Nirala Jacobi:

Welcome SIBO practitioners to another episode of the SIBO Doctor Podcast. And with me today, I have one of the show's favorites, Dr. Jason Hawrelak, who is the third time now on the SIBO Doctor Podcast and always such a pleasure to have him on the show for his wealth of knowledge and everything gastrointestinal.

Nirala Jacobi:

Dr. Hawrelak is a researcher, educator, naturopath, and nutritionist with over two decades of clinical experience. He practices at Gould’s Natural Medicine, a natural medicine apothecary over 130 years old, and a clinic in Hobart, Tasmania. Dr Hawrelak completed his PhD examining the capacity of probiotics, prebiotics, and herbal medicines to modify the gastrointestinal tract microbiota. He is a senior lecturer in complementary and alternative medicines at the University of Tasmania, School of Medicine, where he coordinates the evidence-based complimentary medicines program. He also teaches the gastrointestinal imbalances units at the University of Western States. And five years ago, he started the Probiotic Advisor, a searchable database for researched probiotic strains, which I have certainly found to be an invaluable tool and is a great tool for anyone with a gut focus in their practice. So welcome very, very warmly, Jason.

Jason Hawrelak:

Thank you, Nirala. It's wonderful to be back and to have a chance to chat with you. I always love our chats.

Nirala Jacobi:

I know. We're always just gets off on a tangent, so I'm hoping... I know you're still a little bit under the weather, so I'll keep it not as long as we tend to usually go.

Jason Hawrelak:

Yeah.

Nirala Jacobi:

But today's topic is so fascinating to many of our practitioners that are in the field of gastroenterology because we are talking about parasites and you've just recently released a course about blastocystis and Dientamoeba fragilis. And anyone listening, the link to that course will be in the show notes, where you can access it really easily. And so, I really thought I'd take this opportunity to chat with you about it because a lot of misinformation exists around blastocystis and Dientamoeba.

Jason Hawrelak:

Yes.

Nirala Jacobi:

So we'll start with that, but we'll sort of have a looser conversation about other parasites. But we really want to kind of hone in on that. But people also can... I really do advise you to take his class because it just will clarify a lot about these two protozoans. So let's get started about... Which one do you want to start with? So please start-

Jason Hawrelak:

Why don't we start with blastocystis? I'll probably just end up calling blasto because-

Nirala Jacobi:

Yes, please do.

Jason Hawrelak:

... I've been in Australia long enough that we shorten every [crosstalk 00:04:03].

Nirala Jacobi:

We do, we do.

Jason Hawrelak:

We'll go blasto [inaudible 00:04:07].

Nirala Jacobi:

Great. So tell us more about... Well, my understanding is it hasn't even been classified as an actual parasite for that long. And since then, we've had a lot of time to look at it and a lot of people when they find it in on a stool test think, "Oh, eureka, I found the cause of the problems for this patient," and proceed to treat it. So can you tell us a bit more as to what you found in your research that sort of demystifies blastocystis a little bit.

Jason Hawrelak:

I think the research has shifted around a fair bit on this organism. And I mean, I can go back to when I first started practicing and how I approached blasto versus now, and I think you hit on a few things there. But certainly what I would see, what's common places that someone presents with gut symptoms in perhaps the first stool test we do in that case, because it might have diarrhea stools and they may have even had that since they went to Bali or Mexico or something like that. "Oh, well, let's check." Boom, it shows up that, "Oh, they've got blastocystis there. Therefore, that must be the cause." And mean, I've made this mistake myself in the past too, is you'd stop you're diagnostic workup right there and I do not do that now.

Nirala Jacobi:

Yeah.

