Microbiome/Gut Health

Recent research involving the gut microbiome points to a strong link between the health of our gut and its influence on brain health, including the development of cavernous malformations.

The human microbiome is a community of microbes (bacteria, viruses, parasites, and fungi) that live in and on our bodies. Ideally, these microbes live in balance and play a supportive role in many processes in the body. The gut microbiome requires a protective mucosal layer to prevent unwanted pathogens from entering the system and causing inflammation throughout.

The Microbiome and Cavernous Malformations

In 2017, the Kahn lab published research that identified gram-negative bacteria as playing a large role in the development of cavernous malformation lesions in mice bred with a CCM mutation. It seems that one trigger of lesion development is gram-negative bacteria leaking from the gut to initiate an inflammatory response. This propelled a follow-up study that aimed to identify whether mice bred with CCM mutations are more at risk for having compromised gut linings and, as a result, more lesions.

What the researchers found was that mice bred with the CCM3 gene were more at risk for increased lesion development because these mice had impaired gut mucous production. The compromised mucous production caused the gut lining to be more permeable. When this breakdown in the mucous lining occurs, harmful gram-negative bacteria have an opportunity to leak into the system causing an inflammatory response and more lesions. While mice with CCM1 or CCM2 genes did not have impaired gut mucosal linings, the research demonstrated that when fed a diet high in emulsifiers, they can experience the same damaging effects on the gut lining, causing a proliferation of lesions and increasing the incidence of hemorrhage.

In 2020, results from the first human subject study on the microbiome of cavernous malformation patients were published. The goal was to understand what the gut microbiome looks like and whether this differs from that of the average individual. The research showed that those with sporadic as well as familial cavernous malformation indeed have a unique gut microbiome compared to those without the disease. This distinctive presentation demonstrated an imbalance in gram-negative producing bacteria which leads to lesion development by escaping through a leaky gut lining into the brain.

We now know that gram-negative bacteria leaking through a permeable gut lining into the body can trigger an inflammatory response and drive lesion formation. One of the best ways to mitigate this is by avoiding dietary emulsifiers.

What exactly are emulsifiers and artificial preservatives?

From the research described above, we learned that one of the ways we could actively participate in protecting our gut lining is by avoiding emulsifiers, which are mostly found in processed foods.

Oil and water don’t mix — until an emulsifying agent is added. Emulsifiers and preservatives made from plant, animal, and synthetic sources commonly are added to processed foods such as mayonnaise, ice cream, and baked goods to create a smooth texture, prevent separation, and extend shelf life. Low-fat spreads, margarine, salad dressings, and many other creamy sauces are more examples of foods containing emulsifiers. Emulsifiers are required by law to be included on a food’s ingredient list. The FDA is a great resource for looking up questionable ingredients. Alliance to Cure Cavernous Malformation has created a List of Common Emulsifiers and a List of Emulsifier-Free Foods as aids.  Additionally, this color-coded Emulsifier Scores list can be helpful in deciding what foods to avoid. The lists will be updated periodically.

Keep in mind that the more processed an item is, the more likely it will contain emulsifiers and artificial preservatives. Chemically processed emulsifiers, like polysorbate 80, are more harmful than other emulsifiers found naturally in food, like eggs. Damage is dose-dependent. A small amount of an emulsifier, even a chemically processed emulsifier, once in a while is not going to destroy your gut lining. We should be more concerned about regular use.

What can I do to support my microbiome?

A great place to start is by avoiding emulsifiers and artificial preservatives and by reducing your intake of processed foods. Consuming processed foods increases inflammation, and these foods are typically low in fiber. Incorporating more plants into your diet is an essential way to feed your microbiome. Plants also contain powerful nutrients known as polyphenols which help protect your immune system and regulate inflammation in your body. For more information about following a CCM-healthy diet, check out this presentation from our Patient Conference by Diane Darcy, RD on our YouTube channel.

Here are some short tips to help you incorporate these foods while eliminating emulsifiers from your diet:

Try adding in one new healthy food item per week; over time these will crowd out the more processed foods in your pantry.

Aim for a grocery cart with fruits and veggies representing all the colors of the rainbow; more fiber and color equals a healthier gut and beneficial nutrients to combat inflammation.

Purchase our CCM-Healthy Cookbook for emulsifier free recipe ideas

Are probiotics safe to take if I have cavernous malformation? 

At this time there is no evidence that taking probiotics is beneficial for individuals with cavernous malformation. There have been instances where patients have presented with a hemorrhage who recently started ingesting probiotics. Until we know more, it is recommended that you avoid taking probiotic supplements.


  • Polster SP, Sharma A, Tanes C, et al. Permissive microbiome characterizes human subjects with a neurovascular disease cavernous malformation. Nat Commun. 2020;11(1):2659. Published 2020 May 27.

Updated 4.16.22

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