March 27, 2025 • 54 mins
In this episode, Dr Brad Leech shares the exclusive results of his PhD research, which produced the first comprehensive clinical practice guidelines for intestinal permeability.
Dispelling common myths about "leaky gut syndrome," Dr Leech explains why intestinal hyperpermeability is a legitimate physiological reaction—not a syndrome—and how his meticulously developed, evidence-based guidelines can transform clinical practice.
This episode provides invaluable insights into the following:
- The rigorous methodology behind developing clinical practice guidelines, including stakeholder engagement, comprehensive literature review, and systematic evaluation of over 10,000 research articles
- The critical importance of risk-of-bias assessment when evaluating research—a cornerstone of methodology that helps practitioners look beyond cherry-picked studies and misleading claims
- How to systematically evaluate research quality by examining randomization procedures, analysis methods, conflict of interests and clinical relevance rather than accepting published findings at face value
- Surprising findings about commonly used interventions in intestinal permeability, including evidence that certain probiotics may not be effective for NSAID-induced permeability despite their widespread recommendation
- Evidence-based assessment of treatments for intestinal permeability using the NHMRC grading matrix to evaluate research quality
- Practical recommendations and evidence-supported interventions that meet the threshold for clinical relevance
Dr Leech's work represents a significant advancement in the field, bringing scientific rigour to an area often clouded by opinion and marketing claims.
Learn how these new guidelines can help you make more informed clinical decisions and improve patient outcomes through evidence-based approaches to intestinal permeability.
Connect with Dr Leech: Dr Brad Leech
Read: The IP Guideline
Shownotes and references are available on the Designs for Health website
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DISCLAIMER: The Information provided in the Wellness by Designs podcast is for educational purposes only; the information presented is not intended to be used as medical advice; please seek the advice of a qualified healthcare professional if what you have heard here today raises questions or concerns relating to your health
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:03):
Music.
This is Wellness by Designs,and I'm your host, andrew
Whitfield-Cook.
This is Wellness by Designs,and I'm your host, andrew
(00:23):
Whitfield-Cook.
Joining us today is Dr BradLeet, a PhD nutritionist, and
we'll be talking about leaky gutor intestinal hyperpermeability
, and why it's not a syndrome.
Welcome to.
Speaker 2 (00:40):
Wellness by Designs.
Brad.
How are you?
Andrew?
It's fantastic to be chattingwith you again.
It's a real pleasure and almostan honour to be sharing for the
very first time, and I remembera number of years ago I told
you that I would give you theexclusive when it comes around
to the results of my PhD.
So here we are and I'm ready toshare what we found during the
(01:03):
course of my PhD and I'm readyto share what we found during
the course of my PhD.
Speaker 1 (01:08):
Well, I've got to say the honour is mine, mate,
because I remember you and Isitting down at the centenary of
the NHAA conference inMelbourne and I didn't know you
then.
But wow, you've exploded ontothe scene and you've really
helped to clarify a lot of muddywaters and things that we get
(01:29):
dragged into because they soundnice.
You've cleared up a lot of thisstuff and it's wonderful to see
your work now being finalisedas your PhD.
It's great to see, mate.
Speaker 2 (01:43):
It is really nice to almost be that one to say, hey,
let's clear up the murky waterand provide a bit more evidence
and backing and understanding towhat we call our profession.
Speaker 1 (01:56):
Now I need you to take us through a little bit of
your career and sort of you knowwhat led you to focus on leaky
gut this syndrome we were taughtit was called as a research
subject.
And also, can you take usthrough your supervisors at
(02:18):
Southern Cross Uni as well,please?
Speaker 2 (02:21):
Yeah, so my PhD was at UTS Arkham with Dr Amy Steele
, professor David Sibret and DrErica McIntyre, who are by far
and I say this without any biasthe best supervisors anyone
could ask for.
You have the stats of David,you have the caring and larger
(02:44):
picture of Amy Steele and thenErica.
She's just absolutely wonderfulwhen it comes around to trying
to conceptualise what we'retrying to do with my PhD.
So, to take you a stepbackwards, my career started
back in 2008 now it's a whilenow when I undertook a dance
(03:06):
diploma in Ayurvedic medicine.
Now, what's quite interestinghere is Ayurvedic medicine.
There's a lot of focus on guthealth, and I even recall being
an Ayurvedic practitionertelling a patient leaky gut
syndrome or leaky gut it doesn'texist.
Well, you know, I shake my headnow looking back at what I used
(03:29):
to say, to what I say now.
Fast forward a few years andcompleted my bachelor's, and
then it was my honours wherethis interest in intestinal
permeability really started.
You see, I became quitefascinated with autoimmune
conditions and I wanted to do myhonours, and so I contacted Dr
(03:52):
Jeanette Swoss and I was like Iwant to save the world, I want
to find the cure for allautoimmune conditions.
She sits me down, she goes Brad, first of all we need Amy
Steele.
So we bring Amy Steele into theroom and they say we love your
ambition, but you need to take astep back.
You can't find the cure for allautoimmune disease in an
(04:15):
honours, or even a PhD or alifetime.
You need to pick one small,tiny element of that topic and
focus on that Now.
At that time I was fascinated bya researcher, the pioneer of
intestinal permeability,professor Fasano.
(04:36):
I had the honours of meetinghim a number of years ago and
I've even got a mug with a photoof him and I on it that says Dr
Brad Leach, that I got madeprobably about four years ago.
Almost that encouragement tosay you know what you can do
this.
Anyway, we digress In themeeting we looked at okay, well,
(04:57):
what's a driving factor forautoimmune conditions?
And we fell onto intestinalpermeability.
And so that's really where thefocus of this permeability
started.
Now, at the end of the day, mynumber one goal in all of my
research is to improve howclinicians treat and manage
(05:17):
disease in their patients.
So with that goal in mind, Iundertook a number of different
research topics to supportclinicians in their treatment
and assessment for intestinalpermeability.
So really, in a very short way,that's how it kind of came
about, this concept of what'snow referred to as the IP
(05:39):
guideline and my joy andfascination by intestinal
permeability.
Speaker 1 (05:48):
Well, I can see your joy always, but I have to first
ask before we move on have youmet Alessio yet?
Alessio Fasano.
Speaker 2 (05:58):
Yes, yes, I met him in 2018 over in America and we
were wearing almost matching um,he was wearing a tie and I was
wearing a bow tie and they wereknitted cruciate, and it is a
photo I will treasure for therest of my life.
Speaker 1 (06:16):
I love your idiosyncrasies you wear a bow
tie but you're extremelyartistic.
I won't get off topic, but Ilove your personality, brad.
It's got so many compartmentsto delve into, so let's move on
with the IP guideline, whichyou've mentioned.
So, from conceptualising firstintestinal hyperpermeability,
(06:41):
can we talk first about thissyndrome bit?
Where did it come from?
What's the history of thatwording, that phrase and like
why did it take hold?
Because I can still rememberback in, like the late 90s,
hearing about it and never fullyunderstanding, or sort of
(07:03):
understanding the relevance ofrelevance of it, if you like,
the practicality of it, becauseit was something that was there.
But how do you treat it?
Like you, you know, if you'vegot sinus, if you've got
tiredness, if you've got this,that and the other, you've got
so many causes and they'resaying it's this, it's like,
come on, like, where do we sithere?
Speaker 2 (07:23):
I always had problems with that concept, that it was
and and that's a great question,you see the concept of leaky
gut syndrome.
We have debunked that and Iwill say to my critics, I'll say
to the people who've tagged meon many social media posts to
say intestinal permeabilitydoesn't exist.
Here's this article fromStanford University.
(07:46):
The number of times I've beentagged in this article where
they basically say leaky gutsyndrome doesn't exist.
Now I support that.
There is no such thing as leakygut syndrome, because the
concept of syndrome means thatthere's a group of common signs
and symptoms that someone can beclassified as having like IBS.
But with intestinalpermeability there's no group of
(08:11):
symptoms that everybodypresents with, so we can't
classify it as a syndrome.
Now, in this Harvard article orwas it from Stanford Either or
they go on to say yes,intestinal permeability does
exist.
I 100% support that Wherebythis reaction within the gut not
(08:33):
a condition, not a disease, butthis reaction in the gut called
increased intestinalpermeability.
It's been linked with multipledifferent conditions
gastrointestinal conditions,metabolic conditions, autoimmune
conditions and what theresearch has shown time and time
again is those with intestinalpermeability have got increased
(08:53):
disease activity and severity.
And when you go about treatingintestinal permeability with
some of the interventions thatwe might speak about today.
Their disease activity andseverity reduces.
(09:14):
So very interesting there thatwe have evidence to say that
managing intestinal permeabilityin clinical practice has a
profound impact on how ourpatients are feeling and
presenting.
Speaker 1 (09:24):
Can I ask something?
Just to clear something up inmy mind.
My understanding is thatintestinal permeability is a
normal part of life.
We send out dendritic cellsfrom the gut into the lumen to
sample things normally, but it'sintestinal hyperpermeability
that's the issue.
Am I correct?
Speaker 2 (09:43):
not yes, that's correct.
So we can have intestinalpermeability.
Everyone has that, you know.
It fluctuates with age, itfluctuates with um different
times of the day, but it's whenthere's ongoing, low grade,
chronic, increased intestinalpermeability, that's when it
becomes a problem, right so dowe know a level?
Speaker 1 (10:08):
do we have that sort of data yet to say this is an
acceptable range?
I go, I know we've got to gointo measurement and assessment
then, but do we have thatparameter yet?
Speaker 2 (10:20):
andrew, you are opening up a can of worms.
And when I was in the earlystages of the PhD I looked at
this can of worms and I said, no, this is way too big, way too
difficult, I'm not going there.
But very briefly, what I canmention here is every lab, every
(10:41):
method of assessment isdifferent, and that individual
method of assessment needs to bevalidated.
So we know, for example, stoolzonulin can be or is an accurate
marker for intestinalpermeability when it's actively
being stimulated.
Now that result, or that levelpathology marker within the
(11:04):
stool, that's been validated ina number of different settings
and a number of differentpathologies.
And then you've also got thelactulose-menotol test.
Now every research article willhave a different cutoff
threshold when looking at theratio between lactulose and
menotol.
So you can't collectively forma consensus because each process
(11:27):
the amount of water patientsdrink, the amount of lactulose
and menotol they take, how longthey collect urine for is all
different.
