Melanie Cole, MS (Host): Welcome to Bryan Health Podcast. I'm Melanie Cole. And today, we are really going to learn a lot about gut health, prebiotics and probiotics. We hear these terms a lot. We're going to learn about them today with Dr. Alexander Praus. He's a gastroenterologist with Gastroenterology Specialties, P.C..

Dr. Praus, I'm so glad to have you join us today. So, start by telling us a little bit about what that means when we hear the term gut microbiome, what does it even mean, the bacteria, the general role of it. Give us a little, you know, physiology lesson if you would.

Dr. Alex Praus: Yeah. Thanks for having me. Really excited to talk about this today. This is something that we get a lot of questions on and a little bit of disinformation about the gut microbiome and stuff we're going to talk today. So, we're going to kind of set the record straight. So, the gut microbiome is the collective group of all microorganisms in your gut, starting from really your stomach all the way to your colon. And this includes all the bacteria, fungi, viruses, a group called archea. And these all reside in the gut and kind of make the jungle of the microbiome. And there are about 38 trillion of these. And it's roughly the same number as the total number of human cells in the body. So, you have 38 trillion of these things living inside your gut, and it's extraordinarily diverse. There's thousands of different species of these different bacteria, and they're not uniformly distributed. So, it's not like, "Oh, it's all throughout the gut." It's predominantly in the middle and distal part of your small intestine and colon. And the colon is the one that really houses most of the bacteria in kind of microbiome.

It's really dominated by five different kinds of bacteria. The two major ones are firmicutes and bacteroides, and those make up about 70-90% of the total bacteria with the other types kind of filling in the gaps. It is really kind of developed when we're young, when we're children and infants and stuff like that. And then, as we grow older it becomes kind of more and more constant. So, it's important when you're young to kind of set a good microbiome in your gut. Now, this can be disrupted by a variety of things. It can be disrupted by illness. It can be influenced by diet. It can be disrupted or influenced by antibiotics, or different kind of diseases or illnesses and stuff like that.

It has a variety of different uses. So, it helps with immune system. It helps with digestion. It helps with fermentation of different things that we eat, and kind of making vital nutrients for our diet because we can't process those alone. So, we use this microbiome to help give us energy and nutrition.

Melanie Cole, MS: Well, thank you for that. And I'm glad you said the name of those bacteria and I didn't have to. But so, there's so many theories today, Dr. Praus, about autoimmune diseases that we're seeing on the uptake. And, you know, these kinds of things going on in our body, and some have this theory that we have done some damage and sanitized those gut microbiome that you just explained to us about.

So conversely, we're learning more about ways to help combat that, whether it was antibiotic use or the built environment, whatever is the reason, which we could do a podcast just strictly about that. So, tell us about prebiotics and probiotics. Most people have heard of probiotics, but not prebiotics. Tell us a little bit about the difference and how they're supposed to work, what they're supposed to be doing in the body.

Dr. Alex Praus: Okay. This is great, because we get a lot of questions about this, specifically probiotics. And then, we start to talk about, "Hey, don't forget about prebiotics." So, we'll start with prebiotics. So, prebiotics are really just fibrous, non-digestible material and the kind of soil or nutrients for your microbiome.

And when I reference a microbiome, I call it a jungle or a rainforest because how diverse it is and how it helps each other, and there's competition for resources. And prebiotics are really the food for that rainforest. Now, some people may garden or some people may be into plants where some plants require a more acidic environment or an acidic soil to thrive. Others require a more basic environment or more soil with magnesium or iron or something like that to help them thrive. And if they don't have that, they really struggle. Same thing with our microbiome. We eat food and certain bacteria in our gut, like different kinds of food more than others. And let's say you feed a certain bacteria with high fiber foods like beans or lentils, very fibrous, very nutritious and healthy for us, and that's going to promote what we would consider a more healthy microbiome, and feed those good bacteria so that they can outcompete what we would consider bad bacteria.

And so, when we talk about prebiotics, we're saying, "All right, how are we going to enrich this soil or enrich this microbiome with food for good bacteria so they can outcompete?" Because you can't go in and target, you know, "All right. Well, I want to get rid of this bacteria completely. We don't have therapies or things that can do that. So, we have to rely on, "Hey, all right, we got to give them fuel to outcompete."

