Functional Medicine Bitesized
Functional Medicine Bitesized
How Well Do You Know Your Microbiome?
Welcome back to another episode of Functional Medicine Bitesized.
This time I welcome a LinkedIn friend of mine Elena Panzeri. Elena is a Naturopath and a Nutritional Therapist with an MSc in Nutrition and Genetics. She has a specific interest in the microbiome which led to her current collaboration with Intus Bio, a US biotech start-up.
Our conversation delves into the world of the mircobiome, the good and the bad bacteria and how these can be tested for with the latest advances in mircobiome testing. How exactly do diet and lifestyle affect our mircobiome, how can our bacteria affect the way we age and how do we know what to take when it comes to probiotics? Listen in to find out.
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Fri, Mar 14, 2025 2:45PM • 1:08:29
SUMMARY KEYWORDS
Functional medicine, microbiome, diversity, resilience, alpha diversity, probiotics, inflammation, short chain fatty acids, calorie restriction, longevity, oral microbiome, Fusobacterium nucleatum, gut barrier, personalized nutrition, metagenomics.
SPEAKERS
Peter Williams, Elena Panzeri
Peter Williams 00:13
So welcome everyone. Welcome to our new podcast, functional medicine. Bite Size, of course, I'm Pete, and I've got one of my LinkedIn buddies who I've known for probably the last five years, Elena Panzeri, Elena, good morning. Are you doing (Hi morning,Pete) yeah. So let me tell you a little bit about Elena and why I've got her on the show. The show the look. I've been in the game for a very long time. And, you know, like everyone, we're busy people, and so what you choose to read is important. And there's probably only three people on LinkedIn that put stuff up that I know if I'm going to read it, I know I'm going to learn something and Elena's stuff is always that as soon as something comes up, I know I've got to read it, because I know there's going to be a process on there where there's quite significant information that I'm going to take from that that I never knew before. So firstly, I'd like to thank you for, I mean, the amount of time that you actually put into your pieces on LinkedIn they're always super informative. And really, I suppose that's because, so if we sort of talk about your background, masters in genetics and nutrition, naturopathic clinician, um, sort of consultant in in, if you like, in personalized nutrition and medicine, and this is something that you've done for 20 plus years. So it's not only that you have a brain that is very good at understanding the literature. You've also had more than enough time to apply that in clinical practice. And there's no doubt that when that, when you do write stuff, it's obvious from me that, you know, this is a woman who has, you know, had a lot of experience and understands a lot and always writes great pieces. So thank you for that. So well. Actually, we wanted to talk about this quite a few. There's two things I want to try and get your get your expertise on today, and one of them is around, I suppose, the the title, what is a healthy microbiome, and we can have a conversation, because you also, you're part of the IntusBio,Biosciences. (IntusBio, yeah, yeah), you just explain what your role is there?
Elena Panzeri 02:42
Well, I started collaborating with Intus Biosciences, which is a startup, a biotech startup, in the US, more than two years ago, because I was doing already a lot of research on microbiome I was already suggesting a lot of microbiome testing to pretty much all my patient at that time, I was using metagenomics, which is already a pretty advanced kind of testing for microbiome so I don't know how much you know about the technique for microbiome testing, but when we started many, many years ago, it was very simple. Okay, it was what we call it cystiness. So we simply look at a very specific part of the genomic of bacteria, and we were able to identify a few species, but most of the time just the genus. So very you know, generic kind of microbiome testing. And then we move to metagenomics. Metagenomics is far more sophisticated, and we are able to see the genomes of pretty much everything in a sample. So bacteria, viruses, parasite, everything. But the problem is there are so many microorganisms in a microbiome that is basically impossible to know what to find. So when we are using metagenomics, you need to have a library, okay? So you need to have some sort of reference. But if it is something that has never been seen before, you don't know what it is, okay? So you have no idea. So when I moved to IntusBio, they were doing something completely different, so they are able to see any kind of bacteria. So just bacteria, okay, keep in mind, we are talking about just bacteria, yeah, which constitute more than 90 95% of the microbiome anyway, okay, so they play probably the most important role in the microbiome composition, and they were doing something great, because they are able to see any kind of bacteria down to the strain level. And this is incredibly important, because let's say we are talking about E coli, for example. Sure, E coli can be a very nasty kind of bacteria, but it can be a completely commensal normal bacteria, okay, it really depends on the strain. So some strain can produce toxin, some other strains can even be probiotics, okay, so when I encounter this company, I thought, Oh, wow, this is a game changer. Finally, I can have more information, more specific information, and so I started collaborating with them. I helped them develop a report that was actually actionable, because the key problem in microbiome testing is about having information there for you, the clinician, and also for the patient, they mean something, okay. It's not just about okay, this is a nice report. It's a lot of information, and then what, what you going to do with the the information? Okay? So we work a lot on the actual report, on how to make it actionable, as I said, and I had an amazing opportunity to actually see 1000 of microbiome profile. And this is something that, I mean, this kind of experience is nothing. I mean, you cannot compare it to nothing else, because you cannot go to any master or even PhD and learn so much regarding the actual microbiome composition, because there are so many differences related to, obviously, the diet, the genetic background, the environment, the medication, the supplements. So it's been a pretty amazing experience. I learned a lot, really a lot.
Peter Williams 06:39
So I think a couple of things on that, and I think we should, we should, we should dig into that. I suppose the the question probably to start, that you can maybe start helping us with, is what, again, I can remember conversation I had with an American lab who brought the new microbiome testing out, and they had a full page of bacteria, the bacterial groups, not specific strains. And I said, Look, this is all well and good, but I've got patients who will look at this and see that one strain, you know, one group is high and one group is low, and they're going to panic. What does that mean to them? Yeah, I said, So, what does it mean? Because if I can't have actionable clinical, um, takeaways from that, it's sort of almost not worth doing. I know why you're doing it, because you've developed the technology that allows you to do it, yeah, but you need to, as a clinicians need to have, well, that's all well and good, but what can I tell a patient on Monday? So can we sort of get you to move on to what we understand from where we're going with with, I think, the research with regards to what constitutes a sort of healthy microbiome profile, and what would we expect to see?
