Beating Gut Dysbiosis

Beating Gut Dysbiosis

Of all bodily functions, little surpasses the digestive process when it comes to causing embarrassment and repulsion. Funny noises, bad smells and even pain are for many people the penalty for one of our greatest pleasures, eating. Thus we may come to hate our own guts. They appear to conspire to torment and humiliate, shaming us for being human.

• Those same guts which cause so much distress are really not your own. If you have ever thought that your innards appear to have a life of their own, it’s because, in a sense, they have.

Read And Learn More: Health Problems And Dietary Solutions

• Down there in that dark, murky area of your being exists a parallel universe of invisible microorganisms microbes, transients, opportunists and freeloaders all merrily coexisting along the tube that runs from your mouth to your anus.
• There they live, breed, feed, ferment, evolve, do battle and eventually die or just move on out. So busy are these microorganisms that their combined metabolic activity has often been likened to that of the liver.
• You provide bacteria with a habitat; your body is their home but they are indifferent to you and your concerns. Even so, it is an advantageous arrangement in exchange for food and shelter you get a great deal, as we shall see.
• Rather like small birds pecking insects off the backs of tolerant buffalo, bacteria clean up our digestive tract as part of a tacit, mutually agreeable arrangement we have with them.

An awful lot of bacteria are indigenous to the human body. There are approximately ten times as many bacteria in the human gut as there are cells in the body.

• There are around 400 to 500 species of ‘normal’ bacteria in the digestive system, and many strains of each type. Around 20 types of bacteria make up the majority.
• In total there are approximately 100 trillion bacteria in the gut, creating a weight of around 4 lb and contributing 40 to 60 per cent of the stool mass. Remember that the next time you peer down the lav to examine the denouement of your diet.
• The presence of vast colonies of bacteria in the gut was discovered in the late 19th century. So repulsed were many sensitive (yet solvent) individuals by that discovery that they had their colons removed by the royal surgeon Sir William Arbuthnot Lane as a treatment for what was termed ‘intestinal toxaemia’.
• Today we have come to terms with the residents within, but to a large extent still fail to grasp their significance. When babies pick up all sorts of foul items and cram them into their tiny mouths, we recoil in horror before snatching away the offending object.
• This oral ‘fixation’ is firmly established as one of Sigmund Freud’s stages of psychosexual development, where the infant derives immense gratification from oral stimulation.
• But I can’t help wondering if Freud was totally au fait with the child’s urgent need to colonize the gut with bacteria in order to build immunity as fast as possible. That is, of course, a rather more prosaic take on this reflex action but nonetheless one worthy of consideration.

Defining Dysbiosis

Just as humankind has managed to lay waste to the external ecology, so too do we frequently trash our own internal ecology. Dysbiosis is the opposite of symbiosis it is dissonance instead of harmony. The term was first coined by Dr Elie Metchnikoff, who won the Nobel Prize in 1908 for his work on lactobacilli bacteria and their role in immunity.

• He used it to describe a state of imbalance of intestinal bacteria or altered gut microflora. Dysbiosis is a state whereby an overgrowth of pathogenic, or ‘bad’ bacteria and other undesirable microorganisms creates harmful effects by changing their metabolic activity and colonizing the gut in greater than normal amounts.
• The activity of these dysfunctional bacteria, it is believed, results in the release of potentially toxic products which may play a role in many conditions.
• Common symptoms associated with gut dysbiosis include:
  • Constipation
  • Diarrhoea/loose stools
  • Bloating
  • Excessive gas
  • Abdominal discomfort
  • Abdominal pain
  • Fatigue
  • ‘Foggy’ brain.
• People normally come to see me with digestive problems because they have already consulted their GP and/or undergone various tests but haven’t received a diagnosis because the tests proved negative.
• This suggests to me that the problem may be either dysbiosis or food sensitivity. Gut dysbiosis normally occurs an hour or so after eating – clients often comment they feel fine on waking and that their symptoms only emerge after breakfast or lunch.
• Sometimes they say that symptoms developed immediately after a visit abroad, or after a course of antibiotics. These are all clues that point to dysbiosis, as we shall see further on. But first let’s identify the good, the bad and the downright beastly, and the role they play in our health, or otherwise.

Your Invisible Friends And Foes

There are two main groups of what are often referred to as ‘friendly’ bacteria in the gut: the lactic acid bacteria, and the bifidobacteria. The best-known lactic acid bacteria are L. acidophilus, L. bulgaricus and L. casei. These bacteria are considered ‘commensal’ in that they are natural human gut inhabitants. The friendly bacteria are essential for human health: in exchange for our good health, we give them a nice warm, dark environment with lots of food to feed on.

• The main pathogenic, or ‘bad’ bacteria are the bacteroides, plus shigella, klebsiella, entamoeba, streptococcus, Clostridia and Staphylococcus.
• The Bacteroides are in fact normal inhabitants of the colon and form a large component of colonic bacteria. Even so, they are opportunistic pathogens frequently associated with gut infections and diarrhoea.
• Until birth, the digestive tract is a sterile environment. The birth process puts paid to that, as bacteria are picked up along the birth canal, initiating the colonization process. The next source is touch and breastfeeding.
• Breastfeeding significantly influences the development of flora, as microbial life is known. Breastfed children quickly develop gut flora dominated by lactic acid bacteria and bifidobacteria, especially Bifido infantis.
• Bottle-fed babies have much lower levels of bifidobacteria and their flora contains more Bacteroides. As a result, they have greater susceptibility to infection by pathogenic bacteria.
• It is well-known and accepted that breastfeeding is superior to bottle-feeding, and one of the reasons for this is the protective effect against infection conferred by breastfeeding. The gut flora of the breastfed infant has been shown to reduce the incidence of diarrhoea.
• When weaning begins, the change to solid food marks the development of typical adult flora. The adult digestive tract, which is effectively a muscular tube, measures about 11 metres from mouth to anus.
• The surface of the lining of the gut serves as a barrier which prevents a broad spectrum of undesirables from crossing over into the blood.
• At the same time this lining, which acts like an internal bouncer, has to be able to identify the desirables, specifically nutrients, and let them through.

The start of the digestive system is the mouth, where food is chewed and mixed with saliva secreted by salivary glands.

