April 2013 Issue

Probiotics & IBD
By Sherry Coleman Collins, MS, RD, LD
Today’s Dietitian
Vol. 15 No. 4 P. 34

Emerging research suggests certain bacterial strains may play a role in treating and managing inflammatory bowel diseases.

Wendy, 32, has a history of chronic gastrointestinal (GI) issues that include diarrhea, cramping, and bloating. She presents to her primary care physician with bloody stools and is sent to a specialist for additional testing. After a full assessment, blood work, endoscopy, and colonoscopy, ruling out other potential GI diseases, she’s diagnosed with ulcerative colitis.

Her gastroenterologist prescribes an aggressive round of steroids, antibiotics, and immune-suppressing drugs. After one month, her symptoms subside significantly; her doctor begins weaning her from the steroids; and she completes her antibiotic treatment. But there’s one remaining concern: She’s lost 5 lbs on her already-thin frame. While she no longer experiences pain, she’s not tolerating all foods well and is anemic, so her gastroenterologist refers her to an RD.

Upon initial assessment, the RD notes that Wendy is about 15 lbs underweight, and has dry, listless hair and a pale pallor. Her diet history shows virtually no raw fruits and vegetables or dairy and that she avoids wheat and most grains. Primarily, she eats plain grilled or boiled chicken, scrambled eggs, white rice, potatoes, and cooked carrots. Each day, Wendy drinks about three cups of black coffee, regular soda, and water. She also takes an iron-containing multivitamin/mineral supplement daily.

Recognizing that Wendy suffers from malnutrition, her RD works with her to develop a list of foods she likes and can tolerate, including foods to help boost her iron stores. Working from this list, Wendy creates a menu, adding one new nutrient-dense food every three days to expand her diet and check for tolerance.

Beginning with well-cooked vegetables, the RD expands Wendy’s repertoire to include a wider variety of fruits and vegetables, being careful to avoid those in the cruciferous family, which frequently cause gas. She recommends that Wendy include a high-quality yogurt with multiple strains of beneficial bacteria twice per day. She also suggests eliminating caffeine-containing foods to avoid overstimulating the gut.

After one month of improvement and consulting Wendy’s GI doctor, the RD adds a probiotic supplement to Wendy’s daily regimen. Along with her physician’s care plan, this new dietary intervention helps Wendy raise her diet’s nutrient density, control her anemia, and avoid a flareup of her ulcerative colitis for more than six months.

Story Behind Probiotics
Probiotics aren’t a new concept. Foods that contain friendly bacteria and yeast to cure and extend shelf life, and produce alcohol have been enjoyed for centuries and can be found in virtually all civilizations around the globe. Many of these foods have been touted as having all sorts of health benefits, and over the last few decades, researchers have begun to uncover convincing study findings about the health-supporting activities of these substances.

Moreover, we have a better understanding of the symbiotic relationship between bacteria and humans. According to the National Institutes of Health’s Human Microbiome Project, the human body hosts more than 10 times the number of bacteria as the number of cells. These bacteria cover the entire body, but perhaps the most diverse population is found within the GI tract, where they help digest food, generate vitamins, and combat pathogens.

Probiotics are defined as live microorganisms that provide positive health effects in the host that consumes adequate amounts.1 The health benefits of probiotics are realized through various mechanisms of action, such as creating a balance between beneficial bacteria and pathogens, reducing inflammation in the gut, and the downregulation of immune markers.

With more than 10,000 different microorganisms identified in the human body, it’s essential to remember that strain and dose are important factors when considering the application of probiotics.

Probiotics are used in the treatment and management of inflammatory bowel disease (IBD), which includes a variety of GI diseases, such as Crohn’s disease and ulcerative colitis. Both Crohn’s disease and ulcerative colitis result in similar GI symptoms, including pain, diarrhea, stools with mucus or blood, and ulceration or tissue damage within the alimentary canal. Nutrient deficiencies and malnutrition that can lead to underweight also may occur as well as headaches, fatigue, and anemia.

