Answers on Probiotics, Probiotic Research, Anemia, and Rheumatoid Arthritis

Listener questions – probiotics, probiotic research, anemia, and rheumatoid arthritis.

Today we will cover listener questions, including…

• Sun Exposure
• Probiotics and long-term antibiotics
• What probiotics to take for rheumatoid arthritis
• Probiotic research
• Anemia

Episode Intro

Dr. Michael Ruscio, DC: Hey, everyone. Welcome to Dr. Ruscio, DC Radio. This is Dr. Ruscio, DC here with Erin. We are going to be doing another episode of listener questions. Hey, Erin. Ready to jump in?

Erin Ryan: Yeah, I’m ready. Today, we have a couple of questions about probiotics, so we’ll get to dig in there, which I think will be good for the audience.

[Continue reading below]

In this episode…

Episode Intro … 00:00:40
Is Seasonal Sun Exposure Enough? … 00:00:59
Probiotics Use with Long-term Antibiotics … 00:04:29
Research on Probiotics, Brain Fog … 00:08:57
Further Analysis of Probiotics Study … 00:15:32
Migraines & Gut-Brain Axis … 00:21:58
Gut Health & Anemia? … 00:25:38
Best Probiotic for Rheumatoid Arthritis? … 00:29:33
Has Dysbiosis But Can’t Drink Much Liquid … 00:32:58
Will FMT Work for Food Allergies? … 00:37:26
Understanding Evidence in Context … 00:38:40
Episode Wrap-up … 00:46:13

Is Seasonal Sun Exposure Enough?

This first one is about sun exposure though. Christie  from Canada wants to know:

“Regarding regular sun exposure, have you come across any research on whether it is still beneficial if it’s only seasonal exposure? Us Canadians only get a four to six-month window to have regular sun exposure, then it’s indoors for six to eight months again. Is regular exposure during the spring and summer still beneficial?“

DrMR:   This is a great question. Short answer is, I don’t know. Part of the reason for that is that would require another level of depth of analyzing the research studies that have shown that consistent sun exposure provides health benefit, whereas intermittent or only occasional sun exposure does not pose a health benefit and may even cause harm. As some estimates have found, sun avoidance is as dangerous as smoking.

Now, the bigger question that I need to probe into and see is, are constant exposure groups only those who live in areas where there is year-round exposure? My assumption is probably not. Knowing that so much of research in universities tends to cluster into northern or southern latitude climates that have seasons, my assumption—and this is just an assumption—is that most of the universities doing most of the research where most of these things are being studied and tracked are not in places where they have the luxury of having sun all year round.

My assumption is that when one has the ability to obtain sun exposure, if they are chronically and constantly obtaining sun exposure or just on a regular basis, then they are likely protected even if they have a winter period in which they are unable to obtain sun exposure.

Again, that’s my assumption. I don’t know that to be a fact. But we did discuss this, or Michael Holick posited when he was on the podcast that we likely have evolved mechanisms to help us store vitamin D and perhaps other beneficial effects of the sun in the winter months, as long as we’re filling up our vitamin D banks during the spring, summer and fall.

Officially, from a research perspective, I don’t have an answer there. I think it’s fairly safe to assume that as long as you’re doing the best that you can when you have sun, that that should be sufficient.

ER:       Okay. Yeah, I think that is a good episode to go back to. Is he the one that has the vitamin D app?

DrMR:   Yeah. Michael Holick discovered the 25-hydroxy vitamin D molecule. He’s like the godfather of vitamin D.

ER:       Yep. I downloaded that app, I think it was last year when I heard the episode. And it’s really, really cool. It allows you to choose your location, so I’m sure, even just using that app, you can understand more about how you can create vitamin D for yourself in the sun, no matter what time of year. It should be interesting.

Probiotics Use with Long-Term Antibiotics

The next question is from David.

“Do probiotics work to offset damage caused by long-term antibiotic treatment? I’m on long-term antibiotics for a heart issue. I’m wondering if the Healthy Gut, Healthy You protocol could still help if I take antibiotics throughout the duration.“

DrMR:   Yeah, this is a good question. The data that we have has looked at what happens with probiotics after antibiotic administration. The best data that I have been able to see seems to be in agreement that using probiotics can help encourage the microbiota to return to normal more quickly.