• This saliva softens up food and contains an enzyme called amylase which starts the process of digesting carbohydrates. When you swallow, food passes down the oesophagus, through the oesophageal sphincter and into the stomach.
• The stomach has few bacteria, thanks to the presence of hydrochloric acid – few living organisms can withstand such an acidic environment, which is a good thing when you consider how easily all sorts of critters can find their way onto your plate.
• Fortunately, the stomach has a protective lining which prevents it being dissolved by its own acid. The stomach, which can hold about 1.5 litres of fluid, is like an industrial food-mixer.
• Food is mulched, kneaded and liquefied into a squelch called chyme. Protein digestion begins in the stomach via the action of hydrochloric acid and an enzyme called pepsin.
• Only water, some medicines and alcohol pass through the stomach wall, which explains the hit you get when drinking on an empty stomach.
• After a couple of hours or so of this activity, liquefied food passes through the pyloric valve and enters the first part of the small intestine, the duodenum.
• The small intestine (which is about 7 metres long) is where food is digested and absorbed. It is lined with microscopic, finger-like protrusions called villi which in turn are covered with microvilli. These microvilli are an essential part of absorption.
• In the first part of the duodenum, enzymes pour in from the pancreas. There are three types of enzymes: lipase (to digest fats), amylase (to digest carbohydrates) and protease (to digest protein).
• The pancreas also secretes bicarbonates in order to neutralize the acid from the stomach, and insulin to regulate blood-sugar levels. Bile from the liver emulsifies fats, making them more water-soluble so that enzymes can start digesting them.

The first part of the small intestine is colonized mainly by lactic acid bacteria, in particular L. acidophilus. There may also be small numbers of E. coli (the good kind, as opposed to the killer kind), yeast and a few other microorganisms.

• In the lower part of the small intestine, the dominant group are the bifidobacteria, with some lactobacilli and streptococci.
• Food moves swiftly through the small intestine, and bacteria, in order to avoid being swept away, are able to adhere to the gut lining (the epithelium).
• However, many of these lactic acid bacteria are shed when food passes through, and the effect of this is to lower the pH of the gut, which has a protective effect against pathogens.
• Further down, following digestion and absorption, food passes into the large intestine via the ileocaecal valve. The large intestine, also known as the colon, is around 3-5 feet long.
• Here, the remaining nutrients and water are absorbed and some B vitamins are produced. The vast majority of bacteria in the gut are found in the colon.
• They are mainly Bacteroides, though there are still significant numbers of bifidobacteria. After passing along the ascending, transverse and descending colon, the deconstructed food, now known as faeces, passes into the rectum. Here faeces are held until there is sufficient volume to create a bowel movement.
• A muscular wave, known as peristalsis, causes the faeces to pass out of the anus as stools. Stools are composed of undigested fibre, water, food metabolites and bacteria, both living and dead.

What Bacteria Do For Us

The indigenous bacteria are often described as ‘friendly’, not because of their cheerful disposition but because of the work they do, albeit unwittingly, to promote our health. Human gut bacteria are essential to the health of the whole body, not just the digestive system. These bacteria perform a number of tasks, in particular those outlined below.

Kill Pathogens

• Our microbial friends perform the extremely important task of controlling and preventing the overgrowth of unfriendly, even downright hostile bacteria which, if left to flourish, can cause unpleasant symptoms or disease.
• As well as inhibiting the overgrowth of ‘bad’ bacteria, such as salmonella, Escherichia coli (E. coli 0157) and H. pylori (the microbe now known to cause stomach ulcers), they also keep yeasts such as the various Candida species in check.

Obviously, they do not do all this for purely altruistic reasons: by blocking their competitors they are able to flourish and survive more easily. They do this in a number of ways.

1. They Create an Acid Environment
   • Lactobacillus bacteria such as L. acidophilus feed on carbohydrates, and produce lactic acid in the process. This lactic acid lowers the pH of the gut to around 4.0, and this inhibits most other microbes.
   • E. coli 0157. for example, is a disease-causing microbe which is inactivated in an environment with a pH below 5. The lactic acid bacteria also produce hydrogen peroxide, which inhibits the growth of yeasts such as Candida albicans.
2. They Produce Natural Antibiotic Factors
   1. Friendly bacteria, especially, acidophilus, are able to manufacture antibiotic substances, namely lactocidin, lactobacillin, lactobreven and acidolin.
   2. These can inhibit pathogenic bacteria, including salmonella and E. coli. The bifidobacteria, on the other hand, are effective against pathogenic bacteria in a different way they produce bacteriocins, proteins which are antagonistic to bacteria such as listeria and enterococcus.
3. They Produce Short-chain Fatty Acids: The bifidobacteria, which inhabit mainly the colon, produce short-chain fatty acids (SCFAs), the most abundant being acetic acid. Acetic acid exerts powerful activity against yeasts and bad bacteria.
4. They Create Spatial Exclusion: In sufficient quantities, they constitute an ‘army’ which crowds out invading pathogens along the intestinal lining, preventing bad bacteria, parasites and so on from getting a look-in.

Bacteria Build Immunity

• Gut flora stimulates and influences the immune system, and disturbances in the population of the gut can damage immunity.
• In animals devoid of intestinal bacteria, i.e. which have been bred to have a sterile gut, severe infections occur with little chance of survival.
• Both lactobacilli and bifidobacteria strengthen the ability of immune cells in the gut lining to defend against toxins and pathogenic microorganisms, as well as allergens (substances which trigger an allergic response). They do this through:

• Stimulation of the production of antibodies: With the assistance of good bacteria, the gut makes secretory immunoglobulin A (SigA), an antibody which binds to pathogens, preventing them from attaching themselves to the gut lining.
• Stimulation of gut-associated lymphoid tissue (GALT). GALT represents approximately 60 per cent of the human immune system. Indeed, this GALT constitutes the largest lymphoid organ in the body, and it is highly sensitive to fluctuations in bacterial activity.
• Prevention of inflammation Some bacteria can actually improve the symptoms of inflammatory bowel disorder (IBD) through their anti-inflammatory activity.

Bacteria Improve Digestion

• Friendly bacteria encourage peristalsis and therefore motility of food through the gut, helping to prevent constipation and keeping the bowels regular.
• Lactic acid bacteria such as L. acidophilus produce the enzyme lactase, which is necessary for the digestion of milk sugar (lactose).
• They also help digest proteins and break down bile acids. As we saw in the Solution 5 chapter, bacteria metabolize plant compounds which are then absorbed into the blood and help normalize oestrogen levels.

