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Q #1: Probiotics
I have Crohn's disease. I was looking into probiotics by the names of Primal Defense and Flora Source. Diffrent strains in each. What do you think of their effectiveness with bowel issues? Thanks for the help. (August, 2001)
(Administrator's Note: While the purpose of this web site is to address the nutritional ramifications and interventions associated with HIV disease, we are fielding this question from a Crohn's patient because the diarrheal symptomology can be so similar. Readers should also read Question #2 below for a fuller discussion of the role of acidophilus in its several forms. Also recommended are the Q&A under Diarrhea Remedies on Jennifer's Q&A Page. Virtual Faculty member Donna Tinnerello's article on Diarrhea at the Always Your Choice web site. And of course, Jennifer has several articles on these issues too. Go to Jennifer's Picnic Basket and look for the articles under the "Food: Keeping It In" sub-heading.
A: Charlie Smigelski, RD responds:
Right now, Culturelle (Lactobacillus GG) is being used in clinical trials to establish what help it offers in Crohn's disease. No adverse events have been reported in any of the 6 or 7 trial sites. But data on changes in symptoms or pathology status is not available yet.
I am not familiar with the two probiotics the questioner mentions. I usually suggest Jarrodophilus, available at health food stores, or at the Houston Buyers Club. Or LGG Culturelle, also available at Houston, or directly at Culturelle.
Also, I recommend about 4 or 5 grams a day of glutamine, plus the full RDA of zinc in whatever vitamin one chooses to take. Running low on this mineral or low in glutathione can cause the autoimmune system to rev up. (The glutamine supports better glutathione levels.) In this case, you want to support the regular anti-viral and anti-germ part of the immune system but keep the auto-immune part calmer.
In addition, since Crohn's disease is associated with increased risk of bowel cancers, I would take 200 mcg (micrograms) selenium a day to reduce that risk.
Q #2: Acidophilus, Food & Medications
Are there any foods that I should not eat while taking acidophilus? Is there any interaction with prescription medications (asthma allergy) or while taking prilosec and antibiotics? I am on cipro now and I take medication for irritable bowel. Thank you for any info. (August, 2001)
A: Charlie Smigelski, RD responds:
There are no contra-indications for probiotics with any medicines that I know of, and certainly not with any foods. The beauty of using acidophilus products is that you already have 4 lbs or more of bacteria in your intestine, and the probiotics are just trying to alter the general blend toward a more favourable mix. Agents like prilosec and Cipro
and alcohol and Zantac and antibiotics can all disrupt the normal
balance, so taking the probiotics is just an attempt to restore it.
Q #3: Timing How far apart can I take my two acidophilus pills? I take one at 7AM and the other at 2PM. Is this OK? I also take my calcium the same way with it. Is this OK? Thanks. (January, 2002)
A: Charlie Smigelski, RD responds:
You can take acidophilus pills at any time, together or not. No timing issues. Calcium can be taken at the same time. Calcium spread out across the day is a better idea, and take the calcium with food for better absorption.
Q #4: Acidophilus & AIDS Drugs
Do AIDS drugs kill off friendly bacteria like antibiotics do? Does taking acidophilus really restore them? What's the best form to take it in? (May, 2000)
(Administrator's Note: This question provoked the following give-and-take among the Virtual Faculty. Please read all the entries for a full airing of the subject.)
A: Barbara J. Scott, MPH, RD responds:
HIV antiretroviral medications should not affect the natural flora (bacteria) in your intestinal tract. However, some antibiotics considered "broad spectrum" (they are effective on many different kinds of bacteria) that are taken by persons with HIV may decrease the natural and helpful bacteria normally present in the intestine.
A fair amount of research has been done that shows beneficial effects of providing probiotic organisms (live bacteria that survive passage through the GI tract and have beneficial effects on the host) as live nutritional supplements in foods (especially fermented dairy products like yogurt and acidophilus milk). I was unable to find any research on the effectiveness of taking acidophilus in its "purified" form (such as in a capsule).
