Issue 126 improving gut health in children through diet

COVER STORY: GUT HEALTH

Kate Roberts RD Freelance Dietitan Kate is a Freelance Dietitian with a wide range of clinical experience of working with adults and children from previously working in the NHS, her specialities are Diabetes and Allergies.

IMPROVING GUT HEALTH IN CHILDREN THROUGH DIET We all know that gut health is incredibly important for general health. Research has connected microbial imbalance, or dysbiosis, with many unwanted health outcomes, including multiple sclerosis, diabetes and autism.1 It is, therefore, important to provide children’s guts with good bacteria and food for that bacteria to give them a chance to develop a healthy microbiome.

However, evidence is pretty thin with what advice we can give in the UK. So what can we recommend?

We as health professionals should not forget the basics when it comes to recommending any kind of health promotion. The Mediterranean Diet, as well as all the other benefits, promotes a healthy gut (see Figure 2 overleaf).2 It seems that increasing the proportion of plant-based foods into diets including lots of vegetables, fruit, nuts, seeds and wholegrain carbohydrates improves gut health in association with the other wellknown benefits of disease reduction.

However, it is always important in Paediatrics to consider the child. Excess fibre can cause loose bowels and plantbased diets can be low in energy, iron and B12 if not managed properly. When recommending changes in diet, ensure that all vital nutrients for growth and development are available and that the child’s weight, growth and symptoms are monitored regularly.

PREBIOTICS

Prebiotics are often overlooked, but they are vital for gut health. Prebiotics are certain carbohydrates called oligosaccharides which are indigestible, they ferment in the large intestine and produce short chain

fatty acids. They, along with dietary fibre, provide the substrate that probiotics feed on in the gut.3,4 Following the Mediterranean Diet has been directly associated with an increase in short chain fatty acids in faeces. The beneficial effects were seen in omnivores as well as vegetarians and vegans.2 Child friendly foods that have a high content of prebiotics include apples, oats, leeks, onions, garlic, linseed and wheat bran. It is questionable whether we need to encourage specific prebiotic containing foods if children are having a diet which is high in fruit, vegetables, legumes and whole grains.3 PROBIOTICS

Here are some examples of food and drink that contain good bacteria which can be given to children: • Yoghurt is an excellent and economical source. Certain yoghurts aimed at children do have live bacteria present, but we should encourage parents and carers to look at labels. A cheaper option is to get large containers of live yoghurt to serve, fruit can be added if children do not like plain. Full fat versions are available and contain less sugar.

Dairy free versions are available including soya and coconut. Again, ask parents and carers to check the labels as they need to have bacteria in the ingredients list. www.NHDmag.com July 2017 - Issue 126

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WHAT TO LOOK FOR IN A PROBIOTIC A guide for healthcare professionals CHECK THE LABEL AND QUALITY

Does the label state the full strain name of the microorganism(s) in the product?

Does the label state the number of live cells of the probiotic strain(s) in the product?

NOTE: This should comprise three components: genus, species and strain identifier.

Yakult contains 1010 Lactobacillus casei Shirota per 100 ml, when refrigerated.

Genus (e.g. Lactobacillus), species (e.g. casei) and strain (e.g. Shirota) is stated in full on Yakult’s packaging.

This is equivalent to 6.5 billion live cells per 65ml bottle.

Contact the company.

Are there quality control procedures in place?

NOTE: This is necessary to ensure the product contains the correct strains and number of live microbial cells as stated on the label.

Yakult is acknowledged by experts to be a quality probiotic.

CHECK THE SCIENTIFIC EVIDENCE

Contact the company or access their HCP website, to find the supporting research.

NOTE: (i) Regulatory restrictions mean companies can share research information with HCPs but not the general public; (ii) Not all probiotic research papers can be found on medical literature databases.

The research evidence for Lactobacillus casei Shirota can be found at www.yakult.co.uk/hcp or by contacting science@yakult.co.uk

CHECK FOR GI TRACT SURVIVAL

CHECK FOR EFFICACY OF THE STRAIN

For oral probiotics, are there human intervention trials showing survival of the probiotic strain(s) through the gut?

Check for trials and studies for the probiotic and the particular patient problem

NOTE : In vitro or model studies are not proof of gut survival in vivo.

(important for assessment of safety).

There are several research papers describing human studies showing the gut survival of Lactobacillus casei Shirota.

See expert advice in ‘LcS Insight: HCP Study Day 2014’ and ‘Your Guide to Probiotics’.

