Updates On Leaky Gut, Low FODMAP Diets, and IBS

Episode Intro:

Welcome to Dr. Ruscio Radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now, let’s head to the show.

Dr. Michael Ruscio:

Hey, everyone. This is Dr. Ruscio. Welcome back to Dr. Ruscio Radio. Let’s discuss some updates in gut health care. As you know, we obsess over tracking what’s being published in the scientific literature. We use that to share insights here on the podcast, of course, and also to constantly refine what we are doing at the clinic. There are a number of really insightful findings I want to share – some on SIBO, some on leaky gut, some on dysbiosis. One of the things I want to present here before we jump into this is – When I’m reading a new study, I’m always looking to see if that study reinforces what we’re doing at the clinic. More often than not, that’s the case. If it doesn’t, we’ll modify what we’re doing at the clinic accordingly. I suppose the deepest and most important facet of this is if we have the right clinical model – meaning we’ve been interpreting science now for 10 years the right way and we’ve come up with this clinical approach – then (unless a finding is totally out of left field, no one expected this, this really changes thinking) if we’re using a model that’s reflective of the science, most new science should reinforce what we’re already doing. I hope that makes sense. If we are using a model that’s accordant with the science (and we’ll go through a number of findings here that really reinforce that), we should see the science continue to support what we’re doing.

DrMR:

I should be careful in saying there will invariably be new findings that skew thinking. As one example (as a foreshadow), a study we’ll go over in a moment, found that a low FODMAP diet reduced leaky gut, whereas a gluten-free diet did not. Now, does that sound like it is keeping with our clinical approach and my philosophy, which is FODMAPs may be more important than gluten for some? That creating an anti-inflammatory environment, which sometimes means eating a diet that starves bacteria rather than feeds bacteria can lead to the most benefit in the gut?

DrMR:

And that gluten is not a problem for everyone? And that the low FODMAP diet has merit for gut healing? We shouldn’t be worried that it doesn’t feed bacteria because just indiscriminately feeding bacteria isn’t always the right approach. Let’s jump in and cover some of these studies, and also interpret and weave those into how those can be thought of in your health care plan; in the greater context of how you use this emerging information to continue to refine what you’re doing for your health.

1st Study: Microbiota Subtypes & Low FODMAP Diet

DrMR:

First study – Two microbiota subtypes identified in irritable bowel syndrome with distinct response to the low FODMAP diet. 41 IBS patients, 41 healthy controls. They measured the microbiota and I’m pretty sure they were using the dysbiosis profile from the GA-map, which is also incorporated into the Doctor’s Data dysbiosis assessment. So pre-post microbiota stool assays and the intervention was a four week low FODMAP diet. At baseline, 50% of IBS cases had a pathogenic or a dysbiotic microbiota composition. The low FODMAP diet shifted this to a healthier profile.

DrMR:

A low FODMAP diet (as I’ve been saying for years) can starve bacteria because it’s lower in prebiotics, it’s lower in these compounds that feed gut bacteria. That can actually be corrective and that can be helpful for hitting eubiosis (or balancing the microbiota) and correcting dysbiosis. So, an important finding there. I just want to make sure to weave in the context that some still criticize the low FODMAP diet because it doesn’t feed gut bacteria. I think I’m probably preaching to the choir here when I remind everyone that the trend line, especially in the IBS literature, is pointing to antibacterial approaches tending to be better for these people and for healing the gut than do pro-bacterial approaches. Examples would be a low FODMAP diet TENDS TO work better than a high fiber/high prebiotic diet. Note my language please — “tends to.” It’s not to say that there is no merit to using a higher fiber and a higher prebiotic diet. It can be helpful, but we’re looking at the trend line so we can make the best decisions possible. Where would we start? We would start with the intervention that’s going to help the highest percentage of people the most often – so a low FODMAP diet as compared to a high FODMAP/high fiber diet.

DrMR:

I think the probiotics should also be acknowledged (ironically) as an antibacterial approach, because there’s now been over 20 clinical trials finding that probiotics can cure SIBO. That’s even been summarized in the meta-analysis. Probiotics are more effective than supplemental prebiotics — again, the trendline is in the direction of antibacterial strategies. Of course, herbal antimicrobials are also very helpful, antibiotics (namely rifaximin) are very helpful, and elemental diets that are also antibacterial are very helpful. So, the trendline in the direction of antibacterial strategies seems to be best for rectifying dysbiosis. And as we’ll talk about in a moment, also inflammation and leaky gut.

