Which probiotic should I take?  HA!  Let me see here…hmmm…let me count…I’ve got at least three kinds in the fridge here somewhere.  No, no, no!  Two in the fridge and Bio-Kult in the cupboard above the stove.  Ah, look!  There are two more half-emptied bottles in the upstairs closet from that course of antibiotics I took three years ago for sinusitis, and…

Back to the question.  Which probiotic?  Even the experts can’t agree on this!  Check out the following contradictory statements regarding Lactobacillus plantarum and Bifidobacterium infantis.

“Meta-Analysis of Probiotic Efficacy for Gastrointestinal Diseases” pooled together many studies on probiotics used in gastrointestinal (GI) diseases and concluded:

“Of the 11 species and species mixtures, all showed positive significant effects except for Lactobacillus acidophilus, Lactobacillus plantarum, and Bifidobacterium infantis.”

(I provide some brief tidbits from this meta-analysis at the end of the post, about what the studies were treating and the strains they looked at.  It’s a good read if you have time.)

However, the American Gastroenterological Association’s website states:

“Probiotics, particularlyBifidobacterium infantis, Sacchromyces boulardii, Lactobacillus plantarum and combination probiotics may help regulate how often people with IBS have bowel movements.”

My 12 years of medicinal training (pharmacy school, medical school, and residency) offered NO education on probiotics.  Basically, in residency, it was good enough to just say, “Go get a probiotic to take with your Levaquin.”  My current probiotic knowledge comes from self-experimentation and reading all those internet help-forums and blogs over the last year.  Tells you how much you should trust my site. By the way, I have tried at least Bio-Kult, a couple of brands of Saccharomyces boulardii, two brands of soil based probiotics, Culturelle, Align, Sustenex, a few brands of Lactobacillus, something from the health food store refrigerator with Bifidobacter and 301 other strains, Activia, homemade yogurt, homemade sour cream, homemade sauerkraut, store-bought kimchi, and both homemade and store-bought fermented pickles.  Whew!  Sadly, although other people may have found their ticket with a probiotic, I don’t think that’s going to be my ride.

How’s Your Probiotic Knowledge?  Take a Probiotic Quiz:

Answer True or False to statements you’ll commonly see across the internet.

1.  There is a BEST probiotic.

False.  You can’t fit a square peg into a round hole.  The effectiveness of a probiotic is person dependent, disease dependent, strain dependent, and quality dependent.  That’s a lot of variables to control for.  Your favorite blogger’s probiotic choice probably won’t hurt you, but on the other hand, it may not be the help you were looking for.

One person may do well with a probiotic with just one kind of bacteria whereas another person will do better with a probiotic with many strains of bacteria in it.  Different disease states respond better to different strains of probiotics.  It is helpful to know which strain of species is in your probiotic.  For example, Lactobacillus acidophilus in the above mentioned meta-analysis didn’t benefit the GI diseases looked at, but the specific strain called Lactobacillus acidophilus LB did.  In some cases, knowing the genus (Lactobacillus), species (acidophilus), and strain (LB) becomes very important.  You may want to read up on your condition and choose probiotics with strains that have been found to be effective for that disease state in studies.  And finally, the quality of preparation and handling of the probiotic by the manufacturer and middle-men will make a difference.  If the temperature heats up to a whopping 120 degrees in that semi-truck trailer in the summer, that doesn’t count as “ambient temperatures”, and bacteria will be dying off in the probiotic bottle.

2.  The BEST probiotics need refrigerated.

False.  Bacterial species of different types lie dormant at different temperatures and moisture levels, such as soil based organisms, and do not need refrigerated.  Also, the way the bacteria are processed makes a huge difference.  For example, freeze-dried probiotics don’t need refrigerated, and can lie in a quiescent, viable state for a year or even longer at routine temperatures as long as moisture level is controlled for.  Refrigeration, however, is absolutely necessary for many probiotics, but it still doesn’t imply the probiotic is viable if there were poor handling practices in shipment.  Refrigeration of probiotics will not be harmful, even for the non-refrigerated types.  Refrigeration keeps bacteria in a dormant state, allowing longer shelf-life.  If in doubt, refrigeration is okay.

3.  Probiotics don’t replace your bowel flora.

True (but you must keep reading).  Probiotics don’t permanently replace your bowel flora, but that doesn’t mean they don’t change your bowel flora for the better.  Once you stop taking, say Lactobacillus GG, perhaps you won’t find increased colonies of Lactobacillus GG months later.  But while it was there, the Lactobacillus GG made chemicals to inhibit the growth of other, potentially unwanted, bacteria and yeast.  Plus, it produced acids, like lactic acid, to make the environment more suitable for desirable bacterial strains present in your gut.  Maybe in a way we can say the probiotics allow a “comeback” of the desirables that have been crowded out.  If you add in a form of nutritional rehabilitation (drastically cut back on any sweet intake and grain products), you’ll be even more successful at getting the desirable bacteria back in the game and the undesirables crowded out.  Reminds me of that song line, “Don’t call it a comeback…I’ve been here for years…rockin’ my peers.”  Stupid, I know, but don’t forget I don’t get a dime to write anything.