Jason Hawrelak:

I've learned better to just actually there, you make that that leap. Because there's plenty of researches that's really come out of the last 10 years, maybe 15 years, particularly when we started looking for the prevalence of blasto in healthy populations. And I think that bit of data was missing before that we just [inaudible 00:05:45]. These studies would be done and going, "Oh, this person's got diarrhea. Oh look, there's blasto there. This group of people have diarrhea, they seem to have blasto." So we'd sort of make that sort of link that was there. But once you start doing studies, looking at how prevalent are these organisms in healthy populations.

Jason Hawrelak:

And I think the first study that looked at this in healthy populations with maybe we have some eight. And a small study in Ireland, they found 82% of the healthy people had blastocystis is clearly asymptomatic. And I think that sort of blew their minds because it's like, "Oh." They weren't expecting 82% of these sort of healthy controls without symptoms will actually carry this organism in there. And I think there's plenty of data that's come out since that time showing exactly how prevalent it is in the healthy populations. And even that, that it actually may be playing a role in keeping ecosystems healthy. I think that's the other fascinating aspect too of that. Since we really do testing more accurately and then see the relationships with ecosystems in greater depth. Like we're now associating blastocyst prevalence or presence with more diverse, more healthy ecosystems with lower levels of gut inflammation in the people that they're actually missing that organism for the ecosystem.

Jason Hawrelak:

And it's now possibly that these protozoa organisms like blastocyst has play an apex predator role and actually a very important players in keeping your ecosystem, your bacterial components of ecosystem in balanced and healthy.

Nirala Jacobi:

I think that's going to blow a lot of people's minds what you just said because we're so accustomed to thinking that we would find it in a dysbiotic environment and that there's some problem, but to consider the fact that you find it in really healthy environments is just sort of like a complete set of paradigm shift, I think, for many people when it comes to this particularly protozoan.

Jason Hawrelak:

Yeah. Research in 2016 was really clear showing that the presence of blastocystis [inaudible 00:07:41] with a healthier microbiome status with greater diversity. And when you didn't have it, you're more likely to have a sort of typical Western ecosystem which is bacteroides dominance and other research and shows in 18 showed that asymptomatic carriers, so people that had blasto with no symptoms actually had lower fecal calprotectin compared to those that did not have blasto in the gut.

Nirala Jacobi:

Wow.

Jason Hawrelak:

As well as a lower BMI as well. The people with blastocyst were shown to have a more healthier body mass index.

Nirala Jacobi:

And you're going to go deep into that in your class I know because I had the pleasure of listening to your lecture about this before, so I really do encourage people to tune into that. Now, but there are different subtypes, right?

Jason Hawrelak:

Yes.

Nirala Jacobi:

I mean, there are about 17 different blastocystis subtypes and there was... I'm sure you're aware of it, but then from 2019, that study that showed that subtype seven, the Singaporean strain did seem to be more virulent than other strains and really affect microbiota around it. So do we think that there, it's sort of a strain specific issue around virulence?

Jason Hawrelak:

Yeah. And I think when you look at the data more broadly and research on different subtypes, it certainly suggests it's not necessarily a subtype thing. And if you look at the conflicting data around subtype and potential virulence, there're tremendous amounts of conflicting data. There's some research, there's subtype three is more likely to be problematic. Other says it's type four. Other's say subtype one. Others are complete opposite things. There's really no consensus around that. But there's plenty of research that are indicating that there's probably strains within subtypes that may potentially be involved with... That display greater virulence factors that actually might be key here and this is a pragmatic effort for clinicians to tease out at this time point because we don't have the diagnostic tools to actually differentiate beyond, for the most part, the subtype level.

Jason Hawrelak:

But yes, you mentioned that study from 2019, it was looking at subtypes seven and those isolates. I think there's two different isolates, different strains of subtype seven there were isolated and using the state that were originally probably from asymptomatic patients and they did show that the co-culture with different bacterial components, the ecosystem sort of stimulated the growth of some microbes but actually seem to inhibit the growth of bifidobacteria. And maybe that one in particular was perhaps good at grazing different [inaudible 00:10:12]. The other subtypes seem to be good at grazing on bacteroides interestingly enough, and that there's some type seven isolates, when they sort of injected into the cecum of mice, it had sort of induced for chronic inflammation as well and decrease their [inaudible 00:10:28] counts in that sort of animal model as well. But obviously, it's a slightly stretch to inject these things in high doses versus oral sort of usage for one thing.

