange and co-metabolism of substrates…appropriates consideration of individual human gut microbiome activities will be a necessary part of future personalized health-care paradigms.”


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Reinoculate

• 2-5 lbs of bacteria in colon

• Prefer slightly alkaline environment

• Most pathogens anaerobic

• Most abundant species:

• Lactobacillus acidophilus

• Bifidobacterium bifidum

• Immune stimulation


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Clinical Nutrition: A Functional Approach: 2nd Edition. 2004. pp 206



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Reinoculate

• Natural antibiotics

• GALT

• Balance upset by:

• Ax and other Rx

• Alcohol

• Stress

• S.A.D.


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Probiotics

1. Either symbiotic or pathogenic

2. Help with absorption of nutrients

3. Break down polysaccharides

4. Produce SCFAs - feed flora downstream (butyrate feeds bifidobacteria)

5. Influence the brain

6. Educate the immune system

7. Ensure proper detoxification

8. Oral flora - nitrates to NO

9. Dysbiotic microbes suppress HCl


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Transfer of DNA

• Japanese can break down nori carbohydrate



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Probiotics: Mechanism of Action

Inhibits Pathogenic Bacteria

Improve Epithelial Function ↑ Immunoregulation

↓ Luminal pH Bacteriocidal proteins Colonization resistance ↓ Epithelial binding ↓ Epithelial invasion ↑ beta defensins

↑ SCFA (butyrate) ↑ Healing ↑ Mucous ↑ Apoptosis ↑ Barrier integrity ↑ HSP 25, 72

↑ IL-10, TGFb ↓ THF, IL-12 ↓ T cell proliferation ↑ Apoptosis TH1 cells ↑ sIgA ↓ NFkB

Sartor RB. J Clin Gastro. 2007;41:S37-S43.


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Probiotics - Competition

1. Competitive nutrient consumption

2. Epithelial cell receptor interaction

3. Excretion of antimicrobial substances

4. Interaction with the immune system


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Dysbiosis

• Dysbiosis is the condition of having microbial imbalances on or within the body.

• Dysbiosis is most prominent in the digestive tract or on skin but can also occur on any exposed surface or mucous membrane such as vagina, lungs, nose, sinuses, ears, nails, or eyes.



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Dysbiosis: History• Concept consolidated by Metchnikoff in 1908

• 1376 Medline articles indexed by “dysbiosis” (as of Oct. 2015)

• Other related terms:

• Dysbacteriosis

• Autointoxication

• SIBO

• Mucosal colonization

• Subclinical infection

• Some controversy still exists in the medical literature


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Dysbiosis

• Dysbiosis is not so much about the microbe as it is about the effect of that microbe on a susceptible host; i.e. it is about the relationship between host and microbe.


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Reinoculate

• Kimchi

• Sauerkraut

• Kombucha

• Yoghurt

• Kefir

• Pickles

• Miso



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Reinoculate

• Prebiotics → non-digestible food ingredients that stimulate the growth and health of good bacteria

• Inulin: onions, chicory root, dandelions

• Oligosaccharides: artichokes, leeks, asparagus

• Beta-glucan: seaweed, oats, barley

• Pectin: apples, apricots

• Resistant starch: bananas, potatoes, beans


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FOS and Bifidobacteria

• At least 4g/day to ↑ B.B. with a dose -response noted

• Bifidobacteria:

• Form SCFA

• B-vitamins

• Restores flora after Ax

• Inhibit growth of pathogensSartor RB. Curr Opin Gastroenterol. 2003, 19:358-365.


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Inulin: Clinical Use

• Constipation

• 40g/day for 19 days increased BB and produced soft stools

Kleesen B, et al. AJCN. 1997 May;65(5):1397-402



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Repair

• Anti-inflammatories

• Digestive healing nutrients


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Repair

• Multi vitamin/mineral

• Protein

• Vitamin A and D

• Zinc (Carnosine)

• L-Glutamine

• EFAs

• Quercetin

• Botanical anti-inflammatories


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Vitamin D• Vitamin D deficiency is a

world-wide epidemic,1 2 3

with recent estimates indicating greater than 50% of the global population is at risk.4

• A high prevalence of vitamin D deficiency has been found across all age groups in all populations studied in countries around the globe. 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

1. Prentice, A. Vitamin D deficiency: a global perspective. Nutr Rev. 2008 Oct; 66 (10 Suppl 2): S153-64. 2. Pettifor, J. M. Vitamin D &/or calcium deficiency rickets in infants & children: a global perspective. Indian J Med Res. 2008 Mar; 127 (3): 245-9. 3. Holick, M. F. Chen, T. C. Vitamin D deficiency: a worldwide problem with health consequences. Am J Clin Nutr. 2008 Apr; 87 (4): 1080S-6S. 4. University of California Riverside More Than Half the World’s Population Gets Insufficient Amounts of Vitamin D, Says UC Riverside Biochemist. 15 July 2010; 5. Science Daily Millions Of U.S. Children Low In Vitamin D. 3 Aug 2009; 6. Schwalfenberg, G. K. Genuis, S. J. Hiltz, M. N. Addressing vitamin D deficiency in Canada: a public health innovation whose time has come. Public Health. 2010 Jun; 124 (6): 350-9. 7. Kuriacose, R. Olive, K. E. Prevalence of vitamin D deficiency and insufficiency in northeast Tennessee. South Med J. 2008 Sep; 101 (9): 906-9. 8. Bandeira, F. Griz, L. Dreyer, P. Eufrazino, C. Bandeira, C. Freese, E. Vitamin D deficiency: A global perspective. Arq Bras Endocrinol Metabol. 2006 Aug; 50 (4): 640-6. 9. Ardestani, P. M. Salek, M. Keshteli, A. H. Nejadnik, H. Amini, M. Hosseini, S. M. Rafati, H. Kelishadi, R. Hashemipour, M. Vitamin D status of 6- to 7-year-old children living in Isfahan, Iran.

