Measuring Bile Acids and Short Chain Fatty Acids with Dr. Tom Fabian: Rational Wellness Podcast 421

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Dr. Tom Fabian discusses Measuring Bile Acids and Short Chain Fatty Acids with Dr. Ben Weitz.

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Podcast Highlights

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Dr. Tom Fabian is a Functional Medicine trained PhD, who serves as a clinical education specialist at Diagnostic Solutions Laboratory, which now offers the StoolOMX add on test to their GI Map stool test.

Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure.  Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.

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Podcast Transcript

Dr. Weitz:  Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates and to learn more, check out my website, drweitz.com.  Thanks for joining me, and let’s jump into the podcast. Welcome to the Rational Wellness Podcast.

I’m your host, Dr. Ben Weitz, and today we have the pleasure of speaking with Dr. Tom Fabian, a functional medicine training PhD, an expert in microbiome science. Tom serves as a clinical education specialist at Diagnostic Solutions Lab, the lab that provides the GI Map stool test that we use regularly in our office.  Today we’ll dive into a powerful new tool for gut health assessment, the Stool omics test, an advanced quantitative analysis of bile acids and short chain fatty acids, designed as an add-on to the GI map. Tom, welcome back.

Dr. Fabian: Thanks so much, Ben. Always a pleasure to be here. And thanks so much for inviting me back again.  Looking forward to the conversation.

Dr. Weitz: I love talking poop. It’s funny how patients come in and a lot of times they’re embarrassed talking about their poop, and I let them know. I talk about poop all day long and don’t feel embarrassed about it. It’s an important biomarker for overall health.  Absolutely. Why don’t we kick things off with the big picture? What clinical need inspired the development of this stool omics test?

Dr. Fabian: That’s a great question. So, as you can imagine with the typical comprehensive stool testing that’s available in functional medicine like [00:02:00] Gmap usually we’re targeting the most clinically relevant organisms, the ones that we know most about.  And so that gives you a window into a lot of these. Really actionable microbes when it comes to commensals pathogens, opportunists. But we also wanted to get a bit of a bigger picture. And there’s also growing research now on the products that they’re producing. So the research shows that it’s important to know not only which microbes are there, of course, pathogens versus opportunists versus commensals, and which commensals, which produce, which products like butyrate.  Ultimately, we want to know kind of at the end of that whole production process in terms of their gene expression and then their metabolic activity. What are they actually producing in the gut in terms of these key products, like short chain fatty acids, bile acids that have now been linked both to promoting health depending on the details and the levels as well as [00:03:00] linkage to a wide variety of chronic diseases and conditions as well as symptoms.

Dr. Weitz: Tom, just for those who might be lay persons who are listening to this podcast who are not functional medicine practitioners, could you just briefly explain what a commensal is? What an opportunist is, what a pathogen is?

Dr. Fabian: Absolutely. Yes. So of course pathogen is I think a lot of people are familiar with that.  Those are these microbes that can cause disease. Usually term as an infectious disease. In the gut. We know that there are a number of different microbes that can cause unpleasant symptoms, sometimes even very serious. For example, if there’s excessive diarrhea that can lead to dehydration there can also be certain microbes that can lead to blood in the stool, et cetera.  So there are some that can be serious. There’s a few that are in between opportunist. Are actually kind of in between a beneficial microbe and a pathogen. So with opportunists, they can be present [00:04:00] in the gut at certain levels. It can be fairly normal to have these opportunistic organisms there. We just don’t wanna see them in excess.  We don’t wanna see them in a certain set of circumstances, especially related to symptoms and diseases where they can actually turn. Into essentially pathogens. So that’s why they’re called opportunistic pathogens typically. Then we have what are called commensals. So commensals is essentially kind of the scientific term for beneficial bacteria or kind of more ge generically bacteria that are just normally found in the gut that usually have neutral to beneficial properties.

Dr. Weitz: Good. So why don’t we start with the bile acid picture. How does bile acid metabolism impact fat digestion, microbiome health, gut motility, inflammation?

Dr. Fabian: So there’s a lot to impact there. So I’ve gotta [00:05:00] start out high level. 

Dr. Weitz:  So we, well maybe start by explaining what a bile acid is.

Dr. Fabian: Okay. So bile acids are basically produced by the liver, so it’s within the category of fats and lipids.  They’re basically formed or produced from cholesterol. So they have kind of, that cholesterol molecule is the basis for the production of bile acids. Their main function, at least in terms of what we recognized for decades since they were discovered is to assist in fat digestion and absorption.  So they’re typically basically transferred from the liver, stored in the gallbladder. And then during a meal when there’s fat content in the meal that basically is detected in the gut sends signals back to the gallbladder to start releasing the bile. So the, basically the bile is released into the small intestine to again, assist with this digestion of fat.

