Gut Microbiome Testing in Clinical Practice

Join Elena Panzeri, MSc, for an in-depth discussion on the evolving landscape of microbiome testing technologies. This session explores how GutID’s novel approach differentiates from conventional microbiome tests and examines a real-world case study demonstrating how advanced testing can enable more targeted, clinically meaningful interventions.

• Presenter: Elena Panzeri, MSc (GutID)
• Key Themes: Personalized nutrition, microbiome testing, and clinical real-world interventions.

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Gut Microbiome Testing in Clinical Practice:

Transcript

Dr. Sandi: Welcome, Elena. I am just going to share information with our audience about you. You have degrees in nutrition and genetics. You hold a three-year diploma in neuropathy…naturopathy, not neuropathy. And your area of expertise is personalized nutrition based on the application of functional medicine testing, nutrigenetics, epigenetics, microbiome analysis, and metabolomics.

So, without further ado, I am going to turn it over to you. Welcome, Elena.

Elena: Thank you so much. Thank you for inviting me. So, today, I’m going to try to introduce to you the concept of microbiome, and why the microbiome testing is actually essential in precision medicine and in precision nutrition… By the way, I love the presentation before mine. I totally agree. It’s all about the accuracy of testing, okay? It is about actually suggesting the right test to the right people, and only if they are clinically optionable. You do not suggest a test for the sake of a test. You suggest a test if you are sure that you’re going to make some sort of difference in your patient, you know, kind of life.

But anyway, let’s start from the fundamental question. What is a microbiome? I think there is a lot of confusion regarding the microbiome. Many people thinks is a sort of collection of few names, a little bit of parasite, a little bit of bacteria or viral species or whatever. It’s not like that. The microbiome is a very complex, integrated ecosystem. It means that, yes, it is the collection of different kinds of microorganisms. But these microorganisms, they have coevolved in millions of years. So it’s not that any random virus or any random parasite can become part of your intestinal microbiome.

So this is a community. A very well-established community of many different kinds of microorganisms, to the point that now we are talking about all of the holobiont or metaorganism concept. It mean, it’s like having an organism inside your own organism. So it’s a microbial community. It’s made of many different microorganisms. They share the same environment, the food, and they interact with each other and also with the host, so you, the human.

So there are many biotic and abiotic elements in a microbiome, okay? And there is a lot of dynamic interaction. So, even if, you know, just for the sake of clarity, we tend to classify the microorganism in good and bad and something in the middle. So there are the proper pathogens like Shigella, Salmonella. And then there are the pathobiont. So the kind of bacteria, for example, that can become pathogenic under certain circumstances. And then there are the good ones, right? Like the mucosa protective, the short-chain-fatty-acid producer, or the so-called probiotics. And then the neutral, the commensal.

In reality, yes, we can classify this kind of microorganism in good, bad, or not so good or not so bad. But the reality is, everything in the microbiome is about the right amount, is about the interaction, is about the ratio. So it’s not just a matter of having no pathogen, but is having pretty much everything in the right amount. But at the end of the day, why we care that much about the gut microbiome? Well, because the scientific evidence regarding the effect of the gut microbiome… By the way, there are many other microbiomes. Obviously, there is the oral, the vaginal, the skin, but there is even the bladder, the liver.

But, today, I’m going to focus only on the gut microbiome. So why we are interested in gut microbiome? Because the scientific evidence actually telling us that what is happening in the gut microbiota, it can affect pretty much all system of the body. So the evidence is actually overwhelming. So, pretty obviously, the gut microbiome is affecting digestion, absorption, the barrier integrity, so intestinal permeability, leaky gut, and stuff like that. But, in reality, the gut microbiome is affecting metabolism, immune function, inflammatory responses, and then there are many gut axes. The gut-brain is by far the most famous, but there are so many other gut axes.

So, basically, the composition, the ratio, the interaction of all the organism living in the gut microbiome can impact pretty much all the body system. And then they are very sensitive to anything that is happening inside and also outside. So they are shaped by the diet, by the medication, by the supplement, by the stress level, the lifestyle, pretty much everything. But also the other way around is correct. So what is happening in your microbiome can affect the way you respond to medication, for example, immunotherapy, or you respond to stress or lifestyle. So it’s a very complex kind of interaction.