Elena Panzeri 08:04
Alright, so let's start from the very fundamental kind of you know, basic of what constitute a very healthy microbiome. First of all is about diversity. We really want to see as many species as possible in your microbiome. Just remember, a microbiome in general, not just the gut microbiome, but also the vaginal, the oral, the skin microbiome, yeah, these are all ecosystems. So it's a sort of community. It's like a big city, okay, in a big city, in a big society, when there are many people doing different stuff, is much better. They cannot be all teacher or all daughters, okay. You need to diversify your society, okay? And the same is for an ecosystem like the microbiome. So the more species, the more diversity there is in a microbiome profile, the better. We call it resilience. If there are many different species, your microbiome is more resilient. This means that if something happened, for example, you go through a surgery, you are taking a lot of medication, especially antibiotics, or you're going through a very stressful moment, you are able to bounce back, to go back to baseline, if you are very, very resilient, but if you have just a bunch of very few bacteria, your microbiome is very weak. Okay, so priority number one, I want to see a lot of diversity, what we call alpha diversity in a microbiome. And alpha diversity is a very simple metric, okay, and it's made by two other metrics, richness, which is exactly that, how many species I can see in a microbiome and evenness Okay, so I don't want to see just a lot of different bacteria. They must be very well distributed. It's all about balance. I don't want to see one or two bacteria over growing and taking up a lot of space. Okay? Because there is a limited space and resources, so food in the microbiome. So even if one very good bacteria is taking up a lot of space, it doesn't matter whether it's a pathogen or a probiotic or a commensal, it's not normal, okay, it's becoming over dominant, so we want to see a lot of different species and very well distributed. So
Peter Williams 10:47
Elena, can I just put that into practical? So what this means, as far as I certainly that I've realized, is that maybe you shouldn't be taking the probiotic for the rest of your life, because we're not quite sure about whether that's that becomes maybe something that's maybe not, not so good after a while,
Elena Panzeri 11:09
correct, correct. So that's, that's exactly,
Peter Williams 11:13
are there which, again, I mean, it completely makes sense, because it's the, I suppose the analogy that I heard many years ago it it's the difference between the rainforest and the cornfield. I think that's what we're saying. Is that, you know, if, if the cornfield gets attacked by by some way, shape or form, it all goes Yes, but the the rainforest, because there's so many different species, can, can always come back. Okay, really? And so what? What do you recommend? What do? What do you recommend to people, if they are persistently throwing probiotics down their throat because they've heard they're good for them what is it, generally, they'll probably be okay, or is it something where you're well, it might be okay, it might not be what would you
Elena Panzeri 11:58
First of all, have a test. How do you know whether you're you are in need of probiotics, or you don't need probiotics at all? If you are not testing your microbiome, you don't know Sure, correct? Yeah. It's quite funny, because there are people taking our test and they spend a fortune in 1000 and 1000 of probiotics, and there is no probiotic in their microbiome profile, and they actually challenge us. Say, Oh, your test is not accurate. This is impossible. I've been taking probiotics for years and years and years, and you don't see any lactobacilli or not Bifidobacterium. That's impossible. No, it is possible. It is possible probably you were taking the wrong amount, or maybe something was going on in your microbiome. Maybe there were so many pathogen or so many other kind of bacteria, that there was no space for the probiotics. So if you don't test, you don't know, because you cannot really understand whether you need probiotics or not from symptoms. Okay, that's not enough. And there is another thing, again, the usual distinction between the good and the bad bacteria, okay, yeah, probiotics, generally speaking, are the good ones, sure. But when you look at some probiotic, some microbiome profile, for example, in people with Alzheimer, Parkinson disease, autism or even brain cancer, you start seeing very strange signature. For example, Bifidobacterium species can be very, high. Or Akkermansia can be very, very high. So the usual good bacteria can be completely out of range. So this is not normal. I saw, for example, a pediatric patient in the US a few years ago, he was not taking any probiotics. Okay, zero to brain cancer, okay, and the lactobacillus species was incredibly high. So is this a good thing or a bad thing? Obviously, a very bad things. It could be potentially a signature of a brain cancer or maybe some sort of neurological problem. Okay, so everything in the microbiome is about balance, not too much, not too little, or pretty much everything, he has to be a balance between the good, the bad, the commensal, the probiotics, even the pathogen.
Peter Williams 14:38
Okay, so a couple of I've got a couple of questions on that. Is that what? So we know that, basically, the more diversity we see, the better the Alpha diversity. Is there any other basic markers that we'd be looking at when you're looking at a stool that maybe are associated with an immune function. Maybe you know signatures of you know whether the immune system is unhappy. And Elena, can I ask a real favor for you, because I don't want anyone to miss this. I would really love your volume to come up a little bit more. Yeah, sure, because there's just so much in here that, again. I think even for clinicians, it's like, wow, hang on. You know this? I never knew that so, because I think most people would go, Okay, well, like you lactobacillus in the the 95th percentile, so we're all good, yeah, yeah. And so, so the So, the testing that you're using is that, I mean, well, I think one of the things is, once we've had this, once we once we finished it, I would love to, I probably have to have a look at this test, because I'm not aware of this one, and I'm not aware of something that looks at strainspecifics as well. So okay, so that, again, new aspect for that from that perspective. And I suppose it's a question of, what do we tell people, what do we tell our patients based on on the test data? But what other markers are you looking for and again, I want to bring this in, because you've got this really good understanding of longevity as well. And you know what's clear is that we definitely, we definitely do see some signatures in disease, which, again, you know, I was reading the paper last night that was talking about bifidobacteria being potentially problematic in high levels as you age. So do you think that's, do you think that's, is that associated, or is that a mechanism that is driving the disease on.
