S05E03 | The World of Probiotics with Dr. Jason Hawrelak

Gut health.

What does it even mean? Your pursuit of gut health has probably taken you down a rabbit hole of misinformation, useless concoctions and false promises. So this is where this uncensored podcast comes in. The Gastroenterologist and His Daughter is the first of its kind bringing a specialist gastroenterologist and his daughter, yours truly, to help you navigate the world of all things gut health from mouth to bum and everything in between. Join me, Sandra McHale, gut health specialist, dietitian and founder of Nutrition A to Z, and my father, Wagdi McHale, specialist gastroenterologist and internist, as we unpack the most talked about topics in gut health, covering both the medical and lifestyle aspects of all things gut with a ton of comedy and fecal tete a tete. Right, let's get into it. Today we're joined by Dr. Jason Harlak, a leading researcher, educator and clinician in the world of all things gut, microbiome and probiotics. With 25 years of clinical experience and a PhD focused on how probiotics, prebiotics and herbal medicine shape the gut, he has published extensively, including 20 textbook chapters. Jason sits on the Medical Nutrition Council of the American Society for Nutrition and is a fellow of both the American College of Nutrition and the Naturopaths and Herbalists association of Australia. He's a chief research officer@probioticadvisor.com runs a busy telehealth practice at the Harlac Gut and Microbiome Clinic and leads the Microbiome Restoration center where he trains health professionals in advanced microbiome care. We are beyond thrilled to dive into the science of probiotics with him today. So enjoy this episode. Here we go. Jason, thank you so much for taking the time today to join us all the way from Byron.

You're very welcome, very welcome.

I'm very happy to have all, you know, all of us finally, three different time zones. We've got Australia, we've got Switzerland and Dubai.

Yeah. So we've got evening, evening here. You're probably morning, Sandra.

Yes, yes, it's nine, it's. Yeah, it's 9:00am 12:00 clock here.

Yeah.

Look, before we get into the world of probiotics, we want our listeners to get to know you a little bit better with a few set of questions. So I'm going to start off with if you were a vegetable or fruit, what would you be and why?

I'm going to choose a fruit called the jabari caba. Now, jabari kaba is a Brazilian fruit, but I'VE got a beautiful big tree in my garden and it's pretty stunning because it actually grows it flowers and fruits right off the stem. And when it's in fruit, it looks like these purple golf balls sort of glued to the stem of the tree. It's absolutely stunning. And it just gives. You can get four, sometimes up to six different fruits per fruiting periods per year. And it's the highest known fruit of a specific polyphenol called ellagitannins. And ellagitannins, if you have the right microbiome, they get converted through to urolithins and urolithin A specifically, which is this amazing sort of mitochondrial tonic agent. So for me, it's like. It's very funky.

What does it taste like?

Amazingly good. So good. Like the skin itself has got. It's quite. It's a bit astringent and a little bit sour. But the fruit on the inside is. Oh, it's super delicious. Yeah. And you kind of put the whole little bowl and then you kind of pop it and you get that sort of popping sensation. A bit like those little pearls that people like, but it's full of good fruity goodness instead. And it does have a pip in it which you can just. I just swallow. But it's just. Yeah. And mine just fruited recently, so I've just been enthralled once again with the fruit.

What's the name of the fruit again?

Jabari Kaba.

That's not even going to bother. It's like.

No.

Not even going to attempt with this one. I've actually never heard of it, to be honest with you, and I doubt I'm going to find it in Switzerland.

You will not find it. You'll find it in Brazil is where it's rainforest trees from Brazil. But in many parts of. You find in Hawaii and Florida, like other parts that have a silverish climate, people often grow them as a backyard tree because they're very pretty. They have like bark that kind of peels off in different colors too. So, yeah, it's a beautiful tree to look at, but then you get this amazing fruit at the same time.

Oh, that's beautiful.

Right.

I'm going to try to like that.

Yeah, you should. You see some photos online. It's just. It's beautiful. It's really cool.

All right, next one. If you had to choose one food item for the rest of your life, what would it be?

This is really hard because it's mango season now, so it's like walking past my fruit basket full of These ripe mangoes and just the aroma, it's like, oh, you know, hard to turn down those. But, But I do have a really fondness for jackfruit. Jackfruit is one of my.

Oh, that's an interesting choice.

Yeah, yeah. And again, when it's seasoned, which is not at the moment, but like, my whole kitchen will smell of, of jackfruit. And they can be huge. Like, they can be like 30, 40 kg in size, too, but they're one of those favorite things to eat. Is a good jackfruit.

Dad, have you ever had jackfruit before?

No. Which one?

Jackfruit is very meaty, so a lot of people use it as a meat alternative. I'll actually, I'll make some, I'll make some for you when I'm.

That's the unripe ones. Yeah, unripe is, is a, is a fibrous sort of. They make like pulled porky kind of things.

Exactly.

Very chewy.

Yeah.

But the ripe ones are just the taste and smell and just eating experiences is amazing. And then, then you've also got the seeds that they roast up in such a way.

Exactly, exactly.

So it's like you can, I think there's a saying in India, like, family will never starve if there's a jackfruit tree in the yard.

Yeah.

Cause it' just gives so much food. But it just, I just love the taste and flavor and.

Try it here. It's available in Dubai.

Yes, you can get it in Dubai. You have to go to. I'm not really sure if, like, you've got specialty shops, because I don't think you'll just find. No, you should actually, you should find it in just like the regular supermarkets because it's becoming very, very popular, as I said. Jack. Dad, are you looking it up right now?

You should look up jibari kaba while you're at it, because you'll be, your mind will be blown just by the physical pyramids. But yeah.

All right, so. And finally, what is that one thing that people may not know about you?

Despite the fact I have been recommending and prescribing fermented foods for 25 years, I really don't like the taste of yogurt. Sour, sour fat. I just cannot. I do not like, I, I, I'll eat sauerkrauts and kimchees and kombuchas and all these other things, but sour cream and saddle, like yogurt just do not work for me.

