{"id":7221,"date":"2021-04-21T06:55:00","date_gmt":"2021-04-21T11:55:00","guid":{"rendered":"https:\/\/internationalprobiotics.org\/?p=7221"},"modified":"2021-04-21T08:51:59","modified_gmt":"2021-04-21T13:51:59","slug":"asked-and-answered-again-probiotics-are-safe","status":"publish","type":"post","link":"https:\/\/internationalprobiotics.org\/home\/asked-and-answered-again-probiotics-are-safe\/","title":{"rendered":"Asked and Answered, AGAIN!  Probiotics are safe!"},"content":{"rendered":"\n<p><em><strong>written by Margaret Haldeman, Ph.D., Education &amp; Communication Co-chair<\/strong><\/em><\/p>\n\n\n\n<p>Probiotics are defined as \u201clive microorganisms that, when administered in adequate amounts, confer a health benefit on the host\u201d<sup> 1<\/sup>.&nbsp;To be considered a true probiotic, a microorganism must confer a health benefit when consumed in appropriate amounts.&nbsp;&nbsp;In order to provide a health benefit, this consumption must be safe.&nbsp;&nbsp;In addition to the definition, there are important criteria&nbsp;that&nbsp;illustrate&nbsp;the research that must be done before a microbial&nbsp;strain&nbsp;can be categorized as \u201cprobiotic\u201d.&nbsp; These criteria further define probiotics in the context of efficacy and safety<sup> 2<\/sup>.&nbsp; &nbsp;&nbsp;<\/p>\n\n\n\n<p>Sufficiently characterized&nbsp;<\/p>\n\n\n\n<p>There is a menu of&nbsp;assessments that can be done&nbsp;for&nbsp;microorganisms to&nbsp;help&nbsp;understand their function, including carbohydrate utilization,&nbsp;enzymatic activities, antibiotic susceptibility,&nbsp;and environmental preferences.&nbsp;<\/p>\n\n\n\n<ol type=\"1\"><li>Genus, species&nbsp;and&nbsp;<em>strain<\/em>&nbsp;identified&nbsp;by molecular techniques.<\/li><\/ol>\n\n\n\n<p>The strain designation is often overlooked but we know that some&nbsp;species&nbsp;have strains that&nbsp;are beneficial for health while others may cause health problems.&nbsp;&nbsp;One&nbsp;example&nbsp;of this&nbsp;is&nbsp;the&nbsp;<em>E. coli&nbsp;<\/em>story<em>.&nbsp;&nbsp;E. coli<\/em>&nbsp;K12&nbsp;delivers many health benefits such as&nbsp;vitamin production in the gut&nbsp;while&nbsp;<em>E. coli<\/em>&nbsp;O157:H7 is&nbsp;notorious for causing food poisoning with symptoms of diarrhea and vomiting.&nbsp;<\/p>\n\n\n\n<ul><li>Strains are generally deposited&nbsp;in an internationally recognized culture collection.&nbsp;<\/li><\/ul>\n\n\n\n<p>This helps to ensure that the isolated strain is preserved and available to the scientific community&nbsp;for further development and understanding.<\/p>\n\n\n\n<ul><li>Probiotic benefits are generally strain specific but some health benefits may be common among many strains. Each strain should be supported by clinical study(ies).<\/li><\/ul>\n\n\n\n<p>Safe for the intended use&nbsp;<\/p>\n\n\n\n<p>Lack of transmissible antibiotic resistance genes; antibiotic resistance&nbsp;happens when microorganisms develop abilities to defeat the drugs designed to kill them. The microorganisms then become resistant to the drug. This is one of the biggest challenges for modern medicine and also for animal agriculture. Microorganisms can harbor \u201cresistance genes\u201d.&nbsp; Probiotics are screened to ensure they do not have transmissible resistance genes.<\/p>\n\n\n\n<ol type=\"1\"><li>Identification of genes which can cause other types of virulence.<\/li><li>Persist in a viable state in gastrointestinal tract.&nbsp;<\/li><\/ol>\n\n\n\n<p>The stomach and&nbsp;small intestine encompass harsh environments; acidic pH&nbsp;and bile salts&nbsp;function to control the microorganisms in the gastrointestinal tract by suppressing the growth of pathogens.&nbsp;&nbsp;It is commonly assumed that a probiotic must be robust enough to survive through the upper gastrointestinal tract.&nbsp;<\/p>\n\n\n\n<ul><li>Most are used in foods; including conventional foods, dietary supplements and infant formula, where their intended use is to provide health benefits as part of the daily diet.