Probiotics, Prebiotics and the Gut Microbiome with Dr Jason Hawrelak

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Hello and welcome to today's episode of Natural Health with cnm, the College of Naturopathic Medicine. I'm your host, Michelle Sanchez. Today I'm joined by Dr. Jason Horolak, who's an experienced clinician and probiotic expert who'll be giving us the lowdown on probiotics and prebiotics. He'll explain what the gut microbiome is and its role in relation to health, why probiotic strains are important and what you need to be aware of when taking probiotics. You'll also learn why prebiotics are just as vital for your health as probiotics. Dr. Jason Horolak is a researcher, educator, Western herbalist and naturopathic physician with over 20 years of clinical experience. He did his PhD examining the capacity of probiotics, prebiotics and herbal medicines to modify the gastrointestinal tract microbiota and teaches worldwide on these topics. He has published extensively in these areas, including 20 textbook chapters. Dr. Horolak maintains a busy clinical practice in Hobart, Tasmania where he consults with patients from all over the world. He is currently the Senior Lecturer in Complementary and Alternative Medicines at the University of Tasmania's College of Health and Medicine and is the Chief research officer at ProbioticAdvisor.com, which offers a searchable database that enables easy evidence based prescribing of probiotic products and online resources for clinicians. Hi Jason, thanks so much for joining us today. It's great to have you on the show.

Hi Michelle, it's a pleasure to be here.

The role of the gut microbiome has been in the spotlight in recent years and more people are becoming familiar with probiotics. Prebiotics less so, but the term is now being banded around a lot more. But there does appear to be lots of conflicting information about the use of probiotics and which ones should be taken and when. Luckily though, you're going to give us the lowdown on probiotics and prebiotics today to help our listeners better understand it.

Yes, I'll do my best to condense a lot of information, but we will do our best to do so. Yeah.

Firstly though, please can you tell us a bit about yourself and your experience as a practitioner?

Yeah, I mean, I studied naturopathy in the late 1990s and I finished my four year Bachelor of Naturopathy course in 1999 and then I followed up doing an honors degree and then my PhD looking at the gut microbiota and specifically how we could use herbal medicines and prebiotics and probiotics to alter the gut ecosystem to become a much healthier state. So I've been in the gut world for a long time and I was very lucky to chosen the topic that when I was passionate passion about then and to maintain my, my absolute passion about now, 20 years later on and through that whole journey I've been a clinician and then these days I, you know, lecture on the, on this topic, research on this topic, and still see patients around optimizing gastrointestinal health and the treatment of a range of different gastrointestinal conditions.

Fantastic. And tell us about the Probiotic Advisor, which is an amazing resource for practitioners.

Yeah, like when I first started essentially teaching about the role of probiotics in naturopathic students back in first year, it was probably 2000 or 2001, I started creating documents that essentially were looking at, okay, well, these. I started learning a lot about probiotics when I delved into it, a lot more than what I was taught. And there was certain stuff that came out from that, which I think we'll talk about about different probiotic strains having different attributes and therapeutic indications. So we use a specific probiotic strain for this condition, a different probiotic strain to treat another condition. So I started creating documents around that for my students. And then over the time, as probiotic research bloomed from a couple hundred papers a year to thousands of papers a year, we essentially moved away from paper and moved into an electronic database that people can now search. They can search for health condition that comes up with what probiotic strains and what commercially available products contain those strains and a brief summary of the research that was done on those strains. So you can kind of navigate through different ways. So essentially trying to create a way of making evidence based prescribing of probiotics easy and quick, rather than having to do like a search of the medical literature. Every time you want to just use a product to treat something, it's like, okay, now I can type in this disease condition or health condition. It tells me what to prescribe. And I can also go, okay, I buy this probiotic or grab this one off the shelf and I want to know what's in it and what it's useful for. I can then look it up from that direction as well. Yeah. So it's been a labor of love over the last 20 years to manifest as it is now.

Well, what a fantastic resource. And because it is a bit of a minefield because there are so many different strains and different brands and I think it can be quite overwhelming, especially if you're not an expert in gut health, totally is.

And I think it's not help because all the companies go, ours is the best. No, ours is the best. No, ours is the best. So they're all saying that theirs is the best and they're giving certain reasons why. And I think it's important to see evidence to cut through the health claims to work out one is good for, because theirs might be the best for one thing, but it's unlikely to be best for everything. And there might be another brand with another strain that's better for whatever occasion you're dealing with. And I think, yeah, we have to look beyond the claims made on the label or by manufacturers who are selling it and look at the research behind it.

And we'll go into that in a bit more detail later because it is quite interesting about the strains because you might have, for example, rhamnosis, which is a strain, but there are different types of rhamnosis as well, which have been researched for different things. So people might think they're buying the right one, but not necessarily it isn't the right strain for what they need.

Yes, exactly.

Now, before we get into probiotics, can you firstly explain what the gut microbiome is and its role in relation to one's health?

Yeah, this has been an amazing journey to both be a part of, but also to watch, as you know, because my PhD was in the gut microbiota. So, you know, I've been looking Delvin's area from a research perspective from, you know, since late 1999, early 2000 was when I started delving into it. So you get to see where it was then and where it's at now. It's just been like huge, huge shift. And you go back in time 20 odd years ago, we were talking about the microbiota being important for gastrointestinal health. And maybe we knew it was imbalanced in some gut conditions like inflammatory bowel disease and irritable bowel syndrome. Even that was clear 20 years ago. We also knew that it was actually important for immune system function. And I think this was known within the microbiota circles, but wasn't really that widely known outside that, that we knew that we could take animals and we could give them mega doses of antibiotics and put them in little sterile boxes and essentially their immune system would become totally dysfunctional. They would lose like 90% of their certain immune cells by wiping out their gut flora. And then we could fix that by essentially exposing them to feces from other rats that had A normal microbiome, they would get that microbiome back and all of a sudden their immune system function would normalize again. So we knew that bit too, but the researchers did. But it wasn't that widely known and we knew a little bit about, yeah, it makes some B vitamins and vitamin K. That was probably about it. And I think what's really shifted is our understanding of the fundamental role that this ecosystem plays in those things. Yes. But much wider thing is, in terms of body functions, I think we'd be hard pressed finding any body system that we now know isn't influenced by the microbiota composition. And just taking a step back, the microbiota is just essentially the ecosystem in different environments. When we're talking about the gastrointestinal microbiota, we're essentially talking primarily about the ecosystem in the colon, the large intestine, and we're generally talking about the bacterial component of that. However, there's also a fungal component of the microbiome, there is a protozoal component of that and even a viral component as well as the bacteria. But the most research to date has been looking at the bacteria bit. So that's the section that we know the most about. Even though in some ways we're still no little. You can still get a microbiome report on someone's stool and there will be, let's say, 200 species mentioned on there. We're 200 genera to be more exact. And we may only know a bit of information about 20 or 30 of those species and almost nothing about 100 of those species to give some perspective on that. But again, you skip back 20 years ago and we knew something about five speaking of the picture. So we're learning, we're certainly getting there. And I think we know enough now that we know that one, the ecosystem composition is important and two, we know how to shift certain populations. But every year we learn more and every year we're seeing how vital this ecosystem is. As I said from from before, we were looking at mostly around immune system function and whether it's related to gut diseases or not, and a bit of a nutritional status. But we now know that it plays a huge role in your metabolism in terms of how well you be able to lose weight or how easily pick up weight, your mood. We can change your brain chemistry by changing your gut ecosystem and we can even newer conditions that you never would have thought of related to changes in the microbiome, like high blood pressure. We now know that we can take essentially a poo transplant from Someone with high blood pressure and give that. Well, in this case we're looking at animals. We can give that rat a poo transplant from that person with high blood pressure and that rat will get high blood pressure just from that poo transplant. Yeah. And Alzheimer's. There's even stuff we can take poo from people with Alzheimer's and give it to rats and those rats will develop Alzheimer's lesions in the brain and behaviors. So it's really an amazing area of research currently and I think it just promises so much in terms of the chronic western diseases that we see in the UK and Australia and North America that plague our populations. It's like there's so much of a microbiome underlying cause, I would argue, for those conditions. And that's what we've been teasing out the last 15 years.

