Walk into any grocery store, and you will likely find more than a few “probiotic” products brimming with so-called beneficial bacteria that are supposed to treat everything from constipation to obesity to depression. In addition to foods traditionally prepared with live bacterial cultures (such as yogurt and other fermented dairy products), consumers can now purchase probiotic capsules and pills, fruit juices, cereals, sausages, cookies, candy, granola bars and pet food. Indeed, the popularity of probiotics has grown so much in recent years that manufacturers have even added the microorganisms to cosmetics and mattresses.
A closer look at the science underlying microbe-based treatments, however, shows that most of the health claims for probiotics are pure hype. The majority of studies to date have failed to reveal any benefits in individuals who are already healthy. The bacteria seem to help only those people suffering from a few specific intestinal disorders. “There is no evidence to suggest that people with normal gastrointestinal tracts can benefit from taking probiotics,” says Matthew Ciorba, a gastroenterologist at Washington University in St. Louis. “If you're not in any distress, I would not recommend them.” Emma Allen-Vercoe, a microbiologist at the University of Guelph in Ontario, agrees. For the most part, she says, “the claims that are made are enormously inflated.”
The Numbers Game
This story has played out before, most notably with vitamin supplements, which decades of research have revealed to be completely unnecessary for most adults and, in some cases, dangerous, correlating with higher rates of lung, breast and prostate cancers. But that has not stopped marketers from pushing another nutritional craze. According to a National Institutes of Health survey, the number of adults in the U.S. taking probiotics or their cousins, prebiotics (typically nondigestible fibers that favor the development of gut bacteria), more than quadrupled between 2007 and 2012, from 865,000 people to nearly four million. San Francisco–based business consulting firm Grand View Research estimates that the global probiotics market exceeded $35 billion in 2015 and predicts that it will reach $66 billion by 2024.
The popular frenzy surrounding probiotics is fueled in large part by surging scientific and public interest in the human microbiome: the overlapping ecosystems of bacteria and other microorganisms found throughout the body. The human gastrointestinal system contains about 39 trillion bacteria, according to the latest estimate, most of which reside in the large intestine. In the past 15 years researchers have established that many of these commensal microbes are essential for health. Collectively, they crowd out harmful microbial invaders, break down fibrous foods into more digestible components and produce vitamins such as K and B12.
The idea that consuming probiotics can boost the ability of already well-functioning native bacteria to promote general health is dubious for a couple of reasons. Manufacturers of probiotics often select specific bacterial strains for their products because they know how to grow them in large numbers, not because they are adapted to the human gut or known to improve health. The particular strains of Bifidobacterium or Lactobacillus that are typically found in many yogurts and pills may not be the same kind that can survive the highly acidic environment of the human stomach and from there colonize the gut.
Even if some of the bacteria in a probiotic managed to survive and propagate in the intestine, there would likely be far too few of them to dramatically alter the overall composition of one's internal ecosystem. Whereas the human gut contains tens of trillions of bacteria, there are only between 100 million and a few hundred billion bacteria in a typical serving of yogurt or a microbe-filled pill. Last year a team of scientists at the University of Copenhagen published a review of seven randomized, placebo-controlled trials (the most scientifically rigorous types of studies researchers know how to conduct) investigating whether probiotic supplements—including biscuits, milk-based drinks and capsules—change the diversity of bacteria in fecal samples. Only one study—of 34 healthy volunteers—found a statistically significant change, and there was no indication that it provided a clinical benefit. “A probiotic is still just a drop in a bucket,” says Shira Doron, an infectious disease expert at Tufts Medical Center. “The gut always has orders of magnitude more microbes.”
Despite a growing sense that probiotics do not offer anything of substance to individuals who are already healthy, researchers have documented some benefits for people with certain conditions.
