Dr. Frank Cusimano, PhD, has a doctorate in Nutrition and Metabolic Biology from Columbia University and is currently a medical student at the Arizona College of Osteopathic medicine. Having done his PhD on the gut microbiome, a hot topic, we dive into the science of prebiotics, probiotics, postbiotics and antibiotics. What can we actually recommend to patients to help them with GI upset while on antibiotics? How does the microbiome influence inflammatory bowel disease? How can the gut actually influence our brains? A previous guest discussed how the colon is the window to the soul. Turns out there’s science behind that!
Having been a sponsored athlete as an adult, Dr. Cusimano is currently a medical student uniquely blending his understanding of biochemistry with human physiology and human potential. In college he received both a BS and BA from SMU in Chemistry and Biology and then went on to complete a MS from Johns Hopkins University in Biotechnology concentrating in Bioinformatics, all in addition to his PhD. He is the host of the Surviving Medicine Podcast and a regular contributor for Medscape and Doximity.
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Disclaimer: This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.Dr. Frank Cusumano has a doctorate in nutrition and metabolic biology from Columbia University and is currently a medical student at the Arizona College of Osteopathic Medicine. Having done his PhD on the gut microbiome hot topic right now, we dive into the science of prebiotics, probiotics, post biotics and antibiotics. He teaches us what we can actually recommend to our patients to help them with gi upset while on antibiotics. How does the gut microbiome influence inflammatory bowel disease? How can the gut actually influence our brains? Now previous guests discussed how the colon is the window to the soul and turns out there science behind that, having been a sponsored athlete as an adult. Dr. Cusumano is currently a medical student uniquely blending his understanding of biochemistry with human physiology and human potential. In college, he received his BS in ma from SMU in chemistry and biology and then went on to complete an MS from Johns Hopkins in biotechnology concentrating in bioinformatics, all that in addition to his PhD from Columbia He’s the host of surviving medicine podcast and a regular contributor to medscape and doc SimCity.Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians, Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing kreb cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.And now, here’s Dr. Bradley Block.Dr. Frank Cusumano.Thanks so much for being on the podcast. Thank you. Thank you so much for having me on the podcast. It’s an honor.Well, Antarctica. You’re welcome.All right. So let’s get started. Give us the short version of your PhD thesis.Yeah. So I guess I should have introduced with that or a second ago that when I say when you called me a doctor, a doctor Cusumano, technically it’s a it’s a PhD. So I have a doctorate in nutrition and metabolic biology, and I am in medical school. So I’m doing additional training. I’m a third year medical student, or seventh year, if you add the PhD to it, and I have my PhD is in nutrition and metabolic biology, and I’m uniquely trained in that and the only medical professional I will be the only medical professional with that specific PhD because it’s the only PhD of that kind that is housed in an institute of medicine, which is very unique, and that I was lucky and fortunate to be able to do that. But my PhD thesis was on the gut microbiome. So in the nutrition area, obviously, the bacteria in our stomach and in our small intestine colon played a huge role in the pathophysiology of many disease processes. But my specific topic that I worked on, you know, over the course of my PhD career was I engineered bacteria to modulate intestinal physiology, you know, deal with inflammation and also modulate behavior. You’re along the microbiome gut brain access. So specifically engineering bacteria to serve a specific physiological process in. For me, the most work that I did was in the large intestine.So GMO for the gut microbiome,essentially GMO for the gut microbiome, and that is the right way to think about it, because we were using genetically modified bacteria to serve specific purposes. I thinkthat’s gonna make some people’s head explode because you’ve got this whole, and we’re going to talk about this, but this whole area of pseudoscience, that’s that’s orbiting around the actual science, and these are a lot of hippie dippie people that are non GMO, and then they’re finding out that the person who’s one of their, you know, one of the people that they look up to because of the research that you’ve done in the gut microbiome, you’ve actually used GMO in this secret area of the gut microbiome. I think there’s some people that have head’s gonna explode. Okay, so can you give us any more detail about what that will do? I know there were, you know, for some time there was you weren’t actually talking to people about it because it was so Hush Hush.Correct? Yeah, there was I mean, there’s still there’s patents filed on our research that we were doing. It was at Columbia University. The patents are have gone through so I can talk about it. We haven’t published our paper on it. We have a big one that’s in revisions that we were really excited about. So I may spare out some of the good details. But other than that, we’re going to talk about it. And I think when when I introduce the microbiome, when we talk about the microbiome, the microbiome is something that you know, is has to be specified for location. So when you’re talking about the microbiome, it’s just a collection of bacteria in genes that make up microbes, or any type of bacteria or fungi or Flora on a surface. And so I say gut microbiome, it’s specifically talking to the cashier intestinal tract, versus