Probiotics with Dr. Jason Hawrelak The Probiotic Advisor

What's going on, Everybody? This is Dr. Adam Riddey, and welcome to the next episode of the One Thing podcast. Today we're speaking with a probiotic expert, Dr. Jason Hawerlach, all the way from Tasmania, Australia. He will take us through all the fundamentals of probiotics, and we will speak deeply about clinical applications of probiotics, how to know which ones are proper to select some of the controversies around probiotics. We will walk away with a better understanding of how to utilize probiotics for our health and for specific health conditions. Without further ado, welcome our guest, Dr. Jason Hawerlach. I'm here today with Dr. Jason Horlack. Jason, welcome to the One Thing podcast. It's great to have you here. I thought we could just jump right into the interview and hear a little bit about what brought you into the microbiome space and interest in probiotics.

Thanks, Adam. It's a pleasure to be here and chatting about my favorite topics that you couldn't even get me to shut up about. Now, what started me was almost like one of those random chance events that I was in my final year of my naturopathic training and there was this, this fantastic lecture by one of our senior academics on what the data was around dysbiosis and increased intestinal permeability and different disease states. And this was back in 1999, probably 20 years ago now. Actually, it was probably at the time of his lecture. And it really triggered something in me, an absolute passion drive to learn more. And I was lucky that I was at a research institution and I've trained here in Australia where we have the opportunity to research honors degree, which is essentially where you do a research project. And we actually end up in the end doing a human clinical trial of a prebiotic probiotic herbal combination for the treatment of ibs, which sort of in my literature review started back in 1999 and moved on and followed that up with a PhD looking at the same sort of ectopic area. So amazingly well timed because you had no idea about the boom that was about to happen. But it just was that area that was immense interest to me. And I think it's always been an area of intense interest for naturopaths, broadly speaking, But I think there's some that it just really resonates well with. And for me, that was it. It wasn't a health issue per se, because I would argue that my health issues are mostly lung related, but it's just something that really captivated me and I just had to learn and delve more. And I'm really lucky that I chose a topic that 20 years on, I still find immensely interesting. And I'll still read papers late at night and watch other people lecturing late at night, which, you know, there's a lot of people who do their PhD in a topic that they really found boring and they just did it to get their PhD. Whereas I'm so lucky that I chose a topic that I'm passionate about and still.

Yeah, and it's, it's sort of in the prime time right now. I mean, it's. Yeah, there's just. You can't open your browser without seeing a study every day about the microbiome probiotics. And, you know, it's sort of, you're, you're there at the right time.

Yeah, well, it's pretty amazing to be from, from that time point. And when I was writing my, you know, honors thesis in 2000, like going back and looking at all the probiotic research and all the microbiome research, and you can read all of it back then from the stuff that was done in the 70s, 80s, 90s, there wasn't that much. And there's only a few research centers and researchers around the world who are really focused on it and who are passionate about it. And they managed to pass on that passion. Passion to me as well. So that, that absolute love and this idea of protecting and being custodian of the microbiota really grew out of that early research that was around that time point and certainly expanded dramatically due to changes in technology, which has allowed us to see so much more and allowed now there's thousands of researchers around the world, many, many thousands working on this area. So the level of evidence is just powering new more and more studies all the time, as you said before.

Yeah, yeah. So I think people are familiar with probiotics by now. I mean, people can just go to the supermarkets, grab some yogurt, and they'll see that they're, you know, have been customized to have certain probiotic strains in them and there's kombucha on them on the shelves. So it's not like this conversation is likely to fall in the ears of someone who hasn't heard of probiotics. This is likely to be listened to by clinicians, but also health consumers and people who are dealing with health challenges. But I thought we could start out with just discussing the different types of probiotics, the different categories, because it can get quite confusing for people to understand everything from symbiotics to spore based probiotics. Maybe if you could walk us through just some descriptions of these different categories.

