Obesity and Gut Bacteria: Fecal Transplant Causing Obesity?

Turns out that Granny Smith Apples provide the food that "thin people bacteria" like. So maybe an apple a day is a good thing.

Does My Stool Make me Look Fat – or, Poop, Bugs, and Obesity
There are differences in the gut bacteria between lean and obese people. This has led to the question – how much do our gut bugs have to do with whether we are fat or thin? Some experiments in mice and men have kept this question going.

When mice are given the bugs from obese mice, they become obese. Are we mice or men?

In mice that are germ-free, giving them gut microbes from obese mice the germ free mice become obese.

In humans there have been studies that the “lean body microbes” transferred to people with metabolic syndrome led to improved insulin sensitivity compared to those who had “standard” microbes.

So with that as a background comes a case from Rhode Island where a fecal microbiota transplantation (FMT) was done for a patient who had a chronic infection with antibiotic associated colitis (diarrhea). But then, the patient becomes clinically obese after getting the microbes from her daughter (who, they note, is overweight). The question being – if you get a fecal transplant from someone who is obese, will you become obese, or if you get a fecal transplant from someone who is thin, will you become thing? So first- lets look at this case (names have been changed to protect anonymity).

The case from Rhode Island (or mom gets fecal transplant and gains weight)
You can imagine the frustration for Stacy: for six months one course after another of antibiotics to rid of a bacterial infection in the colon. The treatments were ten days of one antibiotic, two weeks of another, twelve weeks of another, even a probiotic thrown into the mix. Each time it seemed like it was improving, only to come back, after the treatment finished, with more abdominal pain and diarrhea. Along the way the gastroenterologist discovered H. Pylori in the stomach, so more antibiotics to treat that.

So when the gastroenterologist recommended that Stacy undergo a fecal transplant it somehow seemed reasonable. The process would involve taking the fecal bacteria from a relative (she chose her 16 year old daughter, Ruth) and doing colonoscopy to spread the material through her colon.

The whole cycle started with inflammation of her vagina that her doctor prescribed Stacy antibiotics to treat. Unfortunately, around the same time, Stacy had been close to a family member who had Clostridium(the bacteria that causes antibiotic associated diarrhea).

Thankfully the fecal transplant worked, her daughter’s bacteria took up residence in her colon and kicked out the Clostridium. After six months of expensive treatment, and no success, Stacy was free of diarrhea and abdominal pain.

But then Stacy began to gain weight. When Stacy returned to clinic 16 months later she had gone from 136 pounds to 170 pounds. She went on one of the liquid protein, medically supervised diets, but that didn’t seem to help. She was hungry. The GI doctors noted that her daughter was now clinically obese, so they reported this case and noted that when they do fecal transplants, in addition to ruling out other diseases, they were going to make certain the person was not obese.

So did Stacy become obese because she received the bugs for obesity from her daughter?

Skeptical About the Gut Bugs
Stacy was five foot tall and weighed 136 pounds she was chronically ill with an ongoing bacterial infection causing chronic diarrhea,  abdominal pain. The antibiotics she was given pretty much changed her normal gut bacteria, and  led to the antibiotic associated diarrhea. Her BMI (height weight ratio) was 26.6 when she received the transplant (overweight, but not yet obese), and over the course of 16 months gained 34 pounds.

The offending stool bacteria came from her daughter, Ruth, who at five foot one inches and at the time weighed 140 pounds. They said this was overweight, with a BMI of 26.2, but she had the same height-weight ratio as her mom, Stacy, when she “donated” that bacterial organ. Ruth, in those 16 months also gained 30 pounds and has a BMI of 32.

Besides getting some bacteria from someone who had the same height/weight ratio, what other causes could explain this?

When getting rid of H pylori there has been noted an increase in the appetite hormone, ghrelin, and Stacy noted that after she had the treatment something in her changed. Her ghrelin probably increased.   A small increase in appetite, and in this case, it would not take much to account for that weight gain over those sixteen months.

The diet of the mother and daughter are probably similar – they live in the same household, probably eat together, and eat the same things. Both Stacy and Ruth gained about two pounds per month, which means eating about 250 calories a day more than she burned (the equivalent of a single candy bar, or protein bar.) Stacy’s BMR is 1350 calories, and with a sedentary life her body would daily burn about 1620 calories a day. To gain an average of two pounds a month she would need to eat  a diet of about 1870 calories a day.

There is no food log recorded, or even guessed about, what Stacy, or her daughter, ate since her fecal transplant in 2011. One of her doctors put her on a failed diet, liquid protein and exercise program. While a liquid diet and exercise program might cause temporary weight loss, it will not lead to permanent weight loss without lifestyle changes. Most individuals who do the quick fix liquid protein diets end up regaining their weight quickly, and usually a bit more. There is no evidence that this patient, or her daughter, had developed lifestyle changes – although it is probable that the diets of both mother and daughter were similar.

