The probiotic supplement industry is worth billions of dollars, and sales continue to rise every year. Although most people consider probiotics to be safe and effective, the evidence to support their health benefits is inconclusive.1 There are two general reasons why the verdict is still out on the efficacy of probiotics: inadequate regulations [2] and low-quality experimental studies. [1] Probiotics are classified as food supplements, which are regulated differently than pharmaceutical drugs. With pharmaceutical agents, regulatory authorities make sure the product is safe to use as directed and works to treat the condition for which it is intended. On the other hand, food supplements are not tested for safety, efficacy, or quality before being put on the market. [2] Probiotics are generally checked by regulatory agencies to ensure the labels do not claim to prevent or treat specific medical conditions. For example, manufacturers can legally claim that probiotics support the digestive system or immune function. They cannot, however, claim to treat specific digestive or immune system disorders such as diverticulitis or Crohn’s disease. Without regulations to confirm the safety, efficacy, and quality of probiotics, consumers and health care professionals cannot be certain that the products will work for a particular condition or even match the ingredients that are listed on the label.

Secondly, the bulk of the evidence used to support the benefits of probiotic supplementation comes from studies with major problems with their methodology, which include small sample sizes; measuring secondary outcomes that are irrelevant to the efficacy of probiotics; and failing to specify methods of randomization, account for participant withdrawals, follow a double-blind procedure, and check the viability of the bacteria and concentration in the tested probiotic. [1] In addition, no study has yet examined the functionality of the microbiome after a dose of probiotics. The majority of studies look at stool samples, which was recently found to be an inaccurate way to determine whether the probiotics have successfully colonized the GI tract. [3]

Two studies published in the journal, Cell, made discoveries that will change the way researchers and health care professionals think about evaluating and prescribing probiotics. The first study examined stool samples and the results of invasive techniques used to evaluate the microbiome of the GI tract of 15 healthy volunteers before, during, and after the use of a placebo or an 11-strain, commercially-available probiotic. The results showed that the bacteria found in the stool samples did not match the bacteria found in the GI tract. The study also suggested that probiotic colonization depends on the host’s original microbiome in various locations of the GI tract and its susceptibility to the strains of bacteria in the supplement. [3] In other words, the colonization of the probiotic was found to be highly variable in each participant, which suggests a single probiotic is not going to promote the same outcomes for every patient.

The second study published in Cell looked at the rate at which the microbiome returned to normal after a week-long course of a broad-spectrum antibiotic in 21 healthy volunteers. The study participants were then assigned to one of three treatment groups: an 11-strain probiotic, an autologous fecal microbiome transplantation (aFMT), or no treatment. The results showed that the aFMT group had the fastest rate of microbiome reconstitution. The group without treatment recovered after a few weeks. Additionally, the reconstitution of the microbiome in the probiotic group was delayed for at least 5 months after the discontinuation of the supplement. [4]

Why are these two studies important? Although they contained small sample sizes and did not aim to evaluate the efficacy of probiotics, [3] they suggest that the current methods of evaluating the colonization of probiotics likely lead to inaccurate conclusions. They also show that it might not be beneficial to recommend the same probiotic supplement to every patient because the unique composition of the host’s original microbiome appears to influence which strains in the probiotic are able to colonize the GI tract. At worst, one of the studies shows that the use of probiotics after a course of antibiotics could contribute to antibiotic-associated diarrhea and Clostridium difficile infections. [4]

Two more studies recently published in The New England Journal of Medicine found that probiotics do not prevent the progression of moderate-to-severe gastroenteritis in children. [1,5] The first study was a randomized, double-blind, placebo-controlled trial with nearly 900 participants who were admitted to an emergency department (ED) for acute gastroenteritis. The study participants were given a five-day course of a two-strain probiotic containing Lactobacillus rhamnosus and L. helveticus two times per day or a placebo. It was found that the probiotic group did not have significantly better outcomes than the placebo group after 14 days. [5] The second study was also a randomized, double-blind, placebo-controlled trial with almost 1,000 preschool-aged participants who were admitted to EDs for acute gastroenteritis, and they were assigned to either a single-strain probiotic containing L. rhamnosus or placebo for five days. It was also determined that the probiotic treatment did not result in better outcomes for the group that received it. [1] These two studies are important because the results challenge the current recommendations for probiotics in children with acute gastroenteritis. [1,5] One of the studies also mentioned the failure of other large trials to produce significant positive outcomes in adults with Clostridium difficile infections or antibiotic-associated diarrhea, pre-term infants with necrotizing enterocolitis, and symptoms of pharyngitis in a wide range of ages. [1]

So, where does this leave RDs when it comes to making recommendations for probiotic supplements? Since dietetics is a science-based health care profession, dietitians should consult the most recent research before recommending any loosely regulated supplement. RDs need to avoid promoting treatments that are not backed by sound science in order to receive the same respect as other health care practitioners. It is important for RDs to showcase why their professional education and training sets them apart from “certified nutritionists,” and one way to do that is to protect the health of patients (and their wallets) by waiting to see if additional rigorous studies will support the use of probiotic supplements as an effective treatment for certain medical conditions and the promotion of general health and wellness.