Endokrynol Pol. 2010 Jul-Aug; 61 (4): 377-82. 10. Bener, A. Al-Ali, M. Hoffmann, G. F. Vitamin D deficiency in healthy children in a sunny country: associated factors. Int J Food Sci Nutr. 2009; 60 Suppl 560-70. 11. Teale, G. R. Cunningham, C. E. Vitamin D deficiency is common among pregnant women in rural Victoria. Aust N Z J Obstet Gynaecol. 2010 Jun; 50 (3): 259-61. 12. Harinarayan, C. V. Joshi, S. R. Vitamin D status in India--its implications and remedial measures. J Assoc Physicians India. 2009 Jan; 5740-8. 13. Andersen, R. Molgaard, C. Skovgaard, L. T. Brot, C. Cashman, K. D. Chabros, E. Charzewska, J. Flynn, A. Jakobsen, J. Karkkainen, M. Kiely, M. Lamberg-Allardt, C. Moreiras, O. Natri, A. M.

O'Brien, M. Rogalska-Niedzwiedz, M. Ovesen, L. Teenage girls and elderly women living in northern Europe have low winter vitamin D status. Eur J Clin Nutr. 2005 Apr; 59 (4): 533-41. 14. Rodriguez Sangrador, M. Beltran de Miguel, B. Quintanilla Murillas, L. Cuadrado Vives, C. Moreiras Tuny, O. [The contribution of diet and sun exposure to the nutritional status of vitamin D in

elderly Spanish women: the five countries study (OPTIFORD Project)]. Nutr Hosp. 2008 Nov-Dec; 23 (6): 567-76. 15. Bhattoa, H. P. Bettembuk, P. Ganacharya, S. Balogh, A. Prevalence and seasonal variation of hypovitaminosis D and its relationship to bone metabolism in community dwelling postmenopausal

Hungarian women. Osteoporos Int. 2004 Jun; 15 (6): 447-51. 16. Allali, F. El Aichaoui, S. Khazani, H. Benyahia, B. Saoud, B. El Kabbaj, S. Bahiri, R. Abouqal, R. Hajjaj-Hassouni, N. High prevalence of hypovitaminosis D in Morocco: relationship to lifestyle,

physical performance, bone markers, and bone mineral density. Semin Arthritis Rheum. 2009 Jun; 38 (6): 444-51. 17. Du, X. Greenfield, H. Fraser, D. R. Ge, K. Trube, A. Wang, Y. Vitamin D deficiency and associated factors in adolescent girls in Beijing. Am J Clin Nutr. 2001 Oct; 74 (4): 494-500. 18. Peters, B. S. dos Santos, L. C. Fisberg, M. Wood, R. J. Martini, L. A. Prevalence of vitamin D insufficiency in Brazilian adolescents. Ann Nutr Metab. 2009; 54 (1): 15-21. 19. Judkins, A. Eagleton, C. Vitamin D deficiency in pregnant New Zealand women. N Z Med J. 2006; 119 (1241): U2144.



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Vitamin D“[Vitamin D] markedly enhanced tight junctions by increasing junction protein expression and preserved the structural integrity of tight junctions.” Am J Physiol Gastrointest Liver Physiol, 2008 Jan;294(1):G208-160


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Vitamin D“Vitamin D...favours less Inflammation.”

Kidney International, Vol. 68 (2005), pp 1973-1981.


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Zinc Carnosine

“Regarding intestinal permeability, Zinc Carnosine caused an approximate threefold increase in gut integrity and repair.” Gut. 2007 Feb;56(2):168-75



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Zinc Carnosine• Relieves gastric discomfort such as occasional heartburn and

indigestion, upset stomach, mild nausea, bloating, belching, and burping

• Promotes healthy gastric bacterial balance

• Provides antioxidant protection for gastric mucosal cells

• Helps maintain the integrity of the protective gastric mucosal lining by supporting healthy mucus secretion

• Gastro-supportive benefits demonstrated in over 20 published studies


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• Preferential fuel • Vital for mucosal growth,

structure, and function • Deficiency = small bowel

atrophy • Maintains sIgA levels • #1 prescription for ulcers

in Asia

L-Glutamine


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L-Glutamine

“The gastrointestinal tract is by far the greatest user of glutamine in the body, as [the intestinal cells] use glutamine as their principal metabolic fuel.” Alternative Medicine Review Volume 6, Number 4 2001



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L-Glutamine

“[L-Glutamine] decreases villous atrophy, increases jejunal weight, and decreases intestinal permeability.” Alternative Medicine Review Volume 6, Number 4 2001

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335


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Essential Fatty Acids

Omega-3

• Fish, walnuts, flax, chia, eggs

• Anti-inflammatory

Omega-6

• Corn, safflower, red meat, cottonseed

• Anti-inflammatory or pro-inflammatory


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Essential Fatty Acids• Omega 3 converts into

EPA and DHA

• EPA = anti-inflammatory

• DHA = structure

Omega 3 (Flax)

EPA (Fish)

DHA (Fish)PG3 (Anti-inflammatory)



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Essential Fatty Acids

“EPA appears to exert much of its anti-inflammatory benefit by suppressing [pro-inflammatory] activation...thus reducing elaboration of pro-inflammatory mediators.” Nutritional Perspectives, Vol. 28, no. 1, 1-16


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Cell membrane

Phospholipase A2

Arachadonic Acid

Cyclooxygenase Lipooxygenase

Leukotrienes SRS-A

Prostaglandin 2 series

Thromboxane A2

Pharmaceutical modulation of Inflammation

Indomethacin Aspirin Ibuprofen Sulfasalazine

X

Cortisone X

X Colchicine

SulfasalazineX

Mullin GE, et al, Expert Review of Gastroenterology and Hepatology, April 2008


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Botanical Modulation of Inflammation


