Gut Parasites with Dr Jason Hawrelak: Rational Wellness Podcast 169

Weitz Sports Chiropractic and Nutrition
Weitz Sports Chiropractic and Nutrition
Gut Parasites with Dr Jason Hawrelak: Rational Wellness Podcast 169

Dr. Jason Hawrelak speaks about Parasites with Dr. Ben Weitz.

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Podcast Highlights

6:49  Gut parasites used to be considered a more common cause of gut infections 20 years ago, whereas in the last 5 or 10 years in Functional Medicine circles we have come to focus more on conditions like Small Intestinal Bacterial Overgrowth, H. pylori, dysbiosis and fungal overgrowth. What should make us suspect that a patient with digestive symptoms might have a parasite?  The symptoms do overlap with symptoms from conditions like IBS, SIBO, functional dyspepsia, and inflammatory bowel disease.  We have to distinguish between parasites like Giardia and Entamoeba Histolytica that clearly cause serious gut infections from more debatable ones like Blastocystis Hominis and Dientomoeba Fragilis. You might get some history like they have recently travelled overseas and then got a case of traveler’s diarrhea.  We have to do some testing to see what is causing the symptoms and not just stool testing for parasites. If you find Giardia, you can be fairly confident that this is responsible for that patient’s symptoms. But if it is Blastocystis Hominis or Dientomoeba Fragilis we can’t make that assumption, because of the prevalence of these microbes in healthy populations.  Dr. Hawrelak recommends doing a suite of tests to determine what causes these symptoms including not only a PCR stool test but a microbiome analysis stool test, fecal calprotectin or lactoferrin for inflammatory bowel diseases, a fecal occult blood, and SIBO breath testing.

12:00  If you have a patient who has digestive symptoms like gas, bloating, diarrhea or constipation, and they have a positive SIBO breath test and they also have a protozoan organism like Blastocystis and/or Dientomoeba that shows up on a stool test, you should treat the SIBO.  Such protozoans are extremely common and are generally irrelevant to that person’s symptoms.  15-20 years ago SIBO wasn’t that well known and we used to treat such patients for Blastocystis and we would get some results but it would generally not resolve completely. He talked about one patient who he treated for Blastocystis and got somewhat better and then 12 months later was diagnosed with fructose intolerance and went on a low fructose diet and all her symptoms completely resolved and Dr. Hawrelak was upset that he missed that diagnosis.

15:15  It is interesting to consider whether there could be SIPO or Small Intestinal Protozoan Overgrowth as a cause of IBS.  We should probably think of certain protozoans like Blastocystis and Dientomoeba as commensal, as a normal part of a healthy gut.  In fact, Dr. Hawrelak noted that he personally has elevated levels of Blastocystis Hominis on a stool test and no gut symptoms.  Perhaps we’ll be taking protozoan probiotic supplements one day.  On the other hand, taking certain antibiotics like Metronidazole, Flagyl, the most common antibiotic used to kill protozoal organisms, it tends to awaken the pathogenic potential of Blastocystis and increases its capacity to actually cause gut damage and to interact negatively with precancerous cells and become much more virulent. 

20:54  There are 17 different subtypes of Blastocystis Hominis but only 9 have been found in humans and the rest in other animals, like chickens, pigs, cows, etc..  For humans the most common subtypes are 1, 2, 3, and 4, esp. 1 and 3. There is no consistency in the data around which of these subtypes may be more pathological than the others.  Dr. Hawrelak wants to emphasize that when he has a patient who shows elevated Blastocystis or Dientomoeba he used to think that these were primary parasites that needed to be killed to help his patients feel better and now he generally regards these as a normal part of the microbiome in healthy patients. There have been a lot of good studies done in western Europe that have found that 7 out of 10 healthy kids have Dientomoeba in their guts and kids with functional abdominal pain are less likely to have Dientomoeba in their guts than those who are actually healthy.

25:33  In rare cases where he has a patient with significant GI symptoms and who has elevated Blastocystis and no other findings on gut testing, Dr. Hawrelak will treat the protozoan.  Blastocystis Hominis flourishes in an alkaline environment, so he will have patients eat more fiber, prebiotics, and a more plant based whole food diet.  More fiber will lead to more production of short chain fatty acids like butyrate and acetate, which will lower the colonic pH.  That in itself can lower Blastocystis levels.  Dr. Hawrelak will use agents like pomegranate husks and garlic along with saccharomyces cerevisiae boulardii probiotic.

29:57  Of the more clearly pathological parasites, Giardia is the one that Dr. Hawrelak sees most commonly, though less common than when he was practicing in a more rural area of Australia. He said that Giardia will often resolve without the need for specific treatment, but when it is required, he will use raw garlic and have patients press a couple of cloves into capsules or a glass of water and consume it twice per day. One study in Eqypt showed 100% erradication in only 3 days with raw garlic. He will also use pomegranate husk and plantago major ribwort. Dr. Hawrelak used to use berberine containing herbs like coptis, but he is concerned that berberine may have a damaging effect on the microbiome since it reduces bifidobacteria levels.  He will also give saccharomyces cerevisiae boulardii again as a probiotic, since it has been shown to help erradicate Giardia.  The Giardia is an amazing protozoal organism that forms a cyst and when you get one or two of them in the gut, they can cover the entire small bowel with the Giardia trophozote and they can damage the intestinal villi so necessary for absorbing nutrients from our food and damage the brush border and affect the brush border enzymes that are necessary to absorb foods like fructose and lactose.  Saccharomyces boulardii are wonderful for helping to regrow those villi and the brush border and you might do that during, then for at least six to 12 weeks afterwards to speed up healing. 

36:18  When treating worms, especially bigger worms like pinworms, it may be necessary to treat for 10 days, wait 10 days and then treat again for 10 days since eggs laid by the worms will not germinate until the antibiotics or antimicrobials are stopped. But this approach is not necessary with Giardia, which has a short treatment period and does not require using some of the stronger antimicrobial herbs.  For pinworms, Dr. Hawrelak used to use various herbs, including megadoses of wormwood and pomegranate husks and mix some garlic and peppermint essential oil with Vaseline and inserting it around or up the anus. Now he tends to use the prescription anti-parasitic taken once and then again in 10 days and that turns out to be both effective and cost effective and less labor intensive, esp. if it occurs in an entire family. 

