Naturopathic Nutrition Year 2 Assessment & Diagnostics PDF

Naturopathic Nutrition Year 2 Assessment and Diagnostics 1 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Learning Outcomes In today’s lecture you will learn: Functional vs. conventional testing. St...

Naturopathic Nutrition Year 2 Assessment and Diagnostics 1 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Learning Outcomes In today’s lecture you will learn: Functional vs. conventional testing. Stool and SIBO testing. Vaginal and oral microbiome testing. Organic acid testing. Nutritional testing. Thyroid testing. Functional tests covered in this lecture are referred to in relevant Adrenal testing. lectures this year. This is where you DUTCH testing. learn the treatment protocols. 2 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Introduction Introduction: RECAP: As naturopathically-trained nutritional therapists, What is the you have a variety of evaluation tools including rule of 3? tongue, nail and facial diagnoses to help you better understand a client’s problems. Further testing can be utilised to provide you with a more detailed insight into the client’s body functions and dysfunctions. Laboratory tests can support you to guide and refine your therapeutic plan so that it is as effective and individualised as possible. 3 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Functional vs. Conventional Testing Functional testing: Focuses on how body systems are functioning. Diagnostic testing: Looks for markers to diagnose an illness. As naturopathic nutritional therapists we are interested in how the systems of the body are working as a whole, and what we can do with our therapeutic tools to help optimise them. Functional testing can provide a deeper insight into the client’s bodily processes, which helps to find the optimal nutritional and lifestyle plan for a client. It is not used to ‘diagnose’ a disease. 4 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Functional vs. Conventional Testing Scope of practice: There are some crossovers between functional and diagnostic testing. For example: Vitamin D3, thyroid and hormonal testing. It is important to recognise your scope of practice. Only order a test if you feel: – Comfortable with what you will do with the information that comes from the test. – Comfortable in referring to a GP if you find information that worries you in the results. However, testing can be a wonderful adjunct to your ability to support a client in a more holistic way. 5 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Functional vs. Conventional Testing The functional aspect of conventional testing: Diagnostic testing run by a GP can give functional information. It is often helpful to look how close parameters fall to the edge of the ‘reference range’ ― using the range provided by the lab. Be aware that ‘reference ranges’ are diagnostic, whilst ‘optimal ranges’ indicate a need for support to maintain homeostasis. Always ask clients to bring blood test results in, even ‘normal’ ones, so that you can check for optimal functioning. Vitamin D example: Conventional medicine considers levels over 50 nmol / L sufficient. The optimal range is approx. 75-125 nmol / L. © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 6  Functional Testing Benefits: Downsides: Helps to uncover a deeper Functional tests are provided understanding of imbalances to privately, and so can be expensive. help inform a naturopathic plan. Always ask yourself: is the test Can make a plan more likely to change the outcome targeted and effective. / the plan you create? They can sometimes be Allows to quantitatively challenging to read and interpret. measure a client’s progress, which benefits the client As they are not diagnostic, it as they can clearly see can be difficult to communicate improvements. results to medical doctors. © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 7  Functional Testing Interpreting functional tests: The context: When looking at interpreting any What were the symptoms functional test, remember that: at time of testing? – A test is a snapshot in time, and to Do they correlate understand this you need the context. with the results? What is the dietary – We are looking for patterns. One pattern this person marker alone is less relevant, but adheres to? Can this an array of markers occurring in a impact the results in a predictable way? pattern, and with context (symptoms) Is there any activity at gives a clear guide as to the system the test time that could under stress that requires support. affect the results? © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 8  Apply the Functional Testing rule of… Interpreting functional tests: Key point: The presence or absence of a marker does not necessarily equate to disease. Always apply the rule of 3 — for example in the context of using functional testing for SIBO: 1. Clinical symptoms (e.g., bloating after eating, flatulence, constipation). 2. Stool test microbial findings (e.g., raised Methanobrevibacter bacteria). 3. Other stool testing findings indicating poor digestion (e.g., raised faecal fats). 