Today’s podcast topic: taking all your questions about probiotics 101, and prebiotics! What are they, what do they do, who might need them, how do you know what kinds, how much, and how often you might want to take them, refrigerated vs. shelf-stable, ALL THE THINGS. 

First thing to note – research is constantly developing in this area, and there are new studies coming out every month on probiotics, prebiotics, and synbiotics. 

ALSO. Before we get started: A general PSA on supplements. The majority of them are not regulated by the FDA. In the U.S., the FDA can regulate probiotics either as a food ingredient, as a supplement, or even as a drug. Most are sold as dietary supplements, which means they don’t require FDA approval before they are marketed. look for a 3rd party independent lab tested for quality, potency, purity – so you can make sure you’re getting what’s advertised on the bottle. I use sites like labdoor.com and fullscript that do their own testing. Do your research (and double check mine!) 

Last thing – before we even get into probiotics today, we need to understand why they’re important in the first place. Our bodies are made up of about ten trillion cells. Your microbiome includes bacteria, viruses, and fungi that live inside and outside our bodies…and our microbiome cells outnumber human cells by a factor of 10. So we’re more bacteria than we are human. Kind of gross, but definitely really enlightening when it comes to what we should be focusing on when we develop health issues. The microbiome is not only responsible for whether we get sick or not, how our digestion is working, but can also affect our mental abilities and tendencies (ex. Towards anxiety or depression), our cognitive function, food cravings, how we break down and tolerate certain foods, etc. It’s a lot. And this is exactly why we need to be talking about probiotics – because we’re more bacterial than human, and sometimes, we need more of certain kinds of bacteria to help balance things out.

What are probiotics?

As defined by the World Health Organization, probiotics are “Live microorganisms that when administered in adequate amounts confer a health benefit on the host”. (Source) 

• In order to be effective in providing some of the health benefits listed above, probiotics should:
  • Survive passage through the stomach and small intestine to reach the large intestine
  • Produce short chain fatty acids from dietary fiber
  • Maintain colonic pH at about 6 (aka when they get to and pass through your colon, or large intestine)
  • Prevent adherence of pathogens to the small intestine and colonic mucosa
  • Adhere to human colonocytes and enterocytes and help repopulate or recolonize them

WHO MAY NEED PROBIOTICS?

There are thousands of studies documenting the benefits of probiotics, including skin health, gut health, metabolic and cardiovascular health, women’s health, performance and muscle recovery, brain health, basically whole body health. Some of the main benefits include helping modulate the immune system and keeping pathogenic organisms in check. 

So who may need probiotics? Anyone dealing with, or having a history of: 

• Mood disorders, ADHD, depression (gut-brain connection, 90% of serotonin in gut)
• Atopic conditions – food allergies, allergies, eczema, asthma
• Digestive issues – constipation, diarrhea, belching, has, bloating, coated tongue, chronic inflammation, IBD, IBS, diverticulosis
• Increased need for probiotics in pregnancy
• Chronic infections (digestive, vaginal), travel outside US
• Autoimmune disease
• Food cravings, binge eating, standard american diet
• Frequent antibiotics use, history of cesarian section, use of formula as a child
• Dietary – undercooked meats exposure, excess sugar, inadequate fiber in the diet
• No gallbladder, low HCL, lactose intolerance 

What are prebiotics?

As defined by the WHO, a prebiotic is “a substrate that is selectively utilized by host microorganisms conferring a health benefit.” (Source) In layman’s terms, that means food for your gut bacteria that are IN the gut already – unlike probiotics, which is introducing other types of bacterial strains into the gut. Prebiotics are most commonly non-digestible fibers (because your gut microbiome is mainly in your intestines – so you want those fibers to be able to pass through the acidic stomach environment to get to the good gut bugs in the small intestine to feed them!) 

The most common types of prebiotic foods are: Fibers, and ones that are hard to break down for the body, like:

• Green Bananas (and green banana flour)
• Green plantains 
• Cassava or Yucca
• Jimaca 
• Cooked and cooled potatoes (that develop more resistant starch as they are cooled in the refrigerator)
• White rice, cooked and cooled
• Onions and leeks
• Garlic
• Asparagus
• Apples
• Flaxseeds
• And some obscure ones like Jerusalem artichokes and Chicory root
• (note: this is not an exhaustive list!)

