Abstract

The human gut microbiome is often associated with ‘good bacteria’ in marketing campaigns for dietary supplements, probiotic drinks, and fermented foods. Yet, the dynamic and complex community of microbes that make up the gut microbiome is dictated by much more than what we eat. The diversity of the gut microbiome and the consequences of disruption to the microbiota, or ‘dysbiosis,’ on health and wellbeing is highly relevant to all college students and is of particular interest to pre-health science undergraduates. Evidence suggests that many common conditions and ailments, ranging from obesity to psychiatric disorders, are tied to the gut microbiome. Multiple factors, including genetics, environment, and pathogen exposure, influence the diversity of the microbiome and impact our health. In a traditional classroom setting, simulating the changes in the gut microbiome that can occur with everyday events and invasion by pathogens is challenging. In this lesson, students are introduced to the factors that cause changes in our gut microbiome as we age and experience life. The lesson covers the various essential functions of the gut microbiome and the gut-brain axis. Following this, students play a publicly available card game, ‘Gutsy,’ to simulate how events and pathogens exposure impact gut microbiome diversity. Our observations indicate that students are highly engaged with the material and enjoy playing the game.

Primary Image: Image of the cards from the game Gutsy used in the lesson (permission was granted via email and was submitted as a PDF with the manuscript).

Citation

Majewska AA, Hostetter SJ. 2024. Using an Interactive Game, Gutsy, to Examine the Impacts of Pathogens and Everyday Events on the Human Gut Microbiome. CourseSouce 11. https://doi.org/10.24918/cs.2024.24

Lesson Learning Goals

Students will:

• understand how microorganisms interact with both human hosts in beneficial, neutral, or detrimental ways.
• understand why microbes are essential for life as we know it and the processes that support life.
• understand how microorganisms interact with their environment and modify each other.

Lesson Learning Objectives

Students will be able to:

• define microbiome and dysbiosis.
• discuss how commensal microbes impact the gastrointestinal tract and immune system functions.
• explain how the gut microbiome can influence mood and mental health.
• predict how various common events, such as changes in diet, antibiotic use, and pathogen invasion, can impact gut microbiome diversity and cause dysbiosis.

Introduction

The microbiome commonly refers to the collection of microorganisms and their genes that live within and on our bodies, including bacteria, archaea, viruses, fungi, and other microbes. Diverse communities of living microbes, collectively referred to as the microbiota, are found on numerous sites throughout the body, including the skin, urogenital tract, and digestive tract (1). In the last few decades, a growing body of evidence has highlighted how critical the microbiota is for the function of numerous organ systems and host health (2). The commensal microbes in our digestive tract play several vital roles locally, including the promotion of gastrointestinal epithelial integrity and function, facilitation of digestion, and modulation of immune function (3, 4). The gut microbiota also influences the function of distant body systems, most notably the central nervous and immune systems. The communication between the gut microbiota, the intestinal tract, and the central nervous system, termed the ‘microbiota-gut-brain axis,’ is facilitated through numerous routes and is essential for homeostasis (5). For example, gut microbes play an important role in brain development in babies and young children by signaling to the brain cells to divide (6, 7). In fact, the gut microbiome is sometimes referred to as a “second brain” because it produces molecules that transmit signals in the brain (i.e., neurotransmitters) (8). Not surprisingly, emerging research suggests that disruptions to the gut microbiome may be linked to a range of health conditions, including inflammatory bowel disease, obesity, and mental health disorders (8–10). In recent years, our increased awareness of the microbiome’s importance to health has led to the commercial production of myriad ‘probiotic’ products purporting to promote gut health. It has also generated increased interest in the topic among pre-health science students (11, 12).