9 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Standard deviation = Reference Ranges measure of proximity to the mean (average) Reference ranges: Reference ranges are obtained by measuring a sample of the population and then setting the mean and standard deviation parameters of what is viewed as ‘normal’. Reference ranges and units of measurement can vary from lab to lab and in different countries (hence, re-test with the same lab). There can be variances in reference ranges for variabilities such as age, gender, ethnicity — the lab should give the parameters. Again, always look at the pattern and the context ― if a lab result is within reference range but near cut-off and the client has symptoms, function may still be affected. © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 10  Functional Testing Testing companies: You are eligible to set up a student account with all functional medicine test companies. This will give you access to all of their interpretive guides, technical calls and clinical materials. The main functional testing companies are: – Genova, Invivo Healthcare, Regenerus, Cambridge Nutritional Sciences, Biolab UK, Functional Dx. For direct to patient testing: Thriva and Medichecks. Which lab? Consider: What does the company specialise in? What support do they offer? What is the company ethos? 11 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Microbiome Testing Micro from Greek meaning ‘small’ Microbiomes are complex microbial Biome from Greek bios ’life’ ecosystems that occur within different Microbiomes are ecological communities of microorganisms areas (known as niches) of the body found in and on all multicellular (GI, vaginal, oral, skin, urinary etc): organisms Microbiota includes bacteria, Microbiome balance can play a archaea, protists, fungi and viruses role in health and disease, and is key in relation to the concept of the terrain. Microbiome science is constantly changing at a rapid rate. The microbiome is dependant on cultural, dietary, environmental and familial aspects. 12 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Microbiome Testing Gastrointestinal microbiome — stool testing: “All disease starts in the gut” — Hippocrates. Emerging microbiome science supports this in many ways, and newer methodologies in testing has enabled stool testing to gradually become much more available and accurate. You may wish to use stool testing to help optimise a diet for a healthful microbiome, ascertain if there is possible increased intestinal permeability, look for the presence of inflammation, gas-producing bacteria, or in some cases pathogenic microbes. 13 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Commensal = Latin commensalis, Microbiome Testing from com ’with’ + mensa ‘table’ — ‘one who eats at the same table’ Microbiome terms defined: Commensal — microbes that live in harmony with the host (us) and provide a benefit to us. Helicobacter pylori Pathogenic — microbes that possess certain evolutionary advantages to invade our microbiome at a cost to our health. Pathobiont — microbes that live with us and normally don’t pose a problem unless there is clear opportunity. Gram negative bacteria — bacteria that possess an outer cell wall, normally rich in lipopolysaccharides (LPS). LPS — the major component of gram-negative bacteria which have the ability to induce inflammation and immune responses. (Turnbaugh et al. 2007; Littman & 14 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. Pamer, 2011; Kamada et al. 2013)  Also referred to as a Stool Testing ‘CDSA’ = a ‘comprehensive digestive stool analysis’. Stool testing is a good way of What is Metabolic Endotoxaemia? getting a comprehensive snapshot ‘An immune response that becomes a of digestive function and the GI sub-clinical, persistent, low-grade microbiome at a given time: inflammation because of increased circulating endotoxins (LPS)’. It can be helpful when working Normally happens in conjunction with with GI complaints or for more poor GI barrier integrity. chronic systemic illnesses in Can be a risk factor for many chronic diseases such as insulin resistance, which poor GI function might be diabetes, CFS, autoimmunity. relevant. This includes the consideration of metabolic endotoxemia. (Cani et al. 2007; Each lab will provide their own collection instruction guide. Creely et al. 2007) © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 15  polymerase = an enzyme Stool Testing used to assemble DNA occult = hidden Comprehensive stool tests can evaluate: Microbial markers such as commensal bacteria, pathogenic bacteria, parasites, pathobiont microbes, mycology, sometimes worms (these are often best seen visibly in the stool). Host markers — markers made by the human host such as immune, digestive, inflammation, intestinal permeability and occult blood. Methodologies of stool testing mostly include: Polymerase chain reaction (PCR) — DNA testing of the microbe, and doesn’t require a culture. Culture with MALDI-TOF or microbiology assessment. © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 16  pathobiont = microbes Stool Testing that only cause a problem if there is clear opportunity Interpreting stool tests: The presence of a When looking at stool testing, you are microbe or raised marker alone does looking at a relationship between the not always equal individual person and their microbes. disease. People may carry pathobiont microbes, without any issues to their health. We want to look for correlations of the symptoms + microbes + host markers. First and foremost, you must have taken a thorough case including GIT symptoms and dietary patterns to be able to interpret accurately. 