<\/li><\/ul>\n\n\n\n<p>Supported by at least one&nbsp;well-designed,&nbsp;human clinical trial<\/p>\n\n\n\n<p>Once a probiotic is characterized&nbsp;both&nbsp;<em>in vitro<\/em>&nbsp;and <em>in vivo<\/em>, the&nbsp;results can be crafted into a hypothesis for how the strain might benefit health. It is then&nbsp;critical to&nbsp;prove&nbsp;this&nbsp;hypothesis&nbsp;in humans.&nbsp; A well-designed clinical trial will specify the strain and the dose, typically expressed in <em>colony-forming units<\/em> (CFUs),&nbsp;needed to deliver the benefit.&nbsp;<\/p>\n\n\n\n<ol type=\"1\"><li>The probiotic strain must be <strong>alive<\/strong> in sufficient numbers in the product at time of consumption and maintain an efficacious dose throughout shelf life.&nbsp;<\/li><li>A probiotic product must deliver the&nbsp;<strong>dose<\/strong> demonstrated to be clinically effective in order to claim the health benefit.&nbsp;The consumer needs that minimum dose&nbsp;to be guaranteed to the expiration date.&nbsp;<\/li><\/ol>\n\n\n\n<p>The product should meet this dose, or label declaration, throughout the product\u2019s shelf life and that this label declaration should be greater than or equal to the studied dose.<\/p>\n\n\n\n<ul><li>Evaluation of probiotic safety and efficacy should be based on individual interventions and not by grouping interventions using different probiotic strains and combinations of strains into one analysis.<\/li><\/ul>\n\n\n\n<p>Viable probiotic activity&nbsp;guaranteed throughout processing, handling, and storage.<\/p>\n\n\n\n<p>Guarantees&nbsp;through expiration date&nbsp;are dependent on the manufacturing of the bulk probiotic and of the product formula but also by the packaging, shipping and storage of the product.&nbsp;<\/p>\n\n\n\n<ol type=\"1\"><li>The probiotic should remain viable throughout the shelf life<\/li><\/ol>\n\n\n\n<p>A&nbsp;comprehensive&nbsp;approach of&nbsp;<em>in vitro<\/em>,&nbsp;<em>in silico<\/em>, and&nbsp;<em>in vivo<\/em>&nbsp;safety testing&nbsp;to thoroughly characterize&nbsp;probiotic&nbsp;strains&nbsp;can&nbsp;identify&nbsp;features of the strain&nbsp;such as&nbsp;antibiotic resistance or virulence genes, toxin genes, histamine synthesis and&nbsp;oral toxicity&nbsp;that&nbsp;could&nbsp;preclude use as a probiotic&nbsp;due to safety concerns.&nbsp;Strains that meet these criteria and are provided in a product that ensures the maintenance of these criteria, should be considered safe. D-lactate production is sometimes included in the safety evaluation even though it is uncertain that D-lactate production actually is a risk for the consumer; including infants.<\/p>\n\n\n\n<p>In the United States, most probiotics are regulated by the Food and Drug Administration&nbsp;(FDA),&nbsp;<a href=\"https:\/\/www.fda.gov\/food\/dietary-supplements\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.fda.gov\/food\/dietary-supplements<\/a>. Probiotics can be approved by \u201cGenerally Recognized&nbsp;as Safe\u201d&nbsp;(GRAS), self-GRAS and New \u200bDietary \u200bIngredient \u200bNotification (NDIN). Select&nbsp;probiotic strains&nbsp;have undergone rigorous safety assessment&nbsp;for&nbsp;status&nbsp;as&nbsp; GRAS,&nbsp;which is&nbsp;followed by notification of the&nbsp;FDA&nbsp;for comment.&nbsp;This assessment includes many of the aforementioned criteria for a probiotic.&nbsp;In Europe, the&nbsp;European Food Safety Authority\u2019s&nbsp;Qualified&nbsp;Presumption&nbsp;of&nbsp;Safety&nbsp;(QPS)&nbsp;list of microbes&nbsp;includes those that have been assessed as&nbsp;safe for food use. This&nbsp;list is based on a history of safe use&nbsp;and additional&nbsp;relevant data on the absence of acquired resistance or virulence.