I'm surprised.

I know. I get it and I prescribe like, medicinal yogurts frequently over the last 25 years of practice too. But it's just. And then that's enough. I had some fruit and other things too. I can counterbalance that, but I generally don't.

Yeah, see, that's me with kefir. I could not do kefir. I think it's just an acquired. Yeah, no, kefir is out of the question. Don't mind, you know, kimchi, kombucha, miso love. But when it comes to kefir, it's just like my taste buds just go, nope, we're not going to do that. Not today.

No, Mine are unhappy with any sour fat. She can't do it.

I get kefir here, which is very nice and tasty.

Do you like it?

Yeah. When you come. I like something.

No, don't.

Especially at company. Just like yogurt. It's not. It's not a big deal. Especially this company.

Oh, really? Okay, so the brand is.

Is different.

Okay, well, maybe I'll give it one more shot.

Okay. So, Jason, you have been in the forefront of probiotic science for years. So can you tell us what first sparked your interest in this failure?

Yeah, it was actually a. A lecture given to me by who would later become my PhD supervisor. But one of my lectures at university who tours, we were actually talking about the role of the microbiome and this was back in 1999, but the importance of the microbiome in keeping people healthy. And I was just about to finish my degree and I was approached him afterwards like, I really want to do research in this area of dysbiosis microbiome. And he said, okay, well, we're just starting up an honors program, so I'm going to do. Did honors program, did my first clinical trial as part of that and then we went on to do a PhD. So and I think it's that had that capacity. So we've got some black cockatoos going on, but having that capacity of delving into the microbiome. This really had me a chance to look at, okay, all the research on probiotics and prebiotics. And it's from that that it was like, oh, wow. Like I learned about probiotics a bit in my degree, but just nothing about some very important bits like strain specificity. It's just like, whoa, what about that? And we didn't really touch on prebiotics at all during my undergraduate training either. So that was like areas that I really found super fasting and still have. And it felt like it's an area where people in my profession and broader needed. Needed upskilling. Yeah. At that time in Australia, all probiotic supplements were just called acidophilus. All of them. Ah, true. Give them acidophilus. Give that guy acidophilus. This person acidophils. Like, they're not even acidophilus, like they contain bifidobacteria or other species of active saliva, but just clinician that's just referred to them like that. And it's like. And one product would probiotic would do anything. And it's just like, no, no and no. You need to get some good information out there about how things have changed and how essentially different strains have got different attributes and can be used differently, et cetera. So that kind of put me on the. I need to get. Educate my peers in this area with stuff that I gleaned from having that. The pleasure of, you know, spending five, six years just focusing solely on a topic, as one does with a PhD. So you get the CH to dive very deeply into it.

I think it's just interesting because there's still a lot of misinformation about probiotics. And actually, like, one of the most common questions I get is, Sandra, what probiotics do you recommend? So my question to you is, should we all be on a probiotic supplement?

No. Which is I would, because I do see patients, I prescribe lots of probiotics when there's something wrong to treat something that's not working the way that it should. But that's not me currently. Like, you know, if my young one was youngest, was in daycare, this is a while back now, and she and other kids were coming down with viral gastroenteritis. So I'm like, okay, I'm going to take a probiotic that protects me against viral gastroenteritis and will shorten its duration if. If it happens to get into our family. Okay. During influenza season and you're going to be exposed to people who are unwell, we can take probiotics that will enhance immunity, make it less likely to get sick and get sick for shorter periods of time. So I will do that for that stint of time. But I won't take them on a daily basis. No, I'll eat fermented foods daily. I'll take prebiotics, and I do take prebiotic supplements daily and have for years, as well as eating for my microbiome on a daily basis. But I don't take a probiotic on a daily basis and I don't recommend it unless there's Something you're trying to achieve. Because I think this is a thing that I always ask people. Why, what do you want this to do? If you want it to fix your microbiome, it's not gonna do that. Changing your diet or changing your lifestyle or stopping that medication, those things can do that. But probiotics have such a minimal impact on microbiome composition that that's not their. That's not what they're for, really. I think with exceptions, like right after antibiotics, right after chemotherapy, some interventions that cause massive disruptions to that ecosystem, a probiotic can be very useful at that time, window cover some ecological niches, prevent overgrowth of pathogens, help settle things down to reduce side effects, et cetera, and help and help restore your own ecosystem to come back a bit more strongly. But outside those windows, we know now from like 40 years of research that you're. You take a probiotic, it has minimal impact in general on your microbiome. It's not causing massive changes. But you know what does? Eating more fiber, eating more polyphenols, like, there are other things we can do.

You can't sell that, though. Right. So I'm thinking, I was like, a lot of brands might not be happy with you. No. But do you know what? Maybe we can scale that for a bit, just for a second. What are the differences between the terms? So for those that are unfamiliar with probiotics, prebiotics, and even postbiotics, how would you explain the differences?

And symbiotic as well.

And symbiotic. There you go.

