Gut Health Q&A: Akkermansia & Probiotic Misconception

Tune in for an installment of my gut health Q&A, where I answer your questions about all things gut health.

This installment is a probiotic edition, where I’ll touch on probiotic foods, dosing, side effects, and talk about whether the hype around Akkermansia is warranted.

Be sure to tune in!

And if you have any questions you would like answered in a future installment, let me know in the comments!

Is the hype about Akkermansia muciniphila probiotics warranted? 

We do know that lower levels of akkermansia are associated with obesity, type 2 diabetes, and IBD. However, based on human trials, the benefits of akkermansia are similar or inferior to other probiotics. In fact, the research shows that a lactobacillus-bifidobacterium blend probiotics outperformed akkermansia in regards to fasting glucose and insulin resistance.  

What are the best probiotics to take for improving IBS? 

A 2023 meta-analysis found that many different probiotic formulas were effective for IBS. We also see that different strains of the same probiotic species all show benefits, so you don’t have to worry about getting too strain-specific here. What I recommend is to take at least one type of probiotic (saccharomyces, lacto-bifido, or soil-based), but if you want something more effective, I would stack on another probiotic type or two. We refer to this as the triple therapy approach and we aim to publish on this soon. 

Can you tell me why you only recommend taking probiotics for 2-3 months? What should I do after that?

2–3 months is the minimum duration to assess efficacy. In some studies, peak effects weren’t seen for 6 months. So I recommend trialing probiotics for 2–3 months until the benefits plateau, and then you can start to ween down to find your minimum effective dose. (Essentially, you’ll take less and less until you notice symptoms, which will signal that you’ve gone too far.) I break this down more in this article, if you’d like more detail. 

Can probiotics be replaced with fresh sauerkraut, yogurt or kimchi? Or is there a reason to go for the supplements?

Fermented foods are an adequate source of probiotics. There is a caveat here in that the dosing is going to be inconsistent depending on food type, manufacturing, and how often you’re eating it. That’s where supplements can be handy, to fill in where there may be gaps. The other big caveat is that many probiotic foods can be reactive to sensitive guts due to FODMAP and/or histamine content. This is another case where supplements can be preferable. 

What if the probiotics make the symptoms worse? I can’t tolerate even small doses.

I see this in the clinic quite a bit. However, it’s extremely rare that someone can’t tolerate at least one type of probiotic. It’s important to remember that there are three types of probiotics (saccharomyces, lacto-bifido, and soil-based), so it may be that you’d benefit from moving to a different category. 

Other factors to consider are additives that may be causing reactions, so be sure to check for dyes, allergens, and prebiotic content. 300-500 mg of prebiotic content should be good for most, but some probiotics have a much more generous inclusion. Lastly, it could be die-off which should subside after 4–7 days. 

What type of probiotic do I take if I’m having histamine intolerance? Aren’t some strains known to produce more histamine in the body?

This was me. I avoided probiotics for this reason, but I wish I had started them sooner. I now know from looking at the research extensively that probiotics have a net-histamine-lowering effect. And the difference between histamine-containing probiotics and non-histamine-containing probiotics is negligible. So I would suggest trialing a probiotic from each major probiotic category, keeping what works and putting aside what doesn’t.

Why does everywhere on the internet say that lacto-bifido blends are bad for SIBO because it worsens the overgrowth? Is this true? 

In short, no, lacto-bifido is not bad for SIBO. A large part of why this narrative exists is that experts in the space refer to early, poor-quality observational studies when we now have much more research that demonstrates just how effective lacto-bifido can be for SIBO. I actually dedicated a whole episode to this topic that you can watch here.