a colonic microbiome is just the microbiome found in the colon. And they all are very different. They serve different purposes. They have very different compositions. And they have very different genetic profiles. And I think that that’s more of the important part. The research is, as you said, rife with pseudoscience. And it’s it’s rife with pseudoscience, not for the specific reason that we think about pseudoscience and just being blatantly wrong. It’s that they’re early on microbiome research was very naive. And it was done in a way that our tools now are showing us that a lot of the regional research we did was not specific enough or it didn’t hone in on the level of specificity or detail on the research that we needed. Case in point that you may think about is none of the none of the labs doing microbiome research. actually started as microbiome research labs, they typically did not they started as gastroenterology s or gastroenterologist or microbiologists that wanted to do microbiome research. And so most of the P is the primary investigator. We’re not people that trained doing these techniques. I hear researchers talk about the gut microbiome extensively or you know, or medical professionals talk about the gut microbiome, and how they use it for all sorts of treatments. But when you ask them, if they’ve ever sequenced someone’s in fecal samples, if they’ve ever sequenced anyone’s gut microbiome, typically they’ll say no. And that’s the that’s the major issue that that I want, you know, people to understand is that the techniques and tools that we’re using to study the bacteria in your stomach, the tools are advancing so rapidly, that things that we were doing five years ago, are, you know, they’re not only rudimentary, but they give us misinformation. And so understanding where that misinformation lies, and it all comes down to sequencing techniques to genomic preps, to understanding how to analyze the data, the changes that we’re seeing in the past few years, just showed us that our initial findings were sometimes wrong. That’s the important part. I think for a lot of the microbiome research.Well, there are labs out there that if you send them a sample of your gut microbiome, right, you give them a little fecal sample, they will tell you things about yourself. Like this is what you should be eating more of this is what you should be eating less of this is what diseases you’re at risk for. And that, to me sounds like there. That sounds like there could be some fear mongering and capitalization capitalizing on lack of science literacy, or am I just an old curmudgeon that don’t bully that doesn’t believe in new areas of science?No, I mean, you’re not. Most of that is is accurate in your perspective. And those companies dealt with a lot of litigation already early on. And now they’re having to use specific wording or they’re having to do things in a specific way where they can’t talk about medical conditions, or they have to give it to a third party to talk about medical conditions. And the reason why is that, you know, we In 2007, the I think it was the NIH decided that they were going to put like 170 million dollars into understanding the gut microbiome so that we can understand what was best for patients. And what was the healthiest microbiome. And their conclusion after five years in 2012? Was that, you know, we spent 170 million dollars and all we decided was that there is no one correct microbiome. And in fact, it wasn’t which bacteria you have in your stomach. So when you when you send a sample to a lab to sequence your microbiome, they’re gonna tell you, not how many bacteria are, which bacteria are there, they’re going to tell you what relative ratio or population of bacteria are there and they’re only going to go as deep as maybe the genus level. But typically they stay at the family level or the phyla level. But the difference between two bacteria in the same genus is, you know, night and day. It’s not even the different I mean, it’s The difference between me and an elephant, like it’s really is that far. And what matters more is what genes are present in someone’s microbiome, right? So out of all the bacteria in your stomach, each bacteria has a number of genes, and they have, you know, their DNA, which genes are present and which ones are being transcribed, you know, translated into proteins that can do serve a specific function that is way more relevant than which bacteria are there, because the difference between, you know, an E. coli and your stomach for an E. coli in my stomach? Well, it depends a which genus is it? It depends which species is it, and then even to bacteria that are the same species, maybe as far as a rhino and an elephant, and the genes in those are so different that it’s really hard to say, and so that, you know, a lot of those tests, I would say, I don’t recommend for that reason.So what are some other misconceptions that are out there about the gut microbiome?Yeah, misconceptions. The gut microbiome is probably the most fun thing to go over, and a lot of it You know is is around fermented foods like probiotics everyone wants to know which probiotics they should take or if they’re useful well probiotic if you look at the definition of it, it’s a live organ microorganism that when you know taken an adequate amounts, it has some type of health benefit. Well, most bacteria over the counter probiotics don’t have a they haven’t been tested to show health benefits. And most of them aren’t living anymore, or they don’t reconstitute because most probiotics are pill forms and most pill forms, that means the bacteria has been life alized basically dried completely. When placed back into a host, they can come back and become active but over time, their efficacy drops drastically and a lot of them won’t survive the Trent, you know, the transition from your mouth all the way down to let’s say, your small intestine or colon, where