Yeah, yeah. So. So probiotic is essentially live microbes that, when administered, improve health. Okay. And. And in some parts of the world, they, in terms of regulatory authorities, take that very seriously. Like, in terms of you want to label, claim, and call your product a probiotic, it has to have human clinical trials showing it makes a difference to someone's health. And I get that. Actually, I'm quite a fan of that approach. Then you have prebiotics. Prebiotics are like selective fertilizers for your own beneficial microbes that can be essentially. Generally they increase the population of one or select minimal number of beneficial species in the gut that improves your health. Okay. Then you have symbiotics, which are generally a combination of a, in theory, of a good probiotic strain and a adequate dose of a prebiotic. And so there's lots of products called symbiotics that are not. Because they don't actually. The adequate dose of the prebiotic could do anything. And in theory, they should be matched Together well. And that the prebiotic actually feeds a specific probiotic that's in that supplement. And that might sound simple and common sense, but I can tell you in the real world, not many companies are bothered to do things like that. Then postbiotic is a term that. The current definition I'd say is unsettled. Okay. You have the International Society for Probiotics and Prebiotics who define probiotics. They define prebiotics. We've taken on board their definitions for those substances. But postbiotics, they call essentially dead bacteria or the metabolites that when ingested induce health effects. Okay. But if you look at the blogosphere or many people out there publishing stuff on postbiotics, it's a sort of open field. Like some people, it's like bacterial metabolites, some people call short chain fatty acids postbiotics. It's, it's one of those terms that hasn't really settled into a meaning yet. So different people will be using the term very differently. Like for me, I prefer it like postbiotic. This is dead bacteria metabolites. I like that definition because I think we already have term bacterial metabolites or short chain fatty acids. We already have terms that describe what those people I think are. Postbiotic, I think in that ways is kind of like a marketing thing. They're like, oh, we can now market butyrate, for example.

Let's.

Yeah, it's now post product rather than just calling it butyrate. Yeah.

Okay, that's interesting because as I said, I think it's. The terminology also plays a lot with the marketing. Right. Especially with all these brands and supplements that are out there. And speaking of, speaking of marketing, I mean, I'm on social media and there's a lot of hype around gut repair, immune support. Do we have any evidence that can tell us about the efficacy of probiotics to potentially support these claims?

Yeah, for something we certainly do. Immune support, definitely. Like we have a positive Cochrane review on probiotics for reducing the risk of upper risk tract infections and reducing the duration of time. And we've got like dozens of positive clinical trials on that. So I'd say for that category, yes. It doesn't mean that every probiotic will do this because that's not true. But there are some that are particularly good at, at enhancing immunity. And yes, they do definitely have that impact in well designed, randomized, double blind, placebo controlled trials. Yes. For gut healing, there's only a couple of strains. Actually of all the studies, most sure they don't make much difference. From improving gut permeability perspective. But there's a couple strains that we do have definitive evidence, again, in humans, because this is where I put the. Yes. In animal studies, there's a lot more. But if you're actually looking at human studies, there's Lactobacillus rhamnosus, gg, which is. Which is the best research probiotic on earth. There is three, I think three clinical trials in different populations showing improved gut permeability markers after administration. And then there's Saccharomyces cereviaceae variety Boulardii CNCMI 745. I know quite a long name. I'm pedantic with names. So people just call that Saccharomye bullardi, but it's like that's the incorrect name. So when you use. You don't use its proper name. And there is some research on that one. Speeding up healing as well. And we know the mechanism. It releases a compound called polyamines as it traverses through the small intestine. And that speeds up the healing process. And we again have even studies showing that. Yes, that's the result as well. So those two. Yes. For gut healing. But I can tell you that there's a lot of probiotic strains that have been studied that don't seem to have that aspect to it. So you can't just go. Probiotics improve or heal the gut. No, two specific ones can. Yeah. So the difference phrasing.

And speaking of. So hold on. Saccharomyces as well as used for preventing travelers. Diarrhea. Correct. Is that the same strain that we're talking about? Yep.

Yep.

Okay. Because that's one thing that we use to prevent Bali Belly.

Yes, that's right. Yeah. And there's good research for that. And that's one of the best research probiotics too. And that was discovered by Henry Ballard in Thailand, I think, in the 1920s, that there is a cholera outbreak. And you notice that this one is one village where people were drinking tea made out of lychee skin. Were not. They're getting better and not dying of cholera. And he was a microbiologist. He's like, I wonder if there's a microbe in this lychee skin. And there's a Saccharomyces. And he named it after himself, Polarity Eye. And then he sold that to a French company in the 1950s. And this was sold anyway as a probiotic since the 1950s worldwide. But they've since classed. It's no longer a different species. It's actually within the Sarcomaces cerebracea, which is just baker's yeast. It's just a particular variant that seems to like growing at 37 degrees and has different sort of environmental conditions that it likes growing in and different attributes in terms of what it brings to the table than just normal baker's yeast.

Right. For the disease, if we can. Do you think that the probiotic play any role in the Crohn's disease of ulcerative colitis in any active disease? What do you think about that?

Yeah. And as someone who treats patients with IBD using combination usually of dietary work, microbiome work and probiotics, I would say yes. And also from a research perspective. Yes. But again, it's not across the board. I'd say the research in Crohn's is far less.

I was going to say ulcerative colitis. You have a few decent trials out there. Yeah, yeah.

Whereas Crohn's has been a much more difficult one that like lgg, which works in ulcera colitis for maintaining remission, did nothing in Crohn's patients. Yeah. Saccharomyces had a couple of positive studies in Crohn's, but it only seemed to one study that the biggest study to date found it only worked in non smokers, so. And it was an interesting secondary findings. Yeah, it was because it's like, okay, so most my Crohn's aren't smokers, so that's probably fine. But I would like another follow up study that just excludes smokers to see, you know, that's your primary thing you're looking at. I always want to have a look at that. But Crohn's is, as, as many people would agree, often harder to get into remission anyway than, than ulcerative colitis. So it's perhaps not surprising that probiotics can be less effective. And also because I think you can have, you get small bowel and you can have large bowel and it can be such a large part of your gut that can be with Crohn's versus what you might get with ulcerative colitis too. But I do think there's a number of strains that have got efficacy in either inducing remission or maintaining remission in ulcerative colitis these days.

But it's safer to use probiotic in remission phase or in active disease because if it is severely active, we use sometimes with biologic treatment for these people, just combine this with the probiotic. I think in active diseases, not Very proven to have any effect on especially ulcerative colitis, is it?

