Probiotic Advice with Dr. Jason Hawrelak: Rational Wellness Podcast 026

Hey folks, Dr. Ben waits here for another episode of our Rational Wellness Podcast. It's confusing to know what you're supposed to do to be healthy. What should we be eating? How should we be exercising? Should we be avoiding red meat, cheese and butter? Should we be putting butter in our coffee? How should we be exercising? Should we be taking calcium supplements? Are calcium supplements harmful? Should we take fish oil? Is fish oil harmful? My goal is to bring clarity to some of these issues using the top scientific research and interviewing experts in the field who can help us understand some of these issues. Please subscribe to the Rational Wellness podcast on iTunes, Stitcher or YouTube. So let's get started on your road to better health. Hey Rational Wellness Podcasters, thank you for joining us again today and we have a very exciting topic. We are going to talk about probiotics and the benefits that can be derived from taking the correct probiotic strain for the proper usage. Most people in the United States, and most functional medicine practitioners especially, know that taking probiotics can be extremely helpful for our health. But there's so much confusion about which probiotic is the most beneficial. And especially when dealing with specific health issues such as IBS or inflammatory bowel disease or various digestive disorders, you know, which probiotic is really going to be beneficial for us? Is it just a question of how many billion organisms we take, etc. Healthy bacteria and fungi, also known as probiotics, inhabit our body, including our skin, in our mouths, in the vagina, and most importantly in our digestive tracts, especially in our colonial. These healthy critters are crucial for our health. And when these bacteria are out of balance or deficient as a result of poor diet, an unhealthy lifestyle, taking antibiotics or a series of other medications that damage our bacteria, or even just being exposed to pesticides and antiseptics. For example, just like the chlorine found in drinking water, taking probiotic and prebiotic supplements and eating fermented foods can all be beneficial in helping to restore our normal bacterial flora. But in order to help figure out which probiotic might be best to take in particular cases, I've asked our special guest, Dr. Jason Harelick to join us. I'm so excited that Dr. Hauerlich is joining us today. He is a researcher, lecturer, naturopath and Nutritionist with over 17 years of experience and he practices at Gould's Natural Medicine, 136-year-old Natural Medicine Apothecary and Clinic in Hobart, Tasmania, Australia. Dr. Harelik completed his PhD examining the capacity of probiotics, prebiotics and Herbal medicines to modify the gastrointestinal tract microbiota. He's currently the senior Lecturer in complementary and alternative medicines at the University of Tasmania School of Medicine, where he coordinates the evidence Based complementary medicine program. Dr. Harelick also teaches the gastrointestinal imbalances unit within the Masters of Science in Human Nutrition Functional Medicine program at the University of Western States in Portland, Oregon. He's on the Medical Nutrition Council of the American Society for Nutrition and he's a fellow of both the Naturopaths and the Herbalists association of Australia and the American College of Nutrition. Dr. Harelick has developed an incredible database of information about probiotics called the Probiotic Advisor to help practitioners differentiate which probiotic strains and products are appropriate for different conditions. I highly recommend you check it out and subscribe because it's an incredible valuable resource for a very reasonable cost. Dr. Harelick, thank you for joining us today.

Thank you. It's a pleasure to be here.

Okay, I guess we have a little bit of delay when the Internet signal travels from the United States under the oceans to Australia.

Yeah, I think it's probably like 12,000 miles or something like that. I know Columbia is better, but I think it's around that. So it's the longest.

So I guess we'll have to think of ourselves as watching one of those newscasts where we're talking to a newscaster on the other side of the world. So, Dr. Haralek, to start with, can you explain how probiotics can potentially help us restore a healthy balance of bacteria in our choline and digestive tracts?