Now, there was one paper, it may have been published in Cell, that essentially found that probiotics after antibiotics created a latency period where it took longer for the microbiota to return to normal. There was this whole big thing where everyone on the internet—if I’m being totally candid, I think people were looking for something different and doing a bit of clickbait—really wanted to showcase, “Probiotics may not be as good as we thought!”

Whenever something’s coming into vogue, there are always those who are looking for the opportunity to play the contrarian. Which, by one token, I don’t disagree with because there are certainly things that are rising fads that deserve and need to be called out. But what happens, in some cases, is people don’t do their research. And they call something out when they haven’t done adequate research to be able to know if their call-out is accurate or not.

Because we know that probiotics can also help prevent some of the clinical problems that antibiotics can lead to (like diarrhea, bloating, and digestive discomfort), it seems fairly reasonable to say that because probiotics tend to make people healthier and reduce antibiotic-associated side effects, they’re also health-promoting for the microbiota.

When we juxtapose that with looking at a handful of studies—I don’t know exactly how many, but I know there’s been more than one that have found that probiotics encourage a rebalancing after antibiotics in the microbiota—I’m hard-pressed to assign too much value to that one study, especially when that one study, to my recollection, did not correlate with any kind of symptoms. I just want to put that out there, in case people have come across that.

More to the question of long-term antibiotic use, should you be using probiotics? My thinking is, it’s a good hedge. My main concern is really long-term antibiotics potentially causing secondary imbalances like Candida or Clostridium difficile that could be clinically challenging.

I don’t know that there’s been a good study on this, and the reason why is obvious. Ethically, that study would never be approved in a group of healthy people (we’re going to give half the healthy people long-term antibiotics and the other half a placebo, so we’d only really have a group with an ongoing condition that requires probiotics). And then it’s really hard to tease out if there’s any ill change in the individuals. Is that ill change because of the condition being treated or because of the antibiotics?

This is a challenging question to answer from a research perspective. To my knowledge—not that I have done an exhaustive review looking at this specifically—there is not any great data specifically answering this question. But I think it’s safe to say that, as long as you’re using a probiotic, and if you tolerate a prebiotic and, importantly, are eating a healthy diet and also exercising and sleeping (because, remember, those are inputs that affect your microbiota also), then I think you’ve done everything you can do to support and encourage healthy bacteria and a balanced microbiota, and to discourage any negative impacts from the antibiotics in the long term.

ER:       Sounds fair.

Research on Probiotics, Brain Fog & Bloating

That was a perfect lead-in to the next question. It’s a research question about some probiotic research, so I’m curious to hear what you have to say about this.

Lulu Cook:       Hi, Dr. Ruscio. I’m Lulu Cook. I’m a dietitian calling from Australia. I see this new research study from the Clinical and Translational Gastroenterology Journal where researchers from Georgia’s Augusta University found that 22 of 30 patients who regularly took probiotics reported being bloated and having difficulty concentrating. Gut bacteria was discovered in the small intestines of the patients, and patient levels of D-lactic acid, which can be harmful to brain cells, were three times higher than normal.

Curious to hear what you have to say about this. Clearly, many of us use probiotics clinically to help alleviate bloating and cognitive impairment, what we call mental fog. So this study really flips things in a different direction, and I’m curious to hear your perspective on it. I really appreciate the evidence base that you take when you’re reviewing these kinds of studies and all of the information out there on gut health and the gut-brain connection. Thank you so much for what you do. Looking forward to hearing your perspective on this particular study.

DrMR:   Okay, great study. I believe this was the paper published by Satish Rao, who’s been on the podcast. If it is, I have read this paper. This paper is over a year old, so it was a little while ago when I read it. I found it interesting but not highly compelling. Forgive me, I’m trying to recall the exact reasons why, beyond the obvious. Let me start with the obvious.

