The Microbiome Connection Part 3

The Microbiome Connection Part 3: by Mark A. Pimentel

Food poisoning can also disrupt your microbiome and cause IBS symptoms. To minimize your risk of food poisoning, follow these tips: Avoid eating raw foods, such as salads (especially at a salad bar) or raw fish, including sushi. Always heat your food thoroughly. Don’t eat foods that are left at room temperature for a prolonged amount of time (4 or more hours). Avoid eating from street vendors or food trucks, whose sanitation is usually different from that in a restaurant. Food may be unrefrigerated all day and thus be exposed to microorganisms that can cause food poisoning. Avoid eating uncooked vegetables as they are often sprayed or washed with local water. Cook the vegetables and serve them hot. Drink bottled or filtered water rather than tap water, and use bottled water to brush your teeth. Avoid the use of ice cubes, which are likely made from local water. When you bathe or shower, avoid getting water in your mouth. Eat at restaurants that have a reputation for cleanliness and avoid those with code violations. If you eat poultry that’s been frozen, be sure to thaw it fully before cooking it to avoid Salmonella and Campylobacter food poisoning. For the same reason, avoid eating raw eggs. At home, wash all fruits and vegetables thoroughly before eating. Use a non-toxic food detergent, which you may find at your local health food store. Peel the skins off fruit before eating. Wash or sanitize your hands before eating. In hotel rooms, use disposable cups instead of reusable glass or porcelain cups. In some hotels reusable cups are only rinsed rather than properly washed. If you plan to travel to an area that is high-risk for food poisoning, you may want to consider taking half of a rifaximin pill with every meal during your trip, although this is not an FDA-approved treatment. If you’re staying at a rental home or bed-and-breakfast, take further precautions: Clean the countertops. Clean all chopping boards, especially if they’re made of wood. Use separate chopping boards for meat and vegetables. Wash all sponges in the dishwasher. Sponges are known to carry tons of bacteria. To keep food from spoiling quickly, make sure the refrigerator is working properly. Pay attention to expiration dates on the food you buy. Expired food is more likely to contain microorganisms that lead to food poisoning. Let’s talk about our number 2: SIBO. SIBO occurs when there are greater than 1000 bacteria per milliliter (>103/mL) in the small intestine. In SIBO, this excessive quantity of bacteria is not an infection, but rather an over-colonization of specific bacteria in an area where they don’t belong. The bacteria aren’t invading or attacking you; they are your own resident bacteria. SIBO is, in effect, a phenomenon of bacteria dislocated from your large intestine to your small intestine. As the gut descends, the bacteria level varies. Your mouth contains millions of bacteria, but there are less than 100 bacteria per mL in your stomach. (We assume that the high acidity of the stomach kills many of the bacteria.) In the small intestine, the quantity of resident bacteria increases, but there are usually less than 1000 per mL. What causes SIBO symptoms? When food you’ve eaten makes its way into the small intestine to be absorbed, it’s broken down into small pieces and then digested. If you have more bacteria than normal, the bacteria consume the food before you digest it. When the bacteria digest and ferment the food, they produce various gasses: hydrogen, methane, hydrogen sulfide, and carbon dioxide. The excessive amount of gas leads to inflation —like a balloon—of the small intestine. The small intestine, which mostly deals with liquids or solids, isn’t equipped to deal with excess gas. When it fills with gas, it tries to move it forward. But unlike liquids or solids, gas can’t be easily moved, and it becomes trapped in the small intestine. That’s when you feel bloated and your belly may distend. You can’t get rid of the gas because the small intestine is incapable of pushing it forward, whereas when you have gas in the stomach, it can be relieved by belching. Excessive gas in the colon is passed as flatulence. There are, however, mechanisms for gas in the small intestine to disappear. Slowly, the gas is absorbed through your bowel wall into the blood circulation. When the blood passes through the lungs, gasses are released and you breathe them out. That’s why if you have SIBO, you often wake up with a flat belly because you haven’t produced any gas overnight and the gas you have in your bowel has been absorbed into your circulation. Also, the housekeeper waves are active at night while you are fasting, and the waves push the remnants of food toward the colon, thus limiting the amount of food left for the microorganisms to ferment in the small intestine. When you start eating again in the morning, your symptoms return and become worse throughout the day.  