&nbsp;<\/p>\n\n\n\n<p>&nbsp;Primary critics of probiotics typically evaluate&nbsp;through the lens of pharmaceuticals. This classification is incorrect and out of scope: probiotics may be foods or supplements according to the FDA, unless they come with a drug registration. Just as drugs are not solving all the medical problems in the world, probiotics should not be seen as the magic solution to all clinical issues; both have their place within the healthcare system. For the most part, probiotics have not gone through pharmaceutical evaluation processes. As such, probiotics do not make medical claims to treat, cure or prevent disease, unlike drugs. Probiotics are generally not prescribed as an exclusive therapy in disease management, but most often suggested as part of the normal healthy diet or as an adjunct to standard treatment. There is no noted toxicity level and it has been very rare to have an Adverse Event Reporting due to the nature of probiotics. Side effects of probiotics are very rare and mild for healthy individuals, in stark contrast to drugs.&nbsp;&nbsp;<\/p>\n\n\n\n<p>The governmental group&nbsp;<a href=\"https:\/\/www.ahrq.gov\/downloads\/pub\/evidence\/pdf\/probiotics\/probiotics.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">American Health Care Research and Quality (AHRQ)&nbsp;<\/a>&nbsp;has described extensive safety data for probiotic strains in health and illness.&nbsp; The results of this extensive report, showing safety of probiotic therapy in over 600 published clinical trials and case reports, should be reassuring to clinicians and consumers with regard to the safety of probiotic administration in health and disease states<sup> <\/sup><sup>3<\/sup>, although isolated adverse effects of probiotic administration have been reported<sup> <\/sup><sup>4<\/sup>. This extensive AHRQ report indicates that probiotic intervention in both adults and pediatric populations was not found to be associated with any increased risk of infectious morbidity or other adverse events in either health or illness. Notably, this report revealed a trend towards fewer adverse events in ICU patients receiving select probiotic strains.&nbsp;&nbsp;<\/p>\n\n\n\n<p>According to the National Institute of Health (NIH),&nbsp;<a href=\"https:\/\/ods.od.nih.gov\/factsheets\/Probiotics-HealthProfessional\/\" target=\"_blank\" rel=\"noreferrer noopener\">Office of Dietary Supplements (ODS)<\/a>, \u201cMany probiotic strains are derived from species with a long history of safe use in foods or from microorganisms that colonize healthy gastrointestinal tracts\u201d.&nbsp;&nbsp;Probiotics are consumed in increasing quantities, yet there is no evidence of increased levels of infections.&nbsp;The ODS&nbsp;goes on to say that&nbsp;\u201cgiven the large quantities of probiotics consumed around the world, the numbers of opportunistic infections that result from currently marketed probiotics are negligible\u201d. Probiotics are safe for the general population.&nbsp;&nbsp;<\/p>\n\n\n\n<p>Numerous clinical trials of probiotics have been&nbsp;in&nbsp;a range of&nbsp;vulnerable&nbsp;patient groups<sup>5-8<\/sup>, including&nbsp;pre-term infants<sup>9,10<\/sup>,&nbsp;organ transplant patients<sup>11<\/sup>,&nbsp;immunocompromised patients such as&nbsp;HIV-positive volunteers<sup>12,13<\/sup>,&nbsp;critically ill patients<sup>14-16<\/sup>, people&nbsp;treated for&nbsp;cancer<sup>17-19<\/sup>, and elderly populations<sup>20-23<\/sup>&nbsp;at doses ranging as high as 10<sup>12<\/sup>&nbsp;CFU per day.&nbsp;While relatively rare, the most serious adverse effects of probiotics have been&nbsp;bacteremia and fungemia.&nbsp;Due to these rare instances of infection, we know that&nbsp;there are certain populations that&nbsp;should proceed with caution and these are&nbsp;the same&nbsp;populations that are simply at higher risk for all supplements and drugs.&nbsp;Predisposing factors to increased risk for probiotic-induced bacteremia or fungemia, include patients with critical illness and severe underlying disease, compromised immune function, a damaged gastrointestinal barrier, prosthetic heart valves, indwelling central venous catheter, administration of multiple antibiotics, and prolonged treatment with probiotics or use of excessive dosages. Probiotics should be used with caution, or possibly be avoided after risk-benefit evaluation in patients who have such predisposing factors.