And so, prebiotics are made for that, is that we can take prebiotics or use different foods as prebiotics to foster and feed good bacteria to outcompete kind of bad bacteria and set a really good microbiome. So, that's really what a prebiotic is. It's just fertilizer of food to help foster a good microbiome, and using what you already had.

Probiotic on the other side is actually introducing what we would consider healthy bacteria to your gut via capsule or I know there's yogurts, and now there's even soda, like a soda pop, that's considered probiotic. And so, it's just introducing bacteria to your gut that we know is healthy.

And that is truly what prebiotic and probiotics are. The prebiotic, again, the soil that helps foster a good microbiome, and probiotic is introducing additional bacteria or introducing good bacteria to your gut.

Melanie Cole, MS: What a great chemistry lesson that was, talking about pH and basic and all of that. Because it really clicked in my head when you said that Dr. Praus, that one is already there and we're just kind of keeping it going and making sure we utilize it properly. And the other one is actually introducing it into our system. That was an excellent explanation.

So when we think of yogurt, and you talked about soda, well, there's kombucha, there's fermented foods, there's all of these things. So now, tell us about the digestive benefits when we do introduce these things, and we'll get into some of the more food sources and taking a probiotic specifically, but tell us what you have seen as a gastroenterologist for digestive benefits, whether it's immune system functioning or just digestion, bloating. I mean, we all have so much of this.

Dr. Alex Praus: Let's talk about prebiotic first, because I think that that is where all the data is showing that there's actually quite a bit of benefit in a variety of different places for that, much more so than probiotic. And we'll talk about that. So, the prebiotic, the use currently for prebiotic are a variety of things. One, it helps us get essential nutrients, essential short-chain fatty acids, essential amino acids, and helps kind of regulate our gut as well.

So, the prebiotic part of this is that these are at the basis non-digestible food. We don't make an enzyme or anything that we can break down, and we rely on these bacteria to break it down and take the nutrients from this so that we can use it. And what's left is fibrous material. And what this does is allows us to have formed bowel movements, helps regulate our gut immune system. It helps create what's called a tight gut.

There's some terms out there called leaky gut, which can be associated with inflammatory bowel disease, which can be associated with autoimmune diseases. And what these prebiotics do is help limit that, help improve gut inflammation with just everyday stuff or inflammatory bowel disease.

And so, specifically with the data that we currently have, there's a few specific uses for prebiotics. For inflammatory bowel disease, we know that a good diet with low to no processed foods, low sugar, high fibrous diet, or prebiotic diet with a variety of different fibers. Old World grains like barley and oats are really good for you and just the essential prebiotic. Those are all great.

So, we talked about a little bit of inflammatory bowel disease, but what about irritable bowel syndrome, IBS, which is much more common than inflammatory bowel disease? And the results in this are a little more mixed. There is evidence that it can improve symptoms in patients with IBS. So IBS, you have a little bit of abdominal discomfort or you're in pain and changes in bowel movements. And we know that adding in fiber to your diet helps with these symptoms. But specifically, prebiotic or kind of varied fiber can help quite a bit more actually with symptomatic day-to-day IBS type symptoms. And so, that is probably the best role for prebiotics in a general population is it's going to improve your bowel health, that you're going to have what would be considered a more normal bowel movements and regularity. And if you do have some IBS, it can help with symptoms. Is it going to eliminate symptoms? Probably not. But it's going to definitely help.

And then, other things that prebiotics can help with, chronic constipation, which kind of runs with the IBS type symptoms. You're going to have better bowel movements, less episodes of constipation. And then, more specifically, there's one condition that we can use prebiotics for. And that's for C. diff or Clostridium difficile infection prevention. There was one study that showed that it helped a little bit. And so, I think that, with this, you can help prevent C. diff, which is unfortunately not uncommon. More common in patients with healthcare exposure, hospitalizations, antibiotic exposure. And this just gives evidence to say, "Hey, if you have a really healthy microbiome, you're going to outcompete this gut bacteria called C. diff, and it's going to be quite helpful." And that's really the uses for prebiotics at this time. So, it can help with a variety of symptoms and, in the general population, can help with IBS-like symptoms.