Bacteria Provide Energy

• Bacteroides in the colon produce enzymes that ferment and digest dietary fibre, and this fermentation produces short-chain fatty acids – butyrate, propionate, acetate and valerate – which are then absorbed into the blood.
• Acetate and propionate provide energy for the brain, muscles and heart, while butyrate provides about half of the daily energy requirements of the gut lining.

Bacteria Protect Against Heart Disease and Cancer

• The short-chain fatty acids produced by the fermentation of fibre are protective against heart disease and cancer.
• One way they do this is by helping to regulate cholesterol and circulating fat levels. Chronic heart failure is due in part to inflammation, and it has been found that disturbed gut bacteria can trigger the inflammation which leads to this condition.
• We have seen that short-chain fatty acids, produced by the fermentation of carbohydrates by bacteria, provide the body with energy. One of those SCFAs, butyrate, is directly involved in cancer prevention. Butyrate has been shown to kill cancer cells and stimulate the growth of normal cells.
• Friendly bacteria can also prevent the growth of those bacteria that produce nitrates in the colon, which are known to cause cancer of the bowel.

Bacteria Remove Inorganic Toxins: Along with food, we ingest all manner of non-food substances, some of which are natural, some of which are very unnatural. Friendly bacteria help us break down and eliminate toxic substances such as drugs, food additives, mercury, pesticides and other pollutants.

Bacteria Produce Vitamins and Promote the Absorption of Minerals: Lactic acid bacteria manufacture, through their metabolic processes, vitamins B₁, B₂, B₃, B₅, B₆, B₁₂, folate, biotin and vitamin K. Lactic acid bacteria promote the absorption of minerals which require acid for absorption – iron, calcium, magnesium and copper.

The Effects Of Dysbiosis

Dysbiosis has been indicated in numerous health crimes because the products of bacterial metabolism are distributed systemically in the bloodstream. As well as reducing your overall immunity and increasing your risk of cancer and heart disease, dysbiosis is also linked to conditions affecting the nervous system, including chronic fatigue syndrome.

As far as digestive health is concerned, there are two main areas where dysbiosis really does its worst it contributes to inflammatory bowel disease and encourages the proliferation of pathogenic microorganisms – parasites, yeasts and other hangers-on – which are then free to vandalize with impunity.

Inflammatory Bowel Disease (IBD):

• IBD is a general term used to describe a group of chronic inflammatory disorders affecting the bowel, of which the two main types are Crohn’s disease and ulcerative colitis.
• Crohn’s mainly affects the colon but may in fact involve any part of the digestive system. The affected area is thickened with ulceration and the formation of fistulas. The main symptoms are pain, diarrhoea and weight loss.
• As a result of the damage to the intestinal wall, malabsorption occurs. Overgrowth of pathogenic bacteria has been found in studies of patients with this disease, though the only microorganism reported to be strongly associated with Crohn’s disease is E. coli.

Ulcerative colitis is a chronic inflammatory condition of the large bowel and is characterized by bloody diarrhoea. Mucus is also passed in the stool. There are usually cramps in the lower abdomen, with mild abdominal tenderness.

• Dysbiosis is very much linked to IBD, and the bacteroides and other unfriendly bacteria are found to be increased in people with IBD, with significantly reduced numbers of bifidobacteria.
• Studies have repeatedly found different bacterial activity between people with IBD and healthy controls. It is believed that dysbiosis may disturb the partnership between flora and the human immune system, and the effect this has on the immune system may create responses that underlie inflammatory disorders.

Overgrowth of Pathogenic Microorganisms:

Bacteria

• Dysbiosis can create increased vulnerability to pathogenic bacteria such as salmonella, shigella and Klebsiella.
• Salmonella is probably the best known, and causes severe gastrointestinal illness accompanied by pain, cramping, nausea and vomiting. The condition usually resolves without treatment. Shigella causes dysentery.
• In the UK the effect of shigella infection is usually mild, with some abdominal pain and diarrhoea. It can also cause ‘traveller’s diarrhoea’ and in some people, symptoms can be severe.
• Klebsiella pneumoniae is the most common form of klebsiella in hospital patients and can cause pneumonia in susceptible individuals.
• The most common cause of food poisoning in Britain is the bacterium Campylobacter, which is found in raw meat.

Parasites

• Parasites may be intestinal or blood-borne. In the intestines, they are either single-celled microorganisms or helminths – worms, such as roundworms or tapeworms. Worms are generally visible to the naked eye, but not so your single-celled parasites.
• These include various types of amoeba (the most common types are Endolimax nana, Dientamoeba fragilis, Entamoeba histolytica), giardia (most commonly G. lamblia), Blastocystis hominis and Cryptosporidium.
• They may cause no symptoms at all, but if there is an overgrowth, or you are elderly or have a compromised immune system, there are a number of symptoms you may experience if you have one or more of these parasites: abdominal pain, diarrhoea (sometimes alternating with constipation), flatulence, bloating, lower back pain, weight loss and fatigue.
• When I mention the possibility of parasites to clients, a shadow of horror usually passes over their faces. That is because we tend to think of parasites as hairy, bug-eyed beasts trawling through our guts, rather than as invisible microorganisms.

They are extraordinarily common, yet rarely considered by medics. When I talk to my clients who have been trying to deal with their digestive problems for years, and have trolled back and forth to their GP for the duration, I find that any discussion of parasites has rarely occurred.

• How common is parasitic infection? There doesn’t appear to be any data for the UK, but US studies are interesting. In 1987 a survey by the Centers for Disease Control showed a frequency of positivity in 2.6 per cent of laboratory samples.
• By 2000, however, a third of stool samples from 2,896 patients in the US tested positive for intestinal parasites, and, of those, 23 per cent were infected with Blastocystis hominis. Globalization of our lifestyles has led to globalization of our diseases, so it is no wonder that B. hominis and others easily make their way around the world.
• If I suspect a client may have intestinal parasites there are certain questions I always ask. These include: Have you done much travelling recently? Did your symptoms come on suddenly? Do you get painful cramps in the abdomen area? Do you get frequent diarrhoea? A positive answer to any of these questions raises my suspicions, and at this point, I often suggest a lab test.
• If the test result is positive, the culprit is almost always, in my experience, B. hominis. The symptoms commonly associated with Blastocystis – which is able to lodge in the intestinal wall, making it hard to eradicate – are abdominal pain, bloating, cramps, occasional diarrhoea, constipation, aching joints and skin rash. Mental symptoms include fatigue, lassitude and dizziness.
• Transmission is believed to be faecal/oral – a nice way of saying poor toilet hygiene on the part of whoever has cooked or served the offending food. Other parasites are water-borne – giardia and Cryptosporidium are resistant to chlorine and can spread through drinking water.

