Recently I interviewed Dr. Jason Hawrelak, and we talked about the adrenal transformation protocol. If you would prefer to listen the interview you can access it by Clicking Here [1].
Dr. Eric Osansky:
I am very excited to chat with Dr. Jason Hawrelak, as he was actually my instructor when I went through my master’s in nutrition at the University of Western States. I’m not sure why I haven’t invited him to the podcast sooner because I have been following him for so long. I keep mentioning his name when I’m doing my own courses and talking to patients. It’s an honor to have Dr. Jason here. We’re going to be chatting about prebiotics, probiotics, and the gut microbiome as a whole.
I’m going to dive into Dr. Jason’s bio. Dr. Jason Hawrelak is a researcher, educator, western herbalist, and naturopathic physician with over 20 years of clinical experience. He did his Ph. D examining the capacity of probiotics, prebiotics, and herbal medicines to modify the gastrointestinal tract microbiota and teaches worldwide on the topics of microbiota modification and gastrointestinal health. He has published extensively in these areas, including 20 textbook chapters.
Dr. Hawrelak is on the Medical Nutrition council of the American Society of Nutrition. He is a fellow of both the American College of Nutrition and the Naturopaths and Herbalists Association of Australia. Dr. Hawrelak maintains a busy clinical practice in Hobart, Tasmania, Australia, where he consults with patients from all over the world.
Additionally, Dr. Hawrelak is chief research officer at ProbioticAdvisor.com. I must say it’s amazing. That offers a searchable database that enables easy, evidence-based prescribing of probiotic products and online resources for clinicians to learn more about the human microbiome and how they can positively influence these ecosystems. Thank you so much for joining us, Dr. Jason.
Dr. JasonHawrelak:
You’re welcome, Eric. I’m trying to remember how long ago it was that you were a student of mine.
Dr. Eric:
Quite a while. I believe I specifically took your course in the fall of 2013.
Dr. Jason:
Goodness, okay. You were definitely one of the early ones, weren’t you?
Dr. Eric:
Yeah. You no longer teach in Western States, do you?
Dr. Jason:
I’m still there.
Dr. Eric:
Maybe that was in the bio, and I just wasn’t paying attention. I should know this. I have attended your online courses and listened to your podcast. You’re still teaching there.
Dr. Jason:
That’s one of my passions. I thoroughly love teaching. I love nothing more than teaching stuff to practitioners because I love the ripple effects that go out when you can improve the way practitioners are engaging with their patients, improving outcomes, actively changing lives. An honor and privilege but also great joy to teach. Coming onto a podcast like this, too, because you have a chance to reach so many people you otherwise wouldn’t, hopefully improving their lives with information they may have been waiting for, but now is the time to hear it, changing the direction of their health. That’s what we’re hoping for.
Dr. Eric:
Can you give us some of your background? How did you start becoming an expert when it comes to gut microbiome and probiotics? What motivated you to create the website ProbioticAdvisor.com?
Dr. Jason:
Some of it was probably almost chance. In my final year of naturopathic training, there was a lecture around dysbiosis and leaky gut, how it drove so many other chronic diseases. This was back in 1999. That lecture stirred something in me. This stuff is amazing. I really want to delve into the topic and dig into it.
I finished off my naturopathic training and did an honors degree. It’s a research-based project. I folded that into the Ph. D. I did a clinical trial of looking at prebiotics and probiotics in IBS. Changed the gut microbiome. That was 2000. Followed that up with my Ph. D. If I had not showed up to class that day and missed that lecture, my life would have taken a different path. Who knows? Exciting area. I find it immensely exciting still.
How do we change the microbiome in patients with IBS using prebiotics? Probiotics? I started teaching clinical applications in pre and probiotics, essentially back in the latter end of my honors degree, back in 2002, to naturopathic students to share what I learned from spending a year devoted solely to that topic. I learned a lot more than what I was taught in my training. We did a fair amount of stuff, but it was scratching the surface.
There are certain things around strain specificity that was not touched upon in my training. When you delve into the research, some probiotics are good for certain patients, and some strains are good for other applications. It blows your mind and changes the way you look at using probiotics from what I tend to call the old paradigm, which is you do a stool test. You’re low on Bifidobacteria; take some Bifidobacteria. That was the old paradigm.
Versus the new paradigm. Doing clinical trials showing that Bifidobacterium strain P1009 speeds up colon transit time and softens stools; therefore, you use it for people who are constipated who have slow transit time. You wouldn’t use that strain for someone who has diarrhea or an H-pylori infection. The research has built up around probiotics, and you get to see how much differences there are between different strains even within the same species. How important that is around choices we use therapeutically as tools. Making sure we have the ones with the actions required to treat the condition of the patient we are trying to help.
Dr. Eric:
I found that fascinating because I learned that from you. Before that, I didn’t know about how you should use probiotic supplements with specific strains, just like a lot of other practitioners still do. I was just recommending probiotics without knowing anything about them. A lot of practitioners neglect prebiotics as well. Definitely want to look at the strain. You’re looking at a probiotic supplement, and it has Lactobacillus acidophilus. It’s not actually giving the strain. Then you don’t really know the therapeutic benefits that it has.