Cell membrane

Phospholipase A2

Arachadonic Acid


Leukotrienes SRS-A


Thromboxane A2


X

Cortisone X

X Colchicine

SulfasalazineXQuercetin Liquorice root

Quercetin Ginger Turmeric Bromelain White Willow Bark

Quercetin Turmeric Onion Garlic Boswellia

Potentiates cortisol: Liquorice root Turmeric

X X

XX

Ginger



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Turmeric

• Active component: Curcumin

• Anti-inflammatory

• Inhibits leukotriene formation

• Inhibits platelet aggregation

• Promotion of fibrinolysis

• Inhibition of neutrophil inflammatory process

• Stabilization of lysosomal membranes


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Turmeric MechanismHumira,

Remicade

Erbitux, Erlotinib, Geftinib

AsacolBharat B. et al. 2006


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Turmeric

“Turmeric,...or its component curcumin, has shown surprisingly beneficial effects in experimental studies of acute and chronic diseases characterized by an exaggerated inflammatory reaction. There is ample evidence to support its clinical use, both as a prevention and a treatment.” J of Par and Ent Nut Vol. 30,no.1,2006,45-51




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Quercetin

• Inhibits mast cell and basophil degranulation

• Inhibits phospholipase A2 and lipoxygenase


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Rebalance

• Diet

• Balancing the ANS

• Stress

• Sleep

• Exercise

• Connection


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The Second Brain• The gut has more nerve

endings than the spine !

• 90% of all serotonin is made in the gut

• 40-50% of total NE occurs in mesenteric organs



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The Gut-Brain Axis• Vagus nerve

• Signalling to and from the digestive tract


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Vagus Nerve Stimulation

• Gargling

• Singing loudly

• Gagging

• Coffee enemas

• Deep breathing

Kharrazian, Datis. Why My Brain Isn’t Working. 2013.


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Rebalance: Perception

Stimulus

Rest/Digest Stop/Think (PNS)

Fight/Flight/Fright (SNS)

Stress Hormones



& GI Health


Body-Mind and DigestionRest and Digest Stop and Think

(Parasympathetic Nervous System)

or

Fright, Flight or Fight

(Sympathetic Nervous System)


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Stress Causes Changes

• Suppresses lactobacilli, bifidobacteria, and sIgA

• Catecholamines stim. gram- organisms (yersinia, pseudomonas)

• Anger or fear increases Bacteroides fragilis

Develepmental Psychology 1999;35;2:146-155


& GI Health


• Deep breathing/meditation

• Heart rate variability

• Epsom salt baths

• Manual therapies

• Walking, yoga

• Nature

• CBT

• Adaptogens

• Less international travel

• Light therapy

Rebalance

Current Opinion in Gastroenterology. 2006;22(2):128-135



& GI Health


• Remove needs to take place first

• The other R’s can occur sequentially or together

• All R’s must be accounted for

The 5 R’s Guidelines

Leaky Gut Syndrome


& GI Health


Tight Junctions



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Tight Junctions


& GI Health


Leaky Gut Syndrome - Causes• Dysbiosis

• Allergies

• Infections, parasites

• Drugs - NSAIDs, BCP, steroids radiation

• Alcohol

• Putrefying food

• Stress

• Environmental contaminants


& GI Health


The Viscous CycleGI Irritant

Leaky Gut

Allergy, Sensitivity, Microbe

Damage to GI

Malabsorption

Inflammation



& GI Health


GlutenEinkorn14 Chromosomes

Dwarf42 Chromosomes


& GI Health


Celiac: 2x Every 15 years


& GI Health




& GI Health


1. Gluten induces release of zonulin2. Zonulin causes permeability3. Gluten into blood4. Immune mobilization5. Inflammation6. Antigenic memory


& GI Health


Non-Celiac Gluten Sensitivity (NCGS)

“Increased intestinal permeability after gliadin exposure occurs in all individuals.”

Nutrients 2015, 7, 1565-1576.


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Gluten-Related Illness

Non-Celiac Gluten Sensitivity

No KnownReaction

CeliacDisease

• Bone and Joint pain• Osteoporosis• Leg numbness• Muscle Cramps• Unexplained anemia• Migraines

• Bone and Joint pain

• Osteoporosis• Leg numbness• Muscle

Cramps• Unexplained

anemia• Migraines• Behavioural

changes

• Amenorrhea• Infertility• Delayed

growth• Thyroiditis• Tooth

discolouration• Seizures• Dementia• Hepatitis



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Gluten-Related Illness

Non-Celiac Gluten Sensitivity

No KnownReaction

CeliacDisease

• Bone and Joint pain• Osteoporosis• Leg numbness• Muscle Cramps• Unexplained anemia• Migraines

• Bone and Joint pain

• Osteoporosis• Leg numbness• Muscle

Cramps• Unexplained

anemia• Migraines• Behavioural

changes

• Amenorrhea• Infertility• Delayed

growth• Thyroiditis• Tooth

discolouration• Seizures• Dementia• Hepatitis


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Cross-Reactivity

Autoimmune Disease



& GI Health


What Is Autoimmune Disease?

• An inappropriate immune response of the body against substances and tissues normally present in the body.

http://en.wikipedia.org/wiki/Autoimmune_disease


& GI Health


More then 40 autoimmune conditions have been identified, including such common examples as type 1 diabetes, rheumatoid arthritis, and celiac disease. Together they constitute the 3rd leading cause of sickness and death after heart disease and cancer.

Scientific American, March 2007


& GI Health


Why Does The Body Attack Itself?