Yeast Overgrowth:

• There are all sorts of yeasts co-habiting in your gut, and if you have a healthy gut flora they do no harm. However, this balance can go awry if your friendly bacteria are insufficient in number
  to keep them under control, or if you have poor gut immunity or inadequate intestinal pH levels.
• The most commonly found yeasts include Candida krusei, Candida tropicalis and Geotrichum. However, the most common of all is Candida albicans.
• Ordinarily, C. albicans thrives in an alkaline environment, so is controlled by lactic acid bacteria. The hydrogen peroxide also produced by L. acidophilus kills Candida directly.
• Given the right circumstances, Candida, like all yeasts, can flourish and proliferate, and any unchecked growth of their colonies can be explosive, resulting in the production of powerful toxins. Yeasts particularly like warm dark places, so the gastrointestinal tract and vagina, where it manifests as thrush, are particularly accommodating.
• It is believed that C. albicans is able to break down the digestive system’s front line of defence against infectious agents, the antibody SigA.
• The most common physical symptoms of C. albicans overgrowth are abdominal discomfort, constipation and/or diarrhoea, PMS and recurring urinary tract infections, sore muscles and acne.

There may also be fungal infection in the nails, eyes and on the skin, as well as vaginal thrush. The most common mental symptoms include depression, fuzzy thinking, poor memory and concentration, insomnia, mood swings and fatigue. Sensitivity to perfumes, detergents and other chemicals is not uncommon.

• Unlike many other organisms, Candida does nothing useful for us and is a true parasite. It can colonize the entire digestive tract, from mouth to anus.
• In the mouth it is visible as white spots and a coated tongue. It can cause itching around the anus and discharge of mucus. No wonder, then, that people who genuinely have a yeast overgrowth tend to feel sick all over as if the whole body feels toxic.
• The reason for Candida’s systemic assault lies in its ability to change from a yeast form to a fungal form. When it does so, it develops rhizoids, which are rather like the roots of a plant.
• These roots are able to penetrate the gut lining and enter the bloodstream. Candida is then free to travel the body, wreaking havoc as it does so. So too are other toxic substances, thanks to the gut permeability created by the rhizoids.

Getting To The Bottom Of It Dysbiosis

If you have any number of digestive symptoms, you need to find out what exactly is causing them in order to get the appropriate treatment. This means going to your GP and, if necessary, undergoing one or more tests. Your GP might suggest testing for Helicobacter pylori, the bacterium now known to cause stomach ulcers. A breath test is a common procedure for this.

Tests will also help eliminate any concerns about bowel cancer, the third most common cancer and the second most common cause of cancer death in the UK. Tests frequently undertaken include sigmoidoscopy, colonoscopy or endoscopy.

• A colonoscopy is an examination of the rectum for abnormalities, including tumours. A sigmoidoscopy is similar and looks at the lining of the colon and may involve taking a biopsy. An endoscopy involves inserting a camera probe into the stomach and the duodenum to investigate the presence of an ulcer or tumour.
• Another means of examining the bowel for growths is a barium enema, a type of X-ray which involves inserting a tube into the rectum. The inside of the bowel is first coated with a powder called barium sulphate to produce a clearer image.
• A barium enema is used to examine the large bowel (colon and rectum) for problems such as growths (polyps), inflammation (colitis), and tumours. Barium sulphate can also be given as a drink (barium meal) to examine the upper intestinal tract (endoscopy).
• If tests reveal nothing untoward, your GP may diagnose you with irritable bowel syndrome.

Irritable Bowel Syndrome

This is a popular diagnosis where there are plenty of symptoms but no known cause. According to The Gut Trust – ‘the national charity for IBS’ – between 10 and 20 per cent of people living in Western countries fulfil the diagnostic criteria for IBS alone – and this figure does not even include other disorders of the gut.

A diagnosis is made where there is abdominal pain and altered bowel habit. This pain may be in any area of the abdomen, but most frequently in the lower left or right-hand side. There may be either constipation or diarrhoea or alternate episodes of both.

• There may also be bloating, excessive gas and a feeling of incomplete emptying after a bowel movement. There is no specific remedy. I may be a cynic, but I have a theory concerning IBS. I see it as an umbrella term, which, when offered as a diagnosis, could be taken to mean there is something wrong with your digestive system but we don’t know what.
• Neither do we know what to do about it. Try these antispasmodic drugs. Then again, you may be imagining it all. Try these antidepressants.
• It is generally agreed by specialists in the area that the treatment for IBS is neither evidence-based nor efficient.
• That is probably why management often means advising patients that they have to come to terms with their symptoms, perhaps with the help of some antidepressants.
• I have seen many people who have been totally disillusioned by the lack of effective advice given and who consequently refused the treatment offered.
• I strongly suspect that IBS and dysbiosis are one and the same thing, especially as studies have shown that probiotics (friendly bacteria in supplement form) are equally effective as antispasmodic drugs in the alleviation of IBS symptoms.
• In the US, parasitic infection is found in almost half of the diagnosed cases of IBS where testing has occurred. Indeed, the symptoms of IBS and B. hominis infection have been shown to be ‘remarkably similar’. Some researchers even believe that IBS may be caused by B. hominis.
• The problem in the UK is that, because no one usually looks for parasitic infection, it is not usually found.

Dysbiosis Causes

Under certain circumstances, the microflora of the gut can be altered, and indeed severely disrupted. The main, non-diet-related issues are discussed below. Diet-related causes of dysbiosis are discussed in the ‘Return to Balance’ section.

Dysbiosis Drugs

• Certain drugs, including steroids and the contraceptive pill, are known to disturb the human gut microflora, but no drug can obliterate gut bacteria quite the way that antibiotics can.
  Antibiotics are not discriminatory instead they annihilate the good with the bad.
• Lactobacillus acidophilus can be virtually wiped out by a course of antibiotics. This clears a path for hostile bacteria, parasites and pathogenic yeasts to thrive.
• These include E. coli, staphylococci, streptococci and yeasts, notably Candida albicans – yeasts are especially free to proliferate, as they are not affected by antibiotics.
• Even if you don’t take antibiotics you will ingest them in the meats you eat because antibiotics are routinely used in livestock, not just to treat disease but as a preventative measure in intensive farming – cramming animals together in closed buildings makes them vulnerable to infection. As a result, meat contains antibiotic residues, as do milk and milk products.