What is also missing is the microbiome of the daughter and the mother. What is almost certain is that, when the mother was healthy, she and her daughter had nearly identical microbiome. The daughters gut began to be filled with the mother’s bacteria going through the birth canal (assuming it was not a C-section). The daughter, with every toy she put into her mouth picked up the bacteria that the mother shed. The microbiome of mothers and daughters are almost always nearly identical.

Possibilities:

  • Stool bacteria caused increase in weight
  • Loss of H pylori caused increase in appetite, and that small increase led to the weight gain (only 250 calories a day more)
  • Similar diet caused similar weight increase between parent and child.

Occam’s razor would say- they both started out clinically overweight, probably ate the same things, and this was less about gut bacteria and more about their diet. The caution in the article was to use feces from someone who is not obese, as well as individuals who are otherwise healthy. What was lacking in the article was detail about their diet, or a measurement of ghrelin pre fecal transplant and post fecal transplant. What was also missing was the composition of the gut bacteria.

It is clear that bacteria do rule us in some ways- but changing those bacteria is as easy as changing the foods that are fed, one does not need to get a fecal transplant. One study showed that people who ate more Granny Smith Apples had a higher presence of the gut bacteria called Christensenellaceae. When these classes of bacteria were introduced into the guts of mice they had gained less weight than those who did not receive this bacteria.

PreBiotics:

Turns out that Granny Smith Apples provide the food that “thin people bacteria” like. So maybe an apple a day is a good thing.

The fibers and polyphenols in the Granny Smith apples are not digested or altered by the time they reach the colon and the bacteria in the colon who prefer these produce the butyric acid that continues to harbor the growth of those good bacteria. The researchers not only tested Granny Smith but also Braeburn, Fuji, Gala, Golden Delicious, McIntosh, and Red Delicious. Granny Smith was the apple that provided the best source of ingredients to insure high quantities of those good bacteria.

Feeding the foods that cause an increase in the “good” bacteria are called pre-biotics. So our future may be the bacteria that we cultivate- with the food we choose to cultivate it with.

There are a couple of morals to the story:
Random use of antibiotics for most issues are unnecessary and can lead to harm. Stacy may not have needed antibiotics for her vaginal inflammation. Many children do not need antibiotics for ear inflammation, but they do need them for an infection.

If you publish a paper about gut microbiome- you should at least get that microbiome tested to see the bacteria it contains.

I don’t know about you – but given a choice between a fecal transplant for being thin and eating more vegetables and Granny Smith apples- I will take the apples.

No matter what your fecal bacteria are, you can change them by what you eat. What you eat has an impact on your weight.  Increasing the fruits and vegetables in any diet has a positive effect on weight and on health.

The gut microbiome holds many more secrets – and while we are all enthused to find those, lets not forget a few basics – what we eat may have more to do with our weight, and more to do with the bacteria we grow in our guts, than the bacteria have to do with it. Now- do I want the Doritos or that apple?

So do you want a fecal transplant or eat more vegetables? I don’t know- but I prefer my coffee from the top. I also prefer to feed the good bacteria than to get a new set.

References
Assessing non-digestible compounds in apple cultivars and their potential as modulators of obese faecal microbiota in vitro. Condezo-Hoyos L, Mohanty IP, Noratto GD. Food Chem. 2014 Oct 15;161:208-15 Pub Med ID 24837942

Weight Gain After Fecal Microbiota Transplantation. Alang, N, and Kelly, C.R. Open Forum Infect. Disease Vol2, Issue 1.

Gut microbiota from twins discordant for obesity modulate metabolism in mice. Ridaura VK, Faith JJ, Rey FE, et al. Science 2013. Pub Med ID 24009397
Transfer of intestinal microbiota from lean donors increases insulin sensitivity in individuals with metabolic syndrome. Vrieze A, Van Nood E, Holleman F, et al. Gastroenterology. 2013 PMID 22728514

Review article: Associations between Helicobacter pylori and obesity–an ecological study. Lender N, Talley JN, Enck P, et al. Aliument Pharmacol Ther. 2014. PMID 24832176

Ingestion of lactobacillus strain regulates emotional behavior and central GABA receptor expression in a mouse via the vagus nerve. Bravo JA, Forsythe P, Chew MV, et al. Proc Natl Acad Sci U S A. 2011 PMID 21876150

Chef Graham Elliot: Why His Weight Loss Will Work

graham_elliot_weight_loss

Last season you saw Graham Elliot on Master Chef, before he underwent gastric sleeve surgery to reduce weight. Now you see glimpses of him in photos like this one, in some magazines, and see 120 pounds gone over the last year.