Okay. So, if we agree that the gut microbiome is super important and is affecting the risk factor or the health or the biology of pretty much everything, but why do we test the gut microbiome? What is the actual clinical meaning of testing the gut microbiome? Well, we pretty much all work in functional medicine, and in functional medicine, we say, “We test, we do not guess.” So, if you have a patient with a lot of symptoms, you need to understand why these symptoms are actually showing up. What is the actual root cause of the problem? And the gut microbiome is a very good place where to start.

And then you use the microbiome testing also to personalize the intervention. So, for example, I see over and over again a lot of patients taking too many supplements. And the vast majority of the time, they are in contradiction to each other, or they are causing problems. One of the problems, for example, is taking too many probiotics or the wrong kind of probiotics. I usually receive a lot of criticism when I say, “Wait, you need to be careful regarding the probiotics. Not all probiotics are exactly the same or they are needed or they are good.”

So, for example, if you look at this target plot, this amazing representation, then I’m going to tell you exactly what a target plot in our microbiome test actually is. If you look at this patient, she’s a patient in her 40s, and she has a lot of bloating, a lot of pain, a lot of bloating. And she’s been taking probiotics for two or three years. And look at the side effect of the probiotics. Basically, half of the gut microbiome is made by one Bifidobacterium longum. So what is the problem? Bifidobacterium are good bacteria, right?

Well, yes and no. They are good bacteria when they are in the right amount. Half of the gut microbiome made by one Bifidobacterium is really not normal. And, by the way, Bifidobacterium, they ferment. They ferment a lot. So the cause of the problem wasn’t an infection, wasn’t parasite, wasn’t anything else. It was the misuse of probiotics. So you do a gut microbiome test to choose the right kind of supplement or to stop some supplement. And then from a clinical point of view, a gut microbiome test is very useful to decide, “Okay, what is the priority in my intervention? Do I need to work on the short-chain-fatty-acid producer? Do I need to reduce the pro-inflammatory bacteria? Where do I start?”

And then, obviously, one of the most important tools is about prevention. If I see signs, for example, of some bacteria that can increase the risk of cardiovascular disease or even cancer, it’s pretty obvious because we are talking about precision medicine and personalized nutrition, they’re going to try to mitigate the future progression. So I want to change the microbiome now, before the actual disease is present.

And, finally, one of the main reasons why I’m using a microbiome test is about the patient, is about the patient engagement. I want the patient to be part of the process. I don’t want my patient to sit there, and say, “Okay, you tell me whatever you are thinking, and I’m going to do whatever.” I want my patient to be an active part of the process. So, for example, they are eating a lot of processed food. They are not eating enough fiber. They are drinking a lot of alcohol. If I can show the actual effect in the gut microbiome and maybe the changes after two or three or four months when they change the diet, when they start sleeping better, when they stop 10,000 medication supplement, you see the changes in the microbiome, and it’s very powerful. So this can actually increase the adherence, the motivation, and the actual involvement, engagement of your patient.

Now, one of the main problems in microbiome testing is that there are many people who actually believe that the microbiome is always changing. I keep hearing stuff like, “Oh, but the microbiome is different from morning to evening. Oh, it’s going to change based on circadian rhythm or season or during your menstrual cycle.” This is absolutely not true. Your core microbiome is incredibly stable. So you have a sort of fingerprinting, and normally, this core microbiome is made at the very beginning of your life, in the first three years of your life, and it tends to be very consistent, very stable.

Of course, there are some short-term fluctuations, but normally, the fluctuations are due to very specific changes. It’s pretty clear that if you take antibiotic, of course, you’re going to destroy your microbiome, even in a matter of four or five days. But, usually, you need to have very important perturbation to change the microbiome. Otherwise, the microbiome tends to be very stable, very resilient.

I think one of the misunderstandings is to confuse changes in the microbiome composition with temporary functional changes. This is different. So the genes in the bacteria, for example, living in the gut, they can express different function based on what you are eating, the time of the day, or whatever, but the overall composition is incredibly, incredibly stable.

Now, testing, because at the end of the day, I want to tell you which kind of test you can use. I agree, again… I need to say, again, I totally agree with the previous presentation. You need to ask the lab that you chose to actually implement in your clinical practice. You need to ask very specific questions. So when it comes to the microbiome testing, do you know which kind of technology the lab is using? I can tell you the vast majority of my colleagues, they have been using exactly the same, not really microbiome, but GI assessment for years and years, and they don’t even know the technology behind it. And this is crucial.