Yeah, maybe I'll just take a step back too and just look at the definition of probiotics. I think we've all got a general idea, but I think there's some bits that are worth teasing out of the most commonly accepted definition at this time point, which is live microbes that when administered in adequate amounts, confer a health benefit on the host. And if you take that definition apart, there are three components. Live microbes, number one. So even if you have a therapeutic product that has lovely clinical trials on it, showing it works, but it contains dead bacteria, it's actually no longer a probiotic. Secondly is the adequate amounts. And once again, you can often look at the range of probiotic products on the marketplace and see that many might well contain live microbes and they might contain those that have therapeutic effects shown in human studies, but don't have adequate amounts to actually have a therapeutic effect when given in that form and that sort of recommended dosage range. So that again, would not be a probiotic. And the third part of that definition is some parts of the world, take that component where confers a health benefit on the host very, very strictly where you need human clinical trials done on the exact genetically unique strains found in your product for your, you to use the term probiotic to describe your product. Because if it's, if it doesn't have human clinical trials, you won't, you can call it a source of microbes, but you can't actually call it a probiotic itself. So I think it's worth teasing out those, those aspects because if you, if you look at how few products out there that, that claim to be probiotics actually meet that strict definition, and a lot of those would be in that category of, of food. And, and even within that food category, you have what probiotic research would call like, you know, sources of live and active culture, which would be typical Kombuchas, kefirs, sauerkraut, kimchi, where you're getting live microbes in generally large amounts. It's just that they're wild ferments. So you really don't know about the therapy potential. The strains that you're consuming. You don't know about the basic details of those strains. Do they, do they have the characteristics that are essentially vital to have a chance of producing therapeutic effects in humans? And that would be things like gastric acid stability, bile salt stability. So that can survive transit to the upper gut, can it adhere to intestinal cells, does it produce antimicrobial compounds that might have a selective decontaminating effect on the ecosystem or sort of shift the ecosystem to something. And then there's another category of those know, food sources of microbes that actually I'd say would meet the definition of probiotics, where you might have a yogurt base which would use a, you know, nondescript strain of Lactobacillus delbroicii stub species Bulgaricus and Streptococcus thermophilus. Those are the two, two species that have always made milk into what we call yogurt today. But they limit in their capacity to have any sort of greater therapeutic effect because in general they don't have the capacity to deal with gastric acid or bile. So they will generally die in the stomach and small intestine. So what? And this has been known for a long time. So what some companies will do will actually add well characterized, well researched probiotic strains into that yogurt or kefir or, you know, kimchi potentially too. So you're actually getting the. Yes, you're getting the fermenting bugs that are in that wild, you know, varying amounts of microbes, whole range of different species and strains might be there. But then you're also getting these therapeutic strains on top of that. And that would define them as more medicinal, medicinal yogurts or medicinal kefir. So I'd actually separate them quite clearly based on the addition of those human well researched therapeutic strains versus just the wild ferments. Otherwise there.

Okay, so once a probiotic has met the those particular qualifications and they do fit the probiotic definition, then take us from there. So let's say that they do have live microbes and adequate amounts and have been used in clinical trials. There still is separate categories, correct?

Well, I mean, certainly some people would divide them up into, I mean, there might be ones that are based on bifidobacteria based, which generally were, there's a few exceptions to this, but generally were essentially initially isolated from healthy human people's poo. We don't like to think of it that way. My patients don't like to think of the fact that they're ingesting microbes that were originally isolated from someone else's poo. But that's the reality. So some people would describe them as more human origin strains. And the idea has always been that because they came from human guts, that they probably like living in a human intestinal tract environment. In terms of the ph will be to its liking, the temperature will be to its liking, the food that we eat will be to its liking. But there are other probiotics that have other origins. You know, there are Saccharomyces cervaceae, Varadi boulardii was isolated from the skin of lychees. You know, back in the 1920s, Henry Ballard was a microbiologist, went to Southeast Asia and there is, I think there's, from memory, it's a cholera epidemic going through. And he noticed that, that some locals were drinking this tea made from lychee skins and they were one, not getting cholera and two, getting better. Coming from a microbiology background, he obviously assumed there was some microbe on it. So he isolated a yeast which he then named after himself as microbiologists do just totally find in my books. But. And that's been used as a probiotic sold around the world since 1950s, which I think it's is quite fascinating in terms of the duration of time that's been sold as a, you know, a probiotic supplement and that, yeah, isolated from the skin of lychees and there's no other probiotics come from lychees that I'm aware of. And then there's the sort of, I'd argue a newer class that people have brought onto the market in the last, you know, 10 or 15 years, which is so called soil based probiotics that originally had their origin from microbes found in dirt.

Okay. And that's the spore based probiotics.

Many would fit into that category. And taking another step back, that there's some like Bacillus clausii that's been, you know, it's a spore based probiotic that has been sold as a probiotic in Italy for, you know, decades. So that does have a long, long history of use. And there's a, you know, I think there's another Bacillus coagulans that I read about, I can't remember the strain designation, but originally came from, you know, cow intestinal tract. So there are some that have other, other origins as well. And I, I think the research is certainly clear that it doesn't have to be from humans, it just has to be therapeutic. I think that's the clear thing. And that if it doesn't have clinical trials showing it works and it came from a cow or it came from soil or it came from somewhere else, then there's no way of knowing it works essentially. But yeah.

Okay, well then let's go through prebiotics versus probiotics. So besides obvious, if you could just take us through some of the key elements of what a prebiotic is and comparison to probiotics.