The Causes of SIBO STAGNATION: Bacteria don’t build up magically without cause. Think of the colon as a swamp with slow-moving water and the small intestine as a fast-moving river. The most common cause of stagnation is a lack or impairment of cleaning waves in the gut, which occur every 90 to 120 minutes when you aren’t eating. During the fasting state, these waves strip out debris in the gut after a meal. The salad you had for dinner last night has to be cleaned out so that your gastrointestinal tract is ready for breakfast in the morning. WEIGHT-LOSS SURGERY: Bypass weight-loss surgery can also lead to SIBO. One-third of American adults are obese, so weight-loss surgery—or bariatric surgery—is more popular than ever. One of the most common types of weight-loss surgery is Roux-en-Y, known as gastric bypass. This nonreversible surgery works by decreasing the amount of food you can eat at one sitting and by reducing absorption of nutrients. Typically, the surgeon cuts across the top of your stomach and makes it into a pouch about the size of a walnut, drastically reducing the amount of food you can hold in your stomach. The surgeon then cuts a loop of the small intestine and sews it directly onto the pouch. Food bypasses most of your stomach and the first section of your small intestine, thus entering directly into the middle part of your small intestine. This loop of bypassed small intestine is blind to food or liquid passing through it. Because nothing flows through those three feet of the small intestine, they can become stagnant. There are no effective cleansing waves flowing through it, however bacteria can still grow—or overgrow—in it, leading to SIBO. Inflammatory diseases, such as Crohn’s disease and severe celiac disease, cause significant inflammation in the wall of the small intestine and inhibit bowel clearance. They can also lead to strictures (abnormal narrowing) that alter the gut as well and, again, lead to SIBO. Diabetes is one of the most common diseases that affect gut motility. This metabolic disorder causes your blood glucose (blood sugar) levels to be too high. One of the long-term consequences and the most common complication of diabetes is peripheral neuropathy, or nerve damage caused by chronically high blood sugar levels. This leads to numbness, loss of sensation, and sometimes pain in your feet, legs, or hands. The nerve damage can affect the nerves in the gut as well, leading to abnormal gut motility and subsequent SIBO. DRUGS: Narcotics can slow down the gut and lead to SIBO. The opioid crisis has led to many SIBO cases because narcotics precipitate bacterial overgrowth. The main effect of narcotics is pain relief, but they dramatically slow down the gut and cause classic constipation, as well as heartburn, gastric reflux, abdominal discomfort, and opioid-induced bowel dysfunction, which is a potentially debilitating side effect of chronic opioid use. Fortunately, we have drugs, such as methylnaltrexone, that can specifically negate the bad effects of narcotics on the gut without taking away the pain-killing effects. Anticholinergics used in urology and gastroenterology to decrease symptoms of urinary infrequency or abdominal cramps work by slowing down the gut to alleviate cramps, which, in turn, affects gut motility. Antacids used to neutralize stomach acid to reduce heartburn may decrease the amount of acid in the stomach, decreasing its efficacy in killing bacteria and potentially leading to more bacterial overgrowth. However, the link between acid-suppressing agents and SIBO is not yet clear. We have reported in a large study that stronger acid suppressing medicines—called proton pump inhibitors—are not associated with bacterial overgrowth or any drastic change in the small intestine microbiome. Although proton pump inhibitors significantly affect the acidity of the stomach, they don’t affect the acidity of the small intestine. If your small intestine is healthy, it can balance the effects of proton pump inhibitors without an overgrowth of bacteria. The primary—and easiest—method of diagnosing SIBO is through a breath test. Gut bacteria can produce carbon dioxide as a fermentation product, just like the bubbles in beer. We humans also produce carbon dioxide, so looking for this gas won’t reveal whether the carbon dioxide is made by bacteria or by us. Bacteria and other microorganisms also produce hydrogen and methane, which is unique to them. When we find these gasses in the breath, we know they come exclusively from microorganisms in the gut that have migrated to the breath.

