#14 Microbiome Research, Education and Practice with Dr. Jason Hawrelak

Well, I'd like to welcome Dr. Jason Howerlick to the Resilient Biome podcast. Thank you so much for being here.

You're very welcome, Rich. It's a pleasure to be here and chat Gut and microbiome, two favorite topics.

Fantastic. Well, I imagine most people tuning in know who you are, but just to make sure, I just want to read a bio so people know your background. Dr. Jason Howerlick is a researcher, educator and naturopath with over 25 years clinical experience. He did his PhD examining the capacity of probiotics, prebiotics and herbal medicines to modify the gastrointestinal tract microbiota in the early 2000s and has taught widely both in Australia and internationally on these topics for the past 20 plus years. Jason has maintained a busy clinical practice for over a quarter of a century in both Hobart and northern New South Wales in Australia and now teaches primarily within the Microbiome Restoration center, which is where he is lead educator for a range of online practitioner trainings on the microbiome and gastrointestinal health. So I'm sure there's a lot more that could be said, but that'll suffice and we'll, we'll jump into some, some questions here. But first of all, I knew you actually through, through your, your wife dawn, and I knew you're associated with Goulds Medicine. Are you also still working through Goulds and Microbiome Restoration center as well?

Yeah. Yes. The Microbiome Restoration center is sort of my new educational center. Whereas Goulds is still like, I'm still one of the owners of Goulds Natural Medicine, which is a business in Hobart, Tasmania, 1881. It's been around selling natural medicines. So it's got a, for Australia, a long history and we've got a medicinal organic herb farm and we make a lot of our own medicines down there too. So my clinical practice is all virtual these days, but it's still within the sort of Goulds envelope. Yes, still.

Okay. Because I noticed on the, in the Microbiome Restoration center that you can locate a practitioner there as well.

Yes, that's right. Because essentially, you know, one thing that's, I suppose as you're aware, the research on the microbiome has increased in the last last 20 years. And you know, when I started my, you know, PhD, my honors degree in PhD was end of 1999 and I could read every single paper the microbiome and every single paper published in the previous two decades, you know, for, as part of my thesis for my honors degree. And you Fast forward. It's just like, it's intense how that's actually shifted. And I think essentially 20 years ago, you used to be able to get by as a clinician working with patients without, with a little bit of knowledge of the microbiome. And I was okay, you know, whereas I think that's changed. So my passion now is educating clinicians to become microbiome illiterate clinicians about, okay, what best tests to order, how to interpret those tests, how to modify and optimize the microbiome and be aware of the interventions you're prescribing, whether it be dietary or herbal or pharmaceutical, and the microbiome impacts. Because I think we've kind of shifted from 30 years ago. People were, humans were beings that had microbes. That may or may not have been important is certainly the view of Western medicine at that time to now where these holobionts, where the microbes are super key, vital to who we are and what we are. We are this being that's composed of human cells and microbes, non microbe cells and microbe cells working in unison, that creates a human. And because of that shift, we can't be ignorant of the microbiome anymore and unintentionally causing it harm. It's a problem. So I'm really trying to upskill clinicians about, okay, how do we look after this component based on what we've learned over the last 25 years and partly because you see clinicians who, I mean, just trying to get through the field, but without any extra training and actually inadvertently causing harm to patients. I want to see that not infrequently in practice, and it's not intentional, it's just, they just don't know, you know, and that, you know, so 20 years ago, the loss that we didn't know, but geez, we've come so far and do we need to learn tons more? Yes, you know, you know, we get a microbiome readout from someone, it's like, you know, we know what maybe quarter of those species in two, there's a whole bunch we don't. So, you know, that's going and that is constantly expanding. Thankfully, as our knowledge grows, we learn more about different microbes and whether they're beneficial or not, how to modify them, et cetera. But yeah, going back to that, my passion now is really about trying to educate clinicians to become more microbiome literate because that's really given the microbiome plays a role in cancer and heart disease and aging process, and almost Every disease you can actually list that people in Western nations suffer. We, it's imperative that the microbiome is a core part of our treatment approach. May not be the only thing we're doing. You know, I'd be working on a radio or other things too. But we can't ignore the microbiome or implement other strategies that are causing it harm and expect to get good results with our patients long term.

Thank you for that. So a little less time as a practitioner, a lot more as an educator.

At this stage I'm morphing I would say just as of, as of just a couple weeks ago, I've dropped one of my clinic days to spend more time in the educator role. Yeah. Whereas I felt that it was, you know, if, look back over my last 25 years, I've been, I've always practiced in that time and seen patients I've taught from most of that time too. Starting off at Southern Cross University in their undergraduate naturopathy course to University of Western States doing their Masters of Human Nutrition and Functional Medicine where I taught their gastroenterology unit and then at University of Tasmania in the School of Medicine just teaching evidence based complementary medicine. Um, so, so education is always part of that but I think it's always melded well because, and I'd say particularly now because I focused solely on teaching around the microbiome and gut and that's all my, my patient core to that too. So it really feeds each other really well. And because I want to, you know, have to stay up to date to teach my students, it means I'm keeping up to date the literature and it means I get a chance to trial new, new research things, findings out on patients, you know, they're going, hey, this study came out, this looks really good, exciting. Let's trial it and see if we get better results compared to other things that we've been doing. And I think being in that position where having a chance to utilize things that have been researched and seeing the impact as essentially being a clinician too is vital because a number of things in research studies work but don't work in the real world where the dosage is totally wrong or you have to introduce it in a certain way and you don't have that knowledge unless you're a clinician. So to me it's all fed into each other really well, the researcher, educator and clinician and hence why I'm going to keep doing at least probably all three onwards. But I'll focusing a little bit more into the education because it Feels like you can reach, like I can see a number of patients a week, but if I educate clinicians, you can, you can treat hundreds of thousands of patients a week and improve their lives that way. And it just seems like a better good use of my time and energy at this point.