So it needs to be internallyvalidated.
Once we have that internalvalidation, then it can be an
indication of intestinalpermeability.
Speaker 1 (11:47):
Do we have any surrogate markers which we might
use, not the actual things thatwe ingest, but other things
that might be indicative of someissue with the gut, like, for
instance, a raised ESR or aC-reactive protein or high
sensitivity crp?
Speaker 2 (12:07):
you know it's interesting um, one of our
studies found that there was aquite a strong correlation
between intestinal permeability,the markers zonulin, and
inflammatory markers such as crp, esr and calprot.
But it's the chicken or the eggwhat comes first?
Is it the inflammation drivingthe permeability or is it the
(12:29):
permeability driving theinflammation?
So it's quite difficult todetermine exactly which one came
first.
Other markers there are markersout there.
Let's take lipopolysaccharides.
That's quite a utilised markerin research to evaluate the end
(12:51):
result of intestinalpermeability.
So we know if there'sintestinal permeability then
there can be an uptake oflipopolysaccharides, lps, into
the bloodstream.
We don't have a blood pathologymarker available in clinical
practice just yet, but there's anumber of bacteria that we know
(13:11):
that produce LPS and measuringthat in the stool can provide us
with a bit more indications asto could there be a intestinal
permeability in Doris patients.
Does that make sense?
Speaker 1 (13:27):
Yeah, yeah it does.
But I'm glad you say number ofbacteria.
I was always very uncomfortablewhen they said, yeah, it's a
fragment basically of the cellwall of E coli and I thought,
what only E coli I have aproblem with these?
Switch mentalities.
Speaker 2 (13:48):
There's multiple other bacteria Now I can't
recite all of them off by heart,but there's multiple I want to
say about 30 or 40 differentbacteria that can produce LPS,
and so it's another way that wecan collectively look at
permeability.
Although it's not a validatedmarker, it can give us an
(14:09):
indication whether or not ourpatient may have intestinal
permeability.
Speaker 1 (14:16):
Now we've said that you've written a guideline.
I've actually got it up on theother screen here and I've got
to say it's so enlightening, butlike it really seriously is
enlightening because andchallenging I've got to say for
me, because things that Ithought, yep, that's got merit.
It seems like the evidenceisn't there for these things.
So we really have to pull ourheads in and say, okay, how do
(14:40):
we manage this?
And indeed, are we treating theleaky gut or are we treating
the condition which the patientpresents in front of us with and
the leaky gut just happens toget better as we're moving along
.
So I guess, to start treatmentguideline or a practice
guideline.
What is a practice guideline?
(15:01):
What's the term for it?
Speaker 2 (15:04):
It's a clinical practice guideline.
It's a systematically developedstatement that includes
recommendations with theintention to optimise patient
care by assisting practitionerslike you and I naturopaths,
nutritionists, doctors,pharmacists in their decision
making.
Naturopaths, nutritionists,doctors, pharmacists in their
(15:28):
decision making.
So a clinical practiceguideline is required to be
based on published evidence, soresearch, rather than my opinion
alone or anyone else's opinion.
These guidelines are designedto support clinicians in their
decision making for thediagnosis and even the
management of any particulararea, from cancers to
(15:49):
cardiovascular disease tointestinal permeability.
They are actually consideredone of the best ways that we can
present evidence-basedrecommendations to the
clinicians while actuallyreducing any inappropriate care.
Something to note here is therecommendations are not intended
(16:13):
to supersede clinical judgment.
Clinicians are always advisedto consider the patient who's in
front of them first andforemost before actually
following the recommendations inany guidelines.
Recommendations in theguidelines are there to support
(16:34):
and guide clinicians, not to dothe job of a clinician.
Something to note here is youcan have clinical practice
guidelines which are publishedand published in peer review
articles and disseminated tohealthcare practitioners, but
sometimes very small percentageof the time.
(16:54):
These days some of the olderguidelines.
They actually lack structure,and so it's really important
when developing a guideline thatthere is a clear structure to
follow.
Now we are so lucky here inAustralia because we have the
NHMRC Now.
The NHMRC in 2009 and thenupdated in 2017 and 2021, they
(17:21):
produced the NHMRC guidelines aset of guidelines that guideline
developers like myself andother researchers can actually
follow to ensure that theycreate non-biased, accurate,
clinically relevantrecommendations for clinicians.
Something I'll note here is afew listeners will be like oh, I
(17:46):
don't know what a clinicalpractice guideline is, or I've
never used a clinical practiceguideline.
Now, andrew, I know yourbackground is in nursing, so
you'll be like well, this is.
This is very common in ahospital-based setting.
So, um, gps, nurses, integrmedicine practitioners they rely
on clinical practice guidelines, but naturopaths and
(18:10):
nutritionists they don'tnecessarily rely on these
guidelines.
Now, there could be a number offactors why clinicians are not
utilising guidelines.
I believe it's becauseclinicians naturopaths,
nutritionists, herbaliststhey're not actually involved in
(18:31):
guideline development andthereby their views and values
and perspectives and even howthey treat conditions aren't
considered.
Because, let's face it,guidelines on average will take
a million dollars to produce andfive years of somebody, full
time with a team to develop them.
(18:51):
I developed my guideline for alot less than a million dollars,
but that was because it was myentire focus and, let's face it,
I didn't have a life outside ofthis guideline.
I get off track.
So, really, when it comesaround to guideline development,
we actually want naturopaths,nutritionists, members of
(19:16):
associations to actually partakein guideline development and
actually they are ourstakeholders.
And so let's take the IPguideline for an example.
We ensured that we had patientsand educators, clinicians,
major associations that we have,pathology companies, supplement
(19:37):
companies all involved in theguideline to ensure that what I
was producing, what my team wasproducing, was relevant to not
just the patient and clinicianbut also to our whole profession
.
So that basically summariseswhat a clinical practice
guideline is.
Speaker 1 (19:59):
Well, can you take us through, then, just some of the
key points of the guidelines,because, like one of the ones
that's important to me, Iconsult in a pharmacy situation
part time and that is the use ofprobiotics on long term, with
long term NSAID use, and nowpreviously, you know, many years
ago we actually favoured thiswith the use of certain
(20:21):
probiotics, but looking at theevidence here, it seems like
it's very shaky ground to use aprobiotic alone.
Can you take us through theimportance of cherry picking
certain things and how, asnaturopaths, it actually falls
into naturopathic practice in amuch easier way?
Speaker 2 (20:41):
Yeah.
So to answer that question, Ithink we actually need to take a
step back and actuallyunderstand how I developed the
intestinal permeabilityguideline, because I know a lot
of clinicians out there will belike Brad, don't go talking
about the methods on how youdevelop this guideline, just
tell me what are therecommendations and how should I
(21:03):
follow them.
Just tell me what are therecommendations and how should I
follow them.
But it's so important toactually understand how
recommendations are developedbecause I've told multiple
patients hey, this is therecommendation, just like the
recommendation that you've saidabout probiotics and NSAIDs, and
their response is well, hold on, what about this intervention?
(21:24):
Or why did you write it likethat?
So, to use recommendations inany guideline and especially
let's take the IP guideline it'sactually important to consider,
well, what went into actuallydeveloping the intestinal
permeability guideline.
So do you mind if I justmention very briefly those steps
(21:45):
developing the intestinalpermeability guideline?
So do you mind if I justmention very briefly those steps
that I undertook to ensure thatour listeners can understand?
Yep, and fantastic, because Iknow that you've already opened
up the guideline.
You've looked at it, I've gotthe guideline for those watching
.
I have the guideline in my handFor those listening, just
(22:05):
imagine I'm holding the Biblefor intestinal permeability, so
it's very precious, all right.
So, quite broadly speaking,there were five major phases
that we actually undertook todevelop the IP guideline.
We assessed the patients, so wedid a consumer survey.
(22:27):
We looked at the literaturequite extensively, we drafted
the recommendations, so in totalthere were 38 recommendations.
We also got feedback fromstakeholders and then after that
we were left with these finalrecommendations that you, as the
clinicians, can actually readup, read up on and get a better
(22:47):
understanding of how to treatintestinal permeability.
So, quite briefly, the consumersurvey we wanted to ensure that
the recommendations that wewere developing were going to be
appropriate for the patientrather than just focusing on the
evidence.
There's no point developing arecommendation that that
(23:11):
clinicians or patients don'twant to follow.
So we know this.
With pharmaceuticals, we asked589 patients what are the types
of interventions you want to useto treat intestinal
permeability?
Now, only 11% saidpharmaceuticals, where 90% said
(23:34):
I want natural supplements,probiotics, prebiotics, vitamins
, minerals, and that was eventhe same for healthcare
practitioners.
So with that in mind, weundertook, let's say, the most
comprehensive review of theliterature that has ever taken
place when it comes around topossible treatments for
(23:55):
intestinal permeability.
Now, when I say comprehensive,I'm talking over 10,000 articles
I independently read and lookedat.
That was a very sad time in mylife.
It was a very focused time inmy life.
I was doing 60, 70 hours a weekin a little box at UTS just
(24:21):
reading articles.
Anyway, with these articlesthere's a lot of studies that we
actually excluded, for verygood reason.
We know that intestinalpermeability evolves over a
lifetime and that the results ofthe IP guideline we want them
to be focused on adults, so weactually excluded children-based
(24:45):
studies.
The other one to consider is weexcluded studies that looked at
critically ill patients.
Believe it or not, I want tosay about 30%, maybe even 40% of
the recommendations or thetreatments that have been
investigated for intestinalpermeability have been on
critically ill patients Sepsis,sepsis, exactly.
(25:10):
When I say critically ill, I'mtalking end of life.
When I say critically ill, I'mtalking end of life, burn
injuries, kidney disease.
What we know is that is a verydifferent type of intestinal
personality than what you and Iwill see in clinical practice.
So we need to exclude it.
Does that make sense?
Absolutely.
(25:30):
So after we looked at all theresearch, we developed these
recommendations.
So we wanted to ensure that thedeveloped recommendations were
applicable to healthcarepractitioners and also our
patients.
So, based on all of theprevious research we looked at,
we funneled down all thearticles and said let's focus on
(25:53):
the main areas that cliniciansare going to use.
They were the pre andprobiotics, amino acids,
minerals, herbal medicine,omega-3, vitamins and colostrum,
because they're the mainsupplemental, and also add
dietary recommendations, ofcourse, that us, as clinicians,
will actually use to treatintestinal permeability.