&nbsp;In summary, the&nbsp;<a href=\"https:\/\/www.worldgastroenterology.org\/guidelines\/global-guidelines\/probiotics-and-prebiotics\/probiotics-and-prebiotics-english\" target=\"_blank\" rel=\"noreferrer noopener\">World&nbsp;Gastroenterology&nbsp;Organization<\/a>&nbsp;(WGO)&nbsp;advises restricting probiotic use to the strains&nbsp;with&nbsp;proven efficacy for&nbsp;those&nbsp;with compromised immune function or other serious underlying diseases.&nbsp;<\/p>\n\n\n\n<p>As with other approaches, risk assessment and risk management are critical.&nbsp;Risk assessment includes&nbsp;understanding the characteristics and&nbsp;confirming efficacy of the probiotic strain&nbsp;for the&nbsp;intended benefit&nbsp;as demonstrated by at least&nbsp;one well-designed&nbsp;human clinical trial.&nbsp;The complete genome sequence and&nbsp;<em>in vitro&nbsp;<\/em>assessment should support mechanisms of action. The strain\u2019s antibiotic susceptibility profile should be known so that, in the&nbsp;rare case of&nbsp;infection, effective antibiotics are identified.&nbsp;&nbsp;<\/p>\n\n\n\n<p>Product selection plays a role in risk management.&nbsp; Good Manufacturing Practices should be the minimum requirement for a probiotic product.&nbsp; The selected strain should be commercialized in a product known to be validated and delivered at an efficacious dose through shelf life.&nbsp;The presence of excipients that could behave as allergens should be ascertained.&nbsp;Like all foods and dietary supplements, common allergens must be clearly identified and declared on label.<\/p>\n\n\n\n<p>&nbsp;The product should participate in adverse event tracking.&nbsp;&nbsp;In the US,&nbsp;reported adverse events are monitored by the FDA&nbsp;(<a href=\"https:\/\/www.fda.gov\/safety\/medwatch-fda-safety-information-and-adverse-event-reporting-program\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.fda.gov\/safety\/medwatch-fda-safety-information-and-adverse-event-reporting-program<\/a>).This type of&nbsp;surveillance provides a feedback loop to inform best practices.&nbsp;<\/p>\n\n\n\n<p>By following&nbsp;these guidelines&nbsp;we can&nbsp;assure that the products&nbsp;available to the consumer do not&nbsp;misuse the term \u201cprobiotic\u201d&nbsp;and&nbsp;more importantly that these product are efficacious and safe.&nbsp;For additional information about best practices&nbsp;with respect to probiotic products, please&nbsp;visit the&nbsp;IPA website,&nbsp;<a href=\"https:\/\/internationalprobiotics.org\/resources-2\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/internationalprobiotics.org\/resources-2\/<\/a>&nbsp;<\/p>\n\n\n\n<p>1&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Hill, C.<em> et al.<\/em> Expert consensus document. The International Scientific Association for Probiotics and Prebiotics consensus statement on the scope and appropriate use of the term probiotic. <em>Nature reviews. Gastroenterology &amp; hepatology<\/em> <strong>11<\/strong>, 506-514, doi:10.1038\/nrgastro.2014.66 (2014).<\/p>\n\n\n\n<p>2&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Binda, S.<em> et al.<\/em> Criteria to Qualify Microorganisms as \u201cProbiotic\u201d in Foods and Dietary Supplements. <em>Frontiers in Microbiology<\/em> <strong>11<\/strong>, 1662 (2020).<\/p>\n\n\n\n<p>3&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Hempel, S.<em> et al.<\/em> Safety of probiotics used to reduce risk and prevent or treat disease. <em>Evidence report\/technology assessment<\/em>, 1 (2011).<\/p>\n\n\n\n<p>4&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Costa, R. L., Moreira, J., Lorenzo, A. &amp; Lamas, C. C. Infectious complications following probiotic ingestion: a potentially underestimated problem? A systematic review of reports and case series. <em>BMC Complement Altern Med<\/em> <strong>18<\/strong>, 329, doi:10.1186\/s12906-018-2394-3 (2018).<\/p>\n\n\n\n<p>5&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Baldassarre, M. E.<em> et al.<\/em> Lactobacillus GG improves recovery in infants with blood in the stools and presumptive allergic colitis compared with extensively hydrolyzed formula alone. <em>The Journal of pediatrics<\/em> <strong>156<\/strong>, 397-401, doi:10.1016\/j.jpeds.2009.09.012 [doi] (2010).