Neerja Hajela, Ph.D. General Manager - Science and Regulatory Affairs

Yakult Danone India Pvt. Ltd.

Probiotics : What we Know and Where we are Going Next

Global functional foods market revenue by product, 2015 & 2024 (USD Billion)

Functional Foods Market Analysis By Product (Carotenoids, Dietary Fibers, Fatty Acids, Minerals, Prebiotics & Probiotics, Vitamins), By Application, By End-Use (Sports Nutrition, Weight Management, Immunity, Digestive

Health) And Segment Forecasts, 2014 To 2024: Market research Report

Functional Food Market – Probiotics an important category

Expected Probiotic Market Growth (2013-2022)

• Asia-pacific ranks as the fastest growing market, Japan, Europe and the United States represents major market worldwide.

• Industry participants majorly include Chr. Hansen Holding A/S, Yakult Honsha Co., Ltd.,

Danone, Nestle, Probi AB, Danisco A/S, Lallemand Inc., and Arla Foods, Inc.

Probiotics Market Analysis and Reports | UK Conference Series 2017

Intestinal Health – the reason for Probiotics

The Intestine – what we did not know..

Digestion of food and absorption of nutrients

2nd Brain of the Human body- 100 million neurons and 2/3rd of the body’s neurotransmitters

Largest immune organ – 70 % of the immune cells are present here

100 trillion microbes – outnumber the human cells by a factor of 10 – intestinal microbiota

O’Hara A.M. et al. EMBO reports 2006; 7: 688-693.

The intestinal microbiota – the forgotten organ

Dysbiosis of the intestinal microbiota –

link to disease?

Microbes in the Gut

Gut Dysbiosis

Interventions for modulation of the

intestinal microbiota

Favorable modification of the gut flora

ProbioticsLive microorganisms which when administered in adequate amounts confer a health benefit on the host.FAO/WHO (2001)

PrebioticsPrebiotics are non-digestible substances that when consumed provide a beneficial physiological effect on the host by selectively stimulating the favourable growth or activity of a limited number of indigenous bacteria.Gibson GR & Roberfroid MB (1995)

SynbioticsProbiotic + prebiotic (synergy?)

‘Live micro-organisms which, when administered in adequate amounts,

confer a health benefit on the host’

Definition in 2001

Probiotic Guidelines - The Start

“ Guidelines for the Evaluation ofprobiotics in Food. Report of a JointFAO/WHO Working Group onDrafting Guidelines for the Evaluationof probiotics in Food.” London Ontario,Canada. April 30 and May 1, 2002.

Joint Food and Agriculture Organization/World HealthOrganization: Guidelines for the evaluation of probiotics infoods. London, Ontario, Canada; 2002, 1-11.

“live microorganisms that, when administered in adequate amounts, confer a health benefit on the host”

Hill C et al (2014) Nat Rev Gastroenterol Hepatol 11:506–514.

Definition in 2014

Live culturesProbiotic

Not probiotic

Probiotic drugs

Probiotic medical foods

Probiotic foods

Non-oral probiotics

Probiotic animal feed

Defined microbial consortia

Probiotic dietary supplement

Probiotic infant formula

Fermented foods with undefined microbial content

Undefined consortia, including

faecal microbiota transplant

Framework for Probiotic Products

Hill C et al (2014) Nat Rev Gastroenterol Hepatol 11:506–514.

Changing Perception

Low dose food supplement

Old generation

New generation

▪ Inactive▪ Eg. Yoghurts

▪ Not scientifically backed

▪ Doubtful efficacy▪ Eg. Yeast

▪ Scientifically tested

▪ Efficacy demonstrated

▪ Clear proof of concept

Inadequate amounts

Health benefit not

demonstrated

WHO DEFINITION OF PROBIOTICS

“Live microorganismswhich when administeredin adequate amounts,confer a health benefit onthe host.”

“FIT”

“NO FIT”

Probiotic -Characterization and

Benefits

What makes a Probiotic ?