& GI Health


Autoimmune Disease

Genetics Environmental Trigger Gut Permeability

Nat Clin Prac Gastro & Hep, Sept 2005, Vol2;No.9


& GI Health


2. Genetics

1. Trigger

3. Leaky gut


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Genes or Environment?

Arq. Gastroenterol. vol.46 no.1 São Paulo Jan./Mar. 2009

1986-2005: ↑ of 15-24x



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Epigenetics

January, 2011


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Leaky Gut Syndrome“The autoimmune process can be arrested if the interplay between genes and environmental triggers is prevented by re-establishing intestinal barrier function.” Nut Clin Prac Gastro & Hep. Sept 2005 Vol. 2 No.9

Genes Environment

You

“Phenotype”

Allergies and Sensitivities



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Increase of Allergies 1990-2001

BMJ 2003;327:1142


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Allergies Defined

• Allergy (type 1 hypersensitivity): IgE-mediated response

• Sensitivity/Intolerance: IgG-mediated, enzyme deficiency

• “Not all symptoms of allergic response can be ascribed to IgE.” Annals Allergy. 1987;59(2):110-17


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Mechanism of GI Allergy

Mechanism

Immune-Mediated (“GI Allergy”)

Non-Immune-Mediated (“GI Intolerance”)

Holgate, Church and Lichtenstein: Allergy 3rd edition © 2006 Elsevier Ltd.



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Mechanism



IgE-Mediated Reactions

Other Immune Reactions



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Mechanism





Immune Complexes

T-Cell Mediated

IgA Mediated

Late Phase

Immediate Phase



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Mechanism





Toxic (occurring in any individual)

Non-Toxic (individual susceptibility)

Immune Complexes

T-Cell Mediated

IgA Mediated

Late Phase

Immediate Phase




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Mechanism





Toxic (occurring in any individual)

Non-Toxic (individual susceptibility)

Enzymatic (e.g. lactose intolerance)

Pharmacologic (e.g. vasoactive

amines)

Others (e.g. additive

intolerance)

Immune Complexes

T-Cell Mediated

IgA Mediated

Late Phase

Immediate Phase



& GI Health


Food Additives and Allergies

Additive Use Reaction

Sulfites Preservative Asthma, anaphylaxis

MSG Flavour enhancer Chinese restaurant syndrome, asthma, urticaria

Aspartame Sweetener Urticaria

Tartrazine Food dye Urticaria, asthma, hyperactivity in children

Other food dyes Dyes Hyperactivity, urticaria

BHA/BHT Preservative Urticaria

Parabens Preservative Urticaria

Benzoates Preservative Urticaria


& GI Health


Lactose Intolerance

Mahan LK, Escott-Stump S. Food Nutrition and Diet Therapy. Philedelphia, Pa: W.B.Saunders. 1996:625-626

Descent



& GI Health


The Immunoglobulin Isotypes

Allergology International 2007; 56: 349-361


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Symptom Characteristics: IgE vs IgG

IgE “Allergy” IgG “Sensitivity”

Onset Rapid Delayed

Duration Brief-hours Prolonged (days)

Mechanism Mast cell Circulating complexes

Quantity of Food Tiny Tiny, dose dependent

Food Any AnyPatient Awareness Always Rarely

Persistence of Ab Lifelong Months after elimination


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The Immunoglobulin Isotypes

Class Features Major Activity

IgG

Transplacental23 Day half life circulating2-3 months mast cell half life

Protects tissues

IgE

Attaches to mast cellsContact with allergen causes release of histamine, etc.2.3 Day half-life14 Day mast cell half-life

Extreme sensitivityGatekeeper for IgAAnti-parasitic

IgATwo Forms:Serum - MonomerSecretions - Dimer

Protects mucousClears absorbed food



& GI Health


Immunoglobulins and Location


& GI Health


Allergy/Hypersensitivity Testing

IgE IgG, IgG4

SerumSerumSkin Testing


& GI Health


Role of Skin Tests

If an IgE-mediated disorder is likely:

• Negative skin prick test is 95% predictive.

• Positive skin tests predict reaction 40% of the time.

• Size of reaction is important; > 8 mm is 95% predictive when supported by history.

Clark AT, Ewan PW. Interpretation of tests for nut allergy in one thousand patients in relation to allergy or tolerance. Clin Exp Allergy 33:1041-1045, 2003



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IgG Food Allergy Testing

• Good diagnostic tool with some patients

• Used to determine modified elimination diet in patients with IBS

• Groups eliminating real foods (vs sham) were 30% improved

Atkinson W. Sheldon TA, Shaath N, Whorwell PJ. Food elimination based upon IgG antibodies in irritable bowel syndrome: a randomized controlled trial. Gut. 2004;53:1459-64.


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Mullin, Swift, Lipski, Turnbull, Rampertab. Nutr Clin Pract 2010; 25; 192


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Conditions Helped by IgG Testing

• Atopic conditions Awazuhara, H. et al. (1997), el Rafei, A. et al. (1989), Nakagawa, T. et al. (1992), Hofman, T. (1995), Jenmalm, M.C. et al. (2000)

• Migraine headaches Alpay, K. et al. (2010), Mitchell, N. et al. (2011)

• Cystic fibrosis Lucarelli, S. et al. (1994)

• IBS Zar, S. et al. (2005), Atkinson, W. et al. (2004), Drisko, J. et al. (2006)

• Crohn’s Bentz, S. et al. (2010)

• Epilepsy Egger, J. et al. (1989)

• Glomerulonephritis Van der Woude, F.J. et al. (1983)

• ADHD Pelsser, L.M. et al. (2011)



& GI Health


Testing

• “Single entity testing is incomplete” (i.e. IgE, IgG)

Brandtzaeg P. Current understanding of gastrointestinal immunoregulation and its relation to food allergy. Ann N Y Acad Sci. 2002;964:13-45.


