Gut Parasites with Dr Jason Hawrelak: Rational Wellness Podcast 169

Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates and to learn more, check out my website. Thanks for joining me and let's jump into the podcast. Hello Rational Wellness Podcasters. Today I'm very happy to be speaking with Dr. Jason Hauerlick all the way from Australia About Parasites Parasites is a topic in gut health that seems to have fallen out of favor among functional medicine practitioners who deal with patients with gastrointestinal symptoms. In the last five or 10 years, the focus seems to have shifted towards focusing for patients who are negative for having Crohn's and ulcerative colitis. The focus seems to be towards SIBO and ibs. Certain parasites are referred to as protozoans, and protozoans are actually single cell microorganisms and they include a large variety including amoeba, flagellate, ciliate sporozoans. Protozoans are common in fresh, brackish or salt water, as well as in other moist environments, including in extreme environments like hot springs and hypersaline lakes. The protozoans can also form cysts to survive in dry environments in a dormant state. Some protozoans live in our guts without causing harm and may even provide some benefits, while other protozoans may be a significant cause of disease, such as babesia, malaria, giardesis, etc. Protozoans are not frequently found in the stool of patients when undergoing stool testing, especially some of the very sensitive molecular PCR tests. Parasites can take the form of worms or protozoans, of which Blastocystis hominis, dienta, Amoeba fragilis and Giardia are some of the more common parasites. Blastocystis hominis is often considered by functional medicine practitioners to be a particularly difficult microorganism to eradicate and is often associated with a host of gastrointestinal symptoms, including diarrhea. It's also sometimes thought to be associated with Hashimoto's hypothyroid disease, but some of these protozoans may not always be pathological as many of us think, as Dr. Horlick will expl today. One other topic I would like to ask Dr. Horlick about is H. Pylori infection, which at one time was considered an obvious problem when discovered on a stool panel, but is now understood to have a much more complex relationship with our gut. Dr. Jason Horlick is a naturopathic doctor. He's a PhD, he's a master herbalist and he's been in practice for more than 20 years in Australia. He's one of the leading experts in the treatment of gastrointestinal conditions with natural medicines. He's written extensively in Australian and international textbooks and journals on digestive topics. He both sees patients in person and remotely and he also teaches other health care practitioners. He currently coordinates and teaches the Evidence Based Complementary Medicine program in the School of Medicine at the University of Tasmania. And he's the Gastrointestinal Imbalances Lecturer in the Master of Science in Human Nutrition and Functional Medicine program at the University of Western states in Portland, Oregon. Dr. Herolik started and runs an incredible resource to keep track of all the research on the latest probiotic strains called Probiotic Advisor, which I have used and is an extremely, very valuable resource. Dr. Herilicz, thank you so much for joining me today.

You're very welcome, Ben. Nice to be. Nice to speak to you again. It's been a while.

Absolutely. So before we get started, I don't know if you saw 60 Minutes on Sunday, but I have bad news for you. You'll have to close down your probiotic advisor because 60 Minutes reported that there's absolutely no benefit to any probiotic.

Great. What can I tell my patients for the last 20 years? I can say placebo perhaps. You know, I haven't seen that. Actually I should put it on my agenda or something to watch to see what the mainstream media is actually reporting there. Yeah, I think that comes from really misunderstanding some of the nuances around probiotics and rather than taking them to change the ecosystem or to repopulate, which I think is this more popular idea with knowing that they actually have specific effects actions when ingested that has which creates physiological change. So we can use it for helping to eradicate H. Pylori, for example, or for decreasing obesity or for moderating mood. There's a whole bunch of positive clinical trials that it's I think pretty mind blowing to come to that viewpoint that probiotics don't work for anything based on what data has been published for the last 30, 40 years.

Amazing amount of studies. Yeah. And of course that was one of their complaints. You know, we're not going to spend the whole time talking about 60 Minutes, but that was one of their complaints is that the probiotics that you ingest don't actually find themselves to populate the gut. But we know that and that doesn't.

Yeah, that's not surprising. That's not why we should be taking them, at least, you know, what the research has shown us is that if that's why you're doing it, you're not really taking for the right reasons because you're not really going to achieve that. With the current generation that we have, it's pretty rare to have any sort of long term colonization. But that's not to say that that won't be something we generate with future probiotics. If we start making probiotics from things like Akkermansia and Faecala bacterium and Eubacterium, like novel species that might actually have that capacity to stick around for longer periods of time or if not permanently. But reality is that they have therapeutic effects when we take them. Some of them do anyway. If we select them well and make sure they've got the right traits and qualities, and when we stop taking them, that will stop having that effect. Just like any pharmacological agent, whether that be pharmaceutical or hero medic, that they've got an action, when you take it, you cease taking it. It stops having that action.

Yeah. So one of the reasons I really have been looking forward to this discussion is that I really wanted to dive into some information about parasites. When I first got into functional medicine 20, 30 years ago, there was a lot of talk about parasites. In the last five or 10 years, we sort of lost that focus. So I think it's an important topic to talk about. So when you're consulting with a patient, are there any particular symptoms that come up during a consultation that will make you suspect, hey, this could be somebody who's having a problem with parasites?

