Dr. Paul Mason – ‘From fibre to the microbiome: low carb gut health’

Okay So thanks for having me back here again In this talk, I'm going to take you on a tour of gut health and low carbohydrate diets and by the end of it I hope to have convinced you of a few things

Firstly that fiber is not a necessity for a healthy diet Secondly, there are some low carbohydrate foods which commonly cause bloating and other symptoms, and we can identify these, and improve gut symptoms on a low carbohydrate diet, and finally, I want to demonstrate that at the moment there's simply not enough evidence that altering our gut bacteria can lead to weight loss So let's start with fiber This is defined as the carbohydrate portion of plant foods which we can't digest And remember fiber only comes from plant foods

It can be divided into two types: we have a soluble fiber and this is readily able to be fermented by the bacteria in our colons, and this produces gases and something called short chain fatty-acids, and then we have insoluble fiber, that's much more resistant to being broken down by the bacteria in our colon and this is the type of fiber that adds bulk to our stools Now, there's been a lot of suggested benefits to the ingestion of fiber This includes preventing bowel cancer, preventing diverticulosis, helping hemorrhoids, lowering blood sugar levels, and, of course, treating constipation In fact, it is now conventional wisdom that fiber is a necessary component of a healthy diet So

Understandably, many of my patients are concerned about the potential impacts of removing high carbohydrate cereals and breads from their diet So in the Australian diet, these represent 45% of the fiber that the average Australian gets, and when we have a look at the the current governmental advice, they consider that fiber is the best available treatment for constipation (surpassed) by none But this opinion doesn't bear a scientific scrutiny

Now, for such a widely accepted believed claim you'd think there would be compelling evidence to back it up Except there's not I could not locate one randomized control trial expressly looking at symptoms of constipation Sure, there's trials looking at bulky and transit rate and a few other things like that, but when we look at the symptoms of constipation, the research just isn't there So, I'd like to present to you the best trial that I could find

This was a case control study So in this study, 63 patients who presented with constipation were recruited, and high and low fiber diets were compared in these patients, and this also included a zero fiber diet that required the complete cessation of all vegetables, cereals, fruits, wholemeal breads and rice So this graph here represents the percentage of study participants before the study suffering from each of the symptoms listed on the right side So you can see, before the study started all of them had constipation, and strain opening their bowels, and a number also experienced bloating, bleeding, and pain And when the study participants, those who went on a high-fiber diet, we can see that the proportion and suffering symptoms actually increased, especially bloating

So, then there was a reduced fiber arm, and what you can see here is that, those on the reduced fiber diet actually demonstrated a modest reduction in symptoms So, the question is what happened to those, the majority of those in the study who had zero fiber in their diet? This is not a mistake I didn't just forget to put something in the side there Now, not one patient on the zero fiber diet had any symptoms That's quite astonishing really, and these findings were highly statistically significant

Highly They weren't due to random chance Now just out of interest, every single person in the zero fiber group, ended up having one bowel action per day, every day How did this compare to those in the high-fiber group? One bowel action on average every 683 days

Still think that fiber is good for constipation? So, to understand why fiber reduces constipation gives such striking results, let's look at the diagnostic criteria that we as doctors use to diagnose functional constipation, and you'll note that each one of these criterion relates to ease of passage of stool through the anal sphincter, which is quite logical, really Now fiber, especially insoluble fiber, the kind you have in wheat bran has long been heralded for its ability to bulb the stool, to make it bigger, but when you think about it logically, is it making something bigger really the solution, when you're trying to pass it through a small hole? Packing the rectum with feces actually makes it harder to expel the fecal matter, so using fiber to help constipation is analogous to adding more cars to fix a traffic jam, but that's not the only argument People say: "well, it also moistens the stool" Except it doesn't It's been long known and well understood that stool moisture does not vary, regardless of how much fiber or how much water you consume

Fiber does not moisten the stool, and while it's not technically a diagnostic feature, a constipation, bloating is a known issue that many people understand is related to excess consumption of fiber, and the reason for this is because it doesn't get digested in the small bowel, remember that's a definition of fiber, it's not able to be digested So it passes down to the large bowel, which has a large bacterial population, and then these bacteria can ferment the fiber, especially the soluble fiber, and they produce something called short chain fatty-acids, which is heralded as being one of the things which it provides health benefits through, but in the process of this they also produce gases, such as hydrogen and given that the volume of the whole gastrointestinal tract is only about one liter it only takes a relatively modest amount of gas production before you start feeling bloated, and start having an element of abdominal pain, and anybody who lived through the 1980s, anybody remember the bran craze? You can probably attest to that So what we're left with is that, when we look at their best evidence available, fiber worsens constipation It causes bloating and does absolutely nothing to moisten our feces So, how does this relate to low carbohydrate diets? Well, there's a lot of low carb foods that are actually high in fiber So even though 45% of the fiber in the average Australian diet comes from breads and cereals, a lot of the food we replace it with when we go on a low carbohydrate diet are also high in fiber, and some of the staples that we love, Like berries cauliflower and almonds