Okay, now that. That's a very good question. And I think, in all honesty, I think that the role of probiotics is probably overstated in its capacity to do that. Now, I think that there's a very important role for probiotics after an acute insult like antibiotic use or chemotherapy or radiotherapy, where you get some massive shift in the ecosystem, or even after proton pump inhibitors, which we know cause massive alterations in the system as well through their antibiotic like actions. Now, in those instances where you could imagine your normal ecosystem is like a very complete car park with every single parking space filled up. That's what it's supposed to look like. But post antibiotics or chemotherapy, et cetera, you end up having a lot of empty spaces in that car lot. Now, those empty spaces can be taken up by potential pathogens that we happen to ingest at that time period, which is what can happen with clustering difficile, for example, when people are in a hospital setting, or it can just be an overgrowth of bugs. Resistance to the antibiotics will grow into the available space and obviously the more nutrients that are available because there's a lack of competition. So probiotics can play a very important role in those instances of essentially coming in and taking up temporarily those parking places that would otherwise be taken up by potential pathogens. Now, I think the key thing to remember though, is that all probiotics that we ingest as supplements or fermented foods are only temporary visitors to the gut, so that you can't permanently reseed or re inoculate with probiotics. And I think that's one of the biggest myths that persists all the way back from Metchnikoff's days. Metchnikov was the researcher who essentially discover the bacteria that make milk into yogurt. The whole reason why the whole world eats yogurt now is because of research that he did. But his theory at that point is we could permanently inoculate our guts with the yogurt bacteria and they would prevent protein putrefaction and slow down the aging process and keep us healthy. So that myth of permanent colonization from an externally provided lactobacilli, or gift bacteria, persists that time point, even though we now have 30 or 40 years of clinical trials showing that they're essentially temporary visitors in one's gut, alluded to before. They're very important to be taking during those acute insults, after those acute insults for, you know, I always suggest at least six weeks, but ideally three months. But I think an area that has actually received far less attention than what it should in the, in the blogosphere and in practitioner land in the general public, is essentially focusing on foods and process and interventions that actually nourish your own indigenous populations and help them regrow after the insult. Because that, I think is the key aspect of creating a healthy ecosystem is essentially feeding your indigenous populations and feeding the healthy members of indigenous population specifically. And that would focus more on substances like prebiotics and, you know, prebiotics, strictly speaking, are selectively fermented substrates substances which feed a limited number of bacteria in your gut, which promote. Which essentially result in improved health as well as a range of other dietary fibers, also known as colonic foods, or as the research couple at Stanford University called the Sonnenbergs, who call the max microbiota accessible carbohydrates. I kind of like the term, but it reminds me too much McDonald's. So it's never really gratitude stayed with me, but I think the concept of essentially Ingesting more fermentable substrates that actually feed our own indigenous populations is a missing factor. Now, we tend to be focusing a lot on fermented foods, but not so much on fermentable foods. But it's certainly fermentable foods that actually nourish our own indigenous populations to a greater degree.

Now, essentially, these are carbohydrate foods, types of fiber that the bacteria eat. Is that correct?

Yes, yes. So prebiotics in general are indigestible carbohydrates. And I think you're right, the key factors about prebiotic is that it's got to be indigestible. There's a lot of bugs in your colon that would happily munch down on glucose, for example, but you don't get much glucose reaching your colon because that gets absorbed avidly in the upper gut. So it's indigestible carbohydrates, which are things like resistant starches, broadly speaking, you know, fiber. But we have insoluble fibers and soluble fibers of all different shapes and sizes which feed different bugs. Pectins, mucilages and oligosaccharides are examples of, you know, indigestible carbs that essentially reach the colon where they feed your butyrate producing microbes, or bifidobacteria, for example.

And the first thing that comes to my mind is that in the nutrition world right now, one of the biggest trends is trying to reduce your carbohydrates as much as possible. We've gone from the higher carb, low fat diet now to the lower carb, higher fat diet. And we've gone to paleo and now ketogenic. And then you've got practitioners out there saying, don't eat any grains, any beans, you can't even have tomatoes, you can't have any vegetables that have almost any carbohydrate content. And I wonder, in this quest to try to improve our health by reducing carbohydrates, we're probably going to leave out a lot of these crucial fibers found in carbohydrates that are really important for our overall health.

Yes, I think you've got that spot on because. And you can easily assess this if you start using, you know, modern molecular based stool analyses that can actually tell you but the whole picture of the microbiota, not just, you know, four different species, but like a whole gamut. And you start looking at the research that's looked at ketogenic diets, impact on the microbiota, or high protein, low carb, what you tend to see is a pretty similar pattern is a reduction of, of endogenous populations of bifidobacteria, reductions in butyrate producing bacteria in the gut. And when you look at the wonders of butyrate, that's not a good thing. You don't want to be reducing levels of butyrate producing bugs by 50% or 60% over for a long period of time because your overall health will suffer, but also your gut health will suffer too, because compounds like butyrate and other short chain fatty acids, your colon cells, 70% of their energy needs are met through short chain fatty acid production by bacteria in the gut. And by restricting fermentable substrates, we actually limit that and essentially we end up limiting butyrate production. And butyrate, amazing substance that only reaches systemic circulation when you produce more than the colon cells can use as a food source. So you've got to produce a lot of butyrate for it to reach systemic circulation. That's where you get the benefit of it actually healing things like the blood brain barrier, improving insulin sensitivity, improving neurotrophic growth factors in the brain. It's amazing substance, but you can only get that from essentially fermentation of fermentable substrates. And we know from looking at the research that the way most people do those sorts of diets is we have a pretty massive reduction in butyrate producing bacteria and in bifidobacteria as well.

Interesting. So I would like to say to those of you who are following a low carb diet, it's still possible to get that fiber. You just got to be really, really careful that outside of the fats and the protein that you're ingesting, that you're getting most of the rest of your calories from vegetables and other foods that include these types of fibers and not wasting those calories on just chunky, high fat foods. You mentioned butyrate. What about butyrate as a supplement?

I don't even.

What's that?

No, it's a good. Sorry, it's the delay that involved there. I mean, I was going to say I'd add to that too, that certainly there are times and places for such diets that can work in certain situations and for certain disease states. Now, I think what you have to do is beyond like you said about dietary fiber, but I'd suggest actually supplementing additional dietary fiber like psyllium seeds ground up or psyllium husks, which we know enhance butyrate production, but also specifically using prebiotics to help offset some of the damaging effects of such diets of starving out certain bacterial species. So prebiotic substances will help offset some of the potential consequences.