17 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Stool Testing Interpreting stool tests (cont.): Use the interpretative guides provided by the lab doing the test, as each test will require a different reading. Note: Different stool tests will include different target markers. Reference ranges in the microbiome are hard to ascertain as there is a large range of normal, so don’t panic if something is in or out of range — look at the whole pattern. Talk to the lab directly if you are concerned about the amount of one of the microbes. Different dietary models are well known for impacting the microbiota in different ways — so knowing the client’s diet is important to be able to read a stool test accurately. 18 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Stool Testing Dietary Models and the Microbiota: © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. (Rinninella et al. 2019) 19  Ideally repeat a mid- Stool Testing range calprotectin after 6–8 weeks, or after the treatment plan. Host markers — inflammation: Marker: Interpretation: Calprotectin: Flagged as high over 50 µg / g. Between 50‒175 is A protein made ‘mid-range inflammation’. The elevation is triggered by leukocytes by damage to the epithelial lining — in worst case when they have scenarios IBD, ulcers, cancer, but in most migrated to and scenarios, relates to pathogens, NSAIDS etc. are active in the NHS (UK): A screening marker for IBD. GI wall. If over 175 µg / g with symptoms and no It is a diagnosis / investigation, a re-test is required. marker If raised on a second test, it requires referral. of inflammation. Note: NHS boroughs have different cut-offs. 20 (Catalán et al, 2011; Sherwood & Walsham, © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 2016; Walsham & Sherwood, 2016; NICE, 2019)  beta-glucuronidase = de- Stool Testing conjugates molecules such as hormones (e.g. oestrogen) Host markers — inflammation (cont.): Marker: Interpretation: Eosinophil Normal range: 4.6 mcg / g. Raised with intestinal inflammation and in cases of food allergies, parasites, colitis. Host markers — metabolic: Marker: Interpretation: Beta-glucuronidase: Elevated — often due to dysbiosis and An enzyme made by a western diet ↑ in red meat / animal protein. some intestinal bacteria. When high it can interfere with oestrogen excretion (= ↑ circulating oestrogen). 21 (Van Odijk et al. 2006; Jung & Rothenberg, 2014; © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. Kwa et al. 2016; Yang et al. 2017; Baker et al. 2017)  How might Stool Testing you increase PE-1? Host markers — digestion: Marker: Interpretation: Pancreatic elastase (PE-1): Normal range: 200–500 µg / g. Proteolytic enzymes excreted < 200 µg / g — need digestive support. by the pancreas that do not Exocrine (digestive) pancreatic breakdown in the GIT. Correlate with levels insufficiency: 100–200 µg / g. of amylase, trypsin etc. Severe insufficiency: 62ng / g ― might be a sign Antimicrobial peptides of the immune system responding produced by the GI to a breach by microbes, or due wall when breached. to GI inflammation e.g., UC. 23 (Brandtzaeg et al. 2006; Kapel et al. 2009; Langhorst © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. et al. 2009; Mantis et al. 2011; Dzunkova et al. 2016)  Stool Testing Host markers ― intestinal permeability: Marker: Interpretation: Zonulin family peptide: High > 100 µg / g ― may be raised in A peptide produced by severe intestinal permeability (e.g., due to epithelial cells when the poor nutrition, heavy metals, drugs, GI tight junctions are alcohol, dysbiosis) and coeliac disease. open. Note ― even if it is 0, it does not rule out other modes of ‘intestinal permeability.’ The patterns of microbes can also be clues T to intestinal permeability. (Fasano et al. 2000; Exercise: How can you support the intestinal barrier? Fasano, 2012; Moreno-Navarrete et al. 2012) 24 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Stool Testing Commensal bacteria: One of the major indicators of health in the microbiota of humans is diversity. In the commensal markers, check for: ‒ Plenty of diversity (check that all bacteria are accounted for). ‒ Good levels of short-chain fatty acid producers (next slide). ‒ Good levels of Bifidobacterium (check that it is taking up more space than E. coli) and Lactobacilli. Diets lacking diversity (e.g., junk food diet, FODMAP diet), over-eating, antibiotic usage and chronic conditions can impact these levels in an adverse way. 25 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  -ate in chemistry Stool Testing indicates that it is an acid Bacteria: Butyrate Proprionate Acetate Short chain fatty acids (SCFAs): SCFAs are by-products of bacterial fermentation of fibre. The most common being butyrate, propionate and acetate. The epithelial cells of the colon use butyrate as their main fuel source — maintaining the intestinal lining. SCFAs can