4.  I OUGHT to be taking a probiotic.

False (but keep reading).  Some people will do very well with the addition of a probiotic.  Their yeast infections will clear up.  Their IBS diarrhea will subside.  Their immunity will strengthen.  However, for every one of these people, you may find somebody who gets very ill on a probiotic.  Any probiotic.  Any dose of probiotic.  Although it would be nice to get some probiotic in that gut, either with food or with supplements, a person can’t bang his or her head against a wall feeling guilty because Natasha Campbell-McBride, MD says probiotics are a cornerstone to treatment.  If you get sick every time you take a probiotic, work on other things.  Like cutting back sugar sources and grain products.  Also, probiotics are controversial in small intestinal bowel overgrowth (SIBO), a condition caused by too many bacteria defying gravity and peristalsis and moving up to take residence in the small intestine, where they wreak havoc.  And lastly, some severe medical conditions, like pancreatitis, can be contraindications (an absolute no-no).

5.  Probiotics should be started out at low doses.

True.  The probiotic can cause a bit of a disturbance in the GI tract.  Some bacteria will die off, some new ones with new metabolites may flourish, and your body may feel uncomfortable from these effects.  So start slowly and work your way up. If the dose calls for 2 capsules twice daily, I start off with just one capsule, see how I do, and adjust up or down from there.   You may even need to break the capsule open and sprinkle a bit on your food and try to increase as you can.  This is my personal opinion, but I give my new probiotic choices about 2-3 weeks before I ditch them and say, “Not gonna’ work for me.”  I figure 2-3 weeks is enough of a trial when I’m bloated and gassy.  If you want to deal with saccharomyces boulardii bloating for 6 weeks, be my guest.

Although starting low can help you tolerate the probiotic better, driving the dose up can be important to achieve desired effects.  The studies mentioned in the meta-analysis above drove the doses up quite high, describing effective doses from 1 million colony forming units to 50 billion colony forming units.  Read your probiotic label.  It should tell you how many CFUs are in each capsule.  For example, my bottle of SCDophilus has 10 billion CFUs per capsule.

6.  A good probiotic will have FOSs (fructo-oligosaccharides).

False.  A probiotic does not need to have FOS as an ingredient.  In fact, I would suggest that you omit the FOS component, particularly initially.  The FOS is an unabsorbable sugar that bacteria enjoy consuming, and the byproduct for you can be gas with its associated cramping.  Ouch.  FOSs are also called “PREBIOTICS” in contrast to the “PROBIOTICS” we are talking about.

Once things are going well with a particular probiotic, if you want to try a similar one with the addition of FOSes, give it a try.  Then, you’ll know if it was the probiotic or the FOSes if there are any side effects.  The FOSes are there to promote the growth of beneficial bacteria.  Not a bad theory, but in practice, maybe not so applicable.  If you eat fruits and vegetables, those are great sources of FOSs for your bacterial flora!

7.  Side effects of the probiotic are solely due to the bacteria themselves.

False.  If you have (either knowingly or unknowingly, like many people) an intolerance to gluten, soy, or milk, your bad reaction to a probiotic may be due to components used to make the probiotic, not the bacteria itself.  Bio-Kult’s allergy statement says it may contain traces of soy and dairy.  Culturelle’s bacteria are grown with whey, and may contain traces of dairy (although at such low levels it is considered non-immunogenic).  Sustenex Gummy Bears have dairy–it’s no wonder my daughter’s constipation wasn’t budging when I gave her those!

Why take the chance on a bad reaction that will confuse issues you’re trying to work out?  I don’t think it’s worth the money and chance of a reaction to have a product that has soy, dairy, and gluten as potential reactants.  Read those labels!  Look for cellulose type components.  Make sure the probiotic is free of any of those common allergens!  This will really help you narrow down your probiotic choices!