Jason Hawrelak:

Two is worth citing too. That subtype seven is generally a subtype you find in chickens and birds and it is actually very rare in humans. So I would suggest that if someone has symptoms, you've done a thorough workup and subtype seven is actually there, then that may well be correlative and that may be causative in that particular instance because it's such a rare thing versus subtype three which is the most common subtype in humans and extremely common in asymptomatic people, as well as in people with symptoms. So either you can make any assumptions around subtypes three or four or one because they're so commonplace. Unlike subtype seven, which is actually very rare.

Jason Hawrelak:

And agree, a few other studies that have shown that, that's strain within that subtype may have a greater [inaudible 00:11:29] caused the harm in humans. And even the environmental conditions that subtype seven is a little bit different because they're used to being in birds. So I think they actually like some even warmer temperature. So maybe the human gets too cold. [inaudible 00:11:42] do something to one of the temperature.

Nirala Jacobi:

Interesting. So what do you mean actually about apex predator? What does it go after if it's a predator?

Jason Hawrelak:

It eats bacteria is certainly the current thinking around it. And with that idea, the research tells us that people with blastocystis generally have healthier and more diverse ecosystems and the thinking there is that they essentially graze off in bacterial populations and prevent one particular genus from dominating. And certainly, the research today suggests it's generally prevents Bacteroidetes from dominating. Yeah. Which I think is fascinating because I think again, you've talked about misinformation in the blogosphere in the worldwide web, and it's totally is. Because people will make the assumption that blastocyst eat wheat or eat sugar. All these things are such widespread ideas, but we know it actually eats bacteria. That's what it's eating. And you've got trillions of them to have and you've got to independently whether you eat those things or not. Yeah. And I think if you get symptoms because you're eating wheat, it's not because it's blastocyst. It's just something else going on in the gut that we should try to associate what it eat.

Nirala Jacobi:

Right. Well, and you mentioned... I think this is really one of the reasons I wanted to talk to you about this because I know that there's a lot of misinformation about parasites in general and a lot of very generalized recommendations about parasites. And I think our thinking... Of course, I'm not negating, obviously there are some pretty bad parasites out there. But in my practice, I think the most common two are Blastocystis hominis and Dientamoeba fragilis. Both of which you address in your course as really not very problematic for the most part. So that really leaves me with very occasionally, I find a worm or I find there's sometimes even beneficial helminths or what we think of as beneficial helminths in certain circumstances, or worms.

Nirala Jacobi:

So there's just not really a great authority I find on parasites out there because also the testing arena, I think, lacks real accuracy in many, many circumstances. So it's really difficult because we want to be sure as practitioners as that we're treating something that is obviously a pathogen. Like for example, Giardia, that is in the same class of group of parasites, so a protozoan that is very different from these other two that causes a lot more damage and diarrhea and so forth. So yeah, I think it's interesting.

Nirala Jacobi:

Now, getting back to blasto for just a moment, talk to us about... Oh actually, no. I'm on the wrong protozoan because it's Dientamoeba fragilis that uses pinworm as a vector, right? Like in terms of-

Jason Hawrelak:

Potentially. There's been so much debate and discussion around how D. fragilis gets or D. frag, I'm going to call it for short as well, gets passed around. And I think there was this hypothesis a few years back suggesting that pinworms were vector and that hasn't necessarily been disproven. But one of the main supportive arguments for that was the fact that there is no one ever seen a cyst form of D. Fragilis. Well, if we don't see cysts, it's got to be passing some of the way. Maybe it's [inaudible 00:15:21] through pinworm eggs. Yeah. If we do testing, we can see some D. frag DNA in pinworm eggs so maybe that's it. And there's certainly data around that.