Oh, I mean, I think, I mean I'll have to think all the specific studies, like there's definitely research where they've used probiotics to get people obviously with more mild variants also called as intermission without pharmaceutical support. And clinically wise, I've certainly worked with patients who are on biologics and have not achieved remission just through biologics, who they've done diet work and probiotics and other things and achieve remission. So I think that it can work hand in hand and obviously for very extremely severe Crohn's are also kind of throwing a probiotic. I think he's got Buckley's chance of actually being remission on its own. I think when you do layer a bunch of different things in all that together, it's a different story. But yeah, but often we're working alongside conventional meds where they've been in sufficient to get people into remission and or we're trying to keep people in remission long term versus sort of adding things in to try to do that. But I think diet again plays does the lion's share of the work there, not the probiotic.

What about other conditions like irritable bowel syndrome?

Yeah, and this is an area because my PhD was in exactly that. So we tried to come up with a disease that we knew was associated with dysbiosis. And to go, okay, let's see if we can change the microbiome and come up with improvement of disease condition. And irritable bowel syndrome back in the 90s was one of the few diseases that we had a definitive. All the studies showed it was dysbiosis. Even the limited technology we had available to us at that time, which gave me my literature review, my thesis was probiotics and IBS. And you can go back all the way to 1950s and there's positive studies and case reports in the 1950s onwards for probiotics and IBS. Again, it does mean not all strains work. Definitely not. But there are some strains that do seem to be helpful adjuncts that some can help speed up transit time, some can slow transit time, some can help more reduce pain. So we have now we can divide up ones that are better for constipation predominant and some are better for diarrhea predominant, some that are better for just general pain reduction. Yeah. And as someone again that treats a lot of gut conditions over the last 25 years, I don't necessarily find them magical. You know your pain levels go from like 10 down to 1, but you'll have a. Generally we get the right strain, there'll be a reduction. Yeah. And there is the occasional time where it is almost magical in terms of the complete remission of their symptoms from just adding in a probiotic. It's rare. Usually you have to do more than that. So usually you're using it as an adjunct to other things that you're doing, which might be interventional diet or. For me, I use a lot of partially hydrolyzed Guargamma, a prebiotic, in my, my conservation prone IBS patients. And that to me is more of a game changer, usually in terms of changing the dial than the probiotic strain. But I had good results with Bifidactyrain lactis. That's in the Activia yogurt. So Activia yogurt is sold pretty much around the world. They've got a particular strain, DN173010, a couple of clinical trials in conservation problem IBS and it's been shown to speed up transit time and help with visceral hybrid stability. And some people, you just get them to switch their morning yogurt to Activia and all of a sudden they're pooing fantastically well. No more bloating and distension and it can work amazingly well.

Oh, and a side note, we are not sponsored by Activia.

How about using the probiotic with eradication which by loading and if we use it, do you use it during the course of the antibiotic or often the antibiotic cause both.

But I think it's important to use it during because it, it, it one research shows we get better outcomes, we get a higher cure rate of the hprolar, a better eradication rate and we get less side effects from the antibiotics. And three, if you choose the right probiotic, we'll probably get less, probably less microbiome damage and quicker resolution or restoration of the ecosystem afterwards too. Because we know with hprolar, the triple therapy, even like four years, four years afterwards, the microbiome is not recovered to what it was beforehand. So anything we do that can minimize some of the impact is going to be helpful in that situation.

But question is, off the top of your head, do you know any strain specific ones for H. Pylori eradication therapy?

Yeah, The Lactobacillus reuteri DSM17938 which is sold as Biogaia around the world. The Biogaia ones, yeah.

We've got Biogaia. Yeah.

One study published in Italy a while back that had, I think it was a 40% cure rate of phage Polari on its own or they gave it alongside a PPI and 40% cure. I think it was open label study. But still it was pretty good data. And there's other data using alongside antibiotics with good outcomes too in terms of improved eradication rates. But there's a number of. Even saccharomyces I think improves eradication rates, but it definitely will decrease the side effect profile from triple therapy as well. But there's a few these days in terms of. That's one of the better researched areas. And in terms of commercial availability, most countries will be a probiotic option that will enhance efficacy rates for treatment, which is a big thing because we know that efficacy rates are getting less and less for HPLR because of the growing antibiotic resistance. So if you get 90% versus 70%, which is some of the studies are showing, that's a good thing.

My other question is right, because you know, we've spoken about and highlighted strain specificity and I do know, unfortunately a lot of clinicians will just throw random probiotics at their patients. What should clinicians and consumers look for with probiotics?

Yeah. And I think the strains specificity thing is something I've been hammering on for 25 years. This is so important. If you want to know what your probiotic does, you need to know what the strain is and you need to know the research pedigree of that strain. Yeah. And you can have massive differences. And I've got whole lectures where I go into this field about how you can have the same species but have different traits and some will actually not work for this condition. There's some studies where they've been head to head two different strains in the same species, one will work and one will not. You know, the differences can be absolutely that marked. So you have to look at the label going what strains are in it? And then you've got to go look at the medical literature, not what the label says, medical literature, and say, hey, what, what is this actually good for, if anything? Yeah. And I think, because I have a thing is that if I don't trust what supplement companies say, I don't trust what drug companies say, I want to know what the substance is. Then I will look at the medical literature myself and I'll decide whether it's a pro appropriate and how safe it is, et cetera. Because everyone. That's an interest. Both those ones, they'll tweak information to make it seem more efficacious than it possibly is or say more stuff than what it's actually been shown to do in studies. So I think it's imperative that we use studies to guide our prescriber and that makes it impossible for the general public to easily navigate through that. Yeah. And it is confusing, time consuming for clinicians too, in all honesty. Yeah.

The market to get specific ant probiotic, isn't it? If you see in the market the whole range of the probiotic there is, if you try to find one specific probiotic, you won't be able to find it. You have to go through all this and very rarely to have only one probiotic in.

