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3 Probiotics 101

It’s been a whirlwind the last few months. I’m teaching my last lecture in Endocrine tomorrow.. I’m excited it’s on functional medicine approach to pre-diabetes and obesity! The best part about teaching part-time is getting to teach what I’m passionate about. After this, I just have lots of grading and course coordination items. But the course ends next week then I’m off to Seattle, WA to speak on diabetes cardiovascular outcomes trials. It’s the same presentation from December in Anaheim showcased at a different meeting. It’s nice when you spend a lot of time on something, to be able to do it twice! For this blog post, I had a lot of help from two students working on this probiotic series, so thank you to Vineeta Rao and Ruth Gunti for your hard work. Soon they will be my colleagues! Enjoy!

Dr. Hartzler


Welcome to probiotics 101, a guide to all your FAQs!

What are probiotics?

‘Probiotics are defined as live microorganisms, which when administered in adequate amounts, confer a health benefit on the host.’ 1 The microorganisms are bacteria of different strains that process our food into nutrients that benefit our health. Probiotics come from the Latin preposition pro (“for”) and the Greek adjective (biōtikos) meaning “fit for life, lively.” Put together this means that probiotics are for life.

Why use probiotics?

Using probiotics enhances the gut microbiota to better do its job.  The gut microbiota/microbiome is the conglomerate of bacteria that live in your gut and work together to bolster the immune system, to fight against potential infections, and to make nutrients such as vitamins, fats and other molecules that are needed by the body to function. 1  Furthermore facets of our modern day western lifestyle, such as diet, stress, geography, as well as sleep and travel patterns can negatively affect our gut microbiome meaning we don’t have a healthy gut to begin with. 2 In addition to the poor lifestyle factors, the increasingly prevalent use proton pump inhibitors is correlated with and probably contributes to “decreased bacterial richness” of  gut microbiome, an increased amount of oral bacteria that is potentially pathogenic present in the gut, and an overall greater “microbial alterations” in the gut than those on antibiotics. 3

How do probiotics work?

While probiotics are most commonly associated with replacing flora or colonizing the gut, modifications made to the gut microbiota are not likely permanent and reflect only one of many actions that probiotics have in the body. Among these actions are immune modulation, anti-inflammatory activity, pathogen antagonism, production of short chain fatty acids, repairing and strengthening of the intestinal barrier, metabolism of gut cholesterol, and enhanced antibody secretion.4 While not all probiotics encompass all of these features, depending on the strain, a given probiotic may provide one or several of these protective benefits.5

What is genus, species, and strain?

Bacteria are usually classified to the public by three names much like people who have first, middle and last names. Therefore the first name is a broad name termed genus, followed by a more specific name called a species finally followed by a strain number that is further specifies the exact kind of bacteria.  A labeled example is below!

What is the evidence for probiotic use?

Numerous review studies indicate that probiotics are beneficial overall, especially for gut health.6 However, evidence for treating or preventing specific conditions through probiotics is best established through clinical trials that demonstrate how probiotics produce a specific effect. While the number of controlled trials demonstrating specific effects in humans is still growing, probiotics have also been evaluated in animal experiments and or other in vitro studies that demonstrate efficacy and safety in terms of their use. 1  Fermented foods with probiotics in them have been consumed for centuries for health benefits. Additionally, the modern diet lacks prebiotic fiber that contributes to a diverse gut microbiome.7

What is the difference between Bifidobacterium and Lactobacillus genus of bacteria?

Lactobacillus bacteria is a type of bacteria that produces lactic acid as an end-product of its metabolism. Bifidobacterium bacteria on the other hand produce lactic acid and acetic acid; both these substances are important for the maintenance of the gut microbiome. 8,9

Here are some of the bacteria in each genus considered to be probiotics.8

Microorganisms
  considered as probiotics
Lactobacillus speciesBifidobacterium species
L. acidophilus 
L. casei 
L. crispatus 
L. gallinarum
 L. gasseri 
L. johnsonii 
L. paracasei 
L. plantarum 
L. reuteri 
L. rhamnosus
B. adolescentis 
B. animalis 
B. bifidum 
B. breve 
B. infantis 
B. lactis
 B. longum

How to know you are getting a good product?

