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Health Issues Related to Diet

9 Tips for Staying Healthy this Holiday Season

What a terrific time of the year! We just finished sharing a relaxing turkey meal with family and friends, and now it’s time to focus on preparing for the upcoming holidays. This includes shopping in the malls, enjoying holiday treats and parties, and traveling to visit family and friends or going on a vacation.

Unfortunately, the exposure to others and consuming sweets and alcohol is challenging our immune system. This newsletter is about the top nine ways to boost our immune system and avoid developing cold and flu symptoms during this season.

Some Facts about Cold and Flu

Colds and flu (influenza) are virus infections. Cold and flu viruses attack the lining of the upper respiratory tract, which includes the nose, throat and sinuses. The main symptoms of a cold are sore throat, runny nose, cough and congestion of the nasal passages. Unfortunately, there is no cure for the common cold. Additionally, there is no vaccine against the cold viruses since there are too many, and they tend to mutate or change.

Influenza (or flu) is due to two main viruses – type A and B. The symptoms of influenza are similar to the common cold, but are usually more intense and include chills, fever, and body aches. If someone develops the flu, they are generally home ill for at least 2-3 days. Sometimes, especially in children, the illness can be more severe. Flu viruses are constantly changing. Each year the CDC identifies the most common forms of the influenza viruses and develops a vaccine.

The viruses for cold and flu are very contagious and transmission occurs mainly by inhalation of virally infected droplets from coughs and sneezes from infected individuals. Additionally, touching objects infected by droplets and then putting your fingers to your mouth or nose is another source of exposure.

New Study: Probiotic Benefits for Preventing Cold and Flu

Before listing the nine top tips on having a healthy holiday season, I want to report on a recent medical article. There have actually been a number of published clinical studies on the positive benefits of probiotics for the prevention of cold and flu symptoms.

The most recent article by Hao and his associates(1) reviewed 14 randomized clinical trials studying the prevention of upper respiratory tract infections. This study compared probiotics with a placebo. The studies involved 3451 children and adults. They found that the group taking probiotics had less cold and flu episodes and required fewer antibiotic prescriptions than the group taking a placebo. Probiotics reduced the number of individuals who had at least one acute upper respiratory tract infection by 42 percent.

It’s also important to note that side effects of probiotics were minor.

Now…9 Tips for Staying Healthy During the Holiday Season

  • Get the flu vaccine
  • Eat at least 6-8 daily servings of fruits and vegetables to boost the immune system(2)
  • Try to get at least 7 hours of sleep(3)
  • Maintain hydration
  • Exercise 30 minutes at least 5 days a week(4)
  • Avoid crowds if possible
  • Wash hands frequently or use hand sanitizers after touching potentially infected surfaces
  • Take a high quality probiotic…like EndoMune Advanced and EndoMune Junior
  • If you think you have the flu or have been exposed to someone with the flu, contact your physician as you may benefit from taking one of anti-viral flu medications

Thank You!

On a personal note, this is the fifth year that I have written a December newsletter. I want to say that developing EndoMune has turned out to be one of the most gratifying professional activities in my medical career. Researching the latest medical studies on the benefits of probiotics has been challenging, but stimulating. So many people have shared with me how EndoMune has had such a positive effect on their health.

Thank you for your continued support of EndoMune Advanced and EndoMune Junior. We are continuing to work on maintaining the highest quality probiotics and developing new ones.

My very best wishes for a happy and healthy holiday season and New Year!


(1) Probiotics for preventing acute upper respiratory tract infections.Hao Q, Lu Z, Dong BR, Huang CQ, Wu T.Cochrane Database Syst Rev. 2011 Sep 7;9

(2) Am J Lifestyle Med. 2009 Jul;3(1 Suppl):39S-43S. Functional Foods as Modifiers of Cardiovascular Disease. Johnston C.

(3)Sleep and immune function.Besedovsky L, Lange T, Born J.Pflugers Arch. 2011 Nov 10.

(4) Current perspective on exercise immunology. Nieman DC.Curr Sports Med Rep. 2003 Oct;2(5):239-42. Review.

