What Is The Gut-Skin Axis with Alex Manos_en (auto-generated)
okay so good afternoon everyone and thank you for tuning in today on this thursday afternoon and morning afternoon evening to everyone who is watching the recording as obviously you're all aware we're going to be exploring the gut skin access today um so before we dive into the presentation and even before we kind of summarize the objectives which are quite simple and it's probably worthwhile me introducing myself because um some of you are not going to be familiar like me with who i am and what i do here at healthpath so my name is um alex manos i am one of the co-founders of healthpath and i'm the functional medicine director um so i certified with the institute for functional medicine um in 2016 and my background is in nutritional therapy so i have a masters in personalized nutrition a degree in nutritional therapy and i started out in the industry i think 15 years ago now as a personal trainer and sports massage therapist so i sort of evolved over the last 15 years from being more involved in the fitness and health space and over the last few years i very much focused on supporting people with chronic complex conditions ultimately in particular around digestive health um chronic fatigue syndrome and mold illness and mycotoxins but today we are taking a a slightly different focus in the sense that we're going to be talking about conditions associated with the skin but we're going to mix exploring really the connection between the gut and the skin and we're focusing on five of the most common conditions from a skin perspective psoriasis eczema rosacea acne and vitiligo so to ensure that we're all on the same page to begin with ultimately the gut skin axis is obviously referring to this relationship between our digestive tract and our skin and as we go through today's presentation it will become increasingly clear that we have an increasing amount of research showing us that at least in a subset of people with these conditions imbalances within the digestive system in particular when it comes to the gut microbiome and the integrity of the gut lining i.e this concept of leaky gut are incredibly important and can be a real driving force in the imbalances that are then found um on or in the skin so a key question really that we need to to answer today is you know what is this connection and how does it actually work how can two very um distal sites of the body have such an intimate connection um and what we know at this point in time is that the connection comes really through three primary routes shall we say and that is related to our immune system our metabolic health and our nervous system so what we understand is that the gut microbiome is significantly influencing systemic immunity and systemic immunity is significantly associated with some of these conditions especially i would say psoriasis but also um acne eczema and vitiligo ultimately now these connections become even more pronounced when our intestinal barrier is disturbed for whatever reason that may be it could be related to antibiotics it could be related to some form of chronic stress it could be related to poor diet it could be related to sibo small intestine bacterial overgrowth among other factors and when we have this excessive permeability or leakiness to the gut lining it allows certain things to get from the gut into our bloodstream where there will be an immune response leading to inflammation and especially if ongoing that can disrupt our overall immune state or immune system and increase the likelihood of going on to develop some of these conditions the metabolites being produced by our gut microbiome are also intimately connected within this so as we'll see in today's presentation the metabolites that our bacteria produce often in response to the food that we are consuming not only will help maintain a healthy gut lining but also modulate our immune system so one of the most well understood and researched mechanisms of the gut skin access is that a healthy gut microbiome produces a healthy quantity um and a healthy sort of quality gut bacteria metabolites that maintain a healthy gut barrier and a healthy immune system and therefore healthy skin what's really interesting is in some studies we've actually found gut bacteria the locations where psoriasis is in the skin so we also know that certain sort of fragments of bacteria are literally translocating or traveling across the leaky gut lining into our bloods where they're being transported to the site um of the skin condition ultimately so we're going to start with psoriasis in regards to some of the mechanisms i've broken this down into kind of two sections today we're going to briefly talk about each of these conditions and what research we have to help us understand some of the things that might contribute to the condition from a gut perspective and then we're going to talk about interventions that we can consider um in the second part of today so when we think about psoriasis and the role that the guts can play in this condition there was a brilliant paper that came out last year um a current state-of-the-art review on psoriasis and the gut microbiome and to kind of highlight what we're going to very briefly touch on now this paper helped us understand that large intestine imbalances within our bacteria this term dysbiosis microbial metabolites gut inflammation which can be tested for via markers such as calprotectin in a stool test sibo small intestine bacterial overgrowth leaky gut and then gluten reactivity whether that's celiac disease or gluten sensitivity these are the factors that have to be considered if we're trying to understand whether someone's gut health is contributing to their psoriasis so we're gonna there's kind of a slide coming up on each of these so when we think of large intestine dysbiosis what we see in the research is that this is one of if not the most significant findings related to psoriasis and gut health and what we're saying there for is that significant imbalances within the microbiome in the large intestine are a very common and significant finding now one of the reasons why that can be is because there is an issue with the diversity of the microbiome what we see in patients or clients with psoriasis is often their diversity the number of bacteria that reside within that large intestine is actually lower than compared to healthy individuals and there's a relationship between what diversity is there and the severity of the symptoms which it kind of strengthens this argument that there might be a direct relationship between these two things it is worth highlighting that research is mixed as it is for a lot of what we discussed today