Featured Studies

• Akkermansia muciniphila secretes a glucagon-like peptide-1-inducing protein that improves glucose homeostasis and ameliorates metabolic disease in mice: https://pubmed.ncbi.nlm.nih.gov/33820962/ 
• The role of Akkermansia muciniphila in IBD: https://pubmed.ncbi.nlm.nih.gov/36685588/ 
• Strategies to promote abundance of Akkermansia muciniphila, an emerging probiotics in the gut, evidence from dietary intervention studies: https://pubmed.ncbi.nlm.nih.gov/30416539/ 
• Regulation of gut microbiome by ketogenic diet in neurodegenerative diseases: https://pubmed.ncbi.nlm.nih.gov/36313018/ 
• Triggering Akkermansia with dietary polyphenols: A new weapon to combat the metabolic syndrome? : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4856456/ 
• Akkermansia muciniphila abundance is lower in severe obesity, but its increased level after bariatric surgery is not associated with metabolic health improvement: https://pubmed.ncbi.nlm.nih.gov/31265324/ 
• Decreased Abundance of Akkermansia muciniphila Leads to the Impairment of Insulin Secretion and Glucose Homeostasis in Lean Type 2 Diabetes: https://pubmed.ncbi.nlm.nih.gov/34085773/ 
• Outcome-Specific Efficacy of Different Probiotic Strains and Mixtures in IBS: https://pubmed.ncbi.nlm.nih.gov/37686889/ 
• The Efficacy and Safety of Single-Strain Probiotic Formulations Containing Bifidobacterium lactis or Bacillus coagulans in Adult Patients with IBS: https://pubmed.ncbi.nlm.nih.gov/37510953/ 
• A combination of rifaximin and neomycin is most effective in treating IBS patients with methane on lactulose breath test: https://pubmed.ncbi.nlm.nih.gov/19996983/ 
• Probiotics for Preventing and Treating SIBO: https://pubmed.ncbi.nlm.nih.gov/28267052/ 
• The effect of multistrain probiotics on functional constipation in the elderly: https://pubmed.ncbi.nlm.nih.gov/35927504/ 
• Probiotic supplementation improved cognitive function in cognitively impaired and healthy older adults: https://pubmed.ncbi.nlm.nih.gov/36529793/ 
• Lacto-fermented sauerkraut improves symptoms in IBS patients independent of product pasteurisation – a pilot study: https://pubmed.ncbi.nlm.nih.gov/30256365/ 
• Fermented Foods: Definitions and Characteristics, Impact on the Gut Microbiota and Effects on Gastrointestinal Health and Disease: https://pubmed.ncbi.nlm.nih.gov/31387262/ 
• Effects of kefir or milk supplementation on zonulin in overweight subjects: https://pubmed.ncbi.nlm.nih.gov/32171508/ 
• Fermented dairy foods consumption and depressive symptoms: https://pubmed.ncbi.nlm.nih.gov/36745637/ 
• Role of Probiotics in Patients with Allergic Rhinitis: https://pubmed.ncbi.nlm.nih.gov/36405454/ ,
• Effect and safety of probiotics for treating urticaria: https://pubmed.ncbi.nlm.nih.gov/37221968/ 
• The Effectiveness of Probiotics in Treating Food and Cow’s Milk Allergies among Pediatric Age Groups: https://pubmed.ncbi.nlm.nih.gov/37496406/
• Effect of a Preparation of Four Probiotics on Symptoms of Patients with IBS: Association with Intestinal Bacterial Overgrowth: https://pubmed.ncbi.nlm.nih.gov/29508268/

Gut Health Q&A: Constipation, Bloating, Eczema & Parasites

If your gut health isn’t where you want it to be, today’s Q&A will likely be of use to you. 

I’ll be covering some great question submissions like: 

• I’ve tried water, prunes, and fiber, and nothing works for my constipation. What should I do? 
• My bloating and constipation are slowly getting better with your protocol, but are not resolved. What else can I do? 
• I have eczema, rosacea, and loose stool. I was wondering if my skin symptoms could be caused by a gut imbalance? 

To hear answers to these questions and more, please join me. 

Featured Studies

• The Effect of Fermentable, Oligosaccharides, Disaccharides, Monosaccharides, and Polyols (FODMAP) Meals on Transient Lower Esophageal Relaxations (TLESR) in Gastroesophageal Reflux Disease (GERD) Patients with Overlapping Irritable Bowel Syndrome (IBS) – https://pubmed.ncbi.nlm.nih.gov/35565722
• Beneficial effect of probiotics supplements in reflux esophagitis treated with esomeprazole: A randomized controlled trial – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506578
• Gut-Skin Axis: Current Knowledge of the Interrelationship between Microbial Dysbiosis and Skin Conditions – https://pubmed.ncbi.nlm.nih.gov/33670115
• Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication – https://pubmed.ncbi.nlm.nih.gov/18456568
• The role of probiotics in the treatment of adult atopic dermatitis: a meta-analysis of randomized controlled trials – https://pubmed.ncbi.nlm.nih.gov/35978397
• The role of topical probiotics in skin conditions: A systematic review of animal and human studies and implications for future therapies – https://pubmed.ncbi.nlm.nih.gov/31494971
• Probiotics fortify intestinal barrier function: a systematic review and meta-analysis of randomized trials – https://pubmed.ncbi.nlm.nih.gov/37168869
• Systematic review on Endolimax nana: A less well studied intestinal ameba – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4778187

How to BEST Use Probiotics: Expert Answers to Your FAQs

This Q&A is answers to your questions about probiotics, like:

• Do you need to rotate probiotics?
• What’s the best way to take probiotics?
• What if probiotics make me feel worse?
• Do I have to worry about probiotics if I have SIBO?
• And more.