There are many overarching reviews that conclude that probiotics as a whole class are effective, suggesting that many strains share the similar levels of effectiveness. Additionally, there are number of factors that contribute to how probiotics act in our bodies such as genetics, diet and host microbiome that makes it difficult to isolate the effects of one strain over another. However, it is important that the product contains the live bacteria in large doses that will survive the harsh environments of the stomach.6

How much does the specific strain matter when ensuring that you have a good product? As more studies for probiotic use emerge, there is an ongoing controversy about the importance of the strain. On one side of the debate, larger studies that examine multiple clinical trials suggest that probiotics have benefit even when grouping similar strains together in one class. The theory behind this position is that similar strains of probiotics will have actions causing similar effects in the body.6 One the other side of the debate, some clinicians compare strain selection to choosing a particular antibiotic to attack a specific disease-causing microbe.4 Advocates of this position point to the fact that Lactobacillus plantarum DSM 9843 reduces irritable bowel syndrome while Lactobacillus plantarum MF 1298 aggravates the condition and thus conclude that when supporting a specific condition, one should only use a strain that has demonstrated efficacy for that specific condition.10-12

In summary, data for use of probiotics is exploding on a daily basis. Probiotics are useful to promote healthy gut transit and repair and for a myriad of immune benefits.  In addition, data suggests significant changes to the gut microbiome is most easily stimulated by ingestion of prebiotics, which are non-digestible foods that promote and stimulate the growth of bacteria in the gut.13 Prebiotics are often combined with probiotic supplements.  Sometimes they may not be well tolerated by certain individuals especially those that have an imbalance in bacteria. Certain non-gas producing prebiotics may be helpful for some patients. We will talk more about these situations in my next post!

If you are looking for quality probiotics. Please check out my Fullscript store and click on the probiotics category! I’m happy to help with simple questions on products via email or if you are interested in a 1:1 personal GI health consults with my team, please let me know. We are launching tele-health services soon!

SOURCES:

  1. Fijan S. Microorganisms with claimed probiotic properties: an overview of recent literature. Int J Environ Res Public Health. 2014;11(5):4745-67.
  2. Conlon MA, Bird AR. The impact of diet and lifestyle on gut microbiota and human health. Nutrients. 2014;7(1):17-44.
  3. Imhann F, Bonder MJ, Vich vila A, et al. Proton pump inhibitors affect the gut microbiome. Gut. 2016;65(5):740-8.
  4. Probiotic Advisor. The Importance of Strain. https://www.probioticadvisor.com/probiotic-essentials-1/the-importance-of-strain/#.XC-EEPZFxPZ. Accessed January 21, 2019.
  5. Hill, C., et al., Expert consensus document: The International Scientific Association for Probiotics and Prebiotics consensus statement on the scope and appropriate use of the term probiotic. Nat Rev Gastroenterol Hepatol, 2014. 11(8): p. 506-514.
  6. California Dairy Research Foundation. Is it time to consider generic probiotic effects? http://cdrf.org/2013/03/01/is-it-time-to-consider-generic-probiotic-effects/. Updated March 1, 2013. Accessed August 20, 2018.
  7. Holscher HD. Dietary fiber and prebiotics and the gastrointestinal microbiota. Gut Microbes. 2017;8(2):172-184.
  8. Kechagia M, Basoulis D, Konstantopoulou S, et al. Health benefits of probiotics: a review. ISRN Nutr. 2013;2013:481651.
  9. Bifidobacteria Institute. Difference between bifidobacteria and lactobacillus. http://bb536.jp/english/basic/basic03.html. Accessed August 20, 2018.
  10. Ducrotte, P., P. Sawant, and V. Jayanthi, Clinical trial: Lactobacillus plantarum 299v (DSM 9843) improves symptoms of irritable bowel syndrome. World J Gastroenterol, 2012. 18(30): p. 4012-8.
  11. Niedzielin, K., H. Kordecki, and B. Birkenfeld, A controlled, double-blind, randomized study on the efficacy of Lactobacillus plantarum 299V in patients with irritable bowel syndrome. Eur J Gastroenterol Hepatol, 2001. 13: p. 1143-1147.
  12. Ligaarden, S.C., et al., A candidate probiotic with unfavourable effects in subjects with irritable bowel syndrome: a randomised controlled trial. BMC Gastroenterol, 2010. 10: p. 16.
  13. Cashman K. Prebiotics and calcium bioavailability. Curr Issues Intest
    Microbiol. 2003 Mar;4(1):21-32. Review.

Eczema & Probiotics

The majority of this post was written by Dr. Taylor Edwards, who was a medical student that rotated with me earlier this year, now she is a Doctor of Osteopathic Medicine off to residency!  I take medical students from Ohio University and work with the pharmacists in my area to expose them to different areas of pharmacy practice. I also talk to them a lot about functional medicine and depending on the speciality they are interested in, we look at what they could study that will impact how they treat patients in the future.  Dr. Edwards. is training to be a dermatologist so of course we talked about gut health and it’s relationship to atopic conditions such as eczema. I hope you enjoy her post!