In the past five years, for example, several combined analyses of dozens of studies have concluded that probiotics may help prevent some common side effects of treatment with antibiotics. Whenever physicians prescribe these medications, they know they stand a good chance of annihilating entire communities of beneficial bacteria in the intestine, along with whatever problem-causing microbes they are trying to dispel. Normally the body just needs to grab a few bacteria from the environment to reestablish a healthy microbiome. But sometimes the emptied niches get filled up with harmful bacteria that secrete toxins, causing inflammation in the intestine and triggering diarrhea. Adding yogurt or other probiotics—especially the kinds that contain Lactobacillus—during and after a course of antibiotics seems to decrease the chances of subsequently developing these opportunistic infections.
A 2014 review by Cochrane—an independent network of experts who serve as rigorous arbiters of medical research—found that probiotics may be particularly useful in a hospital's neonatal intensive care unit. The addition of beneficial bacteria to a nutritional regimen seems to significantly reduce the likelihood of developing necrotizing enterocolitis, which is a devastating, poorly understood and often fatal gut disease that primarily afflicts preterm infants—especially the smallest and most premature among them. Researchers think that many cases of the disease begin with an opportunistic bacterial infection in the not yet fully developed intestine of an infant. As the illness progresses, gut tissue becomes increasingly inflamed and often starts to die, which can, in turn, rupture the intestine and flood the abdominal cavity with pathogenic microbes that proliferate to dangerous levels. Researchers estimate that 12 percent of preterm infants weighing less than 3.3 pounds will develop necrotizing enterocolitis and that 30 percent of them will not survive. Standard treatment involves a combination of antibiotics, feeding via intravenous tubes, and surgery to remove diseased and dead tissue. Probiotics probably prevent the disorder by boosting the numbers of beneficial bacteria, which may deter the harmful ones.
Probiotics also seem to ameliorate irritable bowel syndrome, a chronic disease characterized by abdominal pain, bloating, and frequent diarrhea or constipation (or a mix of the two). A 2014 review of more than 30 studies, published in the American Journal of Gastroenterology by an international team of researchers, determined that in some cases, probiotics help to relieve the symptoms of irritable bowel syndrome for reasons that are not entirely clear, although it may be that they impede the growth of harmful microbes. The researchers concluded, however, that they did not have enough data to recommend any particular strains of bacteria. Microbiologists often caution that a promising study on a single strain of a particular species of bacteria should not be taken as proof that all probiotics work equally well. “Bacterial strains are so genetically different from one another, and everybody has a different gut microbiota,” Allen-Vercoe says. “There will probably never be a one-size-fits-all probiotic.”
But what if investigators could design probiotics to treat specific individuals? Many researchers think personalized probiotics are the most promising path forward for patients with compromised gut microbiomes. Last year Jens Walter of the University of Alberta and his colleagues published a study that gives a glimpse of this potential future. The researchers decided to see what it would take to get the bacteria in a probiotic to successfully colonize the intestines of 23 volunteers. They chose a particular strain of Bifidobacterium longum that earlier studies had indicated could survive in the human intestine. In the study, the volunteers consumed either a drink containing 10 billion live B. longum bacteria or a placebo in the form of a glucose-based food additive (maltodextrin) each day for two weeks. Periodic fecal samples revealed higher than typical levels of B. longum in participants who did not consume the placebo.
In seven people, however, these bacterial levels persisted for more than five months after the treatment ended. “We never expected they would survive more than a few weeks,” Walter says. A follow-up analysis determined that these seven people had begun the experiment with lower levels of B. longum in the first place. In other words, their gut ecosystems had a vacancy that the probiotic filled. That is exactly the kind of insight that clinicians need to create and recommend more effective probiotics. If a doctor knows that an individual with severe diarrhea has an undersized population of a particular beneficial microbe, for example, then prescribing the missing strain should increase the chance of a successful treatment.
“The key is taking an ecological perspective,” Walter says. “We need to think about which microbes have the right adaptations to survive in a particular gut ecosystem.” Put another way, treatments for microbe-related disorders are most successful when they work in tandem with the human body's many microscopic citizens, not just against them.