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DR DAVIS:
The fundamentals of restoring and maintaining healthy bowel flora
Learn the Essentials
1 in 3 Americans struggle with some form of gastrointestinal distress: acid reflux and heartburn, the bowel urgency of irritable bowel syndrome, chronic constipation, and serious conditions that include ulcerative colitis and Crohn’s disease, among many others. It’s an astounding statistic when you stop to consider that no other organ system is plagued by such a bothersome frequency of conditions among such a high proportion of the population. Does this mean that humans are so poorly adapted to digestive realities that the mere act of obtaining nourishment inevitably leads to gastrointestinal discomfort, distress, or disease?
The answer, of course, is that turning to the seeds of grasses and regarding them as food was a fundamental misjudgment. The seeds of grasses—wheat, rye, barley, corn, sorghum, rice, etc.—served as an available and plentiful source of calories in times of desperation, but it required 10,000 years, the extended lifespan afforded by improved public health measures, and the introduction of genetic changes into grains by ambitious agribusiness companies to make the point: grains do not belong in the human diet. They certainly were never meant to play a dominant role. Humans are incapable of digesting grasses, including the components of their seeds.
It is a common experience in Cureality to remove grains and experience rapid relief from acid reflux, heartburn, and bowel urgency, or to enjoy dramatic improvement in the bloating, discomfort, diarrhea, and bleeding of Crohn’s disease or ulcerative colitis. But it is also common that, after the initial relief, some measure of bloating, loose stools, or constipation persist. Or the symptoms of an autoimmune condition, such as the joint pain and disfigurement of rheumatoid arthritis, or the skin rash of psoriasis, improve—but don’t entirely resolve. Additional efforts are therefore required to tilt the odds in favor of full recovery. Specifically, after removing the bowel destruction of grains, we need to encourage healing of the intestinal lining and replenish healthy bowel flora.
Call in the Reinforcements
Consuming the seeds of grasses disrupts the composition of bowel flora in the human intestinal tract. The bowel toxins in grains, such as gliadin, gliadin-derived peptides, and wheat germ agglutinin, encourage overgrowth of undesirable species. While human bowel flora was regarded for many years as a “black box” of no health consequence, the opposite is proving true: bowel flora composition is proving to be critical for overall health, including gastrointestinal health, metabolic health (blood sugar, blood pressure, etc.), inflammation, autoimmunity, and freedom from colon cancer.
Unfortunately, removing the original problem—grains—does not always allow full repopulation with healthy species, since we cannot create bacterial species out of thin air. Also, residual abnormalities that fail to fully recover after grain removal, such as hypochlorhydria (reduced stomach acid) or reduced release of pancreatic enzymes, can prevent healthy bowel flora from reestablishing a hold. An occasional person may also need to deal with massive overpopulation by unhealthy bacterial species that ascend upward from the colon into the small intestine, even as high as the stomach, called dysbiosis or small intestinal bacterial overgrowth.
Up to 35 percent of people with no other gastrointestinal disease and no symptoms have dysbiosis. Even though irritable bowel syndrome (IBS) is widely regarded as a benign condition, 30 to 85 percent of people with IBS have varying degrees of dysbiosis—IBS is not benign (Sachdev 2013). Overgrowth of undesirable bacterial species is common in the millions of people who take acid-blocking drugs such as Tagamet, Prilosec, Prevacid, Protonix, and Pepcid, or have hypochlorhydria caused by prior grain consumption. In addition, people repeatedly or chronically prescribed antibiotics; diabetics; people who take prescription narcotics (that slow bowel function); people with chronic constipation; and anyone with fibromyalgia, rosacea, restless leg syndrome, Crohn’s disease, ulcerative colitis, celiac disease, and autoimmune diseases, have all been demonstrated to have abnormal bowel flora and/or dysbiosis. It would not be a stretch to claim that, if you live in the modern world, you have some degree of disrupted bowel flora or dysbiosis.