They're in that high fiber group, and if you understand that when they get metabolized in the colon by the bacteria, they can produce gas and bloating, you can understand why if you have a whole bag of nuts, you might feel a degree of discomfort down there So, some of you are probably looking at that going: "you know what? I did have a big plate of cauliflower mash the other night and I did feel a bit funny overnight" So let's turn our attention to something called the short chain fatty acids So you'll remember when once the fiber is fermented by bacteria, it produces these fatty acids, and they're thought to offer some health benefits So these bacteria allow the body to salvage energy from an otherwise unusable source, and provided in the form of fats, and estimates vary widely, but it's commonly considered that about 5% of the energy we actually get from our diet, when we're eating an average diet, actually comes from these short chain fatty acids which are produced from fiber, and it said that these short chain fatty acids nourish the cells that line our colon they're called colonocytes, and this is thought to help improve conditions like inflammatory bowel disease (IBD), and while it's true this is a representation of some of the cells that line the colon, while these cells can use short chain fatty acids for energy, they only do so, by after converting them to ketones first

So if ketones are produced from short chain fatty-acids and that's beneficial, then isn't it logical that ketones in the circulation from being in nutritional ketosis, or in a ketogenic diet would also be beneficial to these cells, they can still get to them, and in fact, the ketones in the circulation are probably even more effective because they're delivered to every colonocyte, not just those in which they're in direct contact with, and this is actually being demonstrated in studies comparing enemas given short chain fatty acids, and ketones given into the circulation, and it's been shown that the ketones given in the circulation are more effective at treating the inflammation of IBD, which might mean the short chain fatty-acids aren't so magical after all, and even if they were, fiber isn't the only source of short chain fatty acids from gut bacteria This is a graph here and it shows a short chain fatty acid production between a plant-based diet, with lots of fiber, and an animal-based diet, with lots of amino acids Here in red, you can see that the short chain fatty acid production is actually higher on the animal-based diet than it is on the plant-based diet So it would seem there's nothing uniquely beneficial about the production of short chain fatty acids from fiber at all So let's turn our attention to one of the other putative benefits of fiber in the diet, that you can control your blood sugar levels, and when you take that in isolation, that's actually correct So this graph here compares blood sugar levels between a diet recommended by the American Diabetes Association, yes with all that spike in blood sugar, diabetic association recommended diet and below that, a diet that's higher in fiber

So you can actually see that the high fiber diet actually does moderate the spikes in insulin to a degree But the point that should probably be made that, if you didn't eat all the carbohydrates in the first place, Then you wouldn't need to worry about controlling the sugars with fiber and even with the fiber, if we convert it to our units, the blood sugar level still goes over 10, and additionally if a diet that I was recommending for diabetes had blood sugar control like that, I'd probably start looking for another job So, let's have a look at this graph This study was also published in the American Diabetes Association Journal, and on the top you can see a control diet with significant spikes in blood sugar level, and on the bottom you can see that height looks massively better, and you know, far better than the diet that you just saw with extra fiber added to it Now the diet on the bottom is what's called a low bagged diet, this stands for low biologically available glucose diet I guess he can't use the term low carb in a diabetes journal, huh? Now for a final thought on whether fiber is a necessary part of a healthy diet, let's just look at a herbivore gut which has a really large cecum, which is where fermentation of fiber occurs and compare it to a human gut

So clearly, you can see that our gastrointestinal tract just isn't set up to metabolize or process fiber in the way that herbivores are So, I'd like to now move on to the next section of my presentation, and have a look at something else that can cause gastric problems on a low-carb diet, and that's something called FODMAPs So FODMAPs, are again carbohydrates, are a group of short-chain carbohydrates with some common features So firstly, they're poorly absorbed in the intestine and because of that they get down to the colon where they can be fermented by the bacteria, again causing gas Much in the same way that happens with soluble fiber and also (the issue of) these FODMAPs is particular carbohydrates attract fluid due to a high level of osmotic activity and that can lead to watery stools, and both of these symptoms are seen in a condition that we call irritable bowel syndrome (IBS), and as well, (besides) causing those stools, FODMAPs can also cause constipation, something else which is seen in IBS, and the way it does that is, when the bacteria metabolized them, they produced methane and methane gas has actually been shown to cause constipation, and when people with this IBS, repeated in lots of different studies, when they're put on a diet that's low in these FODMAPs, about three-quarters of them have significant improvements, and I'd like to illustrate that point with a very interesting study published earlier this year, So there's a condition called non-celiac gluten sensitivity So these patients they get gut symptoms when they eat foods that contain gluten

