Doctors who specialize in geriatric medicine say they're seeing Kentuckians with advanced cancer and other serious illnesses travel out of state to end their lives on their own terms.

It may mean going to Oregon, which as of last week will no longer require a person to establish residency to be eligible for medical aid in dying.

Oregon is one of 10 states, along with the District of Columbia, where the practice is legal.

Dr. Christian Furman, medical director of the Trager Institute and Smock Endowed Chair in Geriatric Medicine at the University of Louisville School of Medicine, explained most of her patients are terminally ill and in their 80s or 90s. She said doctors in Kentucky want to expand the options for these patients and their families.

"We can definitely help with a lot of the pain and symptoms, and taking care of the patient and family as they need care," Furman explained. "But there are those patients where, you know, you just can't."

A recent poll from the nonprofit Compassion & Choices found voters, nationwide and across party lines, are eight times more likely to vote for candidates who sponsor or support medical aid-in-dying legislation.

The American Medical Association is opposed to the practice, however its Code of Medical Ethics affirms that pro and con positions are in moral equilibrium and says physicians may participate in medical aid in dying without violating their ethical obligations.

Furman note it is common for terminally ill patients to refuse food or water, a sign they are ready to end their lives.

"I've never had anybody intentionally say, 'OK I'm going to stop eating and drinking, so I'll die quicker.' I have had people say, they're just ready," Furman recounted. "They've made the decision, they're ready to die, they don't want any life-prolonging treatments."

She added physicians in the state are becoming more aware of the importance of expanding end-of-life options for patients' agency, comfort and care.

"We have a palliative medicine fellowship at U of L, and we teach this in our fellowship, what medical aid in dying is," Furman stressed.

Rep. Josie Raymond, D-Louisville, introduced a bill earlier this year, which would legalize the option in Kentucky.

By Dawn Attride for Sentient.
Broadcast version by Chrystal Blair for Michigan News Connection reporting for the Sentient-Public News Service Collaboration

What's on the menu for a healthy microbiome? High-fiber foods, like broccoli and lentils are key - according to two new studies with two vastly different approaches published in Cell and Nature. As the debate about the role ultra-processed plant-based meat substitutes should play in a healthy diet rages on, these new studies focus on a more balanced, plant-forward approach, finding that a diet high in plants (fruits, vegetables and legumes) is good for a healthy gut. In addition to reducing climate emissions then, adapting a plant-forward diet can help to create a balanced gut microbiome, which in turn can reduce inflammation and risk of developing chronic diseases.

Each of our microbiomes is a nexus of bacteria, specific to factors like our environment, stress and age. Microbiomes can be vastly different among people - and even twins - that they're often likened to a microbial fingerprint of sorts. But we know that diet plays a large role in forming healthy gut bacteria. An Italian team of researchers set out to identify if there are signature microbiomes for vegans, vegetarians and omnivores (people who eat both plants and meat) out of a group of nearly 22,000 people living in the United States, the United Kingdom and Italy. And, as it turns out, there is a pattern of key bacteria associated with each dietary cohort.

How Much Does Diet Affect Your Microbiome?

"As more and more people adopt vegan and vegetarian diets, we wanted to find out how different their microbiomes are and which microorganisms are responsible for these differences," Gloria Fackelmann, postdoctoral researcher at the Department of Cellular, Computational and Integrative Biology, University of Trento, said in a press release. According to the paper, published in Nature, vegan and vegetarian diet signatures were associated with a healthy cardiometabolic system and production of beneficial fatty acids.

"Our data showed that omnivores on average ingest significantly fewer healthy plant-based foods than vegetarians or vegans," the researchers wrote, adding that "optimizing the quality of omnivore diets by increasing dietary plant diversity could lead to better gut health." Omnivores had strong signals of bacteria like A. putredinis, associated with meat consumption, which the paper links to inflammatory bowel disease and an increased risk of colon cancer. However, an important caveat - Fackelmann notes that they didn't measure health markers of these specific participants, they instead looked to the scientific literature of what is known about these bacteria (They did, however, study stool samples - more on this in a bit).

That doesn't mean that excluding animal products automatically equals a healthy microbiome. Here's where that balanced diet comes back in. A varied diet of fiber-rich foods like plants is key. "Avoiding meat or dairy products does not necessarily have a positive effect if it does not come with a variety of quality plant-based products," Nicola Segata, research lead on the paper, said in a press release.

For the microbiome, a critical ingredient is fiber. "Your microbiota is tuned towards digesting fiber predominantly, so eating a largely plant based diet gets more of those nutrients to them," Eric Martens, a professor of microbiology and immunology at University of Michigan Medical School, who was not involved in the studies, tells Sentient.

There was less bacterial diversity in vegetarians and vegans than in omnivores, but another important detail is that diversity doesn't always equal an optimal microbiome. On the one hand, a diverse microbiome means more bacteria, so more opportunity for defense against infections and ability to break down various food types. But that's assuming those bacteria are beneficial and not all bacteria are. A person could have a diverse array of harmful microbes, which would negate the whole concept. So while diversity is important, of more importance is what bacteria are present, rather than how many. "When people hear diversity, we hear about it in the context of biodiversity and always more diversity is better. But for the gut...higher diversity wouldn't exactly equate to having a more favorable microbiome composition," Fackelmann tells Sentient.

