Diane Darcy, RD, “CCM-Healthy Diet,” AA National Patient Conference 2019

I would like to introduce
Diane Darcy who is here from outside of the Angioma Alliance family.
She is the only speaker who isn’t a typical member of our science
meeting or of our patient group. Diane is a Master’s level dietitian-nutritionist.
She has 30 years of practice in the field and in this area.
She has offices in Germantown, Montgomery Village, Rockville, and Woodley
Park. She’s going to share a little bit here about gut health since
we just heard about broken guts. She’s going to help us hear about good guts. Hello and good afternoon everybody. Okay is this better? Okay good. Let me
know in case I wander. I do tend to do that. I’m here to talk a little bit
about the gut microbiome. I don’t really know much about CCM – that’s where you
guys come in. What I know about is the gut. I come from a long line of family
members who had gut problems, so it’s a real interest for me. Just to share a
little bit about our family. Let’s see if I can do this. I got a gift for the
holidays from my son so I’ll just use this. Okay good, all right. We saw the
gift. It was a pillow in the form of an emoji which
apparently, I use too much of in my texting to him. It’s
an important topic to to my family, something my mother suffered from and
I’ve got children who continue to suffer from it. So I have done research and
I’m interested in the field. Right now for CCM, we’ve got,
as a standard of care, surgery and maybe having some symptom management.
But what if we could do something else? What if we could have food as medicine?
There are definite ways that we can influence the gut microbiome through
diet. It is established. What that means clinically is not as well established.
I’m here to tell you some things that you can do. In terms of the probiotics
that you had questions about, I think that we’re a little bit in the Wild West
area. We don’t know. When people are looking at probiotics, what they need to
look at is genus, species, and strains. It’s not just lactobacillus casei. It’s
lactobacillus casei 0594, which makes it really tricky to start
prescribing these things for people. A lot of people use a
shotgun approach. I think no matter what you do, if you eat a better diet and get
some of the things that feed the gut microbiome healthfully, then you’re going
to be in better shape. It’s not going to be harmful. It’s not dangerous and, in
fact, can help in many ways with cardiovascular disease, diabetes, weight
management, mood disorders – a variety of things – and perhaps in CCM as well. Okay. Today, what I’m really
going to talk about is food as medicine as it relates to the gut microbiome and
feeding the gut microbes and what kind of healthy food pattern you might want
to try and adopt to get some help in this area. Animal studies do point to
the gut microbiome as a potential player in the CCM formations. And what about
those microbes? Let’s look at them. There are… I want you to
take this in. Maybe you’ve heard it already. There are 100 trillion microbes
in your intestine, primarily in your colon. Over 3 million genes are
in your colon. Over 3 million. That’s more than in your entire body. These genes
are doing something. They’re making things. They’re making toxins.
They’re making good things. They’re making vitamins. As we’ll see in a minute, we
live in a community with them. I want you to start thinking about this as a
little city in your colon. You’ve got apartment buildings and
you’ve got microbes living in them and what microbe A might be living next to
microbe B, and microbe A makes something that microbe B likes to eat. Then micro
B makes something for the host that the host likes. So microbe A is
happy living next to B, B is happy living next to A, and the host is happy as well.
The microbes interact with each other. They interact with us as the host. The host – our cells, our bodies – interact with those microbes. We do it through a
variety of mechanisms. There are chemical ones. There are neurologic ones. There are growth ones. We’ll see that in a
minute. A healthy microbe community has diversity. The people or the microbes
living in this city, there are a lot of different ones. They are making good
stuff to help each other out. They’re worker bees doing great things.
There are nutrition benefits. These microbes make vitamins for us. They
digest things and make more minerals available. They also make products
that actually feed our colon cells. They feed them, plump them up really nice and
thick, so that you have really a good environment. The guts are not letting
things in that it shouldn’t, and it’s taking things in that it should. There are
immune benefits. If in your city, all of your houses and
apartments are filled with these worker microbes, then pathogens don’t have a
chance to step in and set up residence. Just by virtue of having a
diverse community that’s healthy and populated, you’re not going to get the
pathogens moving in as easily. The next thing is it regulates immune functions.
All along the GI tract, you’ve got a neural network, you’ve got a
lymphatic network, and it’s communicating through byproducts with the microbes.
