Episode #113: Dr. Ghannoum – The Mycobiome & Key Insights to Total Gut Health

My guest is an infectious disease specialist and one of the world’s leading microbiome researchers: Dr. Mahmoud Ghannoum.

Working at the Center for Medical Mycology at Case Western Reserve University and University Hospitals Medical Center has brought Dr. Ghannoum to find and coin the phrase Mycobiome which is where our fungi and bacterial communities live in our body. Mycobiome is different from our microbiome and important to our overall health.

Dr. Mahmoud Ghannoum was called “the leading microbiome researcher in the world” by The Washington Post. He just released a groundbreaking new article about the gut and its connection with COVID-19 and depression. According to the latest findings, organisms found in the microbiome may be able to predict depression in patients. Considering the mental health crisis brought on by the pandemic, this research couldn’t have come at a better time.

Listen to the episode here:

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Key Topics:

• The Microbiome and Mycobiome [00:01:26]
• Tackling Gastrointestinal Issues [00:03:21]
• Lifestyle and Diet [00:07:05]
• Supplements and Vitamins [00:14:33]
• Total Gut Balance [00:18:51]
• Food to Improve Gut Health [00:24:21]
• What Are Biofilms? [00:34:31]
• BIOHM Health [00:36:49]
• Recognizing Gut Issues [00:39:00]

Dr. Ghannoum – The Mycobiome & Key Insights to Total Gut Health

Dr. Ghannoum, thank you for coming to the show. Before we dive in and talk about fungi and bacteria, could you share your story about how you were taking a holiday from your home in Lebanon and you found out that you and your family couldn’t return home?

Overnight, as if you are in Costa Rica and then you cannot come home, you can imagine. That’s exactly what happened with me.

You studied infectious diseases. This is your specialty but you ended up going to this conference that changed the direction of looking further into the microbiome and the impact of the fungi and the bacteria, good and bad. Most of us know about the good and bad bacteria, but it’s now learning about the fungi. You go to this conference and people are talking about the microbiome. Something about this conference made you pivot and change directions into what you were paying attention to.

When I used to go to infectious disease meetings and everybody’s talking about the microbiome, which is the microbes that live in our body. Everybody was talking about bacteria. I said to them, “No, because bacteria and fungus, as well as viruses, live in us, in the gut. You need to look at the total picture.” That’s where I started to advocate this but then I did a study in Crohn’s disease patients. I’ve found that there is an increase in bacteria, the pathogenic ones like E. coli and Serratia, as well as Candida.

With that, I noticed that they come together, they play together, and they start causing issues in our gut. When I published a paper, it received a lot of attention and so many people contacted me, “What can I do?” That’s where my son, Afif, said, “Dad, you have to start doing more of this to help people.” Honestly, that’s what pushed me into this. I am so glad that happened because it’s such an exciting area. I feel happy because I feel that we are trying to help other people.

Did it surprise you when you started talking so much about the fungi, the relationship, the gut, and even Crohn’s disease? With all of these things, did it surprise you to see how many people were in need of this information? It’s interesting because you go from somebody who’s doing all of these papers and studies and now, you’re interacting so much more with people, patients, and people experiencing these issues. What was that like for you?

[bctt tweet=”It’s important to start addressing your diet. You cannot just take probiotics.”]

First of all, it was amazing to me. When people start talking about, “I did not realize so many people have gastrointestinal issues.” This excited me. As a scientist, in academia, you don’t have this opportunity a lot, where you will start to interact with people and say, “Maybe we can do this. Maybe we can do that.” You will laugh at this. I get so excited. They laugh at me because when I give talks, I am enthusiastic, as you can imagine, and they say, “Why are you so enthusiastic about fungus?” I said, “I love fungus.” It’s changed my life and it also allowed me as a professor to go down and translate what we studied into helping people. As scientists, we don’t need drugs. You are so excited and you are so up because you are trying to help people and do something hopefully that will be beneficial.

Over the last few years, especially people have become familiarized with what the microbiome is and we’re always talking about the good and the bad bacteria, but you’re the first person to phrase the mycobiome and the relationship. I thought it was funny how you said that sometimes. They play well together but if the bacteria gets out of hand and the fungus or the fungi gets out of hand that they play and they become a little bit naughty. Where did you get the idea? Share this idea about the mycobiome.