& GI Health


What To Do: Prevention

• Vaginal birth versus C-section


& GI Health


Allergies in Infancy

• Infants gut = leaky

• IgA, IgM, IgE, IgD, IgD in breast milk

• 146K - 970k daltons

• Casein: 121.7K daltons

• Glutenin: 150k daltons

Clinical Nutrition: A Functional Approach: 2nd Edition. 2004. pp 202-203



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What To Do: Prevention

• Breastfeeding

• Maternal fish oils/probiotics

• Prebiotics/probiotics for both


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What To Do: PreventionRESEARCH ARTICLE Open Access

Perinatal probiotic supplementation in theprevention of allergy related disease: 6 yearfollow up of a randomised controlled trialMelanie Rae Simpson1*, Christian Kvikne Dotterud1,2, Ola Storrø1, Roar Johnsen1 and Torbjørn Øien1

Abstract

Background: Perinatal probiotics supplementation has been shown to be effective in the primary preventionof atopic dermatitis (AD) in early childhood, although the long term effects of probiotics on AD and otherallergic diseases is less certain. We have previously reported a significant reduction in the cumulativeincidence of AD at 2 years after maternal probiotic supplementation. In this study we present the effectsof perinatal probiotics given to women from a general population on allergy related diseases in their offspringat 6 years.

Methods: Four hundred and fifteen pregnant women were randomised to receive probiotic or placebo milk ina double-blinded trial from 36 week gestation until 3 months postpartum. Probiotic milk contained Lactobacillusrhamnosos GG, L. acidophilus La-5 and Bifidobacterium animalis subsp. lactis Bb-12. At 6 years, children werere-assessed for AD, atopic sensitisation, asthma and allergic rhinoconjunctivitis (ARC).

Results: At 6 years, 81 and 82 children were assessed for AD in the probiotic and placebo groups, respectively.In a multiple imputation analysis, there was as trend towards a lower cumulative incidence of AD in theprobiotic group compared to the placebo group (OR 0.64, 95 % CI 0.39-1.07, p = 0.086; NNT = 10). This findingwas statistically significantly in the complete case analysis (OR 0.48, 95 % CI 0.25-0.92, p = 0.027, NNT = 6). Theprevalence of asthma and atopic sensitisation, and the cumulative incidence of ARC were not significantlyaffected by the probiotic regime at 6 years of age.

Conclusions: Maternal probiotic ingestion alone may be sufficient for long term reduction in the cumulativeincidence of AD, but not other allergy related diseases.

Trial registration: ClinicalTrials.gov identifier: NCT00159523

Keywords: Allergy, Asthma, Atopic dermatitis, Paediatrics, Prevention, Probiotics, Rhinitis

BackgroundAtopic dermatitis (AD), asthma and allergic rhinocon-junctivitis (ARC) are a major cause of chronic disease inchildhood. A revised version of the “hygiene hypothesis”suggests that the pattern of colonisation and the diver-sity of the intestinal microbiota may be an importantfactor in the increased prevalence of these diseases

observed over the past several decades [1–3]. Subse-quently, probiotics have been investigated in the preven-tion and treatment of allergy related diseases [3–8], withthe strongest evidence emerging for the primary preven-tion of atopic dermatitis [3–5]. Throughout this paperwe refer AD, asthma and ARC as “allergy related dis-eases”, recognising that not all presentations of theseconditions are related to a classic IgE-mediated inflam-matory process.Randomised controlled trials (RCTs) testing probiotics

in the prevention of childhood allergy related disease areheterogeneous and have used a variety of bacterial strains,administration regimes and varying ages of follow-up.

* Correspondence: [email protected] of Public Health and General Practice, Faculty of Medicine,Norwegian University of Science and Technology (NTNU), Postboks 8905,MTFS, 7491, Trondheim, NorwayFull list of author information is available at the end of the article

© 2015 Simpson et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Simpson et al. BMC Dermatology (2015) 15:13 DOI 10.1186/s12895-015-0030-1

“Maternal probiotic ingestion alone may be sufficient for long term reduction in the cumulative incidence of atopic dermatitis…”

Simpson MR, et al. BMC Dermatol. 2015; 15:13


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Allergies in Infancy

• Allergy reactions to foods are much more common in the first few years of life

• Formula feeding associated with increased prevalence of allergy and asthma

Zeiger RS. Dietary aspects of food allergy prevention in infants and children. J Ped Gastro Nutr. 2000;30:S77-S86. Kelly D, Coutts AGP. Early nutrition and the development of immune function in the neonate. Proc Nutr Soc. 2000;59:177-85.



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“In this review, we describe the importance of properly balanced intestinal permeability in oral tolerance induction and address the processes involved in damaging the intestinal barrier in the sensitized epithelium and during allergic reactions. We conclude by speculating on the effect of increased intestinal permeability on the onset of sensitization towards dietary antigens.”


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Gastric Acidity and Allergy

• The gatekeeping function of the stomach in the sensitization and effector phase of food allergy

Untersmayr, E and Jensen-Jarolim, E. The role of protein digestibility and antacids on food allergy outcomes. J Allergy Clin Immunol. 2008 June; 121(6):1301-1310



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Gastric Enzymes

• Reduced allergenicity of melon allergens after incubation with gastric enzymes



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Affects of PPIs on Allergenicity of Proteins

• Gastric digestion substantially decreases the potential of food proteins to bind IgE, which increases the threshold dose of allergens required to elicit symptoms in patients with food allergy

• Double-blind, placebo-controlled, food challenges in these patients with fish allergy resulted in a 10-30 fold higher tolerated allergen dose if the fish proteins were previously subjected to in vitro gastric digestion

• Thus, anti-ulcer agents impeding gastric protein digestion have a major effect on the sensitization and effector phase of food allergy



& GI Health


Allergy Summary

• No one test accounts for all allergies

• IgE and IgG testing both have clinical benefits: they are tools

• Prevention is key

• Comprehensive elimination diet = gold standard

• Healing the gut is critical


Irritable Bowel Syndrome


& GI Health


5 People Diagnosed With IBS


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5 Different Causes

Cause 3Cause 2Cause 1 Cause 4 Cause 5



& GI Health


5 Different Causes

Cause 3Cause 2Cause 1 Cause 4 Cause 5

• Antidepressants • Antispasmodics • Laxatives • Antidiarrheals


& GI Health


Cochrane Review of 40 StudiesThe evidence for drug therapies is

weak and there is no clear evidence of benefit for

antidepressants or bulking agents.