There are metabolic benefits. They modulate gut hormones. They can actually increase
satiety and fullness so you might stop eating faster and you might have a
better body weight. Modulates some of the diabetes hormones, ones that affect blood
sugar. When you look at people with cardiovascular disease, obesity, diabetes,
what you find is the gut microbiome is in fact different. What came first, the
illness or the change in the microbiome? There have been experiments where
they’ve actually done fecal transplants from one person to another, not just
between one laboratory animal and another. As you can imagine this isn’t
done a lot. There was an experiment with someone with diabetes that was in poor
control. They were transplanting for another reason and what they got from
the transplant was six weeks of excellent blood sugar control. The only
change was the fecal transplant. So the gut microbes
do something. The other benefits that we have – we have a gut-brain axis. I want
you to think about this because, honestly, I think we’ve all had
some kind of saying, “I have a gut feeling,” “We have this gut connection”
You’re going to work in your bad mood – “What’s eating you?”
I think we’ve sensed that the gut is related to mood for a long time based
on some of the things that we actually say to one another. It’s actually
true. They do communicate to one another and help regulate mood and behavior.
People are actually looking at the gut microbiome also for other illnesses like
multiple sclerosis, which I didn’t say very well. But nonetheless, it’s something
that they’re looking at. If you have a non-diverse gut microbe community, it is
going to have vacant slots so pathogens that you might eat in your food or
ingest in other ways can take residence and start manufacturing things that are
toxic or not very healthy for your gut microbiome. This can lead to inflammation and
also that leaky gut hypothesis. It sounds like you’ve already had somebody talk
about that. Is that correct? Toxins and microbes are getting
into the body and the immune system’s going like, “whoa what’s happening?” and
sending out other messages. Then things go down a prolonged pathway in
the wrong way. Inflammation is the first step in healing something, so I
don’t want to say it’s always bad. But a systemic inflammation that’s not
shutting down is not a good thing. It can lead to problems with blood sugar, lipid
problems, etc. I want to spend some time on this slide and walk you
through it. This is perhaps a representation of what was drawn over
there. I’m not so good at drawing so you’ve got a slide.
I want to look at this from the standpoint of structure, and then we’ll
move into function. This is part of the intestine. It’s the part that
goes from the small intestine to the large intestine. If you look here, this
part is going toward the mouth and the other side is going towards the other
end which would be more appropriate for the poop pillow that I showed you
earlier. This in here is the inside of the intestine. While the inside of
the intestine is actually technically in your body, it’s really not in your body
yet. Anything that you’re eating has to
get digested and absorbed. Typically what happens is the food comes in. If it’s
easy to digest food, low fiber, really easy to to get at for the enzymes, it
all goes in through the small intestine. Then very little gets to the large
intestine. The large intestine is where most of the microbes are. We want
them to be fed. In fact, the only way they get fed is through what we eat. If we eat
stuff that’s easy to digest, they don’t get to see much and they’re hungry and
they eat the wrong things. By changing our diet, we might be able then to feed
them happier things and things that they can actually get at and might
make them healthier. They’re lining this gut over here. You have one cell layer
thick between you and trillions of genes that are making
lots of stuff. The gut has two main functions. It has to let stuff in that it
wants and has to keep stuff out that it doesn’t want. The way that it does that,
primarily, in the colon, is through the mucous layer. It’s not huge.
It probably is two layers thick, but you want to have a
nice plump mucus layer to protect the rest of the body from the microbes
getting in and toxins getting in. That’s where leaky gut may in part be
happening. The mucus layer is demonstrably changed in a high-fat diet
for example. If we can measure it, having a lower mucus layer, and we can
measure inflammatory markers, a high-fat diet may not be the best idea. The other
thing I want to point out is these cells that are one layer thick are sort
of nice and plump and sitting up next to each other. They’re being fed by the
microbes in the gut. When they’re not being fed, they kind of shrink a little
bit. When there’s inflammation, they can shrink a little bit and things can get
in, not just through the cells then but between the cells. That’s a
little bit more about leaky gut. What do the microbes eat? They eat what we can’t
digest and absorb. Food fiber is really their preferred energy source and
that’s almost exclusively carbohydrate. The food fiber is something that we
can’t break down. Our enzymes can’t get it at it and can’t break it down so that
we can digest it and absorb it, but the microbes can. One thing to know is
that the only thing in our diet that has fiber comes from plants. I’ve got a
question for you. An apple, as well, for anybody who can get this right. What
group of people are having a diet that gives you the most diverse microbe
community? Any guesses? Raise your hand. Repeat the
question? What group of eaters have the most diverse microbe community. Vegans!