So it’s really a critical component to have [00:06:00] adequate levels of bile. It’s not too high, not too low in the small intestine to assist and really kind of optimize fat digestion. That also includes fat soluble vitamins, like vitamins A, D, and K. You need that bal in order to help us absorb those vitamins as well.

So that’s kind of the traditional view in recent years really in the last two decades. As we’ve learned so much more about the microbiome while these studies have come out, especially in the last five to 10 years, but we now know a lot more about how bal both affects the microbiome in terms of its antimicrobial activity in the small intestine.

But we also know that bile can be acted on by the microbiome in a couple different ways that can influence how bile acids. Then can influence our health. So there’s sort of this whole new category beyond just fat digestion, where bile [00:07:00] acids in their microbiome derivatives can influence in particular intestinal health, particularly the intestinal barrier.

Also immune balance metabolic function. There’s a lot of research, for example, that certain bile acids can potentially stimulate the release of GLP one in the gut. There’s also well known, well established effects on motility. So that’s basically this whole movement of contents through the gut, gastrointestinal, motility.

And then as I mentioned, there’s also influence on the microbiome balance itself.

Dr. Weitz: Okay. So, w why don’t we talk about we, me, we mentioned inflammation in a couple of exchanges we had, and we know that inflammation in the gut is an important factor. It’s found in many. Inflammatory gut condition, especially Crohn’s disease and ulcerative colitis.  And on the GI map we measure fecal calprotectin [00:08:00] and we, there’s another marker, eosinophilic activation protein. So we look for inflammation. And how does bio impact inflammation?

Dr. Fabian: Great question. Yeah, so there’s really kind of two ways you can think of this. And it’s based on the two major types of bile acids that are found in the gut.  So the ones that are released from the liver those are referred to as primary bile acids, meaning that they haven’t yet been acted on or changed by the microbiome. Those are the ones that we know are primarily involved in digestion. In normal physiology, normal healthy physiology. Those bile acids, by and large are.

Reabsorbed at the end of the small intestine in the ileum so they can be reused. Your body doesn’t have to keep remaking them constantly. You can reuse a high percentage of them after each meal through that reabsorption, but unfortunately in some patients, they don’t reabsorb them very [00:09:00] efficiently.

They can have issues in the small intestine that interfere with the reabsorption. Some patients might even have excess production of bile acids, so they’re just not efficiently reabsorbed. So it can be either excess production or just not reabsorbing them in the ileum either way. We can get into some of what’s known about the small intestine and what affects that reabsorption, but once they get into the colon, which normally has a very low percentage of those bile acids in a healthy gut that get into the colon, they’re quickly.

Then converted by the microbiome into what are called secondary bile acids. Secondary bile acids have much different properties, physiological properties compared to the primaries. So basically those secondary bile acids can be anti-inflammatory. They can support a healthy intestinal barrier, but if you’re not converting them very well, and also you’re getting an excess coming in.

Then that’s been shown to [00:10:00] stimulate inflammation. There’s several important studies that just came out in the last year or two demonstrating that basically in various ways, those primary vilas that should not be in the colon in excess when they are, that can stimulate motility. So some patients might actually develop diarrhea that’s referred to as bile acid diarrhea.

They found that actually bile acid diarrhea can be present in IBS patients IBSD diarrhea dominant. Up to 30% of those patients may have this scenario. In IBD inflammatory bowel disease, it’s been shown to be a significant factor now in basically affecting the health of the mucosa. So mucosa are usually damaged to some extent in inflammatory bowel disease.

And then that can also stimulate inflammation. So, there are some, you know, details we can get into as far as sort of what they know about how that happens. But we do know that an excess of those primary bile [00:11:00] acids getting into the colon, along with insufficient secondary bile acids, typically is a contributor to inflammation.

And it’s been documented. So

Dr. Weitz: these primary bile acids, they get secreted into the small intestine where they have an important role in fat digestion. And then they’re supposed to be reabsorbed in the distal ileum, right? And the last part is testing. If they’re not properly absorbed, that’s what we call bile acid malabsorption.  They get into the colon. It’s not a good thing. Exactly.

Dr. Fabian: So what we know from a really interesting study that came out, I’d say probably three, four years ago now out of a group in os Austria they actually found that in a high proportion of IBS patients up to 60% and also in inflammatory bowel disease patients I think it was something like 30 40% had biofilm [00:12:00] build up of biofilm in the ileum.  That was basically the main microbe that was characteristic of the biofilm was an overgrowth of e coli. We know e coli under certain circumstances can be inflammatory.

Dr. Weitz:  It can produce it’s major microbe involved in sibo.

