Which probiotics are best for SIBO?
3 Step SIBO Treatment Protocol Reducing inflammation in your gut and improving gut immunity The killing of bad bacteria Rebuilding your gut with good bacteria
How I cured my SIBO naturally?
· Here are a few digestive enzyme supplements that may help IBS and SIBO patients: Klaire Labs SIBB Zymes Rainbow light enzymes
How to heal SIBO naturally?
· Treatment algorithms provide an organized road map for treatment rather than throwing a bunch of treatments at the patient to see which one sticks It is important to know there are different treatments for different SIBO types: Methane vs. Hydrogen for example Prokinetics have a place in SIBO treatment and it’s important to know when to initiate
Which is better for treating SIBO?
· Traditionally, the go-to antibiotics for treatment of SIBO consisted of tetracyclines, fluoroquinolones, and co-trimoxazole. However, rifaximin has emerged as the preferred agent among clinicians for SIBO management. Rifaximin is a nonabsorbable antibiotic which acts against Gram-positive and Gram-negative aerobic and anaerobic bacteria.
What is the most effective treatment for SIBO?
SIBO is often treated with a course of rifaximin 1200 mg/ day for 10-14 days, which is expensive and not routinely covered by many commercial health plans in the United States.
Can you get rid of SIBO permanently?
Can SIBO go away on its own? No, SIBO needs to be addressed to go away. You may unintentionally treat SIBO if you change your diet, switch out medications, or start to exercise regularly.
How do you clear up SIBO?
Antibiotics are the primary treatment for SIBO symptoms. However, studies show that dietary changes, such as limiting sugars and lactose, may also help reduce bacterial overgrowth. The SIBO diet can be used in combination with antibiotics and probiotics.
Can SIBO be cured without antibiotics?
It's also possible to address SIBO without using antibiotics or herbal antimicrobials. Getting rid of bacteria with an antimicrobial protocol isn't always necessary: sometimes building up your gut health and encouraging friendly bacteria to grow is a better idea.
What is the root cause of SIBO?
SIBO commonly results when a circumstance — such as surgery or disease — slows the passage of food and waste products in the digestive tract, creating a breeding ground for bacteria. The excess bacteria often cause diarrhea and may cause weight loss and malnutrition.
What probiotic is best for SIBO?
THE BEST PROBIOTIC FOR SIBO Those who tolerate a variety can work their way up to all three. Lactobacillus and bifidobacterium blends: Both Lactobacillus and Bifidobacterium strains are widely studied for their treatment of various infectious and inflammatory conditions.
What supplements should I take for SIBO?
People with SIBO may need intramuscular injections of vitamin B-12, as well as oral vitamins, calcium and iron supplements. Lactose-free diet. Damage to the small intestine may cause you to lose the ability to digest milk sugar (lactose).
What happens if SIBO is left untreated?
Left untreated, SIBO can lead to serious complications including nutrient deficiencies, dehydration and malnutrition. The condition is treatable, but it can also recur. If you suspect you have SIBO, it's important to work with an experienced physician.
Do probiotics make SIBO worse?
These findings suggest that probiotic use can predispose to overgrowth of methanogenic bacteria. The use of probiotics can potentially increase the risk for methane predominant variant of SIBO which has been associated with constipation-predominant symptoms.
What foods make SIBO worse?
Wheat and rye. Natural and artificial sweeteners, including agave syrup, xylitol, sorbitol, and high fructose corn syrup. Dairy products like cottage cheese or ice cream. Certain vegetables, including onions, garlic, artichokes, cabbage, and cauliflower.
Can SIBO be detected by colonoscopy?
The most common methods for diagnosing SIBO are represented by the hydrogen breath tests, using either lactulose or glucose. gastrointestinal pathology and colonoscopy. This endoscopic investigation could cause changes in gut flora including the occurrence of SIBO.
How fast does Xifaxan work for SIBO?
Most of the subjects exhibited noticeably improved abdominal symptoms after 4 weeks of treatment. The most significant treatment response was observed in the first 4 weeks and the symptoms gradually improved during the treatment period.
Sibo Antibiotics (Pharmaceutical)
Antibiotics are a top choice for most gastroenterologists. They act quickly and are easy to implement. Treatment duration with antibiotics is usual...