It’s therefore time to repopulate the gastrointestinal tract with healthy species, such as Lactobacillus and Bifidobacterium, and tip the scales in favor of Bacterioidetes. Some of this is accomplished simply by increasing their numbers, including species that also produce bacteriocins, proteins that act as natural antibiotics against unhealthy bacteria (Dodd 1994). Among the most effective methods to restore healthy bowel flora is to therefore repopulate with species that produce bacteriocins, such as lactic acid-producing Lactobacillus species (Rea 2013). We begin this process by reintroducing healthy species with probiotics.
Repopulate With Probiotics
While your bowels are likely to repopulate with healthier bacterial strains over months or years as you get exposed to bacteria from all the varied sources of microorganisms in the world, supplementation with a probiotic preparation accelerates the process and ensures repopulation with healthy species, including those that can “outmuscle” the undesirable species.
The composition of probiotic preparations, typically containing a dozen or more Lactobacillus, Bifidobacteria, and other species, therefore constitutes a best guess—since nobody yet knows what the full range of healthy flora looks like—of what may be effective for restoration of bowel health. Probiotics supply a range of healthy bacteria that deprive undesirable species of nutrients, produce bacteriocins, help restore the normal mucous barrier of the intestine, convert indigestible prebiotic fibers to butyrate that heals the intestinal lining, and facilitate normal immune responses (Fitzpatrick 2013).
Bloating and constipation often develop in the first week of grain withdrawal, a consequence of failed transition to healthy bowel flora, not from a lack of fiber. Accordingly, relief from these symptoms typically occur within 24 hours of initiating a probiotic.
Because we eliminate the bowel disrupting effects of grains, the majority of people do well with probiotic supplementation for a period of several weeks, e.g., 6-8, just long enough to repopulate. If symptoms such as heartburn, bloating, or constipation return after that time, it suggests that something else is wrong that is disrupting gastrointestinal health and preventing restoration of healthy bacterial species. Factors that prevent healthy repopulation include conditions such as failed cholecystokinin (CCK) signaling to the pancreas, pancreatic enzyme insufficiency, or autoimmune hypochlorhydria. The best solution is a formal assessment to pinpoint the source of the problem. Occasionally, the situation responds to a more prolonged course of probiotic supplementation, or empiric use of bile acids, stomach acid supplementation with apple cider vinegar or betaine HCL, or pancreatic enzymes (see the Cureality Guide to Bowel Health).
Among the best probiotics are VSL#3, Garden of Life, and ReNew Life brands, with high-potency products in the multibillion colony-forming units, or CFU (a count of microorganisms), range, with better results than with lower-potency preparations. We’ve had best results with doses in the 30 to 50 billion CFU range. Healthy species include Lactobacillus plantarum, L. brevis, L. acidophilus, L. casei, L. paracasei, L. rhamnosus, L. salivarius; Bifidobacterium bifidum, B. lactis, B. subtilis, B. breve, and B. longum. The key with probiotics is therefore to supply sufficient numbers and a broad range of species, ideally a dozen or more. Some probiotic preparations contain a yeast, Saccharomyces boulardii, either as part of a panel of bacterial species or by itself, as clinical studies have demonstrated effects such as protection from Clostridium difficile infection, which can develop after antibiotic use (Venuglopalan 2010). (While refrigeration is helpful, it is not absolutely necessary, as shelf testing of these brands demonstrate preservation of bacterial counts in non-refrigerated capsule form.)
Occasionally, the dysbiosis at the start is so overwhelming that a probiotic is inadequate and a course of antibiotics is required along with the probiotic. This accelerates elimination of E. coli, Klebsiella pneumoniae, Enterococcal species, C. difficile and other unhealthy species. People with Crohn’s disease, ulcerative colitis, celiac disease, and malabsorptive syndromes, as well as in people who have been subjected to multiple courses of antibiotics for other infections, are the most prone to this severe problem. Correction should be undertaken with the supervision of a healthcare practitioner skilled in management of bowel flora.