The most common types of prebiotic supplements are: 

• Fructooligosaccharides (FOS) – the F in FODMAP
• Inulin
• Galactooligosaccharides (GOS)
• Pattially hydrolyzed guar gum (PHGG)

Questions: Probiotics.

The answer to many, if not all of these questions are 1) IT DEPENDS 2) work with a qualified healthcare provider to determine what is right for YOU and your unique health condition and circumstances. Remember I am providing GENERAL information here which should not be taken as a substitute for advice, diagnosis, or treatment by YOUR healthcare professional.

How do you know what probiotics you need, if anything? How much should you be taking?

• • • IT DEPENDS. When looking at studies, you can see therapeutic benefit (depending on the health condition) of anywhere from 2 billion CFU’s to 3.6 trillion at very high doses of VSL-3, which is an extremely high potency probiotic medical food. More does not necessary equal better in probiotic dosing. 
    • In a generally healthy person, you might want to start between 10-30 billion CFU’s daily, testing for your individual tolerance. 
• What are the different kinds of probiotics? 
  • • When you see a probiotic listed a label, it should have three different “names.” These include the genus, species, and strain of the probiotic.
      • Lactobacillus rhamnosis GG →  can help in preventing antibiotic-associated diarrhea, C.difficile treatment, and promoting intestinal barrier function. BUT lactobacillus acidophilus strains are completely different, and the various strains of lactobacillus rhamnosis  are completely different than GG as well.

• Should you start with a full dose or work your way up? 
  • For most people, you should work your way up to the dose your healthcare practitioner recommends.

• What do you do if you can’t handle taking them? (eg. stomach pain, disaster pants, etc.)
  • A note about probiotic foods & supplements: if they make you feel worse every time you eat them, this might be an indicator that there is something else going on. 
  • Raja Dhir, one of the founders of Seed Health, stated on Chris Kresser’s podcast: “just because something feels like it’s not tolerable doesn’t mean that it’s not good for you or doesn’t mean that it’s bad for you,” when talking about probiotics.
• Can you over-do it on pre and probiotics? YOU WILL KNOW. Your digestion will most likely tell you.
• HOW DO I KNOW IF I AM BENEFITING? Look at your current health complaints. Are they getting better within a couple weeks? Gut health, bowel habits, acne or skin conditions, etc.

Let’s talk about Antibiotics and Probiotics. Should you take them together? Should you take probiotics after antibiotics to help repopulate the microbiome?

• The answer used to be a resounding YES. There is a lot of research on specific strands of probiotics (like saccharomyces boulardii,  lactobacillus rhamnosis GG, and Visibiome) as being extremely effective in preventing antibiotic-induced diarrhea and preventing patients who went on antibiotics from an overgrowth of yeast like candida or other opportunistic pathogens (yikes! Bad bugs!) colonizing the gut following a round of antibiotics. HOWEVER.
• Chris Kresser went into great detail on a podcast on a meta analysis (research study) that came out last year talking about how taking probiotics following a course of antibiotics (specifically, two broad-spectrum antibiotics that are commonly prescribed for the treatment of parasites are that are known to completely carpet bomb your gut microbiome) may actually DELAY the recovery of the microbiome, not enhance it, when compared to a control group that took the antibiotics but not the probiotics following the ABX.  BUT. there are a lot of holes in this study – for one, it hasn’t been replicated yet. We also don’t know what the findings would be with different antibiotics, with a different probiotic combination, etc. so we can’t say for sure just based on this study that taking probiotics following antibiotics isn’t helpful at all for the microbiome. It just means we need more research. 
• Post-surgery/antibiotics/gut issues – Include probiotic-rich foods: kombucha, sauerkraut, kimchi, fermented vegetables, pickles (refrigerated) – to help re-build the good gut bacteria after taking antibiotics.

Refrigerated or shelf-stable? Are the ones that are refrigerated always better than shelf-stable? 

