Abstract

A 69-year-old female patient presented with chief concerns of hypertension, hypercholesterolemia, low immunity, and osteoarthritis in June 2006. It was hypothesized that the patient was suffering from dysbiosis based on her presenting symptoms and past medical history. The patient was treated with dietary interventions — specifically, the Eubiotic diet — in order to repair her gut tissues and function, and restore beneficial intestinal flora. After approximately six months on the diet, her symptoms of dysbiosis such as sinus congestion, bitter taste in the mouth, hypochondriac pain, and feeling gassy and bloated, all disappeared and her blood pressure stabilized, resulting in a dramatic reduction in prescription blood pressure medication use. The following report discusses how a naturopathic approach employing the Eubiotic diet is hypothesized to be the major intervention responsible for improving the patient’s hypertension. In this report, the potential physiological mechanisms and rationale are discussed with respect to this novel approach of care with an emphasis given to issues of gastrointestinal health and terrain.

The term “dysbiosis” was first introduced by Dr. Elie Metchnikoff, a Russian scientist, to describe altered pathogenic bacteria in the gut.(1) Intestinal flora consists of the microorganisms normally living in the digestive tract, which serve many necessary functions, such as providing energy, synthesis of vitamins (B group and K), enhancement of gastrointestinal (GI) tract motility and function, stimulation of the immune system, digestion and absorption of food, metabolism of plant compounds and drugs, production of short-chain fatty acids and polyamines, and inhibition of growth of exogenous and harmful bacteria within the host.(2) The GI tract contains approximately 100 trillion viable bacteria.(3) About 99% of the bacteria come from 30 to 40 species.(4) Concentrated in the mucosa are 60-90% of all measured immune parameters, such as mast cells, dendritic cells and macrophages.(5) When the host is healthy and the intestinal microbial population is in a state of balance there is a symbiotic relationship established between the intestinal flora and the host to optimize intestinal and immune function. However, when there is an overgrowth of harmful pathogens, such as Clostridium perfringens and E. coli in the intestines, and decreased concentrations of Bifidobacteria species,(6) ratios activities of the bowel flora can be altered, resulting in dysbiosis. This is often the result of poor diet and lifestyle, antibiotic use, psychological, physical, environmental and emotional stressors, radiation, change in GI peristalsis, surgical trauma, hypochlorhydria, and decreased mucosal immunity.(2,7) It is believed that the growth of these harmful bacteria in the intestine can produce harmful substances that may play a role in chronic diseases, such as hypertension in this case.

Based on available research and clinical data, it is believed there are four common causes of intestinal dysbiosis: putrefaction, fermentation, deficiency, and sensitization.(8)

1) Putrefaction dysbiosis is the result of diets high in fat and animal flesh and with a low intake of insoluble fiber. It often occurs when one consumes animal proteins without enough chewing, or with achlorhydria. When animal proteins are not decomposed, fermentation occurs and amines may be produced, resulting in putrid odor.(2)

2) Fermentation dysbiosis results from inefficient host digestion of dietary starch or sugar leading to an accumulation of short-chain fatty acids (i.e. acetate, propionate, butyrate and valerate),9 lactic acids, and ethanol.(8) This form of dysbiosis usually causes carbohydrate intolerance and fatigue due to an overgrowth of bacteria or fungi in the stomach, small intestine and the ascending colon.(2)

3) Deficiency dysbiosis is often caused by antibiotic exposure or a low soluble-fiber diet, which leads to a deficiency of normal intestinal flora.

4) Sensitization dysbiosis is the result of abnormal immune responses caused by an alteration of the normal intestinal flora.

With the four types of dysbiosis in mind, we describe the following diet that has been called the Eubiotic diet. Eu- is a prefix meaning “good”, —biotic is a suffix meaning “life”,10 Thus, Eubiotic = ‘good life’. The purpose of the Eubiotic diet is to achieve an ideal terrain in the GI that will limit the overgrowth of pathogenic microbes and optimize conditions for the beneficial bacteria. Following the Eubiotic diet is intended to minimize the occurrence of putrefaction, fermentation, deficiency, and sensitization. Although many clinical studies have associated intestinal dysbiosis with inflammatory bowel disease,(11,12) irritable bowel syndrome,(13,14) eczema,(15) asthma,(16) arthritis, and ankylosing spondylitis,(17,18) no studies have investigated its possible relationship to hypertension.

The Eubiotic diet is a specific dietary program initiated to achieve microfloral balance through an increase of insoluble fiber and a decrease of saturated fat, animal flesh, starchy vegetables, and sugar consumption. Following this kind of diet has been shown to lead to a lowering of GI Bacteroides levels and a concomitant increase in the levels of lactic acidproducing bacteria like Bifidobacteria, Lactobacillus, and beneficial lactic acid Streptococcus.(19) In addition, fruits and starchy vegetables are not recommended due to their high sugar content. The basic premise behind the diet is to stop feeding harmful bacteria and instead feed the beneficial intestinal flora. A brief food guideline for the Eubiotic diet is shown in Appendix 1.