With the mycobiome, we call the myco because mycology is the study fungus. Mycobiome is the fungal community. What you find is that within a short time diet, you can change the fungus in your gut. Whereas bacteria takes a little bit longer. You can have an impact quickly in this regard. The most important thing is to understand that these organisms influence each other in good and bad. They could be good for us, they are our friends, but if they are out of balance, then they can cause some issues.

It takes time to make a change in the microbiome, weeks and even months. You say that we can start to positively impact the mycobiome even within 24 hours.

It lives in our skin, mouths, reproductive system, and our gut. That’s where a lot of the study is done but everywhere, you have these microbes. I want people to think of microbes are not all bad. We always want to use everything to kill these microbes. Some of them are good guys so we need to help them and that’s what lives mostly in our gut. When you take antibiotics, you kill the good, the bad, and the ugly. That causes issues. That’s why I said that we need to try to do something that we have less effect on this.

I finished a study where I presented it at a meeting in dermatology where you use a narrow-spectrum antibiotic, which means an antibiotic that can target certain organisms, not everything. It had less effect on our gut, which is great, compared to something which kills everything. To me, we can have a big influence on our microbiome by doing a couple of things. Number one is diet. You need to eat the right type of food.

This Western diet is a disaster. We need to make sure we start eating. You know this story, whole food, natural products, eat fish, try to avoid meat, and all of this stuff. Also, you need to eat some fibers to feed these good organisms or good microbes in your gut because they keep the bad ones under control. Diet is one main factor. The other factor is lifestyle. Lifestyle is important. You need to exercise and you know this better than anybody else.

Something that’s important to me, especially the deeper I go into these practices of lifestyle, is somehow figuring out a way not to even put stress around it. We’ve all seen the person who works out perfectly, they eat perfectly, but there’s this rigidness or this stress that gets put around it. They don’t realize that that in itself can almost neutralize the positive effects or even counteract the good stuff we’re doing. Can you remind us about how stress impacts our gut health?

That’s important. That’s why I say lifestyle. Some people say, “I eat everything good.” One lady, for example, sent us samples to analyze her microbiome and it looks terrible. I look at what she eats and she’s eating well. We have a questionnaire where we ask questions and one of them was stress. We looked at the stress and she is severely stressed.

Because of this, we said, “You need to do meditation. You need to do some yoga.” I make people laugh about yoga. I came from the Mediterranean. Many people don’t do yoga there, especially males. I say to people, “You have to do this because it gives you some relaxation. It will reduce stress.” You need to sleep well because if you don’t sleep well, you are going to affect your microbiome. The diversity and number of beneficial organisms go down, and the bad ones, the pathogens, will increase. A holistic approach. Not one thing to do like take a tablet and we are going to be great.

Can we talk a little bit about sugar and artificial sweeteners and how that impacts the bacteria in our gut and gives rise to the bad bacteria or fungi?

The sugar will feed the bacteria that are what we call pro-inflammatory which means increased inflammation. With respect to the bacteria, there is a group called the proto bacteria which is pro-inflammatory, a red flag for inflammation. If you give it sugar, it will go crazy. It will increase. That’s not good for us because we’ll have more inflammation. The other thing is artificial sweeteners. We published a paper and we showed that this bacteria, in particular, goes up.

The other bad guy is the fungus. Candida loves sugar. The more sugar you eat, the more it loves it. That’s why I say that refined sugar is not a good idea. Sweeteners are not good. I gave them an example. When I was a young boy, we used to drink tea. Tea has so much sugar in it. I went to visit my mom after many years. If she wants to give me tea, I say, “No. I don’t want sugar. Just tea.” She said, “This guy changed. What’s happening?” We had a great laugh so now I enjoy the tea. It has a lovely taste but it will not encourage the bad bugs in my tummy to grow.

A lot of this is intuitive for someone like you who grew up in Lebanon where people are preparing foods. They’re eating diets that we have mostly here in the States, this new diet of processed food. Someone like your mother, when she prepares food for you and her family, it’s that care and it’s also that balance. We’re working with these certain oils and certain types of fats. You’re seeing it but also a lot of this is probably intuitive from the way that you grew up and eating a lot of olive oil, good fats, minimized sugar, and things like that. Do you think that you were ahead in growing up like that?