41:02  H. Pylori is another type of infection that has been famously shown to be the cause of gastric ulcers in a percentage of patients.  What should Functional Medicine practitioners think about seeing an elevation of H. pylori show up on a stool test?  Dr. Hawrelak said that if he had a patients with GI symptoms and H. Pylori showed up on a stool test, he would look to see if there are any virulence factors and then he would follow up with an antibody blood test and a breath test.  If the antibodies and breath test were negative and a small amount of H. pylori showing on a PCR stool test, then its probably benign and not there in large enough amounts to cause any issues. If there are antibody levels and they have symptoms consistent with ulcers or gastritis, then it is important to treat H. pylori.  We know that certain strains of H. Pylori can cause peptic ulcer disease, we know they can cause increased risk of stomach cancer.  But there is also concern about eradicating H. pylori, since if you wipe out this species, what other microbe might start growing there that might be more virulent. Also there are quite benign strains of H. Pylori that might even have some healthful effects for us over time.  We should be especially concerned it we are considering using a triple or quadruple antibiotic cocktail that can cause permanent damage to the microbiome.  On the other hand, we can use some common nutritional products that have very little risk of harm and that can be very effective, like a mixture of the following natural agents: cranberry juice, broccoli sprouts, Lactobacillis reuteri DSM17938 probiotic strain, green tea extract, turkey rhubarb, and pomegranate husks have about a 90-95% eradication rate.  Dr. Harwelak noted that he rarely uses potent antimicrobial herbs like high dose berberine or eregano, clove, or thyme oil, since these can cause damage to the microbiome. 



Dr. Jason Hawrelak is a Naturopathic Doctor, a PhD, and a master herbalist. He has been in practice in Australia for more than 20 years. Dr. Hawrelak is one of the leading experts in the treatment of gastrointestinal conditions with natural medicines and he has written extensively in Australia and International textbooks and journals on digestive topics. He continues to see patients in person and remotely. Dr. Hawrelak has developed an incredible subscription based resource to keep track of all the research on probiotics, called ProbioticAdvisor.

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.



Podcast Transcript

Dr. Weitz:                            Hey. This is Doctor Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts, and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. To learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast. Hello, Rational Wellness podcasters.

Today, I’m very happy to be speaking with Doctor Jason Hawrelak all the way from Australia about parasites. Parasites is a topic in gut health that seems to have fallen out of favor among functional medicine practitioners who deal with patients with gastrointestinal symptoms in the last five or 10 years. The focus seems to have shifted towards focusing for patients who are negative for having Crohn’s and ulcerative colitis, the focus seems to be towards SIBO and IBS.   Certain parasites are referred to as protozoans. Protozoans are actually single cell microorganisms and they include a large variety including amoeba, flagellates, ciliates, protozoans. Protozoans are common in fresh, brackish, or salt water. As well as in other moist environments including in an extreme environments like hot springs, hypersaline lakes. The protozoans can also form cysts to survive in dry environments in a dormant state. Some protozoans live in our guts without causing harm and may even provide some benefits while other protozoans may be a significant cause of disease such as [inaudible 00:01:54], malaria, giardiasis, et cetera. Protozoans are not infrequently found in the stool of patients when undergoing stool testing, especially some of the very sensitive molecular PCR tests. Parasites can take the form of worms or protozoans, of which, Blastocystis Hominis, dientamoeba fragilis, and Giardia are some of the more common parasites. Blastocystis Hominis is often considered by Functional Medicine practitioners to be a particularly difficult microorganism to eradicate and is often associated with a host of gastrointestinal symptoms including diarrhea and it’s also sometimes thought to be associated with Hashimoto’s hypothyroid disease. Some of these protozoans may not always be pathological as many of us think, as Doctor Hawrelak will explain today. One other topic I would like to ask Doctor Hawrelak about is H. Pylori infection, which at one time was considered an obvious problem when discovered on a stool panel, but is now understood to have a much more complex relationship with our gut.

                                                Doctor Jason Hawrelak is a naturopathic doctor. He’s a PhD, he’s a master herbalist, and he’s been in practice for more than 20 years in Australia. He’s one of the leading experts in the treatment of gastrointestinal conditions with natural medicines. He’s written extensively in Australia and international textbooks and journals on digestive topics. He both sees patients in person and remotely, he also teachers other healthcare practitioners. He’s currently coordinates and teaches the evidence based complimentary medicine program in the School of Medicine at the University of Tasmania. He’s the gastrointestinal imbalances lecturer in the master of science and human nutrition, and functional medicine program at the University of Western States in Portland, Oregon. Doctor Hawrelak started and runs an incredible resource to keep track of all the research on the latest probiotic strains called Probiotic Advisor, which I have used and is an extremely valuable resource. Doctor Hawrelak, thank you so much for joining me today.

Dr. Hawrelak:                     You’re very welcome, Ben. Nice to speak to you again. It’s been a while.

Dr. Weitz:                            Absolutely. Before we get started, I don’t know if you saw 60 minutes on Sunday, but I have bad news for you. You’ll have to close down your Probiotic Advisor because 60 minutes reported that there’s absolutely no benefit to any probiotic.

Dr. Hawrelak:                     Great. What can I tell my patients for the last 20 years? I can say it was all placebo perhaps. I haven’t seen that actually. I should put it on my agenda as something to watch to see what the mainstream media is actually reporting there. I think that comes from really misunderstanding some of the nuances around probiotics. Rather than taking them to change the ecosystem or to repopulate, which I think is the more popular idea, with knowing that they actually have specific effects and actions when ingested which creates physiological change, so we can use it for helping to eradicate H. Pylori for example, for decreasing obesity, or for moderating mood. There’s a whole bunch of positive clinical trials that it’s I think pretty mind blowing to come to that viewpoint that probiotics don’t work for anything based on what data has been published for the last 30, 40 years, particularly the last 20 years.

Dr. Weitz:                            Amazing amount of studies. Of course, that was one of their complaints. We’re not going to spend the whole time talking about 60 minutes, but that was one of their complaints that the probiotics that you ingest don’t actually find themselves to populate the gut. We know that.