That makes sense. Yeah. Multiplying your efforts. Yeah, that's wonderful. All right. You mentioned how the gut relates to almost every disease state is there in all the massive research. And that's amazing. The way you described. You could read all the papers back then. Is there any access, you know, gut brain, gut hearth, gut lung, that is maybe the most researched or best understood or they all pretty equal at this stage?

Well, I mean, I think there's areas that are expanding. I still think sort of, you know, maybe gut, Gut is probably the best research because that's where we started off in, in terms of the role of the microbiome in different gut disorders. But I, I think, you know, it's like the gut metabolism, gut brain are probably the other areas that, that have got a fair bit of research that's really bloomed in the last decade. Gut, kidney, kidney disease stuff is like, that's really blooming too. Metabolic diseases, like. Yeah, there's like, it's so many different areas are, are, are really blooming now. But I still think the sort of gut and gut microbiome and gut diseases still probably would be the head of the queue or the biggest number of publications done over the last 30, 40 years. Still.

Thank you for that. Speaking personally, it would be the gut lung access that has been the biggest impact for myself. I had sort of a mild asthma and through diet, gut health and then eventually nose breathing, I got rid of pretty much my asthma. And I can tell though there's a time my bifido crashed and I found my asthma returning. Somewhat interesting. But, but if I get it above a certain level and you know, there could be other bacteria that would do the same thing. But I noticed it was the bifido levels that really made the difference. Yeah, I think I experienced that.

Yeah. Yeah. And I think there are some species that we would call keystone or other word be less redundant in that. Like, we know that there's a fair bit of redundancy in the microbiome which means that, you know, There might be 15 different species that make butyrate and if you have some of those, then you'll probably be fine. We don't necessarily know for sure that Roseberry is definitely better than eubacterium, definitely better than Anorostipes at this point. But we know that they have that sort of functionality. But I think there are others whose role is more pivotal and that when they're lacking, there are more repercussions because nothing else steps up. And in the same way it can do the same job in the same way. And bifid bacteria would fit that category for me. Akkermansia would fit that category. Faecalibacterium would fit category too. And you might even put Oxalobacter too. Even though it's a really small player for some people, its role is just huge as being their only sort of oxalate degrader bacteria in their ecosystem. And when that's gone, there's a lot of deep repercussions from a dietary in a lifestyle perspective. So even though really it's only there at 0.01 or 0.1% of the ecosystem, it's a tiny player when it's there. But just for many people, this plays a pivotal role in helping to degrade oxalates and nothing else can do when they're missing that bacteria. Other people have got other microbes that can step up and do the job, but some people don't.

I love that idea of redundancy. You know, think about most things in the human body don't have that level of redundancy. You know, it's either works or it doesn't work. So that's really fascinating.

Yeah, and I think that's one of the reasons why, you know, researchers have always talked a lot about the importance of diverse diversity of the microbiome or having a diverse microbiome because the idea there is, you have more built in redundancy. So that if you do take a course antibiotics that wipes out three species of B ray producing bacteria, if those are the only three you've got, you're going to be a bit stuffed. But if you've got seven others that haven't been impacted by that particular antibiotic, it may not actually make a huge difference to your day to day functioning. And you might be able to still live a very happy life without those three species. And some antibiotic courses won't make things go extinct, but we know that is not uncommon consequence from antibiotics. There's one paper published in Gut that showed nine species went extinct from one course of intravenous antibiotics. It wasn't even given via the gut, but nine species went extinct forever from that one course. So, you know, some antibiotics definitely have, you know, permanently dramatic altering effects.

And do some, I'm sure some of those Species must naturally return or what. What's the typical result?

Most of the time you will see after a course antibiotics, you see a major disruption. Yeah. And about four weeks afterwards it's re established into something new. It's not the same as it was before. Yeah, it's similar. Ish. Some species may go, may have gone extinct. Some species were, will slowly have come up over those four weeks. Some things have got a major leg up because they had analog resistant genes and they were like super dominant for that first number of weeks while the competition wasn't. But usually about four weeks afterwards is something new sort of base like that stable again? Yeah. And then it won't necessarily change another four weeks later. It won't necessarily be much different at that point. But that initial four weeks is pretty, you know, pretty hugely different. But it does differ a bit per antibiotics. Some like, you know, rifaxim has got relatively mild impacts. It still impacts, you know, butyrate precinct species and it does seem to decrease diversity but about four weeks later it seems to look pretty normal. And then you have ones like clindamycin or ceftriaxone where it's like, you know, it's never the same after that. Yeah.

So the species that rebound are, were they still there in tiny amounts?

Yes.

Must have been okay.

Yeah. And that's how we can sometimes, you know, work on improving different people's diversity where we'll do a microbiome assessment like, oh, we've got a hundred species present. And then we do this other work without intentionally introducing new species in. But we're going, let's have more fiber, let's have more polyphenols, let's exercise more, etc. Whatever the case may be for that person, the next time we do a test, there's 160 species there, you're like, look at that. And they just magically appear. They were always there, but below detectable thresholds. Because all of our testing has got a limit to how well it can see things. So things that are below that threshold we cannot see currently. But when we feed them up to the point where we can see them, then we can. And they're going to be at the point where they can be contributing to your health. And that kind of level.

Yeah. Related to that. I've heard you say most probiotics don't colonize in the gut for very long or sometimes not at all. And so I, I was always wondering, so if I'm, if I take. And I only started taking a probiotic about a Year ago say I'm taking a B long and probiotic and, and it doesn't colonize. But I've got, I think the last time I checked at least six or seven different species of bacterium.

So.

Silly question, but where did they come from? If, because I. They must have colonized at some point. But, but modern probiotics have a difficult time colonizing. So help me understand that, please.