Dr. Fabian: Exactly. So, you know, we know a lot about e coli and then when it’s overgrown in the wrong places it’s not clear exactly why these biofilms develop yet.

They still are studying that. They found that the biofilm was associated with an excess of primary bile acids. So then they found in another study that the excess of primary bile acids then creates an environment in the colon that allows these inflammatory bacteria like e coli to overgrow in the colon as well, particularly in inflammatory bowel disease.

So it seems like these upstream issues that are happening particularly in the small intestine. With biofilm [00:13:00] development in the ileum seems to be related to some of these issues with bile acid, malabsorption, and inflammation.

Dr. Weitz: Now, a lot of people have had their gallbladder removed.  That’s because they get a gallstone or they get gallbladder inflammation or infection and they remove the gallbladder. So without a gallbladder. You don’t have, the body, can’t time the release of bile with that being ingested. So how does that affect this picture?

Dr. Fabian: That’s a good question. So there are a lot of things that can essentially happen as far as complications after surgery like that.

Sometimes there’s some negative effects on that even from the liver when you have the bile coming in not necessarily directly through the gallbladder, but from the liver. There can still be problems with that regulation, but as you mentioned that can be dysregulated. So it’s known from research and we’ve actually [00:14:00] seen some clinical cases already.

Despite the fact this is a fairly new test. We’ve just seen a few of these. But of patients that have had their gallbladder removed, that have persistent symptoms, so they can have a variety of different symptoms, including in some cases ongoing loose stools and diarrhea. For some reason it’s, again, not really clear yet from what’s known in research, but that scenario of removal of the gallbladder and then dysregulation of bile acids seems to be related to the same scenario downstream, where they’re not reabsorbing those bile acids in the ileum de efficiently either.

So there must be some sort of imbalance that causes this dysbiosis, causes this biofilm formation under those circumstances. That can perpetuate these problems for some patients.

Dr. Weitz: Does this indicate another thing we might wanna address when treating a patient with sibo?

Dr. Fabian: I would say [00:15:00] yes. I mean, that seems to be anything that’s happening in the small intestine in terms of overgrowth of opportunists could fall under the umbrella of just generally dysbiosis or sibo.

So if there’s. You know, I would say knowledge from research that suggests what might be going on. It’s a little bit difficult to confirm, and of course we know stool testing is downstream. We can never say for sure, unless the research tells us that a certain organism is only in the small intestine, for example, or only in the stomach like h pylori.

Then we know where it’s coming from even though it’s detected in stool. Some microbes, like e coli, can be small intestine or large intestine or both. We can’t say for sure from a stool test is it really overgrown, but if you’re putting the pieces together and they have bile acid malabsorption, you see an increase on the stool mix in terms of the total bile acids and also the percentage of primary in those scenarios typically.

Then that might suggest that there’s some [00:16:00] upstream issues that you want to further explore in terms of that dysbiosis or sibo.

Dr. Weitz: Now, one of the papers you sent me went into the role of dietary fiber and that how that might play a role in how. Bile acids, increased gut inflammation, and one one of those papers indicated that inulin, which is a common form of fiber, used as a prebiotic.

In fact, many probiotic supplements contain inulin to facilitate the growth of the bacteria. My increased gut inflammation. Can you talk about inulin and what we know about different forms of fiber?

Dr. Fabian: Yeah. Yeah, that’s a really interesting and kind of developing topic. So we know there’s lots of studies showing beneficial effects, especially in terms of short chain fatty acid.

So that’s, you really have to kind of consider, excuse me, the whole gut picture in terms of what [00:17:00] they’re producing, which microbes are there. We certainly wanna also consider the short chain fat. Yes. So they could be compensating. To some extent for some of these issues with bio bile acids. So again, you’re looking at kind of the pros and cons, but this research indicates that inulin under certain circumstances particularly in patients that have inflammatory bowel disease we already know from research and clinical experience that fiber may be a problem for a subset of patients with IBD.

It might make their symptoms worse. So there have been studies to try to figure out why that’s the case and see if we can identify which patients really may be candidates for not not considering inulin fiber, for example. So the studies show that actually what Nulin can do, and of course they’re basically mostly in animal models, so you take it with a grain of.

Although they’re correlating them with what they see in patients in terms of their microbiome, et cetera. But what they found with inulin is that can stimulate [00:18:00] the increase in the bacter bacteria, which are on jmap. So that’s the bact phylum. They are basically capable of metabolizing a wide range of fibers, including inulin.

For reasons that are not fully cleared yet. The inulin seems to especially stimulate those bactes bacteria. They actually produce an enzyme that modifies the bile acids and makes them more damaging in the gut. So that’s what they found in these studies was that the, through the activity of inulin on the bacteria, causing an imbalance, but that then increased the potency of the bile acids.