This is one study, and there are a number of clinical trials showing that probiotics can improve mood. Now, mood is not brain fog, but I look at, perhaps, a better-studied proxy for brain fog as depression and anxiety. Because we have a fairly robust handful of clinical trials showing improved mood with probiotics, that makes me look at the gut-brain connection as able to be favorably modulated by probiotics.

We’re about to release a probiotic article. In fact, by the time this podcast publishes, that may already be out there. I talk about brain fog or fuzzy thinking. In models of Alzheimer’s—so the impaired condition that accompanies Alzheimer’s—two trials have found improvements in cognition with probiotics. One in bipolar disorder found improvements in cognition with probiotics and one in fibromyalgia. So this is where it’s really helpful to look at all of the evidence and not overly assign importance to one study.

Beyond the obvious, which is, the majority of the data seem to point to probiotics being beneficial for cognition likely via, obviously, the gut-brain connection, the less obvious thing is this patient subgroup. Again, I don’t know if they had had any prior surgery and had any kind of anatomical problem or were just chronic IBS patients. I believe these patients were eating fermented foods and using probiotics and had been doing so in the long term.

Now, how you would successfully navigate this still falls within my recommendations, which is, try to find the minimum effective dose. This is where, again, with one study, people want to shout from the rooftops, “Oh my God. Maybe probiotics are bad for your brain because of D-lactic acid.”

Hold on. Let’s not get too carried away. Let’s think about this study’s findings in relation to the clinical recommendations we made, which are: use probiotics, ideally all three, because those tend to have the most benefit in my experience. Then, after you’ve reached your apex of improvement or plateaued and been stable for a little while, then try to find the minimum effective dose. What may have happened here is that these people may have really overshot the landing.

So I think it’s an interesting finding. I think it should be juxtaposed with the more robust number of trials showing improvements in gut-brain function rather than regressions in gut-brain function, but when we look at it in the context of recommendations, if you follow those recommendations, you would still protect yourselves from potential D-lactic acid build-up, because you’re not indiscriminately using probiotics in the long term without trying to find the minimum effective dose.

Hopefully all that helps. But again, it’s a great question. These are things that we should be discussing, but it’s always helpful to juxtapose one finding in the greater context. Gosh, I wish I had those finer point details here. But I do remember there being something else in that study that made me a little bit suspicious. I believe it was a more severe disease subgroup, or they may have had prior intestinal surgery, or something of that nature.

Nonetheless, the majority of the data seems to show benefit. Not to say everyone will benefit. Some people, a small amount, react to certain probiotics. That’s why we use the three categories. Then if you’re trying to find the minimum effective dose, you protect yourself from what I have termed in the past as an over-saturation, where you’ve now overshot the landing, and may be suffering some negative side effects and consequences from using too high a dose for too long. Great question. Hopefully, that helps you navigate some of the nuance.

ER:       Yeah, I was trying to scan that study while you were talking. There is a lot there to look at, but if people are curious, it’s called, “Probiotic use is a link between brain fogginess, severe bloating.” You’re correct. It’s a Satish Rao study, 2018. I’ll move on from that, but if you’re curious, you can check out that study.

Further Analysis of Probiotics Study

DrMR:   Hey, everyone. Sorry. Erin and I paused the recording really quick because I was curious about that brain fog study. Remember me saying there was something about that study that didn’t sit right? I remember, at the time, looking at that study and knowing there was something quite wrong with the conclusion being drawn, but I couldn’t recall here, off the top of my head, what it was.

Firstly, the article that’s being written here seems to be misquoting because, in Satish Rao’s abstract, there were six patients that were examined. I’m not sure where the misquotation is here. But I what I can tell you is, outside of the Science Daily article that’s reporting on this study, the abstract is all that was available. It’s just an AGA abstract. There’s no full paper to pull. In this abstract, as best as anyone can tell, there are six patients. There’s a data table with the data for all six patients.

Here is the thing that drives me nuts about people who talk about health online, and they do so potentially irresponsibly. Now, I don’t know if I read this full Science Daily reporting write up, I would have not been led to think the probiotics were the problem. But if this Science Daily paper is insinuating that, that’s really, really problematic. Here’s why. In the main results of this study, five of the six patients who had bloating and brain fog… Let me take a bigger step back.

