Written by Christopher Kelly
April 6, 2019
[0:00:00]
Christopher: Jason, thank you so much for joining me this afternoon. It is for me but it's early in the morning where you are in Tasmania in Australia, correct?
Jason: It is. The sun is just coming up over the hillside behind my house.
Christopher: That's excellent. I'm so happy to finally see the sun again in Santa Cruz. I was away in Costa Rica at the beginning of the year and it's ridiculously sunny and then I came back and I felt like the sun didn't come out for a full three months and now, finally, we've got some sunshine which I very much appreciate. I hope that you're getting some too.
Jason: Yeah. Well, for us, we're moving into -- We're in autumn now so I'm seeing less and less of the sun, each day gets shorter and shorter, which is my saddest time of the year. I miss the bounty that summer, in terms of by the garden, but that and being outside for long hours a day and just that lovely feel of sunshine that you don't get in winter down here.
Christopher: Well, tell me about how you first became interested in the gut microbiota. Where were you? What problems were you working on? How did it happen?
Jason: It's an interesting question because you could say it was sort of luck of the draw in some ways in that I was in my final year of my naturopathic training, there was a lecture that was given by one of our senior lecturers on dysbiosis and leaky gut. And this was back in 1999. I just got so enthralled with the topic about dysbiosis and leaky gut. At that point I approached him right after lecture and said, "Hey, I really want to do further research on this after I finish my naturopathic training. Can I do my honours degree?" And then that eventually flowed on, so I did my honours degree in 2000 which in Australia is a research based project. We run a small human clinical trial. That was followed up by my PhD working at the same topic. Essentially, I delved into the microbiome or what we call the microflora back then, probiotics and prebiotics, and then late 1999 was when I started putting stuff together, literature review for my thesis and my research project.
Christopher: Can you go into a bit more detail? What was it you investigated?
Jason: We were trying to find a condition that was pretty clear in the literature. This is back in the late 90s, pretty clear, had enough data around dysbiosis being a causative factor. We chose irritable bowel syndrome. And if you go back to that time, there wasn't that much literature around dysbiosis for a lot of conditions like we see now but there was for an IBS from the mid 1980s. So, essentially, we designed a protocol to help normalize the dysbiotic pattern that we tended to see in irritable bowel syndrome patients based on the data at that time which meant that I was giving two different prebiotics and some probiotics, a lot of herbal medicines that were within that class of what we call carminatives, sort of gut anti-spasmodic and herbs that were traditionally used for bloating, distension, cramping, those sorts of symptoms.
This was well and truly before the FODMAP stuff came out, I should stay. We ended up giving two different prebiotics to these patients with the irritable bowel syndrome and they got quite severe bloating and distension from all the interventions. It's a good learning experience for me as someone that had read about the benefits of using prebiotics to normalize gut ecosystem to improve populations of certain microbes in the gut but had no experience actually using on patients.
So, here we go, our first 20 people with irritable bowel syndrome, boom, given mega doses of prebiotics and I felt really bad for these poor office workers, particularly women who had trouble with these large amount of flatulence they had to deal with on a daily basis. It was a great learning experience for me about what not to do with regards IBS patients ever again. Started them off on two different prebiotics at large doses, not a good plan.
Christopher: But what was the standard of care for those people at that time? Were they getting anything better from their gastroenterologist?
Jason: At that time, it's fascinating because we had to write interview hundreds of people to get even a dozen to fit onto my clinical trial because they had to fit such strict criteria, not taking any medications, et cetera. And just hearing people's stories is pretty heart wrenching at that time because most of the people at that time were told that it was all in their head, that irritable bowel syndrome wasn't real, there's all psychological component to it, psychologically not physically, and as someone who's been supposedly in that IBS research field for over 20 years now, it's been amazing to see that acceptance of that diagnostic label as a real condition rather than there's something wrong in your head. You don't need physical medicines. You need to see a psychologist or something. So, it's been nice seeing that shift and the validation of people's actual real experiences. Answering your question, quality of care for these people was particularly poor at that point.
Christopher: So, I've experienced this personally, go see a gastroenterologist of the type that American medical insurance covers and they think it's nothing to do with your diet. They don't really want to look inside unless it's with a scope of some sort and then, for me, they prescribed steroid anti-inflammatory drugs and when those stopped working it's surgery for you. Is it the same story in Australia? Do you think anything has changed since you started investigating the gut microbiota?
Jason: Obviously, a much greater awareness of the microbiota. The microbiome is like a buzz word that most practitioners would have heard of even if I'd say the standard medical practitioner doesn't necessarily know what to do with the term, how to balance that or change that in anybody, but it's perhaps more on the radar. And I would say that there are -- Knowledge has grown in certain practitioners so I would still be hesitant to say that all gastroenterologists are really on to microbiota assessment and what it means now. I think that's not the case. But there's greater portion, I would say, that have some awareness of that than before.
[0:05:12]
And certainly, in terms of general practice care, I do see people get better management of the irritable bowel syndrome now than they would have 20 years ago. And that might be through referral to someone who does know how to work with diet. That happens a lot more now than it did 20 years ago. And because of the, at least in Australia, the fame of the low FODMAP diet, it is very widely applied in practice by both gastros and by general practitioners across the board. I'd say too often, actually. He's got the gut condition. We're not sure what it is. Go into a low FODMAP diet. See if it improves. But that's certainly a better, safer approach than, "Go, here, take this proton-pump inhibitor for six weeks and see if makes a difference," sort of take. Yeah, the trial was mostly medication so I think it's sometimes a default option. We're not sure what to do, try this approach. But that certainly is a much bigger step forward than experimenting with medications and conditions that are hard to classify, hard to diagnose.