Yeah, I mean, the challenge with most symptoms that we'd associate with gut parasites like Giardia, which is undoubtedly a cause of gut infections and gut damage, and Entamoeba histolytica, for example, that are in that camp, versus ones that are much more debatable, like blastocystis and dientamoeba, is that the symptoms overlap with irritable bowel syndrome in some degrees with inflammatory bowel disease, functional dyspepsia, post infectious IBS with sibo. So it's this whole cluster of someone who presents with these symptoms. You really need to do testing to ascertain what's going on. So you might get some clues from history in that, okay, they've just traveled overseas and they went to developing nations and they got a case of traveler's diarrhea. That to me is a red flag that, okay, there may well be something staying the gut from that time of Ingestion and that acute flare, sometimes your body will fight that off. Most of the time it's a bacterial agent anyway that causes traveler's diarrhea. But we do get protozoa as part of components of or as contributors to that overall traveler's diarrhea load. So we really need to do so, yes, we might get that flag on the history, but we really need to do testing to ascertain what's going on. So for me, that wouldn't require or mean just doing stool testing for parasites because I think we will get the potential getting quite lost and missing what's going on if that's all that we do. That's because some microbes like blastocystis and zytamoe are so common in healthy everyday people that if they got, oh, they've got some runny stool and some abdominal pain, you do one test, you do a stool test. It shows that I think there's a decent chance you're going to miss what's really causing that person's issue in that instance. If it happens to Giardia, well, fair enough, that's a different scenario. But if it's dying to be blastocystis, we can't make that assumption that this is the cause of their symptoms because of it, the prevalence of these microbes in healthy populations. So essentially to me it means we've got to do a suite of tests that if they present with that symptom picture that overlaps but still so many other conditions, we actually have to test to rule out those conditions. That would be things like fecal calprotectin or lactoferrin for inflammatory bowel diseases, occult fecal cold blood, for example, also looking for more pathological changes and damage to the smaller large bowel. For me, it would mean SIBO breath testing would be a component of that as well, as well as doing a stool PCR looking for the presence of potential bacterial and protozoal parasites that may have been picked up.

What is your favorite stool test these days?

I would actually use a number in practice, so but I'm based in Australia, so we actually have like the, you know, conventional pathology labs that do a stool based multiplex PCR that looks for the most common protozoal parasites, the most common bacterial causes of diarrhea. So I might run that. But then I'll also do a microbiome assessment as well that looks tells about the bacterial ecosystem as well as doing breath testing. And then the other test looking for inflammatory markers in the colon that might indicate that it's more likely to be inflammatory bowel disease, even some of the more rare ones like lymphocytic colitis or chlagas colitis, for example.

So which microbiome test will you use?

Ah, good question, Ben. These days I'm using one of mostly between two different labs. One lab here in Australia called Microba that does metagenomic sequencing, which means we get very good detail and data from a species level and even level perspective, as well as from genus and higher up the hierarchy up to phyla. It also gives us the markers around levels of LPS production, levels of hydrogen sulfide gas production, for example, that I find can be clinically useful. And then I'm also using thrive as well as my test, particularly for my U.S. patients, where we get that nice snapshot of the bacterial components of the ecosystem.

Yeah, you might check out this biome FX test that Microbiome Labs is promoting now that Kiran Krishnan helped. Fine tuned it looks pretty interesting.

Okay, no, I haven't had a chance to look at that yet.

Yeah, check that out. So if you had a patient who came in your office and they're having some of these symptoms like gas bloating, maybe diarrhea or constipation, and they had a positive SIBO breath test and you also saw a parasite, which would you treat first?

For me, if it showed up a very clear positive on sibo breath testing and blastocystis and or dientamoeba in the stool, I would treat the sibo and I do this all the time. And the presence of blastocystis and dienteba is generally completely irrelevant to that person's symptoms. That's something that I've come to from 20 years of practice and reading more the recent literature around the prevalence of these parasites or parasites, protozoa and protozoa, like organisms in people's guts, is extremely common. And what I found is that most patients who present to me with they go, hey, I've got a positive stool test for blasto or dietuba and they haven't done a breath test yet. We'll do a breath test for sibo and it will actually show up positive. We treat the sibo, their symptoms get better, they still have blasto in their gut afterwards. And I think, you know, and that is so common. And for me it really showed clearly. You know, I go back to how I treated patients, you know, 15, 20 years ago. If they showed up with a positive blast or diapeme, I was like, okay, let's try to kill this, let's focus on that. And sometimes you get symptomatic improvement for sure, but I think at least temporarily, but I still think we were often inadvertently treating the SIBO in these patients rather than which was the cause of their symptoms. Because I wasn't really aware of SIBO in 15, 20 years ago. It wasn't well known as a diagnostic label, and testing wasn't really promoted and discussed and talked about very much. And so I think I've seen that major shift in focus. And one patient also illustrated to me very clearly that they came to see me classic symptoms of bloating, distension, some runnier stools, positive stool tests for blastocystis. And I just made the assumption that that was the cause. So I said, okay, let's treat that. And yeah, there was symptomatic improvement while they were taking the herbs. Then I hadn't seen her for a while. Then she came back. I think it was probably 12 months later. And she said, oh, I was actually diagnosed with fructose intolerance and stopped eating, reduced my fructose. I don't know why. Symptoms went away. And it just really was like, oh, how could I miss that? You know, I really let this patient down by not doing a proper diagnostic workup, that I got fixated on this thing, and that wasn't the cause of her symptoms. She still has blastocyst in her gut, but no symptoms if she goes on a low fructose diet. And that patient really taught me a major lesson that we can't. We're often guilty of this premature diagnostic closure, and I try to be less guilty of that now than I was in the past where we wouldn't do a proper suite of tests to really see what's going on, and we'd get really fixated on that, on that one and actually miss it. And I've had other patients that are subsequently diagnosed with celiac disease, for example, that were by other practitioners diagnosed with blastocystis and not followed up. Can you think that what's the consequences of that missed celiac disease? Because we got so fixated on that blastocystisanus stool test.