Exactly. This reminds me of my mom. You’re making me happy. I remember my mom where she used to go to the market every day, small grocery. She picks her vegetables, lentils, and other nice healthy food and then goes and cooks. We don’t have all this processed food. It’s all healthy. She knows exactly the amount of sugar or salt, for example, in food in particular. You are absolutely right. It’s not one way or the other. It’s that total or the overall type of things you do, which is important.

This is another message that’s confusing. I’m always trying to simplify things. The type of fat impacts our gut health. Which ones do you lean towards? Which ones show up as ones that support us better?

[bctt tweet=”If you don’t sleep well, you are going to affect your microbiome.”]

Saturated fat will encourage the pathogens to grow and also you have a lot of adipose tissue or fat tissues accumulated. That is why we should eat unsaturated or monounsaturated fats rather than saturated fat which causes a problem.

Have you noticed anything in the supplementation area that seems to support the gut or are you focusing on trying to get people the real food? Is there a balance?

If you can get the real stuff, it’s nicer and tastes better. Whereas with a tablet, you take it and it’s like, “It’s a tablet. It’s not the same.” You will enjoy all these herbs. You laugh at me now because of the garlic. I know it tastes wild especially when you sauté it, put it in the oven, roast it. All of these are beneficial. If you don’t have access to that, then supplementation will do as well but it’s not as enjoyable from my point of view.

I am a big believer that if we could have had the soil that we had before and eat those foods, certainly we would be getting a lot of our minerals, nutrients, and vitamins. Do you have any supplements that you personally like to take or suggest for people to take?

Vitamins are also important for us to take, especially vitamin D, vitamin D3 in particular. Vitamin D3 has been shown to reduce the pro-inflammatory bacteria that can cause inflammation. Also, there are other studies in the fungal field where it shows people who have a deficiency in A, B, and C vitamins have more Candida issues with the gut. Putting some nice vitamins into your diet is important. You can get it from vegetables and other sources. It doesn’t have to be a tablet but sometimes if you have an imbalance and you want to aid it fast, taking Vitamin A, B, and C are good. I highly recommend it.

Dr. Ghannoum, I have to say that you seem like such a self-motivated, positive, energetic, and happy person. I know you’re doing a lot of things and you’re busy. You’ve had a busy life. I can’t help but wonder what your secret is?

My wife laughs at me because I’m a self-motivated guy. Sometimes it’s not easy. Sometimes you have to talk to yourself, “I have to do this.” Even though I don’t want to do it, I need to do it. What I do is I wake up in the morning and exercise for half an hour. I used to have an elliptical. Now I’m doing this bike, which I love as well.

In the afternoon, usually, early evening, when I go home, I love to take my dog for a walk. I take him for walks and I love it. It’s good for him and good for me when you go out in nature and walk. That’s how I manage that. I also manage my diet. I try to control it. Especially at lunchtime, I eat good fruits and vegetables. I love tomatoes so much. That’s what I eat at lunchtime. I’m moderate in eating. Sometimes you feel you love food, you eat it, but then you say, “I should stop.” You have to negotiate with yourself sometimes.

We talked earlier about how certain rituals or cultures develop beautiful and supportive practices. One of them would even be religious fasting and things like that. Where you grew up, there was a great practice of fasting. Have you seen the impact of that? Now we’ve modernized it. Now we have people who are fasting as part of being healthy. It’s not necessarily religious practice but for some people it is. We’re seeing modern-day people using this as a way or tool for better health.

For example, in the Middle East, people fast. Now everybody talks about fasting. Fasting is fantastic in moderation. Fasting gives your gastrointestinal tract a break. At the same time, you have certain other cultural feelings. You feel for people if they don’t have food and this sort of thing. This makes you a better person, I hope. When you break the fast, you need to be careful. Some people, when they break the fast, eat everything. You need to control that. I used to laugh when I lived in Kuwait. People fast all day and in the evening, they eat everything. It’s a day for night and night for day, which is not the purpose of fasting.

If someone were going to ask you or come to you for advice and say, “I want to turn the ship around. I want to make sure that I am taking care of my gut. I know I need to make changes.” You have a realistic, impatient approach to this because all of this does take time.

It’s difficult to change old habits as you know. You need to take your time to transition. For example, in the book, Total Gut Balance, I said that it takes maybe two weeks at least to start to change. This is long-term. None of us can stick to a diet forever. The diet you need to select needs to be customizable. Also, you need to have it delicious. Also, not too restrictive. If you restrict people, it’s not good.