Christopher: Well, I'd been aware of your work for at least a couple of years now and I think I've been trying to get you onto the podcast for that long actually. But recently, I'd been enjoying your courses on teachable.com and in particular I enjoy the evidence based nature of your presentations. Can you talk about how you go about navigating the literature and assessing the quality of the evidence? Because you are published in this field and I feel like maybe not everything is equal. You see some stuff that maybe is a cell culture or is done in rodents or something like that and how that applies to humans is not entirely clear. Maybe I'm loading this question up too much now and I should just ask you how you go about assessing the quality of the literature.
Jason: I think I'm lucky in a few ways in that because I've been in this field for truly almost 20 years now, it means that you get a much deeper level of understanding and knowledge of literature too. I mean, when I started you could read every single paper published on the microflora and prebiotics and probiotics in that time and up to that time. I mean, I started my thesis in late '99, early 2000s. You could read everything that had been done up that point and get your head around it and you get to feel the next upcoming number of years or which authors are really good in the area, which people just become introduced to that topic area and don't necessarily have the right requisite background and knowledge. So, I think that actually helps having that background and knowledge.
And also one of the other jobs I do do here in Tasmania, I lecture at the school of medicine here in the University of Tasmania and I teach evidence based complementary medicine courses, which is essentially teaching practitioners how to critique evidence. I would say that has helped me with that too because I think, you're right, that there's a couple aspects to this. One, it's knowing when a result is out of context with the rest of the field. And if we don't know that, we might be doing our best but we might be at a couple of hours searching something, we're like we find one study that, "Oh, wow, check this out."
And you might write a blog on it or something and 20 papers show the complete opposite and you just randomly happen to come across the one that showed the opposite rather than the consistent data. And that's where having a bit of greater background, I think, makes a difference. But, yeah, the other aspect is just being, okay, is this human study that had some major flaws, or it's just an animal study or in utero study that, obviously, have limitations. But sometimes that's the best data that we have so we just have to go with what we've got. But within that context of knowing that there's limitations to the data that we currently have.
Christopher: And do you think we're now at the point where we can assess and manipulate the gut microbiome to improve health outcomes? For a while now -- Actually, I'll tell you what happened. In the beginning, I thought there was great promise and I went down this rabbit hole and interviewed a bunch of researchers and read a lot of papers and I thought, "Yeah, this is it. We can truly manipulate this thing and get improved health outcomes."
And then some moment in time, I don't know exactly when it was, I thought blimey, I'm kind of way off the edge of the ledge here. I'm like Wile E. Coyote and the Roadrunner. I'm like the roadrunner and I've gone off the edge of a cliff and I realized there's no ground underneath me and, "Quick, get back on the cliff before I fall." Maybe all we can really do is assess the gut microbiota for known pathogens and then remove them.
If the history is appropriate, even things that we thought were definitely pathogens like H. pylori turned out to be context dependent, and then I thought, "Oh, well, it's just all totally overblown and I was living on the bleeding edge and so I got caught and now I'm not so sure." But watching your courses again now, I'm kind of more bullish on this whole idea of manipulating the gut microbiota to improve health outcomes. You, obviously, do believe that that's possible, is that right?
Jason: I definitely do. The other hat I wear is I'm a clinician too. Whilst I was doing research I was always treating patients at the same time and I still do now and I think that gives you different context and the chance to try things in real life too because sometimes you read studies and they put something into place and it actually doesn't make a difference. There's times you read the study and you put that intervention into practice and it works fantastically well. So, I've been -- You get that chance of seeing interventions of both clinical trial put into real life practice.
[0:10:05]
But I do think that with the tools we have to assess the microbiota now and the knowledge that has built up research wise in terms of how we can modify with changes in diet and prebiotics, et cetera, we can make pretty significant shifts to that ecosystem and improve people's health as a consequence. And I do see this on a daily basis in my clinical practice. I'd say we've got enough data there and I think it actually does kind of in practice.
Actually, something you said that I think is worth flying about looking for potential pathogens. I think there's a time for that and, I think, I certainly it's due to that too, but I think it's often about the imbalance more so than specific pathogens overgrowth. And I think if you look at the more broad dysbiotic literature, it's more about imbalance rather than just looking at one specific microbe that's out of balance.
If it is something as giardia then, yeah, we treat that, fair enough, or H. pylori, I hear you. I think I still take the "if it's present, you've got gut symptoms, we treat it" approach but there is that other sort of data there that maybe it is. Maybe there are consequences to removing it and, yeah, 20 years from now we'll probably know a firmer answer and we'll probably have the diagnostic tools to assess whether this specific strain of H. pylori that you have or someone else has is actually problematic for them versus a more benign strain. We just don't have that available clinically at this point to help with the decision making so we have to sort of work with the best evidence says and that's one, I think, is removing H. pylori.
But I hear you. Evidence is changing all the time. And also, like when I get up, a microbiota report come in, there are dozens of species and we don't know what they do. They've just been named. We got no idea what role they play. That's true. And that's going to change in 20-30 years from now. But there are certain species we do know what roles that they're playing, I mean, some of which in terms of the important roles and ones that are sort of more pathobiomes which is when their population is in the wrong amount, overgrowth, that they can cause harm. In which case, by changing that, we can actually improve people's state of health.
But if it's in terms of gut integrity, the whole inflammatory status, I think for me, looking at the microbiota is either a driver of inflammation in your system or, otherwise, it's playing an anti-inflammatory role in the system and it's certainly a way I look at when I'm looking at some of the ecosystems in terms of what species are there, what proportion they are. Is this driving inflammation? Is this driving gut damage? Or, conversely, is it actually promoting gut healing? Is it having a systemic anti-inflammatory effect?