Dr. Jason:
No, you don’t. In this day and age, it’s unforgivable for a supplement company to only be providing species-level information. 20 years ago, when I first started, it was a bit more forgivable because the concept around strain was newer. It had been known for a while, but it was a newish idea that we could have marked differences within the same species by the strain designations.
Now, if there is any company that doesn’t list the strain and just has species name, I will not use it as a tool. You just don’t know what it’s useful for until you do research. We don’t know if it survives stomach acid or bile salt exposure, whether it adheres to the gut, whether it produces an antimicrobial compound that is helpful or detrimental in the gut, whether it has any therapeutic effect at all, unless we do research on that specific strain to see what it does in reality.
I can’t help but think of a relatively new psychobiotic, which is a probiotic that has been shown to help with mental illness, that has hit the marketplace in the last couple years. Lactobacillus plantarum PS128. That was originally isolated from a traditional Taiwanese ferment, cabbage mustard green ferment, which is 500 different types of lactic acid, using those bacteria naturally found in the ferment. Through a lot of testing, they isolated that one strain that had psychobiotic effects. When you give it to animals, it changes the amount of serotonin and dopamine in their brain. The animal studies were pretty consistent.
Let’s change it to humans. They gave it to kids on the autism spectrum. Lo and behold, it decreased defiance, repetitive behaviors, and anxiety. They used the same strain in Parkinson’s disease and other conditions like that. It’s phenomenal. You can’t expect any random strain in that fermented food to have the same effect. They isolated that one strain that had the characteristics they were after. A bunch of strains did not. It puts that in perspective.
Scientists do that well, and companies do this well. We have this well-researched, well-characterized agent that has definitive efficacy in these conditions. Versus you can go, “Okay, well, this is a random L-plantarum, and let’s hope it has some impact,” which is where I think a lot of practitioners practice because they are unaware of this strain stuff. “Let’s give some probiotics and see if they help.” It’s hit and miss.
I think they will be missing a lot more, and their patients will be suffering as a consequence of not prescribing things based on the best scientific evidence, and with the way the information has evolved in the last 20-30 years.
Dr. Eric:
According to what you mentioned, having specific strains is more important than having a higher potency, like the colony forming unit (CFU). Not saying it doesn’t make a difference. You want to have at least one billion CFUs for most probiotic strains. Just because something has 100 billion CFUs doesn’t make a difference if it doesn’t have specific, well-researched strains.
Dr. Jason:
No. I like giving this example of antibiotic-associated diarrhea. There is one study that gave Lactobacillus reuteri DFM 17938, which is sold around the world as BioGaia to these elderly people taking antibiotics. They did give 200 million CFUs per day.
Another study looking at elderly people taking antibiotics in hospital settings. The same population. Gave 60 billion Lactobacilli and Bifidobacteria strains.
Fast forward. Two different results. The 60 billion did nothing. Didn’t stop diarrhea at all. Yet the 200 million of that one specific strain worked amazingly well. That is such a clear example of choosing the right strain with the right actions versus billions of the stuff that we don’t know if it works or not, and it turns out it didn’t work.
That same strain combination that didn’t work for antibiotic-associated diarrhea does have some positive research for improving quality of life in IBS patients. It’s not as useful for any condition; it’s not useful definitively for antibiotic-associated diarrhea. The L. reuteri strain that we use in that study, even if we are giving 300x less dosage, does work.
Dr. Eric:
When it comes to specific strains, a question I get from people time to time is fermented foods. Can’t I just take fermented foods instead of taking a probiotic supplement? If it’s for therapeutic purposes, it might be also hit or miss since you don’t know what strains are in the fermented foods.
Dr. Jason:
They are generally wild ferments. You can be very directive with your ferments and use a probiotic strain with well-defined characteristics as your starter. If there is a way of guaranteeing that’s the end product, which you can sometimes do with different microbiome analysis labs. You can send your ferment there and see what’s actually there. It is possible you could make a ferment based on the right strain to make sure you’re getting that strain in a food base, sure.
In terms of what most people are having, they’re wild ferments. Sauerkraut, kimchi, we are just letting the natural bugs found on there ferment that cabbage. You don’t know what you’re going to get. You know the species stuff, fine. It’s most likely Lactobacillus plantarum, some strain within that species. It doesn’t necessarily mean it will have any therapeutic quality to it. Doesn’t mean it will survive transit to the stomach or bile acid exposure or attach to the gut or produce any selectively acting antimicrobial compound, or it might increase an antimicrobial compound that might kill beneficial bacteria. You don’t know any of those things in a wild ferment.
I drink kombucha and eat kimchi and sauerkraut daily. I think they taste great, but I think it’s a way of enhancing your immune reactivity by interaction with different microbes in the environment, which I think is always a part of what humans have done and part of what we should still be doing. Increasing the diversity of our ecosystem by introducing these microbes that are generally temporary visitors.
While you’re eating them, you’re adding another 20, 25, 30 species, depending on how diverse that ferment is, that are in your gut for these temporary time periods. There is no way I would rely on it in the same way that I would the PS128 strain to the kid on the autism spectrum that we know changes neurotransmitters in the brain because other strains of L. plantarum cannot. We know they don’t have that capacity.