Sibo Herbal Antibiotics (Natural)
Herbal antibiotics treat SIBO in the same way that pharmaceutical antibiotics do by killing bacteria. They are widely used by natural practitioners...
Advice For Sibo Treatment
Personally, I have been through many of the different treatment options above and fall into the category of SIBO patients who are difficult to trea...
What is the best diet for SIBO?
Of these, the most widely studied and recommended diet for the treatment of SIBO and IBS is the Low FODMAP diet. In recent years, data from several randomized controlled, case-controlled, and observational studies have found that the Low FODMAP Diet provides a significant amount of relief in the management of SIBO and/or IBS symptoms. In fact, each of these scientific studies has provided consistent results on how this treatment option allowed IBS patients to experience a wide range of symptomatic benefits.1
How long does it take to get rid of SIBO?
Another antimicrobial treatment strategy that has been scientifically proven to reduce SIBO symptoms is the elemental diet as a replacement for all foods for 2-3 weeks. This is an excellent option for someone who does not want to take antibiotics or who has failed to respond to other treatment modalities.
Why is dysmotility important for SIBO?
Dysmotility has been shown to be an underlying cause of SIBO, especially in relapsing SIBO patients.3. In order to promote better gut motility (movement) and prevent SIBO relapse, it is often recommended to incorporate natural prokinetic and/or prokinetic drugs after the completion of antimicrobial treatment.
What is SIBO in medical terms?
Small intestinal bacterial overgrowth (SIBO) is a serious medical condition in which, as indicated by its name, there is an overgrowth of bacteria within the small intestine. Scientific research on SIBO has found that this condition is closely related to irritable bowel syndrome (IBS). In fact, the SIBO Theory for IBS, ...
How long after diet and lifestyle modification can you take probiotics?
If you are still experiencing your symptoms after completely following the diet and lifestyle modification for a period of at least 1-2 months, the next step is to introduce a well researched and strain-specific probiotic into your daily routine, along with other supplements. Throughout this second step, it is extremely important to maintain the diet and lifestyle changes you made during foundational step 1.
What diseases can slow the motility of the small intestine?
Other diseases that can slow motility of the small intestine and therefore also contribute to the occurrence of SIBO include Crohn’s disease, celiac disease, and small bowel adhesions , which is a term used to describe the presence of scar tissue in the small intestine 15.
What are some examples of FODMAPs?
For example, food products containing garlic, dairy with lactose, onions, apples, and beans are often high in FODMAPs.
What is the best treatment for SIBO?
1) Antibiotic Therapy. For now, the "gold standard" treatment for SIBO is the use of antibiotic medications aimed at reducing the bacterial overgrowth in the small intestine. 4 These medications are also thought to reduce any inflammation of the lining of the small intestine that might be causing nutritional malabsorption.
What is the best antibiotic for SIBO?
For now, the primary antibiotic used is Xifaxan. 5 Research indicates that Xifaxan can be quite effective in treating SIBO, ...
What is SIBO in health?
SIBO is a health condition in which there are an excessive amount of bacteria in the small intestine. 2 (In a healthy body, the presence of such bacteria within the small intestine should be minimal, with a large population of such bacteria being present in the large intestine.)
What is the low fodmap diet?
The Low-FODMAP Diet: The low-FODMAP diet was designed to reduce the symptoms of IBS by temporarily restricting the consumption of FODMAPs, carbohydrates found in ordinary foods that can contribute to IBS symptoms. 17 With SIBO, two of the various FODMAP types, lactose and fructose, may be malabsorbed due to inflammation along the lining of the small intestine. In addition to these two, other non-absorbed FODMAPs may be fermented by the bacteria residing inappropriately in the small intestine, leading to bloating and other digestive symptoms.
What are some examples of underlying diseases that contribute to the onset of SIBO?
Underlying disease: Some examples of underlying diseases that contribute to the onset of SIBO include those that impair the motility (speed) of the stomach or small intestine, such as gastroparesis or small bowel dysmotility. These can be treated with prokinetic medications. 9 .
Can probiotics help with SIBO?
In theory, probiotic supplements may be helpful for treating SIBO because they have been shown to have a positive effect on bacterial makeup, to improve the health of the gut lining, and to reduce inflammation. 23 However, significant research on the effectiveness of probiotics in treating SIBO is lacking.
Can SIBO be a partial colonectomy?