It's a great question and I have students ask us and patients ask us all the time over the last 20 some years because we've known for looking at research in the 70s, 80s, 90s, 2000s onwards that probiotic strains we're using do not permanently stick. You know, they don't stay there for months afterwards or years afterwards. It's not as simple as that. They generally will. Maybe some strains, good strains will stick around for seven to 10 days or two weeks and a diminishing amount each day that you sort of, after you stop taking it. There's a rare, you know, One study with one strain of Bifidacterium, I think it's the Ah, 1206 strain from memory that persisted. The only one I've seen persisted for like six months and 30% of people in the study and that's like, wow, that's like by far, by far the best outcome we've ever had. And they argued there's probably two things. One, there was an ecological niche available reproductory in those people and two, that particular strain had better staying capacity. Those are kind of the theories behind it. But it is an interesting thing because we're isolating these probiotics from humans where they are inhabitants and permanent residents and then we're kind of putting into supplements and then giving it to other people and they just don't stick. Yeah. And would they stick in that person's family? Possibly. You know, and I think this is the thing we're still missing some of those little details there of going, you know, so if we took that probiotic from that microbe we isolated from, from, let's say it was a mum and then gave it to the kids, it would stick most likely, very well, likely stick in them. We also know that if we give the probiotic to the mom during pregnancy or the last bit of pregnancy, that that's, that strain could concurrently colonize the infant, moving onwards. Yeah. So there is a window in which we can, and there is some research on some like bifidactrium infantous strains that can permanently stick to. So that's probably another exception to that, that Population infantous strains with human milk and HMOs can actually establish really strongly and permanently colonized. We don't tend to see that with other strains of lactose lipofactory in that age group or in adults per se. And it has been a bit of unanswered a question. And some, I mean even, I mean taking a step back, even fmt, like we're taking whole ecosystems, they don't always engraft either. And researchers still don't know why. You know, even if we pick the people with the best poos possible, like the really super donors and we give them, you know, only a proportion of people will actually will engraft properly. Some will partially engraft, some will entirely not engraft at all. Yeah. And the people who are doesn't engraft, we don't get any sort of benefits from it, which is not surprising. Even though those, you know, often you'd argue they have better staying capacity than your typical probiotic supplements because they definitely do. So there's still reasons we don't know. You know, and I've been to enough probiotic conferences where people are still theorizing even now, like, oh, maybe if we focus so much, like if we spend all of our time trying to isolate a bit of bacteria strain that did permanently colonize, we might get there. You know, the criteria has been surviving gastric acid and bile salt and. Being able to, to attach in vitro to colonocytes and having shelf stability. Those are probably sort of the four sort of major criteria that people have been choosing probiotic strains with. And maybe if we chose another one, okay, long term human colonization capacity and we kept researching, we might find some that have got better capacity. But I think there's, even then there's still unknowns because we just don't know why certain why things will engraft better in some people than in others.

I've heard actually introduced by your wife. Don B. Infantis EBC001 is must be one of those exceptions.

It is, yeah. In, in that, that age group definitely is. Yeah. And I've seen it even. And this isn't necessarily based on research because most of the research has been on in that age group. But I've seen it even in toddlers being able to permanently colonize too when given a lot of HMO support too. Yes. So I think, yes, that is one.

Of those exceptions that says a lot based upon most. Most that don't. Yeah.

Oh yeah, yeah. I mean there are hundreds of studies showing essentially a lack of long term Capacity while you take it. Sure it shows up in your poo but you stop two weeks later it's gone. Yeah. And there's other microbes like e. Coli, the Nissl 1917 strain that you know there's research showing that in some people will stick around for a number of months afterwards too. So that another is a partial exception that it will have a relatively long colonization capacity compared to Lactobacilli or bifid bacteria based probiotics.

Yeah, fascinating. Thank you. In all your work as a clinician what have been some of the more we would say straightforward GI microbiome issues that tend to respond to treatment pretty.

More easily at least Well I think of conditions that we see dysbiosis as being a key driver of ulcerative colitis in that category that I love working with UC patients because they usually respond so well to dietary work, microbiome modification, rural medicines. I get very good results with ulcerative colitis and other types of colitis like collagen colitis, liposit colitis et cetera too are in a similar category and irritable bowel syndrome too. Interesting enough is actually and maybe because my PhD was in IBS specifically in the role of dysbiosis, a dysphotic ecosystem and IBS and we could change that ecosystem in this population using herbs and pre and probiotics. That's been a key passion of mine, a key patient core that I've worked with for over 20 years both as a research scientist and as a clinician that I enjoy working with that population too and feel like have high rates of success. And I think even just when I see relatively simple things like antibiotic associated diarrhea, antibiotic associated ecosystem disturbances particularly early on I think are great to work with too. Sometimes years later they can be sometimes could be had more tricky aspects to them too because of what may float on from dietary choices, other interventions, et cetera that may have made things more complex and harder to deal with.

Well I imagine I think respond well yeah thank you. People with ulcerative colitis listening to that you give them a lot of hope for sure.

Yeah well I'm I mean again if you if you look at the and I again I'm lucky enough to be teacher teach dietary influences on ultra colitis for over 27 one of the first lectures I gave was on on that topic back in probably 2001 and and even piecing together all the the dietary stuff back then we like yeah yeah there's a genetic component but geez it's like gone up 20 traditional period of time. It ain't genes that's doing that, it's lifestyle and diet that's doing that. And, and yeah, and there's been so much work done in that area thankfully. Yeah. If people are able to, to implement the dietary changes etc, we tend to see really good results in terms of getting people remission or keeping them remission long term. So it is a condition that, that I enjoy working with for sure. And I think yeah, even. And sibo too is one condition particularly hydrogen Sibo I think tends to respond generally for majority of people relatively well to, to treatment. Methane Sibo on the other hand, or you know, clotic methane overproduction or imo, it's more hit and miss that for some people responds beautifully really quickly. In other people it's like very slow to slow, slow beast to tame as I tell my patients, because it can just take months of continuous treatment to sort of budge the methane. And whereas other people two weeks and they're pooing like champs and their bloating distension is gone, you're like great, I love those ones. But it's definitely more variable in terms of treatment response as a condition and.

Some of the more you mentioned the methane sibo. Any others that are particularly challenging I.