your colon is actually where most bacteria are most useful. Most of the microbiome until you get to the colon. You know, it has some function and there’s depth events, some things that we’ve learned, but the majority of the bacteria that at least is beneficial, or that can provide a lot of metabolic benefits actually has to get all the way down to the colon, which studying that in humans is very difficult. So,like if you go to GNC or CVS and buy probiotics, because you’re worried about getting an upset stomach, after antibiotics, or in the situation of myself and our listeners, you’re recommending that to your patients, what you’re ultimately recommending is dust. Right? So what’s contained in the pills of probiotics that you’re buying over the counter, laugh alized bacteria, that doesn’t make it to all the way to the place it needs to be. It doesn’t sound like that’s really what’s recommended, or that would be helpful in any way.Correct. And this is where there’s a lot of good research on it, to show that most probiotics for almost every instance isn’t recommended because As a we either don’t know enough, or they haven’t shown any efficacy. I don’t take probiotics. I’ve been studying the microbiome, you know, for five plus years, but I don’t take a probiotic supplement. And if anything, the only thing I recommend to most people is just increase the amount of fiber in their diet. We all know about the different types of fibers, whether it’s soluble or insoluble, and they both have, you know, different motility benefits. But in terms of the gut has many different types of fiber that you can consume, feed the bacteria that are already there, and instead of focused on trying to introduce new strains or new bacteria from pills on the shelf, it’s more important to go to you know, the part of your grocery section where the vegetables are and buy different high fiber foods. Some of them are the ones that are high in you know, a fiber called inulin, which is one of polysaccharides that really does help your bacteria live that’s basically the food that they eat. In going to buy some foods like leeks or bananas or spinach or kale or onions or garlic, anything that can be used for your bacteria as food is actually way better than taking any pills over there on the shelf.So what we should be telling our patients is if they’re on antibiotics, they should eat more fruits and vegetables.Yes. And this is actually when they’re off antibiotics. They should also be eating more fruits and vegetables. Frank, this is groundbreaking. No, great. It’s totally groundbreaking. It’s actually really interesting. So it used to be that when someone gave someone antibiotics, the recommendation was to take a probiotic to help you know, your bacteria, bolster it up so that it could return after the antibiotics to, you know, to a faster position to you know, two papers came out from one of the one of the leading experts in this area, and they actually found that when you when you take an antibiotic, it does wipe out you know, a lot of the bacteria, but taking a probiotic along with that antibiotic actually delays progression of the bacteria coming back that you normally colonize. Why is that? Well, most probiotics that you take over the counter, don’t colonize your gut. Could they potentially be beneficial for a short period of time after you take them? Yes, there’s possible but the bacteria that is present after you take an antibiotic, you need to re you need to get that bacteria that’s still there that survived to the antibiotic, you need to get it to build up its amount and needed to replicate and to survive. And by introducing additional probiotics, what you’re doing is you’re basically competing it for resources. So think of it like, you know, like a war. If you get rid of half of the bad guys, if you get really rid of the majority of the good guys, you don’t want to throw more random soldiers that can’t speak the same language in there. No, what you want to do is you want to let the let the good ones you know, start to grow and repopulate and get back up to speed and that’s the best way to do it, is by increasing your fiber intake when you take a antibiotic to let the good bacteria grow and repopulate.So this is completely different from any of the questions that I sent you but it just in a I don’t feel comfortable answering it, I completely understand. But with regards to the increasing fiber in your diet, there’s a lot of, there are a lot of fiber supplements. There’s a lot of food that has increased the amount of fiber from other sources, like protein bars with added fiber or fiber one makes a breakfast bar with added fiber. But it’s not like it’s like eating an apple where the fiber is innate to the food, it’s been extracted from somewhere and put somewhere else. Do you know if there’s any difference between actually eating it in in its raw form? versus have it having been extracted? Now we know what the hippie dippie answer is going to be, which is, yes, you should eat it in its natural form, if that’s the way it supposed to be. But ultimately, you know, does the gut know the difference between the fiber that starts out in an apple or the fiber that was extracted from an apple put in a breakfast bar and then consumed that way?So this is a great question. And I love this question because it talks about you have to use real science to answer it, but it’s confusing. Science. And so I’ll try to explain this to the listeners taking exogenous fiber from any type of supplement powder or bar. For some reason in our gut, it doesn’t have the same effect as eating whole foods. Why is this? Okay, so So what the the conclusion has come from amongst most of the experts is that when you eat fiber, you’re doing it for mainly two reasons to feed the bacteria that are in your stomach. But also because fiber is broken down by bacteria in our stomach into beneficial secondary metabolites. Some of those