• Soil-based probiotics are generally shelf-stable and strong enough to pass through the stomach to the small intestine without being damaged.
• There are certain, non-soil-based probiotics at extremely high potencies that need to be refrigerated to maintain that potency. Refrigeration can definitely extend shelf life, so if you have one bottle for a couple months, you may want to refrigerate it. Other raw probiotic cultures (like those from Garden of Life) advertize that they must be kept refrigerated to ensure potency. That way, the company says they can guarantee that the potency is the same from the moment it is packaged to the moment it hits your tongue. But my question is – what happens after that? Does it actually survive the stomach? I’m honestly still looking for a solid, resounding yes or no answer for non-soil-based probiotics. 
• According to the Cleveland Clinic, there are specific strands of probiotics that are very fragile and should be refrigerated because they are sensitive to light, heat, moisture, and oxygen – which could all damage their viability before they even get to the small itnestine. These include: “Lactobacillus acidophilus, [lactobacillus] casei, Bifidobacterium bifidum, [Bifidobacterium] adolescentis, [Bifidobacterium] breve, [Bifidobacterium] longum and Saccharomyces boulardii…These probiotic bacteria strains need to be refrigerated so that they remain viable until they are consumed and the person derives full benefit.” So always check your labels to see if your probiotics need to be refrigerated.
• BUT. Refrigerated does not necessarily mean better. Dr. Vincent Pedre, gut health specialist and the author of “Happy Gut”, explained in an interview with Crohns.com that “probiotic supplements are tested to ensure they maintain potency through their expiration date, regardless if they’re shelf-stable or meant to be refrigerated. In other words, a probiotic billed as containing 50 billion CFU (colony-forming units) might leave the factory with 200 billion CFUs, some of which are expected to die off over time.” Refrigeration may slow down the loss of live, active cultures in probiotic supplements, but shelf-stable probiotics should have enough cultures to stay fresh until at least the expiration date on the bottle. (Source)
• Krishnan actually argues that probiotics requiring refrigeration may actually be less effective. (Source) I’ve also heard this from a few other sources (including Just Thrive Health, the sponsor for today’s podcast), saying that if the cultures can’t survive at room temperature in a grocery store, how are they going to survive the 98.6 degree internal temperature of our bodies, and a pH of 1.3 in the stomach? I, for one, would love to see more research on this. 
• What about soil vs. spore-based probiotics? Spore-forming or ground-based probiotics may be more effective than others because the endospores that encapsulate, or protect, the strains are highly resistant to the pH of stomach acid, which may result in a higher delivery output of probiotics to the small intestine. Again, more research to be done here too! 

Are enteric-coated probiotics necessary?

• Some products have an enteric coating, because certain probiotic bacteria need protection in order to survive exposure to stomach acid and other fluids. According to The American Nutrition Association: “In general, Lactobacillus, Bifidobacterium, and Streptococcus species do not need enteric coating as they can survive passage through the stomach. However, L. bulgaricus and S. thermophilus, as well as Leuconostoc and Lactococcus species, cannot survive passage through the stomach. These bacteria are commonly found in yogurt because they are used as starters for dairy products. However, they do not colonize the intestinal tract; so they are likely to have little effect as probiotics. Some bacteria naturally sporulate (“hibernate” within a protective coating) when they are exposed to harsh conditions, and some researchers postulate that sporulated bacteria are more resistant to the harsh conditions found in the intestinal tract. Consequently, another delivery method is to manufacture probiotics in the form of bacterial spores — this is most often used for bacteria of the genus Bacillus.” (Source)
• Probiotic supplements vs. probiotic foods? Fermented foods?
  • Is getting it from food enough? YES except with certain health conditions or times in your life when your gut needs a little more help.
  • “Probiotic foods” – processed foods. Can the probiotics even survive in processing? # of probiotics at the start of processing, but what about at the end? Supplements – expensive pee. Probiotic processed foods – expensive processed food.

How to find research supporting probiotics targeted towards certain conditions? How to find reliable info on what kinds of probiotics to take for anxiety?

• • Pubmed, meta-analysis, not single studies
  • Specialist that focuses on gut health and anxiety (which really, if they’re a nutrition practitioner that specializes in anxiety, they should be a specialist in gut health too because there is such a huge connection between the two!)

Additional Resources on Probiotics 101:

• “Probiotics: Reiterating What They Are and What They Are Not,” published in Frontiers in Microbiology
• “RHR: What the Latest Research Says about Probiotics—with Lucy Mailing,” by Chris Kresser
• Why Probiotic Strains are Important and The Best Probiotic Strains on the Market – from KelseyKinney.com.
• The American Nutrition Association

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