Interesting and important story on fecal transplants in @nytimes



This is definitely worth a read:

Drug Companies and Doctors Battle Over the Future of Fecal Transplants - The New York Times. By Andrew Jacobs. March 3, 2019.

The lead in is good:
CAMBRIDGE, Mass. — There’s a new war raging in health care, with hundreds of millions of dollars at stake and thousands of lives in the balance. The battle, pitting drug companies against doctors and patient advocates, is being fought over the unlikeliest of substances: human excrement.
The story is both interesting and includes some very important stuff going on behind the scenes that may affect the future of fecal transplants as a treatment in t. It seems that a variety of folks including those from companies who are trying to develop treatments mimicking fecal transplants are trying to get the FDA to crack down on the use of actual feces for carrying out fecal transplants.
“The first principle of medicine is do no harm, and at the moment we don’t have a long-term track record of F.M.T.’s adverse effects,” said Dr. Sahil Khanna, an associate professor of gastroenterology at the Mayo Clinic who has conducted industry-funded clinical trials on fecal transplants. “We also need to move away from transferring poo from one person to another.”
and
Drug companies, which have been struggling to funnel patients into the clinical studies that are required for F.D.A. approval, would like federal officials to restrict the stool bank’s ability to distribute fecal matter in the hope that more patients will enroll in their trials.
On the other side are those from places like OpenBiome as well as many clinicians who think that the regulation may have already gone far enough or even too far.
“It is very frustrating to see hyperregulation again ruining a good thing in health care,” said Dr. Colleen Kelly, a gastroenterologist at the Brown University medical school.
and
“I never imagined the solution to my nightmare could be so simple,” he said. “I just hope Big Pharma doesn’t make it unaffordable for the people like me.”

Irresponsible reporting on "poop doping" from the Washington Post

UPDATE 1 - see below - the author updated her article including some of my critiques.
UPDATE 2 - also see Embryette Hyde's post about using (or not using) the American Gut data to inform lifestyle changes
UPDATE 3. June 25. - Boing Boing picked up the story.  Without major caveats.  I posted a comment there pointing to my blog and answered one other comment but then was not aware the discussion was going on much more there until a Tweet today.  Some interesting discussions there and also some strange things.  Some criticisms of me (some reasonable .. some a bit much).
UPDATE 4. June 26. Nicholas Starapoli at the Genetic Literacy Project critiques the stories on poop doping. Poop doping: No, elite athletes can’t improve performance by optimizing gut bacteria
UPDATE 5. Also see Beth Skwarecki Sex, Poop, and Champagne Are Great, But Their Health Benefits Are Overrated

Went on a bit of a Twitter tirade last night. See more below




The Washington Post story, by Marissa Payne, requires a log in but the article is now in other papers that are free online including the Denver Post here.

It is just really bad reporting because the claims of one scientist are presented as facts without any scrutiny and these claims need lots of scrutiny.

Recently this story was covered in Bicycling Magazine and I gave them an "overselling the microbiome" award for their reporting on it.  I guess I am pretty surprised that the Washington Post doubled down on some of the claims.

Here is some commentary on just some of what is wrong with the Post article.

"Peterson, herself a pro endurance mountain biker, has discovered that the most elite athletes in the sport have a certain microbiome living in their intestines that allow them to perform better"
No evidence has been presented anywhere that these microbes "allow them to perform better".  At best, there may be evidence that elite athletes in this case have different microbes.   That as far as I know has not been presented for the case here.  Seems possible.  But this of course does not mean that those microbes they have allow for better performance.  There could be dozens of reasons why such athletes have differences in their micro biomes (e.g., diet, exercise, interactions all effect the microbiome).
Peterson didn’t decide on the fecal transplant solely to enhance her performance during her mountain bike races, but to cure a host of symptoms that have affected her since she was a child and contracted Lyme disease.
Seriously?  This basically is implying that she did a self fecal transplant that enhanced her performance and cured her Lyme disease.  She is an N of 1.  She did a fecal transplant and then some of her self assessed health changed.  What about, say, the placebo effect?  Or, how about - 100 other things changed in her life before and after the fecal transplant which could have affected her.  Or maybe the antibiotics she claimed to have taken before the transplant did something?  Ridiculous to make any claims about her self fecal transplant having any known impact.