(26:16):
So we we gathered all thesearticles, we pulled out all of
the relevant information.
Now this is the point ofdifference we undertook
something called a risk of biasassessment.
Now, before your eyes glazeover, andrew, sit back, relax.
I want to tell you theimportance of a risk of bias
assessment so basically it's a.
(26:39):
It's a huge process where youlook at every tiny little detail
of the article.
You read the article three,four, five times to ensure that
you've that you understand whatthe article was about.
You contact the researcher forany additional information that
may be missing.
Now let me give you an examplehere.
(27:01):
Sometimes not all the time, butsometimes you have studies that
call themselves a RCT, arandomized control trial.
Now when you go through themethods you go hold on this is a
clinical trial.
This is not a randomized trial.
There was no randomizationbehind it.
(27:22):
Because there was norandomization, there's an
increased risk of bias, that theresults may not actually be
what they are.
Another classic example thatcould actually impact risk of
bias when it comes around tothese studies is now the
researchers who are listeningwill totally understand the
(27:43):
clinicians may go oh, I've heardof this before is the methods
of analysis.
So we've got a number ofmethods of analysis intention,
treat, per protocol.
What we know is when an articlewill do a per protocol, then
the results are going to be morefavourable.
But when the researchersanalyse the data intention to
(28:05):
treat, that is includingeveryone that dropped out or who
had side effects or who didn'ttake the intervention.
In their analysis, the resultsare less statistically
significant.
So that's another element atplay.
So, as you can see, a lot'sgoing into developing these
recommendations.
(28:25):
It's not just oh, I have aclinical trial on the
effectiveness on zinc, onintestinal permeability.
We'll make that arecommendation.
There is so much more that goesinto grading the evidence.
What I find, or what weactually utilised, was something
called the MHMRC grading matrix.
(28:47):
So this is a matrix consistingof five different domains to
categorise all the research.
So these domains let me see ifI can record them they are
evidence-based consistency,clinical impact,
generalisability andapplicability.
(29:08):
So what I mean by these isevidence-based, this level.
Now these are graded from A toD.
So if you've got an A grade forevidence-based, it's going to
be a systematic review ofrandomized controlled trials
with low risk of bias, and thenit progressively gets worse
(29:29):
where it's observational studieswith high risk of bias, all the
way down the end.
What is quite cool aboututilising this matrix, this
NHMRC grading matrix, is ittakes into consideration a
number of factors Clinicalimpact.
So we know that results can bestatistically significant but
(29:50):
they're not going to beclinically relevant.
So if I told you to follow thisextreme diet for six months.
It will statisticallysignificantly reduce weight, but
at the end of the six monthsit's only 500 grams.
Yes, that's statisticallysignificant, but is it
clinically relevant?
(30:11):
No, so we can determine howmuch of the permeability was
actually changed and whether ornot that was a huge improvement
Exactly.
And the last component.
Speaker 1 (30:29):
Sorry, you've seen this used in a negative way.
For instance, I remember thecommon conception, the common
knowledge out there is fromdoctors, surgeons, anaesthetists
is stop fish oil two weeksprior to surgery because it will
increase bleeding.
Well, it does, but they lookedat this at the Alfred and it was
(30:50):
200 mil, so it wasstatistically significant, but
it was by no means clinicallysignificant.
Indeed, the Alfred Hospital hadthem on this high-dose fish oil
up until the day before surgery.
So you know it's a perfectexample of a misnomer.
That's still to this day thatmyth is carried through.
Speaker 2 (31:14):
And we've applied this to the results where
sometimes the diet interventionswere just so extreme.
I'm not going to be puttingthat in a recommendation for
clinicians to suggest, becauseadherence is going to be very
poor.
The other one that I'll mentionhere is generalizability.
(31:34):
So a lot of studies aren'tactually conducted in the
Australian population.
You've got studies that areconducted in rural Sahara,
africa or rural China.
Now those studies and I recalla few of them that we actually
excluded they utilized whey andglutamine to reduce intestinal
(31:58):
permeability in young childrenwho are extremely protein
deficient.
Yes, of course that's going tobe beneficial, but can we
actually apply those results tothe Australian population?
I'm going to say no.
So this, this matrix.
I know it might sound a littleconfusing, but I want the
listeners to understand that wehave considered every possible
(32:21):
element.
But the beauty is you don'tneed to understand or memorise
anything that I've justmentioned.
You just need to be aware of itbecause at the end of the day,
we produce these recommendationsand we classify them as a
strong recommendation, arecommendation or a
consensus-based recommendation.
So there's three main levelsthat will determine.
(32:44):
Well, how strong do we believethat you should follow this
recommendation and that'sembedded into the, the
intestinal permeabilityguidelines and even how we write
the recommendations.
So when we dive into some ofthe recommendations, you'll see
that I use terms such as offeror advise when it's a strong
(33:06):
recommendation, so when there'ssystematic reviews backing up
the evidence.
But when there's lower level ofevidence, I'm going to use
terms like may consider a littlebit more free-flowing.
From there, we actuallydeveloped these recommendations
and we sent them to majorstakeholders.
(33:28):
Now, when I say majorstakeholders, I'm talking about
some of the biggest andbrightest professionals in our
profession.
I'm talking Dr Jason Hullerich,I'm talking Dr Nerala Jacobi,
dr Ronald Gurdjieff, dr MichaelOsiki, daini Steele, benedict
(33:48):
Fruidman the list goes on.
What I'm trying to say here isthese amazing, amazing
stakeholders.
They reviewed theserecommendations and they
(34:14):
provided suggestions, a lot ofsuggestions where we tweaked the
recommendations to ensure thatwhen we release it to the public
, this moment, right now, thatclinicians will be like yes, I
agree with this recommendation.
Just before we dive into therecommendations, andrew, I just
want to take a step back andalmost say how important graded
recommendations are.
Now, something to bear in mindis we're in the era of almost
too much research.
Now, I know that's crazy tothink, but there are multiple
(34:37):
studies in one particular area,but the studies will show
different things.
I often see presenters evenmyself, and companies.
They will make a claim basedoff a single study and a lot of
the times there could befundamental problems with that
study.
(34:57):
So I want to actually put acall to action out there.
I want to see more companies,more healthcare professionals,
more presenters actually usinggraded recommendations.
Now, if that's too difficult, Iwant people to be utilising a
risk of bias assessment, toactually not just use here's a
(35:20):
randomised controlled trial, butto systematically look at the
study and go could there be anyconfounding factors that impact
the results?
Is that too much to ask for,andrew?
Speaker 1 (35:33):
the results Is that too much to ask for Andrew?
It's a big ask because, likewhen you consider that something
like 80% of orthodox medicineis without guidelines, without
proper guidelines, withoutproper evidence, this is a big
ask, this stuff, what you'vedone is a mammoth task.
Speaker 2 (35:54):
I'm not talking.
I'm not saying that we need aclinical practice guideline for
everything.
I'm more saying, rather thanjust stating, oh, here's a
research article that promotesthis or is associated with that
disease, to take a step back andto actually make sure that we
read the article to go are theseresults accurate?
(36:17):
Can we trust them?
Speaker 1 (36:18):
Yeah, yeah, and I've seen that some like both ways.
For instance, you know, onearticle on one research paper on
a probiotic was glowing in itsresults.
It had zero dropouts and I wentmeh, I smell a rat.
You know sorry, zero dropouts,100% effective.
(36:39):
And then you've seen theresearch on this particular
probiotic strange vacillate, youknow, between good and you know
of merit and no merit in thiscondition.
So I start to go.
What are we seeing?
What I referred to earlier andthis came down to the wording
(37:07):
that you used is clinicians mayconsider, not to recommend.
So it was really interestingwith regards to a probiotic in
NSAID use and a prebiotic in ncduse.
But wasn't there did I readthis properly that when you
(37:27):
combine them as a symbiotic,then you may consider its use?
And this sort of falls into themore naturopathic treatment
paradigm of not one magic bulletbut a whole treatment
management plan?
Am I?
Speaker 2 (37:45):
correct and you're absolutely correct.
So you've got the intestinalpermeability guideline.
Now I'll direct your attentionto table three.
So this is where we have listedall of the recommendations.
So, Andrew, you've justmentioned recommendation 2.16.
There are 38 differentrecommendations, so maybe we can
(38:08):
discuss some of these Now.
I won't mention all of thembecause that would take way too
long to pull apart, Way too long.
Speaker 1 (38:15):
This is a read, by the way.
This is what are we talkingabout.
We're talking about how manypages?
Speaker 2 (38:23):
38 pages that's only one document, andrew.
There are two other documents,um, one of those documents is 80
pages, the other one is, uh, 45pages.
So, um, okay, so let's diveinto this a bit more.
Nsaids and intestinalpermeability.
What we know is NSAIDs are usedin the research to induce
(38:48):
intestinal permeability.
Okay, it's a very common method.
Multiple studies have looked atwhether or not a particular
intervention is useful atmitigating intestinal
permeability in those patientswho have taken NSAIDs, so to
induce their intestinalpermeability.
Now, you've pointed out hereI've got a section between 2.16
(39:12):
and 2.18, where we looked atwhether or not taking probiotics
, prebiotics or symbiotics hadany protective effect when it
came around to preventingNSAID-induced intestinal
permeability.
What is quite interesting waswe didn't set out to develop
(39:33):
this recommendation.
This was more so that there wasquite a lot of research here.
So these are evidence-basedrecommendations and if we're
looking at the code, there'sthree stars.
So this is it's not thestrongest recommendation, but
it's an opinion.
What I want to emphasize here is, when it comes around to
(39:56):
guideline development, we doneed to consider what the
research says.
Although if I had a patient infront of me and I had the
potential of prescribing a pre,pro or symbiotic.
Would I give it to a patientwho's got NSAID-induced
intestinal permeability?
You know what?
It's not going to help.
Sorry, it's not going to hurt.
(40:19):
It could be beneficial, but theresearch on those particular
strains have shown that ithasn't.
So I am sure that there aresome strains out there that are
very effective at preventingNSAID-induced intestinal
permeability, but unfortunatelythey weren't researched and then
they haven't been researched inthis cohort, thereby we
(40:42):
couldn't include them.
But but I know people areinterested in in nsads, so I'll
give you a bit of a caveat here.
