Beyond Good and Bad Bugs: Rethinking the Gut Microbiome with Elena Panzeri

Welcome back to Functional Medicine Bitesized! It's been a while since we recorded an episode but we are back and I have plenty of exciting guests lined up to be interviewed. 

In this episode, I chat once again with gut microbiome expert Elena Panzeri about what modern microbiome testing can realistically tell us. We explore why the gut should be seen as a complex ecosystem, the limits of using tests for diagnosis, the role of specific bacteria such as Fusobacterium in cancer risk, and why markers like alpha diversity matter more than individual “good” or “bad” bugs. Elena also explains why fiber and prebiotics often outperform probiotics, how factors like diet, medications, and stress over a lifetime shape the microbiome, and why test results must always be interpreted in a holistic clinical context rather than in isolation.

I'm sure you will enjoy this chat with Elena just as much as you enjoyed the first one.

Links mentioned in this episode:

Click here to listen to my first podcast episode with Elena

GutID

Fusobacterium and Colorectal Cancer Risk 

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We would love to hear from you!

Transcript

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Peter Williams  0:03  

So I am back. Yes, I'm back from quite a bit of a sabbatical. I have to say, from doing podcasts. So apologies for that. But Functional Medicine Bite Side is back, and nothing like starting with bringing in a expert in the gut microbiome. So Elena is back, and if you remember, we did a podcast about 18 months ago. So I'm just gonna link that in the show notes because I wanted to bring Elena in again and again. If you're not following Elena Pranzeri on the on LinkedIn, you should. For me, some of the stuff that she writes is real expertise, and I think it's important to to share those out a little bit more. So, Elena, thanks for coming back on.

Elena Panzeri  0:55  

Thanks. Yeah,

Peter Williams  0:56  

obviously we we chat quite a bit, particularly over over WhatsApp on on various aspects of things, so look, I just sort of probably give you a brief run-in for for the listeners. Adie, why don't you do it? Why don't you give us just a sort of brief of of you and what am I doing? Yeah, no idea.

Elena Panzeri  1:15  

After so many years, I started as a naturopath. I will say 25 years ago, if I'm correct, or even longer, and then I am-I mean, I'm so keen to learn. I never stop learning, so I went from natural property. I wasn't really happy enough. I really wanted to have a lot of scientific background and knowledge, and then I came here to the UK. I was in Italy. I started nutritional therapy with Heather Rosa. By the way, I would like to remember Heather at this point. We're going to do it again later. So I went to Westminster. I gained my degree in nutritional therapy, and I started learning about functional medicine. What does it mean? And then I took a master in nutrition and genetics, and I went back for a few years to to Italy where I studied pharmacology, and again nutrition at a postgraduate level, and then I basically started putting everything together. It was like a huge puzzle, where finally all the little pieces actually made sense. So it was nutrition, genetics, epigenetics, and then the microbiome. Actually, the microbiome was there on the background somehow even 20 years ago, because as a natural part, as you can imagine, the gut health is really central, but simply I didn't know the name microbiome. Nobody was talking about the microbiome, but we knew already that anything happening in the gut can affect the brain, can affect the skin, can affect pretty much everything. And anything around 15 years ago, I really got into the microbiome stuff, and I started, you know, reviewing a lot of testing. It was very, very simple testing at that point. It was a cystines, and then later, if you like, we can talk a little bit about technology. But I thought, oh my god, this is a piece of information that I really need in my practice, and so I think at this point I think I review something like I don't know 1000 microbiome tests or more than that. So for me now is so natural to you know include a microbiome test in my practice. I will never never do anything without reviewing the microbiome.

Peter Williams  3:40  

Yeah, and and just to reiterate that you are one of the experts that probably a lot of us know with regards to one of the prime gut microbiome testing companies. Can you just give us a brief overview of that? Because your company is doing something that I don't believe other companies are doing by the way they test.

Elena Panzeri  4:00  

Absolutely, totally different. The company is-I mean, the test is Gut ID by the actual company. It's based in the U.S. and is called Intus Bio, and is a biotech, the typical biotech company. So what we do is incredibly scientific. It's not a typical test. Basically, you can buy online on Amazon or wherever. So what we do is a completely different kind of technology, and we go so deep in the sequencing of the microbiome that we are able to identify the strain level. By the way, just to be absolutely clear, we only and quote only see only bacteria. Okay, we don't we don't look at parasite. We don't see candida. We don't see viruses. However, bacteria actually made up up to 99% of the microbiome or the human microbiome. So at the end of the day, the vast majority of information that you need as a clinician to do something. For your own patient is based on the bacterial composition of the microbiome. So the difference is that we are using a technology. We are looking at very specific gene, the ribosomal gene in bacteria, and we are sequencing three different parts of this ribosomal gene: so the cysteines, the 20 3s, and the ITS. By combining these three little pieces of this gene, we are able to fingerprint the bacteria. So we are so specific, so incredibly deep in the sequencing that we are able to see bacteria that basically are nowhere. They are not classified in any database. This is incredibly important in terms of research and discovering association, for example, between very strange bacteria and condition like I don't know autoimmune problem, cancer, degenerative disorder.

