Gut Check: The Microbiome’s Role in MS (Episode 4)

Payrovi: I love it too. But before we get into the meat of it, let’s do a quick round of fun facts to kick off today’s show. Fun fact number one, you are more microbiome than human. What do you think, Dr. Mirla Avila?

Avila: Well, yeah, there are more microbes living in our body than in your own cells. And for every human cell in your body, there are 5 to 10 microbes, which include viruses, bacteria, and fungi. So very interesting to know that we are basically a sack of microbes. Now the second one, Susan, did you know the gut microbiome forms around birth?

Payrovi: Yeah, I find it actually just fascinating. In fact, I was just looking into some research to find out does it even form earlier than that. And we do have some data that in utero while your mom is pregnant with you, it actually does start.

But really at birth, when you’re exposed to your environment, is when the gut microbiome really starts getting established. And so many different factors influence your gut microbiome. You want to tell us about some of them, Dr. Mirla?

Avila: Yes, actually, we know that when a baby is born in the birth canal, that’s when they get actually colonized. So if a baby is born by C-section, they don’t get the same microbiome initially. And there’s higher risk of asthma and also of allergies.

Payrovi: Absolutely. So factors like breastfeeding, whether or not you played with dirt or had access to areas that were not totally sterile, your diet, antibiotics early in life, whether or not you had pets — really starts influencing what your gut microbiome looks like that forms by about age 2 or 3. All right. I have another fun fact. 80% of our immune cells sit right in the gut, right next to the gut microbiome.

Avila: And I love this fact as a neuroimmunologist because a big part of our immune cells are actually maturing in the gut, in particular ones that are very important and that can cause autoimmunity.

We’re going to talk a little bit more about this, but we know that it is a dynamic environment where our immune system cells and microbes are in constant communication. So our gut bacteria can actually make our immune system be pro-inflammatory or anti-inflammatory — to our benefit or not beneficial.

Payrovi: Yeah. And this really speaks to this idea that everything is connected. Your immune system is intimately involved with the GI tract and taking care of all of our systems. It becomes really key with MS.

Avila: And in fact, T regulatory cells — who call the shots for autoimmunity — mature in the gut and have an intimate relationship with our gut bacteria. I like to call these T cells the godfathers of the immune system, and I like to explain this to my residents when I’m lecturing. So we all think about The Godfather. And, you know, you have these cells that are the antigen-presenting cells that are sampling in our body things that they believe are abnormal. So in the case of MS, they sample a chunk of myelin.

They come to the T regulatory cells, and I imagine them showing this and saying, “Master, this is what I found.” And the T regulatory cell is the one that should say, “No, wait a minute, this is part of our body, and you’re wrong. And now I’m going to kill you.” And that’s exactly what they should be doing. For some reason with autoimmune diseases — and with MS — they’re not calling that shot.

They’re saying, “OK,” and they’re allowing a response to mount and for the immune system to go and attack myelin. So where do these cells mature? In the gut. So that intimate relationship with these T regulatory cells becomes very important for the development of autoimmune disorders.

Payrovi: And one more really interesting fact is that the gut microbiome is stable — but it also shifts, which sounds like a very confusing thing to say. But what do you think about that, Dr. Mirla?

Avila: Yeah, it can shift for our good. And that’s something really good to know — that there are things that we can do to improve it. And at the same time, there are things that happen or things that we do that can actually worsen that gut microbiome, that can make it more susceptible to different disorders.

So we were talking about when somebody is born by C-section or vaginal birth is different, but also the breastfeeding, the diet of the baby, that exposure to other germs — as you said, nonpathogenic germs — can actually improve the gut microbiome.
So I think it’s important for us to understand what are the things that we can do, what are the choices that we can make to improve our microbiome, and also to make it stable and to keep enjoying health and improving our quality of life.

Payrovi: And what I love about what you just said was the word choice. Like, our small daily decisions every day can actually have a powerful influence over the health of the gut microbiome. So making different decisions can help you shift your gut microbiome in a different direction.

Avila: I really think we should consider thinking about food as medicine — and that everything that we eat and drink can influence our health or our immune system.
Payrovi: Absolutely. I mean, that’s actually not a new concept, right? Like, this has been the way we humans thought about health for so long — really like using food and natural substances. And that still holds today. Food can be medicine, or it can be poison, depending on what you’re eating. And making different choices again will just shift the gut microbiome in a different direction.

So I always like to think about the environment — like what is the environment that you’re exposing your different biological systems to? The environment is everything. It’s constantly teaching your gut what it needs to do. It tells your immune system how it needs to behave. And so our small daily behaviors and decisions have quite a powerful impact. So what is the gut microbiome? Do you want to start us off and give your explanation? And I can do mine.