So these, one, two, three, four kind of technology, are the normal technology that you’re going to find right now in the market. And then I’m going to tell you exactly why we are different. So, if we are talking about genetic sequencing, you can find still…although it’s very, very old, you can still find what we call the 16S. In the 16S, you are able to identify only a very specific part of the ribosomal genome of bacteria, but you can only reach the genus level. What does it mean? Genus level is like saying, “Okay, I see a lot of Bifidobacterium, or I see a lot of Clostridium.” But from a clinical point of view, what is the meaning? What are you going to do with this kind of information? There are many different kinds of Bifidobacterium. There are many different kinds of Clostridium. Some are very, very bad, like the C. difficile. Some are very, very good. They are even probiotics. So using the 16S, basically, is not very useful. It’s not good enough.

The vast majority of microbiome, proper microbiome testing in the market, they’re using shotgun metagenomics. What does it mean? They actually sequence everything. They sequence the DNA of bacteria, viruses, fungal species, even protista, parasite, everything. What is the problem? In the shotgun metagenomics, you use a technology that, basically, shatter the DNA in billions of billions of pieces. So the problem is about the reassembly. When you try to reassemble, the genome of all the species is incredibly difficult. So from a bioinformatic point of view, it’s a lot of work. Plus, they make mistake because the reassembly is so difficult. But the main problem with shotgun metagenomics is that they are database dependent. So, if something is not in their database, is not in their library, they’re not going to see it. And this is a big, big limitation.

The other possibility is PCR. PCR is a very common technology, okay? For example, every time that you have an infection or acute GI, you know, infection, gastroenteritis, you can use PCR all the time. PCR is very specific. Is kind of accurate, but it’s very limited. You cannot do a PCR test for a microbiome because there is only a limited number of bacteria or whatever that you can actually see.

And, finally, there is the possibility to do metatranscriptomics. I’m not going to say the name of the test. It’s very famous. There is only one on the market. And they are doing metatranscriptomics. So, instead of looking at the genomes of all the microorganism in the microbiome, they look at the RNA at the transcript. Unfortunately, this is not really useful because it’s only a snapshot. If you ate, I don’t know, a lot of lentils and fiber and polyphenols the day before the testing, obviously, you’re going to transcribe…I mean, your bacteria, your viruses, or whatever, they’re going to transcribe very specific area. So it’s not useful to actually look at the entire microbiome.

So why GutID is different? Because we don’t have the limitation of the 16S. Clearly, we are not PCR-based, and we don’t have the limitation of the metagenomics. Why we don’t have the limitation of the metagenomics? A, because instead of short read, we are doing very long read. Because we are using a completely different technology, we combine the 16S, the 23S, the ITS region of the ribosome or bacterial genome, and we are able to reach the strain level or even sub-strain level. But, even more importantly, we are database independent. Meaning that every time that we see even a completely new bacterium, we don’t care. We don’t need a library. We’re going to see it. We’re going to identify it. We’re going to tell you, “Okay, this is the name, and this is the strain.”

But when we come to the microbiome, what we are looking in a good microbiome, is it possible to say whether a microbiome is a good microbiome or bad microbiome? Because, again, many critics are saying, “It’s impossible. It’s too difficult. In the microbiome, there are so many metrics, so many microorganisms. How can you define whether a microbiome is normal or healthy? It’s basically impossible.” Not true. There are universal metrics that are always valid. I mean, doesn’t matter where you live, so doesn’t matter the geography, doesn’t matter the diet, doesn’t even matter the age or the sex. These kind of universal metrics are always valid.

One of the most important metrics is what we call alpha diversity. And alpha diversity is made by richness. So the many different kind, for example, of bacteria living in the gut. So the more the better, more or less, but also the evenness. So you want to see as many bacteria as possible, but also equally distributed. Remember, balance ratio is everything in the microbiome.

But then, apart from the alpha diversity, you want to see functional diversity. So, again, doesn’t matter where you live or the kind of diet that you are following, you need to have some core function in the gut microbiome. So you need to have, for example, bacteria metabolizing bile acid. You need to have producer of short-chain fatty acid. You need to have producer of vitamin B, or you must have bacteria metabolizing tryptophan. So, for example, producing indoles. So if your microbiome has all these universal metrics under control, we say it’s very resilient. So it’s very strong. It’s very able to bounce back after antibiotics or stress or surgery, trauma or whatever.

