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.

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