Elena Panzeri 16:50
We still don't know. It's like Akkermansia, you know, like Akkermansia Munisiphilia the new star.
Peter Williams 16:58
So, can we? Can we? Because it does seem to be the one that everyone is talking about, talking about akkermansia, yeah. And again, generally, too little is no good. Too much, it's not good, yeah. So you know, it's the Goldilocks effect, isn't it, when we're talking about microbes. So can we have a little bit about akkermansia, what its role is, and what we're understanding, because I know, I know one or two companies in the world have started to produce, I think Pendulum have done one yes, yeah, you don't know of any others. And again, the question is, I would never take it unless I suppose I suppose where I think maybe we have gone is that we're not going to give you anything unless we know we've got test data to support why we would give it you
Elena Panzeri 17:48
correct. First of all, again, take a test. Do you really need akkermansia? What if you take a test and your Akkermansia levels are already pretty, pretty high, so you don't need any supplements, right? And what is akkermansia? Akkermansia mucinifilia, as the name is actually explaining she loves mucin, you know, the kind of gel actually covering the lining of the gut, okay? And akkermansia mucinifilia is very nice, because she cross Feds all the other bacteria, the good bacteria, so she's able to digest the mucin and give food to all the other bacteria, okay. The problem is, when there is too much akkermansia, she can digest too much musin, okay, and she can actually cause some sort of problem in the gut lining and even increase the intestinal permeability. Okay, so this is negative, yes, can
Peter Williams 18:49
I just, just for maybe the less, less informed people is that the there's almost like a sort of mucus layer above the gut lining isn't there, and really it's there to stop things going any further. Yeah,
Elena Panzeri 19:06
it's a protection. It's basically a protection. It's a sort of gel like system. It's covering the gut. Yeah, yeah. So it's good that there is a Akkermanisa akermansia has been very strongly associated with metabolic health. Okay, so if you have a nice, normal, let's say normal level of akermansia, you you are probably protected against metabolic syndrome, diabetes, high blood pressure, so this kind of problem, yeah. The other part is that if Akkermansia is increasing far too much, there is a possibility that you may be at risk of neurological disorder, as I said before, Alzheimer, Parkinson, even multiple sclerosis. Why is that? We don't. No.
Peter Williams 20:00
So would it be? Because the greater the numbers of Akkermansia the potential that your gut permeability may be increased,
Elena Panzeri 20:12
my educated guess, okay, there is no literature. Literature regarding that is the Akkermansia, see, is trying to actually protect the system, okay, so probably there is some sort of attack of inflammation going on, so acrobasa is over growing as a sort of protective mechanism, okay, but unfortunately, the side effect of that are more than the protective effect. This is my educated guess? Yeah, because everything, as you know, in our body is about homeostasis, sure, so we are trying to keep the balance. So if something is going on, akkermansia is one of the, you know, gatekeeper for the gut health, so she's trying to do something, okay, just to rebalance the situation. But unfortunately, this bacterium is creating more problem than solutions. I
Peter Williams 21:08
love, I love the, I love the, the mothering description of Akkermansia here, who feeds all the other ones. I
Elena Panzeri 21:14
like that. That's cool. I call her, I know.
Peter Williams 21:17
No, I think, I think it's very justified on
Elena Panzeri 21:20
that bacterium. So
Peter Williams 21:22
we talked, didn't we? About what we're trying to do here is it's all about having as a diverse and balanced profile as possible with potentially some key bacterial I'm not going to say phylum. So I'm going to say species that that maybe that you would expect to see. Akamansia clearly one of them, although
Elena Panzeri 21:47
is one of them. Faecalobacterium prausnitsi is another one.
Peter Williams 21:52
So can we talk about that one as well? Because it's always one I can't pronounce
Elena Panzeri 21:58
so Faecalbacterium Prausniziii and Akkermanis Mucinifilia are the two main mucosa protective right in the gut? Yeah, so I normally like to see both of them in the right ratio. Okay, so again, not too much, not too little. Another thing that I didn't tell you before, okay, yes, we don't care too much about the pathogens, as long as they are in the correct range, alright. However, there is a specific phylum, which is called Proteobacteria, yeah, I think you've heard about Proteobacteria, yeah. Now, proteobacteria, per se, they are not pathogen, okay? They can be completely commensal kind of bacteria. The problem is they are gram negative bacteria, and they are what we call LP.,
Peter Williams 22:57
yeah, this is quite an important point. Can Can we simplify what gram negative means and the LPS situation, because this is because I think about this. And if I've got high levels of Proteobacteria and low levels of Akkermansia, I'm starting yeah, I'm starting to think about increased risk of gut translocation. And then, you know, it starts to fit all in neurological, sort of neurological aspects. So can you try and simplify that? Because I think this is really quite important. Yeah, on that side,
Elena Panzeri 23:32
So LPS, LPS is simply a molecule. Okay, it's lipo, poly, saccharide. It's a combination of lipids and, basically sugar. Okay, is a normal component of the wall or this, or the wall cell of this bacteria. So it's something totally normal. The problem is, LPS can trigger your immune system, okay, so if you have a very little amount of LPS, your immune system is totally fine. There is no response, there is no reaction, all right, but when there is a lot of LPS actually circulating in the blood, your immune system is on alert. He said, Oh my God, what's going on? Okay? And it triggers a lot of inflammation. So the problem is, when you have a lot of Proteobacteria, so a lot of LPS circulating, you can have any kind of inflammatory response. I'm not just talking about the gut. It could be the skin, it could be the thyroid, it could be the brain, it could be pretty much everything, yeah, by the way, by the way, a very high amount of Proteobacteria have been linked to Alzheimer disease, and there is a very strong evidence for that. So if you look at the microbiome of Alzheimer patient, you're going to see a lot of Proteobacteria. So. Again, is this the cause or is the consequence? We don't know. And
Peter Williams 25:05
look, it completely makes sense. I've, as you know, I'm, I'm very much interested in making sure that barrier protection is always at the front of any clinicians sort of thought process, and most of them don't, because as soon as we start disregarding gut bacteria, or, sorry, gut barrier, oral barrier, I mean, you name it, blood brain barrier, exactly, excellent, starting to we're starting to miss a major mechanism that might be driving the, you know, the process of diseases. And so it makes complete sense. And even, even more so, one of the things I was interested in many years ago is toll-like receptor four (TLR-4), yeah, and because, obviously, I've done quite a reasonable amount of work in the Alzheimer's field. That's the wrong thing to say. I haven't done a reasonable amount of work in the Alzheimer's field. I did the breath. I was an early adopter of the Breseden Protocol. And of course, they're part of our patients that we usually get. But my whole point about this was, again, is that in certain times, certain toll, toll-like receptor four in particular, if we've got someone on a high saturated fat diet, it increases the translocation of the gram negative bacteria as well. And again, it just just shows how complicated all if this is and and how you've gotta be making those decisions. So, yeah, we do x, it might equal y. And, you know, it's never like it's not just about
Elena Panzeri 26:47
It's not just about the probiotics, it's about everything else. So you need to change the composition of the lipid. You need to change, I don't know, the response to glucose, so keep the inflammation down in any possible level. You know, this is why it's so difficult to explain to a patient, that when you do a microbiome test, it's not just about taking a little bit of fiber.