are short chain fatty acids like butyrate eisah, theater a acetate propriate. In for some reason, those bacteria that produce the short chain fatty acids are that produce these beneficial secondary metabolites. They have to be present to do this. But people that don’t eat a naturally high fiber diet don’t have these bacteria present in high enough quantities to produce the benefits that you need from the secondary metabolites. So just taking you know having a poor diet you’re eating you know, No fiber in your diet, but taking a powder, it doesn’t actually serve the same benefit, you get added benefit if you can actually eat a high fiber diet. And then they see an additional benefit if they are taking fiber on a supplement form which typically in that case, it doesn’t eat it because you’re already eating the fiber. So you can’t eat McDonald’s and then put some Metamucil in your coca cola? Yeah, well, it may it may help you on a constipation front, but it won’t help you get the you know, it won’t help you, you know, establish a healthy gut microbiome and it won’t help you get the secondary benefit or the benefits from the secondary metabolites are being fibers getting converted by the bacteria to to produce, you know, the beneficial compoundsin your gut. But if you take some Metamucil and you’ve just eaten a salad, then that mute Metamucil is beneficial.Correct? that’s what that’s what is implies in the Metamucil. I can’t remember what the exact formula in there with the fiber is. But the one that most of these research has been done On his insulin, which is typically the prebiotics that you see on the shelf, so when we’re talking about fiber, not only are we talking about the fiber for motility, but we’re mainly talking about what you consider on the shelf as prebiotics. And that is a term that’s been thrown around a lot recently, on shelves and on supplements and on the news has been way more beneficial than probiotics.Okay, so. So what we should be recommending is, and this is where a place where I know you, you mentioned before the show, you’re reluctant to give, make recommendations because you’re still a medical student, but you do have a PhD. So what you’re saying, you’re recommending we eat more fruits and vegetables, but specifically, if the patients are looking to decrease their gi upset, they, they should they should do that more so maybe than they usually do. And I don’t think you should feel uncomfortable making that recommendation to anybody.Yeah, I think. Yeah, there’s only about one or two really solid indications for adding probiotics and one that’s for the treatment of diarrhea resistant diarrhea in in, you know, adolescents or children. Probiotics have been shown to be pretty have pretty good efficacy, depending on which probiotic it is. So that’s still definitely an indication and I think PT pediatricians will know that. Although the research in the past few years has gone to say maybe that’s not the case, but I think the jury’s still out. So I would say that that’s still probably a general guideline that a lot of people are following. And then also, for patients that have C diff patients that have C. diff, that are receiving antibiotics, probiotics can prevent not only c diff, but they can also prevent the recurrence of people that have had c diff in the past. So I think that those are kind of the three main indications that we’re still seeing a good use of probiotics in a clinical setting. But other than that to patients that are having some gi upset let’s look at your your water intake, your your overall fiber intake and your fruits and vegetables and go from there as opposed to just recommending probiotics blank Need to say, Oh, well, probiotics gonna help your gut immediately, if that makes sense.So you’d mentioned before, rather than consuming ly off alized bacteria to actually consume something that’s fermented. So there’s still bacteria in there. So what about things like yogurt or, you know, the big craze now as kombucha or maybe even a beer with still some yeast in the bottom? Right? What? What about consuming that directly?So in most of the in most of the sense, most of those haven’t been shown to have good efficacy long term or in the clinical setting have not been shown to be effective at all. We see we hear that, you know, yogurts, great but when you look at the actual really good science that’s being done on these, we don’t see any benefit. And there hasn’t been there hasn’t been a good systematic review to show that the researchers conclusive that they’re beneficial. There’s actually most of them saying that they’re inconclusive and they haven’t helped at all or they’ve seen very little. Now most of the time for dairy based yogurts. The reason why they say they help motility is tends to be less from the bacteria that you’re introducing. But for patients that have constipation that take their yogurt help them, you know, have modal you know, better bowel movements, most of that tends to be because most patients are slightly lactose intolerant and so the dairy in there will instigate you to have a have a bowel movement, and that sometimes has been pretty has shown shown pretty good efficacy, but it’s not from the probiotics in the yogurt. It’s from that other side effects. Typically, yes, but it’s a beneficial side effect. So I don’t know if that’s most of the other fermented foods that we think about our you know, kimchi or kombucha, or Kieffer. Most of those To be honest, the benefit is in actual fiber that’s in those kombucha there’s almost none. So there’s your answer right there. They haven’t been shown to have good efficacy. There’s typically most computers as well. yeast and two different bacteria that you know, that colonized but do they pass the stomach with any efficacy there hasn’t been any good research showing it. fermented foods like kimchi Kimchi is actually one of the ones that I do recommend, but I recommend it