Yeah, And I think prebiotics are a class of agents that are poorly utilized by clinicians. That's beginning to change, I must say, but I think that's certainly been the case. And I think it's partly due to a misunderstood or lack of clarity around what the definition actually is, because people often just assume prebiotics feed bacteria and that's it. And it's not quite right because there's again, the strict definition is a substrate that is selectively utilized by host microbes conferring a health benefit. And for a food ingredient or supplement, etc. To be classified as prebiotic, they have to meet four criteria. One, be indigestible so we can't break them down or absorb them because then they won't reach the lower gut to be therapeutic. Two, they act as a selective substrate for one or limited number of what we generally see as beneficial commensal bacteria in the large intestine, primarily. Three, they shift the ecosystem to a healthier state. And four, there's some health benefit that comes from that shift. And when you strictly enforce that definition, there's a lot of things that don't meet that. There's a whole range of dietary fibers which are essential for us to be consuming, but they don't meet that definition of prebiotic because they might feed 30, 40, 50 different species in the gut. And that's not a bad thing. It's just that they're not prebiotics by definition. Whereas a prebiotic really is selective. And if you do really good stool testing, you can clearly see this. The before and after results of supplementing with a prebiotic supplement is you'll see exactly what the research tells you. You see like an increase of, you know, most prebiotic supplements that we have access to now will target bifidobacteria. There are some that will also feed a bit of lactobacilli, some that will feed up faecala bacterium and Akkermansia. Those would be probably the four with best data set. And another group called B tray producing bacteria, which is a broader group of organisms. But you can clearly see the shifts. And this is where I think prebiotics are absolutely wonderful. When you have an ecosystem, you assess the ecosystem and say, okay, the diversity is okay, but you're actually really low in bifidobacteria or potentially below detectable levels of bifidobacteria. Here we can introduce a prebiotic into Their regime. You can do a follow up test in two months. You'll see almost exclusively the bifidobacteria population goes up. It's pretty clear how selective it is. But you also get because, because of the shift in environment that occurs with that prebiotic ingestion, generally a lowering of the ph, because you're getting increased short chain fatty acid production due to feeding Bifidobacteria generally or Faecalobacterium or Akkermansia, you will get a reduction in potential pathogens as well or pathobiont populations. And pathobiont is a term often used in the microbiome literature that's really describing species that when present in the right amounts in the right area are actually helpful and don't cause any harm. But if they have a chance in the wrong environmental conditions or the wrong numbers cause us harm. And then most of the research around dysbiosis is around that definition of pathobionce rather than single isolated pathogens. But what I love about prebiotics is you tend to see pathobiome populations go down with their use as well as species that we tend to classify as beneficial like Bifidobacteria faithi, Kalibactrium, their populations actually increase. You can see massive shifts with that. Now if I got that same patient to eat more fiber, we're still going to have some nice shifts to that ecosystem, but you're not going to have that same thousand fold potentially increase in bifidobacteria as a. There might be a slight increase because they might be enjoying some of the fruits of that fiber too, but they're not going to be selectively fed in the same way as with a prebiotic.

Yeah, I mean I think that's a really big point right there and helpful point because a lot of the patients I'm sure that see you would not tolerate just being loaded up with lots of fiber. And the fact that you can step back and say here's what I see is something that's specifically going to help you versus just kind of taking an aim at the whole ecosystem with increasing fiber in the diet.

Yeah. And we were speaking before this was recorded about the different patient sets we see now. And I still recall the days I could be much more broad with my recommendations. They were generally healthier population base, whereas now we're seeing people that are often far farther along in the disease process.

Yeah.

And I think you have to be more gentle and targeted with how we approach.

I think people are looking for answers in their gut now more than ever. So they're coming to us with all sorts of chronic conditions, not just irritable bowel syndrome or some constipation or diarrhea. This is sort of a complex health condition and they're looking at their gut for answers.

Yeah, yeah. And that's been again, brilliant. Looking at the research out there, from really looking at dysbiosis as a driver of primarily gut conditions to what we see now. Dysbiosis is a driver of anxiety, depression, obesity, type 2 diabetes, non alcoholic fatty liver disease. You know, there's very few western diseases that I would argue that there isn't a degree, if not a lot of research that's built up around dysbiosis as a potent driver of that disease state.

Yeah, yeah. So you've already talked a little bit about this, but I want to go deeper into this. Just certain controversies about probiotics. One of them I'm just going to put out there because a lot of people think that if you're deficient in certain microbiota or a certain genera in the microbiome that you could take a probiotic and it'll fix it. And so I want to talk a little bit about your thoughts about that because I think there's some misconception or gray area around that and then just any other controversies that you like to bring up about probiotics.

Okay, yeah. I mean, I think that's a great starting point. And that's what I would call the permanent colonization mythology. I was taught this too as part of my naturopathic training. And you follow that myth back and probably goes back to Metchnikoff himself, who believed that when we ate yogurt, the yogurt producing bacteria would take up permanent residents in our gut. This is going back to early 1900s. So there's a lot of history behind that myth. Mythology is just sadly not what occurs. Based on research that you can look at the last 30, 40 years of clinical trials on probiotics and 95% of the time there's no long term colonization with their use. If they stick around for a week to two weeks after cessation of use, people, that's very good because you'll see some and they do these follow up tests and you can see that it's there. When they take it, two days later, it's gone, completely gone from that ecosystem. And there's a tremendous body of evidence showing that same thing. So for probiotic researchers, this idea of permit colonization has been a myth for bust long time ago. It's been slow for this message to get out there. So you people do a test, oh, I've got no bifidobacteria here. I can just pop a supplement and I'll be colonized forever from this time point. And that's not the reality of it. There's very few strains of bifidobacteria lacto that have been shown in research to stick around for any duration of time. And even then it's only a relatively small proportion of people that occurs. That just might be the right, you know, environmental conditions. But there's something unique about those potential strains as well. So I think that we have to put paid to that one. And I think that really shifts your consideration and view of the microbiome too, because if you've got this idea that you can just hammer it, take, you know, tons of antibiotics and not worry about the consequences, you can just pop up, you know, a high potency multi cfu, a multi strain high CFU sort of probiotics up and you'll recolonize your gut. Then I think it cheapens. There's no appreciation for the complexity of that ecosystem and the fact that's not real. And I think if you, you have to think of that ecosystem as if you're a custodian of that. And it's not that simple. Yeah, listen, you could do a fecal transplant, but that's a whole new ballgame in terms of getting your head around, you know, somehow getting other people's poo into your system. And that does have the capacity to recolonize it in a much different way than current generation probiotics. It's just that lack of saliva and bifidobacteria in current versions of supplemental forms don't have great capacity to colonize the gut for any length of time. So. Yeah, so myth one.