Studies indicate that a diverse microbiome is associated with better health outcomes and that the microbiome is impacted by numerous factors, including age, diet, genetics, lifestyle, and the environment (4, 13, 14). For example, a diet high in fiber can promote the growth of beneficial gut bacteria, while antibiotic usage can disrupt the balance of gut microbes by reducing species diversity. To further complicate things, pathogenic bacteria can significantly outcompete beneficial gut microbes, leading to decreased microbial diversity and mild to severe gastrointestinal distress (e.g., Helicobacter pylori [15]). In short, the gut microbiome is a dynamic and complex component of human biology that significantly impacts our wellness and health (10). This lesson introduces students to the complexities of the gut microbiome by combining an interactive lecture and small group activities, which then set up the class to play a card game called ‘Gutsy.’ The game Gutsy was created by The American Museum of Natural History (AMNH), as its name suggests, and is focused on the gut microbiome, a community of microbes in our digestive system. The game consists of colorful cards representing microbes, pathogens, everyday events, and quarantine. The microbe cards represent the seven most common phyla of bacteria while the pathogen cards represent five common troublesome bacteria that can infect the human gut. Both types of cards contain interesting facts about the human microbiome, which we utilize for the game activity. The game involves 2–4 players with the goal of being the first player to build a diverse gut without any pathogens. Playing time is fairly short (15–20 minutes) and therefore feasible to include during a typical class session. In the lesson described here, students first become familiar with the gut microbiome composition, function, and health implications when disruption to the microbiota (i.e., dysbiosis) occurs. Students then independently research several common gut pathogens to discern their impact on the gut microbiome and host health. Finally, students play the game, which simulates various real-life events that continually change the diversity of microbes in the gut (e.g., diet, social gathering, and pathogen exposure). At the end, students are asked to predict the impact of several provided scenarios on the gut microbiome.

Several excellent approaches have been proposed to teach the topic of gut microbiome, including “The impact of diet and antibiotics on the gut microbiome” (16) as well as a game “The Human Gut Game: An Inquiry-Based Simulation That Teaches Students How Their Diet and Life Choices Influence the Diversity of Their Gut Microbiome” (17). However, our lesson focuses more on common gut pathogens, the way in which infection is facilitated, and the consequences for the gut microbiome and overall health. Further, because the game is designed for the public, it provides ‘real-world’ scenarios students can easily relate to, and the students can play outside of class with family and friends. This component is particularly useful for courses taught online as the game can be played asynchronously. We see this as one of the main strengths of this lesson. Finally, the game is competitive and invokes student engagement that is difficult to replicate with other activities.

Intended Audience

This lesson is intended for undergraduate biology-related majors, particularly pre-medicine and pre-health science majors. We taught the lesson at an R1 university for biomedical physiology majors.

Required Learning Time

Three 50-minute class periods are recommended (Table 1); however, the module could be reduced to two class periods. We note that playing the game only during one class session without the other activities described here is an option; however, reaching the desired learning objectives outlined in this lesson is unlikely.

Table 1. Timeline of activities. There are three sessions, various in-class activities and two take-home assignments as part of the lesson.

Prerequisite Student Knowledge

Key knowledge that the learners should have includes a basic understanding of the following biological concepts: human body organ functions (gastrointestinal tract and immune system) and microbiology (major classifications of microorganisms, differences between commensals and pathogens, competition for space and resources, etc.). We suggest that students should at the minimum have completed an introductory biology course. Additional recommended courses include introductory microbiology and ecology.

Prerequisite Teacher Knowledge

Instructors require a basic understanding of the human gut microbiome and its common pathogens. Z. Y. Kho and S. K. Lal (10) provide an excellent overview of the human microbiome and the research on links to various health disorders. Instructors can also review information about the human gut microbiome from the Mayo Clinic website. In addition, the CDC website has excellent resources to learn about the common pathogens that can infect the human digestive tract: Escherichia coli, Salmonella, Clostridium difficile, Helicobacter pylori, and Campylobacter spp.