Christopher: Can you talk about some of the tools that you use to assess the gut microbiota? Stool testing? Blood testing? Urine testing? How are you doing it?
Jason: Yeah. So, I would use breath testing to try assess, to some degree, the presence of microbes in the small intestine and when I do test someone who presents with signs and symptoms consistent with SIBO, small intestinal bacterial overgrowth, I will generally breath testing but I do do three sugars. I do fructose. I do glucose and I do lactulose. And I've done this for five years. It's been pretty fascinating seeing the different results and the number of patients I had with [0:12:48] [Indiscernible] and on lactulose is incredible, who actually spike up on fructose or glucose in the first 20 to 40-minute mark.
When you understand that lactulose is selectively fermented, only certain microbes can ferment it, it makes totally sense. So, that's why I'm never particularly happy with using lactulose alone as a tool to assess for SIBO because there are certain microbes like Klebsiella or E. coli bacteroides that we can see in people's gut with SIBO who they just don't eat lactulose. You're never going to get a positive test result with lactulose. I think certainly breath testing with those three sugars is a core aspect of what I do when that is called for with the patient.
And then I do microbiota assessment and most labs use the 16S rRNA system, for the most part, for probably a couple of reasons. The main reason is cost is good and we get a lovely accurate feature of the bacterial composition of the ecosystem. There are labs that are using genomic sequencing that can tell you about fungi and protozoa and bacteria. But I think that opens up, in some ways, new cans of worms because we're all of a sudden seeing that, "You've got lots of fungi going on in your gut."
But it's normal to have a certain amount of fungi growing in your gut. That's sometimes wherein technology's evolving and it's opening up this new discovery and we don't actually know what to do with that discovery at this point and how to put some of that with the microbiome in that category, at least from my perspective, as someone that spent 20 years looking at the bacterial components, I'm pretty comfortable with that. But it's only been the last three or four years that we've delved into the microbiome and I'm not quite sure what to find as normal and the ramifications of actually treating that.
There's been at least one interesting mouse study where they gave these mice an anti-fungal and looked to see what impact it had on both the microbiome but also the bacterial components. And they had a massive effect on both that certain species of the fungus ecosystem went extinct and other species thrived just [0:14:30] [Indiscernible] to that area. But a whole bunch of bacterial population shifted dramatically as a consequence because that's all interconnected, and when you make changes to some part of the ecosystem, there are consequences.
Yeah, so that's my slight concern with using tools that are focusing on areas that I think we have less knowledge or know what to do with. And same with finding a bunch of protozoa species that I've seen practitioners go gung ho and crazy, "Oh my god, you've got some unknown protozoa here. Let's try to kill it," not knowing that it's actually normal and healthy having protozoa populations in our gut too and we're still trying to tease out what that is, what's normal, what roles they're playing, how helpful they are.
[0:15:03]
There's some research that are saying that some of these protozoa species do play pretty pivotal roles as, what's his term, apex predators in the ecosystem just like great white sharks in the oceans or wolves. The Yellowstone National Park is there these species play a role eating certain bacterial populations and keeping them checked. We removed that apex predator, there are consequences there that we didn't know about and haven't considered before.
Christopher: Interesting. I've been very much enjoying your course on advanced probiotic prescribing. Can you talk a little bit about probiotics? Perhaps the definition would be good to start.
Jason: Yeah. I mean, I think the most widely accepted definition of this is live microbes that when administered in adequate amounts produces therapeutic effects. And that includes a few aspects of this definition, three probably that could be teased out. One, it's live microbes. If you have a supplement that contains dead bacteria, it's by definition a probiotic. They have to be live bacteria.
Adequate amounts is the other aspect of this definition too and that if you have a fantastic probiotic strain that's there at tiny amounts, when administered to people, you couldn't even theoretically call that a probiotic either. And then, thirdly, it produces therapeutic effects. In some parts of the world, they take this last part of the claim very seriously. Now, you can't call your product a probiotic unless you have human clinical trials showing that the genetically unique strain found in your product have therapeutic effects versus there are other parts of the world more like Australia and US and Canada where the term probiotic is just used far more loosely.
You will find probiotic supplements that have dozens of clinical trials showing therapeutic effects versus some probiotic strains with absolutely none on the market place. And both can make label claims and both can be widely consumed by consumers and prescribed by prescribers.
Christopher: Now, could you talk about some of the applications where they may be appropriate?
Jason: Yeah. And this is an area that's changed remarkably in 15-20 years, is that when I started looking at probiotics, really forgot stuff and maybe for vaginal thrush as well, but that was really all about it, so inflammatory bowel disease, IBS, post antibiotics and for viral gastroenteritis. This might have been the most common reasons people were prescribing probiotics back in the early 2000s, late 1990s.
Whereas now, the field is as, in terms of application of probiotics, has boomed because of the amount of research that had been done and the fact that we probiotics as having systemic effects and having other effects you never would have considered before. So, I’ve seen probiotics used to treat or prevent postpartum obesity, for example, postnatal depression, depression and anxiety, high blood pressure, high cholesterol levels, urinary tract infections as well as things like threshold bacterial vaginosis, eczema.