Dr. Hawrelak:                     That’s not surprising, that’s now why we should be taking them. At least, what the research has shown us is that if that’s why you’re doing it, you’re not really taking it for the right reasons because you’re not really going to achieve that with the current generation that we have. It’s pretty rare to have any sort of longterm colonization, but that’s not to say that won’t be something we generate with future probiotics if we start making probiotics from things like Akkermansia, [inaudible 00:06:24]. Novel species that might actually have that capacity to stick around for longer periods of time or if not permanently. Reality is that they have therapeutic effects when we take them, some of them do anyway if we select them well and make sure they’ve got the right traits and qualities. When we stop taking them, that will stop having that effect just like any pharmacological agent whether that be pharmaceutical or herbal medicine that they’ve got an action while you take it. You cease taking it, it stops having that action.

Dr. Weitz:                            One of the reasons I really have been looking forward to this discussion is that I really wanted to dive into some information about parasites. When I first got into Functional Medicine 20, 30 years ago, it was a lot of talk about parasites. In the last five or 10 years, we’ve lost that focus, but I think it’s an important topic to talk about. When you’re consulting with a patient, are there any particular symptoms that come up during a consultation that will make you suspect this could be somebody who’s having a problem with parasites?

Dr. Hawrelak:                     I mean, the challenge with most symptoms that we’d associate with gut parasites like Giardia, which is undoubtedly a cause of gut infections, gut damage, Entamoeba Histolytica for example that are in that camp, versus ones that are much more debatable like Blastocystis and Dientomoeba is that the symptoms overlap with irritable bowel syndrome in some degrees with inflammatory bowel disease, functional dyspepsia, post infectious IBS with SIBO. It’s a whole cluster. If someone presents with these symptoms, you really need to do testing to ascertain what’s going on. You might get some clues from history in that they’ve just traveled overseas. They went to developing nations and they got a case of traveler’s diarrhea. That to me is a red flag that there may well be something staying in their gut from that.  That time of ingestion and that acute flair.  Sometimes, your body will fight that off.  Most of the time, it’s a bacterial agent anyway that causes traveler’s diarrhea, but we do get protozoa as part of components of or as contributors to that overall traveler’s diarrhea load.

                                                We might get that flag on the history, but we really need to do testing to ascertain what’s going on. For me, that wouldn’t mean just doing stool testing for parasites because I think we all get the potential of getting quite lost and missing what’s going on if that’s all that we do just because some microbes like Blastocystis and Dientomoeba are so common in healthy everyday people that if they’ve got some runny stool and some abdominal pain, you do one test, you do a stool test. It shows that, I think there’s a decent chance you’re going to miss what’s really causing that person’s issue in that instance. If it happens to be Giardia, fair enough, that’s a different scenario. If it’s Dientomoeba or Blastocystis, we can’t make that assumption that this is the cause of their symptoms because of the prevalence of these microbes in healthy populations. Essentially, to me it means we’ve got to do a suite of tests that if they present with that symptom picture that overlaps with so many other conditions, we actually have to test to rule out those conditions.   That would be things like fecal Calprotectin or Lactoferrin for inflammatory bowel diseases, a fecal occult blood for example also looking for more pathological changes and damage to the small or large bowel. For me, it would mean SIBO breath testing would be a component of that.  As well as doing a stool PCR looking for the presence of potential bacterial and protozoal parasites that may have been picked up from overseas.

Dr. Weitz:                            What is your favorite stool test these days?

Dr. Hawrelak:                     I would actually use a number in practice. I’m based in Australia, so we have the conventional pathology labs that do a stool based multiplex PCR that looks for the most common protozoal parasites, the most common bacterial causes of diarrhea. I might run that, but then also do a microbiome assessment as well that tells about the bacterial ecosystem, as well as doing breath testing. Then, the other tests looking for inflammatory markers.  In the colon, that might indicate that it’s more likely to be inflammatory bowel disease.  Even some of the more rare ones like lymphocytic colitis or collagenous colitis for example.

Dr. Weitz:                            Which microbiome tests will you use?

Dr. Hawrelak:                     Good question. These days, I’m using one of mostly between two different labs. One lab here in Australia called Microbiome that does metagenomic sequencing, which means we get very good detail and data from a species level perspective as well as from genus and higher up the hierarchy up to phylum. It also gives us the markers around levels of LPS production, levels of hydrogen sulfite gas production for example that I find can be clinically useful. Then, I’m also using Thrive as well particularly for my US patients where we get that nice snapshot of the bacterial components of the ecosystem.

Dr. Weitz:                            Yes, you might check out this biome FX test that Microbiome Labs is promoting now that Kiran Krishnan helped fine tune. It looks pretty interesting.

Dr. Hawrelak:                     I haven’t had a chance to look at that yet.

Dr. Weitz:                            Yes, check that out. If you had a patient who came in your office and they’re having some of these symptoms like gas, bloating, maybe diarrhea or constipation, they had a positive SIBO breath test, and you also saw a parasite, which would you treat first?

Dr. Hawrelak:                     For me if it showed up a very clear positive on SIBO breath testing and it had Blastocystis and/or Dientomoeba in the stool, I would treat the SIBO. I do this all the time. The presence of Blastocystis and Dientomoeba is generally completely irrelevant to that person’s symptoms. That’s something I’ve come to from 20 years of practice and reading more the recent literature around the prevalence of these parasites or in parasites. Protozoal and protozoal like organisms in people’s guts is extremely common. What I found is that most patients who present to me with, they go I’ve got a positive stool test for Blasto or Dientomoeba and they haven’t done a breath test yet, we’ll do a breath test for SIBO and it will actually show up positive. We treat the SIBO, their symptoms get better, they still have Blasto in their gut afterwards. That is so common. For me, it really showed clearly … I go back to how I treated patients 15, 20 years ago. If they showed up with a positive Blasto or Dientomoeba, I was like let’s try to kill this. Let’s focus in on that.

                                                Sometimes, you’d get symptomatic improvement for sure, but I think at least temporarily. I still think we were often inadvertently treating the SIBO in these patients, which was the cause of their symptoms because I wasn’t really aware of SIBO 15, 20 years ago. It wasn’t well known as a diagnostic label. Testing wasn’t really promoted, discussed, and talked about very much. I think I’ve seen that major shift in focus. I mean, one patient also illustrated to me very clearly that they came to see me. Classic symptoms of bloating, distention, some runnier stools.  Positive stool test for Blastocystis. I just made the assumption that was the cause. I said let’s treat that. Yes, there was symptomatic improvement while they were taking the herbs. Then, I hadn’t seen them for a while. Then, she came back. I think it was probably 12 months later. She said, “I was actually diagnosed with fructose intolerance. I reduced my level fructose and all my symptoms went away.” I just really was like, how could I miss that? I really let this patient down by not doing a proper diagnostic workup.