Dr. Hartzler

 

Eczema, also called atopic dermatitis, is a common, chronic and relapsing skin condition characterized by extreme itching. Currently, the incidence of eczema in industrialized nations is 20%, representing a 2-3 fold increase in recent decades.1,2 The reason for this increase remains unclear due to the complex etiology of the disease. However, it is reasonable to assume that this increase cannot be explained by genetic factors alone. Research has demonstrated that food allergy, defects in the gut mucosal barrier (ie leaky gut), and increased intestinal permeability may play a role in the development of eczema.3 Dietary manipulation remains a controversial topic in the treatment of atopic diseases, however, some studies show promise for the use of probiotics in the treatment and prevention of atopic dermatitis in young children.4

Probiotics are normal, healthy bacteria of the human gut that can be consumed in food or as dietary supplements.5 Lactobacilli and bifidobacteria are the most studied types of probiotics and are thought to assist the neonatal immune system in creating T-regulatory immune cells that are vital in preventing atopic disease.3,6-8 One large study supports the use of probiotics as preventative care due to findings that the incidence of eczema was 20% lower in infants and children that were exposed to probiotics early in life or during gestation.9

Another study demonstrated that probiotics may represent a helpful adjuvant therapy in the treatment of eczema. Forty young children between the ages of 3 months and 6 years with a diagnosis of eczema were divided equally into two groups and treated with probiotics (a mixture of 7 strains including Lactobacilli and bifidobacteria gena) or placebo. At the end of 8 weeks, the children that were treated with the probiotic mixture demonstrated a significant reduction in the severity of their eczema.10 While not all studies regarding probiotics as a modality to improve eczema have demonstrated consistent results, one large meta-analysis that evaluated data from ten studies and 678 patients found that when compared to placebo, probiotics may play a role in reducing the severity of eczema.11

Along with probiotics, cow’s milk is another area of interest for eczema researchers. Many parents believe the development of eczema in their child was temporally associated with the introduction of cow’s milk or cow’s milk based formula. Nearly 100 studies have examined the influence of hydrolyzed formulas versus cow’s milk based formulas in the development of eczema.  The most well-known study, the GINI study, found that infants given exclusively hydrolyzed formula were 50% less likely to develop eczema compared to infants who were fed cow’s milk based formula (hydrolyzed formula did not show benefit over breast milk).12-16 Soy based formula is often believed to be less allergenic than cow’s milk based formula, however, research does not support this claims.17

Exclusion diets have also been studied in individuals with eczema with less promising results. However, children with eczema and suspected egg allergy may benefit from a diet excluding eggs.18 In situations where special diets are attempted, it is recommended to adhere to the diet for a limited time of 4-8 weeks and then return to a normal diet to assess the efficacy of dietary interventions.4

So the PharmToTable Rx for eczema definitely includes quality probiotics (find them in my fullscript store!) and addressing gut health! My favorite quality probiotics include those by OrthoMolecular, Metagenics, Klaire Labs, and Young Living. For kids omega-3’s and vitamin D are certainly another good idea to reduce inflammation and support gut healing. For breastfed babies, elimination diets for mom are also important if you can figure out the trigger. For formula fed babies, a hydrolyzed formula is a good place to start, but possibly further reducing allergens by moving to a corn-free and hydrolyzed option like Alimentum Ready Feed may be necessary. You definitely have to give it at least a month if not two months to see the full effect.

Also check out this post by the National Eczema Association as well for further reading on this topic! There is also some interested new thoughts and emerging evidence about using probiotics topically to help heal the skin. This article discusses the topic.

References: 

