Because our knowledge of the human microbiome is moving so rapidly, we turned our presentation at this conference into a discussion session so experts in the audience could share their professional knowledge and personal experience. By the end of the session, it was clear that we had barely scratched the surface of the importance of our microscopic kin to our health, to sports performance, and to how we need to think about designing research studies. A list of recommended resources is available at: www.caroltorgan.com/microbiome-sports/. We welcome your input!

1. The Human Microbiome
In Sports Performance and Health
Lawrence E. Armstrong, Ph.D., FACSM
Human Performance Laboratory
Dept. of Kinesiology, University of Connecticut, Storrs, CT
Carol E. Torgan, Ph.D., FACSM
Kinetics Consulting, Bethesda, MD
Twitter: @ctorgan
American College of Sports Medicine Annual Meeting
Indianapolis, IN May, 2013

2. Goals:
1.Introduce you to the human microbiome
2.Provide a forum for brainstorming
3.Encourage you to incorporate the human microbiome
in your thinking and research
4.Encourage you to think broadly about your work

3. Your
Creative Ideas!
Share on Twitter:
#ACSMannualMtg
#microbiome

4. Genetics The science of genes, heredity, and variation in
living organisms
Genomics The study of genomes
(all of an organism’s heredity information)
DNA Sequencing The process of reading the nucleotide
bases (adenine, guanine, cytosine and thymine) in DNA
GWAS Genome-wide association studies

5. Microbiome
The community of organisms that live symbiotically in
and on humans.
Microbes, their genetic elements (genomes), and
environmental interactions in a particular environment.
Microbes include bacteria, fungi, protozoa and viruses.

6. The New York Times, Sunday, May 19, 2013

7. The Human Microbiome ProjectThe Human Microbiome Project
www.commonfund.nih.gov/Hmp/www.commonfund.nih.gov/Hmp/
www.genome.gov/27549144www.genome.gov/27549144

8. Human Microbiome Project (HMP)
 Comprehensive characterization of the human
microbiota and analysis of its role in human health and
disease.
 Data set available worldwide for use by researchers in
efforts to understand and improve health.
 International collaboration of ~ 200 physicians,
microbiologists, and laboratory scientists from
~ 80 universities and scientific institutions.

9. HMP MethodsHMP Methods
 242 (129 male, 113 female)242 (129 male, 113 female)
healthy volunteers sampledhealthy volunteers sampled
longitudinallylongitudinally
 Sample 15-18 sites from:Sample 15-18 sites from:
nasal passages, oral cavities,nasal passages, oral cavities,
skin (behind ear, inner elbow),skin (behind ear, inner elbow),
gastrointestinal tract, urogenital tractgastrointestinal tract, urogenital tract
 Researchers have identified > 85%Researchers have identified > 85%
of all microbe genera in healthyof all microbe genera in healthy
adultsadults

10. The human body contains over
10 times more microbial cells
than human cells: approximately
10,000,000,000,000 (1013
) cells

11.  > 10,000 microbial species in humans> 10,000 microbial species in humans
 ~ 1-3% of your body weight = 2-6 lb of bacteria~ 1-3% of your body weight = 2-6 lb of bacteria
(your brain weighs 3 lb)(your brain weighs 3 lb)
 8 million genes vs. 22 k human genes = 360 fold more8 million genes vs. 22 k human genes = 360 fold more
The human microbiome

12.  has a biomass of 2 kg in the adult intestinal tracthas a biomass of 2 kg in the adult intestinal tract
 is a complex ecosystemis a complex ecosystem
 assists with numerous positive physiological functionsassists with numerous positive physiological functions
 digesting food componentsdigesting food components
 synthesizing vitaminssynthesizing vitamins
 releases a variety of metabolites involved in areleases a variety of metabolites involved in a
homeostatic balance between the microbiota and thehomeostatic balance between the microbiota and the
host (Corthier & Doré, 2010)host (Corthier & Doré, 2010)
The intestinal microbiome

