My friend and colleague, Julie Thompson and her collaborators from The British Dietetic Association, have recently published a systematic analysis on the role of probiotics in IBS. In a recent post she compares her frustrations with the process of trying to find any common theme in the results from studies, she and her colleagues reviewed with the challenges of Herding Cats.
Julie and her colleagues reviewed 35 randomised control studies and 9 systematic reviews of probiotics and IBS. They concluded that no strain- or dose-specific probiotic was consistently effective to improve any IBS symptoms or IBS quality of life. Although there was no convincing benefit for any one product, previous systemic analysis and guidelines all concluded that probiotics were worth trying. And thousands of patients have written to the manufacturers and The IBS Network proclaiming the benefits of their probiotic products. So what are we to think?
Maybe it is not so much a question of ‘what we are to think’ as ‘how we are to think’. In her review Julie describes the results of a variety of methodologies, on a range of products each with their own doses and combinations of bacteria packaged in a variety of formulations. A few years ago, the gold standard was to develop multi-strain formulations with a long shelf life that contained large numbers of viable bacteria that survived passage through the stomach and could seed the colon. Now the data seems that probiotics do not seed the colon; they have to be taken on a daily basis to have any lasting effect. Few products show evidence of surviving passage through the stomach, single strain products are as good as multistrain and products do not even need to be viable to be effective. Heat killed bacteria are just as good. And yet the debates go on and the guidelines and systemic analyses mount up.
It’s a bit like the question of how to vote in tomorrow’s EU Referendum. There is such an abundance of conflicting evidence; such a diversity of opinions, but in the end it is up to how we ‘feel’ about it. A decision is an emotional action; it depends as much on experience and information. We just have to have enough confidence to trust our own informed intuition.
IBS is a personal illness. No one person’s experience of the condition is the same as another’s. People attending self help groups soon realise that there is little common ground in the symptoms, the associations and the context of their illness, except that it affects the bowel and has no definite cause or specific treatment. For medical experts, it remains a riddle wrapped in a mystery inside an enigma’; a medically inexplicable illness. Of course, every expert has their own opinion, and attempts to reach concensus often conclude in recommendations that are at best, bland and at worst, meaningless and unhelpful. How could it be otherwise? It’s a no-brainer. How can medical experts ever hope to capture such a diversity of human experience, especially when so few actually ask the patient? So when you add to that the diversity of treatments for IBS, let alone the range of probiotics, the task becomes impossible. The lack of understanding in any subject is always inversely proportional to the amount of stuff written about it. We are badly in need a paradigm shift for IBS and all ‘functional’ or unexplained illnesses.
As far as probiotics are concerned, they undoubtedly work for some people some of the time, they are not harmful and even NICE conclude they are worth considering. So perhaps this is a decision that can be left to you. Our colonic microbiome is the last great frontier of gastrointestinal research, but the more we find out about it, the more we realise that it too is an expression of the individual, as specific as a fingerprint, but constantly influenced by genetics, diet, physiology, drugs and whatever happens to us. So if you have done your own research and a particular product captures your imagination, why not give it a try it for a while? It won’t do you any harm. It is a bit like choosing a particular food, a toothpaste, a car; they may all be seen as representations of your own personality. It’s what it means to you that counts. We make such decisions all the time and the ones that capture our imagination, tend to work best for us. Faith and belief are so important in treating any illness, particularly inexplicable illnesses like IBS. That is the power of the ‘so called’ placebo effect.
As doctors find out more and more about how to treat the life threatening diseases they can identify; the cancers, inflammatory conditions, heart attacks, strokes, liver failure, so they are left with a whole raft of ailments that are expressions of the personality, and can only be treated by individuals themselves as long as they have appropriate guidance and understanding.
So with ever increasing pressure on the health services, should the role of health care professionals for people with IBS be one of screening for medically treatable conditions and signposting resources to guide the choices of treatment for the rest? At The IBS Network’s recent anniversary conference, IBS, The Patient’s Perspective, the message from the patient advocates was that people with IBS need to take charge of their own condition, informed, advised and guided but not directed by health care professionals. You are more likely to leave your illness and get on with your life if you can be encouraged to take charge.