Yeah. So just to follow up that, then what are they doing? Like where are they living when they're going through your gut transit.

Yeah. And this would depend on your gut transit time too. And that you would, you would know too, Adam, that there are some people whose bowel transit time is like two weeks. So they probably will be pooing at this robotics for two weeks. Unlike someone else who've got a 16 hour transit time, it's probably going to be gone in 24, 48 hours. But they are temporarily taking it residents and that doesn't mean they're not therapeutic. And I think we've got hundreds of clinical trials showing that these agents are therapeutic despite the fact they're not growing and reproducing in any great amount in your gut. So just like I'm not expecting, if a patient is taking her medicine, I'm not expecting them to be permanently fixed necessarily from taking that herb. But the herb is going to have an action that will manifest while they take that herb. And that's exactly how the research on probiotics is gone, is that while you take that probiotic, they will produce a certain action and you will benefit from that action whilst you take it and for a number of days afterwards. And sometimes that might be all you need to do is take it for six weeks to get the full benefit of that. And that might be for, you know, maybe the prevention of antibiotic associated side effects and helping to prevent like a C. Diff overgrowth post antibiotics. Maybe six weeks is totally enough for that action. But there'll be other times where, you know, there are some probiotic strains that, let's just take, say for the sake of argument, can decrease cholesterol levels. So whilst you take it, it'll lower your, you know, it'll break down cholesterol in the gut and you won't absorb it and your cholesterol levels will go down. But you start taking it, the cholesterol levels will go up. Yeah. And there's another strain that, that's used in Europe that produces an ACE inhibitor. And while you drink that fermented milk, you get this in ACE inhibitor and your blood pressure goes down. You cease drinking that milk and cease ingesting that strain, your blood pressure goes back up. You haven't treated any of the underlying issues. Obviously you're just taking something that has a therapeutic effect. Just like if I just give a patient my favorite herb for hypertension is rosella. And after two weeks, almost everyone has a decrease in blood pressure, but if they stop taking it, it stops working. And if we haven't fixed the reason why they have high blood pressure, it's going to go back up. I think it's clearly just looking at probiotics as therapeutic agents that have specific actions. We just need to match the action of the probiotic strain to the condition or physiology we want to change.

That makes a lot of sense to me and I think it's, it will ground us in knowing, you know, how to work with them better, just kind of busting that myth.

So, yeah, for sure. And if you look at the, what, you know, this probiotic trials showing that probiotics are helpful for like cervical dysplasia and, you know, mastitis, and there's a whole anxiety, depression, all these things aren't related to, you know, the lack of probiotic colonization in the gut or lack of, sorry, lack of bifidobacteria populations in the gut. And maybe there is for some of those conditions, but it's truly to do with the action of that particular probiotic strain. And then there's some strains of bifidobacteria that speed up gut transit time. And that's been very helpful for a slow bowel transit time or your constipated patients. But again, they stop taking it. If you haven't fixed the underlying issue, it's going to cease working.

Any other controversies that come to mind to you about probiotics?

I think one of the ones that I've been trying to bust for nearly 20 years now is the antibiotic issue about when do you take the probiotic along, you know, with antibiotics, do you wait until afterwards? Do you do it during? And I could say conclusively, based on, you know, meta analytic data, you know, top grade data, that you take the probiotic during the course of antibiotics, you don't wait till afterwards. Maybe not in the same mouthful. Ideally you want to space it out by a couple hours if you can, but if you can't, same mouth will have to suffice. But we know from, you know, dozens of studies that we actually get less side effects and other studies with other strains show less damage to the ecosystem if you take it concurrently. So there's absolutely no benefit to waiting till afterwards. In fact, you're arguably causing a patient harm if you're telling them to wait until after antibiotics are over before they start ingesting the program.

Yeah. And we're seeing a good trend with even conventional providers making this recommendation. Now, I don't know how it is in Australia, but are you seeing that trend as well?

It's happening more so. But I'm still surprised when I'm in clinical practice how frequently or infrequently people get told that when they're still given a course of antibiotics.

Right.

You know, I'm just surprised despite the. Because the evidence has been there for a long time. It's not, you know, new 2019 research. It's been there for a long time. It's just as, you know, it takes a long time for research to filter out and change practice. Sadly for our patients.