Jason Hawrelak:

But within the last few years, people have actually seen this is form of D. frag for the first time too. So that has led some of the newer D. frag researchers to think that pinworms are not really all that important with the sort of passing on or the spread of D. frag. And D. frag is just so common. When you start looking at research in Western Europe, and I talk to my patients about this all the time, but it's 55% of asymptomatic kids have caught D. frag in their guts. So I mean, what do we do here? Do we just give them all antibiotics? Which some people would argue we suggest because D. frag is present. I mean, it brings up a bunch of questions around appropriate, inappropriate treatment to the presence of microbes that are extremely widespread.

Jason Hawrelak:

And this is where the thing, once we start testing healthy populations, we start seeing how common these organisms are and we're starting to tease out what role these protozoa will play in a healthy gut ecosystem because we're not absent of these bugs. They play important roles, just like the fungi do, just like bacteria do. And these protozoa all have these entwined ecosystems. Nevermind if the consideration of what happens if someone has always comes out and whether it changed that balance that you actually get. And that's [inaudible 00:16:47] too, but it's such a frequently found microbe. And there's some research that found that that kids with D. frag actually had less the instance of soft watery stool, less instance of diarrhea, less instance of fatigue compared to those who actually didn't have it.

Nirala Jacobi:

So why do you think it ever was classified as a parasite, Dientamoeba, now?

Jason Hawrelak:

Well, it's an interesting one and I think a lot of the excitement around treatment came from case studies, like published case reports, where subject A presents with symptoms and diarrhea. We give them antibiotics, their symptoms go away. D. frag is gone. Therefore, D. frag must be the cause of those symptoms. That's I think where most of the difference comes from. And you look at some of the earlier published research on D. frag and they are all these cases of case reports. [inaudible 00:17:39] Look at the results look pretty positive. Some of the early ones were lucky, 85% kids got better from taking course of Flagyl. But then more some of the more recent studies suggest that really that the... Probably most importantly that the one double blind placebo controlled study showed that there was no improvement with antibiotic treatment versus placebo. And that the placebo, the effect of improvement was about 30% is which is you would expect from placebo in IBS like population. And it was exactly what a solid placebo. In fact, there's never no improvement.

Jason Hawrelak:

And I think that really started to put some questions around that. But there are people who are still really attached to that approach and are still can easily quote those earlier case reports that you have I think unrealistically high sort of improvement levels. And really, we should be looking at placebo controlled studies if we're going to look at efficacy because... And the other aspect is when you give a course of antibiotics, it's not like we're just impacting that one organism's population. We're impacting dozens, if not more, species of microbes. And so, it is surprising that sometimes we give antibiotics and people's bloating and distention goes down because we probably kill off a whole bunch of their hundred gas producing bacteria in the colon too, that may probably is only temporary until their populations come up.

Jason Hawrelak:

Yeah. But it makes you just think of... There's a study published in gut last year. They were looking at one individual. This is like 10 to here. We're going on tangents. And I gave him a course of IV antibiotics of ceftriaxone, I think it was. IV antibiotics one off shot and nine species went extinct.

Nirala Jacobi:

Wow.

Jason Hawrelak:

Nine from that one course of antibiotics. And you're like, "Well, who knows what impact we're having on that gut by giving that course of antibiotics?" It's not just the D. frag. It's not like you're specifically targeting that. You're changing a whole bunch of different things in [inaudible 00:19:33].

Nirala Jacobi:

Well, that really brings up this whole idea of sort of ancient species that we co-evolve with and blastocyst is potentially is one of those. And we're making our environment more and more sterile in a way. Actually, where I was going with that is that, some of the research that came out of or the research that I looked at in terms of parasitic studies that have looked at migrants and people coming from developing countries into the Western countries and not just adopting the lifestyle, but when they had stool testing, they had lots of parasites and they were asymptomatic. And then when they received antibiotics for those parasites, that's when their problems started digestively.