Try to have moderation in things. Slowly but surely, you can move. As you start to see even a little improvement, this will encourage you more and you will start to go more and more in the right direction. Once in a while, if you have to eat something you love, it doesn’t matter. I love ice cream. Enjoy it and then avoid eating other stuff for some time and then you’ll be fine.

How do you feel about something like resistant starch? For people who don’t know, you can take potatoes and bake them. It’s the process of eating them. When they’ve cooled down, it creates something called resistant starch. Are you a fan of resistant starch as a way to support your gut?

Yes. Resistant starch is important to have. We can find them in a lot of stuff. For example, bananas before it’s greenish. Barley, for example. You can have a lot of legumes. You have lentils or green beans. All of those have a lot of resistant starch. Do you know why they are important? It’s because these resistant starch can be broken down by beneficial bacteria and that’s what you need.

[bctt tweet=”You need to look at the total picture.”]

Once you break them down, the bacteria take them as food and it starts to produce small molecules or small chemicals that will be beneficial for us like short-chain fatty acids, for example. About half a cup of cooked mashed potato, six ounces, is good. It’s all in moderation. I love potatoes. Specially roasted and sweet potatoes have a lot of fiber. I take half of the potato instead of eating it whole. That’s what you need to do. It’s all in your hand. It’s not difficult.

Dr. Ghannoum, you hear this message over and over when it comes to overall performance or health. It’s variety, watching what oils we are consuming, having different colors, and maybe eating for seasons. Sometimes it’s hard. People are busy. I almost feel like we’ve also lost touch with eating seasonally. Even going to visit your local farmers market and buying what’s available and trying to get as many different colors into your diet. Maybe we could do a snapshot of a way that we want to encourage people to look at it when they’re trying to navigate this part of their health.

I agree. What type of food to eat to improve your gut? I always tell people that it’s like a garden. In the garden in the summer, we all love our roses. We need to give them good fertilizers, good stuff. We need to keep the weeds out. This is exactly in the food. What you need to do is, on a daily basis, have some proteins with every meal. Try to have good oil like olive oil, extra virgin olive oil, or coconut oil. I love that. When you put the salad with the lemon and the garlic, it’s fantastic.

We talked about resistant starch. Corn and oatmeal are all good. Also, the fruit situation. It’s good to have fruits. At lunchtime, that’s what I do. I have fruits and tomatoes as well as some celery, for example. Another thing I love is nuts, especially pistachio. Pistachio is great for your microbiome. It allows the good stuff to grow. You have some options. For example, low fat or nonfat dairy products. I like to have dairy. It’s not necessarily avoiding the whole milk. Try to take nonfat milk or low-fat milk. 1% or 2% is fine. It has good vitamins like vitamin C. It also has protein and casein. All of this will help you.

At the same time, you need to think, “What do I want to avoid?” We talked a lot about sugar, no added sugar, no refined grains, cured meat, which is processed. Anything of these processes has a lot of artificial preservatives or a lot of sugar, salt, and this sort of thing. You don’t need that. Finally, I will say something about alcohol. I don’t say don’t drink at all but you have to limit it because too much alcohol anyway has other issues.

We’ve talked about food, veggies, oils, and meats. I have no issue with alcohol. Personally, I don’t drink. We know alcohol can impact your overall health but does it have a specific impact on the gut? How do you look at alcohol?

If you like alcohol, maybe take one glass three times a week of red wine or even if you like beer but not too much because it has cardiovascular issues and other stuff. Of course, it will also affect the microbiome, which is not good. It causes imbalance. For me, I’ll say moderation. You can see the message all across the board, moderation is the way to go.

In a lot of conversations, you’ll hear that there is this overgrowth of bad bacteria like SIBO. Have you ever done any studies on SIBO and what did you find? Maybe a lot of people experienced this. Is there a way to tackle this by supporting yourself through better eating, exercise, and these other lifestyle things we talked about? Have you found that there are times that it does require something else?

I did a study. Remember, there’s a diet that I developed in Total Gut Balance. It’s a small study, a proof of concept. It’s not huge. I tried to do a bigger one but COVID hit and I couldn’t do it. There were 2 or 3 people in the study with SIBO. They started following what we talked about, the resistant starch. We gave them all this. It took them maybe three weeks to start seeing a little bit of improvement. By week four, we took a questionnaire and it helped them a lot.