The defining differences between Crohn’s disease and ulcerative colitis are the location where ulceration and tissue damage occurs as well as the pattern and type of inflammation. Typically, ulceration in ulcerative colitis is limited to the colon, while Crohn’s disease most often occurs in the small intestine. However, overlap sometimes occurs between the two areas of the GI tract.

An IBD diagnosis may take months or even years until symptoms develop and testing is completed.

Role of Probiotics in IBD Sufferers
Treatment for IBD, as in Wendy’s case, includes a battery of medications, such as anti-inflammatories, steroids, antibiotics, and immunosuppressants. As with all medications, there are negative side effects, including the potential for antibiotic-induced diarrhea, anemia, and an increased risk of osteopenia. Preventing relapse is as important as treating acute occurrences of flareups in IBD. Stress management also is an important consideration for managing the disease.

According to one well-regarded theory, the cause or perpetuation of IBD results from an unbalanced microbiome in the gut.2 This theory implies that the use of probiotics may help rebalance the gut flora in a positive way, shifting from pro- to anti-inflammatory.

Research and Recommendations
Research on probiotics and IBD treatment is dynamic, and with so many strains of bacteria to study, the body of knowledge will continue to rise exponentially over the next decade. According to a recent review, conflicting data and a lack of sufficiently rigorous studies on Crohn’s disease haven’t yielded enough evidence to support or reject probiotic use for this condition.2 However, the report says results of probiotic use in ulcerative colitis have shown enough positive results to make it a promising part of many clinicians’ recommendations.2 The most positive research has been conducted in treating pouchitis, the inflammation that occurs in the pouch created to control stools after a partial colectomy has been performed to treat ulcerative colitis.

The World Gastroenterology Organization Practice Guidelines for the Diagnosis and Management of IBD in 2010 specifically address probiotics but state that their use isn’t supported in the literature for Crohn’s disease or ulcerative colitis. Yet the guidelines for the treatment of pouchitis recognize that research has shown a benefit with the use of specific bacterial strains, such as E coli Nissle 1917, and with the potent probiotic supplement VSL#3.

The American Society for Nutrition released guidelines that support the use of probiotics for ulcerative colitis and pouchitis patients based on research that showed effectiveness with E coli Nissle 1917 and VSL#3 that contains eight strains of bacteria.3 However, the society states the research doesn’t support the use of probiotics in Crohn’s disease. An analysis of 41 studies published in 2012 to review probiotic use in adult IBD patients supported these findings as well.4

Most research has been conducted in adults with IBD; however, the American Academy of Pediatrics addressed this treatment for children and stated that the research doesn’t support probiotic use in children because of unconvincing results and a lack of studies, including adequate numbers of children participating in the studies.5

One significant limiting factor in the research is the lack of rigor among studies. Few studies have included enough subjects, leading to inconclusive findings or results researchers can’t generalize. In addition, the number of potential beneficial bacteria and the challenge of determining how they benefit the human host make it more difficult to reach a consensus on recommendations for specific strains and dosing.

Research also has been done at different phases of disease activity, which makes comparing results more difficult. Some bacteria have shown a positive impact in maintaining remission but not in controlling symptoms during active disease. One positive is that the research has indicated that a very low risk of adverse effects is associated with the use of probiotics in IBD patients. More research is needed to identify what strains and doses may benefit these patients.

Incorporating Probiotics in the Diet
Probiotics are found in a variety of foods, with yogurt perhaps being most popular. Kefir is another great choice that includes many more strains of bacteria than yogurt, perhaps extending health benefits. More unusual probiotic sources include fermented foods such as kimchi, kombucha, and sauerkraut. Some pickled foods are fermented with bacteria.

As probiotics have become more popular, products such as probiotic-fortified juices, chocolates, and even peanut flour have become available, offering nondairy alternatives for clients with milk allergies or lactose intolerance.

For IBD patients, probiotic supplements may be considered since they have good potential and a low risk of adverse effects. Cost can be a barrier, however, since medical insurance generally won’t cover these supplements.