also affect appetite Check for these bacteria and modulate inflammation. on a stool test. Low SCFAs — caused by antibiotic use, low fibre diets, diarrhoea. (Pryde et al. 2002; Fernandez et 26 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. al. 2016; Louis & Flint, 2016)  mucin = a glycoprotein Stool Testing constituent of mucus The mucosal lining: Low mucosal integrity can be associated with local symptoms such as ulcers, IBD and gastritis, but can also be associated with too much cross-talk between the gut microbiota and immune system, resulting in metabolic endotoxemia (i.e., a different type of increased intestinal permeability). The presence of high levels of mucin-degrading bacteria, low diversity of commensal bacteria and high gram-negative bacteria, in conjunction with client symptoms, may reflect this issue. 27 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. (Okurmura, 2018)  Stool Testing Mucin-degrading bacteria: Akkermansia muciniphila is an important mucin-degrading bacteria but equally plays a protective role to the mucosal barrier. Absent levels are a risk factor for metabolic endotoxemia patterns of disease (obesity, insulin resistance, autoimmunity). Note — low FODMAP diets can lower Akkermansia spp. Ruminococcus gnavus (R.gnavus) or R.torques in high amounts, coupled with low diversity, has been proposed as a mechanism for autoimmune disease. Absence of diversity in Bacteroides sub-groups can cause the bacteria to become more mucin-degrading. (Everard et al. 2013; Geerlings 28 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. et al. 2018; Xu et al. 2019)  Hydrogen sulphide gas Stool Testing —think rotten egg smell Gas-producing bacteria: Some bacteria are well known for their ability to cause gas, and can sometimes be implicated in ‘gassy’ symptoms or SIBO. Methanobrevibacter smithii — associated with methane gas production. Desulfovibrio spp. and Bilophila wadsworthia — associated with hydrogen sulphide gas. Many bacteria are hydrogen-producing. If you suspect SIBO (which can be indicated by raised levels of the above strains), you may consider doing a breath test as well. (Ghoshal et al. 2016) © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 29  Stool Testing Pathobionts: Pathobiont bacteria are bacteria that only become pathogenic when there is an opportunity (i.e. if the terrain changes). It is important to compare an abundance of them in relation to the commensal bacteria and host markers. Avoid ‘blaming and shaming’ bacteria just because they are present. Remember — pattern and context. Many well known bacteria fit this picture, e.g., Prevotella copri, Klebsiella spp., Staphylococcus aureus. Always read them within the context of the host markers, symptoms and the health of commensals. (Kamada et al. 2013) 30 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  FIT = faecal immunochemical Helicobacter pylori test (detects minute amounts of blood in faeces) Helicobacter pylori (HP): Many people carry a level of commensal strains of HP. Other more pathogenic strains of HP can carry ‘virulence factors’, allowing them to turn infectious, adhering to and damaging the gastric mucosa. The presence of HP doesn’t always equal disease; read alongside symptoms and markers such as calprotectin and FIT. HP stool testing: Faecal antigen testing — reported as negative or positive. Faecal PCR tests — there will always be an amount of HP. Look for a higher-than-expected amount or presence of virulence factors. 31 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Stool Testing Pure pathogens: Not many, but some microbes are purely pathogenic in nature, and we would rather not carry them at all if possible. Again however, as testing is so sensitive, it is worth checking symptoms to make sure it correlates with your case, and also check the levels. Examples of pathogens: Natural anti-microbials include: – Giardia spp. Oregano oil, garlic (allicin), barberry – Clostridium difficile. bark (and berberine), – Entamoeba histolytica. thyme, clove, sage. – Shigella. 32 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Stool Testing Parasites — not always as bad as they sound? Many of us carry some weird and wonderful sounding amoebas and parasites that might be picked up with extensive testing. Always ask: “Has this parasite proven to be pathogenic in humans, or is it maybe more a sign of healthy diversity?” A good example of a ‘shamed’ parasite is Blastocystis hominis: ‒ In a small number of the population, it may cause IBS-like symptoms. BUT… ‒ It can be found in a high level of healthy population groups, and may also be a sign of health and a diverse microbiome. 