September 2013 Issue

Friendly Bug Invasion
By Juliann Schaeffer
Today’s Dietitian
Vol. 15 No. 9 P. 38

Supermarket shelves are brimming with new probiotic products. Learn more about what’s on the market and how to counsel clients and patients.

The term “probiotics” has become quite the popular bug—er, buzz—word, with recent research touting how these beneficial bacteria and yeasts may improve any number of health conditions, from overall immune function to gut health and more. And consumers aren’t the only ones taking notice: As fast as (if not faster than) they can sift through what’s new, what works, and why, companies are rolling out new products containing probiotics—each purporting its own health claims.

To help dietitians sort through the microflora, Today’s Dietitian interviewed a handful of experts about what types of products RDs may want to recommend and what’s best left sitting on the shelves.

Probiotic Primer
Just what are probiotics and what’s their role in the human body? Probiotics are microorganisms, mainly bacteria, “that exist naturally throughout the digestive tract and support the body in establishing optimal digestion and aid immune function,” says Ashley Koff, RD, founder of the AKA List at, which includes dietary supplements.

“Probiotics work through several mechanisms,” explains Sonya Angelone, MS, RDN, CLT, a spokesperson for the Academy of Nutrition and Dietetics, “and the beneficial effects are based on the strain of probiotic used and the dosage. In general, probiotics keep disease-causing microbes at bay, play a role in immunity, break down certain food components, and synthesize specific nutrients.”

“Humans naturally have between 500 and 1,000 different strains of bacteria [in their bodies], with the colon having the highest concentration,” says Janet Colson, PhD, RD, a professor of nutrition and food science at Middle Tennessee State University in Murfreesboro. “We all differ in the strains of bacteria [we have in our body], and the various strains of bacteria function differently.”

Probiotics are most commonly used to treat minor gastrointestinal upset. According to Maxwell Chait, MD, FACP, FACG, FASGE, AGAF, a gastroenterologist with ColumbiaDoctors Medical Group in Hartsdale, New York, probiotics offer a safe and effective way for clients to restore the natural balance of their digestive system, especially those suffering from constipation, diarrhea, abdominal discomfort, urgency, gas, or bloating, though he says probiotics are used to treat or prevent a broad range of human diseases, conditions, and syndromes.

“Researchers are discovering that friendly bacteria not only promote digestive health but also may stimulate a healthy immune system by crowding out harmful bacteria as well as by generating ‘friendly’ signals to our immune system,” Chait says, adding that studies continue to look into the application of probiotics in the treatment of a wide variety of conditions, including inflammatory bowel disease, vaginal yeast infections, and high cholesterol.

“Randomized double-blind studies have provided evidence of probiotic effectiveness for the treatment and prevention of acute diarrhea and antibiotic-induced diarrhea as well as for the prevention of cow milk–induced food allergy in infants and young children,” Chait continues, noting that research also has shown evidence of the effectiveness of probiotics for the prevention of traveler’s diarrhea, relapsing Clostridium difficile–induced colitis, and urinary tract infections.

“There are also studies indicating that probiotics may be useful for the prevention of respiratory infections in children and dental caries,” Chait adds. “Areas of future interest for the application of probiotics include colon and bladder cancers, diabetes, and rheumatoid arthritis.”

With all this research on the health benefits of probiotics, clients’ interest in these healthy bugs is likely to increase. And interested or not, they’re increasingly being bombarded at the grocery store with more and more items that tout probiotics (or a mix of them) on the packaging, claiming to help with various health conditions.

Probiotic Products
Below, several dietitians provide their thoughts on some of the more popular probiotic-containing products lining store shelves today.

Yogurt is the preferred probiotic food choice of many consumers and is “by far the most commonly known and widely available probiotic food in the United States,” Chait says. Yogurt is made by fermenting milk with certain probiotic strains that then convert lactose into lactic acid, giving the food its characteristic tanginess, Angelone explains.

There are at least two types of probiotics in all yogurts. “Lactobacillus bulgaricus is one of two types of bacteria that must be used as a starter culture for a product to be called yogurt,” explains Chait, noting Streptococcus thermophilus as the other.

Lactobacillus bacteria help break down lactose found in milk products,” he says, adding that this type of bacteria may benefit people with lactose intolerance. “The second bacteria required as a starter culture in yogurt, Streptococcus thermophilus, one of the smallest types of lactic acid bacteria, also benefits people with lactose intolerance and may have other intestinal benefits,” he continues. “This bacterium is important because it produces products with consistent flavor and texture.”

