Health Benefits of Probiotics by

Impacting the Intestinal Barrier Function

Budapest, June 21-23, 2016

P. A. Bron1, M. Kleerebezem2, R.J. Brummer3, P.D. Cani4, A.

Mercenier5, T.T. MacDonald6, C.L. Garcia Rodenas5, J.M. Wells2

1 NIZO food research and BE-Basic Foundation, NL; 2 Wageningen University, NL; 3Örebro University, SE; 4Université catholique de Louvain, BE; 5Nestlé Research

Center, CH; 6 Queen Mary University of London, UK

IPC2016

Introduction

Background

Scope of the review

The GI barrier: a complex multilayer system designed to prevent translocation of microbes, antigens & toxins

from the lumen inside the body

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Gastro-intestinal barrier Mucosal barrier

Perrier C & Corthesy B (2011) Gut permeability and food allergies. Clin Exp Allergy 41, 20-28.

Soderholm et al. (1999) Different intestinal permeability patterns in relatives and spouses of patients with Crohn's disease: an inherited defect in mucosal

defence? Gut 44, 96-100.

Cani, P. D. et al. (2007). "Metabolic Endotoxemia Initiates Obesity and Insulin

Resistance." Diabetes 56, 1761-72.

Leaky gut barrier and disease

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Roxas JL, et al. (2010) Enterohemorrhagic E. coli alters murine intestinal epithelial tight

junction protein expression and barrier function in a Shiga toxin independent manner.

Lab Invest 90, 1152-1168

Camilleri et al. (2012) Irritable bowel syndrome: methods, mechanisms, and

pathophysiology. The confluence of increased permeability, inflammation, and pain in irritable bowel syndrome, Am J PhysiolGastrointest Liver Physiol 303, G775-85.

Julio-Pieper, M, et al. (2014) Review article: intestinal barrier dysfunction and

central nervous system disorders-a controversial association. Aliment.

Pharmacol. Ther 40, 1187-1201

Anand RJ et al. (2007) The role of the intestinal barrier in thepathogenesis of necrotizing

enterocolitis. Shock 27, 124-33

Heyman et al. (2012) Intestinal permeability in coeliac disease: insight into mechanisms and relevance to

pathogenesis, Gut 61, 1355-64.

LEAKY GUT

Allergy

Metabolic Syndrome

Neuro-psychiatric disorders

GI infection

IBD

NEC

IBS

Celiac Disease

Probiotics & barrier mechanisms

Colonization resistance

Antimicrobial compounds

(metabolites, bacteriocins)

Inhibition of toxin production/toxin

degradation

Mucin, antimicrobials & SIgA secretion

Epithelial integrity

Gut motility

Immunomodulation

Commensal microbiota Mucosal barrier

Sanchez, M. et al. (2014) Effect of Lactobacillus rhamnosusCGMCC1.3724 supplementation on weight loss and maintenance in obese men and women. Br J Nutr. 28;111(8):1507-19

Goldenberg J.Z. et al. (2015) Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database Syst Rev. 22;12:CD004827

Clarke G. et al. (2012) Review article: probiotics for the treatment of irritable bowel syndrome-focus on lactic acid bacteria, Aliment PharmacolTher. 35(4):403-13.

AlFaleh K., Anabrees J. (2014) Probiotics for prevention of necrotizing enterocolitis in preterm infants Cochrane Database Syst Rev. 10;4:CD005496

Ghouri Y.A. et al. (2014) Systematic review of randomized controlled trials of probiotics, prebiotics, and synbiotics in inflammatory bowel disease. Clin ExpGastroenterol. 9;7:473-87

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Metabolicsyndrome

GI infections

IBDNEC

IBS

ProbioticsPrebioticsSynbiotics

Probiotics and disease

Scope

Impact of probiotics on mucosal barrier* integrity and

commensal microbiota as mediating factors of their

beneficial effects on model disorders

* Studies on mucosal immunity not included

Results

Probiotics, barrier & management

of model disorders

Probiotics and enteric infection

“Moderate quality evidence suggests a protective effect of probiotics

in preventing AAD” Goldenberg J.Z. et al. (2015) Cochrane Database Syst Rev.