Peter Williams 27:11
So, so can we talk about that? Because I think me and you being I mean, as you say, we've both been doing this a very long time, and the way that we are setting up, the strategy in our minds is going to be so and through no fault of our patient, through our patients, patients are going to believe that you will do a you'll do maybe a microbiome test. And as I said to you, I'm going to give you a bit of fiber. I'm going to give you some probiotics. Job done. And that's absolutely not how we look at this, is it? It's almost like, well, we've got probably 10 or 20 checks and balances that we might need to change, and we've got to layer that in a certain way over a certain time frame that a patient is never, ever going to understand. Why would they, I mean, you know, yeah, and, you know. And I think that is where we are. I think sometimes, with when we see stuff out there, maybe on social media, where you go like that, you go, Oh my god, yeah. Not again. That's never, that's never gonna work, but, but again, I look at that and I think, but that's probably, you know, this guy's probably just haven't been doing it long enough to understand that. Yeah, so I'm assuming you get quite a bit. Do you get sort of, because I do, you know, it's like, I mean, you've been in the game a long time, and you probably get quite a sort of resistance from patients, and, you know, (from clinician as well). Yeah, but again, but even on that, though, if clinicians have not, they've not grown up in the systems thinking process that we have. They're never going to get it, no. So, you know, it is a question of but, I mean, we're probably old enough to go like that. Well, you're wrong. So yeah, and listen, if you don't want to do that way, it's not a problem, but, but you've got to layer things in a certain way in a certain time frame so that the sequences fit. Yeah, it's so important. But a lot of people just can't understand that, and then I don't want to do that. I just want to take some probiotics. I'm like, well, that's not probably the right thing to do. Yeah,
Elena Panzeri 29:19
all the time, all the time. They normally want to start with probiotics, because this is, this is what they know. They've been told probiotics are always good, so if you take the best probiotic brand in the market, you're going to be alright. And then they come to me and say, I don't understand why I'm feeling actually works. I have a lot of bloating, I feel even more constipated, or I know any kind of symptoms, and they say, why? So are you telling me that probiotics are not useful? No, I'm telling you, as I said, you need to follow the correct steps. Like you. I work in functional medicine, and you know that first of all is remove. So I remove the bad guy. Okay, I make the correct amount of space for the good bacteria to thrive. Okay, so if there is any strange over growing bacteria, I want to get rid of this first of all, then I try to decrease the inflammation and improve the mucosal health. And then my very last step could be probiotics, but at the very last stage, because otherwise they're not going to survive. They don't survive maybe, maybe they can do something good. They can decrease a little bit the inflammation. Yeah? So, yeah, you have diarrhea after antibiotics. You are taking probiotics. I do expect you're gonna get better somehow, but this is not what I want to do. It's much, much more than that. Yeah, so, can you
Peter Williams 30:57
Yeah so can you just explain that again? Because I think it's just a really super important point that I think, I think probably most clinicians don't understand, is that you can give a well intended probiotic, but it just doesn't stick.
Elena Panzeri 31:13
Yeah, it doesn't colonise
Peter Williams 31:16
yeah, and so you believe that's because it's not that the probiotic isn't a great product. It's just the fact that the timing and the sequencing that you gave
Elena Panzeri 31:29
it, it's not right, yep, Yeah, correct. That's really
Peter Williams 31:33
interesting. And can we also go into because I suppose what defines a healthy microbiome, I like to think about is how good are they at doing their job. And I talk about stuff like producing short chain fatty acids or and can we explore some of those bacteria? And I suppose what short chain fatty acids are, what were you understanding about them and the local and systemic effects as well? Because, again, yeah, that would be, that would be quite informative. Okay,
Elena Panzeri 32:10
so in a typical microbiome test, we don't measure short chain fatty acid, okay? Or we don't measure any other metabolites. We really measure just the amount of bacteria, and we know that some bacteria are strongly associated with a specific function. Okay, so if you really want to measure short chain fatty acid in the stool, you need to have a further test, a different kind of test. However, we can predict how much short chain fatty acid, for example, you are able to produce by looking at the relative abundance or the bacteria producing short chain fatty acid. Okay, so it's not a direct kind of measurement, but an undirected kind of measurement. Okay, so what are short chain fatty acids? Short chain fatty acid are short kind of lipids, okay, very, very short with two, three or four carbon okay, they are incredibly quickly metabolized and digested. Okay, they don't give us a lot of energy, so they, I mean, they can give some energy. But this is not the reason why we need short chain fatty acid. It's not like saturated fatty acid or omega three, okay. They are a very specific effect on inflammation. For example, they decrease inflammation, they improve the peristalsis. So for example, if you are constipated, you can take some butyrate, which is one of these short chain fatty acid you can improve constipation. But they also have very profound effect on epigenetics, okay? So they can actually modify the way your DNA is expressed, which is a great, great kind of effect. So butyrate for example, can be used for colorectal cancer, okay, or even for IBD, so Crohn's disease, Ulcerative colitis, alright. So you can take it as a supplement. You can take butyrate as a supplement, but the best way is actually to make your own bacteria in your gut produce the short chain fatty acid for you. This is the most natural way to obtain short chain fatty acid, and it's the best way. Okay, what make your bacteria create short chain fatty acid? Very simple fibre. So bacteria ferment fiber. In turn, they give us a byproduct, and the byproduct is short chain fatty acid. Okay, so at the end of the day, I may still suggest to my patient, eat more fiber, but there are so many reasons why I may suggest to take more fiber.