You may luck out on the sauerkraut lottery and have a psychobiotic strain in there, but there is a decent chance you have not. If you take the sauerkraut and feel really happy after, maybe you have won the sauerkraut lottery, and you can use it as a starter culture. With wild ferments, they’re just that. They’re wild. They’re diverse. There is a strength to that. There is a place for that in healing journeys. It’s not really trying to target specific issues.
Dr. Eric:
One thing you also mentioned is with fermented foods in the species or strains that come with them, you’re not sure if it’s going to survive stomach acid. When it comes to commercial probiotics, are typically all of them resistant to stomach acid? That is a concern for some people. If I take it, will it actually reach the desired?
Dr. Jason:
I think this area has probably been overfocused on by companies selling other probiotic preparations to try to make you wary about using Lactobacilli or Bifidobacteria-based ones. “They don’t survive stomach acid anyway, so there’s no point.” It’s been a selling point for other types in the market and has taken hold sadly.
If you went back 30-40 years ago, you’d probably say there is a decent chance that a number in the market would not meet the criteria of survival to the upper gut. Fast forward to now: any preparation that has well-characterized strains like L. rhamnosus GG or DSM17938 or L. plantarum 229B, we know that they survive stomach acid and bile salt exposure. They can show up in your poo after. They did these studies before they brought them to the marketplace.
These days, scientists are generally doing these preliminary studies, taking these 500 strains of Lactobacilli from this fermented Taiwanese traditional food, and we will put them through an obstacle course. Does it survive bile acid exposure, stomach acid exposure? Does it adhere to the gut? Looking at all these different characteristics. They might find 5-10 that do. Those ones, they will take into animal models, and then eventually human studies. You want to see what they do beyond survival. The ones that are well-defined strains, yes. They will survive everything easily.
There is a risk if you’re using probiotics that do not define the strain. You have no idea what you’re getting. The reality is a supplement company can buy well-characterized, well-researched strains that have all the background data done on them at a high price point. Or they can buy at a low price point, where some microbiologist said, “I isolated 500 strains from this sauerkraut and will sell it because it’s cheap.” We have no idea if they have the basic characteristics required. There is always a risk in numerous ways in buying supplements that do not define the strain characteristics.
If we buy the ones that do have the strains and have positive clinical trials showing they work, then we don’t need to worry about whether they will survive in the upper gut or not. We know they work. We have clinical trials showing they work.
Dr. Eric:
I learned that you’re supposed to take probiotics with food because some sources will say not to take it with food.
Dr. Jason:
Yeah. That’s one of those myths I have been trying to bust for 23 years now, Eric. The data was relatively clear back then, and it’s even clearer now. We have better survival with immune. This matters far more now for Lactobacilli or Bifidobacteria-based probiotics. Saccharomyces, doesn’t really matter. Bacillus, doesn’t really matter.
With the new generation of probiotics, like those based on Akkermansia, I reckon they will be better with food, too. They are often impacted by a really low pH. When your stomach is empty, the pH is around 2, 2.5. When you are putting bacteria in there, it’s really acidic. It’s designed to kill bacteria. It does that pretty well. When you have food, the pH goes to 4 or 4.5. It’s closer to neutral. It’s still acidic, but it’s a far cry from pH of 2, 2.5. We have better survival from the bacteria that go through with a pH of 4, 4.5. The bigger the meal, the more buffer the pH has.
There is research that shows that dairy food actually works as a better medium to transport bacteria through. The buffer in pH is even more so. It provides a more neutralish environment for microbes to pass through the stomach intact.
Dr. Eric:
Lactobacillus, Bifido-based bacteria probiotics, take with food. The newer probiotics as well. You mentioned Saccharomycesboulardii, not necessary. If you are taking Bacillus-based, like spore-based probiotics-
Dr. Jason:
The spore-based ones don’t matter. That’s one of their strengths. You can buy some spore-based stuff that is mixed into baking kits that you buy and bake in the oven. Other ones, you add boiling water to herbal tea, and that doesn’t kill them. They are quite resilient and release in the gut. That’s one of their strengths, is their capacity to survive in a wide variety of environmental conditions that would otherwise kill. If you pour boiling water on the Bifido bacteria, they won’t survive. The Bacillus spores will survive and release into your gut at a later time.
Dr. Eric:
Sticking to the topic of spore-based probiotics, I knew a few years ago, not that you weren’t in favor of them, but the research was still behind the Lactobacillus and Bifidobacterium. Do you still feel that way, where there is still a lot of research to be done?
Dr. Jason:
Yes. There are clinical trials showing they do something. For me, that’s the indicator. If there is evidence showing that something is safe and efficacious, a spore-based probiotic will work for this condition. We are seeing that evidence grow. There has been some Enterogermina strain of Bacillus on the Italian market since the 1950s that has a fair bit of research on it. It is an exception that has a higher research base.
In other areas, the products have been overhyped before the research was there. That is the thing that triggered me a bit. If we have these Bifidobacteria and Lactobacilli ones with clinical trials showing they work, and then someone selling the products says, “Don’t use them. Use mine that has no data for it,” it doesn’t feel right to me.
I have been happy to see that the evidence base has been growing on those. You get ones like the Bacillus coagulan GBI-30 6086. There is some interesting research that is useful for rheumatoid arthritis and functional abdominal pain. A couple of conditions with less research data on other probiotic strains. If you were still to compare the total amount of research on Lactobacilli-based bacteria versus Bacilli, the research on the traditional ones far exceeds what we currently have on the Bacillus-based ones.
