Episode 42: How Depression And Anxiety Is Fueled By Your Microbiome
In a one-month period at the beginning of COVID-19, prescriptions for anti-anxiety medications rose 34.1 percent; for antidepressants, 18.6 percent; and for anti-insomnia drugs, 14.8 percent. Clearly, we’re not coping so well with the challenges of a pandemic world.
But, what does the microbiome have to do with the rise in depression and anxiety? And what can we learn about how to better our brains by improving our guts?
On this episode, Andrea is joined by Dr. Ghannoum to discuss the latest emerging research about depression and the microbiome. Dr. G talks about how he’s able to distinguish patients who are depressed solely by their lab results, and sheds light on the actual diversity threshold of microbes that are necessary to keep us out of a depressive state.
The two also talk about how probiotics play a pivotal role in easing depression and they walk through Dr. G’s day, step-by-step, to illustrate the real-life diet and lifestyle choices he makes to stay healthy in mind and body.
On this show, you’ll learn:
- Distinguishing patients with depression from lab results (3:13)
- Microbiome diversity threshold for depression results (7:33)
- Does taking a probiotic help? (8:49)
- How the gut impacts the brain (10:13)
- The role of the vagus nerve (13:37)
- Symptoms that affect the gut’s ability to work (18:40)
- Do symptoms return after probiotics are stopped? (23:21)
- Gut microbes and alcohol (26:36)
- Dr. G’s day, step-by-step (28:22)
- Stress reduction techniques that Dr. G employs (31:48)
- Fecal transplants and their use in the treatment of depression (35:10)
Andrea Wien: Welcome to Microbiome Report. I am your host, Andrea Wien. And today we are talking about something that we've focused on before, but we really felt with COVID, it's so important to be talking about mental health right now. So we're diving into depression and anxiety, and specifically a new study that came out, that's showing very promising results with some probiotics and prebiotics for symptoms of depression and anxiety. So we're talking to Dr. Ghannoum our resident researcher today, but I just wanted to preface the show with a few statistics that have just really been mind blowing for me. So in a recent study of a thousand US respondents, 59% said COVID-19 has affected their mental health. In a one month period at the beginning of COVID prescriptions for anti-anxiety medications, rose 34.1%, for anti-depressants 18.6%. And for anti-insomnia drugs, 14.8%. So these numbers are really staggering.
Then when we look at pregnant women and new mothers, we saw massive jumps in mental health issues during COVID. 40% surveyed had anxiety and 70% with depression. So these numbers are just really alarming and we need to do such a better job as a society in helping people who are struggling with mental illness, which is really the majority of us these days, if these numbers are to be trusted, which I think that they are. So please enjoy the show today. We give some tools and tips, if you are someone who is struggling with depression and anxiety. And how all of that is tied to the microbiome, again, we always come back to gut health and it's so important when we're talking about issues that affect our state of mind. So please enjoy the show. Dr. Ghannoum, thank you so much for coming on the show again.
Dr. Mahmoud Ghannoum: Oh, it's my pleasure. It's always a pleasure talking to you.
Andrea Wien: I know we love to talk to you too. So we're talking today about depression and anxiety, and I know our listeners have heard shows before on the brain gut access, and we've really focused on that in past episodes. But there's some new research out and we want to talk about that today, but we also realize that so many people in COVID right now are dealing with this problem. Some of the statistics that I found in preparation for this episode were just completely mind blowing. I mean, in terms of how many people are taking anti-anxiety medications, anti-depressants, anti-insomnia drugs, the numbers are through the roof. I think in one month time period at the beginning of COVID, for example, the prescriptions for anti-anxiety medications alone, rose 34.1%.
So this is just something that so many people are dealing with, and we know from the research that depression and anxiety are related so closely to the microbiome. And I'd love for you to talk about how you can distinguish patients with depression, just in their lab results. When you look at their lab results, you can see patients that have depression versus not.
Dr. Mahmoud Ghannoum: Sure. I mean, first of all, I really cannot agree with you more that we are living in tough times. This situation nobody have experienced before. Not really knowing what's happening, listening to the news, not seeing your loved one, it's all affecting us and this social distancing, even though I advocated it is very important for us to conquer this pandemic and this virus. It really at the end affects our level of anxiety, our level of depression. And that's why it's really, I'm glad you asked to talk about this and the COVID and how we can address it. Because this is a real problem, and it's not going to go away, even when people start going to where they are anxious. They don't know how to really come back to what they are used to. So with that background, I also agree with you that recent studies and discoveries are showing that depression is related with the constitution, the amount and the species of gut microbiome.