Dysbiosis Stress

• There is plenty of evidence to demonstrate that stress has a significant influence over the activity of bacteria in the gut, however strange this may seem.
• You might think those tiny blighters would be indifferent to your feelings, but you’d be wrong. They too are sensitive, but in a more opportunistic than solicitous manner.
• How stress can cause a dramatic rise in adrenal cortisol levels, cortisol being a major stress hormone. When a group of stressed-out students had saliva and faecal samples taken at the start of a semester and also during the first week of exams (in other words, during periods of low and high stress) researchers found significantly lower levels of lactic acid bacteria during the high-stress condition, when cortisol levels were found to be high.
• This suggests that stress can actually be involved in the initiation of infectious disease, as well as non-infectious diseases such as heart disease and cancer, because of the way it changes the activity of the gut flora.
• The immune system and the central nervous system are known to ’cross-talk’, and the perception of stress by the nervous system causes the release of stress hormones. Infectious, pathogenic bacteria have evolved detection systems to sense stress hormones and then use them to proliferate and initiate infection. What cunning little deviants those pathogens truly are.

Dysbiosis Age

• The elderly are prone to dysbiosis because they have an altered microflora, with decreased numbers of beneficial bacteria.
• People aged over 55 have been shown to have a marked decrease in levels of bifidobacteria, which may make them more susceptible to infection. This decrease in numbers is possibly due to the reduced ability of the bacteria to adhere to the gut lining.
• With fewer friendly bacteria, intestinal immunity is compromised and this can lead to Clostridium difficile-related diarrhoea, one of the most common gastrointestinal infections in the elderly. Antibiotics, not surprisingly, exacerbate dysbiosis in the elderly.
• It is not difficult to imagine the domino-like consequences of frequent antibiotic therapy in the elderly.

Dysbiosis Return To Balance

There are foods which encourage the proliferation of friendly bacteria, and other foods and food components which have the opposite effect, stimulating yeasts and pathogenic organisms so that they flourish. Hence you need to know which foods to avoid and which ones to consume in copious quantities in order to create bacterial harmony in your gut.

Dysbiosis Fibre

• You know fibre is good for you. All that roughage sweeps debris through your colon and keeps you regular. It does lots of good things, like removing cholesterol, old hormones and a variety of toxins, carcinogens and waste from the body.
• Fibre also provides sustenance for your friendly fauna, and a low-fibre diet encourages the proliferation of bad bacteria.
• Fibre is usually categorized as being either soluble or insoluble. High-fibre foods tend to contain a mix of both types. The insoluble type is particularly good because it favours the proliferation of friendly bacteria.

Dysbiosis Insoluble Fibre

• Insoluble fibre forms part of the plant cell wall, giving structure to plants. It is indigestible so passes unabsorbed through the body, taking toxins, carcinogens and other waste products with it.
• Insoluble fibre helps prevent constipation by keeping matter moving along, speeding up transit time, absorbing water and making stools soft and therefore comfortable to pass.
• This non-digestible fibre also appears able to exert beneficial influences on the composition and activity of gut bacteria.
• Undigested fibre is fermented by bacteria in the colon, and this fermentation produces gases (carbon dioxide, hydrogen and methane) and short-chain fatty acids, as described above.
• Good sources of insoluble fibre include:
  • Fruits
  • Vegetables, especially celery and sweetcorn
  • Beans and lentils
  • Oats
  • Whole grains, such as brown rice and wheat.

Dysbiosis Soluble Fibre: Soluble fibre can be partially digested; its beneficial properties include its ability to reduce blood cholesterol and blood pressure, help control blood sugar levels and reduce the risk of certain diseases such as diabetes and gallstones.

Good sources of soluble fibre include:

• Oats
• Beans and lentils
• Fruits – especially berries, apples, pears and citrus fruits
• Vegetables
• Barley.
  • Some fibres are partially soluble, such as oligosaccharides. An oligosaccharide is a short chain of sugar molecules (oligo means ‘few’ and saccharide means ‘sugar’).
  • Fructo-oligosaccharides are a type of oligosaccharide composed of fructose (fruit sugar) molecules and are found in bananas and other fruits, Jerusalem artichokes, onions, barley, garlic, wheat, asparagus, burdock, leeks and chicory.
  • Oligosaccharides are only partially digested, and it is the undigested portion which serves as food for friendly bacteria and stimulates their growth.
  • They have other properties, too some are potent inhibitors of bacterial adhesion – that is, they stop bad bacteria from sticking to the gut lining.
  • This action helps protect against infectious agents, including E. co//.20 Oligosaccharides can significantly change the composition of gut bacteria by favouring the proliferation of friendly bacteria without favouring bad bacteria.

Dysbiosis Sugar And Refined Carbohydrates

• Nothing is as tasty to pathogenic yeasts and other undesirable microorganisms as sugar, sugary foods and refined carbohydrates, devoid of helpful fibre. These pathogens have to eat too, and these are their preferred foods.
• Consumption of refined sugar has been implicated in many gut disorders and is associated with the development of colon cancer, gallstones and Crohn’s disease. A high-sugar diet has also been found to slow down transit time and significantly alter bacterial activity.
• Slow transit time means that undesirable bacteria have more time to flourish and more fodder on which to dine.
• The effect of sugar on microorganisms can be observed right at the beginning of the digestive tract. Sugars, including glucose and sucrose (but not the milk sugar lactose) have been found to significantly promote the adhesion of pathogenic yeasts, namely Candida, to the cells of the mouth.
• Sugary foods and refined carbohydrates should be totally excluded from the diet of anyone with gut dysbiosis. This includes fruit juices but not fruit itself, which is a fantastic source of fibre as well as nutrients which help feed the friendly bacteria.