The purpose of this study was to assess the relationship between brain fog, SIBO, and probiotics. Patients who had been experiencing bloating and distension along with brain fog for more than a year were assessed. They were given a SIBO breath test and a duodenal aspirate (kind of biopsy for SIBO). Also, they measured their D-lactate. So it’s a group of patients who, essentially, have IBS and brain fog. Five of the patients had SIBO, and all six had bloating, brain fog, and fatigue. Okay.

The patients reported the history of yogurt consumption and took probiotics regularly. Here is the key point. Antibiotics resolved the symptoms in five of six of these patients. That doesn’t prove anything. That doesn’t tell you if they had a fairly bad case of dysbiosis and the antibiotics resolved the SIBO, and it was actually the antibiotics treating the SIBO that cleared the brain fog, or anything really.

We can’t just say because these patients had IBS, brain fog, and fatigue, were also taking probiotics and eating yogurt, and then we treated them with antibiotics… therefore, the probiotics were the cause. There are way too many things there that are not accounted for in this study, to be able to proclaim that probiotics were the cause. This is a very small sample size. It’s a very poor study design. I hope Rao does some more work to firm up it’s actually the probiotics causing the problem.

We know that IBS patients have higher scores of fatigue and brain fog. We have talked about that before. In these trials, these are presumably not patients who are all taking probiotics. You have fairly large data analyses on fairly large groups of patients, correlating fatigue and brain fog with IBS. To take six people and say, “Well, those six people were also using probiotics. Therefore, the probiotics are causing the fatigue and brain fog and, oh yeah, because we used antibiotics and their fatigue and brain fog got better, that further somehow supports that the probiotics are causing the brain fog,” as you can see, that assumption is flawed for a myriad of reasons.

It’s also not to say that these patients, some of them, may not have been negatively reacting to the probiotics. But my thinking here is, you saw a typical cohort of patients who had IBS and SIBO—and the resultant brain fog and high D-lactic acid that accompanies that—and the probiotics weren’t strong enough to fix the problem, and the antibiotics were. It’s as simple as that. I doubt very much that the probiotics were the causative factor, because we know that one of the things that can happen in SIBO, because of the overgrowth, is people could have high D-lactic acidosis.

Anyway, Erin and I were just kind of rehashing that. I wanted to share that. This is why I recommend people go right to the research. In this case, if you scroll all the way down on this Science Daily article, you’ll see the actual abstract. Again, what’s being written in that article isn’t really representative of what’s in the abstract. It’s possible that we’ve missed something here in our somewhat live interpretation on this, but I did want to share that because it’s easy to misquote things, and I think we’ve shown that misquotation here.

I wrote up a summary on this article in our clinician’s newsletter in August of 2017, so this study’s a few years old. That’s where I knew there was something smelly about that interpretation, and I’m glad we took a moment to go back and rehash it. If anyone listening is a subscriber to our Future of Functional Medicine Review Clinicians Newsletter, go back to August 2017, and you can see the full write-up on that.

Migraines & Gut-Brain Axis

All right. The next question is from Denise.

“Once in a while, my son gets an exercise-induced migraine. He has found that the best way to stop the intensity is to either vomit or have a bowel movement. Why is this? Does it have to do with the gut-brain axis?“

DrMR:   Interesting. I don’t know that I have a great answer on this one. If it was just exercise-induced migraines, I would think it could be a blood sugar issue, not eating enough, over-training. But when he is able to rectify this by having a bowel movement or vomiting, that adds another layer that makes me suspicious there could be something neurological there. There could be maybe some kind of vagal response he’s stimulating by vomiting and/or going to the bathroom, but that’s beyond my degree of neurological savvy.

I never have any reservation with getting a conventional checkup, but you may want to take him to more of an integrative neurologist, a chiropractic neurologist, or someone who works more in this realm of functional neurology to see if there may be some sort of brain imbalance that he’s self-medicating with either vomiting or by going to the bathroom.

