Everyone’s talking about it: the POOP TRANSPLANT

By now I’m sure you have heard about poop transplants, officially called “fecal microbiota transplantation” or FMT. At first, you may have been completely grossed out or confused or perhaps intrigued… is this real? Does it work? And why would anyone go through this? Let’s answer some of the FAQs since one day soon... poop transplant will likely be a standard therapeutic option!

http://www.nature.com/articles/nrgastro.2011.244

http://www.nature.com/articles/nrgastro.2011.244

 

When would one consider fecal transplant?

The only appropriate indication at this time is in patients with severe and recurrent C. difficile infection who have failed multiple attempts at conventional antibiotic therapy.

But in the future, fecal transplant may be used in any diseases associated with alterations in the gut microbiome including:

IBS (irritable bowel syndrome): reduced microbial diversity + decreased Bacteriodetes

- IBD (inflammatory bowel disease): Reduced microbial diversity

http://www.gastrojournal.org/article/S0016-5085(13)01279-1/pdf

http://www.gastrojournal.org/article/S0016-5085(13)01279-1/pdf

- Obesity, metabolic syndrome, insulin resistance: Reversed Firmicutes:Bacteroides ratio

- Autoimmune disease (multiple sclerosis, idiopathic thrombocytopenic purpura)

- Chronic Fatigue Syndrome: reduced E Coli, overrepresented Enterococcus & Stretococcus

 

So who’s poop are you getting exactly?

Although initially family members and household contact donors were used, now there is a stool donor bank called Openbiome that offers rigorously screened, high-quality traceable poop. They put donors through a very lengthy assessment process including 200-question clinical evaluation, lab screening including over 30 stool and blood tests. Less than 3% of people actually qualify to become donors.  Finally, each sample gets a very detailed RNA sequence characterization.

 

How does the poop get transplanted?

Several routes of transplant have been reported but the optimal protocol is unclear although using colonoscopy appears to have a higher success rate than others.

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1.     Colonoscopy: For the patient, it's no different than getting your routine screening colonoscopy. After getting sedated, a colonoscope is used to spray the poop throughout the colon often starting at the end of the small bowel and including the entire colon. It has been proposed as the preferential route of delivery as it is dispensed under direct visualization to the desired areas and you can evaluate for severity of disease at the same time.

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2.     Nasogastric tube: This involves putting a thin tube down the nose so that fecal material can be delivered to the small bowel and make its way to the colon. This usually requires daily infusions for multiple days.

3.    Oral capsules: Previous studies have used up to 30 frozen capsules on two consecutive days.

4.     Enema: Not ideal, an enema usually only delivers its contents to the left side of the colon, which could possibly limit its efficacy. Not to mention its near impossible to retain an enema for 6 hours!

 

Is it safe?

In short, yes! The adverse effects are mostly the known & expected ones associated with the mode of delivery (colonoscopy, etc). General reported adverse eevents include abdominal discomfort and infection, talthough it has been suggested that FMT using full-spectrum microbiotia has a protective mechanism that prevents infection transmission (not seen with synthetic stool or probiotics).

 

Now that you understand what a poop transplant entails... perhaps the ick-factor has diminished? Keep your eyes open for more FDA approved indications and tons of research on this topic coming your way!

 

The Mediterranean Diet for your GUT

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Patients often ask me what diet to follow and whether or not to count calories, carbs, etc. Especially after watching documentaries like WHAT THE HEALTH, I’ve seen a growing interest in more of a plant-based diet, which is amazing! (I highly recommend for everyone to watch it!). Instead of following a specific diet or going through fads though, I think its best for people to concentrate on developing more of a lifestyle than a diet, such as a lifestyle that revolves around food as healthy, natural nourishment that brings you together with your friends and family. And one of the best lifestyles to follow is the Mediterranean one. In fact, the “Mediterranean diet” has a TON of science to prove its worth including the fact that 2 of the 5 “Blue Zones” — communities around the world where residents live particularly long and healthy lives — are in the Mediterranean region.  Adherence to the diet has been associated with: reduced metabolic syndrome, obesity, type 2 diabetes, reductions in overall mortality, cardiovascular mortality, cancer incidence and mortality, and incidence of Parkinson disease and Alzheimer disease and is effective in primary and secondary prevention of cardiovascular disease. Phew! I’d say that’s impressive!