To cause damage and inflammation in the large intestine.

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Dr. Weitz:  I noticed one of the papers mentioned, or somewhere where they were talking about different forms of fiber. Maybe it was a, maybe it was a webinar on diagnostic solutions lab website.  But they mentioned that whereas inulin in certain cases might cause inflammation, we have partially hydrolyzed gar gum that might decrease inflammation. Do we know why that would be?

Dr. Fabian: Probably because different fibers are acted on by different bacteria, and then they produce a different set of products and they have different effects.  So I’m guessing that with those other fibers, they’re not promoting the tities group that then can make the effects of [00:21:00] primary bile acids worse. So they’re probably. Other microbes that may be their main effect is increasing short chain fatty acids, which actually have an anti-inflammatory effect, particularly butyrate.  So that’s why you really wanna look at the big picture of the microbes, the short chain fatty acids and the vial acids to really put that picture together better.

Dr. Weitz: I noticed the test includes the LCA to DCA ratio. Can you explain the significance of that and how it might affect treatment?

Dr. Fabian: Absolutely, yes.  So it’s basically telling us that there’s an imbalance. So LCA stands for lithocholic acid. That’s one of those major secondary bile acids that are produced by the microbiome. And the DCA is deoxycholic acid. That’s also a major secondary bile acid, also produced by the microbiome. So there are different associations in the research as far as LCA health effects versus DCA [00:22:00] health effects.

So the ratio can, number one, tell us that there’s an imbalance. So even though we might overall have a good level of the secondary bile acids, which is kind of our high level measure of, do things look pretty good? Of when you get into the little bit more granular detail, there can still be imbalances there, and you really wanna have kind of a nice even profile of these secondary bile acids.

As far as, without getting too into the weeds, the imbalance mostly tells us that you wanna look for dysbiosis and try to rebalance the microbiome so you have a more even distribution of products. The con, there’s a little bit of controversy over the health effects. So, LCA, for example, historically has been linked to conditions like colon cancer when it’s in excess.

And I think that still holds up to some extent. It was kind of older research done, you know, a couple decades ago. But now actually to kind of. Flesh out the whole picture. We know that LCA actually for [00:23:00] the most part, unless somebody happens to have, you know, a risk factor for development of colon cancer, it has beneficial effects in many ways.

So it’s, it can be a little bit challenging sometimes to figure out exactly what it means, because there’s research now that shows it promotes a healthy intestinal barrier. LCA has anti-inflammatory activity. And there was a recent study that actually linked LCA to the effects, the positive effects of caloric restriction in aging in an animal model.

So, and there’s lots of links between LCA and LCA related products produced by a diverse microbiome in stimulating the, for example, the GLP one receptor and promoting metabolic health. So it’s really kind of alerting us to. Is there an imbalance? And then what is the presentation of the patient and their risk factors?

Those are always important for [00:24:00] interpretation. Because with a lot of things like hydrogen and sulfide, there’s positive and negative associations, so you want to know what that context is.

Dr. Weitz: It certainly seems like bile is something you want very localized because some patients who have reflux have bile reflux, so if the bile gets too much, bile gets into the colon, that’s a problem.  If it ends up in the esophagus, that’s a problem too.

Dr. Fabian: It is. Yeah. So it’s kind of a, you know, it’s a learning curve in some ways for practitioners who haven’t really necessarily. Focused on assessing bile in their practice. This is giving us a set of information that’s related to what’s happening downstream.  Sometimes it does point to the fact that there may be issues upstream that you want to explore further in terms of liver health, gallbladder, et cetera. So I think it’s another window into giving us some really concrete clues about what’s going on with motility [00:25:00] inflammation, intestinal barrier, et cetera.

More downstream. But again, you wanna look at what are those factors upstream that may be interfering with that process leading to those downstream issues.

Dr. Weitz: Now as functional medicine practitioners, what are some of the strategies we can use if patients have access bile?

Dr. Fabian: Great question. So traditionally, one of the approaches has been to use bile acid binders particularly if patients have bile acid diarrhea.

So I think in gastroenterology that’s still, you know, one of the standard set of tools for consideration in terms of controlling the symptoms. Like

Dr. Weitz: romine on the prescription end.

Dr. Fabian: Exactly.

Dr. Weitz: Yeah.

Dr. Fabian: There’s even some evidence of certain fibers bind to bile acids and may have similar effects in helping to modulate motility.  I think cilium in some cases may do that. I think active HR call, right? So [00:26:00] things that, that basically may help to slow down motility and bind up the bile may be beneficial from a symptom standpoint. So I think there, there’s really gonna be a lot of focus now though on what are these underlying mechanisms causing bile acid malabsorption, such as the biofilm with e coli that I mentioned because of some of the recent studies have shown.