If you have any questions about probiotics, please join me for what I hope are helpful insights.

Featured Studies

• Low FODMAP Diet and Probiotics in Irritable Bowel Syndrome: A Systematic Review With Network Meta-analysis – https://pubmed.ncbi.nlm.nih.gov/35355730/
• Efficacy of Probiotics for Irritable Bowel Syndrome: A Systematic Review and Network Meta-Analysis – https://pubmed.ncbi.nlm.nih.gov/35433498/
• Effects of Lactobacillus supplementation on glycemic and lipid indices in overweight or obese adults: A systematic review and meta-analysis – https://pubmed.ncbi.nlm.nih.gov/35820261/
• Is there a role for modified probiotics as beneficial microbes: a systematic review of the literature – https://pubmed.ncbi.nlm.nih.gov/28884589/
• Health Benefits of Heat-Killed (Tyndallized) Probiotics: An Overview – https://pubmed.ncbi.nlm.nih.gov/31126033/
• Effect of Lactobacillus rhamnosus HN001 and Bifidobacterium longum BB536 on the healthy gut microbiota composition at phyla and species level: A preliminary study – https://pubmed.ncbi.nlm.nih.gov/28487606/
• Probiotics for Preventing and Treating Small Intestinal Bacterial Overgrowth: A Meta-Analysis and Systematic Review of Current Evidence – https://pubmed.ncbi.nlm.nih.gov/28267052/
• Probiotics and Prebiotics in Subclinical Hypothyroidism of Pregnancy with Small Intestinal Bacterial Overgrowth – https://pubmed.ncbi.nlm.nih.gov/37032411/
• Golden bifid might improve diarrhea-predominant irritable bowel syndrome via microbiota modulation – https://pubmed.ncbi.nlm.nih.gov/35578355/
• Metformin with Versus without Concomitant Probiotic Therapy in Newly Diagnosed Patients with Type 2 Diabetes or Prediabetes: A Comparative Analysis in Relation to Glycemic Control, Gastrointestinal Side Effects, and Treatment Compliance – https://pubmed.ncbi.nlm.nih.gov/36098362/
• Preventive Effect of Probiotics on Oral Mucositis Induced by Cancer Treatment: A Systematic Review and Meta-Analysis – https://pubmed.ncbi.nlm.nih.gov/36362057/
• Efficacy and Safety of Bifidobacterium Quadruple Viable Bacteria Combined with Mesalamine against UC Management: A Systematic Review and Meta-Analysis – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9553352/
• Early use of probiotics might prevent antibiotic-associated diarrhea in elderly (>65 years): a systematic review and meta-analysis – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9260993/pdf/12877_2022_Article_3257.pdf
• Efficacy and safety of bifidobacterium quadruple viable tablets in the treatment of Helicobacter pylori-infected peptic ulcer or gastritis patients: a systematic review and meta-analysis – https://pubmed.ncbi.nlm.nih.gov/37161358/

Clearing SIBO Confusion: Answers to FAQs About SIBO & GI Issues

If you have any unanswered questions about SIBO or unresolved GI issues, today’s episode is for you.

I’ll be answering questions from listeners like yourself, looking for gut guidance.

Today’s questions include:

• How do I know if I have SIBO?
• Can I do a hybrid carnivore/elemental diet for SIBO?
• How long can you take antimicrobials for SIBO?
• What’s causing my abdominal distension?
• And more.