The Microbiome Connection Part 2

The Microbiome Connection Part 2: by Mark A. Pimentel

Digestion requires constant, synchronized contractions of the various gut muscles to control the movement of food through the gastrointestinal tract. These contractions are known as gut motility. Motility problems can develop when the nerves and/or muscles of the gut are not working properly. Abnormal gut motility can lead to bloating, pain, nausea, and diarrhea or constipation, all of the symptoms related to IBS. When gut motility is working well, during the feeding phase the stomach pushes food mixed with acid toward the pylorus, which senses whether the food is broken down enough to allow it to pass into the small intestine. The small intestine is responsible for mixing and spreading the food to maximize protein and sugar break down, as well as mixing fats and bile into little packages during the feeding phase. When the stomach is full of food and distends, the gastrocolic reflex signals the colon to empty, and the colon pushes stool forward. This is why you occasionally have a bowel movement after eating. The reflex also functions to drive the existing intestinal contents through the gastrointestinal tract to help make way for ingested food. The very act of eating can provoke an overreaction of this reflex in some patients with IBS because of their heightened visceral (intestinal) sensitivity. IBS patients tend to describe the experience of pain within the internal organs (the viscera) at a more intense level than normal, leading to the classic symptoms of IBS. The Fasting Phase After the feeding phase ends, the fasting phase begins. Initially the small bowel doesn’t move or only partially moves such that food gets mixed with enzymes in the small intestine. When digestion is complete, housekeeper cleaning waves (also known as migrating motor complexes phase 3) begin and occur every 90 to 120 minutes for a few minutes at a time. The waves move into the small intestine, where they push the remnants of undigested food, bowel secretions, and excess bacteria forward and dump them into the large intestine. The housekeeper function is one of the keys to understanding IBS. For those who are significantly affected by IBS, the housekeeping role malfunctions and “cleaning” of the bowel is impaired; that is, more bacteria accumulate and grow on the debris in the small intestine, producing many side-products—including gas—which leads to bloating, abdominal distension, diarrhea, or constipation. Motility issues can also stem from problems in gut immunity. Your gut has millions of immune cells—more immune cells than anywhere else in your body. The intestinal immune system encounters more antigens—toxins or other foreign substances that induce an immune response—than any other part of the body. That’s because you’re bringing the outside world into your body by eating. You need defenses. Your gut is also the home of the body’s largest microbiome. This microbiome ideally contains a healthy balance of bacteria, as well as fungi, parasites, viruses, and archaea (single-cell organisms, including methanogens, which produce methane gas as a metabolic by-product). These microbes live throughout your digestive system. They live in your mouth and in your intestines, and they have different functions and interactions. If the delicate balance of the microbiome is upset, for example, by food poisoning or excessive bacteria in the small intestine, you may develop IBS. Everything you eat affects your microbiome. Various dietary patterns shape the microbiome and can lead to differences in immunity. A more diverse gut microbiome can lead to a more robust, adaptable immune system. The wide variety of protective bacterial strains already found in your gut were partly passed down from your mother at childbirth. Antibiotics, diet, infections, and other factors may reduce their abundance, but these bacteria are usually not completely eradicated. It’s important to nurture and reinforce a healthy gut microbiome. There are numerous beneficial functions of a healthy gut microbiome. Gut microbes modulate other bacteria and facilitate the extraction and fermentation of dietary fibers. They generate heat and can change your basal metabolic rate. They also produce vitamins and are mediators of peptides (small proteins), which play key roles in regulating the activities of other molecules, modulating immune responses, and influencing other bacteria. The way in which the microbiome interacts with the body is important to gastrointestinal function. The human microbiome produces some of the same compounds that are produced by human cells. For example, the microbiome secretes serotonin, a mood chemical, leading some researchers to believe that bacteria can influence mood as well as insulin-like proteins and other chemicals that allow your body to function. Serotonin has a neuromodulating effect that causes nerves to fire and modulate gut function. A disruption in the microbiome may increase serotonin levels and can lead to diarrhea, or, if hormone production is reduced, constipation. Your microbiome contains five specific components that promote health and ward off disease. Diversity of bacteria and fungi in the gut. In the large microbiome city of your gut, the more diverse the population, the healthier it is. You wouldn’t want a city filled only with doctors or lawyers, for example. Distribution of bacteria and fungi. Differing types of bacteria are positioned strategically throughout the gut. For example, the colon bacteria are different from the small intestine bacteria because accumulation of bacteria from the colon in the small intestine leads to SIBO and its associated symptoms. Number and composition of bacteria. In the scientific literature this is described as relative or absolute abundance. With thousands of varieties of bacteria, your microbiome city has occupants with characteristics that allow them to complete their specific tasks. The number of each microbe is proportional to its roles and functions. Five plumbers would not be enough for a big city. You need the right amount of each bacterium for functioning harmony. Products of bacteria. The many inhabitants of your microbiome city produce a wide variety of products, some of which are good and others are bad. For example, some bacteria have properties that reduce inflammation in the gut and others promote normal motility. On the other hand, gas and other chemicals produced by bacteria in the microbiome can contribute to the symptoms of IBS. It’s important to understand that bacteria are not “good” or “bad” all the time. It’s more about maintaining balance in your microbiome. Resiliency. If you look at your microbiome after taking antibiotics, you’ll likely find that the numbers of microorganisms are drastically reduced. Two weeks later, the bacteria repopulate your gut and the microbiome snaps back to normal. That’s resiliency. But if you continue to take courses antibiotics, they can adversely affect your microbiome. The microbiome is like an elastic band that becomes a little less stretchy every time you pull on it. It may not snap back all the way if you take too many antibiotics. Food additives can also disrupt the microbiome. For example, emulsifiers are added to food to make it creamy, or sodium benzoate is added to reduce fungal growth and preserve shelf life. These additives make food more appealing, but they have the potential to disrupt the microbiome. An emulsifier such as polysorbate 80 disrupts mucous membranes and, in effect, emulsifies your microbiome too. And sodium benzoate kills fungi that are supposed to be in the microbiome.