                                                I got fixated on this thing and that wasn’t the cause of her symptoms, she still has Blastocystis in her gut, but no symptoms if she goes on a low fructose diet. That patient really taught me a major lesson that we can’t … We’re often guilty of this premature diagnostic closure. I try to be less guilty of that now than I was in the past where we wouldn’t do a proper suite of tests to really see what’s going on. We’d get really fixated on that one and actually miss it. I’ve had other patients that I’d subsequently diagnosed with celiac disease that were by other practitioners diagnosed with Blastocystis and not followed up. You think, what’s the consequence of that missed celiac disease because we got so fixated on that Blastocystis on a stool test? Huge.

Dr. Weitz:                            Right. I want to go into some more detail on those two protozoans. I wonder if it’s possible that we have SIBO, which is bacterial overgrowth in the small intestine, I wonder if there’s a SIPO, if there could be a protozoan overgrowth in the small intestine that could be creating some of these problems. I asked Doctor Pimentel that when he was speaking at our meeting last month. He said, “We’re still going through all the samples. We’re going to look at that as a possibility.”

Dr. Hawrelak:                     Yes, because I think really with the evolution of technology I’ve used in metagenomics, we can actually take samples and see things that exist that we didn’t know existed before. It is interesting. I think because we’ve changed that technology or evolved into using technology that is far more accurate in its capacity to tell us what’s there, we’re seeing now that we all have protozoal organisms in our gut. That’s totally normal for humans. If you go back 20 years ago, people weren’t thinking that.  We were thinking if there’s a protozoal there, we must need to kill it because it shouldn’t be there.  It’s like, no.  We’re supposed to have fungi in our guts, we’re supposed to have bacteria, and we’re supposed to have protozoal.  They live in this usually beautiful harmonious ecosystem where they’re all interacting in ways that ensure our state of health until we upset that balance in different ways.

Dr. Weitz:                            Are you proposing that we should really think of protozoans in some cases as commensal?

Dr. Hawrelak:                     Definitely. I think certainly in the camp with microbes like Blastocystis and Dientomoeba, I will generally put them into the commensal camp in vast majority of my patients. Personally, I had a stool test done just because I was testing a bunch of different labs. It turns out I’ve got Blastocystis and Dientomoeba in my gut and I’ve got no gut symptoms. Managed to work 60 plus hours a week for the last 10, 15 years. No fatigue issues like the things that people see as symptomatic with these things, I don’t have. Here’s this one clear example of a case of a healthy person that has these microbes there, no symptoms whatsoever. You look at the literature, we find that’s actually fairly common with Blastocystis and Dientomoeba. They are extremely common in healthy people. The more recent research for the last few years have suggested particularly for microbes like Blastocystis that they actually play a pivotal role in keeping our ecosystem healthier verses the loss of our protozoal species that we’ve evolved with over millions of years some scientists and researchers are suggesting is having negative repercussions on our state of health that we see around us. Just like we’ve had that loss of bacterial diversity and loss of arguable fungal diversity that we are just finding out about now, but the repercussions of which I think we see all around us with the Western disease states that we see in practice all the time.

Dr. Weitz:                           Yes. Maybe we’ll be taking protozoan supplements at some point.

Dr. Hawrelak:                     It’s possible, I reckon. Yes.

Dr. Weitz:                           Maybe, it’s a question of balance. Maybe, it’s a question of you’re supposed to have a certain amount, but maybe if the Blastocystis is too high, it’s not a question of it shouldn’t be there, but it shouldn’t be there at that level.

Dr. Hawrelak:                     Yes. I mean, I do think there might be a part of that. Part of that is around environment. I always go back to that, the train is really immensely important for most organisms whether they can be infectious or not. The train is important and I’d dare say it’s similar with some of these microbes too that if we’re eating the right things and living the right lifestyle, then their presence is probably fairly irrelevant. You throw those things way out of balance and you throw other things in the gut out of balance, then maybe their populations or their behaviors change. I think that’s something we can see with microbes. There is some research around that with Blastocystis for example, research published very recently showing that exposure to Metronidazole, Flagyl, the most common antibiotic used to kill protozoal organisms. Well when it doesn’t kill Blastocystis it seems to actually awaken it’s more pathogenic potential that was lying dormant beforehand, exposed to antibiotics, and it increases capacity to actually cause gut damage to interact negatively with precancerous cells and become much more virulent. I think that there is an argument around how we eat, what our lifestyles are like, and potential functionality and behavior of these organisms within our gut that can be different if we ate a completely different diet, different lifestyles, exposed to low levels of antibiotics in our food chain. Maybe we’re bringing up more of the pathogenic potential.

Dr. Weitz:                            I was listening to an interview that Michael Ruscio did with Ilana Gurevich. She was talking about a study that found that species like Blasto and Dientomoeba fragilis, what they do is they change the microbiome enough to make the bacterial neighborhood more pathogenic and predisposed to negative changes either in the small or large bowels. Therefore, they’re maybe setting up things like SIBO.

Dr. Hawrelak:                     Interesting. I haven’t seen any research around that. I’d be happy to be posted some so I can read it. There is certainly some data. There was one study done in 2019 in vitro data getting a subtype seven from a symptomatic isolate subtype seven Blastocystis and giving it to mice. Finding that in in vitro, that it was able to shift the ecosystem. Maybe that’s what she’s referring to. She might be referring to some other study that I’m unaware of. That was interesting in that it did seem to increase levels of more pro inflammatory bacteria like E coli and [inaudible 00:20:51] for example, and decrease levels of bifidobacteria.

Dr. Weitz:                            We need to discuss the subtypes. There’s 17 different subtypes of Blastocystis, right?

Dr. Hawrelak:                     There is and there’s nine that are found in humans. The rest are found in other animals. That said, it’s not like these are only exclusively found in humans. The ones we find in humans, we also find in chickens, primates, pigs, cows, horses, rhinoceroses, zebras, and any animal you can name generally has a Blastocystis that can be in its gut or a number of them. For humans, the most common subtypes are one, two, three, and four. Prominently, types one and three. Extremely common.