So you mean multi strain. Yeah, Multistrain versus Yeah. Have single strain. Well, that's the thing. You need to have a bit. I mean, just like you said, Jason, it's time consuming because, I mean, this is what I. It's like sitting there searching, researching, knowing which brands have what. Because, you know, my clients would come to me and just go, but this says it's clinically proven. I was like, well, and then you pick it up and you're like in test tubes, not in humans. Or like, if it's a study in humans, it's got six people in it. Do you know what I mean? So it's just, it's one of these things that's extremely infuriating that there's still not much regulation. Regulation as to. Well, it depends where you are in the world, I guess. But what's being put on that label?

Yeah, there'll be one site that, well, for me, this is good for antibiotics and there's no studies showing it is. And there's a product right next to it that is. And essentially it means that someone's choosing one that because unbeknownst to them, there's no research on it for that application, but they're kind of allowed to put it on there as a general probiotic claim versus those ones where those systematic review level data showing it reduces side effects and et cetera from Anabar usage and that the label claim won't be anything different.

To the naked eye, another field that I'm extremely interested in is obviously women's health and there's growing interest in the use of probiotics, especially when it comes to things like PCOs or recurrent UTIs. What's your take on the evidence?

Yeah, I mean, I think pcos, there's a little bit of data around that now. I think there's a limit to how much we can expect there without doing dietary, lifestyle stuff and other things. And I think there's actually better research in terms of outcomes on different polyphenols than there is on probiotics and PCOS to date. So again, I'd see it probably as an adjunct treatment that you're doing this and this will help decrease inflammatory load a bit or have a little bit of. Of impact. And you know, there will be more and more strains researched that might have better efficacy as time goes on. Because how do you know whether probiotic strain helps is you have to, you know, in vitro, does it have the attributes that we kind of think of what we want it to have? Does it do this in animal studies? Great. Then we do human studies, you know, so it takes time to go, hey, I want to make a PCOS probiotic. It's like rather than just I can market one that doesn't necessarily have the traits that we're after versus I'm going to develop one from scratch. In which case you're going to have a much better chance of having a bigger impact than general reducing inflammation a bit, which is not a bad thing. But it's not probably going to have again night and day change for someone with PCOS recurrent etoides. I think the data is a bit better. There are a couple strains like the lactose rhamnosus GR1 and the RC14 stain of lactose fermentum that actually have been shown in clinical trials to. There's one study where they compared it to 12 months daily ingestion to 12 months daily addition of antibiotics and they're statistically equivalent in terms of reduction of UTIs, you know, so yes, so I, and I've used those clinically and you often will see them break that, that recurrence cycle, which is great. And there's also research for those strains in bacterial vaginosis and in group B streping as well. So they seem to be able to. And those ones were selected for urinary application. There was a Canadian market bolster called Gregor Reed gr. He named it the GR one as after named it for himself who was just in the 1990s was, was way ahead of the game and going I'm going to find some lactobacilli supportive probiotic strains rather than just ones for the gut. So these ones we know when you ingest them orally, they actually reach the vagina and can colonize at least temporarily in that area. So we got that kind of data set to understand how they were looking.

I Got a question from a listener, actually, because people knew that we were recording this. And one of the questions was, are Probiot safe to take? Are there any side effects? Can they be dangerous?

I think if you compare them to almost any other sort of medical intervention, they'd be seen as immensely safe. Okay. Does that mean that there have not been cases of severe side effects? No. You know, but most of those, the severe ones, like the vast majority of side effects are digestive upset and, you know, a bit of change in bowel pattern or maybe a little bit of bloating, a bit more farty like that. Most of the side effects that your patients are going to experience fit into that realm. But there are cases of fungimia from saccharomyces. But these are generally, if you again, look at the. And that's where the fungus gets into the bloodstream and causes infection. But you look at the cases, they're like neighborhoods. People are already in hospital, they're mentally unwell. And it turns out that actually the nursing staff was administering the saccharomyces supplements in capsule form and then adjusting the catheter, venous catheter. And the saccharomyces went directly into the veins from that way, not from the gut, but from the. Directly to bloodstream by that mechanism. Yeah. So it kind of like suggests that oral use is not such concern. So, I mean, I think we do have some concerns around immensely immunocompromised scenarios.

I was just about to say it.

Yeah.

But we also know there's studies in HIV aids like, you know, years ago, when before there are better treatments and people were more, you know, acutely unwell and that were really well tolerated and made a difference to their quality of life and health. So I think there's a point at which like a degree, a little bit of immunosuppression is not a big concern. But when you start going to more extreme end of it, there's greater concern around it. And I know there's theoretical concerns around chemotherapy and radiotherapy for the same reason. And I think they're more theoretical in that the reality is you've got 100 trillion bacteria in your gut right now, and if you're adding a billion more of what's generally a benign strain, it's unlikely to be problematic. But I can understand that there's some concern because immune system has been sort of smashed down, gut's been damaged. An increasing a novel microbe is a bit of a risk. But we have counterbalancing where studies showing we get Better outcomes and less gut symptoms too. So we sometimes have to weigh these things up about what's most likely to be beneficial versus harmful this particular patient. But in general, the class of probiotics, at least what we've used to date, would be seen as immensely safe and relatively low risk in terms of severe side effects and just mild side effects.

Well, that answers that question. The future of probiotics, what excites you the most?

I think it is novel strains and novel species. Might be a better way to describe it in that traditionally we've had Lactobacillus, we've had Bifidobacterium, we've had a bit of Saccharomyces, there's been one E. Coli, really maybe a couple of E. Coli, but one that's really well known, a little bit of Enterococcus. Like we've been pretty limited in terms of what we've included in probiotic supplements to date up until a couple years ago. Now we're looking at what's called next generation probiotics and these are the ones I'm a bit more intrigued about where we might have Akkermansia or beetroot.

Akkermansia is a big one recently. Right. I'm seeing it a lot in the literature.