Would say in terms of maybe probably patient cohort, but those who come to see me that have been on carnivore type diets or really plant restricted diets, those ones are really hard too because their guts are release, their microbiome is usually really dysfunctional, compositional wise and there's usually a high degree of what I call visceral hypersensitivity that the nerves and their colon are so inflamed and so sensitive that even a tiny bit of gas production from a plant causes them pain and discomfort. So it can be really tricky to try to figure if they've been on it for two years or something. It's like those patients are really, really hard because we have to try to decrease the inflammation visceral hypersensitivity while at the same time they're eating foods that are causing it to. Because that kind of dietary protocol feeds hydrogen sulfide gas producing species and produces lots more hydrogen sulfide gas and that causes visceral hypersensitivity and prevents colon cells from being able to utilize butyrate. And they're also eating a diet that doesn't make any butyrate and starving off the butyrate producers is this horrible store perfect storm of events and that population is really tricky to bring back. And you just wish that it came to see you two years ago when it wasn't, you know, rather than two years down a path. It's actually caused them a lot of gut and microbiome harm.

So you can't really give those patients prebiotics.

Or maybe you gotta. Very slow.

Yeah.

And it's very hit and miss going, okay, let's do a tiny pinch of PHDG. The tiniest pinch of 2 FL. Like a human. Maybe we'll try a little bit indirectly like sometimes and we have to go pre foreign B rate rather than. Actually they might not have much in the way but producers and we can't feed them because gas and they just. The gut can't handle any gas anymore because it's become so sensitive to. To any sort of change in the gut environment. It's a really tricky patient cohort to work with. Yeah.

Speaking of probiotics, prebiotics especially, or probiotics, any of those tend to bring the most help to patients in dysbiosis.

From a microbiome composition perspective, broadly speaking, prebiotics are definitely far more effective at changing the microbiome in broad ways. Yeah. It's not to say that right after course antibiotics, right after course of chemotherapy, where there's a really acute disruptive event that probiotics can be immensely helpful in that situation to help bring a bit of stability and balance in that scenario. Yes. But in terms of making huge changes in microbiome composition, probiotics don't really. You take a probiotic, you'll see some small nudges in a couple of areas, maybe depending on what strain you're using. Whereas if it gives the right prebiotic, you can have a thousand fold increase in bifidobacteria and a hundred fold increase in lactobacilli or 10,000 fold decrease in bacteroides. Like you have these massive shifts from using the right prebiotic and the right dose that you will never get remotely close to achieving with probiotics. You could look at the research on probiotics and impact in the microbiome and it's really across the board pretty minimal. Yeah. So that's not the reason I'm generally giving probiotics is to modify the microbiome. It's because maybe they speed up transit time or maybe they're a psychobotic that can help improve anxiety or depression. Maybe because they're good for gut healing. There's a number of reasons why I will give a probiotic, but not to positively modify the microbiome so much. Although there are some exceptions where some strains like Lactrosil's Reutride DSM17938, which is the biogaia product around the world, that strain does decrease methane production in the gut and it does decrease protobacteria count in the gut. And we had human studies showing that. So yes, it'll have some role to play there. So there are some relative exceptions to that. But still the impact, broadly speaking, on the wider community of the ecosystem will be far, far less than with any prebiotic.

Yet that's what's on all the supermarket shelves is probiotics.

Yeah. And I think. Well, I think prebiotics bring their own challenges because most of them will cause an increase in intestinal gas production. And for those of us whose guts are working well in terms of transit time, we'll just fart more, you know, and that can be a slight inconvenience to, you know, depending on your work situation. More so if it's just increased flatness versus those people whose guts aren't working well, if they have slow transit time or the nerves in their gut are inflamed, then that intestinal gas will cause them to expand outward and experience pain and discomfort with it. So they're not as safe as an off the shelf thing that everyone can just tolerate well because so many people in Western nations are constipated and have slow transit time. So many have a degree of visceral hypersensitivity, so they're going to react to those things. So whilst they do have this profound capacity to alter the microbiome, you have to be almost, you know, selective in terms of their use. Whereas probiotics, there will be people who don't tolerate probiotics too. I've seen them, you know, you would have heard, heard the stories too. But the vast majority of people tolerate probiotics really well, particularly if you're looking at general healthy populations, they tolerate them really well and don't have the. It might be slight, slight change in some discomfort. Not discomfort, but in some gut feeling when they first started or something. But they're generally tolerated really well.

You, you describe my experience perfectly. I radically changed my gut only through prebiotics. I was like three or four years into it before I touched a probiotic. Very powerful. Yeah, yeah.

And I don't take a probiotic daily. Yeah. But I do take prebux daily and I have for, for years and years. But do I take a probiotic? If my young daughter, when she's younger came Back from daycare or child, you know, school with when everyone else has got viral gastroenteritis. Yeah, I will at that point. Or, you know, should I have to expose her to something might be causing microbiome harm. Yes. Or travelers traveling to Southeast Asia where, you know, I'm a high risk of traveler's diarrhea. Yeah. You know, there are certain times I'll definitely take a probiotic or even during, you know, cold or flu season where I'm going to be working with people who are around people that are sick. I will take the right probiotic to help protect me from my boost my immune system to help protect me getting sick. But I wouldn't. I don't take one every single day. But I do take prebiotics daily to, you know, boost my bench or bacteria. And we know, you know, I'm in my early 50s now. And generally what we see in western nations anyway is a reduction of beneficial bacteria counts as people age. And I don't think this is something we generally see in by default, but it does happen to western Westerners and it's like, I don't want that. I want to keep my good guys powered along in great amounts. So prebiotics are a different part of my daily routine until I pass on. Hopefully another 50 years from now.

Yeah, for sure. Speaking of prebiotics, what is your favorite prebiotic and why is it hmo?

Not hmo?

Sort of a trick question. I know that's my favorite. What's your favorite?