8.  Foods are the best source of probiotics for everybody.

False.  Ideally, our probiotics would come from the food we eat, but some people have such severe food intolerances that they can’t tolerate food-source probiotics.  Yogurt?  Can’t eat dairy.  Sauerkraut or kimchi?  Can’t tolerate the histamine by-products in those.  Coconut kefir?  Coconut products give them diarrhea and headaches.  When food sensitivities are that prevalent, there’s not much choice but to turn to supplements.  If you can tolerate probiotic food sources, the amount of CFUs you eat are reported to be humongous.  However, I’m not talking Activia and canned sauerkraut here.  Anything with added sugar raises a red flag and is totally counterproductive.  Anything that has  been pasteurized will have no, or at least greatly reduced, CFU bacterial numbers.

I have some obsessive-compulsive friends, and they say, “Well, I take a supplement because I just like to know how much I’m getting!”  From Breaking the Vicious Cycle’s website, “Its is often claimed that we can get more good bacteria from taking commercial probiotics. This is not the case and yoghurt is a very low cost source of probiotics. 24hr SCD™ yoghurt has a concentration of 3 billion cfu/ml which means that in just a cup of Yoghurt (236ml) you’ll get 708 Billion beneficial bacteria and that’s about 50 times more than that claimed for a typical 15 billion capsule.”

Besides the CFUs of bacteria in the fermented foods, you also are getting some of their metabolites that benefit the GI tract and your body, such as high levels of bioavailable vitamin C in sauerkraut.

Now Apply Your Knowledge…

1.  Dr. Mercola recommends “Complete Probiotics.”  He thinks its great because it has Lactobacillus acidophilus DDS-1 and 9 other strains, is stable at room temperature, has prebiotics, is free of soy/corn/dairy/wheat/gluten and in a vegetable based capsule.  What do you think?

2.  Dr. Natasha Campbell-McBride recommends the Bio-Kult she helped develop.  It has 14 different strains, is stable at room temperature, and contains soy and milk in trace quantities.  What do you think?

3.  Steve and Jordan recommend GI Pro Health’s “SCDophilus.”  SCDophilus needs refrigerated, is gluten/dairy/soy free in a cellulose capsule, and contains “Lactobacillus acidophilus.”  What do you think?

Enough testing, here are my thoughts on probiotics:

1.  Choose a probiotic with no confounding ingredients.  If you’re not very careful, your probiotic may have soy, wheat, or dairy derivatives which may be accounting for symptoms.  Read all labels closely and opt for vegetable/cellulose based capsules.

2.  Forget the FOSes.  They can cause people a lot of bloating and cramping that may have nothing to do with the introduction of the probiotic.

3.  Know your genus, species, and preferably strain.  Start simple.  Try a one-strain product, and see how that goes.  Branch out from there.

4.  Choose reputable.

5.  Listen to your body.  You may need to start with half a capsule–open and sprinkle–and work up, or you may need 1 every other day.  Titrate up as you can, but if after 2-3 weeks you’re still feeling bad from your probiotic, move on.

6.  Try to incorporate fermented foods, but beware of additives such as sugar or preservatives.  Pasteurization defeats the purpose here, except I have read that Bubbies sauerkraut is so active, they have to heat it up a bit to get it to stop being quite so active!  Their pickles are not pasteurized at all.

7.  Work up the dose.  Know how many CFUs are in the product.  Consider looking at research with the problem your trying to target and replicating the doses they use in their studies with success.

8.  Some probiotics need refrigerated and some don’t.  This is not an indicator of quality–except if it needs refrigerated and somewhere along the line it wasn’t!

From the Meta-Analysis Mentioned Above

The above mentioned meta-analysis looked at

• pouchitis
• infectious diarrhea
• irritable bowel syndrome
• Helicobacter pylori
• Clostridium difficile disease
• antibiotic associated diarrhea
• traveler’s diarrhea
• necrotizing enterocolitis

and found that probiotics had a positive significant effect on all of these states except traveler’s diarrhea and necrotizing enterocolitis.

The probiotics looked at were both single-strain products and combined-strain products.

• VSL #3 which contains
  • 4 Lactobacillus species (L. casei, L. plantarum, L. acidophilus, and L. delbrueckii subsp. bulgaricus)
  • 3 Bifidobacterium species (B. longum, B.breve, and B. infantis)
  • Streptococcus salivarius subsp.
• Enterococcus faecium
• Clostridium butyricum
• Lactobacillus acidophilus combined with Bifidobacterium infantis
• Bifidobacterium lactis
• Lactobacillus GG
• Lactobacillus casei
• Streptomyces boulardii
• Lactobacillus acidophilus
  • L. acidophilus LB
  • L. acidophilus with no strain specified
• Lactobacillus plantarum
• Bifidobacterium infantis

Lactobacillus without a specified strain, Lactobacillus plantarum, and Bifidobacterium infantis showed no significant effect on the mentioned disease states.  However, Lactobacillus acidophilus LB did.

As always, this is a live performance, and feedback always appreciated.  All the best to you!