33 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Stool Testing Review TWO stool tests — compare what they include Analysing a stool test: Remember pattern and context. Ask yourself: – Are there signs or symptoms that match the microbe? – Are the host markers abnormal? – Is there gut inflammation? High or low immune function? – Lack of diversity? Presence of pathogenic strains? When markers are out of range, as naturopaths we want to establish why. For example: Low pancreatic elastase might be a result of chronic stress and low HCl. This is crucial in order to address the underlying cause. © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 34  Case Example: Stool Test Jack, 33 years, computer analyst, inactive (long hours at desk). Presenting complaint: Lower abdominal discomfort and loose stools (BSC–6). Bloating after eating large meals, bread and Indian takeaways. Onset: Gradual over about 2 years (aged 29–31) — no specific trigger; Jack mentions he gets stressed with his work demands. Saw gastroenterologist (aged 31): Colonoscopy — told he has IBS. History: Not breastfed, natural birth, lots of antibiotics whilst at university (aged 18–21) — recurrent chest infections. Diet: Pescatarian for 7 years (↑ white fish). High white carbohydrate intake, snacks on dark chocolate, no fruit, mostly vegetables. 35 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Case Example: Stool Test Stool test interpretation: Evidence of intestinal inflammation — we must establish WHY this is the case. Lower inflammation, e.g.: ↓ gluten + sugar, ↑ vit. D3, fish oils (EPA+DHA), curcumin, polyphenols (e.g. quercetin), chamomile. A need for digestive support (e.g. minimising snacking, ↑ bitters – dandelion greens, rocket, gentian Less likely to have ↑ etc.) — possibly low due to chronic intestinal permeability stress, inadequate HCl, snacking. 36 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Case Example: Stool Test Stool test interpretation (cont.): Are all commensals present? A.muciniphila is absent — it has a protective role in the mucosal lining. ↓ levels indicate possible mucosal damage. Polyphenols ↑ Akkermansia (e.g. grape extract). Bacteroides spp., F.prausnitzii and R.bromii should always be abundant. Bacteroides spp. are a little low (can be ↑ by eating whole grains such as brown rice). © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. (Taira et al. 2015; Anhê et al. 2016) 37  Case Example: Stool Test Stool test interpretation (cont.): The 3 bacteria that are typically present: Bilophila, Hafnia and Veillonella. Bilophila and Desulfovibrio spp. may explain bloating. Possible SIBO. ↑ Veillonella spp. — linked with liver disorders. Indicates a need for liver support to help remove excess LPS through the biliary system (e.g., dandelion root, burdock root, artichoke). © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 38 (INVIVO, 2021)  Case Example: Stool Test Stool test interpretation (cont.): ↑ Methanobrevibacter along with Bilophila and Desulfovibrio spp. is suggestive of SIBO. Consider SIBO breath test. SIBO protocol is possibly indicated, with an initial phase of anti-microbials. Ruminococcus gnavus is often present and is normal up to about 8 — beyond this it is associated with mucosal degradation. © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. (Ghoshal et al. 2016) 39  Case Example: Stool Test Stool test interpretation (cont.): No presence of a fungal overgrowth such as candidiasis. Dientamoeba fragilis is present. This is not necessarily problematic, but can be, and might be causing symptoms such as cramping, urgency and diarrhoea. Further supports a need for anti-microbials. 40 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  CFU = colony SIBO Testing forming units Small intestinal bacterial overgrowth (SIBO) = a bacterial count in the small intestine of over 105 CFU / ml. In SIBO, fermentation of carbohydrates in the small intestine results in raised hydrogen or methane. Breath-testing is a non-invasive test that is looking for the gases made by fermenting bacteria (hydrogen or methane) after set points in time in which the patient has ingested a substrate that the bacteria eats. After the substrate is taken, breath samples are collected every 20 or 30 minutes. (INVIVO, 2021) 41 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  SIBO Testing Substrates: Types of substrates (bacterial food) used for the breath test: ‒ Lactulose (very popular — may give false positives as it is known to speed up transit time, making it hard to read). ‒ Glucose (there are less false positives, but absorbs quickly so might not pick up distal positives). ‒ Fructose (less commonly used; gives you the bonus of seeing if there is fructose intolerance). There is contention on which is the best substrate to use as they all have the possibilities of false negatives or even some false positives. 42 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  SIBO Testing SIBO testing: Breath test substrates — rely on your case taking to see what types of foods to which your client reacts worst out of the three substrates, to get an idea of the best substrate to use. Consider doing a SIBO test alongside a stool test as it is rarely present in isolation, it is a part of a bigger ecosystem disorder. Correct the underlying cause: SIBO is frequently associated with poor MMC functioning, low stomach acid and pancreatic juice, poor ileocaecal valve functioning and low IgA. What could these result from? 43 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  SIBO Testing Breath test preparation diet: A strict preparation diet should be done 24 hours before to get an accurate baseline, where microbiota-feeding foods need avoiding. The only foods allowed are: – Any meat / poultry / fish / seafood that is not cured or brined. – Plain, steamed white rice (not brown). – Eggs. – Clear meat broth (made only from the meat, no bone / cartilage or vegetables). – Fats / oils (coconut / olive / vegetable oils, butter, or lard). – Salt and pepper (no other herbs / spices). 