Probiotics & SIBO with Dr. Jason Hawrelak: Rational Wellness Podcast 329

Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates and to learn more, check out my website. Thanks for joining me and let's jump into the podcast. Hello Rational Wellness Podcasters. Our topic for today is Probiotics and Sibo with Dr. Jason Harlick. Sibo, small intestinal bacterial overgrowth, is believed to be the most common cause of irritable bowel syndrome, or ibs. And SIBO is a condition of too many bacteria in the small intestine. Now, why would you want to treat it by ingesting more bacteria when you already have too many? But some studies do show that taking probiotics are helpful for both IBS and sibo. And while some studies show that specific strains, such as Bifidobacterium infantis strain 35624 helps with IBS, other studies and meta analyses just lump various probiotics and often of unspecified strains or mixtures together. This has created somewhat of a mishmash of research confusion. I've talked to Dr. Mark Pimentel about probiotics for SIBO and he basically dismissed it partially because how can you talk about a group of substances? It would be like saying antibiotics, you know, are good for a certain condition. So saying probiotics are good for sibo, you know, from a scientific perspective really doesn't seem to make much sense. Now, there's one prominent doctor in the SIBO world who recommends taking triple probiotic therapy, taking a lacto bifido blend of unspecified strains, a Saccharomyces boulardii product, and a spore based probiotic for patients with sibo. And he says that specific strains don't matter, just, just take one from each category. Some functional medicine practitioners have concluded that the best type of probiotic for patients with SIBO is to take a spore based probiotic, since it won't open up until it gets into the colon and therefore will not add to the bacteria in the small intestine. On the other hand, many functional medicine practitioners in the SIBO space do not recommend taking probiotics while treating SIBO until after you've reduced the number of bacteria with appropriate antibiotics or herbal antimicrobials. And of course, this would make sense based on the 4R or 5R strategy pioneered by the father of functional medicine, Dr. Jeffrey Bland, who taught us to remove, then replace, then reinoculate, and finally repair the gut. And so there you would only use probiotics in phase three, the reinoculate phase. So who better to help us understand this confusion about probiotics for patients with IBS or SIBO than Dr. Jason Harelick joining us from Australia. Dr. Jason Harelick is a researcher, lecturer, naturopath, and Nutritionist with over 20 years of clinical experience with focus on the treatment of gastrointestinal conditions. He's the head of research@probioticadvisor.com which is an incredible database of information about probiotics. He also offers a series of courses that are available adjacent to that program as well. Dr. Harelick completed his PhD examining the capacity of probiotics, prebiotics, and herbal medicines to modify the GI tract. He teaches and lectures on probiotics and the microbiome all over the world. He's written many papers and over 20 textbook chapters. Dr. Jason Harelick, thank you so much for joining us.

Hey, you're very welcome, Ben. I'm glad to be here chatting. Thank you again. But very interesting and apparently controversial topics that we'll be delving into.

Yeah, so why don't we start by talking about SIBO and ibs? And so let's focus in on sibo.

Which.

A lot of the data seems to show is the most common cause of IBS, probably accounting for 60, maybe as much as 70 or more percent, depending upon how we're able to determine if you have sibo. And the way we generally determine if you have SIBO is with a SIBO breath test. And I'd like you to comment about the SIBO breath test and especially about the various substrates that are available that are used in the test, including lactose, glucose, fructose.

Gosh, I don't know where to start. Even so, maybe, maybe I'll like, I'll take a step back and go, listen. My PhD was specifically around dysbiosis, irritable bowel syndrome.

Okay.

We were running clinical studies in ibs, giving them prebiotics and probiotics and herbs to try to influence their microbiome. This was back I started my PhD and my honors degree, which flowed into my PhD in the year 2000. So before people were talking about SIBO as being anything but this really rare condition. And so I had a chance to do, like, this lovely literature view into irritable bowel syndrome and probiotics, and go look back, you know, and found the first studies going back to the 1950s showing probiotics were successful in treating IBS. And a number, not every single strain is Obviously, but the bulk of data suggests that probiotics are helpful for treatment of IBS. Right? That was clear in the early 2000s when this idea of SIBO came out of, you know, so for me, and then SIBO came out as the cause of ibs. And I'm like, well, if SIBO is the cause of IBS and we've got like 50 years of research showing that probiotics successfully treat IBS, then why on earth wouldn't we using probiotics to treat this when we already have 50 years of data showing that apparently it treat, it successfully treats the. This condition, you know, so that's kind of where my background was from, where people were like, oh, don't use probiotics. But it's like if you're, if you're saying this is the cause of IBS and we've got all this data showing probiotics working ibs, it just doesn't make sense that we say we should not take probiotics.

But it's counterintuitive. If the problem is too many bacteria, why are you going to put more bacteria in?

I think it's counterintuitive for if that's the big viewpoint, rather than, okay, it's actually not just too many bacteria, it's too many problematic bacteria or it's too many streptococci or too many E. Coli or Klebsiella that are there. And when you understand that differently, that changes things. Because it's like, okay, because I think that conception around SIBO is changing. And in fact, there's more of a thinking now that it's more about dysbiosis than it is about just overgrowth of bacteria. And you could have overgrowth of some bacteria and never have an issue with it. And you have overgrowth of klebsiella or E. Coli or streptococci and you get symptoms associated with it and potentially gut damage too in the small bowel. So I think under with that understanding, it's like, okay, well, what do we know that probiotics can do? I think there's this misconception and this goes back probably to the 4R 5R type stuff with reinoculation. You can't reinoculate with probiotics. This is an old myth that we should really make sure we be tossed out. And certainly I teach within the function medicine program at University of Western States. And we change that, reinoculate to restore. It's like with the new century, we can't reinoculate with black, rusty and different Bacteria and probiotic supplements. It's not reality. We can help restore populations that are too low, but it gets into that idea of colonization. So I think the idea that, oh, we've got more bacteria because add more and then they just permanently live there, that's not reality. That's not what happens with when we take lactobacilli or bifid bacteria or saccharomyces or et cetera. They do not permanently live in your small bowel or large bowel. They're temporary visitors, so they're passing through. But while they pass through, they may well secrete some bacterial sins or other antimicrobial compounds that reduce levels of pathogens. They might just secrete short chain fatty acids or lactic acid, which changes the environment, which reduces levels of pathogenic bacteria. Some probiotic strains can stimulate the migrating motor complex and help with motility, which is an underlying issue with sibo. Some can certainly help heal up and regenerate small intestinal cells and help the healing process after the sort of, arguably the treatment of sibo. Some strains can reduce visceral hypersensitivity, which is one of the core conditions underlying ibs, where the nerves are hypersensitive to the sensation of gas or the sensation of feces moving through the colon. Some can decrease inflammation, some can enhance secretory IGA production. So if we start looking at what the, the possibility of what probiotics can offer here, it makes total sense that we can use them as a tools to actually help. So, I mean, there's different ways of reducing or changing bacterial ecosystems. Antibiotics is one way, sure, but probiotics is another way, and horrendous are other ways of actually changing ecosystem composition.