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References

1. Schnadower D, Tarr PI, Casper TC, et al. Lactobacillus rhamnosus GG versus placebo for acute gastroenteritis in children. The New England Journal of Medicine. 2018;369(21):2002-2014.
2. de Simone, C. The Unregulated Probiotic Market. Clinical Gastroenterology and Hepatology. 2018; In press.
3. Zmora N, Zilberman-Schapira G, Suez J, et al. Personalized gut mucosal colonization resistance to empiric probiotics is associated with unique host and microbiome features. Cell. 2018;174:1388-1405.
4. Suez J, Zmora N, Zilberman-Schapira G, et al. Post-antibiotic gut mucosal microbiome reconstitution is impaired by probiotics and improved by autologous FMT. Cell. 2018;174:1406-1423.
5. Freedman SB, Williamson-Urquhart S, Farion KJ, et al. Multicenter trial of a combination probiotic for children with gastroenteritis. The New England Journal of Medicine. 2018;379(21):2015-2026.

In practice, patients will frequently paint a picture of their idea of a healthful diet, which is often contradictory, restrictive, and interwoven with the misinformation of diet culture. Their food beliefs are at times distorted, and their intakes are unbalanced with a maldistribution of macronutrients. Think back to the 1970s and ‘80s when the low-fat trend emerged and took the food companies and consumers by storm. Fast forward to now: fat is “back,” protein is on a pedestal, and carbohydrates are the enemy. Food confusion is a common topic seen in practice and it appears that much of the population is affected (1). With the help of the media and its convincing misinformation, people are often looking for a quick fix or answer to their rather complex nutrition problems or questions. While we’ve been bombarded with sub-par research that promotes the current diet trends, the truth is, a healthful diet consists of balance. But what is balance?

The Institute of Medicine (IOM) created the Acceptable Macronutrient Distribution Ranges (AMDR), which recommends consumption of 45 to 65 percent of calories from carbohydrates, 10 to 35 percent from protein, and 20 to 35 percent from fat. Additional recommendations include limiting saturated fat and added sugar while aiming for foods rich in dietary fiber. With “balance” defined, how does the Standard American Diet (SAD) measure up?
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For one, when comparing what we are eating to what we should be eating, our fiber intake is certainly not meeting the mark. In fact, fewer than 3% of Americans meet the minimum fiber recommendations (2). Dietary fiber is an indigestible form of carbohydrate that can help with weight control and gastrointestinal health. High fiber foods include fruits, vegetables, whole grains, and legumes, which the SAD is lacking (3).

If Americans aren’t eating enough fiber, what is making it to the table? Interestingly enough, total carbohydrate intakes are within the recommendations of the AMDR, but they likely stem from low-fiber, highly processed sources. Similarly, Americans are meeting their protein and fat needs, but due to the consumption of animal-based sources, especially cheese (3), saturated fat intake exceeds its mark (4). It’s not exactly the public’s fault; nutrition can be a confusing topic to navigate. Just thumb through a health and fitness magazine; see any ads for fruits and vegetables? Didn’t think so. Instead you will find advertisements promoting foods already over-consumed, like dairy and animal-based products. In knowing where the SAD is falling short and what is being overconsumed, what exactly should Americans be focusing on? Glad you asked. Research has indicated that a vegetarian eating plan most closely resembles that of the dietary recommendations (5). What better way to remedy the fiber deficit while promoting adequate protein and reduced saturated fat intake than by shifting the focus to a plant-based diet?

A diet rich in fruits, vegetables, whole grains, and legumes provides the aforementioned redistribution of macronutrients and can provide a plethora of antioxidants, phytonutrients, vitamins, and minerals, all necessary for growth and development. A plant-based diet has shown to be effective in the prevention and treatment of type 2 diabetes (6), overweight (7), coronary artery disease (8), and cancer (9), some of the most devastating and expensive chronic conditions in the U.S. A plant-based diet also packs a strong benefit for the environment and provides a more compassionate lifestyle benefiting all living beings. It may provide an improved relationship and understanding with food as well. Many testimonials exist on the latter (10), which of course are subjective and therefore a limitation of research, but nonetheless a potential valuable benefit of a plant-based diet.

