Guest Editorial

Guest commentary: Weeding out the ‘good’ and ‘bad’ of probiotics for our patients

Gail Hecht
Gail Hecht

In this exclusive Guest Commentary in cooperation with the American Gastroenterological Association, Gail Hecht, MD, MS, AGAF, offers advice on how health care professionals can best discuss probiotics with their patients.

Probiotic foods and supplements have been on the market for many years but have recently grown in popularity. If you are a medical professional who sees patients with gastrointestinal disorders, you likely have found yourself fielding questions about probiotics and whether patients should take them.

What are probiotics?

Probiotics often described as “live microorganisms that when administered in adequate amounts confer a health benefit on the host,” which is the 2001 definition established by Food and Agriculture Organization of the United Nations and the World Health Organization. In a clinical setting, the “host” is the patient and the “live microorganisms that ... confer a health benefit” are most often bacteria, though they may also include other organisms such as yeast or fungi.

Many patients now understand that there are both “good” and “bad” bacteria, but not all may understand that a single species of bacteria can have “good” and “bad” strains. For example, most patients have heard of E. coli but may not know that there are particular strains that are thought to be probiotics (such as E. coli Nissle) rather than the pathogenic strains that cause food poisoning.

Further, most patients may not be aware that there is a wide variety of bacterial species and strains that have probiotic effects, and that certain communities of bacteria rather than single species or strains result in meaningful health benefits. Finally, recent studies suggest that individuals respond differently to the same probiotic product depending on their diet, genetics, microbiome and other aspects of their health.

Therefore, health care providers should continue to be their patients’ primary resource for clarifying information about probiotics and gut health. The American Gastroenterological Association offers education by specialists on probiotics that you can feel confident in sharing with your patients.

Which patients should take probiotics?

Probiotics are generally thought to be safe for healthy individuals, though recent reports have indicated that the potential harms of probiotic products may be underreported. Individuals who have a chronic disease, are immunocompromised, or otherwise vulnerable (such as the elderly), should always seek guidance from health care providers on whether probiotics may be appropriate.

Much of the research to date has focused on species and strains of Lactobacillus and Bifidobacterium that are thought to have probiotic effects. For example, Bifidobacterium infantis, Lactobacillus plantarum and the yeast Saccharomyces boulardii have been studied in patients with irritable bowel syndrome (IBS) and reported to be helpful with managing symptoms such as bloating.

Health care providers may recommend probiotic foods or supplements to patients during or after treatment with antibiotics. Normally, a person’s microbiome will recover on its own over time to a state generally thought to be stable, though it may not be identical to that person’s microbiome before antibiotics. The rationale for recommending probiotics with antibiotics is to preserve beneficial microorganisms and maintain that patient’s microbiome. For example, in patients with Clostridium difficile (C. diff.), a potentially severe infection often affecting people who have been hospitalized or are in long-term care facilities, probiotics containing Saccharomyces boulardii have been shown to reduce the chance of C. diff recurrence.

However, recent research in Cell has shown that taking probiotic supplements after antibiotics may delay the recovery of that person’s native microbiome and that this effect of probiotics is highly person-specific. More research is needed to understand the long-term consequences of this delayed recovery. However, since we do know that antibiotics can cause harmful changes in the microbiome — especially during vulnerable stages of life — this research serves as a good reminder to carefully consider the potential risk and benefit for individual patients (as for any human intervention) rather than using probiotics indiscriminately.

How to help your patients choose

Medical professionals who treat GI issues are an important resource for patients who suffer from these conditions and may be looking for ways to supplement prescribed therapies with lifestyle-based or over-the-counter interventions. Arming patients with as much evidence-based information as is available on probiotics is critical to direct them towards safe and appropriate products.

It is also important for patients to read product labels, store products as directed, and understand that a more expensive product is not necessarily of higher quality or performance. Product labels may list group and species of the probiotic bacteria in the product but not specific strains. Therefore, patients should be aware that they can call a company or look up information on a company’s website to find out which strains are in a particular product and the research that has been done to support any health claims listed on the product label.

While not every company is reputable or safe, there are companies that have a long history of producing probiotics, increasing the likelihood that these products have been appropriately tested and studied. Providing patients with a helpful list of companies like those listed on the American Gastroenterological Association’s patient resource page on probiotics can help further help people avoid scams or needless risks.

Probiotics and children

Probiotics are also increasingly being used to help children. Research about the use of probiotics in children has grown in recent years. For example, some studies have shown that Lactobacillus rhamnosus and Lactobacillus casei may be helpful in treating diarrhea caused by rotavirus that often affects babies and small children. Conversely, scientists are still not sure if probiotics are helpful to children with inflammatory bowel disease (IBD).

Possible side effects are a concern for any treatment used in children, especially if they suffer from a chronic condition. Health care providers should clarify any possible side effects of probiotics, such as gas or bloating, which are typically mild and short-lasting. More serious side effects are possible, such as allergic reactions to the probiotic itself or other ingredients in the product, in addition to possible infection in individuals with a weak immune system.

You can be a key resource for your patients and their caregivers in understanding important differences in the effectiveness of probiotics for children versus adults for the same GI issue, and, in general, help caregivers be fully informed before they take probiotics or give probiotics to their child.

Knowledge helps keep patients safe

While more research is needed about the effectiveness and safety of probiotics, your patients will have questions about how and when to use them.

Overall, you should be a resource to your patients and help them navigate the information about probiotics to ensure they’re being used effectively. This will ultimately help maximize your patient’s chances of a positive, beneficial experience with probiotics.

For more information: Hecht is chair of the American Gastroenterological Association’s Center for Gut Microbiome Research & Education, as well as professor of medicine and microbiology/immunology and chief, Gastroenterology and Nutrition at Loyola University Medical Center, Maywood, Illinois. She can be reached at media@gastro.org.