So would it be accurate to say in some cases that probiotics are antimicrobial?

Yeah, well, it would be from a SIBO perspective. And I think again, maybe 20 years ago it would have been, you know, there was a lack of research around probiotics in sibo specifically. Yes, there was the probiotics in ibs. The data set was all clear around that there were successful case studies of kids with severe SIBO who were hospitalized and antibiotics weren't working, where they gave them probiotics and the kids got better and got out of hospital. So there were successful case studies, treatment with probiotics of severe life threatening sibo in the 1990s that were published too. So there's already some preliminary data suggested that probiotics would be helpful. But you skip forward now and you look at, look at the data out there. Study after study showing probiotics are helpful for treatment of sibo. And I think you can't just have your head in the sand and say this doesn't exist. And while I agree with Dr. Pimentel that there are issues with meta analyses where you just grab all probiotics and shove them together, it's like saying let's do meta analysis of do drugs treat hypertension? Well, some do, some don't. But if you shove the ones that don't in there with ones that do, you're going to actually get an unclear effect. You're not going to see anything. And that's definitely a problem with probiotic meta analyses where researchers are unaware of this fact. We'll just grab all probiotics and shove it together. And listen, some won't work. If your probiotic strain you're giving doesn't have selective antimicrobial properties or won't help with motility, then is it going to work with sibo? Yeah, perhaps not. Whereas ones that actually do have antimicrobial properties do seem to work for sibo. You know, and I think again you look at there was a meta analysis I think2017. I think it was where they took all the probiotic studies and for sibo and I think they found that in which had some issues with methodology because I think it's grouping all the things together which if anything, occludes beneficial effects, makes it harder to see. But even doing that, There is a 53% eradication rate clearance of SIBO with probiotics in the studies when we pull the data together. And since that was published, there's more and more studies published each year looking at it. Not 50 studies a year, but there's a handful of studies published each year supportive of the use of probiotics to effectively treat SIBO and bring down breath gases, whether I hydrogen or methane or both.

Now is the best way to think about this. Some people have described it sort of as a parking lot. There's only so many parkings spaces and if you park the good bacteria in there, there's no parking spaces left for the bad bacteria. Almost like if we're having some elaborate game of musical chairs and the bad bacteria don't end up with chairs. If there's enough good bacteria there, that's.

Definitely a component there. And I think the other additional bit is whether that microbe can produce something that is antimicrobial. And I think a good example here is Lactobilis Redry DSM17938, which is sold around the world as biogaia. All right, there's a clinical trial giving it to kids who are with reflux disease were given proton pump inhibitors to treat the reflux. And we know the PPIs that is very consistent around this increased risk of SIBO development. So this study was like, okay, what if we give them this probiotic, Will it prevent these kids from getting sibo? And they tested a baseline, tested three months later, SIBO developed in, I think it was 50, 56% of people in the placebo group, 6% of those in the bioguy group. That's a massive difference from a prevention perspective. What's unique about this strain is this strain produces an antimicrobial substance called rutrin. And maybe that is the key reason why it works in that situation. And the dose they're giving is 100 million CFU twice daily, I think was the dose so relatively small. Yet there was another study, similar population of kids taking proton pump inhibitors for, you know, their reflux. And they gave it a combination of lactosiline, bifidobacteria at much higher doses. It did not work. Yeah, did not prevent sibo. And it's like, okay, well, do those specific strains have any indication they would be helpful in this condition, as in producing antimicrobial substances, et cetera? No, they don't have that. So, you know, to me it was like, okay, well, yeah, if we choose our products wisely, we can get therapeutic benefit. And if we just use random off products with no sort of good rationale for the use, I think we're going to hit and miss, miss more often than we actually hit. Whereas I think when we actually using stuff that has theoretical rationale for their use, we're going to get better results. And if we as researchers actually choose the ones that have theoretical evidence of use to research, we're going to get better outcomes than just grabbing, hey, here's a random prolotic, let's see if it works for SIBO prevention versus let's choose one that the traits and qualities we're after in probiotic researchers all the time, like they're looking for, how do we choose the best probiotic for treating vaginal bacterial vaginosis? It's like, let's see, the ones that survive have good ph tolerance, produce d lactic acid, inhibit the growth of those pathogens. You might get a hundred strains to start with, and you put in three bit obstacle course and you come up with three or four that actually tick all the right boxes. And then you take them into study, you know, from that point onwards. And I think this also illustrates, I think some of the differences you said initially around the strains matter. Yeah, yes, strains do matter. We can clearly see that in that kind of research where you can have 20 strains of lacteals crispatus, for example, and only some will have all the criteria that you need to be like a successful general probiotic. And just like we have numerous strains of lactose reuteri, only some produce rutrin. So if you supplement with this strain of lactose rutori that does not produce rutrin, you cannot expect it to have the same effect as the ones that do produce rutrin, like the biogaia one that was used in that successful placebo case. And that's the same strain been used in methane cases too, where it actually significantly reduced methane output and it cleared methane. A number of people in that study as well.

Oh, interesting, because that was going to be my next question, which is how specific can we get? Can we take the results of a sibo breath test, find out the patient has hydrogen sibo, and we know certain organisms tend to cause that. Or is it hydrogen sulfide or is it methane? And then are there specific strains that you would recommend for each type of sibo?

Yeah, I mean, I think as more research comes to the fore and we have access to some of those strains, we'll get better data around here in this area. And again, I was recently looking at the probiotics literature and there's a number of studies that have been published out of China where they're a bit vague in their description of the probiotics that they use compared to other in these studies. So it's hard to necessarily, as a clinician, take that into clinical practice going, okay, well, this combination of probiotics worked in this Chinese study. Can I use these strains? Well, they don't delay the strain, they tell you the species. But so, so as, as each year goes on and we get more research, we will become better at fine tuning and matching these things up. But, but currently we know that the, you know, the retry DSM17938 is helpful for methane. That is, that is, that is clear now.

Now, could you, have you. Is it possible to simply recommend that for a patient with methane sibo without anything else? Is that something you've done? How would you treat kids? Oh, only in kids. Okay.

Because they can't necessarily take the foul tasting herbs that I would usually use. Yeah, but so, so certainly they can work really well on their own in Some people, but I generally I do my best to get the best result as quickly as possible with patients in a way that doesn't harm their, their colonic microbiome in any significant sense. So I'm trying to choose selectively acting antimicrobial herbals, a prebiotic like partially hydrolyzed guar gum. And then for methane I would use the biogaia lactose as well. Yeah, but for some kids who can't do the herbs, why might just use biogai and partially hydrolyzed guar gum. And yes, you can see results in those, those, those, some of those people which is that simple treatment and.

And partially hydrolyzed guar gum you would pick because unlike a lot of prebiotics or forms of fiber that tend to feed SIBO bacteria that has been shown not to exacerbate SIBO symptoms. Right.