The Cochrane Library. N.p., n.d. Web. 08 June 2014.

Drug


& GI Health


Placebo More Effective

Drug effects are smaller than the placebo effect in most

randomized trials.

Spiller R. Clinical Update: irritable bowel syndrome. Lancet. 2007;369:1586-1588.

>Placebo Drug



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“Unmet Needs”“There are significant unmet needs

including lack of familiarity with irritable bowel syndrome, difficulties in diagnosis and lack of effective treatments for the

multiple symptoms of the disorder.”

Dig Liver Dis. 2006 Oct;38(10):717-23. Epub 2006 Jun 27.

?


& GI Health


Who Is Affected?

• 10-15% in North America

• 0.8-28% world-wide

• Mostly women

• Upper-socioeconomic groups

Am J Gastroenterol. 2002;97:S1-5 Best Pract Res Clin Gastroenterol. 2004;18 Gastroenterol Clin North Am. 2005;34:189-204



& GI Health


Rome III Criteria: IBS Diagnosis

• At least 3 months, with onset at least 6 months previously, of recurrent abdominal pain or discomfort associated with 2 or more of the following:

• Improvement with BM

• Change in freq. of BM

• Change in form of stool


& GI Health


IBS Symptoms

? ?

??


& GI Health


Iatrogenesis

• Incorrect diagnosis

• Symptom overlap

• Unnecessary surgeries: cholecystectomy, hysterectomy, appendectomy, back surgery

Gastroenterol Clin North Am. 2005;34:189-204



& GI Health


Food As Trigger

• Food is the #1 trigger

• Increased rate of positive skin-prick

• Food elimination based on IgG

Eur J Clin Nutr. 2006;60:667-672. World J Gastroenterol. 2006;12:2382-2387. Zar, S. et al. (2005) Atkinson, W. et al. (2004) Drisko, J. et al. (2006)


& GI Health


IBS: A Randomized Control Trial IgG Food Allergy Testing

• Diagnostic tool

• Determine modified elimination diet

• Groups eliminating real foods (vs sham) were 30% improved

Gut. 2004;53:1459-64.


& GI Health


Gluten and IBS

• “The clinical presentation of gluten sensitivity is a combination of IBS-like symptoms…”

Nat Rev Gastroenterol Hepatol. May 2012;9(5):295-299.



& GI Health



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FODMAPs and IBS

F ermentable

O ligo

D i M ono-saccharides

A nd

P olyolsGibson PR, Shepard SJ, 2005


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FODMAPs and IBS



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FODMAPs and IBS


& GI Health


Low FODMAPs Improve IBS

Jour of Gastroenterol and Hepatol. 25 (2010) 1366-1373.

“Dietary FODMAPs induce … gastrointestinal and systemic symptoms experienced by patients with IBS.”


& GI Health


Antibiotics

• Upset gut flora

• Predisposes to IBS

Gut. 2006;55:182-190. Am J Gastroenterology. 2002;97:104-108. Eur J Gastroenterol Hepatol. 1998;10:59-62.



& GI Health


Antibiotics and Gut Flora

Altern Med Rev. 2004;9:180-197

No Effect


& GI Health


Antibiotics, Gut Flora, and Probiotics

Red area = AxBlue line = MicrobiomeRed line = SB with AxGreen line = SB after AxBlack dotted = SB during and after

(SB = Saccharomyces Boulardii)

Clin Exp Gastroenterol. 2015; 11:237-255.


& GI Health


Jama. 2004. Vol. 292 No. 7

“The gastrointestinal immune effects of SIBO provide a unifying framework for understanding frequent

observations in IBS…”



& GI Health


Distribution of Bacteria

Lin, H.C. JAMA 2004;292:852-858


& GI Health


SIBO and IBS

• SIBO often found in IBS (78% in one study)

Am J Gastroenterol. 2000;95:3503-3506.


& GI Health


Treating SIBO

Glob Adv in Health and Med. May 2014;3:3 pp 16-25

Response rate:Rifaximin 34% vs Herbal Therapy 46%



& GI Health


Treating SIBO

Glob Adv in Health and Med. May 2014;3:3 pp 16-25

Herbal therapies:• Candibactin-AR and Candibactin-BR (Metagenics)•FC-Cidal and Dysbiocide (Biotics)


& GI Health


23% positive for parasite (3,223/13,857)

• Blastocystis hominis (12.5%)

• Dietamoeba fragilis (3.8%)

• Entamoeba spp. (3.4%)

• Endolimax nana (2.2%)

• Giardia lamblia (0.7%)

Common Parasites

Courtesy of Dr. Patrick Hannaway


& GI Health


Role of Blastocystis Hominis

4x more frequent in those with IBS

B. Hominis treated = resolution in 80%

Am J. Torop. Med. Hyg. 7094), 2004, pp.383-385



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Symptoms persist 3 years after treatment.


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Gut In Balance

• “...the mucosa [is] directly exposed to the external environment and taxed with antigenic loads consisting of commensal bacteria, dietary antigens, and viruses at far greater quantities on a daily basis than the systemic immune system sees in a lifetime.”