The Microbiome Connection Part 1

The Microbiome Connection Part 1: by Mark A. Pimentel

In this book, the author explains how the microbiome of the gut can impact gut illnesses, two of which are highlighted in this blog: IBS and SIBO. Gastrointestinal illnesses are common and it’s important that they are talked about. Let’s start with IBS.

If you’ve had the following symptoms for three or more months, you have IBS: abdominal pain and/or discomfort, diarrhea, constipation, bloating, gas, urgency, incomplete evacuation, relief or worsening of pain with defecation, brain fog, early satiety (a sense of fullness without having eaten much), or both diarrhea and constipation. The last symptoms, diarrhea and constipation, may strike you as impossible, but they have now been classified as one of the three distinct types of IBS. First, there is IBS-C, meaning IBS with constipation. This type is found in 35 percent of patients. Second, there is IBS-D, which is IBS with diarrhea, found in 40 percent of patients. Third is IBS-M (mixed type), which is IBS with alternating bouts of diarrhea and constipation, found in 23 percent of patients. In this category, many patients don’t know whether they will be hit with diarrhea or constipation. During the course of one day, they might be constipated in the morning, but have diarrhea in the afternoon. And within one bowel movement, their stool may be hard at the beginning and watery at the end. So, we now consider IBS-D and IBS-M as one type of IBS disease—Non-constipation IBS—and IBS-C is possibly a different disease, Constipation IBS. Let’s talk about your digestive system. The first point of contact with the digestive system is your mouth, where food begins the journey of digestion. When you think about eating, your brain tells your gut, “Get ready, food is coming.” This turns on the production of saliva, which contains enzymes to begin the breakdown of food. At the same time, the brain sends signals to your stomach and to the colon via the vagus nerve. The signals flip a switch to convert the digestive system from fasting state (“cleaning mode”) to feeding state (“grinding and digesting mode”). The vagus nerve signals also ramp up the pancreas to secrete digestive juices and insulin, the stomach to produce more acid, and the gallbladder to squeeze out bile to help liquify fats and add more blood flow to the gut to gather up nutrients. When you take your first bite of food, the vagus nerve in your brain is excited, and as you swallow it becomes even more excited. By the time the food reaches your stomach, it’s really excited. The brain signals increase in intensity as the food moves closer to the small intestine, where absorption occurs. Remember, the gut has two modes: feeding (digestion) and fasting (cleaning). Two to four hours after you eat and digest a meal, the feeding mode turns off and fasting mode begins. It takes about two hours to digest carbohydrates, and about four hours to digest heavy fatty food or high- protein food. During the fasting mode, waves of electrical activity induce the gut to sweep residual undigested material through the digestive tract. This “housekeeping” role is known as the migrating motor complex. Most often, but not always, this procedure begins in the stomach. The oblong-shaped pancreas is located behind the stomach in the upper left abdomen. It converts food and other nutrients into fuel for the body, and produces pancreatic juice that enters the duodenum of the small intestine. The digestive enzymes secreted by the pancreas help break down proteins, carbohydrates, and fats. The pancreas also produces the hormones insulin and glucagon to help regulate blood sugar. Finally, the pancreas secretes bicarbonate that neutralizes the stomach acid. A balanced pH in the small bowel is crucial for the function of mucosal cells and digestive enzymes. The liver, the largest solid organ in the body, is found in the upper right quadrant of your midsection, just above the colon. It plays an important role in the body’s immune system, as it is the epicenter of detoxification: it will detoxify any toxin it encounters. Alcohol is the most well-known toxin broken down—or metabolized—by the liver. The liver also produces bile acids—the yellowish-brown enzymes that eliminate cholesterol from the body and aid in gut motility for digestion and absorption of fats in the small intestine. Bile acids also contribute to the color of your bowel movements. The gallbladder is a pear-shaped, hollow organ that sits just beneath the liver. In between meals, during the fasting phase, the gallbladder processes, stores, and concentrates bile from the liver. When the gut needs bile, the gallbladder squeezes the right amount out to help digest fats and other components. Once in the gut, some of the bile gets reabsorbed into the blood from the ileum, the last section of the small intestine, and recycles back into the liver. If your gallbladder is removed or is not functioning properly, bile will flow straight from the liver into the small intestine and eventually to the colon, often resulting in diarrhea. It’s important to note that when bacteria encounter bile, they convert it to toxic bile acids (such as deoxycholic acid and lithocholic acid), which are believed to cause diarrhea. This is known as bile acid diarrhea (BAD) and is different from SIBO, but it’s worse when SIBO is present. One of the main causes of bile acid diarrhea is SIBO.

