Are the Benefits of Probiotics Overstated?

Probiotic use is largely misunderstood by consumers and even researchers. The result is that the various benefits of probiotics are often overstated.

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There are several considerations when it comes to taking a probiotic—including choosing a strain proven to offer the benefit that you need at the right dose.

The idea that we should eat live microbes for health benefits is still relatively new, especially in terms of specific disease treatments. These beneficial microbes—probiotics—rarely colonize in the body, but they “can grow, metabolize, and interact” with other members of the microbial community to exert beneficial effects on our health, according to the International Scientific Association for Probiotics and Prebiotics.

That makes probiotics of special interest to someone whose microbial community (microbiome) is perturbed by stress or antibiotic use as probiotics can increase the commensal, or beneficial, bacteria while you are taking them. The microbiome includes bacteria, viruses, fungi, and other microorganisms that live in and on the human body.

There’s no doubt that probiotics offer some pretty spectacular health benefits—particularly when it comes to conditions of the gut. New studies also indicate that probiotics can help resolve infections outside of the gut, support the immune system, manage cholesterol levels that are nudging upward, improve mood and psychological symptoms, and reduce obesity.

However, these results have led to high consumer demand and expectations that may exceed conclusive research and doctor recommendations. In many cases, probiotics are being misused and misunderstood. Current regulations treat probiotics more like a food rather than a medicine. This means that many products are as effective or safe as one might expect.

Some warn that we should have a healthy amount of skepticism about probiotics being benign. Some research has found that probiotics can sometimes even damage health. Often the effects of probiotics are overstated or generalized, which heightens confusion.

There’s No Microbial ‘Blueprint’

Probiotics are typically sold as either a food or a supplement product. They also naturally occur in fermented foods and are present in fruits and vegetables.

Limited medicinal use of probiotics is at least a century old, dating to before antibiotics were discovered. In 1917, Alfred Nissle found that a nonpathogenic strain of Escherichia coli (E. coli) could be isolated from the feces of people who were exposed to severe enteric diseases (severe bloody diarrhea) but didn’t develop symptoms. He went on to do several studies using that E. coli strain to successfully treat sick patients and eventually developed it into a capsule product.

In the decades since, other probiotic-centric treatments have gained anecdotal and scientific support. However, for people who want better gut health but don’t know specifically what’s wrong with them, the right probiotic can be likened to a needle in a haystack. We simply know too little about the microbiome for anyone to make categorical claims about specific bacteria or what is going on inside any specific microbiome.

Gastroenterologist, author, and researcher Dr. Sabine Hazan told The Epoch Times that one of the biggest misconceptions about probiotics is that they will solve dysbiosis or the imbalance between commensal and pathogenic organisms in the gut. Unfortunately, she said, the market is diluted with products that didn’t prove beneficial in research.

“When a product doesn’t make it through a clinical trial and doesn’t show efficacy, you’re allowed to take that bacteria and put it out as a nutraceutical,” Dr. Hazen said. “That’s what’s happening now. We’re seeing all these probiotics coming one by one, but the answer is not in a probiotic.”

Some Probiotics Should Never Be Part of Your Microbiome

Consuming even one strain of a bacteria will affect the whole microbiome, whether you notice benefits or not. If it happens to be a strain that’s not part of your “microbiome signature,” it could cause problems, according to Dr. Hazan.

“Everybody has a signature microbiome,” she said, noting that this collecting of microbes influences everything from intelligence to food preferences.

“When you start globalizing the whole microbiome and you start thinking one microbe from the Italian population now should be in the Chinese population, you are altering that fingerprint microbiome of that person and you could alter their disease pathway.”

Removing microbes is even more problematic. Dr. Hazan said stool microbial analysis tests that are increasing in use can be misleading. Not even the researchers using them fully understand the results, including whether the microbes represented in the stool are alive or dead inside the patient, she said.

“It fools consumers into thinking they have a problem with their bowel, and the microbe is the problem and then they start taking antibiotics, which kills all microbes,” Dr. Hazan said.

She said it is often the loss of one microbe rather than the overgrowth of another that causes disease.

Researchers have not been able to develop a standard model for a healthy human microbiota. In fact, despite the rise of technology that makes identifying microbes faster, not every microorganism living in humans has been identified. New microbes are constantly being discovered. Among the more than 40 trillion bacterial cells living in the human colon are hundreds or thousands of different species.