▪ Stable and well-described organism, Non-toxic, Non-pathogenic , Generally Recognized As Safe (GRAS)

▪ Resistant to Gastric juices, Bile and Pancreatic juices

▪ Able to transit the Gastro-intestinal Tract and transiently colonize the target site – small intestine/ large intestine

▪ Impart a scientifically proven health benefit.

Probiotic Organisms

1. Genus, Species and Strain identification - Phenotypic and Genotypic tests – validated standard methodology

2. In vitro tests to screen potential probiotic strains - Resistance to gastric acid , bile and pancreatic juice- Antimicrobial activity- Bile salt hydrolase activity - Ability to reduce pathogen adhesion

Probiotic Characterization

3. In vivo safety studies in animals - Subsequent testing in animal (rats and mice) models – Assessment of

acute, sub acute and chronic toxicity - Not necessary for strains with documented established use

4. In vivo efficacy studies in animals Validated animal models to be used prior to human trials

6. Evaluation of efficacy in humansClinically significant improvement in condition, reduced risk of disease, or longer time to next occurrence, faster recovery from illness.

7. Probiotic benefits - Acute Gastroenteritis, Irritable Bowel Syndrome, Necrotizing Enterocolitis.

- Probiotic benefits in other aspects of health functionality – obesity and metabolic disorders, prevention of cancers, cognitive and mood enhancing benefits.

5. Evaluation of safety of the probiotic for human use

- Generally Recognized as Safe- Antibiotic Resistance patterns- Toxin production or hemolytic activity - Immune compromised individuals

Study - Meta – analysis; 84 trials ; n - 10351 patients

Eight different Gastrointestinal disorders – Infectious diarrhoea, Pouchitis, AAD, Traveler's diarrhoea, IBS, C diff infection, NEC.

Conclusion: Probiotics are generally beneficial in treatment and prevention of gastrointestinal diseases.

Study : Cochrane review, 63 studies , n- 8014 subjects

Conclusion: Probiotics appear to be safe and shortened duration of diarrhoea andreduced stool frequency in acute infectious diarrhoea.

Allen SJ et al (2010) Cochrane Database of Systematic Reviews 11:CD003048.

An Indian study

3758 children

(1 to 5 years)

Nutrient Group

1864 children

Probiotic Group

1894 children

Probiotic drink

(65 ml/ day）

❖ 12week 12week

Follow up

12week 12week❖

Follow upNutrient

(65 ml/ day)

➢Nutritional assessment (height, weight and mid-arm circumference) will be

done at the ,❖ and (beginning, after 12weeks, and at the end of follow-up)

Double-blind

Controlled TrialDetermine & Compare incidence,

duration, outcome, and pathogens of

acute diarrhoea

7/12/07 10/13/07 1/5/08

Schematic Diagram

Variable Probiotic

(n=1802)

Nutrient

(n=1783)

Protective efficacy

of probiotic (95%

CI)*

Simple analysis#

Percent

Children with

diarrhoea

608 674

Incidence of diarrhoea

– no. of cases /child /

year

0.88 1.029 14 (4-23)

Occurrence of diarrhoea & protective efficacy of the probioticBenefit of the probiotic

Probiotic - Protective efficacy 14% (95% CI: 4%,23%)

Recommendations

European Society for Pediatric Gastroenterology, Hepatology and

Nutrition (ESPGHAN)

Probiotics in the management of acute gastroenteritis in children

Probiotics for children with mild Ulcerative Colitis when standard therapy isn’t

working.

European Society of Primary Care Medicine Probiotics in management of

lower gastrointestinal symptoms in clinical practice.

World Gastroenterology Organization

Probiotics for different gastrointestinal indications - for adults and children.

World Allergy Organization

Likely benefit from probiotic use in pregnant women who are at risk of having

an allergic child or in infants at high risk of developing allergy.

Quantities

▪ Probiotic benefits are strain specific

▪ No general minimal level for the probiotic count

▪ Bifidobacterium infantis 35624 was effective in alleviating symptoms of IBS at 100 million cfu/ day, whereas studies with VSL#3 have used sachets with 300 – 450 billion cfu/day.

