More on Probiotics...

On March 10, 2012, I wrote a blog about probiotics and their limited usefulness. The original blog is below.

Here's an addendum:

According to comments made by Walter Coyle, MD, of the Scripps Clinic in La Jolla, Calif at the American College of Physicians' annual meeting and a report published by MedPageToday, "the science of the intestinal "microbiome" is still in its infancy and it remains unclear what changes to make, let alone how best to make them."

One of the primary reasons relatively little is known about intestinal bacteria is that the mix of gut flora varies greatly between individuals. For example, according to Coyle, a study of three members of the same household revealed that their intestinal bacterial composition differed markedly.

Also, it is believed that both environmental (outside) influences and host factors (the person's own internal activity) both play a role in how an intestinal bacterial community evolves, "host genetic influences [on the gut microbiome] remain unexplored," according to Coyle.

Host factors are considered important because during adulthood, individuals achieve a "characteristic "core" population of intestinal bacteria that remains stable even in the face of disruptions such as antibiotic treatment."

Here's some additional interesting information:

Two major categories of bacteria dominate in the intestine: Firmicutes and Bacteroidetes. Studies have found that obese people tend to have a higher ratio of the former to the latter. In fact, one clinical study of 12 people eating a calorie-restricted diet for one year found that there was no weight loss until the ratio of Firmacutes to Bacteroidetes shifted.

Unfortunately, it is not known if the ratio shifted as a result of metabolic changes or that metabolic changes resulted from a shift of the ratio. So if you are looking to lose weight, don't rush out and buy probiotics with  Bacteroidetes just yet because you may be wasting your money.

There is quite a bit of additional study needed before any reasonable conclusions and therapeutic applications can be derived for safe and effective medicinal use of probiotics. In the interim, probiotics appear to remain somewhat useful for irritable and inflammatory bowel syndromes and with antibiotic usage. Probiotics can also prevent yeast infections for women on antibiotics so I highly recommend their usage while on antibiotics. Remember, you need at least a billion (yes, "b") colonies (read more below). Otherwise, avoid them as you should any other unsubstantiated dietary supplements.

Blog from March 12, 2012:

What About Probiotics?

During my lectures on supplements, I am often asked "What about probiotics?" Before I share my common response with you here, let's first make sure we agree on the definition of a probiotic. According to the NIH's National Center for Complementary and Alternative Medicine, probiotics are defined as follows:

"Probiotics are live microorganisms (in most cases, bacteria) that are similar to beneficial microorganisms found in the human gut. They are also called “friendly bacteria” or “good bacteria.” Probiotics are available to consumers mainly in the form of dietary supplements and foods.

[(Prebiotics are non-digestible food ingredients, like oligofructose and inulin, which stimulate the growth and/or activity of "good bacteria" in the digestive system.)] 

The concept behind probiotics was introduced in the early 20th century, when Nobel laureate Elie Metchnikoff, known as the “father of probiotics,” proposed in The Prolongation of Life: Optimistic Studies that ingesting microorganisms could have substantial health benefits for humans. Microorganisms are invisible to the naked eye and exist virtually everywhere. Scientists continued to investigate the concept, and the term “probiotics”—meaning “for life”—eventually came into use.

Picturing the human body as a “host” for bacteria and other microorganisms is helpful in understanding probiotics. The body, especially the lower gastrointestinal tract (the gut), contains a complex and diverse community of bacteria. (In the body of a healthy adult, cells of microorganisms are estimated to outnumber human cells by a factor of ten to one.) Although we tend to think of bacteria as harmful “germs,” many bacteria actually help the body function properly. Most probiotics are bacteria similar to the beneficial bacteria found naturally in the human gut.

Various mechanisms may account for the effects of probiotics on human health. Possible mechanisms include altering the intestinal “microecology” (e.g., reducing harmful organisms in the intestine), producing antimicrobial compounds (substances that destroy or suppress the growth of microorganisms), and stimulating the body’s immune response.

Probiotics commonly used in the United States include Lactobacillus and Bifidobacterium. There are many specific types of bacteria within each of these two broad groups, and health benefits associated with one type may not hold true for others."