to patients that are having issues or that have zero issues. patients that are kind of you know, want to increase increase the health of their microbiome, they can try Kim cheese and the benefits from Tim cheese typically is from the fiber that’s present in the cabbages that they typically using cheese. It’s not from the bacteria that’s being added. The bacteria that’s fermented in cheese is so little, and most of it is soil based bacteria, which typically tend to be good but they don’t they don’t survive very well in the acidic environment of the stomach, even though they’re locked in even though they’re lactate producing bacteria, they just don’t survive at a pH of two. So I tell people most people that consume kimchi I say if it if it helps you or if it’s great and it doesn’t upset your stomach, great, but if it does upset Your stomach, don’t think taking more of it is going to help just don’t eat it. Right? Because it is going to produce maybe some discomfort if it’s if it’s producing a lot of gas, which you know, some high fiber foods can produce gas and flatulence and if that’s a discomfort for you, then don’t worry about it because it’s not you’re going to get you’re not getting added benefit from it than just eating other types of fruits and vegetables.Interesting. Interesting. So your your PhD thesis, you had mentioned the gut brain access, right? And this is another area that sounds more to me, like pseudoscience and science fiction. But thankfully, you’re on the show and you’re going to help to sort me out on this. So just explain to me what is the gut brain access, like how are these things actually communicating with each other? Although, Episode Number three, was with a gastroenterologist who says that the gut is the window to the soul. So you know you have agreement agreement With her on that, definitely so so just just help clarify what what that means because we’re we’re hearing that the gut microbiome can have an influence on issues like autism and Parkinson’s and dementia. So So how is that? Is that real? And if so, how is that possible?So some of these are tricky, especially for the ones like Parkinson’s and dementia, the newer research is coming out is actually pretty good. But the initial research that’s showing these indications was actually very poorly done. And that’s because you also remember that a lot of this is a chicken in the egg phenomenon of is, is the, you know, what they typically do is they’ll sample 100 patients that have Parkinson’s and then 100 that don’t and they’ll say, Oh, well, these bacteria popped up as being the issue with people that have Parkinson’s. Well, are they present? Is that a chicken or an egg situation? Right? Was that were these the cause of Parkinson’s? Or are these just being predisposed to patients that already have Parkinson’s? Maybe for dietary or motility issues. Because remember, a lot of the gut is affected by the neurons, right? They there’s a term that the gut is a second brain. The guy who coined that phrase was actually the father of neuro gastroenterology. And that was Mike Kirsch on at Columbia who discovered the serotonin receptor in the gut. He was one of my, he was on the committee of my thesis. So he’s someone that I worked with closely. I spent three months in his lab talking to him about it, and kind of wrestling around some of these ideas, but also doing research on what the gut microbiome was affecting the neurons in the gastrointestinal tract. So the enteric nervous system. When you think about the gut brain access, most of it is a communication between anything that’s happening in the gastrointestinal system with the brain. That could be anything from that can be modulated through the neurons through the parasympathetic nervous system through the sympathetic nervous system, through the defense of a ferentz and then also through systemic circulation. Most of the systemic circulation isn’t we originally didn’t think was that much because Most of this is neuron based right? And something like serotonin or something like dopa mean. Most of those won’t survive that long and systemic circulation right for serotonin platelets take it up. And then it doesn’t cross the blood brain barrier. But there are things that are right. One of the precursors of serotonin is tryptophan, tryptophan, when you eat it, it gets absorbed and increasing higher amounts of tryptophan can increase the amount of tryptophan in the brain. And that’s kind of one of these fundamental areas of research right now is trying to figure out from a nutritional standpoint, what we can modulate to affect the brain, some fundamental or some kind of pivotal research went back. Back from McMaster, I think it was back in 2011 or 2013. And that’s when they figured out that one of the major implications between the gut and the brain is the Vegas nerve, right? We all remember learning about the vagus nerve but vaguely remember about its role in the gut. Well, the vagus nerve has He has projections all the way to the V Lie of the small intestine and the colon. And when you sever the vagus nerve in an animal model and you feed it certain bacteria versus not, you do see changes in the brain, that have been recapitulated with specific bacteria. Now, there’s only one that they’re thinking has real proof of being clinically useful. But their clinical trials that they’ve been using for this bacteria, which called JB one hasn’t been shown to have good effect in humans, but in mice, they see that the level of the gamma receptor does increase in can’t remember the exact same spot of the brain. But that is one area that they’re that they’re looking at the research that I was doing was your weight. You’relosing me here, you’re losing me here. What’s the significance of that?So the significance of it is that there are bacteria that could have effects on the brain through the vagus nerve. That is an area that we should really think about and really