Yeah, it's an interesting fiber there. I think we just did a systematic review of this just recently actually. But I think it's nine studies using it for irritable bowel syndrome and all of them are positive. So that's what got me excited when I read these studies on IBS. This goes back to 2016 when I first came across 2015 or 14, not that long ago, but I unaware of it before then do literature search like oh my God, look at this. This substance I was completely ignorant of. And it's got all these studies showing it not only reduces bloating and distension and normalizes bowel pattern in these in patients with IBS and works for constipation problem IBS or diarrhea prominent ibs. So we've got that data and then there are studies using it for showing that it decreases methane output in people that have high methane. And then we have studies where they gave it alongside rifaximin to treat sibo. And I think from memory the eradication rate with partial hydrolyzed gorgon was like 85, 86% versus 60% with disrefaxin on its own. So it significantly improved the outcome. And this was hydrogen dominant sibo. So for me, phdg is integral whether I'm treating hydrogen dominant SIBO or methane. And it is tolerated by most people with sibo, not all. There'll still be some that react to it, but compared to other prebiotic fibers like inulin, phos or glycoly oligosaccharides, it is definitely better tolerated from a gas production.

And do you, do you tend to use that a couple of times a day and you tend to use it away from meals or with meals, it doesn't matter.

With the phdg, it can be with or without meals. Doesn't matter. And generally it's once a day to ease compliance with like 6 or 7 grams. One hit. And it's easy to work with because you can mix into, unlike some fibers, it mixes beautifully into cold water and it's got almost no flavor. So you can mix into cold drink and not. It makes the water a bit thicker, but not really much flavor. Easy to mix into smoothies or easy to add to, you know, breakfast cereals, porridge, whatever you might actually have. It's easy to work with.

Do you know or can you speculate what is it about phcg, partially hydrolyzed guar gum? Why it has this different quality from many other forms of fiber or prebiotic?

Yeah, it's definitely for most people, less gas forming. And I think that's part of it. And I think we know it also feeds butyrate producing species more. So. So if you look at what species utilize substances that we eat, like if we have inulin phos. Yeah, we feed Bifidobacteria and faecalobacterium Achromansia, for example, are three populations that tend to increase. Whereas with pragylidolized guar gum we don't need a little bit of bifid bacteria. But often it's rose berrea and other not so much akkermansing. Interesting that. But it's more of a butyrate producing species. Okay, so it's kind of feeding a different group of bacteria that generally perhaps are not overgrowing in the small bowel. Yeah, we don't tend to see butyrate producing species and don't really show up on any of the literature. Looking at what's growing overgrowing the small bowel in patients with sibo, it's usually streptococci or proteobacteria that show up vast majority of studies to date. So if they can't utilize it as a food source so much, then yeah. But how exactly to improve the efficacy of rifaximin and sibo treatment is an interesting thought. And the researchers initially were doing it because it is a prebiotic like substance and they're using it, using it that way. We know it does improve efficacy, but the mechanism I think is a little less clear. Whereas when it comes to methane, I think it's more clear in that we know that methane producing bacteria, typically Methenobravobacter smithii, is the key one for most People likes living in a more neutral to alkaline physical and kind of doesn't like being bathed in butyrate. So if we ingest a substance that creates more butyrate, we kind of create the conditions that are less conducive to the growth of methane producing bacteria.

What about just adding butyrate as a supplement in such cases of methane?

You can certainly use that as an adjunct agent too. The thing about. What you can sometimes have though, when you use, when you use just butyrates, you can have a. Essentially taking a step back, what does the methane producing bacteria consume? Methanobacter eats hydrogen gas. So if you change the circumstance where you just reduce the levels of methane producing bacteria, the hydrogen gas level can actually increase. So sometimes you can actually have worse bloating or distension from giving butyrate, even though if it's actually dealing with the underlying methane overproduction, but you end up with more hydrogen in the shorter term, which can mean more symptoms as well. So I think I have played a bit with that and I think it can be a useful tool.

So essentially what you're telling us is anytime you have a patient who has methane sibo, there may be hydrogen SIBO that's being masked by the fact that the increased number of methanogens are consuming the hydrogen.

Yeah. And this is clearly the case if it's methane in a small bowel for sure. Like if you've got. Because we're supposed to have hydrogen produced in the colon, so that's normal. So, you know, so if you see it a lack of hydrogen rise in the colon, but you see a spike rise in methane on breath tests that, you know, clearly shows that's the case. But in the small bowel, again, if you see that rise in methane at the 20 or 40 minute mark on a breath test, you know there's hydrogen producers there because otherwise it cannot. Because that's what eating the substance first, they're eating the lactulose or the glucose or the fructose first, they produce hydrogen gas that's eaten by the methane producing bacteria very quickly and you get the spike in methane, not necessarily of hydrogen. So yes, you would actually have hydrogen producers there underneath there that you have to deal with too. And that's what B itself does not do. So I think it's arguably better for colonic methane issues than small bowel methane issues.

So in terms of small bowel, large bowel, when we do the SIBO breath test, there's a time cutoff and there's some controversy about that. Is it 90 minutes? At one point it was 100 minutes. Is it 120? I've talked to some prominent SIBO practitioners who always believe in doing a three hour test because they don't trust that it might only be two hours.

And now what happens? I always do three hour breath tests.

Oh, you.

For hydrogen methane.

Okay.

But I always do lactulose and fructose at a minimum and often lactose, fructose and glucose.

Are you, Are you.

Oh really?

Are you checking for hydrogen sulfide as well? Is the trio Smart available in Australia?

It is. I can arrange it for my North American patients. But I tend not to use Geosmart so much. I tend to stick with the Quintron based testing for hydrogen methane for the most part.

Why?

I think I've seen some results, apparent discrepancies, even some people the same person a minute apart sending the breath samples to different labs or even three. A couple went to the more classic ones that do hydrogen methane and one went to the lab that does triosmart. And the level of hydrogen methane was really accurate. The same. And the two normal labs. Normal labs, but completely, completely, totally different in the Triosmart, 100 fold. A lot different. And I've just seen that enough that I'm just a little bit hesitant to know what to do with that. When the levels of methane hydrogen are multitude lower on that test consistently than I see on the other tests. I'm a little like, yeah, that has.

To do with the way the gases are collected or do you know why?

Question? No, I don't. It's just been enough that I've, I've just been hesitant to go, okay, I'm just not fully going to trust those, personally going to trust those results. I'm going to stick with the sort of more conventional labs because the way that this shows up with hydrogen methane seems consistent between them.

Interesting.

I'm comfortable with that.

And, and you might be missing out on hydrogen sulfide though.

Well, I'm, I'm basing that on. Because I'm testing lactose often glucose and fructose. Yeah.

Okay. All three of those. That's a lot of testing you're. You're talking about. Especially if you're asking everybody to do a three hour test. That's nine hours of testing.

It is, it is, but it's, it's so much more accurate with the information you get. And, and this is a. Maybe two years ago now I went through and said, okay, let's take the last one people We've. We've suspected of SIBO and done breath testing for. If we just only did lactulose, only lactulose, how many people would we picked up with sibo? And it was 73% of those people we would have with SIBO we picked up with just lactulose. If we did fructose alone, only fructose, 85% of people, really?

Fructose is more accurate than lactalose?