Probiotics and the Prevention of Food Allergies

Most of us are familiar with the term “food allergy.” Case in point, children with an allergy to peanuts can experience allergic reactions ranging from hives to coma, or even death. Sensitized children must have medication with them at all times to immediately treat reactions.

Strict avoidance of peanuts is their sole option to stay well. Schools have tried to create awareness for students and their parents to avoid bringing foods like peanut butter to school if there is a child with a peanut allergy.

In the last two weeks, there have been a number of news reports on the dramatic increase in food allergies experienced by children.

In the June issue of the medical journal Pediatrics(1), a study found that about eight percent of children under the age of 18 (almost 6 million) suffer from one or more food allergies. These numbers are twice as high as reported by the CDC in 2007, which reported a rate just below four percent. Additionally, the severity of the episodes has increased.

The lead author of the June study, Dr. Ruchi Gupta, reported that “based on our data, about one in 13 children has a food allergy. We are seeing a lot more cases in schools than we used to see. It does seem that food allergy is on the rise.” In addition, Dr. Gupta noted, “What’s more, nearly two out of every five affected children suffer from a severe food allergy. For these children, accidental ingestion of an allergenic food may lead to difficulty breathing, a sharp drop in blood pressure, and even death.”

With the growing severity of food allergies, how can probiotics help? There are some very interesting studies that suggest probiotics may lessen the risk of food allergies in children.

To get a better understanding of this topic, this newsletter will discuss:

  • What is a “food allergy”
  • What is the cause
  • How to diagnose a food allergy
  • How is a food allergy treated
  • Can probiotics help lessen the risk of developing a food allergy

What is food allergy?

Food allergy is a term used to describe an adverse immune response to a protein in some foods.

When we are born, our intestinal immune cells have to constantly survey what is being ingested. The immune cells determine if they have to mount a protective reaction to a potentially harmful virus, bacteria, parasite or toxin.

Sometimes, the immune cells react to harmless proteins in our food and produce antibodies that can result in allergic reactions like hives, eczema, asthma, rhinitis and gastrointestinal symptoms of cramps, nausea, vomiting and diarrhea.

The most serious reaction is called anaphylaxis, which causes severe breathing difficulty and a major drop in the blood pressure. Oxygen, epinephrine injections and IV fluids can be lifesaving.

Anaphylactic reactions due to food allergies account for 30,000 episodes annually and possibly 200 deaths each year.(2)

The CDC estimates that eight types of foods are responsible for 90 percent of all food allergies in children: milk, eggs, peanuts, tree nuts, fish, shellfish, soy and wheat.

What is the cause of a food allergy?

The exact cause of food allergies is not known. However, there have been several proposed explanations why food allergies occur and have been on the increase over the last 20-30 years.

Factors thought to contribute to food allergies include genetic predisposition and the introduction of foods too early in infancy.

The other major factor is the “Hygiene Theory”.(3) This theory is based on the idea that in the Western developed countries the exposure to harmful bacteria, parasites, viruses and other toxins has decreased due to our efforts at keeping everything sanitized. As a result, our immune system has more time to spend mounting a reaction to harmless proteins in our diet and other allergens like pollens.

Epidemiologic studies have found that the prevalence of allergies is highest in developed countries.

Over the last 30 years there has been a two-to-three fold increase in childhood allergies in developed countries when compared to those less developed.(4)

There have been a number of reports that have found children growing up on a farm have less allergies.(4) Playing with animals and in the dirt may actually be healthy.

How to diagnose food allergies?

A child might have a food allergy, if he/she has recurrent swelling of lips and face, hives, eczema, wheezing, stuffy nose, abdominal pain, diarrhea.

The best method for diagnosing food allergy is to be evaluated by an allergist. The allergist will review the patient’s history and the symptoms or reactions that have been noted after food ingestion. If the allergist feels the symptoms or reactions are consistent with food allergy, special tests can be performed.

Skin testing can aid in detecting the antibody(IgE) to the suspected food protein.

Blood tests can measure IgE antibodies

Sometimes it is necessary to perform a food challenge while being observed by the physician

How is a food allergy treated?