Dysbiosis Fermented Foods

• The tradition of fermenting foods is ancient in certain parts of the world, especially Asia, Africa and Eastern Europe. Bacteria, or a mixture of bacteria and yeasts, can be employed in the fermentation process; the result is increased good bacteria content.
• Fermenting foods also extends their shelf life. Probably the best-known fermented food is live, or ‘bio’ yoghurt. Another well-known fermented product is kefir, a fermented milk drink thought to originate centuries ago in the Caucasus mountains.
• Other fermented foods include sauerkraut, cottage cheese and certain soya bean products: tofu, miso, tempeh, tamari and shoyu. Tamari and shoyu are types of soya sauces. Ternpeh is a soya bean paste fermented with a mould called Rhizopus oligos porous and used as a meat substitute.
• It has a chewy texture and can be fried, baked or steamed. Soya beans can be fermented with rice and barley to make a condiment called miso, using a fungus called Aspergillus oryzae. Miso is usually added to soups, sauces and stews.
• Tofu is soya bean curd. The beans are soaked and crushed and then heated to produce soya milk, which is then coagulated to form a curd.
• It can be added to curries and stews as a meat substitute, though it is rather bland. It does helpfully soak up other flavours, which makes it more palatable. Like meat and fish, it is a complete protein – so ideal for vegetarians and vegans.

Dysbiosis Cruciferous Vegetables

• As you may have noticed by now, these vegetables are true multi-taskers, keeping blood sugar regular, fighting cancer and balancing hormones.
• Another feather in the cruciferous cap is their ability to favour your friendly bacteria. Vegetables such as cauliflower, broccoli, sprouts and cabbage contain compounds called glucosinolates which can be fermented and used as fuel by bacteria, making them prebiotics – foods which feed benign bacteria. You couldn’t design a more human-friendly vegetable.
• Along with glucosinolates, they also contain something called sulforaphane, which in experiments has been shown to inhibit the growth of the bacterial pathogen Helicobacter pylori, which causes stomach ulcers. Indeed, it has been found that sulforaphane inhibits 23 out of 28 different types of disease-causing bacteria. So a sprout isn’t just for Christmas – it’s for as many days of the year as you can manage.

Dysbiosis Fat And Protein

• Interestingly, fat has been shown to have no effect on bacterial activity, with the exception of fish oil, which in animal studies has been shown to decrease the Bacteroides and increase the good bifidobacteria.
• Unfortunately, there have been very few studies on the effects of fat and protein on microbial activity, though one useful study compared the diets of strict vegetarians with people eating a general ‘Western’ diet and found no difference in the types of gut bacteria found in both groups, leading the researchers to conclude that dietary intake of animal fat and protein does not appear to alter gut bacteria.
• Having said that, how well you actually digest the protein you eat does appear to make a big difference. It is especially important that food is properly digested, especially protein, by the time it reaches the colon. The best way to ensure adequate digestion is to chew food thoroughly so that your digestive enzymes can get at it and do their job efficiently.
• Undigested proteins may start to ferment and this creates harmful substances such as ammonia and amines, which are associated with the growth of potentially pathogenic bacteria. Ammonia is thought to be especially toxic to the gut lining.

Probiotics Prebiotics And Anti Fungals

Probiotics are foods and supplements containing live bacteria, and prebiotics are foods and supplements containing foods which feed and encourage friendly bacteria to proliferate. Supplemental probiotics are usually sourced from the bifidobacteria or lactobacilli groups and are of human origin.

It was the aforementioned Dr Elie Metchnikoff who introduced the concept of probiotics at the beginning of the 20th century and who described the good health and longevity of Bulgarian peasants who consumed large quantities of fermented milk.

How Sir William Arbuthnot Lane, he of the famous colon-removal approach to digestive health, explained this development to his colon-less clients is not documented, as far as I am aware, even though these two eminent gentlemen were contemporaries.

• Probiotics and prebiotics are currently among the most researched natural products because they are proving to be of enormous benefit to human health.
• Indeed, use of probiotics and prebiotics is believed to play a role in the prevention and treatment of a number of diseases, including inflammatory bowel disorders, arthritis, allergy and colon cancer.
• There is substantial evidence to show that probiotics and prebiotics can protect against the production of toxins in the gut.
• Perhaps their best feature is their ability to control inflammation. Probiotics do this not only in the gut but also, via their metabolic end-products, throughout the body.
• In the gut itself, supplemental probiotics have been found to be effective in preventing and treating antibiotic-associated diarrhoea, and in suppressing overgrowth of Candida which can arise as a consequence of antibiotic therapy.
• Supplemental prebiotics have been found to increase bifidobacteria and lactobacillus whilst decreasing Bacteroides and Candida.
• Other reported benefits of prebiotics include an improvement in the absorption of minerals in the large bowel.
• We have seen how the ageing process results in a reduction in levels of friendly bacteria in the gut. Many now agree that supplementing probiotics may be beneficial for the elderly, as research suggests that probiotics may improve their immune system.
• Specifically, giving elderly people supplements of Bifidobacterium lactis has been shown to increase levels of T-lymphocytes and natural killer cells, important components of the immune system
• For this reason, it is thought that giving supplements to the elderly in care who have received broad-spectrum antibiotic treatment may be of benefit.

Survival of the Fittest

• The main challenge associated with supplemental bacteria lies in their ability to survive the hostile, highly acidic environment of the stomach so that they arrive at their final destination, the intestines. Studies have shown that not all commercial products are equal to this challenge. To have any therapeutic effect, very large numbers of probiotic bacteria are required.
• No one actually knows precisely what figure we should be aiming for, but it can be assumed that, given the low pH of the stomach and the harsh environment of the digestive tract, more really is more. Most nutritional therapists would not consider a supplement that contained less than one billion viable cells and usually look for a probiotic/prebiotic combination.
• Combining probiotics with prebiotics in supplement form can promote and enhance the survival of the former.

Anti-fungal Agents: There is a substantial number of plant and plant extracts which have been shown to have anti-fungal activity, and these can be taken in the diet, in supplement form or as a tea or drink. Antifungals commonly used by nutritional therapists include

• Caprylic acid from coconut
• Garlic and oleic acid from olive oil
• Pau d’arco (available as a tea)
• Grapefruit seed extract
• Biotin (a b vitamin)
• Aloe vera juice
• Oregano oil
• Berberine-containing plants [berberis vulgaris, berberis aquifoliwn).

Some of these substances also have anti-parasitic effects, especially berberine, garlic, grapefruit seed extract and oregano. Other anti-parasitic agents include black walnut and wormwood.

Dysbiosis Testing

How do you know whether or not you have dysbiosis, and if so whether or not you additionally harbour a yeast overgrowth or even a parasitic infection? How do you tell the difference? This is a particularly tricky question, as symptoms are mainly non-specific. Perhaps you’d rather not know, which is fine because the diet you need to follow is the same regardless of what form of dysbiosis your guts have succumbed to.