It appears that the benefical effects of live bacteria in foods like yogurt come from their ability to stick to some of the cells in the intestine. This "sticking" interferes with the ability of pathogenic (bad) bacteria to stay in the gut, and it also may stimulate the immune system and cause other natural bacteria in the gut to produce substances that inhibit the growth of pathogens. Studies are ongoing to determine the exact probiotic strains that are the most healthful and that survive the best in the intestine. Other potential benefits may include prevention and treatment of diarrheal disease (especially viral but not as conclusive for diarrhea associated with use of antibiotics) and genitourinary tract and vaginal infections, lowering of serum cholesterol, lowing risk of GI cancers, and improvement of lactose absorption and digestion.
Therefore, it appears that it would be helpful to include one or more servings (1 cup) of yogurt with live cultures added each day.
A: Charlie Smigelski, RD responds:
My information on probiotic supplementation comes from having worked with Sherwood Gorbach, MD, for the past three years, as we edit the Tufts Medical School HIV nutrition newsletter Nutrition for Healthy Living.
Sherry is "Mr. Gut Flora", if you ask me, and the pathogen specialist on the Planet. He also edits the journal Clinical Infectious Disease.
When Sherry lectures, he points out that yogurt cultures are mostly killed off by stomach and bile acids. The cultures currently used in them don't survive into the gut and cannot be counted on to populate the gut. (There used to be more durable cultures years ago but not now.) When people in the audience protest, saying that yogurt helps calm their diarrhea, he replies that yogurt is indeed nourishing stuff, and that perhaps the calcium is helping paste their stools together. But the benefit is not from the Lactobacilli strains there.
Sherry isolated a Lactobacillus rhamnosus (as opposed to a L. acidophilus) strain years ago, along with Dr. Goldin at Tufts. It is now call Lactobacillus GG. It is patented and sold as "Culturelle". CVS drugstores are the only ones here in the East that sell it. You can contact CAG Foods, PO Box 2820, Omaha, NE. 68103-0820, to find other distributors. LGG is also in yogurts sold in Europe and South America.
There are more than 100 published papers in various journals, documenting studies of the use of LGG in treating rotavirus in kids, other diarrheas in Pakistan, Thailand, etc. One paper I especially like is in J Allergy Clin Immunol Feb 1997 99(2):179-85. The title is Probiotics: a novel approach in the management of food allergy. It discusses LGG in treating milk hypersensitivity reactions. Another good article on milk-induced inflammatory response is in Clin Exp Allergy 1998 28(12):1474-9.
Usually, LGG is also used to treat diarrhea from antibiotics, like Biaxin, as it withstands attack even by that strong drug. Standard LGG treatment consists of two pills a day for 15 days, and then the "bugs" live happily ever after in your intestines. Interestingly, when I use it to treat diarrhea in patients using Protease Inhibitors, though, I have to use it continuously, not just in a short course. This leads me to believe that something about PI's damages gut flora, inhibits their growth, or both. AZT and D4T, and all the other nukes and non-nukes, do not seem to hurt gut flora.
Now, as for buying other "probiotics" at the natural food store.... There was a British Medical Journal article about six years ago that reported on shopping for about twelve samples (not sure if the stores were limited to Great Britain or not), and nine of the twelve were bogus, i.e., they didn't contain appreciable amounts of acidophilus, and serveral were even contaminated. Sooooo.... buyer beware.
Then again, LGG is pricey, $16 for a two-week course, which is just out of control, as far as I am concerned. But Sherry maintains that all other probiotic products on the market are not thoroughly tested, so you don't know their efficacy. I have thought of making LGG into yogurt, and then having people pass along a starter culture to each other, as if it were a sour dough bread kit. I don't think that would produce a big enough number of "bugs" in a cup of yogurt to actually count as a dose, though.
