April 2017 Issue

Probiotics: Probiotic Beverages
By Sherry Coleman Collins, MS, RDN, LD
Today's Dietitian
Vol. 19, No. 4, P. 20

Category sales are booming as new products hit store shelves.

Probiotics and the microbiome are two of the hottest topics in nutrition. Stemming from research associating gut health with certain probiotic strains that may benefit conditions such as gastrointestinal (GI) disease, obesity, and allergy, the probiotic beverage market is responding with new product innovations.

According to Mike Bush, president of Ganeden Inc, a probiotic manufacturer, and executive board president of the International Probiotics Association, "The functional beverage category has been one of the fastest growing probiotic segments, outside of supplements, boasting double-digit growth." At $35 billion, the probiotics industry is already big business.1

Bush attributes the growth to consumer demand and the availability of more stable probiotic strains to facilitate formulations. "Consumers are looking for convenient ways to get daily doses of clinically studied probiotics, and everyday beverages provide a great option to do so." Bush says their consumer research shows that 70% of respondents prefer to consume probiotics in a food or beverage product rather than in a supplement. In addition, he says 50% of healthy consumers would pay 10% or more for a beverage containing probiotics. Considering these statistics, it's no wonder manufacturers are clamoring to get in on the action.

Strain-Specific Sips
Although probiotic beverages are a growing trend and generally regarded as safe, it's important to consider whether they live up to their espoused health benefits. The key to determining whether a probiotic beverage is worth the investment is to identify the specific bacterial strain and not simply the genus and species. According to Bush, "Consumers should look at the specific strain being used in a probiotic beverage, and make sure that strain has science supporting the survivability, efficacy, and exact health benefits."

Jo Ann Hattner, MPH, RD, coauthor of Gut Insight: Probiotics and Prebiotics for Digestive Health and Well-Being recommends referring to the Clinical Guide to Probiotic Products, available for free at usprobioticguide.com.2 The online reference lists probiotic foods, beverages, and supplements, as well as the probiotic strains they contain; ranked research based on strength; and recommended dosage. Hattner emphasizes that probiotics aren't just good bacteria but good bacteria that have been clinically proven to provide benefit to the host. Here are some of the options available in the marketplace.

Fermented milk beverages have been around for thousands of years. These are generally made with milk from cows, goats, and sheep in the United States and yak, camel, and buffalo in other parts of the world. According to a report by Grand View Research, dairy foods and beverages account for a large share of the probiotics market.1

One of the most common milk-based probiotic beverages in the dairy case has been kefir. Kefir contains yeast and nearly one dozen different bacteria that have been associated with reducing cholesterol, immunoregulation, and the inhibition of certain microorganisms.3 In addition to paying attention to individual strains in kefir, it also may be important to consider the synergistic effect of multiple strains of bacteria and yeast, exopolysaccharides (beneficial and protective substances produced by bacteria), and the potential for increased vitamin, folate, and riboflavin content.4

In the United States, consumers are familiar with drinkable yogurt. Dannon's popular DanActive brand drinkable yogurt contains the strain Lactobacillus casei DN-114 001. In one study of 638 children, daily consumption of a probiotic beverage containing L casei DN-114 001 produced a 19% decrease in the incidence of common infectious disease.5 Another study showed that when stressed adults (n=500), in this case shift workers, drank a probiotic with this strain daily for three months, they were less likely to become ill with common respiratory or GI illnesses.6 This and other studies support its immune-boosting capability.

In addition to probiotic benefits, milk-based beverages also include protein, and many contain a healthful dose of calcium and vitamins D and A. Although they're not milk allergen-free, some of these beverages are lower in lactose, making them potential options for clients who may be lactose intolerant.

