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McKesson Medical-Surgical
Clinical Webinar Series
The Gut Microbiome – Role of Diet and
Supplements (Probiotics & Prebiotics)
March 8, 2017
Lisa Logan R.D., CNSC
Lisa Logan, R.D.,CNSC
Lisa Logan
Enteral Program Manager/Nutrition Support Clinician,
McKesson Medical-Surgical
Lisa Logan is a Certified Nutrition Support Clinician and
member of ADA (American Dietetic Association) and
ASPEN (American Society of Parenteral and Enteral
Nutrition). Lisa has worked in the field of Nutrition Support
for over 30 years. She has held positions in a multitude of
health care settings including: hospitals, rehabilitation
centers, long term care and home care. She has served
as a guest speaker for various nationally known
organizations and institutions including: Cornell Medical
Center, World Health Communications, Inc.,
Presbyterian/St. Luke’s Medical Center, Sandoz
Pharmaceuticals, Inc., Abbey Medical and McGaw, Inc.
Today’s Session
 Describe the influence of the gut microbiome on human physiology
and health
 Factors and influences affecting the gut microbiome
 Compare and contrast how diet and dietary supplements (prebiotics,
probiotics) influence health outcomes by influencing the gut
microflora
 Association between gut microbiota and disease conditions
 Review the role of probiotics for the prevention and treatment of
various diseases
Your Body is Mostly Microbes
Definition
The microbiome is defined as the collective genomes of the
microbes (composed of bacteria, bacteriophage, fungi,
protozoa and viruses) that live inside and on the human
body.
The human microbiome refers to their genomes.
Medicine.emory.edu (This image originally appeared in the Hartford Courant)
Journal of Human Evolution 79 (2015) 125e136
The Gut Microbiome
100 Trillion bacteria cells in
our intestines providing
600,000-2 M genes to each
human
The number of bacteria in the
gut is 10 times that of all cells
in the human body!
Guarner, World Gastroenterology Organisation Global Guidelines, 2011.
Quigley, Nutr Clin Pract, 2012.
Each individual’s
specific microbial
species and strains
will vary—like a
fingerprint
Prepared by the Biological and Environmental Research Information System, Oak Ridge National Laboratory,
Human Microbiome Project goals:
• Develop a reference set of sequences and preliminary
characterization of the human microbiome.
• Provide information about disease and microbiome changes.
• Develop new technologies and tools for computational analysis.
• Establish a data analysis and coordinating center.
• Establish research repositories.
• Examine ethical, legal and social implications of HMP research.
• Evaluate multi-omic data to understand the human microbiome’s
role in health and disease.
commonfund.nih.gov/hmp/initiatives
3 Main Microbiota Groups
Commensal
Bacteria
Cohabit peacefully
Symbiotric
or Mutualist
organisms
Help keep us healthy
Pathogens or
Opportunistic
Flora
Can be harmful
Dethlefsen, McFall-Ngai and Relman 2007
Human Microbiota sites:
Skin and mucous membranes
Oral cavity
Upper respiratory tract
Gastrointestinal tract
Urogenital tract (Urethra, Vagina)
External ear canal
External eye (lids, conjunctiva)
Composition of Bacterial Species in the GI Tract
Antioxidants 2015, 4(1), 1-21;doi:10.3390/antioz4010001
Functions of Gut Bacteria
• Digestion of food
• Convert sugars to SCFAs for energy
• Production of vitamins (K, B complex and fat soluble)
• Modulate genes and neutralize cancer-causing compounds
• Stimulate Immune System
• Stimulate the development of various tissues (i.e..-intestine, capillary
density etc.)
• Prevent colonization of pathogens
• Metabolize drugs
• Intestinal transit
• Colonization resistance
Factors Affecting the Intestinal Micro Ecosystem
• Antibiotics and other medications (PPI’s,
Steroids)
• Microbial infections
• Chronic diarrhea
• Stress
• Chlorinated water
• Radiation and chemotherapy
• Colonic therapies for detoxification
• Diet and alcohol
Comparison of Community-Acquired Matched
Cases and Controls--Medication Variables
Dial, S. et al. JAMA 2005;294:2989-2995.
Copyright restrictions may apply.
Symbiosisonlinepublishing.com
Diet Influences the Microbiome
• Western diet - excessive sugar and fat
• Alcohol
• Not enough fiber
• Artificial sweeteners
SCFAs, Fiber Fermentation and Butyrate
Receptors
Thangaraju M et al J GI Surg 2008, Robert Martindale PhD, MD, Chief, General Surgery
Medical Director Hospital Nutrition Support, Oregon Health and Sciences University
How Sweeteners Are Reshaping Your Gut
Bacteria
• Artificial Sweeteners May Change Our
Gut Bacteria in Dangerous Ways
• Substances such as saccharin may alter
the type of bacteria inside us, could lead
to obesity and diabetes
https://www.drperlmutter.com/artificial-sweeteners-change-gut-bacteria/
Ellen Ruppel Shell on April 1, 2015 in Scientific America
Our Microbiome Changes
As our diet changes
As we
mature
and age
Pets in the
home
Medical conditions and
treatments
With puberty or
pregnancy
Many more factors are being
investigated!
