Surprising Benefits of Probiotics

Intro:

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DrMichaelRuscio:

Hey everyone. Welcome back to Dr. Ruscio Radio. This is Dr. Ruscio and let’s jump in on a number of scientific updates regarding probiotics. Essentially, what I’m going to do here is read through our probiotics cornerstone article or AKA our comprehensive guide to probiotics. If you go to our homepage, you can navigate your way there fairly easily. If you go to the homepage, DrRuscio.com, scroll down and you will see our comprehensive probiotic guide one scroll length down. We’ve pinned this year because it’s kind of an end-all-be-all resource.

DrMR:

I don’t want it to sound like this is the only good resource, but as you know, I and we stay quite abreast of the research regarding probiotics. I really mean it when I say we stay abreast of the research. So with this article that was only written a number of months ago, we’ve added pages of references. So what I want to do here is read through those references and just give you my best run-through of some of the latest published research on probiotics, and get you up to speed in terms of what has recently happened there. So let’s jump in.

Diarrhea and Probiotics

DrMR:

Okay. So let’s start with the topic of diarrhea, specifically antibiotic-associated diarrhea. There were three additional papers, interventional studies that found that probiotics work to reduce antibiotic associated diarrhea. This is important because we’ve discussed in the past that there was this one study that tracked the microbiota and concluded that probiotics, along with antibiotics, delayed the time to which the microbiota returned to normal.

DrMR:

Just a quick context here. This is one study that’s using a measure of “normal microbiota” that’s still being debated. At least to my recollection, it also didn’t track symptoms. So this may sound overly pragmatic, but I think it’s important to point to. Generally speaking, we should really be looking to clinical outcomes, meaning if the person had diarrhea, but a “normal microbiota,” and the other person had a delayed recovery of their microbiota, but didn’t have diarrhea, then I would argue we need to re-frame and re-establish what a normal microbiota should be at that time point after antibiotics. Perhaps some of the perturbations that you’re seeing are secondary to other things, let’s say attenuation of the immune response, and that’s actually the net most beneficial thing for the person, hence the person not having diarrhea.

DrMR:

So I think it’s really important to mention that we should be careful not to look at a microbiota finding and then force that upon someone as the healthy norm to aim for. There’s still a lot here that we need to learn. And as I discussed in Healthy Gut, Healthy You, there are certain changes in differences that we see in certain hunter-gatherer microbiotas like the higher levels of Methanobrevibacter smithii that when we see in Westerners, at least according to some preliminary data, it actually correlates to weight gain and constipation.

DrMR:

So pardon me from being a bit of a pragmatic clinician, but we want to look firstly and foundationally at the overwhelming majority of data that has found fewer side effects associated with antibiotics and/or better ability to clear whatever said harmful infection is ailing the individual when using probiotics plus antibiotics. And this is just more evidence that the overwhelming majority of the data suggest that probiotics combined with antibiotics are probably the best way to go.

DrMR:

While we’re on the topic of diarrhea, there was a systematic review and meta-analysis with S. boulardii that found it was able to prevent Traveler’s diarrhea. The reason why I think this is noteworthy is there are some circles in GI that recommend taking the antibiotic Rifaximin prophylactically when traveling. I’m not necessarily in strong opposition to that.

DrMR:

I think Pimintel was one of the first researchers to put this forth, and if we’re looking at no other recommendation and no other way to reduce and prevent Traveler’s diarrhea, I am 100% with you. But as I see in some of my conventional GI colleagues, there’s this hesitancy to recommend probiotics. And boy, when we have a systematic review and meta-analysis that has shown that S. Boulardii, a probiotic that’s been used in certain fermented foods for a long time, and now we have meta-analyses that this Saccharomyces boulardii probiotic can prevent Traveler’s diarrhea, that would seem like the far more prudent recommendation for Traveler’s diarrhea.

DrMR:

I also have no problem with Rifaximin, but for obvious reasons, I think this is a better starting point in terms of, “Okay, I’ll be traveling. Either I notice that my gut is kind of sensitive and when I travel I’m off plan and off my normal food rhythm, I get diarrhea, or I’m going somewhere where diarrhea is somewhat, endemic.” If you’re a westerner, like certain Southern American countries, then a probiotic seems like a much better item to have in your back pocket.