And that is uh recommendation3.3, and I'll read this one to
you.
And it says clinicians shouldconsider the use of short-term
lactoferrin supplementation forthe treatment of people with
(41:03):
non-steroid anti-inflammatorydrug-induced intestinal
permeability.
So we do have something withevidence that we can recommend
to our patients that has beenshown to be effective at
preventing NSAID-inducedpermeability.
Speaker 1 (41:20):
But not colostrum.
There was no evidence withcolostrum.
Nobody has looked at that onits own.
Speaker 2 (41:27):
DR WEBSTER, that's an interesting one.
Unfortunately, all the researchon colostrum had to be excluded
, so we couldn't produce anyrecommendations for colostrum
because we had to exclude it.
The vast majority, if not all,were in patients with
exercise-induced permeability.
(41:47):
So that was one of ourexclusion criterias, because if
we looked at exercise-inducedpermeability, that opens up a
whole other can of worms.
Heat shock, proteins andeverything Exactly so if anyone
would like to do a clinicalpractice guideline for
exercise-induced permeability, Iwould be happy to provide some
(42:08):
recommendations.
Speaker 1 (42:10):
But yes, that is the risk, andrew FITZ, GIBBONS, if
they're willing to become anabsolute nerd and lock
themselves in a way for a darkroom in a dark room for four
years, having no life um shallwe give you a few more examples
and true of uh recommendationsthat we please, please, all
right.
Speaker 2 (42:25):
So we have recommendations for alcohol use,
dietary fiber, macronutrientratios, energy intake, so that's
kilojoules um gluten-freerecommendations, um a number of
pre-probiotics, umrecommendations for glutamine,
omega-3 and zinc.
Something I'll note here isalcohol.
(42:49):
So I will be the first to saythat alcohol induces intestinal
permeability.
Speaker 1 (42:55):
I'm not afraid to say that afraid to say that.
Speaker 2 (42:58):
But when you look at the research all the research on
alcohol the effect of alcoholon intestinal permeability is
short term.
I'm talking.
Participants would take one ortwo shots of alcohol in a
setting and then measuredintestinal permeability.
So we couldn't actually createa long-term recommendation for
(43:24):
alcohol consumption.
So we actually had to fall backon the Australian Dietary
Guidelines and basically saydon't drink more than what the
guidelines recommend, because wedidn't have the evidence to say
stop drinking.
In saying that, we producedwhat's called a consensus-based
recommendation.
That's where the brainiacs ofthe group sat down and go okay,
(43:46):
well, we know that alcohol canimpact permeability.
There is research to say itdoes, but no long-term.
What can we do?
So we have a recommendationthat people with intestinal
permeability should limit oravoid alcohol consumption when
they're actually treatingintestinal permeability.
(44:06):
Does that make sense?
Speaker 1 (44:09):
yeah, absolutely.
Um, and forgive me, I actuallysaid the wrong thing.
I reread the guidelines and itsays you may consider not using
a symbiotic.
So it it's prebiotics.
Probiotics and synbioticsaren't really recommended for
NSAID-induced intestinalhyperpermeability.
Speaker 2 (44:29):
Wow, with the caveat that those strains, the strains
that were researched, were foundnot to be protective.
That is not to say that there'sother strains out there with
lower levels of evidence thatweren't included, that are
effective, and I love myprebiotics.
I love my prebiotics and I wantthere to be an effective one,
(44:50):
but unfortunately we didn'tinclude any research to support
that.
That's not to say that from thethousand other strains out
there that there isn't aneffective strain.
Speaker 1 (45:01):
Yeah, I mean, you know, look how many species are
we allowed to have in Australia?
14?
Something like that, most ofthem based on milk, not all, but
most of them.
We certainly don't have the joyof being able to access things
like Accomantium, eosinophiliaor Fecali bacteria and
Proutsnitzii or any of thoseones which I'm going to do a
(45:24):
shout-out here to Clara Beltzer,who enlightened me to the
merits of these microbes.
But you know, unfortunately atthis stage we don't have the
facility to use those in atherapeutic environment.
But one point that I make isyou actually wrote this with the
intention that future researchwill change these
(45:47):
recommendations.
Speaker 2 (45:50):
Of course, that is the underlying principle of a
clinical practice guideline.
It's developed every five yearsbecause research is coming out
every single day.
I recall, you know, finalisinga recommendation and then you do
one final sweep of theliterature and realise, oh wait,
this groundbreaking researchhas just been published and I
actually had to get to a pointwhere I said that's it, this is
(46:13):
the cut-off line.
I can't look at any moreresearch because I'd still be
validating the research tillthis date.
So these recommendations arevalid as of 2023.
I would like to say that theoverall trend of these
recommendations will stay veryaccurate for a number of years
(46:34):
to come, but as clinicians, weshould always take these
recommendations in considerationto any new research that has
been done after 2023.
Speaker 1 (46:46):
Yeah, like I noticed, galacto-oligosaccharides isn't
included in there.
I mean, I get it, and I'm surethat you can't.
Speaker 2 (46:57):
Yeah, it's an interesting one where we know
that GOS is very therapeutic atreducing LPS-producing bacteria,
which is linked withpermeability.
But that level of evidence toget into a clinical practice
guideline it didn't meet thatthreshold.
Speaker 1 (47:19):
Indirect evidence rather than direct brad.
There's so much to learn but Ilike really.
People really need to look atthese guidelines.
Where can they download them?
Speaker 2 (47:30):
yeah, so they are free to access um.
I'd like you to, if you can,include them in the show notes
so then they're easy for peopleto definitely to download um.
If not, you can download themon my website, drbradlinchcom,
and you can just download themthere.
There are three documents here.
You've got what's referred toas the ip guideline.
(47:52):
That is basically the summaryof all the recommendations.
For the gut nerds who arewanting a little more
information, you can downloadthe technical report and the
guideline development processdocument, two documents that
have a lot more information.
Speaker 1 (48:14):
For someone who's more wanting to look at this
from a research perspectiverather than a bible that
clinicians should be keeping upon their in their clinic room,
to quickly refer to that, oh yes, I can utilize this, this
treatment recommendation andforgive me, brad, I know we've
sort of covered the sort ofmajor areas, but just but just
(48:36):
quickly, things like zinc,things like herbs, the not the
well, the collagogues you couldinclude, but also the, the
antimicrobial herbs like coptisor golden seal which you know
people are using, can you giveus just a quick synopsis of
whether they're indicated orwhether there's issues with them
(48:56):
?
Yes, of whether they'reindicated or whether there's
issues with them.
Speaker 2 (49:01):
Yes.
So with zinc, there was anumber of studies and it is a
recommendation.
I'm just trying to find it herein the guidelines.
Here we go.
Recommendation 6.1, cliniciansmay consider using zinc
supplementation in the treatmentof patients with intestinal
permeability.
As for herbal medicine, nowunfortunately we couldn't
(49:21):
actually produce anyrecommendations for herbal
medicine.
Believe it or not, there isn'ta lot.
There isn't any studies thatuse a validated method for the
assessment of intestinalpermeability in patients who are
not critically ill over the ageof 18, with appropriate
(49:43):
statistical analyses.
I recall there's some curcuminand there are a number of herbs,
but the study did not utilise avalidated method to assess
intestinal permeability.
Thereby we didn't want toinclude any of those articles
because we wanted to ensure thatthe recommendations that we
produced were of the utmosthighest level of evidence.
Speaker 1 (50:08):
Now I'm going to be attending a talk that you'll be
doing soon, talking about ordiscussing the major conditions
which people present with, whereintestinal hyperpermeability is
a major factor, where we reallyshould be addressing this to
(50:31):
bring the symptomatology andefficient management or
effective management of theseconditions down did I?
That's incorrect but to createeffective management.
Speaker 2 (50:46):
I believe you're referring to a presentation I'm
giving on how to treat themicrobiome and gut-related
conditions and in thatpresentation it's going to be
talking about what can we do tosupport the microbiome, to
support gut-related conditions.
But I'll also be presenting atthe NHAA conference this year
(51:10):
down in Melbourne which I'm veryexcited about on a topic very
dear to my heart on the impactof antimicrobial herbs on the
microbiome and whether or notsome antimicrobial herbs may
actually have a potentiallydetrimental impact on our gut
microbiome.
So I won't give too much away.
(51:31):
But, yes, I've got a number ofupcoming events that I'll be
talking and presenting at overthe next six to five months.
Speaker 1 (51:38):
But you're also doing .
This is a public talk you'redoing, it's on the 23rd of
February and it's one thatpatients can access.
It's a patient guide towellness.
Speaker 2 (51:49):
That's correct.
It's focused on what patientscan do to improve their gut
health.
Speaker 1 (51:55):
Yeah, Wonderful stuff , Brad.
You and I seriously I couldlearn so much off you, just
talking for a couple of hoursand chatting, preferably over a
Pinot Noir.
Speaker 2 (52:10):
That sounds lovely, Andrew.
Speaker 1 (52:13):
But it might transiently affect our
intestinal hyperpermeability.
But there's so much to learnhere and so much to put into
little boxes.
But I love the way that you'vedone it with scientific rigor
but from the point of care, fromthe point of actually caring
for patients to make a positiveimpact in their lives rather
(52:34):
than just selling themsupplements going.
The company said it worked.
I love this rig and it'sfantastic and it and it sees not
just you but it sees naturalmedicine practitioners in a
higher light.
You're improving theprofessionalism of our
professions.
Um, it's, it's fanding.
You're improving the standingof our professions.
(52:56):
So it's wonderful work thatyou've done.
There's so much learned, somuch more for us to learn here
and so much more work that youhave to do to make this a 90
page document.
Speaker 2 (53:09):
Thank you, andrew, and you know I'm only one piece
in the puzzle.
There are amazing researchersout there who are just doing
incredible things for ourprofession.
I know a good friend andcolleague of mine I did my
honours and PhD with her DrJessica Bays.
She's now a postdoctoralresearch fellow at Southern
(53:30):
Cross University and she isproducing incredible work when
it comes around to mental healthand the diet.
So we're very fortunate here inAustralia that we are producing
so many more PhD qualifiedhealthcare practitioners who are
producing quality research toadvance our profession.
(53:50):
You know we've got amazingmentors.
You know Dr Amy Steele, she hasgot so many PhD students.
So it's I'm only one piece ofthe puzzle.
