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Volume 8.15 - 29th October 2018

PREBIOTICS, PROBIOTICS AND THE MICROBIOME Priya Tew Freelance Dietitian and Specialist in Eating Disorders Priya runs Dietitian UK, a freelance dietetic service that specialises in social media and media work, consultancy for food companies, eating disorder support, IBS and Chronic Fatigue. She works with NHS services, The Priory Hospital group and private clinics as well as providing Skype support to clients nationwide.

The world of prebiotics, probiotics and the microbiome has exploded lately and it is definitely an area to stay abreast of and be ready to explain to people in simple terms. There are instant dietary changes that people can make to improve their gut health, potentially their mental health and overall physical health too. THE MICROBIOME

The microbiome is an exciting area of research right now. It has the potential to make some big changes to how we approach nutrition. The gut microbiota is a vast and diverse community of microorganisms in the human intestinal tract, including bacteria, viruses, arachea and unicellular eukaryotes.3 There are 10 times more microbial cells than the number of cells in the human body. The diversity and number of microbes increases through the GI tract from the stomach, with the colon containing the most. This is affected by the current bacterial composition (types of microorganisms) and the abundance. PREBIOTICS

Prebiotics are natural, non-digestible food components that help promote

the growth of beneficial bacteria (probiotics) in the gut. They alter the colonic microbiota in favour of a healthier composition. Fermentation in the colon leads to the production of energy, metabolites and micronutrients and an increase in probiotics. Prebiotics are found naturally in a range of fibre rich foods. These include fermentable oligosaccharides, consisting of three to 10 monosaccharide chains. Often malabsorbed by the small intestine, these foods are instead fermented in the large intestine, giving rise to their benefits. Examples include: • fructans found in main fruit and veg, grains legumes, nuts and inulin; • galacto-oligosaccharides (GOS) found in legumes and beans.

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Table 1: Prebiotics Fructans

GOS

Fruit: nectarines, watermelon, plums, pomegranate,

Legumes: chickpeas, lentils, beans

grapefruit, ripe bananas Veggies: artichokes, cabbage, onions, shallots, spring onions, leeks, garlic, asparagus, broccoli, Brussels sprouts, fennel Grains: wholewheat, rye and barley Legume and nuts: chickpeas, lentils, beans, pistachios, cashews, almonds Other: inulin, dandelion tea Table 2: Examples of fermented foods Fermented foods Live yoghurt

Tempeh

Kefir

Sourdough bread

Aged cheeses

Soy-fermented foods

Kimchi

Fermented sausage

Sauerkraut

Pickles

Miso

PROBIOTICS

Probiotics are live organisms, which when administered in adequate amounts, confer a health benefit.1 These can change/repopulate the intestinal bacteria in order to rebalance the gut flora and include live cultures and fermented foods. They can stimulate the immune system and help decrease the risk of infections by affecting the balance of pathogenic and commensal bacteria. They can reduce the production of pro-inflammatory cytokines, thus counteracting inflammation and cell damage.8 FERMENTED FOODS

There has been a resurgence in the popularity of fermented foods recently, these foods are as old as humans, but we have lost some

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of these traditional methods from our diet culture. As soon as farming and hunting began, fermentation of foods started as a means of preserving food. The varieties we have now in the shops will vary widely depending on method of manufacture, the bacterial cultures added in, plus duration of storage.7 This makes it hard to know if they contain enough live cultures to have a benefit. Now it becomes tricky. How do we know there are enough live cultures in a product for it to be of benefit? On the other hand, at least we know they are unlikely to have a negative effect, so they are worth trying. A study on retail food samples of fermented foods found many contained 10 bacteria/g,5-7 which was classed as a good amount. However, there is no legislation If you would like to order a product sample to be delivered directly to a patient, please visit www.nutriciaproducts.com/samples

*For Healthcare Professionals Only. Probiotic Bifidobacterium breve M-16V and prebiotic scFOS/lcFOS blend. Accurate at the time of publication, November 2018. References: 1. Candy et al. Pediatr Research. 2018;83(3):677-686.

Copyright ÂŠ 2018 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd.

