Should you take probiotics after a round of antibiotics? The answer may surprise you!

Two recent studies have recently been published that cast doubt on taking probiotics to help recover from a course of antibiotics. Crazy right? Ask anyone and they would tell you the opposite (as I would have). However sometimes research comes out that contradicts what we would previously have thought, and we have to be open to the idea that what we believed was in fact incorrect. The saturated-fat-heart-disease hypothesis is a clear example of dietary dogma that has been turned on its head* (and the difficulty that people have getting their heads around).

Gut health 101: The gastrointestinal (GI) tract is like a hollow tube, and the cells of the GI tract are covered by a thick protective gel, and that is the mucus layer (the inside cells of the gut are called the lumen). Each of these areas have a distinct microbial community, however these are rarely studied as they are difficult to get to (unless you have an invasive colonoscopy). The stool microbiome is also part of this gut picture and is the most often studied proxy marker as the gut microbiome and these are often used interchangeably (i.e. the bacteria you see in the stool is what we would expect to find in the gut). Interestingly, one study found that the stool microbiome is not representative of the gut mucosal or lumen microbiome, which really presents a challenge to any practitioner or patient who wants a better understanding of their gut health. It also doesn’t tell us about the gut endothelial microbiome which may be the closest to explaining our gut health as it is the closest bacteria to the gut tissue. They found that there was only a 20% correlation between the stool and the gut microbiome. While stool testing can be helpful for identifying pathogens or parasites, it’s not so useful for us to understanding the presence of ‘good’ or ‘bad’ bacteria. Stool testing is one piece of the puzzle, but it’s better alongside other tests (such as a SIBO test).

When you take probiotics, the presence of these in your gut is transient, and this is something that people are unaware of. Hundreds of trials have showed the safety and efficacy of probiotics in benefiting people, but it’s not typically through the colonisation of our gut. Like many things, we are different in the level of colonisation that occurs when bacteria is introduced into the gut – some people are more permissive than others, and some are really resistant to it. The researchers were not able to determine exactly what makes someone a ‘permissive’ coloniser and a ‘resistant’ coloniser, however suggested that the presence of certain bacteria in the gut may play a role in this. However, they are still beneficial despite this – with significant changes in the gene expression of people who took the probiotics (19 downregulated and 198 upregulated genes), confirming the idea that probiotics work at a cellular level and can enhance the activity of genes in the gut, aid in digestion, stimulate the immune system etc.

A surprising finding from a second study was that probiotics slowed the recovery of the gut microbiome after a round of fairly potent antibiotics. In fact, this is what I (and other practitioners) always recommend their clients do. Flooding the system with good bacteria has been thought to prevent the adverse effects of the antibiotics. The study wanted to see how the probiotics affect the long-term gut ecosystem after a single dose of the broad-spectrum antibiotic ciprofloxacin and metronidazole (to ensure all gut microbiome was wiped out). This particular study (conducted in both mice and humans) split the participants into three groups: one took no probiotic and were left to spontaneously recover; one group took an 11 strain bacteria probiotic for four weeks immediately upon finishing the antibiotics and the final group actually had what is called an autolagus fecal microbiome transplant (aFMT) – this is when a person takes capsules of their own fecal matter that had previously been collected when their gut is in a good space. Remember, the gut doesn’t like change, so what better than to replace the bacteria with some of your own? The results found that treating the gut with a course of probiotics delayed the return of the normal gut microbiota by as long as five months after stopping the probiotic treatment, and microbiota diversity stayed low too – well lower than the group who took nothing. In fact, the researchers found the group left to their own spontaneous recovery had no major differences in their stool microbiota within 21 days post-antibiotics. This is so different to what we understood about the ability of the gut to recover post-antibiotics. Again, there will be differences in what practitioners recommend, but to the best of our knowledge we thought that it took a good 18-24 months for the gut to fully recover from a round of potent antibiotics. This is actually incorrect too: previous research (when you delve further) shows that this may be the case for one or two strains of bacteria, but the majority actually recover fairly quickly and the composition of the gut microbiota resembles pre-treatment composition.