Dr. Eric:
Let’s dive into prebiotics. Can you discuss why prebiotics are so important and perhaps some of the best food and supplement sources of prebiotics?
Dr. Jason:
I think prebiotics, as you alluded to before, are an underutilized tool in most people’s clinical toolkit. Not for me. I was enamored by prebiotics when I started doing my honors degree in 2000. I wasn’t taught anything about them in my naturopathic training. I started reading the studies. There are these things that dramatically change the microbiome, in selective ways, far beyond what we’re going to get by taking a probiotic and eating fermented foods. There is a dramatic impact, and selective.
Let’s look at what a prebiotic is. It’s a selectively fermented compound that encourages the growth of one or more beneficial species of bacteria in the gut to produce health benefits. That’s how it is defined. We only have a limited number of compounds that currently meet that criterion. That would be inulin-type fructans, which we would typically call fructooligosaccharides. Then we have galacto-saccharides.
We have lactulose, which would probably surprise many North Americans because lactulose is one of those things that has now been earmarked as a breath test substrate more than anything else versus as a prebiotic since the 1960s. It was in infant formula as a way of making it more like breast milk. It was pigeonholed in the U.S. with some negative connotation.
When you look at the science behind it, its capacity to alter the ecosystem is fantastic. Its capacity to decrease levels of proteal bacteria like E.coli or Klebsiella in the gut is paralleled as a prebiotic. It works amazingly well. That overgrowth of Bacteroides populations, it will bring down very well.
There is a study published in 1997 which was one that really blew my mind. It was recent when I first started my honors degree. It showed we had a 1,000-fold decrease in Bacteroidespopulations and 100-fold decrease in E.coli populations in the gut when people took lactulose as a bacteria. For every 100 E. coli, there was now one. For every 1,000 Bacteroidi, there was now one. Dramatic impact. 100-fold increase in Bifidabacteria and 10-fold increase in Lactobacilli. These massive shifts.
That got me excited. Clinically, if you see results like that in patients, you see these dramatic shifts in ecosystem composition as a result. We get that in supplemental form for sure. I tend to use them primarily that way. However, we can also get food sources that contain Galacto-oligosaccharides, which is primarily in legumes. We do get some in things like beets for example. It’s scattered in other vegetables, but the amount is tiny. Versus legumes. All legumes have a good amount. That’s what makes legumes give you gas. You get gas because there is indigestible compound called Galacto-oligosaccharides. They reach the colon, feed specific beneficial members of your gut, but you do get some flatulence that comes with that.
Inulin-type fructans, we find more broadly across different foods, like onions and garlic are really rich sources that we have commonly. Also, wheat, rye, barley are decent sources as well. Particularly when people eat a ton of it, which they often do with wheat products.
There are some foods that are less commonly eaten by us as westerners now than our ancestors would have eaten that are quite high, like burdock root. It’s like 10% inulin-type. Jicama root. Yacon tubors have 15%. That’s a South American vegetable. There are a number of traditionally consumed vegetable crops throughout North, Central, and South America that are high in inulin-type fructans. A high part of people’s diets who are traditionally from those areas. Chicory roots, dandelion roots, people with European backgrounds used to go and collect those things to consume. No longer because they taste bitter. We have lost our capacity to deal with bitter flavors as a culture. There are large amounts within those foods. Even dandelion leaves have large amounts as well.
Dr. Eric:
Do you personally take prebiotics in supplement form, or do you rely more on food sources?
Dr. Jason:
I do both. I definitely take my inulin-type fructans daily, and almost partially hydrolyzed guar gum, which is one we haven’t talked about much. It is somewhat unique because it is very good at feeding butyrate-producing bacteria in the gut. Lactulose, galacto-saccharides, they tend to feed Bifidabacterium pretty consistently across the board. They will also increase another group called the Calibacterium as well as having decrease in pathogenic bacteria as well.
Partially hydrolyzedguar gum feeds an array of species in the gut. It doesn’t really lower the levels of potentially pathogenic microbes, so that’s not a strong point. Feeding butyrate producers, which is such an amazing substance. I chose my diet to nurture my microbiome. I choose my foods to nurture my butyrate in the gut. I also supplement with hydrolyzedguar gumin my daily regime.
Dr. Eric:
You mentioned that prebiotics could lower opportunistic or potentially pathogenic microbes. Is there concern that it could do the opposite? Maybe prebiotics would feed the different opportunistic bacteria.
Dr. Jason:
Some of this comes from a study published in the early 2000s that suggested, let’s look at fructosetriglycerides. In this particular study, if you took Klebsiella out of the ecosystem context and put it in a petri dish with some phoss in there, it could grow on that phoss. People got freaked out by this. FOS feeds Klebsiella.
What they didn’t do was look at the other components of that study. Klebsiella in the ecosystem of poop, when phoss was added to the fecal slurry, Klebsiella went down, not up. There are no human studies showing that Klebsiella goes up when we give phoss. It’s like taking research out of context, going, “Oh my god, there is this in vitro study, but we will show all the human studies that shows it does the opposite,” which I find strange.
