Prac%cal Aspects of Func%onal Tes%ng 19 th July 2013 Angela Walker, BSc Nut. Med. mbant CNHC

Transcription

1 Prac%cal Aspects of Func%onal Tes%ng 19 th July 2013 Angela Walker, BSc Nut. Med. mbant CNHC

2 Invivo Clinical Technical Support Our goal is to provide clinicians with: Support on selecting tests and interpretation Confidence & familiarity with using tests Clinical insight & pearls Functional testing in clinical context Self-directed continuous professional development 2

3 Invivo Cinical Aide Memoire Digestive Distress These tests may be useful when considering diges6ve symptoms What these tests tell you Interven6ons to consider (all from Designs for Health)

4 Education Series Using laboratory testing in clinical practice: Digestive distress (already recorded) Stress factor (already recorded) Detoxification & Biotransformation (part 1 recorded) Case Study webinars Case studies in functional testing Your chance to put your cases forward 4

5 Func%onal Tes%ng in Clinical Context

6 Putting functional testing in Clinical Context 6

7 How to investigate? Case History Diet Analysis Presenting Symptoms Home tests Blood tests Functional Nutritional Testing 7

8 Putting functional testing in Clinical Context Functional testing gives another layer of insight as to how the individuals body is functioning 8

9 Nutrient Insufficiency or imbalance Ini%al Biochemical Altera%ons No overt symptoms Impaired Cell Func%on Subclinical manifesta%on Func%onal Changes Early Disease state Diagnosed pathology Late Disease State Adapted from Fig 1.1 in Bralley & Lord 2 nd Ed 9

10 Insights Functional test results don t tell you what to do They provide another layer of insight into how the body is functioning Guidance on where to focus support Take the information from test result and interpret from the perspective of the individual

11 Most popular and versatile tests GIfx Organix Amino Acid IgG4

12 GI Effects

13 Gifx - Overview What the test measures Function / Imbalance through digestive tract How it differs from others available PCR/DNA = ability to look at anaerobes When would you use it Digestive health is at root of optimal health You are what you absorb, not what you eat! How it informs your protocol Tailored 4-R programme Key markers Numerous

14 Digestive Functions touch all points on Matrix Absorp%on & Assimila%on Detoxifica%on & Biotransforma%on Immune & inflamma%on Diges%ve func%on Energy metabolism Communica%on Structural integrity

15 Digestive health goes beyond Parasites

16 Primary Gut Functions Digestion and absorption of nutrients over 70% of our entire immune system resides in the gut Barrier function: friend or foe Metabolism of nutrients (e.g. polyphenols, lignans) Detoxification Enteric Nervous system

17 Microbiome 3.3 million microbial genes, 150 times more than in the human genome 3 different enterotypes i.e. predominants: Bacteroides; Prevotella; Ruminococcus disturbances in the microbiota can be an early warning sign for certain diseases like Crohn s disease or diabetes Personalised nutrition & medicine basis

18 Diet plays central role in shaping microbiota De Filippo, C., et al (2010). PNAS, 107 (33):

19 Functional evaluation of digestive function Remove Replace 4 R Re- inoculate Repair

20 Remove: Pathogens, virus, yeast, parasites, foods Replace: Diges%ve Potency HCL, enzymes, bile salts 4 R Re- inoculate: Re- establish desirable bacteria Repair: Regenerate & heal gut wall

21 Stool Tests PCR vs Culture techniques

22 The Polymerase Chain Reaction is used to amplify a sample of DNA. 22

23 Problems Defining Microbial Population via Culture Anaerobes not cultured (>95%) Changed ecology affects growth patterns (plate v. host) Microbial growth during transport causes potential false positives for opportunistic organisms Microbial balance seen through culture very different from initial sample

24 Advantages of PCR vs. Culture Single specimen collection Ability to ID anaerobes (majority of bugs) Eliminate errors due to growth in transport (no nutritive broth) Sample stability (Formalin fixation) Requires only 1 to 5 cells for ID v. 1,000 to 5,000 for culture Detect parasites with as few as 5 cells per/g versus 25,000 cells per/g with standard techniques 5,000 times more sensitive!

25 So what s the advantage (client speak)? 1. Its the best way we have of looking at the anaerobes, which form the vast majority of (healthy) bacterial in your gut 2. With the older technique, the sample had to be kept live which means that some bugs grew and others died off. 3. We need less sample to pick up more 4. It s the most advanced stool test available 5. Continued innovations

26 Interpretation & Reporting Page Gastrointestinal Function Profile Percentile Ranking by Quintile Results CFU/gram 1st 20% 2nd 40% 3rd 60% 4th 5th 80% Method 95% Referenc Rang Predominant Bacteria (E+007) E+007 Obligate anaerobes Bacteroides sp. Clostridia sp. Prevotella sp. Fusobacteria sp. Streptomyces sp. Mycoplasma sp >= 1.3 >= 1.0 >= 1.1 >= 1.1 >= 1.0 >= 1.2 Percentile Facultative anaerobes Lactobacillus sp. 2.2 Bifidobacter sp >= 1.2 >= 1.8 Obligate aerobes Escherichia coli (E. coli) >= 1.1 Opportunistic Bacteria No clinically significant amounts.

