Gregor Reid FRSCLawson Health Research Institute

University of Western Ontario, London, Canada

gregor@uwo.caTel: 519-646-6100 x65256

Probiotics and Microbiome -Disentangling fact from fake news

The first probiotic

delivery system!

Atlas, as President of the American Society for Microbiology in 1999 when he said “Probiotics may be today’s snake oil…fraudulently peddled by hawkers from the backs of covered wagons”

For someone who was deemed an ‘expert’ on microbes to clean up the Exxon Valdez oil spill, it seems he’s only comfortable if it’s oil.

Failure to have the European Food Safety Agency (one good reason for Brexit) approve our probiotic taken orally for vaginal health. EFSA stated:

“For now, we need a roadmap from the European Union, but we’re running out of road. Quo vadis – EFSA?”

In writing an article like this, why is the headline so dead set against a whole field?

What have we done to upset people so much?

Why do they not understand probiotics?

Would a drug study of warfarin in 8 patients lead JAMA or Cell to publish the paper and produce headlines like this about all pharmaceuticals?

Who do they ask for comment? Colleen Kelly with 24 publications mostly on fecal transplant; Alexander Khoruts with three papers on fecal transplant; Rob Knight, a microbiome computational biologist.

When asked “Why not use the combination of antibiotics and probiotics to reset the gut ecosystem and, ideally, reverse microbiome-associated diseases like inflammatory bowel disease or even obesity?”, Elinav said “I think it’s a very exciting and interesting prospect that needs to be investigated.” He obviously doesn’t read the literature and certainly none of my papers from over 6 years ago! Is the intent to dismiss probiotics then launch his own products? I wouldn’t mind, as long as Cell publishes any study we do on 8 subjects.

FDA: Phase 1 studies are usually conducted in healthy volunteers.

The goal here is to determine what the drug's most frequent side effects are and, often, how the drug is metabolized and excreted.

The number of subjects typically ranges from 20 to 80.

How many studies on 8 or fewer subjects are published on drugs that prove efficacy, get published in Cell and JAMA and lead to headline news? Answer = NONE.

But then again, maybe I need to thank Elinav for showing that my study of ten subjects is incredible and worth featuring in JAMA and the BBC

Heh, it is worse than money down the toilet. It’s actually drugs down the toilet –something JAMA couldn’t possibly discuss!

aus der Beek, T et al. 2016

www.scientificamerican.com/article.cfm?id=ultimate-social-network-bacteria-protects-health

• A skeleton• Tissues and water• Microbes

FAO/WHO Guidelines as a probiotic, published 2002

Food and Agriculture Organization

of the United NationsWorld Health Organization

Strain identification by phenotypic and genotypic methods

Genus, species, strain Deposit strain in international culture collection

Safety assessmentIn vitro and/or animalPhase 1 human study

Double blind, randomized, placebo-controlled (DBPC) phase 2 human trial with sample size

and primary outcome appropriate to determine if strain/product is efficacious

Preferably second independent DBPC

study to confirm results

True Probiotic

Strain(s) in specific product formulation

“Live microorganisms that when administered in adequate amounts confer a health benefit on the host” (FAO/WHO, 2001)(Hill et al. 2014).

So, if you decide to do a clinical study, you’ll choose a proven probiotic, right?Elinav and colleagues chose this………………..

Elinav’s press release: “People have thrown a lot of support to probiotics, even though the literature underlying our understanding of them is very controversial”

Reid et al. Nature Reviews Microbiology 2010

Elinav Press Release: “we wanted to determine whether probiotics such as the ones you buy in the supermarket do colonize the gastrointestinal tract like they're supposed to.”

Even though people with knowledge of probiotics have known for ages that the strains don’t colonize!

“and then whether these probiotics are having any impact on the human host," says senior author Eran Elinav, an immunologist at the Weizmann Institute of Science in Israel.

Sorry, does he not understand the definition of probiotics?