Peter Williams 35:03
So here's the, here's the, the problem with that, because it's such it I believe, because it is I totally agree that I don't think people eat enough fiber, and it's such an old message, yeah, I think people want something a bit more spectacular. And there's nothing better than I see. And conclusively, I keep coming back to it. Like the answer to this is just need to eat more fiber and different types of fibers, and your diverse, different
Elena Panzeri 35:37
Different types of fiber, correct? Because, as you know, we do have patients, for example, following a low FODMAP diet, right? Which is great. It can work, yeah, but it's not forever. You cannot follow a low Fod map diet for years. It can be for a couple of months, not for years. Otherwise, for example, you destroy completely the beauty of material with a low fat man. Okay, so there are people who are in a very strict diet, and they want to avoid, for example, any kind of cereals, any kind of carbs. So they are saying, Oh, but I do eat a lot of fibers. I eat a lot of fruits and veggies. And then I say, alright, but what about resistance starch? What about Beta Glucan? Okay, so there are many different kind of fiber. And again, they are very disappointed, because they see the results from the microbiome test, and there are very little short chain fatty acid producer. Why is that? Because they are not eating enough correct kind of fiber.
Peter Williams 36:47
So do you think a lot of that is because? I think if you listen to anything on social media again, I'll just confirm on it, but that certain whole grains are demonized.
Elena Panzeri 37:02
Yeah, they really hate cereals now I don't know why, especially women, they think, okay, if I eat carbs, if I eat pasta and rice and not, I gonna get fat, right? So they want to avoid cereals first of all, but then they want to avoid fodmap, Okay, number two. And then they read, or they heard somewhere, that low histamine diet is going to be good for them. Okay? So they don't go to any clinician, to any nutritionist like us, and they start implementing a lot of crazy changes in their diet to the point where everything is messed up. Yeah, okay, so just a normal, completely normal diet is much better than any crazy diet.
Peter Williams 37:53
But I wonder whether that is just as I said to you, is just where we are with it has to be more complicated than that. And it's like, no, but, you know, my other clinician said to stay away from all of that. And I'm like, Well, I don't think you should, you know, it's a bit like the nuts and seeds again, to, you know, trying to get those in, you know, okay, unless you're right, maybe, if you are, have a gluten sensitivity, then, you know, there's a there's an argument that, okay, well, we probably need to stay away from those. But I think for me, the and again, Elena, what I don't again, what I find quite difficult is that, is that I feel as though sort of many people in this industry don't actually, and maybe things are run by the bias, rather than actually what the the science is telling us. Because you can find, you can find articles that will, or scientific studies that will, will, poo poo, whole grains. Let's just use that for example, but then you'll probably find millions of articles showing the benefits of whole grains. And I find it quite unusual that people are so and again, I think it's because we probably live in a high, fast society, and I only want the answer now, and they don't want to do that. But the reality is, in science is that you can pick your bias, and you can go and find literature that supports it, and don't go anywhere else, yeah, when actually what you need to do is say, okay, so I did this last week on a I won't tell you what I did it on, but I was listening to someone who's very into very influential in the cardiovascular world, who is saying a certain thing about a certain process or a certain medication. And I thought, Okay, fair enough. This is a chap who is sounds like he knows what he's talking about and then, but it doesn't take you much to say, Okay, well, I'm going to look into what he's saying and to find that it's the complete opposite. So, you know, you think, wow, okay, isn't that really interesting? Is that, you know, that's, you know, many people are listening to these people because they they think that, you know, they are well educated, which they are, but it's a it's a loud voice going against, actually, most of the literature and research that's been done over the last 30 or 40 years, and I find that what's happening here is that bias is dictating healthcare, rather than actual scientist dictating healthcare. Yeah, and it's quite troubling, because a lot of the people you probably have, and a lot of people I probably have, I can give one example of one guy who came in, he'd already been to two cardiologists, and he was refusing to take he was in, he was he had advanced cardiovascular disease, and he was refusing to take a medication because he believed he didn't need to. And i'm like, that's absolute rubbish. Yeah, it's quite it's really interesting that, you know, a bias dictates, I think, a lot of why we do things and and you end up having these patients don't need that you're talking to you, that I'm going to try that, I'm going to try that, I'm going to try that. And in the end, you've got to bring them back to, should we just stick with what the fundamental basics of exactly brings us back to that fiber, brings us back to that whole grains. I mean, you know, I saw which I had to reply to, and actually, Alex Manos, also replied to this one, I was a good Parliament mine, because it was so stupid. Again, another really important influencer was saying you should never eat oats. Why? Well, exactly, you know, because he, well, his, his line was it's peasants food. You know, there's no nutritional value to it. And I just think that's such. It's like, how can you ignore what the nutritional science has told us for all this time? You know for decades, about the importance of oats, the importance of what they contain, and the fibre thats contained in and I just think, God and people are going to stop. And then what happens is patients come in to see you. I know
Elena Panzeri 42:22
they challenge you. Yeah, they say, Oh no, no, I will never eat gluten again. Oh no, oat is evil. We need to go back again to personalization. Okay. What does it mean? It means that maybe a keto diet is good for you, or maybe keto is the wrong decision ever. Maybe you need a lot of carbs. Or maybe not true. What can determine that your genetic background, for example? Yeah. So take a neurogenetic test. Let's see whether you're gonna respond to fat or to carbs in a certain way, and then take a microbiome test, and then anything else. This is the reason why we are insisting so much in suggesting testing, not because we are crazy, not because we are trying to sell tests. Yeah, okay, I do not sell anything. But if you really want me to do a real personalized diet? I need to know what is your background, okay? I need to know how your body is functioning. So if I think you need fiber, if I think you need gluten, i'm going to tell you very clearly you need this kind of diet. This is the best diet for you. Then of course, it's up to the patient to decide. Yeah, I cannot change their mind, but I'm trying to give as many unbiased scientific evidence for whatever I do.