For clients who can't or who choose not to drink dairy, probiotic nondairy beverages are an option. One novel nondairy probiotic beverage is Good Karma's flax milk, which as a bonus, is high in omega-3 fatty acids. Good Karma flax milk probiotic beverage contains the strain Bifidobacterium lactis HN019, which has been proven to help treat constipation in adults. In a study of individuals with constipation (stools one to three times/week), B lactis HN019 was shown to significantly decrease whole gut transit time, with a dose dependent response, after just 14 days of use.7

Juices and Waters
Fruit- and vegetable-based probiotic juice products appeal to a wide variety of consumers, including children, because they taste sweet. They also may be good choices for vegan clients or those with milk allergy. It's important for clients to be mindful that these beverages made with juice may be high in calories, as they're naturally high in sugar. However, probiotic water, including Obi probiotic soda (a mix of water kefir, juice, and stevia), and those made with coconut water are becoming popular; they have few added sugars and may be lower in calories.

GoodBelly brand products contain Lactobacillus plantarum 299v, which has been well studied. In one randomized controlled trial, 214 adult patients with irritable bowel syndrome (IBS) received either placebo or L plantarum 299v for four weeks.8 Those in the treatment group experienced greater improvement of IBS symptoms, especially a reduction in pain and bloating. Kate Scarlata, RDN, a Boston-based licensed dietitian who specializes in the low-FODMAP (fermentable oligo-, di-, and monosaccharides and polyols) diet, IBS, and other digestive disorders, and coauthor of the upcoming book The Low-FODMAP Diet Step by Step: A Personalized Plan to Relieve the Symptoms of IBS and Other Digestive Disorders — With More Than 135 Deliciously Satisfying Recipes, agrees. "I utilize probiotics with my digestive disordered patients with moderate success rates." However, not all juices are FODMAP friendly.

Another promising bacterium being used in products such as Suja Pressed Probiotic Water is Bacillus coagulans GBI-30 6086, marketed as GanedenBC30. In a study of 36 older adults, consuming B coagulans GBI-30 resulted in increased beneficial bacteria (Faecalibacterium prausnitzii) and an increase in anti-inflammatory cytokines.9 Although a small study, the results are encouraging.

Fermented beverages provide a replacement for soda, only they contain small amounts of sugar and big-time fizz. These bubbly brews, such as LIVE Kombucha soda, also may be lower in sugar and calories than other probiotic drinks. Kombucha should contain less than 0.5% alcohol, as that's the legal limit for beverages considered nonalcoholic. However, some clients may want to avoid alcohol altogether and choose not to drink kombucha.

According to Hattner, when it comes to kombucha, there's "not a lot of research." Indeed, in a comprehensive review, researchers said there have been no known human studies using kombucha.10 The heterogeneity of kombucha makes it challenging to study because of the different combinations of beginning substrates (usually tea leaves and sugar), varying fermentation times, and various fungi used to induce fermentation.10

But faithful and fervent kombucha fans are unswayed. In fact, a MarketsandMarkets report shows sales of kombucha are expected to grow by 25% every year from now through 2020 to a value of $1.8 billion.11 Hattner is pragmatic about her response to enthusiastic clients and says, "If it makes you feel good, you're the individual judge of that."

On the Horizon
While most probiotic beverages need refrigeration, new strains, innovative packaging, and technology are changing this. "Previously, probiotics weren't able to survive many beverage manufacturing processes and shelf life," Bush says. "However, thanks to the natural stability of probiotic strains like GanedenBC30, probiotics can now be added to a variety of beverage applications, including fresh and frozen juices, sparkling beverages, tea, coffee, powdered drink mixes, and even water."

In addition to using newer strains that are shelf stable, some manufacturers are providing probiotics in bottle caps or through straws so they can be activated when individuals begin to drink the beverage. To increase the health benefits of probiotic beverages, many manufacturers are adding oats for fiber, satiety, and cholesterol-lowering ability; others are including chia seeds to boost fiber and omega-3 fats, and others are adding protein.