Huge, right? Right. So I want to go into some more detail on those two protozoans, but I wonder if it's possible that, you know, we have sibo, which is bacterial overgrowth of the small intestine. I wonder if there's a sibo, if there could be a protozoan overgrowth in the small intestine that could be creating some of these problems. I asked Dr. Pimentel that when he was speaking at our meeting last month and he said, we're still going through all the samples and we're going to look that as a possibility.

But yeah, because I think really with the evolution and technology of using metagenomics, we can actually take samples and see things that exist that we didn't know existed before. So it is interesting, and I think because we changed that technology or evolved into using technology that is far more accurate in its capacity to tell us what's there. We're all seeing, we're seeing now that we all have protozoal organisms in our gut. That's totally normal for humans. Whereas you go back 20 years ago and people weren't thinking that. We were thinking, if there's a protozoa there, it must be, must need to kill it, because it shouldn't be there. And it's like, no, we're supposed to have fungi, fungi in our guts, supposed to have bacteria, and we're supposed to have protozoa. And they live in this beautiful, usually beautiful, harmonious ecosystem where they're all actually interacting in ways that ensure our state of health until we upset that balance in different ways.

So you're proposing that we should really think of protozoans in some cases as commensal?

Definitely, definitely. And I think certainly in the camp of, with microbes like blastocystis and diatomoeba, I will generally put them into the commensal camp in vast, vast majority of my patients. Now, even though I had a stool test done, just because I was testing a bunch of different labs, and it turns out I've got blastocyst and dientamoeba in my gut and I've got like no gut symptoms. You know, managed to work 60 plus hours per week for the last 10, 15 years. You know, no fatigue issues like the things that people see as symptomatic with these things. I don't have, and here's just one clear example of a case of healthy person that has these microbes. There are no symptoms whatsoever. And you look at the literature, we find out that that's actually fairly common with blastocystis and diente. They are extremely common in healthy people. The more recent research of the last few years have suggested, particularly for microbes like blastocystis, that they actually play a pivotal role in keeping our ecosystem healthier versus the loss of our protozoal species that we've evolved with over millions of years. Some scientists, researchers, are suggesting, is having negative repercussions on our state of health. That we see around us now, just like we've had that loss of bacterial diversity and loss of arguably fungal diversity that we were just finding out about now. But the repercussions of which I think we see all around us with the western disease states that we see in practice all the time.

Yeah, Maybe we'll be taking protozoan supplements at some point.

It's possible, I reckon. Yeah.

And maybe it's a question of balance. Maybe it's a question of you're supposed to have a certain amount, but maybe if the blastocystis is too high, it's not a question of it shouldn't be there, but shouldn't be there at that level.

Yeah, I mean, I do think there might be a part of that, and part of that is around environment, because I always go back to that. The train is really immensely important for most organisms where they can be infectious or not. The train is important. And I dare say it's similar with some of these microbes, too, that if we're eating the right things and living the right lifestyle, then their presence is probably fairly irrelevant. But you throw those things way out of balance, and you throw other things in the gut out of balance, then maybe their populations or their behaviors change. And I think that's something we can see with microbes. And there is some research around that with blastocystis, for example, that some research published very recently showing that exposure to metronidazole. So flagyl, the most common antibiotic used to kill protein organisms. Well, when it doesn't kill blastocystis, it seems to actually awaken its more pathogenic potential that was lying dormant beforehand, exposed to antibiotics, and increases its capacity to potentially cause gut damage, to interact negatively with precancerous cells and become much more virulent. So it's like, okay, you know, so I think that there is an argument around how we, you know, how we eat, what our lifestyle is like, and the potential functionality and behavior of these organisms in our gut. That could be different if we had a completely different diet, different lifestyle, exposed to low levels of antibiotics in our food chain. You know, maybe we're bringing up for more of the pathogenic potential. Potential.

Yeah. I was listening to an interview that Michael Ruscio did with Ilana Gurvich, and she was talking about a study that found that species like Blasto and Amoeba fragilis, what they do is they change the microbiome enough to make the bacterial neighborhood more pathogenic and predisposed to negative changes either in the smaller large bowels so therefore they're maybe setting up things like sibo.