The only proven therapy is food elimination. All patients at risk for anaphylaxis must be trained to identify early symptoms and be prepared to use an auto-injectable epinephrine pen.

Can Probiotics lessen the risk of developing a food allergy?

To understand how probiotics may lessen the risk of food allergies requires a little primer on how the immune system in the intestines works.

Seventy percent of our immune system is in the intestines. Since the intestines serve as our window to our environment, it is important that the intestines monitor our exposure to harmful infections and toxins.

The lymphocytes (immune cells) in the intestines are of several types:

Th1 helps to fight infections due to bacteria and viruses

Th2 responds to infections caused by parasites

If an infant is not exposed to infectious bacteria and viruses, then Th1 will be less active, causing a shift in the balance of activity in favor of the Th2 lymphocytes, producing antibodies to parasites and also to harmless allergens.

Recently, another lymphocyte called a regulatory cell (Treg) has been identified(5). This lymphocyte can regulate the activity of both Th1 and Th2 lymphocytes.

Probiotics can modulate the immune response by acting on the Treg cells. Studies have shown that probiotics can decrease or down regulate the activity of the Th2 cells and lessen the immune reaction against proteins in foods. (6,7) The term “oral tolerance” is used to describe the process when the immune cells don’t mount a reaction.

Mice raised in a germ-free environment do not develop oral tolerance to food protein.(8) But when a mixture of oral probiotics were given to the mice, the IgE antibodies were not produced.

Since 1997, probiotics have been used in the management of food allergy. Infants with eczema due to cow’s milk had improvement when given a probiotic in their formula.(8)

In another study, either probiotics or a placebo were given to mothers during the last 4 weeks of their pregnancy. Their newborn infants were breast fed and given a probiotic supplement or a placebo for 6 months. The children who were exposed to probiotics had a 50% reduction in allergies compared to the placebo group.(9)

Not all clinical studies have shown that probiotics are able to lessen allergic diseases in children.(10) The good news is that the probiotics seem very safe. No serious adverse effects have been reported in the clinical studies.

There is no question that probiotics can influence the intestinal immune system to lessen allergic responses. Some of the future challenges include determining the most effective:

  • Probiotic strains
  • Combination of bacterial species and strains
  • Dose of bacteria in a serving size
  • Timing of introducing the probiotic to the infant/child
  • Duration of probiotic therapy

Take Home Message

If you don’t live on a farm or your child doesn’t include dirt in their diet, you might consider giving your child a probiotic. For women who are allergy prone, taking a probiotic like EndoMune may help prevent eczema in their offspring. In addition, giving EndoMune Junior to your child during infancy may help to lessen the risk of developing allergies. It is always recommended that you talk with your doctor before taking new medications and supplements.

Eat healthy, exercise and live well!

Dr. Hoberman

(1) The Prevalence, Severity, and Distribution of Childhood Food Allergy in the United States.Gupta RS, Springston EE, Warrier MR, Smith B, Kumar R, Pongracic J, Holl JL.Pediatrics. 2011 Jun 20

(2) Epidemiology of anaphylaxis in Olmsted County: A population-based study. Yocum MW, Butterfield JH,Klein JS, Volcheck GW, Schroeder DR, Silverstein MD.Yocum MW,Butterfield JH, Klein JS, Volcheck GW, Schroeder DR, Silverstein MD.

(3) The hygiene theory: fact or fiction? Sheikh A, Strachan DP.Curr Opin Otolaryngol Head Neck Surg. 2004Jun;12(3):232-6. Review.

(4) Exposure to environmental microorganisms and childhood asthma. Ege MJ, Mayer M, Normand AC, Genuneit J, Cookson WO, Braun-Fahrländer C, Heederik D, Piarroux R, von Mutius E; GABRIELA Transregio 22 Study Group. N Engl J Med. 2011 Feb 24;364(8):701-9.

(5) Hygiene theory and allergy and asthma prevention. Liu AH.Paediatr Perinat Epidemiol. 2007 Nov;21 Suppl 3

(6) Probiotics, prebiotics, and synbiotics: impact on the gut immune system and allergic reactions.Gourbeyre P, Denery S, Bodinier M. J Leukoc Biol. 2011 May;89(5):685-95.