Peter Williams  5:59  

So let me just take everything back, just because some people might not understand what we've talked about. We have learned over the last 20 years that humans are a sort of combined species, if you like, human cells and very much bacterial cells, and we think probably the bacteria predominantly that lives in our GI tract is is really important for how our body exists and and how healthy it is, and of course you want it as healthy as possible. What we have the capacity to do with your test now is actually identify the actual strains, and you do this lovely plot, don't you? This lovely colorful plot? Well, hopefully it's colorful and it's diverse because because what that does it visually tells you, and we'll get into this sort of the more I like to call it sort of Jacob's dream colored coat is that the more colors and the more bits we see in general, the healthier the microbiome is because you want a rainforest rather than rather than a single species. So, what I think what I would because I'm pretty sure most people understand a little bit more now about you know we have this microbiome, but what does a what does a microbiome test sort of generally genuinely tell us? Because I think again, you've been quite critical in some of the stuff that you've written, and you're working for for a microbiome company about what we can and can't say. So I wonder whether we can start by sort of exploring what are we looking at, and then sort of what can and can't we say, and what can and can't we diagnose? Because again, I think if I can give you my place on this, it's almost felt in the last couple of years you sort of sort you sort of felt you knew what you were doing and you knew what you understood, and then now as we understand a bit more, it's like everything. As you get more experience, you're like, can't really say that. Can't really sort of suggest that this is associated with that as well. So, and look, this is really important from a point of view of bringing an expert who is looking at microbiome tests every day, because you would think, okay, well, we can think about it. Might be this, or it might be that. And actually, when you write a lot of your stuff, particularly online, you're quite critical about what a lot of the industry is saying, and rightly so, because we don't know.

Elena Panzeri  8:33  

Yeah.

Peter Williams  8:33  

So, can we sort of explore that? Because I think that's a really important section to get into.

Elena Panzeri  8:39  

So, where where to start? What is the microbiome? First of all, there is not one microbiome. There are many different microbiomes. So there is a microbiome associated with your skin, with your saliva, with your liver, with your lungs, with your genitals. Even so, there are many different kind of microbiome. But clearly, the most extensive, the biggest one, is the microbiome in your colon, in your gut. Okay, and it's the one that we are normally looking at. Why? Because the gut microbiome can actually influence pretty much every single system in the body, and now we call it axis, gut axis. So I think pretty much everybody is somehow familiar with the idea of the gut brain axis. Yeah. But then there is a gut liver axis, a gut skin, a gut anything else. Okay. And why the microbiome in the gut is able to influence so many other biological system is because the vast majority of these bacteria actually produce metabolites, and metabolites are little molecule signaling molecule. They can actually reach pretty much every other part of the body. Okay, and so they make changes and they communicate with the body. They communicate. With the nervous system, the immune system, they affect the metabolism. So this is, in a nutshell, is why the microbiome is so important and is able to actually influence pretty much everything. It's about the metabolite. Is what they do. Is the way they communicate with the rest of the system. Okay, but what can we see in a microbiome test, in a microbiome report. Let's just focus on the gut microbiome because it's much easier, and it's because it's the microbiome test that is more available. Okay, and we know so much more about the gut microbiome compared to anything else. What we can see is the actual composition. Okay, so it's not about a list. I think this is the most important misunderstanding. People are looking for names or for some sort of some sort of diagnostic tool. You said something about can I use a microbiome test to diagnose a condition? No, you cannot. At least at the moment, a microbiome test is not a diagnostic test. It's not there to tell you, okay, you have an intestinal infection. Why you should be using a microbiome test to say, I got an infection with, I don't know, E. coli or Shigello, someone else. This is not the aim of the microbiome test. The microbiome test is there to tell you. Okay, this is the overall composition of this incredibly complex ecosystem. So, based on the actual composition, the ratio between the different kind of bacteria, the different different phyla, so the big group in in the microbiome, I can tell you whether there is balance or there is no balance. Okay, I can tell you, for example, some of the function carried out by these bacteria are okay or are not okay, but it's an inference. We are not actually measuring, for example, the metabolites. This is different. The microbiome is basically a genetic test sequencing all the bacteria in the gut, and then making some sort of inference, like okay, this group is bigger than the other group. What does it mean? The diversity is good or is not good? The relative abundance, because remember we are talking about relative abundance, not absolute. Okay, we are not actually measuring the quantity based relative abundance. Okay, so if I say something like 20% of your microbiome is E. coli, obviously this is quite concerning. Okay, not because necessarily E. coli is a pathogen, but it's because of the ratio. Okay, so if you start thinking of the microbiome as an ecosystem, it's so much easier to interpret the data. Okay, but if you are focusing only on the names on list of bacteria, you're gonna lose it. It's so much more difficult because there are potentially millions of different bacteria.

Peter Williams  13:00  

So let me just try and dig down into that a little bit more. So what we're looking at is, you know, let's assume that when we we do the report and it mentions you know short chain fatty acids Or histamine-producing bacteria, it's an inference, as you've just said, isn't it? Because what we're suggesting is that what we can't tell you is just because you have that bacteria, we we're not quite sure how they function. Is that am I getting that right?

Elena Panzeri  13:35  

You are right, but it's a very good approximation. So yeah, if you know what I mean. So, yeah.

Peter Williams  13:42  

So, what we're trying to do, aren't we? Is we're trying to say this looks as we would hope, and then or this doesn't look as we would like, and the inference based off the data and the science is this.

Elena Panzeri  13:57  

Yeah.

Peter Williams  13:58  

And does that match you? And does that match you symptomatically. That's the sort of way I try to mix mix all all that up. And as you said, is that everyone's microbiome is different, and you can have. So one of the things that again, if you can go on, is that you can have noted. I suppose if I step back, is that more simple term would be the good and bad bacteria. Yeah. But again, can you explain how that's not quite because we don't know whether the good or bad sometimes, or whether the bad are good sometimes. So can you sort of go through that, and then I'll try and sort of bring the questions in that I was I was I was thinking of asking you.

Elena Panzeri  14:42  

Yeah, there are some very bad bacteria, like the Fusobacterium, for example.

Peter Williams  14:46  

Can we talk about that one? Because I know you said that you can't infer on that one, or we can't say that if you've got this, then you're going to have this. But Fusobacterium probably slightly different.