It also may be nothing. Some of these things sometimes just work themselves out after a couple months. I don’t know how long this has been, but I would start there. That’s what flags to me the most. But sorry, I don’t have a great answer on this one.

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Gut Health & Anemia

ER:       Okay. We’ll move on to Jason’s question about anemia.

Jason Franz:    Hi, Dr. Ruscio. My name is Jason Franz, and I was diagnosed with aplastic anemia in 2013, treated at the NIH, and have been in remission for about two years until about a year ago. Unfortunately, all three of my blood numbers, platelets, and the RMBs, and the white blood cells all started dropping again. I’ve been working here in Portland, Oregon with a naturopath and an acupuncturist, but we haven’t been able to stem the tide. I’ve also been on the paleo autoimmune, although this whole year has been characterized by more inflammation in my joints and also the return of acid reflux.

I’ve been reading your book, and I signed up to be a new patient. But my question was, when you hear anemia, what specifically do you think might be happening, like maybe fungal or bacterial, or what might be going on there as far as something for me to look at? Thank you.

DrMR:   Okay, great question. With anemia, it increases one’s chance of being hypochlorhydric or low in stomach acid up to about 50%. So it’s certainly possible that there could be low stomach acid production that is opening the door for chronic small intestinal bacteria overgrowth or, potentially, chronic fungal overgrowths and malabsorption of minerals and vitamins like iron.

To firm that up, you can see a gastroenterologist, and they can do an EGD and, essentially, look at the stomach lining and look for what’s known as atrophic gastritis and/or look for antibodies known as anti-parietal cell antibodies via a blood test. That blood test you could do outside of a gastroenterologist’s office. There could be this low stomach acid producing malabsorption and producing dysbiosis. Infection and bleeding are another cause of chronic anemia. Certainly, getting your gut in the healthiest shape that you can would be a great starting point.

That, in my mind, is a great place to start. There’s some interesting speculation by Morley Robbins. He had a posit that low copper is what actually causes low iron. I did not feel he made a compelling case. You could probably tell by listening to that interview. His recommendations I didn’t disagree with, increasing copper-rich foods in the diet. I think there is possibility in that, but the rigorousness with which he was defending his argument I really was not impressed with, unfortunately. Maybe consider looking at bringing in some copper-rich foods into your diet, into investigating and/or empirically experimenting with hydrochloric acid supplementation and, of course, looking for anything in the gut that may be awry, dysbiosis, SIBO.

Anemias can also be caused by celiac. I’m assuming you’ve been worked up for that, and potentially even non-celiac gluten sensitivity, although I believe that’s a bit debatable. But certainly, that comes down to diet and gut health. Then, if there are any other indications of any other chronic infection that may be driving the anemia or a bleed, then you may want to have a conventional workup in tandem, which I’m assuming you probably already have.

Those are a few things to look at. Then when we meet in the clinic, we’ll be able to dig more deeply into some of this and see if we can unravel where this is all coming from.

Best Probiotic for Rheumatoid Arthritis

ER:       Okay, so we’ll move on to Terry’s question. I included this one because we get a lot of questions about specific probiotics for specific issues, and I think it’s always good to hear your take on that. Her question is, what is the best probiotic for rheumatoid arthritis?

DrMR:   Great question. Okay, I’m going to actually cross-reference the article we’re about to release because I just want to pull up a few of these findings here. You’ll see that we break down a study in RA. Just reading right from our article here, three different studies found mixed results for probiotics in treating rheumatoid arthritis disease activity. One study did not show significant improvements, while two others did show significant improvements. Essentially, these improvements vary, but generally, they look like joint swelling and tenderness improving, pain improving, inflammatory markers improving, function improving, or imaging findings improving.

In terms of the best probiotic, I think you can really use any of the three categories. My thinking is that it’s not about what probiotic is best for the joints but rather what probiotic improves the gut-joint connection. The evidence to support that statement comes from the fact that an elemental diet—which is essentially a gut reset, if you will, it’s a gut rest period—has been found, in one study, to be as effective as prednisone in treating RA. That establishes the premise.