To me, if you eat the right type of food that’s going to support your microbiome, reduce all the saturated fats, and lower the inflammation, you are going to help yourself. With SIBO, if there is bacterial colonization, you need maybe to take some antibiotics. You need to talk to your physician to give you antibiotics to try to at least clear the way and then come in with a good diet and maybe some probiotic to rebuild the beneficial organisms. This will help you.

One of the things I found interesting was that you talked about there may be a lot more bacteria in the gut but that the fungi are a lot bigger. Does that play a part in anything or that’s a fun side thing that you’ve noticed in your studies?

I have a beautiful picture of transmission electron microscopy. Do you know what the transmission of microscopy looks like? It’s like you have an orange and you cut it in the middle. When you look at it, you can see the inside of the orange. I have this big fungus and around it, there are twelve different bacteria. I always show it and say, “Size matters.” People love this thing.

I read this book called 10% Human, which implied that we were here to service the colonization of all of these bacteria. The numbers dropped quite a bit about how many per but still, it’s a lot. In this, there was even a passage where the author implied or stated that the gut telepathically gives the brain messages. There are so many fascinating things about this like serotonin levels and all these things. Is there such a thing that the microbiome, the bacteria in the gut sending signals to the brain to get the brain to do the things to support them? Is that even something that you’ve seen or come across?

This is interesting because, in scientific terms, it talks about gut-brain access. The gut talks to your brain and the brain talks to your gut. Before, we used to think, “Our brain is telling us to do everything.” Now, these microbes in our gut, because of the chemicals they make, can go into our bloodstream and go up to our brain and start changing it.

For example, serotonin, more than 90% is made in our gut, so to make you feel happy, it’s in by these organisms. The microbiome is linked to neurodegenerative diseases, for example. I’m doing a study with autistic kids and we looked at the different microbiomes and you can see there is an imbalance. This is an area which I hope soon, we will start publishing some of this work. We found interesting changes both in bacteria and fungi. It’s telling you that what is in your gut affects your brain.

[bctt tweet=”It’s not just the diet, the lifestyle is critical as well.”]

I have one friend in particular that did fecal matter implants and I would love to know how you feel about this. They have a son who’s autistic and for a while, they do all avocado and he has a seizing where the arms are moving and things like that. They have been aggressive in trying all kinds of things and they got a great benefit for a while not only from things like the avocado diet but from the implant. I was wondering, have you studied this? What are your feelings on this? I know it’s intense for people to get this idea but there are people who, if their microbiome isn’t set up correctly, have gotten some benefits from it.

It’s exciting. Now we are trying to understand, “There is some change in the microbiome.” What can you do to try to help? The good thing is this is a science project. We are trying to do some in vitro testing, test tubes, and now we are going to do some animal testing because you need to make sure what you’re doing is going to help them. Finally, hopefully, the advancement and our results may guide us to do also human testing to help. I hope we will be able to help these kids adjust their gastrointestinal symptoms. That’s why they say, “Are you going to retire?” I say, “No. I’m enjoying myself.”

Can you explain what biofilms are? They’re everywhere but I would love it if you could explain what they are.

Let me explain first to people what is a biofilm. The best example is the plaque in our teeth. Every morning and in the evening, we brush our teeth because of this slimy layer that forms if we don’t do that. You can imagine, if you don’t brush for 2 or 3 days, it’s a disaster. What we found are these microbes which we found in the Crohn’s disease patients come together and form what you call biofilm.

The best example is Jell-O. Inside this Jell-O, you have the microbes. They produce this carbohydrate layer and they have Jell-O and inside it are all these bacteria and fungus. When they are there, they are protected. If you even use an antibiotic or use an antifungal, they fight it. Our immune system cannot find them. They become protected. They’re smart. These little critters are smart.

What do we need to do is we need to break that biofilm as we do it in our teeth. If you break it, you then will be able to get into all these bacteria within the Jell-O. That’s what we did with our probiotic. For the sake of transparency, in the biome, that’s how we design our probiotics. We design it so that it is able to break the biofilms. I published that in a paper.