DrMR:

And I guess continuing to swim in the river of diarrhea, a recent randomized controlled trial involving a hundred infants and children from three months to 36 months with acute diarrhea found that the time to recovery from the diarrhea was significantly shorter in the probiotic group, again, using Saccharomyces boulardii as compared to placebo. So really important. We have a placebo controlled trial here, and the length of diarrhea in the probiotic group averaged 65 hours versus 95 hours. So a 30-hour reduction in the incidence of diarrhea.

DrMR:

A few important things to keep in mind. One, I think parents sometimes, and understandably so, revert to, “Well, anything could do something bad, so I’m going to do nothing.” That’s not the best way to operate because operating under fear doesn’t mean you’re actually going to make the best decision. The other is, this did not eliminate the diarrhea. And it’s important to contextualize this, that I would recommend using a probiotic in a case of an infant or a child having diarrhea, but we should also establish the note that this doesn’t necessarily mean that the diarrhea will be gone in half of a day.

DrMR:

Now, there is other evidence showing that it can be used preventatively. In this randomized controlled trial of a hundred infants, it was used as a treatment. So the kids had diarrhea and they’re given the intervention of the probiotics. So this is why I would like to see more parents giving their children probiotics. And we are going to be releasing a children’s probiotic. And to tell you the truth, it’s going to be almost exactly the same as our other probiotic, except we’re going to bring the dose down a little bit, but I’m here conforming to a market pressure, which is it’s hard to educate parents on the fact that we can use the same probiotics for adults as we can for children. Saccharomyces boulardii, yeah, adults, you’ve seen that all the time. Also we can use it in kids.

DrMR:

But to be fair, and I guess in defense of parents, sometimes they just don’t have the bandwidth to do the research to establish that. So consumers trust that if it says woman or children or men’s on the bottle, it’s safer for that population. But I do want to disclose other than the fact that we’re going to be offsetting the dose, so it’ll be a lower dose for children, and just doing some due diligence and fact-checking in case there’s any signal of adverse events, GI upset, and the like, with certain species versus others with children, we’ll make those modifications. I have not seen anything to suggest that, however, I am über-cautious and I’d like to pretty much triple or quadruple check.

DrMR:

So we’ll go through the normal cycles of quality assurance and safety checking, but the main rationale behind this is just to give parents something that’s easier for kids. We’re also probably going to put in a little bit of sweetener and put it in a powder form. So there are some differences, but the big thing I want to just impress upon you here is there are not certain bacterial strains that will cause children to have disease, colonization, or adverse events that are vastly different than adults. And it’s just important to know that because it takes the bogeyman of unknown, and then therefore fear, out of the equation of how do we use probiotics for children? And the Saccharomyces boulardii is an excellent example of that. And there’s also evidence for soil-based or spore forming probiotics in children also. I’m not sure if that’s going to be in this crop of updates as I read through my notes. Let’s see if it’s in here.

Skin Health and Probiotics

DrMR:

Shifting gears for a second to skin health, an additional systematic review was published, suggesting that a combination of oral and topical probiotics may be the most helpful for certain skin conditions such as rosacea, acne, and atopic dermatitis. By the way, all of these references are located in our comprehensive probiotic guide. So if you want to pull them up, they are located there. I will see if we can get these into the references section associated with this transcript. Don’t hate me if we can’t, but I will make that my aim. We recently switched our reference management system, and I’m not sure how easy these are going to be able to parse out to be able to copy and paste into the transcript associated with this podcast. But they are there in the comprehensive probiotic article.

Constipation and Probiotics

DrMR:

And continuing to constipation, a randomized controlled trial involving 80 patients with mild intermittent constipation found that seven weeks on a soil-based probiotic, specifically Bacillus coagulans led to improvements in gut transit time and more complete bowel movements and less abdominal discomfort. Now, this is partially key, and this is one of the key points I make in the cornerstone article or the comprehensive guide. Some have said, “Well, this is the best probiotic for constipation.” And one of the reasons I get irritated by this, by the camp that says, “Well, we really need to be species and strain specific,” is because when you really lay out all the data comparatively, it’s extremely hard to substantiate that claim.