2nd Study: Eosinophilic Esophagitis

DrMR:

The next study: Effect of amino acid-based formula (or an elemental diet) added to four-food elimination diet in adult eosinophilic esophagitis patients: A randomized clinical trial. A group of 40 EOE (or eosinophilic esophagitis) patients were given an elimination diet and the other group was given an elimination diet + an elemental diet.

DrMR:

After six weeks in the group that had the combination of the elimination diet + the elemental diet, there was a better response rate: 48% remission as compared to 25% remission. There was also an improved quality of life only seen in the combination of elimination diet + elemental diet. What this tells us is there’s merit to this hybrid use of the elemental diet that we’ve been advocating for at the clinic and that I discuss in Healthy Gut, Healthy You for years and years. The elemental diet doesn’t have to be exclusive liquid nutrition and nothing else. You can have some food and some elemental and that works well. That’s enough to take the edge off of the gut and we should be careful not to discuss and frame the elemental diet as something that has to be used exclusively. It’s unnecessary and limits the amount of patients who are willing to adopt this approach.

3rd Study: Rifaximin & SIBO

DrMR:

The next study: Efficacy of rifaximin in treating with small intestine bacterial overgrowth: a systematic review and meta-analysis. 21 observational studies and 5 randomized controlled trials They found the overall eradication rate for SIBO when using rifaximin was between 59% to 63%. I should also mention that there was a meta-analysis on probiotic therapy and essentially the meta-analysis found a 53% eradication rate of SIBO. However, when antibiotics (rifaximin) were then added on top of the probiotics, that response rate went from 53% to 85%. Does this approach sound familiar? Start with probiotics, reevaluate, and then consider antimicrobials or antibiotics. Again, exactly codified into how we’re doing things at the clinic. I don’t mean to keep tooting my horn (honk, honk), but I want to try to weave this in so that we all understand the science here is being used to refine our model.

DrMR:

And since I think we’ve done such a good job of interpreting and integrating the science, the new science is continually supporting what we’re doing. Also – to point out for patients and providers – we need to get away from the practice of going right to antimicrobial or antibiotic therapy without first laying the requisite foundational steps — diet and lifestyle as number one. We already discussed how it can (let’s say a low FODMAP is one example) reduce leaky gut and start correcting dysbiosis. OK- we’re already on the right track. Step two — probiotics. And if you really want to get the most yardage out of probiotics, why not combine three different probiotic products together so that you’re taking a triple dose (hence triple therapy) and ostensibly an appreciably better benefit than one probiotic alone. We’re collecting data on this and hoping to publish on this. Step three — now you consider either antimicrobial or antibiotic therapy.

Dr Ruscio Resources:

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4th Study: Cytolethal Distending Toxin B & Vinculin

DrMR:

Perhaps a somewhat prescient remark that I’ve made in the past is being somewhat suspicious of the utility of motility antibody testing. Just as a quick refresher… One of the causes of SIBO is dismotility (or a slowing of motility) that can happen after a bout of food poisoning. You can assess the antibodies that underlie that. These are Cytolethal Distending Toxin and CdtB antibodies. So this next study: Study of Antibodies to Cytolethal Distending Toxin B (CdtB) and Antibodies to Vinculin in Patients with Irritable Bowel Syndrome. This was a retrospective study of 100 IBS patients, and they found anti-Vinculin and anti-CdtB levels were significantly elevated in patients with IBS when compared to healthy controls. However, this is crucial: The difference between these groups (in my opinion) was nominal and clinically insignificant.

DrMR:

Now, this is my interpretation so take it with a grain of salt, but the IBS patients clocked in at a level of 1.58 ng/mL. 1.58 in the one group as compared to 1.13 in the other group. I’m unclear on what cutoffs they’re using to say this line is when you cross over from normal to positive. However, I know that IBSchek (which I’m assuming is the lab that’s doing this) uses a positive range of above 1.6 as to when you become positive. If in this study both groups were negative (1.58 compared to 1.13) then what that tells us, even though there was a difference in the level between groups, both groups were negative. That’s quite important to keep in mind. Another, I think, very clinically relevant contradiction is the fact that the diarrheal patients had the highest antibodies as compared to the constipative patients.