Elena Panzeri  14:59  

Yes. So can you

Peter Williams  15:01  

explain that one because this is this is quite profound of what we found in the literature and what you guys are finding. Yeah,

Elena Panzeri  15:07  

and there is plenty of scientific evidence, by the way, regarding Fusobacterium.

Peter Williams  15:12  

Yes,

Elena Panzeri  15:12  

Fusobacterium species they normally belong to the oral microbiome. Okay, so they normally live in your gum, in your saliva. This is totally normal.

Peter Williams  15:22  

Yeah,

Elena Panzeri  15:22  

it can cause some sort of inflammation, like periodontitis, gum disease. It's not ideal, but it's still fine. But if they find a way to actually translocate, so to move from the saliva, for example, to go to the colon, colonize the colon, they can actually cause cancer, not necessarily 100% of the time, but ideally you don't want to see any foodso bacteria in the gut microbiome, or very very little. So how can they actually translocate from the saliva to the colon? Well, one of the reasons, for example, is when you are lacking stomach acid, okay, because you are continuously swallowing bacteria, obviously from the saliva, okay, but they normally don't survive the stomach acid.

Peter Williams  16:10  

Yeah.

Elena Panzeri  16:11  

So if for whatever reason they are able to reach the colon, and they find the right environment, they can colonize, stay there. They don't give you necessarily symptoms, even for many many years. All these symptoms are incredibly subtle. Okay, until all of a sudden you discover, oh God, I got colorectal cancer, and there is a lot of debate. For example, recently, why so many young people get colorectal cancer in their 40 or 50 or even younger? I'm not saying that necessarily is full of bacteria or microbiome, but there is a very strong evidence that something has changed, probably in the diet, use of antibiotics. We don't exactly know what it is. It's a combination, I suppose, of many different factors, but it's quite likely that there are some of these bacteria in the saliva, translocating, going to the colon, and you know initiating the the process of cancer. And Fusobacterium is a very strong one, especially Fusobacterium nucleatum. So this is a very bad

Peter Williams  17:15  

one. So what's really interesting about that, of course, is that I mean our thinking with patients is you know patients on long term PPIs obviously where their stomach acid secretions are being secreted you start to think about okay you're going to get more bacterial translocation and then certainly as you age and and just some even younger susceptible patients just seem to not be making enough stomach acid and they're always a bit of a concern. I mean, if you remember one of my tests, there was a there was an oral bacteria in my that was I think it was around about 10% It was really high. If you yeah, is that exactly

Elena Panzeri  17:56  

that? It's about the relative abundance.

Peter Williams  17:57  

Yeah,

Elena Panzeri  17:58  

because you can have obviously some E. coli or some stratococcus species coming from the oral microbiome. This is kind of normal, but if they are kept under control in a way, okay, so the relative abundance is within normal ranges. This is not a problem. But if they start over growing, they don't belong to that kind of environment.

Peter Williams  18:20  

So, and again, I think we had a conversation on my test, wasn't it? And that was for me to probably take some stuff, stomach acid tablets for for a period of time. And to be fair, I actually always feel I'm better on when I'm when I'm taking something that helps generate a little bit more stomach acid. And I think systemically it makes sense from a point of view of, you know, I think you're swallowing two to three liters of saliva a day, and that's quite a significant load that comes down into the GI. And of course, Fusobactin nucleatum is also implicated in in breast cancer as well. Which Egg?

Elena Panzeri  18:58  

There are so many associations. I mean, for sure, the colorectal cancer. Nobody can doubt that because the association is incredibly strong. Okay, and we actually know some of the biological mechanism. Okay, regarding inflammation and so far and so on, and genetic modification in the host DNA. But then I saw so many patients with many different kind of cancer, like skin cancer, or kidney cancer, or breast cancer, as you said, and they did have photo bacterium in the colon.

Peter Williams  19:29  

Interesting. So, question on that then, and I don't know whether you can answer this one, but let's assume that you've had a or you have a a patient who is who's recovered from colon cancer.

Elena Panzeri  19:45  

Yeah,

Peter Williams  19:46  

would it that be a patient where you would recommend a microbiome test just because it makes sense that you would?

Elena Panzeri  19:53  

100% 100%

Peter Williams  19:56  

Okay.

Elena Panzeri  19:56  

Again, be careful not to associate simply. The bacterium and colorectal cancer.

Peter Williams  20:02  

Yeah, yeah.

Elena Panzeri  20:02  

This is by far too simplistic. It's a very strong association, but could be something completely different, like yeah, and we're going to talk about many other bacteria. Okay, but yes, in a case of colorectal cancer, if you want to avoid recurrence of the cancer, of course you need to do a microbiome test. I would say even every two or three months.

Peter Williams  20:24  

Right. Okay. That's interesting.

Elena Panzeri  20:26  

If you see Fusobacterium, means that your risk recurrence of colorectal cancer is higher. Doesn't mean that you're gonna get it again, but you're gonna try your best to decrease the Fusobacterium.

Peter Williams  20:39  

Okay. Okay. So, what I think next question I was going to do is we talked about and the simplicity or the simplicity of good and bad bacteria, and we know that there are some bacteria or groups that get I suppose categorized as good, but and you know, and it might be something like lactobacillus group or bifido, but they can also not be so good in certain circumstances. Can you explain that? And can you also explain? I suppose this is leading me onto a sort of you know a layman deciding that they've heard that probiotics are good and I'm going to take a probiotic and what potentially well does that probiotic do anything? Can it be beneficial or can it actually be the opposite?

