Kelsey Marksteiner: I totally understand why there’s confusion about this because honestly there is no perfect definition of either prebiotics or fermentable fibers at this point. It’s something that has been debated for years at this point, and there’s no consistency, really.
Lauren, I sent you that link before with the article, and let me post that article in the chat box here for you guys, too, because it’s a good article. I’ll just post this just so you guys have it, and I can also post it in the Facebook group if you want that. Lauren, if we can scroll down a bit to the second page, I think, it has a chart. Yeah, here we go. Perfect.
This is specifically about prebiotics versus fermentable fibers. From what I have studied about prebiotics and fermentable fibers, prebiotics are the only things that are selectively feeding good bacteria only because it’s part of their definition. It seems to be one of the common parts of the definition over time. You can see on the left-hand side here it’s going through the years and it’s tell you what the definitions have been in different studies. You can see that for most of them it’s talking about selectively stimulating the growth of a limited number of bacteria. Typically that’s going to be good bacteria. I think I’ve actually looked at that particular study, the first one here, and it does talk about selectively stimulating the growth of beneficial bacteria, not what we would consider bad bacteria. That’s what I tend to think of when I think of prebiotics. It’s something that’s nondigestible. It goes to the bacteria. It’s only selectively stimulating good or beneficial bacteria, and it’s causing health benefits to the host because of the stimulation of beneficial bacteria.
Fermentable fibers—and again, this is also debated, too, so take it with a grain of salt—fermentable fiber, to me, from what I’ve seen, it tends to be less selective in what it’s stimulating because it’s a fermentable fiber; it can be fermented by probably most bacteria.
I personally get a little more worried with just fermentable fiber versus prebiotics. In my practice, I really only, for the most part, at least while someone’s dealing with any sort of significant gut issues, I’m really only using prebiotics because I don’t want to sort of accidentally stimulate growth of other types of bacteria. Chris may have a little bit of a different opinion. I know he doesn’t recommend fibers or prebiotics potentially when someone’s dealing with some sort of gut issue in the beginning because a lot of times it’s just not tolerated, and then as soon as someone starts to get a little bit better, you’re reducing counts of bad bacteria, then you can start to add those things in, and typically they’re fairly well tolerated. I generally have the same sort of approach except that sometimes I do use prebiotics right away. It depends on the person, obviously. It depends on their severity of symptoms. It depends on which ones they tolerate. I can tell you that I tend to start with GOS. I use a product from Klaire Labs. It’s called Galactomune. That’s one of my favorites. Most people do pretty well with this, especially if you start very low and slow and you work your way up very, very slowly for most people. That tends to be fine. The FOS is a little bit more problematic because it is a FODMAP. Obviously it’s going to cause that bloating and gas a little bit, and that can be problematic for more people. It tends to cause more bloating and gas than GOS does, I’d say.
In this chart, you can see that it says, “Ingredients considered as prebiotics,” in the third column here, and there’s very few. Prebiotics are a very specific type of carbohydrate here. We’re not talking about a lot of different things that could be considered prebiotics. Generally, for me, I typically am only using FOS and GOS because over time those have stayed pretty consistent. As prebiotics, there are some that are being added, and lactulose actually also has a good history of being a prebiotic substance, as well, but that’s a prescription, here in the US at least, so I’m not using that, really.
As for dosage for these things, just in case you guys want to know, personally I will use 5 grams of GOS, and this is eventually. I start off having someone do an eighth of a teaspoon, so a really, really small amount, and then work their way up to 5 grams per day. Typically that’s going to be in divided doses unless, for whatever reason, they want to do it once a day. They can do that. It’s just more likely they might get some bloating, gas, stomach extension, that sort of experience.
Then with FOS, it’s 10 grams. Same thing, start with about an eighth of a teaspoon. Over time, work your way up to, I think … I use the NOW FOS powder, and I think three heaping scoops, the scoop that they give you in there, is equal to 10 grams. So I typically just have people do a scoop three times a day.