N=8 probiotics2xdaily

N=6 Autologous FMT

N= 7 No treatment

7 days ---- 7 days ciprofloxacin/metronidazole – 28 days intervention – 28 days f/u

20 hours clear liquids then sodium picosulfateto allow endoscopy Day 0 and 21

500mg bidaily + 500mg tridaily

Elinav Press release: “probiotics did not restore fecal alpha diversity to baseline levels 4 weeks following antibiotic cessation”

Fecal 16S rDNA analysis demonstrated that all probiotics related genera were found in stools prior to probiotics supplementation, and Lactobacillus, Lactococcus and Streptococcus significantly expanded in relative abundance following antibiotics treatment.

All four probiotics genera remained significantly elevated compared to baseline during probiotics supplementation, though none were further elevated to the post-antibiotics levels.

Eight healthy nonsmoking volunteers (24 ± 4y) without a history of gastrointestinal symptoms and free of medication were investigated on 4 separate occasions (three bacterial interventions and one placebo control, randomly chosen) in a randomized placebo-controlled cross-over study. Interventions were separated by a 2-week wash-out period.

Volunteers fasted overnight (without breakfast) (no sodium picosulphate flush or 20 hour fasting) and were administered 1 × 150 mL at the start of the intervention, after which they were each 30 min provided with a preparation containing reconstituted freeze-dried bacteria resuspended in maltodextrin solution just before consumption, or only containing the maltodextrin solution (the placebo control), for a period of 6 h when 4–5 tissue samples were obtained from the horizontal part of the duodenum by standard flexible gastroduodenoscopy, at ≈15 cm distal to the pylorus.

Between 400 (stationary vs. placebo) and 800 (midlog vs. placebo) human genes were differentially regulated after consumption of the lactobacilli. These are involved in regulation of hundreds of duodenal mucosal genes that modulate immune responses, cellular metabolism and biogenesis.

Elinav Press Release: "Contrary to the current dogma that probiotics are harmless and benefit everyone, these results reveal a new potential adverse side effect of probiotic use with antibiotics that might even bring long-term consequences."

Did they examine harm? No!

Did they cite papers proving benefits of probiotics with antibiotics? No!

Goldenberg et al. Cochrane Database Syst Rev. 2017 Dec 19;12:CD006095Based on this systematic review and meta-analysis of 31 randomized controlled trials including 8672 patients, moderate certainty evidence suggests that probiotics are effective for preventing Clostridium difficile associated diarrhea (Number Needed To Treat = 42 patients, 95% CI 32 to 58). (the estimated number of patients who need to be treated with the new treatment rather than the standard treatment for one additional patient to benefit).

Hayes and Vargas, Explore (NY). 2016 Nov - Dec;12(6):463-466.The incidence of antibiotic associated diarrhea in randomized, parallel, controlled trials in children (0-18 years) showed 8% in the probiotic group (163/1992) compared to 19% (364/1906) in the control group (RR = 0.46; 95% CI: 0.35-0.61; I2 = 55%, 3898 participants).

Other examples – and they seem to be mounting!

Mice, mice, mice!

13 years later – has anyone proved that obesity is caused by a reduction in Bacteroidetes and increase in Firmicutes?

Has anyone shown that you can make obese people lean with FMT?

NO! But the original mouse study has been debunked

Of the organisms detected by culture in the duodenal aspirates, including Streptococcus, Staphylococcus, Neisseria and Hemophilus, none of them were lactobacilli or bifidobacteria or probiotic organisms, highlighting the lack of correlation with brain fogginess and importance of well-controlled human interventional studies with strict inclusion criteria rather than observational datasets.

Bifidobacterium as a genus does not yield D-lactate as a metabolic end product.

The observational nature of the Rao et al. paper precludes any conclusive link between probiotic consumption and symptoms observed

It is much more likely that the patient population with underlying SIBO in this study sought relief from their gut symptoms by use of probiotics rather than the probiotics being the cause of their symptoms.

In people with a normal gut, D-lactate produced by members of the gut microbiota – including some probiotics – is metabolized by other members of the gut microbiota and does not accumulate. Moreover, the D-lactic acid that was present was not proven to be a result of probiotic growth.

The sensationalist headlines may dissuade safe probiotic use in people who can truly benefit from them

https://isappscience.org/brain-fogginess-probiotics-not-the-cause/

The Rebuttal

Two more negative studies

CONCLUSIONS: Among preschool children with acute gastroenteritis, those who received a 5-day course of L. rhamnosus GG did not have better outcomes than those who received placebo.