Guidelines for Using Probiotics

Still, some scenarios may warrant the use of a probiotic. The International Scientific Association for Probiotics and Prebiotics (ISAPP) is working to educate doctors and patients about the circumstances that call for probiotics—as well as other “biotics,” a term that encompasses all microbiome-supported substances such as prebiotics, synbiotics, and postbiotics.

The nonprofit organization participated in the World Gastroenterology Organisation (WGO) guidelines for using probiotics and prebiotics. Among its work is to dispel myths, help consumers understand when to ask their doctor for a probiotic, and explain how to read labels to pick out a good probiotic.

In 2022, the global market for probiotics was estimated to be $57.8 billion, and it’s expected to grow to $85.4 billion by 2027, according to consulting firm MarketsandMarkets Research.

With more people buying probiotics for their health, the challenge for groups such as ISAPP is to educate consumers about what to look for on labels and how to dose them for a specific condition.

Any probiotic marketed with a recommended health use, such as “promotes digestive health,” should include on its label:

• Storage information: Some are required to be refrigerated, but that doesn’t change the effectiveness, according to ISAPP.
• Manufacturer name and contact information: This is important for reporting adverse events, which are rare.
• Serving size: This helps consumers who are matching dosage to an expected benefit.
• Colony forming units (CFUs): This can range from 100 million to 50 billion. Often, there is a die-off of probiotics during their shelf life, so the label is usually referring to the minimum that will be in the product by the expiration date.
• Expiration date: Using it by this date ensures that it will contain the CFUs on the serving size.
• Strain: This should include the genus, species, and specific strain. This will help you to be able to research the specific benefits that may be expected based on clinical evidence.

The WGO report pointed out that the genus, species, subspecies, and strain designations are agreed upon by the scientific community. However, the trade and product names, as well as strain designations in the marketplace are not universally uniform. This can make it more challenging to link benefits to specific strains at the most effective dose.

Be a Probiotic Detective

The Alliance for Education on Probiotics, with grant support, has taken out some of the guesswork by putting together a searchable chart with broad categories for adult health, women’s health, pediatrics, and functional food. Within those categories, users can filter for specific conditions, such as irritable bowel syndrome (IBS) or mood disorders, and end up with a list of products sorted alphabetically that includes information on the brand name, strain, and dosing.

Most importantly, each has a designated level—three in all—based on clinical evidence. Level I is the highest level of evidence, denoting at least one “well-designed” trial that was randomized for comparison. The lowest, level III, reflects “opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.”

These ratings reflect that in certain specific scenarios, there is, in fact, good evidence that a bacterial strain or blend of strains can improve a symptom or disease. Some scenarios have only one study to support them, while others have several. In many cases—particularly the use of probiotics for stress, anxiety, and depression—the science is still emerging, meaning that it needs replication or larger studies to validate early findings.

Applying the filter for IBS produces 26 results. Among them are three variations of a product called Align—a capsule, a chewable tablet, and an extra-strength capsule—that all include Bifidobacterium longum (formerly B. infantis), strain 35624. Dosing information and the CFUs are listed, as well as four studies found on a drop-down menu.

Bifidobacterium species have a history of safety and, along with Lactobacillus, are the common ones found on the Alliance for Education on Probiotics chart. Dr. Hazan touts the benefits of increasing our Bifidobacteria, which are some of the earliest microbes to populate the human gut in infancy and are the ones that we lose as we age.

While trendy newer probiotics such as Akkermansia are getting a lot of attention, she said, this genus hasn’t proven itself yet. Hence, it is not on the chart.

Leveraging Diet to Boost Healthy Microbes

We can also boost our gut microbes through fermented foods such as yogurt, sauerkraut, and other fermented vegetables, which are often a safer option compared to nutraceuticals, Dr. Hazan said.

However, fermented foods are less likely to be tested for health benefits, according to the ISAPP, and they may be processed by pasteurization, baking, or filtering in ways that remove live cultures. However, fermented food was highlighted in ISAPP’s 2023 review as an area that is beginning to receive more attention.

Understanding exactly how fermented foods work to improve host health is a bit of a mystery, in part because of the complexities of studying food with living organisms. The ISAPP points to research, including a trial of healthy people whose inflammatory markers reduced after 10 weeks of consuming six servings of fermented foods daily. However, according to the organization, more studies are needed to confirm and quantify therapeutic benefits.

The microbiome also thrives on a diverse diet that includes fruits, vegetables, and whole grains of different colors each day, according to Dr. Hazan. As healthy as salad is, eating the same one every day may not be the best choice for the gut microbiome.

“It’s never a one-pill solution,” she said. “You can regain your health the natural way with vitamins and nutrition.”