Jason Hawrelak:

Yeah. And I'm sure, you see this all the time. I certainly do. Where sometimes they had a certain level of symptoms, then after antibiotics, the symptoms flared traumatically or they've never been the same since their sort of antibiotic cocktail they took to deal with the blasto. That's pretty common. And I think, that there's a bunch of reasons is that for species lost, for example, loss of ancestral bacterial organisms that play pivotal roles in their gut that are now extinct to long lasting inflammation that occurs posts those antibiotic usage, plus the potential impact on those protozoal organisms themselves and the role that they're playing in the gut.

Jason Hawrelak:

But there was some fascinating research published recently showing the antibiotics actually could enhance the virulence factors, the virulence of blastocysts isolates as well, which I thought was fascinating. So we're actually encouraging them to behave poorly to antobiotics. Another potential reason why that's problematic.

Nirala Jacobi:

Yeah, and really one of the reasons I wanted to bring up this topic is because, like I said in the at the beginning, there's so many patients that I see that have been through this very journey, where they've been first diagnosed with blastocystis. I think you shared a case very similar to this, but I see many people like that where they're like, "Oh yeah, finally, I've got my blasto under control. It's finally gone, but my symptoms aren't gone or my symptoms are worse."

Jason Hawrelak:

Yeah.

Nirala Jacobi:

So it's that really common scenario that we see because we both have basically functional gut clinics where we deal with a lot of the fallout of this type of approach and really clarifying this for practitioners because if you find blastocystis and Dientamoeba, and or Dientamoeba fragilis, I think basically, the message here is keep looking as to a cause of that patient's symptomatology, right? Would you agree with that?

Jason Hawrelak:

I totally agree with that. And I was guilty of not doing that in the past. I had those scenarios of seeing a patient, I think it was 12 or 13 years after I saw him the first time, I had a chance to see how I might change as a practitioner both in terms of treatment, but particularly from a diagnostic workup perspective. And it makes me realize that, "Oh, whilst I did the best I could at that time with the knowledge that I had and my skillset, we essentially either miss, people will die." I've been there and I've seen this before.

Jason Hawrelak:

Other patients have come to see me recently where diagnosis like CF disease was missed because the number of practitioners were so enamored by the blasto as the cause of the symptom. It's up the workup right there. And then what are the consequences of that person having celiac disease for another three or four years until it gets potentially diagnosed? It's absolutely huge. So I think it's vital that we as clinicians and don't stop at that time point that we can, "Okay, that's interesting." But let's actually keep digging. Given that how common these two organisms are in healthy populations, we can't make the assumption that these are the cause of the symptoms in this person.

Nirala Jacobi:

It always helps when I tell my patients, "Look, I've got blasto. I'm fine. You know, I'm fine. Even if I wanted to treat it, it would just come back. No problem because we live in an endemic area." So I think-

Jason Hawrelak:

I did a stool test for an experiment in my lab, my stool, to a whole bunch of different labs and it turns out, "Oh, I've got blasto and D. frag and I've got [inaudible 00:23:52] not fatigue and I don't have any of the symptoms people associated with that." So I think, I agree. I tend to share that with patients too. And now, I shared with the whole world.

Nirala Jacobi:

Great. Fantastic.

Jason Hawrelak:

I've got blasto and D. frag, and I'm proud.

Nirala Jacobi:

It's like getting back to that kind of re-wilding of our gut in a way.

Jason Hawrelak:

Yeah.

Nirala Jacobi:

But I can also imagine a scenario where it could cause problems. If it eats bacteria and you start off with somebody that has a really, really low diversity and really just low in everything that it could potentially cause problems if it's something, if it's an organism that likes to feed off of other bacteria. I mean, I could imagine a scenario like that.