DrMR:

However, the patients who seem to respond the best (in terms of their symptoms) are patients who have constipation. Resolor (aka Prucalopride) has good evidence for patients with constipation and it can help them quite a bit. Not so much so when patients have diarrhea or at least, as best as I’ve been able to see. I have yet to see a paper – it’s possible I may have missed it – but I do follow the literature on Resolor (aka Prucalopride) that is proclaiming that patients with diarrhea should be on a prokinetic. Yet, when looking at the lab value, the lab value would tell you if patients with autoimmunity need to be treated with prokinetics. Then why do we see the patients with the most autoimmunity are also the ones that have symptoms that are almost contraindicated for the treatment of the prokinetic? Or said more simply – people with the most autoimmunity are the ones with diarrhea. Those patients shouldn’t be given a prokinetic.

DrMR:

Patients with constipation have far less autoimmunity. Yet, they do much better on a prokinetic. This is why I’m really trying to harp on the “treat the patient… don’t treat the numbers” and that lab values are just 1/4 of the data needed to make a decision. In this case, that lab value would be trumped by the three other data points: history, symptoms, and response to treatment. You would choose to – at least in our clinical paradigm – not give a prokinetic to someone with diarrhea, because it’s not indicated, right? The lab suggests that – it’s theory mainly at this point. That’s one data point saying give them a prokinetic. Let’s say they have diarrheal IBS, diarrheal IBS history, plus their symptoms continue to be diarrhealIBS.

DrMR:

Let’s say they go on a low FODMAP diet and do probiotic triple therapy and their symptoms go 70% away, then their treatment response indicates that we’re doing the right thing by using tools that correct dysbiosis. Maybe to get them the rest of the way there, they do a little bit of hybrid elemental dieting (where they replace one meal per day with the elemental) and then they get to 90ish% resolution and they’re very happy. So, now we’ve made a decision from those three data points — their history, their symptoms, and their treatment response. And we haven’t been led in the wrong direction by the one data point of the labs.

5th Study: Gluten, IBS & Antigliadin IgG

DrMR:

Next study: Gluten-Free Diet Reduces Symptoms, Particularly Diarrhea, in Patients With IBS. What they found here was that a gluten-free diet improved symptoms in those with IBS. They also did Anti-gliadin, IgG and IgA, tests to help predict those who would respond better, and they did.

DrMR:

They found that 75% of patients with the Anti-gliadin antibodies improved from gluten-free dieting, whereas 38% of patients with the antibodies improved from gluten-free dieting. And this is one of a few tenable food allergy markers. This is built into many stool tests. It’s not very expensive. That being said, I also wonder if some of these patients – let’s call them non-celiac, gluten sensitive patients – will regain and improve tolerance. So again, this is where labs can get you into trouble. If you mistakenly interpreted an Anti-gliadin lab to mean you can never eat gluten, you could actually miss the fact that through reduction of leaky gut, their antibodies went down or went back to normal and you’ve healed their gut. And now, like with so many other foods, they could have some gluten. This translates to a sizable impact on one’s quality of life.

DrMR:

Picture yourself out at dinner. You can either maybe have a piece of bread or not worry so fastidiously about what you’re ordering. Or you can have that opportunity for fun and social connection partially interfered with the fact that you’re worried about this lab test that your doctor ran two years ago. And even though you’ve got almost no symptoms now, you’re still worried about that. Another paradigm/approach could be “Okay, we’ll use that lab value as 1/4 of the data we use to make a decision, but we’re also going to be pragmatic and share with you that many patients will see improved food tolerance over time.” Since we have this lab value positive, that indicates that you are more likely to be gluten sensitive. However, not everyone who is gluten sensitive needs to avoid gluten all of the time, and people improve their food tolerance with time and after gut healing supports. “So, let’s be a bit more avoidant now. And then in the future, (let’s say in 3 to 6 months), we’ll start reintroducing. And what your body tells us, is the signal that we’ll follow.”

6th Study: Elemental Diet & Laparoscopic Anterior Resection

DrMR:

An additional study essentially found that a pre-operative elemental diet before GI resectioning (or GI surgery) led to lower post-operative complications than did a normal bowel preparation procedure (like a normal bowel flush you do before a colonoscopy.) A pre-operative elemental diet actually worked better than a pre-operative bowel flush. An interesting finding there and supports this thinking that maybe instead of flushing everything out, we eat in such a way that reduces inflammation, reduces dysbiosis and almost for certain, reduces leaky gut, as I’m assuming elemental diets can. I don’t know that that’s been formally documented, but I’d be shocked if that wasn’t found upon study. And so maybe that’s a better way of coming at this, rather than just flushing everything out.

