Microbiomes - More Complexity for Doctors

‘Let thy food be thy medicine and medicine be thy food'.

— Falsely attributed to Hippocrates

It seems to have first been uttered in the 1920s but, whenever and whoever said it, it was right. We have known for a while about diet/disease relationships, but food and medicine are truly two sides of the coin when we think about the microbiome.

I admire doctors but I’m beginning to wonder what the future looks like for them. They are smart, they have to be able to get into medical school and the amount of material they have to memorize is incredible. Even so, the information is constantly changing and it’s difficult to know what to believe (we’ll get back to that). There is so much to medicine we have to have specialties – and each specialty is subdivided into further specialties. Internal medicine, for example, has 21 specialties including gastroenterology, interventional cardiology and nephrology and, get this, internal medicine. 

Even with all those specialties and subspecialties, as Adam Smith said, the “division of labor is limited by the extent of the market.” The extent of the medical market is about to get a lot bigger.

To become a doctor, it often takes up to 10 years of training including four years of medical school, a residency and possibly a fellowship. However, even though we began to discover diet/disease relationships over 100 years ago, today doctors get less than 25 hours (about 3 days) of nutrition training. In fact, less than 20 percent of medical schools make even that much a requirement.

But now there is a whole new branch of science that finds that prevention and treatment for almost every type of disease relies not on treating human cells, but on treating the estimated 39 trillion microbial cells, including bacteria, viruses and fungi, that live in and on our body in microbiomes. The National Institutes of Health’s Human Microbiome Project identified about 10,000 different species affecting everything from cancer, heart disease, depression, diabetes to obesity and, ultimately, longevity. 

To further complicate things, each of us responds differently to different foods based on our microbiome composition. This is one reason we are now thinking about precision (personalized) nutrition (as well as precision medicine). But a new issue is that, in addition to directly affecting different diseases, your microbiome also may also affect whether a medicine works. Your responses to medicines are also somewhat individualized. That’s why, for example, your doctor “tries” a medicine for blood pressure and, if that doesn’t work, tries another. 

Recommended treatments for your microbial mix include your daily diet, which needs to include probiotics (live bacteria found in foods like some yogurts) and prebiotics (fiber and some other carbs that feed your bacteria), postbiotics, antibiotics and poop transfers (from healthy microbiomes to unhealthy ones). Unfortunately, right now, no one knows exactly what constitutes a healthy microbiome although some specific good and bad microbes have been identified. One thing seems relatively certain, a diverse microbiome is best.

A search in Google Scholar on “microbiome” reveals over 800,000 articles and there are already numerous books on the subject. Nevertheless, this research is generally considered to be in its infancy. The effects of microbes on our bodies are likely to revolutionize medicine, both preventive and treatment. 

But yet another complexity that will continue to plague us is, which of those articles and books are right? The former editor of the New England Journal of Medicine said “It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines.” Another editor, of the prestigious journal Lancet, said, “Much of the scientific literature, perhaps half, may simply be untrue.”

So, in addition to learning everything physicians have to learn in their ten years of school now, they are faced with an entirely new area of microbiomes. In addition, they have to be able to sort truth from hype and apply lessons to people as individuals.

No doubt, the medical profession’s division of labor will grow to include more specialties dealing with microbes. I’m also guessing that the future of medicine lies in more artificial intelligence and machine learning (deep learning) programs. Even today there are subspecialty AI programs like one that diagnoses cancer and another that examines treatments for Parkinson’s disease.

Someone will still have to translate research into those programs which will force them to be able to sort out the good research from the bad, but physicians will also have to decide whether the best treatments will be drugs or other existing treatments - or newer treatments to affect microbial dysfunctions. Although these are great medical breakthroughs, the treatment decisions may get to be much more difficult.