Elena Panzeri  21:39  

Yeah, let's start from a very important difference between endogenous and exogenous probiotics, if you like. So, in your gut, you are supposed to have some endogenous probiotics, your own natural, if you like, probiotics.

Peter Williams  21:56  

Yeah.

Elena Panzeri  21:57  

Okay. So you do have some lactobacilli. You do have some bifidobacterium, okay? You do have some acromancia, some Clostridium butyricum producing butyrate and stuff like that. This is normal. They live there, and you probably were born with this kind of probiotics, or this kind of probiotics came into the picture in the first two or three years of your life, okay, so they they belong there. They are natural in a way, but then you can take a probiotic as a supplement, okay. So this is the exogenous kind of probiotics, and again, it's about lactobacilli, even some form of good stretococcus or bifidobacterium, whatever. Acermania, okay, and this is fine. So they are similar to your own natural probiotic, but they take a little bit longer to colonize, and most of the time they are transient. They don't really stay in your gut microbiome. It doesn't mean that they don't they don't do anything beneficial. They do. They decrease inflammation. They improve the digestion. They can improve the immune system. So this is totally fine. Yeah. Please go on. I can see you. You must. I

Peter Williams  23:14  

just think it's because this is a really important point. The important point is that we. And just correct me if I'm incorrect. Is that we're pretty clear that probiotics don't really colonize. They sort of hang around for a couple of weeks. They do the job of what you've talked about because there's a lot of, if you like, cellular signaling going on on the borders, and they're very good at doing that and organizing and stimulating the localized immune system.

Elena Panzeri  23:46  

Yeah,

Peter Williams  23:46  

but they don't they don't take up home, if you like.

Elena Panzeri  23:51  

Normally, they can if you take probiotic for a very long period of time and you are maybe combining, let's say, prebiotic, okay, like a lot of fossa, inuline, and then bifidobacterium for long enough, they're gonna colonize. But it's not necessarily what you want to see, okay? Because this is not a natural kind of stuff. Yeah, so you want to have much more variety, a different kind of probiotics. So if you keep taking the same kind of probiotic for far too long, they're gonna over colonize. Okay, so you can have even the opposite effect.

Peter Williams  24:30  

Sure, and and so one of the questions on this again is that when we look at what makes a healthy microbiome richness, evenness, diversity, etc. You would note some concern if one of these noted probiotic groups or species was represented in the test, and it was way out of the reference range.

Elena Panzeri  24:57  

Exactly. So first of all, before. Before taking any probiotic, unless you are thinking about a week or a couple a week after antibiotics, so I don't think it's gonna make a huge difference. But before taking any probiotic, take a baseline, do a microbiome test, because there are so many patients where the bifidobacterium, for example, are already far too high. Watermelonsia is incredibly high. They never took probiotics before, so they may be high for so many different reasons. Usually, immunological problem, some sort of inflammatory problem. So why disturbing the balance even further by taking probiotics, do a test, and then we're gonna decide: Do you really need acermania, or you want to take acermania simply because acermancia is trendy?

Peter Williams  25:52  

So can we go on to that? Because akermansia is, I like to call it the gardener. Likes to work on trimming the sort of mucosal layer that sort of protects us, but there's an argument, and certainly there's an argument from a point of view of just take akamanzia because it's going to reduce your risk of a leaky gut, if you can use that term. Yeah, but it's problematic, isn't it? If that you and and is there an argument? I think you've told me a few times that sometimes when you see some of these beneficial bacterial species with a sort of abnormally high number, it might be because there's a problem.

Elena Panzeri  26:36  

Absolutely, especially akhirmansia. You know, probably you know that I'm working on my PhD on Parkinson disease and other neurodegenerative disorder. And by the way, we are looking at the links between the oral microbiome and the gut microbiome.

Peter Williams  26:52  

Yeah,

Elena Panzeri  26:53  

and it's so interesting that pretty much all these Parkinson patient, they either have zero acremansia, so no protection for the mucosa, or incredibly higher kermania. So the two may seem to be completely opposite, but in reality, in a way, is the same kind of signal. So you have zero curmansia, so there is no protection in the mucosa, in the intracellular mucosa, or you have far too high acermania because akermansia is trying to protect the mucosa by working too hard, but unfortunately, it's destroying the mucosa itself because it's digesting the mucosal area. Okay, so both the signals are negative: no akermansia, too high acremancia, are both negative detrimental signals.

Peter Williams  27:47  

So this is a really, this is just so insightful because, as you and I know, probably actually even a lot of healthcare providers will go. Acermania Akamanzia is really beneficial for helping the gut microbiome and the gut lining do a job that it needs to do, and it's very very expensive as a supplement.

Elena Panzeri  28:14  

Incredibly expensive. So

Peter Williams  28:16  

the argument on for that is that you might be paying 6070 pound a tub and actually making the situation worse.

Elena Panzeri  28:23  

Yeah, correct. So it is this is

Peter Williams  28:26  

it is a bit of a scary world, and I think the the reality probably I suppose where me and you are in in our careers is that you are much less coming forward with statements because actually the more you know, the more the nuance is there. You're like, God, I'm not too sure I can say anything here. I mean, what can we say? I mean, so I suppose what does make a healthy microbiome is probably, and I know you've gone on probably explained this at the beginning, but can you just give us sort of when you look at the scatter plot that comes in? Yeah, what are the key things? And I know you've me and you have had quite a lot of consultations where you're taking me through it and just picking up. But you've seen 1000s of these tests now, so you'll be really sort of you know almost like the expert of I can tell you what's going on straight away with this one. Yeah, exactly. It takes

Elena Panzeri  29:19  

me a couple of seconds. Yeah. So, can you

Peter Williams  29:22  

explain sort of the key factors that you would look at?

