Finding Freedom from IBS: The Truth About Probiotics and Your Gut

Jessie (00:00):
Welcome to the IBS Nutrition Podcast, your go- to source for navigating the complex diagnosis of irritable bowel syndrome. Here, we dive deep into IBS and discover the power of diet and lifestyle to find freedom from your IBS symptoms. Whether you’re newly diagnosed or have been managing IBS for years, you are in the right place for relief. I’m your host, Jessie Wong, FODMAP dietician and a gut expert. For years, I suffered from debilitating gut symptoms that kept me out of work, feeling constant discomfort in my body and anxious around food. Today, I’m in control of my IBS, able to eat the food I love again, travel whenever I want and spend quality time with loved ones. It is my mission to help you do the same and transform the way you live with IBS. Let’s get started.

(00:53):
Hi everyone. Before we dive into today’s incredible interview, I want to give you a quick heads up about a specific study we discussed in this episode. During our conversation, Dr. John Damianos talked about a fascinating clinical trial he led at the Mayo Clinic. He was studying the effects of a multi-strained probiotics on patients with IBS diarrhea, specifically those dealing with bioacid malabsorption. Because we recorded this interview before Digest Disease Week, also known as DDW, the biggest GI research conference in the world, the result of his study was strictly kept confidential, meaning he couldn’t officially share the outcome during the recording. But the great new is that DDW is over and I was there in person to get you the study results. So I have recorded a special follow-up for you at the very end of this episode where I break down exactly what he learned studying the multi-strained probiotics for IBSD.
(02:13)You are not going to want to miss the twist at the end of his research, so make sure you stick around until the very end of this episode. To hear the official results, now let’s dive into the show.

Hi, welcome to another episode of the IBS Nutrition Podcast.
(02:53)Today, we are diving into a topic that comes up constantly in the IBS world. Probiotics. Many people with IBS wonder whether probiotics can actually help with symptoms like bloating, diarrhea, constipation, and abdominal pain, or whether they’re just another overhyped supplement. The truth is, the science on probiotics is evolving quickly. We now know that not all probiotics are the same. Different strains may have different effects and certain probiotics may be more helpful for specific symptoms or conditions. So today we are talking about where the science currently stands on IBS and probiotics, what the microbiome actually does, and how to know whether probiotics may be worth considering. And we have two amazing guests joining us today. We have Draganas Kokovic Sanji, who is a clinical pharmacist and menopause society certified practitioner. With over two decades of expertise, she has been a pioneer in educating healthcare professionals and patients on managing menopause symptoms and supporting women’s health through natural health products and probiotics.
(04:05)She’s also a global leader in probiotics education. She’s the author of the Annually Updated Clinical Guide to Probiotic Products and the founder of the Alliance for Education on Probiotics, which empowers healthcare professionals and patients with evidence-based tool. And we also have Dr. John Damiano, who is a clinical fellow in gastroenterology and hepatology at the Mayo Clinic in Rochester, Minnesota. His clinical and research interests center on the role of gut microbiota in GI health and disease, and particularly how microbiome therapies can be used to prevent and/or treat disease. He is a member of the Scientific Advisory Committee to the Alliance for Education on Probiotics, and has helped developed medical and pharmacy school curricula on the microbiome and probiotics. He is currently a leading clinical trial of probiotics for patients with chronic diarrhea from bile acid malabsorption. Thank you, both of you, for joining me.

Dragana (05:16):
Thank you for having us.

Jessie (05:18):
Yes. And we are going to discuss a few topics. First of all, we want to talk about what is probiotics, what are the definitions, and what are prebiotics and things that are related. The second topic we’ll talk about is our current evidence of use of probiotics, positive evidence, negative evidence, regulations, recommendations in the US, and how it divers from around the world. And then the third topic is talking about long-term studies on whether taking a probiotics is safe long-term. So let’s go ahead and get started with our first topic. What is a probiotics and what is a prebiotics, post-biotics, and seen biotics? There’s so many biotics these days.

Dragana (05:59):
As you mentioned, biotic is something that is a bit of a buzzword these days. And quite often, I find my patients do not really understand much of the difference. Probiotic, prebiotic, symbiotic, and more of these things entering the realm of biotics. There are specific definitions that are international or globally accepted. They are done by the special consensus statements by the specialists and experts in the area. So probiotic, by definition, is live bacteria that when is administered in adequate amounts, can confer a health benefit to us to host. So basically live and adequate amount and proven health benefit, that is a probiotic. So not all friendly bacteria is probiotic, not all bacteria found in food is probiotic. It has to have a proof and has to be alive in that amount that can actually provide a benefit. So this is a definition on probiotic.