Carrier matrix and probiotic products

Dairy – The Preferred Medium

➢ Low pH of the product – Buffers stomach acidity -ensures viability of the probiotic bacteria.

➢ Short shelf life or refrigeration - Probiotic survival inproduct.

➢ Nutrition and optimal expression of probioticfunctionality

➢ Compliance - Food vs. Pill.

Dairy based probiotic foods represent the largestsegment accounting for nearly 65% of the totalprobiotic food market.

Fermented

Dairy Probiotics

Along with Starter

Yoghurt Curd Cheese

Fermented with the probiotic only

Fermented Milk Drinks

Fermented Dairy Matrices for ProbioticsFermented Dairy Products

BB 12

LA5

Lactobacillus casei strain Shirota

Lactobacillus acidophilus

Lactobacillus acidophillus and Bifidobacterium lactis

Bifidobacterium bifidus, Streptococcus thermophillus, Lactobacillus bulgaricus and Lactobacillus acidophillus strains ( Min 10 7 Bacteria /ml.

Probiotic Foods in Indian Market

Probiotic Strain

Industrial processing as well as the food matrix

Influenced by

Small changes in properties may significantly alter in vivo functionality

➢Adequate Quality Assurance and Good ManufacturingPractices - Safety and Efficacy

➢CODEX General Principles of Food Hygiene andGuidelines for application of Hazard Analysis andCritical Control Point (HACCP) should be followed.

Manufacturing Process

▪Safety

▪Stability

▪Survival

▪Efficacy

Probiotic Product

Probiotic Guidelines and Regulations

Probiotic categorization across the Globe

Guidelines for evaluation of candidate probiotic strains

Strain Identification by Phenotypic and Genotypic Methods• Genus, Species and Strain• Deposit strain in an Internationally Recognized collection

Screening of Potential Probiotic Strains• In vitro Tests

In vivo studies in validated animal models for :• Safety• Efficacy

In vivo studies in humans for clinical evaluations • Phase 1 (Safety)• Phase 2 (Efficacy)• Phase 3 (Effectiveness)*

PROBIOTIC FOODS

Labeling Requirements• Genus, Species, Strain• Minimum viable numbers of Probiotics at the level at which efficacy is claimed and at

the end of shelf-life• Health claim (s)• Serving size for efficacy• Storage conditions

MINISTRY OF HEALTH AND FAMILY WELFARE (FOOD SAFETY AND STANDARDS AUTHORITY OF INDIA) NOTIFICATION New

Delhi, the 23rd December , 2016

Gazette Notification of Food Safety and Standards (Food or Health Supplements, Nutraceuticals, Foods for Special Dietary Uses, Foods for Special Medical Purpose,

Functional Foods and Novel Food) Regulations, 2016 (Uploaded on:

06.01.2017).

(iii) Every package of probiotic food shall carry the following information on the label, namely:-

a) the words “PROBIOTIC FOOD”;b) Genus and species including strain designation or culture collection

number, where applicable, in brackets where probiotics are mentioned in the list of ingredients;

c) Viable numbers at the end of the shelf-life of probiotic strain corresponding to the level at which the efficacy is claimed;

d) the recommended serving size which shall deliver the effective viable dose of probiotics related to health claims and recommended duration of use, proper storage temperature conditions, and time limit for ‘Best Use’ after opening the container;

e) an advisory warning ‘NOT FOR MEDICINAL USE’ prominently written; and

f) a warning or any other precaution to be taken while consuming, known side effects, if any, contraindications, and product-drug interactions, as applicable.

Labelling for Probiotic Foods

Cost savings from patients who do not acquire an infection or recover more quickly – driving forces in making probiotics a part of the health care system.

Use of probiotics to prevent and treat respiratory tract infections – saving of $100 million /year (Canada and France).

We live in a microbial world – its time to design how we live around the microbes rather than only respond when the wrong ones attack us.

Why probiotics?

We are them

&

They are us