Dr. Weitz:                            Is one of those subtypes more pathological potentially than the other?

Dr. Hawrelak:                     Well, there’s been a lot of research trying to tease that out and I would say the research has been generally … has not shown any clarity around that at all. The only small pivot I’d say there is subtype seven is very rare in humans. It’s mostly found in animals, birds. Chickens particularly, they sometimes carry seven. That study that looked at those shifts in bacterial ecosystems was associated with symptomatic type seven isolates. If I had a patient and it did show up a subtype seven Blasto and all the other tests came up negative as in normal, then I might be inclined to go let’s see about eradicating this organism because it could likely be a cause of their symptoms in your case. I certainly don’t think the data is consistent enough because you’ll find one study that goes subtype three is more common with IBS patients. Another study will go subtype three was totally not and it’s subtype one. Another study will show subtype four. There’s no consistency around the findings.

Dr. Weitz:                            Right. I just want to highlight the fact that what you’re discussing is that Blastocystis Hominis, which I still think a lot of functional medicine practitioners if they see that on a stool test are going to say you’ve got this parasite and this parasite is pathological. This is probably the cause of your symptoms. You’re saying that in a majority of cases, it’s probably not the cause of their symptoms and you may be missing another important underlying cause of their symptoms and you may be going up the wrong path focusing on eradicating the Blastocystis Hominis.

Dr. Hawrelak:                     Yes, that is definitely my viewpoint for sure.

Dr. Weitz:                            I just want to make sure that everybody understands that.

Dr. Hawrelak:                     Fair enough, yes. It’s something that for me has evolved over 20 years of practice, of dealing with patients who present with gut symptoms and Blastocystis on stool test from what I used to do, to what the research is saying, and to what I do now and the results you actually see. I generally will see something else. When we do a suite of tests and make sure we don’t stop our diagnostic procedures so early, we’ll find something else that actually explains it. You treat that something else, their symptoms go away, Blastocystis or Dientomoeba are still there. There’s that component of it, but it’s also just the fact it’s so common. I mean, Dientomoeba in Western Europe where a lot of good studies have been done, it’s found in up to seven out of 10 healthy kids have got Dientomoeba in their guts. What’s normal, what’s not normal? Kids with functional abdominal pain are less likely to have Dientomoeba in their guts than those who are actually healthy.  I still have practitioners here, integrated practitioners who wanted to use antibiotics or a suite of antibiotics to try to kill that Dientamoeba because it shows up on the stool test. Yet, the data tells us that it’s actually immensely common in kids. It’s more common in healthier guts and it’s unlikely to be a common cause of the gut symptoms when you look at the research in totality. Yes, if you’re going to be selective and not look at the broader literature, find a study going look we gave them antibiotics and the case study’s showing they improved, will quote that study rather than looking at the totality of data or looking at only one to date, randomized placebo controlled trial that looked at kids with chronic gut symptoms and had Dientamoeba present and that seemed to be the only … everything else had been essentially ruled out. They said they’ve got these kids with chronic gut pain, they’ve got Dientomoeba, let’s give them antibiotics or placebo. Let’s see the response.   Do you know what the response was? Placebo was equally effective as antibiotics for reducing these kids’ symptoms. There was no difference between them. There was no correlation between eradication in Dientomoeba and any change in symptoms. I think the really good quality data is not suggesting that particularly things like Dientomoeba when we’re talking about now is a cause in symptoms in kids and that it is immensely common in health population.

Dr. Weitz:                           In those rare cases when you have a patient with elevated levels of Blastocystis Hominis and you don’t find any other pathology, what natural treatments have you found to be the most effective?

Dr. Hawrelak:                     It’s been years since I’ve found a patient like that, Ben.

Dr. Weitz:                           Really? Okay.

Dr. Hawrelak:                     I can tell you it’s actually really rare that I don’t find something else that’s going on. The biggest challenge can be teasing out the post infectious IBS from a case of Blastocystis induced infection, gut symptoms because you’ll have a similar picture where someone will travel overseas, they’ll get traveler’s diarrhea, their gut’s never well since. You do a stool test, only thing that shows up is Blastocystis. Now, that Blastocystis could have been present in their gut for the last 10 years, 20 years, or 30 years and not be remotely relevant to what’s going on because we know that post infectious IBS happens where two things once post infectious SIBO develops, that’s pretty common. Then, you have more the colonic inflammation that persists after the infection is gone. You might have traveler’s diarrhea caused by E Coli.  It causes colonic inflammation and visceral hypersensitivity that persists for weeks, to months, to years after that infection.  There’s no more infecting agent present, you just have this residual inflammation that impacts.  Causes bloating, distension, may alter transit time a wee bit. Certainly, holds a sensation in the gut, so you feel a small amount of gas being produced. We know that’s common in literature. Yet if you do a stool test and you found Blasto in that case, you might go I want to kill the Blasto. That’s the cause, but it may not be because it may just be post infectious IBS. That’s I think the area that can be the most tricky to navigate because you’ll have normal tests come back. They may not have SIBO, but they can still have post infectious IBS and there’s no test for that. It’s based on history and their symptom pattern.

Dr. Weitz:                           Not to kick a dead horse, but one more attempt.  What if the stool test shows a really high level of Blasto? Does that raise any suspicions or not?

Dr. Hawrelak:                     I think …

Dr. Weitz:                           No.

Dr. Hawrelak:                     It would depend on the overall path from the history side.  It wouldn’t rely solely on that.  Looking at their symptom picture, looking at their history.  Let’s assume if there was someone, now it’s been years since I’ve had one of those patients that I think Blastocystis is the cause of their symptoms. Then, there are certainly some herbal preparations, et cetera, that I would use to try to help reduce levels, but you’re also focusing on trying to optimize the microbiome as well, heal up inflammation in the gut, and improve their overall vitality and health anyway.  I think for me those are always the core aspects.  What can I do to improve this person’s state of health?  What can I do to make the ecosystem a more healthy environment that’s less conducive to bringing out the bad behavior in things like Blastocystis?