27 Interpretation & Reporting Page Gastrointestinal Function Profile Pathogenic Bacteria Helicobacter pylori <0.01 E. coli 0157:H7 <0.01 Clostridium difficile <0.01 Campylobacter sp. <0.01 Metho 95% Reference Range <=1.0E+005 <=1.0E+005 <=1.0E+005 <=1.0E+005 Quantified Yeast/Fungi Saccharomyces sp. +2 => 1000 pg DNA/g specimen Expected Value Neg Semi quant based on DNA/g Parasites Parasite present; taxonomy unavailable. Positive Expected Value Neg A taxonomy unavailable finding likely indicates an ingested protozoan and not a human parasite. It does not indicate treatment unless patient symptoms and other inflammatory markers are consistent with parasite infection. Adiposity Index Positives for parasites Firmicutes Bacteroidetes <= 80 >= 20 Drug Resistance Genes

28 H Pylori Historically Gifx included fecal (PCR) probe for H Pylori We used to recommend more than one H. pylori test used to determine if the patient s H. pylori status is positive or negative (referral to GP) And / Or Is clinical picture consistent with H Pylori infection?

29 Improvements to Gifx - Pathogenic Bacteria 2100 Gastrointestinal Function Profile - Stool Methodology: DNA Analysis, GC/MS, Microscopic, Colorimetric, Automated Chemistry, ELISA Pathogenic Bacteria Expected Value Helicobacter pylori - Molecular Probe Helicobacter pylori - EIA Campylobacter spp. - Molecular Probe Campylobacter spp. - EIA Shiga toxin E. coli* Clostridium difficile* *Positive results are confirmed by EIA Positive Negative Positive Positive Negative Negative Negative Negative Negative Negative Negative Negative

30 What does it mean clinically? More clinically relevant information on pathogens: H Pylori If probe (DNA) is positive the EIA (stool antigen) will be run If Probe (DNA) is positive and EIA negative AND no clinical symptoms, then probably no real evidence to treat H Pylori

31 Remove: Pathogens, virus, yeast, parasites, foods Replace: Diges%ve Potency HCL, enzymes, bile salts Re- balance Reinoculate: Re- establish desirable bacteria Repair: Regenerate & heal gut wall

32 Page 3: Re-Balance/ Restoration ability 2100 Gastrointestinal Function Profile Percentile Ranking by Quintile Results 1st 2nd 3rd 4th 5th 95% Reference 20% 40% 60% 80% Range Beneficial SCFA 53 Total SCFA 69 >= n-butyrate 9.1 >= Acetate % % Butyrate % % Propionate % % Valerate % 0.7 L % mm/g mm/g SCFA s = enterocyte energy source Inflammation 3.1 Lactoferrin 0.4 <= 6.3 ug/ml WBCs Neg Neg-Rare Mucus Neg Neg Immunology Fecal siga mg/dl 6.4 Anti-gliadin siga 3.6 <= 21.4 mg/dl Markers for Immune responses

33 Role of SCFA s Produced by bacterial fermentation of complex carbohydrates Colonic motility Promote visceral blood flow Prevent overgrowth of potential pathogens Energy source for colonocytes (perhaps cellular signaling activation) Butyrate specifically promotes normal colonocyte phenotype, preventing colorectal cancer Fecal excretion of ammonia positively associated with SCFA levels McOrist et al J. Nutr. May 1, 2011 vol. 141 no Wang et al 2012 J. Nutr. January 1, 2012 vol. 142 no

34 Lactoferrin vs. Calprotectin Both are good markers of intestinal inflammation distinguish: Inflammatory Bowel Disease (IBD) from Irritable Bowel Syndrome(IBS) Lactoferrin uniquely discriminates: Active from inactive inflammation Buderus S, Lohmann N, Lentze MJ, University Children s Medical Center Bonn, Germany, Boone J, Lyerly D, TechLab Inc., Blacksburg Va. Clinical Evaluation of the IBD-CHEK Test for Detecting Elevated Fecal Lactoferrin as an Indicator of Intestinal Inflammation in Pediatric Patients

35 siga Forms immune complexes with pathogens and allergens, preventing them from binding to and penetrating intestine mucosa Fecal & saliva don t always correlate

36 Gifx Page Gastrointestinal Function Profile - Stool Methodology: DNA Analysis, GC/MS, Microscopic, Colorimetric, Automated Chemistry, ELISA Results 95% Reference Range Additional Tests ph 7.2 H t RBCs Neg Neg Color Brown Digestion Elastase 1 Triglycerides Putrefactive SCFA H H 200 t t t > 100 ug/g <= 181 mg/dl <= 7.4 mm/g Vegetable Fibers Rare None-Few Absorption LCFAs Total Fat Cholesterol H H H 9.1 t t t <= 15.1 mmol/l <= 18.9 mmol/l <= 191 mg/dl

37 Digestion Markers Elevated Fecal Triglycerides Indicate incomplete fat hydrolysis i.e. maldigestion Not enough secretion or activation of pancreatic lipase Elevated Putrefactic SCFA s Protein maldigestion. Result from bacterial fermentation of undigested protein.