I believe the types of probiotics used were category one (our Lactobacillus-Bifidobacterium blend would be an example of a category one probiotic). But that’s more likely due to the fact that category one probiotics have, far and away, the most research studies. I don’t think it’s that they’re any better.

Let’s say you have some gut inflammation and some dysbiosis, and you use a category one probiotic, and that’s not enough, in and of itself, to tip things back into balance. I wouldn’t want you to be, in this case, what I’d call evidence-limited and only use a category one probiotic and not at least run a responsible trial on all three at the same time, because all three at the same time may lead to the gut healing that gets you symptomatic improvement with your RA.

Now, that’s a bit speculative, but I think that’s well-informed speculation. The evidence-based answer is category one alone or a Lactobacillus-Bifidobacterium blend. The evidence-based but not evidence-limited and clinically informed would be try all three categories of probiotic at once, and see if you notice appreciable impact there. If not, consider moving on to other therapies like potentially trying an elemental diet.

Dybiosis & Pain When Drinking Fluids

ER:       Okay. Our next question is an audio question. This is another question about a youngster.

Listener:        Hi, Dr. Ruscio. My 13-year-old son has had abdominal pain, bloating, and reflux since 2015. Drinking any fluid or eating food with a high fluid content causes him significant pain. The fluid literally stays in his stomach. He has multiple food allergies, gut dysbiosis, leaky gut, Candida overgrowth, and he still tests positive for Dientamoeba fragilis. I can’t seem to move forward with his healing if he’s not drinking and taking his medications. Do you know what’s causing the pain, and do you know how we can resolve it?

DrMR:   The first thing my mind goes to is, if we can make improvements with his dysbiosis, many of these other symptoms will likely improve, so the pain, the bloating, the reflux, the fluid causing pain. I’d need to ask some more questions in terms of how much fluid can he have? Can he have some probiotics? Can he swallow some probiotic capsules with a minimal amount of fluid? Can those probiotic capsules be put in his food? Same thing with antimicrobials.

There’s some nuance here that I don’t know, that would be helpful in trying to provide advice. But what I would say is try to find the path of least resistance to therapies that can help treat the dysbiosis. The most fruitful there, really, in my opinion, would be probiotics, antimicrobials, and then, in conjunction with that, potentially also considering immunoglobulin therapy or our Gut Rebuild Nutrients.

What this may end up looking like is, you make a small amount of headway in one or two or three-week increments. This sometimes eludes people. And rightfully so, if you’re dealing with lots of reactions, sometimes people can overlook the fact that they have improved, but they’ve only improved by 15% or so, and they’ve improved 15% over a three-week period. Because there are still symptoms and still reactions occurring, it’s easy to overlook the fact that forward headway has been made.

That’s what strikes me as potentially the best path forward here, which is to try to find therapies that you can get in and then try to zoom out from the day-to-day, which is probably disheartening, “Oh, he’s suffering. He’s having these reactions.” Try to zoom out and be able to get more of a sense of, “Okay, week one compared to week three. There are still reactions. There’s still pain. There’s still all this, but is it getting any better?”

I’d try to step away from this as you can and take periodic interval assessments. And use those to see, are you moving forward? Because that sometimes will be the difference between a patient sticking with a program or not. That’s where I think having a clinician can be helpful, because if you don’t see someone for three to four weeks, it’s easy to see the progress in between and reassure people, “Boy, last time we were here, the symptom severity was at least 15% greater than it appears to be today, so we’re making forward headway. I understand it’s unpleasant still having the symptoms, but we’re trending in the right direction.”

Those are some thoughts. Yeah, I wish I had more information because this sounds like something that would really benefit from a clinician’s touch. So I don’t think it’d be a bad idea to find a clinician to work with. Hopefully, that will help you, motivate you to either work with a clinician or give you some guidance in trying to navigate this yourself.

Will FMT Work for Food Allergies?

ER:       Okay. I’ve got one more question for you. Is there data that suggests FMT will work for food allergies?

