Are probiotics worth the money?

Tegan Taylor: Norman, would you say you're pro-biotic or anti-biotic?

Norman Swan: I'm sort of equivocating on antibiotics, because they're not necessarily always good for you, you've got to be careful about them. And probiotics, the jury is out.

Tegan Taylor: Oh, I really thought you were going to be a real fence-sitter on that. But that's actually more decisive than I expected.

Norman Swan: Yeah.

Tegan Taylor: Have you been a user of probiotics in the past?

Norman Swan: Only in natural foods.

Tegan Taylor: Okay. Well, I think that's something that we're going to talk about today.

Norman Swan: Is it?

Tegan Taylor: Yes, because here we are on What's That Rash?. I am health reporter Tegan Taylor, coming to you from Jagera and Turrbal land.

Norman Swan: And I'm physician and journalist Dr Norman Swan, coming to you from Gadigal land, part of the Eora Nation.

Tegan Taylor: And today we're talking about probiotics. Today's question comes from Sophie:

Sophie: Hi, there. I just had a question about taking probiotics with antibiotics. I recently had a certain chest infection. and I was on two lots of different antibiotics, and also some steroids. And the pharmacist suggested that I take a probiotic in the morning and also in the afternoon. So yeah, I was just wondering if it was worthwhile or not.

Tegan Taylor: So that's Sophie, asking about whether probiotics are worth her money, I suppose antibiotics are quite a specific case, I do want to talk to that, but also whether they're worth it in general.

Norman Swan: So the theory here is…well, it's not just theory, antibiotics kill bugs, and they don't just kill the bugs that they're intended to kill, they can actually knock around your microbiome in your bowel so that when the antibiotics hits your bowel, particularly the large bowel, they clean it out to some extent, and it can cause diarrhoea because the microbiome helps to really consolidate the poo.

Tegan Taylor: Okay, wow, we're two minutes in and we've already mentioned diarrhoea and poo. This is off to a flying start. A running start, some might say.

Norman Swan: Very good. So look, there's a well-known phenomenon of antibiotic induced diarrhoea. There's also antibiotic induced fungal infections. And there's also an antibiotic induced condition, which thankfully is fairly rare, called C. difficile, Clostridium difficile. So antibiotics can really mess with you, and so you should only take them when you need them. The question is, do probiotics help? What are we talking about here? We're talking about supplements that you buy in the chemist which contain a variety of bacteria.

Tegan Taylor: Yeah, I mean, the stuff that you buy in the chemist, there's a shelf and a half of them. They're capsules, which is what I remember being offered at some stage of my life. But they come in little chocolate balls, you can get gummies and stuff now. And the claims that they make are…I mean, they're really promising a lot. They're talking about your microbiome, which I suppose we should define in a bit, but they're also saying, oh, you know, it's your immune system, and it might even improve your mood. Like, there's just a lot flying around here.

Norman Swan: There is. And you'll read articles about different conditions, which we'll come to later, where they're confident that probiotics are going to go to make a difference. But in fact, the evidence is not there. But if you're looking at it on the shelf, and you've just taken antibiotics, or you're feeling a bit low, there's a probiotic for you. Question is, does it work?

Tegan Taylor: Yeah. Well, can we come back to the gut microbiome, because it's one of those things that, like, no one had heard about it until, I don't know, I'm going to pick a number of years out of a hat and it feels like it's going to be wrong, like 10-ish years, I don't know, and then all of a sudden it was everywhere; gut microbiome, it's so important, you've got to support it. And what we're talking about are these colonies of trillions of bacteria that live all over your body, including in your gut, that are good for you in ways that we're really only beginning to understand.

Norman Swan: Look, Tegan, maybe just a minute on the microbiome and we will get a sense of that. Essentially, these bugs in the bowel are really important for the way the body functions, from the immune system to even affecting how the brain works. And the communication systems in the gut are very similar to the communication systems in the brain. So this makes a lot of sense. And there is a growing amount of evidence that by influencing what happens in the gut, you can influence mood, for example, depression and anxiety and have an antidepressant effect.