Wow, it's fascinating. And so why would that be? So say for example, you mentioned that you transferred somebody with Alzheimer's or a rat with Alzheimer's, passing that onto another rat. Is it because of the harmful bacteria in that microbiome, microbiota of that other rat that's got Alzheimer's?

Essentially, yes. It's an imbalanced ecosystem that is able to create the same kind of disease state that it was in the other host as well. And conversely, we were able to clear away Alzheimer's plaques in the brain from doing a poo transplant from young healthy rats that didn't have Alzheimer's. And that's mind blowing too, that you can actually clear away the brain damage that we would have thought was relatively permanent by changing the gut microbiota. And we're still teasing it in terms of what species are doing what in that, but I think it's such an exciting area. And there's even case reports of people with Alzheimer's disease who happen to take a fecal transplant for a different condition, a life threatening gut infection called Clostridium difficile infection. And then they no longer had Alzheimer's afterwards and it's just like, oh yeah, we've seen it.

Rats, it's mind blowing.

But there's also some case studies in humans having the same kind of effect. It is totally mind blowing. And it is really. We'd see one way of looking at the ecosystem is that there are species that drive inflammation upwards and there's other species that decrease inflammation downwards in your system. So when the balance is right, you end up having these anti inflammatory compounds produced by these gut microbes which decrease inflammation not just in the gut, but everywhere, even in the brain. Yet when the balance is wrong, we actually have these pro inflammatory species releasing compounds which actually cause neurological damage and inflammation in the brain as well as inflammation elsewhere too. And this is why we're seeing that the role of an imbalanced gut ecosystem for things from Alzheimer's disease and anxiety to depression, chronic fatigue syndrome, metabolic syndrome, obesity, even osteoporosis is being linked to altered gut flora now. And I think it's really got to do with that anti inflammatory or pro inflammatory balance.

Fascinating. So how would it work in terms of with humans? That's kind of rat models they've done. Is it, would it be a case of, I'm assuming they don't do transplants in humans or how would it work with humans?

They're starting to, yeah. There are research groups doing fecal transplants looking at things like depression, anxiety, obesity. Yeah. And this is very new. So I'd say just watch the literature of the next five years and there's going to be a lot of papers published looking at this. Remember having a chat with some Israeli researchers recently and they're doing fecal transplants for fibromyalgia patients. I think expecting positive results. The animal studies are often just more about proving causation because people often go okay, oh well just because people with this disease have this kind of imbalanced ecosystem doesn't mean this causes that. And it's true, it may not. But then if we're able to take that essentially do a fecal transplant from, create the disease in the other model, we should essentially show causation and once we have that then we can start doing more human studies about how we can alter that ecosystem for the better and yes, even doing fecal transplants. And I do think that essentially pre will be the medicine of the future as long as we have maintain some good healthy microbiota donors to have. Because there's just not that many of us in western nations anymore that actually have, I would say a really healthy, robust, diverse, well balanced ecosystem. Because of just the way things have gone in western societies with C section births and formula feeding and antibiotic use and proton pump inhibitor use and non sterile anti inflammatory use and alcohol junk food, high levels of stress, little time in nature, less sleep than is ideal. You combine that all together, we just end up having this major loss of diversity and ecosystem health amongst westerners. So there's a smaller pool to choose from from an ideal donor perspective, but there's still obviously people within that broader populace who are, you know, have maybe had a fortunate early childhood where they were born vaginally and breastfed and not given lots of antibiotics, that they have a more robust and diverse ecosystem that weakens used to repopulate the broader human population.

So their poo is going to be like gold.

Yes. I do recall meeting a partner of one of my patients years ago who was born in Denmark, who had home birth which we know is associated with better bacterial composition than a hospital birth. Breastfed exclusively for six months and for I think probably two years all up. He was in his 40s, never of course Vanibotox his entire life, never, not one. And he ate pretty well and he was healthy and fit and had a good mental state. And like you're that unicorn. It's like your poo is immensely valuable. You don't know it yet, but people like you are such a rarity who actually we know that they essentially have the full gamut of bacteria that were gifted down the family line. Because I think that's the other aspect that we don't necessarily consider too, that we have this sort of species, that this diversity gets passed down and once we essentially cause extinction level events, we have less diversity to pass on. So each generation of westerner gets less and less diverse ecosystem than the one before that. So it's just such a rarity to have a full gamut of microbes still there. And that's why those researchers going out to Amazonian rainforest and collecting their poo samples from natives in that area and collecting poo samples from hunter gathered tribes in Africa to go, okay, well these are intact ecosystems, we need to really preserve them. So we have an idea of what the human ecosystem is supposed to look like. Because you know, we've lost so much of that in western nations and other nations that are, they're developing, following that sort of western healthcare model and western levels of hygiene, etc. And food, we tend to lose the diversity in their ecosystems as well.

And it just seems to be getting worse every year, doesn't it?

Yes.

So can it be replenished? Somebody has got a gut that's in a, that they've had a few courses of antibiotics and can, can they get ever get back to sort of near where their gut was when they were born, if they were born vaginally and breastfed, et cetera?

