Gut Dysbiosis Testing

• The presentation is about testing for dysbiosis in the gut.
• The speaker has no conflict of interest in relation to this presentation.
• The presentation is by Jill C. Carnahan, MD, of Flatiron Functional Medicine in Louisville, CO.

Objectives

• Discuss the importance of microbial diversity in the gut.
• Diagnose common gastrointestinal and immune system complaints through the DIG-IN acronym.
• Review advanced laboratory testing options for mal-absorption, intestinal permeability, and nutritional assessment.

Microbial Biodiversity

• Greater microbial diversity associates with the body's ability to deal with stressors, including opportunistic pathogens or dietary perturbations.
• Individuals with disease are more likely to have alterations in the gut microbiome than healthy controls.
• Reduced microbial diversity has multiple associations with illness in the literature.
• Factors impacting microbiota include caesarean section versus vaginal birth and breast milk versus commercial formula.
• Infants born vaginally were colonized with their mother's vaginal microbiota, including Lactobacillus, Prevotella, and Sneathia spp.
• Caesarean section born infants become colonized by bacteria found on the skin surface: Staphylococcus, Corynebacterium, and Propionibacterium species.

Antibiotics and the Microbiome

• Early antibiotic use resulting in a disturbed gut microbiome, can have profound and lasting effects on an organism's metabolic profile
• A study determined the effect of orally administered antibiotics in children.
• Exposure to a single antibiotic prescription is not associated with higher risk.
• Treatment with 2-5 antibiotic courses is associated with an increase in diabetic risk for penicillin, cephalosporins, macrolides, and quinolones
• The risk increased with the number of antibiotic courses and reached 1.37 (95%CI 1.19-1.58) for >5 courses of quinolones
• No association exists between exposure to anti-virals and anti-fungals and diabetes risk.

Factors Influencing Microbiota Diversity

• The development of neonate microbiota is influenced by initial colonization and developing factors.
• Initial colonization includes transfer of maternal vaginal, colonic and skin microbiota, mode of delivery, antibiotic exposure and environment.
• Factors in microbiota development include host genetics, maternal diet, breast vs. formula feeding, antibiotics exposure, environmental exposure and the developing immune system.
• Stable microbiota is acquired by 2-4 years.
• Multiple factors influence the density, diversity, and activity of gut bacteria, including external influences, health conditions, internal host properties, and diseases.
• External influences include diet, prebiotics, probiotics, antibiotic usage, illness, lifestyle, and living environment
• Internal host properties include age, genetics, stress, physiologic processes, and the anatomical structure and physiology of the digestive tract.
• Reduced bacterial diversity of the infant's intestinal flora is associated with increased risk of allergic sensitization, allergic rhinitis, and peripheral blood eosinophilia.
• Microbe populations change as we age.
• Lower diversity of bacteria in guts correlates with higher levels of body fat and inflammation.
• Dietary intervention with high-fiber foods, such as fruit and vegetables, led to increased bacterial richness and improved clinical symptoms associated with obesity.
• A low fat, plant polysaccharide-rich diet changed to a high fat, high sugar Western diet alters the microbiota in one day in germ-free mice.
• Coffee consumption decreases the Firmicutes to Bacteroidetes ratio and normally associates it with high-fat feeding.
• Coffee increases levels of short-chain fatty acids while lowering levels of branched-chain amino acids.
• Dietary polyphenols naturally occurring in coffee and cocoa are extensively metabolized by gut bacteria into anti-inflammatory end-products.
• Good microbes such as Bifidobacterium and lactic acid bacteria feast on chocolate and grow and ferment it, producing anti-inflammatory compounds.

Stool Analysis

• Stool analysis evaluates key clinical markers in four functional areas: Infection, Inflammation, Insufficiency (Digestive), and Imbalance (Metabolic).
• Tests show the level of each individual biomarker and the degree of clinical impact, with an overall score of high, medium, or low provided for each functional pillar. The Infection pillars tests for any parasite or pathogen present.
• The inflammation pillar is tested with Calprotectin, EPX, and Fecal IgA.
• The insufficiency pillar tests PE-1, Total Fecal Fats, and Total Protein Products.
• The imbalance box tests n-Butyrate, Total SCFA, Beta-glucuronidase, Lactobacillus, Bifidobacterium, E. coli, and any potential pathogen. The test has three main categories that it measures, Digestion and Absorption, Inflammation and Immunity, and Gastrointestinal Microbiome.

Digestion and Absorption

• Measures Pancreatic Elastase 1 which digests proteins.
• Measures Products of Protein Breakdown (Putrifactive SCFAs).
• Measures Fecal Fat.
• Pancreatic Elastase is a proteolytic enzyme secreted by the pancreas.
• Pancreatic Elastase reflects overall enzyme production like amylase, lipase and protease.
• Pancreatic Elastase isn't affected by supplemental enzymes.
• Pancreatic Elastase is a non-invasive marker for evaluating exocrine pancreatic function, with 90 -100% sensitivity and 93 - 98% specificity.
• Normal pancreatic Elastase level is > 350 μg/g
• Pancreatic Elastase ranging between 200-350 μg/g indicates declining pancreatic function and suggests supplementation.
• Pancreatic Elastase ranging between 100-200 μg/g implies Moderate pancreatic insufficiency Supplementation with a broad array of pancreatic enzymes.
• Values less than 100 μg/g imply Severe pancreatic insufficiency.
• Supplemental with broad array of pancreatic enzymes.
• Pancreatic Elastase use for initial determination of pancreatic insufficiency and to monitor function in patients under treatment.