When considering supplements, it’s important to understand which strains of live bacteria are recommended for patients to purchase. Dietitians should work with the client’s physician to ensure they’re aware and supportive of this treatment.

Some bacteria that have been studied in humans for their potential clinical relevancy in ulcerative colitis, Crohn’s disease, and pouchitis are listed below. These bacteria, along with probiotics, were delivered via a supplement with or without standard medical treatment or after medically induced remission2:

• Ulcerative colitis: E coli Nissle 1917; VSL#3, a blend of bacteria to include Bifidobacterium breve, Bifidobacterium longum, Bifidobacterium infantis, Lactobacillus acidophilus, Lactobacillus plantarum, Lactobacillus casei, Lactobacillus bulgaricus, Streptococcus thermophile; Lactobacillus boulardi; and Lactobacillus rhamnosis GG

• Crohn’s disease: L boulardi, L rhamnosis GG, Lactobacillus johnsonii, and VSL#3 (Probiotics haven’t shown significant benefit in Crohn’s disease, with most studies having too few subjects and showing no statistical difference in outcomes compared with controls.)

• Pouchitis: VSL#3 and Lactobacillus GG

This list should help nutrition professionals develop a framework for beginning the conversation about probiotics use in IBD patients. It’s important to remember that different strains provide different positive benefits and have been shown to have clinically unique relevance with regard to treating Crohn’s disease vs. ulcerative colitis. It’s suggested that nutrition professionals research the appropriate strain for recommended dosing information and remain connected as an interdisciplinary part of the patient’s healthcare team.

As probiotics are added to the diet in supplement or food form, patients must consume them regularly. Loss of beneficial bacteria through bowel movements necessitates constant replacement of those bacteria. In addition, bacteria need food to survive, so consider including prebiotics, which are substances that serve as fuel for probiotic bacteria. Prebiotics include inulin, fructo-oligosaccharides, and resistant starch, which may be added to foods such as yogurt, high-fiber snack bars, cereals, and granola.6

Much to Learn
It’s important to recognize that the research in this area is limited and emerging. While probiotics seem to have great potential for IBD patients, the current research doesn’t fully support their use. However, they seem to show the most promise in helping to maintain remission in ulcerative colitis once it has been achieved through traditional pharmacologic intervention and as an adjunctive treatment for pouchitis. More research is needed to determine what strains and at what dose probiotics become most useful as part of clinical intervention. Probiotics should be carefully considered as part of an overall care plan that includes medication, nutrition intervention, and lifestyle management.

— Sherry Coleman Collins, MS, RD, LD, is an Atlanta-based dietitian who has worked in clinical pediatrics and school foodservice, where she gained hands-on experience working with students, families, and staff to manage food allergies.

 

References
1. Sanders ME. Probiotics: definition, sources, selection, and uses. Clin Infect Dis. 2008;46 Suppl 2:S58–61.

2. Calafiore, A, Gionchetti P, Calabrese C, et al. Probiotics, prebiotics and antibiotics in the treatment of inflammatory bowel disease. J Gastroenterol Hepatol. 2012;1(6):97-106.

3. Haller D, Antione JM, Bengmark S, Enck P, Rijkers GT, Lenoir-Wijnkoop I. Guidance for substantiating the evidence for beneficial effects of probiotics: probiotics in chronic inflammatory bowel disease and the functional disorder irritable bowel syndrome. J Nutr. 2010;140(3):690S-697S.

4. Jonkers D, Penders J, Masclee A, Pierik M. Probiotics in the management of inflammatory bowel disease: a systematic review of intervention studies in adult patients. Drugs. 2012;72(6):803-823.

5. Thomas DW, Greer FR; American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition. Probiotics and prebiotics in pediatrics. Pediatrics. 2010;126(6):1217-1231.

6. Douglas LC, Sanders ME. Probiotics and prebiotics in dietetics practice. J Am Diet Assoc. 2008;108(3):510-521.