Yeah. So that one went from being this is an important gut microbe that we don't know how to grow. Oh actually we can eventually learn how to grow it in a lab to maybe we should start keep using it as a, as a probiotic for 20 year period. And there'll be other species that go through that process too like Faecalia bacterium or some bead rate producing microbes and probably lots of others in the upcoming years. So I think that's kind of exciting. And that will just have different products that can do different things. Yeah. Because Akkermansia does seem to have a somewhat unique way of altering our. Interacting with our metabolism.

Metabolism, that's right.

So and if we're missing it, we seem to have consequences. And therefore in those people that are missing it, I think there's a role for supplementation. I think if you've got it taking more, I think you're better off just trying to encourage your own Akkermansia in that case to get to a higher amount. If it's not there inadequate amounts, but if it is extinct, and for some people it is, they've taken enough antibodies over time, it is gone and they might have metabolic dysfunction in part as a consequence of that, then actually supplement without commands. It makes sense. And it does seem to be helpful.

For in those populations because I was looking around again. I mean, this is, this is for another probably episode or topic. You know, some clients of mine would come with a microbiome test. Again, there's a lot of, you know, question marks there, but what question would you like to ask dad?

Okay, this, the. How about the microbiome testing?

That was literally my question. What are your thoughts, Jason?

I use microbiotum assessments a lot in my practice, like almost every patient, and I find them immensely helpful to see what's going on and to gauge interventional efficacy, I suppose outcomes like, have we. Yeah, I want to know if their symptoms change, obviously in the disease states and other markers. But here we have a chance to go, okay, let's implement these dietary changes and this prebiotic substance and we can do a time point two months later. What impact has it actually had? Yeah, and we also get clues about what is driving disease processes from that as well. I think we get to interpret the microbiome tests in greater detail. You go, oh, there's definitely drivers from that. Because I think that's one of the things that's been been amazing over the last 25 years is that shift from associations of, oh, people with this disease have a different microbiome. We don't know whether it's causative or not. It might just be because it occurs after disease because they change the diet. To actually know these things are causative in that we can do these poo transplants. Like we can take a poo transplant from hypertension, give it to rats, they get high blood pressure. We can take a poo transplant with depression, give it to rats, they get depressed. Kids with autism give it to rats, they develop autism like behaviors. It's like there's so many disease now where actually it's moved from microbiome being, oh, it's interesting, maybe it's correlative to actually this is a huge causative thing. And enough research that's teased out about, okay, the lack of bureau production is a key role or excess Proteobacteria, enterobacteriaceae and the release of LPS lipopolysaccharide, that's driving this dysfunction. And those things are immensely modifiable with diet and lifestyle and prebiotics. And you change that and then the whole disease outcome alters. And this is something that is so microbiome restoration or optimization, I think has been a cornerstone of my practice probably the last 10 years since we've access to better stool tests.

Well, that's the thing. Right. I think it's just the accessibility because in Europe I would say we only have a handful of that are some decent labs. Because I mean one of the things or one of the complaints that clinicians would see is like, right, if you send a stool test to three different labs, you're going to get three different values, three different results.

Yeah.

And which one do we trust?

Yeah, and that's not a bad question. And I've done that myself. I remember saying my stools down with the six different labs and getting different results from each one.

You did.

This is like a decade ago. Yeah, okay. But I think as someone who's, who works in this field and as long as you stick within, like there's some tests I wouldn't use at all and I had some doubts with their trustworthiness and how useful, like how accurate the information is. But there's other tests that are like between 16s tests and shotgun test, you're going to get some differences because it's slightly different testing terminology. Some things are going to be the same, but if you did the same sample, you get some differences, some would be the same. But if you stay within that in terms of you make clinical decisions based on that, you test and follow up on that, I can say that clinically it works, that you get improvements in patients health and you get to see it in that ecosystem. And I've done a lot of 16s tests and a lot of shotgun tests, mostly shotgun these days because it's come down in price and it will be bad.

Exactly.

Yeah. But I have found them to be really both technology to be immensely helpful in practice and made a huge difference to finding cause of what's driving different conditions.

Will it guide you to specific treatment or a specific antibiotic?

Well, I don't use antibiotics, but I will use prebiotics, I'll use probiotics, dietary stuff. But yes, for sure, like every week of my practice life I'm analyzing someone's microbiome and going, okay, you've got too much of this, you've got too little that eat these, eat more legumes, take this fructaligosaccharide or take lactulose or parkin hydrolyzed guar gum. Eat more polyphenols to feed these ones. I also use herbal medicines to alter and reduce levels of those that are in excess. Like the skin of pomegranate. Pomegranate husk is one of those polyphenol rich extracts that's got studies showing it Will reduce levels of enterobacteriacea and proteobacteria, but actually not harm. But increased bifidobacteria, for example, and increased B ray present microbes. So there's a range of tools we can use to shift that. But yes, that's the corn store by practice is doing exactly that of looking at that and going, okay, how is this contributing to their. Does he say listen occasionally it's not. Sometimes you get this beautiful ecosystem. You're like, okay, it's not that we can just put that aside and do something else. But I can tell you that's rare for most people. There's definitely. And I do look at the world through a microbiome lens. Somebody's researched the microbiome for 25 years. It's like I am looking that and I'm looking and I'm seeing these connections that other people wouldn't necessarily see. But I also treat patients and they get better from that approach. So, you know, and I think the data has so shown the importance of the microbiome, how important that is over the last 20 years. Yeah.

All this advice will be mentioned in the testing of the microbiome, isn't it?

And sometimes the microbiome tests, you mean.

Okay, yeah, you get the. After the. The results, you get the advice and therapeutic options in the test themselves. Will it will. Shall we go with this?

I don't mean.

I was just about to say that's just extremely generic. And this is. That's the problem. Right. It's extremely generic. And I think my clients would have the exact same thing. Like when you read these reports, they're like, okay, so what do I do? I was like, well, you need to work with someone who can interpret these results.