The gut microbiome is resilient, perhaps more so than what I (and others) had believed. This is only good news!

The researchers found the lactobacillus in the probiotic was what prevented the colonisation of the native bacteria in those that took the probiotic. This is the most commonly used bacteria in most probiotic strains. Again, this doesn’t mean that probiotics are NOT helpful in general (from the immune regulating benefits and what I’ve mentioned above) and we also don’t know how other probiotics which don’t contain the lactobacillus bacteria affect the gut (such as the yeast saccharomyces boulardis). There are so many different combinations of antibiotics and probiotics out there – and this is specific to this particular strain of probiotics and the type of antibiotic used. So it’s by no means the nail in the coffin for probiotics post-antibiotics, however it does call into question the broad recommendation and is something worth talking to your health practitioner about.

*I’ve linked to one academic’s thoughts, and could have also linked to many many more (and studies) such as this one or this one. But this isn’t a post about saturated fat so I didn’t.

probiotics

LIttle microbiota in your body are more resilient than you think… so we may need to leave them to do their thing. PC: oregonsportsnews.com

Injury-prone? Read this.

Nothing derails an athlete like an injury. We all know that consistency is one of the most important aspects to perform at your best, but getting to the start line in one piece is one of the biggest challenges that athletes face – particularly endurance athletes. For me, I have a long standing battle with my calves, and many people I talk to are similar: an old achillies injury, a hamstring problem, a niggly hip. However, this is hope! I listened to this great podcast where one of the leading researchers (Keith Baar) talked about his research that is helping athletes avoid injury and (when injured) recover more quickly. It is so practical and easy to apply that I had to share it. And whilst this is related specifically to athletes, I can’t think of any reason this couldn’t apply to anyone who may not think of themselves as an ‘athlete’ but struggles with an ongoing muscle or bone ailment.

A bit of background: Collagen, the most abundant protein form in the body, is made up of two amino acids, glycine and proline. It is found in bones, muscles, tendons and ligaments and has an almost scaffolding effect, to provide form and structure. Modern diets don’t contain a lot of glycine – it is found in the cartilage, bones and gelatinous part of animals and most people prefer the leaner cuts of meat (such as a steak, or a chicken breast). Most athletes I talk to would fall into this category; traditional sports nutrition guidelines would encourage them to fill up on carbohydrate, eat a moderate amount of lean protein and choose those leaner cuts of meat to ensure fat intake is kept low. Another easy source of glycine is found in gelatine – the wide, grainy powder found in the baking aisle used as a gelling agent in cooking. It is made predominantly of left over parts of the animal (bone, skin etc) that would otherwise not be used and has become more popular recently for its health promoting properties. Gelatine has also garnered the attention of sport scientists for its potential role in healing from injury and injury prevention.

While mere mortals wouldn’t typically think of tendon stiffness as a good thing, sport scientists have shown that the higher degree of stiffness you have in your muscle tendons, the better efficiency you’re going to have when using them. For a runner this would mean you’d expend less energy overall at a higher given intensity. And who doesn’t want that?

Tendon stiffness is determined largely by the amount of collagen AND the crosslinking of it. the collagen (tissue). Cross linking is determined by enzymatic processes that occur in the body, the expression and the activity of these enzymes increases when we are active. Baar’s research found that when they combined vitamin C (important for collagen synthesis) with glycine (one of the most common amino acids in collagen) there was an increase in strength of ligaments the engineered in the laboratory. They then conducted clinical trials in athletes to determine if this could be translated to a real world situation.

They conducted a randomised clinical trial, whereby they gave the group either a placebo, 5g or 15g of gelatine and measured the amino acids present in the blood stream over the following three hours. They found that the glycine peaked within the blood an hour after consuming the supplement. When they took the blood samples from the athletes and put it into their engineered ligament, they found an increase in the amount of collagen present in the ligament – a slight increase with 5g and a substantial increase with 15g of gelatine. Importantly, they found improved strength and stiffness in the ligaments that had the increase in collagen formation.

