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Omnivore Vs. Plant-Based Diet the Effects of a Low-Fomap Diet for Sibo/Ibs

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Omnivore Vs. Plant-Based Diet the Effects of a Low-Fomap Diet for Sibo/Ibs OMNIVORE VS. PLANT-BASED DIET THE EFFECTS OF A LOW-FOMAP DIET FOR SIBO/IBS PLANT-BASED NUTRITION HEALTH CONFERENCE 2019 BY: ANGIE SADEGHI, MD “IT’S ALL ABOUT THE BIOME“ • “Within one linear centimeter of your lower colon, there lives and works more bacteria (about 100 billion) than all humans who have ever been born. • Yet many people continue to assert that it is we who are in charge of the world.” Neil deGrasse Tyson GUT MICROBIOME: Bacteria, Viruses, Fungi, Archaea, Protozoa Collective genome contains at least 100x as many genes as our own eukaryote genome Grenham S, Front Physiol, 2011 Topping DL, Clifton PM. Physiol Rev 2001 Jul;81(3):1031-64. SHORT CHAIN FATTY ACIDS McNabney and Henagan. Nutrients 2017, 9, 1348 OMNIVOROUS VS. PLANT-BASED Whole Food Plant-based diet: Omnivorous Diet: Fiber Rich: Low-moderate fiber -Average fiber intake 60-100 g/day -Average fiber intake 10-50 g/ day Fruits Fruits Vegetables Vegetables Legumes Grains Grains Nuts Nuts Seeds Seeds Meat *** Eggs *** Low in fat: Dairy *** No cholesterol Small amount of saturated fat Moderate to high levels of saturated fat and cholesterol OMNIVOROUS DIET VS. PLANT-BASED DIET • Non-evidence based recommendations • Fish and eggs • Less “gassy foods” to “starve the SIBO” • The paleo diet • The auto-immune diet • Food combining • Carnivore diet • Keto diet • Evidence-based recommendations for controlling SIBO/IBS symptoms • Low-FODMAP diet Filippo et al. Proc Natl Acad Sci USA. 2010 Aug 17; 107(33):14691-14696 • Compared 14 healthy Burkina Faso (BF) in rural Africa children to 15 European children • BF children consume the traditional rural African diet • Low in fat and animal protein • Rich in starch, fiber, and plant polysaccharides • Mainly cereals (millet grain, sorghum), legumes (black-eyed peas, called Niébé), and vegetables Filippo et al. Proc Natl Acad Sci USA. 2010 Aug 17; 107(33):14691-14696 • The EU children eat a typical western diet • High in animal protein, animal fat, and low in fiber • The fiber average content in EU diet • 5.6 g/d (0.67%) in 1- to 2-y-old children • 8.4 g/d (0.9%) in 2- to 6-y-old children • The average amount of fiber in BF diet • 10.0 g/d (2.26%) in 1- to 2-y-old children • 14.2 g/d (3.19%) in 2- to 6-y-old children Filippo et al. Proc Natl Acad Sci USA. 2010 Aug 17; 107(33):14691-14696 Deflippo et al. Proc Natl Acad Sci USA. 2010 Aug 17; 107(33):14691-14696 Filippo et al. Proc Natl Acad Sci USA. 2010 Aug 17; 107(33):14691-14696 • Collected bacterial data: • 326 individuals aged 0–17 years • 83 Malawian, 65 Amerindian, and 178 residents of the USA • 202 adults aged 18–70 years • 31 Malawian, 35 Amerindian, and 136 residents of the USA Yatsunenko et al. Nature. 