So it's great to have thesupport and have so many peers
who are doing so much to supportour profession.
Speaker 1 (54:08):
Thank you so much, dr Brad Leach, for joining us
today and sharing your wealth ofknowledge, but also your care
for not just the profession butalso your patients.
I really admire you.
Thanks so much for joining uson Wellness by Designs today.
It's my pleasure, andrew alsoyour patients.
I really admire you.
Thanks so much for joining uson Wellness by Designs today.
Speaker 2 (54:23):
It's my pleasure, Andrew.
Thank you.
Speaker 1 (54:26):
And thank you everyone for joining us.
Remember you can catch up onall and I mean all of the show
notes that we'll have for youtoday.
There'll be a lot and, ofcourse, the other podcasts.
On the Designs for Healthwebsite, I'm Andrew
Whitfield-Cook.
This is other podcasts on theDesigns for Health website.
I'm Andrew Whitfield-Cook.
(54:47):
This is Wellness by Designs.
Music.
This is Wellness by Designs,and I'm your host, andrew
Whitfield-Cook.
This is Wellness by Designs,and I'm your host, andrew
(00:23):
Whitfield-Cook.
Joining us today is Dr BradLeet, a PhD nutritionist, and
we'll be talking about leaky gutor intestinal hyperpermeability
, and why it's not a syndrome.
Welcome to.
Speaker 2 (00:40):
Wellness by Designs.
Brad.
How are you?
Andrew?
It's fantastic to be chattingwith you again.
It's a real pleasure and almostan honour to be sharing for the
very first time, and I remembera number of years ago I told
you that I would give you theexclusive when it comes around
to the results of my PhD.
So here we are and I'm ready toshare what we found during the
(01:03):
course of my PhD and I'm readyto share what we found during
the course of my PhD.
Speaker 1 (01:08):
Well, I've got to say the honour is mine, mate,
because I remember you and Isitting down at the centenary of
the NHAA conference inMelbourne and I didn't know you
then.
But wow, you've exploded ontothe scene and you've really
helped to clarify a lot of muddywaters and things that we get
(01:29):
dragged into because they soundnice.
You've cleared up a lot of thisstuff and it's wonderful to see
your work now being finalisedas your PhD.
It's great to see, mate.
Speaker 2 (01:43):
It is really nice to almost be that one to say, hey,
let's clear up the murky waterand provide a bit more evidence
and backing and understanding towhat we call our profession.
Speaker 1 (01:56):
Now I need you to take us through a little bit of
your career and sort of you knowwhat led you to focus on leaky
gut this syndrome we were taughtit was called as a research
subject.
And also, can you take usthrough your supervisors at
(02:18):
Southern Cross Uni as well,please?
Speaker 2 (02:21):
Yeah, so my PhD was at UTS Arkham with Dr Amy Steele
, professor David Sibret and DrErica McIntyre, who are by far
and I say this without any biasthe best supervisors anyone
could ask for.
You have the stats of David,you have the caring and larger
(02:44):
picture of Amy Steele and thenErica.
She's just absolutely wonderfulwhen it comes around to trying
to conceptualise what we'retrying to do with my PhD.
So, to take you a stepbackwards, my career started
back in 2008 now it's a whilenow when I undertook a dance
(03:06):
diploma in Ayurvedic medicine.
Now, what's quite interestinghere is Ayurvedic medicine.
There's a lot of focus on guthealth, and I even recall being
an Ayurvedic practitionertelling a patient leaky gut
syndrome or leaky gut it doesn'texist.
Well, you know, I shake my headnow looking back at what I used
(03:29):
to say, to what I say now.
Fast forward a few years andcompleted my bachelor's, and
then it was my honours wherethis interest in intestinal
permeability really started.
You see, I became quitefascinated with autoimmune
conditions and I wanted to do myhonours, and so I contacted Dr
(03:52):
Jeanette Swoss and I was like Iwant to save the world, I want
to find the cure for allautoimmune conditions.
She sits me down, she goes Brad, first of all we need Amy
Steele.
So we bring Amy Steele into theroom and they say we love your
ambition, but you need to take astep back.
You can't find the cure for allautoimmune disease in an
(04:15):
honours, or even a PhD or alifetime.
You need to pick one small,tiny element of that topic and
focus on that Now.
At that time I was fascinated bya researcher, the pioneer of
intestinal permeability,professor Fasano.
(04:36):
I had the honours of meetinghim a number of years ago and
I've even got a mug with a photoof him and I on it that says Dr
Brad Leach, that I got madeprobably about four years ago.
Almost that encouragement tosay you know what you can do
this.
Anyway, we digress In themeeting we looked at okay, well,
(04:57):
what's a driving factor forautoimmune conditions?
And we fell onto intestinalpermeability.
And so that's really where thefocus of this permeability
started.
Now, at the end of the day, mynumber one goal in all of my
research is to improve howclinicians treat and manage
(05:17):
disease in their patients.
So with that goal in mind, Iundertook a number of different
research topics to supportclinicians in their treatment
and assessment for intestinalpermeability.
So really, in a very short way,that's how it kind of came
about, this concept of what'snow referred to as the IP
(05:39):
guideline and my joy andfascination by intestinal
permeability.
Speaker 1 (05:48):
Well, I can see your joy always, but I have to first
ask before we move on have youmet Alessio yet?
Alessio Fasano.
Speaker 2 (05:58):
Yes, yes, I met him in 2018 over in America and we
were wearing almost matching um,he was wearing a tie and I was
wearing a bow tie and they wereknitted cruciate, and it is a
photo I will treasure for therest of my life.
Speaker 1 (06:16):
I love your idiosyncrasies you wear a bow
tie but you're extremelyartistic.
I won't get off topic, but Ilove your personality, brad.
It's got so many compartmentsto delve into, so let's move on
with the IP guideline, whichyou've mentioned.
So, from conceptualising firstintestinal hyperpermeability,
(06:41):
can we talk first about thissyndrome bit?
Where did it come from?
What's the history of thatwording, that phrase and like
why did it take hold?
Because I can still rememberback in, like the late 90s,
hearing about it and never fullyunderstanding, or sort of
(07:03):
understanding the relevance ofrelevance of it, if you like,
the practicality of it, becauseit was something that was there.
But how do you treat it?
Like you, you know, if you'vegot sinus, if you've got
tiredness, if you've got this,that and the other, you've got
so many causes and they'resaying it's this, it's like,
come on, like, where do we sithere?
Speaker 2 (07:23):
I always had problems with that concept, that it was
and and that's a great question,you see the concept of leaky
gut syndrome.
We have debunked that and Iwill say to my critics, I'll say
to the people who've tagged meon many social media posts to
say intestinal permeabilitydoesn't exist.
Here's this article fromStanford University.
(07:46):
The number of times I've beentagged in this article where
they basically say leaky gutsyndrome doesn't exist.
Now I support that.
There is no such thing as leakygut syndrome, because the
concept of syndrome means thatthere's a group of common signs
and symptoms that someone can beclassified as having like IBS.
But with intestinalpermeability there's no group of
(08:11):
symptoms that everybodypresents with, so we can't
classify it as a syndrome.
Now, in this Harvard article orwas it from Stanford Either or
they go on to say yes,intestinal permeability does
exist.
I 100% support that Wherebythis reaction within the gut not
(08:33):
a condition, not a disease, butthis reaction in the gut called
increased intestinalpermeability.
It's been linked with multipledifferent conditions
gastrointestinal conditions,metabolic conditions, autoimmune
conditions and what theresearch has shown time and time
again is those with intestinalpermeability have got increased
(08:53):
disease activity and severity.
And when you go about treatingintestinal permeability with
some of the interventions thatwe might speak about today.
Their disease activity andseverity reduces.
(09:14):
So very interesting there thatwe have evidence to say that
managing intestinal permeabilityin clinical practice has a
profound impact on how ourpatients are feeling and
presenting.
Speaker 1 (09:24):
Can I ask something?
Just to clear something up inmy mind.
My understanding is thatintestinal permeability is a
normal part of life.
We send out dendritic cellsfrom the gut into the lumen to
sample things normally, but it'sintestinal hyperpermeability
that's the issue.
Am I correct?
Speaker 2 (09:43):
not yes, that's correct.
So we can have intestinalpermeability.
Everyone has that, you know.
It fluctuates with age, itfluctuates with um different
times of the day, but it's whenthere's ongoing, low grade,
chronic, increased intestinalpermeability, that's when it
becomes a problem, right so dowe know a level?
Speaker 1 (10:08):
do we have that sort of data yet to say this is an
acceptable range?
I go, I know we've got to gointo measurement and assessment
then, but do we have thatparameter yet?
Speaker 2 (10:20):
andrew, you are opening up a can of worms.
And when I was in the earlystages of the PhD I looked at
this can of worms and I said, no, this is way too big, way too
difficult, I'm not going there.
But very briefly, what I canmention here is every lab, every
(10:41):
method of assessment isdifferent, and that individual
method of assessment needs to bevalidated.
So we know, for example, stoolzonulin can be or is an accurate
marker for intestinalpermeability when it's actively
being stimulated.
Now that result, or that levelpathology marker within the
(11:04):
stool, that's been validated ina number of different settings
and a number of differentpathologies.
And then you've also got thelactulose-menotol test.
Now every research article willhave a different cutoff
threshold when looking at theratio between lactulose and
menotol.
So you can't collectively forma consensus because each process
(11:27):
the amount of water patientsdrink, the amount of lactulose
and menotol they take, how longthey collect urine for is all
different.
So it needs to be internallyvalidated.
Once we have that internalvalidation, then it can be an
indication of intestinalpermeability.
Speaker 1 (11:47):
Do we have any surrogate markers which we might
use, not the actual things thatwe ingest, but other things
that might be indicative of someissue with the gut, like, for
instance, a raised ESR or aC-reactive protein or high
sensitivity crp?
Speaker 2 (12:07):
you know it's interesting um, one of our
studies found that there was aquite a strong correlation
between intestinal permeability,the markers zonulin, and
inflammatory markers such as crp, esr and calprot.
But it's the chicken or the eggwhat comes first?
Is it the inflammation drivingthe permeability or is it the
(12:29):
permeability driving theinflammation?
So it's quite difficult todetermine exactly which one came
first.
Other markers there are markersout there.
Let's take lipopolysaccharides.
That's quite a utilised markerin research to evaluate the end
(12:51):
result of intestinalpermeability.