(7) Food allergy and probiotics in childhood. del Giudice MM, Leonardi S, Maiello N, Brunese FP. J Clin Gastroenterol. 2010 Sep;44 Suppl 1:S22-5.

(8) Probiotics: a novel approach in the management of food allergy.Majamaa H, Isolauri E.J Allergy Clin Immunol. 1997 Feb;99(2):179-85

(9) Probiotics and prevention of atopic disease: 4-year follow-up of a randomised placebo-controlled trial.Kalliomäki M, Salminen S, Poussa T, Arvilommi H, Isolauri E. Lancet. 2003 May 31;361

(10) Probiotics in prevention of IgE-associated eczema: a double-blind, randomized, placebo-controlled trial.Abrahamsson TR, Jakobsson T, Böttcher MF, Fredrikson M, Jenmalm MC, Björkstén B, Oldaeus G.J Allergy Clin Immunol. 2007 May;119(5)

Are Bugs in the Gut Good for Your Skin

Over the years, I have reviewed many of the diverse health benefits of probiotics, and the list keeps getting longer.

Probiotics have been shown to lessen the risk of:

  • Irritable Bowel Syndrome symptoms
  • Infectious diarrhea
  • Antibiotic related diarrhea
  • Vaginal yeast infections
  • Recurrent female urinary tract infections
  • Cold and flu illness symptoms in children
  • Allergy related disorders like eczema
  • Colon cancer

Most of the benefits of probiotics are related to their direct effects in the intestines, but there are extra-intestinal benefits.

For example, the probiotic bacteria can stimulate the intestinal immune cells to release substances into the blood stream that will then strengthen the immune cell functions in the upper respiratory tract. The result is to lessen the flu and cold symptoms of cough, runny nose and fever.

So how does taking a probiotic orally have a benefit for our skin? It has to do with modifying the reactions of the immune cells in the skin.

Numerous recent human clinical trials involving the immune system have found that probiotic supplementation might be useful in the management of skin allergies like eczema and dry skin (1,2,3).

Protective Function of Probiotics

There are several recent studies that have demonstrated that UV exposure induces dramatic changes in the skin’s immune functions(4,5), and how probiotics may be protective.

Part of the aging process of the skin is related to our frequent exposure to UV radiation, which causes inflammation. The result is damage to skin collagen and cell DNA. We all know that repeated sun exposure increases the risk for wrinkles and skin cancer.

To determine if probiotics could modify the skin’s immune reaction to UV exposure, 54 volunteers were randomized in two groups (27 each group) taking a placebo or a probiotic for 8 weeks before UV exposure(6). Biopsies of the skin were taken to determine the effects of the probiotic versus the placebo on the immune reaction of the skin.

The results found that the probiotic could modulate the immune reaction and lessen the inflammatory damage. The authors of the study concluded that probiotics may “represent a new strategy for photoprotection.”

There are even studies looking at a topical cream containing probiotics. A recent clinical trial demonstrated that the bacterial extracts of cultured probiotics regulated skin reactivity and dryness in healthy female volunteers(7). So far these are clinical studies; there are no commercial preparations available.

The point is, though, that there is very exciting new research into how the intestinal bacteria can affect our overall health…even the skin!

I am often asked if it is worthwhile taking a probiotic daily. Several years ago I said to take them only if you have some intestinal problems, or if you are taking an antibiotic. Today, I truly believe probiotics should be considered a daily healthy supplement.

Take Home Message

If you are going on an outdoor outing, make sure you use sunscreen and take a good probiotic like EndoMune.

Eat healthy, exercise and live well!
Dr. Hoberman

(1) Probiotics and down-regulation of the allergic response. Kalliomäki MA, Isolauri E.Immunol Allergy Clin North Am. 2004 Nov;24(4):739-52

(2) The development of gut immune responses and gut microbiota: effects of probiotics in prevention and treatment of allergic disease.Rautava S, Isolauri E Curr Issues Intest Microbiol. 2002 Mar;3(1):15-22.