• 99% of the time, the job of the immune system is to NOT respond!

Mayer L. Mucosal Immunity. Pediatrics 2003;111:1595-1600.

✗


& GI Health


Bifidobacterium, Lactobacillus, Placebo in IBS Over 8 Weeks

Gastroenterology. 2005;128(3):541-551



& GI Health


Peppermint Oil

• Natural antispasmodic

• C. Albicans

• Note: Relaxes LES

J Gastroenterol 1997;32:765-68


& GI Health


Peppermint Oil

ECPO (%) Placebo (%)

Abdominal Pain 79 43

Abdominal distension 83 29

Stool frequency 83 33

Stomach rumble 73 31

Flatulence 79 22.5

J Gastroenterol 1997;32:765-68


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Stress and IBS


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Stress as Trigger

• Life events increase symptoms

• General stress

• Disease stress

Gut. 1998;43:256-261. Nurs Res. 2007;56:399-406. J Psychosom Res. 1998;44:537-545.

Inflammatory Bowel Disease



& GI Health


IBD: Theories of Etiology

Genetic

Infection Immunologic

Psychosomatic Diet


& GI Health


Genes or Environment?

Arq. Gastroenterol. vol.46 no.1 São Paulo Jan./Mar. 2009

1986-2005: ↑ of 15-24x


& GI Health


Diet: What Don’t We Know?

• The best diet for IBD



& GI Health


Not knowing the

right thing

doesn't necessarily mean

we don’t know

the wrong thing.


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• Gluten: Increases intestinal permeability

• Fibre: High fibre beneficial

• FODMAPs: May worsen symptoms

• Dairy: Increases incidence

• Meat: Mainly red and processed

• PUFAs: Omega-3s are protective

Clinical Implications of Diet on IBD

Integrated Healthcare Practitioners. June/July 2014, p. 55


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IBD and Diet: What we know...

• Formula feeding

• “SAD” diet

• Refined sugar (Study: 122g/day vs 65g/day)

• Food allergies: wheat and dairy

• Reduced intake of omega-3Thornton JR, Emmett PM, Heaton KW. Br Med J 1979;279:762-764. Jones VA et al. Lancet. 1985 Jul 27;2(8448):177-80. Shoda R, Matsueda K, Yamato S, Umeda N. Am J Clin Nutr 1996;63:741-745 Cashman KD, Shanahan F. Eur J Gastroenterol Hepatol. 2003;15:607-613 O’Sullivan M, O’Morain C. Best Pract Res Clin Gastroenterol. 2006;20:561-573



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Formula Feeding and IBD

• Less likely to have been breastfed = higher risk of IBD

• Breastfeeding:

• Protects against enteric infection

• Develops GI immune system

• Delays antigenic exposure

Cashman & Shanahan, 2003 O’Sullivan & O’Morain, 2006



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Cow’s Milk Allergy and IBD

• Implicated as antecedent precursor to IBD

• Association between allergic asthma, rhinitis, and the subsequent development of IBD (particularly UC)

Cashman & Shanahan, 2003 Glassman, Newman, Berezin, & Gryboski, 1990 Ceyhan, Karakurt, Cevik, & Sungur, 2003 D’Arienzo et al.2002 Weng, Liu, Barcellos, Allison, & Herrington, 2007



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Specific Carbohydrate Diet

• Eliminate: Grain, Lactose, Sucrose

• More effective for Crohn’s

• Meat, fish, eggs, most vegetables, fruits, nut flours, aged cheese, homemade yoghurt, honey

• High sucrose predisposes to Crohn’s

• Control of Crohn’s enhanced by sucrose eliminationMatsui et al., 1990; Martini & Brandes, 1976; Thurton, Emmet, & Heaton, 1979; Mayberry, Rhodfes, & Newcombe

Heaton, Thornton, & Emmet, 1979


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FODMAPs and Crohn’s

F ermentable

O ligo

D i M ono-saccharides

A nd

P olyolsGibson PR, Shepard SJ, 2005


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Low Sulfur Diet in Ulcerative C.

• Protein = ↑ sulfide in colon

• Protein (esp. meat), total sulfur and sulfates influence relapse

• Some evidence for low sulfur dietRoediger, 1998

Jowett et al., 2004

Magee, Richardson, Hughes, & Cummings, 2000



& GI Health


Crohn’s Disease: Exclusion Diets

78 Patients ✗Eliminate✓ Maintain

Riordan et al., 1993




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Percentage in remission (%)

0

17.5

35

52.5

70

6 Months 2 Years

Steroids Diet

70%

34%38%

21%

Riordan et al., 1993


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• Exclusion diet:

• 1 meat (lamb or chicken), 1 starch (rice or potatoes), 1 fruit, 1 vegetable

• Provocation

• Most common allergens: wheat, cow’s dairy, corn, yeast, tomatoes, citrus, eggs, and cruciferous veg.

• Maintenance

• Result: Relapse of under 10%/yearAlun Jones, Workman, & Freeman, 1985



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Crohn’s Disease and Yeast

• Many CD patients have AB to Baker’s/Brewer’s yeast

• Increases TNF-alpha

Barnes et al., 1990

Konrad et al., 2004



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IBD and Deficiencies



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Vitamin D“Vitamin D deficiency may compromise the mucosal barrier, leading to increased susceptibility to mucosal damage and increased risk of IBD.” Am J Physiol Gastrointest Liver Physiol, 2008 Jan;294(1):G208-16


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Alimentary Pharmacology & Therapeutics Volume 32, Issue 3 pages 377- 383, 11 MAY 2010

• Patients received 1200iu/day

• Blood levels started at 69 nmol/L and went to 96 nmol/L at 3 months

• Vitamin D group: 13% relapse

• Placebo: 29% relapse

Clinical Trial: Vitamin D3 treatment in Crohn’s disease




& GI Health


Zinc

• Approximately 45% of those with Crohn’s = deficient

• Disease activity correlated with zinc deficiency

J Physiol Gastrointest Liver Physiol, 2008 Jan;294(1):G208-160


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Essential Fatty Acids“When ...evaluating the role of fish oil in the treatment of ulcerative colitis, 3 of 3 studies showed statistically significant improvement in the study group that received fish oil supplementation.” Nutrition in Clinical Practice 23:9, Feb 2008



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Fish Oils and IBD:Animal Studies

• 6/6 mice models of ulcerative colitis showed protection from injury and healing with omega-3 fatty acids.