Yeah. And so one of the, I mean, one of the top aspects of your website, the Probiotic Advisor, is that you go through and you have sort of a ranking of research on probiotics and which clinical conditions are most likely to benefit from probiotic use and specific strains. So that is a really helpful resource for anybody listening out there. And I just wanted to mention that. But I wanted to go into just a few of these clinical applications, probiotics, some of the most noteworthy that you could think of that maybe are that's emerging and some that have just been solid for a long time.

Yeah, because I think that is interesting because you go back and I'd say what are considered to be more traditional uses of probiotics, which are generally around the gut stuff. You know, I remember looking at when I did my literature review finding studies of probiotics and IBS going back to 1950s, you know, so that's, that's been known for a long time. Found bowel disease, antibiotic associated issues. Generally they were given afterwards, you know, thrush issues. I'd say those would make up the bulk of probiotic use for a long time. But what's been fascinating is just seeing that shift from now. We're seeing research of probiotics for Alzheimer's disease, for anxiety, for rheumatoid arthritis, for asthma, prevention, for prevention of mastitis, recurrent mastitis, for treatment of cervical dysplasia, celiac disease, chronic fatigue syndrome, you know, the list goes on. In fact, there's a whole large list in my database that you can just look by conditions and these are human clinical trials on strains that are commercially available. And sometimes there's a number of other strains that there's some research on probiotics and endometriosis for example. It's just that these strains aren't commercially available at this time point that have shown great efficacy for that condition. And I think that over the coming years we'll get access to more of these tools in our clinical practice because that's already happening at a quick pace. But we'll just start having this huge, essentially what I would call a probiotic Materia medica to coexist beside our herbal Materia medica and then our normal vitamins and minerals in our dispensary to help our patients. Because there's going to be soon you'll be have 30 or 40 different probiotic strains you could potentially recommend for different health conditions. So it's an exciting time to be a clinician really in our field.

Yeah, I'm really glad you brought up the point of availability, Zito. One of the strains that has jumped out in the research for IBD specifically I think colitis, ulcerative colitis, is the E coli NISSL1917. And that's. It seems like it has really great evidence behind it, but we can't get it here in North America. And I know some patients have traveled to Germany to get it. It's a really good point that we just don't have access to all these strains.

No, no, we don't. I'm lucky that we do have access to the Nissel 1917 strain in Australia. But I must say, I was at a microbiome probiotic conference in Italy about three years ago now, and it was like kid in the candy shop for me. When I went to the pharmacy there, it was like, oh, you've got this strain, you've got this strain, you got this strain. And I end up with these huge shopping bags full of probiotic products to take home because I was just so excited to actually have access to the ones that I've read about. These are like, ones you've read about in the research, but they're just not available here. And that is slowly changing. And I think Europe is actually quite ahead of the game when it comes to probiotic research and certainly probiotic product availability, but that is seeping through here and seeping through in the North American market. So we've got that to look forward to. But the E. Coli one is a different scenario because, you know, it's been available as a probiotic in Germany since the 1920s. Long time in the marketplace, Great safety profile. But I think because it's an E. Coli, North American regulatory authorities are extremely cautious about its use, despite its long, long history of safe use. And, you know, we're probably talking, you know, many dozens, if not over 100 clinical trials showing a great safety profile.

Yeah, that's really a good point. And I think it'll be interesting to see over the course of the next few years if we're going to see increased access throughout the world for various strains. And hopefully, I imagine there's some various forces at play, like marketing and essentially business agreements that are required to bring strains to various other regions.

Yes. And sometimes that means there's exclusivity as well, like cultural and L rhymnosis gg, for example. I think they had an exclusivity agreement on the US Market for a long time that maybe just has lapsed or something like that because of this. Now more products with that strain in it, for example.

Okay, well, if someone is going to shop for a probiotic and let's say they don't have a healthcare provider helping them make this decision. What are some general criteria that you would mention?

That's a tricky question, Adam. I think, to be honest, you need a healthcare provider to adequately work your way through the probiotic literature and to find the the best one to help you. If you're just generally healthy and wanting some sort of microbial exposure, you're better off just having fermented foods like sauerkraut and kimchi or even some nondescript yogurt. They're all fine if you're just after some sort of microbial interaction going on. And we know that even those yogurt bacteria that die in the stomach and small bowel people that eat yogurt, their immune system is ramped up a bit more and they're less likely, their Natural killer selectivity, etc. Tends to be a bit ramped up. So. So even exposure to dead microbes, which is the worst case scenario of eating sauerkraut kimchi Kee, for example, will tend to improve your general immunity. So you get sick less often. So that's a good thing. But if you're trying to target specific health conditions, you're really better off either becoming really research savvy yourself. But I think you're better off working with a health professional who already is very research savvy and has clinical experience they can bring to the equation because it's a challenging area to navigate based on label claims. And if that's what you're relying on is, you know, somebody's not trained as healthcare professional to read the label and then decide whether to take something or not, you'll be lost and you won't, you definitely won't end up, except for random chance of finding the product that's gonna be best suited to help you. And essentially you could arguably be wasting your resources doing that. And you're better off really working with a clinician who, who is well read and knowledgeable the field of probiotics and has experience in helping people with a similar condition to what you've got.