I've probably, I'm gonna have to say there's two because they're just quite different. Lactulose is my favorite prebiotic for dramatically altering the ecosystem. It reduces levels of protobacteria immensely well and reasonable of overgrowth Bacteroides immensely well. Which are things we see commonly in Western nations. And it can also be used for high levels of Prevotella too. Feeds bifidobacteria, feeds faecali bacterium. Higher doses, feeds lactobacilli and also. Sometimes Akkermansia too. Not always Akkermansia, but sometimes. Yes. So it has an impact. But in terms of its capacity to reduce levels of pathogens and pathobionts, there's no other a prebiotic that comes close to it. Like you, you get like, you know, 10,000 fold decreases of pathogens. It's just like, it's really, really amazing stuff. Plus you can use it, you know, for so laxative in higher doses too, you know, so it does have its applications there. But then I also like partially hydrolyzed guar gum because of its broad tolerability. Yeah. So phdg is tolerated by vast majority of people? Yeah, at therapeutic doses. Not everyone. I've got patients who don't or we have to start with a pinch and then build up over two months to get to a close to therapy dose. But I do work with a very sensitive cohort these days. But what I like about PSG is that we can use in diarrhea, we can use in constipation, and it has a normalizing effect on the gut. It can either speed up transit time or slow up transit time, depending what we kind of need it to do. Blends easily into things too. So it's like really easy to mix into. You know, from practicality perspective, it's hot drinks, cold drinks, smoothies, yogurts, breakfast cereals, any of those things. Works for PhD because it has no, no flavor and, and it is very soluble, but it also feeds B ray producing microbes. And I think that that is also a really cool attribute that it's, it's, it complements other prebiotics like lachulose or inulin or gauss in their great capacity to increase bifidobacteria. Whereas phdg. Yeah, a little bit bifida, sure. But you don't get these like hundred or thousand fold increases with bifid bacteria with phdgg, at least not in my clinical experience. But you do get blooms of a range of butyrate producing species in a way that's usually well tolerated as well. So it can be a great one to start with those people that have more sensitive guts to broader increasing their fiber intake. Because sometimes you can look at a microbiome and go, what you need is you need a ton more plants, a ton more fib, lots more variety, lots more polyphenols. But they can't go there right now because they've got a, you know, the transit time is really slow, they've got visceral hypersensitivity. So any sort of, you know, fibery type things will cause any gas production, will cause discomfort, pain, bloating, slowing of the bowels. You have to work so slowly. You can't do much dietary stuff initially. Some things you can do, but, but a lot of stuff you can't do even if that would like, you know, fix the, the microbiome perspective. It's like it's gonna make their life a living hell while you do that to that point. So you, whereas PhD is a lovely thing for many of these people, you can and slowly build up some of them relatively rapidly and then start increasing butyrate production, feeding those butyrate producers and butyrate can then heal the damaged inflamed colon cells, help improve motility. It can also help change the ecosystem because of the acidity, to help enhance the growth of the benefit of bacteria. So it's a very useful supplement in that population, for sure. And that's the other reason why I use it. And you can use it in hydrogen sibo and methane sibo too. Again, not across the world with every patient, but in general. Yes, generally safe in ibs. Like, we did a systematic review of clinical trials on phdg in irritable bowel syndrome patients, and every single study shows that it works. And it's one of those ones where it's like, I didn't know PhD existed until 2015, 10 years ago, never heard of it. And I started reading the studies on it, I was like, oh, wow, this stuff sounds interesting. Every study positive, I want to bring it in. So at that point, you couldn't get it in Australia, so we started bringing in from, from the US and using our patients. And the results were just absolutely brilliant. You know, in terms of tolerability and effects was so great that it became like, you know, for me, a complete, what's the word? But constant. Or the important tools in my, in my toolbox, which again, you know, 10 years plus ago, I'd never used, I didn't know even existed. Yeah, but it's great. Yeah. And I do use HMOs from time to time too. And again, probably some people were, they might be too sensitive for lactulose gauss or Foss England, where we want to increase bifidobacteria, but we can't use some of those other tools which can have, I would argue, more profound effects in the microbiome. But they're more gas forming. Broadly speaking, for most people, I was.

At about 2 to 3% Bifido and HMO took it over 8%. Yeah.

Okay.

So, yeah.

What's the dose?

Pretty much all the E. Right.

Well, I mean, they, they love lactulose, they love goss and phosphate, but. Yeah. And some strains, like infant is obviously loves HMO specifically, but what sort of dose were you using? I'm just curious, Rich.

I was only using one. I started out with just one gram a day.

Okay.

Yeah, that's cool.

That's a good, good response. I, I wouldn't say clinically. I would see that, that from that dose of HMO in most people. But I'm glad It did for you.

It could have been because I had a. Yeah, for sure. I had a base of four other prebiotics that I was taking that got me up to 3%. So maybe this.

Yeah, synergy. Yeah, yeah, synergy effect. Great.

Yeah, sure. I appreciate though you mentioning lactulose and as your unapologetically your favorite for listeners in the United States, I. I think it still requires a prescription. I don't know why it's a weird.