so there is a study that actually showed that microbiome diversity had increased in some patients with psoriasis and i don't think that should be overly surprising in the sense that nothing that i say today is 100 percent present in patients with psoriasis these are key findings that a subset of people with psoriasis or eczema or vitiligo may have and therefore may need ruling in or ruling out through certain functional tests so a question obviously becomes well what contributes to the dysbiosis in the first place and that could be related to antibiotics stress we actually see that those living in more rural environments generally have a greater diversity into their microbiome than those living in urban environments one of the reasons being is that our gut microbiome is partly a representative of the microbiome around us um you know around our environment there are organisms bacteria that are living they're living on pretty much most surfaces and that exposure is a really important part of developing a robust immune system as many of us know with this hygiene hypothesis that has been around for a while the fact that in the modern world we live in an increasingly more sterile environment and we need that exposure especially in the first three or so years of life to develop a healthy robust well-modulated immune system but not only are we living in some ways in a more sterile environment certainly in regards to our exposure to sort of certain natural organisms but many of us are being exposed to environmental pollution and that could be everything from pollution from cars and buses if we live or work in cities and through to obviously more national or global concerns around industries for example and the pollution that is being released nutrient deficiencies poor diets just general poor health may also have an impact on the health and diversity of our microbiome so the microbiome in our gut isn't just influenced by these external inputs or stimuli is impacted by our health and therefore it is a bi-directional relationship the healthier we we are as a human as a whole organism the healthier the sub-components of us and that includes our microbiome leaky gut has been associated with psoriasis and that is because leaky gut when chronic will contribute to systemic inflammation which will disrupt all of our microbiomes and has been associated with psoriasis sibo has been not only associated with psoriasis but the eradication of the bacterial overgrowth in our small intestine has been shown to improve the symptoms of psoriasis again strengthening the relationship between the two here so the conclusion from this paper was that psoriasis as well as rosacea made benefits for the treatments of sibo we also see in a different paper that absorption seems to be compromised in those with psoriasis so in this study 60 percent of participants um had altered absorption compared to three percent of the controls in the study so the healthy individuals compared to those with psoriasis now of those 33 people with psoriasis that had a degree of malabsorption six percent were then found to actually have celiac disease remember that we've mentioned celiac disease and gluten sensitivity is a a common ish finding in those with psoriasis in this study six percent had celiac disease in the small intestine so over one in five people with psoriasis may have sibo three percent had parasitic infections and only one patient presented with isofina phenelic and gastroenteritis so inflammation related to um specific immune activity shall we say and then we have microbial metabolites so what some of these studies have found that in patients with psoriasis they have a depletion in what we call short chain fatty acids scfas these short chain fatty acids are produced by certain bacteria and the bacteria produce these fatty acids by fermenting our dietary fiber and therefore if we're not eating enough dietary fiber that might be one reason why we see lower levels of short chain fatty acids but again and what is less well known and less well understood is that the bacteria themselves can have an issue with the fermentation process and the production of these fatty acids when they themselves aren't particularly healthy which takes us back to we can't separate the guts from the host i.e uri but we do know therefore that supporting the microbiomes ability to produce these short-chain fatty acids is important and it means that in the short term there might be some people who would benefit from supplementing what we can so we can supplement butyrate which is one of the main short chain fatty acids produced by certain gut bacteria we also see in these studies increased amounts of slightly more problematic metabolites one that is just referred to as tmao so there is a metabolite imbalance within patients with psoriasis there isn't isn't necessarily always easy to test for ultimately either and some research suggests that these imbalances regarding the microbial metabolites are some of the most significant findings um i personally have this sort of perception or belief that the fitter the host the fit of the bacteria we do know that people who are adequately physically active so people who are doing appropriate levels of exercise on a daily weekly basis generally do produce more short-chain fatty acids such as butyrate so exercise is actually a great therapy to support gut health if done at appropriate intensity and volume and what i mean by that is too much exercise people who are doing lots of um you know serious endurance work maybe training for marathons or longer events that can actually be quite problematic for gut health in some people gut inflammation so six out of ten patients in one study were had elevated calprotectin calprotectin is an inflammatory marker that can be tested for in the stool and is actually often used by gps and other practitioners as a way to differentiate between someone with about syndrome to someone with inflammatory bowels so when calprotectin is significantly elevated it can actually in one with inflammatory bowel disease which is an autoimmune condition now bear in mind that psoriasis is thought by something to potentially be an autoimmune condition and then that suddenly makes a lot more sense as well one reason being the biggest risk factor for having an autoimmune disease is having an autoimmune disease i.e when you have one you're much more likely to go on to develop another one unless you get that first one under control obviously so in summary we need to be thinking about the microbiome in the large intestine and that's where something like a stool test can be helpful we need to think about microbial metabolites things like short chain fatty acids such as