44 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Transition to the SIBO Testing large intestine occurs at around 90 mins Interpretation: Gases analysed: Positive result: Increase in hydrogen: A rise of 20 ppm before 90 minutes. Increase in methane: A rise of 12 ppm before 90 minutes (or in severe constipation, a rise as little as 3 ppm might indicate a problem). Increase in combined A combined rise of 15 ppm before 90 methane / hydrogen: minutes. When fructose is used as the substrate, fructose intolerance can also be determined by a rise of gas in the large intestine after 120 minutes. 45 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  SIBO Testing SIBO Test Results Example: Positive for hydrogen and methane. This is the same information as above, but plotted on a graph. 46 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Vaginal Microbiome Testing bacterial vaginosis = an imbalance of the The vaginal microbiome (VMB): Lactobacilli dominant vaginal composition Plays a crucial role in vaginal, reproductive and maternal health. 1 billion bacteria / gram of vaginal fluid in reproductive-age women. The VMB is affected by numerous host factors as shown in the image. When to test the VMB? Bacterial vaginosis (BV), recurrent thrush, infertility, miscarriages, endometriosis and to provide an insight into vaginal ecology and its interaction with host immunity. © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. (Kamińska & Gajecka, 2017) 47  Vaginal Microbiome Testing Vaginal testing markers: Test using a swab into the vagina (at home) Marker: Interpretation: pH: Low vaginal pH indicates high A healthy vagina (of a reproductive age levels of lactic acid and a woman) has an acidic pH of around 3.8 healthy vaginal microbiota. to 4.5. This should prevent pathogenic High vaginal pH (>4.5) is microbes from growing. Lactobacilli play indicative of overgrowth of a major role in producing hydrogen BV-associated bacteria and peroxide to maintain the pH. vaginal dysbiosis. Interleukin beta-1: Healthy: 220 pg / ml — epithelial cells break apart (e.g., infection). BV or candida overgrowth. 48 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. (Fichorova et al. 2004; INVIVO, 2021)  Vaginal Microbiome Testing Vaginal microbial markers (cont.): Lactobacilli produce lactic acid, creating an acidic environment that is inhospitable to many non-Lactobacillus commensals and potential vaginal pathogens. Vaginal health is associated with low community diversity, but Lactobacilli dominance. More diversity = a shift in pH and host immune response modifications. Look to see that Lactobacilli are taking up the most space. 49 (O’Hanlon et al. 2013) © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. Vaginal Microbiome Testing Case example: 55 year old menopausal client. Presents with a watery-grey vaginal discharge / hot flushes. Results show: Very low Lactobacillus + lots of commensals overgrowing (= ↑ diversity) + ↑ IL-1 indicating inflammation. Indicative of BV. © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 50  Vaginal Microbiome Testing Supporting the VMB: Avoid: Soap in the vagina (wash with water only); antibiotics; the copper coil (↑ the colonisation of BV-associated microbiota); common lubricants (opt for jojoba oil which is similar to semen pH); excessive simple carbohydrates and alcohol; smoking (by-products are secreted into the vagina); vaginal douching. Include: Vaginal probiotics. Optimise the oral and GI microbiomes which have been shown to have an impact on the vaginal flora. Menopausal oestrogen support (e.g. flaxseeds, black cohosh etc.) Diet: Focus on a diverse range of prebiotic and probiotic foods to support Lactobacilli growth, as well as polyphenols. © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 51  Oral Microbiome Testing The oral microbiome is another niche microbiome in the body, harbouring approximately 2 billion bacteria. Dysbiosis of the oral microbiome is associated with tooth decay, periodontitis and even oral cancer. Some of these bacteria can also be associated with cardiovascular disease, autoimmune conditions (e.g., RA) and Alzheimer’s disease, as periodontitis = chronic the more pathogenic ones can release inflammation of the tissues that surround and support the teeth endotoxins (LPS) into the bloodstream. (Mustapha et al. 2007; 52 Paquette et al. 2007; Friedewald et al. 2009; © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. Kebschull et al. 2010; Zelkha et al. 2010)  Oral Microbiome Testing Pathogens in the oral microbiota: The ‘orange complex’ bacteria are ones that are starting to biofilm together and recruit an unhealthy biofilm in the mouth. The ‘red complex’ are pathogens highly associated with disease. (Socransky & Haffajee, 1998; Syrjänen et al. 2011; Pushalkar et al. 2012) © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 53  www.naturopathy- Oral Microbiome Testing uk.com/resources/ resources-dentists How to support the oral microbiome: Diet: Optimise levels