No, not, not. I mean, yeah, to give a very simple answer to that one, it's not a simple process. Yeah, I mean there was a paper published in a great UK journal, Gut, you know, one of my favorite gastroenterology journals, a few years ago and they found that a single course of antibiotics, this paper, nine species of bacteria went extinct in this person's gut. Nine permanently gone from that single course. And you think, oh man, those people who take two courses a year, and that's pretty standard little than people who might take five or ten a year. You know what impact that might have essentially with our current generation of probiotics that we have? No, we can't reinoculate or replenish that. Now that's not to say in essentially we're stuck with fecal transplants or probably breast milk too. No one's researched this yet, but we do get a wide gamut of different microbes in breast milk that in theory should be able to have the same kind of casing effect as what we get with a fecal transplant. But again, not yet researched. Yeah, and I do think that in five or ten years time there will be probiotic supplements that are kind of are essentially poo transplants without the poo, which make it far more palatable for most of us to deal with to go, okay, well, yeah, we're just taking a microbe supplement that's really diverse that might be able to replenish those species and also going to take a step further than that. I think in another decade beyond that, there'll be fecal banks where when you're a child, your poo will be stored away and then if you have to take a course of antibiotics for a needed indication, like a life threatening, limb threatening infection, you take it and then you essentially self reinoculate with your own poo. And that will bring all those microbes back. But again, I think that's a little bit further ahead in the future, but it will happen. But I think the next generation probiotics that will be much more diverse may have a chance of helping with that loss of diversity. We'll have to kind of wait and see for sure as those things become developed in research and see whether they have great colonization capacity or not. Because that's certainly something that is quite limited with our current generation probiotics that are essentially based around primarily Lactobacillus and Bifidobacterium, we know they have from 40, 50 years of research on these tools have very limited capacity to permanently colonize or stay in your gut. So yes, they're there when you take them, but two weeks after you stop that probiotic supplement, they're gone. And what we're hoping for is that that next generation probiotic supplements might actually be able to colonize and stay for forever or at least a much longer period of time than one or two weeks.

So, interesting. Now, so somebody wanted to have a look at their microbiome or, you know, to see what kind of bacteria, what they might be lacking, and what sort of gut testing should they be looking at.

Yeah, I mean, broadly speaking, it's sort of a little bit technical. There's three different options of stool tests, I would say. There's PCR tests, there's another technology called 16S RRNA, and then there's shotgun metadronomic sequencing tests. And actually there's a fourth, there's culturing. And culturing is the old style, where we take a sample of poo and we'd wipe it on some petri dish and we'd look to see what would grow. And that's something scientists were doing since the late 1800s. But we've recently worked out over the last 20 years that it's particularly poor way of assessing what's in the gut, because most species in the gut do not grow in petri dishes, so that you don't get a clear picture of what's going on. But in terms, what I've loved seeing over the last decade is how the technology to assess the microbiome has really become available and cost effective, too. I still recall 15 years ago, patients paying $800 for a test that would tell them about 12 species of bacteria in their gut. And now there's places you can have around $100 mark and see all the different species of the bacteria that are there. And those are tests that are often using a technology called 16S RRNA because it's a lab in the UK called BioMEsite, and I have no affiliation with Biomesite, but they do 16s RNA. It's a relatively inexpensive test and you get this beautiful snapshot of the entirety of the ecosystem. And those are the kind of tests that give me that beautiful snapshot of its entirety. And it can tell us how diverse that ecosystem is and the spread of the species, how many species are present. Those are the tests that I really like. I think, think the PCR tests often don't tell us those things. They don't tell us what diversity, although they might make a hypothesis around it. And they don't tell us all the species that are present because they're only testing for certain ones that are there to far limited degree. And shotgun tests, a particular technique of looking at DNA. So it sounds like shotgun. Can we break it into small little pieces, like shotgun pellets? I suppose is where the idea came from. They're fantastic too, but they are often a notch higher up in cost. They might be two or three times as much as a 16s RRNA test.

Okay, thank you for explaining that. Yeah, we'll pop some details in the show notes about those. But it's always better to, in terms of interpretation of these test results, to do that via a practitioner anyways, isn't it?

Yeah, I would highly recommend that because there are. There's a lot there and like gobbledygo. Yeah. For most. And even for a lot of practitioners it is too, to be honest. And. Yeah. So I think it's working with a practitioner who's familiar with the sort of new world of the microbiome versus what we knew existed 20 years ago and familiar with that testing technology and with tools to use to shift that ecosystem are the ones to work with. Because you can really, I can say as a clinician who's been working on Microbiota modification for 20 years, you can achieve a tremendous amount of change in a wide range of different disease states by improving the health of that ecosystem. But that's much easier to do with guidance from people who know how to interpret that test and can help you get the best out of your food choices and supplemental choices.

Definitely. Now let's move on to probiotics. So a lot of people do know what probiotics are in terms of. They know it after a course of antibiotics to replenish the gut bacteria. And quite often doctors will say, oh, go and get some probiotics. So they'll pop off to the shop and just get whichever brand's on offer. But they do a lot more than this. Can you explain to us what probiotics are and how they work?