 

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So, what exactly is the Med diet?

·      A TON OF: fruits, vegetables, whole grains, beans/legumes, nuts, seeds, fish, olive oil (important source of monounsaturated fat vs saturated)

·      MEDIUM: wine consumption, poultry, dairy

·      SPARINGLY: red meat, processed foods including added sugar, white bread

adapted from the  NYPost

adapted from the NYPost

 

When I say it s not a hip trendy diet…

·      The Med Diet was first described in the 1960s by Ancel Keys after results of the epidemiological “Seven Countries Study,” which demonstrated that the populations bordering the Mediterranean Sea had a lower incidence of cardiovascular disease and cancer.

 

It’s more than a diet. It's a lifestyle.

adapted from the  NYPost

adapted from the NYPost

·      In 2010, UNESCO described it as “the set of skills, knowledge, rituals, symbols, and traditions raging from the landscape to the table, which in the Mediterranean basin concerns the crops, harvesting, picking, fishing, animal husbandry, conservation, processing, cooking, and particularly sharing and consuming of food.

 

What are the specific evidence-based health benefits?

·      CANCER PREVENTION: Studies have found that a Med diet is associated with decreased risk for COLORECTAL, prostate, oropharyngeal, and breast cancer. In Mediterranean countries there is a lower incidence of breast, endometrial, colorectal, and prostate cancer compared with Western countries. These cancers have been hypothesized to have a relationship to diet, in that a low consumption of fruits/vegetables and a high consumption of red meat correlate with cancer incidence. By statistical modeling, some epidemiologists estimate that up to 25% of colorectal cancer could be prevented in Western countries if diets were changed to reflect Mediterranean practices

·      NAFLD (non-alcoholic fatty liver disease) is one of the most common chronic liver diseases worldwide and the spread of it in the West is strongly associated with the increasing prevalence of obesity and type 2 diabetes due to lifestyle and dietary habits. One large study found that adherence to the Med-Diet was inversely associated with insulin resistance, the main driver of NAFLD. Those with higher adherence had a progressive reduction of risk of having NAFLD and a more favorable metabolic profile including lower triglycerides and blood glucose. Another study of 4,700 adults from the NHANES cohort, showed that relationship between Med-Diet and insulin resistance may be mediated by abdominal fat. It is also a high antioxidant diet as it contains polyphenols and vitamin E, important in fatty liver as oxidative stress is one important factor implicated in NAFLD onset.

adapted from the  NEJM

adapted from the NEJM

·      WEIGHT LOSS : A 2-year study published in New England Journal of Medicine  compared a Med diet, Atkins diet, and a low-fat diet. At the end of 2 years, the weight loss was −4.4 kg for the Med diet group. In 24 months they lost 2 BMI points and  …

o   Decreased: waist circumference, blood pressure, CRP, leptin, fasting plasma glucose and HOMA-IR, liver tests.

o   Increased: HDL, adiponectin

o   The Med diet group had a higher ratio of monounsaturated to saturated fat than the other groups (P<0.001) and a higher intake of dietary fiber (P = 0.002)

The Lancet also published about an unrestricted-calorie, high-vegetable-fat Med diet associated with decreased weight and less gain in central fat compared with a control diet. These results lend support to advice not restricting intake of healthy fats for weight maintenance.

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My gut-friendly suggestion would be to make sure any seafood/meat you eat is antibiotic-free and don't eat much of it! And try to avoid dairy. Otherwise the Med diet is as gut-friendly as they get! #gutlove

 

 

What IS the deal with the Turmeric craze & what are the health benefits???

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Turmeric is everywhere these days. You can even order a Turmeric latte in some Starbucks and Whole Foods! So why exactly has is Turmeric so hot right now- does it even have evidence based health benefits, and for what? Let’s get into it.