of prebiotic fibres and polyphenols. Probiotic foods (e.g., kombucha, kefir). Minimise processed carbohydrates and trans-fats. Avoid snacking (it does not allow time for the oral pH to recover between meals). Avoid mercury fillings / remove them using a specialist dentist. Brush your teeth at least twice a day. Floss with a ‘water-pik’. Oil pull. Rinse salt water around the mouth. Scrape your tongue (balances the oral microbiome). Use a probiotic mouthwash. Avoid smoking, antibiotics. Use biofilm disruptors such as NAC where appropriate. © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 54  Stool and Vaginal Test: Case Exercise Open the TWO results documents labelled ‘Case A’. Using the INVIVO interpretative guides for the stool test (GI Ecologix) and vaginal microbiome test (Vaginal Ecologix) identify key findings and write aims and recommendations for this client. Maxi, female, 37, works in marketing. IUI = intrauterine insemination Presentation: Has been trying to conceive for 4 years. After 2 years of not falling pregnant, she had Clomid and IUI twice — falling pregnant and miscarrying under 8 weeks both times. 2 IVF cycles privately. In cycle 1, the embryo didn’t take. In cycle 2 she fell pregnant but miscarried again before 8 weeks. Suspected high NK cells. © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 55  Stool and Vaginal Test: Case Exercise Has had multiple courses of antibiotics, as well as the hormonal interventions of IVF. Hormones have been tested multiple times. Diet: Started a Mediterranean diet, but doesn’t always stick to it. Supplements: Pre-conception care multivitamin with methylated B vitamins and a probiotic containing Lactobacilli. Other: Getting frequent colds and feels generally run down. Slight vaginal soreness after intercourse; vaginal mucus is prolific and grey and depending on her cycle, sometimes fishy smelling. Periods are normally regular, but not so much since the latest IVF. ‒ She is getting mild bloating and is anxious and wants to try another IVF round quickly. © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 56  Organic Acid Testing (OAT) Organic acids are natural by-products (metabolites) created from the functioning of many enzymatic pathways in the body — including mitochondrial activity. They can be measured by urinalysis. They are used to get a window into the functioning of these pathways — all of which need certain nutrients as co-factors. It is an indirect way of identifying needs for vitamins and minerals, and other factors. It is a functional assessment of nutrient status. © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ. 57  Organic Acid Testing (OAT) Which clients might benefit from organic acid testing? Cases of chronic fatigue, suspected nutritional deficiencies, suspected mitochondrial dysfunction, autism, mood disorders. Where to obtain an OAT? Biolab (now at Viva Health), Genova, Invivo (Biotek lab) and Regenerus (Great Plains Lab) — some have environmental pollutants or extra microbial markers included. Quiz: Considering that OAT is useful for assessing mitochondrial activity, recap the stages of ATP production. What nutrients are needed? 58 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Organic Acid Testing (OAT) OAT benefits: OAT downsides: Can give you a good overview of Can be hard to interpret — use metabolic function — helping you the specific interpretation guides to see where areas of weakness provided by each lab and might be in biochemical pathways their support materials. and therefore, an extra need for Diet eaten at the time of certain nutrients. the test can really impact on Can help to guide your markers — changing the results. naturopathic care plan Not measuring the vitamin into clear areas that need directly — so you are making an addressing or further investigation assumption based on function. 59 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Organic Acid Testing (OAT) OAT metabolite groups: Ketone and fatty acid Markers associated with oxidation metabolites. nutritional function. Indicators of detoxification. Metabolites associated. Amino acid metabolites. with the Krebs Cycle. Bacterial metabolites Some neurotransmitter associated with dysbiosis. metabolites. Some tests include. Oxalate metabolism. environmental toxins such Glycolysis metabolites (balance as exposure to phthalates, between lactate / pyruvate). parabens, toluene etc. 60 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Organic Acid Testing (OAT) Interpreting OATs: Outcome is displayed by showing how far the client’s result is from the mean (away from the average). When reading results, you are looking for organic acids that are out of range in relation to the pathways they belong to, to see what needs support (see next slide). Every lab provides a very thorough interpretive guide and nutrient overview. This is what needs to be used to interpret the test — even experienced practitioners have to use these guides. Remember — it is a snapshot in time, all functional tests need context to interpret (symptoms, dietary pattern, case assessment). 