13. Nature 473: 2640-2644, 2011

14.  Looking for commonalities and differences betweenLooking for commonalities and differences between
gut microbiomes across different populationsgut microbiomes across different populations
 Combined the data from 39 individualCombined the data from 39 individual
metagenomes (n = 39 Danish, French, Italian,metagenomes (n = 39 Danish, French, Italian,
Spanish, Japanese, and American)Spanish, Japanese, and American)
 Research is difficult: complexity of sampling, DNAResearch is difficult: complexity of sampling, DNA
prep, processing, DNA sequencing, analysis.prep, processing, DNA sequencing, analysis.
 Physiological, nutritional, and environmentalPhysiological, nutritional, and environmental
conditions varied across individuals.conditions varied across individuals.

16. Interactive
You are encouraged to step to the floor microphones
to introduce your creative ideas regarding future
ways that we can study the microbiome as a factor in
health, sports medicine and the exercise sciences
Format

17. Your
Creative Ideas

18. Please share your ideas!
• How might the human microbiome be involved
in your area of specialization?
• What experimental research designs might be
employed to test your ideas?
• What practical applications do you see?

19. One Example
Scandinavian Journal of Medicine & Science in Sports
22(4): 581 - 582, 2012

20. Exertional Heatstroke
• elevated body temperature
• tissue damage
• systemic inflammation
• increased intestinal permeability, especially at
tight junctions in the gut epithelial membrane
(Dokladny et al., 2006)

21. Advanced Exertional Heatstroke:
Hyperthermia with Collapse & Hypotension
Shock:
• endotoxin
• lipopolysaccharide
• endotoxemia
Intestinal Epithelium

22. http://www.horseshoecrab.org/med/img/Endo.jpg
Bacterial cell
membrane will
degrade due to
action of
antibiotics,
immune system
action, and
severe
hyperthermia.
This will release
pieces of the
membrane into
the circulation.
Gram-negative bacteria

23. http://www.horseshoecrab.org/med/img/Endo.jpg
Lipopolysaccharide
(LPS)
O-Poly-Saccharide
Allows bacterium
to defend itself
against host
defenses
Lipid A
• Anchors the
chain to the
membrane.
• Responsible for
toxicity of LPS
• Treatment can
decrease lethality

24. Endotoxin
• Internal poison (i.e., lipopolysaccharide)
• When LPS enters the blood, high concentrations may
cause cardiovascular insufficiency typical of shock. This
condition is known as endotoxemia.

25. Exertional Heatstroke
The extent of damage to the intestinal wall and the
magnitude of endotoxin leakage into the circulation are
critical determinants of multi-organ failure and mortality.
(Gathiram et al, 1981; Brock-Utne et al., 1988; Bouchama et al., 1991)

26. A Testable Hypothesis
“We believe that gut bacteria represent one intrinsic
modulator of exertional heatstroke.”
Why?

27. A Testable Hypothesis
The intestinal microbiome (gut microrganisms):
• Can be viewed as a virtual organ within an organ
(O’Hara & Shanahan, 2006)
• Mounting evidence indicates that these cells play
a key role in illnesses/conditions such as
asthma, Crohn's disease, psoriasis, and obesity.

28. Exertional Heatstroke
• Tissue cooling reduced intestinal permeability
(Rav Acha et al., 2004)
• Whole-body cooling of human exertional heatstroke
patients reduced circulating levels of
• LPS
• TNFα
• Interleukin-1α
(Bouchama et al., 1991)
This supports the widely-recognized therapy of cold
water immersion as the treatment of choice
(Casa et al., 2007)

29. Exertional Heatstroke
• Prophylactic administration of LPS antibodies (anti-LPS)
reduced morbidity and mortality in primates with extreme
hyperthermia (Gathiram et al., 1987)
• The above facts implicate the gut as a major factor in the
etiology of exertional heatstroke.