Turmeric is a spice derived from the tropical plant Curcuma longa, a member of the ginger family (Zingiberaceae). Curcumin, the principal curcuminoid found in turmeric, is generally considered its most active ingredient). In addition to its use as a spice and pigment, turmeric has been used in India  and China for medicinal purposes for centuries. Recently, evidence that curcumin may have anti-inflammatory and anticancer activity has lead to its discovery in mainstream culture, media, and diet.

What is it good for???

1. Functional dyspepsia:

- How does it work? Turmeric has been found to increase biliary secretion, promote contraction of the gallbladder, and act as an antispasmodic.  

- Research: In a placebo-controlled trial performed in Thailand, turmeric (2 g/day) was found to significantly improve dyspeptic symptoms (P = 0.003)

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2. Inflammatory bowel disease: Ulcerative Colitis

- How does it work? Turmeric prevents formation of free radical species, inhibits lipopolysaccharide-induced nitric oxide synthase (iNOS) gene expression, decreases TNF-α and IL-1β production,  inhibits nuclear factor (NF)-κB activation and cytokines thought to be necessary to IBD; and if thats not enough-- inhibits the synthesis of proinflammatory prostaglandins and leukotrienes.

- Research: An RCT of 43 patients who had UC in remission received curcumin enema for 6 months and compared results with patients who received placebo, 4.65% of those receiving curcumin suffered relapse versus 20.5% of individuals who received placebo.

adapted from drweill.com

adapted from drweill.com

3. Colon cancer prevention:

- How does it work? Curcumin decreases inflammation and expression of inflammatory COX-2 and endogenous DNA damage in adenomatous (pre-cancerous)tissue.

- Research: Studies have shown  turmeric to have chemopreventive activity in mouse models of familial cancer syndromes where it inhibits the development of intestinal adenomas.

4. Liver fibrosis

- How does it work? TGF-beta is a major cytokine involved in the promotion of fibrosis and scarring of the liver that leads to cirrhosis.

Research: Curcumin may block TGF-beta signaling and has been found to reduce the severity of steatohepatitis (inflamed fatty liver) in mice.

BUT HOLD ON A MINUTE…

- Optimal doses of curcumin for cancer chemoprevention or therapeutic use have NOT been established.

- Safety has not been established in pregnancy/lactation

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- Adverse side effects have been reported, including nausea, diarrhea, abdominal pain, headache, rash, yellow stool

- Turmeric inhibits platelets therefore increases risk of bleeding in people taking anticoagulants or antiplateltes agents (aspirin, Plavix, Coumadin, etc)

Conclusion: Enjoy your Turmeric latte but don't buy into the hype yet. Hopefully more research on it soon! #gutlove

Low FODMAP diet is great for IBS... but make sure you add a prebiotic + probiotic!

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IBS is thought to affect up to 15% of the population and is characterized by abdominal pain, bloating, gas, and alternating bowel habits. The low FODMAP (fermentable, oligo-, di-, mono-saccharides, and polyols) diet is commonly used as a first-line therapy and restricts dietary intake of fermentable short-chain carbohydrates including the oligosaccharides, fructans, and galacto-oligosaccharides (GOS). FODMAPs are foods (ex. cow milk, wheat) that cause symptoms due to poor absorption in the small intestine, resulting in an osmotic effect increasing water delivery into the gut, and rapid fermentation by the colonic microbiota leading to A LOT OF GAS. This extra water and gas production distends the bowel, worsening the symptoms of IBS. FODMAPs also have effects on gut microbiota, immune function, and mucosal permeability that could also affect IBS symptoms. Reducing dietary intake of FODMAPs provides an improvement of IBS symptoms in the majority of patients. In fact, up to 50% of patients with IBS-D had adequate symptom relief of their pain and bloating.

One issue with the low FODMAP diet is that it is ‘anti-prebiotic’ in the effect it has on raising stool pH and reducing stool Bifidobacteria in the microbiome as well as short-chain fatty acids like butyrate which are important to colonic epithelium and barrier function. Low concentrations of bifidobacteria have been associated with higher pain levels in IBS. What can you do about this? Take a prebiotic & probiotic while you’re on low FODMAP!