What are some of the most. What are some of the most important prebiotic supplements to take or products to take?

Yeah. Now, I think the ones that make up the mainstay of my clinical practice would be latulose and partially hydrolyzed guar gum, galactooligosaccharides, and also a combination of inulin, which is a long chain fructooligosaccharide, and then oligofructose, which is a short chain fructooligosaccharides, so you can get a combination of both, both those. So I use oxygen, all four of them, a lot in practice, but they all have different effects and some overlapping effects. But there'd be nuances about when you would use one over another. And certain populations will cope well with one but not cope well necessarily with another.

So for those of us who are familiar with, especially functional medicine practitioners who are familiar with treating patients with irritable bowel syndrome caused by small intestinal bacterial overgrowth, or we're used to having the patient take a lactalose breath test, and then if that test comes back positive for hydrogen or methane gas, then we're going to put them on a specific program to reduce the small intestinal bacterial overgrowth. But the last thing that most of us would consider doing is using lactalose, since lactalose is responsible for. For causing nose gases to be produced that cause the symptoms of irritable bowel syndrome, like abdominal discomfort and gas and bloating and diarrhea and constipation, etc. So it's surprising to hear that you say that ingesting lactalose is actually a good thing.

Yeah, I can understand you're thinking of that one. And it's interesting, interesting for me because I started researching this area back in, started doing my literature review for my honors degree back in 1999. So I came across Latchewitz as a prebiotic. It used to be added to infant formula as a prebiotic. And we know clearly it meets the definition that it selectively feeds a certain number of beneficial bacteria, but bifidobacteria, for example, Lactobacilli, thecalibacterium. But it does indeed increase hydrogen gas production, which then can either be converted through to methane in some people or just stays as hydrogen in others, and hence can be used as breath testing. And if you follow that, the history of the latulose Breath test back. It used to be used as a marker of gut transit time from mouth to cecum. So that's where it was used for a long time before it was patented as a tool to investigate sibo. It was used for an oral sequel transit time test until people started questioning, because lactose itself has got the capacity to speed up small bowel transit time, which I use it for as a therapy tool. Then that suggested that it's not actually necessarily all that accurate because in some people who take it, it speeds up the action and the fermentation is actually occurring in the colon, not the small bowel, even at the sort of 90 minute mark, or even potentially at the 60 minute mark in some people. So to add a bit of further confusion in there, but if you step back and go, okay, lactulose has got a long history of use as a prebiotic substance. Yes, there'll be some people who react to with tremendous amounts of gas and symptoms, people who've got sibo, some people have got IBS and not SIBO, who also react to it with bloating and distension and pain. But there's a whole bunch of other people who don't have those conditions who actually get the benefits of taking lactulose. I've used lactulose as a tool to decrease recurrent urinary tract infections for 15 years. And there's clinical trials showing that ingestion of lactulose reduces the risk of recurrent UTIs, and it does that by decreasing E. Coli counts in the gut. Most urinary tract infections are caused by E. Coli, and the E. Coli is making the journey from anus to vagina to urethra. So we know that lactose decreases E. Coli counts in the gut at a certain dose by about a hundredfold. So that means there's 100 times less bacteria able to make that journey. It works as a clinical tool. It works for candida infections as well. There's other research showing a 97% reduced Candida count. And, and this was a in vitro study called a SHIME, the Simulator of the Human Intestine Microbial Environment SHIME Study. But there's a 97% reduction in Candida within 24 hours of introduction of lactulose due to its prebiotic actions. So I think it's got a range of actions and benefits that some people won't really get derived the benefits from if they have certain gut conditions. But I do often use lactic dose in SIBO patients too. But just SIBO Patients who don't respond negatively to lactulose. And there are some. That's you.

Interesting. Yeah. I heard you speak on somebody else's podcast, the Sibo Dr. Podcast that you. Typically when you have a patient you suspect of sibo, you'll do the glucose, fructose and lactulose breath tests.

Yeah, because we know lactulose is selectively fermented. It's not going to be eaten by Klebsiella, it's not going to be eaten by E. Coli, not beaten by Bacteroides. If those are the bugs that are present in the small bowel, and we have good research showing those bugs often are, it's not going to come up with the rise with lactulose. You just won't get it. And it's been a enjoyable learning process. In fact, doing those three tests on so many patients now that I see no rise in lactulose, but I'll see a rise on fructose or rise in glucose at the 20 minute mark or 15 minute mark, or 30 or 45 minute mark. Clearly it's happening in a small bowel, but the bugs that are present don't eat lactulose. And that's a situation where I would use lactose as a therapy tool to speed up small bowel transit time and also to alter the environment of the small bowel to one that's less conducive to the growth of Bacteroides, E. Coli and Klebsiella, for example, because they don't like an acidic ph in general. And lactose has got a good capacity to, when it's fermented by beneficial bugs, to change the PH to one that's more acidic and less conducive to their growth.