DrMR:

And so we discussed that different combinations of a category one probiotic, a Lactobacillus and Bifidobacterium-predominated blend, different formulas have been used comparatively and both found improvements in constipation. Now we see a different categorical type all together, the soil-based probiotic, and they also showed improvement.

DrMR:

And here’s where I come in. Up until now, I believe this was the first study of its kind, or at least a high-quality study, that found improvements in constipation with a soil-based probiotic. Yet I have been using them for patients with constipation for years and years now because of this paradigm of being evidence-based, but not evidence-limited. Meaning if we’re seeing various probiotics, different ones can all help constipation, I’m not going to withhold a very likely beneficial type of probiotic that is a soil-based probiotic for someone with constipation because we have other evidence with that soil-based probiotic type in IBS and we have seen benefits.

DrMR:

So there wasn’t specifically a trial looking at just constipation, but it would be too evidence limited. You’d be too confined if you only use a soil-based probiotic in someone who had constipation after there was a randomized controlled trial. There’s a balance of wanting to use the evidence to guide your decision-making, but I guess that’s just it. It’s going to guide your decision making. If there’s clear evidence of this proof, we don’t use. If there’s no evidence showing any kind of benefit, we probably shouldn’t use. If there’s an array of evidence for various benefits, similar to the one that you’re hoping to get, but not for that exactly, and it’s safe as probiotics are, it would make sense not to be too inside the box and make that leap so to speak. So I am not surprised at all by this finding. And I believe this is the first one that has found that a soil-based probiotic can improve constipation and gut transit. So it’s not surprising to me at all.

Cognitive Function

DrMR:

Shifting over to cognitive function, there was an updated meta-analysis of seven randomized controlled trials and also 11 animal studies that concluded that probiotics enhance cognitive function. The effects of probiotics on cognitive impairment were greater for those who had cognitive impairment than it was for healthy individuals. So this makes sense. If someone has cognitive impairment, they have more to potentially gain from an intervention that helps improve the gut-brain connection. If someone is healthy, then getting them beyond baseline cognition would be nice, but is less likely. And that’s what we’re seeing here.

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Probiotics and Pre-Term and Other Infants

DrMR:

Going back to infants, probiotics and pre-term infants. A meta-analysis of five studies involving 1,200 pre-term infants found that probiotics were associated with lower rates of mortality and necrotizing enterocolitis. So the safety and efficacy of probiotics, even in at risk populations of pre-term infants should really be pointed to. And again, my concern here is the pediatrician who doesn’t know this body of literature well, and rightfully so, reverts to, “Well, if I don’t know, I’m going to say nothing.”

DrMR:

And I appreciate that perspective. What I’m trying to showcase here is that you should bring some of these references to your pediatrician if you really want to run these decisions through them, or find a pediatrician who has a better working knowledge in natural medicine and have that follow-up discussion, because a meta-analysis of five studies in pre-term infants is pretty powerful and showing benefits.

DrMR:

So we run the risk of doing harm if we don’t know a body of literature. And because of that, we revert to the cautious, “Well, don’t do anything.” But if that recommendation increases the likelihood of harm, because the intervention could help the individual, then we’re violating the first Do No Harm oath. So we want to be careful. I get both sides of it. You don’t want to be recommending things willy-nilly to children, but it’s important to be aware of the growing evidence-base here. And we also had talked about in the last podcast I did for the first iteration of this comprehensive probiotic guide, that even infants in the NICU, neonatal intensive care unit, were found to benefit from probiotics. So important study there.

DrMR:

Another similar study that probiotics were beneficial as part of a treatment program for newborns with jaundice. What about allergy? A placebo controlled trial in 250 children with allergic rhinitis, runny nose, essentially, due to allergies, were being treated with conventional steroids and anti-histamines, and found that after three months of adding in probiotics, the probiotic group had a significant reduction in symptoms and less need for conventional medication compared to the placebo group.