Part 6: More on Body Image, Bloating, Constipation, and Binge Eating

Part 6: More on Body Image, Bloating, Constipation, and Binge Eating

Based on the book "The Science of Nutrition" by Rhiannon Lambert

WHAT IS A DETOX diet AND DETOX TEA? "Detox" is a buzzword in the diet industry. Many products and diet plans promise to rid the body of toxins, help you lose weight, and even reduce cellulite. But detoxes are unnecessary, because your body has a highly effective detoxification system of its own. The truth is, we don’t need to “cleanse” or detox ourselves at all, and following this sort of diet will not have this desired effect. The idea of feeling clean after a detox diet is what spurs dieters to embark repeatedly on expensive and immensely restrictive detox diets. We come into contact with environmental toxins every single day in the air we breathe and the food we eat, for instance. The body is a wonderful organism, which, through the action of the liver, effectively removes toxins and waste products that make it into the body system. Breakfast appears to be especially important when maintaining a healthy weight. Research suggests that controlling food intake across the day is more manageable on a full stomach in the morning—people who eat breakfast appear to be more likely to maintain weight loss in the long term. MENOPAUSE For most women, menopause is a natural aging process during which they lose their period due to declining estrogen levels. Plant compounds called phytoestrogens may help ease hot flashes and night sweats, the most common symptoms. So far, research has focused on one type—isoflavones—found in soybeans and soy-based foods and drinks. WHY DO I FEEL BLOATED? Bloating is the sensation associated with gas in our gut, when your abdomen feels swollen and is commonly distended. It can make us feel uncomfortably full and is sometimes accompanied by pain, flatulence, and nausea. Even in a “fasted” state, our gastrointestinal tract contains gases, which increase after eating due to swallowing air and gases produced during digestion. But it is normal for our stomachs to distend when we eat a meal—they are not supposed to remain flat! WHY AM I CONSTIPATED? Constipation can be frustrating and sometimes painful, resulting in a lot of straining and hard poop. Slow transit constipation occurs when your stool takes such a long time to get through the large intestine, much of its water content is absorbed and it turns hard and dry. Evacuation disorder comes down to the final push to excrete the stool, when coordination of the muscles involved is poor. This could have been a result of childhood toilet habits or be a structural problem of your biology. • Constipation-predominant irritable bowel syndrome is a type of IBS mostly owed to constipation. HOW CAN I STOP BINGE EATING? Binge eating is often explained as eating when we’re not hungry or overeating to provide a temporary distraction from something painful. But the relationship between food and mood goes far beyond that specific moment. Emotional eating is often a way of compensating for a lack of coping skills. And for some, this pattern can become a compulsion. It’s important to note that binge-eating disorder is a serious mental illness where people who eat large quantities of food can feel like they are out of control, which can be incredibly distressing. Binges can leave the individual feeling disconnected from what they’re doing during a binge. They can even forget what they have eaten afterward. Everyone is an emotional eater to some degree. Stress, boredom, anxiety, or sleep-deprivation can make us want to eat