And I dare say that list will ever expand when we're using in the next few years. There's studies ongoing now looking at [0:17:47] [Indiscernible] disease and Parkinson's, et cetera. It's a matter of watching this space as this list expands out. And I think what's been fascinating too is just the research has been done detailing the different mechanisms of action of probiotics that are far beyond the sort of, the old idea that they are just placeholders that we'd just -- We take some antibiotics or we just take some probiotics and then we just take up some parking places for a short period of time versus probiotics that are producing things like GABA or serotonin that might have impact, things like gut transit time or even mood, for example, or the probiotics producing polyamines that help you with a damaged gut, or some probiotics producing an ACE inhibitor, for example, that actually can lower blood pressure when ingested or if you eat some yoghurt that's fermented with a strain of Lactobacillus helveticus, then you can actually lower your blood pressure by consuming that yogurt because of that ACE inhibitor.
It's fascinating to see this change. And I think it's really what I would call the new probiotic paradigm, is we're prescribing probiotics due to the actions that they have. And I would say that's very similar to the field of herb medicine or pharmaceuticals is that if someone has high blood pressure, we're prescribing, I could prescribe a herb that lowers blood pressure. A medical doctor would prescribe a pharmaceutical that lowers blood pressure. But there are some probiotics that actually have that capacity too.
Now, do they fix the reason why you have high blood pressure? In that case, no. You don't change your diet. You don't change your lifestyle. You've got to take that probiotic daily to get that action but you're going to get that action very safe benign way compared to using a pharmaceutical, for example. I think that way of using probiotics is what the researchers were detailing is that we're looking for the actions and attributes of specific probiotic strains and then matching them to the disease condition or state that needs to be shifted. And that can be simple thing as slow bowel constipation where people have a transit time in their gut that's five days from mouth to anus, is that there's some probiotic strains that speeds that up to 24-36 hours which is a dramatic improvement and they generally feel much better both from a brain fog mental capacity as well as bloating distention abdominal pain, sort of category two. Yeah. And I think there's good illustrations that show that new probiotic prescribing. I think that's what the research in medicine.
Christopher: And do you think the probiotics are permanently changing the gut microbiota? Do you think they colonize?
[0:19:59]
Jason: No. For the most part, no. I think we've got good data on that. This is one of the things I've been trying to bust for 18 years of teaching practitioners, is that the research data tells us that in the vast majority of individuals, the vast majority of probiotic strains that we currently have access to, they don't permanently stay. They're only temporary visitors. Does that mean that we don't use them? No. it just means they're not doing that aspect of things. I think that's an important point to get across.
And I also think that changes things too because I think sometimes people almost have a lack of respect for the gut microbiota because I think, A, I can just damage all I want and let's pop some probiotic pills and we see they recolonize and all will be right. No. That's not what happens. It's nowhere near that simple. And even, gosh, your ecosystem maintains maybe on average 160 different species and just taking some strains from two different genera to live Bifidobacteria can't recede or fix up the fact that you're lacking Oxalobacter or Roseburia or other key gut species, for example.
I think we need to move on both counts, both in terms of realizing this is a much more complex ecosystem and even if they did recede the current probiotic we have access to, wouldn't, can't fix up a severe dysbiotic state. All you would do best is introduce some Bifidobacteria and some lactobacilli to that, for the most part. But we do have 30-40 years of research telling us that if they stick around for two weeks after you stop taking them that's actually a good outcome. Most strains don't even stick around for that long. We rarely do find the odd exception where it persists long for in an individual.
Christopher: And then what about fermented food and drink, do you think they can be as good as or even better than supplements?
Jason: I think they're different. Probiotics, I wouldn't even classify as those as kimchi, sauerkraut, et cetera, kombucha as probiotics or probiotic foods. They may be live food to contain the live and active cultures. That's how they'd be classified because they're wild ferments and that means you don't quite know what you get in the end. They're often really quite diverse ferment, so something like kefir. Kombucha contains dozens of different species in the end product but every single batch can vary dramatically, using milk as a starter for your kefir versus the dried food and water, they call water kefir, it would end up with quite different bacterial and fungal populations.
I understand because you're feeding them different things. You got different populations of microbes and you can't expect them to do similar things because the population of microbes is completely different. That just does not make any sense. Even vast variation of what Lactobacillus plantarum strains I've got on my cabbage or in my garden in Tasmania is going to be different strains that are found in your backyard in California.
Are they going to have different effects? Probably. Would there be any therapeutic effects? Maybe there'd be not. And that's the thing. These strains aren't defined, aren't clinically researched. We don't necessarily know if they have therapeutic effects or not. You might randomly come by chance having this one with amazing capacity to promote gut healing and it survives stomach acid, survives bile salt, attaches to your gut. It produces healing of damaged small bowel. You might randomly come across that but you might randomly have a strain of Lactobacillus plantarum in your sauerkraut or kimchi that doesn't thrive gastric acid or bile salts and it's attached to your gut and compete with pathogens in your gut.
So, it's just random. And I think that's why there's hesitation amongst researchers to term them as probiotics and there's hesitation from clinicians like myself relying on the [0:23:10] [Indiscernible] tools. Yes, I get patients to eat them. I eat these things daily too. But I will prescribe specific probiotic strains and heavy actions I'm after for these patients that are doing the bulk of the work but I'm quite happy with people consuming.
I think there's something healing about making up some of these fermented foods as part of your healing journey. I think that's something wonderful so we promote that aspect of it. But I don't think we can rely on them as therapeutic tools in the same way as we can with well-defined, well-characterized, well-researched probiotic strains found in different parts. You can get those probiotic strain added to different ferments like yoghurts or fermented drinks afterwards. So, yeah, you're getting that multitude of fermented bugs that have made that sort of ferment but then they're adding a specific strain afterwards to get picture that this product has therapeutic effects. That's possible and you also get these well-categorized ones in capsule or powder or oils whichever forms these days.
Christopher: I feel like that was one of the key takeaways from your probiotic teaching, was that the characteristics are strain specific. So, if you don't know the strain then you don't know.