SIBO may also be experienced by those who have undergone a partial (otherwise known as a subtotal) colectomy, due to a possible resulting impairment of the ileocecal valve which can thus allow colonic bacteria to flow backwards into the small intestine. 13 In addition, a slowing of the small intestine's cleansing wave, due to the colectomy, can set the stage for the bacteria to proliferate.
What causes SIBO?
Let’s just see how it goes and if you find that they’re chronic, then you begin investigating the underlying cause. Adhesions are, I would say, the number two most common underlying cause of SIBO. Number one is food poisoning and that causes an autoimmune situation that damages the nerves in the small intestine and decreases motility. So we get stagnation. That’s number one.
Does Functional Medicine Formulations contain probiotics?
DrMR: Hi, everyone. Let’s talk about probiotics, which helped to make this podcast possible. Functional Medicine Formulations contain a line of probiotics that I personally developed, and I’m super excited to be able to offer you the same probiotics that I’ve been using in the clinic for years and are a byproduct of an extensive review of the literature plus my own clinical experience.
Is vagal healing needed in SIBO?
A whole thing on limbic retraining and how to help that, how to help vagal healing of the vagal nerve is certainly an issue in a lot of SIBO cases. I don’t think it’s needed in all SIBO cases obviously. Sometimes it’s more simple and easy, but for the more difficult cases that can be very, very helpful.
Is SIBO hard to treat?
But the thing of it is , SIBO in and of itself is not that hard to treat if you have the proper education and you know what you’re doing. Yeah, there’s times where you have to, it takes a little longer and you have to work things through. Of course, there are always circumstances like that.
Is SIBO incurable?
So a person like that, that’s an incurable condition. It doesn’t mean it can’t be managed very well, such that there are very few symptoms, but SIBO is always going to be an issue that needs to be managed in people like that.
How to treat SIBO?
An elemental diet consisting of predigested micronutrients has also been suggested as an option to potentially relieve symptoms of SIBO. The proposed benefit of the diet stems from the high amount of predigested micronutrients that are mostly absorbed within the proximal small bowel, thus limiting the delivery of nutrients to the distal portion of the small bowel. A retrospective study examined the potential benefit of elemental diet among patients with SIBO. In the study (n = 124) patients were treated with an elemental diet for a period of 14 days. The overall symptomatic response rate among this cohort was 85%, as indicated by normalization of breath tests [36]. Despite promising data, such a diet may not be sustainable for many due to high cost, especially for those without prescription or insurance coverage. While dietary modification represents a short-term and therapeutic maneuver, the idea that it can treat bacterial overgrowth long term should be avoided, as often times the underlying risk factors for SIBO remain.
What antibiotics are used for SIBO?
Traditionally, the go-to antibiotics for treatment of SIBO consisted of tetracyclines, fluoroquinolones, and co-trimoxazole. However, rifaximin has emerged as the preferred agent among clinicians for SIBO management. Rifaximin is a nonabsorbable antibiotic which acts against Gram-positive and Gram-negative aerobic and anaerobic bacteria. The preferred use of rifaximin stems from its reduced toxicity profile and its utility in irritable bowel syndrome, a diagnosis with significant clinical overlap with SIBO. Furthermore, data shows that rifaximin can act as a “eubotic” agent by preserving colonic flora while increasing the relative abundance of lactobacilli and bifidobacteria in the gut [24]. The eradication rate of SIBO also seems to be dose-related. A previously conducted study reported a dose-dependent eradication rate where higher doses of rifaximin were associated with a higher eradication rate [25]. In a recent meta-analysis aimed at investigating the effectiveness of rifaximin in bacterial overgrowth, the efficacy of rifaximin in eradicating SIBO was 64% as compared to 41% with other systemic antibiotics, including tetracyclines and metronidazole [26]. Another meta-analysis looking at eight studies showed that the effectiveness of rifaximin in the normalization rate of breath testing was 49.5% [27].
What are the benefits of probiotics for SIBO?
