Rational Wellness Podcast 026: Probiotic Advice with Dr. Jason Hawrelak

Dr. Jason Hawrelak from Australia speaks to Dr. Ben Weitz about probiotics and which particular strain has which properties. 

5:19  I asked Dr. Hawrelak to explain how probiotics can help restore a healthy balance of bacteria in our colon and digestive tract? Dr. Hawrelak said that the role of probiotics is overstated to do this, though there is a great benefit for the use of probiotics in specific situations such as after an acute insult, such as after antibiotic use or chemotherapy or radiation, where you get some massive shift in the ecosystem.  Or even after the use of proton pump inhibitors, which we know cause alterations in our system, as well.  A normal ecosystem is like a parking lot with every spot is filled. But after antibiotics or chemotherapy, etc. there are suddenly all these empty parking spaces.  These empty spaces can be taken up by potential pathogens that we ingest, which is what can happen with Claustridium Diffocile in a hospital. Or it can just be an overgrowth of of bugs that are resistant to the antibiotics.  Probiotics can be very helpful in coming in and temporarily taking up these parking spaces. The key thing to remember is that probiotics or fermented foods are only temporary visitors to the gut.  One of the biggest myths is that when we take probiotics is that they can reseed our gut, going all the way back to Metchnikoff, who is the researcher who discovered the bacteria that makes yogurt out of milk. His theory was that we could permanently innoculate our gut and this would prevent protein putrefaction and slow down the aging process.  What has gotten far less attention is foods and supplements like prebiotics that feed your own indigenous population of bacteria and help them to grow.  We focus a lot on fermented foods but not so much on fermentable foods, which are indigestible carbohydrates (fiber) that the bacteria ingest. These include fibers, pectins, resistant starches, and oligosaccharides. 

10:25  I said that the first thing that comes to my mind is that it is a current trend in nutrition to reduce carbohydrate intake as much as possible by following a lower carb, higher fat diet such as a paleo or a ketogenic diet.  And in this quest to improve our health by reducing carbohydrate intake we may be leaving out these fibers that are so important to our health.  Dr. Hawrelak agreed and said that you can see this if you do a molecular based stool analysis of the microbiota, you tend to see a reduction of bacterial diversity.  Also when you look at the research related to low carb/high protein diets you see a reduction of bifido bacteria and of butyrate producing populations in the gut and butyrate is a really good thing, so such changes are not beneficial. Both your gut health and your overall health can suffer.  Dr. Hawrelak explains that 70% of the energy needs of the cells in your colon are met by butyrate and other short chain fatty acids produced by gut bacteria. By limiting fermentable carbohydrates, you limit this. Butyrate is an amazing substance and when you produce more than the colon cells can use and it reaches the systemic circulation, it can help to heal the blood brain barrier, improves insulin sensitivity, and improves neurotropic growth factors.  You can only get butyrate from bacterial fermentation of fermentable substrates and when people follow a low carbohydrate diet, they do get a decrease in bacterial fermentation.

13:10  I mentioned that those who follow a low carb diet can get some of these fibers by making sure that they consume a lot of vegetables. Dr. Hawrelak pointed out that they should also supplement with ground psyllium seeds or husks and also using prebiotic supplements. Dr. Hawrelak said he likes supplementing with lactulose, partially hydrolyzed gar gum, galactooligosaccharides, and a combination of inulin, which is a long chain fructooligosaccharide, and oligofructose, a short chain fructooligosaccharide.  They all have somewhat different effects.

15:21  I interjected with the thought that for those of us who are Functional Medicine practitioners who treat IBS and send our patients for lactulose breath testing to diagnose this condition and because lactulose will result in the production of hydrogen and methane gases and cause gas and bloating and abdominal discomfort and the all the other symptoms of IBS.  So using lactulose as a supplement is the last thing many of us would think of doing. Dr. Hawrelak explained that he first came across lactulose as a prebiotic while doing research for his Honor’s degree in 1999 and it used to be added to infant formula as a prebiotic.  Lactulose helps to selectively feed certain bacteria, including bifido, lactobaccilli, and faecalibacterium prausnitzii, but it does increase hydrogen gas production, which can then be converted in some into methane gas.  The SIBO breath test used to be used a marker of gut transit time from mouth to secum. But then it was questioned since lactulose speeds up bowel transit time, which is what Dr. Hawrelak uses it for. He noted that patients with SIBO and IBS who will react to taking lactulose, but there are a whole bunch of other patients who don’t have those conditions who get the benefit of taking lactulose. Dr. Hawrelak said that he uses lactulose to decrease the recurrence of ear infections and there are studies showing that lactulose reduces the recurrence of UTIs.  It does that by decreasing E. coli counts in the gut.  Most ear infections are caused by E. coli and E. coli is making the journey from anus to vagina to urethra.  There is also a study that shows that lactulose reduces candida counts by 97% in 24 hours.