Interesting. Now, I haven't seen any research around that and I'd be happy to be posted some so I can read it. And there is certainly some data. There was one study done in 2019, in vitro data getting a subtype 7 from symptomatic isolate subtype 7, blastocystis, and giving it to mice and finding that and in vitro that it was able to shift the ecosystem. And maybe that's what she's referring to. She might be referring to some other study that I'm unaware of. But that was interesting in that it did seem to increase levels of more pro inflammatory bacteria like E. Coli and Bacteroides, for example, and decreased levels of bifidobacteria.

And so we need to discuss the subtypes. So there's 17 different subtypes of Blastocystis, right?

There is. And there's nine that are found in humans, so the rest are found in other animals. And that said, it's not like these are only exclusively found in humans. They are the ones we find in humans. We also find in chickens and in primates and in pigs and cows and horses and all, and rhinoceroses and zebras. And any animal you can name generally can have a hazard plastic system that can be in its gut or a number of them. I mean, for humans, the most common subtypes are 1, 2, 3 and 4, probably types 1 and 3 extremely common.

Now, is one of those subtypes more pathological potentially than the other?

Well, there's been a lot of research trying to tease that out. And I would say the research has been generally has not shown any clarity around that at all. So the only small pivot I'd say there is, subtype 7 is very rare in humans. It's mostly found in animals, birds, sorry, chickens, particularly like, they carry subtype 7. And that study that looked at those shifts in bacterial ecosystems was associated with symptomatic type 7 isolates. So if I had a patient and it did show up a subtype 7 blasto and all the other tests came up negative or as a normal, then I might be inclined to go, okay, well, let's see about eradicating this organism because it could likely be a cause of their symptoms in your case. But I certainly don't think the data is consistent enough because this is. You'll find one study that goes, oh, was subtype 3 was more common in IBS patients. Another study would go, no, subtype three was totally not. It was subtype One, Another study would show subtype four. There's no consistency around the findings.

Right. So I just want to highlight the fact that what you're discussing is that Blastocystis hominis, which I still think a lot of functional medicine practitioners, if they see that on a stool test, are going to say, boy, you've got this parasite and this parasite is pathological and this is probably the cause of your symptoms. You're saying that in a majority cases it's probably not the cause of their symptoms and you may be missing another important underlying cause of their symptoms and you may be going up the wrong path. Focusing on eradicating the Blastocystis hominis.

Yes, that is, that's definitely my viewpoint for sure.

Right. I just want to make sure that everybody understands that because.

Yeah, no, fair enough. Yeah. And it's something that for me, it's evolved over 20 years of practice, you know, of dealing with patients who present with gut symptoms and the blastocyst on stool tests, from what I used to do to what the research is saying and to what I do now and the results that you actually see. Okay, so now we'll see something else than that. When we do a suite of tests and make sure we don't stop our diagnostic procedures so early, we'll find something else that actually explains that. You treat that something else, their symptoms go away. Blastocystis or dientamoeba are still there. Yeah. So there's that component of it, but it's also just the fact it's so common, you know, I mean, dienteba in Western Europe, where a lot of good studies have been done, it's found in, you know, up to 7 out of 10 healthy kids who've got dienteba in their guts. So what's normal, what's not normal? Kids with functional abdominal pain are less likely to have dienteba in their guts than those who actually are healthy. So I still have practitioners here, integrated practitioners, who wanted to use antibiotics or suite of antibiotics to try to kill that dienty media because it shows up on a stool test. Yet the data tells us that it's actually immensely common in kids and it's more common in healthier guts and it's unlikely to be a common cause of the gut symptoms. When you look at the research in totality. Yeah. You can find, if you're going to be self selective and not look at the broader literature, find a study going, oh, look, we gave them antibiotics and there's a case study showing that they improved. Yeah, we'll quote that study rather than looking at the totality of data or looking at the only one to date, randomized placebo controlled trial that looked at kids with chronic gut symptoms and had diatomoeba present. And that seemed to be the only potential. Everything else had been essentially ruled out. So I said, okay, he's got these kids with chronic gut pain, they've got Dienteva, let's give them antibiotics or placebo and let's see the response. You know what the response was? Placebo was equally effective as antibiotics for reducing these kids symptoms. There's no difference between them and there was no correlation between the eradication of Dienteva and any change of symptoms. So I think the really good quality data is not suggesting that particularly things like Dienteva we're talking about now is a cause of symptoms in kids and that it is immensely common in healthy populations.

So in those rare cases when you have a patient with elevated levels of blastocystis hominis and you don't find any other pathology, what natural treatments have you found to be the most effective?

It's been years since I've found a patient like that, Ben.

Oh really?