I reckon it is. And listen, we need, like, further clarity. I don't have a. My own, like, hospital setting where I can do, like, you know, aspirin culture on. On people to. To verify things. So what I'm using is essentially that same criteria, you know, rise of 20 parts per million at. At 90 minutes, whether that be with glucose or fructose. Because for me, why are we defining sibo by if it eats. If it eats glucose, it's sibo, but if it eats fructose, it's not sibo at the 20 minute mark. Like, that's just stupid to me. It's like there are bacteria there eating sugar that aren't supposed to be there. Right. Whether eating glucose or fructose, it's still bloody sibo, you know, Like, I don't understand where people are like, oh, no, it's only SIBO if it's glucose or lactulose. But if the same bugs are eating lactose, it's no longer sibo. It's like, of course it's sibo because it's defined by the time where the gases are produced.

Well, actually. Actually, when it comes to methane, time doesn't even matter anymore. Right. Because it's emo and it could be in the large intestine.

That's right, yeah.

So are you routinely doing stool testing as well to see if there's anthemogenes? Okay, you are, yeah.

So we're looking for methadone, which don't always show up on stool tests. I must, I must say, breast testing is far better accuracy for picking up methane status, for sure. But also looking for hydrogen sulfide gas producers on stool test, too. So let's say if I'm suspecting SIBO and it might be hydrogen sulfide is sort of the background as a possibility. We do lactulose, we do fructose, we do glucose. All right. The glucose and fructose completely normal. No sign of excess. No bump at all because there shouldn't be any bumps with hydrogen or methane's normal. Lactulose flatlines to three hours. All right. At this Point I'm thinking, okay, this is possibly hydrogen sulfide. Sibo. What does the microbiome picture look like? Do I have elevated levels of hydrogen sulfide gas producers on that or do I have.

So those are Disulfavibrio and Bilophylla are two classic ones.

You can also have, you know those fusobacterium that would rarely be involved but can be okay. And protobacteria, some protobacteria when overgrowth can produce hydrogen sulfide too. So you'd be looking at those. But, but the classic ones would be Bilophyla and the sulfur. And not all stool tests sadly test for Bilophylla. It's, it's harder to define and I think that's, I wouldn't use a stool test. It doesn't tell me about Bilophila, to be honest, because it's such a commonly overgrown hydrogen sulfide gas producer that if you don't test for it, you will never see it and you won't know.

So which stool tests include bilifi?

The ones that do shotgun sequencing, like shotgun the genomic sequencing. So that would be things like Nirvana, Biome, Cosmos, ID in the States and Microba here in Australia. And they, you know, micro kids overseas too. They, they will test for Bilofala and the self of Vibrio.

I know the sofa Vibrio is on the GI map. I'm not sure that one is a.

Bit easier to come by. For whatever reason people have gone, let's focus on the Sofibrio. Yeah. Bilophila is actually in my experience looking at, you know, thousands of stool samples is more often overgrown than the sulfur bio. Because Bilophylla is a, its name gives away Bilophila. It loves eating bile. Bile is its thing. So you tend to see it bloom when people who do like keto type diets or high fat diets, high saturated fat diets tend to have these major blooms of Bilophylla.

Oh, interesting.

And it's just sad that you can't see it. If you're doing a stool test that can't see Billophylla, you have no idea that this diet is feeding blooming these hydro.

And there you are doing a low carb diet, thinking you're starving your bacteria and you're actually feeding some of them.

Feeding some of them. Yeah, that's right. So to me I would not do any stool test. It does not do Bilophyla because you need to be able to look at that. So yeah, so I would look at that. I'd also look for acetogens too. There are certain bacteria that we know that eat hydrogen and convert it through to acetate. So you're not gonna get any breath gases with that.

Oh, wait a minute, which ones are those?

They're, they're the less characterized at this time point.

This is, this is a, this is new breaking news.

Well, it's been around for a long time, but it just hasn't been discussed even that much for some reason. You know, listen, even the methane constipation stuff, I moved house recently and I had to unpack, you know, sort through my papers in my garage. I had boxes and boxes of papers that I collect as part of my PhD. You know, they're all given away. I know, that's why I give it away, most of them. But I came across one paper from 1980s and they were looking at methane output and people were constipated and they're like, I think there might be a correlation here between people who are constipated, have high methane output. And not only that, they gave them tons of sulfur as a supplement. And these people shifted their hydrogen dynamics from methane to hydrogen sulfide from the sulfur and they got up and their bowels sped up and they no longer had constipation. Yeah, and this is research in the 1980s. You sort of forget that stuff like that was. People were on it at that point, but some people were, you know, because they're already looking at, you know, where does the hydrogen go? It's like it could be methane or hydrogen sulfide. And let's see if we can shift it between that and they could and effectively treat constipation by giving sulfur, you know, so whether that's an approach we want to be doing, I don't know, because hydrogen sulfide gas is pretty, not particularly great. So I don't think we want to be shifting people from tons of methane to tons of hydrogen sulfide. But it was interesting. They were doing it. But one of other pathways that hydrogen can go to, it can become acetate. So we have a number of groups of bacteria, colon hydrenotrophs, who eat hydrogen. So you know, methane producing bacteria, or methane producing archaea, sorry, hydrogen sulfide gas producing bacteria. And then we have the acetogens, those that eat hydrogen and make acetate. And that's not a gas. So. And it's a lovely short chain fatty acid with anti inflammatory effects.

Right.

So that's obviously great if we could have more of that going on. In fact, kind of a tangent here, but I Just read a study in Japan recently and they were looking at methane producing status and acetogens in this Japanese population. And I think it was only 7% of the Japanese population had methinogens present. Yeah. Whereas for Westerns it's like 90% of us have gotogens in our gut. The rate of constipation is very tiny and a lot of their hydrogen went to become acetate in Japan. Whereas for westerners that's more of a rare situation.

What are some of the species that are acetogens?

There is one of the key ones we see is Blatia hydranotrophica. I think from memory. Yeah. With his name. No, again you need to be using the right stool test to see that one and that where you would have to use shotgun metrogenic sequencing that you can get down to the species level to look to go what sort of bloty do you have? And whether you've got that via acetate. Acetate. The ones that essentially consume hydrogen make acetate as a consequence. And the cool thing is too that particular species can actually cross feed faecalobacterium. So you have this beautiful relationship where we have this guy that eats hydrogen and it makes acetate and it shares somewhat acetate with Faecalobacterium profniti who makes butyrate with that shared acetate. So to me it's a beautiful relationship. And it's like this is why we should be trying to encourage acidogenesis when we, we can. But essentially that occurs when the ph of this in the colon is much lower. Yeah. So when we have a ph of like five and a half or less, we tend to have a much more the capacity for acetogens to thrive, whereas they don't live in a neutral ph that we tend to see in Westerners. Yeah. So you can also be looking at stool ph as one of the markers that can help indicate whether it.

That's because we're, that's because we're all drinking our alkaline water to make ourselves healthier.

I think it's a lack of fiber for the most part. You don't eat plant foods, you don't eat fiber, you don't produce short term fatty acids. You don't get the change in ph.

So essentially you're saying that Americans are full of shit.