Jessie (06:08):
Well, now let’s also move on to maybe what prebiotics are.

John (06:14):
If we understand the good bacteria in the microbiome, which as Dragana was mentioning, not necessarily probiotics, but the beneficial gut bacteria that are endogenous to our microbiota, there are substrates in the diet and in the environment which can either enrich or can deplete these microbes. And so our understanding of prebiotics are substrates or food you can think of for these beneficial bacteria. So they’re substrates that are preferentially used by beneficial bacteria to proliferate, to maintain colonization in the microbiome and to create beneficial metabolites. So you can think of it as food for the good health sustaining bacteria in the endogenous microbiome. Jessie (06:08):
Right. And are prebiotics mostly fiber?

John (06:18):
Fiber is the most common category of prebiotic, but there are actually many other components that can be considered as prebiotic, substrates for beneficial bacteria and their utilization, their growth, the promotion of beneficial metabolites. And another main category that’s often overlooked is polyphenols. So a lot of the components in fruits and vegetables, some of the components that make them vibrant and colorful actually have direct prebiotic effects and stimulate the growth and production of beneficial bacteria and their metabolite.

Dragana (06:51):
That’s fascinating. And also just to add, keeping in mind, not all fiber is prebiotic. There are fermentable and non-fermentable fiber, so not all fiber is prebiotic. So it’s kind of really confusing, defining even prebiotic properly.

Jessie (07:10):
Right. And I would say for IBS patients, oftentimes we are recommending the load FODMAP diets and that is removing a lot of the prebiotics from their diets because FODMAPs are fermentable fibers that are really beneficial for patient’s guts. So those would be a prebiotic fiber. Well, yes, it’s not as straightforward as it seems. Yes. And now what about symbiotic? I think that is a name that we are seeing a lot more, but what is the science behind it?

Dragana (07:44):
I’ll jump in right here. So symbiotic is also defined specifically by the consensus statements, and there are different kinds of symbiotics, but basically just to keep it simple, symbiotic is a combination of a beneficial bacteria that has a proven benefit and food that will feed that same bacteria or prebiotic that will feed commensal bacteria in our gut when administered along with this probiotic. So basically a combination of pro and prebiotic together that have a proof that will actually provide a health benefit that is symbiotics. So it’s not only just any kind of probiotic and any kind of potential prebiotic will be called symbiotic. They has to have a proof, they either work well together or they feed the commensal bacteria.

Jessie (08:38):
Okay, that’s great to know. Okay. And last one is postbiotic.

John (08:44):
Sure. So a postbiotic is a non-living component that is derived from bacteria that has some sort of beneficial effect. And our gut microbes create many different types of metabolites, hormones, various byproducts. And so to give a concrete example, one of the very potent effects that our most beneficial gut microbes has is the ability to ferment fiber into short-chain fatty acids. And these short-chain fatty acids like acetate and butyrate are profoundly anti-inflammatory and have effects both locally and systemically. And so the concept of a postbiotic is can you take something that is a beneficial metabolite or byproduct of bacteria and just isolate that one product. So butyrate, for example, if you isolate butyrate and administer butyrate, that itself would be considered a postbiotic.

Jessie (09:56):
Okay. And we are seeing some products that claims to be postbiotics on the market. What are the science here so far about these products?

Dragana (10:07):
I’ll jump in again. Yes, you are seeing lots of different kinds of products call themselves probiotic, prebiotic, postbiotic. I would also add that there is still lots of discussion about postbiotic. Definitions are proposed, but still not globally accepted what postbiotic is. So as John mentioned, butyrate, for example, is one, but still in a discussion whether it’s a metabolite, is it product of fermentation done by bacteria, or is it remnant of the bacteria in animate or unlived bacteria and parts of the bacteria is that postbiotic? So again, proving the benefit of it, which is replicable, so that’s kind of also challenging. So products right now, there is a bit of a gray area, what is postbiotic from the marketing kind of stand. Any dead bacteria would be postbiotic, but does it have actually health benefit? That’s a big question.

John (11:19):
Think this applies to all of the biotics types of products, especially in place, I think we’ll come to this a little bit later too, in places that lack stricter regulation, there really is no accountability from the company’s standpoint to prove that what’s in their product is actually what’s on the label and that it has a demonstrable health benefit. I mean, even something as simple as a probiotic that says, “Oh, we have this much of this bacteria.” There’s no guarantee that that’s actually true. And I think that applies across the board for any type of biotics type product.

Jessie (11:58):
Well, since we are talking about regulation, why don’t we stay on the topic? Now, Dr. Damianos, you are an expert in this area. Can you explain to us what regulations are there in the US in terms of regulating supplements and probiotics in particular?

John (12:16):
This is such an important question. And I often liken this somewhat jokingly to the Wild West because at least in the United States, there’s really a frightening lack of regulation. And this stems from the simple fact that in the United States, probiotics are considered supplements, not medications. And so they fall outside of the regulatory purview of the FDA. And so because of this, companies really are not held accountable for what’s on their labels. There’s no mechanism to hold them accountable for this. And does this have functional consequences? It absolutely does. There have been now numerous studies where researchers will go into a grocery store or pharmacy and take a sampling of probiotics at random off the shelf and then perform sequencing analyses to see if there’s concordance between the label and what’s actually in the product. And unfortunately, what’s been found over and over is that there are many discrepancies between the label and the product.
(13:26)And there are specific discrepancies, including discrepancies in dose. So there may be a lower dose than what’s listed. There may be a discrepancy in strains. So they may say that there’s a particular strain or mix of strains, but there may be other strains, not the proper ones, and even potentially unlisted ones. There is the potential for antimicrobial resistance genes. That’s been shown, which I find very frightening, that some microbes actually harbor these antimicrobial resistance genes, which might further antimicrobial resistance. And so for all these reasons, we really need to move beyond telling patients to take a probiotic or to give them this carte blanche of try any probiotic and give them very tailored recommendations based on their unique personal circumstance and point them toward not just specific formulations, but specific companies and products that we know follow strict production principles that we can say with in good faith, we know exactly what we’re giving you.
(14:42)We know the dose, we know what’s in it, we know that it’s not contaminated with these other contaminants and microbes, et cetera. Now, we’ll probably go into some of these resources like the Alliance for Education on Probiotics. We’ll definitely talk about that. I think there’s reason to be optimistic in the future. The FDA now has a category of live biotherapeutic products. And there are two agents which are approved both for the treatment of recurrent clostradioid difficile infection. And I know that a lot of probiotics companies are eyeing that label to say, “Can we change our formulation and apply for an indication through the FDA under this live biotherapeutic product category?” And so I have a sneaking suspicion, and I know that there are some companies racing to do this, that we’re probably going to see clinical trials coming out that have a goal of these probiotics for all intents and purposes, fall under this label of live biotherapeutic products from the FDA, and we’ll be able to give patients a much more confident answer at that point.

Jessie (16:00):
That is wonderful.

Dragana (16:02):
Yeah. I want to add something else. John, you’re talking about regulation in USA and regulation in Canada, where I am, are maybe a little bit stricter, maybe more defined. But again, there’s not much of the enforcing of that regulation. Any company producing probiotic needs to file all the information and data with the natural health product directorate with Can Health Canada, but they don’t have to put the label strain on the label. And what that means in a real life is, for example, I’m not going to mention any brand names, but there was a brand name very recognizable in Canada that up to 2010 contained lactobacillus rhamnosus GG, which is well-known strain with good, lots of proof of benefit. And this particular product was stocked in most of the hospitals. It’s on a hospital formulary. In 2010, that company stopped having a right to distribute the strain in Canada.
(17:13)They have changed the strain to lactobacilism noses HA111, which does not have any proven benefit. It’s not harmful, but has no benefit. However, if you don’t know, strain is not listed on a label and people in hospitals assume it’s exactly the same as what I’ve given before. So the last 15 years, these patients were given probiotic that does not have any proof. So those are situations that can actually have really far reaching consequences. And this is something that we are trying to educate everybody about and change.

Jessie (17:53):
Yes. Well, since we are talking about this, well, we’ll talk about recommendations per country, like what the US recommends in terms of treating IBS and probiotics, but let’s talk about labeling for probiotics. What is a probiotic strain? What is the labeling? I’d like to think of it as a first name, middle name, and last name, but you guys have better vocabulary. Yeah.

Dragana (18:20):
So again, it is really a confusing part of the probiotic is when my patient tell me, “Oh, I’m taking lactobacillus.” Thinking that told me everything about it, it’s almost like taking a medication. We don’t know which one. So the bacteria is defined by genus, species, and strain. So those long names, lactobacillus, which is now all broken down to even more subgenuses, and then you have the species, acidophilus, for example, and then you have series of numbers and letters that defines the strain. And the last part is the most important one, giving you the information about actual bacteria. And this is, I would say the most difficult part because communicating with patients, it’s difficult. Nobody remembers those numbers and letters at the end and communicating the dose format and everything else, it’s really challenging. And again, John can jump in, but this is one of the main reason why we started producing and publishing the clinical guide to probiotic products, basically putting all that information in a chart form, but connecting it with the brand names available in different markets at any particular time.
(19:50)And because this changes frequently, we update this guide annually and we update the guide because information and evidence also is changing and growing, so we can adjust and review the new evidence every year.

Jessie (20:06):
Well, thank you for sharing that. I think one of the things I hear a lot is too, when patients go bioprobiotics, they read the labels. Let’s say it says lectospacillus rhinosis, but it doesn’t have the strain after it. So we really have no idea what is in the bottle. It’s definitely not … Well, it probably is not LGG, which is what we usually recommend, like lactose bacillus, rhinosis GG. But then if it doesn’t say GG, we can assume that it is GG.

John (20:33):
And I often use the analogy of E. Coli. If I just say E. Coli, that doesn’t really mean anything. I mean, you might think of if you’ve ever had a UTI that was attributed to E. Coli or a patient in the hospital had a bloodstream infection from E. Coli, or if you read news stories recently about B for lettuce contaminated by E. Coli leading to a recall or a child who developed kidney failure from hemolytic uremic syndrome from E. Coli. Those are all big scary things, but there are also probiotic strains of E. Coli like E. Coli Nisley, which has some evidence in patients with ulcerative colitis. And so there probably are effects and mechanisms of probiotics that occur at varying taxonomic levels. And some of these are probably shared, but a lot of effects are actually strain specific. And that is just the fundamental point when it comes to probiotic selection is we have to really understand the effects at a strain specific level and tailor our recommendations to patients based on that.

Jessie (21:45):
Yes. Well, let’s also talk about the guide since we are talking about this. How can patients find the guide? And that’s something we use in our clinic as well.

Dragana (21:54):
So the guide is something that has been in works for almost two decades. We started with the Canadian guide first and then US Guide a little bit later. We even tied the European versions of the guide. So the guide, the goal is to provide a guide free of charge. So it’s easily accessible for the clinicians and patients on as a website or as a mobile app. Website in US is usprobioticguide.com. So basically very simple, usprobioticguide.com or on your app store, just put probiotic guide. You’ll see three versions, US, Canadian, and UK, pick one that is in your region. And once you download it, you can actually use it offline as well. And it’s the website and mobile app are interactive. You can actually search by your indication, your age, or just to scroll down and see all the probiotic brains that have been listed and you can see what can be used for, what kind of studies we reviewed to actually assign that indication to the product and what level of evidence or recommendation we assign to the product.

Jessie (23:10):
Also, a word of caution just for our listeners. Anytime you’re trialing a supplement, make sure to talk to your healthcare providers about this and understanding what outcome measures that you are hoping to achieve with the supplement so you are tracking your symptom progress. It’s a great guide and I hope anybody listening to the podcast look it up, especially clinicians, because we hear doctors recommending probiotics all the time, but they don’t tell patients what to get. Just go to the grocery store, see what’s available. And most things on the grocery stores are not evidence-based. I hate to say that, but that’s just the reality of where we are living in the US and probably in Canada as well. All right. Well, next, let’s talk about recommendations according to guidelines. Where are we in terms of IBS recommendations?

John (23:58):
So I can speak to the US Professional Society guidelines that come from the Gastroenterology Societies. Both the American College of Gastroenterology Guideline on IBS and the American Gastroenterological Association Guideline for IBS recommend against probiotics actually for IBS outside of the context of a clinical trial. Now, the US is somewhat of an outlier here because if you look at other professional GI Society guidelines such as in Canada and in the UK, probiotics are recommended. So where does this disconnect come from? Well, it comes from a few different places. Number one, it comes with some of the inherent challenges of the probiotics literature. And some of these I alluded to before. In the United States, with the lack of regulation that we have since probiotics are considered supplements, there’s a lot of challenges to performing robust high quality clinical trials. So a lot of the evidence for probiotics comes from small trials with high rates of bias.
(25:09)There’s a lot of heterogeneity, even if you’re looking across the same strain, there’s often different doses, different durations, different trial setups. And so it’s very difficult to get high quality data from probiotics. And so because of that, the US societies have endorsed caution in probiotics. Now, does that mean that there’s not benefit? Absolutely not. There has been consistent benefit in IBS. And in fact, the AGA did a technical review in 2020, and they looked at probiotics for various indications, and they made some positive recommendations, some negative recommendations. And IBS, they actually made no recommendations because they said, “There’s conflicting data. There’s too many confounders here. We actually can’t make a recommendation here.” Consistently though across not just clinical trials, but meta analyses, there has been modest benefit for probiotics. And now we’re beyond the point of looking at meta-analyses which cross different strains, which makes no sense at all.
(26:19)And we’re at the point where we can do meta-analysis on particular strains and do network meta-analyses that try to compare efficacy across strains when there’s no good head-to-head studies. And there is a consistent benefit for global symptoms of IBS, specific symptoms of IBS, including abdominal pain, bloating and distension and diarrhea particularly. And the most robust meta-analysis to date was in 2023 and looked at specific strains, which was excellent in my view. And so I do suspect given the consistency of the evidence and the relative consensus globally, I do suspect that the next American GI Society guidelines, at least one of them is probably going to have somewhat of a positive recommendation for probiotics. That’s my sneaking suspicion.

Jessie (27:21):
Right. Well, and the hope is it will be more strain specific, right?

John (27:26):
And I think it probably will be. And I’m optimistic for that because for those of you who follow the guidelines in inflammatory bowel disease, the AGA came out with a clinical practice guidance on pouchitis and inflammatory disorders with the pouch in patients with IBD who have undergone ileoanal pouch anastomosis surgeries. And for the first time in the US, probiotics were included as a recommendation. They specifically recommended probiotics to prevent recurrent pouchitis in patients who’ve experienced one episode of pouchitis, but they went one step further and they recommended a specific formulation, which is an eight strain high dose probiotic formulation. And so they actually called it out by name because that’s where the data was derived from. So I’m very optimistic that people are thinking about these things, having these conversations. And so I really would not be surprised if specific probiotics were recommended in the next set of guidelines.

Dragana (28:26):
That is our ultimate goal to actually have those specific recommendation and specific kind of comparison. Just to add to what Dr. Damianos mentioned, last year we worked with Dr. Domianos and with a few other experts and prepared the online continuing education module on IBS, in which we compare the different guidelines globally. And then we kind of did kind of a deep dive into the studies, what specific symptoms were helped with what specific strain or combination of strains. So it’s really good, very comprehensive review of the probiotics in IBS. It’s available free of charge for self-paced study at home on the Alliance for Education on Probiotic website, which is aeprobio.com website. So I would definitely encourage you, if you’d like to know more about what specific studies we’re talking about as strains, it’s in that online module. And also communicating this information with the patients, we have the education guides for patients, which is one page PDFs, Canadian and US versions are available, and you can actually provide this to the patient email or print, which explains the probiotics in IBS, but also on the backside has a list of products that have been proven and are included in the Guide for this specific indication.
(30:02)This also is updated annually to reflect what is listed in the clinical guide provided products.

Jessie (30:09):
That’s amazing. We’ll make sure to include the links in the show notes. So anybody who wants to learn more, I really encourage you to learn more before you trial or pay money for any of these products. They’re really expensive. And if you get something that’s not potentially helpful and can potentially be harmful in some cases. Now, our last topic here is about long-term health consequences with taking probiotics. Where are we on the science in this space?

John (30:37):
That’s a really important question and it’s somewhat of a black box. And I say somewhat because it’s very difficult to truly suss out effects of therapies that patients are on. And this is true with any therapy for years and years and years. So there are a few things which I think provide optimism. And there are also a few things that I think should make us a little bit cautious. And I’ll begin with the optimistic things. One is which we live in a time where probiotic clinical trials are exploding. There’s so much enthusiasm and excitement about probiotics, and there are many, many clinical trials.
(31:30)Every day I read about a new clinical trial that’s starting. And as part of that, you hope that there is good assessment of adverse events. And there’s really reassuring safety data from clinical trials that have spanned decades at this point. We have a lot of safety data. Now that said, there’s a great review from another great probiotics organization, which is ISAP, the International Society for the Study of Prebiotics and Probiotics, I believe is what it’s called. And they’re a fantastic organization. And they wrote a few years back a comprehensive review on the safety of probiotics. And one of the things that came to light was that a lot of probiotics clinical trials actually do not adhere to the recommended standards for safety reporting outcomes, particularly following the completion of a clinical trial. So even though we have really reassuring safety data from trials, we do have to be cautioned that some folks are not adhering to the recommended monitoring.
(32:39)Now, similarly, another reason that we can be optimistic is that the FDA also has an adverse event reporting system. And there are over 10 million reports of probiotics and the safety of probiotics. And adverse events, I believe it was 74 out of 10,000 reports made. So really reassuring safety data from over time and pharmacovigilance studies that the FDA has done. Now, the ISAP review brings up some really good points. One being the potential non-adherence to safety and adverse monitoring protocols. Another one is just a lot of the unknowns of what chronic use does to the endogenous microbiome. What effect does exogenous microsupplementation have? Are you actually hindering the microbiome in any way? Are you causing immune activation? Because we know that probiotics interface with the immune system. Are you causing excess immune activation that could actually precipitate autoimmune disorders? We’ve seen this phenomenon in fecal microbiotic transplantation.
(33:55)And similarly, I brought up antimicrobial resistance genes. Many, even probiotics do harbor antimicrobial resistance genes. And what does that do to the global threat of antimicrobial resistance? So these are all very good questions that I think still need to be answered. Another question that often comes up is immunocompetent versus immunocompromised. A lot of our data comes from the immune competent populations, but there are much fewer data in the immunocompromised populations. And it’s one of the most common questions I get from clinicians of, are probiotics safe in immunocompromised populations? And I think in general, they are. We actually have a lot of good safety data, but probiotics rarely can cause invasive tissue infections and bloodstream infections. And when it happens, it is most commonly in the most severely immunocompromised patients. So I think we need to learn a lot more about the safety of long-term use, and particularly in higher risk patients like those who are immunosuppressed or not immunocompetent.

Jessie (35:10):
Yeah. Well, I want to share a little bit. When I did my training to become a dietician, I actually worked in a GI hospital and one of the units that I spent a lot of time in was the GI transplant units. And at the time I was thinking, why don’t we try probiotics with the patients? And my dieticians leading, teaching me, my preceptors were saying, “We don’t have safety data. We don’t know if it’s safe for them because that for patients who have had transplants, they’re immunocompromised one. And then they also may have higher risk of blood infections from their surgery.” So I think that’s something we don’t often think about. We think of it as something very benign, like what Dr. Damiano was saying has good safety data, but is it for everybody? It may not be for everybody. I want to go back to the first point you were making.
(36:00)You were saying companies were not complying with reporting adverse events. I want to just clarify that and make sure everybody listening understand what you were talking about. So you’re saying mostly safety, like they report everything, but sometimes they might withhold information and that’s what ISAP was finding.

John (36:18):
Well, it’s not necessarily that they were withholding information or that they were being dishonest about the findings. It’s more about that the recommended monitoring principles to see if patients were having adverse events during the clinical trial and after the clinical trial weren’t always being followed. So it’s not like they were being dishonest. It’s more that they may be missing adverse events if they weren’t following these protocols properly.

Jessie (36:47):
Gotcha, gotcha. Okay. Well, thank you for clarifying. Now, I know Dragana, you have a couple stories that you want to share with us of patients how using probiotics was helpful or maybe not helpful for them. Jagala, do you want to go ahead?

Dragana (37:02):
Some always interesting stories, anecdotes from my own patients, it’s almost doing detective work. One thing I wanted to say just before COVID, I was working in primary care in a clinic and we started asking patients specifically if they are taking probiotics because up to then they would tell us, we would always reconcile their medication list that we have on our electronic medical record. They would ask what vitamin supplements they would be very forwarding to tell us what they’re taking. But for probiotics, they were just not even thinking it’s a supplement. They would think, “Oh, it’s a natural something, good bacteria.” So we were so surprised that up to 95% of our patients were taking probiotics. They had no idea what they’re taking or why. They just heard it’s good. So they were taking. Even those low socioeconomic status areas, people were wasting their money on things that they did not need.
(38:01)So that’s number one. Throughout COVID and after we had a bit of pandemic lockdown, did not see patients in person for some time. And I’m seeing my diabetic patient that A1C went up very significantly and we were anticipating that maybe we need to move from the oral medications to insulin because something is not working. What happened, actually, this particular patient, this older lady that lived alone, kids to support her immune system in COVID, purchased a combination of strains that nobody knows what’s in it in one of those big grocery store brands, and she was taking it. I guess she had a reaction to it, or I’m not sure whether there was to probiotic or to filler, and she developed diarrhea. That was really difficult to control. So in order to fix it, she discontinued her oral medications for diabetes. And then she stopped exercising because she could not go out to exercise, to walk, because she was afraid of controlling her bowel movements, et cetera.
(39:08)So her sugars were not controlled. When she reported everything, we decided that we will maybe stop the probiotic, maybe introduce something to contract that bowel movements. In two weeks, the issue completely resolved after which she stopped probiotic. So we were planning to provide some other recommendation for different probiotic that will stop diarrhea. She refused to even touch probiotics in the future and we resolved, we restarted her oral medication for diabetes. So that was a resolve. It’s example of things that she did not need probiotics. She took something that has no evidence and she had a reaction that could have had some really far-reaching consequences for her complication of diabetes. So that’s one example. Another example also is me working in a community pharmacy years ago, seeing patients would come almost once a week to purchase Imodium or loperamide. Always hunched over in a big jacket, really not friendly, not talking to us to the point when I noticed this kind of frequent purchasing of Immodium, I engaged with her.
(40:21)Somehow she said she has IBS, she tried everything, she has fed up with everybody recommending something, nothing is working, she cannot function. So I recommended just a trial of a probiotic lactobacillus plantarm 299. We had a nice brand recognizable in Canada. So she took it kind of very reluctantly to try. A few months later, I’m seeing somebody that is waving to me and thanking me and just going to purchase something. And I said, “Who is this person?” Never seen this patient in my life. My technician said, “This is the same lady that was coming in all hunched over in a big jacket and not wanting to … This is exactly the same person because this is local person. They know them.” And I guess she says, “Thank you for giving me my life back.” It was such a simple recommendation. She completely resolved all the symptoms and was able to function differently.
(41:22)So just kind of the dramatic examples of if you need something, get something that has a proven benefit and evidence. And if you don’t need it, there’s no point of wasting your time and money.

Jessie (41:38):
Yeah. Dr. Damianos, do you want to share some? I want to also say something too before you start is we in our clinic see a lot of elderlies taking probiotics and having significant diarrhea. And as soon as they stop, or if their doctor decide to try them on a dose of rifaximin, it just stops everything as long as they don’t take the probiotics. So be very careful. If you’re listening to the podcast, check in with your parents as well, make sure they’re not just taking random things off the shelf. Yeah. Dr. Damianos, tell us your clinical experience.

John (42:11):
Absolutely. And first, I just want to echo one thing that Dragana said. I’ve really come to, in my clinical practice too, when I am looking at my patient’s medications in the electronic health record and I see that a probiotic is listed. I always make it a habit to ask what probiotic they’re taking. And I don’t have physical data like Dragana did, but I would say 90 to 95% of the time in my experience, they don’t know. And they say, “Yeah, I just take this probiotic.” And I asked why? And it’s like, “Well, I’ve heard that this might be good for me. ” And so there’s a lot of opportunity for education when we face these circumstances. There’s so many stories that I could tell that relate to probiotics. I’ll kind of share two, one general one and one specific one. A general one is where, and this is a question that I get asked a lot, is where do you position probiotics in the management of IBS?
(43:20)Because nowadays, we’re at a very fortunate place where we have effective diets, effective medications, effective talk therapies, gut-directed hypnosis, there’s virtual reality and AI-based tools, there’s devices, there’s supplements. We have this menu of options that’s exploded. So where do you place probiotics? And in my experience, the patients that find the most benefit from probiotics are these, what might be called subclinical chronic gastrointestinal symptoms or subclinical IBS. And there’s emerging evidence on this patient population, which is that we know from a lot of different studies that chronic gastrointestinal symptoms are the most common types of symptoms that the general population experiences. And a subset of those will have severe clinical level symptoms that meet ROME-5 criteria for disorders of gut brain interaction like IBS, but there’s a really substantial portion of the population that has chronic abdominal pain, altered bowel habits, bloating that doesn’t quite meet criteria, but they still have very bothersome symptoms.
(44:37)These folks are not included in clinical trials. Their insurance companies often do not cover them for IBS medications because they don’t meet the criteria. And I find that these patients tend to respond very well to probiotics. This subclinical chronic GI symptom group, I find, responds well. Now, to give a concrete example, one of the other problems of studies of probiotics in IBS is the heterogeneity of IBS. IBS is, in many ways, an umbrella term that’s often kind of inappropriately used to explain symptoms that to date have not been elucidated under a unifying diagnosis. And we know that there are many both mimickers of IBS, but also conditions that go hand in hand that many patients with IBS have. And I’m very fortunate at my institution that we can test for bile acid malabsorption, which is present in about a third of patients with IBS, particularly IBS with diarrhea.
(45:46)And so I have recently with my colleagues and my mentors designed a clinical trial of a probiotic for patients with chronic diarrhea from bile acid malabsorption, this IBS type idiopathic bile acid malabsorption, not patients who have had their ileum resected or have another structural and mechanical reason that they would be malabsorbing bile acids, but this IBS phenotype, IBSD phenotype of bile acid malabsorption. And we’re using a probiotic that has been very well studied and has benefit in other gastrointestinal conditions. And I can’t speak to the results of the study, even though I know them, they’re embargoed because we’ll be presenting them at a digestive disease week in just a couple weeks from now. But what I can tell you is I’ve had a few patients who I’ve tried to enroll into the trial when we were enrolling still and who didn’t meet criteria for various … We had very strict inclusion, exclusion criteria.
(46:55)And I still offered them the probiotic to say, “Listen, I don’t have the results, but we have reason to believe that this would be effective. You’re having this chronic diarrhea, you’ve tried all these other things, you’ve not responded to bile acid sequestrants. And so if you want to try it, I think it’s reasonable, a self-limited trial.” And so one patient agreed, and I got two calls from her. The first call was she was very excited because that same day she brought her dog to the vet and her dog was actually prescribed the same probiotic, which was a first for me. And then the second was a month later, I asked her to give me an update and she said, just like Dragona’s patient said, “Thanks for giving my life back.” She said, “This has made a tremendous difference in my life.” And I hope that our clinical trial will kind of affirm that, but it’s really rewarding whether it’s a probiotic or not, when you can help a patient get their symptoms under control, get their life back, get the control back.
(48:00)And I’m sure Jagan and I both have so many stories of patients just like this. So I could talk all day about this, but I thought those were good representative examples. Dragana (48:13):
It’s interesting, John, is I have different kinds of patients, different kinds of patients with chronic conditions. You have a patient with diabetes and you control their sugar and you know that by controlling the sugar, you’re preventing complications or you’re giving the statin for some very high cholesterol that is ticking bomb for heart attack. Those patients never send me flowers, but patients that we resolve IBS symptoms, they send flowers, cookies to the whole office and everything else. So those patients are extremely great because they feel the difference. They feel difference very quickly.