They then had the athletes jump-rope for six minutes (the length of time required to get a response from tissue cells in the bones, tendons and cartilage), rest for six hours, take the supplement again, wait an hour (for the peak amino acid expression) and jump-rope again. They did this three times a day for three days. The researchers found a doubling in the athletes’ collagen synthesis for those supplementing with 15g of gelatine, mostly from the bone.

What this shows us is if we want to improve the collagen response to an exercise bout, we can easily do this by adding gelatine as a supplement. Baar felt the initial study can be looked at as a bone recovery protocol. If we have an athlete who breaks a bone –  in the foot, a bone in the leg, bone in the back, what you can do is you can have them take the 15g gelatine alongside 50mg of vitamin C and then do five minutes of exercise an hour later. Now clearly this isn’t weighted activity – if you have access to an AlterG at your local university sports science lab that would be brilliant – something that is going to just direct those nutrients to where they need to go. Repeat this every 6h because it takes that long to get the cells to return to a state that they will then be responsive. The researchers suggest this is going to speed recovery time, something all athletes are interested in.

The above study can also be used as an injury prevention protocol, as the overall goal is to improve the mechanics of the connective tissue, reduce fatigue-related damage and optimise its strength and resilience. The protocol is the same; consume the 15g gelatine and 50mg of vitamin C then perform 5 min of activity that is going to load the area they are most concerned with. Long distance runners, for example, could supplement and then an hour later do 5-6 minutes of jump roping as this is going to load the hips, Achilles tendon, calves, tibia and femur – all areas of concern. For our long distance runners, they do five to six minutes of jump rope because if you have a history of tibial stress fractures or hip stress fractures or Achilles problems or plantar fasciitis, all of those structures are going to be loaded by the jump rope. They’re going to get just enough of a stimulus in that six minutes to have a response. Unlike muscle, bones and connective tissue don’t have a great blood supply – therefore providing nutrients then doing the exercise is like wringing out a sponge – suck the water out and it will suck up what’s left in the environment. The exercise impact is like wringing out the sponge, therefore the tissue will be responsive to up taking the nutrients.

Currently they’ve just tested the 5g and the 15g of gelatine – and while anecdotally the 5g has received favourable responses, the 15g amount was significantly more effective. The researchers don’t know for now if this is better scaled to body weight, but studies are underway to determine this. The study that is discussed here is in review and is about to be published.

In summary:

Bone healing / injury prevention protocol

  1. 15g gelatine + 50 mg vitamin C* (either added to smoothies, glass of water etc)
  2. Wait an hour for peak amino acid presentation in the bloodstream
  3. Undertake 5-6 minutes of activity that loads the area of interest (can be non-weighted) to direct nutrients to that area. For an ankle injury, this can be simply (carefully) tracing the alphabet with your ankle
  4. Do this every 6h
  5. (for injury prevention) – can do this anytime – or take the gelatine + vitamin C an hour before training if the training is including drills/warm up that targets area of interest.

*a little bit less than the amount of vitamin C found in a kiwifruit, most vitamin C tablets are over 250 mg, but you could easily have this instead.

Gelatine: I use the Great Lakes Gelatin, this is definitely pricier than what you’d find in the supermarket. This (and the I Quit Sugar brand or Vital Proteins brand) are marketed as being derived from either pig or beef that have been sustainably farmed and pasture raised. They are also free from additives and preservatives. You can purchase either the gelatine that will gel, or the collagen peptides which is the collagen broken down into smaller amino acid peptides. I haven’t seen any New Zealand gelatine – our cattle industry is one of the best. The brand in the supermarket I’ve seen (Mckenzie’s) includes a preservative which wouldn’t make it ideal for anyone wanting to use it for gut healing purposes (it’s 220, sulphite dioxide – many people are sensitive to this) and they don’t make the same animal and environmentally friendly claims. Further, if you do have an injury then the levels of inflammation in your tissues will likely be higher, and while the inflammation may not stem from your gut, it can affect your sensitivity to constituents in food such as preservatives and additives you would otherwise be fine with. In terms of the injury prevention effect though, I’ve seen nothing to suggest they wouldn’t be on par – so choose the one you can afford.