Bile acid binders actually might have a downside that in some patients certainly not all patients, but in patients probably more with the IBD inflammatory bile disease scenario, that it’s bringing in essentially excess bile that’s kind of bound up. But they’ve shown in those studies that somehow that bile still stimulates inflammation.

In some of these patients. So, that may be something just to keep in mind for patients that are not reacting well to bile acid binders or other approaches with fiber, as we just talked about with inulin. Similar effects were shown even with cilium [00:27:00] in terms of the potential, mostly, again, in an IBD scenario, inflammatory bowel disease.

So just some concerns there that practitioners want to be aware of. That even though it might help with symptoms particularly motility in the short term there may be some downsides to consider there and also looking at alternatives.

Dr. Weitz: It’s interesting because we focus a lot on motility in the functional medicine world when we are looking at trying to treat patients with IBS and sibo and generally that condition tends to be more associated with decreased motility, and yet we’re using strategies to increase motility.  So you wonder if. If where bile plays a role in all of this, and you know, patients who are taking pro kinetics, whether they’re prescription or natural it may improve motility, but maybe it increases bile. On the other hand, things that [00:28:00] slow down motility you mentioned GLP one agonist, they slow motility, so they might actually decrease bile, ending up getting into the colon.

Dr. Fabian: So there, there can be some complications there to consider, but overall the research indicates that both for short-chain fatty acids and for bile acids, that usually you’re gonna see, you’re more likely to see a deficiency in both of those because both short-chain fatty acids and bile acids are known probably as far as the microbial metabolites, they’re probably one of the best studied.  As far as their effects on motility and also the mechanisms, right? So understanding the mechanisms is really important. We know both short chain fatty acids and bile acids can interact with receptors in the gut that basically participate in regulating motility. So if you have insufficient levels of both of those.

Or just one category. For some things you might see low bile acids, but normal short [00:29:00] chain fatty acids. If they have constipation, then you may wanna suspect that their lack of bile acids may be a factor in their constipation. So there’s a actually quite a bit of research on bile acids that they can affect motility and essentially promote motility in, in two main ways.

One is acting as a natural prokinetic. That’s one of their main functions. So we’re thinking about, you know, prokinetics are talked about a lot in IBS and placebo field, and we’re usually thinking of supplements, herbals, things like that. Right? We kind of forget that we have these natural factors produced in the gut and modified by the microbiome in a healthy gut.

Of course, that naturally regulate motility, so we would do want to take that into account. And then if of course you have an excess that can cause bile acid malabsorption, bile acid diarrhea.

Dr. Weitz: Now, herbal bitters are often used to enhance digestion, and it’s often said that they stimulate bile [00:30:00] production or bile movement.  First of all, do we, how much do we know that really occurs? Or is that just something we think might occur? And then b might that be some of the benefits? Like I’ve seen herbal bidders in some pro natural, pro motility agents, right?

Dr. Fabian: Yeah. So I’m not, I can’t say that I’m not familiar with the research on herbal prokinetics.  Certainly we know that bitters and other things are pretty well documented to help stimulate the secretory part of digestion. So that’s usually used when there, we suspect that patients may have low pancreatic enzymes, low stomach acid, et cetera. There’s this interaction between secretory activity and also motility.

I don’t, can’t say that it’s all fully understood yet. And that is one of the ways in which bile acids, I mentioned the prokinetic effect, but also bile acids stimulate secretory activity, especially in the colon, [00:31:00] so they can act as a bit of a stool softener. But as far as how the herbals interact, it’s probably somewhat specific to the components that are in each different type of herb.  I’m not really that familiar with exactly how they might stimulate motility in a secretory versus a prokinetic. That both of those can become into play in terms of improving constipation.

Dr. Weitz: Okay, well let’s go into short chain fatty acids and what do short chain fatty acids what important information do they give us and how do they help us to improve our patient’s gut health?

Dr. Fabian: So this one is definitely a bit of a different scenario in terms of interpretation compared to bile acids. So, when we’re talking about production of short chain fatty acids, that’s part of the equation. You want to have good levels, you don’t wanna have insufficient or excessive levels. On stools, we have one of the pieces of information that’s included is the total.  Short chain fatty [00:32:00] acids in absolute terms. So we know basically how much is contained in the stool. What we see in the stool reflects production, which is basically by the, largely by the colon microbiome but also absorption. So that’s unlike bile. Acids are mostly reabsorbed in the ileum. Short chain fatty acids are absorbed actively.  In the colon. So there’s actual transporters in the colon to absorb short chain fatty acids. And that’s how they can have their effects on colon health. For example, we know 70% of the energy of these colon cells, the cells that line the colon, they derive from short chain fatty acids, especially butyrate.