Yeah, and I would say they probably don't do that bit well either. They call it recolonizing after antibiotics. No, they don't actually, but they can help if taken alongside the right probiotic. When taken alongside, antibiotics can reduce the risk of diarrhea and gut side effects. It can reduce the degree of damage caused and can hasten the restoration of the gut ecosystem and convers the wrong probiotic. Given alongside antibiotics, some research shows, can actually slow down the rate of regeneration of the normal gut ecosystem post antibiotics. So I think this really probably comes back to using the right strain for that task, and maybe that's a good place to start. Probiotics are defined as live microbes that, when administered in adequate amounts, cause health benefits. That's the strict definition that we all kind of Follow from a science perspective. And what's important when we're looking at probiotics is we now know that within any given species, and you mentioned Laxilis rhamnosus before species of bacteria, but there are thousands of different strains. And I think the good way of looking at this is looking at the analogy of dogs. All dogs are the same species, but we can have Cavalier King Charles and we can have a Chihuahua, we can have an Irish wolfhound, German Shepherd. They're different. Even though they're the same species, they have different traits and different, different personality traits, different physical traits. When it comes to bacterial strains may not look physically different, but their characteristics or traits can be dramatically different, even within the same species. So there will be some, like lacto rhinosis. Gg, for example, is one of those strains we can use alongside antibiotics to reduce the risk of side effects and I think to hasten the restoration of a healthy gut ecosystem. But it doesn't work to prevent urinary tract infections. But however, another strain, Lacteals rhamnosus GR1, does work to protect against urinary tract infections. So even though they're within the same species, there are different strains within that grouping, which means they can have different effects. And I think that's important to note. But I think also important to note is that as we've done more research over the last mostly 20 years, we've seen that probiotics aren't just about going into your gut. After a course of antibiotics, we now know that probiotics can have specific therapeutic effects like they can be anti inflammatory, they can slow down your gut transit time or speed up your gut transit time. They can help heal up a damaged gut or a leaky gut. They can change how your immune system works by ramping up the arm of your immune system that protects against viral infections or bacterial infections and then toning down that arm of the immune system that is involved with allergies or even, I would argue, autoimmunity as well. As, you know, there's some strains that are particularly good at helping reduce levels of bad bacteria in the gut or fungal candida in the gut and other strains that don't have that capacity. And since we've been able to tease these things out more, so we're now seeing that probiotics, there's a whole huge range of uses of probiotics that weren't on our radar, you know, 15, 20 years ago, where we're mostly talking about antibiotics. Yes, there's some stuff with Utal bowel syndrome or Gut infections, constipation, those are the kind of things we use probiotics for. For 20, 30, 40 years ago. Boom. You fast forward now, it's like, oh, we can use. There's human clinical trials using probiotics to treat cervical dysplasia, to prevent mastitis, for prevention of diabetes during pregnancy, obesity after pregnancy, anxiety, depression, to prevent respiratory tract infections, to prevent urinary tract infections that I kind of alluded to before, to treat type 2 diabetes, to improve blood sugar control and metabolic syndrome, obesity, food allergies, hay fever, asthma. We have probiotics that work in all those different range of conditions now because we've kind of worked out that, okay, well some of these ones that have these broad acting anti inflammatory effects might work on a few of these other conditions that go far beyond the sort of limited gut reseeding that we once used probiotics for, which as I said, they're not even particularly good for that in the end, they've got a range of other things they can be used for. Even like some recent research on osteoporosis where you're like, you know, bone loss associated with aging. You would not have thought of probiotics being helpful for that even 10 years ago. But there is, there's a clinical trial showing a strain of lactose reuteri. It's got a weird name of 6475. That's its strain name, but it actually helps reduce bone loss in women with osteoporosis.

It's fascinating, isn't it? Yeah, it's. The amount of research coming out is amazing.

Yes. And much harder to keep up to these days. I must say, as someone that when I started off, I could read every single study published on probiotics that came out for the first number of years and all the backlog too. And that's not the case now because now there's like, I think it's 5,000 studies to publish a year or something like that. It's outrageous the amount of information coming out now. Wow.

That's why we need the Probiotic Advisor website. Definitely. Because as you say, there's probably a lot of practitioners out there as well that might not be familiar with all the things that you're talking about today in terms of different strains.

No, because I think we're often stuck in that old paradigm of just using them. If maybe you do a stool test and it shows you low and lactobacilli, take some lactobacilli or you take a horse antibiotics and take a probiotic Then I think that's really shifted what I'd say a new paradigm of probiotic use where we're using them similar to where you might use her own medicines for a specific action. So like, okay, this probiotic is anti inflammatory, this one helps with anxiety, this one helps with cognitive function, this one helps with type 2 diabetes. And yes, we're still doing these. The other things behind the scenes, like for type 2 diabetes, you got to exercise more and you have to eat better and things like that too. But the probiotics will work as a nice band aid in the shorter term while we try to get people to work on the underlying drivers of their different disease states.

Now, why does some probiotics need to be kept in the fridge, whereas others are heat stable? And is one type better than the other?

No, it's just kind of the different traits and qualities that they have. And I would say that, that essentially from the probably mid-90s onwards, when they started looking at coming up with new probiotic strains for the marketplace, they would essentially put potential probiotic strains through an obstacle course. And that obstacle course was, okay, do you tolerate stomach acid? Do you tolerate bile from your liver? Do you attach to the gut? Do you produce any antimicrobial compounds? And do those compounds work against good bacteria or do they work against bad bacteria? And what's its shelf life? Can you live at room temperature or not? And I remember reading, probably the first modern probiotic strain is one called Lactophilus rhamnosus gg. And GG stands for the two researchers who isolated this one, golden and Gorbach. And this came from the gut of a healthy Swedish person from memory. But there was over 100, I think, strains to start with. And this is the one that came through the obstacle course and ticked all the boxes, including shelf life at room temperature. And since then, a number of probiotics chains have come through a similar process of, okay, we might start off with isolate 100 from someone else's gut or from a fermented food, for example, we put it through the optical course and one or two survive, tick all the boxes, get the gold medal in the end, and they have good shelf stability and they can live at room temperature and there's no law, or they can be at room temperature without any loss of viability. But there are other strains that don't have that, but they might have a lot of other positive characteristics. So they might go, okay, well, this one isn't ideal from a storage perspective, but it has lots of other good traits. So we'll still use it as a probiotic supplement, but we'll make sure it's actually shipped with refrigeration to maintain viability at that time. So we can't necessarily say ones that have refrigeration are better or worse than the ones that are not. They just have different strengths, I suppose in terms of stability, one of the characteristics we look at, but. But arguably less so from a therapeutic perspective, more so. It has to do with ease of use and ease of commercial transport, et cetera.

Okay, makes sense. Thanks for tuning in to today's episode of Natural Health. With CNM still to come, I talked to Dr. Horolak about which strains of probiotics are best for specific conditions, how food sources of probiotics compared to the supplemental flavor form, and why prebiotics are just as important for your health. Are you or a loved one struggling with health issues? Would you like to change career and become a natural therapist? CNM offers a wide range of short courses and diploma training both online and in class. Contact us today for a limited time to save 10% on short courses using the code podcast, visit www.cnmpodcast.com.

Now can.

You explain the strengths and what CFU means? So if somebody's looking at the bottle, you know, because that relates to the strength and are the more billions the.

Better you would get that idea. You read the blog. Most bloggers your sites would say that like, oh yes, the more the better. But the research doesn't say that with any sort of consistent message at all. Now CFU stands for colony forming units. So one bacteria is one cfu. And just with bacteria they can multiply up. So that's why we call it. It can make a colony. That one bacteria can grow into a colony of bacteria. So hence the name. There is a minimum dose for the most part. Now there is a minimum dose that we're often looking at when it comes to probiotic supplements. And that's 1 billion or 10 to the 9 CFU. And I would say there's pretty general consensus from a research perspective that when probiotics are used at a dose below that point, it's probably for many strains it is inadequate and we may not get a sufficient amount of bacteria to have a therapeutic effect, whereas anything above that point seems to be efficacious. What isn't clear is that there's any necessary advantage to giving 100 billion over 1 billion in some conditions for some strains. I would argue that there is, but I would say that that's not a general argument. That goes across because you'll find studies that show that actually sometimes a lower dose is more effective than the higher dose in the study where they use three different doses. And there's other strains that we know that work at a much lower dose, like The Lactis retry. DSM17938. Catchy name. I know. We know that one works at 100 million bacteria, so 10 to the 8th, so 10 times less than other probiotic strains. It has a lot of studies showing it works at that dose. So we don't need to give any more than that to get a therapy effect. Now for certain conditions there might be advantage to giving more of that strain. But to give some context here, looking at a study looking at antibiotic use and we know that we can give 100 million bacteria twice daily and we can prevent that population from developing antibiotic associated diarrhea and side effects. Yet there can be another study looking at the same kind of population of older adults receiving a course of antibiotics that took 60 billion CFU of four different strains of bacteria. And they had no impact on decreasing antibiotic associated side effects at all. None. So showing Even though there's 300 times the dose and there was four strains versus one strain, the one strain at lower dose worked because it had the qualities and traits required to be helpful for that situation versus those four strains did not and so therefore could not be helpful. So it's one thing that we look at is making sure there's a minimum required dosage, which I put is about 1 billion CFU or 10 to 9 CFU. But it's not the only thing we need to look at when it comes to probiotic supplements. Having the strain designations there on the label is more important. And having those strains having the right attributes and actions to help with condition you're wanting help with is more important.