Empoweredsustenance.com
How the Brain and Gut connect
The Enteric Nervous System is
embedded in the lining of the GI system:
• Esophagus
• Stomach
• Small intestine
• Colon
Serotonin-Neurotransmiter
• Manufactured in the brain,
however, 90-95% of our supply is
found in the digestive tract
• Vital for communication
• Essential to motility and gut
sensations
• Considered to be a “feel good”
hormone
Defining Probiotics
• “For Life”
• Live microorganisms (bacteria
or yeast) that may confer a
health benefit on the host;
improves intestinal balance or
indigenous flora
• First described in the early
1900s
• The termed “Probiotic” coined
in 1960s
FAO-WHO report, 2001.
https://norkinvirology.wordpress.com/2016/11/03/elie-metchnikoff-the-father-of-innate-immunity/
Most Common Strains
• Lactobacillus
• Bifidobacterium
• Saccharomyces
• Escherichia
• Lactococcus
• Bacillus
Advantages – Multiple Mechanisms of Action
• Use may reduce exposure of antibiotics
• Produce lactic acid- lowers the pH of intestines and inhibiting bacterial villains
such as Clostridium, Salmonella, Shigella, E. coli, etc.
• Decreases the production of a variety of toxic or carcinogenic metabolites.
• Delivery of microbial enzymes
• Aid absorption of minerals, especially calcium, due to increased intestinal acidity.
•
Production of β- D- galactosidase enzymes that break down lactose.
•
Produce vitamins (especially Vitamin B and vitamin K)
• Act
as barriers to prevent harmful bacteria from colonizing the intestines
Jayanti Tokas1, Deepika Gupta1, Shalini Jain2 and Hariom Yadav2*
1Department of Biochemistry, CCS-HAU, Hisar, Haryana, India
2NIDDK, National Institutes of Health, Bethesda, MD, USA
Side Effects of Probiotics
• Possible bloating, diarrhea, abdominal
pain
• Excess amounts cause infection that
require medical attentions
• Possible interaction with
immunosupressive drugs (translocation
possible)
Probiotics – Need More Data
• Genus, species, and strain (mono or
multistrain)
– Pre, pro or synbiotic?
• How to assess activity/viability of bacterial
strains
• Recommended storage conditions-whether or
not refrigeration is necessary and shelf life
• Delivery system – micro-encapsulation,
packaging solution
• Safety standards
Probiotic-Rich Foods
 Yogurt
 Kvass
 Kefir
 Tempeh
 Sauerkraut
 Miso
 Pickles
 Kombucha
Probiotic Products
Foods
• Dairy products like yogurt, kefir
• Probiotic-fortified foods like Good Belly, Activia, Attune
• Fermented foods like sauerkraut, pickles, kimchee, miso,
tempeh, kombucha tea
• Dietary supplements-tablets, capsules and sachets
Prebiotics - Definition
“Prebiotics are non-digestible but fermentable
oligosaccharides that are specifically designed to change
the composition and activity of the intestinal microbiota
with prospect to promote the health of the host.”
“A synbiotics is a combination of one or more probiotics and
prebiotics.”
Foods Naturally High in Prebiotics
 Tomatoes
 Chicory
 Berries
 Onions
 Dandelion Greens
 Bananas
 Artichokes
 Asparagus
 Flax Seeds
 Garlic
 Leeks
 Legumes
Characteristics of Prebiotics
• Should not be hydrolyzed or absorbed in the upper part of G.I
tract.
• Should be a selective substrate for one or a limited number of
potentially bacterial commercial to the colon culture protagonist.
• Should be able to alter the colonic microflora towards a healthier
composition or selectively stimulates the growth and or activity of
intestinal bacteria associated with health and well being.
• Should help increase the absorption of certain minerals such as
calcium and magnesium.
• Favorable effect on the immune system and provide improved
resistance against infection.