Jason: That's exactly right. And the [0:24:14] [Indiscernible] you just don't know. You don't know what you're getting. I mean, you can be creative in that I've had colleagues here who use the Saccharomyces cerevisiae boulardii strain that's been used in the research studies to make their ginger beer, for example. And because you're adding that as the sole fermented organism to create that, that's what's going to be in there when drinking that ginger beer.
You're not 100% sure about the dose but at least you know you're getting most likely therapeutic amounts of that specific strain. That's pretty atypical with wild ferments that we're only adding this one organism to create the culture. We're using sauerkraut, kimchi, et cetera, it's multitudes of organisms that might already be on that cabbage waiting to grow once we create the right conditions.
Christopher: Could you talk about what you look for in a probiotic product? Can you mention any red flags that you see?
[0:24:58]
Jason: It's an interesting journey for me over this time period of educating the industry and consumers and practitioners. I went through and phone companies, probiotic supplement companies that were selling in the market and say, "Hey, tell me what strains of bacteria found I your supplements." Most of them at that point had no idea what a strain was and they would just list off species and sometimes the species were actually different. Like there's a product called acidophilus fiber that actually contained a Lactobacillus rhamnosus. There was a sort of errors in labeling that were far more widespread then. But they are still happening now that you'll find products that are marketed that contains species that don't exist and I think those things are red flags.
Like a product says it contains, what is it, Lactobacillus bifidus. Drop it. Don't take it because that species doesn't exist and it was already renamed 30-40 plus years ago. If there's still a supplier who's selling Lactobacillus bifidus, that's a worry. You should not buy from them. The same, Lactobacillus sporogenes is actually a type of Bacillus coagulans. Again, these are sort of red flags when the names are, obviously, wrong.
Other red flags are just insufficient dosing of specific strains. So, you would look at the number of strains that are found in the supplement, make sure that all of them are above what I would call that minimum therapeutic dose which generally speaking you look at about the one billion CFU marks. CFU is colony forming units. One CFU equals one bacterium, and bacteria can just [0:26:17] [Indiscernible] rapidly without having sex, which is pretty cool. They can go from one to large numbers if given the right circumstance. One CFU, one bacterium.
And there's a billion, at least a billion CFU of each strain, then at least we know we've got a potential therapeutic effect. Now, there is the occasional exception that I should just flag like the Lactobacillus reuteri DSM 17938 which is a probiotic strain that's widely available in North America, Australia and Europe, worldwide. And this strain has got dozens of clinical trials showing that it works at a lower dose. So, ten to the eighth or 100 CFU per dose. So, you don't need to worry about, "Oh my god, this one's too low." That one's fine. That dose, we know it works.
But otherwise, you would look at that billion CFUs as the minimum. And you can't just add them altogether. You have to make sure that each one is at that therapeutic dose level for the best chance of having therapeutic effect. This has changed over time too and in the past we were looking for more simple things that has, there'd been data, research done showing that this probiotic strain can handle gastric acid, can handle bile salts, can at least survive the upper gut.
If so, the maybe we can just try and see if it works in a condition. And that's perhaps where I was at 18 years ago because we had such a lack of data from research on specific probiotic strains and what they were good for, what actions they had. And I think this has changed dramatically over that last 15 plus years because we now have such a data collection there that it's much more easy to prescribe probiotics in evidence based manner rather than on experimenting on patients like this one might do something. We don't know. Let's try it. It has some of the right attributes. Whereas now, this one has the right action to treat the condition you have and let's try that first off.
Christopher: Just to clarify, when you say the strain level, so that would be underneath the species. So, all dogs versus a Dalmatian, right?
Jason: Yeah, that's right. I think that dog analogy is very useful because I think people understand that, that you've got Chihuahuas, Irish wolfhound, German shepherds, Rottweiler. They're all the same species, Canis familiaris, but they're quite remarkably different of depending what genes are turned off or on. And it's very similar with any species of lactobacillus or bifidobacteria, and that Lactobacillus acidophilus, there will be potentially hundreds of, thousands of different strains with different gene turned off or on. That can actually determine whether they're going to have a therapeutic effect or not, whether they survive gastric acid, whether they survive bile salts. There's basic attributes as well as the most important. Do they actually have therapeutic effect in humans when consumed, are strain dependent attributes.
Christopher: You know, Jason, what we really need is a searchable database. Have you thought about that?
Jason: I have. And I created one. But it's interesting because it started off with paper documents and as research grew my documents got thicker and thicker and they went from having one document to having three different ones with multiple pages. You had to look up the research on the strain and where you found that strain, et cetera, et cetera, just going to be huge and then -- It was five years ago we decided to clump all that data that I collected over ten years of summarizing studies into a searchable database called the Probiotic Advisor to advise people on the best probiotic to take to try to make this the simple process because I'm a clinician and it's pretty time important to do a MEDLINE search for every single patient.
If you want to see it in terms of trying to get a better idea of -- Because sometimes it's contrasting results that are there too and the database tries to make prescribing easy based on the data that we've got and even how to assess whether a probiotic supplement is worth taking or not by looking at the strains that are contained therein and the research there is on it. I think we're about to dump another 360 odd clinical trials onto the database in the next while. I mean, that we probably summarized over 800 clinical trials on specific probiotic strains to date and we've got hundreds of products through Canada and the US and Australia now.
Christopher: It's great. And giving the citations and you rate the quality of the evidence too. That's fantastic. It must have been so much work. Did you do it all yourself? Did you have a team of researchers that helped you?