DrMR:   Good question. I don’t know that I’ve read anything there one way or the other. There may be a study there. I don’t know that I’ve read one on food allergy. IBS, yes. We know that food reactivity is a fairly sizable part or kind of a syndrome that accompanies IBS. The literature with IBS is still preliminary, and there are some challenges there.

It may be that IBS patients need more FMTs to see the same results than, let’s say, a C. diff patient needs. So I think there’s still some there to learn. In terms of, have FMTs been looked at for food allergy directly, like a dairy allergy or a wheat allergy or an anaphylactic nut allergy? I don’t believe they have been. Or if they have been, I haven’t seen that study.

ER:       Okay. I think we’re good on questions for today.

Understanding Evidence in Context

DrMR:   All right, folks. Well, thank you, everyone, for the questions.

Unfortunately, there’s this tough dividing line to traverse between science and media. The messages don’t always make their way out of the scientific community into the media sphere appropriately. I guess that’s part of what our job is, to try to strike that balance of translating science in a responsible way. Maybe I should amend the word responsibility. I hope that most are not trying to do things irresponsibly on purpose.

I think sometimes if you don’t have the level of familiarity with these things that you need to. It can be an honest mistake but, nonetheless, a mistake that can really be harmful. Unfortunately, I think probiotics are getting some negative attention that I think is really undeserved. I think probiotics in SIBO is one of the most shining examples of that. It just seems that conventional gastroenterologists have a hard time with getting behind probiotics. Sorry for the tangent here. This is something I write about in the probiotics article.

When Mark Pimentel came on the podcast and we had the chance to discuss probiotics, I appreciated his answer of us needing better data regarding probiotics. After I reflected on that, I said to myself, “Could this be a platitudinous dodge?” Because who can really argue with, “Well, we need more and better data”? It’s hard to argue with that reflexively, but the more I thought about it, I felt like that was kind of a dodge. I say that because we have such a wealth of research. We have meta-analyses of clinical trials.

Now, his criticism was we really need larger clinical trials. The analogy I use in this probiotic article is, that’s like saying a Porsche isn’t good enough, and a Ferrari is the only car that will do. When we set it up like that, we realize how silly of a comparison that is. A Porsche starts at about 60-ish thousand dollars. A Ferrari starts at about $250,000. They’re both awesome cars. Both levels of data would be considered at the peak of the evidence-based pyramid, meaning a meta-analysis of small clinical trials with patients ranging from 10 to maybe 50 or maybe 100 as compared to what Pimentel would like to see, which would be a meta-analysis of clinical trials with thousands of patients.

Sure, that would be even better yet still. But to say that we’re not able or willing to offer patients recommendations regarding probiotics because we have the Porsche level of scientific evidence, I really take issue with. Especially when what’s being offered instead are antispasmodic agents or these semi-laxative or stimulants that are used for constipation which, oftentimes, patients do not like being on. Between the antibiotics and the antispasmodics and the stimulants, a lot of patients don’t love being on those, and I can’t say that those pose less of a risk than probiotics.

This is why it’s good to have these conversations and go through these things as reasonably as possible, especially because—coming back to my original point here—gastroenterologists (Satish Rao also being a gastroenterologist) just seem like they’re resistant to probiotics. And I understand being cautious, but again, if we have meta-analyses of clinical trials in IBS and one meta-analysis in SIBO, why wouldn’t you incorporate probiotics into your care recommendations? I have a hard time getting behind that.

This is why I’m glad we have our podcast here to pose a different viewpoint. In this case, a conventional gastroenterologist Satish Rao, who I know, respect, and like, may be a little bit biased against probiotics. It seems that the media attention likes to go, rightfully so, to some of these major universities and quote some of the researchers there. The real travesty is, if there is a bias there, then that bias trickles its way down to the consumer as they read the stuff being propagated by the media.

Hopefully, our podcast provides a nice antidote to that, and really looks to the data first and not to the “experts.” Why that is relevant is because, Erin, as you can attest, and as so many patients of mine can attest to, and people who read the book and have used some of the probiotic protocol information that we put out there, you can see huge benefits from doing that.