Well, Australians and Canadians too, I'm going to say. And they often are. There's like, there's often days worth of poo inside those of those populations. A lot of patients I work with have got days where Worth of poo that are there. You know, I heard one patient, I get them to do the. And this is one test I do for all patients. I get them do the bile transit time test, a very low tech test. You eat some corn on the cob or some quinoa, black quinoa. You don't chew it. Write down exactly when you eat it. You write down when it starts coming out and when it finishes coming out in your poo. But my champion one is I think it was 20, 25 days before the corn started coming out.

Why did.

Yeah, and she was, she was only pooing every two or three days, so I knew it was going to be slow, but I had no idea.

25 days?

Yeah. And you think how much fecal matter is loaded in that colon?

Yeah.

And no wonder. She was like chronically unwell and felt horrific all the time. It's like. Yeah, well, that's. That explains a lot of it there.

How did you treat that?

Oh, this is a patient. This is a patient maybe 10 years ago. So we're going back fair? Well, I can't recall, but we certainly focused on trying to speed up transit time.

Did you ever get her colonic?

Listen, I think a colonic would have been helpful in the short term. I'm a bit cautious around the potential impact on the colon from a long term perspective, but I think it's a. Let's get weeks worth of poo sure. To get you feeling a bit, a bit better. But I much prefer working from this way than that way. Although I don't think the odd enemy, I think is quite convenient. But I do think colonics where you're washing the colon a bit more. Are you likely to have more changes to the microbiome as a consequence?

Do you think that some of the new generation of probiotics like Akkermansia is now available? And I think that fecal bacteria, Prudnitsky is starting.

I think it's available probably not far off. I would recognize not far off.

So these are like anaerobic strains that hadn't been available because of the difficulty of producing them. Yes, I've read some that they may potentially, potentially be colonizers of the gut in some cases. Is that. What have you, what have you seen?

Yeah, I can only speak clinically thus far with my patients who've taken the pendulum. Pendulum glucose control.

Yep.

And I have not seen Akkermansia show up on any stool test yet when my patients have taken it. When they did have Akkermansia beforehand, I had High hopes. I was excited. I'm like maybe we can because we've tried to revive your Akkermansia population is extinct in your gut, you do not have it. Maybe we can recolonize with this supplement. But thus far and listen, it's only been maybe 10 to 15 patients. So I'm not like okay saying no, it never does it. But I have not seen them do it in any of my patients thus far. And they've been taking the supplement at the same time they're doing the stool test even and it hasn't even showed up on the stool test which I've of was, you know, slightly sad about because I thought at least if they showed up, well, they take took it right positive around that and maybe a chance of it sticking around. But when they're taking it so far.

Interesting.

Yeah. And this is, we're it's first generation Akkermansia. So who knows, it maybe wasn't selected as, as the core attribute was how, how good it could colonize. Yeah. Because I think there's some discussion around, you know, that in general our current generation lactobif bacteria do not colonize an acidic degree in kids or adults. Yet if we gave the same ones to breastfeeding moms or to moms when they're pregnant, they can actually colonize that infant for life. So it's interesting there's a window they could permanently colonize. Yeah. Interesting enough. Interesting. But it won't older populations. But there's one study with one type of bifid bacteria. It's code strain was maybe ah, 2,106 or something. I can't, I could be a little bit off with that one. It's been a few years since I read the study, but it did colonize in 30% of people I think from memory for up to six months. You know, so it's like okay, if a strain is chosen where the main criteria is, it can stay and maybe they'll like screen hundreds of different types of bifid bacteria to find one with that long lasting capacity to colonize. Yeah. So I would say that in the future we might have bifid bacteria that can colonize. We might have Akkermansia or fecalobacterium that can colonize. I would just say perhaps at the moment we certainly don't have that in general with lacto bifid bacteria and at least in my experience we don't have that with Akkermansia yet.

Do we know specific prebiotics that can make certain bacteria Flourish in the gut, especially maybe ones that have, you know, are really low.

Yeah, for sure. And I think this is where prebiotics shine is where you're trying to make specific changes to that ecosystem going, okay, well you are. And this is something that I do in my practice all the time. I do analysis. Okay, you're low in bif bacteria, low in Akmansia, let's say hopefully they're there. They're just maybe a thousand fold less than where you happy to be or a hundred fold less than what they should be. Then yes, you could go, okay, well let's go. Inulin phos or otherwise known as oligofructose enriched inulin, very good at feeding both bifidobacteria and Akkermansia as well as faecalobacterium. So you have this substance that we can generally effectively use to target increased population of those three species without feeding other things for the most part in most people. And then partially hydrolyzed guar gum, good for a range of butyrate producing species. Then we have galactoligosaccharides which would be bifidobacteria and fecalobacterium for the most part. But Gauss can also decrease hydrogen sulfide producers like the sulfur and Bilophylla. And inulin phos can also decrease bilophila populations too. So we can use these tools to decrease levels of bugs we don't want and the same time encourage levels we do want. And that's the thing I absolutely love about prebiotics is that that capacity to, let's say your guts overgrown with proteobacteria, you got large amounts of protobacteria pre product like lactulose, which I think kind of gets a bit of a bad name in the US because it's the food source in the lactulous breath test. But it reduces levels of protobacteria brilliantly well in the colon. It is amazingly effective at doing so. You've got studies showing that, and I can say from 20 years of practice of using lactulose, it effectively reduces populations in the gut. So you can use something that is increasing levels of good guys, decreasing levels of pathogens all at the same time.

So you're saying for hydrogen sulfide, Sibo fos and GOS combination might be part of an effective strategy?

Yeah, you'd have to gauge what their tolerance because sometimes they will get that. One thing that hydro sulfide gas does is induces visceral hypersensitivity. So it makes the nerves in the colon more susceptible to gas related pain and discomfort. So you have to kind of gauge where your patient's at with that because you know, if they're, they've had H2S overgrowth for a long time, often visual hyper can be intense. So you do anything that increases gas production in the colon, such as give gauss or inulin fos that gas. Discomfort will cause excruciating discomfort, comfort and pain. So you have to kind of approach it differently depending where they're at with their symptoms and how far along they've had this H2S issue with. Because if you get them early on and they don't have that damage yet, then. Yes, because essentially what we should be getting when we, when we ingest gauss or immune foss is farting. We should just get flattest. If our gut's working beautifully, just gas, that's it. But if we have issues there where we have bloated, distension, pain, cramping, worsening, constipation, there's something else underlying that that we need to deal with. And those tools may not be appropriate at this time. And we might use other strategies. I mean, I think luckily with hydrogen sulfide gas producers, for the most part, Bilophylla is eats bile. Yeah. So you just like, okay, make sure they're not taking ox bile supplements. That can cause a massive bloom in hydrogen sulfide gas producers that most people again aren't aware of. Because you have chance for Bilopila. But reduce saturated fat, that's a very quick and easy way to deal with Bilophila for most people.

But bile helps to break down any kind of fats. Why saturated fats that.