Yeah. And implanted for you too. Because I think that's the thing too is like sometimes it's like someone who's got IBS and reservoir hypersensitivity, let's say in slow bowel transit time. But they have low B ray producers. I'm like, okay, well, I want you to eat more resistant starches and more legumes. Will that feed your beer producers? Yeah, but Jesus is going to cause some horrible pain and discomfort.

Exactly.

In that process. So you have to like, okay, how do we deal with this bit? How do we bring it in at the right pace, et cetera. Yeah. So this is where the tricky bit comes is I like. And looking at different tests around the world, like there's some that do amazingly. Like there's one in Australia that does a really. They've done a great job of, of having evidence based guidelines with, you know, stars of how, you know, et cetera. But it's still, you can't implement that for that patient until you, yeah, until you work out what's going to work for them in terms of where they're at, you know, and, and that there's a lab that's done a great job and other ones have done nowhere near as good of a job. So, so they can give you some ideas. To be honest, I never look at them, but if you're not used to, used to soil testing, you can look at them and get some ideas, but it doesn't mean that they're going to be applicable to that.

That's what I tell everyone and I even sometimes it's funny because gastroenterologists, I've had a few would come to me, well, like, we can do that. We can do, you know, we've given them the advice. I was like, oh, just like you said, that person is extremely sensitive to resistant starch and it tells you that they should be eating, you know, potato salads or lots of barley. I was like, well, that was one of their trigger foods. Of course we want them to be eating that at some point, but it just does not make sense. So I think. No, exactly. So it's really about interpretation and perhaps even just educating clinicians on how to interpret these results and get dietitians or specialists on board as well who work in this field.

Yeah, well, I do a whole course on this actually. My compiler interpretation results because of this, because it's exact issue. I think it's something that we clinicians need to know. But it's also become so complicated and because the knowledge base has grown so much that, that you can't expect someone without any upskilling to know it. I think that's the thing. Like you go back 20 years ago, it's like we knew so little. And my microbiome test 25 years ago looked at four microbes. Activacillus, Bifidobacterium, Enterococcus and Escherichia. That's it, you know, and we're gauging people's health based on that. And you know, that it was probably simpler in that day and age, but now we're getting results with like 400 species. Most, some of which we still have no idea what they do. We all agree on that. But other ones were like, actually this is clearly problematic. This one's clearly healthful in its current range and we have the ones that are in between the pathobionts that we're in the right zone, they're great. But if you get too much and even Akkermansia is that, you know, if you get too much Akkermansia and you're not going to ever get that with supplements but if you do have that too much Akramasia growing in your gut, it, it can cause inflammatory changes and thinner pseudo protective mucus layer. But not having enough, you get right leaky got in metabolic defects. So you're supposed to be like right in the zone, you know. And I think there's a number of microbes that we're realizing fit into that category which are technically referred to as pathobiolons. Yeah.

All right. Well, as we slowly come to a close, although we don't want to let you go, but I think it's probably bedtime. No, it's not even bedtime where you are. We've got a quick window. Don't worry, I'm in bed by 8:30. Sleep with the kids. Dad, you're a night owl.

Yeah, I'm. I sleep after, after seeing the football match of Liverpool. So about.

You gotta wake, wake up a bit late to get to that to see that one live.

No, no, I, I got early, I used to sleep about 11 or 12 and I got up 7 o'. Clock. It's okay.

That's worth.

No worries.

All right, so the quick fire round of questions.

Yep.

One probiotic myth that drives you crazy.

That the more strains and the higher cfu, the better the probiotic. That drives me crazy because it's not true. And usually, often, not always often they choose the cheapest strains possible.

Exactly.

Half as much in there that have no research base. Because when you're a company you're trying to come up with a probiotic product, you can pay premium for clinically trialed products that have got huge scientific data behind them or you can pay really low for strains that got nothing and you can pack more of them into a supplement. So some companies choose that and because they can push, there's more, more strains, more cfu. It doesn't guarantee you're going to get. In fact, yeah, a lot of those products are far worse than the single strains that we know exactly what they're doing.

Some patients tell me this, you know, I got this probiotic, it's 100 billion.

Yeah.

So how about that?

Yeah, but it's education, right? It just comes down to educating the public. But the problem is it's all these marketing claims and you know, people who don't know better because they're desperate or they just want any, you know, I'm not going to say quick fixes, but I completely agree. I think it's really about educating the public as much as we can as, as clinicians. Next question your go to fermented food. We clearly establish that it's not.

Not yogurt. I love vegan kimchi so I don't like the fishiness to it but vegan kimchi I love. So I've got four different types of vegan kimchi in my fridge right now. So I've had different ones for different meals.

Very good. And one thing you wish everyone knew about the gut microbiome.

How vital it is and this is getting out there. But as someone who's been 25 years of talking about it, this is like so vitally important for you. And I think even I like this idea of custodianship as well because we're born with a certain number of microbes and we're gifted to from our parents and we kind of give that to our kids. Yeah. But we only give our kids what we have. So we've got to be a custodian to try to ensure that we have this wide diversity, nice richness of this ecosystem to pass on to the next generation. Because what we find in Western nations is we're narrowing that every generation. We're getting less and less to the next generation. And many. And I would argue, and I would agree that that sort of dysbotic state or lack of keystone species is kind of what's involved with the chronic disease epidemic that we see around us.

Wasn't there a documentary? Sorry, I have to just bring this in. Is it the Great Extinction or something similar? Something about. I'll remember. But it was a brilliant documentary about how a lot of microbial species are becoming extinct and we're never going to get them back.

Yeah. And I'm thankful that there's researchers out there who are going to like the Amazon rainforest, exactly what they're doing and they're confusing them. So at least we've got some record of what humans used to have.

Exactly. That's exactly. I cannot remember that documentary, but it was great. I remember I went to the, to the screening and it was, it was a brilliant document.

I think it was called the Great Extinction because I'm totally fascinated by that area. Totally.

And that's what they were doing. They were actually going around the world collecting microbes and freezing them and there's like a microbiome bank I'M not sure if it's built already or they're building it, which I'm in the North Pole.