And then, obviously, whatever is in the gut microbiome should sustain the health of the host. So we don’t want to have a lot of pathogen, a lot of pathobiont, a lot of pro-inflammatory bacteria like the Proteobacteria because they have LPS, lipopolysaccharide. So it’s not really a matter of zero pathogen, zero proteobacteria, or zero pathobiont, but it’s about actually keeping everything under control.

Now, in our microbiome test, we represent all the bacteria with this kind of target plot. So we upload all the information of all the bacteria that we see, and we organize it in this target plot. And this is a taxonomic kind of organization. So you’re going to see, at the center, the bacteria, and then you move. The more you move to the external rings, you’re going to see the species, and then the outermost ring, this kind of ring with a lot of numbers, these are the strains.

So, generally, speaking, if you look at these two microbiome profile, even if you are not an expert in microbiome, what is the main difference? If you look at the microbiome profile on the left, you see a lot of colors, meaning a lot of diversity. But it’s not just about the diversity. There is a very nice distribution. There is no bacterium, for example, is overgrowing. They are very nice. But if you look at the microbiome profile on the right, what is the problem? The problem is, number one, the lack of diversity. I don’t see so many lovely colors, so many different strains, but then it’s also the lack of evenness. There is one specific bacterium overgrowing. And it’s not a bad bacterium. This is, unfortunately, callanderi. It’s a completely normal commensal. So the problem is not about the name of the bacterium, but how they are distributed and how they work together.

Let’s talk a little bit about the good bacteria, like the probiotics. Do you need a lot of probiotics? Absolutely not. Gut microbiome health is far more than, more is better. You don’t want to see a lot of probiotics. You want to see the right amount of probiotics, okay? Because the balance is far more important than just the number. The same is for the mucosa protection, like the Faecalibacterium prausnitzii, the Akkermansia muciniphila. Yes, you want to have it, but not too many. Exactly the same for the short-chain-fatty-acid producer. Generally speaking, they decrease the inflammation, they support the immune tolerance, they support intestinal permeability, but too many short-chain fatty acids, or maybe the ratio is not quite right, is a problem. It’s another sign of dysbiosis. So you need to look at the microbiome and interpret the microbiome, again, as an ecosystem.

Now, the problem is…okay, let’s say that you understood that the microbiome is very important, that you can test it in a very accurate way, but then what? Because the real question is, “Okay, I have a very nice test. I see the result. But can I do something to change the microbiome?” Well, obviously, yes. This is what I do every single day. And you can change the microbiome even when it’s very, very bad. This is a patient of mine. She’s a doctor, actually. She has two kind of cancer. And this on the left was her microbiome profile when she came to me. The microbiome score was, well, obviously, zero. She did have a lot of pro-inflammatory bacteria, a lot of pathogen, E. coli, Shigella, and a huge amount of procarcinogen Fusobacterium.

Now, look at what happened after simply six weeks of intervention. The microbiome profile is completely different. So you, basically, don’t see any Fusobacterium. There is very little E. coli. There is no Shigella anymore, and you can even see some Akkermansia muciniphila. I didn’t give any Akkermansia as a supplement. Simply, the microbiome has regained the balance on its own. So, yes, you can change the microbiome profile. Diet is fundamental, okay? I mean, in these cases, diet alone is not going to be enough, okay? You need to use a very specific supplement. But most of the time, if you want to maintain very good results, you need to do some sort of lifestyle intervention. Diet, physical activity, stress level, sleep, everything is going to maintain the very good results.

Caution with supplements. I told you, please do not tell your patient or your customer to take many supplements altogether, especially when you’re trying to rebalance the microbiome. Choose one or two supplements, stay with the supplement, check and track the changes, and then you can add something else. The more is not the better. Your microbiome is going to look very, very strange when you are taking a lot of supplements, and then monitor. Because you cannot have a simple baseline and then leave the patient. You need to keep testing and then decide what to do. Now, there are different kinds of intervention, and this is going to be my very last slide, and then I will be more than happy to answer as many questions as you like.

Now, what can you do for the microbiome? To change the microbiome, it really depends on what is your special field, okay? If you are like me, a proper functional medicine clinician, and let’s say, you see a lot of Fusobacterium, a lot of pathogens, or very bad bacteria, you need to use very strong antimicrobial, okay? If you don’t have any confidence, you cannot do that. So you need to ask maybe a clinician to do something like that.