[0:30:02]
Jason: Initially, I did it all myself. Up until 2005, everything was mine. But now I've got a team of naturopaths that I've handpicked because they've done training in terms of [0:30:14] [Indiscernible] but critique studies also had to deal with the [0:30:17] [Indiscernible] helped me out to keep that updated because probiotic research have expanded dramatically. As I said, just this last 12 months there's nearly 400 studies we'd added in. That's a lot of hours of reading there on top of everything else, trying to get on top of microbiota stuff, et cetera. So, yeah, I have help.
Christopher: One of the things I enjoyed about you as well is that you're not here to sell probiotics. You don't have any financial affiliation with any manufacturer of probiotics. But if you don't mind me asking, where do you get your probiotics? Is it going to be somewhat very different in down under than it is going to be in North America or the UK, for example?
Jason: Luckily, the strains that we have access to are pretty similar even if the brand might be different here in Australia versus Canada and the US, for example. We can get Lactobacillus rhamnosus GG which is the best research probiotic bug in the world as lots of useful applications and you can get in Canada, the US and Australia, different companies, but we still have access to it. Presumably, definitely, Europe. I'm not sure UK, on top of my head, but widely Europe for sure.
I think there's a lot of those well researched strains that are broadly available in many western nations. And there are some parts of Europe that are well ahead on this count. I went to a probiotic conference in Italy in 2015 and I went to this chemist on the side street and it was just like in probiotic heaven. There's so many strains that I don't have access to here that I've read the clinical trials on and I was like a kid in the candy shop just buying and buying all the probiotics and take home.
Christopher: Suitcase full of probiotics.
Jason: It was a bit like that. It was. The number of strains in the market place are always going to be increasing too because what we've limited to on the database is those that are commercially available because there's a whole bunch of stuff -- Like there's a combination of Japanese strains that are useful for endometriosis, for example, good clinical trial, but they're not commercially available so we don't bother summarizing the study and having the details there. They can just essentially frustrate people like me that are like, "Damn, if you do the research, it's positive you'd get it at the marketplace." Because there's like a novel treatment approach that's safe that can help millions of women with endometriosis but sadly it's not there yet. But as each year expands we do get access to more of these well-researched strains. That material medica, our choice of probiotic strains, that have medicinal action expands every year, which is fantastic.
Christopher: What new strains are you most excited about that aren't available yet?
Jason: I think it's probably some of the more novel, strains from novel species. I think that's the other thing we can look forward to is, rather than having most every probiotic supplement between Lactobacilli and bifidobacterium, in the future we'll be getting ones from Akkermansia and faecalibacterium, roseburia, a new bacterium, and a range of other sort of gut species. I think that's what I'm looking forward to having a broader range of tools in the toolkit because we know that some of those species like akkermansia is one of those key species in our gut that plays many pivotal roles for our overall health.
We also know that there's some patients that through medication choices are often uninformed sadly or dietary choices have obliterated or made their Akkermansia go extinct. At the moment there's no way of fixing that extinction besides a fecal transplant. I look forward to when that, "Hey, here's an Akkermansia capsule." And we don't know at this point, whether they will have better long term survivability in the gut compared to Lactobacilli and bifidobacterium, which had been, as I said before, [0:33:32] [Indiscernible].
Or maybe they will. Maybe we can give a strain of Akkermansia once and it will stay in your gut permanently. Fantastic. Let's hope so. But we'll know that in a few year's time. At the very worse, we can give it to them for perhaps two or three days to maintain viable counts in the gut which might be enough to promote healing of the damaged gut to improve metabolic status, to improve weight management, for example. There's a few other things that Akkermansia populations have been linked with in humans. Low populations have been found to be an increased risk of obesity and type II diabetes and metabolic disturbances, et cetera.
And there was some research team in Europe who were trying to isolate the strains of Akkermansia and faecalibacterium as novel probiotic supplements to tend to be useful in a range of other conditions. We have had great success so far with probiotics like potentially Chrohn's disease, for example. That's been pretty hit or miss, sorry, when it comes to probiotics to date. And it might be that this strain of faecalibacterium that produces butyrate and other anti-inflammatory gut healing compounds will be a hit when treating Chrohn's disease. But we'll have to wait and see.
Christopher: Do you think anyone is close to having the complete end to end solution where you do an assessment and a recommendation for probiotics and/or diet? You're expecting to see that anytime soon?
Jason: Anything that we do now, we base on the best available evidence that we have now and we look back and go, "Oh, we could have done that better." It's often that way. I look back how I treated patients 15 years ago and I'm like, "Oh, I could have done a better job if I had that same knowledge I brought now." It will always be that way.
[0:35:01]
I do think that we can do a microbiota assessment and I can look at that and go, "Okay, how is this contributing to your disease or how is this contributing to your lack of health? How can we change this?" And then you can see the benefits and that's really around changes in diet and I use prebiotics tremendously in my clinical practice and I use probiotics too but I'd say that in terms of altering the microbiota, it's prebiotics and changes in diet that do the heavy lifting.
Christopher: Can you talk about some of those changes? So, I've been to a conference in San Francisco a couple of years ago where I saw Justin Sonnenburg present. I know you're familiar with his work because you cited it in your courses. And he was promoting a diet that was rich in plants, as many different varieties of plants as possible. Is that the same type of approach that you take?
Jason: Very much is. I think that's what the current data certainly suggest. The other factors involved with microbiota health is diversity of the ecosystem. That's a key factor that comes through numerous research fields to date, is diversity of the ecosystem equals better health. So, high diversity, better health outcomes. And the best way of achieving higher diversity is actually with increasing the diversity of plant foods you have on a daily basis. So, for me, that's a huge recommendation to suggest to the vast majority of my patients, if not all. There need to be nuance and change depending on their overall sensitivities, but that's what we're aiming for, is having the widest variety of plant foods on a daily basis and I give my patients something to aim for so I say aim for 40 plus different whole food, plant food per week which I think is genuinely achievable for most patients. I know there's some that they're not. And then patients will often take that further and go, "Hey, I got 50 this week. Hey, it's 60."