38 Digestion & Absorption Markers Elevated LCFA s Malabsorption (probably) due to maldigestion LCFA easily absorbed in fully functioning mucosa, but not in short bowel syndrome or if issues with mucosal integrity Clinical Pearl: ORen the LCFA s will be seen when there is gluten sensi%vity Elevated total fat & or Cholesterol: Usually signals malabsorp%on.

39 Gifx Summary Technology allows greater precision in identifying exactly what is in the gut: Anaerobes are in majority Insight into Immune & Inflammation status of gut Digestive & absorption potency Leads to a tailored 4-R programme 39

40 Organix

41 Organix What the test measures: Functional imbalance across core systems How it differs from others available Technology used in lab; markers selected When would you use it Baseline of functional assessment How it informs your protocol Identifies your priorities Key markers Numerous

42 What are Organic Acids Products of metabolic processes e.g: Central Energy pathway /Citric acid cycle Neurotransmitter breakdown

43 Functional Indicators of Nutrient Deficiency A E 1 B A Intermediary metabolite E n Enzyme Coenzyme (derived from vitamins) Cofactor (mineral ion) E 2 C E 3 Urine D 43

44 Organic Acids of Bacterial Products Bacteria Polyphenols Amino Acids Carbohydrates Organic Acids

45 Markers give insight into. Central Energy Pathway Citric Acid Cycle status B vitamin status Oxidative status Neurotransmitter status Detoxification and biotransformation Digestion status (Small intestine)

46 A window into biochemical pathways Figure 6.1: Lord RS, Bralley JA, eds. Laboratory Evaluations for Integrative and Functional Medicine. Duluth, GA: Metametrix Institute; 2008.

47 Case Study 1 40 year old women Health goals: Weight loss; hormone balance; fertility Symptoms: thinning hair; water retention; amenorrhea; constipation; muscle cramp / tense Italian; moved to Netherlands and then UK Slightly under-active thyroid in May 2012; endocrinology specialist ruled out July 2012

48 Case 1 Investigations Vitamin D: 19nmol/L Plasma zinc: 8.1 ( ) RBC Magnesium: 2.05 (2.08-3) Omega 6: All in normal except DGLA Omega 3: All low except DHA

49 Case Study 1 B-Complex Vitamin Markers (B1, B2, B3, B5, B6, Biotin) 15. a-ketoisovalerate <DL* 0.25 <= a-ketoisocaproate 0.23 <= a-keto-ß-methylvalerate 0.38 t t 0.34 <= Xanthurenate 0.17 <= ß-Hydroxyisovalerate 4.6 <= 11.5 Methylation Cofactor Markers (B12, Folate) 20. Methylmalonate 2.1 H <= Formiminoglutamate 1.2 t <= 2.2 t t t Oxidative Damage and Antioxidant Markers (Vitamin C and other antioxidants) 28. p-hydroxyphenyllactate 0.11 <= Hydroxy-2-deoxyguanosine 6.3 H t <= 7.6 (Units for 8-hydroxy-2-deoxyguanosine are ng/mg creatinine) t 0.39

50 Case 1: Interpretation & recommendations Impaired methylation Address core nutrient depletions B12, Folate (Methylation) Vitamin D, Zinc, Magnesium, ALA, EPA Vitality of zinc, EFA s, vitamin D and methylation for fertility and anti-ox status Gluten free, micro-nutrient dense diet

51 Case 1: Interpretation & recommendations B12 / Folic acid (sublingual) (800mcg folate; 2000mcg B12 DfH Zinc Supreme (30mg Zinc glycinate Chelate plus co-factors) DfH Magnesium citrate powder (300mg) DfH Ultimate Antiox Full Spectrum EPA (1500mg) Follow up tests; 3 months

52 Summary - Organix Broad insight on the functional matrix for an individual case

53 Amino Acids

54 Amino Acids - building blocks Feed into citric acid cycle Precursors to neurotransmitters Detoxification conjugation Adds extra layer of depth when used with Organix