I can tell you it's actually really rare. I don't find what else, something else that's going on. And the biggest challenge can be teasing out the post infectious IBS from a case of blastocyst or induced infection like, you know, sick gut symptoms. Because you'll have a similar picture where someone will travel overseas, they'll get traveler's diarrhea, their gut's never. Well, since you do a stool test only, that shows up with blastocystis. Now that blastocystis could have been present in their gut for the last 10 years or 20 years or 30 years and not be remotely relevant to what's going on. Because we know that post infectious IBS happens where two things once post infectious placebo develops, that's pretty common and then you also have more of the chronic inflammation that persists after the infection is gone. So you might have a traveler's diarrhea caused by E. Coli. It's caused colonic inflammation and visceral hypersensitivity that persists for weeks to months to years after that infection. So there's no more infecting agent present. You just have this residual inflammation that impacts, causes bloating, distension, may alter transit time a wee bit, certainly alters sensation in the gut. So you feel even small amount of gas being produced. We know that's common in the literature yet if you did stool tests and you found blasto, in that case you might go, I want to kill the blasto. That's the cause. But it may not be because it may just be post infectious ibs. So that's, I think, the area that can be the most tricky to navigate because you'll have normal tests come back. They may not have sibo, but they can still have post infectious ibs. And there's no test for that. It's based on history and their symptom pattern.

And not to kick a dead horse, but one more attempt. What if the stool test shows like a really high level of blasto? Does that raise any suspicions or not?

I think no. It would depend on the overall pattern of history. So I wouldn't rely solely on that. Looking at their symptom picture, looking at their history. Now let's assume if there was someone, it's been years since I've had one of those patients that I think blastocyst is, is the cause of their symptoms. And then I do. There are certainly some herbal preparations, et cetera, that I would use to try to help reduce levels. But you're also focusing on trying to optimize the microbiome as well and heal up inflammation in the gut and improve their overall vitality and health. Anyway, so I think for me those are always the core aspects. Okay, what can I do to improve this person's state of health? What can I do to make the ecosystem a more healthy environment that's less conducive to bringing out the bad behavior in things like blastocystis? You know, we know that blastocystis likes living at a more neutral alkaline ph. It doesn't like living in acidic environment in the colon or levels can be certainly reduced that way. So, you know, the focus is on having a lot more fiber and using prebiotics, eating probably plant based whole food diet as ways of actually shifting the ecosystem in the colon. So it's actually one more healthy. But two, there's more production of short chain fatty acids like butyrate acetate for example, that then will then lower the pH. And that in itself can be effective in decreasing levels of blastocystis just by changing the environment.

Okay, yeah.

And then I might complement that with some herbs. And these days, because of my concerns about causing collateral damage to the colonic ecosystem that I try to avoid as much as I can, when I can, I'll use agents like pomegranate husk and garlic, which we know that can be effective against blastocystis in the best data that we really have at this juncture of time is in vitro studies or animal studies, for example, mostly in vitro. And you use that alongside Saccharomyces surveyceae variety Boulardii biocodex material, which we know has got the positive research for eradicating blastocystis in a human trial, alongside the other agents that I talked about, that they're focusing on improving the ecosystem balance in the colon and that will generally one, sometimes eradicate the blastocystis, but two, certainly improve their symptoms and importantly their overall state of health and well being.

So let's go on to some of the more pathological parasites. Which ones do you see most commonly?

I would say giardia would definitely be top of my list. And these days I work in a inner city environment that is a colder climate, so I don't think see giardia as often as I once did. But my first number of years of practice I was living in the subtropics where people drank creek water and rainwater for most of their sort of. That's rural, so people were often bush walking and they're hiking and drinking the water from creeks, etc. So Giardia was much more common back then. So I had a lot of chance to hone, hone my practice on giardia treatment over the years. Now I tend to see it more in the odd returning traveler or I see the odd person who's got a chronic infection of giardia that they weren't able to get rid of with their previous course of antibiotics.

So what is some of your favorite natural agents for treating Giardia? And also do you cycle your use of these?

Generally there's no need. My experience with giardia is that it's immensely responsible to the right treatments and target treatment with natural medicine. So I would be using raw garlic ideally, and if they're very sensitive, we might use an allicin based product. But most of my patients have tolerated raw garlic. A couple cloves pressed into either a little capsule or a little glass of water and swig it down a couple times a day. There's one study out of Egypt that showed, I think a 100% eradication rate by day three on having substantially blended raw garlic. Wow, three days, that's impressive.

Yeah.