And the reason why diversity is important is because it's actually the diversity of the microbes. The fiber isn't just one thing. So, eating 100 grams of fiber from broccoli is not the same as getting 100 grams of fiber from range of nuts, seeds, fruits, vegetables, whole grains, legumes. You're actually going to feed a much wider variety of microbes when you have a much more diversity of plant foods in the diet than if you just have equal amount of fiber but it's from five different foods, which is still better than none, but you're not going to feed the same diversity of microbes. I concur that, generally from a microbiota perspective, predominantly plant based and the widest diversity possible.
Christopher: Do you have any tips about how to go about that as a practical concern? It's not always easy to make changes to your diet like that. What do you say to your patients?
Jason: I do think that microbiota assessment helps with this. I would say that that compliance with dietary changes like this is actually better since I started doing microbiota testing than when I didn't because people, it's like caring for a garden. It's almost like it's external. Like it's easier to take responsibility and care for looking after something else than sometimes it is yourself, so to speak. I do think that for whatever reason when we look at this microbiota picture going okay, you're low in this, this and this and the best way of increasing your diversity, the best way of feeding up your butyrate producers, bifidobacterium, faecalibacterium, et cetera, is eating these foods in this way, I find compliance in general is much better.
I run workshops on this too, both online but also in public here locally. And people that we touch base three months after our initial workshops and we get to look at microbiota afterwards, what's changed, but just touch base on how they've gone with keeping up with the dietary recommendations, et cetera. And the vast majority has stuck with it very well which I've been pleased to see because you don't necessarily think that's going to be the case.
Even people that are generally okay health wise but they stuck with it because they feel better after a time of following it but initially they might be doing it to improve their microbiome which, I said, is like looking in after nurturing their inner garden.
Christopher: That's great. So, you're seeing consistent cause and effect with the gut microbiome 16S assessment then. It's not like you get the retest back and like, "I have no idea what just happened. You're telling me that you did what I said yet this is not what I expected to see at all. You're not seeing any of that. You're seeing nice consistent results.
Jason: 19 out of 20 times, yes.
Christopher: Okay. And do you mind name dropping the name of a lab?
Jason: I've got no connection with any labs, but I tend to use uBiome because of the tech and the cost. You can do three uBiomes even [0:39:09] [Indiscernible] the often have specials, which just means it's really doable for follow-ups. That to me is a huge thing. Before we had access to some of the ones using the cheaper access, we had tools like Genova GI Effects Profile which for my patients was $650, $700 for a single test.
Christopher: It's too much.
Jason: Yeah. We sometimes use that as an initial diagnostic tool but there's no way I would ever do a follow-up test to go, "Hey, have we changed it?" If we just go by, okay, you're feeling better, great. Soon, it's made changes. Whereas now, because of the cost, it's actually really easy to do follow-ups. We'll do follow-ups at two months and then for about four months we'll go, "Okay, what's changing? Are things moving the way they should? How can we adjust the doses? Have you gone with the dietary changes?"
Because sometimes you're getting objective data but they're compliant with that too. But you do get the rare one where they've been compliant with the data, they've been compliant with the prebiotics and the ecosystem has just responded weirdly and really, as I said, this is quite rate. I can think of only two or three in my practice, thank goodness.
[0:40:05]
They come to you like, "I don't know why this hasn't shifted that way." This is not what the research said. This is not what I generally see. And this is where the individual nuances that come with these ecosystems. They come into it and for a reason their bifidobacterium, the faecalibacterium, et cetera, just didn't respond the way that 95% of other people's does. Luckily, it's pretty rare whereas majority of the people you see changes. That's one thing I certainly was curious about when I first started using it because I used to use other CDSAs, comprehensive stool analysis.
And I did that as part of my research and my original clinical trial and even in my IBS patients back in 2000 where we had these 20 patients with IBS, we gave them prebiotics, we gave them over 100 billion lactobacilli probiotics per day and we did these follow-up CSAs and they didn't show any change in bacterial populations at all. And that was my red flag that I think there's something wrong with this tech because these people are fighting like that. The prebiotics are working. They're taking the stuff.
The probiotic was made specifically for my clinical trials. It's only a couple of weeks old. This is vital, alive bugs. There's no way they shouldn't be showing up in their poo. But there's an issue with the culturing technology that was used at that time which meant that I was hesitant to use them from that time point. Certainly when I started using things like uBiome, obviously, I wanted to see does what you're eating match this outcome, one, in terms of your microbiota composition? Two, when we make these changes, do the changes show up in your stool? And they consistently barring the odd outlier.
Christopher: That's great. And then, obviously, uBiome is giving you the resolution of data that you need. I looked at it a long time and the resolution wasn't there. I even wrote a piece of software that -- Data was there if you downloaded the raw data, it was there, and I used a Python library.
Jason: That's right.
Christopher: Yeah. I mean, obviously, uBiome -- It's been a while. It's been a couple of years since I've looked at it. So, obviously, they've updated the software.
Jason: Yeah. I mean, there's a lot of stuff on the web interface that I don't pay attention to at all. I should just flag that. But there are bits that I do and I look at the phyla data, what percentage are the phyla, and I look at the genera data and I will look at the CSV file, which is a downloadable Excel file that will go down to some of the species level information and tell me information about levels of Methanobrevibacter, for example, that you don't get in their web interface.
