My parents ate yogurt, so as a kid I ate yogurt. It was not a favorite food but since store-bought brands included sugary fruit mixed in it was OK as an occasional snack or breakfast item. I had a friend whose parents made their own yogurt; it was plain, no fruit, and tasted pungent and twangy. I didn’t like it even though his parents told me that it was better for me than store-bought because it had more probiotics in it that helped my stomach digest food; they also said that sugar wasn’t good for me. That didn’t mean anything to me because I liked sugar and I didn’t know or care about probiotics because as a kid I could eat almost anything, and my digestion was fine.

As an adult yogurt was not a part of my regular diet. Then I went to medical school, focused on becoming a GI doctor, and learned a lot about digestion. Along the way, I also learned about the history and theory of probiotics and watched as their popularity grew as many health claims were made by various manufacturers of foods and supplements containing probiotics.

The fundamental claim is that probiotics create healthy flora (biological colonies) in the digestive system to help replace harmful microbes with useful microbes. The foundation for this claim came from the ancient Greeks and Romans who used fermentation as a process to preserve dairy foods thus resulting in cheese. Doctors in the early 1900’s based a theory that eating fermented milk would help support the growth of harmless lactic-acid bacteria (such as acidophilus) in the intestine and decrease the intestinal pH, and that this would suppress the growth of proteolytic bacteria that may result in the production of gas and or constipation.

No one wants to be gassy or experience constipation so acidophilus became a popular probiotic. Fast forward to today and the marketing message is that adding more probiotics will help restore and balance our gut flora. This is an easy concept to grasp, and thus, probiotics have continued in their popularity.

GI Doctor’s Probiotic Guidelines

As a board-certified Gastroenterologist, I believe strongly that good health starts in the gut. I have done significant research on probiotics and other products to support a healthy gut so when HCP Live posted an article stating that The American Gastroenterology Association (AGA) has released new guidelines concerning the use of probiotics I took note.

This study and article shed new light on probiotics and gut health and will certainly result in a debate. One of my clinical observations concerning probiotics is that they have not been proven to be able to withstand the environmental impact of moving through the entire GI tract and lose their effectiveness along the way.

I frequently have a conversation with my patients emphasizing that we don’t have any good data indicating that probiotics help, but, unless the patient is immunosuppressed there is likely no harm. About 10% of people on probiotics feel better which is about the same as placebo. Also, we have found patients that battle gas or bloating tend to do worse if on probiotics.

If someone wants to try a probiotic I’m ok with that but if they don’t feel it’s making a positive difference after 3-4 weeks, I don’t recommend continuing. As for in my practice, I have more confidence in other natural solutions that are effective in supporting gut health throughout the GI tract. We will discuss these and other gut health subjects in future Gut Check podcast episodes. As always, when considering taking any OTC dietary supplements, please discuss with your doctor first to determine if they are right for you

Probiotic Pros and Cons

Here are the pros and cons key points I took away from the HCP probiotic article mentioned above.

Probiotic Pros

  • To prevent C. difficile infections for both adults and children who take antibiotics, certain probiotics should be considered. These probiotics should also be used for the management of pouchitis, a complication of ulcerative colitis that has been treated surgically in the past.

Probiotic Cons

  • The AGA has released new guidelines calling for the use of certain probiotics in some circumstances while recommending against their use for other situations.
  • A team, led by Grace L. Su, MD, Division of Gastroenterology and Hepatology, University of Michigan, has released new clinical guidelines for the relationship between the use of probiotics and gastrointestinal conditions.
  • The investigators found after reviewing the literature currently available using the GRADE method that there is not enough evidence that supports the use of probiotics for the majority of digestive conditions, including Crohn’s disease, ulcerative colitis, irritable bowel syndrome (IBS), and C. difficile infections.
  • “Patients taking probiotics for Crohn’s, ulcerative colitis or IBS should consider stopping,” guideline panel chair Su said in a statement. “The supplements can be costly and there isn’t enough evidence to prove a benefit or confirm lack of harm. Talk with your doctor.”
  • The investigators also recommend against the use of probiotics for acute infectious gastroenteritis in pediatric patients.
  • “While our guideline does highlight a few use cases for probiotics, it, more importantly, underscores that the public’s assumptions about the benefits of probiotics are not well-founded and that there is also a major variation in results based on the formulation of the probiotic product,” Su said.
  • The new AGA guidelines represent the first set of clinical guidelines that focus on probiotics across multiple gastrointestinal diseases, while also focusing on the effect of each single-strain or multi-strain formulation of probiotics independently, rather than grouping them all as “probiotics.”
  • The guideline panel chair recommends well-designed clinical trials to refine the new AGA recommendations on probiotics while investigating other clinical conditions relevant to gastroenterology.
  • In recent months, the AGA has updated several different clinical guidelines in the wake of the coronavirus disease 2019 (COVID-19) pandemic, including new guidelines for ulcerative colitis, IBD, gastrointestinal and liver manifestations, and for gastroenterologists in general for dealing with new safety protocols during the pandemic.

Summary

I have met with many experts in the field of microbiology and using probiotics to improve our health. The underlying tone is that probiotics do amazing things in the lab and in petri dishes, the hard part if getting those same results to happen in a person. Our bodies are built to defend ourselves from the outside world, and this includes killing billions of bacteria daily that we are exposed to. When you take in probiotics, there is no guarantee that those ‘good’ bacteria will reach your colon where your microbiome lives. There have been some recent studies that probiotics can even make certain problems like bacterial overgrowth (SIBO) worse.

What I tell all my patients is that if you are taking a probiotic and you feel it is helping, great keep taking it. If you have been trying probiotics and not noticing a difference, it is ok to stop and consider different ways to help your microbiome. I personally prefer a spore-based probiotic because of the data that shows it has a higher chance of surviving to reach the colon. I also prefer taking in fermented foods like kimchi, or sauerkraut where the bacteria are protected by a polyphenol shield to help the survival of the live active bacteria.

The most important thing you can do for your microbiome is helping them stay diverse and healthy, and the best way always comes down to lifestyle and diet. Treat your microbiome right and it will treat you right.