So what lives in your gut definitely affect your state of depression? In fact, about 60% of anxious and depressed persons have been described to have intestinal dysfunction, something problem, such as irritable bowel syndrome. Also, a number of researchers looked at animal studies, which suggested that the intestinal microbiome, in other words, what the microbiome, both bacteria and fungi that live in our gut induce changes of brain chemistry and behavior. And one such study showed that increased antibiotic prescription, for example, was related to mania severity. And as you know, the antibiotics you are affecting the gut microbiome. And of course, by changing this, you causing not only change in the microbiota, but this change is affecting our behavior and also affect our mood. So that's really the connection where we have between depression and the microbiome. Now, your question about how can you distinguish patients with depression in lab results of their microbiome makeup?
So what's really so interesting is that there are studies to start to look at people with depression and those without depression. And what they found that the people with depression, their micro-organisms are different from those healthy people or normal, if you will. Now, these studies, what they are showing is that the level of abundance, how much organisms is there have been decreased in those with depression, also the diversity. How many different microbes are there is also changed. More specifically, which is very interesting. They found that people with depression have a low level or low abundance of bifidobacterium and lactobacillus. And you know that these are good bugs, which help our body to fight diseases as well as they keep the bad organisms under control.
So when you have a reduction in these organisms, what's happening, you are having more depression. And that's of course, because of the gut brain access and how our gut affects our brain.
Andrea Wien: And I want to take a step back and talk about that for a second, but I am curious, do you know in the research, like, is there a diversity or an abundance thresholds? If someone has less than this many strains or more than this many... You can kind of tell symptomatology wise. So if someone has low in bifidobacterium, let's say, do we know how much they need?
Dr. Mahmoud Ghannoum: Oh, definitely. In our studies with the microbiome, we looked at what you expect to have a healthy microbiome. What level of bifidobacterium, what level of lactobacillus and other good bugs, like saccharomyces, for example. Cerevisiae, which is a fungus, which is a good bug. We know how much we need and what we did to know that we looked at nearly a thousand person or thousand people who are what we call normal or healthy. And we found what is their level. Like you have to have out of the total abundance, definitely you need more than two to 5% of those. A lot of the time you find really low levels of these organisms. So having about 2% of bifidobacterium will be really good for your gut health.
Andrea Wien: So if you find someone let's say they have 0.5%, is giving them a probiotic or telling them to eat yogurt enough, can we just give them those strains and we see improvements? And I think this is what some of the recently published studies that we're going to talk about today, giving someone a probiotic with some of these things has been shown to help ease the depression.
Dr. Mahmoud Ghannoum: Certainly. What you do really is we do gut testing as you know. In BIOHM, we do gut testing where we characterize their profile of bacteria and fungus. And we look at those good bugs and bad bugs. So relevant to what you are asking, if we find that there is low abundance of bifidobacterium, then we recommend that they take a probiotic that has these organisms. And also, as you mentioned, eating yogurt with live culture provided it is unsweetened is also helpful from that. And this will be one way to start rebalancing our gut and really reducing the depression as well.
Andrea Wien: Okay. Before we get too far down this path of things that people can do, because I know people are very curious to hear more about that. But I do want to take a step back and just give an overview of how the gut and the brain are communicating. So things like the vagus nerve, our gut is creating hormones. Let's talk about that background a little bit. So if someone's coming to this show for the first time in this episode, and they're saying, "Wait a minute, like I have no idea how something that's happening in my gut and the microbes that are in there could possibly be impacting what's happening in my brain." Can you talk about that connection?
Dr. Mahmoud Ghannoum: I really think this is really very important area that we need to make it clear to people because a lot of people, as you said, they don't know how is our gut affecting our brain and how our brain affect our gut. I can tell you, the studies in the last 10 or so years started to look at the brain and the gut. And for a long time, what we thought, we thought everything is controlled by the brain. Now we are starting to know, based on this research is that there is communication between the brain and the gut. They actually talk back and forth. And by this communication, we call the gut brain access because they talk together. And for a lot of the time, we used to think that only our brain tells us do this, do that. Now with this new science, we are seeing that both of them they talk together.