butyrate we need to potentially rule out inflammation via markers like calprotectin we need to kind of con consider sibo leaky gut and then gluten reactivity as well so there's a really strong link in the research between psoriasis and gut health and i would argue based on the research i found that the this is probably the skin condition with the strongest connection at this point in time at least so what about rosacea well there's research looking at microbiome diversity here as well so there are only a couple of studies at this point in time um that have looked into this and there's been a bit of inconsistency so one study found that alpha diversity was lower and the other one didn't but both studies point to significant differences in beta diversity between those with roses compared to healthy volunteers now alpha diversity and beta diversity are slightly difference alpha diversity is related really to the richness of the microbiome how many actual species of bacteria are present within your large intestine and that might be something like 150 while there are something like i think a thousand species of bacteria that can be in the intestine most of us have something between 100 and 250 depending on how resilient and diverse that microbiome is beta diversity is actually looking at your microbiome from sort of also not just a richness perspective but also a composition perspective comparing it to a healthy cohort sort of a healthy reference range and then giving results so what we're saying here is that 50 percent of studies so far i.e one has shown that actually the richness of the microbiome the number of species of bacteria that are there was lower and the other study said it was similar but both studies showed that the compositional and richness of the microbiome was less and therefore again it's great information that at some level the microbiome is compromised in paper in people with rosacea and what's interesting is this condition has been associated with most gi conditions ranging from inflammatory bowel disease to irritable bowel syndrome to celiac disease to reflux h pylori and sibo and i've put inflammatory bowel disease in bowls because the research has stated that this has the most connection with the skin condition and to strengthen the argument that the gut has a relationship here is the fact that medications to eradicate sibo i.e antibiotics and medications or antibiotics to eradicate h pylori have actually been shown to provide effective and prolonged therapeutic response to rosacea meaning there's improvements so there's clearly a relationship between the gut and the skin in this condition as well and this takes us back to really i guess the overarching principle of the gut skin axis at this point in time which we've already mentioned you know this presentation could be kept super short and simple with this understanding that the microbiome is modulating our systemic immune system and our systemic immune system is having a profound impact on the health of our skin and therefore if we can improve microbiome diversity and composition which will by default in many ways improve its metabolites production we're reinforcing the barrier of the gut we're having a more well-balanced immune system systemically and therefore we're at much reduced risk of developing any of these skin conditions that we're talking about so let's look at eczema well in eczema there is a strong relationship with allergies and eczema and what we know through the research is that again the microbiome through its production of not just short chain fatty acids but especially in relation to sort of eczema or atopic dermatitis other metabolites including d tryptophan conjugated linoleic acid or cla as you can see in the image and other derivatives of our microbiome they're having a direct impact on various receptors and immune cells uh you can see on the left hand side of this image trek trig cells are often described as the quarterbacks of the immune system they're there helping regulate and manage the immune response um and short chain fatty acids such as butyrate help maintain a healthy um state of these treg cells and as a result our immune system is much more well modulated appropriate immune response is isn't one that might um contribute to development of allergies and therefore we see improvement or a reduction in atopic dermatitis or eczema so again we have some really strong mechanistic understanding around how the gut influences the skin within the context of eczema as well i don't think no so in regards to eczema things like mode of birth where we vaginal born or c-section where we breast-fed or bottle-fed did we live in rural or urban environments was there a family pet did we go to kind of kindergarten or nursery so essentially did the things happen that meant we were exposed appropriately to all sorts of different bacteria and organisms that meant that our microbiome in the first three four five years of life could develop as robustly as it could do to ensure that we have an appropriate immune system and therefore aren't at risk of developing allergies or things like eczema so this is really close to my heart because from really a few weeks old i developed horrendous eczema to the point that when my mum walked in in the morning when i was certainly a few months old um there would be blood on my skin from me just itching myself all night um and i was someone that was vaginally born i was breastfed but there was probably something going on in my mom's health that she wasn't aware of that meant that i was being exposed to something and therefore didn't have this immune system that develops as it should have and that's led to and this is me sort of my theory of my own health journey that led to me having certain low level allergies throughout my life and also an immune system that is a little bit more susceptible to psoriasis so if my self-care isn't as good as it could be if i'm stressed at work or whatever it may be i can have tiny patches of psoriasis to this day that pop up and it's almost a barometer for me around how well is my physiology doing and that goes back to really those first three years or so so when we think about our state of health at this point in time we can't ignore our entire life story because it all relates to how we are today then we have acne and acne is one where there are some really strong connections separate to the gut as well so insulin resistance um you know blood sugar dysregulation sex hormone imbalances inflammation from whatever cause that may be as well as microbial dysbiosis these are really um significant causative factors in acne which isn't too surprising when we think of you know our teenagers when they're going through