Still, despite all the health benefits probiotic beverages may provide, RDs should caution clients and counsel them effectively. "Although most research suggests probiotic use is safe and often beneficial, the truth is many available products in the marketplace have not been tested in the research setting, including many of the probiotic beverages," Scarlata says, adding that not all products are suitable for all clients. "I believe we need to proceed with caution with probiotic overuse, as the gut microbiome is a diverse but fragile ecosystem," Scarlata continues. "I think the notion that any one probiotic will offer health benefits for everybody or the thought that more is better when it comes to probiotics is misguided and unsubstantiated in the literature."

In addition, RDs should be ready to counsel clients on what probiotics may be best for their specific condition and how to find them in the marketplace. Hattner says once you've confirmed the appropriate probiotic strain, clients should start with a small amount to determine tolerance, using the product for a few weeks without any other changes to determine whether it works. Balance the contribution of extra calories from whole milk or sweetened beverages and recommend the ones that fit best into clients' overall needs. Finally, these products are expensive when considering the cost per serving, so discuss with clients the cost-benefit ratio compared with other proven interventions.

— Sherry Coleman Collins, MS, RDN, LD, is president of Southern Fried Nutrition Services in Atlanta, specializing in food allergies and sensitivities, digestive disorders, and nutrition communications.

1. Grand View Research. Probiotics market analysis by application (probiotic foods & beverages (dairy products, non-dairy products, cereals, baked food, fermented meat products, dry food), probiotic dietary supplements (food supplements, nutritional supplements, specialty nutrients, infant formula), animal feed probiotics), by end-use (human probiotics, animal probiotics) and segment forecast to 2024. http://www.grandviewresearch.com/industry-analysis/probiotics-market. Published September 2016.

2. Skokovic-Sunjic D. Clinical guide to probiotic products. US Probiotic Guide website. www.usprobioticguide.com. Updated 2016.

3. Soccol CR, Prado MRM, Garcia LMB, Rodrigues C, Medeiros ABP, Soccol VT. Current developments in probiotics. J Microb Biochem Technol. 2014;7(1):11-20.

4. Marsh AJ, Hill C, Ross RP, Cotter PD. Fermented beverages with health-promoting potential: past and future perspectives. Trends Food Sci Technol. 2014;38(2):113-124.

5. Merenstein D, Murphy M, Fokar A, et al. Use of a fermented dairy probiotic drink containing Lactobacillus casei (DN-114 001) to decrease the rate of illness in kids: the DRINK study. A patient-oriented, double-blind, cluster-randomized, placebo-controlled, clinical trial. Eur J Clin Nutr. 2010;64(7):669-677.

6. Guillemard E, Tanguy J, Flavigny A, de la Motte S, Schrezenmeir J. Effects of consumption of a fermented dairy product containing the probiotic Lactobacillus casei DN-114 001 on common respiratory and gastrointestinal infections in shift workers in a randomized controlled trial. J Am Coll Nutr. 2010;29(5):455-468.

7. Waller PA, Gopal PK, Leyer GJ, et al. Dose-response effect of Bifidobacterium lactis HN019 on whole gut transit time and functional gastrointestinal symptoms in adults. Scand J Gastroenterol. 2011;46(9):1057-1064.

8. Ducrotté P, Sawant P, Jayanthi V. Clinical trial: Lactobacillus plantarum 299v (DSM 9843) improves symptoms of irritable bowel syndrome. World J Gastroenterol. 2012;18(30):4012-4018.

9. Nyangale EP, Farmer S, Cash HA, Keller D, Chernoff D, Gibson GR. Bacillus coagulans GBI-30, 6086 modulates Faecalibacterium prausnitzii in older men and women. J Nutr. 2015;145(7):1446-1452.

10. Jayabalan R, Malbaša RV, Lončar ES, Vitas JV, Sathishkumar M. A review on kombucha tea — microbiology, composition, fermentation, beneficial effects, toxicity, and tea fungus. Compr Rev Food Sci Food Saf. 2014;13(4):538-550.

11. Kombucha market worth USD 1.8 billion USD by 2020. MarketsandMarkets website. http://www.marketsandmarkets.com/PressReleases/kombucha.asp. Published 2015.