In fact, based on these discoveries, scientists are starting to say that, we define the brain as a whole brain. And what they mean by that, it's a brain made of the brain, which everybody knows about, the microbiome and the gut. So we have whole brain and this whole brain, sometimes when we look at the microbiome alone, we are even calling them second brain. In other words, these two, they were together. And really the first evidence that there is gut brain access came from a work of an army surgeon who studied gastric juices. He looked at gastric juices, which are secreted by fistulas, which occur in the stomach and what they found that intestinal function was related to the mood. Even before that, over 70 years ago, researchers, two of them called Stokes and Bilberry. They really were the first to propose that there is gusto intestinal mechanism for microbes, how they interact and affect our depression.
And what they found that among the remedies that could be used to deduce the depression is the use of a probiotic strain called lactobacillus acidophilus. Again, it is one of the good organisms that are probiotics. Now there are many aspects of this gut brain access that have been recently validated. So even though we know that the brain affect the gut and the gut affect the brain, scientific evidence to support this is really becoming more and more clear. And we are seeing more and more data to show that this communication is important, not only in our gut, but also in different parts of our body, including depression.
Andrea Wien: Now, how is this communication happening? Because it's not happening like you and I are talking to each other. So how is the brain actually talking to the gut and vice versa?
Dr. Mahmoud Ghannoum: This is really, again, another important question, because there are separate parts. How does that work? I can tell you the gut-brain communication, how it happens is that there are a number of systems that can facilitate this communication. For example, the autonomic nervous system, the enteric nervous system, which is in our gut as well as the neuroendocrine system, the hormones, as well as the immune system. All of these work together, but of particular interest is the vagus nerve because the vagus nerve is the primary connection between the brain and the intestinal track. So let me tell you first, what is the vagus nerve? This nerve runs from the brain through the face and thorax to the abdomen. And it was shown that this vagus nerve can affect the central nervous system effects on behavior. There are animal studies to prove this. What they showed that if you remove the vagus nerves, animals then will not show behavioral changes or central nervous system changes.
So this is really very strong evidence that the vagus nerve is one of the tools that combine this. Now there are other ways which I can give you where the brain affect our gut and then the microbiome affect our brain. So if we want at the beginning to look at how messages from the brain affects our gut microbiome. And the good example is when we consider cortisol. Now, if you have changes in the level of cortisol, we are going to have an effect on our body where our body response to stress. And once you have increase in the stress, this will lead to gastrointestinal or gut disturbances, which in turn cause an imbalance or dysbiosis in our gut microbial community. So you can see the brain, the message from the brain, the cortisol is affecting the community. And when this happens, we can affect a number of the situations.
Like for example, these changes impact our eating habits, nutrient absorption, as well as weight management. Now the other way, now, if you look at it, how our microbiome send messages that affect our brain. And that can be seen when we have imbalance in our gut microbiome, which means we have disturbance our microbiome organisms in our gut, both bacteria and fungi, they are not balanced. When we have this imbalance microbiota, these microbes start to send chemicals or what we call neurotransmitters are released in the brain. Such as the best known is the serotonin, for example, and dopamine. Now these chemicals, as you know, impact our mood, increase anxiety and depression. And may bring about not only this. This was of course, as you know, depressed people or they are anxious. They tend to eat more.
So it changes our eating habits. It could also cause other disturbances to our gut microbiota. Now, when this happens, again, we have certain changes. For example, these will affect our mood. They will increase our stress and anxiety and they lead to decrease food intake.
Andrea Wien: The Microbiome Report is brought to you by BIOHM Health. Want to take action to improve your gut, but don't know where to start. Take the first step with BIOHM's Gut Report. You'll receive a full measurement of the bacteria and fungi in your gut, as well as actionable recommendations on exactly how to optimize your gut health from BIOHM's team of microbiome trained nutritionists.
I think that you made such an important point about the serotonin too. And I think a lot of people don't know that the majority of the serotonin in your body is made in the gut. So if you have dysbiosis going on, then forget about it even getting up to the brain. It's not even being produced in the gut because you have microbes that are out of whack or leaky gut or some other symptoms that might be going on that are really impacting the gut's ability to do its job. So we're so focused on things like SSRIs and medications for depression and anxiety, but it's like, if you don't even have the product to begin with, then we certainly can't make it more effective in the brain if it doesn't exist there.