Well, it's a sulfur compound. When we're ingesting dairy fat particular, but also other saturated fats, the sulfur content in our bile is higher for whatever reason. Oh, and that feeds Bilophylla to a far greater degree than olive oil.

So you want to reduce the bile and the sulfur.

Yeah, but particularly. But yeah, yes, both. But particularly it's about changing the types of fat consumed. But I mean, sometimes it's overall fat too. But certainly you don't tend to see Bilophylla blooms from olive oil avocados in that sen seeds being a gorgin on them. That does not happen. It is from dairy fat, butter, ghee, coconut oil, palm oil. Those are the things that will cause blooms of Bilophylla. So it's often easy to deal with that by, by changing diet. Now they can also be encouraged by supplements like, like chondroitin sulfate or glucosamine sulfate, again, that aren't always on people's radar. And. And sulfur based preservers, synthetic ones used in processed foods. So we'll. We'll cut out those.

Oh, oh, you're saying those are. They contain sulfur so they could.

And they can feed hyd hydrogen sulfide gas producers too. Yeah. So that when people take chondroitin sulfate or glucosamine sulfate long term, which is often the case for things like osteoarthritis, we have to be aware that they can negatively impact the colonic ecosystem by encouraging the growth of hydrogen sulfide gas producers.

Yeah. There's studies showing that glucosamine sulfate reduces cardiovascular events by 30%. So it's a real beneficial for cardiovascular as well.

Well, yeah, it's interesting substance in that way. And I think it's just worthwhile keeping tabs on how that individual person's ecosystem is responding to that dose of sulfur and whether they're having a bloom of hydrogen sulfide gas producers or not as a consequence of its use.

Interesting. What do you think about biofilm busting? Is that something that should be done in combating sibo? Do bacteria that cause sibo encase themselves in a biofilm and does that make it like, for example, the methane reducers tend to grow into mucus. So is. And that's sort of a biofilm. So does. Does that mean you need to. You know what, I talked to Dr. Bar one time and he was saying that he thinks that taking Akkermansia, which eats mucus, that that makes it easier to get at the methane T. Bone.

Well, that's interesting. Interesting idea. I mean it's certainly. Akkermansi is one of the species in the gut that does indeed consume mucus. Calabactrinium does as well. But. And others.

But right now what about using. Coming back to. What about using agents that supposedly break up biofilms to make it easier to get rid of the.

Yeah. Okay. My main concern here is that beneficial bacteria live in biofilm too. Yeah. Because I think this is conception that some people have. Okay, guys live in biofilm. The good guys are just playing around and don't. It's like that's not true. They do too. So if we're giving something that is non selective and breaks down biofilm of all bacteria, good and bad, then we're actually harming beneficial species too. Yeah. Unless you've got an agent that can selectively and only break down the biofilm of pathogens and leave the good guys Alone and that you could, you could research that before you marketed your product. You could do that research in vitro and go, hey look, our biofilm busting product doesn't break down bifidobacteria or faecalobacterium or akkerman the biofilm, but it does klebsiella and E. Coli. You know, wouldn't that be great? But they don't do that generally. It's like kills bad guys. So therefore it must be fine for everyone to take.

Is there any biofilm busting agent that you know of where, where they have done that, looked at that?

Not in that kind of sense. But we do know that there are home medicines. For example, like oh, look at pomegranate husk. So that the skin of the pomegranate fruit markedly antibacterial against pathogenic bacteria, leaves bifidobacteria alone. And actually, and who actually leaves lacto silolone encourages the growth of bifid bacteria. So you have a selectively acting substance that can, that can break down the biofilm of pathogens. We've got clear data around that, both bacterial and fungal pathogens, but actually encourages levels of beneficial species. Yeah. So for me it's like I'm going to use that, thank you very much as my tool to try to.

Where do you get pomegranate husk from?

No, well, but interestingly enough, listen, it's used in from Chinese medicine for 1800 years. It's been used Ayurvedic medicine for over 2000 years. It was used by western herbalists and European herbalists up until probably about a hundred years ago. Widely it just dropped out and it's North American and Australian kind of practice in the last maybe 50 years or something like that you can find in old, old herbals from the early 1900s. Talked about using it too. I don't know why it dropped out. But you, you could do a PubMed search of like husk. Punica granada is its botanical name. Antimicrobial or even Google Scholar it. And you'll get like hundreds of papers. It's so well researched as an antimicrobial agent. Yeah. It kills worms, it kills giardia, it kills other entamoeba, kills a range of fungi, kills pathogenic bacteria, but leaves good bacteria alone. And for me I'm just gobsmacked that there aren't more people in industry who are like oh my God, look at this. Something that's got, got like hundreds of research papers on it. Why don't we make a product with that. And listen, it's happened here in Australia. I mean I've been talking about the wonders of pomegranate husk for 20, 20 years and now there's like four or five different products with pomegranate husk in the market for clinicians access. But okay to, to, to go there, you can buy the powder, you know, you can buy organic pomegranate husk powder. What I love too is it's a waste product. It's like they're, they're throwing it out anyway. So it's not no ecological concerns about its use. We're not like finding something when you.

Get organic pome husk powder.

Well, there's a, there's a brand in the States called Esutras E S U T R A S that does organic paran husk skin powder, probably a peel. And it'll become more, as more people are aware of it, more people start requesting it and then that'll make a change in terms of how accessible it is. But there's, you know, as I said, unlike some things where we worry about ecological concerns about harvesting goldenseal or coptis or something like that, because they're these rare slow growing plants. Like this is the waste product of a huge industry that we can buy organic pomegranates, we can get organic skins and we can make medicine from that. And we should be given its research base, it's long, which have used over thousands of years and its selectivity of action.

Yeah, I know you've talked on other podcasts about being worried about some of the antimicrobials as potentially damaging the microbiome as well.

Well, yeah, and that came directly out of my PhD research where we were looking at the impact of herbs on the microbiome and I was like, oh, look at the herbs that cause harm. And it just occurred to me, what are these herbs doing to our good guys? And no one had done any research around that back early 2000s. So I was like, okay, I want to do this in vitro experiment of trying to grow these benefitobacteria, expose them to a range of different herbs that we use our antimicrobial herbs and see the impact. And it was fascinating to see because there were some substances like the berberine containing herbs like goldenseal or ricoptus chinensis that were amazingly good at killing bifidobacteria. They're good at killing bifidacteria. Lactozillae were more resilient, but there wasn't a dose that you could kill bad guys without harming beneficial species. But there are other things like garlic that could kill Candida and a range of pathogenic bacteria and completely leave good guys intact. Whereas if you got the dose of garlic up high enough, yeah, it would harm the good guys as well. So for me that was pretty pivotal research project that really changed my thinking around stuff going, okay, well these herbs can cause harm. Maybe we should choose the ones that are acting selectively. And that's really been the core of my practice since, you know, early 2000s when I, when I sort of did that, sort of, that research project. And now we have clear, clear data on some studies looking at long term berberine use in blood sugar control. And yeah, yeah, Dilton, it brought down blood lipids and improved blood sugar control but, but it hammered bifidobacteria populations, it decreased butyrate producing species, it decreased diversity of the ecosystem and perhaps most surprisingly caused blooms of E. Coli, Klebsiella, Citrobacter and a range of protobacter that bloomed with long term use of berberine, which I think was fascinating because I was not expecting that. I was expecting, yeah, bifida and diversity are going to go down with its use, long term use and probably butyrate producers with long term use. Short term use doesn't seem to have such a big impact. But I was not expecting blooms of harmful proteobacteria associated with, you know, I.