Proc Natl Acad Sci U S A. 2006;103(30):11276-11281. Clin Nutr. 2006;25(3):466-476. Nutrition. 2006;22(3):275-282. World J Gastroenterol. 2005;11(47):7466-7472. Proc Natl Acad Sci U S A. 2005;102(21):7671-7676. Inflamm Bowel Dis. 2005;11(4):340-349.

Fish Oil Placebo

Protection UC



& GI Health


Ulcerative Colitis - Summary• 9 randomized controlled trials

• 4.7 g EPA/DHA/day (Average)

• Duration 35 weeks (Average)

Two or more:

• Reduce ulceration

• Reduce overall disease

• Reduce drug use

• Reduce relapse

• Increase remission


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Cell membrane

Phospholipase A2

Arachadonic Acid


Leukotrienes SRS-A


Thromboxane A2

Pharmaceutical modulation of Inflammation


X

Cortisone X

X Colchicine

SulfasalazineX



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Botanical Modulation of Inflammation


Cell membrane

Phospholipase A2

Arachadonic Acid


Leukotrienes SRS-A


Thromboxane A2


X

Cortisone X

X Colchicine

SulfasalazineXQuercetin Liquorice root

Quercetin Ginger Turmeric Bromelain White Willow Bark

Quercetin Turmeric Onion Garlic Boswellia

Potentiates cortisol: Liquorice root Turmeric

X X

XX

Ginger



& GI Health


Turmeric

“Studies involving curcumin to date in the field of IBD have been consistently positive.” Nutrition in Clinical Practice 23:49-62, Feb 2008



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Quercetin

• “We suggest that the addition of polyphenols (quercetin)...would improve outcomes of patients with IBD...”

Gut 56:426-436, Mar 2007



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Induction of Remission in Ulcerative Colitis with High-Dose Probiotics

• 34 patients with active UC (non-responsive to conventional treatment), were given 3.6 trillion cfu of bacteria daily for six weeks.

• Treatment of patients with mild to moderate UC resulted in a combined induction of remission/response rate of 77% -- with no adverse events.

• Bacterial species in the probiotic product were detected at the target site.

Am J Gastroenterol. 2005;100:1539-1546.

53%

24%



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• Chronic stress, adverse life events, and depression can cause a relapse in patients with IBD

• HPA function, gut flora, mast cell activation, and CRF mediate the effect of stress on inflammation in IBD

• The symptoms of IBD may be exacerbated by the effects of stress on gut motility and fluid secretion

• There is a need for further studies of the potential benefits of stress reduction therapy in IBD

Psychological Stress and IBD

Mawdsley J E, Rampton D S Gut 2005;54:1481-1491


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Mawdsley J E, Rampton D S Gut 2005;54:1481-1491



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• Meditation

• Light Exercise

• Yoga

• Acupuncture, massage, bodywork

• Nature walks

• Music


Digestive Healing Diets



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Diets For GI Healing

• Gluten-Free/Casein-Free

• SCD Diet

• FODMAP

• Low Sulphur Diet

• Comprehensive Elimination Diet

• Anti-Fungal Diet

• Anti-Inflammatory Diet

• Restoration Diet

• Palaeolithic Diet (Autoimmune)

• GAPS Diet



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Diets For GI Healing

What do these all have in common?

Elimination No processed foods No refined sugar Good fats


Digestive Healing Foods


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Functional Foods


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Fibre: Friend or Foe?


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FibreEast Africans • 100 g of Fibre • 18-24 hours

transit time

North Americans • 25 g of Fibre • 72 hours transit time

Jensen, Bernard. Dr. Jensen’s Guide to Better Bowel Care. Avery: 1999.


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Relax, sir. The hair in your soup provides fibre.



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FibreSoluble Fibre:

• Soothing • Partially and Completely

Fermented: • Short Chain Fatty Acids • Gases

Insoluble Fibre: • Not fermented • Speeds transit time • Adds bulk


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Mucilaginous Foods/Herbs

• Slippery elm powder

• Marshmallow root

• Flax seed

• Chia seed

• Aloe vera

• Okra


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Bone Broths

• Gelatin

• Free amino acids

• Calcium

• Glycinate

• Proline

• Phosphorus

• Hyaluronic acid

• Chondroitin sulfate

• Magnesium

• Potassium

• Sulfate

• Fluoride



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Cabbage Juice

• Original research: Cheney 1949-1952

• 66% improvement within 4 days

• 80% symptom-free within 1 week

• Replicable

• Dosage: 1 quart fresh, green cabbage juice in divided doses for 7-10 days

Cheney, G. (1952) "Vitamin U therapy of peptic ulcer." California Medicine, 77:4, 248-252


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Therapeutic Diet/Food Summary

• Choose the appropriate diet (GET/RID)

• Eliminate problematic foods

• Choose therapeutic foods


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Factors to Consider

• Symptom control

• Modified diet

• Heal the gut

• Reintroduce and rebalance





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Current

EvidencePatient’s

Story


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Personalized


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Applied Knowledge Is Power.



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evidence-based clinical nutrition and integrative healthcare

Thank you!


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