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This information is intended for Healthcare Professionals only. Neocate Syneo is a Food for Special Medical Purposes for the dietary management of Cowâ&#x20AC;&#x2122;s Milk Allergy, multiple food protein allergies and other conditions requiring an Amino Acid-based Formula, and must be used under medical supervision after full consideration of all feeding options, including breastfeeding. *Accurate at time of publication, November 2018 Probiotic Bifidobacterium breve M-16V and prebiotic scFOS/lcFOS blend CMA: Cowâ&#x20AC;&#x2122;s Milk Allergy AAF: Amino Acid-based Formula References: 1. Candy et al. Pediatr Research. 2018;83(3):677-686 2. Burks W. et al. Pediatr Allergy Immunol 2015;26:316-322 3. De Boissieu D. et al. J Pediatr 1997; 131(5):744-747 4. Vanderhoof JA. et al. J Pediatr 1997; 131 (5):741-744 Nutricia Advanced Medical Nutrition, White Horse Business Park, Trowbridge, Wiltshire, BA14 0XQ

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Table 3: Strength of efficacy for probiotics with identified strain designations5 Disease indication

Net ≥ 2 significant RCTs (number of significant RCTs/nonsignificant RCTs)

At least two RCTs with significant efficacy (number of significant RCTs/non-significant RCTs)

Prevention AAD

Saccharomyces boulardii I-745 (11+/6−) Lactobacillus acidophilus CL1285+ Lactobacillus casei LBC80R+

Enterococcus faecalis SF68 (2+/1−) L. rhamnosus GG (2+/4−) Lactobacillus reuteri 55730 (2+/1−)

Lactobacillus rhamnosus CLR2 (4+/0)a L. casei DN114001 (2+/0−) Paid AAD

S. boulardii I-745 (7+/3−)

L. helveticus R52 + L. rhamnosus R11 (2+/1−)

CDI-primary

None

L. acidophilus CL1285 + L. casei LBC80R + L. rhamnosus CLR2 (2+/2−)a

Nosocomial infections

None

L. rhamnosus GG (2+/2−)

Travellers’ diarrhoea

S. boulardii I-745 (2+/0−)

Treatment Paediatric acute diarrhoea

S. boulardii I-745 (25+/4−) L. rhamnosus GG (12+/3−) L. reuteri DSN 17938 (3+/0−) L. acidophilus LB (3+/1−) L. casei DN114001 (3+/0−) VSL#3b (2+/0−) Bac. clausii OC/SN/R (3+/1−)

L. helveticus R52 + L. rhamnosus R11 (2+/1−)

Irritable bowel syndrome

B. infantis 35624 (2+/0−) L. rhamnosus GG (2+/2−) L. plantarum 299v (4+/1−) S. boulardii I I-745 (2+/2−)

L. rhamnosus GG+ L. rhamnosus VSL#3b (2+/2−) LC705 + B. breve Bb99 + Prop. freudenreichii shermanii Jc (2+/0−)

H. pylori eradication

L. helveticus R52 + L. rhamnosus R11 (4+/1−)

S. boulardii I-745 (5+/11−) L. reuteri 55730 (2+/2−) L. acidophilus La5 + B. animalis spp. lactis Bb12 (3+/2−)

Inflammatory bowel disease

VSL#3b (8+/2−)

S. boulardii I-745 (2+/1−)

CDI-recurrences

S. boulardii I-745 (2+/0−)

AAD, antibiotic-associated diarrhoea; B., Bifidobacterium; Bac, Bacillus; CDI, clostridium difficile infections; E., Enterococcus; L., Lactobacillus; Prop., Propionibacterium; S., saccharomyces. a) Includes two dose treatment arms from one trial. b) VSL#3, a mix of eight strains (B. breve, B. longum, B. infantis, L. acidophilus, L. plantarum, L. paracasei, L. debrueckii spp. bulgaricus, and Streptococcs thermophilus).

on what a relevant dose is, or to check that these foods contain the beneficial bacteria at all.2 The health benefits of probiotics include positives for gut health, improvements in glucose tolerance, blood lipid profiles and digestive function. However this is evolving research and we need more randomised clinical trials (RCTs) to help us really see the effects.6

Firmucites and bacteroicetes make up around 90% of the bacteria in the gut; however, there are also smaller strains that have important roles and shouldn’t be forgotten, eg, Bifidobacteria and Lactobacillus. The gut microbiota influences the whole body and GI tract in various ways, including affecting gut permeability and tight junction formation.

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Volume 8.15 - 29th October 2018

A study on retail food samples of fermented foods found many contained 10 bacteria/g, which was classed as a good amount.

Fermentation of oligosaccharides and fibre, including beta-glucans and psyllium, leads to the production of short-chain fatty acids, acetate, propionate and butyrate. These are used by the intestinal epithelial for energy and can lower the luminal pH so inhibit pathogen growth. The production of these chemicals can also affect immunomodulation via stimulating the production of certain cytokines, inhibiting others and, therefore, playing a role in the regulation of proinflammatory and anti-inflammatory cascades.3 GUT HEALTH STUDY

The link between gut microbe diversity and diet was investigated in more than 1500 people in an observational study. The American Gut Project4 used citizen scientists, so the public donated their time and personal data for analysis. The results showed that eating 30 or more plant-based foods a week leads to a more diverse microbiome, compared to 10 or less plants foods a week. In the study, those who ate more plant foods had fewer genes for antibiotic resistance in fecal samples. There was a potential positive mental health effect seen too. Those with PTSD, schizophrenia, depression of bipolar disorder had more bacteria in common with others suffering from similar conditions than the controls, suggesting a bacterial link that could potentially be changed via diet.4 One key thing to note from this study is that diversity was key, so eating a variety of plant foods over the week is more beneficial than having the same ones day in and day out.