Scientific Teaching Themes

Active Learning

This interactive lesson includes several active learning components: think-pair-share, open-ended questions, small group learning, jigsaw activity, and game-based learning (Table 1). The selected strategies help ensure that all students participate and that the lesson is student-centered. Think-pair-share and small group activities are used during the first two class sessions. During the small group activities, students are presented with a question, discuss it with their group, and report a group solution to the rest of the class. The jigsaw activity offers the additional benefits of individual student accountability for completing the assignment, peer learning, and engagement (18, 19). These three cooperative learning activities invoke critical thinking, assist students in formulating their own knowledge, promote collaboration, and have positive impacts on student achievement (20–24). During the final session, students work in groups of four to play the game ‘Gutsy’. The incorporation of game-based learning into the final lesson reinforces the concepts discussed during the first two sessions, invokes motivation, and promotes engagement. Additionally, playing a game in class further impacts learning by providing contextual information and peer interactions (25).

It is important to note that with any group work, some issues may arise that can be detrimental to the student experience and disproportionately disadvantage some individuals. Inequitable participation between group members can perpetuate social status and stereotypes and reinforce personal biases (26). There are several recommendations to address these issues. First, prior to any group work, students should develop ‘group norms’ (27). Further, assigning tasks or roles for each student in the group (e.g., notetaker, reporter) has been suggested (27). In the context of the activities described here, we suggest using an arbitrary criterion to assign the roles (e.g., the person who ate a salad most recently will report to the rest of the class). Further, it is recommended to pair minority students together and not place them separately into different groups (28). Therefore, instructors are encouraged to form groups instead of allowing the students to self-select, as the former has been shown to lead to higher learning outcomes (29). It is essential to continually monitor contributions made by each student and identify when any issues arise, such as one student dominating the discussion. For additional recommendations on inclusive group work see (27, 30, 31).

Assessment

Student learning was assessed using formative and summative questions. The formative assessment consisted of think-pair-share type questions during the in-class session 1, which allowed real-time evaluation of students’ prior knowledge and ongoing understanding of lesson content. Questions are posted on the slides, which are available in Supporting File S1. There are also three summative assessments in this module that align with the learning outcomes: (i) student responses to the pre-class assignment (for instructions, see Supporting File S2), (ii) exit ticket consisting of both multiple choice and free response questions (administered following the in-class game, available in Supporting File S3), and (iii) post-class assignment that consists of several questions (see Supporting File S4). Students had seven days to complete the post-class assignment.

Inclusive Teaching

This lesson focuses on a topic that is relevant to the students and is therefore expected to garner substantial interest. The small group activities foster the exchange of ideas, collaboration, and community building. For example, in the second part of the jigsaw activity, students engage in peer-to-peer instruction about pathogens and, therefore, cooperative learning (18). The jigsaw method, developed over fifty years ago by Elliot Aronson to promote collaborative learning amongst elementary school students from disparate backgrounds, has repeatedly proven effective at promoting equity and inclusion in diverse learning environments (32, 33). Further, the exit ticket questions engage students in self-reflection on their learning and additional topics about the microbiome that interest them. The game also provides a different way to engage with the material. Together, the variety of activities in this lesson provides multiple means of engagement, a key component of the universal design framework (34).

Lesson Plan

There are five components to this lesson: (i) a pre-class assignment, (ii) the jigsaw activity, (iii) a game activity, (iv) an exit ticket, and (v) post-class free-response questions (Table 1). The lesson is completed within three 50-minute class periods and requires students to work outside of class before the second class session and after the last class session (~1 hour each, respectively).

Preparation

To teach this lesson, first, print out (and cut if needed) enough sets of the game for your class size. Each game set is intended for 2 to 4 players. We recommend that instructors play the game at least once to become familiar with the rules. The pre-class and post-class assignments should be uploaded to your learning management system. Upload of written game instructions (pages 1–2 of the PDF of the card game) or video is also encouraged.

Pre-Class Activity

Prior to the second session, students complete an inquiry into a pathogen that appears in the game. Students are asked to explain what type of pathogen it is, how it is transmitted, its impacts on the gut microbiome, and treatment strategies. Also, they are asked to describe how the pathogen can infect the host (i.e., describe virulence factors or the molecules that assist the pathogen in colonizing the host and cause disease).