7th Study: Gluten Ingestion & FODMAP Restriction

DrMR:

Coming back to that gluten study from just now and the practical approach of eliminate and then reintroduce… we have this study: Effect of Gluten Ingestion and FODMAP Restriction on Intestinal Epithelial Integrity (or leaky gut) in Patients with IBS and Self-Reported Non-Celiac Gluten Sensitivity. 33 IBS patients had their leaky guts (or their intestinal permeability) measured. And participants were on a gluten-free diet and instructed to adopt a low FODMAP diet and then challenge themselves with either gluten or placebo. Gluten ingestion had no effect on intestinal permeability markers or symptoms, and a low FODMAP diet reduced the marker of intestinal permeability by 3000% essentially, and reduced symptoms.

DrMR:

It’s not a battle about what’s better – gluten or low FODMAP – but it’s to help articulate that symptoms are very important. So in this case, gluten reintroduction did not elicit symptoms, and it did not impact intestinal permeability. However, FODMAP reduction improved symptoms and reduced leaky gut. Again, coming back to the four component model, we can use these lab values, but we want to use those lab values in juxtaposition to people’s history, their symptoms, and their treatment response. In this case, if they saw improvements in how they were feeling from low FODMAP, that would be the way to go, and we wouldn’t necessarily want to just use lab markers exclusively to guide this. What I’m trying to tie together here is you could make the argument that the intervention that’s best for symptoms is usually going to be best for lab values.

Dr Ruscio Resources:

Hi, everyone. If you are in need of help, we have a number of resources for you. Healthy Gut, Healthy You – my book and your complete self-help guide to healing your gut. If you’re not a do-it-yourselfer, there is the clinic – The Ruscio Institute for Functional Medicine – and our growing clinical and supporting research team will be happy to help you. We do offer monthly support calls for our patients where I answer questions and and help them along their path. Health coaching support calls every other week. We also offer health coaching, independent of the clinic, for those perhaps reading the book and/or looking for guidance with diet, supplementation, et cetera. There’s also the store that has our elemental diet line, our probiotics, and other gut health and health supportive supplements. And for clinicians, there is our FFMR – Future of Functional Medicine Review database – which contains case studies from our clinic, research reviews, and practice guidelines. Visit drruscio.com/resources to learn more.

8th Study: Zonulin & Mood Symptoms

DrMR:

Another study here about zonulin – the marker of leaky gut – did not find any correlation between zonulin levels and depression severity. I just mention that because while there’s definitely a trend showing that zonulin correlates with various syndromes or diseases, it’s not a perfect marker, and you won’t always see zonulin positive. We do know that probiotics can improve depression, but how do we account for the fact that probiotics improve depression, but this study did not find that those who are depressed have leaky gut? Well, there could be other mechanisms through which the probiotics are improving depression. As a clinician, you’re looking at outcomes first – what improves how the patient feels. And the secondary objective is trying to understand the mechanism. However, much of functional medicine unfortunately (although this is getting better) leads first with treating the mechanisms, hoping that the symptoms will improve.

DrMR:

And what this does is it puts an unnecessary intermediary step in between you and how you treat the patient. And the argument we’ve been making now for years is that leads to worse results. And we are actually drafting a paper now to submit to a peer reviewed medical journal, trying to make that case as cogently as possible. Hopefully we’ll have that published within six months.

9th Study: Biofeedback & IBS

DrMR:

Another study here looking at biofeedback assisted stress management for patients with IBS. After eight weeks, they found that IBS patients who use biofeedback to manage their stress had a greater reduction in IBS, a reduction in depression, and a better quality of life. So, another point of evidence for the diet, lifestyle, and gut foundations model that we use. This would actually be a good piece of evidence showing how important lifestyle is towards the end point of improving one’s not only gut health (as in IBS symptoms), but also brain health, depressive symptoms, and quality of life.

10th Study: Oral Microbiota & Small Intestine Microbiome

DrMR:

Another approach here – 250 duodenal (small intestinal) aspirates (samples) from the small intestine were paired with 21 saliva samples. Essentially, what their results suggested is there is a transmission of the oral microbiota into the duodenum. A facet, a subset of SIBO, may be this mouth bacteria trickling downward, and then overgrowing in the small intestine, as opposed to the hypothesis that Pimentel is championing, which is this acute bout of food poisoning then causes autoimmunity. And that autoimmunity throws off motility.