The Gastric Sleeve Surgery

The surgery is simple in concept – we remove excess stomach, and a bit extra to leave behind a stomach that will hold about 1/2 cup of food. It works in two ways:

(a) Patients get full faster
(b) Reduces hunger – the stomach makes hormones responsible for hunger

We have done this surgery since 2000, and it has remarkable results with patients. But it isn’t the easy way out, and it does not mean success. Risks of the surgery include a 2.5% chance of the staple line breaking down in the first month. If that happens it often means more operations, procedures, days in the ICU. There is also a risk of bleeding requiring a transfusion, and the usual risks of any surgery.

It Isn’t The Easy Way Out

Some have asked why Graham Elliot would do this, or said that this surgery is the “easy way out.”
It isn’t – you still have to work for your weight loss, and it isn’t easy when you are use to being able to eat a normal size meal but now cannot.

It isn’t the easy way out because you put yourself in the hands of a surgeon, you lose control, and like any surgery, you risk your life. No matter how experienced or skilled the surgeon is there are always going to be staple lines that don’t heal or may leak. There can be underlying heart disease not seen by the most experienced cardiologist that can kill you.

Why He Will Succeed

The “average” weight loss is 75% of your excess body weight in the first year, and more after that. But the question is not what happens in the first year, or even the first three years. As any experienced weight loss surgeon will tell you, the real question is what will happen in five years?

In doing this surgery for over ten years we have studied the key habits of successful patients, those who make the sleeve work. We even have an online course for the gastric sleeve.  The one key that Chef Elliot has is he knows how to cook, and he knows how to cook small. He can pack flavor into a bite size amounts of food.

Graham Elliot can make small food packed with flavor

One of our favorite meals was 18 courses over five hours at his restaurant. Each bit of food was packed with flavor. Small bites. Things that could easily fit into his new stomach. This is the challenge that sleeve patients have – to cook small with lots of flavor.

Sleeve patients who are successful five years out – cook, eat well but small, and look for flavor. This Michelin Star (2), youngest chef ever to receive them, knows how to load those bites with flavor.

Patients who do not succeed don’t cook, they fill their stomachs with bland food, and ultimately stretch their stomachs out to the original size. We expect some stretching of the stomach, but typically we go from 1/2 cup to 1 1/2 cups in the first year and that is where it stays. The unsuccessful patient stretches their stomach back to its normal size that holds 8 1/2 cups.

One of the things we learned is that patients who don’t succeed eat out a lot- but they eat out at common, chain restaurants. Patients who eat at great places, like Graham Elliot’s restaurant, succeed – because they know good food.

But if He Can Cook Why Can’t He Lose Weight?

We don’t understand obesity. It may be an underlying symptom of some yet undiscovered disease. The ability to cook and cook well, and eat well does not mean you can do it on your own: that is like saying because you have gasoline you should be able to go 50 miles an hour – and not having the automobile to put the gas in. Weight Loss Surgery is a remarkable tool, a tool that some people need, and is the only successful tool out there for morbid obesity. Recently, the Lap-Band was approved by the FDA for treatment of non-morbid obesity.

Thank You Graham

Whenever a celebrity gets weight loss surgery it helps people realize that this can be done, and is an option for obesity. Showing that you can eat well is a key that many weight loss surgery patients need to hear.

There is one word to describe the style of Graham Elliot and his restaurant – “cool”

Dr. Terry Simpson is a weight loss surgeon who has done weight loss surgery for over twenty years. He is currently writing his fifth book about how the guts work. His practice is in Phoenix, and although he did perform the operation on Graham Elliot, he has eaten at his restaurant!

Beer Diet: What We Learned

beer and sausage diet

The “Beer Diet” – I’m the doctor that supervised Evo Terra as he spent every October for the last three years drinking beer and eating sausages – and while doing this lost weight, lowered his cholesterol, lowered his body fat, and lowered his C-reactive protein and blood homocysteine levels (measures of the body’s inflammatory response).

Here are the Five big lessons we have learned from this experiment:
 
(1) Science Rules

No matter what you wish to say, there is nothing like a scientific experiment to prove if something works or not. This was not a “fad” diet, this was a carefully controlled experiment, where the conditions were controlled and his blood chemistry was examined on a weekly basis as well as his body measurements. Doing this experiment still shows that what we think we know, when placed to the test, may not stand the test of science.