I do the genera uBiome too. In this case, we want to get species level data. Their ecosystem is 97% lactobacilli but I want to know what species of lactobacilli and their CSV file was great for that when it comes to the genera. So, I use it a lot of the gut ecosystem but also for assessing the general ecosystem too.
Christopher: Interesting.
Jason: It is important not to get too caught up in some of the stuff in its initial stages. The diversity score is fantastic and very applicable for people then that sort of percentage of where they're at on that spectrum is like, okay, my diversity -- I've been to the 90% of the samples in the uBiome poo library and their poo library is probably a couple hundred thousand samples now. That's good. Or it's at the 0% or 2%. It's like that's really, really bad and we're looking at the spread of bugs as well as the number of species present and then we get that as well as looking at the said phyla level data and genus level data.
Christopher: Well, Jason, I want to be respectful of your time but I also want you to tease us with the content for what I think is your latest course. Maybe I could get you to do that by asking you the question, does the microbiota alter mood?
Jason: Yes. It does. And I think this is a fascinating area that I wouldn't ever guess 19, 18 years ago that there's going to be this major connection that there is and I think it's been pretty amazing what's been teased at the last few years both in terms of -- I summarized some of these studies in that presentation but the impact of antibiotics on mood, impact of proton pump inhibitors on mood, and the capacity to increase the risk of depression.
I think it's fascinating because those classes of drugs are very good at killing microbes in your gut and we forget this with proton pump inhibitors. We think it just decreases hydrochloric acid output. Yeah, it does. But it also has an antibacterial effect. You take that long term and your ecosystem gets almost as damaged as if you're taking antibiotic long term. In fact, some researchers suggest damage in terms of loss of diversity, loss of species, richness. It's massive and now those data has shown increase the risk of depression.
I think it's pretty incredible and some of the research that showed that you can, in fact, transmit depression from one being to another by doing a fecal transplant, which I think is also pretty mind blowing that you can shift brain chemistry by changing gut bacterial populations, which is pretty, pretty amazing. I think it opens up a whole new field and certainly as clinician you get a whole new bunch of tools for your tool kit for helping people who are depressed and didn't have access to before.
I think you're arguably working more deeply how to treat patients who are depressed. It's just like, hey, take some St. John's wort or saffron or turmeric. Yes, you get certain improvements, no doubt. And we got good clinical data showing that these things work.
[0:45:03]
But I do think that alterations to things like gut integrity and the microbiome goes to deeper level and I think this is really important when trying to treat the cause of that when there's no -- I mean, obviously, there are cases where causes, you just lost your wife or your son or your daughter, something like that, that's a different scenario. But cases where there's no obvious reason for this person to be depressed but there's something not quite right then the data is suggesting that the microbiota is a key player in that situation.
Christopher: Well, I will, of course, link to your Probiotic Advisor searchable database and your courses on teachable.com, that is advanced probiotic prescribing and depression, anxiety and the gastrointestinal tract microbiota. The $64,000-quesiton is: Are you seeing patients remotely at the moment? I'm not expecting many people in Tasmania to be able to come and see you right now but I'm sure there's going to be lots of people listening elsewhere in the world. Can you see patients remotely? Do you have any room in your practice?
Jason: Yeah, I do see patients remotely. Most of my patients these days are remote and are not local.
Christopher: Yeah. As lovely as I'm sure it is in Tasmania.
Jason: Yeah. We got a two-year waiting list for new patients but I should flag that I do have a gut fellowship where I've got three or four practitioners who work with me on cases and I got them involved to help deal with the overwhelming waiting list and people wanting help. They've been trained in my approaches to things and microbiota assessment, et cetera and how it links with all these different conditions and we actually workshop cases as a group. So, you actually get a few different heads working together on treatment strategy, et cetera. I think it's a good model to try to expand that out. So, despite myself having a two-year wait list, it's sort of associates don’t. So, if you're interested, there's possibility of just getting help without--
Christopher: Okay. And so I can link to a directory of practitioners or just do people need to contact you directly?
Jason: I can give you link to my clinic space and my reception team are well-versed in how to funnel patients into the gut fellowship.
Christopher: Okay. Well, that's fantastic. Is there anything else that you'd like to mention anything I should link to in the show notes that you can find for this episode over at nourishbalancethrive.com/podcast? Is there anything else, Jason, I should link to?
Jason: No. I think you've covered it very well, thank you.
Christopher: Well, this has been fantastic. Thank you so much for your time. I very much appreciate you. Keep up the good work. Keep making those training courses on teachable. I really enjoy that software for teaching people new stuffs. It's really great, really slick. I very much have been enjoying this. Thank you.
Jason: I love teaching so the capacity to live here in Tassie, which is one of those remote places on earth, is actually teach practitioners all over the world. It's amazing how technology has opened that up as a possibility. Because when I first moved down here, one of the things I was really sad about was missing teaching. So, I'm glad. We might have the cleanest air on earth and the cleanest water on earth but there's not many people to teach so it's nice to have that capacity to do so.
Christopher: Yeah. I mean, it works both ways, right? Before, you just have to choose from whoever was available locally and now, "Oh, there's this amazing guy but he's in Tasmania." Now, that doesn't matter. You can just learn from the best person in the world online which I think is also fantastic.
Jason: Yeah. Very cool.
Christopher: Excellent. Thank you, Jason. I very much appreciate you.
Jason: Thanks for the offer to come up and I'm glad we can we could tee it up after a bit of toing and froing over for the time. We finally found the time to make it work. Thank you.
Christopher: Thanks.
[0:48:20] End of Audio
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