But let’s say that you’re a health coach, and you already changed because you asked maybe a colleague to use some antimicrobial. What can you do to keep the results? Well, you can do a lot, like dietary intervention. You can start combining fiber and polyphenol and fermented food. You can even start giving prebiotic, like FOS or inulin, or you can try different kinds of diet, or if you are very, very confident, you can start personalizing even more. So at the end of the day, if you have a very accurate test, you have accurate results, and you can do something. If you’re not confident about the accuracy and the reliability of the result, do not do anything. Do not start actually suggesting Akkermansia randomly or any other probiotics or butyrate. So everything has to be guided by a very precise and accurate testing. Otherwise, the risk is that you’re going to give the wrong recommendation. And this is it.

Dr. Sandi: Thank you for that wonderful presentation. And I think what we’re all hearing, test don’t guess, and also the power of health coaches to provide education and to help people become questioners, to be aware of the many types of testing out there and how some of them might not be as accurate or as well researched as others. So I want to make sure we turn to some questions for you. So are you still enrolling in the Parkinson’s gut research?

Elena: I am. Yeah, actually, I just started.

Dr. Sandi: Okay.

Elena: So we are doing many different kinds of research. I base in London, in the UK. So my patient, my participant are here in London, but we are recruiting in the U.S. as well. So please reach out.

Dr. Sandi: Okay. Devin says, “Yes, it’s important to help people think critically about their food. How do you encourage this safely in regard to…I’m not sure, ARFID?

Elena: So the problem is about education. Start with the supplements. Let’s be honest. Many patients, because supplements are actually available, you don’t need a prescription. You start listening to a podcast or reading some book, and all these patients are taking A to Z. And the problem is they don’t know what they’re doing. They don’t know the side effect. So my role, or the health coach role, is to actually educate. When you are taking a microbiome test, as I was saying before, the best approach is probably to stop all the supplements, and then reintroduce one by one, and then see the effect because this is a scientific approach. This is evidence-based. If you start taking everything because you are believing they’re going to do something good is a problem, is really a problem.

Dr. Sandi: Very, very wise. So, hyperpermeability leaky gut, is it possible to repair the junctions, and…? Can you speak on that?

Elena: Absolutely, yes. First of all, what is the cause? You need to find the root cause of leaky gut. Why there is an increased permeability? It could be the inflammation. So, for example, you look back at the microbiome test, and you see there are a lot of pro-inflammatory bacteria. So, first of all, you reduce the source of inflammation. Or maybe the inflammation is coming from alcohol or ultra-processed food. So, again, you look at the root cause of the problem. And then you start repairing, okay?

So I normally follow the classical four hours or five hours of functional medicine. So, if there are some bad bacteria, I start with the removing. And then little by little, I repair. Can you repair the mucosa? Absolutely, yes. For example, glutamine. We do have a lot of targeted supplements that reduce the mucosa inflammation and intestinal permeability. But, first of all, target the root cause. What is causing the increased intestinal permeability?

Dr. Sandi: Great, that makes so much sense. Carrie wants to know about molds in our environment, pesticides, fungicides. How are they causing major disruptions in gut healths over time, or are they?

Elena: They are causing a lot of disruption, but also taking antifungal medication or supplement can cause a lot of disruption. So, I know mold is very important. By the way, in our test, we look at the bacteria. We don’t look at the fungal species. But even if you are doing some sort of protocol against mold, please test the microbiome. Because it’s possible that some of the supplements are actually disrupting the microbiome stability. So, be careful. If you are taking medication, even more, even more important.

Dr. Sandi: I think that’s a major thing, to be careful and have awareness of these effects. Can the GutID microbiome test identify species which may be facilitating peanut allergy?

Elena: The problem is we identify any kind of bacterial species, any strains. Is it possible to actually link a specific bacterium to a specific allergy? No, I don’t think it’s possible. I don’t think it’s possible because it would be very easy. I mean, you eliminate the bacterium, you eliminate the allergy, which is not possible. But, again, you can look at the overall composition and improve the resilience of the microbiome. Again, looking at the immune activation, the inflammation, the short-chain fatty acids. So it’s not that specific only for peanut kind of allergy or any kind of allergy, but you can improve the overall environment. That’s for sure.