So they need to get across that epithelial lining so they’re continually absorbed. Some of those even continue on. Into the portal circulation that goes to the liver. The liver may metabolize some of those and has metabolic effects where they may sort [00:33:00] of pass them on into systemic circulation, where these short chain fatty acids have effects on the brain, positive effects such as butyrate skin muscle health, et cetera.

So they’re really important for local health in the gut. Also systemic health. But we want to, when we’re interpreting that, we want to consider, it’s not just production. Traditionally in functional medicine, when we see short chain fatty acids on stool test, we’re usually interpreting those in terms of production.

So if we see, oh, butyrate is low, that must mean that butyrate producers are low or they’re just not producing enough butyrate. We also know though, from. Lots of studies that transit time. So in constipation for example, which usually reflects a longer transit time, there’s more time for absorbing those short chain fatty acids.

So you end up with very little in the stool sample. So the two things you want to consider are the production. So you’re looking at the microbes, you’re looking at those [00:34:00] commensals that produce short chain fatty acids, looking at their levels, but you’re also considering the patient’s bowel habits.

Potential transit time. So in constipation, you’re much more likely to see low levels for those patients. So in that case, you know, they might actually have a good level of the short chain fatty acid producers. They might be getting plenty of fiber, so you don’t necessarily need to work on that end of the problem.  You’re working more on the motility side. So if you happen to see the patient also has low bile acids, for example, that could be one of the reasons why motility is low. So you want to focus on. Improving liver, gall bladder health, maybe even considering bile acid supplements.

Dr. Weitz: If we see low levels of short chain fatty acids like butyrate.  What do? What do you think? Obviously it depends on the patient, but what do you think are some of the most effective interventions? Is it better to give prebiotic fibers to feed the [00:35:00] bacteria? Is it better to give specific probiotic strains? Is it better to just give butyrate?

Dr. Fabian: I would say all of the above to consider.  Okay. So studies do show that fiber, for example, can be synergistic with polyphenols in certain probiotics. And we actually summarize that as the, 

Dr. Weitz: and polyphenols a lot of people refer to as postbiotics now,

Dr. Fabian: Poly. So the products the microbiome can produce from some polyphenols like uro, litan a, that uro litan a would be a post biotic because it’s produced by the microbiome from a polyphenol.

So yes, definitely those polyphenols are important for generating some of those postbiotics. And that’s actually one of the four Ps that we talk about. So you have your prebiotics, meaning making sure there’s not just enough fiber, but you wanna make sure there’s the right types of fiber. And Diagnostic Solutions Lab did put out a webinar that’s recorded, so it’s available [00:36:00] through our YouTube channel on our website last fall.

The team put together a great webinar and accompanying resource. As a fiber guide because we always say patients need more fiber when they seem to have a microbiome issue. But the devil’s in the details there as we just talked about. Some patients may not be candidates for inulin at all, for example.

So it’s, it can give you a good guide on what types of fiber may be relevant for constipation, diarrhea, inflammation, et cetera. So there’s a little bit of a learning curve there too, in terms of the fibers. But when it comes to butyrate. So in the context of those four Ps, we have fiber. As far as fiber, we know resistant starch is a well study for helping to promote butyrate production in many people.

I think partially hydrolyzed gure gum also fairly well documented there. There’s one more that I’m forgetting, hopefully that’ll come to me. But so there are definitely specific types of fiber that we know can promote butyrate. And then the second thing would be polyphenols. So we [00:37:00] know that there’s quite a bit of evidence.

Polyphenols can promote not just butyrate producers, but the very bacteria that can help supply those butyrate producers with the precursors they need to make butyrate. So a great example would be bifidobacteria. Bifidobacterium can produce lactate and acetate butyrate. Producers take those other short chain fatty acids and make butyrate.

So again, those prebiotics and the polyphenols can help probiotic bacteria grow that cross feeded the butyrate producers. The third P would be probiotics. So just what we were talking about, lactobacillus, bifidobacterium, and others, even akkermansia. Those can all sort of help promote a healthy ecosystem that supports butyrate producers.

And then there kind, there’s basically butyrate, which is a post biotic. It’s in that category along with Uli a and others. Those are products produced by the microbiome. A growing number of studies shows that [00:38:00] butyrate supplementation has many potential beneficial effects, but especially on helping the entire.

Colon ecosystem potentially to create a better environment for these butyrate producers and other bacteria. And that’s been shown in research to be probably due to the effect that butyrate feeds the colon cells. When the colon cells are fed by butyrate, then the colon cells participate in creating an anaerobic environment in the gut.