Elena Panzeri  29:26  

I think we mentioned already diversity. So, alpha diversity. So, what is alpha diversity? Alpha diversity is a very fundamental metric, and is an association of two measurements: richness and evenness. So richness literally means you want to see as many different species as possible. Okay, because we said many times this is an ecosystem. We want to have many different bacteria performing many different function, but at the same time, it's a matter of. Evenness, so equal distribution.

Peter Williams  30:02  

Yeah.

Elena Panzeri  30:03  

So if you have 3000 different bacteria, which is great, doesn't happen. It's far less than that. But let's say you have an amazing kind of richness, but you have one single bacterium making up I don't know 50% of your microbiome. So the actual distribution is off.

Peter Williams  30:19  

Yeah.

Elena Panzeri  30:20  

And this is no ideal.

Peter Williams  30:21  

Yeah.

Elena Panzeri  30:21  

So alpha diversity is a very simple kind of metric to say, okay, this microbiome is balanced or is out of balance. Okay, and is universal, meaning that you can live in India, you can live in the US, you can live in Brazil. Doesn't really matter. Doesn't even matter what is your typical diet? Okay, so alpha diversity is really a pretty good metric.

Peter Williams  30:46  

And if you remember one of my tests, we had a beneficial bacteria that was associated with high plant foods. I do have a high plant food diet. I do love carbs. So, but I'd like to think, and and what we found wasn't there that there was a bacteria that was really high. Actually, I think it was somewhere 30, maybe even 40% of that one sort of bacterial species. And although it's it was a commensal,

Elena Panzeri  31:16  

yeah,

Peter Williams  31:17  

as you discussed with me, and it's not a pathogenic bacteria. We think it's a beneficial one. It's too high.

Elena Panzeri  31:23  

Exactly. So you see, if you move away from the list of very good, very bad bacteria, you are looking at the microbiome as an ecosystem. So in terms of ratio, how they communicate with each other, how much space they are using, how many resources they are using? So it's so much easier to think. Okay, this is a commencer, fantastic. It can do something amazing and very very good, but it has to remain within normal ranges.

Peter Williams  31:55  

Yeah, and what's really interesting about that is that we again, I suppose, the beauty of doing the test and coming back to you and having conversations is that you're you. I'm pretty sure you said to me that sometimes when you have commensal bacteria that are overrepresented,

Elena Panzeri  32:12  

yeah,

Peter Williams  32:12  

they take up space particularly, but and and that reduces the capacity of you to be able to do a good job job with like a probiotic supplement.

Elena Panzeri  32:22  

Exactly. So there are so many clients, so many patients actually complaining when they see the microbiome test results. They say, "Oh, this is impossible. Your test must be wrong because I've been taking probiotics for six months, and I see zero probiotics. I don't have any bad or nasty bacteria, so why they are not colonizing? So why my microbiome is looking so weird? Well, maybe it's not a problem of pathogen, but as you said, could be a commensal like a Segatella corpora or something like that, or some bacterias taking up a lot of space. Okay, space means resources. It means that this bacterium is taking up taking up a lot of space, but also it's eating the food that other bacteria should be eating. Okay, so literally there is no space for the good bacteria to colonize. So you are taking a lot of probiotics, as I said. They are still doing something good, like anti-fat or whatever.

Peter Williams  33:27  

Yeah.

Elena Panzeri  33:28  

But literally, there is no space.

Peter Williams  33:30  

Yeah.

Elena Panzeri  33:30  

So they cannot stay there.

Peter Williams  33:31  

Yeah. So, and I think that's a really cool thing. Well, that's certainly something that I had to learn is that that may be an issue with regards to why several months of mixed probiotics haven't done the job that they want them to do, and I think this is always a difficulty, isn't it? Is that patients come in with a an understanding and a bias that if I take this, I should expect that, and

Elena Panzeri  34:01  

yeah,

Peter Williams  34:01  

doesn't quite work out like that.

Elena Panzeri  34:03  

Exactly, we are we are a very complex system biology.

Peter Williams  34:08  

Can we talk about the role of prebiotics? And importantly, my daily staple, which was advised from you guys, which is good old psyllium husks. Yeah. So can can we can we go on to? Yeah, going

Elena Panzeri  34:24  

back.

Peter Williams  34:24  

Oh my god, and talk about the relationship with psyllium husks that I have. Brilliant. Can can we talk about why this

Elena Panzeri  34:31  

fiber and all other fiber?

Peter Williams  34:33  

Can we talk? Yeah, if we can move on to fiber as well, because there is a lot of people online that will suggest to us that you don't need fiber at all. I mean, there's some crazy, there's some crazy stuff out there. But and happy to listen to their to to their voices and opinions. But I will strongly disagree with you know. So can we can we talk about that?

Elena Panzeri  35:00  

About fiber,

Peter Williams  35:01  

about fiber and about prebiotics and why they may be a better choice than probiotics in in a lot of cases when we're trying to help the microbiome.

Elena Panzeri  35:10  

Well, first of all, you cannot stay without fiber. Okay, you know that I love ketogenic diet, for example. I do like paleo diet. I do like many different kind of diet. They are not necessarily strictly vegetarian or vegan, but your many of your bacteria in the gut actually survive on fiber. So if you starve these bacteria, they're gonna die.

Peter Williams  35:37  

Yeah. And

Elena Panzeri  35:38  

one of the reasons why we want to have this bacteria is again about the metabolites, so they digest the fiber, and they give you back something very very precious, which is short chain fatty acid. Sure. Okay, and you need that. So what is the point again in spending a lot of money, for example, buying butyrate? Okay, one of the short chain fatty acid, but you are starving your own bacteria, creating short chain fatty acid. Okay, so fiber is absolutely necessary. So you can be on a ketogenic diet, absolutely fine for whatever reason, for example, cancer, even Parkinson, Alzheimer, whatever. It's totally fine, but please take some fiber, okay? Because if you star completely this kind of bacteria, you're gonna side effect, and it's one of the reasons why people cannot stay in a ketogenic diet for far too long, for example.

