Dr Frassetto: Unique Opportunity to Drive Paleo Diet Study v. ADA Whole Wheat/Gluten 'Healthy Diet' for PCOS

Crowd-Sourced n=4

Thank you all Gentle Readers for participating earlier in one of the first gut microbiome QS study when I posted on Crowd-Sourced N=4: A Family Science Project of Resistant Starch on Gut Biome

Allan and his family reported their self monitored blood glucoses here. AmGut results soon as it takes about half a year.




UCSF Paleo Diet v ADA Whole Wheat Healthy Diet for PCOS

At UCSF Dr Lynda Frassetto et al are requesting help to prove the value and merit of the paleo diet for insulin resistant states such as PCOS. She is working collaboratively with other researchers to obtain funding for the next landmark study. What they collect via Crowdfund can be retained even if they do not reach the $40,000 goal. Dr Frassetto and I believe the paleo diet offers many hormonal and cognitive/behavioral benefits for those with insulin resistant states. I've spoken with Dr Frassetto to promote the diet at an EBT conference for emotional behavior therapy (Wired for Joy) because their participants see great mental and brain changes that complement the program.

What is needed is well designed and articulated studies like her earlier, seminal Paleo study that showed dramatic normalization of blood pressures in pre-hypertensive adults. This was not a low carb study but a basic, no grains, no legumes, no dairy paleo diet including some tubers (carrots, yams, etc). Her goal is to prove health benefits again for a group of patients that have few medical options (metformin, starvation weight loss diets, IVF, fertility treatment, etc). As you are aware in the paleosphere, many cases of spontaneous fertility and resolution of PCOS are commonplace.

A few days ago, they opened their UCSF-Crowdfund account and received $2855 already. Government funding has become scarcer of late. Many of the medical personnel for this study are in fact all volunteering their time according to Dr Frassetto. Unlike the prior study, outpatient food is not provided. Nutri Sci students (like I used to be LOL) from UC Berkeley will be volunteering to counsel diet information to trial participants. Costs for Free-testosterone, insulin, and other lab hormone measurements will be covered by funds collected.

Polycystic ovary syndrome (PCOS) is a syndrome which includes elevated androgen levels, irregular menstrual cycles and insulin resistance. Standard treatments, which include weight loss and medications to improve insulin secretion are only partly successful, and may require that young women take medications for decades.
The study investigators have been evaluating the effects of specific diets on insulin resistance in healthy volunteers and subjects with type 2 diabetes, and have found that subjects with insulin resistance seem to respond particularly well to these diet regimens.
Volunteers with PCOS are being asked to participate to see if following these diets can help regularize your menstrual cycles. The results of this study may help improve fertility treatments for women with PCOS.

An incentive from UCSF has thrown in:

Special early-bird incentive: Meet us at the Ancestral Health Symposium

Dr. Lynda Frassetto and Dr. Ashley Mason will be attending the Ancestral Health Symposium in Berkeley, CA August 7-9. We'd be happy to meet with you and talk about the study -- or if you donate at the $250 level, we'll take you to lunch and talk about anything you want!

Project Details ~~  http://clinicaltrials.gov/ct2/show/NCT02190097

How we'll spend the money

All $40,000 will go to costs for the study – the study personnel are all volunteering their time! Here's our approximate budget:

$20,000: Laboratory tests of insulin resistance and other biological outcomes.
$12,000: Research supplies and lab space.
$4000: Payments to participants for providing questionnaires, urine and blood samples, and uterine images.
$4000: Tracking and staying in touch with participants, data entry and administrative support.

Stephan G. at Whole Health also shares his thoughts: HERE

Thank you for your support!

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Legumes and Potatoes are Certainly P-A-L-E-O

Tubers are as Ancient as Bipedalism

The Paleolithic Age started ~2.6 mya and extended to only 12,000 years ago. The last Homo neanderthalensis existed up to ~25,000 years ago, and in fact their DNA exists in nearly all of us. One of our ancient human ancestors, Australopithecine boisei (formerly known as Paranthropus boisei), did not eat the stiff and hard textured nuts that their tough jaws and mean bite alluded to, but instead appeared to consume a diet rich in soft sedge tubers (including tigernuts) that grew buried in the soft land near waterways and shorelines. He had nickname, Nutcracker man. And lived with great longevity from 2.4 mya to 1.4 mya, impressively longer (that I'm aware of) than any other hominin ancestor that humans have had. Nutcracker man indeed started our human evolution with increasingly larger brain sizes during his 1 million year reign and likely planted the seeds for yet even larger brain sizes in 'subsequent prototypes' in Homo.