<\/p>\n\n\n\n<p>6&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Grenov, B.<em> et al.<\/em> Effect of probiotics on diarrhea in children with severe acute malnutrition: a randomized controlled study in Uganda. <em>Journal of pediatric gastroenterology and nutrition<\/em> <strong>64<\/strong>, 396-403 (2017).<\/p>\n\n\n\n<p>7&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Kara, S., Volkan, B. &amp; Erten, I. Lactobacillus rhamnosus GG can protect malnourished children. <em>Beneficial microbes<\/em> <strong>10<\/strong>, 237-244 (2019).<\/p>\n\n\n\n<p>8&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Bajaj, J. S.<em> et al.<\/em> Randomised clinical trial: Lactobacillus GG modulates gut microbiome, metabolome and endotoxemia in patients with cirrhosis. <em>Alimentary Pharmacology &amp; Therapeutics<\/em> <strong>39<\/strong>, 1113-1125, doi:10.1111\/apt.12695 (2014).<\/p>\n\n\n\n<p>9&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Cui, X., Shi, Y., Gao, S., Xue, X. &amp; Fu, J. Effects of Lactobacillus reuteri DSM 17938 in preterm infants: a double-blinded randomized controlled study. <em>Italian journal of pediatrics<\/em> <strong>45<\/strong>, 140, doi:10.1186\/s13052-019-0716-9 (2019).<\/p>\n\n\n\n<p>10&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Xu, L.<em> et al.<\/em> A double-blinded randomized trial on growth and feeding tolerance with Saccharomyces boulardii CNCM I-745 in formula-fed preterm infants. <em>Jornal de pediatria<\/em> <strong>92<\/strong>, 296-301, doi:10.1016\/j.jped.2015.08.013 (2016).<\/p>\n\n\n\n<p>11&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Gr\u0105t, M.<em> et al.<\/em> Effects of continuous use of probiotics before liver transplantation: A randomized, double-blind, placebo-controlled trial. <em>Clin Nutr<\/em> <strong>36<\/strong>, 1530-1539, doi:10.1016\/j.clnu.2017.04.021 (2017).<\/p>\n\n\n\n<p>12&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Arnbjerg, C. J.<em> et al.<\/em> Effect of Lactobacillus rhamnosus GG supplementation on intestinal inflammation assessed by PET\/MRI scans and gut microbiota composition in HIV-infected individuals. <em>JAIDS Journal of Acquired Immune Deficiency Syndromes<\/em> <strong>78<\/strong>, 450-457 (2018).<\/p>\n\n\n\n<p>13&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Ishizaki, A.<em> et al.<\/em> Effects of Short-Term Probiotic Ingestion on Immune Profiles and Microbial Translocation among HIV-1-Infected Vietnamese Children. <em>International journal of molecular sciences<\/em> <strong>18<\/strong>, doi:10.3390\/ijms18102185 (2017).<\/p>\n\n\n\n<p>14&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Mahmoodpoor, A.<em> et al.<\/em> Effect of a Probiotic Preparation on Ventilator-Associated Pneumonia in Critically Ill Patients Admitted to the Intensive Care Unit: A Prospective Double-Blind Randomized Controlled Trial. <em>Nutr Clin Pract<\/em> <strong>34<\/strong>, 156-162, doi:10.1002\/ncp.10191 (2019).<\/p>\n\n\n\n<p>15&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Morrow, L. E., Kollef, M. H. &amp; Casale, T. B. Probiotic prophylaxis of ventilator-associated pneumonia: a blinded, randomized, controlled trial. <em>American journal of respiratory and critical care medicine<\/em> <strong>182<\/strong>, 1058-1064 (2010).<\/p>\n\n\n\n<p>16&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Angurana, S. K.<em> et al.<\/em> Evaluation of Effect of Probiotics on Cytokine Levels in Critically Ill Children With Severe Sepsis: A Double-Blind, Placebo-Controlled Trial. <em>Crit Care Med<\/em> <strong>46<\/strong>, 1656-1664, doi:10.1097\/ccm.0000000000003279 (2018).<\/p>\n\n\n\n<p>17&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Zaharuddin, L., Mokhtar, N. M., Muhammad Nawawi, K. N. &amp; Raja Ali, R. A. A randomized double-blind placebo-controlled trial of probiotics in post-surgical colorectal cancer. <em>BMC Gastroenterol<\/em> <strong>19<\/strong>, 131, doi:10.1186\/s12876-019-1047-4 (2019).