If you are interested in adapting to a plant-based diet, you should understand that there is no one-size-fits-all approach. A great transition may include focusing on plant-based alternatives to some of your favorite recipes or products, such as bean-based taco fillings instead of the beef-based variety, or a pulsed chickpea salad rather than egg salad in sandwiches or lettuce cups. A plant-based diet should still be modeled after the recommendations of the Dietary Guidelines and the MyPlate method may be employed to minimize the guess work of meal planning. In fact, vegan registered dietitians Ginny Messina (11) and Julieanna Hever (12) have created vegan adaptations of the standard plate.

If recipes are your thing, check out some of my favorite vegan recipe resources, including Minimalist Baker (13), Forks Over Knives (14), and Bosh (15). As with all dietary changes, small steps are key, and evidence-based guidelines, along with tasty recipe resources, are imperative for navigating the transition. So, what will be your first step?

About Anja:
Anja is a registered dietitian providing nutrition education in the Patient-Centered Medical Home setting. Captivated by the benefits of plant-based nutrition, she has researched and personally followed a plant-based, vegan lifestyle for many years. After finishing graduate school, Anja completed the T. Colin Campbell Plant Based Nutrition Certification through eCornell and has continued to build upon that knowledge base to write personally and professionally on the benefits of plant-based living.


Sources:

1. https://foodinsight.org/sites/default/files/2017-FHS-press-release-FINAL.pdf
2. https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/0102/usualintaketables2001-02.pdf
3. https://cspinet.org/sites/default/files/attachment/changing_american_diet_13.pdf
4. https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/1516/Table_5_EIN_GEN_15.pdf
5. https://www.ncbi.nlm.nih.gov/pubmed/23758767
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466941/
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466943/
8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4315380/
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048091/
10. https://www.bustle.com/p/how-going-vegan-healed-my-relationship-with-food-my-body-36268
11. https://www.theveganrd.com/vegan-nutrition-101/food-guide-for-vegans/
12. http://plantbaseddietitian.com/the-plant-based-food-guide-pyramid/
13. https://minimalistbaker.com/
14. https://www.forksoverknives.com/recipes/
15. https://www.bosh.tv/recipes

As chronic diseases continue to rise across the United States, patients are beginning to demand more holistic approaches rather than popping pills to heal themselves. As we know, inflammation underlies most chronic diseases and conditions, such as autoimmune disease, inflammatory bowel disease (IBD), type 2 diabetes, arthritis, cardiovascular disease (CVD), cancer and chronic pain. Although there is no standardized anti-inflammatory diet, there are foods that are thought to either reduce or increase inflammation. Educating patients about what these foods are and how to incorporate them into their diet may help reduce their symptoms. But before diving into that, let’s review the science!

Pathophysiology of inflammation: Inflammatory conditions (e.g. infection, acute illness, trauma, toxins, diseases, physical stress) trigger the acute immune response to release eicosanoids and cytokines, which mobilize nutrients required to synthesize positive acute-phase reactants and leukocytes. [1] Cytokines (specifically IL-1beta, TNF-alpha, IL-6) increase the breakdown of muscle protein to meet the demand for energy during the inflammatory response. [1] Tissue injury results in declining values of serum albumin, prealbumin and transferrin (also known as negative acute-phase reactants). As the body begins to heal itself, a negative feedback cycle occurs, and inflammation ceases. If these mechanisms of acute inflammation fail to resist infection or heal an injury, chronic inflammation ensues. [2]
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Various nutrients in foods have been shown to reduce inflammatory markers. [1] Anti-inflammatory foods are high in fiber and have a low glycemic index, and typically include omega-3 fatty acids, antioxidants and polyphenols, and prebiotics and probiotics.