L bulgaricus and S thermophilus are the only two cultures required by law to be present in yogurt, but many yogurt products contain additional strains as well. “Bifidus regularis is added to some yogurts as a way to increase bacterial survival as yogurt passes through the highly acidic stomach into the intestines and increases its ability to prevent intestinal disorders,” Chait says. Both L bulgaricus and S thermophilus easily break down in the stomach when exposed to acid and may not be able to colonize the intestinal tract, he adds.

Angelone mentions two other examples of yogurt with additional strains. “Bifidobacterium lactis is added to YoPlus yogurt, and Bifidobacterium animalis is in Dannon’s Activia yogurt,” she says, adding that limited research has shown that such products may benefit clients’ digestive issues, such as constipation.

When perusing the dairy aisle for a good yogurt option, Angelone tells clients to be cautious about health claims and watch what’s mentioned on the labels. “These can be misleading,” she says. “Some of these products may contain a significant amount of added sugar, and some yogurts don’t have many active and live cultures, so read the label.”

Koff also tells clients to avoid yogurt products with added sugars. It can be just as easy—and often less expensive—to buy a plain variety and add seasonal fruit at home. “The quality of the yogurt also matters; avoid dairy from animals given antibiotics, as that works against their dairy’s probiotic levels,” she says. Koff recommends Stonyfield Farm, Straus Family Creamery, and Clover Organic Farms as good organic yogurt options.

“The big thing is to make sure [any yogurt product] includes ‘live and active cultures’ on the label,” Colson says. “Also, eat it before the ‘best if used by’ date, as the bacterial count decreases with age. And avoid cooking it—heat destroys the live, active cultures.

“I recommend Greek yogurt for those who are looking for more protein and regular yogurt for those who need more calcium,” she adds.

Probably one of the better sources of probiotics because of its sheer potency is kefir. Originating centuries ago in the Eastern European Caucasus Mountains, kefir generally is known as a fermented dairy product that contains several major strains of bacteria “as well as some beneficial yeast that aren’t found in yogurt,” according to Chait.

“While kefir usually is a fermented dairy product, it also can be made from coconut milk, coconut water, or even sweetened water,” Angelone adds.

“Its flavor is more tart than milk and similar to a yogurt drink,” Chait says. As with yogurt, “the live cultures in it act to predigest lactose, making kefir better tolerated” for clients who are lactose intolerant, he notes.

Chait explains that kefir’s bacterial count consists of approximately 83% to 90% Lactobacillus strains, including Lactococcus lactis, Lactobacillus delbrueckii/bulgaricus, Lactobacillus helveticus, Lactobacillus casei pseudoplantarum, and Lactobacillus brevis. “Yeasts comprise 10% to 17% of the microorganisms and include Kluyveromyces marxianus, Saccharomyces cerevisiae, Candida inconspicua, and Candida maris,” he says.

In addition to probiotics, kefir also contains calcium, B vitamins, and vitamin K2, making it beneficial for bone health, Angelone says. “Kefir also has been shown to suppress mast cell degranulation and [inflammatory chemical] cytokine production,” she adds.

Here, too, Angelone cautions clients about sugar content. “Some kefir is loaded with sugar,” she says. “Look for a brand with minimal additives or extra ingredients.”
Koff’s favorite kefir products are the plain varieties from Green Valley Organics as well as coconut water kefirs.

There are seemingly countless nutritional supplements on the market today in the form of capsules, liquids, powders, and tablets, and probiotic varieties are no exception. Some purport to improve more general symptoms such as overall digestive or immune health, while others claim to improve more specific disorders such as irritable bowel syndrome (IBS). Overall, Angelone says probiotic supplements so far have been shown to benefit several conditions.

“Probiotics have been found to be helpful with constipation, traveler’s diarrhea, antibiotic-induced diarrhea, ulcerative colitis, gas and bloating from IBS, yeast and bacterial vaginosis, pouchitis, and Helicobacter pylori infections,” Angelone says. “VSL#3 is considered a medical food and has good research supporting its use in the dietary management of ulcerative colitis, ileal pouch, and IBS symptoms. Some studies even have found benefit for people with rheumatoid arthritis as well as other conditions.”

But just as there are many different probiotics, it’s necessary to research which ones are best for each patient and client. “There are many different probiotics, and some of them will be more effective than others. It’s vital to know what to look for in a probiotic supplement,” Chait says.

According to Chait, a few helpful tips include doing research and reading labels for certain key items, such as probiotic count—and higher culture counts aren’t the only indicator of a good product. “Many people spend time looking through the shelves of the various probiotics to find the ones that have the highest billions count,” he explains. “While a high billions count is important, it isn’t the all in all. The most important thing is that the microorganisms in the probiotic supplements are engineered to be as effective as possible and survive the trip through the digestive system.”

