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In this issue, Dr. Frank Kim discusses the how good bacteria in the human gut play a role in maintaining health and how sometimes they need a little help. Read on...

You might believe that your body is mostly human, but you'd be wrong. In fact, it's mostly bacterial - at least by the numbers. In the womb, the human digestive tract is sterile. However, in the first few weeks after birth, it rapidly acquires bacteria of many types. By adulthood, the typical human body harbors about 100 trillion bacterial cells (yes, that's 14 zeros) from at least 500 different species. This is about 10 times the number of human cells. So, as humans, we are outnumbered 10 to 1. However, bacterial cells are much smaller than human cells - so by weight the average adult only carries about 2 pounds of bacteria - mostly within the digestive system. Fortunately, not all bacteria are bad guys and the majority of these bacteria are considered "friendly." Some aid in digestion. Others keep "bad" bacteria at bay by competing with harmful bacteria in the intestines - just like grass in a healthy lawn limits the growth of weeds. This process helps maintain a healthy intestinal tract while at the same time stimulating the body's natural immune defenses.

What are probiotics?
You may be familiar with antibiotics, but a lot of people are not really clear about what probiotics are. Despite the way it sounds, probiotics are not new steroids to be used by baseball players. The word, probiotic by definition is "for life." This name is now mostly used in reference to concentrated supplements of beneficial or "good" bacteria given to humans or animals to treat and possibly prevent a clinical disorder. Probiotics may have some beneficial properties if you get enough of them - especially in improving symptoms of certain digestive disorders. The usefulness of probiotics had been touted long before the name was coined. The ability of beneficial bacteria, for example, to transform milk into a longer lasting food was recorded back 6,000 years ago.

How do probiotics work?
This is not completely understood. It is assumed that probiotics help primarily by suppressing the growth of pathogenic, or "bad," bacteria in the digestive tract. In some way, they may also strengthen the intestinal barrier that lies between us and the outside world. Lastly, they also may be helpful by directing our immune system against these bad bacteria.

Common probiotics
In recent years, much research has been done in the development of probiotics. The list continues to grow including strains such as lactobacillus, which helps recolonize in the small bowel and Saccharomyces boulardii, a non-pathogenic strain of yeast. These studies suggest that certain probiotics species given alone or in combination may reduce symptoms of several digestive diseases such as inflammatory bowel disease (Ulcerative colitis, Crohn's disease) and, as mentioned above, antibiotic-induced diarrhea.

1. Yogurt. The first consideration is yogurt. Despite popular belief, yogurt is NOT really thought to be a very potent probiotic. Although yogurt is commonly advertised as a source of healthy bacteria, most of the bacteria cultures contained in yogurt don't survive in the acidic stomach environment. Most die long before they can reach the small and large intestine below. A dead bacteria is useless. Also, most yogurts contain the bacterial strain Lactobacillus acidophilus - a bacteria not normally found in the gut and not considered a good probiotic. (A few yogurts such as Stoneyfield contain Lactobacillus reuteri, which is a beneficial bacteria.) That said, yogurt is still a good source of nutrition, especially calcium.

2. Flora-Q. Currently, one of the most common available preparations include Flora-Q, which is a blend of proprietary bacteria with strange names like Lactobacillus, Bifidobacterium, and Streptococcus thermophilus. Each Flora-Q capsule contains over 4 billion freeze-dried bacteria. To prevent stomach acid from killing these bacteria, this special capsule does not dissolve until it leaves the stomach and enters the small intestine where the bacteria are rehydrated and come alive. The recommended dose is just one a day.

3. Culturelle. Culturelle is a formulation of Lactobacillus GG, or LGG for short, a patented "healthy" bacterial strain which takes its name from its discoverers, Drs. Gorbach & Goldin of Tufts University in Boston, Massachusetts. They analyzed over a thousand different strains for ideal "health promoting/probiotic" characteristics and chose the LGG strain as the ideal probiotic. In study after study, LGG has been proven to better withstand stomach acid and form a stronger barrier to bad bacteria than other common Lactobacillus strains found in yogurt.

