Probiotics for the Gut
A Guide for Primary Care Physicians
Dr Jarrod Lee
Gastroenterologist & Advanced Endoscopist
Mt Eliz...
Ilya Metchnikov (1845 – 1916)
• “The Father of Probiotics”
• Russian biologist, zoologist
and protozoologist
• Nobel prize...
Human body
• 10 trillion human cells;
23,000 human genes
• 100 trillion bacteria; 3
million genes
“If gut bacteria are
mak...
4
Gut Microbiota
5
6
7
8
How Do
We Start?
9
Definitions
• Probiotics:
– Live microorganisms that confer a health benefit on the
host when administered in adequate amo...
Lactic Acid Bacteria
• Used for preservation of food by fermentation for
thousands of years
– Fermentation: process by whi...
Lactic Acid
Bacteria
12
Probiotic Nomenclature
• Probiotic strains are identified by genus,
species and an alphanumeric designation
• Marketing an...
Legal Definition
NONE!!!
2011 WGO Minimum Criteria:
• Specified by genus and strain
• Alive
• Delivered in adequate dose t...
Prebiotics
• Mostly used as food ingredients
– E.g. biscuits, cereals, chocolates, spreads, dairy products
• Common prebio...
16
17
Clinical Indications
How Does It Work?
18
Infectious Diarrhea
• Treatment
– 2004 Cochrane review (23 RCTs, 1917 patients) showed
probiotics significantly reduced di...
Antibiotic Associated Diarrhea
• Antibiotics cause disturbances in gut flora which lead
to reduced resistance to pathogens...
• 19 RCTs, 1650 patients
• Probiotics significantly better than placebo
– RR of symptoms persisting 0.71
– NNT 4
• No diff...
22
Safety
• Safe, few side effects
– Flatulence and mild discomfort
– Mild, self limited
– No long term safety data
• No know...
What Probiotic Strain?
• Lactobacillus and Bifidobacterium species
– Have the most evidence for digestive disorders
– Pref...
25
What Dose?
• In general, higher dosages of > 5 billion CFUs per day
in children, and > 10 billion CFUs per day in adults
w...
How Long?
• Survive in the human gut and
detectable in stool
• Do not colonize the gut and not
detectable 1-4 weeks after ...
Which One to Choose?
28
29
Lacteol Fort
• Lactobacillus acidophilus
• Heat killed and freeze dried
• Works by exclusion:
– Adheres to brush border ce...
31
32
33
Conclusion
Probiotics are:
• Well proven in studies for specific gut disorders
• Safe to use, but avoid in short gut, seve...
35
Thank You
Questions to
drjarrodlee@gmail.com
36
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Probiotics for the Gut - A Guide for Primary Care Physicians

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Probiotics have been shown to be of benefit in several gut disorders. Today, probiotics are a multibillion dollar industry, with a myriad of options that can be confusing. This presentation introduces the fundamentals of probiotics to primary care doctors for use in their daily practice.

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Probiotics for the Gut - A Guide for Primary Care Physicians