19:15  I mentioned that I heard Dr. Hawrelak speak on the SIBO Doctor podcast that when he has a patient that he suspects of having SIBO that he will have the patient take the SIBO breath test three times using lactulose, glucose, and fructose as substrates. This is because lactulose is selectively fermented by certain species of bacteria. Lactulose will not be eaten by Klebsiella,  bacteroidites, or E. coli and we have good research that these bugs are often present in the small bowel. By doing all three of these tests on thousands of patients he sees a lot of patients who test negative using lactulose but positive using glucose or fructose. If the patient has SIBO that reacts to glucose or fructose but not lactulose, Dr. Hawrelak will use lactulose as a prebiotic in those patients to speed up small bowel transit time. Also, since lactulose will create an acidic pH in the small bowel and this is less conducive to the growth of E. coli, bacteroidites, and Klebsiella. Just doing the lactulose breath test will likely result in a significant amount of false negative test results. If the glucose test is positive but the lactulose test is negative then you know the bugs that are in your small intestine are bugs that can’t eat lactulose and you can target them better with your herbal or antibiotic approaches.

21:58  I asked if there are there specific strains of probiotics that can be effective against SIBO? Dr. Hawrelak said that there are strains of probiotics that can improve the migrating motor complex or improve motility, some that can heal a damaged, leaky gut, some strains that can function as selective antimicrobials, some strains can reduce visceral hypersensitivity, reduce intestinal inflammation, and others can enhance production of secretory IGA. For example the Lactobacillis casei CRL341 has the capacity to decrease bugs in the small intestine and this is very strain specific. A combination of this Lactobacillis casei CRL 341 and the CRL 730 strain of Acidophilus  which have been shown in a well designed clinical trial to be effective for treating SIBO.  Unfortunately this combination is not currently available in the US.  There is a combination of strains that is available in Argentina called Bioflora which showed an 82% reduction in symptoms in patients with SIBO as compared to Flagil, which had a 52% reduction in symptoms. Dr. Hawrelak mentioned that there is one strain, Bacillis clausii, that is clinically available that has a 30 day clinical trial that showed a 47% erradiction rate of SIBO.  There was one study out of China that showed an 81% erradication of SIBO rate, though they did not report what strains were used.  Lactobacillis reuteri 17938 is a commercially available strain (the BioGaia Gastrus product) that has been shown to be effective with methane dominant SIBO.  The following study showed a close to 2/3 reduction of methane gas in those patients who took this Lactobacillis reuteri 17938 probiotic:  http://www.europeanreview.org/wp/wp-content/uploads/1702-1708-L.-reuteri-in-methane-producer-constipated-patients.pdf  

29:43  I asked which strains of probiotics might be helpful in improving intestinal motility or the Migrating Motor Complex? Dr. Hawrelak said that there are two different strains of Bifidobacterium Animalis Lactis DN 173 010 and Bifidobacterium Animalis Lactis CNCM 1-2494  that increase whole gut transit time but they are only available in Dannon’s Activia, which contains a bunch of unhealthy ingredients like sugar. But it can cause a massive shift in gut transit time in a two week period. Another strain is Bifidobacterium Lactis HN019 which is now available in several different products in Australia and the US.  For a while this strain was only available in a probiotic from Xymogen, Probiomax, which has a good amount of that strain and it has been shown to reduce gut transit time from 40-50 hours to the low 20s in just two weeks. So in SIBO patients with slow gut transit time, we can use a probiotic as a prokinetic.  There is one animal study using a combination of Lactobaccilis Ramnosus GG and Bifidobacterium Lactis BD12 showing that it improves the cleansing waves of the migrating motor complex. 