Avila: Of course. So gut microbiome would be — basically consists of bacteria, yeast, viruses, fungi, and other microbes that live in our gut. And we have microbiome actually everywhere — in our skin and different organs.
But when we’re talking about the gut microbiome, these are specific for the gut. And there are several groups of bacteria and fungi. And as we were talking about, depending on our food and many other aspects that we can influence, we can have a pro-inflammatory or an anti-inflammatory gut bacteria.

Payrovi: Yeah. And I also want to just bring everyone’s attention to like where the gut microbiome is. It actually is in the large intestine. And the gut is such a dynamic environment — it is constantly changing and shifting.

The cells in your GI tract are replacing themselves every three days, and the health of your gut microbiome can influence what that lining of the GI tract can look like. So it’s a very large number of cells that live in the large intestine and have a lot to do with human health. So, Dr. Mirla, why is the gut microbiome important in multiple sclerosis?

Avila: So studies have shown that in MS there is a dysregulation of the gut bacteria, meaning that there are higher numbers of a group of bacteria called Firmicutes, which tend to create in our immune system a pro-inflammatory reaction — in particular with a, um, in our immune system there’s a way that we communicate or our immune system communicates, and these are called interleukin. That’s the name of that little substance or protein that they use to communicate.

So IL-17 or interleukin 17 gets expressed highly in MS in the gut when we have more Firmicutes. And — but the good thing is that we’re going to talk about — there are ways that you can actually improve that gut bacteria. And we’re also talking about these T regulatory cells that I like to nickname the godfathers of the immune system. These are the ones responsible for calling the shots and triggering autoimmune disease. And these actually mature in the gut.

Payrovi: Yeah. So I think of the gut microbiome as like this giant switchboard that takes information from the environment, translates it, and figures out who needs to know about it and communicates it to other systems. And that’s happening all the time between the gut microbiome and the immune system. And so one of the backdoor ways of trying to influence the course of MS is to start thinking about the gut microbiome and how can we push it toward a more favorable growth of bacteria that we want present there. All right. So we know that there’s a ton of bacteria sitting there.

And I always tell my patients, I go, you know, you think that you are carrying around a gut microbiome within you. But because we’re so outnumbered by them, it’s like they’re carrying — the gut microbiome is carrying you around, right? Because we’re definitely outnumbered. So what are the functions of some of these microbes that hang out in our large intestine? You know, we give them a place to sleep and live, we give them nutrients for food so they can grow and thrive. But what do we get back from them in exchange?

Avila: So definitely they’re important in educating our immune system — as we were talking about the T regulatory cells and other cells. They’re very important for us to be able to digest our food and absorb certain vitamins, in particular vitamin B12 and K. They also make mood molecules.

And there are studies that have shown that if somebody has depression, it may be also the fault of part of the GI tract that can be contributing to this. I’m not saying that in its entirety, but there have been studies. Other neurological diseases seem to also get started in the gut.

There have been a lot of studies now linking Parkinson’s, for example, with some changes in gut bacteria early in the disease. But we also know that they’re important in regulating health in general and the gut environment — and also very important for us to be able to detox from other substances.

Payrovi: Absolutely. Like, having these bugs there allows us to push detox — you know, removal of substances out of the body — a little more efficiently. And when these bugs are not present in adequate amounts, all of these functions start to fall apart. And there’s many things that can help or harm the gut microbiome. So let’s dig into that. So what are some of the factors that can really help shift the gut microbiome, Dr. Mirla?

Avila: So definitely food. We want to think about food — as I like telling my patients — think about how things were before humans started putting chemicals in our food. How they come from nature — that’s the best way to approach it. Because processed foods that have a lot of chemicals — these are not meant to be in nature.
They’re not nurturing your gut biome. They’re not nurturing your body.

On the contrary, they can actually be damaging your gut bacteria. What are the foods that have anti-inflammatory properties? That would be vegetables, fruits that have antioxidants. If you want to have an animal protein, fish is a great source.
Now, we say not every single day because of the mercury that sometimes fish can have, especially large fish. But definitely it’s a better type of protein. So foods that can trigger immune inflammation, for example, are large amounts of red meats, eggs, saturated fat, and processed foods. And sometimes it’s difficult — I live in Texas, and everything is red meat. And I enjoy red meat every now and then. But I tell my patients, don’t do it every single day. Try to choose good things. Try to add more things to your diet and to limit the ones that may be more inflammatory — and just eat a little bit of that, and not too much of it.