Peter Williams 43:53
Yeah, isn't it interesting? Because again, I think at our age now we we don't bother, we both bother trying to justify why we do it. This is the, yeah, really interesting. And again, I suppose you know, the patient will always come in with with their story and their understanding of what they think is most appropriate. Can we talk about some of the some of the inflammatory markers, maybe that we would look at, as far as on a what we'd expect to see whether it's whether it's some of the inflammatory markers, whether it's the pH of of the GI tract, as far as how they predict health,
Elena Panzeri 44:40
again, the pro inflammatory markers are not actually part of microbiome testing. Okay, so if you're thinking of something like calprotectin, sure it's not part of microbiome testing. Microbiome testing is really just about looking at the kind of bacteria. All kind of bacteria live in your gut. This is it. Again, you can make some prediction. Okay, so we go back. If the short chain fatty acid producer are very low, I can predict a lot of inflammation. If there is Akkermansia and the famous Faecalbacterium Prausniziii. See, I can predict that the mucosa health is not so great, so it's a sort of prediction. But if you really want to know whether or not there is some sort of specific gi inflammation, you need to measure calprotectin. Yeah, so this is what I normally recommend. Take a microbiome test, if you have any doubt at heart, protecting on his own, yeah, and it's very easy, it's not too expensive, and this is what I normally do. So
Peter Williams 45:49
let me ask you another question on that, because I know we're talking specifically about the microbiome testing, and I apologize because those inflammatory tests like Sig IGA and, yeah, yeah, add ons, but how so let me ask you a question. Obviously, as we age, our capacity to maybe produce optimal stomach acid and maybe to produce optimal signaling from the pancreas, to to produce PE1 and digestive enzymes and keep that digestive process. How much do you think that is part of the picture with regards to digestive health?
Elena Panzeri 46:30
Of course, it's part of the picture. It's not just a problem with older patients. As you know, there are many young patients, for example, taking PPI, sure. Okay, so it's not just a matter of getting older. So it really depends on the kind of medication you're taking, kind of diet, the stress level. You see, we are going back to the fundamental again, yeah, you need to really assess pretty much everything that is going on in a patient's life, are they eating slowly? There is a lot of stress. Is there any symptoms of very poor digestion? There is undigested food in the stools. So this is why, in a typical functional medicine consultation, you ask a lot of questions, yeah, because we really want to know, from the mouth to the anus, what is going on. So we are asking, how are your teeth? How is your oral health? For example, are you able to chew properly? Are you eating slowly or very quickly? Okay, do you feel bloated immediately after your meal. So there are so many questions for us. The clinician can give us some clues of what is going on, okay? And as for getting older? I mean, yes, of course, everything is slowing down when you get older, but it doesn't have to be much worse than before. So when we talk about the microbiome of a very old patients, what do I expect to see, if they are in very good health, I expect to see pretty much the same as what I see in a very young patient. So a lot of diversity, some good probiotics, some Akkermansia, not a lot of again, proteobacteria, zero fuso bacteria, so it's pretty much the same.
Peter Williams 48:31
Elena, do you think that is because a healthy older person is doing all the right things, as far as the lifestyle, and it's the lifestyle that is, that particularly the the food, but I think about the exercise and the sleep aspect there is, it's almost like coming back round to keep the microbiome in in the appropriate place that it should. Yeah, yeah.
Elena Panzeri 48:58
Normally these people, they follow a very traditional diet. Okay? They are not excluding entire categories of food. They just eat normally. They eat a little bit, not too much, okay, so they normally are in a sort of calorie restriction diet without even knowing it. Okay. They are just, they just follow what their body is telling them to eat, yeah. They even when they are hungry. They sleep when they are you know that they feel they need to go to sleep. They're just following very natural rhythms.
Peter Williams 49:35
So on that question, I think there's no doubt, because obviously, I'm trying to do some stuff around longevity at the moment, and obviously trying to dig into quite a lot of the research and try and get an understanding of how the microbiome fits within that picture. And you've wrote quite a few bits and pieces with regards to longevity, which are incredibly helpful. There's not a lot, though, is there. When we look at this, I think, you know, you could look on social media and you think, Okay, right? So if I take this product, then I'm going to live long. And we're pretty clear that that's not the case. So, you know, by all means, take the product, but I don't think it's going to put 10 years on your life. And, in fact, we don't know actually what really works. What we do know is that, on a general, on a sort of a systemic basis, that some degree of calorie restriction Yes. And again, I just want to be clear about what I mean by this clearly works Yes, and we know, we know that works, yes, and I come back to what I'm trying to think about on this is that I also come back to even keeping, sort of and using almost like outdated metrics, like, you know, We're trying to bring you back to what we consider an optimal BMI is a real sort of outdated metric. Would be something where, if you were working to that long term, you're going to be covering a whole host of bases with regards to reducing inflammation, reducing, I mean just systemic aspects of longevity, and that's done fundamentally through making sure that you your energy output is greater than your energy intake and calorie restriction seems to be clear in the literature that it definitely works. How you do it over time is a different matter? What do we know that? I mean, maybe I don't know whether you do know. What do we know that? How do you think it's I was going to think how the microbiome responds to a sort of reduction in calories? Do you think it's just because it creates less trouble to deal with?