Class Activities

Start the first class with a mini-lecture on the microbiome (use provided slides Supporting File S1). The presentation helps to get students thinking about their own gut microbiome and what might impact the diversity of microbes in their gut. Following the mini-lecture, a slide is displayed with questions about the gut microbiome that students answer in a think-pair-share fashion. The first set of questions intends to assess students’ prior knowledge of the microbiome, while the second set of questions asks students to predict how everyday ‘events’ would change the microbiome and impact health. The answers to questions assessing students’ prior knowledge can help the instructor gauge whether any of the materials should be adjusted. For instance, during our first iteration of the lesson, we noted that many students explained that the microbiome is composed of ‘good’ bacteria only. Therefore, in the second iteration, we emphasized the other orders of the microbiome and emphasized that some microbes can be pathogenic.

The everyday ‘events’ are directly pulled from the game, which students play later in the lesson. Student pairs write out their answers so that they are visible to everyone (on large sticky notes, Padlet, Jamboard, or similar) and verbally share answers with the rest of the class. At this point, the instructor has the option of posing follow-up questions to prompt discussion. A mini-lecture on the interactions between microbes and host diet takes up the last 10 minutes of the class.

The second day of class also starts with a mini-lecture. This lecture focuses on the mechanisms by which gut microbes impact changes in the microbiome and the host. Next, students engage in the jigsaw activity (for a detailed explanation of the jigsaw method, see here). This activity is based on the pre-class assignment in which students investigate one of six pathogens to answer questions. These pathogens were chosen because they appear in the game. Additional or fewer pathogens can be used, depending on class size. At the start of the jigsaw, students who investigated the same pathogen form “expert groups” and discuss the answers to the questions and identify any discrepancies in answers. Following the discussion, one student from each pathogen expert group teams up with students of different pathogen expert group to form “jigsaw groups.” Each student in this new team is now the ‘expert’ on the pathogen and takes turns sharing information about the pathogen. Depending on class size, instructors explain any other pathogens that the students did not investigate. The class is wrapped up with a brief overview and a video about fecal transplants, a topic included in the game.

The third class is predominantly focused on playing the card game. The instructor starts the class with a 5-minute explanation of how to play the game or shows a short video (5 minutes) on how to play the game. For the game, students are divided into groups so that each group's members have investigated a different pathogen for the jigsaw activity. The instructor distributes a set of playing cards to each group. Students play two rounds of the game, with the first round providing practice for playing the game. At the beginning of the game, students read out the facts on the bottom of their cards to the other players. During active play, each player reads the card-specific facts upon drawing a new card. When students trigger a stored action during play, they announce the action (e.g., “kiss,” “fecal transplant,” “sneeze,” etc.) and the action they are taking in response (e.g., “Remove one pathogen from any one player’s Gut”).

Post-Class Assignment

Students are required to answer several reflective questions about the game and predict the potential outcomes of certain gut microbiome disturbances (see Supporting File S4).

Teaching Discussion

General Observations

Students were highly engaged in the lesson and expressed positive perceptions of the game as a learning tool on this topic. Most students indicated that the game was useful in facilitating their learning. The post-class assignment, which serves as an assessment at the end of the lesson, was completed by all 29 students enrolled in the course in Spring 2023. Results indicated that 86% of the students provided a correct answer for Q1 (How does our gut acquire rare microbes?), 97% for Q2 (Do you think gut microbiome is different between someone who eats only meat and dairy versus someone with a plant-based diet?), 90% for Q3 (How would the impact on the gut microbiome of a broad-spectrum antibiotic differ from narrow-spectrum antibiotic?), and 93% for Q4 (Imagine you had to take a broad-spectrum antibiotic for a skin infection and immediately after you acquired the pathogen Campylobacter jejuni. What do you predict will happen to your microbiome diversity?). Overall, the assessment outcomes suggest the lesson aided students in their understanding of the complexities of the microbiome.