say okay, are there other bacteria that can do this, how is the bacteria doing this? We don’t necessarily know. But we have to remember that when you think about the bacteria in your stomach, it’s not the bacteria isn’t totally wiped out from, you know, if it’s in your gut, then it’s beneficial bacteria depends on the location of where the bacteria is. So certain bacteria aren’t, they don’t have no efficacy for having any benefits to the gut unless you put them right up against the epithelial layer where they can interact with some of these neuronal projections that are that are between the epithelial cells of the gut. And that’s the that’s the things that we’re learning and that we’re now doing research on that we didn’t do five years ago, because we didn’t have the tools. We didn’t have the knowledge and we didn’t have the understanding to be able to do that.Then how does it get so so it’s influencing the vagus nerve, but then how does that translate into something like dementia? That seems to me like such a big leap? Yeah, correctly, I would think it would, the bacteria might have Something to do with you know, the parasympathetic nervous system and gut motility, but specifically influencing brain activity, like complex centers of the brain, I just don’t see that. I can’t I can’t make that leap. And that’s I also don’t have the the physiology background of a lot of the stuff that you’re discussing. So it is it is a little harder for me to follow. But But still, I just can you help us get there?Yeah. So that’s the hard part is I think that we there’s still a lot of areas that we don’t know, we don’t know how it’s making that now we, we know that on the neuronal side of the GI of the GI system, there are specific bacteria that can increase the amount of neurons in the gut. So that means that they’re increasing. How many neurons make up the main turret Plexus or the Auerbach’s Plexus in the intestine that helps with motility now translating that up through the vagus nerve or up through the parasympathetic nervous system to the brain to create neuronal changes in the brain. That is where we typically fall short. And there are some researchers that are trying to do it live in Italy. There’s there’s good research, and there’s also want to do that trying to do this. But your questions are good to have, because I think that your skepticism is a skepticism we need in science because we’re not finding, for example, the bacteria that I was working on, we haven’t figured out directly we saw some behavioral issues. But when we say behavioral issues because of probiotics that we’ve engineered to do stuff, yes, we know what it’s doing in the gut. But on the brain, we don’t know what it’s doing. And we don’t know where it’s having these effects. Maybe it could be having these effects because it’s affecting motility. And as you know, as anybody knows, go through have diarrhea for five days. And next thing you know, you feel terrible, you can’t sleep properly, you’re up at night, you have a little bit more anxiety or a little more high stress, or vice versa. You can’t prove For a few days, and now you’re stressed out, your stomach hurts, you’re not eating as much you’re trying to drink. But these issues fundamentally do affect our emotion and our behavior. But it may not be as much as just directly affecting a specific spot in the brain, if that makes sense.Yeah. Yeah. So it seems like my follow up question is, is there evidence in using probiotics to alter or prevent disease in these non bowel diseases? We’re still in our infancy and learning about them. So to think that we can take something, especially after all you said about probiotics. It doesn’t it doesn’t seem like we’re there yet. But what about for bowel diseases? Right. What is the effect of the gut microbiome on say inflammatory bowel disease?Yeah, for inflammatory bowel disease. I think that there’s been some trials that have that have shown that, you know, some of the probiotics work or could help and then in the majority of them, there hasn’t been so I think the most recent reviews that they’ve done for inflammatory bowel disease. Were there Crohn’s or ulcerative colitis, probiotics haven’t been shown to have a big effect. Why is that? Well, you have to think when someone has inflammatory bowel disease, you’re not just thinking about the bacteria in there, the the tissues inflamed, right? The immune cells are activated. And the area that Everyone misses, whether in gastroenterology or not, is the mucosal layer that protects protects the epithelial lining of the GI tract. If that mucosal layer is degraded, or it’s completely destroyed, because in inflammatory bowel disease, a lot of cases it’s completely destroyed. Throwing back probiotics at it isn’t going to help. You need to let the actual cells heal. Let the epithelial cells heal and then you need to have them build back up their mucosal layer for the bacteria to live because mostly bacteria live in the mucosal layer, not, you know, right up against the epithelial cells. Does that make sense? That’s really interesting becauseas an otolaryngologist, we think a lot about the size of the sinuses. mucosa ciliary flow and a lot of what you’re trying to do is restore mucosa, ciliary flow, and that mucus blanket and the direction that the cilia are pushing it. So, in this, this is an era ago, we used to just strip away the sinuses and remove the mucosa and think that you remove the disease, but then it gets replaced with scar and you just you need that mucosa and you need that mucus layer.Yeah, yeah, well, you need you not only need that mucus layer in the gut, that bacteria actually eat that mucosal layer, right there specific bacteria like Akram, Anthea, you could send affiliates that actually use that mucosa layer as a new nutrient source. So if that’s not present, these bacteria aren’t going to be very happy or they’re not going to be able to thrive. And