So we know if there'sintestinal permeability then
there can be an uptake oflipopolysaccharides, lps, into
the bloodstream.
We don't have a blood pathologymarker available in clinical
practice just yet, but there's anumber of bacteria that we know
(13:11):
that produce LPS and measuringthat in the stool can provide us
with a bit more indications asto could there be a intestinal
permeability in Doris patients.
Does that make sense?
Speaker 1 (13:27):
Yeah, yeah it does.
But I'm glad you say number ofbacteria.
I was always very uncomfortablewhen they said, yeah, it's a
fragment basically of the cellwall of E coli and I thought,
what only E coli I have aproblem with these?
Switch mentalities.
Speaker 2 (13:48):
There's multiple other bacteria Now I can't
recite all of them off by heart,but there's multiple I want to
say about 30 or 40 differentbacteria that can produce LPS,
and so it's another way that wecan collectively look at
permeability.
Although it's not a validatedmarker, it can give us an
(14:09):
indication whether or not ourpatient may have intestinal
permeability.
Speaker 1 (14:16):
Now we've said that you've written a guideline.
I've actually got it up on theother screen here and I've got
to say it's so enlightening, butlike it really seriously is
enlightening because andchallenging I've got to say for
me, because things that Ithought, yep, that's got merit.
It seems like the evidenceisn't there for these things.
So we really have to pull ourheads in and say, okay, how do
(14:40):
we manage this?
And indeed, are we treating theleaky gut or are we treating
the condition which the patientpresents in front of us with and
the leaky gut just happens toget better as we're moving along
.
So I guess, to start treatmentguideline or a practice
guideline.
What is a practice guideline?
(15:01):
What's the term for it?
Speaker 2 (15:04):
It's a clinical practice guideline.
It's a systematically developedstatement that includes
recommendations with theintention to optimise patient
care by assisting practitionerslike you and I naturopaths,
nutritionists, doctors,pharmacists in their decision
making.
Naturopaths, nutritionists,doctors, pharmacists in their
(15:28):
decision making.
So a clinical practiceguideline is required to be
based on published evidence, soresearch, rather than my opinion
alone or anyone else's opinion.
These guidelines are designedto support clinicians in their
decision making for thediagnosis and even the
management of any particulararea, from cancers to
(15:49):
cardiovascular disease tointestinal permeability.
They are actually consideredone of the best ways that we can
present evidence-basedrecommendations to the
clinicians while actuallyreducing any inappropriate care.
Something to note here is therecommendations are not intended
(16:13):
to supersede clinical judgment.
Clinicians are always advisedto consider the patient who's in
front of them first andforemost before actually
following the recommendations inany guidelines.
Recommendations in theguidelines are there to support
(16:34):
and guide clinicians, not to dothe job of a clinician.
Something to note here is youcan have clinical practice
guidelines which are publishedand published in peer review
articles and disseminated tohealthcare practitioners, but
sometimes very small percentageof the time.
(16:54):
These days some of the olderguidelines.
They actually lack structure,and so it's really important
when developing a guideline thatthere is a clear structure to
follow.
Now we are so lucky here inAustralia because we have the
NHMRC Now.
The NHMRC in 2009 and thenupdated in 2017 and 2021, they
(17:21):
produced the NHMRC guidelines aset of guidelines that guideline
developers like myself andother researchers can actually
follow to ensure that theycreate non-biased, accurate,
clinically relevantrecommendations for clinicians.
Something I'll note here is afew listeners will be like oh, I
(17:46):
don't know what a clinicalpractice guideline is, or I've
never used a clinical practiceguideline.
Now, andrew, I know yourbackground is in nursing, so
you'll be like well, this is.
This is very common in ahospital-based setting.
So, um, gps, nurses, integrmedicine practitioners they rely
on clinical practice guidelines, but naturopaths and
(18:10):
nutritionists they don'tnecessarily rely on these
guidelines.
Now, there could be a number offactors why clinicians are not
utilising guidelines.
I believe it's becauseclinicians naturopaths,
nutritionists, herbaliststhey're not actually involved in
(18:31):
guideline development andthereby their views and values
and perspectives and even howthey treat conditions aren't
considered.
Because, let's face it,guidelines on average will take
a million dollars to produce andfive years of somebody, full
time with a team to develop them.
(18:51):
I developed my guideline for alot less than a million dollars,
but that was because it was myentire focus and, let's face it,
I didn't have a life outside ofthis guideline.
I get off track.
So, really, when it comesaround to guideline development,
we actually want naturopaths,nutritionists, members of
(19:16):
associations to actually partakein guideline development and
actually they are ourstakeholders.
And so let's take the IPguideline for an example.
We ensured that we had patientsand educators, clinicians,
major associations that we have,pathology companies, supplement
(19:37):
companies all involved in theguideline to ensure that what I
was producing, what my team wasproducing, was relevant to not
just the patient and clinicianbut also to our whole profession
.
So that basically summariseswhat a clinical practice
guideline is.
Speaker 1 (19:59):
Well, can you take us through, then, just some of the
key points of the guidelines,because, like one of the ones
that's important to me, Iconsult in a pharmacy situation
part time and that is the use ofprobiotics on long term, with
long term NSAID use, and nowpreviously, you know, many years
ago we actually favoured thiswith the use of certain
(20:21):
probiotics, but looking at theevidence here, it seems like
it's very shaky ground to use aprobiotic alone.
Can you take us through theimportance of cherry picking
certain things and how, asnaturopaths, it actually falls
into naturopathic practice in amuch easier way?
Speaker 2 (20:41):
Yeah.
So to answer that question, Ithink we actually need to take a
step back and actuallyunderstand how I developed the
intestinal permeabilityguideline, because I know a lot
of clinicians out there will belike Brad, don't go talking
about the methods on how youdevelop this guideline, just
tell me what are therecommendations and how should I
(21:03):
follow them.
Just tell me what are therecommendations and how should I
follow them.
But it's so important toactually understand how
recommendations are developedbecause I've told multiple
patients hey, this is therecommendation, just like the
recommendation that you've saidabout probiotics and NSAIDs, and
their response is well, hold on, what about this intervention?
(21:24):
Or why did you write it likethat?
So, to use recommendations inany guideline and especially
let's take the IP guideline it'sactually important to consider,
well, what went into actuallydeveloping the intestinal
permeability guideline.
So do you mind if I justmention very briefly those steps
(21:45):
developing the intestinalpermeability guideline?
So do you mind if I justmention very briefly those steps
that I undertook to ensure thatour listeners can understand?
Yep, and fantastic, because Iknow that you've already opened
up the guideline.
You've looked at it, I've gotthe guideline for those watching
.
I have the guideline in my handFor those listening, just
(22:05):
imagine I'm holding the Biblefor intestinal permeability, so
it's very precious, all right.
So, quite broadly speaking,there were five major phases
that we actually undertook todevelop the IP guideline.
We assessed the patients, so wedid a consumer survey.
(22:27):
We looked at the literaturequite extensively, we drafted
the recommendations, so in totalthere were 38 recommendations.
We also got feedback fromstakeholders and then after that
we were left with these finalrecommendations that you, as the
clinicians, can actually readup, read up on and get a better
(22:47):
understanding of how to treatintestinal permeability.
So, quite briefly, the consumersurvey we wanted to ensure that
the recommendations that wewere developing were going to be
appropriate for the patientrather than just focusing on the
evidence.
There's no point developing arecommendation that that
(23:11):
clinicians or patients don'twant to follow.
So we know this.
With pharmaceuticals, we asked589 patients what are the types
of interventions you want to useto treat intestinal
permeability?
Now, only 11% saidpharmaceuticals, where 90% said
(23:34):
I want natural supplements,probiotics, prebiotics, vitamins
, minerals, and that was eventhe same for healthcare
practitioners.
So with that in mind, weundertook, let's say, the most
comprehensive review of theliterature that has ever taken
place when it comes around topossible treatments for
(23:55):
intestinal permeability.
Now, when I say comprehensive,I'm talking over 10,000 articles
I independently read and lookedat.
That was a very sad time in mylife.
It was a very focused time inmy life.
I was doing 60, 70 hours a weekin a little box at UTS just
(24:21):
reading articles.
Anyway, with these articlesthere's a lot of studies that we
actually excluded, for verygood reason.
We know that intestinalpermeability evolves over a
lifetime and that the results ofthe IP guideline we want them
to be focused on adults, so weactually excluded children-based
(24:45):
studies.
The other one to consider is weexcluded studies that looked at
critically ill patients.
Believe it or not, I want tosay about 30%, maybe even 40% of
the recommendations or thetreatments that have been
investigated for intestinalpermeability have been on
critically ill patients Sepsis,sepsis, exactly.
(25:10):
When I say critically ill, I'mtalking end of life.
When I say critically ill, I'mtalking end of life, burn
injuries, kidney disease.
What we know is that is a verydifferent type of intestinal
personality than what you and Iwill see in clinical practice.
So we need to exclude it.
Does that make sense?
Absolutely.
(25:30):
So after we looked at all theresearch, we developed these
recommendations.
So we wanted to ensure that thedeveloped recommendations were
applicable to healthcarepractitioners and also our
patients.
So, based on all of theprevious research we looked at,
we funneled down all thearticles and said let's focus on
(25:53):
the main areas that cliniciansare going to use.
They were the pre andprobiotics, amino acids,
minerals, herbal medicine,omega-3, vitamins and colostrum,
because they're the mainsupplemental, and also add
dietary recommendations, ofcourse, that us, as clinicians,
will actually use to treatintestinal permeability.
(26:16):
So we we gathered all thesearticles, we pulled out all of
the relevant information.
Now this is the point ofdifference we undertook
something called a risk of biasassessment.
Now, before your eyes glazeover, andrew, sit back, relax.
I want to tell you theimportance of a risk of bias
assessment so basically it's a.
(26:39):
It's a huge process where youlook at every tiny little detail
of the article.
You read the article three,four, five times to ensure that
you've that you understand whatthe article was about.
You contact the researcher forany additional information that
may be missing.
Now let me give you an examplehere.
(27:01):
Sometimes not all the time, butsometimes you have studies that
call themselves a RCT, arandomized control trial.
Now when you go through themethods you go hold on this is a
clinical trial.
This is not a randomized trial.
There was no randomizationbehind it.
(27:22):
Because there was norandomization, there's an
increased risk of bias, that theresults may not actually be
what they are.