And as you said, it's going to be dependent on the person and the condition and, and all of those factors.

Yeah. And this is where it starts getting more complex. Yeah. Because you know, we different, potentially different probiotic strains that we use for anxiety than there will be for, you know, high cholesterol, for example.

Okay, Are you able to give us some examples of particular conditions where specific strains are recommended?

Yeah, yeah. I mean, I think osteoporosis, like I mentioned before, it's, It's a lactose retry 6475 is a strain with good research in that area. Depression. There's been some good research with the combination of lacto cilus, acidophilus strain LA5 and bifidobacterium lactus strain BB12 and that's osteoarthritis. There's some research on Lactozilis cassii strain Serota type 2 diabetes. It's the same two strains that were helpful for depression actually. It's the lacto cyst acidophilis chain La5 and the bifidactyramelaxis. Fact, it's strained. BB12 has got some good research for type 2 diabetes and maybe to finish off constipation. That's a common condition they don't often talk about, but is really common. And I treat a lot of patients with constipation and I think there's two strains that I've had good research studies on and I've seen work well in a lot of people over the years. And that again is Lactose Retry DSM17938, that strain that I mentioned before, that's also helpful for antibiotic association side effects. And then Bifidacterium lactose strain HN019, also helpful for speeding up transit time and helping with constipation. To give a few.

Well, thank you very much. Yes, it's. Yeah. How do you remember all these names?

Yeah, 22 years of looking at them actually.

Yes. Yeah. So, yeah, you definitely need to look at the research before taking probiotics willy nilly, that's for sure. Yeah.

And there was a research study that came out of Israel a few years back that I think to me illustrated this point very well. And this is a study where they gave some probiotic alongside antibiotics afterwards and they looked to see what impact it had on the microbiota of these people in terms of how did it restore after antibiotics, did it restore it better? And it turns out that with this particular probiotic, the combination they used, it was an Israeli supplement, actually slowed the restoration and you could argue caused harm to the gut ecosystem with its use. So it's like, oh, look at that. So you really want to be careful with what probiotics you use, not choosing some random ones. Use the ones that have got researched showing that they're helpful for that condition at hand, because otherwise you might get that rare situation because it turns out that the Lactobacillus that was in this specific Israeli supplement produced a compound that was selectively active against your good bacteria in your colon that were trying to regrow. So because they were taking this supplement, it actually slowed the growth of these good bacteria and slowed their return. And it's like, okay, well, that means that supplement is useless for that task and that supplement might be used for something else, but not for that, that's for sure. But there'll be other strains that we know have got good research alongside antibiotics that we can use in that situation without having to worry about it. So I think, yeah, I've got some concerns about experimenting too much with random probiotics, hoping they will work. When we, this day and age, we can, we don't need to experiment for very often we can actually use evidence to inform our decisions and to tell us which products to take for different conditions.

Yeah, I think the issue is, you know, for decent probiotics, they are like, they are quite expensive sometimes. And I think people just go pick the cheapest one quite often in the local health shop and not, you know, just thinking that they all do the same thing. And I think that's the issue very much the case.

And I think it's the thing that we know that the reason these things are expensive is because research costs money. Definitely the people that have done that, okay, let's take 200 strains, put them to an obstacle course, and we get the one or two that comes at the end. And then they might do some animal studies and then they might do some human clinical trials on that before it even hits the marketplace. So that's like a lot of money went into that and not surprising they want to recoup some of that money when they sell that off versus someone else and just go, I'm just going to grab some random black dropsilla that I found in some sauerkraut, put this into a supplements form and start selling it super cheap. Who doesn't do any of the background research when it comes to products? I think you really get, you get what you pay for, or at least you know what you're getting when you, when you pay more, because you should be getting the research that, that shows that these strains have got the attributes and the traits that you're wanting.

It's like any supplement, isn't it? You know, you buy, you know, with minerals and vitamins, it's the same thing. You're getting a more bioavailable, absorbable form, whereas the cheaper ones tend to be, you know, cheaper forms of the minerals and vitamins.

Yeah, that's often the case. Very much so.

Now there are some different schools of thought about the best time to take probiotics. Some indicate before food, whereas others stay after food. What are your recommendations?

I think the research has become pretty clear on this over again. The last 20 years, because I think I was even taught to take it away from food as part of my naturopathic training. But we now know that you get better survival through the stomach, which is what you want. You want these bacteria to be alive when they get out of the stomach into your small intestine. We get better survival with a meal. And the bigger your meal is, the better your survival of the bacteria are. So I always tell my patients to do it either just before a meal or midway through a meal, or just right following a meal, but not on an empty stomach. We now know that the physical, the acidity of your stomach is far, far greater when your stomach is empty. It's like might be page of two, two and a half when your stomach is empty, but that goes up towards neutral somewhere around four, four and a half when you've got a meal in there. And research even seem to show that meals with higher dairy content or higher grain content even, I think buffer the ph even more. So you get better survival again with those meals. But in general, just think of, okay, the bigger the meal, the better survival the probiotics strains there will be to the stomach.

So lunch and dinner, preferably, yeah. And are there any safety issues to be aware of? I mean, are probiotics safe for babies, children, pregnant women and those on medication? And can they be taken long term?