22;12:CD004827

“Moderate quality evidence suggests that probiotics are both safe

and effective for preventing Clostridium difficile-associated diarrhea”Goldenberg J.Z. et al. (2013) Cochrane Database Syst Rev. 31;5:CD006095

“There is evidence that selected strains of probiotics decrease the

duration of acute gastroenteritis” Vandenplas Y. (2016) Best Pract Res Clin

Gastroenterol. 2016 Feb;30(1):49-53

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Probiotics & pathogen challenges to the

barrier

Colonization resistance

B. longum Bar33 and L. helveticus Bar13

C. difficile, C. perfringens, E. faecium,

Campylobacter in elderly volunteers(Rampelli 2013)

Antimicrobial compounds

Reuterin (L. reuteri) inhibits enteric

pathogens (Cleusix 200 7)

Abp 118 (L. salivarius UCC118) inhibits L.

monocytogenes translocation (Corr 2007).

Inhibition of toxin production/toxin

degradation

B breve Yakult STEC Shiga toxin in

vitro and in vivo (Asahara 2004)

S. boulardii protease degrades Toxin A

from C. difficile (Castagliuolo 2014)

Mucin expression

Adherent Lactobacillus spp mucin

expression and prevent EPEC adherence in

vitro (Mack 1999)

Inhibition of pathogen-induced disruption

of epithelial integrity

L acidophilus (Sherman 2005), L plantarum (Mangell

2002), L casei (Parassol 2005), reduce the EHEC

and EPEC increase in permeability in vitro

SIgA production

L. plantarum P8 fecal SIgA in middle-age

and elderly humans (Wang 2014).

Direct effects on pathogens Mucosal barrier modulation

Probiotics and NEC

“Enteral supplementation of probiotics prevents severe NEC and all

cause mortality in preterm infants. Our updated review of available

evidence strongly supports a change in practice.” AlFaleh K., Anabrees

J. (2014) Cochrane Database Syst Rev. 10;4:CD005496

“Supplementation with prebiotic oligosaccharides was safe and did

not result in decreased incidence of NEC” Srinivasjois R. et al. (2013) Clin

Nutr. 32(6):958-65

“In VLBW infants, probiotic (Bifidobacterium lactis) and synbiotic

(Bifidobacterium lactis plus inulin) but not prebiotic (inulin) alone

decrease NEC” Dilli D. et al. (2015) J. Pediatr. 166:545-51

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Beneficial effects

B. longum subsp. infantis (Underwood 2012), B.

lactis BB12 (Mohan 2006), S. boulardii (Costalos

2003) bifidobacteria, potential

pathogens

L. rhamnosus LGG (Manzoni 2006; Romeo 2011),

L. reuteri ATCC 55730 (Romeo 2011) and L.

reuteri DSM 17938 (Oncel 2015) prevent

Candida colonization

Inconsistent effects

No effects of LGG+BB536 (Rougé 2010)

LGG Gram + and anaerobic species diversity

in preterms under 1500 g but not in more

mature infants (Agarwal 2003)

In preterm infants

B. lactis BB12 permeability (Stratiki 2007),

fecal SIgA, fecal calprotectin (Mohan 2008)

Heat-inactivated B. breve C50/S.

thermophilus 065 fecal SIgA in partially

breast-fed infants, but not in exclusively

formula-fed (Campeotto 2011)

In animal models

permeability to small solutes,

macromolecules and endotoxin, bacterial

translocation to extraintestinal tissues

Restored expression and localization of TJ

and adherens junctions proteins

enterocyte proliferation, migration,

apoptosis

Normalized expression of TLRs, mucins

antimicrobials

Microbiota modulation Mucosal barrier modulation

Probiotics, immature barrier & NEC

Probiotics and IBD

“There is insufficient data to recommend probiotics for use in

CD. There is evidence to support the use of (some) probiotics for

induction1 and maintenance of remission in UC2 and pouchitis3.

Future quality studies are needed to confirm whether probiotics,

prebiotics, and synbiotics have a definite role in induction or

maintenance of remission in CD, UC, and pouchitis”

Ghouri Y.A. et al. (2014) Clin Exp Gastroenterol. 9;7:473-87

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1 VSL#3, 2 E. coli Nissle 1917 & L. rhamnosus GG, 3 VSL# 3

Probiotics, barrier & IBD

VSL#3 Lactobacillus, Bifidobacterium and S. salivarius in UC (Venturi 1999); total bacterial

numbers, richness and diversity of the bacterial microbiota & diversity of fungal flora (Kuhbacher

2006)

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Microbiota modulation

Mucosal barrier modulation

Increased epithelial integrity Probiotics protect against cytokine-driven epithelial barrier dysfunction (multiple in vitro studies)

P40 component of L rhamnosus GG prevents cytokine-induced hyperpermeability and

ameliorates DSS-induced colitis in mice (Yan 2011)

Soluble factor from B infantis increases ZO-1 and occludin in epithelial cell lines and improves

colitis in IL10 Ko mice (Ewaschuk 2008)

L. plantarum duodenal perfusion in healthy individuals results in structural changes in ZO-1 and

occludin, associated with reduced permeability (Karczewski 2011)

Stimulation of antimicrobial production by the mucosa B. breve NCC 22950 normalized RegIII-γ expression (not permeability) and decreased

susceptibility to DSS colitis in Nod1(-/-); Nod2(-/-) mice (Natividad 2012)

Probiotics and IBS

“Probiotics are effective treatments for IBS, although

which individual species and strains are the most

beneficial remains unclear. Further evidence is required

before the role of prebiotics or synbiotics in IBS is

known.”