DrMR:

It may moreso be that it’s colonic bacteria creeping upward that causes SIBO. And some of the more contemporary thinking is suggesting an oral bacteria down into the small intestine is how SIBO occurs. Now in defense of Pimentel’s hypothesis, you could argue that both Pimentel’s and McCallum’s hypotheses could be occurring at the same time. What do I mean by that? You could have a problem with motility and this slow, small intestinal motility, but what happens in that scenario isn’t colon bacteria refluxing upward into the small intestine, but rather that slow motility in the small intestine allows those oral bacteria as they come down to linger in the small intestine for too long and therefore overgrow. I wanted to be careful not to cherry pick and straw man evidence to discredit some of Pimentel’s hypothesis because I do see there being merit to it.

DrMR:

I do feel that the motility hypothesis in SIBO represents probably a minority of cases rather than a majority. I think the top down of the oral down hypothesis has more plausibility and more merit. However, the way I describe this and I guess the hypothesis that I operate under chiefly is more of this wear and tear sort of hypothesis. By this, I mean if you have SIBO or IBS, I don’t think there’s anything wrong with you. If you have back pain or ankle pain, I’m not going jump to diagnose you with a disease, but rather let’s look at what you’re doing and let’s fix the environmental variables so that your system gets back to healthy, full function. And the evidence for this is fairly plentiful. With lifestyle, we just discussed that biofeedback or stress reduction strategies improve IBS. We know exercise improves IBS.

Episode Wrap-Up

DrMR:

We know that diet can rectify dysbiosis, reduce leaky guts, and improve IBS symptoms. We know probiotics can fix IBS and can correct SIBO. Just because someone benefits from these therapies, it doesn’t tell me that they’re diseased or dysfunctional or broken. It just tells me that we live in a world that probably isn’t optimal for healthy well being. And that starts before birth all the way up through adulthood — early antibiotic use… living in a somewhat hygienic atmosphere… lack of contact with dirt, soil, and animals… antibiotics… processed food… circadian disruption… and this leads to wear and tear on the gut. You having SIBO positive doesn’t mean you have a disease. In fact, I really just see that more as a byproduct of this environmental mismatch — the environment we are in is mismatched with our genetics and that leads to dysfunction. And if we can just change some of those environmental variables and correct the mismatch, you’re going to be fine.

DrMR:

I try to be careful about not letting patients get wrapped up into thinking they have a thing if they really probably don’t. That’s a little bit at odds with medical research and wanting to quantify these things and isolate them and have percentages and understand mechanism. What you’re doing as a clinician, as a researcher, as a scientist is different than the conversation that you have with a patient. The most experienced, tenured, appropriate, and evolved way of interpreting these medical diagnoses, mechanisms, and understanding of the pathophysiology leads to more of a “Hey, there’s not really anything wrong with you. This to me seems more like wear and tear; an environmental mismatch.” And even though we have these lab markers and these mechanisms that I have in the back of my head as a clinician, as a scientist, as researcher — I’m not going to imbue all of that to you.

DrMR:

I have to have a filter that prevents me from sharing all of that because without all the other context in my mind, you may come away with the worst possible case interpretation of the meaning of the fact that you have high zonulin… you have Vinculin antibodies. Those things in my mind are interesting, and we need to use them to learn how to help people, but they tend to lead patients astray. Albeit, maybe this seems overly simplistic, but a better way to interpret a lot of what you think is wrong with someone (especially with things like SIBO & IBS) would be that environmental mismatch hypothesis.

DrMR:

Well, I think that’s sufficient for today. Those are a number of updates from gut health research at large. I’m keeping a different list for probiotics, a different list for thyroid. And I’ll rotate through doing different podcast updates as this and tie in some of the thinking and rationale that showcases how I’m interpreting these findings and how we should use them to update our care models; how we can use these findings to communicate with patients. Alrighty. Well, I hope that was helpful and I will talk to you guys next time. Bye-bye.

Outro:

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• Two microbiota subtypes identified in irritable bowel syndrome with distinct responses to the low FODMAP diet
  • 41 IBS patients, 41 healthy controls
  • Measured microbiota before and after 4 weeks of low FODMAP diet
  • 50% of IBS cases had a “pathogenic microbial composition”
  • A low FODMAP diet shifted this to a healthier profile

• Effect of amino acid-based formula added to four-food elimination in adult eosinophilic esophagitis patients: A randomized clinical trial
  • 41 patients w/ eosinophilic esophagitis (EoE)
  • Randomized to:
    • Elimination diet
    • Or elimination diet + elemental diet
  • After 6 weeks, the elimination + elemental diet had:
    • better remission rate (48% vs 25%)
    • Improvement of quality of life (elimination diet alone had NO improvement)
  • Commentary: An elemental diet can improve EoE and increase quality of life.