Long term, yes. And I think the safety profile in general is pretty exceptional. Now there are some, you know, occasional cases, what's called bacteremia, where bacteria gets into the bloodstream and causes an infection. And that's usually in people that are in hospital, near extremely unwell to begin with. And I think they're often severely immunocompromised where the immune system just can't deal with things too much and they get that sort of bacterial introduction and comes through and is problematic. So I think there are certain little pockets of populations that we're more cautious around and certainly have no concerns around infants greater than 6 months of age, below 6 months of age when they're breastfed. I prefer to work via the mom and give the probiotic to the mom and then it comes out through the breast milk, through that process, if they're formula fed, then I'm totally happy giving it straight to little infants in that instance. And pregnant women. Yeah, there's some good research on probiotics for prevention of postpartum obesity. So, so that's good. And for, oh gosh, what is it wracking my brain now? And prevention of mastitis for sure. And Gestational diabetes. That's what it was. Yeah. Prevention of gestational diabetes. So there's a few good reasons, as well as allergies in your offspring. So there's research showing that the right strain during pregnancy and following birth can actually prevent eczema and allergic disease developing in your offspring. So there's a few good reasons to use it during pregnancy.

Now, particular foods also contain sources of probiotics, things like yogurts, kefir, and fermented foods. How do food sources compare to the supplemental form of probiotics?

Yeah, from a strict researcher perspective, we'd actually separate those out. So we've got probiotics that are these really well defined, well characterized living microbes that we know have therapeutic effects when consumed. Then we have foods that contain active microbes that aren't so well characterized. And this would be your traditional yogurts, your kefirs, kombucha, sauerkraut, kimchis, all those things would fit into that category. And they're generally not considered from a researcher perspective, to be probiotics because they don't meet, I suppose, the strictest definition of having a definitive health. The strains contained in that fermentation have specific health benefits because they're wild ferments. And that's not a bad thing. I mean, I had sauerkraut and kimchi for lunch and breakfast today, as I do most days, and drank kombucha. I love eating my fermented foods and getting exposed to a wide range of microbes, but I'm not expecting them to be therapeutic in the same way that I am with a supplement. So from researcher perspective, we like separating those things out. Again, this is a wild mixture of stuff. And in my case, kombucha here will have different microbes than yours will in your house, and my surrogate will have different ones. And even the strains of bacteria in my yogurt will be. The species will be the same, but it'll be different strains and yogurts a range of parts of the world. And because of those differences, we can't necessarily expect to get the exact same sort of therapeutic effects. Whereas when using lactose rhinosis gg, that one strain, it might have a different brand in different parts of the world, but that same strain we've got that we know exactly what we're getting. We know what the traits and qualities of that are.

Yes, and thanks for clarifying that.

You can make yogurt with that spiked with a well characterized probiotic strain, and then that becomes a probiotic yogurt or what I would call medicinal yogurt, but the normal microbes that are just making fermenting milk to become this sort of thick stuff that we call yogurt are not therapeutic. And they generally die in the stomach and small intestine. So they're not. It's not a probiotic thing, it's just like, yeah, it's made milk taste better and we're getting some essentially dead bacterial bits when we ingest it, which is not a bad thing, but you can spike that. So there'll be brands of yogurts and I don't know the UK market particularly well from a yogurt perspective, but there are brands here in Australia, in North America, where the manufacturers will go, yeah, we'll add our yogurt producing bacteria, but then we'll spike it with some therapeutic, well characterized probiotic strains. And then we actually have just a different way of taking those probiotics as a food source instead of as a powder or capsule.

And you can make your own at home, can't you? With there are companies that sell the probiotics that you can make your own yogurt, is that right?

Yeah, I mean, I think the thing is always worth double checking is that the probiotic strain that you're trying to grow can eat, find food and nourishment in the medium you're trying to grow in. So to give you an example, there's certain some lactobacilli or bifid bacteria that don't eat lactose, for example, which is milk sugar. So if you try to grow it in milk, it won't grow, but those ones might eat the sugars found in soy milk, for example, or you could add, because there's ways of being creative with this. So you could have your milk, cow's milk, as a media even for that strain, but then you can put some special sugar in there that it does like, and then it will grow in that media and still ferment it, but not actually eat the lactose and the milk. Certainly a bit more complex, but it's essentially making sure that the probiotic strains that you're wanting to grow can eat what's in the medium you want it to grow in. And it's not always as simple as what people make it out to be.

Indeed, indeed, yes, as we're finding out today. Now, let's talk about prebiotics. Can you explain what prebiotics are and why they're important?

Yeah, I think they are, for me, one of the most immensely useful tools in my Clinical practice and probably the tools that have the biggest impact on changing the microbiotic composition bar major changes in diet. But prebiotics are immense in that capacity. So prebiotics are selectively fermented substrates that encourage the growth of one or limited number of beneficial species in the gut. A way of looking at this is, let's say you've got a garden bed that's got a bunch of weeds and the maybe the broccoli you're trying to grow. Imagine if you could just throw this fertilizer onto your garden bed, then only the broccoli could eat it and it couldn't be utilized by any of the weeds. And the broccoli would grow, grow hugely and super quickly and shaded all those weeds, so all the weeds would kind of die back. And in the end, you just had a bed that was full of broccoli. That's kind of what prebiotics do, is that they selectively nurture one or limited number of beneficial species who then take over more territory, change the environment in such, it's less conducive to the growth of bad bacteria or bad fungi, too, I would even argue. So they're really shifting that ecosystem. But it's the selectivity of fermentation that separates them from other things that are just fibers. I'm a huge fan of fibers, and I think we should be eating a wide range of dietary fiber daily to feed a wide range of microbes in our gut. But what's different between just fibers and prebiotics is that selectivity of fermentation. So with, with prebiotics, it's just one or a couple different species that are eating that, whereas fibers, it might be dozens of different species, and you want both. But there'll be times where you're like, I want to really target it. If I do a microbiome analysis, and this patient is really low in bifidobacteria and really low in another species called Faecalobacterium. I go, okay, well, I can give a specific prebiotic supplement that will target both those species, and they'll go up. And yes, I'll probably make some other dietary suggestions to nurture a wide range of species. But I might use inulin or oligofructose to feed their Fecalobacterium and Bifidobacterium. And then lo and behold, four weeks later or six weeks later, we can do another test. And you go, oh, look, those species have gone up very clearly from this intervention. Yeah. So for me, they're mentally helpful because they can help rebalance that ecosystem by feeding up those anti inflammatory gut healing species. And as a consequence of that we get reductions generally of more pathogenic or harmful pro inflammatory species. So I love their capacity to rebalance things. Yeah, so it's not even just feeding up good guys, it's actually often lowering levels of bad bacteria too. Not all prebiotics are equally good at that latter aspect of lowering levels of bad guys, but some certainly are. And for me that's why they're kind of first line treatment. Because we've got that capacity to optimize that ecosystem without the risk of collateral damage we might have with obviously anti antibiotics or I'd even argue some herbal antimicrobials can cause collateral damage to the gut too. And we just, I just love the win win situation we get with the prebiotics. Plus compliance wise, it's often good because they taste like sugar. So they're generally pretty easy to take. Even for people who, you know, have trouble with foul tasting things, this isn't one of them. As a naturopath, I prescribe lots of foul tasting things to my patients, but this is a category of stuff that's generally either bland and nothing or actually sweet and quite pleasant to take. And I would say there's probably three prebiotics that are the most well researched and most well known and available. And that's fructooligosaccharides, which are things like inulin or oligofructose. There's galactooligosaccharides and then there is lactulose. And lactulose is one of the weird ones that's actually everywhere. Every single chemist or drugstore has got lactulose in it. And in large doses it works as a laxative, but it turns out in low doses it works as a prebiotic and a selective fertilizer. For a good bacteria, it's probably just 1/6 the dose that's used as a laxative.