Phoss can cause gas and bloating and dysfunction. I might fart or bloat more if I take it. Bloating in dissension is a sign that your gut is not working well, and you need to do something to look at what’s going on there, whether it’s slow transit time or SIBO that is driving that that you need to address. It’s not that the phoss is feeding the bad bacteria. That’s where people sometimes go, “We have this in vitro study. I eat this, and I get bloated. I’m in pain. Therefore, it must be feeding Klebsiella. That’s why I’m in pain.” That is ignoring the human studies that don’t show that.
I can say from giving phoss to thousands of patients, and doing pre and post sampling, microbiome analysis, you do not see these things go up on phosssupplementation. It’s not reality.
Dr. Eric:
If a practitioner was to do a stool test, and it showed a few opportunistic bacteria, which is common. Let’s say there is Streptococcus, Staphylococcus, Klebsiella. Some practitioners might say to give antimicrobials such as oregano. Would a better approach be to give them some prebiotics, or even probiotics, to do things to increase stomach acid? Or is there justification for antimicrobials, even if they are just opportunistic and not necessarily pathogenic?
Dr. Jason:
Good question. I think it depends on what’s there and how far off normal it is. I do see some people look at the results. Streptococcus is in the red, but it’s a tiny bit above the normal range. That’s not problematic really. Sometimes, you might have E.coli tenfold higher than normal range. That’s problematic, and I might use a combination effect. I might use saccharomyces cerevisiae or DSM 17393 or a compound called Reuterin to target E.coli, and I will use lactulose, which will bring E.coli down. I might use an herb, too. I’m very selective.
This came out of my Ph. D research. We were curious about what impact different herbal antimicrobials might have on the gut ecosystem. This is back in 2001/2002. We did some in vitro research at that time. Grab some bacteria that are representative of the keystone species we knew about at that time that we could grow in petri dishes. We will expose them to different herbal antimicrobials and see if they only kill pathogens and leave good guys intact, or if they kill everything, or if they lower good guys in lower concentrations. We were really curious.
It turns out that some of those ones did do that. Citrus seed extract killed everything; if anything, it was more effective at killing the good bacteria than it was the pathogens. We used Clindamycin as our positive control, which is a pretty full-on antibiotic. It wiped out Clindamycin as the concentration. It killed everything.
We had things like garlic that only targeted things like candida, E.coli, and left Lactobacilli and Bifidobacteria alone. We had oregano essential oil that was good at killing Bifidobacteria, but sadly Lactobacilli was fine. It did kill some pathogens, too. Berberine-containing herbs were also good at killing Bifidobacteria. Lactobacilli were a bit more tolerable to it, and it killed some of the pathogens.
It was an interesting project. It became integral to my choice of herbs. Antibiotics cause damage, but herbs are fine. No. Hold on, that’s not true. Depending on what herb we use, what form we use, what concentration we give it in, what dose, we can kill lots of beneficial bacteria with our herbs. That really changed the way I practice from that point on. I can choose things that work selectively as much as I can, which thankfully is most of the time. We can choose something that will target the E.coli but leave Bifidobacteria and butyrate producers alone.
There is more research that has come out in that vein in the past 20 years around how herbs are more selective and certain ones are not. You shouldn’t underestimate the impact of the right prebiotic and probiotic for shifting things in the gut, too. If it’s only a minor imbalance, I will often use dietary changes, prebiotics, and probiotics to shift things.
I had some patients with Crohn’s, and 50% of their ecosystem was E. coli. Some context here: Normally, E. coli are 0.01%, or 0.1%. That’s the normal range. I had two people where it was 50%. In that case, I am not just using prebiotics and probiotics. I am also adding herbal medicines. One of the benefits is that it targets Klebsiella, Streptococci, E. coli, but leave butyrate producers alone. They go up if we utilize it. Some herbs are just amazing in their selectivity. When you get on board with targeting things and doing things in a selective way, putting the microbiome first, we end up with better results long-term for our patients.
You can look at things like berberine, which we know does kill a different range of pathogens. Some interesting research has come out about longer-term use of berberine, where it causes decreases in the diversity of the ecosystem. It produces butyrate-producing species in longer-term use. It reduces Bifidobacteria populations with longer use. Importantly, it increases levels of E.coli, Klebsiella, and other nasty bacteria, which is one thing that should be on clinicians’ radar when talking about.
Berberine is a new “let’s use it for everything” supplement. When there is research done on the impact to the microbiome, there are definitely some negative impacts with long-term use that should be on our radar. If you are using it or cholesterol or metabolic health, where you are giving it daily for long periods of time, you need to be aware of the significant dysbiotic effects it has on the gut.
Dr. Eric:
That’s interesting. I know oregano oil can be harsh, as can citrus seed extract. Maybe I need to dive deeper into berberine. If you do a search on PubMed with berberine and gut microbiome, a lot of it seems to be positive. But I guess you can’t argue with the research in terms of it does affect some of the good bacteria like Bifido.
Dr. Jason:
More surprising is look at the research of long-term use on humans. I think that’s a short-term thing, which might be one thing. I don’t mind using berberine for short periods of time. A couple weeks, no issue. But if you start giving it daily for months, that’s where you start seeing more substantive negative impacts of its use.