Ford AC. et al. (2014) Am J Gastroenterol. 2014 Oct;109(10):1547-61

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Probiotics, barrier & IBS

Multispecies probiotic: Microbiota stabilization (Kajander 2008); increased Clostridia and

Enterococcus (Lyra 2010)

Multispecies probiotic: no effect (Brigidi 2001)

B. animalis subsp. lactis CNCM I-2494 reduced B. wadsworthia and increased the butyrate-

producing potential of the commensal microbiota (Veiga 2014)

Microbiota modulation

Mucosal barrier modulation

Increased epithelial integrity Lactibiane Tolerance® occludin expression, prevented hyperpermeability and visceral

hypersensitivity induced by LPS, stress or IBS luminal metabolites (Nebot-Vivinus 2014)

B. longum HB55020 and L. acidophilus HB56003 claudin-1 and occludin expression,

reduced inflammatory markers and prevented hypersensitivity in a model of PI-IBS (Wang 2014)

B. lactis CNCM I-2494 prevented hyperpermeability and endotoxemia induced by stress and

restored occludin and JAM-A expression (Agostini 2012)

Mucus layer L. farciminis prevented stress-mediated alterations in mucin O-glycosylation and mucus

physical properties. It also prevented hyperpermeability and hypersensitivity (Da Silva 2014)

Probiotics and metabolic disease

Probiotics

L. gasseri SBT2055 reduced fat-mass gain, body weight and waist-to-hip ratio in

overweight subjects (Kadooka Y et al. (2013). Br J Nutr. 14;110(9):1696-703)

VSL#3 improved insulin sensitivity and reduced total cholesterol, triglyceride,

LDL, and VLDL and increased HDL in overweight adults (Rajkumar, H. et al. (2014)

Mediators Inflamm. 2014, 8)

L. rhamnosus CGMCC1.3724 helped to reduce body weight in overweight

women but not in men (Sanchez, M. et al. (2014) Br J Nutr. 28;111(8):1507-19)

Pre- and Synbiotics

Enhanced weight loss and improved glucose regulation in obese adults with FOS

supplements (Parnell J.A. & Reimer, R.A. (2009) Am. J. Clin. Nutr. 89:1751-9)

Reduced endotoxemia, insulin resistance, steatosis and metabolic inflammatory

markers by B longum + FOS in NASH patients (Malaguarnera M. et al. (2012) Dig.

Dis. Sci. 57:545-53)

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Probiotics, barrier & metabolic disease

L. salivarius Ls-33 ATCC SD5208: Bacteroides-Prevotella-

Porphyromonas/Firmicutes ratio in obese adolescents (Larsen 2013), but no effects

on metabolic outcomes

VSL#3: total aerobes, total anaerobes, Lactobacillus, Bifidobacterium,

Streptococcus in overweight adults (Rajkumar,2014)

Microbiota modulation

Mucosal barrier modulation

L. casei Shirota insulin resistance and endotoxemia in diet-induced obese mice (Naito 2011)

B. longum endotoxemia, fat mass, insulin resistance, blood pressure in diet-

induced obese rat (Chen 2011)

B. animalis subsp. lactis 420 supressed bacteremia and reduced insulin resistance

and inflammation in high fat diet-fed mice (Amar et al. 2011)

Conclusions & Gaps

Conclusions & Gaps

(Some) Probiotics have the potential to prevent and/or treat

multiple disorders. Evidence ranges from good/fair (AGE,

NEC, UC, pouchitis, IBS) to emerging (metabolic disease)

(Some) Probiotics positively modulate microbiota composition

and barrier integrity, which possibly explains their impact on

health and disease (at least partially)

? Good quality, clinical trials in well-defined populations

comparing the effect of different doses and/or strains on both

clinical and barrier outcomes are required

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Thank you!

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VCt CCt VLr CLr

Bifidobacterium abundance

VCtCCt VLrCLr

Phylogenetic similarity

VCt CCtVLrCLr

2 weeks 4 months

V=vaginal, C=C-section; Ct=control formula; Lr=L. reuteri formula