Jayanti Tokas1, Deepika Gupta1, Shalini Jain2 and Hariom Yadav2*
1Department of Biochemistry, CCS-HAU, Hisar, Haryana, India
2NIDDK, National Institutes of Health, Bethesda, MD, USA
Conditions That Could Benefit from Probiotics
• Crohn’s Disease
• Helicobacter pylori
• Ulcerative Colitis
•
• Pouchitis
• Candida vaginal
infections/UTI’s
• Allergy/Exema
• Irritable Bowel Syndrome
• High Cholesterol
Robert Martindale PhD, MD – presentation 2/21/2013
Lactose Intolerance
• Bacterial Vaginosis
• Autism/Depression
Acute Infectious Diarrhea
• Probiotic administration reduced duration of diarrhea (by
about 25 hours) and reduced stool frequency (by one less
diarrheal stool on day 2 after intervention)
• Based on review of 63 studies, primarily in infants and
young children
• No adverse events were attributed to probiotic intervention
Allen, Cochrane DB Review 2010
Antibiotic-Associated Diarrhea
• Prevention of primary or recurrent infection
• S. boulardii
• L. rhamnosus GG
• L. casei DN-114 001
• May prevent C. difficile diarrhea
Hempel S et al JAMA May 9, 2012
Diarrhea Related to C. difficile
• Probiotics prevent an estimated 33 episodes of C. difficile
diarrhea for every 1000 people treated
• Controls had more adverse events than patients given the
probiotics—thus safety is verified
• Bifidobacterium, Lactobacillus, Saccharomyces, and
Streptococcus spp, alone or in combination.
• Patients in intervention groups took probiotics for the
duration of their antibiotic treatment and for up to two weeks
longer.
Ann Intern Med 2012
Oregon Health and Sciences University Protocol
for Synbiotic Use in Hospitalized Adult Patients
Indications :Patients at risk for developing AAD, CDI
(broad spectrum antibiotics, ex: fluoroquinones)
Contraindications :Immunosuppressed patients (ex: BMT)
(neutrophil count <500)
Route and Dosage:
Oral 4 ounces Nancy’s Yogurt or Kefir BID
1 pack Benefiber QID
Feeding Tube 80 ml Nancy’s Kefir + 1 pack Benefiber + 60ml sterile
water TID
Robert Martindale PhD, MD, Chief, General Surgery, Medical Director Hospital Nutrition Support, Oregon Health and Sciences
University
Crohn’s Disease
• Studies are lacking
• One small study suggested did not
show that probiotics had any effect
on treating active Crohn’s Disease
Butterworth, Cochrane DB Review, 2008.
Ulcerative Colitis
• Conventional treatment combined with probiotic therapy does not
provide any additional benefit over conventional treatment alone
in patients with mild to moderate ulcerative colitis
• Probiotics do not appear to maintain remission, but data is limited
• Escherichia coli Nissle may be equivalent to mesalazine in
maintaining remission
Mallon, Cochrane DB review 2008; Naidoo,Cochrane DB review 2011 Guarner, J Clin Gastroenterology, 2012
Pouchitis
• Strong evidence that probiotics are useful in inducing
and maintaining remission or pouchitis
• VSL #3
Guarner, J Clin Gastrenterol, 2012
Irritable Bowel Syndrome
•
Symptom improvement from B. infantis 35624
•
Bloating, flatulence, constipation
•
L. reuteri may improve colicky symptoms in breastfed
babies
Guarner, J Clin Gastrenterol, 2012.
Probiotics for IBS
• Irritable bowel syndrome (IBS) is a common disorder
of the intestines that leads to crampy pain,
gassiness, bloating and changes in bowel habits.
• Adequate relief reported in 47% (11% in placebo)
• Improved global symptom score, pain,
distension/bloating and stool urgency.
Guglielmetti S, et al. RCT: Bifidobacterium bidfidum MIMBb75 significantly alleviates IBS and improves QOL-a DBPCS. Aliment
Pharmacolo Ther. 2011. 33(10)
Autism Research
Our intestines are home to a diverse community of beneficial
organisms. This community may be altered in problematic ways
in some individuals with autism.
Upper Respiratory Tract Infections
•
Probiotics reduced the number of participants experiencing
episodes of acute upper respiratory tract infections
•
Some suggestion that less antibiotics were prescribed for
the people on probiotics
•
10 studies included, but not done in the elderly
Hao, Cochrane DB Review 2011
Critical Illness
Probiotics are believed to be protective via:
• Maintaining the gut barrier
• Inhibit growth or killing of pathogens via production of
antimicrobial molecules
• Compete with pathogens for binding sites
• Attenuate the inflammatory process/ immunomodulation
Morrow, Nutr Clin Practice, 2012
Probiotics in the ICU
Reduced incidence of VAP (vent-associated pneumonia) and
reduced ICU length of stay
L. rhamnosus
Patients received fewer days of antibiotics and had less C.
difficile diarrhea
Robert Martindale PhD, MD – presentation 2/21/2013
Other
Insufficient evidence, but suggestive of benefit in Bacterial
Vaginosis when used along with metrondiazole or estriol
Probiotic usage lowered plasma ammonia levels in people with
Hepatic Encephalopathy, but its significance is unknown
Senok, Cochrane DB Review 2009; McGee, Cochrane DB Review, 2011
Characteristics of Effective Probiotics
• Able to survive the passage through the digestive system.