This report describes how following a specific diet, the Eubiotic diet, was associated with a clinically significant reduction in blood pressure. We hypothesize that this benefit is a result of adherence to the Eubiotic diet and a concomitant improvement in the patient’s gastrointestinal flora and associated dysbiosis.

Case Description

PB is a 69-year-old Caribbean female who presented with hypertension, post-nasal drip, sinus congestion, a bitter taste in her mouth, hypochondriac pain, dry throat and mouth, and increased thirst. PB’s past medical history includes chronic stomach pain, gastritis, hematuria, gingivitis, atherosclerosis, and prior appendectomy and cholecystectomy. Her hypertension was controlled with enalapril (5mg bid) and aspirin (81mg qd). Table 1 details the medication and supplements the patient was taking at the time of her first visit.

Recent medical history included dysbiotic syndrome, such as sinus congestion, bitter taste in the mouth, hypochondriac pain, gassy and bloated feeling, hypertension, and atherosclerosis. Naturopathic treatment commenced with the addition of the Eubiotic diet, nutritional supplementation, nebulized glutathione, exercise, constitutional hydrotherapy, homeopathic treatment, and lifestyle counselling. The Eubiotic diet in combination with nutritional supplementation was designed to improve the gastrointestinal flora, whereas the exercise, hydrotherapy, nebulized glutathione, and lifestyle counselling were initiated to improve the overall health and well-being of the patient.

The patient began the Eubiotic diet on Aug 31 2006. She continued to experience her negative dysbiotic symptoms mentioned above after four weeks, and a constitutional homeopathic remedy, Dioscorea villosa 200C (one dose, 3 pellets), was prescribed to address the symptoms of hypochondriac pain, bitter taste in the mouth, and ear-nosethroat problems. The remedy was taken on day 29 of the diet (Sept 28 ‘06) and a week later the patient reported resolution of her hypochondriac pain.

By day 36, Oct 5 ‘06, PB had regained some of her energy and was carrying out daily living activities without difficulty (determined by using energy scales during the regular visits). It was noted that her blood pressure (BP) was lower by a 10 point drop in systolic pressure and an 18 point drop in diastolic pressure when compared to Aug 4 ’06, even though her medication use had not changed. Table 3: Current medication and supplementation use. case reportS 45 IntJNM 4(1): 2009

The patient began to report frequent dizziness at the same time, especially when her BP fell below 120/60mmHg. The patient was referred to her family doctor to discuss the possibility of adjusting the dosage of enalapril. Table 2 and Figures 1-3 illustrate the patient’s blood pressure changes over time.

Patient’s weight was measured and body mass index (BMI), body fat, and lean body mass were determined by using a body fat analyzer and reference charts from Dr. Barry Sear’s Zone Diet at each visit. Data for these outcomes is not included as there was no significant change over time in any of these endpoints.

Based on the linear regression lines in Figures 2 and 3, the patient’s average BP over the past 217 days was about 121/69mmHg. If we are to assume that the regression line provides an effective measure of change over time, then based on this assumption the patient’s starting BP is calculated to be 124/70mmHg and her final BP 118/68mmHg. This change corresponds to a 6 point drop in systolic BP and nearly a 2 point drop in diastolic BP. These changes are further magnified if we assume that the initial blood pressure value of 134/83mmHg is a more accurate reflection of the patient’s hypertensive status to begin with. Although there is a trend towards decrease being witnessed, no test for statistical significance was conducted on the changes observed.

On day 106 (Dec 14 ‘06), PB decreased her blood pressure medication from 10mg of enalapril daily to 7.5mg. She continued to feel dizzy and weak upon waking and on her own volition decided to stop taking daily aspirin (81mg). PB began to take greater responsibility for her own health and would titrate her medication based on self-monitoring her blood pressure three times per day. From January until April 2007, she had not taken any aspirin, but would occasionally take hawthorn (as needed) or enalapril (averaging 2.5mg/ wk). Her decision to take enalapril or hawthorn depended mostly on her level of anxiety.

At this point, her current working diagnoses continued to be dysbiosis, controlled hypertension, and atherosclerosis. Her current medication and supplements are listed in Table 3.

Discussion

The result of most importance with respect to this report is the control achieved in the patient’s blood pressure. The absolute changes in the diastolic and systolic blood pressure numbers are not of great clinical significance. What is most relevant, however, is that the drug previously used to control the blood pressure was dramatically reduced over the course of treatment. This, of course, is of clinical and personal significance to the patient.