The Feed and Caring of Healthy Bowel Flora: Prebiotics
By the time food reaches the human colon—where most microorganisms dwell—most of the nutrients have been absorbed. Species that thrive in the colon are therefore those that have adapted to obtaining nutrition from the remnants of human digestion, i.e., the components left over after passing through some 20-feet of gastrointestinal tract. In particular, they thrive on indigestible fibers. Provide bacteria with appropriate indigestible fibers and healthy species proliferate and metabolize fibers into fatty acids acetate, propionate, and butyrate, that nourish intestinal cells. Butyrate is also a source of energy for the intestinal lining and is necessary for its health. Because such indigestible fibers allow healthy bowel flora to proliferate and thrive, they are often called prebiotics. They are also known as resistant starches, because they are resistant to human digestion. Prebiotic fibers are a critical part of a bowel health program and can make or break an effort to reverse conditions such as autoimmune disease or diabetes. In particular, lactose-fermenting Lactobacillus and Bifidobacteria families that humans harbor in our bowels thrive on prebiotic fibers.
Not all fibers act as prebiotics. In fact, most dietary fibers do not provide this nutritional function to bowel microorganisms. Prebiotics are indeed fibers in the sense that they are polymeric (multiunit) polysaccharides, i.e., long chains of sugars. Prebiotic fibers are, however, distinct from cellulose fibers of grains and grasses, the same fiber found in wood from trees. Humans cannot digest cellulose, unlike ruminants, such as cows and goats, that have complex digestive systems evolved to break down cellulose and other components of grasses.
Enriching the diet with prebiotic fibers encourages growth of Lactobacillus and Bifidobacteria that yield butyrate for intestinal health that has been associated with health benefits that include: - Reduced blood sugar
- Increased sensitivity to insulin
- Reduced blood pressure
- Reduced triglycerides
- Reduced inflammation of inflammatory bowel disease
- Reduced risk for colon cancer
(D’Argenio 1999; Slavin 2013)
Prebiotic fibers encourage proliferation of species that express the enzyme, bile acid hydrolase, that reduces intestinal reabsorption of bile acids from the intestinal tract, thereby reducing cholesterol production in the liver and resulting in reductions of LDL cholesterol (Wong 2007).
Primitive humans commonly consumed the energy storage organs of plants, roots and tubers, rich in prebiotic fibers. This practice is documented in the anthropological record as far back as pre-Homo Australopithecines and is thereby deeply rooted in human dietary adaptation (Laden 2005). Unfortunately, the modern roots and tubers that remain in the human diet, such as white potatoes and sweet potatoes, tend to be forms chosen for high starch content. Because they are not eaten raw, but cooked, fibers are converted from indigestible polysaccharide form to sugars that provide no prebiotic benefit.
The average person ingests 5 grams of prebiotic fibers per day. When grains are eliminated from the diet, as in the Cureality nutritional program, we potentially fall below this average intake unless we address this specifically. Increased butyrate production begins with fiber intakes of 8 to 9 grams per day, but 20 grams per day is likely to represent the ideal intake, judging by observations of fatty acid production and measures of metabolic benefits, such as reductions in blood sugar. Foods that contain modest quantities of prebiotic fibers include vegetables (especially Brussels sprouts, cabbage, garlic, and onions), fruits, and nuts that contribute a few grams to the diet. The richest sources of such fibers, however, are unripe bananas, starchy legumes and tubers, such as beans and potatoes.
The foods with the greatest prebiotic fiber content include: - Green bananas and plantains: 27 to 30 g fiber in one medium banana
- Raw white potato (peeled): 20 to 24 g fiber per one medium potato
- Hummus or roasted chickpeas: 15 g fiber per 1/4 cup (10 g net carbohydrates in 1/4 cup)
- Lentils: 2.5 g fiber in 1/2 cup (11 g net carbohydrates)
- Beans: 3.7 g fiber in 1/2 cup (22 g net carbohydrates)
- Inulin: 5 g fiber per teaspoon
(Muir 1992; Jenkins 1987; Murphy 2008)
Green unripe bananas and raw potatoes are essentially inedible. They are most easily incorporated into diet by blending into a smoothie. Inulin can be purchased as a powder in health food stores. It is important that such fibers should not be heated, as heating will degrade fibers down into sugars.