In children who presented to the emergency department with gastroenteritis, twice-daily administration of a combined L. rhamnosus-L. helveticus probiotic did not prevent the development of moderate-to-severe gastroenteritis within 14 days after enrollment.

https://www.alamy.de/kleiner-junge-kind-sitzt-auf-der-toilette-wc-toilette-oder-moor-von-der-seite-mit-multi-farbige-jersey-oder-jumper-naoh-image4686827.html

The problems:

1. The patients had serious diarrhea and were in the Emergency Department. This is not the patient category probiotics are designed to help. Indeed, nothing helps apart from oral hydration.

2. Why did they not follow the guidelines that states probiotics must be given in the first 48 hours? For rotavirus infection, LGG was effective when given in first 24 hours (Majamaa et al. 1995).In the GG/L. helveticus study patients were included up to 72 hours with diarrhea who then went to emerg.

3. Children 3 months to 4 years of age came in acute gastroenteritis, defined as three or more episodes of watery stools per day, with or without vomiting. They had either no detectable pathogens or some serious ones.

4. They then received 5 days probiotics or placebo and were assessed for the primary outcome of moderate to severe gastroenteritis (which they already had).

5. The authors report 35% adverse events when few if any could be attributed to probiotic use.

Diarrhea in children

Meta-analyses conclude there is a reduction of diarrheal duration of approximately 24 h (17–30 h) for L. rhamnosus GG, Lactobacillus acidophilus, Lactobacillus bulgaricus and L. reuteri) and Streptomyces. boulardii.

The ESPGHAN (European Society for Paediatric Gastroenterology Hepatology and Nutrition) Working Group on Probiotics and Prebiotics published in 2014 recommendations regarding the use of probiotics in the treatment of AGE, recommending Lactobacillus rhamnosus GG, L. reuteri DSM 17938 and S. boulardii CNCM I-745.

J Pediatr Gastroenterol Nutr, 58 (2014), pp. 531-539

What is at the root of the problem?

• Too many products called probiotic that have strains not tested in humans

• Too many products making un-verified claims

• Sparse educational programs in medical school on probiotics and the microbiome –graduates learn how to dispense drugs and cut through skin.

• Too many rodent studies making conclusions suggesting unproven relevance to humans

• Journalists no longer with expertise in science or the time to analyze papers – their employer and many scientific journals are driven by Almetric scores

• Government regulatory systems established when there was snake oil and covered wagons, and that still think foods and supplements don’t prevent or treat disease.

• Researchers making up their own terms but never defining them – Post-biotic, psychobiotic, live biotherapeutic, dead probiotics…………

Solutions• Disband EFSA

• Protest at the EFSA committee members and politicians who put them there. How do you think the need for HIV research got people’s attention and then lots of funding leading to effective anti-retrovirals?

• Ignore EFSA. Don’t put claims on labels, and let scientists publish the data explaining the outcomes of product use.

• Host educational programs for journalists and bloggers to explain how to analyze the microbiome data, what questions to ask about claims on press releases, and what a probiotic is and is not.

• Stand up and be counted! Respond to garbage and idiotic comments no matter the reputation of the journal or scientist!

• Produce more human data from well-designed studies.

• Expand the boundaries to the planet – fish, honey bees, soil, plants, animals

For the scientists who clearly have no idea about probiotics and for the people who do not take the time to understand what a probotic is and is not, and who then write stories disproportionately lambasting a whole field, a very, very, very important person has a message for you.

https://imgflip.com/memetemplate/74370358/Trump-Pointing

In summary

1. Let’s stop trying to pull the wool over everyone’s eyes, with mouse studies irrelevant to humans, under the guise of ‘mechanisms’, or sensational headings based on poor studies

2. Fake news sells. We get the Andy Warhol analogy.

3. The probiotic definition was founded on science, as was ISAPP. When people misrepresent it, call them out!

4. We are microbe-filled beings in a microbial world. We need to translate our knowledge in ways that will benefit humanity and the planet.

5. Study probiotics in HUMANS and if study results are negative, so be it – just keep probing.

http://www.picturequotes.com/in-the-future-everyone-will-be-famous-for-15-minutes-quote-736