Okay, so now you have a good broad understanding of what they are, the question remains should you actively consume them?  I have studied this subject extensively, and yet I claim no definitive expertise on it because there is so much ongoing study. However, here is what I can tell you.

As far as I have come to understand after review of multiple sources, probiotics do no harm. Of course, that statement only holds true within reasonable limits. If outlandish quantities were consumed (trillions), I'm not sure what would happen.  For example, even drinking too much water can be harmful as it would overwhelm the kidneys and flood the gastrointestinal system.

So if it probiotics aren't harmful, does that make them helpful?  For general use, the jury is still out, but the overwhelming consensus and numerous previous studies suggest that they provide no real benefit for a person with a healthy gut.  Changing the bacteria composition of one's gut is not easy under normal circumstances, and in fact, most commercially available probiotic products neither contain sufficient colonies (need at least 1 billion) nor the wide range of different types of good bacteria to make any difference.

(As a side note, carnivores (meat eaters) typically have different bacteria colonies than herbivores (plant eaters). The significance of this fact is not well understood at this time. Also, immediate family members often have the same bacterial colonies and if a family member wants to be restored to their historical composition after a bout of serious infection or illness, it can be accomplished by fecal implant through a nasogastric tube or sometimes through a fecal enema.)

So when are probiotics helpful? They are helpful when you are taking a course of antibiotics, which by definition kills all bacteria, good and bad. The probiotics help to replenish the healthy bacteria even as the unhealthy perish. Probiotics are also believed, based on several studies, to be helpful with diarrhea, dysentery, and allergic gastritis.  In fact, with diarrhea related illness, they are said to reduce symptoms and duration of disease by as much as 50%.

(On a personal note, I can attest to their apparent efficacy after recently being afflicted with such a viral illness. Taking probiotics gave me some relief, even if it was only through peace of mind that I was doing something to help myself. Imodium and electrolyte replacement with pedialyte helped as well.)

Some studies report benefits from taking probiotics with Irritable Bowel Syndrome (IBS) and inflammatory bowel diseases such as Crohn's Disease (Terminal Ileitis) and Ulcerative Colitis. They are also reported to be useful for atopic eczema (a skin condition most commonly seen in infants) and with Helicobacter Pylori or H Pylori as it is often referred, infections, now known as the main cause of gastric ulcers.

The good news is that studies are continuing and we expect to have more definitive answers in the not too distant futures.

In the interim, I suggest you save your money and only use probiotics when either something has already gone wrong that may be amenable to correction with probiotics, or in the case of you are taking antibiotics where they may prove protective.

Notwithstanding, make sure that you only use products that contain at least 1 billion colonies and have at least a few different strains.   VSL3, Bio-K, and Lactobacillus GG seem to be three reputable products. (No, I have no financial or other relationship whatsoever with any of these manufacturers.)

The best advice I can give you is be careful what you put in your mouth, don't eat anything if you are not sure it is fresh, and wash your hands well before eating. Also, learn how to manage your stress. These protective measures may spare you ever needing a probiotic. Stay healthy, my friends!

Update for September 2013

A very recent study shed light on the effectiveness/ineffectiveness of probiotics. This recent well designed study failed to show any benefits for probiotics in preventing Antibiotic Associated Diarrhea (AAD). This is significant because many doctors, myself included, often recommend adding probiotics when taking antibiotics for the specific reason to prevent AAD and Clostridia Dificile superinfection. This new study throws that recommendation into disrepute and knocks off yet another reason to take probiotics.

I Just Don't Know

Today's blog has two parts and thought-trains.

Part 1

I typically don't read Glamour Magazine. However knowing my penchant for all things related to vitamins, my youngest daughter was delighted to share an article she came across in the magazine. The gist of the article were the responses from three experts to a question regarding the appropriateness of taking multivitamins after recent studies have suggested they may be harmful.