For probiotics, much less helpful, unfortunately. So, we talked about earlier, probiotics are the introduction of a bunch of bacteria to your already very full gut. So again, we have about 38 trillion different bacteria living in our gut and a lot of these probiotics introduce 7 billion bacteria or so in capsules or yogurt or drink or something like that. And in getting kind of ready to talk about this, I was like, "All right, so what are some of the experts saying about probiotics? Because that's what I know. We don't have a good probiotic yet really. And someone likened it to dropping a little drop of food coloring into an ocean. And I was like, "Wow, that is a great picture to say. It is not going to do really anything. You're not going to change the color of the ocean with one little drop." And so unfortunately, probiotics, there's hundreds of them on the market. And the data that we have shows that none of them work well. There are very specific, uses for a few different probiotics that in our general population, it's very rare that we would run into them. They're mostly used in the pediatric and neonatal population for very specific uses. But in the general population, a lot of people will use them for IBS or functional GI disorders, and the data does not show that they really work well. They can have some improvement in IBS-like symptoms. But after many, many studies and a lot of evaluation on these, the data just says they probably don't work very well. So if I were to make a recommendation on prebiotic or probiotic for anything, I would lean more towards a prebiotic, high-fiber diet, varied fiber, than any kind of probiotic.

Melanie Cole, MS: Well, okay. So, that was really interesting. And coming from an expert such as yourself, even more so, what do we do with this information? Do we want to concentrate more on prebiotics than probiotics, although they do no harm, so maybe they don't help as much as we might like, but they also do know harm. What would you like us to take away from this episode today? What do you want us to do? Give us your best recommendations here about whether we should,because there are, as you say, so many on the market, Dr. Praus. And some are behind the pharmacy counter, some are in the refrigerator section, we don't know, and there's just tons of them. But then, they're also sort of being in many fermented foods, sauerkraut, kimchi, kombucha, all of these great things. But those are prebiotic as well. So, what do you want us to do with this information? Give us your best advice here.

Dr. Alex Praus: You know when I talk with patients who say, "Hey, I'm on this probiotic." And they say, "Hey, it helps. I don't know why. But when I take it, my gut feels better, I feel better." And I say, "I don't have evidence that it doesn't, and keep taking it. If you feel better and your symptoms, which you're seeing me for are better on this, I don't have evidence right now to say to stop taking it, because there are people that are going to respond a little differently."

But in that same patient, I say, "Hey, make sure that you're getting a good fiber dose every day. You know, the American diet right now has changed drastically over the past decades, 50, 60 years ago. And now, we're very low fiber. We don't get 10, 12, even 15 grams of fiber on a day on average. And we really should be aiming for 25 or 38, so at least double of the fiber intake we're getting daily.

And so, my best recommendation is this. If you are taking a probiotic and you find benefit from it, great. I'm glad you find benefit. I don't have evidence to say to stop it. But start a higher fiber diet, start old world grains, fermented foods. Give your microbiome the nutrients and soil it needs to foster, a good environment and outcompete some of the bad bacteria and don't give them a chance to cause problems.

So, that's my recommendation. High fiber diet, low to no processed foods, low sugar. And if you are taking a probiotic and finding benefit, great. If you're not, try stopping it and just continue with the prebiotic.

Melanie Cole, MS: Great advice. What an excellent episode this was. You gave us so much to think about and so much great information that we can trust. Dr. Praus, that was just excellent. Thank you again for joining us and in really sharing your incredible expertise. And I'd also like to thank our Bryan Foundation partner, Learfield Pinnacle Bank Arena.

And to listen to more podcasts from our experts, like Dr. Praus, you can always visit bryanhealth.org/podcasts. That concludes this episode of Bryan Health Podcast. Please always remember to subscribe, rate and review Bryan Health podcast on Apple Podcast, Spotify, iHeart, and Pandora. Until next time, I'm Melanie Cole.