2010 May; 486(7402): 222–227. Yatsunenko et al. Nature. ; 486(7402): 222–227 MICROBIOME DIVERSITY Yatsunenko et al. Nature. ; 486(7402): 222–227. Note: High-fat chow: -vegetable oil -lard Hildebrandt et al. Physiol Rev. 2001 Jul;81(3):1031-64. -Both wild-type and KO mice stayed lean on the standard chow diet -Upon switching to a high-fat diet Wild-type mice became obese KO mice remained lean Hildebrandt et al. Physiol Rev. 2001 Jul;81(3):1031-64. HIGH FAT DIET (HFD) • Large alterations upon switching mice to a high fat diet : • Increased Firmicutes and Proteobacteria • Decreased Bacteriodes • Microbiota changes seen independent of obesity • Therefore a high-fat diet itself, and not the obese state, accounts for the changes in the gut microbiota Hildebrandt et al. Physiol Rev. 2001 Jul;81(3):1031-64. Desai et all. Cell. 2016 Nov 17; 167 (5): 1139-1353 GUT MUCUS LAYER • First line of defense against invading pathogens • Produced by Goblet cells • Tightly adherent to the epithelium • Poorly colonized • Nutritional aspect: • Composed of mucin-2 glycoprotein (MUC2) • Has a high polysaccharide content • Apart from dietary fiber, alternative energy source • Bacteroides • Evolved to shift from dietary polysaccharides to mucus glycan metabolism in the absence of fiber Desai et all. Cell. 2016 Nov 17; 167 (5): 1139-1353 Desai et all. Cell. 2016 Nov 17; 167 (5): 1139-1353 A high-fat diet: • Endotoxemia measured by plasma Lipopolysaccharides (LPS) • LPS are a byproduct of intestinal bacteria • Strongly increased intestinal permeability • Reduced the expression of genes coding for proteins of the tight junctions Cani PD et al. Diabetes. 2008; 57(6):1470 Stenman et al. World J Gastroenterol. 2012 Mar 7; 18(9): 923–929 Stenman et al. World J Gastroenterol. 2012 Mar 7; 18(9): 923–929 PRIMARY AND SECONDARY BILE SALTS Adv Nutr 2019;00:1–15 Adv Nutr 2019;00:1–15 Lawrence et al. Nature. 2014 Jan 23;505(7484):559-63. Lawrence et al. Nature. 2014 Jan 23;505(7484):559-63. METABOLITES High TMAO levels cause 2-3 fold increase in risk of heart disease For every 10 micromlar increase in TMAO, there is a 7.6% increase in all cause mortality as shown in a study of over 25K participants Zeneng, et. al. European Heart J., Vol 40, Issue 7, 14 February 2019, Pages 583–594 Sciattarella, et. al. European Heart J., Vol. 38, Issue 39, 14 October 2017, Pages 2948–2956 PROBIOTICS 9/23/19 35 Suez et al. Cell 2018 Sep 6;174(6):1406-1423 Suez et al. Cell 2018 Sep 6;174(6):1406-1423 Suez et al. Cell 2018 Sep 6;174(6):1406-1423 Suez et al. Cell 2018 Sep 6;174(6):1406-1423 REMEMBER THE 4 FUNDAMENTALS • High Fiber diet- good • Low fiber diet- bad • High fat diet- bad • Animal protein- bad SMALL INTESTINAL BACTERIAL OVERGROWTH SIBO • Symptoms • Clinical manifestations • Diagnose • Etiologies • Treatment options *** • Reverse Elimination Diet • Challenges • Expected timeline for resolution when someone is fully compliant • What can a practitioner expect when they begin treatment SIBO • A 2018 meta analysis found that 38% of IBS cases were caused by SIBO • Not all IBS is SIBO Chen, Et. Al. J Gastroenterol. 2018 Jul;53(7):807-818 IBS-DIARRHEA Pimentel et al. N Engl J Med 2011; 364:22-32 SYMPTOMS ASSOCIATED WITH SIBO • Abdominal pain/discomfort • Bloating • Abdominal distension • Diarrhea or constipation • Foul smelling flatulence • Reflux/burping Weiss, et, al. Dermatol Pract Concept. 2017 Oct; 7(4): 31–37 Weinstock, et. al. J Amer. Acad. Dermotology. May 2013Volume 68, Issue 5, Pages 875–876 CLINICAL MANIFESTATIONS OF SIBO • Steatorrhea • Vitamin/mineral deficiency • — Fat-soluble vitamins (A, D, E, K) • — Vitamin B12 • Vitamin excess • — Folate Lappinga P, et al. Arch Pathol Lab Med. 2010 Feb;134(2):264-70 Dukowicz, et. al. Gastroenterol Hepatol (N Y). 