A recent meta-analysis suggested that probiotics are effective in reducing the bacterial burden in SIBO patients and alleviating their symptoms [29]. Furthermore, probiotics may enhance the effectiveness of antibiotics as demonstrated in a recent study where patients treated with rifaximin along with probiotics (Lactobacillus casei)had greater improvement in their symptoms with dual therapy as opposed to antibiotics alone [30]. In contrast, a recent study has also shown that probiotics may provoke symptoms among SIBO patients including gas, bloating, and brain fogginess [31]. In the study, probiotic cessation, and a course of antibiotics, resolved brain fogginess while improving other gastrointestinal symptoms (p = 0.005) in 23/30 subjects (77%). This suggests that not all probiotics are of equal efficacy and should be used with caution in patients with SIBO. A 2018 study aimed at assessing how recent probiotic use effects breath testing yielded interesting results that have some questioning the role of probiotics in SIBO management (Mitten E, Goldin A: S660: Recent probiotic use is independently associated with methane-positive breath test for small intestinal bacterial overgrowth. Presented at the 2018 American College of Gastroenterology Annual Scientific Mtg. and Postgraduate Course, October 5-10, 2018, Philadelphia, PA). The study showed that probiotic use within one month was independently associated with increased methane positive LBT in patients presenting with suspected SIBO symptoms. Probiotic users were significantly more likely to have positive LBT compared to non-users (93.6% vs 65.7%, p = 0.003). More specifically, those individuals with recent probiotic use were more likely to have methane-positive LBT but not hydrogen-positive LBT. These findings suggest that probiotic use can predispose to overgrowth of methanogenic bacteria. The use of probiotics can potentially increase the risk for methane predominant variant of SIBO which has been associated with constipation-predominant symptoms. The lack of clear consensus regarding probiotic use suggests that additional large scale studies are needed to better understand the effects of probiotics on SIBO risk.
What are the risks of SIBO?
Structural abnormalities involving the ileocecal valve have also been cited as a potential risk factor for SIBO. The proposed mechanism involves abnormal or inappropriate reflux of colonic microbiota into the ileal portion of the small intestine [11]. A study aimed to assess the relationship between ileocecal valve pressures and SIBO concluded that low ileocecal valve pressures do predispose patients to bacterial overgrowth in the small intestine, with positive results observed in 15 out of 23 subjects (65.2%), as determined by positive lactulose breath testing (LBT) [12]. Ileocecal junction pressures were significantly higher in LBT-negative subjects compared to LBT-positive subjects (79.9% vs. 45.1%, respectively; p < 0.01). Despite this data, additional large-scale studies are needed to further elucidate the relationship between ileocecal valve dysfunction and SIBO.
What is SIBO in a patient?
Small intestinal bacterial overgrowth (SIBO) is a commonly diagnosed gastrointestinal disorder affecting millions of individuals throughout the United States. It refers to a condition in which there is an excess and imbalance of small intestinal bacteria. Despite its prevalence, it remains underdiagnosed due to the invasive nature of diagnostic testing. Symptoms observed in SIBO, including abdominal distension, bloating, diarrhea, and gas formation, are nonspecific and can overlap with other gastrointestinal disorders. Frequently cited predisposing factors include gastric acid suppression, dysmotility, gastric bypass, and opioids. The diagnostic gold standard remains small bowel aspirate and culture. However, due to its invasive nature, it remains an unpopular method among patients and clinicians alike. Glucose and lactulose breath testing have become the go-to diagnostic method in clinical practice due to its noninvasive nature and low cost. Treatment is guided towards the eradication of bacteria in the small bowel and usually consists of a prolonged course of oral antibiotics. Due to recent advances in our understanding of the human microbiome, we are surely poised for a transformation in our approach to diagnosing and treating this condition.
What are the risk factors for SIBO?
The most common risk factors for abnormal or excessive small bowel bacterial overgrowth include disturbances in the small bowel anatomy and motility. Frequently cited examples include diabetic enteropathy, underlying connective tissue disease, chronic opiate use, diverticula, small bowel adhesions, and blind limbs. Additionally, impairments in the normal biochemical clearance of bacteria also predispose to bacterial overgrowth. This includes hypochloremia caused by chronic proton pump inhibitor (PPI) use and reduced pancreaticobiliary secretions caused by chronic pancreatitis.
What is the gold standard for SIBO?
The current gold standard for diagnosis remains a quantitative culture of aspirated small bowel fluid. However, the high cost of the procedure, combined with its invasive nature, has made it less than ideal for many patients. Furthermore, limitations of the procedure, including varying bacterial concentrations along with the small bowel and possible contamination by oropharyngeal flora, make it impractical for routine clinical use. Also, it is important to note that a high percentage of the bacteria colonizing the gut cannot be cultured and that patchy distribution of bacteria along with the small bowel that prevents accurate quantification of bacterial overgrowth [13-15].