For further support on what to look for in a probiotic or to access the research behind Yakult, then please visit www.yakult.co.uk/hcp contact science@yakult.co.uk or call 020 8842 7600 This resource is intended for healthcare professionals. Not to be distributed to patients.

GUT HEALTH Figure 1: Mediterranean Diet Pyramid

source: www.mediterradiet.org/nutrition/mediterranean_diet_pyramid

• Actimel produces probiotic drinks specifically for children aged three and up which contains two strains of Lactobacilli. It is unclear how many are contained from information given. Actimel contains 11.2g of sugars per serving (100g).

• Fermented drinks such as kefir and kombucha are suitable for children, these can be homemade. They do need special equipment. They can be purchased but are expensive.

• Other fermented foods include miso, sauerkraut, kimchi, and lacto-fermented vegetables such as pickles. A lot of bought versions in mainstream shops will no longer be live. It is possible to make them at home.

It may be tricky to get older or picky children to accept foods such as these. Also remember that many of these foods have a high sodium content.

Always remember that fermented food needs to be introduced gradually, large portions too fast could cause nasty symptoms. Please see Priya Tew’s article on fermented foods on pages 16-19 in this issue for more information.

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ARE THERE FOODS TO AVOID?

Diet is known to effect the microbiome and changes occur swiftly. Diets which are high in fat and sugar have been shown to negatively affect microbes present.5 It has also been reported by some ‘health experts’ that processed food disrupts gut microbiota. The term ‘processed’ is very vague and can refer simply to cooking or freezing. The only evidence for this is in a study which looked at the effect of dietary emulsifiers on the gut bacteria of mice.6 It did effect the gut mucosa; however, I’m not sure how easy it is to find if foods contain carboxymethylcellulose or polysorbate-80 and whether this would have the same affects in humans.

Therefore, encouraging healthy eating and nudging people away from high fat and high sugar foods is better than demonising any specific foods.

SUPPLEMENTS

There are many probiotics for sale which are marketed for children including capsules, chewy tablets and even chocolate. They are available

GUT HEALTH

. . . it is best to recommend that children are eating healthily based on the Mediterranean Diet, including plenty of vegetables, legumes, fruit and wholegrains . . . online and in health and wellness shops. There is no firm evidence for health professionals to recommend any in particular for general gut health.

There are hundreds of different strains of each bacteria within different classes of probiotics such as Lactobacilli and Bifidobacteria. There has been evidence that providing certain strains of probiotics can help specific problems.

For example, providing certain probiotics to children taking antibiotics can reduce the risk of antibiotic-associated diarrhoea.7 It may be that we have to wait for individual stool analysis to be less expensive, more reliable and widely available before dietitians and other

healthcare professionals can recommend specific strains with confidence.

CONCLUSION

In summary, it is best to recommend that children are eating healthily based on the Mediterranean Diet, including plenty of vegetables, legumes, fruit and wholegrains and reducing high fat and high sugar foods where possible. This should cover the prebiotics needed to provide nutrition for any probiotics consumed. Increasing probiotic foods daily is a good aim, but remember to consider the family’s situation in terms of time, skills and money available. A live yoghurt daily is better than nothing.

References 1 Jason Lloyd-Price, Galeb Abu-Ali and Curtis Huttenhower. The healthy human microbiome. Genome Medicine (2016) 8:51 DOI 10.1186/ s13073-016-0307-y 2 De Filippis F, Pellegrini N, Vannini L, et al. High-level adherence to a Mediterranean diet beneficially impacts the gut microbiota and associated metabolome. Gut 2016;65:1812-1821 3 Blaut M. Relationship of prebiotics and food to intestinal microflora. EurJNutr41 [Suppl1] (2002):I/11–I/16. DOI 10.1007/s00394-002-1102-7 4 Cummings JH, Macfarlane GT and Englyst HN. Prebiotic digestion and fermentation. February 2001, vol 73, no 2, 415s-420s 5 Tilg H and Kaser A. Gut microbiome, obesity, and metabolic dysfunction. J Clin Invest. 2011;121(6) :2126-2132. doi:10.1172/JCI58109 6 Chassaing B et al. Dietary emulsifiers impact the mouse gut microbiota promoting colitis and metabolic syndrome. Nature. 2015 Mar 5; 519 (7541): 92-96. doi:10.1038/nature14232 7 Brian S Alper, Monica Zangwill, James LaRue, Eric W. Manheimer (2017). Evidence for clinical practice - Do probiotics reduce the risk of antibioticassociated diarrhoea (AAD) in children taking antibiotics? European Journal of Integrative Medicine Volume 12, June 2017, Pages 129-130

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