Gail Hecht
Gail Hecht

In this exclusive Guest Commentary in cooperation with the American Gastroenterological Association, Gail Hecht, MD, MS, AGAF, offers advice on how health care professionals can best discuss probiotics with their patients.

Probiotic foods and supplements have been on the market for many years but have recently grown in popularity. If you are a medical professional who sees patients with gastrointestinal disorders, you likely have found yourself fielding questions about probiotics and whether patients should take them.

What are probiotics?

Probiotics often described as “live microorganisms that when administered in adequate amounts confer a health benefit on the host,” which is the 2001 definition established by Food and Agriculture Organization of the United Nations and the World Health Organization. In a clinical setting, the “host” is the patient and the “live microorganisms that ... confer a health benefit” are most often bacteria, though they may also include other organisms such as yeast or fungi.

Many patients now understand that there are both “good” and “bad” bacteria, but not all may understand that a single species of bacteria can have “good” and “bad” strains. For example, most patients have heard of E. coli but may not know that there are particular strains that are thought to be probiotics (such as E. coli Nissle) rather than the pathogenic strains that cause food poisoning.

Further, most patients may not be aware that there is a wide variety of bacterial species and strains that have probiotic effects, and that certain communities of bacteria rather than single species or strains result in meaningful health benefits. Finally, recent studies suggest that individuals respond differently to the same probiotic product depending on their diet, genetics, microbiome and other aspects of their health.

Therefore, health care providers should continue to be their patients’ primary resource for clarifying information about probiotics and gut health. The American Gastroenterological Association offers education by specialists on probiotics that you can feel confident in sharing with your patients.

Which patients should take probiotics?

Probiotics are generally thought to be safe for healthy individuals, though recent reports have indicated that the potential harms of probiotic products may be underreported. Individuals who have a chronic disease, are immunocompromised, or otherwise vulnerable (such as the elderly), should always seek guidance from health care providers on whether probiotics may be appropriate.

Much of the research to date has focused on species and strains of Lactobacillus and Bifidobacterium that are thought to have probiotic effects. For example, Bifidobacterium infantis, Lactobacillus plantarum and the yeast Saccharomyces boulardii have been studied in patients with irritable bowel syndrome (IBS) and reported to be helpful with managing symptoms such as bloating.

Health care providers may recommend probiotic foods or supplements to patients during or after treatment with antibiotics. Normally, a person’s microbiome will recover on its own over time to a state generally thought to be stable, though it may not be identical to that person’s microbiome before antibiotics. The rationale for recommending probiotics with antibiotics is to preserve beneficial microorganisms and maintain that patient’s microbiome. For example, in patients with Clostridium difficile (C. diff.), a potentially severe infection often affecting people who have been hospitalized or are in long-term care facilities, probiotics containing Saccharomyces boulardii have been shown to reduce the chance of C. diff recurrence.

However, recent research in Cell has shown that taking probiotic supplements after antibiotics may delay the recovery of that person’s native microbiome and that this effect of probiotics is highly person-specific. More research is needed to understand the long-term consequences of this delayed recovery. However, since we do know that antibiotics can cause harmful changes in the microbiome — especially during vulnerable stages of life — this research serves as a good reminder to carefully consider the potential risk and benefit for individual patients (as for any human intervention) rather than using probiotics indiscriminately.

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How to help your patients choose

Medical professionals who treat GI issues are an important resource for patients who suffer from these conditions and may be looking for ways to supplement prescribed therapies with lifestyle-based or over-the-counter interventions. Arming patients with as much evidence-based information as is available on probiotics is critical to direct them towards safe and appropriate products.

It is also important for patients to read product labels, store products as directed, and understand that a more expensive product is not necessarily of higher quality or performance. Product labels may list group and species of the probiotic bacteria in the product but not specific strains. Therefore, patients should be aware that they can call a company or look up information on a company’s website to find out which strains are in a particular product and the research that has been done to support any health claims listed on the product label.

While not every company is reputable or safe, there are companies that have a long history of producing probiotics, increasing the likelihood that these products have been appropriately tested and studied. Providing patients with a helpful list of companies like those listed on the American Gastroenterological Association’s patient resource page on probiotics can help further help people avoid scams or needless risks.

Probiotics and children

Probiotics are also increasingly being used to help children. Research about the use of probiotics in children has grown in recent years. For example, some studies have shown that Lactobacillus rhamnosus and Lactobacillus casei may be helpful in treating diarrhea caused by rotavirus that often affects babies and small children. Conversely, scientists are still not sure if probiotics are helpful to children with inflammatory bowel disease (IBD).

Possible side effects are a concern for any treatment used in children, especially if they suffer from a chronic condition. Health care providers should clarify any possible side effects of probiotics, such as gas or bloating, which are typically mild and short-lasting. More serious side effects are possible, such as allergic reactions to the probiotic itself or other ingredients in the product, in addition to possible infection in individuals with a weak immune system.

You can be a key resource for your patients and their caregivers in understanding important differences in the effectiveness of probiotics for children versus adults for the same GI issue, and, in general, help caregivers be fully informed before they take probiotics or give probiotics to their child.

Knowledge helps keep patients safe

While more research is needed about the effectiveness and safety of probiotics, your patients will have questions about how and when to use them.

Overall, you should be a resource to your patients and help them navigate the information about probiotics to ensure they’re being used effectively. This will ultimately help maximize your patient’s chances of a positive, beneficial experience with probiotics.

For more information: Hecht is chair of the American Gastroenterological Association’s Center for Gut Microbiome Research & Education, as well as professor of medicine and microbiology/immunology and chief, Gastroenterology and Nutrition at Loyola University Medical Center, Maywood, Illinois. She can be reached at media@gastro.org.