Dysbiosis and Low FODMAP, Plus Other Research Updates - Dr. Michael Ruscio, DC

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Dysbiosis and Low FODMAP, Plus Other Research Updates

Looking at the efficacy of fecal microbiota transplantation, cognitive behavioral therapy, butyrate, probiotics, and other interventions on IBS, SIBO, and more

When looking for a way to heal your gut, it’s important to listen to what the research says. In this episode, the latest gut health studies feature the following interventions: 

  • Fecal microbiota transplantation (FMT)
  • Butyrate
  • The low FODMAP diet
  • Probiotics 
  • Prokinetics
  • Meditation 
  • Internet-based cognitive behavioral therapy (CBT)

Listen in to discover more about the efficacy of these interventions on IBS, SIBO, acid reflux, and more.

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➕ Dr. Ruscio’s, DC Notes

Efficacy of fecal microbiota transplantation for patients with irritable bowel syndrome at three years after transplantation

  • 125 IBS patients randomized to: 
    • Placebo
    • Single FMT 
  • After 3 years, patients who received FMT experienced:
    • Higher response rates (68% FMT vs  27% placebo)
    • Less fatigue
    • Greater quality of life 
    • NO side effects
  • Commentary: FMT led to long-term, sustained improvement in patients with IBS. 


Exocrine Pancreatic Insufficiency is Undiagnosed in Some Patients with Diarrhea-Predominant Irritable Bowel Syndrome Using the Rome IV Criteria

  • 140 patients with IBS-D, all tested for exocrine pancreatic insufficiency (EPI)
    • Fecal elastase-1 <100 µg/g was considered positive
  • In the 5% of patients that tested positive for EPI, dyspepsia was the most common symptom
  • Treatment with pancreatic enzymes led to improved:
    • IBS severity
    • Abdominal pain 
    • Bloating
    • Stool consistency
  • Commentary: EPI is relatively rare (5%) in patients with IBS-D, however it may be an important differential diagnosis to consider in patients with non-responsive diarrhea and dyspepsia.


Internet-Delivered Cognitive Behavioral Therapy in Patients With Irritable Bowel Syndrome: Systematic Review and Meta-Analysis

  • 9 RCTs on patients with IBS
  • Internet-based cognitive behavioral therapy (CBT) led to improved: 
    • IBS symptoms (moderate effect size) 
    • Quality of life (moderate effect size) 
  • Commentary: Internet-based CBT may be a cost-effective treatment option for patients with IBS. 


The effectiveness of microencapsulated sodium butyrate at reducing symptoms in patients with irritable bowel syndrome

  • 2,990 IBS patients, treated with sodium butyrate (150 mg twice/day) 
  • After 3 months, butyrate led to improved: 
    • Abdominal pain (5/10 severity → 2/10 severity) 
    • Gas (6 → 2) 
    • Diarrhea (5 → 2) 
    • Constipation (4.5 → 2.5)
    • Stool urgency (4 → 1.5) 
    • Nausea (1.5 → 0.5)
    • Quality of life (6.6/10 → 3.6/10) 
  • 94% of participants reported they would continue using butyrate 
  • Commentary: Butyrate supplementation led to improvements in IBS symptoms. Keep in mind there was no placebo group, and we know there is a strong placebo-response in this patient population. 


A Low-FODMAP Diet Provides Benefits for Functional Gastrointestinal Symptoms but Not for Improving Stool Consistency and Mucosal Inflammation in IBD: A Systematic Review and Meta-Analysis

  • 9 studies, 446 participants with IBD 
  • Compared to control groups, the low FODMAP diet (LFD) led to improved:
    • IBD symptom score (large effect size) 
    • Crohn’s disease symptom score (large effect size) 
  • LFD did NOT improve:
    • Stool consistency 
    • Ulcerative colitis symptom score 
    • Fecal calprotectin 
  • Commentary: LFD led to improved overall symptoms of IBD, but NOT stool consistency or fecal calprotectin. 


The prevalence of intestinal dysbiosis in patients referred for antireflux surgery

  • Retrospective study of 104 patients referred for reflux correction surgery
  • All had lactulose breath test for SIBO
  • 39.4% had SIBO, 35.6% had methanogen overgrowth
  • Those w/ dysbiosis were more likely to have:
    • Bloating (75% vs 49%)
    • Belching (60% vs 34%)
  • Commentary: SIBO may be a contributing factor to reflux. 


This study found dysbiosis was more frequent in subjects positive for anti-CdtB antibodies, but antibodies did not discriminate. 

  • It also found antibodies in 64% of healthy controls. 
  • This strengthens previous mention that dysbiosis could be an underlying cause of antibodies. 

Piggy backing off of Joe’s study

  • 67 IBS patients randomized to standard IBS or Low FOD diet x4 weeks
  • GA-map Dysibosis test performed at baseline could discriminate who would be likely to benefit from Low FOD diet
    • Non-responders to a low FODMAP diet (but not a traditional IBS diet) had higher DI scores than responders at baseline 
  • A low FODMAP intervention was associated with an increase in Dysbiosis Index (DI) scores in 42% of patients; while decreased DI scores were recorded in 33% of patients following a traditional IBS diet. → how can we account for this discrepancy between lab results and clinical outcomes (in other words, their test got worse but we have plenty of evidence that suggests a LFD helps)


Long-Term Effects of a Web-Based Low-FODMAP Diet Versus Probiotic Treatment for Irritable Bowel Syndrome, Including Shotgun Analyses of Microbiota: Randomized, Double-Crossover Clinical Trial

  • Cross-over study of 34 IBS patients, 6 healthy controls
  • Randomized to probiotic (VSL#3) or low FODMAP diet x4 weeks, then cross-over to the other intervention
  • Results:
    • 55% response rate for LFD
    • 62% response rate for probiotics
    • No difference in IBS symptom reduction between two groups (-127 LFD, -130 probiotics)
    • Response to treatment was NOT able to be predicted using metagenomic microbiome sequencing
  • Commentary: This study (although small) shows the efficacy of both probiotics and a LFD for IBS. It also suggests that changes in the microbiota are not predictive of treatment success. 