How long does a SIBO treatment last?
Most protocols last around 30 days per cycle and vary by the type of SIBO you have. Depending on methane gas levels, more than one round of treatment may be required. In terms of specific herbs, a lot of the research comes from livestock where methane production is a significant environmental concern.
What is the name of the overgrowth of a sibo?
Methane SIBO is its own special kind of overgrowth. It even might finally have its own name - Intestinal Methanogen Overgrowth (IMO). But for now, understanding how it differs from the more common hydrogen form of SIBO is critical to developing a treatment protocol that addresses its well established defences.
How much weight can you gain with methane sibo?
This methane SIBO weight gain is something that I experienced first hand, gaining over 10 kg in the space of two months before testing positive for methane SIBO (and then losing it again post-treatment). It’s also something we see a lot with our clients who have methane SIBO constipation. The good news is it’s fixable.
Is SIBO constipation worse than diarrhea?
While you might think SIBO constipation is preferable to diarrhea , and symptomatically in the short-term you might be right, constipation caused by these methanogens can create a vicious cycle of SIBO that is harder to break than the traditional SIBO-D, diarrhea type.
Is methane sibo a GI condition?
But for now, understanding how it differs from the more common hydrogen form of SIBO is critical to developing a treatment protocol that addresses its well established defences. From chronic constipation and fat-loss resistance, to interpreting test results and choosing interventions, constipation methane SIBO is an extremely complex GI condition and one that is particularly difficult to treat.
Does lactobacillus reuteri help with constipation?
In another study, the probiotic Lactobacillus reuteri ( 17938) had a beneficial effect on chronic constipation via decreases in methane production (as well as hydrogen), including the complete eradication of methane in 11 of the study patients. As with prebiotics, probiotics for SIBO can be a delicate balance to find.
Do probiotics help with constipation?
There is both clinical and scientific evidence for probiotics improving constipation outcomes. The challenge is that while certain beneficial bacteria families are helpful, the literature suggests strain, quantity and other ingredients all matter. Bifidobacterium lactis ( HN019) strain has been shown to improve transit time while Bifidobacterium infantis ( 35624) using a product known as Align, actually increased methane levels. In another study, the probiotic Lactobacillus reuteri ( 17938) had a beneficial effect on chronic constipation via decreases in methane production (as well as hydrogen), including the complete eradication of methane in 11 of the study patients.
What are the risks of SIBO?
Consequently, certain health conditions or lifestyle choices may increase your risk of developing SIBO: 1 Gastrointestinal infections: Such as post-infectious IBS (Irritable Bowel Syndrome) 2 Chronic use of antacids: Long-term antacid use (such as omeprazole) reduces acid production in the stomach. Consistently low levels of stomach acid can lead to bacterial overgrowth in the stomach and small intestine ( 3, 4 ). 3 Immunodeficiency Syndrome: Disorders that can suppress our immune system – such as AIDS and IgA antibody deficiency – provide an ideal environment for harmful bacteria to thrive ( 5 ). 4 Celiac disease: Celiac disease can disturb how food moves through the intestines, particularly if it remains undiagnosed or is poorly managed. This leads to increased bacterial growth in the gut ( 6, 7 ). 5 Aging: In general, older people are at increased risk for SIBO because our digestive tract gets weaker with age. This is thought to be caused by reduced physical activity, weight gain, ongoing medication use and general weakening of the gastrointestinal tract ( 8, 9 ). 6 Alcoholism: Chronic alcohol consumption appears to increase risk of SIBO ( 10 ). 7 Gastroparesis: There is a strong overlap between symptoms, and it seems those with gastroparesis (also known as delayed gastric emptying) are more likely to have SIBO ( 32 ).
Why do older people have SIBO?
Aging: In general, older people are at increased risk for SIBO because our digestive tract gets weaker with age.
What is low fodmap diet?
The process of identifying and removing problem FODMAPs from the diet is known as a low FODMAP diet, and is clinically proven to treat IBS ( 26 ).
What is SIBO in a symbiotic relationship?