The moors, peatlands, and marshlands of Scotland and northern Europe were very similiar to the Paleo 'nutriscape' and terrain during the transition from Ice Ages to mega C4 sedge and grasslands. I suspect our ancestors consumed a pretty heady diet of plant fiber and starch because sedge tubers/corms/rhizomes (including tiger nuts), cattail bulbs, water chestnuts, wild carrots, yams, and other starchy roots were common underground storage organs (USOs).  Tubers like tigernuts and other underground sedge roots had a different, more evolved form of photosynthesis that required less molecules of water and selected during the shift in weather from moist and aquatic to dry grasslands. The final electron donor switched from water which had become intermittently scarce to sugar/starch molecules. During intermittent freezing and warm periods, sugar and starch additionally served another role as a buffer from cold trauma and frost.

Tigernuts and sedges were offspring of the new C4 photosynthetic plants and grew plentifully. Papyrus is also an example of a sedge. C4 plants and roots produced a radiation signal that was found in great amounts in C13/C14 isotope density studies from enamel and Nutcracker remains from 1-2 mya. Being sweet, starchy and high in protein, it was no wonder that our ancient ancestor found sedge tubers and tigernuts so delightful to exploit.

In the Paleolithic Age, both Homo and Australopithecine fed themselves well enough to not only survive the Ice Ages, predators, pathogens and newly discovered bipedalism, but also to grow a higher capacity cranium. One of the leading theories for this is digestible carbohydrates. Without complex carbohydrates and high fiber starches from USOs it is unlikely that fruit and honey alone would have exploded the process of encephalization. For tens of millions of years our primate cousins had failed to forge larger brains as frugivores. What changed? Researchers Brown et al reviewed the diet of our primal forefathers and noted they likely consumed "high carbohydrate sources including plants particularly those with underground storage organs (USOs) such as reed mace (Typha), common reed (Phragmites), water chestnut (Trapa natans) and yellow water lily (Nuphar lutea). USOs have repeatedly been implicated in hominin evolution and particularly encephalisation and bipedalism in the Africa [83], [72], [84]–[85] although this has been challenged [86]."

USOs provide valuable nutrients for brain fuel: zinc, magnesium, carbohydrates, sucrose, vitamin C (one serving, almost 50% of RDA), and protein. In terms of the brain-gut evolution, digging for tubers also tied our ancestors to the ground in more ways than the descent from the arboreal heavens to terra firma living and bipedalism. SBO probiotics (soil-based organisms) clung to every new bite of dirt-covered tubers. For tree hugging primates, the new terrain brought not only fresh and novel food, but also broad exposures to a whole new world of micro-organisms. Remember, diet (dirt lol) is the biggest driver of the microbiota and evolution of the gut. Transformation of gut and brain occurred simultaneously I believe. Our herbivore colon shrunk as our brains exponentially expanded... or even doubled: gut and cranium.

AG Brown et al, 2013
Site Distribution at the Edge of the Palaeolithic World: A Nutritional Niche Approach

This paper presents data from the English Channel area of Britain and Northern France on the spatial distribution of Lower to early Middle Palaeolithic pre-MIS5 interglacial sites which are used to test the contention that the pattern of the richest sites is a real archaeological distribution and not of taphonomic origin. These sites show a marked concentration in the middle-lower reaches of river valleys with most being upstream of, but close to, estimated interglacial tidal limits. A plant and animal database derived from Middle-Late Pleistocene sites in the region is used to estimate the potentially edible foods and their distribution in the typically undulating landscape of the region. This is then converted into the potential availability of macronutrients (proteins, carbohydrates, fats) and selected micronutrients. The floodplain is shown to be the optimum location in the nutritional landscape (nutriscape). In addition to both absolute and seasonal macronutrient advantages the floodplains could have provided foods rich in key micronutrients, which are linked to better health, the maintenance of fertility and minimization of infant mortality. Such places may have been seen as ‘good (or healthy) places’ explaining the high number of artefacts accumulated by repeated visitation over long periods of time and possible occupation. The distribution of these sites reflects the richest aquatic and wetland successional habitats along valley floors. Such locations would have provided foods rich in a wide range of nutrients, importantly including those in short supply at these latitudes. When combined with other benefits, the high nutrient diversity made these locations the optimal niche in northwest European mixed temperate woodland environments. It is argued here that the use of these nutritionally advantageous locations as nodal or central points facilitated a healthy variant of the Palaeolithic diet which permitted habitation at the edge of these hominins’ range.