And 100% reduction symptoms or essentially elimination symptoms by three, six hours into the treatment protocol. Wow, that's very quick. So garlic's definitely on my list. And these days I would be using pomegranate husk and Usually plantain, plantago major, ribwort, which is one of those herbs that grows as a weed almost everywhere in North America here in Australia. And it's got some lovely potent anti Giardia activity, but it's actually has some healing anti inflammatory effects on the gut as well. And it doesn't taste too bad and it doesn't have that sort of broad killing effect that I might get, you know, with something that was more berberine containing herbs. So years ago when I first started practicing, I used more berberine containing herbs and it's certainly effective for Giardia. No doubt. I would be using Coptis chinensis, which is contains more berberine than goldenseal or other other berberine containing herbs like Mahonia aquifolium or Berberis vulgaris, a lot more. And it's undoubtedly effective. But I also know from research I did as part of my PhD is that it reduces levels of bifidobacteria and it's not such a big deal for 10 days, which is the usual treatment period for Giardia. But given I can get the same results without having to worry about any collateral damage to my bifidobacteria populations and patients, if I use pomegranate and husk and rhubworth and garlic, I'll choose that. Then I would give Saccharomyces cervaceae variety Blardii. Biocodex again is my probiotic of choice because there's good data on that in Giardia, both for helping to eradicate, but and I think this is the important aspect too, is that a number of people have symptoms that persist long term post Giardia. And this is because giardia, amazing, amazing little preservism that you know when it exists from its little cyst, you often get one or two little guys that come out of that, but they can cover up every single little bit of your proximal small bowel. Every little millimeter of space will be covered with the Giardia trophozoid. And they can actually cause a lot of damage as part of that they can cause nutritional issues in the short term and that you're going to malabsorb. Most things you eat are gonna be malabsorbed because they're just like covering that entire area. They're gonna eat what those foods and you don't get much, if any, but they'll also cause a fair bit of damage to the small bowel. And this can sometimes mean that there's a bunch of symptoms that persist even after Eradication. So you might go kill off the giardia with antibiotics or with her own medicines in my probiotics and nutritional supplements. But they might still have some persistent diarrhea, persistent lactose intolerance, persistent fructose intolerance that comes from afterwards. Because when you sort of flatten those villi you all of a sudden and you damage the brush border. You don't have lactase on those brush border enzymes anymore. And the fructose transporter is very much impacted by inflammation. So if we inflame the small bowel, we really limit the capacity of that fructose transporter to, to pull up the fructose and take it in. So we can often get the secondary lactose and fructose intolerance. And the saccharomyces are wonderful for helping to regrow those villi and the brush border on those villa. So you might do that during but then for at least six to 12 weeks afterwards to speed up healing.

Interesting. So the villi are damaged by the parasite or by the giardia because they've.

Got a little ventral disc that sort of sucks on onto it and actually causes tissue damage, inflammation.

You have to have the giardia for a long time for that to happen.

One would say the longer you've got it, the more severe the level of inflation would be. But there's a caveat there because we know that most people will throw off giardia in three weeks with no treatment at all. So I think from memory it's around 90% of people. You give them giardia, you do nothing. In three weeks it'll be gone. In 90% of people it's going to be an uncomfortable three weeks. Lots of diarrhea, lots of bloating, lots nausea. I don't recommend it, but we know that the immune system can generally deal with it. Except for people that have iga. Insufficiencies tend to be the biggest issue where they will have it. It's impossible for them to throw off giardia if they don't produce enough signatory IGA in the gut. There's some people that it tends to be a chronic infection. Yeah. But even a week to two weeks is still enough to actually cause a degree of malabsorption. And depending on how severe the infection was and how much of the small bowel was covered will dictate how much of that post infectious symptomatology we have to deal with. And post infectious damage we need to heal up to get patients function back to a good level. And Absorbing food again, the way that they should be.

Interesting. Have you heard this concept that when trying to kill a parasite because the parasites are laying eggs, that you want to use, like the antimicrobials, for 10 days and then wait 10 days because supposedly in the presence of the antimicrobials, the eggs won't germinate. They'll wait until the antimicrobials are gone, then the eggs will germinate and you'll have more giardia, or other parasite, and so then you'll have a reinfection. So therefore there's this thought that you treat for 10 days, you wait 10 days, and then you treat again for 10 days.

Yeah, I mean, I certainly will do that with helminths, like actual, like bigger worms, pinworms. I will follow that approach. I dealt with giardia and I haven't seen any cases where that particular approach has been problematic in that instance. I mean, I think if we're choosing agents that are not going to cause collateral damage to the ecosystem, then there's no qualms with that approach at all. To be on the safety side, I just don't think I've never seen it necessary with giardia. So what's your by far the most common one that I would be treating in practice?

What's your protocol for pinworms?

It's a tricky one. I've tried lots of different things and to be honest, these days I actually recommend the pharmaceutical ones from the pharmacy because they work. Yeah, I can give you herbs that taste absolutely ghastly and garlic sort of indirectly, and essential oil. Put in a little bit of Vaseline around the anus at night. You can do all that for weeks at a time and we'll get okay results. Or I can give you like a one little dose of that chocolate and 10 days later another dose of that thing and they're gone. And it's far less costly. You're often treating a whole family. I've trial and error, lots of different things, and maybe some people have got much better results with herbs than I ever had. But we're using megadoses of wormwood and pomegranate husk, which has got anti worming activity too. And listen, it certainly brought worms down. Oiling up a little tiny clove of garlic that's been peeled and inserting up the anus, that helps break the cycle a bit, but, you know, and then same way with putting some peppermint central oil around little Vaseline around the anus is that the worms come out to lay their eggs. And like, I don't like that oil. So they go back and you can help break the cycle. But it's labor intensive. And to do herbs for a family for a month, that whole process is costly. Yeah. And it's, it's. And I still don't find the results as effective as just doing the pharmaceutical twice. And in this case, I'm not worried about the collateral damage to the gut ecosystem because the data today doesn't suggest that there's much in the way of a collateral damage, because, you know, worms are actually more related to us than they are to bacteria. So, you know, the agents that are targeting those worms actually have more capacity to cause US side effects than they do kill bacteria directly. So. So, yeah, I'm not so concerned. And that's my approach now. Just not so exciting as using, oh, you got to use this fantastic herb. But I just didn't find the result with the herbs is what I've got with the pharmaceutical. And the cost differential didn't make it worthwhile.