They may well be involved in irritable bowel syndrome. There's a whole series of conditions where abnormalities in the microbiome or restrictions in the microbiome could make a big difference, which is a long way from saying, though, that taking a probiotic is going to solve the problem. There are trillions of bugs in the bowel, of huge diversity, which ones are you going to choose? And the ones they tend to choose are the ones which are easiest to get into the bowel.

Tegan Taylor: That was 61 seconds. I am so impressed.

Norman Swan: Look…I had four more seconds…

Tegan Taylor: You've obviously worked in broadcasting for a very long time.

Norman Swan: By the way, it goes back to the early 20th century. The immunologist who discovered the white blood cell called the macrophage, which is the white blood cell that chomps up rubbish in the body and bacteria and so on, Ilya Metchnikoff, he was obsessed with the microbiome, he thought it was incredibly important for health. And in fact, he commercialised yoghurt as a therapeutic. He believed that the harmful effects of bacteria in the gut could be combated by fermented substances, and that it was possible that this could actually extend life, for example. And this goes to the fact that there was a belief that people who lived in the mountains in the Balkans and in Greece who ate yoghurt all the time, lived to ripe old ages. And so he pioneered and promoted the consumption of yoghurt.

Tegan Taylor: Incredible, and I said 10 years, I was so, so far off. What, like just normal yoghurt?

Norman Swan: I can't remember the story exactly, but I think he might have lost quite a lot of money on the yoghurt. And he certainly didn't live to…well, he lived to a reasonable age for the time, into his 70s.

Tegan Taylor: It wasn't the fountain of youth he was promising.

Norman Swan: Yeah, I think they were expecting him to live much longer than 71 and the poor sod died too soon. But life expectancy in those days was probably 55.

Tegan Taylor: He undermined his own yoghurt empire.

Norman Swan: That's right. So Metchnikoff recognised this, these bugs produce substances which can actually influence and send messages to the immune system. And not only to the immune system, the chemical messengers that are in the bowel, almost every chemical messenger that's in the bowel is there in the brain as well. So this complexity of the microbiome, and the interaction with the rest of the body is very important for health and disease.

Tegan Taylor: So then I guess the question is, is a probiotic that I'm ordering over the counter, is it actually able to do that really complicated job?

Norman Swan: And the answer at the moment seems to be no. Not that the theory is wrong, so the microbiome is incredibly important, but it's incredibly complex. There's been a lot of research and a lot of trials into whether taking one of these probiotic supplements, when you're on antibiotics, will prevent the onset of diarrhoea. And some trials say yes, some trials say no, a lot of them have been done in children. And the balance of evidence is it maybe has a small effect on the risk of diarrhoea after antibiotics, but it's not a big effect. The question is, would kombucha or fresh yoghurt (going back to Metchnikoff) do a better job? And that's not entirely clear either, although the range of bugs in something like yoghurt or kombucha may well be wider than you get in a capsule.

Tegan Taylor: I think the thing about the capsules that's important to call out is that it's a premium, patented product, and so they've got to have something different to what their mates have, and they've got to be able to grow it, and they've got to be able to grow it at scale, and they've got to be able to transport it and put it in a plastic bottle for you to have. The gut bugs that tick those boxes might not necessarily be the same gut bugs that are doing you the most good inside you.

Norman Swan: You can answer this question, Tegan, for yourself, because you went to actually a centre in South Australia, based on the premise that a small range of bacteria in a probiotic capsule is just not enough.

Tegan Taylor: Yeah, exactly. So I did go to this commercial facility in Adelaide that's trying to basically get from poo transplants, it's almost like a blood donation thing, you get a donor and you get a patient, usually someone who's really, really sick, and you give them basically a transplant or a transfusion, to something where it is more like going to your pharmacy and buying something that's tailored. And they're trying to sort of brew up big vats of the most important gut bacteria and identify which ones are the most important and then give a cocktail of those. So, many different types of that, that they would give to a person.

Norman Swan: But here's the thing…

Tegan Taylor: I think I know what you're about to say; how do you get it to the butt?

Norman Swan: Well, it's either a colonoscope or a catheter or an enema.

Tegan Taylor: Because you don't want to be swallowing this stuff, and it breaking free before it gets to where it needs to be.