A Systematic Review and Meta-analysis of Randomized Control Trials: Combination Treatment With Proton Pump Inhibitor Plus Prokinetic for Gastroesophageal Reflux Disease

  • 16 studies, 1,446 participants w/ GERD
    • 727 receiving PPI only
    • 719 receiving PPI + prokinetic
  • The PPI + prokinetic resulted in greater improvement of GERD symptoms regardless of prokinetic type or GERD severity
  • No difference in quality of life or adverse effects
  • Commentary: PPI + prokinetic is superior to PPI alone in those w/ GERD.
    • Dr. Rusico wanted to add he has mixed emotions about prokinetics.  He quickly checked this study and had his hesitancy reinforced by this quote
      • 4 In Asia, the most commonly used prokinetics are mosapride, itopride, and domperidone. However, another prokinetic agent, cisapride, has been withdrawn from the market owing to its association with fatal heart arrhythmia
    • We aim to treat dysmotility further upstream, although still lacking robust data to support our approach. 


A Meta-Analysis of Microbial Therapy Against Metabolic Syndrome: Evidence From Randomized Controlled Trials

  • 42 RCTs examining effect of microbial therapy (probiotics, prebiotics, FMT) for improving metabolic syndrome
  • Microbial therapy resulted in:
    • Reduced waist circumference (effect size -0.26)
    • Reduced fasting glucose (effect size -0.35)
    • Reduced total cholesterol (effect size -0.36)
    • Reduced LDL-C (effect size -0.42)
    • Reduced triglycerides (effect size -0.38)
    • Increased HDL-C (0.28)
    • No change in A1C or systolic blood pressure
  • Commentary: This meta-analysis suggested that GI therapies can improve most metabolic parameters w/ a small effect size. 


Effect of continuous positive airway pressure on gastroesophageal reflux in patients with obstructive sleep apnea: a meta-analysis

  • 10 studies, 272 patients w/ sleep apnea
  • CPAP therapy reduced reflux symptoms
    • More reduction w/ longer use of CPAP
  • Commentary: Given that reflux is common in those w/ sleep apnea, treating sleep disordered breathing may be an important part of getting optimal GI health improvement. 


Feasibility of a low FODMAPs diet without initial dietician intervention in the management of patients with irritable bowel syndrome: a prospective study

  • 35 IBS patients, all given low FODMAP diet handout
  • After 6 weeks: 
    • 52% followed LFD regularly
    • 28% sometimes followed
    • 20% barely/did not follow
  • All symptoms (except constipation) decreased significantly
  • 77% reported symptom satisfaction
  • Commentary: This study showed a large response rate despite a lack of full diet adherence. This is why we at the clinic do not push our patients into 100% compliance with diets – this can often lead to anxiety and unwarranted fear around food. 


Effectiveness of Crohn’s Disease Exclusion Diet for Induction of Remission in Crohn’s Disease Adult Patients

  • 32 Crohn’s Disease patients put on Crohn’s Disease Exclusion Diet (50% of calories and elemental diet (50% of calories)
  • After 3 months:
    • Clinical remission in 82%
    • Lower calprotectin
  • Commentary: A CDED + partial elemental dieting has a very notable positive effect on those w/ Crohn’s Disease. 


Psychological Interventions for Irritable Bowel Syndrome: A Meta-Analysis of Iranian Randomized Trials

  • 20 RCTs
  • Psychological interventions (e.g. meditation, relaxation) had a large effect size at improving:
    • IBS symptom severity ( effect size -1.2)
    • Anxiety (-0.97)
    • Depression (-0.86)
    • Quality of life (-0.64)
  • Commentary: Addressing limbic imbalances can be a very impactful line of therapy for improving IBS. 


Helicobacter Pylori CagA Virulence Gene and Severe Esophagastroduodenal Diseases: Is there an association?

  • Gastric biopsies from 117 patients w/ various esogastroduodenal diseases
  • H pylori detected in 66% of patients, 80.5% had cagA virulence gene
  • The cagA gene was NOT associated w/ severity of disease
  • Commentary: Contrary to popular belief, the cagA virulence gene was not associated with upper GI disease severity in this study.

Sponsored Resources

Hey there listeners. This is Erin Ryan with the Dr. Ruscio, DC team back to answer just a few more questions about elemental heal.

  • You asked, will the carbs in elemental heal feed fungus or candida? So there’s no real set research on this yet, but in Dr. Ruscio’s, DC opinion, no. This formula is absorbed in the first few feet of the upper intestines. So it should starve fungus, just like it does bacteria.
  • How to reintroduce foods after the two week elemental heal protocol? Okay, so you wanna start slow and use a very limited number of foods. Maybe start with steamed veggies or something like that. Stay away from raw veggies or charred meats, but take the time to introduce things very slowly so you can notice how you feel
  • What about intense workouts while on the two week protocol? Since this is a time to sort of reset the gut and have it rest from digestion, it’s probably a pretty good time to just rest your body altogether. So if you can do something restorative like yoga or walking, that’s probably even better.

There’s a lot more info about elemental heal on our website, drruscio.com. There are customer reviews, research, scientific evidence, ingredients. Anything you wanna know about elemental heal is there on the shop page. You can learn more and purchase elemental heal at drruscio.com/EH, that’s drrsucio.com/EH.

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