If symptoms such as bloating or loose stools due to inadequate intake of prebiotic fibers, or derangement of metabolic markers such as high blood sugar or triglycerides, are present, several weeks of supplementation are generally necessary before a response is obtained. Plentiful gas can be an issue at the start, but wears off over several weeks. It is best to begin with a low dose, such as 5-10 grams fiber per day, and slowly increase to the desired intake over time. (Too much too soon can result in abdominal pain.) The care and feeding of healthy bowel flora with prebiotics is something that needs to be pursued for a lifetime if ideal bowel health is your goal.
Incorporate Fermented Foods
Fermentation is as old as humans. Prior to modern refrigeration, fermentation was a common method used to preserve foods through, for instance, an extended cold season. Fermentation is part of the natural process of decay that occurs whenever food sits exposed to the air, the product of lactate-fermenting bacteria that are all around us. Food beneath the rot—unexposed to air, but in an anaerobic environment—was not only safe to consume, but was also tasty. We now know that fermented foods also provide health benefits.
Lactic acid acts as a natural preservative, as it creates an acidic pH that kills microorganisms unhealthy for human consumption. Lactic acid is also responsible for the characteristic tangy flavor and sensation of fermented foods. But the health benefits don’t come from the lactic acid, but by consuming the microorganisms in fermented foods. In a fascinating convergence of food and bowel health, fermented foods serve as a source for lactate-fermenting organisms, including Lactobacillus and Bifidobacterium, that we know to be healthy for the human intestine, and contribute to health benefits provided by cultivating healthy bowel flora, including reductions in LDL cholesterol, improved intestinal health, and weight control (Heller 2001).
The quantity of bacteria contained within a fermented food varies depending on the composition of the food, the duration of fermentation, temperature, and other factors. The number can range from trivial, as in most commercial yogurts and kefirs (unless a manufacturer adds more microorganisms prior to sale), to billions, as in kimchi (fermented Korean cabbage); sauerkraut (uncanned and unheated, not the pickled sauerkraut sold in grocery stores); kombucha (fermented tea); takuan (Japanese fermented daikon radish); natto (fermented soybeans); and garum (fermented fish sauce). While bacterial counts in these foods can occasionally range into the billions, they more commonly number at lower levels in the millions of CFUs per serving (Rizkalla 2000; Schillinger 1999). Commercial yogurts and kefirs, i.e., fermented dairy products, are also typically made with excessive quantities of sugar, high-fructose corn syrup, and other unhealthy ingredients and should therefore be avoided. Some fermented dairy products, such as cheese and cottage cheese, do not provide any significant probiotic bacteria, as the whey fraction is removed after fermentation along with much of the bacterial content.You can make your own healthier versions of yogurt and kefir, however, and you can ferment your own cabbage, cucumbers, and other vegetables, as well. (See Cureality Kitchen recipes.)
Fermented foods typically have one or two, and rarely more than four, dominant species. This contrasts this with the best probiotic supplements that contain multiple, often a dozen or more, species. The relatively modest CFU counts and limited species of fermented foods therefore make them most useful to maintain healthy bowel flora, while a commercial probiotic with 30-50 billion CFUs and a broad range of species is a superior method to obtain accelerated repopulation with healthy species, especially during recovery from celiac disease, Crohn’s disease, or ulcerative colitis. In these situations, there is a clearly documented benefit to taking large quantities of a wide variety of probiotic bacterial species, not the limited species and numbers provided by fermented foods. Nonetheless, once a probiotic regimen has been completed and you incorporate sources of prebiotic fibers, the addition of fermented foods provides another ongoing method to maintain healthy bacterial populations.
The least costly way to incorporate fermented foods in your lifestyle is to make them yourself. There is limited availability in the refrigerated section of health food stores or health supermarkets. The label will usually specify “contains live cultures” or something similar. Avoid canned or bottled fermented foods, as the canning or bottling process kills the bacteria. Making your own fermented foods is surprisingly easy; see Cureality Kitchen recipes: The Basics of Fermentation.)
Remove toxins, especially grains and sugars, repopulate the intestinal tract with high-potency probiotics, nourish them with prebiotic resistant fibers, and make occasional contributions to healthy species with fermented foods, and you have a terrific program that serves as the cornerstone for the care and feeding of healthy bowel flora. For additional discussion on how to approach specific abdominal symptoms, see the Cureality Guide to Bowel Health (see the next post) |