they’ve actually some newer research is showing out that patients that are in the ICU, that have some of this degradation of the mucosal layer, giving them probiotic, this actually could increase their risk. Have septicemia Now you may be thinking, Okay, the link, the link between taking a probiotic and getting it into your blood system seems like that would never happen. But if you look in PubMed, there are multiple articles now proving that it’s the same exact strains with some modifications that have gotten from probiotic form into the blood system of some of these patients, where that’s happening, how that’s happening. I think that there’s still a lot of room for explanation. I think the science is still at its infancy. But that’s an area that this idea of just throwing probiotics or bacteria or trying to make the microbiome more robust. I think there’s going to be some times where we have to pump the brakes and think about, okay, what are the real indications? And what are the potential cause or harm that we’re doing, you know, recommending these or taking these on patients that maybe don’t need it?But it sounds like it ties into what you said earlier about introducing the probiotic actually being competition that you’re introducing rather than improving the function of the backend. that’s already there. Exam sounds like that sounds like what they’re doing what they tried to do with the best of intentions in the ICU.Yeah. And when I when I’m saying this a lot of it’s from specific strains. Now there are strains out there that researchers are looking at specific ones that could help patients with pouch itis or patients with inflammatory bowel disease. Those are specific strains. They’re not, you know, are there specific species, they’re not just a blanket over the counter recommendation. And so those until one of those is approved by the FDA, as that a probiotic on the species level is being recommended for a specific disease process. Until we get there the row the science is not robust enough to recommend it for most diseases except the you know, the indications that I mentioned earlier.Yeah. So something that we had talked about before that I want to definitely don’t want to miss is antibiotics. Right? So antibiotics, we were concerned about antibiotic resistance. We’re concerned about gi upset. We’re concerned about C. diff. But you had mentioned there are some other unintended consequences of antibiotics. So could you discuss that?Yeah, the unintended consequences, I think actually mentioned in a roundabout way, and that is that mostly antibiotics will basically slough off the mucosal layer of the gastrointestinal tract, or they have unintended consequences of patients that take antibiotics for years at younger ages are at increased risk of having metabolic syndrome or having increased risk of having obesity or type two diabetes. Some of these we’re not sure why now, there’s a lot of theories and a lot of research that’s indicating that it could be a meta genome level. So some antibiotics may affect the meta genome in the epithelium of the gastrointestinal tract that’s translating to the pancreas and translating to the liver. And then there’s other research that indicating that using antibiotics for long periods of time can affect the amount of short chain fatty acids that are produced later in life, which is basically the beneficial secondary metabolites that our bacteria produce, to actually give us benefit. doing that, you know, for a long period of time is really you know, damaging.So one thing that we also talked about before the show is your your lifestyle choice. You are plant based, and again, being an old fogy myself. I’m only 40 But still, the term plant based for me is new and I have no idea what the difference is between plant based and vegetarian or plant based and vegan. I know the difference between vegan and vegetarian. I understand enough about that. But this new term plant based to me sounds like someone who mostly eat plants, but couldn’t quite give up bacon. Or it’s a vegetarian with a PR problem. Right? Like, like prunes prunes have a PR problem. So they tried to rename themselves dried plums and it didn’t work out so well for them because still prunes but plant based may may be a little stick stickier. So so you describe yourself as plant based. What does that mean to you? And what does that mean to the public?Yeah, so so first before we talk about this issue, one of the things that I do want to set straight is there’s now in the news, a lot of hype for plant based or veganism, especially because a lot of documentaries are, you know, the advocates that are really pushing for it. Now, I’ve been plant based for over 10 years. And so when I say I’ve been plant based, it’s not because it’s a fad, or it’s not something that you know, happened overnight and I want to talk about it. I’ve been playing bass for 10 years and I don’t talk about it that much, because that’s just a part of my lifestyle who I am. What is the difference between plant based veganism and vegetarianism? So plant based, it used to be that plant based was someone who was vegan, who chose not to be associated with the PR issue with veganism or vegetarianism. plant based was you know, fully vegan, no animal products. It was no no meats or no cheeses. It was just fruits, vegetables. Nuts seeds, whole grains, beans, lagoons those specific nutrients and it was a focus on eating whole foods as opposed to eating processed foods. So you can obviously be vegan or vegetarian and eat only processed foods right? You can buy those at the grocery store whereas plant based was focusing on whole food plant based foods. Goodexample is Oreos are vegan.Correct? Exactly. Oreos are vegan, but would it fall into plant based? Well, I mean it depends how strictly you’re you’re saying your whole foot whole food plant based vegan person, you know follows that diet. Now the difference between vegan