Right. So I'm just going to put this out there. So going out and selecting the probiotic with the most different species and the highest CFU count is not necessarily meaning you're making a good decision.

Definitely not. No. I think you're right though. It's a great question or a great comment because there are so many people out there in the blogosphere who thinks all that matters is getting multi strain and high cfu, and that's not what the research tells us at all. And you can look at great Example of antibiotic associated side effects, antibiotic associated diarrhea specifically. And I'll look at the results of two different studies. One study used 60 billion CFU per day. CFU's colony forming units. So you. So a single bacterium is a colony forming unit, 60 billion of four different strains, two types of lactobacilli and two types of bifidobacteria and they gave it to them alongside antibiotics to try to decrease the incidence of antibiotic associated diarrhea and C. Diff infection. Now the study used one strain, Lactose Reuteride DSM17938 at a dose of 200 million CFU per day. 200 million. So 600 times less single strain. Look at the results of those studies and you find that the four strains in that 60 billion CFU did not help reduce incidence of antibiotic associated side effects or C. Diff. Whereas the 200 million CFU per day of the single strain of L. Reuteri did significantly decrease diarrhea rates and reduce C. Diff sort of instance as well from memory. So that's a classic example showing that a single single strain with the right action has the right qualities for that task was the best job, did the work that we wanted to. But the other strains that might be good for something else. In fact there are some research on those same four strains that failed at antibiotic associated diarrhea that they're helpful in ibs. They might have some for example anti inflammatory activity in the gut that could be helpful for ibs, but they were completely useless for preventing anor associated diarrhea. And I think that is an example that clearly shows that just choosing high CFE multi strain over strains that have the actions that you're after will generally result in far less therapeutic outcomes. Worse therapeutic outcomes.

Okay, so you have a very eloquent and scientific way of looking at the microbiome based on some of the classes I've seen you teach and so your methodology. Can you just share a little bit about some of the testing you do and where you see that going?

Yeah. These days because of the affordability, I tend to check the microbiome composition for nearly every patient. And this has been a great breakthrough for someone that's been reading about microbiomes for nearly 20 years and that. But not having access to tools to properly assess until probably the last five or six years where the cost point made it actually more doable. And the technology has come down in price in terms of getting a proper view of the microbiome. Because previous Stool tests had some degree of certainly helpfulness in clinical practice, but they were lacking their capacity to give you a full complete picture of the microbiome, unlike today's ones that really do a good job of that aspect. So for me, I would often do intestinal permeability tests for many of my patients because I think that again, leaky gut is a common driver. And rather than making the assumption that patients have it, I find it more useful to actually assess. And I use the lactulus mannitol test, which I know is uncool in some circles, but it's still arguably the most validated, valid test for assessing for gut leakiness. And, and you get that lovely baseline of going, okay, not only do you have leaky gut, but how severe is your leaky gut as well? And for me that is immensely helpful because it motivates patients because healing leaky gut is something that I find because I do lots of follow up testing after pre treatment testing is generally a 3, 6, 9, 12 month process that you can see how severe it is. That gives you an idea of what the timeframe will be. And it's also, they may not feel much different from taking it leaky gut healing protocol for three months or six months. And you know, you're asking them to spend, you know, a fair bit of only money but their energy and timing to fit this into their routine to take, you know, their megadoses of glutamine and what else it might actually be. And I find it's much better compliance wise if they have a definitive diagnosis of what's going on. And we also have the capacity to do a follow up test and I can think of one patient, chronic fatigue syndrome. We did a microbiome assessment and leaky gut assessment and gut was definitely leaky and definitely dysbiotic state. We addressed those two things and working with him touching base 12 months later and he was about 80% better pretty consistently across the board, which is not a bad outcome. And I think we're both happy with that, but we're like obviously not totally content with sticking it being 80% better. We did a, you know, a follow up gut permeability test and lo and behold, his gut permeability had improved by around 80%. I'm not, not even joking but it still hadn't normalized yet. And for me this was like, ah, okay, this is a perfect example because if I just would have done that single Test at the 12 month time point, I would have gone, okay, your guts leaky, but would had no idea of going okay, it's actually improved a lot. It means that what we're doing is working. It's just going to take more time in your case. And this was a case where it took longer than what most patients would for whatever reason. But I think doing that initial testing was extremely important in that case first to get an idea of where we're at and how much longer we would take to get to where we both wanted that patient to go.

Such a great example. Thank you.