• Efficacy of rifaximin in treating with small intestine bacterial overgrowth: a systematic review and meta-analysis
  • 21 observational studies, 5 RCTs, 874 patients
  • Rifaximin’s overall eradication rate of SIBO was 59-63%
  • Higher efficacy for higher doses

• Study of Antibodies to Cytolethal Distending Toxin B (CdtB) and Antibodies to Vinculin in Patients with Irritable Bowel Syndrome
  • Retrospective study of 100 IBS patients
  • Anti-vinculin and anti-CdtB levels were significantly elevated in patients with IBS (1.58 ng/ml) when compared to control subjects (1.13 ng/ml)
  • Anti-vinculin level was significantly higher in the IBS-D subtype than the other subtypes 
  • Commentary: Two things to note here:
    • 1) This study showed increased antibodies in IBS patients compared to healthy controls but the degree of difference is fairly low
    • 2) IBS-D had the highest antibody levels despite evidence suggesting that IBS-C benefits the most from prokinetics

• Gluten-Free Diet Reduces Symptoms, Particularly Diarrhea, in Patients With Irritable Bowel Syndrome and Antigliadin IgG
  • Prospective study of 50 IBS patients, 25 healthy controls
  • IBS patients with antigliadin IgG and IgA reported less diarrhea than patients without these antibodies
  • After 4 weeks of a gluten-free diet:
    • IBS symptoms improved in 75% with antigliadin IgG and IgA and in 38% without the antibodies
    • The presence of antigliadin IgG was associated with overall reductions in symptoms (OR 129 compared with patients without antibodies)
    • No effect on GI symptoms or gut function in controls
  • Symptoms were reduced even in patients with antigliadin IgG and IgA who reduced gluten intake but were not strictly compliant with the GFD
  • Commentary: Those w/ antigliadin antibodies may respond better to a GFD but larger studies are needed. Symptoms can be improved even if a patient is not very strict with the diet.

• Preoperative Elemental Diet before Laparoscopic Anterior Resection in Patients with Advanced Stenotic Rectal Cancer
  • 74 patients w/ rectal cancer scheduled for colectomy
    • 42 underwent 10-day elemental diet for prep
    • 32 underwent normal bowel prep
  • The elemental diet group had lower postoperative complications (OR 6.0)
  • Commentary: Elemental dieting may be an effective replacement to conventional bowel prep for those undergoing bowel surgery.

• Effect of Gluten Ingestion and FODMAP Restriction on Intestinal Epithelial Integrity in Patients with Irritable Bowel Syndrome and Self-Reported Non-Coeliac Gluten Sensitivity
  • 33 IBS patients, measured markers of intestinal permeability
  • Participants were on gluten-free diet instructed to adopt low FODMAP diet and then challenge themselves w/ either gluten or placebo 
  • Results:
    • Gluten ingestion had NO effect on intestinal permeability markers or symptoms
    • A low FODMAP diet reduced a marker of intestinal permeability (by 3,335%) and reduced symptoms
  • Commentary: Reducing FODMAP intake may have more efficacy than reducing gluten in those w/ IBS.

• Sex differences in zonulin in affective disorders and associations with current mood symptoms
  • 55 depressed participants, 37 euthymic participants, measured serum zonulin
  • NO correlation between serum zonulin levels and depression severity.
  • Commentary: This highlights serum zonulin’s relatively poor accuracy.

• A Biofeedback-Assisted Stress Management Program for Patients with Irritable Bowel Syndrome: a Randomised Controlled Trial
  • 46 IBS patients, randomized to biofeedback stress-management therapy or no treatment
  • After 8 weeks, the stress-management therapy had:
    • Greater reduction in IBS symptoms
    • Reduction in depressive symptoms
    • Better quality of life
  • Commentary: The biofeedback tool used in this study was a portable device used to train the patient to monitor the physical reactions (respiration rate, quality of a single breath, heart rate, and heart rate variability with breathing). The device used in this study can be found here.

• Quantitative sequencing clarifies the role of disruptor taxa, oral microbiota, and strict anaerobes in the human small-intestine microbiome
  • 250 duodenal-aspirate samples and 21 paired duodenum-saliva samples from participants in the REIMAGINE study
  • Results suggest that there is transmission of oral microbiota into the duodenum
  • Commentary: This study gives support to the top-down approach of SIBO pathogenesis.

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