Dr. Sandi: Suppose there’s a practitioner, would you recommend a practitioner use something else if they’re using a current PCR testing? And why…what’s the procedure?

Elena: I specifically mentioned PCR because there are so many tests in the market, very, very famous. They are using PCR. It’s still okay if your patient has a very acute situation, like a gastroenteritis or a food poison, basically, you can use a PCR test. If you want to look at the overall microbiome composition, PCR is absolutely not the correct one. Absolutely not.

Dr. Sandi: Okay. I think we answered that. We’ve had a number of questions come in about that. What kind of Ig test would you recommend, let’s see, here in Italy?

Elena: So, Ig test for food sensitivity?

Dr. Sandi: I think, yeah. Why does it…? Yeah.

Elena: Yeah, yeah, yeah. There are many kinds of lab. If we are talking about lab, there are different labs here in Europe, in the UK, in the U.S. exactly like the previous panelists were saying, IgG testing is a little bit controversial. I mean, it’s not a proper allergies, so it’s not IgE. It’s something in the middle. We know that there is some sort of immunological reaction, but we are not 100% sure. Still, it can still guide your clinical decision. My personal view is to look at elimination diet. If you have any doubt, better to go with elimination diet, which is the core standard, and then little by little, you reintroduce the food. This is the best way. It costs nothing, by the way.

Dr. Sandi: Yes. And that is something that health coaches can support people through very successfully. Recommended ways to account for different dietary patterns, like carnivore, ketogenic, Mediterranean, when looking at interpreting gut microbiome results.

Elena: Hundred percent. Hundred percent. Again, there is no perfect diet for everyone. Personally, I use a low ketogenic diet, especially for Parkinson’s patient or patient with neurodegenerative disorder, but it’s not the diet for everyone. So every time that you are implementing a very specific diet, especially when it’s keto, low carbs, paleo, something like that, you need to verify the side effect. For example, some Bifidobacterium, they’re going to completely disappear in a low carbs. Why? Because they love fiber and very specific fiber or in a very low FODMAP diet. So it’s still okay as long as you are checking the side effect on the microbiome, and then you can correct.

Dr. Sandi: I think we already answered… I think we know your answer, your take on the five-hour protocol in combination with testing. In favor of that. And do you have a discount code for your test?

Elena: We have. I forgot to actually share it.

Dr. Sandi: We will share that. Rest assured, you will get that.

Elena: Yeah, we are offering a 40% discount for today.

Dr. Sandi: Okay. Fantastic.

Elena: I can encourage anyone to actually take the test, and then I’m going to help them interpret the results. Because if you are not taking the test for yourself, it’s so difficult to actually understand the real meaning and how powerful is to have microbiome test results.

Dr. Sandi: Yes, yes. And the beauty of these tests is that as a health coach, as your role as can provide education, you ask the right questions, you suggest, or they themselves, the clients are going to try lifestyle changes, and then you might suggest repeating that test. A question came in. How can you categorize a microbiome profile? Is 0 out of 100 or higher?

Elena: Okay, we do have a microbiome score, and we do have some algorithm, okay? And the algorithm is taken into…is a bioinformatic kind of calculation. So it’s quite complex. But to simplify in the microbiome score, we are considering metrics, like the percentage of Fusobacterium or the percentage of pro-inflammatory Proteobacteria or the resistance, so the possibility to carry antibiotic resistant genes. So we are calculating all the major metrics, and then we come out with a very specific microbiome score.

Dr. Sandi: Okay. How can they contact you regarding the Parkinson study?

Elena: You can reach out directly to my email to GutID, and then I can answer.

Dr. Sandi: Fantastic. Okay. Well, we are coming to the end of our time together. “And do you see health coaches recommending this type of tests?” And I’m going to answer that. So health coaches can increase awareness that these tests are available. And as you have heard from other presenters, health coaches can make sure that what if…they can do the homework to help to understand differences, like they can educate clients on what is being measured, accuracy, the reputation of the company, and then they can provide that, and they can support people to become empowered. So it’s not you recommending as the health coach, but it is the client recommending for themselves like, “I’m going to do this. And I’m going to take charge of my health,” and that is most powerful.

So as we come to a close, I want to thank you. That was a really powerful presentation, and we are excited for your work. And it’s really been an honor to have you here today to provide this education. And, yes, we will follow your work, and best of luck, and very exciting work that you are doing. So thank you for being with us. Bye now.

Elena: Bye.