Also, it’s important to respect traditional wisdom, in that berberine-containing herbs were never given to people long-term in any traditional medicine system. They are always seen in short-term use, like Coptis chinensis, traditional Chinese medicine, really high in berberine. Always short-term use, don’t use long-term. Goldenseal was always seen as a short-term use. Don’t use it long-term. That is more from the North American/Western medicine.
This wisdom that was there around these things, and we have pulled out this potent antimicrobial compound, thinking it improves luxury control. Let’s give it to everybody long-term for years. Let’s fix this diet or lifestyle. Don’t do that. Let’s just give them this one magic pill. We’ll see there are negative consequences to the magic pill, whether it comes from the herb or the pharmaceutical lab, if we are not treating the underlying diet and lifestyle factors that led to that occurring.
Again, I think berberine in the short term is fine, but I think the data is clearly showing there are long-term negative consequences from the microbiota perspective. And unexpected, like the growth of E. coli/Klebsiella strains and blooms with long-term berberine use. Maybe you get this initial suppression, but then the bacteria become resistant to it, and then they end up growing as a consequence of continued use.
Dr. Eric:
Very interesting. Speaking of randomly killing antimicrobials, what do you think of practitioners who treat everybody for parasites? As you know, I interviewed Dr. Nerala Jacobi and asked her the same question. I’m sure I know what your answer will be as well. If you could talk about putting everybody on an antiparasitic protocol, even if it’s without berberine. Let’s take berberine out of the equation and other antimicrobials. Also, if you could expand on Blastocystis hominis, is it more commensal or pathogenic? There is also some controversy on that as well.
Dr. Jason:
There is definitely controversy around it. How the evidence has changed over 20 years. If you had asked me this 20 years ago, as a clinician, if I had someone who presented with gut symptoms and took a stool test that said Blastocystis, I would have said to treat it. Fast forward 20 years ago, no. I will work this patient up really thoroughly. 95% or even higher of the time, we find something else that is causing their symptoms. Generally, it’s SIBO. They haven’t been adequately breath tested for SIBO. They took a stool test, and they have symptoms, and they see Blasto and presume it’s the cause, stopping their diagnostic workup there. That’s the biggest mistake. All that focus is on this microbe.
If you start looking at recent data, it’s being viewed in a different light. It’s being associated with better, higher quality, more diverse gut ecosystems. People are now arguing it has an apex predator role in the gut. Just like wolves in Yellowstone National Park or great white sharks out in the ocean, they actually are the apex predator, and their job is to keep other populations in check. If we wipe out that population, there are consequences to the ecosystem, allowing other bacterial species to dominate.
Blastocystis is a bacteria eater. Some argue it keeps certain types from overwhelming, which is what we tend to see in Western culture. The lack of Blastocystis might be the reason why. I think the crappy Western diet is probably the reason, but it’s also the connection with the lack of species. Enough people in North America take antibiotics, and it’s not there anymore.
A billion people worldwide have Blastocystis in the gut. There are a lot of super-duper healthy people with Blasto in the gut. I’m putting my hand up here. I was doing stool test experiments, and it turns out I have Blastocystis in my gut. Do I have gut symptoms? No. Do I have fatigue or brain fog? All the things people attribute to that, I don’t have. If you subtest me, there are other people who have this in the gut, and it’s not a problem. Sometimes, the issue is if we stop our diagnostic workup as “You have this stool test, and you have these symptoms; therefore, that must be the cause,” that is the issue.
I do think that there is enough data out there to suggest to me there will be in rare cases a potential for Blastocystis to be a problem for a patient. I think we have to rule out everything first. After you do that, you rule out SIBO and everything else, but you do have this bug. Maybe it came from a case of travelers’ diarrhea. You didn’t have the bug before. Now you have symptoms. There is some stuff in the history that might make us think this is the likely cause. I would still focus on microbiome optimization, improving the health of the gut, and then seeing how symptoms go from that point over trying to kill this thing.
If it was as simple as pulling one of them out, there wouldn’t be this discussion. Here in Australia, there are people who run centers that do triple antibiotic cocktails, three different antibiotics poorly, sometimes at the same time as doing three antibiotics sprayed by colonoscopy as a way of trying to get rid of this bug because it’s been blamed as the cause of this person’s brain fog, fatigue, or gut symptoms. Then I am stuck with trying to mop up these people’s Blasto being gone, but now they are a hell of a lot worse than they were before because their ecosystems have been decimated trying to get rid of this. It’s a massive loss of diversity.
Weighing out the potential risks versus benefits with treatment. When there is lack of definitive evidence showing this as a problem, then I think we have to be very cautious about using big guns to target. Let’s make you healthier and see how you feel. It’s a different way of looking at it.
Can we potentially induce better behavior? We know with certain microbes—not with Blastocystis yet—if we make the environment more acidic, by adding more fiber or prebiotics, we actually bring out better behavior in potentially pathogenic microbes. We can turn different genes off and on. They can produce beta-glucuronidase, or toxic metabolites goes down. Candida, we can change the pH, which doesn’t grow hyphae that can burrow in your tissue but instead stays in bud form. We have enough data that if we can change the environment to a healthier one, we can bring out the best behavior in certain microbes and suppress negative behavior. The bug might still be there, but it’s not a problem in terms of the context of the environment.