Yeah. And I think microbiome assessment now that, that you can get, particularly when you're US based, you know, access to labs that are offering that testing American Gut Project previously, you buy them up until two weeks ago or potentially thrive or you can, you can get, you know, 16s RNA technology to, to, to look at the, the main genera and their proportion that ecosystem for around the hundred dollar mark. And that is a game changer. I certainly found it to be. So, you know, before that I was using some functional tests that, that gave you a look at, you know, inflammatory markers in the gut and immune markers, short chain fatty acids, which I love that, that comp stuff too. But you might get a look at, you know, 12 species or maybe 20 species that are in the gut and the more advanced ones, that's nothing at the hundred. Some species that might actually be there and getting the overall diversity score. And those tests might have been for some of my patients we were paying, this is an Australian thing But you know, $800 for the test or $600 for the test, it's like that's a whopping big investment. And as a one off for initial screen, sure. But for follow up, you know, I was not going there for follow ups. But when it's around the hundred dollar mark for follow up tests, it's been brilliant to actually be able to do frequent follow ups. Have my interventions that I'm recommending made the changes we wanted and it helps you to gauge dietary compliance as well. You know, might suggest that based on their initial microbiome you can see clearly what species are being fed and what are not. There are other things, factors that have to be considered too in terms of antibiotic use and you know, pretty initial seeding from the family too. But you can clearly see, okay, well your Bilophylla wadsworthii is high and that species eats bile. Only eats bile. And only eats bile really that comes from us eating saturated fats primarily. So you can clearly see relationship going. Okay, well if your Bilophylla is like five times higher than Normal amounts. You're generally feeding it very well. And what in your diet are you eating that's feeding that species? And that's one of the core species in your gut that produces hydrogen sulfide gas. So obviously I want to know about that population. And any, any test that you do that just does culturing as an aside, will never tell you about that because they can't find that species, they can't grow it. You need to use molecular based tests to do so. But it allows you to look at that and go, okay, this is a dietary change we have to make. This is what you're feeding inadvertently. And I find it really has been immensely helpful for compliance with, follow up with, with dietary interventions because they can see clearly what impact their current diet regime is having on their microbiome. And it's something. But the motivation that's different when it's healing and growing their inner garden. That's different than when it might be just looking after themselves. And this is a funny concept, but it's like they're looking after a garden that they're quite willing to do other interventions with and be more diligent because they don't want to like, you know, feed the weeds and kill off their good bacteria in a different way than looking after themselves. Even though they're obviously all connected, but they see it a little bit differently. Most of my patients certainly help with motivation for patients to make the right dietary changes and take the right supplements, et cetera. And they find it fascinating to see the change. They're super excited by follow up tests to go, what have we changed? I've been eating 40, 60, 45 foods per week this week eating more of these red polyphenols. I've been taking my prebiotics. What's changed? And it's absolutely fantastic as a clinician to look at that and go, okay, yeah, I can see you've been compliant as well. We've had the recommended changes or what you would view to be the normal changes in the ecosystem based on what you're, what you're doing or not. And that also can bring up talking point. Okay, well your, perhaps you haven't been as compliant as you had on certain aspects of things. What can we tease out about this as well? So I found them, to me, there are essential tools in my toolkit now that, yeah, this in 10 years ago I would have practiced without them, but I could not practice without those tools now and nor get the results that you tend to see. I see now compared to, yeah, I.

Agree they Just have really helped crystallize some of these concepts, which can help us be more personalized in our recommendations.

Yes, definitely.

So, back to probiotics. Just we're going to close our interview here in just a bit, but I just wanted to just get a few comments about dangers, warnings and contraindications in probiotic use.

Yeah. Now if you look at the research data around probiotics and there's been a couple of systematic reviews that have been essentially safety reviews and they've generally found that there's one systematic review that included data from 620 odd probiotic studies finding that there was like 90 no increased risk of any adverse events in the probiotic group versus placebo groups. So no increased risk of GI side effects or infections or serious adverse events. And there was another review done in pediatric populations showing that kids that took probiotics had less side effects than those on the placebo. So I'd say that in general they are very well tolerated class of agents. That said, I think for me the main caution is around the use of saccharomyces based probiotics and immunocompromised patients, particularly those who are severely immunocompromised. And the data tells us those that are essentially in hospital bed, they've got an IV drip going into their system because those are the ones that have had the instance of fungimia and have been very extremely unwell from that. And the research tells us that the saccharomyces actually got in not from oral use, but from staff that were handling the capsules and then handling the IV fluid equipment and then it got directly into the bloodstream that way. So I think there's a major caveat around there. Whereas I mean, there is certainly research in HIV AIDS populations in the 90s, early 2000s using saccharomyces with good results without any instance of side effects. So I think, I think it's just certain types of immunocompromised patients where you'd be extremely cautious and try to weigh up the benefits versus drawbacks in regard to C Diff? Probably primarily.

Great, thank you. And I'd like to just hear a take home message from you, but first, could you just give us a little bit of a summary of some of the things you're working on right now, maybe how people could learn more about your work work and follow you and some highlights of some of the things you're up to today?

