There are a variety of strategies being pursued to make pharmaceutical products out of microbiome research. Broadly those are: 1: "bugs as drugs" - genetically engineered microbes that perform some function. The idea here is that having the microbe in situ performing some function will be a much better way to administer a particular compound (or set of compounds), or remove a compound, than a traditional pharmaceutical. Large pharma companies have studied phenylketonuria as a metabolic disease for which the bugs as drugs approach would be great. Find a microbe that consumes phenlyalanine at a high rate and administer it at high levels (or get it to stably engraft in the host) and you have a treatment that would be vastly better than current dietary regimes. 2: "community engineering" - this takes many forms from fecal transplant, to trying to engraft a certain small cocktail of strains, to altering what the in situ community is doing by feeding a probiotic. The idea here is that there are tens of thousands of metabolites that microbes are producing in the gut, and by balancing or tailoring the set of metabolites that are made, you can improve health. Fecal transplants have good data for clearing recurrent C. diff in phase III clinical trials - this is the best developed of the microbial therapeutic strategies currently. Everything else is phase I or before. 3: "microbial natural products" - this is the world I work in (shameless self-promotion - if you want to come work at a very early stage microbiome startup email me at [email protected]). The idea here is to find the particular chemicals/metabolites that microbes make that have positive influences on our physiology. Most research here is focused on immune conditions, metabolic syndrome/dietary stuff, though there is increasing interest in depression and other conditions.

At a broad scale, I would say it will be 1-2 years before fecal transplants receive approval as a therapy for recurrent C. diff infection, at least 5 years before a bug-as-drug will be available, and at least 7 years before a microbe-derived natural product is on the market as a pharmaceutical. It takes an incredible amount of work to get from these associational studies to a pharma-grade product.

In the interim, I think there will continue to be a bunch of diagnostics and probiotics companies that (IMO) are bordering on absolute nonsense. There is very little predictive value to the tests supplied by most of these companies, and the data on probiotic efficacy is bad in humans. There is good evidence of probiotic and prebiotic effectiveness in animal husbandry (e.g. fish and livestock) but the data just aren't there in humans.

Thank you, appreciate the breakdown. With so much focus on the gut research recently I feel like we are on the cusp of bringing together lots of things and new understandings and that hopefully happens soon

Also have an IBS diagnosis.

Had a great doctor that helped me get started, after many that did a shoddy job, and this has been my experience as well.

Very much a 'seems like IBS, try low FODMAP, see what works and doesn't via experience,' which was pretty amazing/alarming how little is understood about our guts.

I'd love to know when the science is going to start catching up. Especially since I think it'll be interesting to find out if something has been added to our diets that's causing an increase in intolerance over the last decade+.

I'm in the same boat as you. After some clueless doctors, I'm in the 'try low FODMAP' phase currently, and for the first time I'm improving.

I mean, we know there isn't a cure for now but it's good to have something similar to a 'normal life' again.

I also have my fingers crossed waiting for science to do its job.

I share your suspicion about current Western diets.

I'm wondering if someone can help, re low FODMAP diet, as I'm finding some contradictory information about which foods are low FODMAP.

For example, at [1], Chickpeas are listed as low FODMAP, but at [2] they're listed as "high". Similarly for Green bell peppers.

Thanks for any help.

[1] https://www.ibsdiets.org/wp-content/uploads/2016/03/IBSDiets... [2] https://med.virginia.edu/ginutrition/wp-content/uploads/site...

I recommend you check out the app from Monash [1]. It’s a paid app but really worth it and its been incredibly helpful for me (I say this as a user, not affiliated with them). AFAIK it contains the largest number of tested foods and they keep adding new foods and retesting and updating older food quantities and list out the specific fodmap associated with each food. From what I have found online, every other source is either outdated or mostly copies the data from here.

ICYDK (From the studies I have read online) Researchers from Monash were the first ones to identify low fodmaps and they continually release research studies in this area.

To answer your question about chickpeas - right now I see 2 different tested versions in the app - one is Canned chickpeas - this says quarter cup (42g) should mostly be fine but half cup (84g) contains moderate amounts of Oligos-GOS (one of the fodmpas).

Green bell peppers - 52g should be ok but 75 to 80g contains high amount of sorbitol.

The app uses a traffic system (red, blue, green lights) to indicate the quantities

[1] https://www.monashfodmap.com/ibs-central/i-have-ibs/get-the-...

Another vote for the app. We've recommended it to others as well. (Only one of my doctors, the last, recommended it to me. I assume the others didn't know about it. All have been family medicine/general practitioners.)

What eventually got me is that certain foods which were listed as low FODMAP were also trigger foods for my symptoms.

So if it doesn't seem to be working, there may have a similar issue.

Thank you.

> Very much a 'seems like IBS, try low FODMAP, see what works and doesn't via experience,' which was pretty amazing/alarming how little is understood about our guts.

Yes exactly this.

> Especially since I think it'll be interesting to find out if something has been added to our diets that's causing an increase in intolerance over the last decade+.

One thing I read is that western diets severely lack in fiber which usually leads to loss of microbiome diversity [1]. But studies like this are still early stages, we need targeted results based on all this to really have any effect.

[1] https://nautil.us/how-the-western-diet-has-derailed-our-evol...