Very interesting. When people discuss what percentage of patients with IBS have SIBO, there's this big range. Some of the studies show 40%, 70%. It's interesting. Most of the doctors, functional medicine practitioners I know in the United States, especially in Los Angeles, we pretty much just do the lactalose testing. And I wonder if we're missing a lot of patients by not doing the glucose and the fructose testing as well.

Well, it's suggested data says that you are.

Yes.

Interesting that there's one study that was done comparing like they had put a scope down there, made sure these people did have Sibo, then they give them the different tests and it turns out that I think lactulose was only able to discern one third of those people that actually had sibo and I think we understand that lactose is selectively fermented and not all bugs have got the right machinery to break it down, unlike glucose, in which all the bugs can eat glucose. That you get a much better accuracy by doing a spread of sugars. And you also get a bit more of a nuanced answer about what bugs are there. Because if you have a raised glucose but a flat line lactulose, you know the bugs. But there are bugs that can't eat lactulose, which probably means it's bugs like Bacteroides, E. Coli, Klebsiella, for example. And then you could target your or your herbal medicines or if you use antibiotics, you could use them, target them a bit more specifically as well.

Right, interesting. Are there specific strains of probiotics that can be beneficial for treating patients with small intestinal bacterial overgrowth?

Yeah, yeah, I think there is and I think there's a number of ways that probiotics can be, can be helpful. And this again is one of those areas. I think there's a lot of mythology out there that's been around for a while, which I think is starting to shift, thankfully. But if you start looking at what actions that different probiotic strains can have and how they could benefit potentially people with sibo, you've got the capacity to improve the migrating motor complex or improve motility. You've got the capacity to heal a damaged, leaky gut. Some strains will work as selective antimicrobials. You've got the capacity to reduce visceral hypersensitivity, which we know is a key factor underlying irritable bowel syndrome. And certainly some, some people with SIBO have got that same issue. There's some strains that can decrease intestinal inflammation and others that can up secretary IGA production in the gut. And secretory IGA is one of our main immune factors for I suppose keeping bug counts a little bit lower than what they otherwise would be. So enhancing that production can be another helpful tool. So I think there's a number way probiotics can be helpful. And then when you start looking at the literature about what studies have been done, the vast majority of studies have actually shown positive results for using, you know, probiotics in sibo. Now, the thing about probiotics, which you hinted to at the very beginning with the intro, is that in the actions are strain specific because the lactose case, CRL431, has got the capacity to, to decrease, you know, bug counts in the small bowel. It does not mean that another strain of lcassi has got the same capacity. That's the reality of it. So you've really got to match the probiotic strains that we know work to the condition that you're wanting to treat to get the best results.

So which ones work for sibo? Can you give us some particulars? And the product names certainly come out.

This makes it slightly more tricky in that a lot of the combinations that are available for Sibo aren't commonly available in Canada, the U.S. or Australia, where most and my patients actually dwell. I know, I look at the literature too and go, if I knew there's a clinical trial showing, you know, randomized, double blind placebo controlled trial showing a combination helped deal with Sibo, I would probably, if I was a company, try to get those strains and come up with a new product showing work and bring it to the North American market. But some people have been a bit slow off the mark with that one, in my opinion. You know, so it's a combination of the CRL4.3 1 strain of lactose Cassii and the CRL730 strain of acidophilus, which have been Lactobacillus acidophilus, to be more exact, which have been shown to be effective in a well designed clinical trial for treating Sibo, for example. So that one is not currently available. There's a combination found in Argentina called Bioflora, which had, I think 82% reduction in symptoms, SIBO based symptoms versus the control, which was Flagyl, which had a 52% reduction in symptoms.

Wait a minute, what was the percentage reduction in symptoms?

82% with probiotic combination versus 52%. Yeah. With 52% with Flagyl, which was, you know, the antibiotic comparison. Yeah, but again, if you live in Argentina, you can get that combination, as.

Far as I'm aware of professional supplement brands like Metagenics. Are you guys listening? So let's grab some of these strains and make them available.

Yeah. And there is one strain that's a commercially available in Italy and has been for a long time, which is Bacillus clausii strain, and it's sold as Enterojamina. And there's a 30 day clinical trial that found a 47% eradication rate of Sibo, you know, so which is still a pretty impressive outcome based on. That's all you're doing. And there's no dietary changes, there's nothing else, it's just the probiotic administration. And again, that's available in Italy for those lucky Italians with Sibo. But, but it's not so easily available for us. Yeah. And there was one very cool study with probably the best results I've seen yet, which was actually a Jap Chinese study. But the, the description of what they used was amazingly poor. They called like bifidobacteria, triple viable capsule, no dose, no species, let alone strain. Details. But it did have an 81% eradication rate of the same versus 25% in placebo. So, you know, good results. But we can't actually implement it in a practical level because we don't know what was used in that particular supplement. But it adds to that body of knowledge that probiotics can be very helpful clinical tools.

Now I heard you mention a particular strain that was beneficial for methane, sibo, which is particularly difficult to treat. Can you tell us about that?