                                                We know that Blastocystis likes living at a more neutral or alkaline PH. It doesn’t like living in an acidic environment in the colon or levels can be certainly reduced that way. The focus is on having a lot more fiber, using prebiotics, eating predominantly plant based whole food diet as ways of actually shifting the ecosystem in the colon, so it’s actually one more healthy, but two there’s more production of short chain fatty acids like butyrate acetate for example that then will lower the PH. That in itself can be effective in decreasing levels of Blastocystis just by changing the environment. Then, I might compliment that with some herbs. These days because of my concerns of causing collateral damage to the colonic ecosystem, I try to avoid as much as I can when I can. I’ll use agents like pomegranate husks and garlic, which we know that can be effective against Blastocystis. The best data that we really have at this juncture of time is in vitro studies or animal studies for example. Mostly, in vitro. I do use that alongside saccharomyces cerevisiae boulardii, which we know has got the positive research for eradicating Blastocystis in the human trial alongside the other agents I talked about that they’re focusing on improving the ecosystem balance in the colon. That will generally one sometimes eradicate the Blastocystis, but two certainly improve their symptoms and importantly their overall state of health and well being.

Dr. Weitz:                            Let’s go on to some of the more pathological parasites. Which ones do you see most commonly?

Dr. Hawrelak:                     I would say Giardia would definitely be top of my list. I work in an inner city environment that is a colder climate, so I don’t see Giardia as often as I once did. My first number of years in practice, I was living in the subtropics where people drank creek water and rain water for most of their … it was rural and people were often bush walking, hiking and drinking the water from creeks, et cetera. Giardia was much more common back then, so I had a lot of chance to hone my practice on Giardia treatment over the years. Now, I tend to see it more in the odd returning traveler or I see the odd person who’s got a chronic infection of Giardia that they weren’t able to get rid of with their previous course of antibiotics.

Dr. Weitz:                            What is some of your favorite natural agents for treating Giardia? Also, do you cycle your use of these?

Dr. Hawrelak:                     Generally, there’s no need. My experience with Giardia is it’s immensely responsible to the right treatments and target treatment with natural medicines. I would use raw garlic ideally and if they’re very sensitive, we might use an allicin based product, but most of my patients have tolerated raw garlic. A couple cloves pressed into either little capsules or a little glass of water and swig it down a couple times a day. There’s one study out of Egypt that showed I think a hundred percent eradication rate by day three on having essentially blended raw garlic.

Dr. Weitz:                            Wow, three days.

Dr. Hawrelak:                     That’s impressive. A hundred percent reduction of symptoms or essentially elimination of symptoms by 36 hours into the treatment protocol. That’s very quick. Garlic’s definitely on my list. These days, I would be using pomegranate husk and usually plantain, plantago major ribwort, which is one of those herbs that grows as a weed almost everywhere in North America and here in Australia.  It’s got some lovely potent anti-Giardia activity, but it actually has some healing anti-inflammatory effects on the gut as well. It doesn’t taste too bad and it doesn’t have that broad killing effect that I might get with something that was more berberine containing herbs.  Years ago when I first started practicing, I used more berberine containing herbs and it’s certainly effective for Giardia, no doubt.  I would be using coptis chinensis, which contains more berberine than goldenseal or other berberine containing herbs like Mahonia aquifolium or Berberis vulgaris a lot more. It’s undoubtedly effective, but I also know from research I did as part of my PhD that it reduces levels of bifidobacteria. It’s not such a big deal for 10 days, which is a usual treatment period for Giardia, but given I can get the same results without having to worry about any collateral damage to my bifidobacteria populations in patients if I use pomegranate husk, ribwort, and garlic, I’ll choose that.  Then, I would give saccharomyces cerevisiae boulardii again as my probiotic of choice because there’s good data on that in Giardia both for helping to eradicate, but I think this is the important aspect too. A number of people have symptoms that persist long term post Giardia. It’s because Giardia, amazing little protozoal organism that when it exits from it’s little cyst, you often get one or two little guys that come out of that, but they can cover up every single little bit of your proximal small bowel, every little millimeter of space will be covered with Giardia trophozoite. They can actually cause a lot of damage as part of that. They can cause nutritional issues in the short term in that most things you eat are going to be malabsorbed because they’re just covering that entire area, they’re going to eat those foods, you don’t get much if any. They’ll also cause a fair bit of damage to the small bowel. This can sometimes mean that there’s a bunch of symptoms that persist even after eradications.  You might kill off the Giardia with antibiotics or with herbal medicines in my case in probiotics and nutritional supplements, but they might still have some persistent diarrhea, persistent lactose intolerance, persistent fructose intolerance that comes from afterwards because when you flatten those villi and you damage the brush border, you don’t have lactates on those brush enzymes anymore. The fructose transporter is very much impacted by inflammation. If we inflame the small bowel, we really limit the capacity of that fructose transported to pull up the fructose and take it in. We can often get this secondary lactose and fructose intolerance. The saccharomyces boulardii is wonderful for helping to regrow those villi and the brush border. You might do that during, then for at least six to 12 weeks afterwards to speed up healing.

Dr. Weitz:                            Interesting. The villi are damaged by the parasite.

Dr. Hawrelak:                     Yes, by the Giardia because they’ve got this little ventral disc that sucks onto it and actually causes tissue damage, inflammation. It’s a crazy little guy.

Dr. Weitz:                            Do you have to have Giardia for a long time for that to happen?

Dr. Hawrelak:                     One would say the longer you’ve got it, the more severe the level of inflammation would be. There’s a caveat there because we know that most people will throw off Giardia in three weeks with no treatment at all. I think from memory, it’s around 90 percent of people who get Giardia, you do nothing. In three weeks, it’ll be gone in 90 percent of people. It’s going to be an uncomfortable three weeks. There’ll be lots of diarrhea, lots of bloating, lots of nausea. I don’t recommend it, but we know that the immune system can generally deal with it, except for people that have IgA insufficiencies tend to be the biggest issue where they will have it … it’s impossible for them to throw off Giardia if they don’t produce enough secretory IGA in the gut. There’s some people that it tends to be a chronic infection. Even a week to two weeks is still enough to actually cause a degree of malabsorption. Depending on how severe the infection was and how much of the small bowel was covered will dictate how much of that post infectious symptomatology we have to deal with and post infectious damage we need to heal up to get patients’ function back to a good level and absorbing food again the way that they should be.