Small Intestinal Bacterial Overgrowth (SIBO) is a digestive disorder characterized by excessive bacteria in the small intestine ( 1 ). These bacteria then ferment (interact with food particles and nutrients) to cause a wide range of symptoms. Unlike the large intestine (also known as the gut or colon), which contains most of your gut bacteria, ...
What causes SIBO in the gut?
Researchers suspect SIBO is caused by a combination of decreased pancreatic enzymes, bile acids and gut motility.
Is SIBO a good bacteria?
A healthy and diverse gut bacteria is important for health. However, an overgrowth of this bacteria in the small intestine – known as SIBO – can cause serious problems. This article takes a detailed look at SIBO and what dietary changes are scientifically shown to help. Contents [ hide]
Does omeprazole help with SIBO?
To be fair, though, some research found no significant benefits. One clinical trial on children treated with omeprazole found that probiotics didn’t help, at least not in preventing SIBO ( 24, 25 ). Until we know more, probiotics are not recommended until after completing the antibiotic protocol and a low FODMAP diet.
What is the best treatment for SIBO?
Antibiotics, both herbal and pharmaceutical are the primary treatments for SIBO. Because most medical doctors still don’t recognize SIBO as the primary cause of IBS it can often be a frustrating endeavor to get the correct medicine from your GP or even gastroenterologist.
How to treat SIBO?
You can take oregano oil orally to help with your SIBO, and the best form is through an emulsified tablet which bypasses the stomach having a full impact in the small intestine.
What to do after sibo is eradicated?
After the bacteria from SIBO are eradicated, you may want to supplement with probiotics. MegaSporeBiotic is my go-to recommendation that combines the benefits of probiotics and antioxidants.
What is the first phase of gut treatment for SIBO?
The first phase of gut treatment for SIBO is to eradicate the harmful bacteria in the small intestine.
What is the best antibiotic for SIBO?
The good news is that treating SIBO with herbal antibiotic therapies has the equivalent efficacy to treating SIBO with the traditional antibiotic rifaximin (Zaxine)!
Can antibiotics cause SIBO?
Additionally, many people develop SIBO after prolonged antibiotic use. So herbal antibiotics may prevent further complications for those whose SIBO was triggered by traditional antibiotics in the first place.
Do antibiotics help the gut?
Herbal antibiotics, in addition to helping to eradicate the bad gut bacteria, can provide many additional health benefits for your digestive system. I’ll frequently combine the treatments below when treating my patients.
What is the most important part of SIBO?
Because of this, the most important part of treating SIBO is to listen to your body and iterating on your treatment. I've included the most common (and effective) probiotics that I've successfully used to treat SIBO patients (including myself when I was sick).
What are the symptoms of SIBO?
These conditions lead to the characteristic symptoms of SIBO (and explain why the symptoms range from abdominal gas and bloating to depression and skin conditions): 1 Gas and bloating 2 Constipation or Diarrhea 3 Autoimmune disease 4 Nausea 5 Acid reflux 6 IBS like symptoms 7 Abdominal pain or abdominal cramps 8 Digestive issues or trouble digesting your food 9 Malabsorption of nutrients and minerals 10 Gut inflammation and system inflammation 11 Weight gain (or weight loss) 12 Skin issues like acne, eczema or rosacea 13 Fatigue or low energy 14 Mood changes
What is SIBO in the gut?
Remember that SIBO is a condition which results in an overgrowth of bacteria in the small intestines. It might be counter-intuitive when you consider that probiotics (meaning adding more bacteria to your gut) may actually treat SIBO, but this is indeed the case. SIBO represents a condition of dysbiosis in the gut.
What is SIBO in biology?
SIBO represents a condition of dysbiosis in the gut.
Why does SIBO cause gas?
Gas, in the setting of SIBO, is caused by multiple factors ranging from bacterial gas production to abnormal handling of the gas inside the intestinal tract: No matter how you look at it, gas/bloating/abdominal distention is not good for your GI tract.
How do supplements help the GI tract?
Certain medications and supplements help increase the activity and propulsion of the GI tract which can help normalize bowel movements and help reduce bacterial load in the gut.
Is fermented food good for SIBO?
Fermented foods should be considered mandatory in the treatment of SIBO as they provide far more probiotics than any probiotic supplement ever will (7). One final piece of advice: . It's also worth considering when, how often and how much you take when you supplement with probiotics.