Yes. So that was a. And that one is commercially available. Thank goodness. So that one is Lactose Reuteri DSM17938, which is otherwise known as the Biogaia strain, which might be an easier way to remember it than it's, it's numeric code name. And the BioGaia preparation is available in Canada, the US and Australia as probiotic drops or lozenges in a few different forms. Now there is a recent study suggestion just published in the last few months looking at methane people who are constipated. So functional constipation with high methane loading. And we've known for a number of years that this particular strain is helpful for functional constipation that increases number of bowel movements per week. But there's an Italian research team that sort of tried to piece together how is it doing that? Is it working by decreasing methane output? And yes, it turns out that it did so in this particular study, relatively small study, I think There was about 20 people in the study, but they still found that after four weeks administration that, that methane, overall methane production decreased by nearly two thirds. And the 55% of subjects did not produce methane at the end of the four week trial versus that did at the beginning. On top of that they're doing an extra two bowel movements per week. You know, so it's, it's, you know, going from four to six point something. So, you know, it seemed to be working probably via that mechanism. Now, whether that particular strain of rhyth is somewhat unique in its capacity to produce an antimicrobial substance called reuterin that not all other strains of lactose reuteri can produce, only some can. That might be how it's actually working. So we don't necessarily know exactly how it's suppressing Methenobivir, Methenibrecter, but we know it does have the capacity to do so. And this is one of the few human clinical trials on non antibiotic treatments for methane, essentially methane overgrowth or overproduction of methane in the gut. Wow.

Amazing. So a probiotic that actually has an antimicrobial effect other than just crowding out the other bacteria. Because some of them work that way as well.

Yes. And the more you look at probiotic mechanisms action, you can see that they work in a much broader way. There's even some probiotics that decrease pathogenic gene exhibition by certain virulent strains of bacteria. They can work by no number of different ways. But we don't know whether this one did it through changing the environment. So it's a bit more acidic. But I think probably that might be part of the picture because Methenobrivibacter smithii sort of likes growing at a more neutral pH and doesn't really like an acidic environment. But my theory is that it may well have been due to the Rutran, which is a potent antimicrobial compound produced by the Biogaia strain of Lactobis retroin.

You mentioned that there are particular strains that can promote GI motility and or the migrating motor complex which is part of the mechanism by which Sibo occurs. Can you tell us about those?

Yeah, certainly the. There's two different strains of bifidateral lactase that have shown capacity to speed, you know, whole gut transit time. So from mouth to toilet bowl essentially. And that's bifactorating lactus DN173010, which is only available worldwide in one brand of yogurt called Activia, sadly, because I've looked at the Activia ingredient list for North Americans and it's not ideal. Not so clean. And I think I'd have hesitation recommending my patients to consume such a thing myself. In Australia I was lucky. They used to have a Greek non flavored one that actually was quite, quite okay. And it did actually work really well for my functional constipated patients, which was great because it's a pretty easy, easy thing, just have changes. Branded yogurt they're eating and all of a sudden, you know, the transit time goes from 48 hours down to 21 hours, massive shift and even just a two week time period. But that strain is only available in that brand of yogurt, sadly. And another strain of bifiductrinolact is HN019, which is commercially available in a number of brands in Australia and in America as well. You know, for a while it was only available in like the Zymogen brand in the us so certainly that that brand has been widely used because it's got a decent amount of that specific strain in it. And again, you're looking at, you know, the clinical trials showed that one, there was a dose response, so a higher dose had a, had a greater effect than a lower dose. But secondly, that, you know, whole gut transit time decreased from, you know, 40, 50 hours down to the, the low 20s just after two weeks of ingestion. So it's a pretty massive shift. And for me, they are core aspects of particularly my slow gut transit time. Sibo patients of using probiotics as prokinetics. Wow. Which I think the research says actually works in my clinical experience tells me it tends to work too. And there's been one study, an animal study, using a combination of Lactobacillus rhamnosis GG and Bifidacterium lactus BB12 in combination, showing it actually increased the migrating motor complex sort of cleansing waves as well. So we've got some data there, but so far only in animal study.

Great. I mean, it's my understanding that anything that would increase GI motility, if you take it at night, when you haven't eaten for a long time and you're not going to eat for hours, would have the same effect on the migrating motor complex.

Yeah, it would be interesting because they didn't look necessarily the specifics of how it happened. We do, you know, the mechanism by which it does, so we know it. Does it, does it do it in every single patient? Sadly not. I wish there was an intervention that worked in every single patient, but reality is there's not. But it does do it in a lot of patients, you know, and you get not only just sibo patients, but people with functional constipation. Sometimes it's as simple as giving them the right probiotic strain with definite evidence of efficacy for that scenario and it works. And then you can still work on improving their background diet and the lifestyle that may have contributed to their slow gut transit time in the first place.

Great. Are there particular strains of probiotics that can help to heal a leaky gut?