Thing because the US market is so unregulated in so many ways. But not with lactulose. You know, it's no more dangerous than magnesium or vitamin C. That. Yeah, if you took enough of it long enough you get diarrhea that might result in electrolyte issues. You know, similar sort of risk profile there. But yet it's such a benign something. You'd be added to infant formula in the 1960s. It was an idea before its time, but as a way of making essentially it's a bifidis factor that when babies had formula with lactulose they became dominated by bifidobacteria and if they had normal formula they were dominated by a wide range of bacteroides and really diverse ecosystem, which we don't want. But that was way before people were open to the idea of prebiotics and engine formula. So that didn't last very long. But it's such a benign thing. But yeah, I think US is the only country in the entire world where it's regulated as a pharmaceutical versus everywhere else that's just sold in the chemists pharmacy. Yes, it's in the laxative section and yes, in large doses it does work as an osmotic laxative. But we're talking quite different dosages. Like typical laxative dosages are 30 or 40 milliliters in one hit, whereas the minimum dose for have a prebiotic effect is probably just like 2 grams, 3 mils. So it's like one tenth the kind of dose. And yeah, there's definitely a dose response. We get bigger microbiome changes with higher doses of lactulose. And that's clearly been shown in studies too. And in my practice too, bigger doses cause much more profound changes. But the minimum dose is just like 3ml, which is a pretty small amount. And for many countries it's immensely cheap too. Like in Australia we could buy 500 mils for, for 10 bucks and that will, that's like you know, over three months supply for $10. Which is like absolutely fantastic from a price point. And again It's a sweet syrup. So compliance tends to be pretty good from a taste perspective anyway. But it does increase gas. Yeah. And that's where again, slowly increasing the dose. But again, probably the only caveat where it can be problematic is placebo cases where they have bacteria that need actually in the small bowel. I think that's the area where it would be contraindicated to my mind. So, you know, there is a patient cohort where I just don't go, hey. And potentially with somebody with high methane to excess methane production, the gut can react poorly to lactulose too. They're not all. Some actually it works really well as a laxative and can be therapeutic, but others would just blow up like a balloon and their concentration gets worse. So there's a couple areas where you've got to be cautious around the use of lactose. For sure.

Well, you motivated me. I'm going to, I'm going to get myself. Yeah, I'll, I'll get a prescription for it if I. Of course I have to. So I, I will.

Yeah. I know some US patients just order it online from a chemist in Canada or even Australia, you know, and just get it shipped over. But oh, but yes, you can get shipped for it. Just make sure. Again, the US market's strange because they, they like adding fluorescent pink and artificial colors, artificial sweeteners and things to the lactulose. So just don't get any with those things in it. It's got, it's supposed to be crystal clear liquid that's already sweet. And it's blowing my mind that they bother adding artificial sweeteners to it because it's already sweet. It tastes like sugar syrup. Like why would you have to add more? But for the US market, they do. They make it fluorescent pink and green and orange and add more sweetener to it. So avoid that brand. I think there are brands that are clean in the US but they're hard to come by.

Okay, that's a good tip. Thank you. I'm guessing you're familiar on Facebook there's a 16,000 member gut club stool test discussion group which, you know, the normal person is an interest in that. But. But 16, 000 people are probably more.

Than that who just didn't know it exists.

For sure. For sure. And I find a lot of very sick people on there and a lot of very smart people helping others. I appreciate that And I just mentioned that I had the opportunity to interview you and what questions they might have. So as time allows, maybe I could throw a Couple of those questions at you. Yeah, this first one's a little bit longer, but the question is how important is it to you that your clients be assessed for potential non gastrointestinal risk factors like biotoxins, environmental toxins, improper immune activation, damage to immune cells like with chronic Bartonella medical therapies, certain enzymes, nutrients, including COVID vaccine, its immunological toxicological impact, harming the natural form and function of the gut. So all those things together, I mean.

I think as a clinician, like when I first see patients, I spend 90 minutes with them and a lot of that is a history taking. Yeah, going I want to hear your story in, in great detail. And you really trying to. And I do look at, you know, Obviously I spent 25 years just researching the microbiome and treating mostly micro related things. I do look at the world through a microbiome lens. Yeah. And if you have a Lyme predator, discontreated Lyme for the last 20 years, they look at the Lyme lens. So they're going to look at things differently than the way I look at things. So it's putting that idea of a bias towards the importance of the gut microbiome. And obviously we're taking a case, we'll try to get some details there and then yes, if we suspect something else might be at play, we might do some testing depending on the costs associated with that. I mean I think that list of stuff you said there, I mean some of the things I probably still can't test particularly well for, other things would cost a lot of money to do. So it's like, okay, is that the best use of resources for this person? Maybe for some people it is, some people it's not. I still think that. I think again based on my experience too, but like just the key role of the microbiome is we can still, I mean obviously if someone had a COVID vaccine and then their gut been poor since then, I want to know that information. It's one of those key attributes. They're like boom. I want to take it out in my mind that may have been because we know for some people it definitely negatively impacted microbiome composition. I don't know if it did for everybody. I don't really have enough research to answer that question. But for some people, definitely did and definitely bifidactory is one of the groups that was impacted by that. That's something that flags in my head. But we'll do a microbiome assessment, we'll see if that's exactly what we see in that case. But I think, think again going looping back around that by working on improving gut functionality and that includes things like gut permeability, gut transit time. Because so many people are slow really it's huge that people have, have they might know they're slow. I think that's the other thing too. They might go, I'm doing one poo a day and I've got a type four in the Bristol stool scale, therefore my transit time is fine. No, you can't assume that. I've had so many patients that are actually fecally loaded who are doing one bound movement a day in a type four in the Bristol stool scale and didn't they were fecally loaded until we did some motility testing? You know, so it's like, yeah, so I did think, okay, you've motility is a huge thing. Improve that, improve. You've got pre molility and you improve microbiome composition. So many things improve, you know how your immune system functions improves, you know, how your brain functions improves. So many things improve from that, that even if you do have other things going on, that can't be a bad thing. Doing that to me that's like, it's like, like core underlying things. And I think there's an old naturopathic ideas if, if in doubt, treat the gut or out cheat the gut first. Because we've always known that this is like where so many things emanate from. So we need to prioritize that bit. And yes, sometimes there might be other things going on elsewhere. There might be. I work with some people that are doing like mold detoxes on here, but I'm helping with the microbiome bit at the same time, you know, so sometimes we're working, they're working on a clinician who just does that and I'm working on the microbiome component. That definitely occurs.

Makes sense. You're just increasing the overall health and resiliency. Yeah, yeah, I love it. Another question, if I can question asks, why are we having to wait so long to get a technology that can measure the small intestinal microbiome with the DNA shotgun technology, their products being tested, they use a capsule you swallow. I got to interview professors working on one of those. They can take, take one or more samples as it goes through the small intestine. This guy ends by saying it seems straightforward but we never get these products through regulation. Do you have much comment on that?