Yeah, I mean, one of the areas that I'm super keen on, and this goes back when I first Started too is looking at the impact of herbs on the microbiome. Just in the herbs. I've always, I was really fascinated after my honors research was like, okay, what? You know, we know that herbs can be antibacterial against pathogens and pathobions, but can they potentially negatively impact beneficial bacterial populations in the gut as well? So that to me is an area of keen interest that I'm really keeping an eye on and really trying to choose agents that can work selectively, that can work to target pathogens and pathobionts, but don't harm our beneficial bacterial populations. Because I think there is a capacity of some of our agents that we have access to as clinicians to actually cause harm to those populations and if used for a longer period of time, result in similar impact that you would from courses of, you know, antibiotics. And so I think we need to have that on our radar. So that's an area that I'm avidly delving into. Yeah. So in terms of. And I mean, I do obviously have the Probiotic Advisor database that you flagged before, which is really designed to make evidence based prescribing of probiotics easy for clinicians, you know, because you're busy, I get that. I'm busy too. And trying to go look up in Medline what studies might be available on different probiotics to help this pick the patient. Great, you can do that. But we've got a database to try to make that far simpler. And for me, this database started from bits of paper I used to give my students because I've been teaching about probiotics and their uses to naturopathic students from 2000 onwards. And it started off because researchers far less of it. You have a few pieces of paper five or 10 years, there was quite a few pieces of paper and eventually five years ago, I was like, I need to shove this into a database. It's like searchable. You don't have to search through five different documents and multiple pages of trying to align the strain with the research and the condition and where you find that strain and all these different products. So we can put that into database to make that far easier. And I've also got a range of courses that are designed primarily for clinicians to upskill around, you know, gut microbiome and its relationship to overall health and vagina microbiome too. And I think this is another area that is very much under considered in women's health, particularly around fertility, but more broadly about women's health and demetriosis is the importance of a healthy vaginal ecosystem that's not dysbiotic. You can have a dysbiotic vaginal ecosystem and be completely asymptomatic. And this disposes of thriving inflammation locally in the area, but even systemically that we need to have on our radar. So one of my goals is to, you know, obviously the clinician treating patients, but I really like sharing what I can with clinicians to upskill them so they've got a better data set and more tools at hand to better help their patients.

That's great. Well, I feel upskilled right now just talking with you for the last hour. So thank you very much. And any closing thoughts? Just take home messages for today's visit.

Yeah, I mean, I would say probably big things were choose your probiotic tools wisely and base that on evidence, independent evidence, on the strains that are contained in that supplement, not on manufacturer information, industry information. Secondly, prebiotics, as I mentioned before, I think are very undervalued. A class of agents with they have a great therapy potential and nothing shifts the gut ecosystem in the same way as prebiotics. So I'd say if you're not familiar with the class of tools, look at the research and start using them on your patients, not just gut patients. But, you know, there's decent research showing up for prebiotics and they're used for modifying the stress response, for helping with anxiety, obesity, type 2 diabetes. There's a whole toolkit there that you probably don't know about, that you should because they're generally inexpensive and compliance is easy. You know, most of the things I prescribe are foul tasting herbal liquids. These taste like sugar. So it's really easy to get patients to take these long term. And I can't imagine my practice without them. And if you are practicing without them, you're really missing out on a wide range of therapy tools that can transform how you treat not just gut conditions, but systemic conditions.

Yeah, yeah, that's great. And I'll put some links in the show notes to more information about prebiotics and the different types of prebiotics so that we can pack in some of that learning for them from this episode. And well, thank you so much, Jason, for being with us today. This was really great. You took us through a journey about probiotics and prebiotics and various testing. It was very helpful and I learned a lot. And thank you for sharing this time with us.

You're very welcome, Adam. I've enjoyed it thoroughly, as you can tell. I mean, you keep going for hours, but I know we can't.

All right, well, thank you and I hope to catch up with you sometimes.

Tuning in to the Back podcast and.

The other my guest, Dr. Jason Powerlight.

My name is Dr. That'd be great. I'm the host of the One Thing Podcast, YouTube. I really appreciate you all tuning in and please take a moment just to hear some concluding thoughts on this episode and also please like the episode in your podcast player if if you found it useful, informative or inspiring. And please share the episode with people that you care about. So here's some concluding thoughts. I use probiotics quite extensively in practice, but I don't use them usually right out of the gates with people. Sure, if someone is doing generally well with their health and they're looking for preventative medicine ideas, we might use probiotics as a preventative health intervention. However, it's usually used in the setting of helping stabilize the gut or stabilize inflammation in other areas of the body body such as with chronic skin disorders or allergies. Also using it more and more with mental health conditions. I have seen probiotics do a lot of things clinically. We usually see when they're used right and with the correct strains, better stool consistency, better intestinal transit function and the core quality of stools are improved. I also see in some patients less anxiety and depression. With the right strain of probiotics, symptoms of intestinal permeability seem to reduce, such as brain fog and also skin disruption. We also see less gas and bloating. Those are some of the really obvious signs that a probiotic is beneficial and I am really moving in the direction like we talked about in the in the podcast of using prebiotics and using them wisely and helping people to get more flexible with their diet so that they can expand the prebiotic intake in their diet. As we are aware, that's probably a better long term move than taking a probiotic. Also growing interest in my practice is the rise of fecal microbial transplant and its applications to shift the microbiome more permanently than say a probiotic. So for now I think taking some of the advice of Dr. Harborlak and really investigating specific strains, not falling to hype of clarity claims on labels, but actually going in and figuring out what strain is needed for a specific problem and then using quality manufacturers that are doing testing and have proven that there's viable organisms in the product products you're buying. So this was hopefully as informative to you as it was for me. And again, see you next time on the One Thing Podcast thanks again for tuning in.