Yeah, and I think we'll see more and more research coming out. There's been probably a fair bit of animal research done. My, you know, I prefer using human studies when I, when I can to support my prescriptions and the One strain that has probably the best evidence for healing up damaged gut is the Saccharomyces cereviaceae variety Boulardii Biocodex, or also known as the LIO strain, which has got good evidence showing it's completely to return small bowel architecture to normal and heal leaky gut when it's been damaged. And the study was done, the one I can think of was done in kids that had giardia and they had. Giardia was treated, but they had chronic ongoing diarrhea and villus flattening. So rather than these beautiful villi, they had flattening and they gave them the right saccharomyces and then had it put a scope down there afterwards. And most kids actually had a return of normal architecture to the small bowel. So it's got a great capacity to speed it up. And as a clinician that does some pre and post, pre and post testing for leaky gut, it does work well. So that's my preparation choice for healing up a damaged leaky gut.

Interesting. So that could probably potentially be beneficial for a patient with a parasite as well.

Yes. And certainly there's been a number of studies using that same saccharomyces supplement alongside antibiotics to treat giardia and entamoeba. And it actually improves eradication rate dramatically. So, yes, it improves eradication also. It actually helps heal up the damage that's caused afterwards, so. Very much so.

Wow, that's awesome. I heard you talk about, can you explain how Saccharomyces boulardi was first discovered?

Yeah, it's an interesting story, actually. And essentially it was a French microbiologist, Henri Bullard, who was traveling in the Indochina area, probably called Thailand or thereabouts now, and there's an outbreak of cholera and people were getting very, very sick all around him. But he noticed that there are some people making a preparation after the skin of lychees and also of mangosteen, which are both tropical fruit and delicious tropical fruit, I might add. But they're making medicines that are essentially tea out of the skins of those fruit. And the people who are drinking this weren't getting sick and. Or were getting better. So he had his microbiology hat on, obviously. So he was like, okay, I wonder if there's a microbe on the skin of lychees that's actually contributing to the treatment or the prevention of cholera in this case. Now, it's interesting for me, as a somebody who is an herbalist, I'd be looking at what compounds are in the skin of the lychee or the mangosteen that are actually causing the change in diarrhea. But because he had his micro hat on, that's what he looked for. Isolated a yeast from the skin which he then named after himself. We knew it was a Saccharomyces, so he called it Saccharomyces boulardii and essentially he took that back and commercialized it. So I think it's been sold as a probiotic supplement from the 1940s onwards in Europe. And now there's that same Boulardi. Well, now the name has changed because we now know that it's actually within the same species, the Saccharomini Cerebeceae, which is just normal baker's yeast, but it's a unique organism within that species. So we now call it Saccharomyces cerviacei variety Boulardii and codic preparation that has been used because he sold it to a company in France called Biocodex and they've been selling it from the 1940s or 50s onwards. And pretty much 95% of the research done on Saccharomyces, so called Boulardii, has been done on that exact Biocodex preparation. There's been very little done on other versions.

Interesting. And it is, my understanding is among the other benefits of Saccharomyces, one of the benefits is in treating yeast or fungal overgrowth, is that correct?

Yeah, it does have the capacity to suppress the growth of bugs like Candida and other sort of intestinal yeasts. You know, it's been number of clinical trials for antibiotic associated diarrhea in terms of having to prevent it. Some research on clostride difficile infections as well. And that particular strain has got the capacity to even break down Clostridium difficile toxins as well. Which, which maybe which is somewhat unique, right?

Yes, yes, yes.

Also some research in Crohn's disease and ulcer research in ulcerative colitis. It's, it's. And even some neuro bowel syndrome. So there's a number of studies looking at that, that, that particular strain. It does seem to have a wide spread of actions, but I think a lot of it does go down to, to, you know, improving the ecosystem in the gut. But it does seem to have that capacity too and helping to, to restore, store a healthy ecosystem after antibiotics more quickly. There's some very good research on that, but importantly to heal a damaged gut, you know, because as you would know and most functional medicine practitioners would know that leaky gut contributes to most western diseases that we see. Even things, simple things like obesity, type 2 diabetes, metabolic syndrome, we now know are linked to leaky gut and increased absorption of endotoxins. So, you know, things that improve or speed up healing of of damaged gut are going to have a range of flow on health benefits for people.

Interesting. So saccharomyces is beneficial for inflammatory bowel disease like Crohn's and ulcerative colitis. Are there other probiotics that are beneficial for treating those inflammatory bowel conditions or would saccharomyces be the best one to use?

Well, for Crohn's it's been a bit hit and miss in all honesty, in that the most research on probiotics and Crohn's has been disappointing. Saccharomyces, the only one that has shown some degree of efficacy fairly consistently in the most recent study, which is the biggest study in the best designed study, interestingly enough, it didn't work in the whole, whole group population, but it did work in non smokers. So some people who don't smoke, there's a 78% reduction in, I think it was flare ups and people that took the saccharomyces. If you did smoke, it didn't seem to actually make much difference. So. Yeah, but that seems to have the best evidence. Whereas most other strains had actually failed in Crohn's so far. But for things like ulcerative colitis, I think the data has been more consistently positive for a wide range of strains. So that you could have like the combination BSL number three has got some evidence for preventing pouchitis infections, but also for, you know, inducing remission in people that were having a hard time gaining remission when their disease was in a flare. You've got Lactobacillus, rhamnosis, gg, which has been used to maintain remission. In fact, this one particular study, they used it, compared it to Mesalazine, its capacity to keep people with ulcerative colitis in remission. And LDG actually worked better then. So I think we've got that particular strain I often use in my ulcerative colitis patients in those who are in remission. But I will sometimes use bugs like VSL combinations like VSL number three to help induce remission. And there's also some research on E. Coli NSSLR 1917, that one specific variety of E. Coli helping people to go into remission with ulcerative colitis as well. But it tends to be, it's available for me here in Australia and I think sadly not so easy for you guys in America. But it is a moderately expensive supplements, so it may not be my first port of call. I might go with LGG first off and then if it doesn't work, use the NISSL 1917.