-Omega-3 FA: Foods that have polyunsaturated fatty acids omega-3 DHA and EPA reduce the production of cytokines. [2] Sources include fatty fish, such as salmon, sardines, mackerel and oysters. Plant foods such as walnuts, chia seeds, flaxseeds and hempseeds contain omega-3 ALA, but DHA and EPA seem to be more effective in lowering inflammation. In general, replacing saturated and trans fat with polyunsaturated and monounsaturated fat reduces markers of inflammation (EAL Grade 1). [3]

- Antioxidants and polyphenols in plant foods: Antioxidants help fight free radical damage to cells and reduce production of C-reactive protein and histamine. [1] Polyphenols are phytochemicals in plants that have shown anti-inflammatory effects. Although most plant foods contain these anti-inflammatory properties, fruits and vegetables that seem to contain the most include cruciferous vegetables, onions, garlic, berries, citrus fruits, pomegranates and cherries. [1] Spices and herbs such as turmeric, ginger, rosemary, cinnamon, red chili powder, and black pepper contain antioxidants and polyphenols that prevent free radical formation. [4]

-Pre and probiotics for a happy gut: Although more research on the microbiome is needed, there is some evidence that supports consuming pre and probiotics for a healthy gut ecology, which in turn reduces inflammation. [1] For prebiotics, plant foods containing inulin and oligofructose are preferred because both can be fermented by the gut and promote growth of “good” bacteria.   Prebiotic sources are bananas, asparagus, onion, garlic, chicory and artichokes. Probiotics are the actual bacteria themselves and can be found in fermented foods such as miso, sauerkraut, yogurt, kimchi, kefir, tempeh and kombucha.

-High fiber and low glycemic foods: Refined carbohydrates, such as products with white flour, cakes, pastries, white rice, flour tortillas and pasta, have a higher glycemic load, which when consumed lead to higher post-prandial glucose and insulin levels, and can cause inflammation (which is unfortunate, since refined carbs are so delicious!). These refined carbs also tend to have little fiber as well. Carbohydrates high in fiber tend to have a low glycemic load, with the greatest protection from c-reactive protein seen at a total fiber level above 22 grams per day. [5] Foods high in fiber should be introduced slowly to reduce possible gastrointestinal distress.
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Of course, every person is unique and has different tolerances which need to be accounted for. Food journaling with symptoms are needed to discover these intolerances. Common intolerances include dairy, wheat, eggs, veggies from the nightshade group, and artificial flavors and sweeteners. Also, sleep hygiene is incredibly important; 7-8 hours of sleep per night is optimal for anti-inflammatory effects.

The bottom line:

• Although more research is needed, promoting anti-inflammatory foods may be helpful in controlling symptoms in patients who are experiencing chronic pain or IBD, CVD, type 2 diabetes, arthritis, autoimmune diseases and cancer.
• Nutrients that are most known to be anti-inflammatory include heart-healthy omega-3, antioxidants and polyphenols, and pre and probiotics. They contain high amounts of fiber and have a low glycemic index.
• To make the anti-inflammatory diet more personalized, have patients journal their symptoms along with food intakes to discover possible intolerances. Encourage patients to try to get 7-8 hours of sleep per night, too.
• RDs can encourage patients to live happier and healthier lives by embracing the quote, “Let food be thy medicine and medicine be thy food” (Hippocrates).

Check out the recipe below for an easy and delicious way to incorporate anti-inflammatory spices into a beverage!
 
 
ANTI-INFLAMMATORY GOLDEN MILK *
Serving size: 2
Ingredients:

• 1 1/2 cups light canned coconut milk
• 1 1/2 cups unsweetened almond milk
• 1 1/2 tsp ground turmeric
• 1/4 tsp ground ginger
• 1/4 tsp ground cinnamon
• 1 Tbsp coconut oil
• 1 pinch ground black pepper
• Sweetener of choice (i.e. maple syrup, coconut sugar, or stevia to taste)

 
Instructions:

1. Add all ingredients to a saucepan over medium heat. Whisk to combine until mixture is bubbling, but not boiling.
2. Serve immediately and enjoy!

 
*Adapted from Minimalist Baker
 
 



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Sources

1. Mahan, L. K., Escott-Stump, S., & Raymond, J. (2011). Krause’s food & nutrition care process (14th ed.). Philadelphia, PA: Saunders. 103-1040.
2. Franz, M. (2014, February). Nutrition, inflammation, and disease. Retrieved November 1, 2018, from https://www.todaysdietitian.com/newarchives/020314p44.shtml
3. Academy of Nutrition and Dietetics. Disorders of lipid metabolism: Saturated and unsaturated fat (2010). Retrieved November 1, 2018, from https://www.andeal.org/evidence.cfm?evidence_summary_id=251264&highlight=saturated fat&home=1
4. Supplement and herbs guide. (n.d.). Retrieved November 2, 2018, from https://www.arthritis.org/living-with-arthritis/treatments/natural/supplements-herbs/guide/
5. Ma Y, Griffith JA, Chasan-Taber L, et al. Association between dietary fiber and serum C- reactive protein. Am J Clin Nur. 2006;83 (4):760-766.