33:19  I asked if there are particular strains of probiotics that can heal a leaky gut?  Dr. Hawrelak explained that the strain that has the most research to support that it helps with leaky gut is the Saccharomyces cerevisiae variety Boulardii biocodex that has good evidence that it can return the small bowel architecture to normal to heal a leaky gut. It also helps with eradicating parasites like Giardia and healing the damaged gut resulting from such a parasite. Dr. Hawrelak then explains how Saccharamyces was first discovered. It was a French microbiologist, named Henri Boulard, who encountered an outbreak of cholera and he noticed that some folks were making a preparation from the skin of a lychee and of mangosteens, which are both tropical fruits, and the folks who drank the tea of these fruits were not getting sick or were getting better.  Boulard isolated a yeast from the skin of the lychee that he named after himself, calling it Saccharamyces boulardii  and he commercialized it and it has been sold since the 1940s as a probiotic supplement.  Boulardi sold it to Biocodex and 90% of the research on Saccharomyces was done on this particular strain. This strain has been shown to prevent antibiotic associated diarrhea and has activity against Claustridium diffocile infection and has the ability to break down C. diff toxins.  There is also research with this probiotic and Crohn’s and Ulcerative Colitis, as well as some studies on Irritable Bowel Syndrome. 

38.50  I asked if there are other probiotic strains that are beneficial for Inflammatory Bowel Diseases, like Crohn’s and Ulcerative Colitis.  Dr. Hawrelak said that only Saccharamyces boulardii has been shown to be effective for Crohn’s, but there are other products that can help with Ulcerative Colitis (UC). VSL 3 has some efficacy for pouchitis infections and also helping patients with UC gain remission. Lactobacillis Ramnosus GG which has been shown to maintain remission. In one study it was compared with mesalazine in keeping patients in remission and Lactobacillis Ramnosus GG actually worked better. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2036.2006.02927.x/pdf   There is also some research on E coli Nissle 1917 helping patients with UC to go into remission and Crohn’s as well.  Here is a review paper I found on some of these products: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257670/ 

41:10  I mentioned Dr. Sidney Baker’s work with using parasites therapeutically to treat IBD and Dr. Hawrelak said that this was outside of his area of expertise.  He said that he was familiar with and receptive to using microbial fecal transplants for IBD and he is more comfortable with this than using worms to treat patients. Dr. Hawrelak mentioned that diseases like Crohn’s and UC were not particularly common 50 or 60 years ago and perhaps there are bacterial strains that we have lost in our microbiome that might have protected us against them.

43:10  I asked what Dr. Hawrelak thinks about soil based or spore based probiotics?  Dr. Hawrelak said that he can’t make a recommendation on a whole classification of probiotics and he does not feel that there is enough research done yet on such species that are not normally found in the human gut, esp. when there is enough good research on standard various strains of probiotics. 

45:50  I asked if there is a therapeutic value in getting a stool sample that maps the microbiome and administering probiotics that are low to balance out the microbiome and increase bacterial diversity.  Also is there value in looking at the ratio of firmicutes to bacteroides?  Dr. Hawrelak said that doing a molecular based stool test is very helpful since many species cannot be cultured and many of these species are very helpful.  But Dr. Hawrelak said that in order to change a microbiome you have to get the patient to change their diet and take specific prebiotics that will facilitate the growth of particular species of bacteria.   If you are low in bifido bacteria, you can take bifido bacteria probiotics and while you are taking it, you will have more bifido in your intestines, but once you stop, they will disappear. So the better approach is to use diet and lifestyle and prebiotics and prebiotic foods that will nurture their endogenous population of bifido bacteria, etc. to increase bacterial diversity.  Dr. Hawrelak explained that current research does not support the benefit of focusing on the firmicutes:bacterioidites ratio.  Dr. Hawrelak recommends using The American Gut Project or uBiome or Genova’s GI Effects, though it only looks at 24 different species. 


Dr. Jason Hawrelak is in practice and available to see patients at his clinic in Australia at http://www.gouldsnaturalmedicine.com.au/jasonhawrelak  and you can subscribe to his marvelous service that provides all the latest information about probiotics, The Probiotic Advisor at https://www.probioticadvisor.com/  Dr. Ben Weitz is available for nutrition consultations by calling 310-395-3111.  


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