Dr. Mahmoud Ghannoum: Absolutely. That's why it's really very important that we focus on our gut microbiome and try to bring it to balance. Because as you said, you will create an optimal environment so that your gut speak to your brain and vice versa, and you will have homeostasis or balance.
Andrea Wien: Let's come back to this new study because I think there's been some information out there that probiotics maybe aren't very helpful. People are taking them. They don't really know why. So there's been almost a reversal of the good news on probiotics, but there was a new study that was recently published and it looked at probiotics that were taken with or without prebiotics. So prebiotics really being the food that these bacteria are eating. And it found that using these products helped to ease depression in the study participants. So we mentioned that this could have been helpful because it was flooding the gut with those strains that could have been low.
It could have been increasing the diversity of the strains if people didn't have these, but what else may have been going on? Is there potential that these probiotics were helping to maybe heal some gut linings? What else might've been happening?
Dr. Mahmoud Ghannoum: I think you are touching upon a very important point, which is okay, we take probiotic, we balance the gut. So what happens there? A number of things happen. Number one, when you have these probiotics, what they do, they give support to the beneficial organisms in our gut. When these beneficial organisms are happy and growing very well, they start to produce chemicals or metabolites. And these chemicals play a role to improve our immunity and also to increase the communication between our gut and brain. Some of them, a lot of people talk about they are called short chain, fatty acids. And these short chain acids, when they are produced, they play a role in improving our immunity. And by improving our immunity, we have really anti-inflammatory cytokines so we can reduce the inflammation. So all in all this will come down and start to improve our mood and feel much better.
Now you mentioned about the prebiotic. Prebiotic is another way, instead of using the probiotic, which as you know, live organisms or good microbial strains. The prebiotic basically when we use them, what we are doing, we are feeding the good bugs again. And of course, once you feed them, they are growing, not only they produce the metabolites, which I mentioned, or the good molecules that will help us. They also keep the bad bugs, such as candida, such as E. Coli under control. And once you do this, you are going to improve your gut lining because these bad bugs, they come together. They form a biofilm over our gut lining and they start causing damage, which leads to leaky gut. So having good support of the beneficial organisms, guess what happened? They will have better communication with our brain. They will get rid of the bad bugs.
So we don't have damage to gut lining. Another important thing, once you get rid of this biofilm that is formed by the pathogen, you are going to increase also nutrient absorption. So you are going to increase, for example, vitamin C absorption. In fact, we published a study where we showed that using a probiotic like the one we discovered and developed at Biome is able to break down these biofilms. And by breaking those biofilms, we showed that we had an increase in vitamin C absorbance, as well as casein, which is a good protein present, for example, in dairy.
Andrea Wien: So what happens when people stop taking the probiotics? These people on this study, their depression was eased. They found some relief. They started to heal. What happens if they stopped taking them, are their depressive symptoms going to come back?
Dr. Mahmoud Ghannoum: This is really what happens. Remember we talked about having a probiotic, but to answer your question, I want to expand a little bit about the probiotic are not panacea. You really need some other things to support them. So having probiotic is good, but you need have a more holistic approach, will be necessary to make sure you have your balance microbes. And of course, as a result of that, you are going to have less depression. Specifically, we need to eat more nutrient dense meals. We need to have more vegetables, more resistant starch. While at the same time, we should cut back on fast food and refined sugars. Because it has been shown that refined sugars really support the growth of the organism or the fungus called candida, which is a bad news. Well, we talked about probiotic. We talked about good diet, but in addition, it's very important that you have a good lifestyle.
What I mean by that? What I mean is that it will be important to do some exercise. It doesn't have to be really intense exercise. Moderate exercise is very good. Try to improve your sleep, seven to eight hours, if you can. You should also try to relieve your stress. So once you put all these together, you are going to balance your gut and then you are going to feel great. So now the question that you asked, what happens if you stop taking probiotic. Now, it all depends on where you are in your microbiome balance. If you already took a probiotic, you followed all these approaches, which I mentioned, the holistic approach. Then your gut is balanced back. You stop taking probiotic, then depression is not going to come back reading its ugly head very fast. How about if you feel that you are not following all these and you need support with probiotic, you should take them.
And if you don't have balance and you stop probiotic, then it is likely that depression may occur faster than when you have the balanced situation.