Okay! I’m back here. All right. I just threw an apple to the winner who knew
that the vegan diet – where you’re eating nothing but plants – those eaters have the
most diverse microbe community. The reason is that they’re eating the most fiber. Now of course you could have somebody eating
a really rotten vegetarian diet. You know that’s not who we’re talking about. We’re
not talking about eating pastries – white flour and sugar. We’re talking about
eating a healthy vegan diet. They’re gonna have the most diverse microbiome. We have something called the Standard
American Diet. They do all these studies looking at what people
are eating and give an average. The diet is called SAD, which is
kind of a good way to look at it. It’s a low fiber diet. You’ve got hungry
microbes. What are they eating? They could be eating the mucous layer. They could be
eating each other. They’re vacating their apartments. They’re having a hard time.
They’re leaving themselves open, or the host open, to having some problems.
Usually, it’s a high saturated fat diet. There are lots of meat that they’re
eating, butter, high fat dairy. That’s been shown to decrease
the mucus layer. Processed foods – you’ve heard about this a little
bit already. You’ve got a lot of emulsifiers, salt, sugar. All of these things
negatively impact the gut microbiome or the surrounding community and tissues.
It produces low diversity and inflammation. Mucus layer compromise as well. This
is an example of a processed food. We can process foods to be easier
to digest. In fact, cooking, in a way, is processing.
I would recommend that you cook your plants for some things like beans.
Lectins are high in beans and when you cook them, they’re gone. You
don’t want to eat a raw bean. I’m not saying not to process at all.
I think the problem starts happening is when you start
adding a lot of sugar, a lot of salt, and a lot of the the emulsifiers. Then I
think you start getting into trouble. When manufacturers are making food items
that have a lot of water and a lot of fat in them, like ice cream might. Fat and
water don’t mix. The emulsifier is the thing that puts them together. You have
hydrophilic and hydrophobic components to these molecules. The
emulsifiers are what keep them in suspension. If you go to make a salad
dressing with vinegar, that would be water base and the oil would be a fat
base. You can shake them up and they kind of mix a little bit, but they’re going to
separate right out. An emulsifier, a mild one might be paprika,
just a spice, can help emulsify a little bit. It’s not a very strong one. If
you put something like the polysorbate 80 in there, you’re never going to have
it separate. When I was in food science labs, we used to use
centrifuges to do different emulsions and then try to spin them down and see
which emulsifier had the strongest effect for keeping the fat and
the liquid together. It was kind of fun. This has polysorbate 80. I’m
going to just point to it now. That and carboxymethyl cellulose are two
of the ones that have been implicated in recent research. I want to point out that
I think that these are probably dose-based. If you have a half a cup of ice
cream once a month with grandkids or your children, I’m not sure that you’re
going to totally disrupt the microbe community. If you’re sitting down eating
a half gallon of ice cream, I think you’re in trouble for a variety of
reasons. Come see me. Mostly processed food – the
list of ingredients is very, very lengthy. I think that might be a good giveaway.
Then you can always look at that list of ingredients. If you look at the
nutrition facts, you can also see that there’s a lot of saturated fat – 4.5 grams,
that’s a fair amount. I try to limit my saturated fat to anything under 3
grams per serving. The total carbohydrate has almost everything from
sugar. The new labels will pull out – this an old label – the new ones will pull out
the added sugar so you can tell what’s naturally in the food, like there’s
natural sugar in milk, and some of the sugar label there would be that. We doing
okay so far? Okay. What we want to do to make your gut happier and healthier
is feed the microbes. First thing to do is remove that SAD diet. Get away from
unhealthy foods. Start eating healthier foods – leaner protein,
plant-forward diet, unsaturated fats. What I’d like to do today is primarily
focus, for time constraints, on the plant diet. The plant diet, and
eating in this more healthy replaceable way, will give you more vitamins and
minerals. That’s going to help heal the gut from prior problems. What’s a
happy healthy gut want to eat? Plant forward diet. Again, plants are the only
place where you’re going to find the fiber that’s going to feed them.