Peter Williams  36:36  

Sure, sure.

Elena Panzeri  36:36  

So they need to counterbalance.

Peter Williams  36:38  

Yeah. Can we talk about just the why prebiotics and fiber seem to be, in most cases, a better choice than than like a probiotic supplement?

Elena Panzeri  36:53  

Because again, think about the ecosystem, okay, the environment. So you want to have the probiotics, but you need to give the probiotics the food to survive. So you need a house, you need you need a home, and you need food and resources. Okay, so you want to have your own probiotics, but then you need to feed the probiotics, and the food for probiotics is prebiotic. But there are many different kind of fibers, and again, there is a lot of misunderstanding regarding fiber. Many of our patients are coming to us and say, "Oh, but I eat a lot of fruits and veggies, so what are you talking about? Is plenty of fiber? Well, not necessarily. You need many different kind of fiber. You need beta glucan resistant starch. Yeah, yeah. For example, people who are avoiding completely carbs, they are not eating carbs at all. Just a little bit of veggies or low GI fruits.

Peter Williams  37:53  

Yeah,

Elena Panzeri  37:53  

they are probably they are missing out on so many other fiber.

Peter Williams  37:58  

Agreed. One

Elena Panzeri  37:58  

of the reasons, for example, why bifidobacterium is zero in many of these patients?

Peter Williams  38:04  

Yeah, which is again is a really good point from a point of view of, and I don't, I don't, I sort of don't know why we we keep coming back to. Well, I think, I think there's a difference between ultra processed and excessive calories coming from carbohydrates. That yeah, and then there's a big difference between whole grain, oats. Yeah, well, oats in particular. Again, I mean, I have, I have, as I said to you after our microbiome discussions with me, I make this. I make an oat bran porridge in the morning that has quite a bit of psyllium husks through

Elena Panzeri  38:46  

it, yeah,

Peter Williams  38:46  

and then nuts and seeds across the top, yeah, with some fruit on the on the top, and obviously I put a enough protein to make that a decent meal, and that is my sort of mixed fiber, and and again. it's not just for that as well. It has a cardiovascular aspect to it as well, as you know.

Elena Panzeri  39:09  

Reducing the lipid and the glycemia, appetite. I mean, yeah.

Peter Williams  39:13  

I think it's so. I don't know what that's about. Again, I'm not a fan of of carnivore people that you hear now. Don't get me wrong. I think used very short term for very specific reasons. The lovely

Elena Panzeri  39:29  

again about personalization, right?

Peter Williams  39:31  

I think it might.

Elena Panzeri  39:31  

Tomorrow I need a ketogenic diet. Better ketogenic diet for a few months. I

Peter Williams  39:36  

totally totally agree on that. Were as I said, were it gets a little bit well. I was trying to write a piece recently, and it was a question of you've got to choose the right diet for the right patient at the right time.

Elena Panzeri  39:51  

Yes,

Peter Williams  39:51  

and so that's where the arguments, like you know, if you've got SIBO or something like that, then maybe as you say. Very low carbohydrate diet, or a specific sort of choice. Oh,

Elena Panzeri  40:03  

yeah, yeah,

Peter Williams  40:04  

might make sense for a bit

Elena Panzeri  40:06  

for a couple of months, not forever, not forever.

Peter Williams  40:08  

Just, just on that, we know that your test can't. It can't. What do you? Actually, let me take a step back because the last time we probably had a conversation, you'd you'd probably been with looking at the the certainly the gut ID test for probably 18 months, and now we're several years down the line. You've seen 1000s of the tests. What what lessons have you been taught over that period that you didn't know before? What are the key metrics that you've learned from looking and assessing at all of these test results?

Elena Panzeri  40:49  

I would say lesson number one: Do not have expectation. Do not think that you're gonna see a very specific microbiome profile based, for example, on your patient diet. This is so typical. Your patient is having the perfect diet, at least on paper, and then the microbiome is looking awful, or the other way around. Your customer, your patient, is having a pretty average or crap diet, and the microbiome is not that bad.

Peter Williams  41:22  

And why do you think that is? Because

Elena Panzeri  41:23  

this is

Peter Williams  41:24  

what this is the this is the almost like squeaky bum time sometimes when a patient's gut ID comes back and you're like, oh Christ, that's that doesn't look as good as I thought it was, and they're on an amazing diet. And then the other side is Christ. How are we getting away with that when we know that their diet's not as good? So what what can you make from that?

Elena Panzeri  41:48  

Well, the microbiome wasn't born yesterday. You didn't make up your microbiome in a couple of days. So even if your diet right now is very good, maybe 20 years ago wasn't that good, but it's not just about the diet. What about the medication, for example? What about the stress level? Did you have any trauma? Did you have surgery? People really don't think about that. Even my my colleagues they say, "Ah, I don't get it. Why this microbiome is looking bad when my patient is doing everything perfectly. Well, because your patient is 2030, 5060,

Peter Williams  42:29  

So

Elena Panzeri  42:30  

we are looking at the entire history of the patient. Okay, they got a lot of I don't know antibiotics when they were a child, and now you see the side effect 20 years later,

Peter Williams  42:42  

so that's really interesting because this is the absolute. What you've just said there is the conversation I have. Obviously, most of my work's in cardiology now, and some patients will have a cardiovascular event, might be a heart attack, and yet for the last five years they've been absolutely perfect, and they come back and say, "Why has this happened? Given that I'm absolutely perfect on everything, and my argument on that is, this disease

Elena Panzeri  43:11  

is a disease

Peter Williams  43:12  

that starts when when you're a baby.