The first response came from a PhD who works at the Fred Hutchinson Cancer Research Center whose response was basically no, they are not needed. The second response came from a MD and professor of prevention at a Harvard teaching hospital who basically said no except in specific cases like folate during pregnancy shown to avoid birth defects. The third response came from Dr. Michael Roizen, the Chief Wellness Officer of the Cleveland Clinic who basically said yes because people don't eat good diets.

I was infuriated that he answered as he did. I met the man a little over a year ago when I visited the Cleveland Clinic in Ohio. The purposes of the trip was to explore partnership with him and the Clinic regarding my new prevention initiative. (For full disclosure, there were a number of subsequent conversations and correspondences after the trip as I vigorously pursued the opportunity. Eventually, however, I walked away because I found their terms of partnership to be highly lopsided.)

Notwithstanding, during the trip, I had an opportunity to speak to Dr. Roizen in privacy. During that time, which was relatively early in my auditing the field of prevention, I asked Dr. Roizen which dietary supplements he believed stood out among all others and that he would personally recommend for daily consumption. His list included baby aspirin, fish oil, probiotics, Vitamin D, and turmeric.

On the surface, it's not a bad list. Under the right set of circumstances, the first four have clear benefits. However, he did not know my medical history and therefore it was probably imprudent to him to make such specific recommendations, but then again I asked and he was happy to oblige. (Read more about this in part 2 of this blog.) 

For example, aspirin can prevent platelet aggregation (thereby decreasing blood clots) and some studies show some benefit in preventing colon cancer, but aspirin can also increase gastric bleeding and can lead to the development of macular degeneration. Given my history of gastric ulcer, aspirin is a tough choice.

One of my recent blogs dealt with fish oil at length, so just to summarize, its not the panacea everyone has made it out to be and given the option, eating fish like Wild Alaskan Salmon beats it hands-down.

Another one of my blogs dealt with probiotics and an extensive body of research supports my assertion that probiotics have no benefit if you have a generally healthy gut. They can be beneficial when taking antibiotics and when dealing with inflammation of the bowels, but they are not useful routinely.

Many people are apparently (I say apparently because no one knows for sure) Vitamin D deficient because of lack of sun exposure. However, treating anything on presumption, I believe is a mistake. First of all, many foods are fortified with Vitamin D so even though one does not get much sun exposure one is not necessarily deficient. Second, it is easy enough to check for a Vitamin D deficiency and by doing so the result will indicate if you there is a need to supplement and also how much should be taken.

So viewed in their entirety, the first four suggestions from Dr. Roizen were not outlandish as they generally do not cause harm (except for aspirin.) and may be beneficial at times. Tumeric, however, is another story.

Dr. Roizen told me that tumeric prevents Alzheimer's and is good for brain health. Based on Dr. Roizen's suggestion that day (and my hearing him repeat the same advice a few days later on the Retirement  Living TV channel), I naively purchased tumeric and began to add it regularly to my food.

Unfortunately, the highly staining substance turned my teeth bright yellow.  After this disconcerting turn of events, I began intensively researching tumeric and discovered two disturbing facts. First, tumeric has little validated science to support its use for the indications Dr. Roizen asserted. Second, I discovered that in the absence of a black pepper called piperine, tumeric is very poorly absorbed by normal ingestion and so adding it to my food was an effort in futility, except if turning my teeth yellow was my endgame. (By the way, I had to go to a dentist to get rid of the stain.)

Despite these five recommendations, I should have been even more wary of Dr. Roizen's advice when he also practically whispered to me, as to share a well-kept secret, that a certain statin drug had also been shown to decrease the development of Alzheimer's. The whispering should have been the giveaway. All statins are now widely accepted to have no efficacy for such purposes, but I suppose he was depending on some source of information to make his claim.

So now you know why it was disturbing for me to read about Dr. Roizen confidently disseminating advice about multivitamins.

Part 2

After reading Dr. Roizen's comments, I became curious about his background and read his bio available online. I find his credentials to be excellent.  I started thinking why a person like him would spew out what I believe is basically worthless, if not harmful advice, with such certainty. I also started thinking about Dr. Oz, a close friend of Dr. Roizen, (they've authored a number of books together and Dr. Roizen is an adviser to the Dr. Oz Show). Like Roizen, Oz's credentials are also top-notch.