Elena Panzeri 52:05
Okay, this is a very complicated kind of question. So first of all, let's make a difference between calorie restriction and intermittent fasting. Yeah, because I think people actually mix the two. The two are not exactly the same. I totally agree.
Peter Williams 52:21
I think this is again where, you know, people are getting it completely wrong. Yeah, yeah.
Elena Panzeri 52:28
They heard the intermittent fasting is going to prolong their life, so they're now fasting for 20 hours. Yeah, okay, and they are messing up the metabolism even further. Why? Because they don't eat, obviously. So your liver is producing more glucose because your brain cannot stay without glucose. So they have this incredible fluctuation in the glycemia, meaning more inflammation, and then they end up being incredibly hungry and eating all together. So clearly this is not a healthy habit. Okay, so it may be true for some people. Again, for some people, a selected group of people, maybe intermittent fasting is the right answer. But for all the other the answer is eating less overall, meaning you have your breakfast, a little bit of snack, and lunch, another snack and a dinner, okay, not eating all together, very little of everything. But it's about maintaining, again, homeostasis balance. Okay, we don't want to see this crazy spikes up and down in the glycemia. We want to maintain a very nice kind of concentration, okay, because a very stable glycemia means less inflammation. Yeah. So for a calorie restriction is the only real intervention for longevity, yeah, more than anything else, more than anything else, how it can be sustained? Well, this is another question, because in order to be really effective, you must decrease the intake of calorie at least 20% okay, and this is not feasible for everyone. Okay, so again, you need to personalize the kind of intervention. But even if you don't go really into a proper calorie restriction diet, even just decreasing a little bit, the calorie intake is going to make a huge, massive difference, huge. So
Peter Williams 54:40
I'm gonna, I'm gonna come back with you on that one. The reality of trying to put someone in a calorie restriction, as we've seen in the scientific literature, I think, is almost impossible to do. It's impossible. They're gonna die. Yeah, so, and it's a miserable existence. Look. This is where. This is where. What I'm trying to say to to everyone who comes into me who's like that, I said, Look, we're trying to bring you down to what we believe is a just an optimal um weight, body composition, etc, and the only real way to do because exercise isn't going to give you that exercise not great for Well, that's the wrong thing to say. It depends how much you do. But you know, we we do quite a bit of genetics around mechanisms that that look at how, how effective you are at stable, generating fat, burning from from exercise. And for most people, you've got to do a huge amount of exercise to get the contribution from, you know, overall calorie sort of your overall calorie restriction from exercise. And it's not that some people don't do that, but you know, the three times a week yoga isn't going to cut it so and you know, the quicker people get onto that. I mean, this is the classic around exercise, is that unless you're in the gym, lifting hard, or, you know, going for it outside, you're not going to get the benefits that you want you think you're going to get. And so that's what we're working for. We're working to, you know, and again, I bring it back to on an almost unbelievably simplistic, slightly outdated metric. You know, I think trying to bring you into that optimal BMI position is not a bad marker for us to work towards. Yeah. Now, of course, the argument on that would could be that, you know, what you're not looking at there is maybe the the risk of visceral adipose tissue differences and again. And maybe you could just go to maybe a waist to height on that one which, which is for their benefit. But again, if you like, yeah, we can. And we do that again, depending we do that. And again, it is a it does throw up some some surprises. So you know that that's really interesting. But again, it comes back to this fundamental basic, isn't it? Is that actually humans are, or your body responds really well if you just don't eat that much
Elena Panzeri 57:11
exactly, exactly you don't need it. And so my question to
Peter Williams 57:16
you, then, what? What does that? What do we what do we know? And I don't know whether you do what do we know with how that changes the microbiome? Is it it changes a lot of the species, or is it that it's just less work or less risk for the microbiome and the GI tract, if
Elena Panzeri 57:36
If you eat less, for example, the bad bacteria, the famous Proteobacteria, the pro inflammatory ones, they tend to decrease quite dramatically. And Akkermansia, if you do a lot of fasting, akkermansia tend to increase. Okay, so already a couple of markers are getting right, alright, so the bad ones are going down and the good ones are going up. Okay, so something so simple as eating less can actually dramatically change your microbiome. Akermansia, I do not have the full evidence, but I'm doing some sort of internal research in people doing fasting. I can tell you probably akkermansia is going to be the sort of biomarker for that, because it does change a lot during fasting, during fasting or just eating less.