DrMR:

Sometimes I feel like a probiotic heretic because it’s one of the most important bases or fundamentals of what I advocate for gut health. But when you look at this body of evidence, it’s really hard to not make this a foundational pillar recommendation. Now, does this mean that everyone gets probiotics all the time, there’s no personalization, there’s no listening to the individual, people are on these forever and never come off them? No, I mean, it’s really important to contextualize that it’s crucial to use these things the right way. But this is why it’s so disheartening, let’s say, when the SIBO community says, “Oh, well don’t use probiotics if you have SIBO,” despite the overwhelming majority of evidence not supporting that. Not only are we withholding something that could help the SIBO, but also all these other things.

Depression and Probiotics

DrMR:

One of these other things is depression. A systematic review and meta-analysis now of 19 studies. So the amount of studies in these meta-analyses for anxiety and depression is growing. Participants were treated with probiotics and showed a significantly greater improvement in depressive symptoms than those receiving placebo. So again, really important that we are having a control group here. A recent meta-analysis found, I believe it was 35% placebo in IBS. So that’s IBS, not depression, but placebo is a substantial factor. So we have that garnered against here.

DrMR:

Continuing, probiotics were especially beneficial in patients with major depressive disorder. I should also mention that multiple species probiotics were more effective in reducing depressive symptoms. And continuing, an additional meta-analysis found that multiple strain, multiple species probiotics were more effective than single strain, single species in improving or reducing depressive symptoms.

Species and Strain

DrMR:

Now to the note of species and strain, just to clarify that species is your broader designation. So Bifidobacterium infantis, and then Bifidobacterium infantis has a further designation into a certain strain designation subtype, if you will. And I haven’t published this yet, I’ve been waiting until I got back on the horse for doing videos because I wanted to have the visual aids for this, but we went through a process of taking all of the well-studied traditional probiotic formulas. So all of the big VSL#3, like they’ve been around for years and years and years and are from big companies, they’ve been able to fund large studies.

DrMR:

We took the big formulas of the category one type, the Lactobacillus and Bifidobacterium predominated strains, and we put them into a table where we had formula next to formula next to formula. So all of the probiotics that have been well-studied in IBS of the category one type and shown to be effective. We put in every individual cell of the Excel sheet that we were putting this into the species and then the strain designation. And so what I was able to do is look at each one, continuing from the example a moment ago, each formula that used Bifidobacterium infantis and then what is the strain designation.

DrMR:

And what you see, and a very telling exercise and why I think we need the visual aid, is the strain designation is different in nearly every formula, yet they’re all showing benefit for IBS. The way I interpret this, and I do need to fact check this further, so take this with a small grain of salt, but the way I’m interpreting this is these companies are making the probiotics. So they are presumably going to make a probiotic with something that they can claim unique ownership over. So they will make a slightly different probiotic. They’ll use that subtype difference.

DrMR:

Just to use an arbitrary designation, let’s say you have Bifidobacterium infantis subtype A1, and then you could have subtype BF23. And the way I interpret this is at one point in time there was no research in IBS with Bifidobacterium infantis. And then some company made a probiotic and they probably made it with the easiest to procure starter kit, if you will, for growing a certain species and a certain strain designation of said species. That’s what they used. And then another company wanted to make a probiotic too, but perhaps the one probiotic was proprietary or they were trying to do something to distinguish or differentiate their strain designation, so they used a different strain.

DrMR:

I haven’t seen anywhere, and perhaps I’ve missed it, but I haven’t seen a list of the strains that we know are good of Bifidobacterium infantis, using the same example, and here are the ones that are bad. All these different strains have been used of all these different species of probiotics and they’ve all shown benefit. So this is an area where I think some get too into the weeds, and in keeping with the earlier example of being evidence-based, but not being evidence-limited, I don’t think we need to wait for big companies that have the budgets to create their own strains to use certain strains or be limited by using probiotics down to the level of strain designation.

DrMR:

We’ve shown when going even more different, so if you have two different Bifidobacterium strains, those are going to be only ever so minimally different. Now zooming out a level, you have species. So the species are going to be more different. That would be Lactobacillus acidophilus, species one, Bifidobacterium infantis, species two. We’ve been able to illustrate with some of these examples I’ve read through, and some of the other examples in the original version of the probiotics comprehensive guide article, that even zooming all the way out to the species level, we see the same benefit from different species.