Why, I asked myself, are such erudite men propagating such apparently bad advice about dietary supplements?  Why were they either ignoring or reaching different conclusions that I do from the numerous studies now widely available that show the dangers of dietary supplementation?

So let's assume for a moment that I am reaching the more valid conclusions. If so, what causes them to support the industry? Your first instinct may be to say money, but I dismiss money as the main motivator because I suspect they have already accumulated enough to live quite comfortably and I don't believe that for such distinguished and successful clinicians, it is the end to end all.

So what's the answer? I thought back to a recent episode of The Dr. Oz Show. The guest was a cryptographer (hand-writing expert). As part of the show, the expert analyzed a writing sample from Dr. Oz. His conclusion based on how Dr. Oz forms a wide-open at the bottom scripted 's.' was that this demonstrates that Dr. Oz is very susceptible to the opinion of others. Basically, he concluded that Dr. Oz's popularity stems from his genuine desire to please others. I think most people would agree that this is a pretty good trait to possess.

Let me preface my next comments by stating I have basically no training in psychotherapy. All that follows is conjecture. If you are interested, allow me to speculate why I think this trait of wanting to please others can be problematic especially for physicians in the limelight.

Most physicians are highly intelligent and possess a great deal of accumulated knowledge. Patients know this and expect doctors to be able to routinely answer their questions. However, the body of clinical knowledge, which continues to grow daily, is already far beyond anyone's grasp and that is why there are many specialties and sub-specialties in medicine.

For doctors in the limelight, however, they work hard to create a persona of all-knowing. They want to be viewed as saviors of sorts, able to help both small and wide audiences alike. They never want to disappoint by saying I don't know or I'm not sure.

This realization has caused me to think about my own approach. Until a few weeks ago, I grew more confident in my assertions and more provocative in my conclusions. Then a funny thing happened which I wrote about in another blog. During one of my lectures, an audience member challenged my statements virtually one by one. This forced me to recalibrate and make sure that everything I was saying was defensible. I think my conclusions were generally accurate, but generally was no longer good enough.  I realized after that talk that I was falling into the same trap that I think many before me have fallen into.  I realized that because almost nothing in regards to science can be said with absolute certainty, that it is not fair for someone who can get up and comfortably speak to an audience to assert otherwise.  A speaker should not be expected to always please his or her audience out of expediency if it is the truth that the audience needs and wants.

I believe that many of the doctors like Hyman, Oz, Roizen, etc, say what they say not because it will make them even more money; rather, because it will make their audiences like them more as they offer simple solutions to complicated problems. Some problems require the audience to work hard to accomplish effective solutions and promising quick fixes may be dangerous and inappropriate.

I promise to keep Mark Twain's words close to heart whenever I speak and write. Twain said "it's not what you know that gets you into trouble, it's what you know for sure that does."  Accordingly, as I continue to learn more about dietary supplements, I will work hard to report the facts (if they can be called as much), not my biases. I promise to answer "I just don't know" when that is the most appropriate answer. I think my patients and audiences deserve no less. What do you think?

What About Probiotics?

During my lectures on supplements, I am often asked "What about probiotics?" Before I share my common response with you here, let's first make sure we agree on the definition of a probiotic. According to the NIH's National Center for Complementary and Alternative Medicine, probiotics are defined as follows:

"Probiotics are live microorganisms (in most cases, bacteria) that are similar to beneficial microorganisms found in the human gut. They are also called “friendly bacteria” or “good bacteria.” Probiotics are available to consumers mainly in the form of dietary supplements and foods.

[(Prebiotics are non-digestible food ingredients, like oligofructose and inulin, which stimulate the growth and/or activity of "good bacteria" in the digestive system.)] 

The concept behind probiotics was introduced in the early 20th century, when Nobel laureate Elie Metchnikoff, known as the “father of probiotics,” proposed in The Prolongation of Life: Optimistic Studies that ingesting microorganisms could have substantial health benefits for humans. Microorganisms are invisible to the naked eye and exist virtually everywhere. Scientists continued to investigate the concept, and the term “probiotics”—meaning “for life”—eventually came into use.