SUPPLEMENTATION

There are many probiotics available and they are often expensive, so which are the right ones to direct people to without them wasting money? This gets complicated, as many probiotics are strain specific. There can be several thousand strains of one species (eg, Lactobacillus) and each strain has its own unique properties and impact on the body. One big issue we face as clinicians is which probiotic to recommend, the market is huge and the evidence is very much up and coming. Telling people to just “take a probiotic” is too broad and is pretty much a lucky dip. Much of the research conducted either fails to mention the specific strains used, or pools different strains together, therefore diluting down the results. The other complication is that formulations of probiotics can change over time. Now, not only is it important to look at the strain of probiotics, but also the impact that it has on a specific disease. Obviously, there is not point recommending a strain of probiotic that is useful for diarrhoea prevention for a patient who has H. pylori infection! A recent systematic review looked at the research from 1970-2017, specifically focusing on the strains and disease states.5 A total of 228 trials were included. Strong evidence was found for the efficacy of specific probiotics for six disease states: AAD (antibiotic associated diarrhoea), CDI (clostridium difficile infections), IBD, IBS, TD (traveller’s diarrhoea), acute paediatric diarrhoea and for H. pylori infections.

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The strongest evidence was found for the VSL#3 mixture (B. breve BB02, B. longum BL03, B. infantis BI04, L. acidophilus BA05, L. plantarum BP06, L. paracasei BP07, L. helveticus BD08, Strept. thermophiles BT01). There were six trials with significant efficacy

for the treatment of IBD. the strength of efficacy for identified strain designations randomised controlled trials findings for the prevention disease.5

Table 3 shows probiotics with and at least two with significant or treatment of

TAKE HOMES MESSAGES 1 Encourage people to eat a diverse amount of plant-based foods. This doesn’t have to mean that they go vegetarian or vegan, but just the message of eating more plant foods every day. 30 or more plant foods may seem a lot in a week, but everyone can start by increasing from where they are, adding five different portions a week. 2 Fermented foods may be a useful source of probiotics. Adding live yoghurt and pickles can be a simple way to do this. 3 Prebiotic foods are plentiful and link into the message of eating more plant-based foods. Using the message that these foods are prebiotics may encourage some people to eat more of them. 4 When recommending probiotic supplements for disease states, check the evidence for the specific strains that work. References 1 Morelli L, Capurso L. FAO/WHO guidelines on probiotics: 10 years later. J Clin Gastroenterol. 2012; 46 Suppl: S1-S2 2 Rezac S et al (2018). Fermented foods as a dietary source of live organisms. From Microbiol 9: 1785 3 Pen Nutrition - Gastrointestinal System - Microbiota 4 MacDonald D et al (2018). American Gut: an open platform for citizen-science microbe research. Am Soc for Microbiology, May/June 2018. Vol 3. Issues 3. e00031-18 5 McFarland LV et al (2018). Strain-specifity and disease-specificity of probiotic efficacy: a systematic review and meta-analysis. Front Med (Lausanne). 2018; 5: 124 6 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 Gastro Hepat (2014).11(8):506-14.10.1038/nrgastro.2014.66 [PubMed [Cross Ref] 7 Carrie Dennet. The facts about fermented foods. Today’s Dietitian. Vol 20 (4). p 24 www.todaysdietitian.com/newarchives/0418p24.shtml

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Questions relating to: Prebiotics, probiotics and the microbiome Type your answers below, download and save or print for your records, or print and complete by hand. Q.1

What makes up the gut microbiome?

Q.2

Explain the role of prebiotics in the gut, giving examples of foods in which they naturally occur.

Q.3

What is a probiotic and what effect does it have on the human gut?

Q.4

What did the American Gut Project reveal about plant-based diets?

Q.5

Explain the issues surrounding the recommendation of probiotics.

Q.6

How does the fermentation of oligosaccharides play a role in the regulation of pro-inflammatory and anti-inflammatory cascades?

Q.7

In the Gut health study the one key thing to note was that diversity was key - why?

Q.8

Give three messages to encourage patients in their choices relating to pre- and probiotics

Please type additional notes here . . .