2007 Feb; 3(2): 112–122 CAUSES OF SIBO CAUSES OF SIBO • Structural/Anatomic • St•ruc—tuSmallral/A nintestineatomic diverticula • — SmallSmall intestineintestine stricturesdiverticul a(radiation, medications, Crohn's disease) • — SurgicallySmall inte screatedtine str iblindcture loopss (radiation, medications, Crohn's disease) • — ResectionSurgically cofre ileocecalated blin dvalve loops • — FistulasResectio betweenn of ileoc proximalecal valv eand distal bowel • — GastricFistulas resectionbetween proximal and distal bowel • Motility• — G aDisordersstric resection • M•ot—ilityGastroparesis Disorders • — SmallGastro bowelpares idysmotilitys • — CeliacSmall bdiseaseowel dysmotility • — ChronicCeliac d iconstipationsease • Irritable• — C hBowelronic cSyndromeonstipation • Irritable Bowel Syndrome CAUSES OF SIBO CONT. •Elderly •Metabolic Disorders — Diabetes — Hypochlorhydria — Obesity •Organ System Dysfunction • — Cirrhosis • — Renal failure • — Pancreatitis • — HIV • — Crohn's disease • — Celiac disease • — Malnutrition/eating disorders •Medications • — Recurrent antibiotics • — Gastric acid suppression • — Chronic narcotic use CAUSES OF SIBO CONT. • Endocrine disorders — Hypothyroidism — In a 2007 study, 54% of patients with hypothyroidism have SIBO • Alcoholism • Neurological diseases — Parkinson’s disease • Fibromyalgia Lauritano, et. al. J of Clin Endocrinology & Metabolism, Volume 92, Issue 11, 1 November 2007, Pages 4180–4184 SMALL INTESTINAL BACTERIA OVERGROWTH: NOT CAUSES • Vegan diet • High fiber diet • Whole food plant-based diet DIAGNOSIS OF SIBO • Aspirate of small bowel • >100,000 CFU/ML of aspirate BREATH TEST: Substrates used: Glucose or Lactulose Positive test: Rise of Hydrogen >20 PPM over baseline in the first 90 minutes of testing Peak methane levels >10 PPM at any point during the test is a positive result SIBO GASSES: • Hydrogen producing bacteria • Anaerobic bacteria • Cause diarrhea • Produce serotonin, which can further increase motility • Methane producing organisms • Anaerobic archaea organisms • Linked with Constipation • Hydrogen Sulfide producing bacteria • Only found in 1-2% of SIBO patients • Usually linked with diarrhea & sulfur smelling gas • Bacteria acquire large amounts of sulfur from proteins, mainly cysteine & methionine and reduce sulfur to hydrogen sulfide • Hard to diagnose (no current commercially available testing available) Triantafyllou, et. al. J Neurogastroenterol Motil 2014; 20(1): 31-40 GOALS OF TREATMENT • PREVENT RELAPSE! • 44% of patients successfully treated with antibiotics relapse within 9 months • Goal of treatment: • Treat the underlying cause • Provide nutritional support • Improve gut microbiome diversity • Decrease inflammation • Improve gut mucosal integrity • Treat the overgrowth with antimicrobials Bures, et. al. World J Gastroenterol. 2010 Jun 28; 16(24): 2978–2990 NUTRITION THERAPY • FODMAP DIET (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and polyols) • Developed by Monash University in Sidney Australia in 2005 • Only indicated in research to be utilized for 6-8 weeks • Problems: • Eliminates a lot of the prebiotic rich foods • Decrease microbiome diversity • Some people end of eating more animal products due to limited food options • It doesn’t cure SIBO “band-aid therapy” • Short-term solution • Reintroduction of foods can be difficult • Utilize a “Reverse Elimination Diet” to re-challenge and re-feed the gut microbiome LOW FODMAP DIET REDUCES SCFA Sloan, et. al. PLoS One. 2018; 13(7): e0201410. • There was a decrease of Bifidobacteria • There was a 47% reduction of total bacterial load Halmos, et.
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