Dr. Weitz:                            Interesting. Have you heard this concept that when trying to kill a parasite because parasites are laying eggs, that you want to use the antimicrobials for 10 days, then wait 10 days because supposedly in the presence of the antimicrobials, the eggs won’t germinate, they’ll wait until the antimicrobials are gone, then the eggs will germinate and you’ll have more Giardia or other parasite? Then, you’ll have a reinfection, so therefore there’s this thought that you treat for 10 days, you wait 10 days, and then you treat again for 10 days.

Dr. Hawrelak:                     Yes. I mean, I certainly will do that with helminth, actual bigger worms, pinworms, et cetera. I will follow that approach. I don’t with Giardia and I haven’t seen any cases where that particular approach has been problematic in that instance. I think if we’re choosing agents that are not going to cause collateral damage to the ecosystem, then I got no qualms with that approach at all to err on the safety side. I’ve never seen it necessary with Giardia. That’s by far the most common one I would be treating in practice.

Dr. Weitz:                            What’s your protocol for pinworms?

Dr. Hawrelak:                     It’s a tricky one. I’ve tried lots of different things. To be honest these days, I actually recommend the pharmaceutical ones from the pharmacy because they work. Yes, I can give you herbs that taste absolutely ghastly, garlic [inaudible 00:37:55], and essential oil put in a little bit of Vaseline around the anus at night, you can do all that for weeks at a time and will get okay results, or I can give one little dose of that chocolate, 10 days later another dose of that thing, and they’re gone. It’s far less costly. You’re often treating a whole family. I’ve trialed and error-ed lots of different things. Maybe some people have got much better results with herbs than I ever had, but we’re using megadoses of wormwood and pomegranate husks which has got anti worming activity too. Listen, it’s certainly brought worms down. Oiling up a tiny a tiny clove of garlic that’s been peeled and inserting up the anus, that helps break the cycle of bit.

                                                Same way with putting some peppermint essential oil around, a little Vaseline around the anus. The worms come out to lay their eggs and are like I don’t like that oil, so they go back in and it’ll help break the cycle. It’s labor intensive. To do herbs for a family of four for a month, that whole process, is costly. I still don’t find the results as effective as just doing the pharmaceutical twice. In this case, I’m not worried about the collateral damage to the gut ecosystem because the data to date doesn’t suggest this much in the way of collateral damage because worms are actually more related to us than they are to bacteria. The agents that are targeting those worms actually have more capacity to cause us side effects than they do kill bacteria directly. I’m not so concerned and that’s my approach now, which is not so exciting as you got to use this fantastic herb, but I just didn’t find the result with the herbs as what I’ve got with the pharmaceutical. The cost differential didn’t make it worthwhile.

Dr. Weitz:                            Speaking of worms, have you looked into helminth therapy, the therapeutic use of worms? A couple of worms that are used is the pig whipworm or the human hookworm. I’ve read some articles where they’re being used for allergies, autoimmune conditions, inflammatory gut disorders like Crohn’s and ulcerative colitis.

Dr. Hawrelak:                     I’m not super familiar with the literature around that. I’m a little bit around the uses of [inaudible 00:40:05] for celiac disease.

Dr. Weitz:                            Yes, that’s the hookworm.

Dr. Hawrelak:                     That’s right. When I looked at the results, they were very underwhelming in terms of [inaudible 00:40:18]. It was like, okay. They gave them these worms, they had a bought of severe enteritis, and they got a lot of pain from the worms. Then, it slightly diminished the degree of inflammation caused by subsequent gluten exposure. To me, that was underwhelming. Okay. Yes, you made the gluten, you got less gut damage than if you didn’t, but it still didn’t completely stop the gut damage and it didn’t completely stop the pain from ingesting the gluten. Plus, you had the pain and discomfort from ingesting the hookworm in the first place. I thought the worm results were very underwhelming for celiac disease. That doesn’t mean that they might be more useful for inflammatory bowel disease and other conditions. I’m not so familiar with the literature there, not enough to make any judgment calls on their efficacy or not.

Dr. Weitz:                            I like to ask you about one more topic about H. Pylori. H. Pylori is another infection in the gut. Often, occurs in the stomach. There’s a whole story everybody’s probably familiar with that it could be related to ulcers and we have that whole story about Doctor Marshal giving himself H. Pylori causing ulcers. Anyway, H. Pylori is another thing that comes up on stool tests a lot. We’ve learned more and more how H. Pylori’s an important part of the gut. It may not necessarily be pathological.  What’s your take on H. Pylori?  When is it pathological?  How do we know?

Dr. Hawrelak:                     That’s another great thread of questions. I think we’ll answer this question differently in five years’ time than what we can now.

Dr. Weitz:                            I mean, we do have the virulence factors that give us an idea of whether we’re reacting or not.

Dr. Hawrelak:                     That’s right, we’ve got some of them. I think that’s a step in the right direction. For me if I had H. Pylori show up on the stool test for example, I would look at the presence of the virulence factors. That’s the first thing I would do because that’s usually in that same test that might pick up the H. Pylori and tell me those things are present. I would always follow that up with doing a antibody test like a blood test or a breath test because for me I want to see, is the body reacting to that H. Pylori? Is it increasing antibodies to the H. Pylori? Is it high enough of a count that it’s actually showing up on a more conventional test rather than using these genetic markers? Those to me really tell me the data that I’m after as well as, do they have symptoms that coincide with gastritis, gastric ulcer or peptic ulcers? If they do, then I would go H. Pylori’s probably related to what’s going on there.  If I have a patient where they have it negative, no antibodies in the blood, nothing on the breath test, and a small amount in the stool that showed up on a PCR based test that didn’t show any markers of virulence, then I wouldn’t worry about its presence at all because I would be thinking it’s probably benign, it’s probably there in tiny amounts, not enough to cause any issues. Conversely if it actually showed up with antibody levels, they’ve got symptoms that are consistent with peptic ulcers or gastritis, then I would generally treat H. Pylori in that case. For me, it’s always this balance. We know that certain strains of H. Pylori can cause peptic ulcer disease, we know they can cause increased risk of stomach cancer. That is clear. There’s also some concerns about the eradication of that species. One, leaving an ecological vacuum and what will grow in there. What’s next if we take that species out? Some other microbe might start growing in there. That might be more virulent than that. Second point is there are quite benign strains of H. Pylori that might even have some healthful effects for us over time.