Norman Swan: No, no, it could be just halitosis times 500. But seriously, the problem with the probiotics is you're swallowing them and it's got to get through the acid of the stomach, through the enzymes of the small bowel, before it gets to where it needs to be, which is where the microbiome mostly is in the bowel, which is in the large bowel, the colon. And what people are doing with faecal transplants is putting it directly into the colon, which is where it needs to be.

Tegan Taylor: So that's like really, really useful for people who are very, very sick. Like, the place that I went, the therapy that I've developed is used for C. difficile infections, like you were saying, but it's not something that every person can wander into their pharmacy and buy and self-administer. There's something very convenient about these over-the-counter products. So, coming back to Sophie's question, is there value in it for the everyday person?

Norman Swan: My view, looking at the literature, is it's very limited. Save your money. Kombucha, yoghurt give you a good dose of probiotics, some beers even actually do, not that I'm suggesting you go on beer. But a rich diet, which is going to force the bugs in your bowel to be richer and more diverse…

Tegan Taylor: So when you say a rich diet, you mean like a nutrient rich, fibre rich diet?

Norman Swan: That's right. Thank you for correcting me. But that's right, a nutrient rich diet with a wide variety of vegetables, not a lot of meat. In other words, the Mediterranean style diet gives you a very diverse microbiome, which is anti-inflammatory, which really just settles things down and gets the immune system in order. So this is the prebiotic approach, what you eat makes a difference and, sure, throw in fermented foods like yoghurt and kombucha and things like that, but it's the range of foods that you eat. And with antibiotic induced diarrhoea and preventing that, you might as well just have a diverse diet and have the microbiome in good enough shape. In fact, there's a little bit of evidence that taking probiotics delays the recovery of the microbiome. So I would just be natural.

Tegan Taylor: Norman 'Natural' Swan. Before we close this off completely, do you see probiotics getting to this point sometime in the future where they really are very worthwhile?

Norman Swan: The answer is yes. Interesting work in Canada by the late Professor John Bienenstock, he found a very specific organism in the microbiome that actually had an antidepressant effect. And that's launched a whole area which is called nutritional psychiatry. We've got a leader in this field, Felice Jacka at Deakin University in Melbourne. And there's really good research going on into this link between the gut and the brain, and that will bear fruit, so to speak.

Tegan Taylor: So, the long and the short of it is the stuff that's on the shelf is probably not worth your money. A varied diet is good for you. And Norman's a massive, massive fan of faecal transplants.

Norman Swan: I'm clenching my buttocks as I say that.

Tegan Taylor: Oh, well, Sophie, I think that answers your question. And we did want to say a huge thanks to those of you who sent in questions. We've had people querying whether it's even possible to enjoy exercise at all. Greg's a bit dim on the idea of enjoying any form of exercise. Any response to that, Norman?

Norman Swan: Well, as a masochistic Scotsman, Scottish Australian, you know, I go with that, you've just got to punish yourself. Life is not for enjoyment.

Tegan Taylor: You and Greg are obviously are birds of a feather. And Patrick wrote in to say he actually loved playing soccer as a young'un, but discovered that his knees didn't like playing soccer anymore. And he's discovered pickleball, which I mainly know about from…I think it's an American thing.

Norman Swan: Yeah, it's huge in the United States, but Patrick's lost five kilos doing pickleball. He loves the social aspects. And, you know, we should all just pick up a paddle and get on with it.

Tegan Taylor: Have you had a go of pickleball before?

Norman Swan: No, no, it's opaque to me. And then I am taking the risk I might enjoy it, so why…

Tegan Taylor: Well, we better not have that.

Norman Swan: No, no.

Tegan Taylor: And one more question from Margie asking whether high intensity interval training is appropriate if you have high blood pressure.

Norman Swan: We'll take that on notice and we'll come back to Margie when we deal with HIIT.

Tegan Taylor: Well, you know where to send your questions. But if you've forgotten I will remind you right now, you can send us a DM at the @abchealth Instagram account.

Norman Swan: Or you can email us at thatrash@abc.net.au. And we will see you next time.

Tegan Taylor: See you then.