Koff agrees: “More isn’t necessarily better [in relation to the] quantity of probiotic bacteria and, in fact, a lot of the stated numbers [on products] refer to the amount of bacteria alive when packaged. This doesn’t mean how many there are when you get the product and how many will survive in your digestive tract.”

In general, Chait recommends choosing a product that contains a probiotic count of at least 3 billion to 4 billion. He also suggests RDs conduct their own research before recommending a particular supplement to clients for several reasons. One, a product that contains multiple probiotic strains tends to be better than a supplement with only one variety but only to a certain extent. “The more strains of bacteria included in the probiotic, the more likely the supplement will be to take effect,” he says. “Certain probiotic supplements have a number of different strains that can affect the various parts of the body, and these supplements tend to be effective at helping keep the entire digestive system in good working order. But on the flip side, having too many strains of bacteria may result in one of the strains being far stronger than the rest and killing them all. Always do research to ensure that the multiple strains in each of the probiotic supplements can coexist harmoniously.”

In addition, not all strains have been shown to affect or improve the same medical conditions, so RDs should research which strains are best for whatever ailment a particular client or patient wants to treat. Lactobacillus rhamnosus and Saccharomyces boulardii (which is a yeast, not a bacterium) are said to be two of the more beneficial strains. S boulardii in products such as Florastor is great for traveler’s diarrhea, Koff says, while Lactobacillus strains have been shown to be more effective for improving immune function.

When suggesting probiotic supplements to her own clients, Koff most often recommends Align and New Chapter Organics All-Flora.

“Few products include Bifido bacteria, but they should,” Koff says. “And for many people, using a quality Bifido strain like Bifantis [unique to Align probiotics], which only provides Bifido bacterium [no Lactobacilli], helps to support optimal digestive function when taken daily.”

“There are a few probiotic supplements that I’ve found to be very helpful for women with yeast or bacterial vaginosis,” Angelone says. “This can be a better option than taking medications that only provide a temporary fix and often have side effects.”
Regarding what strains to look for in a particular supplement, Angelone says L rhamnosus, Lactobacillus reuteri, and Lactobacillus fermentum have been found to be effective for yeast infections and bacterial vaginosis. Her go-to probiotic recommendations include Jarrow’s fem-dophilus, Klaire Labs Ther-Biotic Women’s Formula, and Integrative Therapeutics’ Pro-Flora Women’s probiotic.

She also recommends the product FloraMyces, which contains S boulardii yeast probiotics that are especially beneficial for use with antibiotics and while traveling. “Culturelle has Lactobacillus rhamnosus and has some good research to support gastrointestinal health,” she adds.

“As long as you can do research into the various probiotic supplements, you can ensure that the companies that sell the probiotic supplements have done theirs,” Chait says. “Make sure you find the best probiotic supplement that has been tried and tested through the various required clinical studies, and you can ensure that you find a supplement that will be most effective.”

For further information, Angelone suggests RDs read Consumer Lab’s recent review of probiotic supplements.

Granola Bars/Cereals
Probiotics also are being added to shelf-stable food products such as granola bars and cereals, which underlines the bacteria’s popularity as of late. New England Naturals, GranBiotics, and Attune Foods are a few companies offering granola, cereal, or bar products touting probiotics among their ingredients. But RDs interviewed here agreed that whether or not the beneficial bacteria retain their potency in such products, granola and other cereal options can be an expensive way to get probiotics.

“I prefer my clients to get them from foods where they naturally occur or quality supplements,” Koff says.

Several dairy and nondairy drinks with probiotics also are available, most containing some strain of either Lactobacilli or Bifidus bacteria, Angelone says.
“Kombucha tea is a fermented tea that has probiotics, but the levels of active cultures may be diminished depending on handling and may not be appropriate for someone with candida,” she says. “Some soy milks also contain added probiotics. Acidophilus milk is fermented with Lactobacillus acidophilus and is easier to digest for some people.”

But here, too, sugar can be a concern. Angelone notes how Yakult probiotic drink contains beneficial Lactobacillus casei Shirota—but also 11 g of sugar in a 2.7-oz bottle. GoodBelly probiotic fruit drink, another option, has 20 billion Lactobacillus plantarum (except the citrus varieties, which have 10 billion live cultures) in their 8-oz servings, but these also contain between 13 and 26 g of sugar.

“Although some drinks like GoodBelly fruit drinks are good sources of probiotics, they also have a significant amount of calories and sugar per 8-oz serving,” Angelone says, adding that she prefers recommending supplements, which come without added calories and sugar.

