Presented by Sharon ErdrichMHSc (Hons), NZRN, Reg Nut (NSNZ)

Reg Naturopath & Medical Herbalist (NMHNZ)

PhD Candidate (USyd)

• Potential conflicts of interest

• Own and practice from House of Health, offering a Breath testing service, aiding in the diagnosis of functional gastrointestinal disorders.

• Digestive symptoms

• Commonly Dairy Free, Gluten Free

• Food intolerances

• Avoiding legumes, onions, some fruits

• Feel better on low FODMAP diet

• Feel better eating Paleo

• Restrictions may help, may only help a bit/temporary

• +/- vague systemic symptoms

• Food Confusion.4

I’m allergic to fish, eggs

and garlic

..and I’m gluten-free, dairy-free and allergic to

tomatoes

What do you

suggest we get?

OUT!

ENZYMES

Gluten

fructose

Candida

• Many patients present with the conviction their symptoms are due to 'food allergies’

• Seldom substantiated by objective testing

• Doctors often attribute to psychological factors

• Many practitioners jump to the conclusion that food allergy or intolerance is responsible for nearly everything

BUT IS IT?

Current prevalence of food allergy:

• 10% of children up to 1 year old

• 4-8% of children up to 5 years

• 2% of adults

Australasian Society of Clinical Immunology and Allergy. Food Allergy [Available from: https://www.allergy.org.au/patients/food-allergy/food-allergy].

• “Allergy” should be reserved for true IgE-mediated reactions

• usually onset in childhood

• commonly react to 1-2 specific foods

• E.g., milk, eggs, wheat, fish or peanuts

Loblay, R.H., and Swain A.R., (2006) Food intolerance Clinical Immunology Research Centre, University of Sydney, NSW 2006;

Australasian Society of Clinical Immunology and Allergy. Food Allergy [Available from: https://www.allergy.org.au/patients/food-allergy/food-allergy].

•Mainly non-atopic people

•Affects skin, GIT, URT, CNS

•Provoked by a variety of chemical substances (natural and/or artificial)

• Effects are dose-related• Salicylates, histamine, additives etc.

Loblay, R.H., and Swain A.R., (2006) Food intolerance Clinical Immunology Research Centre, University of Sydney, NSW 2006

© Australian Bureau of Statistics

Atopic family history

Early onset of eczema

Severity of eczema

Resistant to treatment

Gastrointestinal symptoms

Faltering growth

http://www.londonallergy.com/category/statistics/

•Reflux, eructation

•Abdominal bloating, pain, excessive gas

•Constipation (? worse for fibre, lactulose)

•Diarrhoea• or both

•Probiotics MAY NOT help

• “Prebiotics make me worse”

• Low ferritin, but intolerant to iron

In a patient near you!

Quiz them about• Pineapple• Spinach• Nuts/seeds (esp Walnuts, peanuts, sesame

seeds..)• Strawberries• Cocoa (chocolate)• Alcohol, vinegars, • Tea, coffee• Ginger, pepper• Chili• …… Histamine symptoms are aggravated by Kiwifruit

Histamine comes in foodInherent amine (Avocadoes)

Accumulates in the aging process

Some foods “liberate” histamine

Egg white

Citrus

Shellfish

Impaired gut degradation of histamine (DAO)

Compounds BLOCK DAO Alcohol,

NSAID,s

Gut bacteria (or probiotics) can PRODUCE histamine

• Disequilibrium of accumulated histamine and the capacity for histamine degradation.

• Low DAO activity → histamine excess →symptoms mimicking allergic reaction

• Genetic, copper deficiency or injury to brush border

• HNMT (histamine N-methyltransferase) inactivates histamine in the intracellular space

• Genetic

• Ingestion of histamine-rich food or alcohol/drugs stimulating histamine release or blocking DAO may provoke:• diarrhoea, headache, rhinoconjunctival

symptoms, asthma, hypotension, arrhythmia, urticaria, pruritus, flushing, and more

• Symptoms are multi-faceted, can be reduced by:• Histamine-free diet• Antihistamines

THE EXISTENCE OF HISTAMINE INTOLERANCE IS UNDERESTIMATEDAm J Clin Nut, 2007. 85(5), 1185–1196.

Summary of histamine-mediated symptoms

Adapted with permission from Maintz L et al. Dtsch Artzebl2006;103:A3477-83.

Am J Clin Nut, 2007. 85(5), 1185–1196.