  1. Thestrup-Pedersen K. Treatment principles of atopic dermatitis. J Eur Acad Dermatol Venereol. 2002;16(1):1-9. http://www.ncbi.nlm.nih.gov/pubmed/11952283. Accessed February 11, 2018.
  2. Eichenfield LF, Hanifin JM, Beck LA, et al. Atopic Dermatitis and Asthma: Parallels in the Evolution of Treatment. Pediatrics. 2003;111(3):608-616. doi:10.1542/peds.111.3.608.
  3. Isolauri E. Intestinal involvement in atopic disease. J R Soc Med. 1997;90 Suppl 30:15-20. http://www.ncbi.nlm.nih.gov/pubmed/9176124. Accessed February 11, 2018.
  4. Finch J, Munhutu MN, Whitaker-Worth DL. Atopic dermatitis and nutrition. Clin Dermatol. 2010;28(6):605-614. doi:10.1016/j.clindermatol.2010.03.032.
  5. Salminen S, Bouley C, Boutron-Ruault MC, et al. Functional food science and gastrointestinal physiology and function. Br J Nutr. 1998;80 Suppl 1:S147-71. http://www.ncbi.nlm.nih.gov/pubmed/9849357. Accessed February 11, 2018.
  6. Smits HH, Engering A, van der Kleij D, et al. Selective probiotic bacteria induce IL-10–producing regulatory T cells in vitro by modulating dendritic cell function through dendritic cell–specific intercellular adhesion molecule 3–grabbing nonintegrin. J Allergy Clin Immunol. 2005;115(6):1260-1267. doi:10.1016/J.JACI.2005.03.036.
  7. Prescott SL, Björkstén B. Probiotics for the prevention or treatment of allergic diseases. J Allergy Clin Immunol. 2007;120(2):255-262. doi:10.1016/J.JACI.2007.04.027.
  8. Pessi T, Sütas Y, Hurme M, Isolauri E. Interleukin-10 generation in atopic children following oral Lactobacillus rhamnosus GG. Clin Exp Allergy. 2000;30(12):1804-1808. http://www.ncbi.nlm.nih.gov/pubmed/11122221. Accessed February 11, 2018.
  9. Pelucchi C, Chatenoud L, Turati F, et al. Probiotics Supplementation During Pregnancy or Infancy for the Prevention of Atopic Dermatitis. Epidemiology. 2012;23(3):402-414. doi:10.1097/EDE.0b013e31824d5da2.
  10.   Farid R, Ahanchian H, Jabbari F, Moghiman T. Effect of a new synbiotic mixture on atopic dermatitis in children: a randomized-controlled trial. Iran J Pediatr. 2011;21(2):225-230. http://www.ncbi.nlm.nih.gov/pubmed/23056792. Accessed February 11, 2018.
  11.   Michail SK, Stolfi A, Johnson T, Onady GM. Efficacy of probiotics in the treatment of pediatric atopic dermatitis: a meta-analysis of randomized controlled trials. Ann Allergy, Asthma Immunol. 2008;101(5):508-516. doi:10.1016/S1081-1206(10)60290-6.
  12.   Laubereau B, Brockow I, Zirngibl A, et al. Effect of breast-feeding on the development of atopic dermatitis during the first 3 years of life—results from the GINI-birth cohort study. J Pediatr. 2004;144(5):602-607. doi:10.1016/J.JPEDS.2003.12.029.
  13.   Banks JR. THE EFFECT OF HYDROLYZED COW’S MILK FORMULA FOR ALLERGY PREVENTION IN THE FIRST YEAR OF LIFE: THE GERMAN INFANT NUTRITIONAL INTERVENTION STUDY, A RANDOMIZED, DOUBLE-BLIND TRIAL. Pediatrics. 2004;114(2):521-522. doi:10.1542/peds.114.2.S1.521-b.
  14.   Oldaeus G, Anjou K, Björkstén B, Moran JR, Kjellman NI. Extensively and partially hydrolysed infant formulas for allergy prophylaxis. Arch Dis Child. 1997;77(1):4-10. http://www.ncbi.nlm.nih.gov/pubmed/9279143. Accessed February 11, 2018.
  15.   Halken S, Hansen KS, Jacobsen HP, et al. Comparison of a partially hydrolyzed infant formula with two extensively hydrolyzed formulas for allergy prevention: a prospective, randomized study. Pediatr Allergy Immunol. 2000;11(3):149-161. http://www.ncbi.nlm.nih.gov/pubmed/10981524. Accessed February 11, 2018.
  16.   Nentwich I, Michková E, Nevoral J, Urbanek R, Szépfalusi Z. Cow’s milk-specific cellular and humoral immune responses and atopy skin symptoms in infants from atopic families fed a partially (pHF) or extensively (eHF) hydrolyzed infant formula. Allergy. 2001;56(12):1144-1156. http://www.ncbi.nlm.nih.gov/pubmed/11736743. Accessed February 11, 2018.
  17.   Osborn DA, Sinn JK. Soy formula for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev. October 2006. doi:10.1002/14651858.CD003741.pub4.
  18.   Lever R, MacDonald C, Waugh P, Aitchison T. Randomised controlled trial of advice on an egg exclusion diet in young children with atopic eczema and sensitivity to eggs. Pediatr Allergy Immunol. 1998;9(1):13-19. http://www.ncbi.nlm.nih.gov/pubmed/9560837. Accessed February 11, 2018.