Pancreatic Elastase Testing

• Tests Patients with Unexplained diarrhea, Weight loss, Other signs of malabsorpton, and Abdominal pain.
• Pancreatic Exocrine dysfunction can relate to Chronic Pancreatitis, diabetes, celiac disease, inflammatory bowel disease, Cystic fibrosis, alcohol consumption, gallstone disease.
• Fecal PE1 testing may have reduced sensitivity for detecting mild pancreatic exocrine insufficiency in children.
• Chronic pancreatitis patients may have compromised antioxidant systems.
• Treatments include Smoking cessation and Reduced alcohol consumption.
• Also treatments include Small frequent meals and Replace fat-soluble vitamins.
• Other treatments include Supplemental lipase or pancreatic enzymes (Choose Pancreatin)
• Pancreatic Elastase Treatment, don't use Plant-based enzymes because they is are not strong enough for severe EPI.
• Rule out EPI in all patients with celiac disease in the presence of overt malnutrition or in cases of persistent gastrointestinal symptoms despite a gluten-free diet.
• Inadequate protein digestion plus fermentation by anaerobic bacteria lead to Small Intestinal Bacterial Overgrowth (SIBO) and symptoms like Bloating immediately after meals or Intolerance to fructose
• Measures Organic Acids in Malabsorption Markers (Indoleacetic Acid (IAA) and Phenylacetic Acid (PAA)).
• Also tests 1-Methylhistidine which is Low in Vegetarians with low protein consumption but High following High dietary intake of animal protein or Catabolism of muscle tissue.

Low Stomach Acid

• Causes include Advanced age (30% of elderly) or the Use of proton pump inhibitors.
• Symptoms include Bloating/belching after meals or Intolerance for protein.
• Consequences include Small Intestinal Bacterial Overgrowth or Dysbiosis – altered gut bacteria.

Inflammation and Immunology

• This pillar tests for Calprotectin and EPX primary markers of inflammation.
• Calprotectin is found in extra lysosomal cytosol of the neutrophil and accounts for ~ 60% of the cytosolic protein.
• Calprotectin Elevations can indicate Inflammatory Bowel Disease.
• Calprotectin is FDA-cleared and capable of differentiating IBS from IBD.
• A meta-analysis found that screening evaluated adults for IBD and measured calprotectin levels produce a 67% reduction in the number of adults undergoing endoscopy.
• Values > 120 μg/g is significant inflammation; with > 250 μg/g indicating active disease.
• Eosinophilic Protein X is released in eosinophil degranulation, is a sensitive marker for Gl inflammation, may predict relapse in IBD, stable in transport up to 7 days, and a sensitive marker for low-level inflammation.
• High levels of Fecal IgA is response to eliminate pathogens in Gl tract indicates sensitivities to foods; and can be tested for by eliminating foods in the diet. Tests also measures Lactoferrin for bacteria or yeast overgrowth

The Gut Microbiome

• Intestinal Dysbiosis exists when there is imbalanced microorganisms.
• The overgrowth of micro-organisms of low intrinsic virulence induces disease by altering the nutritional status, the immune response and the elimination capacity of the host.
• Dysbiosis many causes, including SAD(high fat and simple carbs)
• Dysbiosis can lead to multiple disorders including IBS and weight imbalances.
• Several markers may be used to check for this, as tested include Malabsorption and Dysbiosis Markers (Indoleacetic Acid (IAA) and Phenylacetic Acid (PAA)) and bacterial.
• Normal Bacerial function occurs, as tested, which are crucial to metabolic function. Like good SCFAs.
• Imbalances include reduced production of beneficial of SCFAs but too much Beta glucoronidase.
• For LOW Beneficial SCFAS it is recommended to Increase dietary fiber or take Prebiotics & probiotics.
• Short-chain fatty acids (SCFAs) are produced by the fermentation of dietary fibers by gut bacteria.
• Primary SCFAs such as acetate, propionate, and butyrate in play roles in cardiovascular disease, gastrointestinal health and intestinal permeability, mood, immune function, and sleep.
• SCFAs control body weight, and insulin sensitivity.
• Consumption of high fiber foods increases the production of Butyrate.
• Imbalances tested using PCR to Identify overgrowth of certain types is bad and good.
• Treat the gut for the correct types of pathogens with testing results.

Leaky Gut

• Zonulin regulates gut integrity and increased levels in the blood may indicate increased Intestinal Permeability.
• Causes if leaky Gut include Toxic exposure, bad diet, and a stressful Emotional state.
• Gut pathogen test also measures Intestinal Antigenic Permeability Screen for things like Actomyosin, and Occludin.
• Treatment requires balancing the Gut.