But I've always wondered what the like the Yamamato Indian tribe, like Venezuelan Amazon rainforest with like no contact with Westerners. And the first people that come say, hey, can we take your poo? It's a weird conception of like, sure.

There you go.

Yeah.

All right, final quick round we've got. Are there any probiotics that you personally take? And why not daily?

No, but I'll share my prebiotics. I take daily. I take fructoligosaccharides daily, partially hydrolyzed gargon daily and galactool oligosaccharides daily. And this is to often as people age, I'm getting to that point where the microbiome starts shifting and it's like you're getting less bifidobacteria, less butyrate producers. And listen, I do everything I can diet wise, but I'm like, I want to take some extra food for my good guys as well. So I take this and I've been doing this prebiotics daily for probably over a decade now as well. Yeah. And then indeed increased absorption of calcium, increased absorption of magnesium, less respiratory tract infections. Like there's all these pluses that come from prebiotics and they're inexpensive of easy to get in some like, like food allergic would say it's like sugar, you know, it's like it's just like a teaspoon of sugar after a meal. Like. Yeah. Anyway, it's easy to get in a lot of research for, for med walk health and type 2 diabetes. Now there's a whole meta analysis using inulin phos for for diabetes with excellent results. So yeah, they're good things and I think they're more important to take daily than a probiotic for sure.

I'm a hundred percent behind. I do take phdg when I do remember, but that's a staple. I mean I did have that today in my smoothie. So I have my big green smoothie here which with all the goodness. Dad, is there anything that you want to ask?

I think at least you covered a lot of things which is, which was amazing discussion about probiotic and microbiome. It's very, very informative.

All right, well, to close off the podcast, Jason, could you share your three personal gut health habits and where listeners can find you.

Three personal. Well, I think prebiotics I've already shared.

There you go.

Taking prebiotics daily I think is Hugely important. Eating predominantly plant based diet doesn't have to be completely plant. It's gonna be mostly plant, whole food, nothing ultra processed and have wide variety. And eating a rainbow of foods. Yes, we got lots of different colors. Cause different colors will give us different polyphenols which will feed different microbes, different variety of foodstuffs, like lots of legumes and nuts and seeds and whole grains, fruits, veggies, means we're getting lots of different fiber shapes and sizes which feeds a wider diversity of our microbes. The sort of core ways of enhancing our richness and diversity of our ecosystem. And thirdly, I'd say grow a garden and an edible garden ideally, but even like an ornamental garden, we still get some microbiome support from that. But for me, I've just got a garden. Let's wander around in the morning and I'll pick. I've got probably nine different types of greens that I'm growing in my garden which I'll have for breakfast and other ones at night. So I think just having a garden like that where you can just meander, harvest, smell, touch, interact with, we know we're exchanging microbes all the time. And people that actually have a garden that they interact with have got more diverse ecosystems and those that grow food from the garden have more diverse ecosystems. So you can tie those two in together I think is a lovely thing and it brings me joy too. But I also just love it. It's going out and grabbing things to eat, which I think we've historically always done until recently. So it's nice to.

Yeah, I love that. I mean we've got, we've got two massive veggie, kind of veggie patches on the balcony because I mean again, you can grow anywhere, you don't have to have space. I mean, dad, you've got, well, you're in Dubai. Like the climate is a problem. I think.

Yes, we do, we do only in winter. You know, your mom is doing only in winter, but summer is very hot for anything. But she, she does everything in winter, which is very nice.

Yeah.

From farm to table, literally.

Yeah. And I mean I'm lucky. I've got a half acre block that's in the subtropics and we get lots of rain. So it's like 12 month growing season. And we have some trees like moringa trees and another tree called katuk where you just get leaves 12 months of the year off the tree. You know, you don't have to replant it like lettuce every, every few months. It's like what it's constantly giving, which it's, you know, one of the benefits of this climate. It's that.

All right, so where can listeners find you? And you mentioned a course as well.

Yeah, So I have kind of two things. One is the Microbiome Restoration Center. That's my sort of course portal where I'm educating health professionals around essentially the microbiome and how to interpret tests and its role in all these different conditions. Not even just got conditions, but more broad than that. And then I've got the Probiotic Advisor, which grew out of my probiotic teaching that started off with some paper notes back in the early 2000s and lecture notes to actually now it's an online searchable database to make that prescribing easy of probiotics. You can type in antibiotics and it'll show up which probiotic strains got clinical trials, whether it's systematic reviews or RCT data. And where do you find those strains too, in terms of what products? That's trying to make this easy. Because I like, he was like, yeah, I can go look at Medline and do all this, but it's like, okay, I'm a clinician, I'm busy. I've got all these notes because I've been teaching on this topic for 20 some years. And I shoved it all into an online database that we update. So that means you can search depression and it comes up what strains to use for depression and anxiety in a summary. It's the trial.

I'll definitely pop that in the show notes as well. Well, dad, I'll send you the link because I see your face, you're like, ooh, can I find this out now?

The course, very interesting. Just if you have this course to interpretation of the microbiome, it'll be fantastic.

Yeah, yeah, no, I, I, that's, I'm teaching, I'm in week eight of my course right now and I, I love it. It goes for a 10, 10 week course. But yeah, it's, we got people from all over the world actually in all different backgrounds too. So that's, that's been great too. And we look at tests available in other parts of the world, not just, just one country centric, which is good.

All right, well, we're wrapping this up. Thank you again. I know we can. Dad wants to keep you here. I can see that. He's like, I'm, you know, I've dropped out and I missed out on a few things, but thank you again. It was a brilliant, brilliant episode. And, and yeah, we'll definitely keep in touch.

Thank you for listening to this week's episode of the Gastroenterologist and His Daughter podcast. Don't forget to join us again. And if you've been enjoying our chats, make sure you subscribe, follow or leave a review on your chosen platform.