55 Essential Amino Acids All essential AA required for biosynthesis of enzymes, receptors, transport proteins, structure proteins BCAA Isoleucine, Leucine & Valine Growth & maintenance skeletal muscle Catabolic intermediaries feed into CAC Phenylalanine; Precursor to tyrosine

56 Conditionally Essential AA Arginine: Maintains nitrogen status & helps ammonia clearance Taurine: Bile formation Glycine: Detoxification Histitine & Valine: Indicators for an increased demand (stress or disease) as proteolysis exceeds demand

57 Case Study 3 - Background Female aged 33 BMI 18 Asthma from age 8, much improved since reducing dairy Kidney Infection age 10. Frequent antibiotics Constipation from age 15 Glandular Fever age 20, undiagnosed for a few months, resolved in 10 months, used homeopathy Migraine and headaches. Two migraine a year, worsened over past two years, can throw up. Allergy to seafood

58 Case Study 3 - Background Early diet: high in white refined bread, white sugars, limited vegetables. Current Diet Wholegrains, beans pulses, vegetables, oily fish, limited meat. Chocolate cravings. Limited on proteins (not protein with each meal). Dairy limited to yogurt, can crave ice cream. Digestion: typically bowel movement every 2 to 3 days. Can experience fatigue post meal. Queries over sensitivities to certain foods. Sleepiness after meals, can vary even after identical meal; negative thought about food am I going to be able to digest this properly. Skin breakouts. Often cold. Body odour Goals: Improve digestion, reduce bloating and understand intolerances. Improve energy & memory. Improve skin, improve circulation.

59 Case 3 Test Findings

60 Case Study 3 Amino Acids

61 Case 3 - Interpretation Sulphur significantly low Role of Sulphur: detoxification pathways healthy structures in the body The sulphur amino acids are all in range, so either her need is particularly high (query mercury which binds sulphur compounds), or something is happening in the pathways e.g. cysteine to sulphur. Urea cycle amino acids: imbalances Urea cycle co-factors are: Magnesium, zinc, manganese, B6. Address amino acid (precursor) imbalance Orotate elevated (urea cycle overload) NB: IgG4 positive for Egg & Milk, these were eliminated.

62 Case 3 Protocol Antioxidant based multi V&M. (120mg Mg; 1.5mg Mn, 100mg NAC) NAC (200mg) ALA (100mg). Amino acid formula 5g twice a day, Magnesium 500mg before the test, yet still problems in urea cycle where Mg is a co-factor, take up to over 600mg.

63 Case 3 Client Feedback & progress Follow up tests showed improved amino & sulphur levels. Improved skin Improved energy Improved resilience

64 Amino Acids - Summary What the test measures: Amino acid levels How it differs from others available NA (although blood spot vs urine) When would you use it Works very well with Organix for deeper insight How it informs your protocol Custom amino blend Amino acid usage Key markers Essential and conditionally essential aminos

65 Food Sensitivity Testing IgG 4

66 Food Sensitivity Testing The challenges: Versus elimination diet (gold standard) Understand what tests can and cant measure

67 IgG4 Food Sensitivity Testing from Metametrix Patent-pending method assures practically ZERO false positives IgG4 the best IgG sub-class to reflect chronic exposure to food antigens Newer blood spot technology comparable to serum blood draw Genetically modified corn

68 IgG4 & Food IgE designed to react quickly to relatively small amounts of antigen Food represents huge opportunity for antigenic responses, primarily an IgG response IgG involved in delayed or prolonged reaction to allergens ( Type 3 hypersensitivity ) IgG and food antigens form complexes and circulate in blood: Trigger complement Accumulate in various tissues Localised inflammation Chap 28 Textbook of FM; Chap 7 Bralley & Lord 68

69 IgG Importance of class 4 subclasses: 1-4 IgG1 are initial response to foods IgG 2& 3 not generally related to foods With continued exposure, IgG1 will class switch to 4 IgG4 doesn t activate complement but the IgG1 will have IgG4 has a blocking action for IgE i.e. protection against anaphylactic reaction

70 Assessing IgG reactions 20 or Greater IgG4 Reactions: If more than twenty foods have an IgG reaction intestinal permeability problem is indicated, leaky gut. 5 to 19 IgG4 Reactions: Intestinal permeability may be a problem, and steps should be taken as indicated above. Few IgG4 Reactions: If there are one to five reactions to foods, these should again be eliminated from the diet to test for involvement in patient symptoms. Reintroduce food in 4 to 6 weeks.

71 IgG4 - Summary What the test measures: IgG4 responses to foods 30 or 90 How it differs from others available Many use other classes of IgG leading to false positives When would you use it IP; digestive health (inflammation); How it informs your protocol Tailoring an elimination programme Key markers Relative IgG4 responses to foods

72 Invivo Cinical Aide Memoire The Stress Factor These tests may be useful when considering symptoms of chronic stress What these tests tell you Interven6ons to consider (all from Designs for Health)