Interesting. I heard Dr. Sydney Baker talk about the use of actually parasites for treating inflammatory bowel disorders. What do you know about the potential use of parasites? As, you know, most people think of probiotics as bacteria, but we've been talking about saccharomyces, which is a form of yeast, that's a probiotic and there are also parasites, isn't that correct?

There is, and that's a little bit outside my area of expertise. I'm familiar a bit with research generally and I think looks like a potentially promising treatment in some, in some research studies. I mean, I think there's also promising research looking at fecal microbial transplants which perhaps are more up my alley. My alley. I'm much more open to inject, you know, people actually getting other people's fecal transplant than I am probably forgetting other sort of worm species in there. But from an evolutionary perspective, I can understand that we would have always had intestinal worms as part of our ecosystems up until relatively recently, and I think that's part of that. The hygiene hypothesis aspect is we're missing some certain travelers like parasites that may actually help keep some of those diseases in check. In a similar way, Martin Blaser put forth the idea of the disappearing microbiota hypothesis that over the last few generations, particularly westerners, we've lost a lot, if not most of our microbiota. So we're missing a number of species that may well have been playing protective roles against developing conditions like celiac disease or ulcerative colitis or Crohn's, because those things were not particularly common 50, 60 years ago, but they're much more common now and genes haven't changed in that time, Environment has, food has, and certainly the combination of environment and food on our gut has changed things a lot.

Right. So it's become very popular to recommend soil based probiotics and now spore based probiotics. What do you think about the value of those types of probiotics? Is there enough data to really recommend them?

You can't put. Well, for me, it's like I can't make a recommendation on a whole class of probably probiotics at this juncture because, you know, my soil, I can go dig it in my garden here in Tasmania will have different microbes in soil somewhere else. And to assume that they're going to do the same thing just because they're found in soil I think is illogical. And I think that's one of the things issues I've got with some of the things of going okay, it's almost like this idea that humans were born sterile, that we ate dirt and we were colonized. It's not the way it worked. You know, all animals have got microbiotas and passed on through through evolutionary pathways from mother to next generation that whole sort of way along. And I think there's probably not enough research done on specific preparations for me to feel wholly comfortable recommending them as a full stop thing. Particularly when there is good research on other probiotic preparations derived from Lactobacilli and bifid bacteria. And I'm certainly not anti using strains that are found that aren't in those genera or aren't necessarily found in the human gut. I'm okay with that as long as there's research showing that they're 1 safe and 2 efficacious, you know, so I'm unwilling to experiment with something that doesn't have that sort of data set. And I'm happy to see that that research is growing and there is some like that entered amina preparation. Natalie's got a decent amount of research on it. It's certainly very safe and used for a long period of time. Help for certain conditions, no doubt. But I don't think we can assume because that particular strain is that other strains will will have the same sort of efficacy or even within the same species, let alone different actual species altogether. Yes, and sometimes I think there's some places that are promoting soil based and spore based ones putting misinformation about the lack of efficacy of standard probiotics and I think that's poor form too that you don't need to try to put down your competition to make your product look I think you can just make it part of a group because it's good research on it showing it works. Because we have ample data showing that the number of probiotics from the Lactobacilli and bifidobacteria camps and sarcomaces actually have therapeutic effects. And you can't ignore all the randomized double blind placebo controlled trials and meta analyses suggesting that they actually work and have benefit.

Interesting. So let me just ask you one final question. Is there a real therapeutic value for practitioners to send a patient for a stool test look at especially one of the Functional medicine, stool tests that looks at the balance of the commensal and all the different bacteria in the colon, try to get a sense of the whole microbiome and then looking at which species are low and trying to particularly supplement those to create a balance. And also there's a lot of discussion that when you analyze the microbiome you want to have more diversity of species and you also want to have this proper ratio of firmicutes to Bacteroides. Is there a lot of therapeutic value in tinkering with the microbiome in that way?