And all those would come in supplemental form, like in granules or.

Yeah, often with the fructal. Oligosaccharides is typically a powder. Galact, oligosaccharides powder, lactulose, usually liquid, but you can in some circumstances buy powder too, but it's much more expensive. The liquid is quite inexpensive.

And how would one take those? Would it be alongside the probiotic or separately?

Well, if you're trying to, there's something called a symbiotic effect. A symbiotic is where often you're trying to take a prebiotic at the same time as a specific probiotic to encourage its growth in the gut after you ingest it. And if that's what you're going for, then yes, you could take it at the same time, assuming you've done your research and that the probiotic you take can consume that exact prebiotic take, you're taking it. It's not always that straightforward. But typically what you're trying to do with the prebiotic is change your gut ecosystem for the better. So it doesn't matter when you take that in regards to the probiotic, it doesn't matter when you take it reference to food, because it's going to reach the colon or large intestine in its own way at any time. So you don't need to worry about that aspect of things. Often the recommended approach that I use is start low and go slow. So let's say the minimum therapeutic dose of inulin. We know that one of the types of fructoseaccharides is 1 teaspoon or 3 grams per day. That's a typical kind of dose for a kid or minimum dose for an adult. But we often won't start at that dose. We might start with a quarter teaspoon for the first week, then half a teaspoon for the next week and slowly build up. And this depends a bit on how well your gut's working, that if your gut is working really well and you ingest this prebiotic, you'll probably just get a bit more flatus, that's it. Often less smelly flatus, just more of it. But if your gut's not working well, you can get bloating and distension and pain associated with prebiotic ingestion. So it's always worthwhile. One I think there's benefits of doing this with a practitioner, but you can experiment with them. It's just doing it slowly and building the dose upwards to get that minimum therapeutic dose and not just going, okay, well, these three prebiotics are all great. I'm just going to start taking all three right now. I have had the odd workshop participant do that, and they were complaining of bloating and discomfort and tremendous amount of flatulence as a consequence of that, which they put up with for a few weeks till the gut normalized and evolved to deal with that. And that's what generally is occurring, is that we're feeding different species up and then they're producing more gas. But we have other species in your gut who deal with that gas, but they take a while for their populations to increase. So we can help that ecosystem adapt by moving slowly and increasing the dose every sort of five to seven days.

And again, would you able to take those fairly long term or is it sort of in sort of short spurts?

Definitely long term and there's some great research on prebiotics. We know they often will improve your immune response, you get less respiratory tract infections when you take them, they improve your absorption of calcium and probably magnesium. So there are long term health attributes, gains from their continual use as well as their shifting of the ecosystem perspective. So I take prebiotics daily and have for years, whereas I only take probiotics interestingly enough, when I have something I need help with, which could be if my little one comes home from school or from care with viral gastroenteritis. Well, hey, I'm going to take a probiotic to help reduce my chance of getting it in shorter duration or travelers diarrhea. Yes, they'll take, there'll be certain things I'm taking it for, whereas prebiotics are part of my daily regime to optimize my gut ecosystem moving forward. So I think they're definitely great long term and in terms of just making sure I cover the dosages for all those ones. Lactulose, 1 teaspoon is the minimum therapeutic dose and with galactool oligosaccharides or gauss again it's around 3 grams is a minimum therapeutic dose. So you can kind of hover along those lower levels of dosages and have less chance of gas related side effects long term. But we do know in this case there is often a dose response when it comes to the degree of change to the ecosystem that if we take a higher dose of lactulose for example, we'll have a more substantial change in ecosystem composition than 1 teaspoon if we took 6 teaspoons. So there'll be occasional patients. We work up to a higher dose to get a bigger change. But that will depend on what the ecosystem looks like and how we're trying to, to, to adjust it. But I think just in terms of playing around with it, you can stick with the lower doses and get the health benefits that we've been talking about in terms of microbiota optimization and just.

Starting with one and then maybe introducing another one. Or would you stop that one and then start another one?

No, there'll be times where I'm giving two or three, occasionally four different prebiotics at the same time depending on what we're trying to target with that ecosystem. So you can Certainly do them layer in, but take them at the same time. But I do think it makes sense to layer it in. So you start off with one for a while, then go, yeah, I'm stable on this one. Then introduce the next one and slowly build up. And this really depends on how sensitive your guts are. I mean, these days with my patients, they're really sensitive, so I have to go really slowly with them. But I recall 10, 15 years ago when my patient group was quite different. And when I run workshops to just general healthy public who just wants to get healthier, they can often just start with the 1 teaspoon dose to begin with, and that's fine. And then the next week they can put in the second prebiotic. The next week. You know, in three weeks from now, they can be taking all three prebiotics, no issue. But there'll be some more sensitive patients with gut issues that I work with that it's like, you know, might take six months to get to that point in more, you know, sensitive folk.

Yes, absolutely. Now what? There are also some food sources of prebiotics. Can you explain what those ones are and does it work out? Is it the same in terms of the probiotic foods? You separate them out as well?

No, in this case, we can very much use food sources to get our prebiotics, at least when it comes to the fructal oligosaccharides we can find in a range of foods from asparagus, artichokes, Jerusalem artichokes, glow artichokes, garlic, onions, wheat and rye all contain a decent amount of fructosaccharides. In fact, there are some roots that are less consumed now, but probably were more so by our ancestors, like burdock root and. And dandelion root, that are actually quite high in fructosaccharides. We just don't consume them much anymore. So you can certainly do it. And there's no disadvantage to achieving your dose of phos from food sources versus a powder. In fact, I'd say there's more advantage from having a food source. It's just trying to make sure you consume daily or almost daily the right amount through your foods. That's fine and it works really well, so no issue there. Galact oligosaccharides are slightly trickier in that probably the only food source that gives you a good load of gauss is legumes. Pretty much across the board. There's less in things like red lentils have got less. And you might find that barlotti beans or lima beans, for example, or split peas have got sensually more. And this is the reason why legumes are often seen as being flat, as inducing, because they are. It's the gas in legumes, which is indigestible sugar, that selectively feeds your beneficial species as a consequence of their use. So yes, you get gas, but yes, you're feeding your good bacteria at that same time. It is a good thing. Yeah, we have to get used to flattest being actually good. And the more fiber and more prebiotics we consume, generally the more flattest that we're actually going to produce, comparatively. But generally when we're eating more fibery things or prebiotics, the smell actually decreases. So while you might have an increase in volume, the stink factor actually goes down, which is good because it's often fat bit that's more problematic for many people.