<\/p>\n\n\n\n<p>18&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Linn, Y. H., Thu, K. K. &amp; Win, N. H. H. Effect of Probiotics for the Prevention of Acute Radiation-Induced Diarrhoea Among Cervical Cancer Patients: a Randomized Double-Blind Placebo-Controlled Study. <em>Probiotics Antimicrob Proteins<\/em> <strong>11<\/strong>, 638-647, doi:10.1007\/s12602-018-9408-9 (2019).<\/p>\n\n\n\n<p>19&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; \u00d6sterlund, P.<em> et al.<\/em> Lactobacillus supplementation for diarrhoea related to chemotherapy of colorectal cancer: A randomised study. <em>British journal of cancer<\/em> <strong>97<\/strong>, 1028-1034 (2007).<\/p>\n\n\n\n<p>20&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Wang, B.<em> et al.<\/em> Probiotics to prevent respiratory infections in nursing homes: a pilot randomized controlled trial. <em>Journal of the American Geriatrics Society<\/em> <strong>66<\/strong>, 1346-1352 (2018).<\/p>\n\n\n\n<p>21&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Kobayashi, Y., Kuhara, T., Oki, M. &amp; Xiao, J. Z. Effects of Bifidobacterium breve A1 on the cognitive function of older adults with memory complaints: a randomised, double-blind, placebo-controlled trial. <em>Benef Microbes<\/em> <strong>10<\/strong>, 511-520, doi:10.3920\/bm2018.0170 (2019).<\/p>\n\n\n\n<p>22&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Fonoll\u00e1, J.<em> et al.<\/em> Effects of Lactobacillus coryniformis K8 CECT5711 on the immune response to influenza vaccination and the assessment of common respiratory symptoms in elderly subjects: a randomized controlled trial. <em>Eur J Nutr<\/em> <strong>58<\/strong>, 83-90, doi:10.1007\/s00394-017-1573-1 (2019).<\/p>\n\n\n\n<p>23&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Lei, M., Hua, L. M. &amp; Wang, D. W. The effect of probiotic treatment on elderly patients with distal radius fracture: a prospective double-blind, placebo-controlled randomised clinical trial. <em>Benef Microbes<\/em> <strong>7<\/strong>, 631-637, doi:10.3920\/bm2016.0067 (2016).<\/p>\n","protected":false},"excerpt":{"rendered":"<p>written by Margaret Haldeman, Ph.D., Education &amp; Communication Co-chair Probiotics are defined as \u201clive microorganisms that, when administered in adequate amounts, confer a health benefit on the host\u201d 1.&nbsp;To be considered a true probiotic, a microorganism must confer a health benefit when consumed in appropriate amounts.&nbsp;&nbsp;In order to provide a health benefit, this consumption must [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":7223,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"_eb_attr":"","_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[369],"tags":[633,634],"_links":{"self":[{"href":"https:\/\/internationalprobiotics.org\/home\/wp-json\/wp\/v2\/posts\/7221"}],"collection":[{"href":"https:\/\/internationalprobiotics.org\/home\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/internationalprobiotics.org\/home\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/internationalprobiotics.org\/home\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/internationalprobiotics.org\/home\/wp-json\/wp\/v2\/comments?post=7221"}],"version-history":[{"count":2,"href":"https:\/\/internationalprobiotics.org\/home\/wp-json\/wp\/v2\/posts\/7221\/revisions"}],"predecessor-version":[{"id":7225,"href":"https:\/\/internationalprobiotics.org\/home\/wp-json\/wp\/v2\/posts\/7221\/revisions\/7225"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/internationalprobiotics.org\/home\/wp-json\/wp\/v2\/media\/7223"}],"wp:attachment":[{"href":"https:\/\/internationalprobiotics.org\/home\/wp-json\/wp\/v2\/media?parent=7221"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/internationalprobiotics.org\/home\/wp-json\/wp\/v2\/categories?post=7221"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/internationalprobiotics.org\/home\/wp-json\/wp\/v2\/tags?post=7221"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}