                                                It’s just we don’t necessarily have the technology yet and this is where I would say five or 10 years’ time where we know a good chunk of virulence factors now, but we’re still discovering new things. We might discover more, we might be able to get down to strain subtype. [inaudible 00:44:30], look at the genes of this specific strain. Beyond that, and yes. There’s a greater risk of it being a problem, let’s get rid of it. For me if I’m using natural agents that don’t have the capacity to cause widespread damage to the colon ecosystem, I’m not that worried. If I’m going let’s eat some broccoli sprouts for two weeks, have some cranberry concentrate, and take this herb, et cetera, that can be in my experience very effective at getting rid of H. Pylori. I’m not worried about treatment so much. If there’s patients taking triple or quadruple antibiotic cocktail, then we’re talking about big life … essentially, it’s life altering in the respect that colonic ecosystem that will inadvertently be smashed by that antibiotic cocktail will be permanently changed. It will never go back to the way it was before. When we’re talking about those bigger interventions, then I think we need to consider much more about the risk/benefit ratio that are different when we’re looking at using natural medicines to treat the H. Pylori. That the risk is far less, so it’s quite a different way of considering it.

Dr. Weitz:                            The natural agents you would use would be mastic gum and maybe something else?

Dr. Hawrelak:                     I would usually use a combination of things. You look at the data about natural medicine, there’ll be ones today showing a 16 percent eradication with cranberry juice. 16 percent, not fantastic, but it’s better than none. There’s one study that used the Lactobacillis reuteri DSM17938 strain. I think it had over 50 percent eradication rate just with that single strain. You combine that and I might combine broccoli sprouts, which I think at a 78 percent eradication rate from memory.  You’re going let’s add a few of these things together and nigellis sativa, so black seed again had over 60 percent eradication rate on its own. You’re doing a few of those things together. Then, I might use some herbs like green tea, rhubarb, pomegranate husks for example, turkey rhubarb, and in my experience we follow a protocol that’s for most of my patients around six weeks. It’s around a 90 percent eradication rate, which is really I would argue better than what we’re getting with antibiotics these days. At the first time they started using antibiotic cocktails like triple therapy, they were looking at 90, 95 percent eradication rate. Now, some of the recent studies are like 50, 60, 40 percent eradication rate because of antibiotic resistance.

                                                I’ve been impressed at how well a combination of herbal agents and natural supplements work versus using them just on their own, much more [inaudible 00:47:14] to get the occasional time just getting one of those things to work for a patient. My experience has been again through a fair bit of trial and error with patients, it actually makes more sense and I get the best results with doing a much more intense protocol for a six week stint. Then, do follow up testing, and go, yes. It’s gone. Generally, that combination of things works well. You get synergy between those agents.

Dr. Weitz:                            You think natural agents like oregano, berberine, and maybe some of these other antimicrobials could potentially have negative effects on the microbiome.

Dr. Hawrelak:                     I would say from both of some of the in vitro research I did as part of my PhD and from clinical work with patients doing pre and post testing, yes. That berberine I think clearly can diminish overall diversity of an ecosystem and reduce levels of bifidobacteria specifically. Some of those species may be fine with it. I’ve even seen one patient who managed to essentially result in the extinction of bifidobacteria population from taking high dose berberine for longer periods of times, so I’ve got some caution around that. Again, some plant essential oils, so oregano essential oil, thyme essential oil, clove essential oil that are potent antibacterial agents. They totally are, anti protozoal, and anti fungal agents. They’ve got a wide set of actions, but I do think they have come collateral damaging effects in the gut too. I think there can be times and places for more potent agents. I try to follow that, the naturopathic therapeutic order where we use the agents that are less likely to cause harm first. Then, we move along that order to those that have greater capacity of causing harm if the other ones don’t do the job. I’ll rarely use berberine when I’m treating Giardia these days, I’ll rarely use berberine or oregano essential oil for treating SIBO these days because I think there are other herbs that are effective that don’t have the collateral damaging effect that those herbs have.

Dr. Weitz:                            That’s interesting because I haven’t seen that sort of negative effect on a microbiome from berberine. I also treat diabetics. We very regularly use a pretty decent dosage of berberine on a regular basis. I have seen no increased gut problems coming from that.

Dr. Hawrelak:                     I wouldn’t say [inaudible 00:49:36]. Obviously, it’s got issues. Although, sometimes longer term I think that can manifest. In terms of populations of bifidobacteria, I would suggest if you haven’t yet, using the test that uses either [inaudible 00:49:48] looking at proportions of bifidobacteria or metagenomic sequencing for bifidobacteria pre and post, you might get a slightly different picture with that rather than some of the previous tests that use two plus four ways of measuring things, which are far less clear what’s going on. You may see that.

Dr. Weitz:                            We’ve been using the GI map with quantitative PCR.

Dr. Hawrelak:                     Okay.

Dr. Weitz:                            Good. Excellent. Thank you for sharing some fascinating information with us.

Dr. Hawrelak:                     You’re very welcome. I’m glad I could come back and chat to you, Ben. It was good.

Dr. Weitz:                            Good. I’m glad we could make this happen across the world even in the midst of the coronavirus pandemic. How can listeners and viewers get ahold of you and find out about some of your … I know you have a number of courses that are available?

Dr. Hawrelak:                     Yes, we’ve got one on Dientomoeba and Blastocystis because I’m trying to get that information out there about that. That change in conception that research has actually made manifest. Also, ones on Giardia too as it turns out. The microbiome, probably more broadly lactose intolerance, fructose intolerance, we’ve got a few different lecture out there on the Probiotic Advisor site. My passion is really around the gut microbiome, probiotics, and prebiotics. I’ve been in this area for 20 years when I first started my honors and my PhD research, so I love this area and I love being a clinician still so you get a chance to actually work with patients and see what works. Sometimes, what works in research doesn’t always manifest in clinical change in any beneficial way or it just doesn’t work in reality. It’s been nice to go, what does? What doesn’t? Over years of working with patients too.

Dr. Weitz:                            What’s the website for the Probiotic Advisor? That’s where they can find new courses, right?

Dr. Hawrelak:                     Yes. Www.ProbioticAdvisor.com. Then, we’ve got a teachable courses page too. I think we’ve got 12 or 13 courses up there now around microbiome and gut health more broadly.

Dr. Weitz:                            Great. Thank you so much.

Dr. Hawrelak:                     You’re welcome, Ben. Nice chatting again.

Dr. Weitz:                            Nice chatting with you too. I’ll talk to you soon.



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