Yeah. So if it is smelly, that's more like, oh, that, that probably doesn't agree with you or something's going on there.

Well, I mean, I think sometimes there can be a transition where you can go from that. If you, you continue on that prebiotic for two or three weeks, the smell might be only for the first week and then it sort of moves through. And that's kind of. We're changing the ecosystem dynamics a bit and we have to allow the prebiotic to work, to be consumed by the good bacteria, to change the environment, to decrease the level of bacteria that are causing the stink. Essentially it's the microbes that are eating bile, microbes that are eating protein. They're called protein putrefiers that add most of the stink factor. And in general, prebiotics would reduce their populations over time. But some people, that can happen more quickly and some people, it's more of a slower process. So people who come to me complaining of really stinky flattest, we will look at reducing dietary factors that feed those species, but at the same time will take prebiotics to change that balance more quickly from the other kind of rate of going, let's feed the good bacteria, they'll change the ecosystem dynamics and the PH of the environment so it's less conducive to the growth of these more distinctifying microbes to help deodorize the flattest in the end.

And what are some of the foods that feed those microbes that are causing the smell?

Well, it's often meat, actually. It's. It's meat that can be chicken, that can be beef. It doesn't really matter in that regard. It's the protein level that the hydrogen sulfide gas producers that make those stinky compounds are often protein consumers and they also eat bile. So generally higher fat diets often lead to more stinky fattest too. But I would say even more than that. It's probably because I don't think olive oil or avocados or nuts and seeds tend to have this end result. It tends to be saturated fat. So saturated fat we find in dairy foods particularly are good at feeding bad bacteria called Bilopyla wadsworthii and Bilophylla. Its name is bioloving. And it just loves it when people eat dairy fat. Loves it because we produce a different type of bile in our liver to help digest that dairy fat, which is really high in sulfur. And then this microbilophyll just eats that sulfur compound and creates hydrogen sulfide gas which is what stinks up the flatus. So those are the things we kind of look at going, okay, well let's shift your dynamic and have a of lot lot more plant based foods. It doesn't have to be all plant based, just more plant based. Make sure there's fiber with each meal. Not just a chunk of steak with a couple chips, but a small bit of steak and salad and brown rice and a whole bunch of other foods to offset that. And we know that if we have enough fiber or prebiotics alongside the dose of protein, we can actually limit that protein putrefaction and the production of hydrogen sulfide gas that occurs with an individual meal as well.

Now just to finish up, what's your party advice on probiotics, prebiotics and gut health? Anything for our listeners?

Well, I mean I think if we want to take care of that ecosystem, the best we can is being cautious around the use of pharmaceuticals and using them when they're needed. But not for viral infections. For example, we don't need antibiotics for viral infections, but they're still prescribed. I think there's that. But I think the other aspects is choosing dietary strategies that nurture the widest range of microbes that we possibly can, particularly the anti inflammatory sort of gut healing ones. And that to me is predominantly plant based, high fiber, wide diversity of different foodstuffs, avoiding all sort of processed foods, going with whole foods all the time and choosing foods that contain those prebiotic compounds I mentioned before. That's kind of the best way we best strategies we can have to optimize the ecosystem and then we get all the health benefits that flow on from that, which are a myriad. I'd say there's just so many that we're still teasing out.

Great advice on the medication front. Antibiotics obviously we know affects gut flora. How about other medications, things like paracetamol, ibuprofen, these types. Do they also alter your microbiome?

Yeah, and this is only really the last probably five, six years that they've started looking at things besides antibiotics and the impact they have. So it's early days yet. And I think that list of medications that alter the gut ecosystem in negative ways is growing and will continue to grow. But the ones that have got the best research now are things like proton pump inhibitors that are used for reflux and they are so widely prescribed for life for many of these people that take them. And we know that they have essentially antibiotic like effects on the gut ecosystem. They really negatively impact diversity. You do get extinction level events with taking proton pump inhibitors, so they're definitely in that category. Ibuprofen and other sort of non steroidal anti inflammatory drugs are also in the category of encouraging the growth of bad bacteria and lowering levels of beneficial species as well. In fact, there's some research to suggest that's the way in which they cause gut bleeding is through the changing of the gut microbiome and they actually changed the ecosystems of the bacteria were able to cause the gut damage. Which I think is fascinating because we know that ibuprofen, other non steroidal anti inflammatories cause gut bleeding. But the recent research is suggesting it's doing that because of the dysbiosis, the negative changes to the ecosystem that they actually induce. Those are the ones as well as things like chemotherapy. But I'll put chemotherapy in a bit of a different category because there are times where it's obviously very much needed. So what we're trying to do in that situation is attenuate the changes as best we can and restore things as best we can afterwards. But I do think that things like proton pump inhibitors, NSAIDs, we know from looking at the research that they are over prescribed. They're taken by way too many people that don't actually get benefit from them, they just get the harm. So we just have to be really cautious around those ones and make sure that they're used when they're needed to be, but not used overly, which they sort of are currently.

Thank you so much for sharing your worth of knowledge with us. It's been so insightful, Jason, and so fascinating. Where can our listeners find out more information about you and the work that you do?

You're very welcome. It's been a pleasure to chat about this. As I said, it's my passion, so I very much like sharing the information and getting people to implement changes to change the microbiomes and essentially change their lives. That's the idea. You can find out more about me, I suppose. I do run some courses by my Probiotic Advisor website. We've got the database, which is mostly for practitioners, but we do have some courses there too, just to teach people to look after the microbiome and how to treat different sorts of gastrointestinal conditions that they might be encountering as well. So that's probably a good part to look at. And I do practice as a clinician to work one on one on improving one's microbiomes and to improve one's health.

Well, that's all we've got time for today. Thanks for listening and a big thank you to Dr. Horolak for sharing his wealth of knowledge with us. You can find all the information discussed today and more about Dr. Horolak in the Show Notes on the podcast website@www.cnmpodcast.com. and if you're interested in learning more about gut health, nutrition, naturopathy or herbal medicine, check out CNM's range of short online courses and diploma training on the CNM website at www.naturopathy-uk.com. we have a series of open events coming up in the next few months and you can find all the details on the event section of the website. Thanks so much for joining us today. If you enjoyed the show, make sure you subscribe through your favorite podcatcher so you don't miss any future episodes while you're there. We'd love it if you could leave us a rating or review as this helps us when creating new content.