• In IBD and IBS, histamine levels are increased

• IBD assoc with decreased H2 receptor function (higher gut pH)

• Possible role of histamine producing gut bacteria

• Klebsiella pneumoniae (11/50 strains)

• Morganella morganii

• E.coli

• Hafnia alvei

• Lactobacillus vaginalis

• Lactabacillus saerimneri strain 30a

• Aeromonas hydrophlia (NCIMB1135)

• Citrobacter freundii

• Bifidobacterium adolecentis

• Bifidobacterium longum

• Bifidobacterium pseudocatenulatum

• Enterococcus species (including faceium, faecalis, and avium)

• Lactabacillus crispatus

• Lactabacillus fermentum

• Lactabacillus gasseri

• Lactobacillus salivarius

• Streptococcus vestibularis

Microb Ecol Hth Dis 2017 Vol28 (1 ) | J Allergy Clin Imm 2016 Vol 138, (5) 1491–1494.e7

• Some bacteria are present along whole GIT

• Gradient from stomach to distal colon

• Changing density

• Changes in main genus

• Driven primarily by pH

A) TOO MANY bacteria present in the small intestine. OR……

B) ALTERED distribution of bacteria: usually distally located anaerobic bacteria now found in SI.

= SIBO: Small Intestine Bacterial Overgrowth

• Gut bacteria produce GAS:

• Hydrogen (H2) = diarrhoea

• Methane (CH4) = constipation

• Hydrogen Sulphide (H2S):

• rotten egg gas & oftendiarrhoea

Common Culprits in BacterialOvergrowth

• The bacteria that are most commonly found to be involved are:

• Anaerobes

• Bacteroides in 39%, Lactobacillus in 25%, and Clostridium in 20%

• Aerobes

• Strep in 60%, E. coli in 36%, Staph in 13%, and Klebsiella in 11%.

• In another study

• E coli in 37%, Enterococcus species in 32%, Klebsiella in 24%, and Proteus mirabilis in 6.5%.

27Am J Gastroenterol. 1999;94(5):1327-1331.

Arq Gastroenterol. 2008;45(3):212-218.

• Lactase deficiency

• Over-consumption

• Brush border damage (e.g., Coeliac)

• Proximal bacterial overgrowth. E,g. • Lactobacillus• Streptococcus• (non-pathogenic)

E.coli• Not all species can

ferment lactose75% of adults in the world (but only 10% of Northern

Europeans) → varying degrees of diarrhoea, nausea,

abdominal pain and flatulence http://www.microbiologybook.org/fox/enterobact.htm

• Gluten• Gliadin• Fructans• Glyphosate• STE

?

Am J Gastroenterol. 2009 Jun;104(6):1587-94. doi: 10.1038/ajg.2009.188.

Is it IBS, Coeliac Disease or something in between?

Between Coeliac Disease and IBS:The “No Man’s Land” of Gluten Sensitivity

Non-Coeliac Gluten Sensitivity

• “Non-coeliac gluten sensitivity is characterized by symptom improvement after gluten withdrawal in absence of coeliac disease”

• RISKS OF DEVELOPING NCGS• Early life antibiotics or LSCS birth

• Increases in Proteobacter sp and inc severeity of gluten response

• Altered microbiome (low Bifido, high Staph, high Bacteroides fragilis• Risk increased with HLA genotypes

• HLA-DQ2 → increased Firmicutes, Proteobacter & decreased Actinobacter• FUT2 → decreased secretions, lower diversity, ++ Bifido sp.

• RISK MITIGATED BY• Delayed introduction of gluten• Breastfeeding while introducing gluten to the child’s diet

BMC Microbiol. 11, 219 (2011) ,PLoS ONE 7, e30791 (2012), Gut 64, 406–417 (2015) ,PLoS ONE 9, e94863 (2014).

84 patients w/ gluten reactivity

16 (19%) were positive for SIBO by breath test

3 had fructose intolerance

3 had lactose intolerance

= Importance of screening for other gut pathologies in cases of refractory CD or ongoing NCG/WS

Dig. Dis. Sci. 59, 1255–1261 (2014)

• Gliadin: can upregulate zonulin, which disrupts tight junctions• (Is stool zonulin a marker for gliadin intolerance?)

• Fructans: fructo-oligosaccharide. High in Gluten• FODMAP (improved GI symptoms on low FODMAP diet, worse w/gluten or whey)

• Amylase trypsin inhibitors: → immune activation, increases NF-kB & inflammation• lower in older varieties

• Wheat germ agglutinin: a lectin, increases histamine secretion & inflammation. Abs to WGA found in healthy people

• Glyphosate: interferes w/digestion of wheat. Alters microbiome• Salmonella is resistant, Bifido, Lactobacillus & Enterococcus are susceptible

Nature Communications 9, 4630 (2018)

•Up to 1/3 of people w/CD remain symptomatic on a GF diet

• In one study:• 66% of these had SIBO• 15% had lactose intolerance• 15% had parasites• 7% was accidental gluten

•All became symptom-free w/treatment

The American Journal of Gastroenterology 98, 839–843 (2003).