But when we test them for celiac disease, it all looks normal Now the thing to understand is that foods that contain gluten, also often contain something called fructans, and and this is one of the FODMAPs So, this study recruited patients with this non-gluten celiac sensitivity, and gave them specially made bars, some of them had fructan in them, some had gluten and some had neither, and what you can see on the right, is that their symptoms were far worse when they're given the fructans than when they're getting gluten So it appears the diagnosis of non-celiac gluten sensitivity is in fact a problem with FODMAPs So how does this relate to the low-carb diet? Because we don't tend to eat much wheat, right? True but FODMAPs are found in a number of other foods some of which are seen on a low carbohydrate diet

and unfortunately, this includes cauliflower Again, one of the staples which we also saw was high in fiber So if you've ever wondered why you feel bloated or constipated after cauliflower mash, you may have just found the answer Now let's have a look at the P in FODMAPs and this stands for Polyols, which represents artificial sweeteners called sugar alcohols Now because they essentially provide calorie free sweetness, polyols are used widely in a lot of low carb bars and sweets

The problem is they're poorly absorbed, they attract water, they produce gas, they give you loose stools, and many people on low carb diets have suffered diarrhea as a consequence of having one too many Atkins bar Now I'd like to touch on what we call the microbiome Now this reflects the colonies of bacteria or microbes that exist within the human body But in particular we're going to focus on those in the colon, in the large bowel It's often been said that we've got 10 times more bacteria than we do human cells

That's an exaggeration, when we actually look at the science, they do outnumber us by about 13 to 1 but not quite 10 times So we're going to focus on the microbes right down at the bottom of this arrow here and the question I want to specifically address is, can these bacteria make us fat? Because that's what we've been hearing a lot about recently Now we've got more than a thousand different types of bacteria within our gut, but 90% of these come from one of two main groups: the firmicutes phyla or the bacteroidetes, and the firmicutes phyla has actually been associated in a number of studies with obesity, while the bacteroidetes has been associated with weight loss, and the graph here demonstrates how when you lose weight, the bacteroidetes actually increases But the thing to understand about bacteria is that, they have very specific conditions for their growth Some prefer oxygen, some don't some like fiber, some don't, and so on

And the bacteria, if they like the conditions you give them, if they like the nutrition you provide them, they will proliferate So simply by providing a different source of nutrition, we can change the bacterial colonies in our gut And these changes occur rapidly Within a single day, it's been documented that you can get major changes in the bacteria within your gut But the big question is, can we deliberately change the balance of bacteria to lose weight? Now a key point here is that the bacteroidetes phyla, which is associated with weight loss, also happens to be associated with high-fat ketogenic diets

This has been found in studies of children on this kind of diet when they've been having their epilepsy managed So it becomes the case of the chicken or the egg Is it a change in bacterial population? Or the change in the diet that leads to the weight loss? So back in 2006, is this famous paper that was published that showed that an obese microbiota could make mice fat So they had some germ-free mice, and they gave these germ-free mice some bacteria from some fat mice and from some skinny mice, and they actually found that the bacteria from the fat mice made these germ-free mice fatter And this is why this graph here demonstrates short chain fatty acid production comparing the two groups, and what you can see is that the obese bacteria led to an increased energy harvest by way of producing more short chain fatty acids

But that doesn't mean that you can simply transplant bacteria in our colons to lose weight Firstly, the bacteria were transplanted into germ-free mice There was no competition from other bacteria It's highly unlikely that if you transplanted bacteria into a gut that had an existing colony, that it would do as well Secondly, the extra energy was derived from fiber

So if you're on a low fiber diet then there would have been no finding, and the fact that there short chain fatty-acids are then converted into ketones, which as we know, is an appetite suppressant, means that in the real world when we're not on calorie controlled diets, when we're not just in a cage with a limited amount of food that our volitional food intake becomes important So the ketones that are produced from the short chain fatty-acids probably would have had an appetite suppressant effect, and those mice would be predicted to then eat less So it's not clearly apparent that we can simply change our gut bacteria to lose weight Far more likely is that changing a diet permits weight loss, and that's associated with the changing gut bacteria, not the cause It's the age-old conundrum

Is it causation or is it correlation? So as a final demonstration that what we eat does influence a gut bacteria and not always in a good way, let's have a look at this study So trehalose is a sugar composed of two glucose molecules But it's fairly recent and that it's been in our food supply It was only approved for use in Australia in 2003, and that was after some Japanese scientists discovered a way to mass-produce it back in about 2000 And it's not very sweet but it is very effective at lowering the freezing point of food

And because of that it's used in a lot of things like ice cream Now the problem is that a particularly harmful bacteria called Clostridium difficile is very fond of trehalose and The increased consumption since the early 2000s has been associated with an increase in a dangerous condition called pseudomembranous colitis associated with this bug So what we eat changes our gut bacteria So to conclude, I'd like to leave you with three key messages: fiber is not a necessity for a healthy diet; Secondly, even on a low carbohydrate diet, certain foods contain high levels of fiber or FODMAPs that can cause stomach upset, and you need to be aware of this; and finally the whole concept of altering our microbiome for weight loss is a bridge too far with the current understanding of science Thank you

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