Picturing the human body as a “host” for bacteria and other microorganisms is helpful in understanding probiotics. The body, especially the lower gastrointestinal tract (the gut), contains a complex and diverse community of bacteria. (In the body of a healthy adult, cells of microorganisms are estimated to outnumber human cells by a factor of ten to one.) Although we tend to think of bacteria as harmful “germs,” many bacteria actually help the body function properly. Most probiotics are bacteria similar to the beneficial bacteria found naturally in the human gut.

Various mechanisms may account for the effects of probiotics on human health. Possible mechanisms include altering the intestinal “microecology” (e.g., reducing harmful organisms in the intestine), producing antimicrobial compounds (substances that destroy or suppress the growth of microorganisms), and stimulating the body’s immune response.

Probiotics commonly used in the United States include Lactobacillus and Bifidobacterium. There are many specific types of bacteria within each of these two broad groups, and health benefits associated with one type may not hold true for others."

Okay, so now you have a good broad understanding of what they are, the question remains should you actively consume them?  I have studied this subject extensively, and yet I claim no definitive expertise on it because there is so much ongoing study. However, here is what I can tell you.

As far as I have come to understand after review of multiple sources, probiotics do no harm. Of course, that statement only holds true within reasonable limits. If outlandish quantities were consumed (trillions), I'm not sure what would happen.  For example, even drinking too much water can be harmful as it would overwhelm the kidneys and flood the gastrointestinal system.

So if it probiotics aren't harmful, does that make them helpful?  For general use, the jury is still out, but the overwhelming consensus and numerous previous studies suggest that they provide no real benefit for a person with a healthy gut.  Changing the bacteria composition of one's gut is not easy under normal circumstances, and in fact, most commercially available probiotic products neither contain sufficient colonies (need at least 1 billion) nor the wide range of different types of good bacteria to make any difference.

(As a side note, carnivores (meat eaters) typically have different bacteria colonies than herbivores (plant eaters). The significance of this fact is not well understood at this time. Also, immediate family members often have the same bacterial colonies and if a family member wants to be restored to their historical composition after a bout of serious infection or illness, it can be accomplished by fecal implant through a nasogastric tube or sometimes through a fecal enema.)

So when are probiotics helpful? They are helpful when you are taking a course of antibiotics, which by definition kills all bacteria, good and bad. The probiotics help to replenish the healthy bacteria even as the unhealthy perish. Probiotics are also believed, based on several studies, to be helpful with diarrhea, dysentery, and allergic gastritis.  In fact, with diarrhea related illness, they are said to reduce symptoms and duration of disease by as much as 50%.

(On a personal note, I can attest to their apparent efficacy after recently being afflicted with such a viral illness. Taking probiotics gave me some relief, even if it was only through peace of mind that I was doing something to help myself. Imodium and electrolyte replacement with pedialyte helped as well.)

Some studies report benefits from taking probiotics with Irritable Bowel Syndrome (IBS) and inflammatory bowel diseases such as Crohn's Disease (Terminal Ileitis) and Ulcerative Colitis. They are also reported to be useful for atopic eczema (a skin condition most commonly seen in infants) and with Helicobacter Pylori or H Pylori as it is often referred, infections, now known as the main cause of gastric ulcers.

The good news is that studies are continuing and we expect to have more definitive answers in the not too distant futures.

In the interim, I suggest you save your money and only use probiotics when either something has already gone wrong that may be amenable to correction with probiotics, or in the case of you are taking antibiotics where they may prove protective.

Notwithstanding, make sure that you only use products that contain at least 1 billion colonies and have at least a few different strains.   VSL3, Bio-K, and Lactobacillus GG seem to be three reputable products. (No, I have no financial or other relationship whatsoever with any of these manufacturers.)

The best advice I can give you is be careful what you put in your mouth, don't eat anything if you are not sure it is fresh, and wash your hands well before eating. Also, learn how to manage your stress. These protective measures may spare you ever needing a probiotic. Stay healthy, my friends!