Then there is this
“I had no microbes to help me break down food, and I had picked up bugs in the lab where I was working because my system was so weak and susceptible,” she told Bicycling.
This is a pretty stunning claim. She had no microbes that help break down food before this?  And she also had been infected by microbes from the lab where she worked?  I don't buy either of these claims.

And what about
“I just did it at home,” she said of the February 2014 procedure. “It’s not fun, but it’s pretty basic.”
Referring to home fecal transplants.  I mean, I am all for people doing really whatever they want at home.  But they should do it with their eyes as wide open as their other parts.  And that requires the full poop on fecal transplants.  They have real and potential risks (e.g., see this).  One can get pathogens from them.  The transplant itself could have negative effects.  And if one assumes the microbiome has major effects, then one might get other unwanted traits from the donor too.  It is dangerous to promote self fecal transplants without discussing any of the possible risks.

Overall, I find this reporting by the Post to be dangerous.  And no the one caveat in the article below is not enough
Peterson said it’s too early to make any concrete conclusions about how the microbiome affects performance, but she’s convinced there’s enough evidence to suggest it does make a difference.
How about instead of "she is not convinced" saying "There is no evidence for any of her claims and this is snake oil".  That would be more accurate.





UPDATE June 21 2:54 PM

Marissa Payne updated her story with some comments from me

See https://twitter.com/MarissaPayne/status/877631691883298816

Because the text has been changed in the Washington Post story I am posting the text here from the Denver Post version in case it gets updated too, so people can see the original.

-------------------------------
To be a professional cyclist, one must have guts, microbiologist Lauren Peterson says, and she doesn’t just mean that in the metaphorical sense. Peterson, herself a pro endurance mountain biker, has discovered that the most elite athletes in the sport have a certain microbiome living in their intestines that allow them to perform better, and if you don’t have it, well, there may soon be a way to get it.

“Call it poop doping if you must,” Peterson told Bicycling magazine last week about her research.

Peterson, a research scientist at the Jackson Laboratory for Genomic Medicine in Farmington, Connecticut, heads up an initiative called the Athlete Microbiome Project, in which she compares stool samples of elite cyclists to amateur bikers. Her findings strikingly shine a light on a handful of microorganisms that apparently separate the guts of elite athletes from average people.

The most important, perhaps, is Prevotella. Not typically found in American and European gut microbiomes, Prevotella is thought to play a role in enhancing muscle recovery.

“In my sampling, only half of cyclists have Prevotella, but top racers always have it,” she told Bicycling. “It’s not even in 10 percent of non-athletes.”

Peterson reports she hosts Prevotella in her own gut – but not naturally. In fact, she might be the first case of “poop doping,” thanks to a fecal transplant she administered herself three years ago. Her donor? Another elite athlete.

Peterson didn’t decide on the fecal transplant solely to enhance her performance during her mountain bike races, but to cure a host of symptoms that have affected her since she was a child and contracted Lyme disease.

“I had no microbes to help me break down food, and I had picked up bugs in the lab where I was working because my system was so weak and susceptible,” she told Bicycling.

But, she continued, “I couldn’t find a doctor who could help me” since in the United States, fecal transplants are only performed to treat serious cases of Clostridium difficile, a disease that causes chronic diarrhea. And so Peterson went rogue.

Peterson detailed her decision to perform the “risky” procedure on herself on the podcast “Nourish Balance Thrive” last year. She admitted to thinking it was a “bad idea” at first because if not done with proper screenings of both parties, it could worsen a person’s problems. But through chance, she came across a donor, an elite long-distance racer, who had his microbiome mapped and screened after a case of food poisoning, which showed he was otherwise healthy. So Peterson took antibiotics to wipe out her own gut bacteria and essentially performed a reverse enema.

“I just did it at home,” she said of the February 2014 procedure. “It’s not fun, but it’s pretty basic.”