  1. 1. Probiotics for the Gut A Guide for Primary Care Physicians Dr Jarrod Lee Gastroenterologist & Advanced Endoscopist Mt Elizabeth Novena Hospital 1
  2. 2. Ilya Metchnikov (1845 – 1916) • “The Father of Probiotics” • Russian biologist, zoologist and protozoologist • Nobel prize in 1908 for work on phagocytosis • “Prolongation of Life: Optimistic Studies” (1907) – Proposed that ingesting bacteria could have health benefits and prolong life 2
  3. 3. Human body • 10 trillion human cells; 23,000 human genes • 100 trillion bacteria; 3 million genes “If gut bacteria are making you ill, can swapping them out make you healthy?” 3Economist 2012
  4. 4. 4 Gut Microbiota
  5. 5. 5
  6. 6. 6
  7. 7. 7
  8. 8. 8
  9. 9. How Do We Start? 9
  10. 10. Definitions • Probiotics: – Live microorganisms that confer a health benefit on the host when administered in adequate amounts • Prebiotic: – Dietary substances that nurture a selected group of micro- organisms in the gut – Favouring the growth of beneficial over harmful bacteria • Synbiotics: – Products that contain both probiotics and prebiotics 10
  11. 11. Lactic Acid Bacteria • Used for preservation of food by fermentation for thousands of years – Fermentation: process by which a microorganism transforms food into other products • Found in many yoghurts – But yoghurts not considered probiotics as not shown to have an adequate number of viable bacteria specifically shown to confer health benefits • Includes Lactobacillus, Lactococcus, Streptococcus 11
  12. 12. Lactic Acid Bacteria 12
  13. 13. Probiotic Nomenclature • Probiotic strains are identified by genus, species and an alphanumeric designation • Marketing and trade names are not regulated, e.g. LGG 13 Genus Species Strain Lactobacillus rhamnosus GG Lactobacillus casei DN-144 001
  14. 14. Legal Definition NONE!!! 2011 WGO Minimum Criteria: • Specified by genus and strain • Alive • Delivered in adequate dose through end of shelf life • Efficacious in controlled human studies • Safe for intended use 14
  15. 15. Prebiotics • Mostly used as food ingredients – E.g. biscuits, cereals, chocolates, spreads, dairy products • Common prebiotics: oligofructose, inulin, lactulose – Oligofructose found naturally in: wheat, onions, bananas, honey, garlic, leeks • Fermentation of oligofructose in colon: – Increases bifidobacteria numbers – Increases fecal weight, and shortens GI transit time • Increased colonic bifidobacteria inhibits pathogens, reduces ammonia levels, and produces vitamins 15
  16. 16. 16
  17. 17. 17 Clinical Indications
  18. 18. How Does It Work? 18
  19. 19. Infectious Diarrhea • Treatment – 2004 Cochrane review (23 RCTs, 1917 patients) showed probiotics significantly reduced diarrhea duration by a mean of 30.5 hours – 2007 meta-analysis showed similar effect in children • Prevention – 2007 meta-analysis (12 RCTs, 4709 patients) showed modest decrease in risk of travellers diarrhea with probiotics; RR 0.85 19BMJ 2007; Travel Med Infect Dis 2007
  20. 20. Antibiotic Associated Diarrhea • Antibiotics cause disturbances in gut flora which lead to reduced resistance to pathogens such as Clostridium difficile • Latest meta-analyses: 2013 Cochrane review – 23 RCTs, 4213 patients (adults and children) – Probiotics significantly reduced risk of diarrhea by 64% (2.0% vs 5.5%) – Adverse events reduced by 20% – Similar findings in earlier meta-analyses • Greatest benefit if started within 72H of antibiotics 20
  21. 21. • 19 RCTs, 1650 patients • Probiotics significantly better than placebo – RR of symptoms persisting 0.71 – NNT 4 • No difference in type of probiotic used • More useful for pain, bloating, global improvement • A meta-analysis of 3 RCTs showed similar effect in children 21Gut 2010; APT 2011
  22. 22. 22
  23. 23. Safety • Safe, few side effects – Flatulence and mild discomfort – Mild, self limited – No long term safety data • No known interactions with other medications or supplements • Rare reports of pathological infection • Avoid in: short gut syndrome, severely ill or immune compromised patients 23
  24. 24. What Probiotic Strain? • Lactobacillus and Bifidobacterium species – Have the most evidence for digestive disorders – Preferred probiotics for these conditions – Lactobacillus (especially LGG) has strongest evidence for acute infectious diarrhea – Bifidobacterium has strongest evidence for IBS • Saccharomyces boulardii – probiotic yeast strain – proven to be beneficial in diarrhoea conditions – potential advantage of resistance to most antibiotics 24
  25. 25. 25
  26. 26. What Dose? • In general, higher dosages of > 5 billion CFUs per day in children, and > 10 billion CFUs per day in adults were associated with better outcomes • Studies with Saccharomyces boulardii use a dose of 250 to 500 mg per day • No evidence that even higher dosages are unsafe, but may be more expensive and unnecessary 26
  27. 27. How Long? • Survive in the human gut and detectable in stool • Do not colonize the gut and not detectable 1-4 weeks after stopping • Sustained benefit requires continued consumption 27
  28. 28. Which One to Choose? 28
  29. 29. 29
  30. 30. Lacteol Fort • Lactobacillus acidophilus • Heat killed and freeze dried • Works by exclusion: – Adheres to brush border cells – Prevents pathogens from attaching, colonizing and drawing fluid • “Stimulates growth of acidogenic flora and IgA synthesis” 30
  31. 31. 31
  32. 32. 32
  33. 33. 33
  34. 34. Conclusion Probiotics are: • Well proven in studies for specific gut disorders • Safe to use, but avoid in short gut, severely ill or immune compromised patients • Symptomatic effects may be modest; may be best used as adjuncts rather than replacements for conventional therapy • Selection should consider clinical indication, strain and dosage 34
  35. 35. 35
  36. 36. Thank You Questions to drjarrodlee@gmail.com 36

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