I think it will happen. I, I just, I share that. I, I just particularly with some of those patients. Like if we knew what bacteria were, what the imbalance was in the small bowel, we would be able to target treatment so much better. Yeah, the moment like, oh, they have a hydrogen, or they make me thin or they might make like H2S. That's kind of the breakdown, but it's like, what's H2S producer? You know, is it, is it, you know, hemophilus? Is it klebsiella? Is it the sulfa vibrio? It's like, yes, we kind of would love to get that level of detail and I don't think we're that far off, you know, speaking from, you know, gastroenterology colleagues around the world. I mean these things are now in research centers putting through the tests and I think probably in five years time we will have access to such tools. Yeah, probably not me as a natural physician, but you know, gastroenterologists will have access to those tools longer term. I'm hoping there'll be such things more easily available for other clinicians like myself or in the general public to access to where if it's just swallowing a capsule that has no risk of harm with it and the cost isn't probably going to be that much in the end. And once they get a technology working, well, hopefully it'll be quite easy to access these tools. Yeah, just like, well, like one day I hope there's a. Again this will happen, whether it's the next five years or more like 20 years. But we'll have toilets that will analyze our poo instantly when we empty our bowels and give us a readout of our microbiome for the day, you know, so we get that sort of instantaneous feedback rather than you have to wait, you know, three or four weeks from a lab between results. One day we'll get that.

That's, that's fascinating. I was just going to ask you what technologies that you hope can be developed? You know, so if you could wave your magic wand, would it be the, the toilet that could, that could identify species or something else?

I would love, I would love quick, quick turnaround times because I think particularly for things like that where you're getting acute insult to the microbiome, I would just love, not have to wait four weeks to see exactly what the level of harm is. And listen, when there is acute insult, like not put antibiotics or chemotherapy, we don't wait four weeks to try tree. We'll, we'll put things in place and make assumptions around what's going on. But geez, it'd be nice to get really quick results going exactly what's going on so we can target things really specifically. So I think that would be definitely on that list. But I'd also put that small bowel assessor because just to know what's going on with that individual person's small intestinal microbiome would be fantastic because it might make all the difference for those people. Some people who are not responsive to the usual things. And that's where a tool like that would be immensely helpful, less so when it's like people respond really well to, you know, we can do you know, non inventional breath tests. But again this is swelling a capsule getting information non intervention too. It might end up being quick turnaround time and inexpensive to do. So yeah, that tool I think would be, would also be a major game changer too. And that one seems less far off than the toilet. That will give you instantaneous readouts but that will happen in the future. And I think the other thing would be maybe a good stool bank in that when infant babies are born we maybe take sample of their poo. Maybe once a year we take a sample of their poo and just freeze it and put it aside for them in case they do need to take a horse antibiotics. Then we can reinoculate them with their own ecosystems. Again because it takes out all the concerns around disease transfer or from fmt, I think or, or personality transfer or metabolic health transfer. Like a bunch of different things come from, from FMT research. When you're getting poo from somebody else, a poo transplant. But when it's self transplant we don't have to worry any of those things. Yeah. And it also means we're guaranteed to have engraftment. Yeah. And I think this will actually mean that we don't have the same level of each generation. Westerners we're getting less and less diverse ecosystems, you know because we can only pass on the microbes that we have, you know. So when I was born I was you gifted number of microbes from my family members. Mostly mum, but a bit of dad too, probably a little sister as well. And then I proceeded to take a ton of antibiotics as a kid. You know I grew up in the 70s in Canada and they were like oh you've got a sniffle, take this antibiotic. Oh you've got a slight cough, another antibiotic. It's just like so many antibiotics growing up and my even was hammered and the diversity went less and less and less. So I can only pass on these microbes to my Kids, you know, because of that. And then they're going to start with that and then if they get exposed to antibiotics, which thankfully they have not, then, then they would be, you know, impacted and they're, we get less and less and that's what we see in these restorations. And this would fix that because every time you. Because life. Antibiotics can be life saving. We shouldn't use them for a bloody sniffle or for you know, viral bronchitis, but they can be life and life saving. We want to use them for those things. And if we just use them for those things only antibodies would last us for far longer too from a stewardship perspective. We'd have their use and efficacy for many more years. We use them appropriately. But then we could reinoculate with your own ecosystem and then you wouldn't have any microbiome harm. From the experience that I think would be a game changer too. And that should be something that could be implemented relatively straightforward. And there's been some research around that. In Canadian study where they had people, when they went into hospital, they took a poo transplant, they took a poo sample in the hospital and they had their procedure, then they gave them a poo transplant afterwards. And those that had their own own poo back given had like no C. Diff infections and were at hospital. So much better, you know, and which totally makes sense. Yeah. And it is by far the best way of re establishing ecosystem after a major harmful event. Like of course antibiotics is not, not prebiotics, not probiotics, but your own specimen transplant.

You're giving some entrepreneurs out there some great business ideas.

I hope so. I would love someone to actually do this and I'd love if we read the standard practices that we actually have a sample. And when I think people get their head around the importance of the microbiome, it's like why the hell did we not do this before? We're giving all these interventions that are killing bits of you standard protocol to young kids and we have a very easy way of actually reinoculating so they don't actually have any harm from that intervention or we just ignore it and they get potentially lifelong harm. We know antibiotic use in kids leads to increased rates of obesity and asthma and allergies and a whole bunch of different things. It has long term consequences. You know, reading studies antibiotic use in middle aged women increasing their, the aging of their brain and causing cognitive decline or speed and cognitive decline. It's like, you know, these things are preventable if we just do a buddy Poo transplant afterwards. It's like. And it doesn't not that costly of an intervention. Just getting your head around the importance of actually doing it.

I would think a company like Tiny Health, at least in the US I understand gathering the largest database of infant, you know, stool tests that would seem to be a natural part of their business, you know, to offer that.