Paleo People Loved Legumes

Neanderthals probably didn't do a fantastic job with legumes and small grain grasses because now they are extinct. It took a few dozen thousands of years...a slow demise, if that one of the reasons for their demise. During the latter portion of the Paleolithic, smarter hominids came along and figured out how to soak and cook legumes and SGGs. Food processing easily removes toxins and transforms them toxic, hard bumps of plant seeds into edible and delicious sources of starch, fiber, fat and protein.

Wrangtham et al in 'The Evolution of Hominin Diets' (2009) discusses the use of legumes in the end of Paleolithic Age, before the advent of agriculture. Plant evidence doesn't survive time well. What was unearthed was corroborated at a variety of sites widely distributed throughout Europe and Eurasia.

Legumes may be questionably Paleo® but they are unquestionably bionic for the gut microbiota and fuels the most important populations throughout the entire length of gut. The special fibers in legumes are unequaled when it comes to the combination of both RS3 and non-starch polysaccharides. Instead of raising blood sugars, legumes are low glycemic index meaning they impact insulin minimally or in fact lower it. Legumes have no dearth of clinical human trials that demonstrate its value for significantly lowering cancer, inflammation, insulin resistance, blood sugars, and gastrointestinal disorders.

Wrangtham et al in 'The Evolution of Hominin Diets' (2009)
"The richest food plant assemblage of Mousterian date, at
Kebara Cave in Israel, is dominated by a legume seeds of a
range of species, the form of some of which might suggest
collection while underripe (Lev et al., 2005). Towards the endof the Paleolithic, legume finds are scattered across Europe,
for example the pea and bitter vetch at Öküzini, Turkey; lentil
at Konispol cave, Albania; and vetches and other legumes at
Santa Maira, Alacant, Spain (Baales et al., 2002). Another
rich example of pre-agricultural legume foragers comes from
Hallam Cemi in Turkish Anatolia (Savard et al., 2006).



New Environments and New Plant
Strategies

Monocot stems and legume pods may have provided a significant mass of plant foods during the expansion into thel ower latitudes of Eurasia, where a vast array of yams and
legumes have emerged in the modern human food web as
domesticated plants. Moving further northwards still, these
kinds of resources diminish significantly, both in diversity
and in biomass availability. The quest for plant foods will
have presented an increasing challenge.
The cooler northern vegetation stands would have been
characterised by a range of open biomes including “arctic
steppe” (Cwynar and Ritchie, 1980; Zazula et al., 2003)
and closed vegetations characterised by woody dicots and
coniferous trees. Woody dicots are reasonably rich in edible
nuts, kernels, and fruits and, in certain families, edible roots
and tubers. As mentioned above, the lower the biological
productivity, the greater evolutionary pressure to protects eeds and storage organs from predation, and so it is generally
true that, especially as they move northwards, human
feeders are presented with a more complex “landscape of
toxicity” by dicots than tends to be the case with monocots,
particularly in the context of the seeds and tubers upon whicht he plant itself relies to cross the non-growing season. The  kind of transferable ecological 
knowledge that allowed feedersto move from one monocot to another in more southerly
biomes is not directly transferable to the dicots in northerly
biomes. 

Read: "Gory Details -- Here’s the poop on getting your gut microbiome analyzed"

Interesting read:

https://www.sciencenews.org/blog/gory-details/here%E2%80%99s-poop-getting-your-gut-microbiome-analyzed

"Here’s the poop on getting your gut microbiome analyzed"

I asked two different companies to analyze my gut microbiome. American Gut (left) gave nearly opposite results to those from uBiome (right) with respect to the major phyla of bacteria in a duplicate sample.