Interesting. So speaking of worms, have you looked into helminth therapy, the therapeutic use of worms? A couple of worms that are used as the pig whip worm or the human hookworm. I've read some articles where they're being used for allergies, autoimmune conditions, inflammatory gut disorders like Crohn's and ulcerative colitis.

Yeah, I'm not super familiar with the literature around that. I'm a little bit around the uses of necator americanus for celiac disease.

Yeah, yeah, that's. That's the hookworm.

Yeah, that's right.

Yeah.

And when I looked at the results, they were very underwhelming in terms of the outcome. It was like, okay, they gave them these worms and they had like, you know, bout of severe enteritis. They got a lot of pain from the worms, and then it slightly diminished the degree of inflammation caused by subsequent gluten exposure. To me, that was underwhelming. It's like, yeah, okay, yes, there at the gluten, you got less gut damage. And if you didn't. But it still didn't completely stop the gut damage, and it didn't completely stop the pain from ingesting the gluten. Plus you had the pain and discomfort from ingesting the hookworm in the first place. So I thought the results were very underwhelming for CVAC disease. Now, it doesn't mean that they might be more useful for inflammatory bowel disease or other conditions. And I'm not so Familiar with the literature, they're not enough to make any judgment calls on their efficacy or not.

Good. I'd like to ask you about one more topic about H. Pylori. H. Pylori is another infection in the gut, often occurs in the stomach. And there's a whole story, everybody's probably familiar with it, that it could be related to ulcers. And we have that whole story about Dr. Marshall giving himself H. Pylori causing. Anyway, so H. Pylori is another thing that comes up on stool tests a lot. And we've learned more and more how H. Pylori is an important part of the gut and so may not necessarily be pathological. So what's your take on H. Pylori? When is it pathological? How do we know?

It's another great set of questions. And I think we'll answer this question differently in five years time than what we can now do have, like the.

Virulence factors that give us an idea of whether we're reacting.

That's right, we've got some of them. And I think that's a step in the right direction. So for me, if I had H. Proli show up on a stool test, for example, I would look at the presence of the virulence factors. That's the first thing I would do because that's usually in that same test that might pick up the H. Proli and tell me those things are present. I would always follow that up with doing a antibody test, like a blood test or a breath test, because for me, I want to see, okay, is the body reacting to that H. Polar. Is it producing antibodies to the H. Polar eye?

Right, yeah.

Is it high enough count that it's actually showing up on a more conventional test rather than using these genetic markers? Those to me, really tell me the data that I'm after as well as do they have symptoms that go inside with gastritis or gastric ulcer? Peptic ulcers? Yeah. If they do, then I would go, okay, yeah, H. Pilar is probably related to what's going on there. But if I have a patient where they have a negative, no antibodies in the blood and nothing on the way of breath test, and a small amount in the stool that showed up on a, you know, PCR based test that didn't show any markers of virulence, then I wouldn't worry about it, its presence at all. Because I'd be thinking, okay, it's probably benign, it's probably there in tiny amounts, not enough to cause any issues. But conversely, if it actually showed up with, you know, antibody levels and they've got symptoms that are. That are consistent with peptic ulcers or gastritis. Then I would generally treat H. Pylori in that case. And for me, I worry it's always this balance. Yeah. That we know that certain strains of H. Polar can cause peptic ulcer disease. We know they can cause increased risk of stomach cancer. That is clear. But there's also some concerns about the eradication of that species. About one leaving an ecological vacuum and what will grow in there. What's next if we take that species out, some other microbe might start growing in there and that might be more virulent than that. And second point is that there probably are quite benign strains of H. Pylori that might even have some healthful effects for us over time. It's just we don't necessarily have the technology yet. And this is where I say five or 10 years time. That where we know a good chunk of virulence factors now. But we're still discovering new things, so we might discover more. We might be able to get down to strain subtyping. Okay. Okay. Well, your strains look at the genes of this specific strain beyond that, and yes, there's a greater risk of it being a problem. Let's get rid of it. And for me, if I'm using agents, natural agents that don't have the capacity to cause a wide widespread damage to the colon ecosystem, I'm not that worried if I'm going, okay, let's eat some broccoli sprouts for two weeks and have some cranberry concentrate and take this herb and some et cetera. That can be, in my experience, very effective at getting rid of H. Pylori. I'm not worried about treatment so much, but if it's patients taking a triple or antibiotic or quadruple antibiotic cocktail, then we're talking about big life. Essentially, it's life altering in the respect that that ecosystem, colonic ecosystem, that will inadvertently be smashed by that antibiotic cocktail will be permanently changed. It will never go back to the way it was before. So when we're talking about those bigger interventions, then I think we need to consider much more about the risk benefit ratio that are different when we're looking at using natural medicines to treat the H. Pylori, that the risk is far less. So it's quite a different way of considering it.