Some people just like to know their nemesis (lots of people, I find). If you are one of those people, there is only one way a home stool test. Before you gag, rest assured that this does not involve tipping a turd into a jiffy bag and then slipping out under cover of darkness to post it. It’s much more dignified and hygienic, I’m happy to confirm.

• Before I explain, let me first say that unfortunately, the best, most accurate tests are simply not available on the NHS. NHS tests are not sensitive enough to detect microorganisms such as Blastocystis hominis, nor to examine the ratio of friendly to unfriendly bacteria.
• If you really want to know quite specifically what sort of microflora you possess, or whether or not you have parasites or a yeast infection, I recommend a comprehensive parasitology stool analysis.
• This is a gem of a test as it takes all the guesswork out of identifying intestinal offenders. The comprehensive parasitology detects all the usual suspects, as well as some of the lesser spotted microbes, including Blastocystis hominis (without doubt the most frequently observed faecal parasite), Cryptosporidium, various amoebae, flagellates and just about anything that has no right to be living off your metabolic processes.
• The test involves three test tubes containing a formaldehyde solution. All you do is take a very small stool extract with the little spade provided, put it in the test tube, screw the top on and give it a good shake.
• Then you put the test tubes in the prepaid, prelabelled bag marked ‘my stool sample’ (only kidding it says no such thing) and put it in the post.

What Should You Do The Dysbiosis

Here is a step-by-step guide to reversing dysbiosis and its attendant overgrowths of pathogenic microorganisms. You need to eliminate the possibility that you have an inflammatory bowel disorder, cancer or any other serious gastrointestinal disorder. Your GP may decide to run tests such as those described above. He or she may even decide to test you for giardiasis, one of the few parasitic infections for which NHS testing is available.

If no medical diagnosis is forthcoming, you might want to consider the possibility that you have dysbiosis. If you feel you would like to test for this, see the Resources chapter. However, bear in mind that if you do indeed have dysbiosis, coupled with a parasitic infection, you should not attempt to tackle this without professional help.

From the list of anti-parasitic agents, you can see that there are many plant extracts which can be deployed.

• Some of these are very powerful and you need to know what you are doing to get the correct dosage with the desired effect without side effects. I advise you to consult either a nutritional therapist experienced in dealing with parasites or a medical herbalist with similar experience.
• If testing reveals you have a yeast overgrowth, such as Candida albicans, follow the diet advice below. I have seen many clients who, upon testing, find they do indeed have a yeast infection.
• However, a surprising number of people merely have dysbiosis without yeast overgrowth. Candida albicans overgrowth has been the diagnosis of far too many complementary therapists when dealing with just about any symptom, ranging from depression to diarrhoea.
• The traditional ‘anti-candida’ diet, so readily prescribed by so many complementary therapists, is severely restrictive and involves not only eliminating all refined carbohydrates and sugar, which is fair enough, but also fruit (because it contains fruit sugar so must be bad), mushrooms (because surely mushroom equals fungus equals bad) and fermented foods (because fermentation must be bad, too, as it suggests bacterial and yeast activity).
• Bread, tinned foods and many others are also prohibited. Despite there being no evidence to support this hairshirt regime, people frequently do embark upon it and end up feeling wretched when they fail to persevere for the prescribed number of weeks or months.

A few years ago I saw a client who came to me with what she believed to be recurrent thrush. She had been on the anti-candida diet for two years, on the advice of her reflexologist. To her credit, and my amazement, she had followed it strictly for that time, but she was miserable. In tears, she told me she couldn’t stand it any longer, especially as she still had thrush anyway.

• I thought it highly unlikely that any yeast, after two years of starvation, would have any hope of survival in any part of her body and advised that she see her GP for a test for something else – vaginosis. She did, and tested positive for Gardnerella vaginalis, not Candida.
• Gardnerella, a bacterium, is a prime cause of vaginosis, a condition which causes symptoms similar to thrush but is not the same thing. Untreated, vaginosis can lead to complications in pregnancy and may increase your risk of developing pelvic inflammatory disease.
• I must confess that in my early, evangelical days I too preached the doctrine of forbidden fruits (and the rest) with regard to Candida albicans until I realized the non-necessity and impossibility of such a restrictive, punishing approach. Now I find that by making more moderate dietary alterations, pathogenic yeasts and other undesirable microorganisms retreat into harmlessness.
• Only occasionally is it necessary to resort to powerful antifungals. So if your test results suggest yeast overgrowth, or you suspect as much, consider the following dietary advice first. After a couple of weeks introduce probiotics (supplemented with prebiotics).
• You could also add gentle antifungals such as aloe vera juice and pau d’arco tea, both available from any health food shop. If this fails it is time to call in the professionals – but I suspect that in many cases this won’t be necessary.
• If testing indicates dysbiosis without Candida or parasites, simply follow the advice below. If you do not undergo testing but suspect dysbiosis, this programme should also prove to be well worth a try.

Diet For Dysbiosis

• Eat lots of
  • Garlic, raw wherever possible
  • Olive oil – on everything
  • Vegetables – as many and as varied as possible
  • Cruciferous vegetables: sprouts, cabbage, kale, broccoli, cauliflower
  • Fruit – all that FOS
  • FOS-rich vegetables
  • All beans and lentils
  • Oats
  • Nuts and seeds
  • Live natural yoghurt
  • Tofu, tempeh and other fermented foods
  • Fish, especially oily fish
• Avoid
  • Sugar
  • Anything with sugar added
  • Anything refined: white rice, pasta, pastry, etc.
  • Savoury snacks such as crisps, biscuits, etc.
  • High-glycaemic index foods
• Restrict or avoid
  • Alcohol
  • Avoid beer completely
• Neutral foods
  • Meat (buy organic to avoid those antibiotics)
  • Dairy (again, organic is better)
  • Eggs
  • White fish, shellfish

As you can see, this regime is not really too onerous. The ‘eat lots of column is pretty generous compared to the others. If you are making massive dietary changes, expect those to be reflected in your wind-breaking habits. Initially, expect to be unsociable as your gut adjusts to the changes in microbial activity. Once you adjust to all this fibre and goodness, so too will your overexcited friendly bacteria and the windiness will calm down.

Dysbiosis Germ Theories

Most people are now aware of the perils of indiscriminate antibiotic use. Antibiotics carpet-bomb the gut, destroying good and bad bacteria alike and with no preference for either. It is not difficult to imagine the consequences to your health of destroying those bacteria which are not just ‘friendly’ but which are an essential component of immunity against disease.