Those anaerobes the microbes in the large intestine, the colon are mostly anaerobic. They need an anaerobic environment, meaning lack of oxygen in order to grow. So butyrate actually promotes that anaerobic environment. Right. So I just talked about a lot of information here, so you may have questions or clarification on some of that.

Dr. Weitz: Yeah. I. Yeah, this is a whole new thing. So it’s gonna take a while I think, to really understand [00:39:00] it for most practitioners, including myself. But part of the test reports on branch chain fatty acids. What are the significance of branch chain fatty acids?

Dr. Fabian: Good question. So, we included those because again, there’s a lot of accumulating research now that they help inform us on the state of the colon health, so particularly in relation to the short chains. So you can almost see the short chain fatty acids in the branch chain fatty acids as being antagonistic to each other. So in a healthy gut, we’ve got plenty of fermentable fiber, fermentable carbs of the right kind that can promote short chain fatty acid production.  As you go through the colon, so a lot of that happens in the first part of the colon that fiber fermentation is happening primarily there and into the transverse colon in a typical person. First the microbiome is metabolizing the [00:40:00] fibers that gets depleted eventually, and then towards the end of the colon, microbes start to transition to protein fermentation.

So they’ll basically turn to amino acids for energy when they don’t have enough fiber. And that’s normal to an extent. So you wanna have a little bit of protein fermentation in a healthy gut, but not excessive amounts. Lots of studies show that when you have an excess of these protein fermentation products, that can increase the risk for certain things like it’s been associated with colon cancer, for example.

Some of those products are detected in serum and might be related to poor kidney health, for example. Maybe even issues, gut, brain issues. I think there’s some links, for example, with autism. So you definitely don’t want excessive protein fermentation. The main factor that we know, or I should say factors that increase protein fermentation would be constipation.

So that’s slow motility. You’re exhausting the fiber fermentation kind of early on. [00:41:00] And then because of this smoke slow motility, you’re allowing protein fermentation to happen for a much longer period. Producing more of those products. So you’re more likely to see higher protein fermentation and those various products that are on stools in constipation.

But it can also be due to ex excessive protein intake, which is a concern given the focus on high protein diets for muscle building. As always, in functional medicine, we’re looking at the context of the individual. So you wanna know, is that individual actually handling their protein well? Are they, excuse me, are they digesting and absorbing their protein?

Because if they’re not doing that efficiently, then you’re getting more protein into the colon that can increase this protein fermentation that can have negative effects.

Dr. Weitz: Interesting. So certainly, yeah, I was gonna say, since we do have a lot of focus on [00:42:00] protein intake for building muscle. We also have the popularity among a segment of the functional medicine community that’s using lower carbohydrate diets that are usually higher fat, but also tend to have a little more protein like the ketogenic diet which is being used for brain health, for Alzheimer’s, for all kinds of things.  And and even now the carnivore diet. I’m wondering if. Maybe what we need to think about is for people who want or find those types of dietary approaches helpful, would there be a fiber protein ratio that helps to balance this out?

Dr. Fabian: So research does support that. Now, whether or not there’s sort of a, you know, identifiable ratio I don’t think there’s enough really research yet to say.

A certain amount with a certain [00:43:00] protein. Probably you have to sort of ballpark that and then do some gut testing to see how well you’re doing in that scenario. Again, by looking at your short chains and your branch chain fatty acid production. But there’s a lot of research going back, probably at least a couple decades, showing that adequate fiber intake and adequate polyphenol intake.

Can counteract to a large extent the protein fermentation. So that is probably one of the best well established ways to mitigate the concerns about excess protein. Plus, and this is, I think really interesting research. I’d like to see more research along these lines that we’re always thinking protein for muscle health, muscle building, but it turns out indirectly fiber actually participates in that process.

By promoting these short chain fatty acids that can go into circulation. And as I mentioned earlier, one of the tissues that those short chain fatty acids influence is muscle. [00:44:00] So certain studies recently have shown that these t regulatory cells those are your anti-inflammatory immune cells that are promoted by short chain fatty acids, especially butyrate.

Those can travel from the gut to the muscle. Then help to promote normal regeneration and repair. So say for example you have a hard workout and your muscles are sort of repairing, regenerating after that, building a new muscle indirectly fiber through its effects on the immune balance can affect that process.

Butyrate itself is known to have some effects, positive effects in the muscle. So, you certainly want to think about kind of the bigger picture in terms of overall diet effects. Supporting Muscle health.