Elena Panzeri  43:14  

Yep.

Peter Williams  43:14  

And so, my what we're looking at is that maybe there was enough sort of damage that had been done to that point that it put you into an incident, regardless of how well you treated yourself through those last five years. So that's really interesting. It's almost like you build the house at the beginning, and how that house is treated throughout the years dictates. So and so you're clear that that's the way we need to think about the microbiome.

Elena Panzeri  43:43  

Absolutely, absolutely. Plus, the bacteria actually adapt to the new environment. Okay, so they are incredibly good at adaptation. So if you are living in a very, for example, stressful kind of environment, and it's not just about the diet; it's about I don't know a difficult job, a difficult relationship, or whatever is happening in your life. Obviously, this is gonna affect your adrenal glands, your nervous system, your hormones, and the bacteria. They don't live isolated. As I said at the very beginning, they communicate. Okay, it's a bidirectional communication between the nervous system, the immune system, the metabolic system. So anything that is happening to you, the host, is happening at the same time to your bacteria. So you are not sleeping enough. At some point, your bacteria they gonna change, they gonna adapt to the new environment, okay? Or you are taking too many supplements. This is my favorite kind of subject. People are taking too many supplements, and again, I'm not against supplement as much as I'm not against probiotics. But if you are taking 40 supplements. And then you do a microbiome test, and something is looking very, very strange. I have no idea what is causing what. Okay, so my first suggestion is stop everything. If you really want to see your baseline microbiome, stop everything. Or if you don't want to stop, I cannot guarantee I'm able to change your microbiome.

Peter Williams  45:25  

Yeah, and how does that go down with with patients? Very

Elena Panzeri  45:27  

bad because they don't get it. They said, "But A is good, B is very good. There is a lot of evidence regarding C, and in the last podcast I heard that D is excellent for metabolic health. Yes, every single one is very good all together. Not necessarily.

Peter Williams  45:46  

Yeah.

Elena Panzeri  45:46  

Not necessarily. There are far too many.

Peter Williams  45:48  

Right. Interesting. What? So, I think what we're saying again, again here is that this comes back to on a on a single patient level. We just don't know. Yeah, as I said to you, we've seen. I mean, I can think about one guy that me and Henry, one of the cardiologists I work with. This is a guy that every single sort of biomarker associated with with poor cardiovascular health he has, and he's had for a few years. And yet, on imaging, we see no evidence of disease yet, so kind of kind of cool that you get these super outliers that just sort of. But these are

Elena Panzeri  46:29  

exceptions. Yeah, they're

Peter Williams  46:31  

exceptions, of course. And and again, you can't take anything from that because, as I say to everyone, these are exceptions. These are not the rule. What else have you learned then? What else, from a point of view of because I know when we were looking at my results, there was a key thing, and I keep coming back to it. It was just so simple: is that Pete, maybe you should probably take some psyllium horse for a period of time. So, what what other key things have you learned and found, and sort of you've implemented with patients where it's given you the most sort of beneficial change? What would be your advice?

Elena Panzeri  47:12  

Start with very simple intervention, especially at the very beginning. Then you can sophisticate your kind of protocol, but the very beginning, try to focus on very simple metrics. We were talking about alpha diversity, so don't even think about probiotics or omega three, anything else. If the alpha diversity, the richness is not good enough, work with or any other fiber that you trust, that you like, you have a lot of evidence. They are working. Try to improve the alpha diversity, for example.

Peter Williams  47:49  

And is that and and so, would you use specific fibers or would you use a combination?

Elena Panzeri  47:57  

As you know, I normally start with cilium mask simply because it's very, it's it's not giving a lot of side effect.

Peter Williams  48:04  

Yeah, it's very

Elena Panzeri  48:06  

yeah, like false inorling amazing. I mean, you can boost bifidobacterium in a couple of weeks with this kind of prebiotics, but you have a lot of fermentation, a lot of gas, and many of these patients are already complaining about bloating or about any kind of problem. So start very very easy, and see the mask. Usually there are again there are few exceptions because individuals are different. Okay, but I would say 80% of the time I don't see any side effect. We see the mask, and you can improve the alpha diversity and specifically the richness in four to six weeks, so it's very very easy.

Peter Williams  48:46  

Yeah, and and and what else? So so we're definitely clear that prebiotics, polyphenols. So you know the richness of the diet from from those, you know whether I don't know, extra virgin olive oil, whether it's berries, so you're very much. We should be still hopefully, depending on an individual, trying to have a diversity of the

Elena Panzeri  49:13  

diet,

Peter Williams  49:13  

nuts and seeds, of course. We want we want those in as well. Is there anything else? Again, anything else over the years that has surprised you, or any any patterns that you see consistently that sort of you've learned something from, or you're concerned about when you see. I mean, I know you talked about

Elena Panzeri  49:36  

pattern again. Apart from the alpha diversity, when you see a lot of pro-inflammatory bacteria, pro-inflammatory taxa. It could be pathogen, it could be proteobacteria increasing the inflammation. I tend to use a lot of antimicrobial, gentle antimicrobial, to try to decrease the pro-inflammatory bacteria, and then I can combine. My my best combination for me is fiber, so CD mask and antimicrobial. So you can work at the same time in decreasing the pro-inflammatory taxa and improving the the resilience of the microbiome. But I do have a surprise for you. It doesn't work for everybody.

Peter Williams  50:19  

Sure.