Dr. Eric:
Do you take a similar approach with H-pylori?If someone has it in the absence of symptoms, would you also say to leave it alone?
Dr. Jason:
It would depend on the test I did. When I am testing for H-pylori, I am specifically doing it because I think it’s causing symptoms in that patient. I think there are a couple of stool tests out there that test it in everybody, that find it in 80% of tests, which isn’t correlated with any follow-up analysis in most of those cases. I am more cautious to run those things. If you have H-pylori that shows up on a random stool test that isn’t backed up by other tests and technologies, like breath testing or scoping or blood tests for antibodies or normal fecal antigen. If those show up clear, then no, I would not treat it based on that.
If I do have patients who show up with a positive urine or breath test, then they would be doing that because they have symptoms consistent with H-pylori causing a problem. I would treat it.
You bring up a point in that there are people who argue, and I agree, that there are likely benign strains of H-pylori that are not problematic, and then there are some that are problematic. There are certain things we can test for, like CAG, and some of those other things that are virulence factors that we know about now. We don’t know about all virulence factors, so we can’t say, “It doesn’t have these two virulence factors; therefore, it must be benign.” I don’t think we’re at that point yet. In another 15-20 years, we will have a better picture about when it’s appropriate to treat it and when it’s not.
I do think when people have upper gut symptoms consistent with this, and it’s present, then I will treat. But I am also able to use herbal medicines and dietary interventions to target it without causing major microbiome damage. To me, that puts it in a different perspective. If every patient had to take a triple cocktail and quadruple therapy to get rid of it, I would want more distinctive evidence that it was harmful. Versus you take this herbal medicine for six weeks, eat some broccoli sprouts and drink some cranberry juice, and take this probiotic, and we get 90% efficacy rate doing that.
I have less qualms about taking out the H-pylori and leaving everything else intact. That to me is close, selective tweezering of pulling out the microbe and leaving everything else in a good state, that we can get with some things like H-pylori.
Dr. Eric:
The final question I have for you is leaky gut testing. I attended one of your online courses where you discuss some of the different testing. I don’t want to put words in your mouth, but I think you mentioned zonulin is not completely accurate as a marker.
Dr. Jason:
It’s been interesting watching the research in this area. Some people will pooh-pooh the lactulose mannitol tests because it’s old technology. It’s accurate technology. We’ve been using it for a long time. It’s still considered the gold standard by people who are specialized in this area who don’t work for a lab trying to promote something else. When you start looking at the data around, taking bloodstream sampling for zonulin does not correlate with the gold standard. Most research suggests it does not.
More importantly, there is research looking at what the test is even looking for. It turns out the tests looking for zonulin aren’t finding zonulin; they’re finding something else. Some studies show it might be haptoglobin or complement C3 or another zonulin-like compound, but it’s not finding zonulin anyway. The correlation between that and the gold standard is pretty consistently poor. It’s not even finding what it’s purported to find, which is zonulin.
Some people think that we should be tossing out every single study that’s done using bloodstream testing of zonulin because of its poor accuracy. Never mind the fact that maybe 10% of people don’t produce zonulin, so they will always not have zonulin show up, but will have a leaky gut. It’s a problematic thing.
Are we always finding zonulin or a similar compound to zonulin that we can make an assumption with? It doesn’t always correlate with bloodstream zonulin or lactulose mannitol. The occasional study with fecal zonulin suggests it may correlate. It’s usually mixed but mostly negative with fecal zonulin. Blood zonulin is questionable as a marker, and I won’t rely on it as a way of assessing leaky gut.
It’s pushed more in the States because lactulose is a prescription item. It means that nutritionists, dieticians, etc., can’t prescribe lactulose mannitol test because it has a drug in it. In Australia and pretty much every other country in the world, lactulose is common over the counter. It’s a thing everyone has access to, and we can all prescribe this test really easily. Over there, you can’t. You can if you are a medical practitioner or naturopath in certain states. But it means there is more of a push to go, “Okay, well, we can’t use this test, so let’s see if we can find something else.” People have jumped on it way before the data supported it as being accurate. I think the tests were developed- They can’t find zonulin. The test is supposed to find it, and it’s not. It’s finding something else.
Dr. Eric:
That’s good to know. I’m glad I asked you that question. I know I said that was my last one. In 2018, when I took one of your courses, I think you said you used to use uBiome for biome testing, but since then, they have gone out of business. Do you currently use any companies for gut microbiome testing?
Dr. Jason:
Yeah. My patient base is spread around the world, which means I have different labs in different continents I work with, all using different technologies. Broadly speaking, there is probably two types of tests that I would use in practice, tests that use 16S RNA technology to look at the microbiome.
In the States, Ombre does that. They were called Thrive. There are limitations with it, but you do get a beautiful snapshot of the whole ecosystem at a low price point of around $100, which I think is fantastic. You can track changers in the key species, Bifidobacteria, Lactobacilli, butyrate-producing species. You can target that there and see the impact of your dietary changes and prebiotics relatively quickly and inexpensively for follow-up.
There is a test in the UK called Biomesight that also uses 16S RNA, which has a better microbe library and fills in some of the gaps we currently have with Thrive. It’s not particularly good at telling us bacteria populations, so each of those tests has its strong and weak points. Ombre is not good with proteobacteria for example. Can’t see Bilophila, which is a bile-loving organism that produces hydrogen sulfide gas. If we take their data and put it through the Biomesight library, we can see proteobacteria and Bilophila. There are ways of working around that issue.