30. Exertional Heatstroke
• Animal research suggests that the intestinal microbiome
is more plastic than previously anticipated (Manichanh et
al., 2011). This suggests that the human microbiome may
be selectively remodeled, with bacterial transplants or
specialty pharmaconutrients such as glutamine or
neuropeptides (O’Hara & Kudsk, 2000).
• Probiotics may someday be selectively prescribed to
enhance intestinal barrier function (Brand & Reinecker,
2002) or specific anti-inflammatory effects (Galdeano &
Perdignon, 2006), prior to intense or prolonged exercise in
hot environments.

31. Your
Creative Ideas

32. Please share your ideas!
• How might the human microbiome be
involved in your area of specialization?
• What experimental research designs
might be employed to test your ideas?
• What practical applications do you see?

33. Beetroot juice and exercise performance

34. Methods
“Subjects were instructed to keep a food and
physical activity diary …. to arrive at the
laboratory in a rested and fully hydrated state
following an overnight fast, and to avoid
strenuous activity in the 24 h preceding each
testing session. …”

35. And….
“… to abstain from using antibacterial
mouthwash and chewing gum throughout
the study because these are known to
eradicate the oral bacteria that are
necessary for the conversion of nitrate to
nitrite.”

36. Inorganic nitrate (NO3
-
)
nitrite (NO2
-
)
nitrogen oxides, such as nitric oxide (NO)
Physiological changes
Humans don’t have the
enzyme for this step.
Bacteria on the back of
our tongues do this for us.
Beetroot juice journey

37. Your
Creative Ideas

38. Please share your ideas!
• How might the human microbiome be
involved in your area of specialization?
• What experimental research designs
might be employed to test your ideas?
What controls are needed?
• What practical applications do you see?

39. The Skin Microbiome
Skin = 1.8 m2
of
microbial real estate
Blue circles:
sebaceous or oily
Green circles: moist
(typically skin creases)
Red circles:
dry, flat surfaces
The skin microbiome. Nat Rev Microbiol.
Grice EA, Segre JA. 2011 Apr;9(4):244-53.

40. The Skin Microbiome
Can be affected by:
• Lotions, soaps,
cosmetics
• Temperature, humidity
• Contact with others
The skin microbiome. Nat Rev Microbiol.
Grice EA, Segre JA. 2011 Apr;9(4):244-53.

41. • Teammates share distinct skin microbial communities
• Opposing teams’ bacterial communities converged
during the course of a roller derby bout
• The human skin microbiome shifts in composition
during activities involving human to human contact
• Contact sports provide an ideal setting in which to
evaluate dispersal of microorganisms between people

42. Parents who clean their baby’s
pacifier by sucking on it may
reduce that child’s allergies
in later life.

43. Your
Creative Ideas

44. Please share your ideas!
• How might the human microbiome be
involved in your area of specialization?
• What experimental research designs
might be employed to test your ideas?
• What practical applications do you see?

45. The microbiome interacts with
the intestinal epithelium:
• direct contact
• metabolic products
• fragments of cell wall (LPS)

46. The intestinal
microbiota plays a
role in the
development of the
host’s innate and
adaptive immune
responses
Eur. J. Clinical Nutrition (2002), 56, suppl 3, S60-64

48. Complex interactions between bacteria,
the gut, and tissue immune systems could
be a prerequisite for metabolic disease.

49. Enterotypes of the human gut microbiome.
Arumugam et al. Nature 473: 2640-2644, 2011

50. Previous studies
suggest that gut
bacteria may
influence behavior.
This research in mice
suggests that gut
bacteria may influence
a wide variety of brain
and psychiatric
disorders, such as
depression, autism,
and schizophrenia.
Science News, Oct. 8, 2011, pg 9

51. Nature Reviews. Endocrinology 7: 639-646, 2011
• A number of studies describe characteristic differences between the
composition and/or activity of the gut microbiota of lean individuals and
those with obesity.
• Although these data are controversial, they suggest that specific
phyla, classes or species of bacteria, or bacterial metabolic activities
could be beneficial or detrimental to patients with obesity.
• The gut microbiota is, therefore, a potential nutritional and
pharmacological target in the management of obesity and obesity-
related disorders.