For more gut stool analysis consider the following functional medicine labs:

Stool -- Genova Diagnostics, Biohealth, Great Plains, Doctor's Data, etc
Urine -- Genova Diagnostics (ONE, Nutri Eval, Organix, etc)


The stool testing gives a partial view of what's inside that the Am Gut and uBiome lack -- protozoa, helminths, parasites, pathogenic yeasts, fungi, and the pathogenic bacterial overgrowths compared with symbiotic, beneficial commensal populations (E coli, Bifido, Enterococcus, Lacto, SBOs, etc)

Urine testing gives a partial view of what's going out of the gut


Caveat: all the current testing is imperfect including functional medicine testing, but what they can reveal are the (more stable) pathobionts and yeasts, which usually survive and thrive once colonization resistance and gut barriers are no longer functioning well or at all.  Recently 16S pyrosequencing was done as part of the Ribosomal Database Project (RDP) on a sample of healthy Korean gut microbiota. Geographical differences were seen compared to other Asian and American countries however between Korean guts, there was homology and core phylogenetic similarities.

In 8 Koreans (below), their guts were tracked monthly for 3 time points. Temporally, great shifts are notable on nearly every gut. I think it indicates clearly that our gut is like a playground. Kids, toddlers, nannies and teenagers all vie for spots and it's constantly shifting over time. Studies show even between meals, the microbiota show significant shifts. A diet protocol can shift populations in only day.

Temporal Month-to-Month Microbiota Shifts
Korean RDP, 2011
Source

AHS and Gut Microbiota Robustness, Diversity and Meandering

Robust, Meandering Gut
Source: van den Abbeele, 2013

The Ancestral Health Symposium is less than one month away, August 7 to 9th at UC Berkeley campus!

Several gut talks will be available (in addition to mine) which I am highly excited about:

The Gut; Diet, Flora, Health and Disease: Research and Recommendations
The environment of westernized societies is vastly different than that seen in non-westernized societies or during our developmental history. Differing lines of data show that exposure to dirt and bugs cause disease while other data show exposure prevents disease. How do we account for this discordance? More importantly how do we use this data to become healthier? While there is still very much we do not know about this field, this talk will attempt to critically examine trends in the data so as to extract practical applications for the attendees.
Speaker: Michael Ruscio, D.C., B.S.

Lifestyle and Autoimmune Disease: It's Still About Your Gut, but Not All About What You Eat
A variety of factors contribute to the development of autoimmune disease, among them genetics, leaky gut, and nutritional deficiencies. Although the power of therapeutic diets in the management of autoimmune disease is becoming increasingly recognized, an underemphasis on lifestyle contributors to immune dysfunction and gut health jeopardizes the efficacy of nutritional intervention. Chronic stress, inadequate sleep, inactivity and overtraining each negatively impact the health of the gut by interfering with digestion, damaging the gut barrier, or altering the gut microbiome. Understanding why and how to address lifestyle factors will enable the autoimmune disease patient to fully benefit from diet modifications.
Speaker: Sarah Ballantyne, H.B.Sc., Ph.D.

Bone Broth and Health: A Look at the Science
A South American proverb claims "Good broth will resurrect the dead." While that's clearly an exaggeration, chicken soup has enjoyed a reputation as "Jewish penicillin" and bone broths are served to convalescents all over the world. In this presentation, Dr. Daniel will review the science that supports consuming bone broth for healthy bones, joints, skin, digestion, immunity and emotional stability. She will discuss 19th and early 20th century studies on gelatin, as well as recent investigations into the "conditionally essential" amino acids proline, glycine and glutamine and "the essential sugars" N-Acetylglucosamine and N-Acetylgalactosamine. Finally, she will report on Dr. John F. Prudden's clinical trials healing osteoarthritis, rheumatoid arthritis, Crohn's, and even cancer with cartilage. In short, much science supports the ancestral wisdom of consuming bone broth.
Speaker: Kaayla Daniel, Ph.D., CCN



Cry Me a River: Robustness and Diversity in the Gut

Van den Abbeele and his colleagues in Belgium recently published on probiotics (eg microbial network units) and fiber/prebiotics. They establish that a meandering-river-like gut has optimal function because it has freedom and power to be flexible and adapt to shifting environmental factors analogous to a meandering river ecosystem. I like the vision that these researchers create. By following the energy flow of water that starts with low energy potential (like plant fiber v. pack of Oreo cookies), higher ecological niches and higher microbial diversity are created. Studies support that the higher the diversity and abundance, the more stable and robust the gut environment to changes. With less legs to stand on, the gut ecosystem collapses far more easily under small pressure or stressors. The factors they list as modern stressors include C sections, formula diet, antibiotics and high digestible, refined, Western diets. Antibiotics can originate may originate from both livestock/dairy/egg sources and healthcare.