Elena Panzeri  50:19  

Very recently, I'm actually observing a few patients. Some are very symptomatic. Some other are completely without symptom, with a lot of Klebsiella pneumoniae. Klebsiella is a very nasty one. Okay, again, a strong association with the risk of cancer, many kind of cancer like pancreatic cancer, but it could be any kind of cancer. Klebsiella pneumoniae is a proper, proper pathogen. Now, usually, I'm able to decrease the Klebsiella with my antimicrobial, but I'm seeing a group of patients who are incredibly resistant. So, the more antimicrobial I use, the more the Klebsiella is overgrowing, so I'm changing my approach. You see, I'm able to change adapt my approach. I'm not saying you need to use antimicrobial 100% of the time. With this patient, I'm going back. I'm using probiotic and fiber. Okay. So completely counterintuitive. Why? Because probably their environment is different. So again, it's so important to look at the test. And if you are not having the results that you were expecting, change the approach.

Peter Williams  51:34  

Yeah.

Elena Panzeri  51:35  

There is no shame. If you need to change the approach, you need to change the approach.

Peter Williams  51:40  

I just think the key on this is that you know you're probably one of the leading experts, and what is clear on this is that we are making some well, like many many things that we do, we're trying to do best estimates.

Elena Panzeri  51:53  

Yeah,

Peter Williams  51:54  

we don't have any definitives, do we? Particularly with regards to how we treat the microbiome, and I think what you're saying is throwing a lot of antimicrobials at a microbiome may not be the best idea.

Elena Panzeri  52:08  

Not not always, or at least you need to check again after a couple of months. You need to check again because generally speaking, natural antimicrobial they are not as strong as antibiotics. Okay, so they tend not to decrease the alpha diversity, for example. But again, it depends. It depends on your individual. It depends on your specific patient.

Peter Williams  52:30  

Yeah. What What? Where's the future?

Elena Panzeri  52:33  

The future, I would say, is the combination of many different microbiome. So probably we're gonna start with a combination oral and gut microbiome because the ink is so incredibly strong.

Peter Williams  52:46  

Yeah,

Elena Panzeri  52:47  

and then actually using many different multi omics is not just about the microbiome; it's about combination of different layers.

Peter Williams  52:56  

So, I mean, I've I've worked with oral microbiome quite strongly for the last 1015 years. Anyway, there's no doubt. Again, it influences both. I used to call it disease by gravity, because obviously, if you've got poor oral health, then you're going to be swallowing bacteria generally that are pro-inflammatory into the gut, and if your stomach acid secretions aren't good enough, yeah, then a lot of them are going to get through. And you know, I'm one of them because, as I said to you, we've we've tested some of mine, and and there's an unusual amount of I can't remember which one it was, but but it was much higher than it should be. It wasn't particularly a pathogen, but it's evidence that maybe I need to think about that. That's really interesting. Any anything else? Anything else that you think is? And I suppose if we want to summarize this up in in in the next few minutes, what is the basic advice that you give to individuals and the general public? I mean, of course, we've got to look at this, and again, it's it's a sort of you've got to live as healthier life as possible. We don't know what that is for every individual, but most people associate probably the gut microbiome with the foods that they would give, and maybe again, people listening to this is that the supplements or the fibers that they would give as well. And I know you can't give because everyone's everyone's different. But what would be your usual sort of? Is there a is there a sort of baseline that you would say if you did this, you'd probably probably do reasonably okay?

Elena Panzeri  54:33  

So difficult without actually knowing the medical history of the patient. But I would say try to eat a very diverse diet, so the worst of the worst of the microbiome profiles I've been reviewing is belonging to people restricting the diet for whatever reason. Okay, they believe that low carbs or whatever vegan is the best. No carbs, only meat. Any kind of restriction is going to affect the microbiome.

Peter Williams  55:05  

Yeah, that's really helpful because I think again, the I can always remember one lady that I saw, and her diet was essentially predominantly salmon with vegetables. Yeah, and I was saying to you, probably from an energetic perspective, for sort of the calorific value, is probably great, and that's one of the reasons why you're lean and you're exercising a lot. Yeah, but there's no diversity to this value, and you know that's a problem. And so you know we've had to build her out over time. Actually, to be fair, she's done pretty well on on that on that side. But yeah, I think that's one of the key things, and the same foods all the times probably not a

Elena Panzeri  55:45  

excellent

Peter Williams  55:46  

good thing to do. So there's an argument that one week you you eat Italian, the next week you eat Thai, the next week you eat you eat whatever, and I think that's not a bad. You're certainly, I'm not suggesting you do that because there's lots of other stuff that goes with that, but we're talking about not to be afraid with diverse climate choices.

Elena Panzeri  56:07  

Yes, yes.

Peter Williams  56:09  

Okay. Anything else that you would like to finish with, Elena? Because as I say, I we know that well, certainly the people in the industry know that you're the you're the go-to from a point of view of if we need to understand anything about the the gut microbiome, you're probably the lady to speak to. Is there anything else? Anything that you could give us from words of wisdom?

Elena Panzeri  56:31  

Yeah, as much as I love the microbiome, do not expect to have all the answer from a microbiome test. Don't ask me to fix your depression necessarily. Don't ask me to fix your cardiovascular health necessarily, based only on the microbiome. And if you are a clinician, use the microbiome as a piece of the puzzle again. Not out of context. You need to think about holistically your patient.

Peter Williams  57:02  

Yeah, brilliant. All right, that was superb as usual. I thank you so much for your time. Great to have you back on.

Elena Panzeri  57:12  

Thanks again, and

Peter Williams  57:13  

we'll speak to you soon. I'll put everything in the in the in the show notes as well. Cheers, Elena.

Elena Panzeri  57:19  

Thanks, Pete.

Transcribed by https://otter.ai