61 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Organic Acid Testing (OAT) OAT in clinic: OAT can be purchased as a stand-alone test, which is often the cheapest option. Many practitioners that use genetic testing use an OAT test alongside to see if there is an impact on pathways from suspected problems in the genetic tests. – For example: Low levels of catecholamine metabolites (OAT) might be accompanied by methylation SNPs (genetic test). OAT markers are often incorporated into other nutritional panels such as many of the large Genova nutritional panels that offer tests with multi-methodologies in them (e.g., NutriEval testing). 62 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Organic Acid Testing (OAT) Sample report: The headings tell you what pathways are being covered The numbers Indication give you a of a low quick reference vitamin C to the status interpretation (common at the end and to see). Focus on also to cross optimising reference in the vitamin C interpretative status. guides. The results are placed on a scale showing how far the result is from the mean (average). 63 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Organic Acid Testing (OAT) Sample report section and corresponding parts of interpretation guide: How might this translate into a clinical presentation? How might you address these findings? 64 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Note: ‘Case B’ can be found OAT: Case Exercise on your student portal under the lecture notes. Open ‘Case B’. Using the Great Plains Laboratory OAT interpretive guide, identify key findings and write aims and recommendations. Rachel, female, 40 years old, finance director (high stress), gave up work due to her health last year. Mother of 2 boys (aged 2 and 4). Presents with: Chronic nocturnal pruritus on face, neck and abdomen, atopic eczema and asthma, seasonal allergies, insomnia (due to itching), low energy. Food intake: Gluten, dairy and refined sugar free, cooks all food from scratch, grazes on home-baked snacks. 65 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  OAT: Case Exercise Case B — Rachel (cont.): Beverages: Recently switched to decaffeinated coffee (2 per day). Observations: Scarred and thickened skin in areas. Blood tests: ↑ ESR, ↓ vitamin D. Additional: Symptoms became worse after breastfeeding last son, ceased 1 year ago. During first pregnancy diagnosed with eczema herpeticum (HSV-1), vaccinated as a child and given flu shot when pregnant both times. Tonsillectomy and glandular fever in teens. 66 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  serum = Nutritional Testing refers to blood Nutritional testing options: Serum testing — good for standard nutrients like vitamin B12 and D3. Also good for inflammatory markers. Red blood cell (RBC) testing — can show minerals and toxic elements taken up into RBCs, which is a good indicator of ‘tissue levels’. Urine testing — either looking for organic metabolites, or pure excretion (organic acid testing or toxic metal profiles). Hair mineral testing — to see what minerals have been laid down in the hair. 67 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Nutritional Testing Testing for deficiencies can be challenging: One place you can look for clues is the blood (serum). This doesn’t always tell you how the tissue is utilising a vitamin or mineral, and as many are under homeostatic control, the blood levels stay quite stable until an extreme is reached. You may need to look at other markers to assess the functioning of certain pathways that require those nutrients. – For example, an organic acid test which is a urine test. 68 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Nutritional Testing Serum options: Serum vitamin B12 and serum folate: - B12: The ‘active form’ of B12 is holotranscobalamin. - Homocysteine is a functional biomarker for low B9 and B12. - Methylmalonic acid (MMA) is a more sensitive index of B12 status compared to serum B12. It can be tested via serum and urine. The most common cause of raised MMA in the urine is vitamin B12 deficiency. Serum ferritin (iron storage capacity): - More accurate than testing serum iron. Optimal ranges will differ (e.g., male, female, child), but they are approx. 30-100 ug / L. 69 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Nutritional Testing Serum options (cont.): Vitamin D3: Optimal levels of over 75 nmol / L, but many practitioners prefer it between 100 nmol / L to 150 nmol / L. Serum magnesium: Will only show up a very frank deficiency — consider testing cellular levels instead. Serum calcium: Is generally only for showing kidney / hormonal problems as it is under such strict homeostatic control it only drops out of reference range in the extreme. Consider other forms of testing functional levels (e.g., RBC nutrients, OAT). 70 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Refer to the lipids Nutritional Testing lecture in nutrition year 1 Essential fatty acids (EFA’s): Specialised labs can test the omega-3 to 6 ratio and blood levels of all EFAs. Genova report showing, for example: Omega 6:3 ratio A need to increase LA (e.g., sesame) (Great Plains lab): and lower arachidonic acid (e.g., meat). 10:1 omega 6:3 ratio 71 © CNM: Nutrition 2: Assessment and Diagnostics. DC / BQ.  Serum Testing – Other Inflammatory markers: Marker: Interpretation: C-Reactive Normal CRP range: