Should You Take a Probiotic for IBS? The Truth Behind the Hype with Bailey Hanna, RD

Jessie Wong (00:00):

Hi everyone. Welcome to a new season of IBS Nutrition podcast, and today I have a very special guest with me. And the topic we are talking about today is a question I get all the time and I can’t tell you how many hundreds of times I’ve gotten these questions about probiotics. So let’s welcome our speaker or our guest today, Bailey Hanna Bailey is a registered dietitian with a master’s degree in nutrition and dietetics from Loma Linda University. She specialises in IBS and digestive health and is the founder of IBS probiotics.org. A completely brand new resource decides to cut through the marketing noise and deliver evidence-based answers about probiotics use in IBS. Oh my God. Hi Bailey, how are you?

Bailey Hanna (00:51):

Hi, I am good. Thank you so much for having me on. I’m so happy to be here.

Jessie Wong (00:55):

I am so glad that you agreed to join us because there is just so much noise in the probiotic space. Everybody’s promising something, but then when we look at the research, there’s a huge gap in there and I’m so glad you are here to talk all about that. It can really help people cut through the noise and maybe not waste money or maybe sacrifice, maybe get hurt sometimes by these products. So let’s just get started. Okay. So let’s start with the basics. What is a probio?

Bailey Hanna (01:27):

So by definition, a probiotic is a live microorganism that when administered in adequate amounts provides a health benefit to the host, which would be us. So basically a microorganism that is defined and it is alive and it has evidence of benefits ideally from something like a randomised placebo controlled trial. So that’s kind of the gist. There’s a lot of confusion I think that people have about what exactly qualifies as a probiotic. You’ll often hear someone saying, oh, I had some kimchi and that had probiotics. Not exactly that would provide you with some live and active cultures and different microbes, but they’re not defined. So probiotics have to be very defined and we have to know exactly what we’re taking.

Jessie Wong (02:15):

Okay. Now there are two other terms that’s very similar to probiotics. If you can explain it before we go into more depth about the research, that would be great. One is prebiotics and the other one is sea biotics. Oh, actually, I guess symbiotics is something we hear all the time too. And

Bailey Hanna (02:34):

Yes, so a prebiotic is, you can think of it as kind of like the food for the microbes that you already have in your gut. So they help to support selectively certain beneficial microbes help those two proliferate. Whereas a symbiotic is kind of a combination where you take both a probiotic and a prebiotic and you put it together and there’s two types of symbiotics. So you can have complementary symbiotics where you have a probiotic and prebiotic that kind of work independently. So the prebiotic is just supporting your native gut microbes or you can have a synergistic symbiotic where you have a very specially chosen prebiotic that the probiotic that you’re taking feeds off of. So that’s kind of a little bit of background there. As for postbiotics. So I think there’s a lot of confusion about this term actually. So I believe the latest ISAP definition def defines postbiotics as inanimate microbes.

(03:35):

So basically microbes that maybe previously were kind of a probiotic in nature, but they have been deactivated. And postbiotics can also include metabolites of these inanimate microbes, but that is not actually required. It can just be the dead microbe, but it can also include other things like metabolites that probiotics create, short chain fatty acids, those sorts of things. And I think a lot of confusion happens there because people believe that the postbiotics are the short chain fatty acids and other metabolites, but that’s actually not the case. Those don’t have to be there, but they can be included.

Jessie Wong (04:13):

Okay, awesome. And you mentioned isap. I want to clarify for everybody listening. That is the International Scientific Associations for probiotics and prebiotics. So they are doing the bulk of the research or analysing the bulk of research for us and sharing with us the information. That is awesome. Thank you for clearing up the space. Now we hear a lot, and we use that term a lot as well in our practise, and that is strain specific probiotics for symptoms. Can you talk a little bit about what a strain is? How do we identify a probiotic strength? We see a lot of the time say a bottle saying lactobacillus, but it doesn’t have something else after that. Is that a strain?

Bailey Hanna (04:58):

No, not quite. So I think a really good analogy to use here, it would be like if you were saying, okay, I want to get a dog and just classify dogs in a broad sense, but if you start thinking about different types of dogs, there’s clearly a very different, clearly there’s a major difference between a chihuahua and a Great Dane and maybe the kind of lifestyle activities you would engage with either of these types of dogs. So you have to think of probiotics the same way. They have very specific kind of niche indications and very specific strains do specific things. And so you probably don’t want to get the chihuahua if you’re looking for a running partner. Same way, if you’re looking for a probiotic that’s going to help you with bloating, you’re going to want to find a strain that’s very specific to that.

(05:43):

And so the way you can identify this is in the name. So here’s an example of a probiotic that is listed out to the strain level bacillus coagulants, unique I two. So coagulants, once I’ve said that much, I have identified that probiotic at the species level. But the last part, I said unique I two, that third segment that is the strain level, and usually it’s going to be a combination of letters or numbers. Or another one would be like bacillus coagulants, Mt C, C 5 8 56. The MTCC 5 8 56 is kind of what designates it at the strain level. There are some rare instances where we can still achieve benefits at the species level. We mostly see that for probiotics found in certain fermented dairy products like yoghourts. We know that there are some species levels effects when it comes to helping break down lactose and possibly helping with lactose intolerance, but that’s kind of rare and more of the exception when you are looking into a probiotic that you’re, if you’re looking for a supplement, you’re definitely going to want species level identification.

Jessie Wong (06:59):

Species level,

Bailey Hanna (07:00):

Or sorry, straight

Jessie Wong (07:02):

Strain level.

Bailey Hanna (07:02):

Let me correct myself there. Strain level, not species level. Yes. Strain level identification. Yeah,

Jessie Wong (07:08):

Right. Looking for the, so I like to simplify a little bit for our listener. So if you are looking for a string, you will see most likely the first name, the middle name, and the last name on a bottle. When you are buying a probiotics for a probiotic string, if you don’t see the last part of the last name, which includes usually maybe a name with a number or alphabetical letters with numbers, then you’re not buying the string. And my understanding, sometimes companies don’t put the strings in the bottle is because if they can’t source the string, they’re going to switch it out for a different string and it would still be the same genius and species, but then it would be a different strain. Is that correct?

Bailey Hanna (07:52):

I mean, I would say it’s very possible. It’s also hard to identify products at the strain level if you come up with some kind of everything but the kitchen sink kind of blend, which you see a lot about there, which we’ll talk about that soon, why you probably don’t want to go for that. But what’s really tricky is we don’t have great essays to actually clarify these products down to the strain level. So I think they do that maybe so that they can kind of cover themselves, so they don’t actually have to prove what something is down to the strain level. But the problem with that is that you as the consumer now have no idea what these strains are or if there is any evidence tied to those strains for particular benefits you might be looking to achieve. And so it works on their behalf because they likely can’t prove down to the strain level what’s in their product, given the testing options we have available to us. But it really does not work on the behalf of consumers because now you just don’t know.

Jessie Wong (08:51):

Yeah. Oh, well now you brought up research. That would be our next topic, and I think people really want to learn about it. What is the state of research when it comes to probiotics? What are the evidence, what is also the quality, quantity and regulation? We’ll go through one at a

Bailey Hanna (09:06):

Time. So when it comes to my understanding of evidence quality for probiotics, I can mostly speak towards what I know in the realm of IBS. That’s the area that I’m most familiar with. And I would say that it varies depending on the specific product and the study design and what all went into that. There are some studies that have decent design, whereas there’s other studies that just really I would not trust. I would not take any clinical takeaways from those results because of the study design. I would say overall, there have been a lot of studies done on different probiotics in IBS, but it’s not like there’s any one single probiotic that’s ever been studied to the level that you see for a drug trial where you have multiple phase trials. So we have some soft evidence that shows a potential benefit here and there, not consistently across the board for all probiotics, but here and there where maybe a probiotic could be considered.

(10:16):

But there are a lot of pitfalls to that research that we have to be aware of as well. A lot of this is industry funded. That doesn’t mean that we automatically discredit the results because if the industry was not funding these things, we probably just wouldn’t have any data. But we do have to be careful and really pay attention to their methods and what they’ve done to ensure that we are trusting the results that they’re presenting to us. And a lot of these studies are also fairly small. There’s an exception here and there with 300 plus participant studies, but we have to recognise that we have kind of smaller population sizes that a lot of this evidence is coming from. So it’s a mixed bag here and there you see something that can allow us to have cautious optimism, but we should not conflate that as top tier evidence, surpassing other therapies that have a little bit more backing like diet therapies. And so it’s just helpful to contextualise where we are. I’m going

Jessie Wong (11:18):

To pause you here a little bit. I don’t know if I said it earlier. We are going to, well Bailey specifically will be giving out recommendations for IBS patients later on, but we do want to lay out the groundwork of understanding for probiotics first so that you have a better understanding. But later on, Bailey is going to share a five step recommendations for IBS patients so that you can pick the right string or work with your provider to choose the right thing for your rights condition or the symptoms that you want to work on. Okay. Let’s keep talking. Yeah, I think this is getting a bit deeper, and I think people don’t hear enough about this. A lot of the times we are just bashed with the marketing, with the advertisement, with endorsement from influencers, which beware not everybody’s speaking the truth. And of course they’re paid to say good things, they’re not going to say the bad things. And that’s something we will talk about in the research realm as well.

Bailey Hanna (12:12):

Well

Jessie Wong (12:12):

Actually since we are talking about it, let’s talk about this. There are research about different strains of probiotics and sometimes they only publish the positive results. They don’t always publish if something doesn’t go. So we don’t know if there are adverse effects. Sometimes that happens to it. Will you elaborate a little bit more on that?

Bailey Hanna (12:31):

So I think a really big pitfall for probiotic literature in general, and this is something that has been brought up many, many times, is that we need more structured adverse events monitoring in different probiotic studies. So it’s a big question mark of are we always capturing if something is going wrong? And then we also don’t have a lot of long-term follow-up data. So I think that that’s another thing to keep in mind about evidence quality and the literature. There are still things that we don’t know and hopefully we’ll start seeing more guidance on how to better structure probiotic clinical trials to capture some of that and to monitor things over the long term so that we can start filling those knowledge gaps.

Jessie Wong (13:20):

That’s amazing. Okay, so we are still talking about quality of the research. What about the quantity? I think you also mentioned length of the research, most of the research are pretty short term. Will you talk more about that and what is the long-term implication for us as a general population?

Bailey Hanna (13:36):

I would say most of the studies that I’ve encountered that are randomised placebo controlled trials of probiotics and IBS, which was my focus when putting together the resource we’ll talk about here soon, those studies would vary in duration from anywhere from four weeks to six months, and it was kind of all over the map. But I think for the most part, we only have short-term data, so we don’t really know what happens beyond certain time points. If somebody can reach a plateau effect where maybe they achieved initial benefits and do those dissipate, do they persist? How long can they persist after you stop? One of the cool things that I learned while going through a lot of the literature was that there were some cases where a probiotics effects would have a carryover effect for maybe 10 or so days, but then we didn’t have any more data beyond that.

(14:27):

And I think that would be really interesting from an administration standpoint of knowing, okay, how often do I need to take this and can I take breaks and maintain benefits? How long can I maintain those benefits? But I think when we don’t have long-term data, it kind of creates pitfalls with just the unknown, not knowing where things might go in the future or what certain risks or benefits might be, and also if there’s a way to sustain some of those benefits. So hopefully that will be something we see in the future that we start paying more attention to longer term studies and surveillance efforts to see what happens over the long run.

Jessie Wong (15:09):

Okay. So how long are usually the studies right now? Is it usually four weeks, eight weeks? Do you see anything longer than that?

Bailey Hanna (15:19):

I feel like eight to 12 weeks is more standard. I mean here and there you’ll have the shorter four weeks studies, but I think eight weeks is probably the most standard, but I’ve seen up to six months, that was one of the longer trials,

Jessie Wong (15:35):

But there are very few studies that would go to

Bailey Hanna (15:38):

Beyond that, at least in ibs

Jessie Wong (15:40):

It’s a lot of money. Right? Yeah.

Bailey Hanna (15:42):

Okay.

Jessie Wong (15:43):

Now, one of the biggest myth I hear on social media, on TV everywhere or even from friends and family is that you need to take a probiotics to improve your gut health. What is your take on that? Especially after reviewing all the research studies?

Bailey Hanna (16:00):

I think there is absolutely no evidence that someone needs to take a probiotic for general gut health purposes. I think if you want to take a probiotic, you need to be taking it for a very specific reason, like bloating, for example, or constipation. You have to have something very specific in mind that you want to address because otherwise, if you’re looking for general gut health, I think you should go for general interventions, right? Like a general healthy higher fibre diet, maybe incorporating some fermented foods. Go for those types of strategies and put your money and resources and time into working on that. And just remember that probiotics are for specifics, so don’t fall for any kind of marketing hype that’s pushing this whole gut health narrative on you. What does that even mean? I think we need to ask what does that mean in what context? And clarify what that means for you before you consider a probiotic.

Jessie Wong (16:58):

I love that. And when we talk about gut health foundation, we are really talking about getting enough fibre. And most, we know per research, 90% of Americans are not getting enough fibre daily. And we are talking about 25 grammes to 35 grammes depending on body size, depending on your own guts, and that is a lot of fibre every single day. 90% of people in America are not getting enough fibre. So that’s number one thing to work on. And then also eat more varieties. It’s not just shoving fibre supplements down your gut. You really want more diverse fibre into your gut and feeding different kinds of microbiome in there and help them thrive. If you only eat one type of fibre source, then you’re really only feeding one group of microbes. So the basics, the foundation is really eating, hitting your fibre goal and eating a wide variety of diets, feeding your gut microbiome and also sleep, stress, drinking enough fluids, moving your body, all those things that really helps improve gut health and general health.

(17:58):

There’s just no magic wand here with a probiotics, or at least not that we know yet that can actually improve gut health or gut function. Oh, I love this and I love what you’re saying, and research is limited quality can vary greatly. There’s a lot of quantities out there. How much, what would you say, looking at all the IBS research in there, what would you say is the percentage of a high quality research versus, or maybe, you know what, give us an example of a bad quality research. For those of you listening, if you don’t follow Bailey, you need to follow her on Instagram or TikTok. It’s Bailey Hannah Rd. She shares the most hilarious reviews about a probiotics trial. I’m going to let Bailey speak here about some of the interesting research and why they’re not validated.

Bailey Hanna (18:53):

Yes. So I think a while back, I had done a reel about this one study that I came across while putting everything together and basically this study, they had used a tool to measure symptoms of people with IBS to see if the probiotic improved IBS symptoms. But the problem was they added a lot of parameters to this tool that had never been part of the tool when it was actually validated and shown to work. And so they were adding in mood symptoms for a digestive symptom frequency questionnaire. And maybe that’s not a great idea, especially when we have a lot of other different types of tools that we can use that are validated for assessing those types of things. And I guess just doing it in a way where they were creating a study that if you weren’t quite sure what was going on, it would probably look like this probiotic was very impressive and had these broad spectrum effects, but it was a lot of data manipulation happening.

(19:58):

And it kind of takes knowing a little bit about these things, knowing about the tools that they’re using, what they’re supposed to look like, and then understanding how they’ve kind of just eliminated validity of these tools that they’re using to create these results. Or, I’m trying to think. There were so many things wrong with this one study that I was thinking of. Oh, there was another separate incident where I was looking over a study and notice that there were no inferential statistics. And by that I mean typically when you’re reading through a study, you’ll see things like a P value, which is telling us that there’s a difference from an intervention compared to a placebo group, and it looks like a 0.0005 or whatever. It’s a 0.00 whatever. It’s that kind of number. So there would be times where these stats would be totally missing and they would report data without any form of statistics, just like, oh, there was a percentage improvement.

(21:01):

And then upon closer inspection by a statistician that I worked with on this resource I’m telling you about soon, it was kind of this realisation that all of these things that they said were significant effects when we actually ran the stats ourselves, they were not significant effects. And so sometimes it’s not something you’re going to be able to spot just by reading a study. Sometimes it actually takes a very thorough analysis. And that’s so scary when you have research out there that has been constructed to create marketing materials, but that doesn’t have any sort of quality to it. And so that’s one of the things on IBS probiotics.org that we focused a lot on creating an evidence grading structure and system for ranking probiotic studies so that people can understand that if they are to try something, it comes from evidence quality that is at whatever level. And we also had firm disqualifiers where some data, we did not choose to give a probiotic credit for a benefit for whatever symptom it was claiming because the evidence quality was so poor that the results were not trustworthy and

Jessie Wong (22:18):

Wow. And these are the probiotics that we see in supermarkets online and everywhere, right?

Bailey Hanna (22:26):

Yeah, I mean, it kind of depends. So there are some more well-known options that had decent evidence, but then there were some that did not have great evidence. I think what gets really tricky though is that there are so many products that have no evidence at all. So many products that have just been thrown together. They have never been studied in a randomised placebo controlled trial and shown to have any sort of benefit. It’s just whatever someone dreamed up in their own mind. And I didn’t even touch those products with the database, with the IBS probiotics.org database. I was exclusively looking at what actually had evidence because that’s kind of a non-starter. If we don’t even have baseline level of evidence on a probiotic, then we shouldn’t even be contemplating it because we have no idea what it’s going to do.

Jessie Wong (23:16):

Absolutely. Now tell us more about this tool that you’ve created. It’s IBS probiotics.org.

Bailey Hanna (23:24):

So this is basically an ad-free website that you can go to totally freely available where I’ve worked to collect data from randomised placebo controlled trials of probiotics in IBS and organise that data so that you can get a better sense of which probiotics have been studied and shown promise for which specific symptoms or not shown promise. Sometimes they had neutral effects. And then basically the goal of this resource is to facilitate better conversations with medical providers and IBS patients when discussing what the evidence is for different probiotic interventions and another way that the website supports that goal. There’s a section that also talks about the guidelines for probiotics and IBS that have been published across the globe because there’s a little bit of regional variance there, and I think it helps to understand just the landscape when having these types of conversations and not automatically going in, assuming that a probiotic will be recommended.

Jessie Wong (24:34):

That’s great. Well, you brought up guidelines. Can you talk about what is the guideline right now in the US versus what is going on in the world? There are some IBS guidelines that recommends probiotics, but not all guidelines recommends probiotics. Can you touch a little bit on that?

Bailey Hanna (24:52):

Yeah, absolutely. So there are valid reasons for why guidelines in the United States might choose to go with that more conservative stance, but then on the other hand, you have guidelines coming out of countries like Japan or Canada that do endorse the use of probiotics in IBS. And I wouldn’t say that those recommendations are necessarily wrong either. There are justifications that could be made for that as well. So on the conservative kind of no stance, I think some of the things that you could bring up as a reason for taking that stance would be any sort of evidence quality concerns like we were talking about before, maybe small population sizes, risk of bias, industry funded studies, those types of things. And so that’s all very relevant. Also, things like dose uncertainties. Have we got enough evidence for any one particular probiotic to say, yes, this is it.

(25:50):

This is something we can recommend. So that makes sense in that context. I also think that something I’ve observed that’s kind of interesting, but maybe part of the picture maybe not, is countries that have less regulation as is the case with the United States, maybe have aired more on the side of a no, because you have to consider the population context in which those recommendations are being made. Maybe in countries that don’t have such a reactive type of enforcement system like we have here where we put a product onto the market and then we regulate later if there’s a problem and we need to step in. And that’s assuming we have enough resources to actually pull that off. Other countries don’t take that approach and regulate in advance before a product hits the consumer. And so it kind of makes sense how other countries that have regulatory steps in place to catch problems before they happen to regulate language around what a product can be used for before it’s given to the consumer, how they maybe would be a little bit more open to the option of a probiotic in IBS.

(27:09):

Because when you look at the data, yes, there are evidence quality concerns as a whole, but here and there are some options that have shown some promise. And I think the case that one could make for a yes stance is that we’re definitely always in need of additional therapies in IBS. I think sometimes we get to a point where we’ve made it as far as we can with the options that we have available, and nobody would ever want to say no to additional therapeutic options if there’s something that could potentially be helpful. So I think that that would be the kind of case for a yes, but that is not the case in the United States with our current guidelines.

Jessie Wong (27:50):

I love that, and that really explains why we don’t really recommend it in here. Now that brings us to probably our last point. What is your recommendations for IBS patients, especially the ones in the United States?

Bailey Hanna (28:05):

I guess my recommendation would be first and foremost, I think probiotics, given that we don’t have a unanimous consensus from all guidelines, I would likely look more towards other interventions first that we are a little bit more unanimous about, for example, like diet interventions. I think probiotics could be something to consider if you have exhausted other options that have a little bit more validation and consistent recommendations, and you’re still kind of not quite where you were hoping to be with symptom management, I think it’s reasonable at that point to consider a probiotic with your medical provider because you’ve already followed the guidelines at that point, right? You’ve already taken the steps and maybe you’re looking for some additional options. But I think that if you’re going to do that, you need to do that in a very structured way. So for one, you need to ensure that you’re a good candidate for a probiotic.

(29:05):

And I think you do that with your medical provider who can walk you through and see what you’ve tried, what you may want to consider trying still. You need to make sure that there may not be any specific safety issues for you on a personal level. For example, if you’re someone who’s immunocompromised, you really want to talk with your physician about that before you try a probiotic. That’s not to say that it’s totally off the table, but that would be a situation where you would want physician approval and monitoring if you were going to go that route. There are some rare instances where patients who are critically ill or immunocompromised taking a probiotic have run into issues like a bloodstream infection from a probiotic, for example. Very rare, but it can happen. So make sure you’re a candidate. And another thing, like we were talking about before, to be a candidate for a probiotic, you have to have a specific need that you’re trying to address.

(29:55):

It should not be, oh, I’m looking for general gut health, right? General gut health. We seek out general broad kind of interventions that we should all be aiming for anyway, just like getting the basics down. Probiotics are for specifics. And then I think from there, if you’ve determined that if you went alongside your provider, have determined that maybe a probiotic is an option to consider, I think what’s very, very important and what the resource I’ve put together aims to do is you need to match higher quality evidence of the evidence that we have out there with your specific symptom needs. And by that I mean you need to find research that is a randomised placebo controlled trial, must be placebo controlled due to the high placebo response rate in IBS. And it needs to show that a probiotic has shown promise for these specific symptoms that you are looking to address. And you also need to find other details within that research regarding the dose, the form, and the duration that a probiotic was taken. And that is going to form the basis for any kind of probiotic trial. So the website that I’ve put together, IBS probiotics.org essentially organises that information in a way that it’s easier to find so you don’t have to sort as much and also has some additional stuff that we can talk about in a bit to help with decision-making Related to that,

Jessie Wong (31:31):

I’m just looking on your website now and I’m seeing how many things have been, how many strings or brands have been disqualified, that’s eye opening. That tells us the state of research really must, a lot of the research out there is been very recognised or national international brand names. They may not actually have the research to back it up, but what they usually have when they’re internationally recognised is a very strong marketing budget. Would you

Bailey Hanna (32:00):

Agree? I would say that’s a big part of it. And funny enough, the whole basis for me creating this resource was I had worked with this one student intern that I was a preceptor for and she had very severe IBS and had exhausted a lot of options and she wanted to try a probiotic, and she asked me for my opinion, and I was like, honestly, I find it all confusing. Guidelines are all over the place. And I told her, I heard that this probiotic has been studied in IBS, so maybe that’s a place to start. And she tried it and surprise, surprise, nothing changed, no benefits. And when I dug into it a little bit more, I realised, okay, the evidence quality was really not that great, and the studies do not suggest that the probiotic actually would’ve addressed the specific symptoms that she was struggling with.

(32:46):

And I realised that even for myself as a clinician, I had just made a recommendation based more off of marketing hype than off of actual evidence. And it just totally lit this fire in me and made it to where I was starting to collect all of these different spreadsheets for myself where I’m organising like, okay, this probiotic did this and this one did this. And then bringing in a statistician later to help me organise that even further to see like, okay, were these effects truly seen if we look at it and recalculate their stats and which effects were strongest? So that’s kind of the basis of what the tool does. And it all started because I as an IBS dietitian, a clinician was duped by marketing hype. So yeah, I think it’s pervasive. It impacts all of us. It kind of gets into our psyche and if we really want to spend our money wisely and not fall prey to that, we have to look at things a little bit more critically and it takes time to do that. And so that’s why I work to put together that resource.

Jessie Wong (33:51):

I really appreciate you putting this resource together. I think we were still talking about the five considerations for I

(33:58):

Patients, but I also want to maybe jump in and share a client story real quick about misuse of probiotics is that you have, for any patients listening, you have to find the right strain that matches what your symptoms are. And actually, one of our previous client who came to us for significant diarrhoea, she went to a different dietitian, she went to her doctors, they actually recommended her and a probiotics that have evidence for IBS, however, that probiotic string had evidence for constipation, and for her, she struggles with diarrhoea, so it did nothing for her, and it potentially actually made her diarrhoea worse. So usually the first recommendation as a clinician in IBS and we see a lot of patient is stop everything you’re taking. Let’s see, because sometimes the probiotics or even the medication could be the reason why you are having all these symptoms. And we see this all the times now. I’m going to give you the mic again. So let’s walk through that. Five key considerations

Bailey Hanna (35:01):

You have

Jessie Wong (35:02):

For IBS patients.

Bailey Hanna (35:04):

Yes, and I love that example you shared. I feel like that illustrates so perfectly how important it is to take this kind of symptom specific approach. But I guess the third step comes down to after you’ve done all of your due diligence and you’ve actually been able to find something that has shown promise for these specific symptoms you’re looking to manage, you then are in this position where you need to find a reputable product. You can’t just go and take anything again, especially in the United States with our regulatory framework. So some of the things, there are a lot of considerations when it comes to finding a reputable commercial product. I think the most important one though is you want to find a product that has independent third party testing and verification for three things, purity. So to know that there are not any contaminants, potency, you want to make sure that the dose that’s stated on the bottle is actually in there and that it will be at an appropriate dose through till expiration. And then identity, you want strain level identification confirmed through this independent testing, I think you

Jessie Wong (36:22):

Say third party testing

Bailey Hanna (36:24):

To third party testing,

Jessie Wong (36:25):

Confirm the strain because otherwise we as consumers would not know what’s actually in the bottle, right?

Bailey Hanna (36:31):

And this is actually one of the areas where most commercial probiotics get disqualified. Most companies, if they have not put their products together very thoughtfully and they’ve done the whole kitchen sink sort of blend, are not going to have an easy time actually verifying down to the strain level that a product is containing the strains that they claim because we just do not have sensitive enough testing to do that. Also, if you have this mix that has bifidobacterium and lactobacillus, all of these different things grow on different types of assays. So how are you going to measure all of these things all together and actually prove viability very easily of all of these specific strains? So less is more, I would say, if you’re going to take a blend that’s especially like a mega blend, you want it to be one that’s actually been validated in research independently so that you can have an idea of what to expect.

(37:35):

Because if you’re trying to piece together the effects of a 16 strain probiotic where, okay, sure, maybe some of these strains have been studied here and there at these doses, and we’re just going to throw them all together and see what happens. We don’t really have a lot, we have no evidence that that’s actually going to work. And again, we’re not going to be able to verify what’s actually in that product given the limitations of current testing methods. So I think that’s a really big landmine. Another huge landmine to keep in mind for people who have IBS is other ingredients that are put into the probiotic. So you just want to be careful with that. And this doesn’t apply across the board because people have different levels of tolerance to different things. So sometimes someone maybe can tolerate a little bit of insulin just fine, and it’s not a disqualifier, but for someone that’s very inulin sensitive, you’re going to want to be mindful of added prebiotics or added sugar alcohols in gummies.

(38:32):

Gummies are the worst offenders. You don’t really want to take something that’s increasing all of these variables with different prebiotics and sugar alcohols and stuff, especially in IBS, because now you’re not going to be able to easily disentangle the effects of the probiotic from potential side effects of the ingredients in the probiotic. And I think the other major landmine that I would just call to people’s attention, I feel like the human psyche, we think that if there’s a lot of things listed on a label that maybe we’re getting added value, all of these different kind of cool sounding herbs and polyphenols, and I just want to offer a word of caution about that and kind of restructure our way of thinking of this. So I was chatting with a lady that does independent third party verification for probiotic companies, and she told me this horror story where a probiotic company was trying to create a synergistic beneficial kind of blend, and they added in a polyphenol with their probiotic.

(39:46):

And sadly, that polyphenol just so happened to have antimicrobial effects and killed the entire batch of probiotics. And this is such a disaster because they probably paid minimum order quantity of 15 grand to produce this batch of probiotics, and it’s useless. And who knows, I don’t know who the company was or what happened after that or if that product got sold, but now every single time I see these mega lists of all of these different herbs that are probably not even dosed in a way that they would even do anything, I don’t feel more confident in that product. I feel like there have been some added variables that I’m a bit more concerned about. So a thoughtful formulator that’s

Jessie Wong (40:31):

Destabilise the formula, right?

Bailey Hanna (40:33):

No,

Jessie Wong (40:34):

This is a really important point. I just kind of want to recap it for everybody listening. So you are talking about this third party testing company who tested the product and found out the products doesn’t have any life culture in it. So they found this because it was third party tested and most of the products out there are not third party tested. So we have really no idea what’s going on in a bottle. That’s what you are saying. And it’s so important to find a third party testing company or to find a product that has been third party tested. Now, big question for you here. What are we looking for when we are looking for a third party testing company? Do they have a label on a bottle? What will it

Bailey Hanna (41:13):

Say? I mean, sometimes there are labels. For example, like USP is sort of the gold standard. NSFI think is another one. There are so many different ones, but I think one thing to keep in mind is USP certification. It’s a very expensive certification, so it’s usually going to be reserved for very, very large companies that can pay $60,000 or whatever it may be to get that verification. So I would say at a bare minimum, the company needs to be able to provide evidence of purity, potency and identity through an independent report. Whether they have that extra step or not, that would be ideal. You may not always encounter it, but at a bare minimum, there needs to be evidence that they have looked for purity, potency and identity.

Jessie Wong (42:08):

But how would we as consumer know, we can’t trust what’s put on the bottle unless we see a seal or a label. And I mean we still want to confirm it, but yeah,

Bailey Hanna (42:18):

So they should be able to produce the reports from an independent lab that is not from them, from Soros lab or whatever it may be. They should be able to produce independent results.

Jessie Wong (42:29):

And we can’t perhaps go on the website of a probiotics and look for that report. And if they are legitimate, they will put that report somewhere on their websites, right?

Bailey Hanna (42:37):

Yes. Now another thing, so there is kind of this companion embedded site on IBS probiotics.org called probiotic finder.org. We kind of separated it a bit from the original resource because we wanted any brand specific information to be away from a lot of the data. And also because a lot of the different brands that may contain different probiotics, those probiotics strains can be present in more than one brand. So if you go on some of the individual pages on IBS probiotics.org, there is a button you can click to view that resource. And so that website has kind of a collection of different probiotics that we found that met certain criteria for showing different beneficial effects in IBS populations and organises probiotics that contain different strains that were studied based off of do they have additional irritants and things that may trigger symptoms? Do they have a transparent formula where all of the CFU dosing information is clear? Are they including all of these excess strains that have never been studied in IBS? Do they have third party independent verification posted on their website? So all of that has kind of been collected in that one space to help with the clarifying different companies that have checked certain boxes. But again, I feel like this is a great thing to navigate with a medical provider to ensure that you are still arriving at options that are more suited to your needs if you are someone who is a candidate for a probiotic.

Jessie Wong (44:22):

Right? Yes. Let’s go back to the five consideration. So the first consideration is to confirm that you are a candidate, clarify your therapeutic goals. Second is matching, finding a high quality evidence drain or brand that is specific to the patient’s need. And the third would be finding a reputable commercial products, right? Avoiding you roads here, avoiding probiotic landmines. And you’ve already shared a lot of landmine with us.

Bailey Hanna (44:50):

Yes.

Jessie Wong (44:51):

Okay. Step four and five if you want to go through that.

Bailey Hanna (44:54):

Sure. So I think the fourth step, so okay, you’ve gotten to the point where you’ve found a product that you want to try now you need to be thoughtful with how you’re going to go about that. So I think one of the most important things is to really be careful to isolate your variables. I think it gets really tricky if someone starts a low FODMAP diet and they’re starting a probiotic. Now we have different variables that are maybe interacting at once and we’re not getting a very clear picture of how any one intervention is working. So I would say take a probiotic in isolation so you can do this experiment and see how it works specifically for you. Additionally, I think the biggest question I always get when it comes to how to take a probiotic is just specifics related to that. Should you take it with food without food in the morning, in the evening, more than once a day?

(45:53):

All of these kinds of things. And I think we have drastically over complicated this question. So how you take a probiotic or the best way to take a probiotic, there is not one singular answer because that would be assuming that all probiotics have the same sort of survivability and the same kinds of dosing mechanisms needed same place in the GI tract, whether they’re where they’re active. So the best way to take a probiotic is for one, according to the dose that has been studied, but for two, according to manufacturer instructions. Because if you are taking a reputable product, then the formulators should have done all of the mental gymnastics for you in advance, and that’s cue to kind of just breathe a sigh of relief and say, all right, they say, I can take it with or without food in the morning. That’s that, right? And just go with it. So that is step four thoughtful application.

Jessie Wong (46:52):

That’s really good to know. Yes. And that is one question that we get all the time. When do I take it? Do I take it with food? Not with food, yeah. Okay. Follow the manufacturer instruction.

Bailey Hanna (47:03):

Yeah, they’ve already figured it all out for you. And then the fifth thing is, okay, so you’ve taken a probiotic. You’ve got to evaluate and monitor your personal response to that. So one of the things that we should have identified all the way back at step two is duration. How long was a probiotic taken in a clinical trial before a benefit was achieved that we’re personally looking to benefit or personally looking to achieve? So when you go into a probiotic trial, you need to have guardrails already in place. If I’m taking a probiotic where the evidence has shown that benefits were achieved within eight weeks, that’s my cutoff to reassess. So I’m going to try it and see if I achieve the benefit I’m going for by eight weeks, and if I haven’t, I’m going to stop taking it because there is no point in taking a probiotic that is not actually helping us.

(47:57):

The other thing too, we want to be mindful that probiotics do take a little bit of time to work. It’s not going to be a ride away kind of thing. There can be some time, especially in the first one to two weeks, where things might be a little bit different, a little dicey, maybe a little bit more bloated, loose stools during an adaptation period. That doesn’t always happen. But on occasion, that can be a thing that happens as a result of trying a new probiotic. I would say if is tolerable, it’s okay to sit with that for up to two weeks. But if you’re still experiencing that after two weeks, I would stop. I would personally stop because I feel like at that point, it’s maybe just not a good fit for you. And it is never normal to have severe abdominal pain, severe worsening of GI symptoms.

(48:41):

If ever you are at a point where you’re just having these really severe reactions to a probiotic, it’s just maybe not the right fit for you. And something I always like to tell people is that no matter what you’ve read about a probiotic, no matter how promising it sounds, no matter how alluring the marketing may be, every single probiotic clinical trial I have read had responders and non-responders, and sometimes we’re just not responders. The final test is always going to be your symptom experience, not what someone else told you, and not just whatever researcher or hype might be behind the product. Really just get in touch with how you respond and trust that.

Jessie Wong (49:25):

Absolutely. Oh my God, this is so good. Well, Bailey, thank you so much for your time. Well, for every episode we have, I actually like to share maybe a few good stories as well. And this one could be related to probiotics. And I love that you are talking about these five valid points because most people do not think through it before they try something. And one of my clients, I know there’s not a whole lot of studies about probiotics and sibo, but one of our previous clients who came to us, he had nonstop diarrhoea. He was losing weight loss about 30 to 40 pounds. He went to his P-C-P-P-C-P sent him to us, and we talked, we kind of work out on a diets and lifestyle kind of aspect, but we also dive deeper to find out what is really going on. He didn’t quite like that area.

(50:12):

He went to a different practitioner, actually did a lot of tests, one of those tests that have no evidence that it actually helps IBS and was prescribed a tonne of supplements. He was giving himself B12 shots at one point. So when things didn’t get better, he came back and we looked at what’s going on. And the first thing I found was that he was taking a probiotics, and the probiotics was actually giving him the nonstop diarrhoea. And these are the side effects that we are not seeing being captured in research, but we actually see that all the time in clinic, which is why our first recommendation is always, please stop everything you’re taking, especially probiotics.

(50:54):

And what happened was when we then sent him back to his PCP and also sent him to a GI as well to get further evaluation, what we suspected was that he had Sibos more intestine bacteria overgrowth. Well, I shouldn’t say there’s not a whole lot of research. We know there are research suggesting that taking probiotics of certain kind can’t put people at higher risk of having sibo. And that’s exactly what happened to him. And once we got his SIBO treated, his diarrhoea stopped. He was on the low for diet because he lost weight. He had a really, really sensitive gut at that point. But good thing is everything was fine. He went back to the gi, got all the tests done, everything was fine, and we were able to reintroduce all the FO maps without any issue. Toward the end of working together, this is like a six month project for us. This is a very severe case of IBS. Obviously, toward the end, he actually reverted back to more constipation. And I asked him, did you have constipation to begin with? And he was thinking back, right? Why did he start taking the probiotics? The reason was he had some bloating,

Bailey Hanna (51:56):

And

Jessie Wong (51:56):

Now after working together, we know exactly what caused the bloating. The bloating was caused by constipation, and he took some probiotics recommended by some friends to resolve the bloating, and it ended up giving him significant diarrhoea and causing significant weight loss as well. So like what you are saying, there are some research, but most of them do not have research, especially in the US market. There’s not a whole lot of regulation about this and be very, very careful.

Bailey Hanna (52:27):

I think that’s such a great cautionary tale. And it also kind of goes back to what we were talking about in step one where you really want to confirm with your medical provider if you are a good candidate, and part of that confirmation process would be your medical provider looking to see, okay, have we exhausted other steps that might be a better first step before we bring in a probiotic or even consider that as a therapeutic intervention? Because it sounds like he kind of ended up working in reverse and not arriving at what was going to be most therapeutic and helpful for him on an individual level through a probiotic on top as a bandaid and hope for the best, and it didn’t go well. And I think that that’s a really a great cautionary tale of how not to use probiotics. You need to get some other foundational things down first, and that’s when you can start contemplating and working with a medical provider to see if you’re a good candidate and you may not be a good candidate for one.

(53:23):

And another thing that you pointed out that I think is so, so important, he got all of these tests and was doing all of these types of interventions. I think there’s such a pull right now towards people trying these direct to consumer microbiome tests, and I get it. We all want to take a test that tells us, take this, and then you’re going to feel better. But I think we need to be very, very careful with that because there is just no good evidence that those tests actually result in beneficial outcomes if we’re using them in a prognostic kind of way. So

Jessie Wong (54:00):

Anyone who are listening who wants to learn more about these tests, we actually had an episode with Dr. Andrea Love talking about tests that you probably don’t need for IBS and why they are a red flag. So gut microbiome testing, food sensitivity tests, and then also some breath tests. We talked a lot about that, so if you want to go listen to it, it is episode six of the IBS Nutrition podcast. It’s so important because we see people spending thousands of dollars on these tests, supplements, and sometimes very restrictive regimens, especially when it comes to the food sensitivity tests. Everything you eat will come back positive and providers will tell you to cut out everything. And that’s exactly what happened to this client as well. He came to me and was like, I don’t know what I can eat because everything they say, I can’t eat anything. And I said, just throw that thing away. Don’t

Bailey Hanna (54:49):

Look at it again. Just don’t

Jessie Wong (54:50):

Do it. Don’t make yourself afraid of the food you love. And he did not have any food intolerances. It all really just started with mild bloating and that probiotics. So

Bailey Hanna (55:00):

Yeah, goodness gracious. Yeah, it’s so important to get the key things down and not go into those sort of unproven, non-validated testing options. It can really get you into a bad place. On that note, there was actually a study recently where a microbiome testing company tried to do prescriptive microbiome testing in IBS to give probiotics to a different population. And the results from that I found very fascinating, but not in a great way for them. So there was this company, they prescribed probiotics according to microbiome testing, and they claimed that there was a benefit in IBS. But then I looked at the results and it was a symbiotic combination I think that they were offering. So the study had no placebo control, so we don’t really know for starters how this intervention would’ve compared had they given people placebo. But the thing that got me really just kind of perplexed, they used this symptom monitoring tool called the IBS symptom severity score very commonly used in IBS clinical trials, and I am very familiar with this tool, and they claimed that they achieved a benefit, but when I actually looked, so the people in this study, I think the overall average point improvement on this scale, this IBS symptom severity scale, which is normally like a 500 point scale, was by 38 points.

(56:38):

Now, maybe that sounds great, but it’s not. And here’s why. Because we’ve had validation testing done on this tool both in 1997 and in 2016, and we have an idea of the minimum point improvement that you need to see on this tool for it to actually be clinically meaningful. And that range is between 50 to 95 points. We’ve gotten slightly different results every time we’ve validated this tool. So they had a 38 point improvement, this is what would be on par, if not potentially even worse than a placebo. Now on the other hand, there are probiotic studies in the database that use this exact same tool. There was one in particular that was one of the higher quality studies that achieved a 145 point reduction on the IBS symptom severity score, and they did no microbiome testing in advance. So until these companies are able to show and prove that they can beat out just an empiric trial where you just take it and see what happens based off of symptom specific evidence that already exists, we can’t use this information for anything to tell someone what to do. We should not be using this in any sort of interventional context. Really, I think it should be reserved for research context right now given where we are. So just know that the evidence isn’t there, and if it was, they would be able to prove that what they’re doing is superior to empiric trials and they haven’t done that yet.

Jessie Wong (58:13):

Yeah. Well, thank you for sharing that. Again, it just tells us that having things being researched and being promoted because they have research doesn’t mean the research was good quality or have evidence that it actually works. So it’s always important to talk to your provider and maybe a provider that understands what they are doing and understands where to look for the evidence and have a guide to what Bailey has, the IBS probiotics.org charts to help guide clinical decisions when you are working with your provider. Oh my goodness. Thank you so much, Bailey. This is extremely helpful because there’s just so much confusion out there when it comes to Proma probiotics. Some of them are so expensive and we know more money doesn’t mean they work better.

Bailey Hanna (58:57):

So, so true and thank you for having me. I’m so happy that I’ve been able to be here and talk about this, but yeah, you’re right. It’s just because you’ve paid a lot for something does not necessarily mean it’s going to be effective for you. It’s so important to really isolate what’s going to have the most potential to help, and then allow yourself to sort out, okay, did it actually help me? Did it actually improve those symptoms and kind of fall back on that as the final thing that determines if it was actually worthwhile for you.

Jessie Wong (59:28):

Yeah. Okay. Thank you.