Jason Hawrelak:

Yeah. And I think it comes back to those naturopathic ideals we have of that the terrain is most important, not the organism, that would if we change the train and improve the microbiome health, improve their health, host health, improve gut function in general, that we changed the environment so it's not so conducive to the sort of more pathogenics or either a range of organisms in the gut that reclassified pathobionts. So those that in long balance or the wrong conditions can cause harm, but in the right amounts actually have a healthful role to play in an ecosystem. And I think we, as natural medicine practices, have got that. Important aspects of a philosophy that I think sometimes we've forgotten that the terrain is important and if we actually optimize them, optimize their overall health, then it's-

Nirala Jacobi:

Yes.

Jason Hawrelak:

... maybe at first surprising, but laying it off not how your patients are improved and they still have blasto or D. Frag and it's completely irrelevant because they're doing great and their guts going great and they've got lovely healthy ecosystem.

Nirala Jacobi:

Yeah. And it's definitely been... I can understand that that journey is sometimes difficult for practitioners because it's easy to kill something. It seems easy to use antimicrobials and things like that and to use much more of a judicious approach for the terrain is sometimes... Or a more measured I should say, approach. And I have to say that in my years of doing this, I'm much more hesitant to just go in there and start killing.

Jason Hawrelak:

Yeah.

Nirala Jacobi:

So definitely, that's been my experience and I hope that people listening will also kind of pause and think about using caution when you're dealing also with parasites. Now, okay, so the message here with those two, blasto and D. frag is just keep looking. If you find them, they may not be the cause of your symptoms. And patients listening, obviously, this is not meant as medical advice. You'd still need to talk to your doctor and your medical provider because we don't know your circumstance. Would you say that there is a concern in those that are perhaps immunocompromised or is that totally irrelevant?

Jason Hawrelak:

I don't think that's backed up with the data to date. And in fact, blastocystis just seems really uncommon in colorectal cancer, extremely uncommon in inflammatory bowel disease patients, like Crohn's and UC patients are far less likely to have blasto present than healthy controls and in colorectal cancer. So I think the data to date doesn't suggest that that's necessarily the case. I mean, there's still lots more research to be done. So we'll see as we start... As long as we start doing studies, case control studies a bit more appropriately where we're actually matching to healthy controls. And I think this has been one of the biggest issues with blasto studies to date is they're not actually, they're looking at a disease population and then going, "Oh look, there's an association." Rather than going, "Okay, well it's age, sex, match healthy controls and see whether they've got blasto or not." And we start by doing that, we start getting different test results.

Jason Hawrelak:

And it reminds me, there's a study that was done in Senegal in Africa, and they looked at kids with chronic diarrhea and 100% of these kids had blastocystis. And if they would've stopped there, they would have gone, "Hey, 100% of the kids who have blasto, that's obviously problematic, but they tested healthy controls as well. Oh, 100% of them, present [inaudible 00:28:05], okay." And we can't make the same leap that we would've made before that.

Jason Hawrelak:

So I think for some of the things that we're talking about here, I think it probably remains to be teased out better. You would guess based on the data that we have that in people whose ecosystems are far more less healthy, less diverse, more levels of pro-inflammatory species, path of virulence, crap sort of West... Sorry, more standard American, Australian diet. Lots of [inaudible 00:28:37] gut damage. Also, antibiotic usage that might increase the virulence of some of these protozoa organism. Then there's probably an increased chance of them actually being problematic in certain populations versus not, if you put that same microbe in a healthy person's gut wouldn't be a problem.

Speaker 1:

Thank you for listening to the SIBO Doctor Podcast. We hope you found the information in this episode useful in the treatment of your SIBO patients. Thanks to our sponsors, sibotest.com, a breath testing service with easy online ordering, and Quintron, maker of outstanding breath testing equipment. Tune in again for another episode of the SIBO Doctor Podcast. Thanks again for listening.