Yeah. And you have to have like, you know, special deep freezes etc and size and etc. To actually do it. But it's not the technology exists now to do it very easily. You know, I know there's even a U.S. i think they're called tend tnd that was designing a toilet seat attachment to that. You just poo into this the thing you sit onto the bullet. So you just do it bio move it like normal. It collects a specimen, you kind of spin it and then it just fills these capsules full of fmt, you know, and you don't have to touch it or anything.

Wow.

You know, and that I think there, I don't know where they're in commercialization now. I think it's just when using research settings and there might be some, you know, weird legal loopholes have to get through because it's for fmt. But you know, again the stuff is there, it's doable with the current technology. It just requires people willing to do it and. Yeah, but I think that could be such a game changer for so many different people because we just see, I mean the gut club is full of people that have been harmed from antibiotics and other things that have caused microbiome harm. And if you had a reset point in a time where your health is really good, you can use that and get that bit back, you know, so.

Those samples have to be frozen. You can't like dehydrate them. Would that kill everything?

It's a bit outside my area of expertise, but from my understanding would have to be under sort of minus 80 degrees and you know, like a proper for. For long term storage with any loss of viability. I think it has to be under a certain temperature. Yeah, got it. Yeah. And I don't think dehydration would work. No. Because some of the microbes are just so sensitive to air. Like the vast majority of really healthful microbes in a colon are strict anaerobics and do not tolerate oxygen. Question at all. Yeah.

FMTS is what first got me interested in. In the microbiome. I don't know, at least 12 years ago.

Okay.

I happened upon an article and I thought, wow, you Know, eliminating c. Diff within 24 hours and, and now, you know, changing autistic children's outcomes. Yeah.

And Parkinson's and Alzheimer's. So much potential problems enormous for this, for that intervention if you're getting good donors. And I think that's the other challenge in this modern world is actually getting people that actually tick those, those right boxes. And I recall a partner of one of my patients years ago, and I wish I got their names, I can remember their name now. It's lost in my paper filing system from 20 years ago. But he was born at home in the Netherlands and he was in his like, like I think probably mid-30s at that point. Never had a course antibiotics his entire life. You know, he, he was, he was breastfed. He was, his parents were kind of, you know, alternative folks. So they had like healthy whole food, organic diet his entire life. Never unwell medically, really well, sharp as attack, brain was firing like, man, you're poo. It's like you're one in a million in that you, you were sort of gifted, had the best, best, the ideal sort of initial circumstances of sort of home birth, you know, solely breastfed, no antibiotics, good diet all the way through from living in a healthy parent, in a parent household too, where they hate healthy food, et cetera. So that is so rare, you know, in Western nations. And I think getting donors like that are, you know, and yes, I could see the advantage of, you know, people talk about getting donors from the had, you know, Hadza, these sort of tribes that are, you know, the living where humans always have. And I think, yes, there's great value in doing that too. Whether they're the best match for someone in Australia or Canada or us is another question from microbiome perspective. But I think getting some, like a healthy Western one might be a better match in terms of engraftment. I mean, again, time will tell that there will be things missing from people in Papua New guinea or rural Mexico or the Amazonian rainforest that actually play pivotal roles that all Westerners are missing, that we all want back. I'm open to that too, obviously. But I think in terms of a match, finding those sort of people in Western nations would be good for us all and if we could actually store their approval because I think that's getting back to. I'm going to be the sidetrack. But in terms of having good donors for fmt because I think that's the thing is finding really good donors because some centers are like, like, oh, you know, you know, as long as we Clear for all these diseases. Great. That's a nice baseline. Love it. But, you know, then it's like, oh, okay, no antibiotics in three months and you eat. Just eat Mediterranean diet for a week before you give a pre Snapple. I'm like, really? You know, that's. That's kind of the criteria after for a donor. Like, no antibiotics in three months. And maybe that's okay for C. Diff and probably is, but. But in terms of like, optimal health or ulcera colitis or Crohn's disease, other conditions where the competition of the ecosystem not just having some microbes matters, we need to choose our donors really well. And there are some centers worldwide that are moving in that direction and doing their best to source really good donors with lovely ecosystems as well.

There was a company paying, I think it was $500 per sample for potential FMT.

Listen, if you meet those criteria, you are one in a million or something, if you can meet all criteria. So I. I can understand they're being paid a decent amount to. To look after themselves, eat really well and exercise well, etc, do all those things so that your ecosystems in Prime Point moving forwards from that too. I get that. Yeah. Because they are rare. We pay for things that are rare. And actually having a amazing stool sample donator, it's. It's rare. You know, there's good ones and there's okay ones, but finding those that are just like, you know, the unicorns, they're not rare. They're. They're hard to combine.

Yeah. Interesting. Well, Dr. Hallock, you've given us a lot of your time. I really appreciate it, but I have a last question for you, since this is the Resilient Biome podcast, and you know, I named it that intentionally. Right. My goal is to have a resilient gut. It may not be perfect all the time, but if it's resilient, what would be your top recommendation that our listeners can do to have a more resilient biome?

Oh, that's a tough one. In terms of one thing. I mean, I think you could broadly say eat more whole plant foods. That's probably the. The key thing that most of us aren't doing enough of. You know, there's things we could add on to that, like buy food from your local farmer's market, buy organic food as much as you can, and buy, like, eat a rainbow of different colors for different polyphenols, and they all fit into that kind of umbrella as. As best ways of encouraging a diverse range of health microbes in that part of your the makeup makeup system but also in terms of metabolites we get from them that have a range of health affirming, age defying properties.

Thank you. It's so glorious that what's good for us is good for our bacteria and.

Vice versa so and it's good for broader external environment too like and I think buying from your local farmers market from people who are growing stuff organically with good steward soil stewardship etc, it's a win, win, win for everybody in that kind of situation. We all get better and healthier from that process.

Yeah, well said. Yeah. Well again thank you for your time. I I wish you the best especially as you're multiplying your efforts. I love that you're just wanting to be able to share with so many more people impact so many more people so we really appreciate that.

Ah, cheers Richard, it's been lovely chatting to you too. It's a good, good conversation. Yeah I enjoyed it.

Yeah I enjoyed it. Thank you so much.