Dr. Weitz: This could also be. A negative effect of being on a a lower fiber diet, such as a low [00:45:00] FODMAP diet for a long period of time.  Yes, in the functional medicine world, we often treat patients with a low FODMAP diet. Which we find to be helpful. And then we usually try to broaden the diet and get ’em to have more and more fiber and higher FODMAP foods as tolerated. But there’s a percentage of patients that just find that they can never get back to eating that fiber.  And this is pointing to another potential long-term negative effect of not having a higher fiber diet.

Dr. Fabian: My, my guess based on the research is yes, that there’s likely to be some significant negative effects long term. It’s gonna be somewhat individual. But I suspect that a fair amount of this traces to how individuals actually can handle the carbohydrates and fiber that they’re consuming.  So if you have, for example, various factors contributing to carbohydrate intolerance. [00:46:00] Of course in the short term, you’re likely to feel better when you cut down on those and maybe even switch to a carnivore diet. So from a symptomatic standpoint, we know there’s lots of things that can help with symptoms in the short term, but have long-term negative effects like antibiotics, for example.

Interestingly, there’s research now coming out from a couple different studies showing that fiber, which we think is mostly just active in the colon fiber, actually can also promote small intestinal health. One particular study showed that Klebsiella, which can be one of the bad guys in the small intestine when it’s overgrown is inhibited by fiber even in the small intestine.

They didn’t really work out the mechanism, but this sort of a lot of studies that showed that fiber and the short chain fatty acids that they lead to. Can inhibit the bad guys. These opportunists like Klebsiella e equal citrobacter, proteus, et cetera, that can be particularly overgrown in the small intestine.

So that would be my guess. [00:47:00] And there’s also some evidence that some of these microbes in the small intestine like staphylococcus reus, can actually interfere with the brush border enzymes. And we know deficiency in brush border enzymes with the classic example being lactase leading to lactose intolerance.

When you have a deficiency due to dysbiosis in the small intestine, that might be one of the factors you wanna look at as far as these patients that just seem to not tolerate carbohydrates or fibers very well. So always thinking upstream I think is helpful.

Dr. Weitz: So we need to wrap in the next five minutes or so.  So I’m thinking maybe you could walk us through a case where the stool, all mixed results helped change the clinical approach and then we’ll conclude.

Dr. Fabian: So, because it’s a new test and we do consults on these so far, because it’s only been out for a couple months, I don’t have follow up cases yet.  Okay. That I can speak about. I only [00:48:00] have the primary cases. So the one I had mentioned earlier, we’ve had a few of these examples, whether it’s cholecystectomy, so removal of their gallbladder leading to this increase in the primary bile acids in the colon. And then we see that often associated with inflammatory bacteria.

Recent research shows that there is that connection. Excess primary bile acids in the colon can lead to increase in inflammatory bacteria. So that would suggest, you know, looking at ways to. Reduce some of those inflammatory bacteria using our typical functional medicine tools for dysbiosis, for example.

Even considering biofilm inhibitors, if that seems to be part of the picture. So that’s something that we talked about in the consult is some of these research based insights that might help guide them in which way they want to go. And then. Certainly with inflammatory bowel disease, I’ve probably seen two or three Crohn’s disease cases, similar scenario.

But usually the bile [00:49:00] acid malabsorption was more significant in those cases where the total was quite high and the percent primary was high and the percent secondary was low. And all of those have been linked to potentially worsening scenarios in IBD. Again, that helps the practitioner understand that these are some things they want might wanna look at in terms of supporting and targeting in order to help improve, potentially improve the patient’s situation.

Dr. Weitz: Tom, this has been incredibly informative and I think the stool one makes test looks like a real. Benefit for precision gut health assessment. Where can practitioners go to learn more about it and order the test?

Dr. Fabian: The simplest way is just to go to the diagnostic solutions lab.com website. That’s all just basically one string diagnostic solutions lab.com.  And then you’ll see that there’s the test menu. It’s listed under the GI Maps. If you look at the dropdown menu on our different tests, you’ll see GI Map. And because it’s an add-on stool can’t be ordered alone by itself. It needs to be added on to the GI map. You’ll just see it there and basically when you go to that page, it gives you all the information you need to order the test.

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Dr. Weitz: Okay. And so thank you everybody for joining us and thank you Tom for spreading this information with us. And for those listening, if you find this helpful, please share the episode. Leave us a review on Apple Podcast or Spotify, and we’ll see you next time on the Rational Wellness Podcast.  Thanks so much, Ben. Thanks Tom. Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would very much appreciate it if you could go to Apple Podcasts or Spotify and give us a five star readings and review.  As you may know, I continue to accept a limited number of new patients per month for functional medicine if you would like help. Overcoming a gut or other chronic health condition and want to prevent chronic problems and wanna promote longevity, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111 and we can set you up for a consultation for functional medicine and I will talk to everybody next week.