Within a month, Peterson said, she began feeling better than she’d felt in years.

“I had more energy than I knew what to do with,” she told the same podcast last year. “Like everything just changed.”

More importantly for her life’s work, however, her own success with the fecal transplant gave her the idea to start the Athlete Microbiome Project, for which she rounded up 35 of her cycling friends, according to the Scientist magazine, to kick off her research.

Along with Prevotella, Peterson said she also identified another possibly performance-enhancing microbe called Methanobrevibacter archaea, which Peterson found to be more prevalent in the samples from elite athletes. This bacteria’s function is also opaque, however, Peterson told the Scientist, “it allows your entire gut microbiome to work more efficiently” by more effectively breaking down complex carbohydrates in the gut.

Peterson said it’s too early to make any concrete conclusions about how the microbiome affects performance, but she’s convinced there’s enough evidence to suggest it does make a difference.

“What we’re learning is going to change a lot for cyclists as well as the rest of the population,” Petersen told Bicycling magazine. “If you get tested and you’re missing something, maybe in three years you’ll be able to get it through a pill instead of a fecal transplant. We’ve got data that no one has ever seen before, and we’re learning a lot. And I think I can say with confidence that bacterial doping . . . is coming soon.”

Well, crap – crap does a crappy job as a treatment sometimes (re: fecal trasnplants and IBD)

Well, this seems like seriously big news in the microbiome world: Fecal Tx Flunks IBD Test but Optimism High.  Charles Bankhead reports on results presented at the "Digestive Disease Week" meeting.  At the meeting Paul Moayyedi from McMaster University reported that a clinical trial of fecal microbial transplants (FMT for short) was stopped midway through the trial due to "lack of efficacy".  More specifically Bankhead reports
The investigators found no significant differences in the primary outcome or any of the secondary outcomes, which included the Inflammatory Bowel Disease Questionnaire and the EQ5D health status assessment
The researcher seems enthusiastic about FMT still but certainly this means that FMT for IBD is not going to be like FMT for CDiff (just wanted to make sure I got in a lot of abbreviations there).  I am sure there will be much more to come on FMT and it would be good to see more detail on what was presented at the meeting (a paper, or poster, or such).  But for now, this hopefully will temper some of the overselling of FMT that is going around (e.g., Overselling the microbiome award: Mercola/Perlmutter on fecal transplants for severe neurological dysfunction).


Related posts:

Overselling the microbiome award: Mercola/Perlmutter on fecal transplants for severe neurological dysfunction

Well, this is pretty scary.



An automated Google Search I have picked up a hit to an article by Mercola about an interview he did with David Perlmutter: Key Dietary Strategies to Protect Yourself from Alzheimer’s : Natural Wellness Review

And the article covers many topics but one is pretty over the top.  There is a section on recommendations by Dr. Perlmutter to promote brain health.  And one of them is quoted below:
Fecal transplantation, in cases of severe neurological dysfunction where poor gut flora appears to be a contributing factor. Your microbiome is critical for multiple reasons, including regulating the set point of inflammation, producing neurotransmitters like serotonin, and modulating systems associated with brain function and brain health. This form of therapy is now the standard of care for life-threatening C. difficile infections.
Yup.  He is recommending fecla transplants to treat severe neurological dysfunction.  Not the first person to suggest a connection between microbes and neurology.  Not the first person to say that maybe trying to change the microbiome might be an interesting thing to test as a treatment for some issues.  But with no caveats here they just jump right in to using this to treat neurological dysfunction.  This is just grossly over the top and will likely mislead many many people with neurological dysfunctions into thinking fecal transplants are a known effective treatment.  I wonder if Dr. Perlmutter will start offerring home fecal transplant kits for sale on his web site (which I will not link to here).

Now, I think microbes are important.  And I think there is potential here for fecal transplants for a lot of issues.  But potential is different than proven.  By a long show.  And people like Mercola and Dr. Perlmutter should be ashamed for misleading people like this.  And thus they are today's winners of an "Overselling the Microbiome" award.