Complex Cross-feeding in the Anti-Fragile,
Robust Ecosystem
Le Chatelier et al, 2013

In our gut different currencies exist; this works much like in a thriving village, various services and goods are exchanged depending on the talents and gifts of the inhabitants. Gut microbes exchange carbon (CO2, SCFA, lactate, etc and methane, CH4) and gasses (H2, sulfur) and extensively cross-feed each other. A healthy colon has biochemical pathways similar to a compost heap for degradation. Intimate cross-feeding of by-products of plant fiber breakdown (carbs --> shorter carbs --> oligosaccharides --> glucose, fructose, etc) feeds groups with different specialties in breaking down a broad variety of fiber. A productive community will have higher diversity and skilled enzymes for cutting a variety of plant fiber and resistant starches.

Studies are far back as ~20 yrs have shown that resistant starch is not broken down in the guts of ~25% of healthy controls (Cummings 1996; Hylla et al 1998). The same is true for inulin prebiotics. The keystone or 'star players' were extinct. How do you play if the star players are missing? Game over?

Obese rodent models have broken guts. What about RS digestion? Impaired? Quite. No weight loss was seen when obese mice models failed to ferment resistant starch (RS2) in an RS feeding study (Zhou, 2009).



Absent Allies in Obesity and Insulin Resistance

Le Chatelier et al recently reported that "Here we report the human gut microbial composition in a population sample of 123 non-obese and 169 obese Danish individuals. We find two groups of individuals that differ by the number of gut microbial genes and thus gut bacterial richness. They contain known and previously unknown bacterial species at different proportions; individuals with a low bacterial richness (23% of the population ['low gene count', LGC]) are characterized by more marked overall adiposity, insulin resistance and dyslipidaemia and a more pronounced inflammatory phenotype when compared with high bacterial richness individuals ['high gene count', HGC]. The obese individuals among the lower bacterial richness group also gain more weight over time. Only a few bacterial species are sufficient to distinguish between individuals with high and low bacterial richness, and even between lean and obese participants."

The bacteria-poor with low diversity and microbial abundance (LGC) had the following observations:

1. decreased butyrate producers: Clostridiales (Anaerotruncus colihominis, Butyrivibrio crossotus, anti-inflammatory F prausnitzii), M smithii
2. increased mucus degradation potential (more R gnavus, torques; extinct Akkermansia)
3. decreased methane and hydrogen production potential combined with higher hydrogen sulfide creation potential
4. increase in Shigella, Campylobacter, and Staph overgrowths
5. increased indicators of oxidative stress (peroxidase)
6. inflammatory phenotypes -- high leptin, low adiponectin, insulin resistance, elevated FIAF (ANGPLT4), high insulin, high BG, adiposity, high TG, low HDL, high hsCRP

In lean, bacteria-rich folks, the below following species were potently higher in abundance. These are part of the hallmark of optimal gut health, our ancestral core microbiota.
* F. prausnitzii
* Bifidobacteria
*  Lactobacillus
* Butyrovibrio
* Alistipes
* Coprococcus
* Akkermansia
* M. smithii


'Richness of human gut microbiome correlates with metabolic markers', Le Chatelier et al, 2013, PDF and REVIEW.

Species of bacteria limit weight gain 
Researchers also observed that obese people in the bacteria-deficient group gained more weight over time than individuals in the other group. In bacteria-poor individuals, eight specific species of bacteria were present in low numbers, or were even absent altogether. These species may have a protective role in preventing weight gain and in the long run their detection will open the way to the development of new probiotics that will help to combat weight gain. 

With identifying and quantifying only a few species, researchers can fingerprint and differentiate the lean versus the sick/insulin resistant individuals harboring the less robust, non-meandering gut microbiotas.

Again, show me your gut microbiota, and I'll show you missing allies.

7 Steps to a More Robust, Meandering-River Gut



Synergy

The 7 Steps works for many because it combines healthy environmental organisms (grit/SBO probiotics/plant organisms/mud/manure) with the optimal fuel for the gut microbiota...evolutionary plant fiber from ancestral tubers, whole seeds/grains, and legumes. Synbiotics are probiotics + prebiotics and our most ancestral foods combined these because before 50-70 years ago, most places in the world still did not have running water, household toilets or ubiquitous triclosan, hand sanitizers or soap! Prior to refrigeration, unspoiled food was fresh, fermented or semi-fermented.