DrMR:

So if the same benefit and benefits at large have been shown by different species, why would being less different make the probiotics work any differently? So let me say a different way. Different species are vastly more different than different strains. Different species-level comparisons have shown that the more different probiotics all work. So why would we then say, “Well, we need to know the exact strain,” because the strain is less different and we’ve already established that the more different species also produce the same effect.

DrMR:

Now, there is some nuance here. There are certain strains of E. coli that are pathogenic. So there is some fact-checking that needs to go into place. I want to say that I don’t have everything single detail here quadruple-checked, but there’s also this need to be able to make a decision and not just keep analyzing until the cows come home, because there is something known as paralysis analysis, and we don’t want to be the clinicians who say, “Well, we’re not going to use probiotics until there’s at least one randomized controlled trial with over 3,000 participants.” I mean, by that time, you will have wasted years and years of being able to help people with probiotics.

DrMR:

So in any case, there’s maybe more here to follow on that. I’m just not sure if people care that much. I’m not sure if you, listening to or reading this, care to go that deep in the species/strain debate in terms of are the strains highly relevant. I certainly have not found them to be. I haven’t even found the species to be, but as some of these studies have quoted, the multi-species or multi-strain, and oftentimes in the research papers they use those terms interchangeably, so it’s important to point that out. In fact, really oftentimes multi-strain is said, but the way the authors are referring to the papers, they really should be saying multi-species because you’ll see in many abstracts the strain is not even listed. Sometimes even in the methods, the strains are not listed.

Multi-Species Probiotics

DrMR:

But what we’ve been talking about is the multi-species probiotics show benefit over the single-species probiotic. And this is what kind of gave birth to the combining of the traditional Lactobacillus-Bifidobacterium blend type probiotics with the Saccharomyces boulardii probiotics, for which we’ve talked about some new research today and with the soil-based probiotics, which we also talked about in some of the new research today, and using all three of those together. Because this is a continuation of the same finding that if we take a single species probiotic versus a multi-species probiotic, the multi-species works better.

DrMR:

So why not take one multi-species probiotic, Lacto-Bif blend, combine that with another multi-species probiotic, soil-based blend, and then add Saccharomyces in addition to that. And that’s really the Triple Therapy that I’ve been advocating for and we’ve been using in the clinic. We’re now collecting data on that pre/post symptom scores and pre/post trio-smart SIBO breath tests. So we’re hoping to publish something that really substantiates this, but the clinical signal here has been pretty strong and irrefutable.

DrMR:

So definitely something that I think is really important to keep in mind, which is this broader presentation of probiotics seems to be better than single. And the other factor here that I find frustrating sometimes is people want to find the one species or one strain for the one thing, the constipation, the depression, the joint pain. And again, that’s making this unnecessarily complicated. And to some extent, if I may say so with all due empathy for my colleagues, it’s probably subjecting people to an undue degree of harm because it may take longer for the person to heal and improve because you’re kind of on this witch hunt for what the specific species or strain is. You’re missing the bigger clinical picture.

DrMR:

It’s almost like saying we’re not going to use an herb for some sort of GI pathogen or SIBO until we have a genetic analysis to know what herbs are going to be the most effective. We don’t need to do that. We know an array of different herbs can be effective. We don’t need to limit ourselves to gene testing or susceptibility testing to say which ones we use. By the time that data comes in, you could already be on the other side of clearing the infection and onto further steps in the healing algorithm.