These things taste really great, so I actually recommend that people do a powder versus doing a capsule because it’s more cost effective, and it tastes like cotton candy, so most of your patients are going to be happy with it. Those are honestly the two that I use the most. Inulin, I think, has a pretty good history, too, of being a prebiotic, but I don’t tend to use it a ton. I find that some people have a little bit worse reaction to that. Like I said before, the GOS, I think, tends to be the best tolerated, so I usually start there.
Laura is asking, “But with SIBO, there can be good bacteria, just in the wrong place.” Yes, that’s definitely true. This also goes back to the idea that you need to kind of bring bacteria out of hiding to kill it. If you’re feeding the bacteria, they’re very happy, they’re out and about, they’re more able to be killed. They’re not in hiding. They’re not being starved. That’s actually why I tend to use these sorts of things. Or you can use the partially hydrolyzed guar gum, which has been shown to be helpful in getting rid of SIBO, or making antibiotics more effective. It’s the same sort of idea there. It’s allowing that bacteria to have a food source, and that’s the theory as to why it tends to work better to get rid of SIBO, because the antibiotics have a better chance of actually killing a lot more of the bacteria.
Chris recommends a bunch of different fermentable fibers to take. I do think that’s a really great idea, but you definitely want to be careful with that, especially in the beginning, if someone is having actual gut-related symptoms. If they’re having bloating, they’re having gas, they’re having abdominal discomfort, anything like that, I would just caution you to be very cautious with the fermentable fibers themselves just because I’ve had people respond poorly to them.
I tell people that they can expect an increase in bloating and gas as they first start. If you think about it, these bacteria, when they get a food source, they are producing gas as a result when they “eat” the food source. That’s a good way to explain it to patients because then they’re like, “Oh, well, it’s producing gas, so no wonder I’m getting a little bit of excessive gas or a little bit of bloating.” That’s totally normal. It’s going to happen for anyone, whether they have any sort of gut issue or not, and the key here is to just get your gut bacteria used to having that food source around. That’s why you start really low and you work your way up very, very slowly. For FOS and GOS, like I said, it’s that 10 grams for FOS and 5 grams for GOS that have been shown to be bifidogenic, meaning that it’s increasing the amount of bifidobacteria, with the least amount of side effects. That’s why you want to recommend those dosages as an eventual goal, but definitely don’t start people there because they will stop it very quickly most likely because they’ll have a lot of gas, they won’t feel very good, and you’re just going to kind of go back to square one.
Make sure you’re explaining this very carefully to patients and you’re setting up an expectation that there’s going to be some increase in bloating and gas. Just tell them that it shouldn’t be really bad, and if it’s really bad, they’re really not feeling good, chances are it’s not a great choice for them at the moment, or at least whatever one you started them on is not a great choice, so you could try a different type of prebiotic and see if they do better with that. Yeah, just make sure they know what’s about to happen, and that will make it more likely for them to actually follow your instructions of starting low and slow. I don’t know why my patients are like this, but a lot of times they want to just jump to whatever the end dosage is, but if they know that there might be some consequences to that, they’re more likely to sort of start where I’m telling them to start and go very slowly.
In terms of going slowly, what I usually recommend is that … so say they start with an eighth of a teaspoon the first day. As long as they do fine with it and they’re not getting a lot of bloating or anything, even the next day they could add another eighth of a teaspoon at a different time of day. Then you get to the second day and you’re on an eighth of a teaspoon twice a day. Maybe the third day, again, if they did fine with the previous two days, you add another eighth of a teaspoon later in the day, so now it’s three times a day. And this is for FOS because you end up doing it three times a day. If you’re doing GOS, I would do it twice a day because it’s a little bit less that they end up having to take overall. Then kind of follow that pattern every day if they’re doing fine. For some people, maybe do every other day if they’re having a little bit of trouble getting used to the higher dose each time, but typically I tell people, “As long as you feel fine when you increase the dosage, you can do it the next day. If you didn’t feel fine, do that same dosage that you just added up to for another day or another two days, until you sort of feel like your body has gotten used to that level of prebiotic, and then increase it.” Eventually for FOS, it’s going to be about a scoop, I guess, that comes with the NOW FOS powder, three times a day, and GOS twice a day. Just give your people a little bit of an idea of what’s going to happen, and you should be fine.