• Antibiotics provide an opportunity for bacteria to mutate into bigger, stronger versions of themselves, requiring bigger, stronger antibiotics to wipe them out. This procedure has given rise to the aptly termed ‘superbug’ – antibiotic-resistant bacteria such as MRSA. Bugs such as MRSA (methicillin-resistant S. aureus) didn’t just arise naturally, or by chance we bred them.
• We’ve got ourselves into a right mess now. In order to contain the spread of superbugs, we have to use antibacterial sprays, wipes and other paraphernalia, which can only lead to further mutations of these bacteria, thereby reducing our resistance to antibiotic-resistant superbugs such as MRSA.
• Superbugs lead to superinfections. More scrupulous hygiene in hospitals has led to a decline in the incidence of MRSA infection, but other bacteria are flourishing, having outwitted their antibiotic nemeses.
• Shigella is showing increasing resistance, as is Streptococcus pneumoniae, enterococcus, klebsiella, Citrobacter freundii, M. tuberculosis, salmonella and Helicobacter pylori. According to the UK Health Protection Agency, antibiotic use is a major contributor to the development of gastrointestinal disease, with the bacterium Clostridium difficile now commonly contracted in hospitals. Bacterial infections can spread like wildfire with globalization of our lifestyles has come globalization of disease.

Another major factor in the creation of superbugs is the overuse of antibiotics on intensively reared livestock – farming has been implicated in the rise of both MRSA and E. coli.A0 The total volume of antibiotics used in the UK for farming purposes, in 2007, was 387 tonnes.

• According to the Government’s Chief Medical Officer, every time an antibiotic is used it becomes less effective in the population as a whole, and every unnecessary use of antibiotics in animals or agriculture ‘is potentially signing a death warrant for a future patient’.
• It may be essential to use antibacterial products in hospitals and other environments where there are vulnerable and sick people at risk of infection, but what I find disturbing is the creeping insinuation from advertising that danger from germs lurks everywhere in our homes.

Healthy people living in healthy environments do not need to sterilize every inch of their homes, despite cynical suggestions to the contrary.

• The fact is it is futile to regard all bacteria as the enemy. There are some extremely dangerous, life-threatening bugs out there, and that is when antibiotics really come into their own. Certain conditions such as meningitis, pneumonia and septicaemia can be deadly without them.
• We can win certain battles, but the war is unwinnable: bacteria were here long before we were, and will still be here long after we are gone.
• Indeed, they are our oldest ancestors, the first form of life that appeared about 4 billion years ago. They still rule the Earth.
• They are present everywhere on the planet and in the Earth’s crust. They don’t even mind living on radioactive waste, so human skin poses no challenge whatsoever to their omnipresence.
• Skin is swarming with bacteria, and that’s the way it’s meant to be. There are on average one million bacteria on every square inch. Also present on our skin is sweat. Sweat contains a protein called cathelicidin, a natural antibiotic.
• It has potent anti-microbial activity and provides a barrier for protection against infection from pathogenic bacteria.
• This has been described by researchers as an ‘ancient and efficient innate defence mechanism’, which explains why skin infections are relatively rare considering our constant exposure to external pathogens.
• Those of us who see no need for antibacterial hand washes, sprays and so on are not dying in droves.
  We’ve got ourselves stuck in a loop and it’s hard to see a way out.
• An exit strategy does exist, however, even though it is yet to form part of any public health pronouncement accept that bacteria control us, despite our efforts to control them, and build up your immunity by looking after your invisible friends. Learn to love the life within.

Dysbiosis Case History

Maggie was 33 years old, with a stressful job in publishing, coping with constipation, digestive discomfort (she could only manage very small meals), very low energy all the time, headaches, mild depression and recurrent thrush. She had seen her doctor frequently and was apparently quite healthy. Her diet wasn’t too bad at all there was salad arid other green vegetables, but Maggie had a sweet tooth and was fond of sweetened yoghurts and refined carbohydrates such as pasta and pizza.

• She also rather liked white wine and drank regularly. Most worrying, though, was her antibiotic history: like so many people I see, she had a history of regular antibiotic intake, in her case because of recurrent cystitis.
• For over ten years she had taken around three courses a year (which is nothing, compared to some people I’ve seen). I suggested a comprehensive parasitology test, but somehow we never got around to doing one. It wasn’t really necessary, as it turned out. I was quite confident that underlying all her problems was a state of gut dysbiosis, quite probably with yeast overgrowth.
• I recommended cutting all sweet foods and most carbohydrates from her diet, other than porridge and, of course, fruit and vegetables. I developed a plan which was packed with plant foods high in fibre, including beans and lentils. Out went the alcohol as well.
• I recommended a good basic multivitamin and -mineral and extra vitamin C to help strengthen Maggie’s immune system. I also recommended a hefty dose of probiotics (combining both lactic acid bacteria, Bifidobacteria and fructooligosaccharides).
• I saw Maggie three weeks later. She had stuck to the diet regime and was eating lots of live yoghurt with fresh fruit, lentils, chickpeas and other beans, green salads and other vegetables, nuts and oily fish. Her constipation and digestive discomfort (mainly flatulence and bloating) had completely gone, as had her regular headaches. Her energy levels had improved but were still not ideal, and she reported feeling ‘stronger’ and her depression had improved, although not vanished.
• I decided that Maggie’s dysbiosis was probably quite severe and that extra help was needed, so this time kept her diet the same but added in a few extra anti-fungal supplements – oregano oil and caprylic acid. She was to stay on the probiotics.
• The third and final time I saw Maggie was four weeks later. With regard to her digestion, she said the changes were ‘phenomenal’. In addition, her energy was now really good and her mild depression had lifted. In my notes I recorded that Maggie had commented that she ‘felt like a normal human being’. Naturally, I was as delighted as she was.
• I advised that she stay on her new dietary regime as much as possible but not to worry about the occasional blip, as I felt her immune system would now be able to cope. I also felt that occasional social drinking would do no harm, and suggested she stick with red wine. I’m glad to say, in the nicest possible way, that I never saw Maggie again.

Dysbiosis Further Investigations

If this chapter resonates with you, I strongly advise you to read the Solution 8 chapter straight away. Dysbiosis and leaky gut frequently (though not always) go hand in hand, and in order to have a healthy gut you may need to deal with both issues.