So the natural agents you would use would be mastic gum and maybe something.

Else, or I would usually use a combination of things and you look at the data about natural medicines and there were one study showing like maybe 16% eradication with cranberry juice. 16%. Not fantastic, but it's better than none. There's one study that used The Lactopilis reuteri DSM17938 strain and I think had like it was over 50% eradication rate. Okay. Just with that single strain. So, okay, so you combine that and I might combine broccoli sprouts, which I think had a 78% eradication rate from memory. Yeah. So you're going, okay, let's add a few of these things together. Nigella sativa. So black seed again had a. I think it was over 60% eradication rate on its own. And you're doing a few of those things together. And then I might use some herbs like green tea and rhubarb and pomegranate husk, for example, turkey rhubarb. And in my experience we follow a protocol that's for most my patients around six weeks and it's around a 90% eradication rate, which was really, I would argue better than what we're getting with antibiotics these days that at the first time they started using antibiotic cocktails like triple therapy, they were looking at 90, 95% eradication rate. Now some of the recent studies are like 50, 60, 40% eradication rate because of antibiotic resistance. I've been impressed at how well a combination of herbal agents, natural supplements work versus using them just on their own. Much more limited efficacy to get the occasional time where just giving one of those things will work for a patient. But my experience has been again, through a fair bit of trial and error with patients, it actually makes more sense. And I get the best results with doing a much more intense protocol for a six week stint, then do follow up testing and go, yes, it's gone. And generally that combination of things works well. You get synergy between those agents.

So you think natural agents like oregano and berberine and maybe some of these other antimicrobials could potentially have negative effects on the microbiome?

I would say from both some of the in vitro research I did as part of my PhD and from clinical work with patients doing pre and post testing. Yes, that berberine I think clearly can diminish overall diversity of an ecosystem and reduce levels of bifidobacteria specifically. It may not, you know, some of those species may be fine with it. But my experience, and I've even seen one patient who managed to, you know, essentially result in Extinction of the bifidobacteria population from taking high dose berberine for longer periods of time. Yes. So I've got some caution around that. And again, about essential. Some plant essential oils. Yes. So oregano essential oil, thyme essential oil, clove essential oil that are potent antibacterial agents. They totally are. And antiprotozoal and antifungal agents, they've got a wide spread of actions. But I do think that they have some collateral damaging effects in the gut too. And I think there can be times and places for more potent agents. And I try to follow that the naturopathic therapeutic order, where we use the agents that are less likely to cause harm first, then we move along that order to those that have greater capacity causing harm if the other ones don't do the job. So I'll rarely use berberine when I'm treating giardia these days. I'll rarely use berberine oregano essential oil for treating Sibo these days because I think there are other herbs that are effective yet that don't have the collateral damaging effect that those herbs have.

That's interesting because I haven't seen that sort of negative effect on the microbiome from berberine. And I also treat diabetics and we very regularly use pretty decent dosage of berberine on a regular basis. And I have seen no increased gut problems coming from that.

Yeah, I wouldn't say obvious gut issues more, although sometimes longer term I think that that can manifest. But in terms of populations of bifidobacteria, and I would suggest, if you haven't yet, of using the tests that use either 16s RRNA looking at proportions of bifidobacteria or metagenomic sequencing for bifidobacteria pre and post. And you might get a slightly different picture with that rather than some of the previous tests that use two plus four plus sort of ways of measuring things which are far less clear. What's, what's going on? We've been using, you may see that.

Yeah, we've been using a GI map with the quantitative pcr. Okay, okay, good. Excellent. Thank you for sharing some fascinating information with us.

Ah, you're very welcome. I'm glad I could come back and chat to you, Ben.

It was good, good, good. I'm glad we could make this happen across the world, even in the midst of the coronavirus pandemic. And so how can listeners and viewers get a hold of you and find out about some of your. I know you have a number of courses that are available, correct?

Yeah, yeah. In fact, we've got one on Dientevo and Blastocystis. I'm trying to get that information out there, but that change in conception that research has actually made manifest. Also ones on Giardia too, as it turns out. But the microbiome, probably more broadly lactose intolerance, fructose intolerance. I got a few different lectures out there on the Probiotic Advisor site. But you're right, my passion is really around the gut microbiome and probiotics and prebiotics. And I've been in this area for 20 years when I first started my honours and my PhD research. So I love this area and I love being a clinician still. So you get a chance to actually, you know, work with patients and see what works. Because sometimes what works in research doesn't always manifest in clinical change any beneficial way, or they just doesn't work in reality. So it's been nice to go. Okay, what does, what doesn't over years of working with patients too.

So what's the website for the Probiotic Advisor? And that's essentially new courses, right?

Yeah, yeah. Www.probioticadvisor.com. and then we've got a teachable courses page too, that's got. I think we've got 12 or 13 courses up there now around microbiome and gut health more broadly.

Great, thank you so much.

You're welcome, Ben, nice chatting again.

Nice chatting with you too. I'll talk to you soon.