Koff agrees: “I find that these [products] have too much added sugar, thereby working at cross-purposes with my goals for my clients as it relates to probiotics, such as optimizing digestion, achieving a healthy weight, supporting optimal immune function, and thus I don’t recommend them,” she says.

If clients insist on buying one of these drinks, Angelone suggests they seek products with fewer grams of sugar and ensure the label mentions the all-important live and active cultures.

Naturally Fermented Foods
Don’t forget to remind clients that probiotics also can be found naturally (though generally in much lesser quantities) in foods such as unpasteurized sauerkraut, kimchi (spicy fermented vegetables mixed with seasonings), and fermented soybean products, including tempeh, miso, and natto, Chait says.

How to Counsel Clients
When it comes to counseling clients on this subject, Koff says dietitians should educate themselves on the role of probiotics; the food, beverage, and supplemental sources of probiotics; and the quality of probiotics, including strain specificity (what research says regarding different probiotic strains) to help clients understand the role of probiotics in the body.

As there are two different types of probiotics, bacteria and yeast, Angelone says it’s also important for RDs to understand the difference between them. “Bacterial probiotics aren’t very effective with antibiotics since they’re inactivated by the medication,” she explains. “Yeast probiotics such as S boulardii can help decrease antibiotic-related diarrhea by protecting the gastrointestinal tract.

“Since probiotic strains vary greatly in quality and health benefits, RDs must be familiar with the various types of probiotic supplements and which ones are most effective for specific conditions,” Angelone says. “The methods of culturing, packaging, and handling can have a huge impact on the effectiveness of the probiotic, and most probiotics need to be refrigerated to maintain viable colonies.”

Although probiotic supplements have few side effects, Angelone says that caution still should be used with older patients, those with reduced immunity, children, and pregnant and lactating women. “RDs should be careful not to use probiotics for medical conditions without working with a physician, since some symptoms such as abdominal gas can be a sign of a more serious underlying condition,” she says.

In general, Angelone says RDs should stress the fact that the word “probiotic” isn’t enough to determine whether a product will be effective for a particular health concern.

Keeping in mind these points—and keeping their eye on upcoming research—will help ensure that dietitians and their clients see the most benefit from these organisms.

“Since there’s so much research in this area, RDs need to keep informed of the emerging research that links gut bacteria to several conditions, including autism, eczema, rheumatoid arthritis, heart disease, and more,” Angelone says. “Gut bacteria have the ability to shape our health now and in the future.”

— Juliann Schaeffer is a freelance writer and editor based in Allentown, Pennsylvania, and a frequent contributor to Today’s Dietitian.


Getting Probiotics in New Ways
Yogurt and supplements aren’t the only ways to get probiotics. Here’s a sampling of products that are putting a different spin on these friendly bugs. From an ice cream treat to an oral health option, companies are branching out when it comes to eating or ingesting these beneficial bacteria.

Available in four flavors, THRIVE Frozen Nutrition is an ice cream–type product that’s formulated to provide an extra punch of nutrition. In addition to containing four different strains of probiotics aimed at aiding digestive health, such as Lactobacillus acidophilus, Bifidobacteria, Streptococcus thermophilus, and Lactobacillus bulgaricus, it also contains 9 g of protein, 3 g of fiber, and 25% or more of the recommended daily intakes of 24 different vitamins and minerals.

EvoraPlus, the first probiotic tablet designed specifically for oral care, contains a concentrated blend of probiotics. By naturally adhering to teeth and below the gumline to crowd out bacteria that cause bad breath, EvoraPlus aims to support and maintain good tooth and gum health.

Nordic Naturals recently introduced Omega Probiotic, which seeks to address omega-3s and probiotic supplementation in one pill. The supplement blends fish oil and live probiotic spores for digestive and gastrointestinal health, and each serving provides more than 2 billion probiotic spores.

Kids also can get a little digestive aid from Florajen’s Florajen4Kids, supplements designed specifically for children. A mix of freeze-dried B lactis Bi-07, B lactis HN019, L acidophilus NCFM, and Lactobacillus rhamnosus HN001, these capsules aim to help little ones establish and maintain a healthy gut repertoire for digestive and immune health benefits.

In lieu of freeze-drying, Dr. Ohhira’s Probiotics by Essential Formulas uses an ancient Japanese three-to-five year fermentation process for its probiotic supplements. A blend of 12 probiotic strains, along with a prebiotic culture medium (fermented vegetables and mushrooms to nourish the probiotics) and pH-balancing organic acids, these capsules are stable at room temperature and are intended to improve digestive and immune health.

— JS