Peter Williams 58:31
And why do you think that is? Again,
Elena Panzeri 58:33
I think it's a sort of balance mechanism. Okay, there is less food around you. Remember, akkermansia is cross feeding the other bacteria. So maybe it's some sort of compensatory mechanism. There's less food around, but the bacteria need to survive, so let me digest, again, a little bit of mucin and give more energy to the other bacteria. Again, educating gussing in here, I'm not sure, but I can say your akkermansia does change a lot if you stop eating, or if you are eating less and you are introducing less calorie and
Peter Williams 59:09
just talking about long and the longevity aspect is there is the other, other aspects of longevity that I mean clearly for me, as I say, as originally, as an exercise scientist, it's very clear to me that, again, when we're talking about absolutes, calorie restriction absolutes, but getting yourself as fit, as strong as possible, means you're going to live longer. There's no doubt about, yes, absolutely, that's a that's again, is another aspect of probably just one of very few that were clear on the literature. But again, it's not quite a sexy pill, and you're going to go out and do it. But is there anything else that you look at and you think this may have legs,
Elena Panzeri 59:58
again, longevity Is about what? is about living longer but in very good health. And when we say good health, we are not just talking about lack of disease. We are talking about energy. We are talking about enthusiasm. We are talking about I want to live. I want to discover I love living okay. So if you want to prolong life, you need to have balance again. So even if the microbiome testing seems to be very complicated, if you know very little, just go back to the fundamentals, diversity, very little proteo bacteria, not a lot of pathogen. And actually, I forgot to mention another very important phylum, which is the fuso bacteria. Okay, okay, yeah, very quickly, foods of bacteria, they can live in your mouth, so in the oral microbiome, yeah, but they shouldn't be translocating to the gut. Yeah If this happens for whatever reason, foods of bacteria can 100% trigger colorectal cancer, yeah, 100% there is the evidence. Okay? Zero doubts. Probably even pancreatic cancer. So
Peter Williams 1:01:18
can I? Obviously, I've done a lot of work in the oral microbiome, which is where I like to call it FB, because I always like to show up in things, which is generally where you see it. So as far as I understand, we're either swallowing it or it. It's getting into the lymphatics and going down into into the tummy. And it's very clear that it is a it is a player with regards to those cancers. It's also a player that I've read in breast cancer as well. Oh,
Elena Panzeri 1:01:47
I'm so glad you said that. You know why? Because I do have a patient. This patient is in India, okay? And she has breast cancer, braca positive. We did all the testing a few months ago, and she did a microbiome test. In the microbiome test, there was a lot of fusobacterium nucleotide, okay, strongly associated with any kind of cancer. So I explained to her, Okay, you do have breast cancer. Clear. You are braca positive, but please be careful. We need to work on fuso bacterium because it can increase the risk of colorectal cancer. And by the way, colorectal cancer is one of the cancer linked with braca, yeah. So we did a protocol, obviously, she had chemotherapy and then radiotherapy, whatever, and we brought down the fuso bacterium to almost nothing right now for the patient, maybe this doesn't mean anything, okay, but for me, this is actual prevention, but so,
Peter Williams 1:02:49
so that's but, but that's classically what your patient's not going to see. And it's the same thought process that I'm that I'm always thinking about, is that we need to do this because of the potential consequences that might go on on that side, exactly because, I suppose it comes back to what we did, what we talked about barrier dysfunction, didn't we? Haven't we, if you will, have a barrier that is more permeable than and again, I think this comes back to, I know we're talking about the gut and the microbiome, but for me, the the oral microbiome is part of the gut anyway. I don't see that. Yes, I agree. And of course, if we don't keep our barriers closed, or if we don't keep our barriers optimal, then the risk is just bacteria have the opportunity to get into places that we don't want to get. And you know, it's incredible, isn't it? That, yes, that FB can can was is being found in breast cancer. Yeah, does it get there? When you think about it, you're like, Wow, that's so could. Because what you're saying there is that we really do need to go back and make sure we're concentrating on what's going on in your mouth that may have consequences to your your breast cancer strategy. We're not saying it, by the
Elena Panzeri 1:04:05
way, by the way, the patient was vegetarian, strictly vegetarian, eating a lot of carbs and a lot of sugar, no protein whatsoever. Her vitamin B 12 was non existent. Interesting. No vitamin D. I mean, you see, it's not just just about the microbiome, sure, sure, yeah. And she was absolutely sure that her diet was perfect. She said, I'm vegetarian. I cannot get breast cancer, right? Breast cancer is associated with animal protein. Well, not really, clearly, No, clearly, no. This is why it's so important to test before getting sick, to prevent
Peter Williams 1:04:51
yeah, where did, where does this put us? Then where? What would be? Let's try and summarize this up. Yeah. Right? Because I think most people listening into this podcast, well, again, I'm assuming it's a mix, but we do get sort of general public who have an interest in health and maybe an interest in in functional medicine, per se, what? And I suppose it comes back to, I think what we're saying is it comes back to make sure you do the basics well, yeah, what would be the, what would be the key points that, the key points of information that we could give to people, with regards to, if you do this, this is probably, again, we're making assumptions, because we don't have the test data. And, you know, obviously, once we get data on individuals and we understand their story, we can, we can have a better idea of how we play things out over time. And I think, you know, the the conversation would be here is that, you know test and don't guess, so we know where we're at. But what would be your your general public advice to people who probably have a little bit of understanding about the microbiome and want to keep it as healthy as possible. What would you recommend without testing? Without well again, without testing. Yeah. I mean, it's clear we need to test at some stage.
Elena Panzeri 1:06:19
Without testing is really, really hard, because maybe you don't have any GI symptoms, or you believe you don't have any symptoms, because when you actually ask your patient, they start saying, No, totally fine. Digestion is totally fine. Yeah, I go to the loo two times a week, and for them, this is natural, this is totally normal and it's not - okay. So without testing, it's really hard because I have no idea, yeah, but at least try to have a very diverse diet. Try not to do any crazy diet, avoiding entire category of foods if there is no reason for doing that, and at least talk to a professional, okay, don't do a DIY kind of diet, because it never works. So a little bit of fermented dairy, kefir or fermented food like kombucha, these kind of things, they really help. Okay, they really help. So fibre, so nuts and seeds Omega three, because omega three are now considered sort of prebiotics. Okay, so the usual stuff, fish, a lot of extra virgin olive oil. Okay. Again, to decrease the inflammation, try to have a very diverse diet, but at some point, please take a test. Yeah, because you never know. Maybe you took antibiotics 20 years ago, they messed up your microbiome and you have no idea of what's going on.
Peter Williams 1:07:58
Alright, that's a great place to end. Elena, thank you so much. We've so totally got to get you on again. I think it's just, it's just a real minefield of of what we understand and what we don't understand. And as I said to you, you've got such a wealth of expertise. It's, it's just really great having you on and picking your expertise on all of this stuff. So thank you so much for your pleasure. All right, I'm just going to.