Heard you say something like that. I did a little data searching on berberine and there were some papers that even showed that it was beneficial for butyrate producers. That it has a beneficial effect.

Yeah. And I think short term versus long term is one of the factors. And it's okay. There's a couple studies out of China that were, they used hundreds of participants. They're actually large studies. And with three months of use. Yeah. Versus two weeks of use or four weeks of use. And. And then you saw kind of different patterns. We saw the blooms of Proteobacteria, the clear decrease of bifidobacteria and clear decrease of B ray producers and we may not see that decrease of B reproducers in the short term studies. Okay.

So when we're talking about, when you're talking about berberine, there are different products on the market, market. And I was talking to one of the manufacturers and they said, look, when we're trying to use berberine as an antimicrobial, we're giving you berberine from all these different herbs mixed together. When we're using berberine as a blood sugar or it's actually berberine is like one of the few substances that's been shown to reverse atherosclerotic plaque in arteries.

Grease.

When we're using it for that purpose, we're using berberine hydro. What is it called?

Hydrochloride.

Hydrochloride.

Yeah.

And, and that has a different action than berberine being derived from herbs. Do you think that makes a difference?

No, I think it's got to do with absorption. I think that's what's, what's key is that berberine derived from copsus. I think it's gonna be same as bourbon hydrochloride from a action standpoint. I think it's whether it's absorbed or not. And berberine, the challenge with berberine is it is very poorly absorbed for the most part because our peak glycoprotein pump doesn't like it. So it gets into the cell and your enterocytes like, oh, I don't want this thing, and spits it back out into the lumen of the gut. So because of that, most of the bourbon you ingest stays in the colon where it interacts with the ecosystem and long term causes harm to that ecosystem. Now, there are ways of probably trying to enhance the absorption of berberine, and there are some companies that have focused on that where they can combine it with phosphatidylcholine same way they do with turmeric or boswellia. They can combine, or green tea extract. They can combine it with phosphylcholine, which increases absorption. Clinically, I've used black pepper or piperine to improve the absorption of berberine as well, to get it out of the gut to into the bloodstream. For me, I'm using it to treat dental abscess infections where I want the antimicrobial action of berberine, but I don't want it in the gut, I want it in the bloodstream. And piperine turns off peak lycoprotein pumps and enterocytes, so you actually end up with a ton more berberine in your bloodstream if you take it with piperine. So there are ways of modulating it so you get, increase the absorption and decrease colonic damage with its use. But I think it's, it's imperative that we're aware of the fact that it does harm the microbiome with long term use too, because we might have options like if we go, all right, berberine is one way of controlling blood sugar, but so is nigella. Nigella sativa, black seed. Tons of studies on that showing Very similar results. And you don't get the microbiota harm with black seed. Yeah. So Mike, there's often, often choices with atherosclerosis. I came across a study that used to used, I think it was Pycnogenol and Goticola showing clearance of plaque, artery plaque with long term yeast. And again, okay. I'm much more comfortable using that for months to years than I am berberine. I don't mind using berberine for two weeks. No issue at all for treating giardia, something I don't mind using for two weeks or I don't mind again treating a dental abscess where I'm giving it or other systemic infection with black pepper to enhance the absorption for 10 to 14 days. But I'm really cautious about any more than 14 days use. We don't necessarily know at what point we get that sort of more substantive microbiome harm with bourbon. We can just say the studies that looked at three months definitely showed it the damage that was done. So yeah, for me it is. I'd certainly be cautious. It's something to recommend on a daily basis for years. Such a substance.

Yeah, I haven't seen that. But.

Yeah, it would be interesting if you did shotgun management sequencing with all your patients post. So you do that beforehand, do it after three months and see the impact. I can just say that I've seen it with my patients and I've seen the research is clear. With long term use there are certain patterns that you start seeing with it that are not positive.

You just mentioned turmeric. I've been using curcumin, like a highly absorbed form of curcumin to help with some patients with visceral hypersensitivity. I've seen a couple of papers on that. What do you think about that?

Yeah, love it. I love it. And I use it heaps for that same purpose too. I use Iberogast lots for that. It's a herbal combination.

Right.

For a reason. It's hard to come by in the US but in Australia and in Europe.

It'S much easier somehow. For a while it wasn't available at all and something happened with the manufacturer. I don't know.

Yeah, I'm not sure. I mean we had constant access to it here, so I'm not sure what happened overseas, but as something that. That effectively decreases visceral hypertensicity with patients.

Patients.

Yeah, even because I think I've got some patients who have IBS and they go, oh, I tried a bergast for two weeks. And it didn't decrease my symptoms. I'm like, well yeah, we're lucky if it decreases symptoms. And a lot of people will decrease bloating and distension and you know, and abdominal pain, cramping. Sure. But we're using it to decrease visceral hypersensitivity and that takes, you know, three plus months of use to see that kind of benefit. And I use it all the time with, with you know, a well absorbed turmeric, you know, phytosome extract, so that they're. And usually within three to six months, there's a massive improvement in their visceral hypersensitivity, which means that their diet, it can be expanded. They can have more onions and garlic and legumes and other things that nurture a wide range of beneficial microbes they may have had to cut out because their, their gut was so sensitive to gas.

Interesting. So, so some people might be able to tolerate a much lower level of gas. So it's not just about getting the gas down.

It's. Yeah, yeah, that's very clear from the IBS research that, yeah, there is some research showing that people with IBS have produced more gas, but there's more research showing that they're sensitive, sensitive to the gas being produced. And I always tell this example to my patients, but they put these special balloons up their butts and they plump up those balloons. And people with IBS will complain of pain when the balloon is this full, whereas normal people with balloon is that full before they get the same degree of pain and discomfort because the nerves are just hypersensitive and they can be pretty extreme.

If you take the population from West Hollywood or not. I'm just kidding. So what do you think about soil based probiotics addicts?

Ah, listen, I'm, I've been organic gardening for over 30 years. I love it and I organic garden all the time. I'm in nature and I'm drinking creek water. You know, I'm exposing myself to lots of wild microbes and I think.

Are you, you drinking creek water?

I do drink. Well, not from like a dirty source obviously, but from a. And I'm out in the rainforest and it looks clean. Yes, I'll drink creek water. I was out in Canada up in the highland Rocky Mountains where again, I don't think people were peeing, pooing upstream. And I'm happy drinking creek water. And I wouldn't even worry if it was like healthy people peeing or poo to be honest. It's just like people who don't have such healthy gut ecosystems or have gard or something. I don't want to drink their, their downstream water. But it is an interesting way of picking up microbes from the environment anyway, you know, and I think we, we even know that. Interesting. Even having a more diverse garden. If you have a wider diversity of plants growing in your garden, you have a more diverse gut ecosystem as well, you know, so there, there are, we're certainly always picking up microbes for the environment generally Standard pre.