4. Florastor. The other one is Florastor, which is Saccharomyces boulardii 250 mg. Florastor is non-pathogenic (good) yeast, not a bacterium like other probiotics. It has been useful in patients with acute and chronic diarrhea, epecially when caused by broad-spectrum antibiotic, so-called "traveler's diarrhea," and may be helpful in those with bloating and gas associated with bowel problems. This preparation is available without a prescription and the recommended dose is one capsule twice a day.

5. VSL#3. Another recent formulation is called VSL #3, which is sold by Nature's Pharmaceutical. There are 450 billion freeze-dried lactic acid bacteria in each packet of VSL#3 which is taken once daily. VSL#3 can be mixed with yogurt, applesauce, ice-cream or any cold food or non-carbonated beverage.

Probiotics and digestive disease

Pouchitis. Surgical treatment for severe ulcerative colitis often means removal of the entire colon. In some cases, a small "pouch" is constructed to connect the small intestine to the anus. Occasionaly, this pouch can become inflamed, a conditional termed "pouchitis." Several small studies indicate that VSL#3 may be effective in treating and preventing pouchitis.

Antibiotic Induced Diarrhea
We all know that antibiotics are medications that kill bacteria. Since their discovery over fifty years ago, antibiotics have certainly been a key factor in keeping us healthy. Their ability to fight infection has saved countless lives, but there is a downside as well. As with all powerful medications, side effects may sometimes occur. Antibiotics are not selective to just the bad bacteria and usually destroy some of the good bacteria in the intestinal tract. This may contribute to a myriad of other gastrointestinal disorders, the most common of which is an antibiotic-induced colitis, known as C-difficile colitis (see previous newsletter).

There have been a lot of studies looking at the use of probiotics in antibiotic associated diarrhea or C-difficile diarrhea. At least four studies using the Saccharomyces boulardii, and have been shown to be of benefit. All studies were put together and there was approximately a 60% reduction in the antibiotic induced diarrhea compared to placebo.

Other Possible Uses. People have tried these probiotics in acute infectious diarrhea. The studies have shown very little benefit probably because most acute illnesses are self-limited and are usually non-complicated. Also, the safety of its use needs to be established in children. Other areas of research include irritable bowel syndrome, lactose intolerance, collagenous colitis, vaginal yeast infections, allergies and eczema, but those studies are ongoing and at this point really cannot be recommended universally. Please work closely with your physician if you wish to attempt a trial of probiotics in these unproven areas.

A cautionary note
Despite the promise of probiotics and the desire of many indivuals to try a "natural remedy," the consumer must be wary. In the name of profit, there is much hype. Many products are advertised as probiotics though proof is lacking. Only certain strains have been shown to convey health benefits. Not only must the strain of bacteria be correct, the quantity must be sufficient. And the bacteria must be able to survive the harsh acid barrier of the stomach and deliver live bacteria into the intestinal tract below. For example, in an unofficial study, certain groups of probiotics were purchased from a general health store and only 50% of them were able to grow any live bacteria, thus it is unlikely that they would be very effective.

From a safety point of view, these products have been incredibly safe. In general, no side effects have been reported except a few cases of severe fungus infection when Florastor has been administered to hospitalized patients with weak immune systems (AIDS, transplant, chemotherapy) and central venous catheters.

The future of probiotics is uncertain
Several years ago, I went into an organic food store and they were sampling Blue Corn Chips. "They are proven to be the best tasting, they're all natural," chirped the salesperson. "What makes them the best tasting?", I asked. "Well..umm..they're all natural." It is certainly appealing to try to treat GI disorders in a "natural way." Certainly, in some circumstances, probiotics have been found to be a useful aid in the treatment of some diseases. We await well controlled future studies before we can universally proclaim that "natural" probiotics, are the next "Blue Corn."