RuscioResources:

Hi everyone. This is Dr. Ruscio. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to DrRuscio.com/resources, you will see a few links you can click through for more. Firstly, there is the clinic, which I’m immensely proud of the fact that we deliver cost-effective, simple, but highly-efficacious functional medicine. There’s also my book, Healthy Gut, Healthy You, which has been proven to allow those who have been unable to improve their health, even after seeing numerous doctors, to be able to help them finally feel better. There’s also our store where there’s a number of products like our Elemental Heal line, our Probiotic line, and other gut-supportive and health-supportive supplements. Health coaching. We now offer health coaching. So if you’ve read the book or listened to a podcast like this one, or are reading about a product and you need some help with how or when to use or how to integrate with diet, we now offer health coaching to help you along your way. And then finally, if you’re a clinician, there is our clinicians’ newsletter, the Future of Functional Medicine Review, which I’m very proud to say, we’ve now had doctors who’ve read that newsletter find challenging cases in their practices, apply what we teach in the newsletter, and be able to help these patients who are otherwise considered challenging cases. Everything for these resources can be accessed through DrRuscio.com/resources. Alrighty, back to the show.

DrMR:

So in any a case, there’s some editorializing combined with a review of studies. So there are about 21 studies that we’ve added to the article. I should also mention just as a reminder, and hopefully you caught this, but these were pretty much all either meta-analyses or clinical trials. And this is important because we don’t want to founder in theory, because when we founder in theory this is where we get some of these more zoomed in, mechanistic, albeit I think mostly well-intentioned, arguments. Well, because this strain does this one thing on the luminal surface in the intestines, it’s going to be better for ‘XYZ.’ It’s going to be better is kind of the key phrase there.

DrMR:

This is why we’re using a filter system to make sure that we’re not going into early research, mechanism, cell line, animal data, and we’re applying a filter so that you are protected and really only served up the information that tells you, “Hey, when people who are feeling this do that, here’s what happens.” So if you’re feeling like this and you do that, there are some pretty good assurances that will happen to you also. So if you have anxiety, depression, diarrhea, or a kid who is sick, or a kid with allergic rhinitis, now you have some good evidence here in terms of probiotic interventions being able to help with those things amidst a few others.

DrMR:

So anyway, those are some updates on probiotics. Those have all been incorporated into our comprehensive probiotic guide. I hope you found this helpful. If people want to leave me some feedback on if they want to see a deep dive into the species/strain comparison and non-relevance, then I’d be happy to do that. I’ve got a bunch of the data, but I’d probably need to go through a little bit of work to reformat it to make it feel less like you’re in a high school calculus or algebra class as you’re looking at this spreadsheet. So that’s really been the main hang-up. It’s just trying to convert it into a way that’s more able to be visually representative of the trend and not require what took me a lot of time of scrolling, comparing, and going back and forth.

Triple-Therapy Stick

DrMR:

But yeah, hopefully that was helpful. And one more reminder that we have since released the probiotic Triple Therapy packs. We’ve taken the Lacto-Bifido blend probiotic, the Saccharomyces boulardii probiotic, and the soil-based probiotic, and instead of having to open up three bottles and take out a couple pills, we’ve essentially taken those pills, pulled them open, poured them all into one sort of like a Crystal Light tear stick. So you have one stick you pull out of the box, tear, pour into a glass of water, stir and boom. There you have your three probiotics in one very easy to dose and non-refrigeration required serving to make taking the three probiotics a little bit easier.

Episode Wrap-Up

DrMR:

Okay, so hopefully this was helpful. Remember, if you need assistance, there are a lot of resources out there for you. There’s Healthy Gut, Healthy You, there are the Triple Therapy probiotic packs, and there’s also Healthy Gut, Healthy You. That is the rundown on 20-some odd new high-quality trials or meta-analyses on how this simple, safe therapy of probiotics can really be helpful. Again, I want to be careful not to come off as a probiotic zealot. They aren’t going to fix everything. But if we’re looking to move through different trials to figure out what’s going to get your body as healthy as possible, diet and lifestyle are always a foundation and always not so easy.

DrMR:

So there’s a lot there to unpack, but diet and lifestyle would be your foundation. Personalize your diet, get to bed on time, make sure you’re exercising, you have some enjoyment, you’re getting time outside, you’re getting time in the sun. And the next step from there would really be probiotics. That’s why I harp on it, because it’s a foundational pillar. And if we can get the foundation right, just like addressing the root cause of a problem, a lot of the symptomatic branches will then take care of themselves. Okay guys, hopefully you found this helpful and I will talk to you next time.

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