Even thinking about Mona. Her conversation was published a couple months ago. She had been to numerous doctors, and no one ever thought about low FODMAP plus probiotics. This poor girl even went to the ER. She was so distraught about her reflux. Surprise, surprise, low FODMAP and probiotics and after a month, she is 90% better.

That’s why it’s important to me to get this information out there, because if you look at the clinical literature, that’s what you see. But sometimes bias gets in the way, and the people who suffer are the people reading, trying to educate themselves, figure out how to fix themselves, and solve their problems. Which is why—pardon the long outro here—I’m so fortunate that we have this podcast and we’re able to share this information with people.

ER:       Yeah, I agree.

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Episode Wrap-Up

DrMR:   You have anything you wanted to say there, Erin, or should we wrap it up here?

ER:       Just one quick thing is that, especially in the SIBO landscape, I still look and see a lot of conversations in that area, and everyone’s so desperate to find out what their cause is so they don’t have a relapse. They’re so terrified of relapse. Having gone through that myself, I actually just use low FODMAP and probiotics as my sweep-up protocol. Every time I start to feel a few symptoms, I don’t freak out.

And so many people are like, “I can’t have this again. I can’t go through this again.” The good news is you don’t have to. You can just have this quick-hitter protocol. For me, it works. I don’t know about anybody else, but it’s such an easy thing to go back to that I feel like I have control of. I don’t have to spend a ton of money on antimicrobials, and I don’t have to stress. I just think it’s a good tool, at least, for me.

DrMR:   Yeah. And you’re a sensitive patient.

ER:       I react to everything.

DrMR:   Yeah, you’re definitely sensitive and reactive. I want to point that out because sometimes people will say, “Well, I’m a tough case,” or, “I see complex cases.” I do too! I see quite a number of those. That’s why we put the probiotics out in three different categories, just in case a sensitive person does react.

Even I, myself, have noticed that, over the past few years, some of my lingering symptoms, again, are way better than the almost crippling brain fog and insomnia I had when I had an active infection, but I still had some lingering stuff. I’ve really noticed, over the past few years as I’ve been using probiotics (as I probably talked about before, my daily gut health routine is all three of our probiotics plus Gut Rebuild Nutrients), that keeps me to a point now where I haven’t had… My main symptom, really, was this periodic food-reactive brain fog. I can’t remember the last time that I had that.

I needed to do more than just treat my parasite. I wish I had known, because I had used a probiotic here and a probiotic there, but it wasn’t until I used all three at the same time that I really saw a large movement, and then the last little finishing touch was adding the Gut Rebuild Nutrients. That, for me, is a simple protocol, but worked and continues to work incredibly well.

Then with you, Erin, just periodically reverting back to low FODMAP and probiotics is all you need. You don’t have to go back to a clinician and have a repeat stool test, and a repeat blood test, and all this craziness.

ER:       Yep, that’s the big message, I think.

DrMR:   Yeah. There’s a time and a place for that, but we don’t need to jump to a doctor’s office visit so quickly. Again, I want to be careful to say that if you ever have any inkling to go see a doctor, make sure you get checked out, especially conventionally. I think it’s important to have conventional evaluations, because they’re looking for different things than we are in integrative medicine and alternative medicine.

But for an IBS case, to go through the rigor of repeat stool tests, repeat breath tests, maybe antibody profiles… so much of that just doesn’t need to be done. There are so many great examples of it—Erin, you being one—that I just am glad the message is getting out there and to share this with people. Because, gosh, how much would that save you? It’s probably $200, and then two tests, if those are being done, you’re looking at, at least, another $400.

ER:       Oh yeah, at least.

DrMR:   Plus follow-up visit, so you’re looking at probably $800 saved just by coming to the conclusion that you can help unravel a regression if you touch back on low FODMAP and probiotics. Amazing.

ER:       Yeah.

DrMR:   All right, so now that Erin and I have gotten all that out, thanks, guys, for listening. Hopefully, you’re finding this as exciting as we are. If not, we’re in serious trouble! Otherwise, guys, thank you for your questions. Keep them coming, and we will talk to you next time.

What do you think? I would like to hear your thoughts or experience with this.

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