As a more affordable alternative, I recommend that people use Jarrodophilus pills, a product that is sold at most Buyers Clubs. It seems to work and costs only $7 per 50 day supply. Jarrow does his homework. He goes to major international meetings, and he tries to formulate clinically expert products. I don't know exactly which strains of L. acidophilus, or L. plantarum, etc. he is using, but my patients do find it helpful. I have heard good reports about the Shaklee probiotic as well.
A: Ken Stringer, Web Site Administrator responds:
So what do we tell the reader/site visitor? Barbara concludes, based on the studies she's found, that eating yogurt may be helpful, while Charlie says that if it is helpful, it's not due to the bacteria. Can you give any more guidance on this?
A: Donna Tinnerello, MS, RD, CN/D responds:
I recently read in the Tufts Newsletter information that concurs with Charlie: There is really not enough live culture in yogurt to be of any real value. Sherry Gorbach may have been an influence in that opinion expressed by Tufts MDs. Unfortunately, this has been a subject of ongoing debate for years and yogurt manufacturers use this claim as a selling point. We even have a doctor at the Cabrini Medical Center who pours it down nasogastric tubes.
But I do personally tell people who are lactose intolerant to eat yogurt; most of them who are are not profoundly intolerant can eat yogurt without abdominal pain, bloating or diarrhea. It seems there is enough live culture in yogurt to at least digest the lactose and thereby prevent the discomfort.
I bet any group of healthcare providers you get together will debate this topic. As I said, it is longstanding and the hype in ads and labels keeps fueling the fire.
A: Barbara J. Scott, MPH, RD responds:
The references I used were all from 1999-2000. Perhaps I should have gone back a little further, but two of the references reported meta-analyses of studies to try to summarize the research to date on probiotics in foods (mainly lactobacilus GG, lactobacillus acidophilus, bifidobacterium bifidum and enteroccocus faecium).
In general, though the findings were not 100% consistent across the board, there did tend to be more studies with positive findings than those which found no effect. So I based my yogurt recommendation on that. The bottom line, I would say, is that it can't hurt and it might help.
A: Charlie Smigelski, RD responds:
Were there any acidophilus-pill studies, or were they all yogurt-eating studies?
A: Barbara J. Scott, MPH, RD responds:
All of the studies were with fermented dairy products. I couldn't find any acidophilus pill studies even though I looked specifically for those. Doesn't mean there aren't any; I just didn't find them going back four or five years in the Medline search.
Interestingly, I did find some studies that showed effectiveness of ingesting yogurt with live cultures (vs "placebo" yogurt with no live cultures) on prevention and treatment of vaginal yeast infections in HIV+ women. The study showed positive results. So as Donna said, I think the question hasn't been answered as to survival of these organisms through the GI tract.
A: Charlie Smigelski, RD responds:
I haven't heard about those yeast studies, but I still think that the cultures being used nowadays just don't survive in the gut the way they used to. I do agree, though, that the yogurt can't hurt you, and even if the "help" is only a placebo effect, who cares? Help is help.
My primary recommenation, though, is to take the probiotics in the pill forms I mentioned above. And for most people trying to manage HIV-related diarrhea from their HAART therapy that includes a PI, an effective treatment includes a combination of:
1. A bulking agent like Citrucil once a day;
2. Two probiotic pills a day;
3. Several pieces of fruit a day, and
4. Occasional Immodium (antidiarrheal) pill to prevent "accidents" (i.e., too sudden a need for a toilet bowl too far away).
A: Donna Tinnerello, MS, RD, CN/D responds:
As long as we are getting to the bottom of this, anyone have a take on yogurt for lactose intolerance? Am I on target for the bacteria digesting the lactose? I do see it well tolerated in folks with lactose intolerance and the literature supports it, but am interested in what others have seen.
A: Charlie Smigelski, RD responds:
Yes, I too find yogurt is well tolerated in lactose sensitivity, except in extreme cases. I also have the impression that some live cultures do live long enough in the gut to warm up, populate, and finish off whatever remaining lactose there is in the yogurt.