The goal of the treatment plan was to use the Eubiotic diet to repair her intestinal flora, reduce toxic amines produced by bacterial putrefaction of food, lower her blood pressure, increase immunity, improve energy levels and enhance overall health. We hypothesize that her high blood pressure was partially caused by dysbiosis. Based on the data and outcomes realized, we hypothesize that the Eubiotic diet not only improved the patient’s overall health, but lowered her blood pressure as well.

According to clinical studies, diets high in protein and sulfates (primarily derived from food additives) have been shown to play a role in the production of potentially toxic products in the gut.(20) The production and absorption of toxic metabolites, referred to as bowel toxemia,21 may have contributed to the patient’s pathology. The patient’s previous diet was high in animal protein, animal fat, simple carbohydrates, sugar, and low in insoluble fiber. The patient’s typical diet may have resulted in bowel toxemia and the production of irritant toxic amines. As a result, chronic exposure to these metabolites may have made her digestive system hypersensitive and caused it to react to antigens it normally would not react to, such as carbohydrates, animal proteins, sweets, fruits, juices, and even spices. In the case of dysbiosis, vasoactive and neurotoxic amines, such as histamine, octopamine, tryptamine, and many others are produced by bacterial putrefaction of food, or more specifically by bacterial decarboxylation of amino acids. These toxic amines are absorbed through the portal circulation and deaminated in the liver.(21) The pathway is detailed in Figure 4. The symptoms of hypochondriac pain, stomach irritation, food intolerance, bitter taste, and intestinal activity are believed to be closely associated with the patient’s dysbiosis and ‘bowel toxemia’. Regarding the cause of hypertension, it is believed that the production of potentially harmful bacterial metabolites could be an important etiologic agent. The accumulation of ammonia, amines, phenols, sulfide, and indoles could lead to a reduction in metabolic efficiency and an increased production of reactive metabolites,2 such as increased production of histamine, octopamine, or tryptamine.(23) It is hypothesized that this harmful accumulation could lead to hypertension through the following process. Primarily, the toxic amines could overwhelm the liver’s detoxification function, in turn decreasing perfusion of the kidneys’ juxtaglomerular apparatus resulting in an increased release of the enzyme renin.(24) Once renin is released, it converts angiotensinogen to angiotensin I that is then converted to angiotensin II by angiotensinconverting enzyme (ACE), found in the lung capillaries, and causes vasoconstriction and eventually increases blood pressure.(24) Thus as kidney perfusion decreases and renin is increased, a rise in BP would follow. When the harmful metabolites are in the bloodstream, the kidneys become the only real route of elimination and detoxification. As the interference of the kidneys’ normal function occurs, such as regulation of fluids and minerals, fluid retention may result.(24) This may also explain why our patient has woken up with swollen ankles and pitting edema on her legs in the past.

We hypothesize that the Eubiotic diet provides optimal conditions for the growth of beneficial intestinal flora and at the same time reduces toxic amines produced by bacterial putrefaction of food. The Eubiotic diet may then help to keep the liver, stomach, kidneys and other body systems from becoming overwhelmed. When organ systems work more efficiently, energy and immunity are improved. Blood pressure may thus be reduced by decreased arteriolar resistance (especially renal) and through increased cardiac output. One provocative hypothetical possibility is that ‘essential’ hypertension, of generally unknown cause, may in fact be due in part to dysbiosis and imbalances within the intestinal flora. Although intestinal flora could contribute to PB’s high blood pressure, her family history of renal disease plays an important role as well. It is interesting to note that the Eubiotic diet may also have improved her kidney function. In the past, her urinalysis results often showed hematuria, but her recent urinalysis results were normal. These changes correlated with the changed diet as well as other naturopathic recommendations. Unfortunately her urinary pH was not measured at each visit; otherwise urinary pH may have been a good method of monitoring her progress on the Eubiotic diet since it is believed that the reduction in amine production would correct to a shift in urinary pH.

Conclusion

Given other recommendations for care, the holistic treatment approach used with PB does not allow a perfectly clear picture of exactly what treatment produced what results. This, in addition to the fact that ours is an observational report without comparator or means for replication, imposes some strict limitations with respect to the conclusions that can be drawn. That said, the clinicians in charge of the patient’s care, BK and SL, are confident that the Eubiotic diet was responsible for the improvements exhibited by PB.

Although the patient’s hypertension was partially controlled by medications, her blood pressure often exceeded the normal range. We believe that the Eubiotic diet was the core component of our naturopathic treatment, and was most responsible for helping control this patient’s high blood pressure. We also believe that dysbiosis was the root cause of the condition and treated accordingly. This unique case helps elucidate potential connections between systemic dysbiosis, kidney damage, and high blood pressure. The case highlights a generally unrecognized treatment approach for hypertension and emphasizes the need for scientific and clinical exploration. Further research should include an appropriate comparator group and be conducted to explore the benefits of this diet for high blood pressure specifically.

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