their hormonal changes when they might be eating a slightly worse diet contributing to blood sugar dysregulation and things like this all driving this condition so this is an interesting little quote from this paper and basically what the one of the studies found that individuals with acne had a high local burden of lipid peroxidation meaning that the fats in the cell were basically being oxidized they were being damaged um and as a result they had a really high demand for certain antioxidants so we can see straight away that antioxidants may be really helpful in supporting people with acne what's also really interesting is that prebiotics and probiotics have been shown to reduce systemic markers of inflammation and oxidative stress and therefore help with this concept that we've just mentioned also remember in the last side we said that inflammation is a causative factor of acne whatever's causing that inflammation pro and prebiotics may be able to help just modify that while we address the actual underlying issue um and obviously probiotics not only can help and prebiotics moderate they help modify the gut microbiome specific ones can help modify the gut lining but some studies indicate they can also modify the microbiome of distal sites meaning the microbiome in our skin or on our skin in our lungs in our respiratory tracts in our sort of vaginal tract or urinary tract we've got these microbiomes all over the body it's not just the gut microbiome and modifying the gut seems to have an impact at least sometimes on these more distal microbiomes as well and therefore pro and prebiotics have been found to be quite helpful for acne then we have vitiligo so this is something that is a little bit more complex in some ways and from what i can find there's a little bit less research than some of these other skin based conditions but like all of them there are environmental triggers there are genetic polymorphisms so you might be genetically predisposed metabolic alterations taking us back to this concept of blood sugar dysregulation and insulin resistance and also autoimmunity they are all things that we need to be considering and when we look at the interventions for some of these conditions there is a strong overlap um at least without taking a more personalized approach which would mean really no a case study would be needed from that perspective but in vitiligo we do see reduced richness and diversity so again the microbiome is compromised in people with this condition modulating the microbiome and looking to improve that microbiome diversity again through the use of prebiotics probiotics and postbiotics which is a relatively new term referring to these metabolites that are produced by bacteria and probiotics but also fecal microbiota transplants all of these things that can help modulate the microbiome could therefore be an alternative complementary approach to supporting people with the condition so with all of that in mind it becomes very apparent what tests we might want to consider from a gut skin perspective comprehensive stool testing will be looking at microbiome diversity we'll be looking at butyrate-producing bacteria it will be looking at cow protecting an inflammatory marker it will be looking at key organisms other than boots rate that help maintain a healthy gut lining and it will be looking to see whether you have a um adequate production of digestive enzymes it can give you sometimes signs about whether you may have an overgrowth of bacteria in the small intestine we can also do sibo breath testing which we've seen as a really strong component of a lot of these skin based conditions and we might want to consider some form of food reactivity testing and that could be anything from getting tested for celiac disease by your gp or doing some allergy testing by your gp in a referral to doing some food intolerance testing or some sensitivity testing and these are actually all very different food reactions food intolerances are related to when you're lacking an enzyme to digest the sugar found in the foods so the most obvious example is lactose intolerance when you're lactose intolerant you're lacking the lactase enzyme to digest and break down the lactose so it can be absorbed properly in your small intestine fructose intolerance is also very common in people with digestive disorders a sensitivity and an allergy are both immune based reactions whereas a food intolerance is nothing really to do with your immune system sensitivities are more related to antibodies like igg and iga and allergy you're looking at ige antibodies so they're three distinct mechanisms meaning that you can't do one of them and know with a hundred percent certainty that you're okay consuming the foods which makes food reactivity testing quite complex ultimately which is why even in the research most of the time the gold standard is still the elimination of the foods completely 100 it has to go and then approximately 30 days later reintroducing it to see whether you experience an adverse reaction and you've got two opportunities some people will notice the removal of the foods you notice an improvement in some symptoms that's obviously a sign that yeah you need to keep that out but bringing it back in can be a really powerful way of understanding how things are going and if you do that with more than one foods then obviously you need to reintroduce them to understand well which ones can you reintroduce and which ones may you actually want to continue avoiding for the time being the elimination diets is lit it really is one of the most powerful tools we have when it comes to understanding the connection between our health and food so gluten dairy corn soy eggs sugar alcohol some people include um pork and actually beef in there and i have a colleague that does an awful lot of comprehensive elimination diets and she's been really surprised how many people seem to actually be having some form of adverse reaction to beef which i thought was really interesting she works with a lot of people with autoimmune conditions so there could be a connection there and then leaky gut testing um do we want to consider what's going on specifically in the barrier of guts so these are the tests from a gut skin perspective i was debating to whether to add a bullet point here which says just something like you know a practitioner recommended test because it's important to appreciate that today we are focusing on the gut and the skin um stress environmental toxins such as mycotoxins or heavy metals such as mercury certain other types of infections including viral infections have been associated with some of these skin-based conditions so it's not just the gut that needs to be investigated really