By Alex Martinez

In recent years, understanding of the importance of the microbial community in our gastrointestinal (GI) tract, or gut microbiome, to human health has exponentially increased. With the gut microbiome in focus, new discoveries have been made on the crosstalk between the microbiome, nerves in the gut and the central nervous system (CNS), collectively known as the Gut-Brain-Axis (GBA). 

The GBA is a unique bi-directional communication system where the gut microbiome can interact with the CNS and vice versa. Messages from the CNS can reach the gut, impact gut function, modulate the immune system and even lead to changes in the composition of the microbiome. Adding further intrigue is the evidence that the gut microbiome is dynamic, rapidly influenced by prescription drugs as well as modifiable lifestyle factors including psychosocial stress, sleep, exercise and diet.

The translation of these exciting and important discoveries into clinical practice remains an ongoing process. Based, in large part, on a social media enabled patient self-advocacy movement, logical conditions such as irritable bowel syndrome (IBS), are now being recognized as GBA disorders.

However, there are many more conditions that are increasingly associated with GBA dysfunction in the scientific literature that do not have the same level of awareness. The recent, yet substantial, body of evidence indicates an association with disorders of the GBA and conditions as diverse as depression, anxiety, schizophrenia, neurodegeneration, autism and even auto-immune diseases such as rheumatoid arthritis.

A few examples to consider:

• Depression: Microbiome dysbiosis has been observed in clinical studies. In translational models, when mice received a fecal microbiota transplant (FMT) from depressed humans, they exhibited depressive-like behavior.
• Autism: A majority of individuals with autism present with additional comorbidities, including diarrhea, abdominal pain, constipation, gastroesophageal reflux, and other GI symptoms, with nearly a quarter having a specific GI diagnosis. In limited clinical studies, FMT has improved autism symptoms from baseline.
• Schizophrenia: Specific levels of microbes in the gut microbiome have been identified as related to the risk and severity of schizophrenia. Additional evidence suggests that dysbiosis of the gut microbiome may lead to inflammation in the CNS.
• Parkinson’s Disease: Constipation, abdominal cramping, and bloating are often seen in individuals with Parkinson’s disease. Several studies have shown that constipation may occur prior to motor system symptoms There also appears to be differences in the microbiomes of individuals studied with and without Parkinson’s disease.
• Rheumatoid Arthritis: In recent clinical studies, findings depicted the microbiomes of patients with rheumatoid arthritis were different compared to healthy controls and that the microbiome in patients may contribute to the immune dysregulation that damages their

For this wave of disorder with emerging GBA association, healthcare provider engagement is critical to educate patients and add to the body of clinical evidence to accelerate the development of new diagnostic and treatment guidelines, novel treatment strategies and ultimately, targeted new therapeutics.

How to drive awareness of GBA disorders and ask the right questions

• Take inventory of the relevant current professional guidelines to incorporate microbiome diagnostics or GI symptoms collection into practice. This is an area where continuing education is particularly useful to staying current on such a rapidly evolving field.

• Self-evaluate how you incorporate gut health symptoms into your patient histories, evaluations, and records. Consider using a validated instrument such as the Bristol Stool Form Scale to collect valuable data without increasing administrative burden.

• Create a plan to educate patients with GI symptoms, with an emphasis on modifiable lifestyle factors such as stress reduction, sleep improvement, exercise, and diet modification – since dysregulation of the microbiome can be reduced with even small improvements in lifestyle. With no specific microbiome treatments FDA approved, be prepared to field patient questions on probiotics and other gut health supplements that have begun marketing to consumers with limited evidence.

• Encourage patients to track their GI symptoms and bowel movements between visits, to help them and you understand the relationship between their primary condition and their gut health. This will also serve to make any recommended lifestyle changes more relevant and actionable at home.

• Finally, ensure you have a referral network that can support your practice, including evaluation for GBA disorders, since the GBA is bidirectional, being evaluated and treated by mental health professionals, gastroenterology specialists and dieticians can all potentially benefit patients.

 We are on the path to rediscovering how prescient Hippocrates was when he said, “all disease begins in the gut” over two millennia ago. In the future, we believe GI symptoms and bowel movements tracking will be as routine and important as traditional vital signs. Until then, we hope the above will spur creativity into how to integrate this emerging field into practice.

Alexander Martinez, JD is a former Silicon Valley corporate lawyer turned biotechnology entrepreneur. His thorough understanding of the industry and areas for improvement, in parallel with his own patient journey, inspired him to make a public health impact and seek novel medicines for broad patient populations that have been previously underserved by the traditional pharmaceutical industry. Alex is currently the CEO and Co-Founder of Intrinsic Medicine, a therapeutics company leveraging human milk biology to transform irritable bowel syndrome (IBS) and other Gut-Brain Axis (GBA) disorders.