Andrea Wien: You know what I think is so interesting too. And I'm thinking through this today in preparation for this call, so many more people have been drinking more heavily in quarantine, especially at the beginning of COVID than before. And so we see this rise in depression and also this rise in alcohol use. And those two things combined, there has to be some type of correlation there in my mind. And we did a whole episode with you and Marie Fairbairns about alcohol and how it impacts the microbiome, but there's a strong connection between that anxiety. Perhaps people feel the next day after drinking depression and what's happening to the microbes when they're doused in alcohol. So maybe we could just take a quick second to talk about what the research says there.
Dr. Mahmoud Ghannoum: Well, I mean, the research, as you mentioned, is really very clear. Drinking alcohol to excess is bad news, not only for cardiovascular issues and whatever, but it has direct effect on the microbiome. And we are increasing the bad guys and decreasing the good beneficial microbes such as bifidobacterium, lactobacillus, saccharomyces [inaudible 00:27:02]. So to me in the book, which I published Total Gut Balance, I stressed that it's very important to limit your alcohol intake. Maximum, maybe three glasses of wine a week. Not more because by taking this excessive drink, especially as what's happening in the COVID era in this pandemic, you are causing a disturbance in your microbiome.
And as we clearly discussed, if you have disturbance in the microbiome, you are going to end up having depression and anxiety. So very clear relationship here.
Andrea Wien: So I think what might be really helpful for people, we always kind of give the same advice of either nutrient dense diet, get your stress levels down, sleep enough. It would be really interesting to hear kind of the ideal day or maybe even knowing what you know, as a scientist doing this work. Can you walk us through like, what time are you waking up? What are you eating for breakfast, lunch, and dinner? What supplementation are you taking to make sure that your gut is healthy? Or what would you recommend to someone to get them to a good place that they're dealing with some of these things? I think those specifics could be really helpful for someone to hear.
Dr. Mahmoud Ghannoum: Sure. I mean, what I do, like I wake up very early, especially now I got a new dog. He is about a year old and he wakes up so early. So I come down, I feed my dog and then when he's happy, happy camper, he filled his tummy, I go down and exercise. I have at home an elliptical machine, which I love. I had it for many years actually. And what happens is I enjoy the exercise while watching a little bit of television. I try to avoid watching the news. Honestly, it is depressing. So it's good to try to listen, to watch other television programs while you are exercising. Even you will love some cartoons or this morning I was looking at and they started to watch Tom and Jerry. I was laughing because it reminded me of my little kids when they were growing up.
It is such fun. Even now I still find it funny. So that's one thing. After I finish, I go up and we have coffee and breakfast with my wife. I eat oatmeal. I eat berries. I really tend to have a lot of oatmeal. I love it. If I want a little bit of sweetness, I have maybe one spoonful of honey, but that's about it. And after that I go to work. At about 10:00, I have a little bit of snack. Usually it's nuts, pistachios. I try to have a variety, even though I think pistachios have been shown to be the best of all knocks for microbiome. But I like to have elements and other stuff. And then at lunch time, these days I am eating salad and I have a small tuna, where it's really in water.
I add it there. I add some lemon to it because it's a lemon, I love. Lemon and fish. So that's what I do. Then in the evening, I come home and my wife, she is really preparing lovely food for us where it's mainly like, for example, we had salmon. I love salmon. It's so great. Not only from the taste, but also have omega-3. It has good proteins. And also we have vegetables which are roasted as well. So this is really what I eat a lot of the time. Sometimes I love sweets. So I have a small piece of chocolate. I love chocolate, especially dark chocolate. My wife, she hates that. She like her regular chocolate. So each one of us would have his own little piece. But by that time, because these days I'm very happy, but also I am tired, maybe 8:00, 9:00. I am just dead.
I sleep on the sofa or lie down in the sofa. And my wife is watching films. And to me it's always a new film because I never finish it. So that's how I do. I spend my day.
Andrea Wien: And we were talking about how busy everything is right now. Do you have any stress reduction techniques that you like to do, if things are really getting crazy?