We noted that students were particularly interested and surprised by the links between mental health and the microbiome. While this lesson briefly touches on the gut-brain axis and the concept that our gut microbiome acts as a second brain due to the neurotransmitters it produces, it does not delve into the various mechanisms underlying the association. We noted that most students are familiar with the gut microbiome but are less familiar with the idea that microbial communities are present on the skin and urogenital tract. We also observed that students often assumed the worst-case scenario impact on health when discussing the impact of everyday events on microbiome diversity. The activity could be modified to explicitly ask students about severe and mild outcomes.

Potential Variations

This lesson can be easily extended to take a deeper dive into the many fascinating facets of the human microbiome. One option is adding a second jigsaw activity in which students are assigned to read one of several recent scientific articles on the microbiota-gut-brain axis for students to consider how neurological and psychiatric disorders may be linked to the microbiome. Additional activities could include small group work in which students take several minutes to look into the main groups of microbes (e.g., Tenericutes) and report back to the rest of the class on their dominant characteristics and functions. The main groups include Tenericutes, Verrucomicrobia, Cyanobacteria, Actinobacteria, Proteobacteria, Firmicutes, and Bacteroidetes. These main groups are depicted on the cards of the game Gutsy. It is important to note that the game itself provides three potential variants, one of which is called Epidemic, that could be used by instructors interested in emphasizing disease dynamics on the population level.

Another option is to incorporate culturally responsive strategies more explicitly into the lesson. Culturally responsive pedagogy honors and validates the student’s cultural heritage and social identity (35). Students could share the use of fermented foods (e.g., kimchi, curtido) and beverages (e.g., kombucha) in their communities and cultures. The game itself highlights how different cultures and non-western diets can impact gut microbiome, which further provides an opportunity for students to reflect on their identities and the microbiome composition.

Finally, instructors may choose to assign a pre-test. The AMNH website, contains a short assessment that includes two multiple-choice and three “Fact or Fiction” questions about the human microbiome. The results of the pre-test could be used to gauge students’ prior knowledge of the subject and allow the instructor to adjust some content of the lesson based on the pre-test outcomes.

Considerations for Online Implementation

The lesson can be adapted to an online teaching environment. For a synchronous implementation, mini-lectures can be presented in Zoom (or a similar video conferencing platform), and small-group activities can take place in break-out rooms with the instructor checking in on each group during this time. During the synchronous meeting with the jigsaw activity, expert groups would first discuss the answers in the breakout room and then reshuffle to new breakout rooms.

For asynchronous implementation, the mini-lectures could be recorded and posted on the learning management system. The instructor can choose to punctuate the mini-lectures with open-ended questions or create asynchronous discussion boards where students answer questions and share ideas after watching mini-lectures. Discussion boards can also be used for group activities, such as the jigsaw activity. First, students from the expert group synthesize and reflect on the answers to the questions by posting and responding to other posts. Second, each member of the expert group is assigned to a new discussion board with new members to discuss the topic.

Finally, because the card game is not easily transferred to a synchronous online session we suggest the students play the game asynchronously. Students would be asked to download, print, and play the game with friends or family. The students could be asked to engage friends in the content by providing an overview of what they learned about the microbiome and the different pathogens. A written reflection on the game and discussion with friends and family is recommended to help the instructors assess student learning.

Supporting Materials

• S1. Gutsy – PowerPoint lecture slides

• S2. Gutsy – Jigsaw activity pre-class assignment and instructions

• S3. Gutsy – Game exit ticket

• S4. Gutsy – Post-class assignment

Acknowledgments

We want to thank Dax Ovid and Sherry Clouser for playing the card game with us and for valuable feedback on our initial thoughts on the activities. We are also thankful for the Spring 2023 FMN Writing Studio and feedback on the manuscript from Rebecca Seipelt-Thiemann and Yeidaliz Garcia.

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