CROSS-REACTIVITY (ESP TO RYE

GRASS & APPLE POLLEN)PLoS One. 2013; 8(1): e53680.

http://www.tgw1916.net/

• Distinctive odour on flatus, stool.

• Generally feel very unwell

• Diarrhoea

Intolerant to

• High sulphur supplements

• Methionine, Chondroitin or Glucosamine sulphate, MSM, a-Lipoic Acid

• High-sulphur foods

• All animal protein• Worse on Paleo diet

• Cruciferous vegetables

• Allium family

• Genetic: CBS mutations

• If only Sulphites (E22x) – consider molybdenum deficiency

• Hydrogen-sulphide producers include

• Citrobacter, Escherichia coli, Pseudomonas, Desulfovibrio, Citrobacter, Salmonella, Giardia and Klebsiella

• 2011 study of 37 IBS patients and 20 healthy subjects

• Pseudomonas aeruginosa (H2S-producer) was significantly more abundant in both the small intestine and stool of IBS patients than in healthy controls

J Med Microbiol. 2011 Feb;60(Pt 2):236-45

• Tyramine Intolerance• Looks very similar to histamine but eggs & spinach are low in tyramine, but

histamine triggers• More common in people taking MOAI’s

• Salicylate allergy• leaves, bark, roots, skin and seeds of plants (is a protective factor)

• Oxalate intolerance• Usually associated with pain. Joints, muscles, dysuria• Better for supplemental calcium• Can be aggravated by dysbiosis (absence of Oxalobacter formigenes)

• Susceptible to erythromycin, metronidazole, quinolone antibiotics such as Ciprofloxacin J Endourol. 2011 Apr; 25(4): 673–679.

Amylase insufficiency (genetics)

Overgrowth of normal commensal starch-feeders:

• Bacteroides sp

• Ruminococcus

• Prevotella

• Klebsiella sp.

• Collinsella

• Some Streptococci

• Clostridium sp

ABIS Encyclopaedia,mSphere. 2018 May-Jun; 3(3): e00086-18.

Kumara

White Rice

Uncle Ben’s White Rice

Chickpeas

Potato

Hash browns

Sushi

41

JAMA. 2004;292(7):852-858.

Distribution of Intestinal Bacterial Flora in Normal Gut and in Distal Small Intestinal Bacterial Overgrowth

How Carbohydrate Malabsorption Influences Gut Bacteria

• Fructose, lactose, sucrose• Usually absorbed in the proximal small intestine

• Absorption impaired due to • Enzyme deficiency

(Genetic or pathological)

• Carbohydrate overload

→ Fuel for opportunistic, commensal bacteria and/or archaea

• Also more complex carbs which may not be fully absorbed before reaching distal bacteria• May create osmotic effect (diarrhoea)

42

43Am J Gastroenterol 2017; 112:775–784

Performance of breath tests6. We suggest that the presence of bacterial overgrowth should be ruled out before performing lactose or fructose breath testing. (100% agreement)

• Female, 29 years old presents with food intolerances and gluten sensitivity.

• Reports abdominal bloating, discomfort within an hour or so after various foods. Abdo cramps, BO 2-3/day, loose (BSC#-5-6), nil blood or mucous. Symptoms better for bowel motion

• Fatigue

• Hx of GF diet for 2/12, did improve but now other foods are causing the same symptoms.

• Concerned re food allergies, possible Coeliac disease.

• Worried about nutritional problems and her social life from increasingly restrictive diet

Coeliac disease

Non-coeliac gluten

sensitivity

Other food sensitivities

Food allergies

IBS

Another FGID?

Small intestinal bacterial

overgrowth?

?

48

1. Test sugar consumed after collecting baseline sample

2. SI bacteria ferment unabsorbed sugar, producing

hydrogen and/or methane gas

3. Gases are absorbed into the blood stream and transported to

the lungs

4. Hydrogen, methane & carbon dioxide are

measured in the breath

• Medication restrictions/washout periods after antibiotics, unusual diarrhoea

• Prep period 24-48 hours• Restricted diet

• low residue = low fermentable

• Overnight fast (water only)

Sample Analysis• 8-day window for sample analysis

• Samples extracted by the Alveolac®

• Quintron® Breath Tracker

• Uses gas chromatography

• Gold standard in breath testing

• Evaluates

• Methane

• Hydrogen

• Carbon dioxide

• Corrects automatically based on CO2

content

49

is a symptom. These are

some common causes

Get to the cause of the underlying cause of adverse food-related reactions – Ultimately we’ll have less of this.