Dr. Mahmoud Ghannoum: Yeah. I mean the first thing I've mentioned, I have my dog. I love to take him for a walk. Even the evening when I come, I take him for a walk. And oh, it's really very relaxing. Also, during the day, especially in the afternoon, I forgot to say. I'm so busy. I am tired, especially so many Zoom meetings, so many calls. I just stop for about 15 minutes, close my eyes and just think about nothing. Try to really take it out. And in the evening also what I do, I just put my phone up away in my office so that I don't listen to it, or I don't respond to emails. I love at the weekends in particular to go out into the nature. I go for hikes. I love it. Especially these days. And really Ohio has fantastic places to enjoy yourself and just be close to nature, enjoy the beautiful air and the scenery. So that's what I do.
Andrea Wien: I love that you brought up putting your cell phone away. I think so many people are on their phone. The second they wake up, it's checking email or text messages. And then it's the last thing that they're doing before they go to bed. And then they're wondering why they're not sleeping well. And that blue light really I've found has such an impact. And now we're learning in the research. We've seen some of the studies come out that having a cell phone close to your body can really impact the microbiota. I think it's too soon to say, with any definitive proof what's going on there. But I think it is interesting that there could be a connection there as well. So I love that you mentioned putting that away as a stress reduction.
Dr. Mahmoud Ghannoum: It really is. Because these days I sometimes tell people we used to send a letter for somebody. It takes three days to arrive, they respond to you. You don't hear from them, or maybe you have a phone call, but now we have the phone. We have to answer it, even so many robocalls as well, which I'm sure people get. And then you have the emails, you have the texts, you have all these apps, which tells you about something, just came up, Wall Street Journal or whatever. So we are all the time really flooded with these connections, which are not good because a lot of it is you really can wait until later, if you want to see something, but you cannot keep all the responding to all these.
So the cell phone, even though it helped us a lot, and I really liked the technology, but sometimes you really needed to take it in your hand and limit the use of that. Otherwise, it will take over your life.
Andrea Wien: Absolutely. All right, one last thing I want to talk to you about in this realm is fecal transplants. So this is something that is very hot topic right now, especially for some of the C. Diff and things that are really hard to cure, get rid of in hospital settings, especially. But could this potentially be an area to explore in the future as a treatment for depression and anxiety, if we know that those microbes are really driving so much of that gut brain connection?
Dr. Mahmoud Ghannoum: First of all, I really agree with you about fecal microbial transplant is very effective in C. Diff and I attended a number of talks and there are a number of publications where it shows that fecal transplant is really very beneficial in that case. Now regarding fecal transplant for depression and anxiety, I looked at the literature and the literature suggest that fecal transplant may be really a promising treatment option for several neurological disorders. However, available evidence is still scanty and we need to have more studies. Now some of the studies that are available, there are starting to show that this could be very good. And what they're telling us is that fecal transplant appears to be a promising candidate for helping us with depression.
It actually suggests that they have efficacy with a few side effects, as well as adverse events are really low in the papers which I looked at. Now, even though the effectiveness and the tolerability, like it's safe, as I mentioned, or fecal transplant as been reported in these studies, it makes a good promising potential. However, there are some points that we need to really also consider. For example, there is a potential drawback currently in the procedure itself, although the costs are comparable to anti-depressant, it is still really relatively expensive. And a labor intensive process to replace the other psychiatry treatment. Also, the safety of fecal transplant have also not been sufficiently understood and it's associated with stigma as well.
So we really need to go over that and the FDA actually came out and said that we need to be careful with fecal transplant because couple of patients, one of them died from fecal transplant. Another one was really exposed to a resistant bacterial strain. So these issues, they need to be taken into consideration. Now to end up with respect to this point, I really suggest that we really need to do large double blind randomized control clinical trials so that we know what's the effectiveness of fecal transplant in neurological disorders. So it has promise, but we need more.
Andrea Wien: Dr. Ghannoum, as always thank you so much. It's such a pleasure to have you and your wide breadth of knowledge. We really appreciate how much time and effort you put into researching all of these topics for us, so we have a better understanding of what's going on inside the brain and the gut. So thank you so much for your work and we will, of course, talk to you soon.
Dr. Mahmoud Ghannoum: Thank you very much. It's really always a great pleasure, Andrea, and I wish you the very best in this day and age. And one last message to everybody. I am an optimistic person. We are going to get over this. So keep going, keep your confidence and always have hope. Thank you very much.
Andrea Wien: Thank you so much. As always, thank you so much for listening. I am your host, Andrea Wien, and you are listening to the Microbiome Report. As always you can visit us online at biohmblog.com. Until next time, stay safe.
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