It’s in fruits, vegetables, whole grains, beans, nuts, seeds, plant-based foods. It’s not
gonna be in meat. Not going to be in butter. Not going to be in a variety of other
things. A high-fiber diet – 28, 30 or more grams a day,
high polyphenol content. Polyphenols are compounds in plants. Plants have
been giving medicine – drugs – for a number of years. For example,
digitalis came from the plant foxglove. Aspirin came from willow bark. Plants
have compounds in them that can affect us. Polyphenols give the plant
the color typically, so makes blueberries blue. It’s in tea.
It would be in olive oil, the extra virgin where it’s nice and green.
Those are polyphenols making that olive oil colorful. Polyphenols have
direct effects of being antioxidants and anti-inflammatory compounds. They’re
also utilized by the microbes to make products that are healthy for us. Low
processed foods, so you’re not getting a lot of extra sugar and salt and
emulsifiers in your food. You’re cooking at home. Unfortunately, in our fast-paced
life that’s come to be a challenge. Using liquid oils that are plant-based
rather than high-saturated fat foods. This is coming from a Mediterranean
eating pattern. This is not the whole Mediterranean eating pattern. It’s only
the plant-based part. What you’re looking to do in this pattern… It’s a healthy
one. It’s been used for weight. It’s been used for cardiovascular disease. It has
been used for diabetes. It gets the fiber up where it needs to be. As you can
see on the slide – you may not be able to see it so on the back, I’m not sure.
Can you see it in the back? No? Okay sorry.
Basically, what this comes down to is, it says that every day you want to
have whole grains, maybe up to a cup and a half. You can have more
if your calorie needs are higher, but these would be minimums.
You want to have two cups of fruit a day and you want to have three cups of
vegetables a day. There are some specific foods listed there that would be high in
phenolic compounds. It gives you a fiber allotment as well. Two cups of
legume a week and three ounces of nuts or seeds weekly. The total fiber – it varies
depending upon the individual food items. Some foods are higher in fiber than
others. But it ends up being about 34 grams to maybe 46 with that minimum
intake of plants. You’d certainly be feeding the gut microbiome (yay!) when you
eat in the Mediterranean plant pattern. By the way, it was listed in 2019
as the best diet by US World and News Report. Basically what I’m telling you –
supersize these, not supersize the hamburgers or the fries at McDonald’s. It
might require a few more cooking lessons, but it’s definitely worth the
input. Taking frozen vegetables which don’t have a sauce on them would be a
nice way to go. Drizzling them with olive oil, adding in some spices, that would be
a way to try to get more vegetables in. It’s not just salads. There are
plenty of resources, both cookbooks and online, that can help with that.
Tonight I hear you’re on your own for dinner, so I thought since I’m not going
out with you that I would give you an idea for what to do. We’ve got a menu
list here. The green tea is there because going to give you phenolic
compounds. I want you to have that for the anti-inflammation and the
antioxidant. Grilled salmon – it’s going to give you a vitamin D and it’s also going
to give you omega 3 fatty acids, which are going to lower inflammation rate.
We’re gonna have baked sweet potatoes and we’re going to get
fiber from there. The tea is not going to have much fiber. The salmon of course
it’s not going to have fiber, but we’re going to start to get it with our
vegetables. It’s also going to have Vitamin A value which is healthy in any
epithelial tissue that would be in the gut. Then you’re gonna have salad
with extra virgin olive oil and a little bit of vinegar. The salad greens have
some vitamin A value and they’re gonna have some magnesium, a few other things
that your body would like. The extra-virgin olive oil, as we talked
about, has polyphenolic compounds. The vinegar might even, probably not, but might even
have some some fermented food capacity in it if it was like a
cider vinegar that had the mother in it. Steamed garlic greens.