Personally, I think there's a tremendous amount of. I use fecal microbial reanalysis with most of my patients. I've been in clinical practice for, as you said before, 17 years and these days I would only rely on. To really assess the health of microbiota you need to use molecular techniques that can tell you more than you can't tell how healthy ecosystem is. For looking at four different species or six different species. Like just looking at Mytheria, E. Coli streptococci isn't enough to tell you what's going on. You need a test that can actually assess things like diversity because that is an important value that we should be assessing. And you need one that can look at a whole bunch of anaerobes that we can't grow, we can't culture, like Faecalobacterium, Achermansia, Eubacterium, Roseburea, Intestobacter, Subdola, granules, a number of species that are key butyrate producers that we can't grow. So I think if you're using the right tests, you can tell a tremendous amount of information and from that you can actually come up with a whole range of interventions that can be helpful. But I think there's challenges with relying on older technologies like culturing to try to assess the health of the microbiota. Yes, it can tell us about pathogens, that's great, I'm totally up for that. But if they can't tell us about the health of the ecosystem, they can't tell us about diversity. Because diversity is a measure of how many species are present. And if you're looking for six species, you can't tell the other 80 or 90 or 100 species are actually like and what population dynamics there are. Because diversity is a marker of two things. One is the number of species present, but also the spread. And you're not going to get that for any sort of culture based test technique. So yes, a molecular technique that tells you the whole picture can Tell you tremendous amounts of data and including but pathobions like the sulfovibrio and bilophylla that are essentially bile acid eaters that we can't grow in culture. And those bugs go up on typical high fat diets. And we need to know that if that's actually happening with patients. For me this is an important thing and I run workshops for practitioners working through that or became more comfortable with the molecular techniques because it's something that most of us weren't trained in. It's new technology, a whole bunch of new species that we're not even aware of, that we weren't taught about, that actually do play key roles. And there's still species being discovered that we have no idea what they do yet, but we know that they're actually there. But I think the benefit of that is working how to change lifestyle, how to change diet, how to use prebiotics to really alter the ecosystem. Because if you're low in bifidobacteria, yes, you can supplement bifidobacteria and whilst they're taking that supplement, it's going to show up as being a decent amount on that stool test. But as soon as they stop, it's going to go down. So if I know that they're low in bifidobacteria, I'm going to go, okay, what prebiotics can I get them to use? What prebiotic rich foods can I get them to take? What prebiotic like foods can I get them to eat and drink daily to nurture their endogenous populations? But we're also looking at B tray producers like the Calabactrium and Roseburia eubacterium ruinococci that again we can work out the low what foods we need more of to nurture them. And I think that is the strongest data that's there is using prebiotics and dietary and lifestyle factors to alter diversity, increase levels of beneficial bugs. Rather than using probiotics which really in an intact ecosystem actually have a limited capacity to alter things, they can do some tweaks to it, but they're nowhere near as strong as changing diet and using prebiotics which can cause massive shifts in the ecosystem. And using molecular analysis techniques, you can see that clearly in your own patients, in yourself as well. It's harder to see with the old technology.

So are there particular in terms of.

The Firmicutes bacteroides ratio?

Yeah, go ahead.

Sorry, it's a delay again. The Firmicutes bacteroidetes ratio, when research first Came out looking at that ratio back in 2005, 2006 et cetera. It seemed like it was an important ratio to actually be focused on. Now I think there's been a number of research studies done over the last, published over the last few five years or so suggesting otherwise. So I don't particularly think there's a huge amount of the data is not there to put a huge focus on the fermicia disease Bacteroides ratio. Now I think what's more important is looking at yes, levels of Bacteroides per se, looking at levels of Proteobacteria per se because those are both bugs that contain lipopolysaccharide or endotoxin. And some people will have those bugs who make up 20% of the ecosystem. Sometimes they'll make up 70, 80% of what's there. And that means 80% of your gut bugs are endotoxin rich, which is problematic and certainly very pro inflammatory. So knowing those sort of breakdown, bigger phyto level data is important, but then also knowing levels of more specific species like Faecalobacterium and Akkermansia as well as Bifidobacteria that are really got guardian species, very protective species that are really important to know about.

Interesting.

All right, so you had a question I think leading to what, what tests, what lab tests you can actually use now. Now for North Americans you've got people like the American Gut project, you've got Ubiome that can give you that sort of sort of data. There's Genova GI effects dual profile that uses, uses some molecular techniques too. They only look at I think 24 different species but a lot of those are important key players. So you still get a lot of data there whereas you get a much fuller picture with Eubiome or American project.

Awesome. Well this is an amazing discussion. I thank you so much for joining us today. Jason, Dr. Harelick, for patients and practitioners who'd like to get a hold of you or who'd like to sign up for your Probiotic Advisor, what's the best way for them to get in touch with you and also to find out.

Probiotic Advisor, sorry, yeah, the Probiotic Advisor. If you even just, if you just Google Probiotic Advisor, it'll come up and there's, there's certainly for practitioners there's a chance to give a 24 hour spin trial for free. So have a play around and have a look. I just urge people to watch. There's a little video that goes for five minutes telling people how to get the best most use out of it. So people do that. They tend to find it easier to play around with. From that point onwards, the database is always increasing in size, adding new products and adding new research, which is always exciting because things change on a weekly basis these days with the probiotic field. Now for patients, I do practice in clinic clinics called Gould's Natural Medicine in Hobart, and I do offer appointments, et cetera. Again, that could be Googled. And then there's a contact form there for people who might be interested in seeing in a patient context.

That's great. Excellent. Thank you so much for joining us.