"More recently, another plausible mechanism has surfaced in the synbiotic combination of resistant starch, Lactobacillus acidophilus and Bifidobacterium lactis [34]. These investigations identified enhanced apoptosis of carcinogen-damaged cells in rat colon by the combination treatment [34]. In contrast, the probiotics provided no protection when a low resistant starch diet was fed and the resistant starch had no protective response in the absence of the probiotic [35]. (Davis, Milner 2009)"

REBIOSIS with Probiotics: Enterococcus faecalis

Erotic Bar Chill Out Lounge

Rebiosis

In healing the gut, rebiosis needs to occur -- reintroduction of lost life to a dysbiotic terrain. Nearly all health conditions being studied are now emerging with correlations to intestinal dysbiosis. And as we know by fixing dysbiosis, we can resolve many health conditions from allergies to autism spectrum to hypertension.

The loss of our microbial 'limbs' in the gut can likely be attributed to 4 main factors:
(1) altered birth: mothers that lacked commensals, C-section birth, use of formula
(2) widespread use of antibiotics in healthcare
(3) sanitation (food, processed pickles, hands, water/soil, fecal contaminated drinking water, etc)
(4) pollution and toxins -- mercury, arsenic, xenoestrogens (do you have moobies?), etc

Enterococcus wiped out by Amoxicillin
Petersen, Round, 2014

Probiotics

From the last post, the lost of several flora strains occurs with common antibiotics such as amoxicillin, cephalexin, and ciprofloxacin. In some people these are easily replenished by consuming a fiber and RS rich diet but on a strict Paleo or VLC diet, the fuel for our probiotics are severely lacking. I think further degradation of the microbiota and health can occur. This is not measurable in modern terms unless we look to functional medicine to assess gut function using tests from Genova Diagnostics, Biohealth or Doctor's Data. Thank you to gentle readers who have sent me their results! I'll get to them and appreciate your patience.

A couple of probiotic strains, Enterococcus faecium and E. faecalis, help to fill in where antibiotic damage has occurred to the gut. In Germany, we got to try to Symbioflor (red) which contains E. faecalis. My daughter had a smidgen of eczema on a cheek after stress from finals. This probiotic helped to rebalance the gut-skin axis and helped the eczema disappear completely (and being a teen, it wasn't overnight or fast lol).

The studies for E. faecalis are great. Europe is always more progressive for this type of research and development. The studies showed clinically significant improvement across the board in immunomodulatory function in tonsillitis, upper respiratory tract infections, immune status, bronchitis, sinusitis, and irritable colon.

Source (p.164)

In short....

Re-biosis = re-establishment of healthy balance and harmony to microbial ecosystem 

--WEED

--FEED

--SEED mutualists, commensal microbial populations

WEED

--botanicals, probiotics/prebiotics

--exercise doubles butyrate

FEED

--gluten-free, dairy-free, allergen free (GMO soy, corn, egg whites, omega-6 oil) for 3-6 months

--bone broth (glycine, minerals), glutamine, poached egg yolks (vitamin A, PC, choline, folates, B12)

--glucomannan, inulin, cooked resistant starch (RS3 preferred over RS2), psyllium, pectin, etc

Fiber rich diet

Lotus root

Water chestnut

Purple potatoes

Carrots

White mountain yam (3-4 kinds in Asia)

Burdock

Konjac

Yacon

Kudzu

Yam

Purple sweet potatoes

Pumpkin

Heirloom potatoes

Whole GF grains (croix, purple/red/black/brown rice, amaranth, millet, buckwheat, sorghum, oats)

Legumes (purple speckled, red, adzuki, white, fava, pea, mung,etc)

Lentils

Heirloom maize

Seeds, nuts: lotus seed, almond, etc

Cellophane mung bean and sweet potato (jap chae) noodles and sheets

SEED

--minimally washed, trusted vegs

--Lactobacillus, SBOs—fermented items: kraut, kimchee, natto, kombucha, kefir

--probiotics

• Symbioflor (E coli Nissle + E faecalis; E faecalis)
• AOR Probiotic-3 (E faecalis, formerly known as S faecalis)