Payrovi: I also try to work on diversity of diet with patients. The more unique foods you have in your diet, the more number of unique bugs you can grow in your gut microbiome. So if you are eating 10 or 15 or 20 different unique foods in seven days — like, that’s just not enough.

I play a game with my patients where it’s like the 50 ingredient challenge. Can you hit at least 50 different foods in seven days? Because we want to grow a very diverse gut microbiome. And then just kind of piggybacking on what you said about food, there are two groups of foods that are highly efficient in getting you the gut microbiome that you want. So there’s prebiotics and probiotics.

Prebiotics are the foods that contain the right kind of fiber that your good bacteria can actually eat and fuel themselves and start producing all of those immune molecules, neurotransmitters, mood molecules, etc. — doing all those great functions that Dr. Mirla mentioned. And these are foods like garlic, onion, green leafy vegetables, banana, kiwi, etc. And then there’s the probiotic foods.

Payrovi: And most people, I think when they hear probiotic, they’re thinking about the supplement. But I’m actually talking about the food that’s fermented with lots of live bacteria in that food, where you might actually see the label say live active cultures in there. And if it’s in the refrigerator, it’s got even more living bugs in there for you.

So if you can start eating these foods and eating a variety of them — not just eating onions as your prebiotics or eating sauerkraut as your probiotics — if you can have a variety, it’ll really help diversify your gut microbiome and get more of those good bugs. Yeah, it’s just going to be much more chemically diverse than just like taking your fiber supplement every day. So I think that’s really good advice.
And actually I’ve seen some research lately that shows that eating prebiotics — you know, those fibrous foods that feed the gut bacteria — is actually more impactful than probiotics, which is the fermented foods. So if you had to focus on one, I’d pick the prebiotics. But of course both are important.

Avila: So lifestyle is also very important. You know, exercise, sleeping, managing stress, avoiding things that are toxins — for example, too much alcohol can also damage your gut. We have spoken about smoking. If somebody smokes, that’s a big detriment to your immune system in general. So there are many things that we can do to improve our overall health.

Payrovi: Yeah. And again, that’s your environment, right? Smoking is one signal from your environment. The type of food you eat is another kind of signal. Whether it was a big plant-based food with like a piece of chicken on it versus a chicken sandwich from a fast food place. So just these little small decisions throughout your day can have a really big, long-term impact on your gut microbiome if you keep up with them. And finally, you know, medications can influence the gut microbiome in a negative way.

The first thing that comes to mind is antibiotics. I mean, the job of antibiotics is to kill bacteria, and it’s not going to just kill the ones that are in your infection — they’re going to also influence what’s living in your large intestine as well. Even acid blocker medications — I mean, these are some of the most commonly prescribed medicines that are being used very long term. And one thing that you just reminded me of that I want to mention is people always say, “OK, I have to take antibiotics.

How do I rebuild my gut microbiome back?” And like, the answer is the same. Prebiotics, probiotics, good lifestyle habits, and getting a good variety of those foods in so that you can really repopulate with the desirable bugs. All right. So what is in the future for us MS patients, based on what we know about the gut microbiome and what we can use to influence the health of it?

Avila: So there’s a lot of studies going on testing the microbiome and understanding a little bit what that means. And currently, our tests look at which bacteria are present and what levels. And we’re able also to measure basically what is the metabolic activity of that gut microbiome.

And what does this tell us? So I was mentioning that studies have shown that MS patients have a higher number of Firmicutes than Bacteroides. And Firmicutes are a group of bacteria that favor this inflammation, as I was mentioning. But there are many things that we were saying that we can do to ask a patient to revert that and improve that gut health and hopefully favor the Bacteroides, which are the ones that lead to anti-inflammatory response.

But there are also some studies going on on how to do fecal transplants. Actually, we don’t have one right now here in our center, but there are some in Europe in which they’re doing it either with an enema — and then they put fecal material that has been cleaned and they put the bacteria in — or you can also take it as a capsule. We know this a lot — what’s needed.

For example, if you have heard about C. diff, and these are patients that have this colonization of a bacteria that is very dangerous, that causes diarrhea, we know that that can be cured with fecal transplants. So with autoimmune diseases, they’re looking into this and seeing if that can make a difference.

But we don’t have to wait for these studies to be approved and for us to have a fecal transplant, because we can make these changes ourselves. It takes longer — takes about three months to make a full change in our gut — but by making little-by-little good additions to our choices, we’re going to be making a difference in the long term.

Payrovi: Absolutely.