52. A relationship between gut flora metabolism and
CVD pathogenesis may aid development of
novel diagnostic tests and therapeutic approaches
for atherosclerotic heart disease.

53. Your
Creative Ideas

54. Please share your ideas!
• How might the human microbiome be
involved in your area of specialization?
• What experimental research designs
might be employed to test your ideas?
• What practical applications do you see?

55. Factors that may influence the microbiome:
 Antibiotic use
 Birth (vaginal vs. caesarian)
 Diet (food and supplements)
 Hygiene (mouthwash, lotions, sanitizers)
 Built environment (materials, cleaning)
 Social environment (family, friends, teammates, pets)
 Physical environment (altitude, heat, spaceflight)
 What else?

56. The microbiome and the
International Space Station (ISS)
microBEnet
www.microbe.net/project-iss-
microbiome-collaboration-with-science-
cheerleaders
Also see:
NASA
http://www.nasa.gov/mission_pages/station/
research/experiments/1010.html
J. Craig Venter Institute
http://www.jcvi.org/cms/research/projects/a
stronaut-microbiome/

57. Using the microbiome for diagnostics:
 Bacterial biomarkers
 Determine risk /susceptibility for conditions
 Diagnose conditions before clinical symptoms
appear (heart disease, Parkinson's??)
 Diagnose over-training?
 What else?

58. Using the microbiome for treatments:
Fecal Microbiota Transplants (FMT)
 “Infusion of a fecal suspension from a healthy
individual into the gastrointestinal tract of an individual
with colonic disease.”
 Used to treat C. difficile colitis (bowel inflammation)
 Goal: re-establish normal intestinal composition
Diseases = altered / imbalanced microbial composition
T. J. Borody, J. Campbell, Gastroenterol Clin N Am 41, p 781-803, 2012

59. Fecal Microbiota Transplants (FMT)
Procedure
 Donor history (similar to blood donation)
 Obtain stool sample, homogenize with saline, filter
 Administer:
 Nasogastric tube
 Enema
 Colonoscope
 Perform within 6-24 hours of obtaining sample
 Future: frozen samples, lyophilized powder (capsules?)
T. J. Borody, J. Campbell, Gastroenterol Clin N Am 41, p 781-803, 2012

60. Fecal Microbiota Transplants (FMT)
As of May 2013 the FDA requires
Investigational New Drug (IND) application
(Because FMT meet the definition of a biologic therapy)

61. Ethical, legal, social issues:
Should probiotic mixes designed to manipulate the
microbiome be regulated?
Should you take samples of your microbiome when
you are healthy and store them, so you can repopulate
your communities if you get sick?
Will this change what it means to be ‘human’?

62. Could the microbiome
be used as an ergogenic aid?
Instead of blood doping,
could there be bacterial doping?
(metabolism, over-training, travel)

63. Athlete Biological Passport
“The fundamental principle of the Athlete
Biological Passport is based on the monitoring
of selected biological parameters over time
that will indirectly reveal the effects of doping
rather than attempting to detect the doping
substance itself.”
- World Anti-Doping Agency (WADA)
www.wada-ama.org/en/Science-Medicine/Athlete-
Biological-Passport/
Will this become the
Athlete MicroBiological Passport?

64. µBiome
http://ubiome.com/
DIY Science (Citizen science)
American Gut Project
http://humanfoodproject.com/americangut/

65. Your Final
Ideas

66. Please continue our conversation …
Share comments and ideas
Follow the buzz on Twitter: #microbiome
List of recommended references available at:
www.caroltorgan.com/microbiome-sports/
Thank you for participating!