You come out with this huge study and in 2016, you’re surprised by people wanting more information from you on how they can have better gut health and now you’ve got not only the microbiome but the mycobiome. You decide to figure out a product to support people in that and then you came up with BIOHM Health. Maybe you can share why you did that and what that’s been like.

It’s important to start addressing your diet. It is not a substitute. You cannot just take probiotics. If you do that, everything is going hunky-dory but sometimes let’s say you take an antibiotic, then I would propose to have some probiotics because we want to support the beneficial organisms there. You can also take the vitamins. The vitamins A, B, and C are good to have.

Prebiotics are fiber, which feeds the beneficial organisms. We have some new product, Super Greens, which not only have a little bit of probiotic but also have some nice plant extract, which has been shown to help with inflammation and other stuff. They taste good, at least that’s what they tell me. You can add them to drinks. In a way, you are supporting the system, not trying to just use that as the way only.

It’s important for people to feel like they can take charge of it though. There are times that taking a round of antibiotics is essential. Maybe they’ve had surgery or something. I hope that we don’t scare people, that somehow they’ve had to go on a cycle of that or they haven’t dealt with this, it’s not something they can take charge of. There is something they can do.

That’s what I recommend after you take the probiotic because you have to take it. If you have an infection, if you have the surgery and you need to take an antibiotic, it’s important that you do that because we don’t want the organism that causes infection to survive. Once you do that, I would recommend that you take in some supplements that can help you to rebuild back the beneficial organisms like probiotic and prebiotic. That will help replenish, reverse, and maintain the microbiome.

If someone’s reading this and maybe they feel off for elimination or moods or maybe gut swelling or bloating, is there a way to start to get all of this checked out, a starting point?

First of all, if you have certain symptoms, you feel you have bloating, you have constipation, you have sometimes diarrhea, then there you know is something not right. One way to do it is, “Do I have microbiome imbalance?” There are a number of components including biome that people could send their stool samples and they can look at the makeup there. Based on that personalized testing, there are recommendations that are specific to rebalance the microbiome.

For example, if you see that there is a Candida, then you try to tell them, “This is what you need to follow, the vitamins, the sugar ratio.” If it is Proteobacteria, the inflammatory, “Take fiber. Take vitamin B and C.” Based on that testing, you will be able to address some of these issues, and then start putting a way of life that’s going to help it as well because it’s important. It’s not just the diet, the lifestyle is critical as well.

A lot of us have issues with Candida. Is there a specific way someone can navigate this? Sometimes these things get thrown under broad umbrellas. I would be interested if you had some clear, specific ideas about dealing with Candida.

Saccharomyces boulardii is a yeast like Saccharomyces cerevisiae. It’s the baker’s yeast. We use it for bread, baking, and beer. The studies have shown that it is a good micro. It keeps Candida under control. Also in our study and another study from France, they looked at people with gut issues and they found that there is a decrease in Saccharomyces cerevisiae, so having it will be good.

Maybe if someone’s looking for a way to get started, is there a place or a way that they can reach out and maybe get some more information from you?

If they go to BIOHMHealth.com, they can reach out to me and I’m happy to help in any way.

Dr. Mahmoud Ghannoum, I want to thank you so much for your time and your passion for this area. It impacts a lot of us. I have always been trying to find better ways to keep these delicate balances easier and it isn’t always easy. I appreciate all of your work and want to say thank you for joining the show.

Thank you. It’s a pleasure to be with you, honestly. I loved it.

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Resources mentioned:

• Dr. Ghannoum
• Total Gut Balance
• 10% Human
• Super Greens

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About Dr. Mahmoud Ghannoum

Dr. Ghannoum is widely considered the leading microbiome researcher in the world. He lectures at many institutions, such as the National Institutes of Health, on the microbiome and his breakthrough research in the probiotic space. He is also the scientist who named the mycobiome. He is the founder of BIOHM, the first company to engineer elegant products and tests that address the total microbiome of both bacteria and fungi, allowing consumers to maintain total digestive health.

After making the breakthrough discovery that bad bacteria and bad fungus work together to create digestive plaque (a discovery covered globally by outlets such as CBS News, Scientific American, Forbes, and USA Today). During his career, he has published several books on fungus and over 400 peer-reviewed scientific papers. His work has been cited almost 18,000 times by other scientists. He has received over $25 million in funding for his research from the National Institutes of Health.