Jessie (48:48):
Yes. GI conditions are very debilitating and for any of our listeners, they would understand. Well, I really want to say thank you for all of your time, sharing your knowledge with us. And Dr. Damianos, I can’t wait to hear the results at DDW in about two weeks. Any last words you want to share with IBS patients or maybe clinicians listening to the episode?

John (49:12):
I would say that don’t discount probiotics. I think a lot of clinicians in particular throw out the baby with the bath water. Don’t let the lack of regulation and the methodological limitations that are inherent in the probiotics field deter you from using effective therapies with patients. We have to empower ourselves and our patients to turn to evidence-based resources like the clinical guide and like ISAP to rely on the experts who think about these things and do the legwork for us and provide evidence-based recommendations for our patients.

Dragana (49:52):
Just to echo John’s words, definitely encourage patients and clinicians to check the resources that you put together, that you work hard. The whole team is working hard to provide annually updated, best reflective, up-to-date evidence on probiotics. Everything is all there online as mobile app, even in print, just check the Alliance for Education on Probiotics Resources, a clinical guide. And if any questions, any issues, let us know. And thank you again, Jessie, for getting us together and letting us speak about our favorite topic. Thank you.

John (50:39):
Yeah. Thank you, Jessie, for having us. And it’s always a great honor to be with Dragana, who’s just been such a pioneer. So I’ve always in the face of greatness when I get to be on the same podium as her.

Jessie (50:52):
Thank you. But Dragana, thank you for starting the guide because we all rely on it and it is a useful guide. Like I said earlier, all of the links will be included in the show notes for anybody listening. So thank you again.

Jessie (51:12):
Welcome back. As promised at the beginning of the episode, I’m here to share the official results from Dr. Damianos clinical trial on probiotics and IBS diarrhea, which he just presented at Digest Disease Week. I had the opportunity to review the research at the conference and Dr. Damianos also sent me an email summarizing the final data and there is a fascinating twist at the end regarding the power of diet. Now, I want to read you his exact email so you can learn the findings directly from him and here’s what he shared. The main positive finding from the study where that’s the probiotics reduced fecal CDCA level, a toxic primary bile acid that promotes diarrhea, inflammation, and increased permeability and it improved intestinal permeability. Leaky gut. Okay. Symptoms like the number of stools and stool form did not differ between probiotics and placebo group. The point about the diet is that we had all participants follow a whole food diet prior to the test for intestinal permeability.

(52:24) Even though all of the participants had a prior diagnosis of bile acid malabsorption, many of them no longer had it at the time of the initial testing, which I suspect may be due to the whole foods diet. This makes me think that further research should look into whether a whole foods diet can treat bile acid malabsorption and why process food may promote bile acid malabsorption. End of his quote. Okay. As a dietitian, I find this incredibly validating. It’s a powerful reminder that while targeted supplements and probiotics have their place in healing the gut environment, the foundation of your diet is extremely important in managing GI disorders. Improving your diet can have a profound impact on managing your symptoms. So thank you everybody for sticking around to the end to hear the updates. I will make sure to link the clinical guide and all the resources we discussed in today’s show in the show notes.

Thank you for tuning into the IBS Nutrition Podcast. We hope today’s episode has brought you closer to understanding and managing IBS. Remember, you are not alone on this journey and finding freedom is possible. For more on IBS, make sure to follow us on your favorite podcast platforms and please leave us a five-star review. We would really appreciate that. You can access links mentioned in this episode in the show notes to learn more about your type of IBS and how to identify your own food or lifestyle triggers. Register for our free IBS Masterclass, Three Steps to IBS Relief for our proven, holistic three-steps approach to managing IBS once and for all. Until next time, take good care of your gut and hears to your health and happiness.