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1. Probiotic: Studies have shown that co-administration of the probiotic VSL#3 increased numbers of Bifidobacterium species in the microbiome, compared with placebo, and may be given to restore these bacteria to patients on a low FODMAP diet. In addition, Align contains Bidifobacterium and could be considered if VSL#3 is too pricey.

2. Prebiotic: Studies showed the prebiotic B-galacto-oligosaccharide resulted in significantly greater symptom improvement between controls (30.4%), those on the low FODMAP diet alone (50%) and those on the low FODMAP diet + prebiotic (66.7%). Other prebiotics to consider are prebiotin and benefiber.

So if you suffer from IBS and are on a low FODMAP diet, make sure you're protecting your micro biome's diversity with a pre & probiotic! 

Stop eating EMULSIFIERS... today!!!!

It’s almost impossible to avoid all the chemicals and artificial food additives in the inflammatory and disease-provoking western diet but today you can make one extremely important decision—stop eating EMULSIFIERS. I was surprised to find emulsifiers lurking in my pantry snuck into baked goods that were otherwise  touted as being healthy (low calorie, dairy free, etc). Take this weekend to review the ingredients of food you are eating  and TOSS anything with emulsifiers... to prevent gut inflammation, leaky gut, metabolic syndrome, obesity and cancer!

What are emulsifiers?? They are chemicals that are added to processed foods to enhance texture and stabilize processed foods, leading to extended shelf-life. There are many and have unappetizing chemical names like soy lecithin, distilled monoglycerides, and cellulose gum.

Why are they bad??

adapted from  University of Michigan

adapted from University of Michigan

1. Emulsifiers directly influence your microbiome & create inflammation in the gut. Emulsifiers decrease the diversity of the microbiome and directly break down the protective mucosal lining of the gut so that microbes get closer to the cells lining your gut which activates the gut immune system and results in gut inflammation, changes in metabolism and ultimately chronic gut inflammatory diseases, an altered microbiome and leaky gut. Studies have shown that hat administration of emulsifiers resulted in microbiota encroaching into the protective mucus, alterations in microbiota composition, including an increase of bacteria that produced proinflammatory flagellin (FliC) and lipopolysaccharide (LPS), and development of chronic inflammation. Such inflammation was associated with metabolic disease and increased incidence/severity of overt colitis in susceptible animals.

2. Emulsifiers influence your microbiome to promote metabolic syndrome. Metabolic syndrome is a risk factor for chronic diseases such as diabetes, obesity and heart disease and inflammatory bowel disease (IBD).

3. Emulsifiers create the ideal conditions for triggering colon cancer. A study found that after 3 months of feeding animals emulsifiers they showed changes in their gut microbes that were consistent with promoting tumor growth. The higher levels of inflammation created by the microbial changes are a  perfect cancer-growing environment.

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What can you do to protect yourself from gut inflammation, leaky gut, and chronic GI diseases?

READ EVERY LABEL & EVERY INGREDIENT!!! 

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Food regulations limit the amount of each emulsifier present in a particular food but don't restrict the number of emulsifiers allowed.Luckily, most labels actually have the emulsifier labeled as “emulsifier”. But here are some other scientific names to look out for and avoid: 

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  • Bread

    • Dough strengtheners (diacetyl tartaric acid esters and sodium or calcium stearoyl-2-lactylate)

    • Dough softeners (mono- and diglycerides of fatty acids)

  • Chocolate

    • Lecithin

    • Sorbitan tristearate

    • Ammonium phosphatide

  • Ice cream, sorbet, milkshakes, frozen yogurt

    • Mono and diglycerides of fatty acid, lecithin and polysorbates

  • Margarine

    • Mono and diglycerides of fatty acids and lecithin. Citric acid esters of mono and diglycerides,  polyglycerol esters.

  • Processed meat

    • Mono and diglycerides of fatty acids and citric acid esters

  • Baked good

    • Soy lecithin, distilled monoglycerides

In general, these are all processed foods that you should avoid anyway if you're following the #feedyourgut diet to keep obesity, inflammation, and cancer at bay. Toss: processed bread, margarine, mayonnaise, creamy sauces, candy, processed salad dressing, cream cheese, and ALL packaged processed foods

Take home point: #EATREALFOOD. #gutlove