Three perspectives on probiotics

probiotic pills on white background

Probiotics are a growing global commodity, with the pharmacist being called upon to help customers sort the facts from the fiction

While a myriad health claims exist with very limited clinical evidence, there are some established health benefits.

The World Health Organisation defines probiotics as ‘live micro-organisms, which when administered in adequate amounts, confer a health benefit on the host.’ This definition has prevailed and is still widely used today but where the contention lies is in what exactly the health benefits are.

If you search good old Dr Google, as let’s face it many of us do, you’ll find a plethora of conflicting information claiming probiotics improve digestion, boost immunity, reduce the risk of certain cancers, prevent constipation and diarrhoea and lower triglyceride levels. So it’s no wonder that many people view probiotics as a ‘magic pills’, that can do them no harm yet could potentially do them a great deal of good. If only it were that simple!


What the pharmacist says

Debbie Rigby, consultant clinical pharmacist, DR Pharmacy Consulting, says,The human microbiome is an exciting area of current research from newborns to older people. Pharmacists need to recognise the human microbiota changes with age. The composition of the microbiome varies by anatomical site and interpersonal variation is substantial. Dysbiosis or an imbalance in gut microbes is associated with many diseases. 

“The ‘normal flora’ of the gastrointestinal tract includes lactobacillus, bifidobacterium and about 400 other strains of bacteria, fungi, and parasites. Strains of lactobacillus and bifidobacterium bacteria are the most commonly used probiotics, as they can survive the passage to the gut and form part of normal healthy intestinal flora.

“There is some evidence from trials that probiotics may prevent antibiotic-associated diarrhoea in some adults and children. But limitations with the trials mean that the true effect of probiotics is uncertain, as is the most effective product or dose.

I think it’s important for pharmacists to know where the evidence lies, which probiotic is supported by evidence for particular conditions.

Research on probiotics overall is largely positive for reducing the risk of diarrhoea related to antibiotic use. Disruption to the gut flora by repeated courses of antibiotics can be addressed with probiotics. Many probiotics have been studied for antibiotic-associated diarrhoea. It makes sense that probiotics might have a role here.

“Antibiotics kill off the normal flora and in the process set up a situation that is ripe for growth of pathogenic organisms. Taking a probiotic is thought to replenish the normal, healthy bacteria and therefore prevent over-colonization of pathogenic bacteria. Yet I don’t think patients should be advised to take probiotics with every course of antibiotics; pharmacists need to advise consumers that it will not necessarily work. For example, the number needed to treat (NNT) is 8—this means that about 8 people would need to be treated to prevent one additional case of antibiotic-associated diarrhoea.”

Rigby says, “Pharmacists can play an important role in reassuring consumers and parents that viral infections and the common cold do not require antibiotics; unnecessary use contributes to personal and population antibiotic resistance.” 

She adds that one of the big challenges for pharmacists recommending different products is that different species and strains have very different effects. 

“Seldom do claims of health benefits on the product packaging connect the precise probiotic strain inside to a particular condition. Often research is conducted with a particular species and strain that may not be commercially available. For example, there is good evidence that Lactobacillus rhamnosus GG accelerates resolution of cow’s milk allergy in infants, and also reduces eczema.  

“However, there is limited evidence or evidence of no benefit for use of probiotics for post-antibiotic vulvovaginitis, urinary tract infections and general health (being simply ‘good for you’).

“Unless specific strains are commercially available, products with multiple strains are best recommended with the dose of probiotics also making a difference. Products with 5-10B CFUs (colony forming units) are not sufficient; it’s like filling a lake one drop at a time. It’s also important to remember that the benefits of probiotics are lost within weeks, and therefore should be used long-term. 

“If a consumer wishes to use probiotics for a health condition that lacks high quality evidence, I would discuss their expectations and give them a timeline in which to assess whether it has made a difference or not. If no benefit or improvement in symptoms has occurred in a reasonable period, then I would not recommend continuation and wasting money.”


What the naturopath says

“Probiotics are a complex area of healthcare and I have found in my practice that prescribing the appropriate probiotics along with a supportive diet works wonders in improving the health of many of my patients. Taking an over-the-counter (OTC) multi-strain probiotic is a good practice, although people who are very immune compromised should seek professional advice beforehand, says Jan Purser, naturopathic nutritionist.

Antibiotics can alter the gut microbiome by killing beneficial bacteria. It can take the gut up to 18 months to recover from just one course of antibiotics.” In such instances Purser will often recommend taking probiotics.