Please join me. And if you have any questions you’d like answered on the next round, you can submit them here: https://www.speakpipe.com/DrRuscioRadio

Featured Studies

• Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus – https://pubmed.ncbi.nlm.nih.gov/28323273/
• Small Intestinal Bacterial Overgrowth in Irritable Bowel Syndrome: A Systematic Review and Meta-Analysis of Case-Control Studies – https://pubmed.ncbi.nlm.nih.gov/31913194/
• Prevalence and predictors of small intestinal bacterial overgrowth in irritable bowel syndrome: a systematic review and meta-analysis – https://pubmed.ncbi.nlm.nih.gov/29761234/
• A systematic review and meta-analysis on the prevalence of non-malignant, organic gastrointestinal disorders misdiagnosed as irritable bowel syndrome – https://pubmed.ncbi.nlm.nih.gov/35121775/
• Effect of a Preparation of Four Probiotics on Symptoms of Patients with Irritable Bowel Syndrome: Association with Intestinal Bacterial Overgrowth – https://pubmed.ncbi.nlm.nih.gov/29508268/
• Efficacy of rifaximin in treating with small intestine bacterial overgrowth: a systematic review and meta-analysis – https://pubmed.ncbi.nlm.nih.gov/34767484/
• Herbal therapy is equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth – https://pubmed.ncbi.nlm.nih.gov/24891990/
• Low FODMAP diet reduces gastrointestinal symptoms in irritable bowel syndrome and clinical response could be predicted by symptom severity: A randomized crossover trial – https://pubmed.ncbi.nlm.nih.gov/36384081/
• Prevalence of small intestinal bacterial overgrowth in irritable bowel syndrome (IBS): Correlating H2 or CH4 production with severity of IBS – https://pubmed.ncbi.nlm.nih.gov/37125253/
• A 14-day elemental diet is highly effective in normalizing the lactulose breath test – https://pubmed.ncbi.nlm.nih.gov/14992438/
• Enteral nutritional therapy for induction of remission in Crohn’s disease – https://pubmed.ncbi.nlm.nih.gov/29607496/
• Efficacy of Dietary Treatment for Inducing Disease Remission in Eosinophilic Gastroenteritis – https://pubmed.ncbi.nlm.nih.gov/25699593/
• Rheumatoid arthritis and dietary interventions: systematic review of clinical trials – https://pubmed.ncbi.nlm.nih.gov/32585000/
• Physiology, Gastrocolic Reflex – https://www.ncbi.nlm.nih.gov/books/NBK549888/#:~:text=The%20gastrocolic%20reflex%20has%20correlations,diarrhea%2C%20bloating%2C%20and%20tenesmus

What Are the Optimal Ranges for Thyroid Labs? & More Listener Questions

What are the optimal ranges for thyroid labs? Today I’ll answer this and other listener-submitted questions about thyroid health.

Tune in to hear answers to questions like:

• If my labs are normal could it still be a thyroid issue?
• How do I know if I need thyroid hormone?
• How can I wean off thyroid medication?

And more.

Featured Studies

• Association of Thyroid Hormone Therapy With Quality of Life and Thyroid-Related Symptoms in Patients With Subclinical Hypothyroidism: A Systematic Review and Meta-analysis – https://pubmed.ncbi.nlm.nih.gov/30285179/
• Small changes in thyroxine dosage do not produce measurable changes in hypothyroid symptoms, well-being, or quality of life: results of a double-blind, randomized clinical trial – https://pubmed.ncbi.nlm.nih.gov/16670161/
• Anti-Thyroperoxidase Antibody Levels >500 IU/ml Indicate a Moderately Increased Risk for Developing Hypothyroidism in Autoimmune Thyroiditis – https://pubmed.ncbi.nlm.nih.gov/27607246/
• Combined treatment with Myo-inositol and selenium ensures euthyroidism in subclinical hypothyroidism patients with autoimmune thyroiditis –
  https://pubmed.ncbi.nlm.nih.gov/24224112/
• Clinical Outcomes After Discontinuation of Thyroid Hormone Replacement: A Systematic Review and Meta-Analysis – https://pubmed.ncbi.nlm.nih.gov/33161885/
• Transient high thyroid stimulating hormone and hypothyroidism incidence during follow up of subclinical hypothyroidism – https://pubmed.ncbi.nlm.nih.gov/34879182/
• Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study – https://pubmed.ncbi.nlm.nih.gov/32294476/
• Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III) – https://pubmed.ncbi.nlm.nih.gov/11836274/
• The Relationship between Gastrointestinal Health, Micronutrient Concentrations, and Autoimmunity: A Focus on the Thyroid – https://pubmed.ncbi.nlm.nih.gov/36079838/

You Asked How to Improve Fatigue and Energy Levels—Here's the Answer

Patients and listeners alike have been asking how to improve fatigue and energy levels a LOT recently. So in this episode, I address seven different listener questions about this, and I bet one will help you conquer your fatigue and increase your energy levels.