In the Nature study, the participants' stool samples were analyzed using shotgun metagenomic sequencing, which yields highly specific information about the species of gut bacteria present. Interestingly, they found that vegans had more soil-derived microbes and omnivores more dairy, highlighting that gut bacterial members may come directly from the food we eat.

Looking To a Non-Industrialized Diet for Answers

In a different vein, a team of microbiologists based in Ireland tested the effects of a non-industrialized diet on the microbiome - in other words, mostly plants and low in processed foods. "Industrialization has drastically impacted our gut microbiome, likely increasing the risk of chronic diseases," Jens Walter, a professor of Ecology, Food, and the Microbiome at University College Cork, tells Sentient. Walter and his colleagues developed a diet - called the NiMe diet (Non-industrialized Microbiome Restore) - high in plants and fiber and low in meat and processed foods, based on the eating habits of rural Papua New Guineans.

In a strictly human controlled trial, 30 participants followed this diet and consumed L. reuteri, a beneficial bacterium found in the gut of rural Papua New Guineans but rarely found in industrialized microbiomes. Unlike the Nature study, Walter and his colleagues directly measured the health risk factors of participants and found that after just three weeks, the diet had decreased low-density lipoprotein (LDL) cholesterol by 17 percent, reduced blood sugar by six percent and reduced levels of a protein associated with heart disease. Martens put more emphasis on the findings of this paper, as the authors both staged a dietary intervention and measured the health effects, rather than finding correlations with the scientific literature.

The magnitude of the findings was surprising, Walter tells Sentient. "I didn't think a three-week study would be enough to improve blood glucose or cholesterol," he says. Another surprise was that participants lost weight even though the calories were the same as their usual diet. The researchers are sharing their "NiMe diet" with the public via online free recipes on Instagram.

In practice, shifting to a non-industrialized diet may be difficult. We are increasingly consuming more ultra-processed foods and less whole foods than we were just two decades ago. Misleading food marketing claims and the rise of various dubious "wellness" trends also make grocery shopping for a healthy diet that much harder. Keep it simple, Martens says. He recommends supplementing your diet with plant-based fiber from whole sources as opposed to picking up the quick-fix fiber snack bar.

The Bottom Line

No matter the specific details of your diet, the microbiome is crucial in all stages of life to maintain health. Research shows food and lifestyle changes can bolster protection against chronic diseases, although this tends to be challenging for most Americans just based on what we actually eat. Small incremental changes towards eating more plants may feel like a less daunting prescription. These studies, among others, act as a signal that dietary tweaks and increased intake of high fiber food like plants can reap significant microbiome and health benefits.


Dawn Attride wrote this article for Sentient.


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About 1.3 million Missourians are currently enrolled in Medicaid and nonprofits around the state have warned proposed federal cuts would be devastating.

In Missouri, children are the largest group served by Medicaid, with 61% enrolled. States could face more than $800 billion in Medicaid cuts and more than $200 billion in the Supplemental Nutrition Assistance Program, known as SNAP or food stamps.

McClain Bryant Macklin, vice president of policy and impact for the Kansas City nonprofit Health Forward Foundation, emphasized how important Medicaid is to the organization.

"From a policy perspective as well as where we tend to lend our funding support is squarely in that direction, and Medicaid access has been our primary policy issue, really since our inception," Bryant Macklin explained. "It's just our number one priority."

Supporters of the cuts argued Medicaid is inefficient because of waste and fraud, and restructuring or reducing funding could improve sustainability.

Bryant Macklin noted the Health Forward Foundation played a key role in advocating for Medicaid expansion in Missouri, contributing to policy changes which extended coverage to thousands of low-income residents. She stressed as a Medicaid expansion state, Missouri will need to find funding from other critical sources, which could result in further challenges.

"State legislators are going to be forced to -- and administrators forced to -- find those dollars elsewhere," Bryant Macklin pointed out. "That elsewhere will be from other key social services that folks are relying upon and that the state has grown accustomed to receiving that federal support."

Those in favor of the cuts said they would give states greater control over Medicaid through block grants, which are fixed amounts of federal funding states can use with more flexibility, to tailor programs to local needs and priorities.

Indiana is losing millions in public health funding as the federal government cuts grants for state and local programs.

In Marion County, officials confirmed the immediate loss of a $450,000 immunization grant, leaving employees searching for ways to continue vaccination efforts amid ongoing disease outbreaks.

Dr. Virginia Caine, director and chief medical officer for the Marion County Health Department, highlighted the cuts during a town hall hosted by Rep. André Carson, D-Ind.

"We are now seeing that they've cut all state and local health departments budgets," Caine explained. "We have to be very concerned about our ability to protect the public."

Caine noted the federal government eliminated $13.1 billion in funding for state and local health departments, part of a broader rollback of pandemic-era grants. Indiana Department of Health legislative director Rachel Swartwood recently commented the state's goal is to ensure no direct services to Hoosiers are interrupted.

State health officials estimate Indiana will lose about $40 million because of the cuts. Additionally, the U.S. Department of Health and Human Services recently announced plans to eliminate 10,000 full-time jobs. The totality of the cuts is very concerning for Caine.

"When we had this fentanyl epidemic with overdoes -- we have the bird flu taking place across this country -- we have to be concerned," Caine emphasized. "Do we have the workforce to come out and meet these demands?"

Marion County officials are evaluating how to fill the funding gap. Caine added the department has 300 positions supported by grants and expressed concern job losses and service reductions could follow if no alternative funding emerges.


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