more of different foods (or not eat). The problem occurs when our emotions rule how we eat. If we overeat in response to something difficult or painful, we can get caught in the binge-restrict cycle. A binge is followed by guilt, even shame and embarrassment, which can cause an individual to restrict their food intake to compensate. Restriction triggers obsessive thoughts of food and so the cycle begins again. If you can spend time developing new coping strategies for emotional issues, it may help you get to the core of what is really going on and beat the binge-restrict cycle. The binge-restrict cycle can happen to anybody, not just those with eating disorders. If you ever find yourself stuck in the binge-restrict cycle, think about the following: SELF-WORTH Be prepared to work on yourself. Analyze your expectations and values and learn to grow your self-worth and self-esteem. Seek the help of a professional therapist if necessary. FOOD DIARY Work on a food–mood diary. Eat three balanced meals a day and two to three snacks; enough to maintain your body weight—you need to get out of the binge-restrict cycle before trying to lose weight. FEELINGS Understand your feelings. What is your eating style? Are there a lot of rules? Feelings of guilt or sadness? How do you feel if you break one of your rules, and how do you respond? TRIGGERS Identify your triggers. See whether you can recognize yourself in any of the common binge eating triggers below and think about how these states might affect you throughout your day: ANGER | ANXIETY | WORRY | FEAR DEPRESSION | NEGATIVITY | BOREDOM GUILT | SHAME. NEGATIVE THOUGHTS Challenge negative thoughts. Consider naming that inner critic inside your head. You may be surprised to find that you are bullying yourself— a sign that some self-soothing is required. KINDNESS Be kind to yourself. Remember that your body needs food for fuel. If your body is receiving the nutrition it needs, you are less likely to suffer from ill health. You deserve to eat and enjoy food. People with eating disorders use disordered eating as a way of coping with difficult situations or feelings. This behavior can include limiting food intake; eating very large quantities of food at once; getting rid of eaten food through unhealthy means (e.g., vomiting, misusing laxatives, fasting, or exercising excessively); or a combination of these. There’s no single cause, and sufferers might not have all the symptoms of any one eating disorder. Many people are diagnosed with “other specified feeding or eating disorder” (OSFED), which means their symptoms don’t exactly match what doctors check for to diagnose binge-eating disorder, anorexia, or bulimia, but that doesn’t mean that it’s not still very serious. Recognizing the symptoms of eating disorders and knowing they manifest differently from person to person, which can make them tricky to spot. Here are some signs to look out for: BEHAVIORAL SIGNS • Spending a lot of time worrying about your weight and body shape • Avoiding socializing when you think food will be involved • Eating very little food• Making yourself vomit or taking laxatives after you eat • Exercising too much • Having very strict habits or routines around food • Changes in your mood, such as being withdrawn, anxious, or depressed PHYSICAL SIGNS • Feeling cold, tired, or dizzy • Pains, tingling, or numbness in your arms and legs (poor circulation) • Racing heartbeat, fainting, or feeling faint • Problems with your digestion, such as bloating, constipation, or diarrhea • Your weight being very high or very low for someone of your age and height • Not getting your period.