Another classic example thatcould actually impact risk of
bias when it comes around tothese studies is now the
researchers who are listeningwill totally understand the
(27:43):
clinicians may go oh, I've heardof this before is the methods
of analysis.
So we've got a number ofmethods of analysis intention,
treat, per protocol.
What we know is when an articlewill do a per protocol, then
the results are going to be morefavourable.
But when the researchersanalyse the data intention to
(28:05):
treat, that is includingeveryone that dropped out or who
had side effects or who didn'ttake the intervention.
In their analysis, the resultsare less statistically
significant.
So that's another element atplay.
So, as you can see, a lot'sgoing into developing these
recommendations.
(28:25):
It's not just oh, I have aclinical trial on the
effectiveness on zinc, onintestinal permeability.
We'll make that arecommendation.
There is so much more that goesinto grading the evidence.
What I find, or what weactually utilised, was something
called the MHMRC grading matrix.
(28:47):
So this is a matrix consistingof five different domains to
categorise all the research.
So these domains let me see ifI can record them they are
evidence-based consistency,clinical impact,
generalisability andapplicability.
(29:08):
So what I mean by these isevidence-based, this level.
Now these are graded from A toD.
So if you've got an A grade forevidence-based, it's going to
be a systematic review ofrandomized controlled trials
with low risk of bias, and thenit progressively gets worse
(29:29):
where it's observational studieswith high risk of bias, all the
way down the end.
What is quite cool aboututilising this matrix, this
NHMRC grading matrix, is ittakes into consideration a
number of factors Clinicalimpact.
So we know that results can bestatistically significant but
(29:50):
they're not going to beclinically relevant.
So if I told you to follow thisextreme diet for six months.
It will statisticallysignificantly reduce weight, but
at the end of the six monthsit's only 500 grams.
Yes, that's statisticallysignificant, but is it
clinically relevant?
(30:11):
No, so we can determine howmuch of the permeability was
actually changed and whether ornot that was a huge improvement
Exactly.
And the last component.
Speaker 1 (30:29):
Sorry, you've seen this used in a negative way.
For instance, I remember thecommon conception, the common
knowledge out there is fromdoctors, surgeons, anaesthetists
is stop fish oil two weeksprior to surgery because it will
increase bleeding.
Well, it does, but they lookedat this at the Alfred and it was
(30:50):
200 mil, so it wasstatistically significant, but
it was by no means clinicallysignificant.
Indeed, the Alfred Hospital hadthem on this high-dose fish oil
up until the day before surgery.
So you know it's a perfectexample of a misnomer.
That's still to this day thatmyth is carried through.
Speaker 2 (31:14):
And we've applied this to the results where
sometimes the diet interventionswere just so extreme.
I'm not going to be puttingthat in a recommendation for
clinicians to suggest, becauseadherence is going to be very
poor.
The other one that I'll mentionhere is generalizability.
(31:34):
So a lot of studies aren'tactually conducted in the
Australian population.
You've got studies that areconducted in rural Sahara,
africa or rural China.
Now those studies and I recalla few of them that we actually
excluded they utilized whey andglutamine to reduce intestinal
(31:58):
permeability in young childrenwho are extremely protein
deficient.
Yes, of course that's going tobe beneficial, but can we
actually apply those results tothe Australian population?
I'm going to say no.
So this, this matrix.
I know it might sound a littleconfusing, but I want the
listeners to understand that wehave considered every possible
(32:21):
element.
But the beauty is you don'tneed to understand or memorise
anything that I've justmentioned.
You just need to be aware of itbecause at the end of the day,
we produce these recommendationsand we classify them as a
strong recommendation, arecommendation or a
consensus-based recommendation.
So there's three main levelsthat will determine.
(32:44):
Well, how strong do we believethat you should follow this
recommendation and that'sembedded into the, the
intestinal permeabilityguidelines and even how we write
the recommendations.
So when we dive into some ofthe recommendations, you'll see
that I use terms such as offeror advise when it's a strong
(33:06):
recommendation, so when there'ssystematic reviews backing up
the evidence.
But when there's lower level ofevidence, I'm going to use
terms like may consider a littlebit more free-flowing.
From there, we actuallydeveloped these recommendations
and we sent them to majorstakeholders.
(33:28):
Now, when I say majorstakeholders, I'm talking about
some of the biggest andbrightest professionals in our
profession.
I'm talking Dr Jason Hullerich,I'm talking Dr Nerala Jacobi,
dr Ronald Gurdjieff, dr MichaelOsiki, daini Steele, benedict
(33:48):
Fruidman the list goes on.
What I'm trying to say here isthese amazing, amazing
stakeholders.
They reviewed theserecommendations and they
(34:14):
provided suggestions, a lot ofsuggestions where we tweaked the
recommendations to ensure thatwhen we release it to the public
, this moment, right now, thatclinicians will be like yes, I
agree with this recommendation.
Just before we dive into therecommendations, andrew, I just
want to take a step back andalmost say how important graded
recommendations are.
Now, something to bear in mindis we're in the era of almost
too much research.
Now, I know that's crazy tothink, but there are multiple
(34:37):
studies in one particular area,but the studies will show
different things.
I often see presenters evenmyself, and companies.
They will make a claim basedoff a single study and a lot of
the times there could befundamental problems with that
study.
(34:57):
So I want to actually put acall to action out there.
I want to see more companies,more healthcare professionals,
more presenters actually usinggraded recommendations.
Now, if that's too difficult, Iwant people to be utilising a
risk of bias assessment, toactually not just use here's a
(35:20):
randomised controlled trial, butto systematically look at the
study and go could there be anyconfounding factors that impact
the results?
Is that too much to ask for,andrew?
Speaker 1 (35:33):
the results Is that too much to ask for Andrew?
It's a big ask because, likewhen you consider that something
like 80% of orthodox medicineis without guidelines, without
proper guidelines, withoutproper evidence, this is a big
ask, this stuff, what you'vedone is a mammoth task.
Speaker 2 (35:54):
I'm not talking.
I'm not saying that we need aclinical practice guideline for
everything.
I'm more saying, rather thanjust stating, oh, here's a
research article that promotesthis or is associated with that
disease, to take a step back andto actually make sure that we
read the article to go are theseresults accurate?
(36:17):
Can we trust them?
Speaker 1 (36:18):
Yeah, yeah, and I've seen that some like both ways.
For instance, you know, onearticle on one research paper on
a probiotic was glowing in itsresults.
It had zero dropouts and I wentmeh, I smell a rat.
You know sorry, zero dropouts,100% effective.
(36:39):
And then you've seen theresearch on this particular
probiotic strange vacillate, youknow, between good and you know
of merit and no merit in thiscondition.
So I start to go.
What are we seeing?
What I referred to earlier andthis came down to the wording
(37:07):
that you used is clinicians mayconsider, not to recommend.
So it was really interestingwith regards to a probiotic in
NSAID use and a prebiotic in ncduse.
But wasn't there did I readthis properly that when you
(37:27):
combine them as a symbiotic,then you may consider its use?
And this sort of falls into themore naturopathic treatment
paradigm of not one magic bulletbut a whole treatment
management plan?
Am I?
Speaker 2 (37:45):
correct and you're absolutely correct.
So you've got the intestinalpermeability guideline.
Now I'll direct your attentionto table three.
So this is where we have listedall of the recommendations.
So, Andrew, you've justmentioned recommendation 2.16.
There are 38 differentrecommendations, so maybe we can
(38:08):
discuss some of these Now.
I won't mention all of thembecause that would take way too
long to pull apart, Way too long.
Speaker 1 (38:15):
This is a read, by the way.
This is what are we talkingabout.
We're talking about how manypages?
Speaker 2 (38:23):
38 pages that's only one document, andrew.
There are two other documents,um, one of those documents is 80
pages, the other one is, uh, 45pages.
So, um, okay, so let's diveinto this a bit more.
Nsaids and intestinalpermeability.
What we know is NSAIDs are usedin the research to induce
(38:48):
intestinal permeability.
Okay, it's a very common method.
Multiple studies have looked atwhether or not a particular
intervention is useful atmitigating intestinal
permeability in those patientswho have taken NSAIDs, so to
induce their intestinalpermeability.
Now, you've pointed out hereI've got a section between 2.16
(39:12):
and 2.18, where we looked atwhether or not taking probiotics
, prebiotics or symbiotics hadany protective effect when it
came around to preventingNSAID-induced intestinal
permeability.
What is quite interesting waswe didn't set out to develop
(39:33):
this recommendation.
This was more so that there wasquite a lot of research here.
So these are evidence-basedrecommendations and if we're
looking at the code, there'sthree stars.
So this is it's not thestrongest recommendation, but
it's an opinion.
What I want to emphasize here is, when it comes around to
(39:56):
guideline development, we doneed to consider what the
research says.
Although if I had a patient infront of me and I had the
potential of prescribing a pre,pro or symbiotic.
Would I give it to a patientwho's got NSAID-induced
intestinal permeability?
You know what?
It's not going to help.
Sorry, it's not going to hurt.
(40:19):
It could be beneficial, but theresearch on those particular
strains have shown that ithasn't.
So I am sure that there aresome strains out there that are
very effective at preventingNSAID-induced intestinal
permeability, but unfortunatelythey weren't researched and then
they haven't been researched inthis cohort, thereby we
(40:42):
couldn't include them.
But but I know people areinterested in in nsads, so I'll
give you a bit of a caveat here.
And that is uh recommendation3.3, and I'll read this one to
you.
And it says clinicians shouldconsider the use of short-term
lactoferrin supplementation forthe treatment of people with
(41:03):
non-steroid anti-inflammatorydrug-induced intestinal
permeability.
So we do have something withevidence that we can recommend
to our patients that has beenshown to be effective at
preventing NSAID-inducedpermeability.
Speaker 1 (41:20):
But not colostrum.
There was no evidence withcolostrum.
Nobody has looked at that onits own.
Speaker 2 (41:27):
DR WEBSTER, that's an interesting one.
Unfortunately, all the researchon colostrum had to be excluded
, so we couldn't produce anyrecommendations for colostrum
because we had to exclude it.
The vast majority, if not all,were in patients with
exercise-induced permeability.
(41:47):
So that was one of ourexclusion criterias, because if
we looked at exercise-inducedpermeability, that opens up a
whole other can of worms.