Oh, so I'm really referring to spore based probiotics.

Well, I mean you are talking about soy based ones too, but I suppose I'm taking the.

Yeah, I think soil spore based are often referred to as soil based.

Yeah, yeah.

Are they the same or not?

Well, I don't think all soil based ones will be spore former. Okay, okay.

But spore soil based. Okay, I see.

Certainly the ones that people are marketing are often marketing at. They are spore based based and originally probably derived from soil as well.

Okay.

Yeah. I mean I think there's a growing body of evidence building around the use which I'm really happy to see. I think they're overhyped initially compared to the evidence base and I think that's changing is where evidence comes on board. So I mean for me it's always around evidence. If there's evidence that this product is safe and efficacious, whether it comes from soil or it comes from the skin of lychees or it came from some healthy Swedish person's gut or another sweet version of breast milk like the retry DS came from someone's breast milk. You know, for example, I'm totally happy to use it if it's safe and efficacious. And again, I don't mind if it comes from soil or whatnot. Yeah. I just think that the evidence base for them as class compared to bifobacterial activ or even saccharomyces is just a lot less at the moment. Yeah. But you know, there's research on bacillus quagulans, GBI therapy.36086 I think from memory is his code name strain name that for rheumatoid arthritis. Yeah. And there's no other probiotic with good data for rheumatoid arthritis. So I will definitely use that in that condition for sure. You know, so I think if it has something that's unique or better evidence based, I would totally use them irrespective of where they came from. Right. Yeah. I think just sometimes the Generalizations out there are sometimes a bit much like, oh, it comes from the soil, therefore we should all be in general suggesting it. It's like, well, what soil? Where, which part of the world soil would be different elsewhere? The assumption that something that lived in garden soil is going to be very happy in your gut. Growing at 37 degrees in quite a different environment than soil is a bit much too if you're expecting it to permanently recolonize. But we know that sometimes you can pick up bugs from the soil and have them stay for long periods of time. And we know that people who are active gardeners in summer, they can have a tremendous number of increased microbes, some people, compared to what it is in winter when they're not active gardens gardening, where you have temporary visitors of these soil based, so derived microbes as well.

You mentioned a specific probiotic that helps with rheumatoid arthritis. The GI MAP stool test, which we tend to do a lot, has a section where they have bacteria that may be correlated with autoimmune conditions. And there's a certain amount of data showing that those specific bacteria that are. There's a certain level of correlation with specific autoimmune conditions. And so if those bacteria are overgrown, you know, the idea is maybe if I could reduce that bacteria, maybe we could have some benefit. What do you think? Do you think there's any. Where are we. Is it still pretty speculative?

Oh, I think it's a, it's a bit speculative, but. But you know, we see disease associations, microbiota, certain patterns with certain disease states all the time. And I can say I'm a clinician too, so I'm a researcher, clinician. I see patients, so I see what works and what doesn't work. And I'm happy to prescribe things that work clinically too, that haven't even researched necessarily yet either. So I'm okay with some relatively novel stuff of going, okay, there's a study that shows is that low akkermansia or low bifidia in eczema seems to be a common pattern. And I go, okay, well I will increase bifidobacteria in my eczema population. And clinically you see good results by doing that in terms of decreased allergies and decreased reactivity. So I will base my decisions along that too. Yeah. So I think, yes, there would be a degree of perspective that's there, but you might have to again trace that back. I'm not familiar with all the microbes that they associate with increased risk of autoimmunity and you might just want to double check that I'm going, okay, well do I concur by my view of the connection between those ones? But I'm open to that approach in general of the different disease associations associated with diseases with different microbiota patterns and how we can modify that to change the disease process because that's something I do every day in clinical practice and.

See the results of Great, awesome discussion question Jason, thank you so much. I could ask you 100 more questions but I appreciate your time and I respect it. So tell our listeners and viewers about the things you have to offer the Probiotic Advisor. Your courses, where can they go?

Yeah, so we set up the Probiotic Advisor as a independent evidence based access point, accessible information around probiotics so we can work out so you can take industry out of the way, out of the equation and go what is the evidence to say about this Probiotics trained for this condition. So it's a searchable database where you can type in a condition or a product and you work out what the research says it should be used for. And that's been going for a number of years and that's one of my babies that came out again of wanting people to be as evidence based when possible and choosing to get. We really want to improve outcomes with patients. That's where it gets boils down to. And if we can do that by using evidence to go, okay, this probiotics chain works for this condition. This one doesn't use one that works, don't use one that doesn't, you know, and don't even just guess, maybe it'll work. Just use the one that works. And I also offer a range of courses through the Microbiome Restoration center as well. And I'm mostly targeting clinicians, you know, because I love teaching clinicians around gut health and microbiome restoration. So we have, you know, two, two general courses, you know, natural and functional medicine, approaches to gastrointestinal conditions and then another sort of 10 week course which is advanced microbiome manipulation which is all about some of the concepts we talked about today, but about, you know, different testing approaches and different labs and interpretations, but also how to modify ecosystems in beneficial ways in a way that for me I think it came out of my PhD looking at the wonders of the microbiome. You know, I've been integrated or indoctrinated in the wonders of the microbiome from, you know, late 90s when I started my first reading around the microbiome is choosing therapeutic approaches that Minimize harm from the microbiome perspective, which is an old naturopathic concept of first two, no harm. And I think if we have choices of tools, we can choose berberine or we can choose pomegranate husk. I'm going to choose Bombay and husk. If I can get the same outcomes without the negative outcomes on microbiome perspective, I will choose that first. So that underlying philosophy runs through my teaching is to optimize ecosystem and minimize agents that cause harm or interventions that cause harm as much as we can. And also being aware I had a patient last week who ketogenic diet for child epilepsy made a huge difference, huge difference to having daily seizures that were uncontrollable to having mild seizures daily from going ketogenic diet. But our focus will be on how do we maintain your ecosystem health when you're on this diet that you need to be on because it's really helpful for you. How do we make sure you're still feeding your benefit bacteria and how do we prevent the bloom of harmful species that with the long term term could potentially actually be counterproductive to what we're trying to achieve in terms of neurological inflammation, you know, so I think always having that as a how do we optimize microbiome health for this person and how do we choose agents that are most likely to do that as at the forefront of our minds as clinicians?

That's great. And if listeners want to work with you.

I do see patients through Gould's Natural Medicine, which is my clinic down in Hobart, although I'm not in Hobart now, but I see patients internationally, completely online these days.

Okay, great. Thank you so much. Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review. That way more people will discover the Rational Wellness Podcast. And I wanted to let everybody know that I do have some openings for new patients so I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions, or for an executive health screen. And to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. And that usually means we're going to do some more detailed lab work, stool testing, sometimes urine testing, and we're going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective. So if you're interested, please call my Santa Monica White Sports, Chiropractic and Nutrition office at 310-39-5311 and we can set you up for a new consultation for functional medicine. I'll talk to everybody next week.