There are labs that use shotgun metagenomic sequencing, which is really cool because you can go down the species level accurately and down to the strain level. You can tell people are taking L. Rhamnosus GG, the probiotic, because I can see it show up in their poo. It’s pretty cool. The cool thing about shotgun metagenomics is you get to see fungi and protozoa bugs and bacteria, and even genetic pathways, too, for the production of certain compounds, like hydrogen sulfide gas or methane.
There is a labhere in Australia called Microba that uses shotgun that I do a lot of. The major downside is the cost point; it’s $300-350 per test, which is a lot more than the $100 for Ombre. I also use NirvanaBiome or CosmosID in the States, who also does shotgun. The price point is a bit higher. But we do get more data to work with.
One of the biggest issues with 16S, which is uBiome and Biomesight, is their species level differentiation is not so good. We can’t go which Bifidobacteria species are in there. We can when we’re using shotgun techniques; we can get that species level detail in fine, nuanced ways.
Dr. Eric:
Does Viome use 16S?
Dr. Jason:
Viome uses shotgun. They use arguably the best technology to look at the ecosystem. But as a clinician, I don’t get much out of the reports. They’re more designed for the general public. Eat more of this food, eat less of that food. As far as telling you what the ecosystem looks like, so I can advise that patient how to modify it, I don’t get the data I need from Viome. But the technology they’re using is good.
Dr. Eric:
All right. Thank you so much for sharing your knowledge, Dr. Jason. I’m sure there is a lot more you could talk about. Is there anything I didn’t ask you that you have a burning desire to share? If not, can you give a brief summary as to what direction they can go as far as looking more into taking care of their gut microbiome?
Dr. Jason:
I think we covered a lot of good topics. I can’t overestimate the importance of looking after your microbiome. Changing the way you look at it as being a custodian. It is a custodian of this ecosystem, not just for yourself, but for future generations. Particularly if you haven’t had kids yet, you will be passing on the microbes to the next generation, so you want the ecosystem to be as diverse as possible.
It is not always straightforward to eat the way I’m going to mention here because sometimes you have SIBO or IBS or other things that may complicate things. But in general, you want to eat predominantly plants. Not completely plants necessarily. You can if you want. Predominantly plants. Whole foods. High fiber. Avoiding all processed foods. Anything with weird food chemicals, emulsifiers, completely avoid. Olive oil, bright colors, purple potatoes, purple sweet potatoes, choosing lots of bright berries. A wide variety of as many rainbow colors as you can in your diet. The widest diversity of different plant foods in your diet. Spices, like cumin and coriander. A mixture of different things. The key is diversity of different foods, particularly plant foods and whole foods.
It would be poor of me to neglect lifestyle stuff, too. Get out in nature. Go bush walking, hiking out in natural environments. Garden. People who do organic gardening pick up more microbes and have a diverse ecosystem. People who have the widest variety of plants growing in their garden have a more diverse ecosystems in their gut, which is also a fascinating correlation. Since I read that study, I have been planting out in my garden like mad with a wide variety of different species as possible, so I can interact with different plants and get different microbes.
Dr. Eric:
I think you once said 40 different types of plant-based foods per week. Do you still recommend that?
Dr. Jason:
Yes, I still recommend that. Not that 40 is a magical number because I think 50 is arguably better, but I think 40 is achievable for most people. How many different types of plant foods are you having that week?
To make this easier, Granny Smith apple, Red Delicious apple, Fuji apple are three different foods. Red quinoa, black quinoa, white quinoa, three different foods. When you look at it that way, it becomes easier to achieve that 40. By doing so, we do see the improving of diversity in the ecosystem. The richness of the ecosystem will improve when we are able to eat that way.
Dr. Eric:
Not just fruits and vegetables, but nuts and seeds. Would those also count?
Dr. Jason:
Nuts, seeds, legumes. Legumes have been demonized more recently, but they are fantastic for feeding the microbiome. They really are. They contain lactulosesaccharides. If you eat Suzuki beans or black beans, you are getting beautiful polyphenols, which feed other beneficial bacteria. Soluble fibers, which feed butyrate-producing species. As a food group, that provides a lot of nurture and nourishment for beneficial members of your gut microbiome. Legumes are fantastic. They have been unfairly demonized in the last 10 years sadly.
Dr. Eric:
Where can people find out more about you? ProbioticAdvisor.com?
Dr. Jason:
That’s where my probiotic database is, which is trying to make evidence-based prescribing of probiotics easy for clinicians and people who don’t have access to them. I have a range of courses on there, too, mostly geared for practitioners because probably my main passion is educating clinicians to reach more patients.
There are some courses there for the general public who are up on health, which is a decent proportion of people these days. That is one thing that has changed a lot in the last 20 years, is people’s general knowledge in health, which is way beyond where it was 20 years ago. We have courses for those people, too.
Dr. Eric:
Thank you again for your time. I appreciate you sharing your knowledge on probiotics, prebiotics, and the gut microbiome.
Dr. Jason:
You’re welcome. Nice chatting with you, Eric.