(2) A Calorie is still a Calorie

1500 calories a day for Evo would predict weight loss – and it did. He lost weight while drinking 6 beers a day and eating sausages — total caloric intake was 1500 calories a day. In fact, he lost more weight than would be predicted by the calorie model. Did those calories just disappear into thin air? Evo is not immune from the laws of physics, but what a person does with the calories is every bit as important as the calorie itself. While his body consumed 1500 calories on average, his body didn’t use them all – some were used by bacteria inhabiting his gut, some were not absorbed and passed on. He clearly didn’t store any calories.

(3) Scale or Fail

Kitchen Sclae

Weighing food helps you know how much you are eating. It is part of science-

Evo was very careful about his calorie intake. He weighed his sausages, and he knew precisely how much sausage he was going to eat. This was not unlimited sausage and beer diet, this was portion controlled – calorie controlled experiment.

In over 20 years of weight loss successful patients follow the dictim “use the scale to measure what I eat or fail because my eyes will overcome me.” This is balanced against people who say they eat “unlimited” amounts of “fats and meat” or unlimited amounts of “raw vegetables.” The raw vegetables are more easy to understand – it is difficult to get the calorie requirement if you eat a lot of vegetables and even fruits. A cup of blueberries is 85 calories. One cup of chopped broccoli is 31 calories. But a 12 ounce New York strip steak has over 500 calories. I don’t think someone will eat a three steaks a day- but if that was all you ate, you would have about 1650 calories, which is less than most people will burn.  In my book “Losing the Last 30 pounds” I noted that most diets that say you can have something unlimited really gets translated to “you are going to get sick of eating this, and when you get sick of it you will eat less.” The science of this is your palate is overwhelmed with a single flavor and you tend to eat less of it.  So you can start out eating steak every night on an Atkins diet and after a month you won’t ever want to see a steak again.

I can report, that Evo is not tired of beer – he still loves a wide variety of high quality craft beers – but the flavors are different in each of those beers, so his palate is not overwhelmed.  He was happy to give up sausages for a bit.

(4) Science beats Statistics

You have heard “processed meat is bad for you” or that if you drink beer you will get a “beer belly.” Some of that is based on large population studies where they look at the disease of the groups as they divide them up into what they have eaten. A statistical analysis is done and the conclusions are made that “red meat is bad for you” or “processed food is bad for you,” or “beer is bad for you if you drink more than a couple at a time.” Those statistics are not a science experiment – where you take an individual- and under controlled conditions see how their body reacts to what they eat. We have those conditions.
Here is the other problem with lots of those population studies: they are making a guess as to how much meat they ate, or sausage, or if they even know what processed food is, then they are hopeful that they know what people will die or suffer from and try to correlate it back to the bad data entry. In this case, we were certain what he ate, and we were certain how much he ate, and what he drank. We were also certain how his body reacted to them.

(5) Vegans and Paleo will never be happy unless you do it their way

Paleo man

Early paleo man was often reminded to not bring in that old wooly mammoth – it stunk up the cave. She would have been happier had he brought in beer and sausage (at least beer until football was invented)

Physicians who have a bias to eating vegan or by eating like a caveman were the most skeptical of this data. Vegans say “well the beer is ok, not great, but at least it isn’t processed meat.” Paleolithic dieters say “the sausage is ok, because it is meat, but the beer can lead to beer belly because it will increase insulin production.”

Both groups of physicians would tell me that this diet is dangerous, and that Evo’s blood levels of (pick your favorite lab value) would increase.  We checked his blood chemistry for all of the indicators you could imagine. None of them increased – in fact, all of them decreased. One of my vegetarian friends, and fellow physician, who is writing a book about why vegetable protein is the only way to go- said that just wait, and things will get worse.  It has been three years – and it seems every time Evo gets on the diet his blood levels , cholesterol, C-reactive protein, homocysteine went down.

I follow a number of physicians on Twitter. When they tweet about science reports, they always tweet about the reports that confirm their bias. My fellow paleo doctors always tweet about the latest study from Sweden showing how saturated fat isn’t bad for your diet, and my fellow vegan physicians always show the latest study that saturated fat is bad for you.

Does this provide any definitive answer to those questions? No- it does not. People are as varied as can be, and how each of our bodies reacts to food depends a great deal on our genetic make-up. You know that thin person who can eat all the junk in the world and not get beyond 95 pounds.  Or the person with celiac disease, for whom gluten laden products leads to illness.  One person can eat a bag of peanuts without difficulty, and another person is killed by eating one peanut.  This does not mean peanuts are bad for you or gluten is bad for you – unless you have those conditions.

ONE FINAL NOTE (from the legal staff of Dewey, Chetum, and Howe): this was an experiment done under controlled conditions, with an informed patient, a surgeon, and a lot of lab work. I am not advocating or advising this diet- because there was more to it- this is just an observation and reporting of an experiment