and vegetarian is obviously the difference between dairy consumption cheeses and milk. And then there’s a lacto ovo vegetarians that consume eggs. And then some people will say they’re vegetarian but they’re more pescetarian and occasionally have fish but plant based now in the past probably six months because of the the hype of the word plant based. It has now a lot of people Do consume animal products, whether they’re it’s, you know, chicken or whether it’s bacon, or whether it’s fish associated themselves with dog plant based because they say oh, and primarily plant based. And they do deviate from being strictly plant based, if that makes sense. So I think that the, the terminology is so new that a lot of people don’t necessarily know where they fall. I just say plant based because it doesn’t turn heads. And if I say vegan, everyone thinks I’m gonna yell at them because they’re wearing leather. I prefer when, but that’s not my focus at all. My focus is typically on on just the food, and it’s for the reason of most of the science that I’ve studied.So you’re plant based because you want to be left alone. All right, everybody, please take the hint. When you see Frank at a restaurant, just you can ask him for his autograph. Please. Don’t harass him about his food choices. He’s plant based. Leave him alone.Yeah, and my wife laughs because my wife I mean, she’s an omnivore but she’s jokes and she tells everyone she’s a carnivore, and she does that specifically Because she thinks it’s funny, I’m playing bass, she’s carnivore, she doesn’t follow the same diet, and it has never really gotten in the way of our relationship we’ve been married for over four years. And that really hasn’t been an issue. So the idea that it’s a stigma that it’s, you know, as political as left first write isn’t necessarily the case for everyone.You do what works for you, and leave you alone.Exactly. Right. Well, isthere anything related to the gut microbiome that we haven’t discussed yet that you think bears mentioning?I mean, there’s obviously a ton of research that could be mentioned, right? We know that the microbiome is affected by certain things in in our diet, whether that’s the amount of Coleen or the amount of carnitine that someone’s consuming and that gets converted by the bacteria in our stomach to TMA which then in our liver gets converted to tmo, which now baby maybe a new linker for cardiovascular disease or some other illnesses. A lot of the sciences pretty good is pretty good and pretty robust on it. But using it as a clinical indicator hasn’t been hasn’t been established well enough yet. But I think that there’s there are a ton of topics that we could obviously talk about and go over. I would I would kind of be more interested in just to tell people that if they are interested, if they have questions about the gut microbiome, they can always email me or asked me, obviously, I’m a medical student. So I’m busy. I’m studying a lot. And I’m actually still working on papers, I’m still doing additional research, which as anyone knows, in the medical profession is difficult to balance. But I’m happy to answer other questions if you have any specific ones. And you must be so tired all the time from not eating any meat.That’s what they say. But you know, forjust kidding, I’m just kidding. I’m justso yeah, well, I mean, I think that that’s actually a great area that people need to be wary of is most people that transition to this day, under consume calories drastically. And if they’re plant curious or they’re eating curious or whatever, most of them, just don’t consume enough calories, whereas if you consume enough calories, I mean, it could really, it actually is the opposite. He can have a huge energy boost. But you know, it really just depends on on hair consuming, but you don’t I mean, this isn’t necessarily the healthiest way for everyone. And I tell people that because it depends on what level of scrutiny, you’re gonna look at your food. And if you’re just removing things and not replacing it with other things, and you’re going to have real issues.And be sure to send a sample of your poop to an unlicensed lab so they can tell you what diet you should be using. Andtake your mind zactly. Exactly.Right. So where can people find you online?Yeah, if they want to find me online, I have both a personal Twitter and Instagram, Twitter, I’m not that active on Instagram a little bit more active. And I share some of the science. I don’t give medical advice, but I share some of the science about what some of the newer research is showing or where it’s going in the nutrition front and microbiome front. If you’re interested. I do have a medical podcast as well. It’s not we don’t talk anything about the gut microbiome. We never really When talking about plant based really except a few episodes, majority of it are for medical students and for residents where we interview physicians or residents that are about to finish their training and talk to them about the medical education process. It’s called surviving medicine because we all know medicine is hard. It takes a lot of time it takes a lot out of you and burnouts a real issue. So we discussed topics like that on our on our podcast, but it’s typically only focused on that, that that area, but from every different specialty, and then been the links, I’m sure there’ll be in your show notes, but that is surviving medicine.org there’s five more minutes in podcasts and on Instagram, that’s surviving dot medicine. If you look us up, you can find this.Dr. Frank Cusumano. Congratulations on the PhD and thanks so much for being on the show. Thank you so much.That was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring calm or wherever you get your podcasts. If you have a question for previous guests or have an idea for a future episode, send a comment on the web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.Transcribed by https://otter.ai