• Able to attach to the intestinal epithelia and colonize.
• Able to maintain good viability.
• Able to utilize the nutrients and substrates in a normal diet.
• Capable of exerting a beneficial effect on the host.
• Stability of desired characteristics during processing, storage and
transportation.
• Anti-inflammatory, antimutagenic, immunostimulatory, non pathogenic
and non toxic.
Probiotic choices
• Not regulated by the FDA
• See Consumer lab handouts
• Question manufacture information (quality assurance,
label vs. content, viability of bacterial species)
• Validate biomarkers for assessing function and activity
Probiotic Summary
• Living microorganisms with multiple mechanisms of action
• Some applications to prevent and treat infectious diseases
• An alternative to antibiotics in some situations
• May have other applications, e.g. allergy, cancer, colitis, IBS
• Product selection is very important
Use Caution With:
• Immunocompromised patients
• Prosthetic heart valves
• Septic patients
• ICU or organ failure patients
Summary
 Living microorganisms with multiple mechanisms of action
 Good safety profile
 Some applications to prevent and treat infectious diseases
 An alternative to antibiotics in some situations
 May have other applications, e.g. allergy, cancer, colitis, IBS
 Product selection is very important
Conclusions
• Manipulation of gut flora may be an integral part of weight
loss and different disease treatments in the future
• The human microbiome project and research is just
beginning
• Gut flora by their genes, metabolic activity and by-products
influence our immunity, metabolism, weight, health and
disease
• More studies are needed to focus on mechanisms that
interact and influence our gut flora
Questions?
References
Health and Nutritional Properties of Probiotics in Food Including
Powder Milk with Live Lactic Acid Bacteria. FAO-WHO, 2001
Guarner, F. World Gastroenterology Organization Global
Guidelines: Probiotics and Prebiotics 2011. Jour Clin
Gastroenterol, 2012;46(6).
Quigley EMM. Prebiotics and Probiotics: their role in the
management of gastrointestinal disorders in adults. Nutr in Clin
Practice. 2012;27:195-200.
References
Ciorba M. A Gastroenterologist’s Guide to Probiotics. Clin
Gastroenterol Hepatol. 2012; 10:960-968.
Johnston B. Probiotics for the Prevention of Clostridium difficileAssociated Diarrhea. Ann Intern Med 2012; 157(12): 878-888
Morrow L. Probiotics in the Intensive Care Unit. Nutr Clin
Practice, 2012; 27:235-241.
References
Allen SJ, Martinez EG, Gregorio GV, Dans LF. Probiotics for
Treating Acute Infectious Diarrhoea. The Cochrane
Collaboration, 2010.
Hempel S, Newberry S, Maher A, Wang Z, Miles J, Shanman
R, Johnsen B, Shekelle P. Probiotics for the Prevention and
Treatment of Antibiotic-Associated Diarrhea: A Systematic
Review and Meta-Analysis. JAMA, 2012.
Pillai A, Nelson RL. Probiotics for Treatment of Clostridium
Difficile-Associated Colitis in Adults. The Cochrane
Collaboration, 2008
References
Butterworth AD, Thomas AG, Akobeng AK. Probiotics for
Induction or remission of Crohn’s Disease. The Cochrane
Collaboration, 2008.
Mallon PT, McKay D, Kirk SJ, Gardiner K. Probiotics for
Induction of Remission in Ulcerative Colitis. The Cochrane
Collaboration, 2008.
Naidoo K, Gordon M, Fagbemi AO, Thomas AG, Akobeng AK.
Probiotics for the Maitenance of Remission in Ulcerative Colitis.
The Cochrane Collaboration, 2011.
References
Hao Q, Lu S, Dong BR, Huang CQ, Wu T. Probiotics for Preventing Acute
Upper Respiratory Tract Infections. The Cochrane Collaboration, 2011.
Senok AC, Verstraelen H, Temmerman M, Botta GA. Probiotics for the
Treatment of Bacterial Vaginosis. The Cochrane Collaboration, 2009.
McGee RG, Bakens A, Wiley K, Riordan SM, Webster AC. Probiotics for
Patients with Hepatic Encephalopathy. The Cochrane Collaboration, 2011
.
Chutkan, Robynne. The Microbiome Solution, 2015.
Thank You!
Lisa Logan R.D., CNSC
Enteral Program Manager/Nutrition Support Clinician
McKesson Extended Care Clinical Resource Team
[email protected]
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