Believe it or not, garlic and onions are quite good at having
polyphenols and they have some fiber in them so they’re healthy to eat. Fresh
fruit and nuts, of course, because you’re meeting your requirement for the
Mediterranean diet and they contain the polyphenolic compounds. The
Mediterranean diet does talk about having some wine in the diet. Again, you
can go overboard and then you have to start subtracting the benefit, but there
are polyphenols in both red and white wine. The amount to drink is five ounces
for a woman, maybe 10 ounces for a man, but you have to be cautious because this
can hurt the gut microbiome. Again, it’s dose-based and a balance
and a personal preference. If you are not drinking now, I’m not
advocating that you start. That’s kind of the end of Feed Your Gut,
and I am hoping you got something out of it. I’m interested in any questions
that you might have. QUESTION: Is there any harm to drinking black coffee? The question was about
black coffee. Is that okay to drink? Yes, there are phenolic compounds in there
and they’ve actually had some studies that demonstrate when people drink it, it
seems like there’s a lower risk for, I believe, it’s diabetes. So, yes, it’s
fine. I think you can go overboard. You always have to
couch these these things, like if you if you’re if you have a problem with
caffeine, with tachycardia or something like that, then, of course, we’d have to
revisit that. If you have reflux disease, both decaffeinated and caffeinated
beverages seem to be a problem, so you have to individualize a little bit with
everything. But for a generally healthy person, yeah. QUESTION: I’ve read some different things about light roast versus dark roast coffees, regarding, I think it’s carcinogens. Do you know what the latest is on it? I think dose is important there. Anytime you have high heat or lots of caramelization in the food, you create
these advanced glycation end products that have carcinogenic effect
potentially. Whenever we talk about risk, it’s always got to be with the idea that
not everybody’s going to be at risk. I’ve seen trials where they’ve given
three dozen eggs to people and nothing happens to their cholesterol for some,
but not all. It always is an individual response. It is something that
you would want to to limit. I think when you do cook, it’s
good not to burn meat. I think it’s good not to burn anything. I think lower,
slower cooking is probably overall healthier. QUESTION: What about yogurt in the diet? What are your thoughts? I think yogurt is wonderful if it has active cultures. It’s got the probiotic in it.
Pretty bioavailable calcium. It’s going to give you vitamin D. It can be a pretty
good protein source. I am definitely pro-yogurt. QUESTION: By eating the right diet, you’re going to have a happy gut, but is there any way of measuring a happy gut? That’s a good
question. Do we see changes with diet in the microbiome? We sure do. The way
most people measure the microbiome is through stool samples.
There have been studies where they went in and did the biopsies. As you can
imagine, those aren’t done very often with humans. There’s not a big
correlation between stool sample and what’s actually in the community higher
up. We are also developing the metabolomics piece of science. That’s
going to give us a lot more detail. If I supplement you with a probiotic
lactobacillus, whatever the strain is, I know that I can say what that
organism is, but I don’t know what it’s doing. The omics piece is going to
tell you what it’s making. I think that’s more relevant. You might take
in the right bug but it may not be making what you need it to make.
That’s the more relevant piece and that’s what makes therapeutic
interventions so challenging. There are trillions of these
things in there. I think everybody
has about a third of the same – I’ve seen that number – and two-thirds are different
among people. When you start giving a high-fat diet, within two to six days you
start seeing the stool change, so the microbes are different. When you start
feeding a plant-based diet, again, same thing. It changes. So we can demonstrate
some changes through the stool. I can’t say what’s happening throughout.
I can’t say that it’s colonizing anything. As soon as I stop feeding you a
probiotic, it’s gonna stop coming out in the stole the same ratios as it did before.
People who take probiotics sometimes see a benefit.
Allergies are one of those things that that I’ve seen in the literature as
saying they perceive a difference. I can’t say whether it’s a
placebo effect or if it’s real. There are microbiologists who worry
about supplementing with probiotics and conferring… I mean the worst case
scenario honestly would be conferring a benefit of antibiotic resistance. If I
feed you a lactobacillus casei that can resist erythromycin, then it could, by
rubbing elbows in the community, pass it on to another bug, which may spell bad
news for you. It feels to me like it’s the Wild West,
but I think feeding it well is not going to hurt. We do
see in studies that there are benefits from from eating higher plant-based
foods. I’m not saying no animal products at all, as evidenced by the menu I gave you,
but, by and large, having more plants and giving more fiber to the
microbiome so it will encourage the growth of beneficial healthy bacteria
and feed your gut. Okay, thank you everybody.