Heat shock, proteins andeverything Exactly so if anyone
would like to do a clinicalpractice guideline for
exercise-induced permeability, Iwould be happy to provide some
(42:08):
recommendations.
Speaker 1 (42:10):
But yes, that is the risk, andrew FITZ, GIBBONS, if
they're willing to become anabsolute nerd and lock
themselves in a way for a darkroom in a dark room for four
years, having no life um shallwe give you a few more examples
and true of uh recommendationsthat we please, please, all
right.
Speaker 2 (42:25):
So we have recommendations for alcohol use,
dietary fiber, macronutrientratios, energy intake, so that's
kilojoules um gluten-freerecommendations, um a number of
pre-probiotics, umrecommendations for glutamine,
omega-3 and zinc.
Something I'll note here isalcohol.
(42:49):
So I will be the first to saythat alcohol induces intestinal
permeability.
Speaker 1 (42:55):
I'm not afraid to say that afraid to say that.
Speaker 2 (42:58):
But when you look at the research all the research on
alcohol the effect of alcoholon intestinal permeability is
short term.
I'm talking.
Participants would take one ortwo shots of alcohol in a
setting and then measuredintestinal permeability.
So we couldn't actually createa long-term recommendation for
(43:24):
alcohol consumption.
So we actually had to fall backon the Australian Dietary
Guidelines and basically saydon't drink more than what the
guidelines recommend, because wedidn't have the evidence to say
stop drinking.
In saying that, we producedwhat's called a consensus-based
recommendation.
That's where the brainiacs ofthe group sat down and go okay,
(43:46):
well, we know that alcohol canimpact permeability.
There is research to say itdoes, but no long-term.
What can we do?
So we have a recommendationthat people with intestinal
permeability should limit oravoid alcohol consumption when
they're actually treatingintestinal permeability.
(44:06):
Does that make sense?
Speaker 1 (44:09):
yeah, absolutely.
Um, and forgive me, I actuallysaid the wrong thing.
I reread the guidelines and itsays you may consider not using
a symbiotic.
So it it's prebiotics.
Probiotics and synbioticsaren't really recommended for
NSAID-induced intestinalhyperpermeability.
Speaker 2 (44:29):
Wow, with the caveat that those strains, the strains
that were researched, were foundnot to be protective.
That is not to say that there'sother strains out there with
lower levels of evidence thatweren't included, that are
effective, and I love myprebiotics.
I love my prebiotics and I wantthere to be an effective one,
(44:50):
but unfortunately we didn'tinclude any research to support
that.
That's not to say that from thethousand other strains out
there that there isn't aneffective strain.
Speaker 1 (45:01):
Yeah, I mean, you know, look how many species are
we allowed to have in Australia?
14?
Something like that, most ofthem based on milk, not all, but
most of them.
We certainly don't have the joyof being able to access things
like Accomantium, eosinophiliaor Fecali bacteria and
Proutsnitzii or any of thoseones which I'm going to do a
(45:24):
shout-out here to Clara Beltzer,who enlightened me to the
merits of these microbes.
But you know, unfortunately atthis stage we don't have the
facility to use those in atherapeutic environment.
But one point that I make isyou actually wrote this with the
intention that future researchwill change these
(45:47):
recommendations.
Speaker 2 (45:50):
Of course, that is the underlying principle of a
clinical practice guideline.
It's developed every five yearsbecause research is coming out
every single day.
I recall, you know, finalisinga recommendation and then you do
one final sweep of theliterature and realise, oh wait,
this groundbreaking researchhas just been published and I
actually had to get to a pointwhere I said that's it, this is
(46:13):
the cut-off line.
I can't look at any moreresearch because I'd still be
validating the research tillthis date.
So these recommendations arevalid as of 2023.
I would like to say that theoverall trend of these
recommendations will stay veryaccurate for a number of years
(46:34):
to come, but as clinicians, weshould always take these
recommendations in considerationto any new research that has
been done after 2023.
Speaker 1 (46:46):
Yeah, like I noticed, galacto-oligosaccharides isn't
included in there.
I mean, I get it, and I'm surethat you can't.
Speaker 2 (46:57):
Yeah, it's an interesting one where we know
that GOS is very therapeutic atreducing LPS-producing bacteria,
which is linked withpermeability.
But that level of evidence toget into a clinical practice
guideline it didn't meet thatthreshold.
Speaker 1 (47:19):
Indirect evidence rather than direct brad.
There's so much to learn but Ilike really.
People really need to look atthese guidelines.
Where can they download them?
Speaker 2 (47:30):
yeah, so they are free to access um.
I'd like you to, if you can,include them in the show notes
so then they're easy for peopleto definitely to download um.
If not, you can download themon my website, drbradlinchcom,
and you can just download themthere.
There are three documents here.
You've got what's referred toas the ip guideline.
(47:52):
That is basically the summaryof all the recommendations.
For the gut nerds who arewanting a little more
information, you can downloadthe technical report and the
guideline development processdocument, two documents that
have a lot more information.
Speaker 1 (48:14):
For someone who's more wanting to look at this
from a research perspectiverather than a bible that
clinicians should be keeping upon their in their clinic room,
to quickly refer to that, oh yes, I can utilize this, this
treatment recommendation andforgive me, brad, I know we've
sort of covered the sort ofmajor areas, but just but just
(48:36):
quickly, things like zinc,things like herbs, the not the
well, the collagogues you couldinclude, but also the, the
antimicrobial herbs like coptisor golden seal which you know
people are using, can you giveus just a quick synopsis of
whether they're indicated orwhether there's issues with them
(48:56):
?
Yes, of whether they'reindicated or whether there's
issues with them.
Speaker 2 (49:01):
Yes.
So with zinc, there was anumber of studies and it is a
recommendation.
I'm just trying to find it herein the guidelines.
Here we go.
Recommendation 6.1, cliniciansmay consider using zinc
supplementation in the treatmentof patients with intestinal
permeability.
As for herbal medicine, nowunfortunately we couldn't
(49:21):
actually produce anyrecommendations for herbal
medicine.
Believe it or not, there isn'ta lot.
There isn't any studies thatuse a validated method for the
assessment of intestinalpermeability in patients who are
not critically ill over the ageof 18, with appropriate
(49:43):
statistical analyses.
I recall there's some curcuminand there are a number of herbs,
but the study did not utilise avalidated method to assess
intestinal permeability.
Thereby we didn't want toinclude any of those articles
because we wanted to ensure thatthe recommendations that we
produced were of the utmosthighest level of evidence.
Speaker 1 (50:08):
Now I'm going to be attending a talk that you'll be
doing soon, talking about ordiscussing the major conditions
which people present with, whereintestinal hyperpermeability is
a major factor, where we reallyshould be addressing this to
(50:31):
bring the symptomatology andefficient management or
effective management of theseconditions down did I?
That's incorrect but to createeffective management.
Speaker 2 (50:46):
I believe you're referring to a presentation I'm
giving on how to treat themicrobiome and gut-related
conditions and in thatpresentation it's going to be
talking about what can we do tosupport the microbiome, to
support gut-related conditions.
But I'll also be presenting atthe NHAA conference this year
(51:10):
down in Melbourne which I'm veryexcited about on a topic very
dear to my heart on the impactof antimicrobial herbs on the
microbiome and whether or notsome antimicrobial herbs may
actually have a potentiallydetrimental impact on our gut
microbiome.
So I won't give too much away.
(51:31):
But, yes, I've got a number ofupcoming events that I'll be
talking and presenting at overthe next six to five months.
Speaker 1 (51:38):
But you're also doing .
This is a public talk you'redoing, it's on the 23rd of
February and it's one thatpatients can access.
It's a patient guide towellness.
Speaker 2 (51:49):
That's correct.
It's focused on what patientscan do to improve their gut
health.
Speaker 1 (51:55):
Yeah, Wonderful stuff , Brad.
You and I seriously I couldlearn so much off you, just
talking for a couple of hoursand chatting, preferably over a
Pinot Noir.
Speaker 2 (52:10):
That sounds lovely, Andrew.
Speaker 1 (52:13):
But it might transiently affect our
intestinal hyperpermeability.
But there's so much to learnhere and so much to put into
little boxes.
But I love the way that you'vedone it with scientific rigor
but from the point of care, fromthe point of actually caring
for patients to make a positiveimpact in their lives rather
(52:34):
than just selling themsupplements going.
The company said it worked.
I love this rig and it'sfantastic and it and it sees not
just you but it sees naturalmedicine practitioners in a
higher light.
You're improving theprofessionalism of our
professions.
Um, it's, it's fanding.
You're improving the standingof our professions.
(52:56):
So it's wonderful work thatyou've done.
There's so much learned, somuch more for us to learn here
and so much more work that youhave to do to make this a 90
page document.
Speaker 2 (53:09):
Thank you, andrew, and you know I'm only one piece
in the puzzle.
There are amazing researchersout there who are just doing
incredible things for ourprofession.
I know a good friend andcolleague of mine I did my
honours and PhD with her DrJessica Bays.
She's now a postdoctoralresearch fellow at Southern
(53:30):
Cross University and she isproducing incredible work when
it comes around to mental healthand the diet.
So we're very fortunate here inAustralia that we are producing
so many more PhD qualifiedhealthcare practitioners who are
producing quality research toadvance our profession.
(53:50):
You know we've got amazingmentors.
You know Dr Amy Steele, she hasgot so many PhD students.
So it's I'm only one piece ofthe puzzle.
So it's great to have thesupport and have so many peers
who are doing so much to supportour profession.
Speaker 1 (54:08):
Thank you so much, dr Brad Leach, for joining us
today and sharing your wealth ofknowledge, but also your care
for not just the profession butalso your patients.
I really admire you.
Thanks so much for joining uson Wellness by Designs today.
It's my pleasure, andrew alsoyour patients.
I really admire you.
Thanks so much for joining uson Wellness by Designs today.
Speaker 2 (54:23):
It's my pleasure, Andrew.
Thank you.
Speaker 1 (54:26):
And thank you everyone for joining us.
Remember you can catch up onall and I mean all of the show
notes that we'll have for youtoday.
There'll be a lot and, ofcourse, the other podcasts.
On the Designs for Healthwebsite, I'm Andrew
Whitfield-Cook.
This is other podcasts on theDesigns for Health website.
I'm Andrew Whitfield-Cook.
(54:47):
This is Wellness by Designs.
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