Biotics: Are you pre-, pro-, or syn-?

One of my patients had to start taking prophylactic antibiotics last week for chronic urinary tract infections. Good for her in one, hugely important way - chronic UTIs can be dangerous - but … a daily, nonspecific antibiotic dose for the foreseeable future? Not good for her GI tract.

Treating chronic constipation is a must when addressing chronic UTIs. Constipation means there is a backup of stool in the rectum, and that stool cooks up a lot of bacteria that can find its way into the bladder. But when the constipation is stubborn, as it often is, the UTIs can be stubborn, too. Sometimes a long-term course of antibiotics is necessary.

So what can my patient do to help her gut health? It got me wondering if there had been any update in the world of probiotic research. (If you read The Constipation Game Plan, you know that, at the time that I wrote it, there really was insufficient evidence to recommend probiotics for all constipated patients. Too much variability in strains, quality, and dosage recommendations.)

Turns out, the world of probiotic research is lively and exciting! A great synthesis of the research was published in the journal Frontiers in Nutrition in December, 2022, entitled “Probiotics, prebiotics, and synbiotics in chronic constipation: Outstanding aspects to be considered for the current evidence”.

(Frontiers in Nutrition is a peer-reviewed open-access journal, meaning anybody can access the research articles it publishes. This journal and other open-access publications are critical for those of who aren’t associated with institutions to keep up on the research.)

To refresh your memory, a probiotic is a living bacteria that you introduce to your gut (via a pill or via cultured or fermented foods) to benefit your overall health. For our purposes, we are interested in probiotics that improve the speed at which stool moves through the large intestine, and/or softens stool. And therein lies the problem! One strain of bacteria might help you poop, and a different strain might actually back you up. This is why I’ve always been hesitant about picking up just any probiotic from the store and hoping it helps with constipation.

But there’s good news! According to the Frontiers in Nutrition article, recent research supports using two strains in particular to address constipation: Bifidobacterium Lactis and Lactobacillus Casei Shirota. The research shows these two strains to be most effective when taken for greater than 28 days, in both small and large doses, and in isolated forms (capsules or powders).

And then we enter the world of prebiotics, which, to be honest, weren’t even on my radar a few years ago. Prebiotics are foods we consume that we can’t digest ourselves, but are digestible by our microbiome. Mind-blowing, right? Turns out, when you eat garlic, onions, asparagus, yams, and a whole list of other whole foods, you aren’t just feeding yourself. You’re feeding your gut bacteria.

You can - and should! - get probiotics by including a wide variety of whole grains and fruits and vegetables in your diet. But, according to this article, it looks like you can get some benefits from prebiotic supplements as well. The most effective one is inulin, which is a chicory root fiber that is already widely used in fiber supplements.

(The article makes clear, though, that more research needs to be done. The writers were able to find 6 animal studies of prebiotics and 8 human ones. And there is not enough research to state how long a person should take prebiotics, and what specific dose.)

I’ve had so many families over the years tell me that fiber gummies seem to be pretty effective at treating constipation. I’ve always had a “if it works, go for it” stance about fiber gummies, because they are often made with inulin and I was never sure that inulin was the best way to consume fiber. But this research confirms what some of my patients have experienced … that inulin-based fiber gummies can be useful in treating constipation.

So, to summarize, based on the most recent research, I’ll recommend my patients try:

• A probiotic supplement with Bifidobacterium Lactis and/or Lactobacillus Casei Shirota;
• A fiber gummy with inulin as the primary form of fiber;
• And, as always: Eat whole grains and fruits and vegetables with every meal.

I will continue to emphasize that no dietary change is a silver bullet for treating chronic constipation, and a pre- or probiotic supplement that works for one person may not work for the next person. But supplementing with pre- and probiotics certainly seems worth a shot.

(Side note: synbiotics are newer products that include probiotic bacteria in a prebiotic substrate - like buying your seeds and your fertilizer in one packet. I just don’t think there’s enough research to make a recommendation in this category, and it’s probably more cost effective to just buy the pre- and probiotics separately).

I hope this helps you and your patients and family members! Please let me know if you’ve found specific pre- and probiotics that you’ve liked! I’ll look into them and pass them along to my patients.

Best wishes,
Christine Stephenson, PT, DPT