“I might suggest taking a good broad spectrum probiotic before going to bed and at least two to three hours away from the antibiotics to try to restore gut health. At the same time, eat foods that contain resistant starch to feed the healthy bacteria in the gut. These might include slippery elm powder, brown rice, legumes, cooled roast potatoes and wholegrain foods rather than white flour and processed foods. 

In addition including a little fermented food in your daily diet is helpful such as kimchi, yoghurt, kefir and sauerkraut. It’s also vital to avoid overly processed foods and excess sugars as these can cause an imbalance in the gut by feeding less desirable bacteria. Alcohol also undermines gut health as does chronic stress and several types of medications, both OTC and prescription only.” 

Danielle Fairbrother, naturopath and technical services manager for Health World, says, “Whilst the term ‘probiotic’ is loosely defined as a bacteria that confers health benefits, not all probiotics act the same and their physiological effects are very specific to the probiotic strain.

“In the same way that a mechanic, hairdresser and school teacher all have very different roles within a community, so do probiotic strains within the body. Just as you wouldn’t take your car to the hairdresser to be repaired if it breaks down (hopefully you take it to the mechanic), you shouldn’t choose a probiotic strain that hasn’t been validated for the specific health benefits you are hoping to achieve. When it comes to gut health, there are several strains with extensive human evidence to support their benefits.

“Perhaps the most acknowledged indication for probiotics is their use alongside antibiotics to minimise the significant effects antibiotics can have on gut flora, potentially leading to unwanted digestive symptoms. When taken at a daily dose of 12.5 billion each, the strains lactobacillus acidophilus NCFM and bifidobacterium lactis Bi-07 have been shown to help maintain healthy flora levels during antibiotic administration. These effects are mediated through various mechanisms, but are essentially the result of these bacterial strains creating a favourable environment for other healthy commensal microflora.

However, these digestive benefits are not just useful for those undergoing antibiotic therapy. The more the science in this area evolves, the more we understand that the health of our gut microbiome is very vulnerable to daily insults such as stress, ageing, inactivity, a highly refined diet, and other medications outside of antibiotics suggesting that most people could benefit from this daily probiotic combination to protect their intestinal flora.

“Outside of daily microbiome protection and co-administration alongside antibiotics, a considerable area of research has focused on the use of probiotics to treat gastrointestinal conditions such as medically diagnosed Irritable Bowel Syndrome (IBS). In this instance, the strain lactobacillus plantarum 299v, has some of the most impressive evidence with one trial in over 200 individuals finding it significantly improved symptoms of IBS over three weeks of treatment and another trial finding that it improved abdominal pain, regularity of bowel habits, and decreased flatulence in up to 95% of subjects with IBS.”

Fairbrother points out, “Evidence is linking bacterial gut flora to many aspects of human health, causing probiotic manufacture and prescribing to go through the roof. As this research evolves we’re learning that when selecting a probiotic, correct storage conditions and strain-specific actions are key to achieving positive results.”


What the microbiologist says

Associate Professor Andrew Holmes, from the Microbiology unit within the School of Molecular Bioscience, University of Sydney, says, “The principal of probiotics is now well validated; where there is a deficiency in some process that is dependent on microbes in the gastrointestinal tract you can improve health by adding back in the microbes.  However, this has been widely over interpreted. When the deficiency is due to a specific microbe you could, in principle, add back just that microbe. This is what most OTC probiotics claim to do but I’m not aware of a single case where this is validated.

“When the deficiency is a specific type of pathology, for example inflammation and a single microbe is capable of addressing that, you could in principle take high doses and achieve a benefit.  This is where many strain-specific probiotic preparations have been developed and there is some evidence for efficacy.  

“For all non-specific health issues involving microbes probiotics are best thought of as one possible part of a broad-based solution that would need to consider lifestyle aspects such as diet as well.”

Holmes says that while taking probiotics daily won’t hurt you, there’s no evidence to suggest that such a blind approach is beneficial to health.

In an article, ‘Probiotics: facts and myths’, published in Clinical Microbiology and Infection authors concluded, “There is scientific evidence that specific strains of probiotic microorganisms confer benefits to the health of the host and are safe for human use. However, these cannot be extrapolated to other strains, as such effects are strain-specific. Use of probiotics has potential benefits for conditions such as gastrointestinal infections, genitourinary infections, allergies and certain bowel disorders, all of which afflict a considerable proportion of the global population. However, considerable work is required to affirm these benefits.”

For pharmacy, the most obvious use of probiotics, and an area where there is evidence, is alongside the use of antibiotics. If pharmacists can use this interaction with the customer to explain the potentially negative impact of antibiotics on gut flora it might go some way to helping reduce antibiotic resistance.

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