(3) Probiotics during the first 7 years of life: a cumulative risk reduction of eczema in a randomized, placebo-controlled trial.Kalliomäki M, Salminen S, Poussa T, Isolauri E.J Allergy Clin Immunol. 2007 Apr;119(4):1019-21. Epub 2007 Feb 7.

(4) Sunlight and skin cancer: lessons from the immune system.Ullrich SE. Mol Carcinog. 2007 Aug;46(8):629-33. Review

(5) Alterations in human epidermal Langerhans cells by ultraviolet radiation: quantitativeand morphological study.Seité S, Zucchi H, Moyal D, Tison S, Compan D, Christiaens F, Gueniche A, Fourtanier A.Br J Dermatol. 2003 Feb;148(2):291-9

(6) Probiotics for photoprotection.Guéniche A, Philippe D, Bastien P, Blum S, Buyukpamukcu E, Castiel-Higounenc I.Dermatoendocrinol. 2009 Sep;1(5):275-9

(7) Bifidobacterium longum lysate, a new ingredient for reactive skin.
Guéniche A, Bastien P, Ovigne JM, Kermici M, Courchay G, Chevalier V, Breton L, Castiel-Higounenc I.Exp Dermatol. 2010 Aug;19(8):e1-8


Probiotics Provide Insurance Against Salmonella

What do peanut butter, pistachios, cantaloupes, and eggs have in common? They have all been recent sources of Salmonella food borne illnesses in humans.

Since we are in the middle of a nationwide outbreak of a Salmonella infection due to contaminated eggs, I thought it would be of interest to discuss the benefits of probiotics against Salmonella infections.

If you are feeling paranoid about what to eat, you may feel safer taking EndoMune after reading this newsletter.

There are a number of reasons why probiotics may prevent or shorten the duration of a bout of infectious diarrhea like Salmonella.


  1. Secrete bacteriocins (proteins that can kill harmful invading bacteria)
  2. Produce products like lactic acid and hydrogen peroxide that inhibit infectious bacteria
  3. Stimulate the intestinal immune system to release antibodies and inflammatory cells to destroy the hostile bacteria
  4. Carpet the intestinal lining to prevent the harmful bacteria from attaching and invading the intestinal lining cells

With the knowledge that probiotics can have a beneficial effect against infectious bacteria, researchers have done several types of investigations.The following are studies where probiotics have been shown to be helpful:

Acute Infectious Diarrhea

A number of controlled trials(1) have compared probiotics versus placebo when treating children and adults with acute infectious diarrhea, including Salmonella. The general finding was that probiotic could reduce the duration and severity of the illness. The diarrheal illnesses were shortened, on average, 1-2 days in the individuals who were taking a probiotic.

Traveler’s Diarrhea

The cause of traveler’s diarrhea is exposure to food and water that has been contaminated with fecal matter due to poor sanitary and public health conditions. The organisms that cause the diarrhea are bacteria, viruses and parasites. Studies have found that bacteria like E. coli, Shigella, Salmonella and Campylobacter account for 80% of the episodes. There have been a number of published controlled trials giving travelers either probiotics or placebos. A review(5) of 12 well done clinical trials found that probiotics were safe and generally effective in preventing traveler’s diarrhea. Compared to the travelers receiving a placebo, the probiotic travelers had about 25-50% fewer bouts of diarrhea.

Experiemental Studies

Several recent research studies have investigated how probiotics inhibit Salmonella. One study(6)incubated either Salmonella alone or the combination of probiotics and Salmonella on cultures of human colon cells. The immune reactions in the intestinal cells that were exposed to the probiotic with the Salmonella were much greater than that seen in the cells in contact with only the Salmonella. The study showed that the probiotics could stimulate the release of protective immune reactions against the Salmonella bacteria.

In another study(7), one group of mice were fed probiotics for seven days before being challenged with Salmonella. The other group did not receive the probiotic. The survival rate was greater and the infection milder in the group receiving the probiotics. Studies of the intestinal fluid found much higher levels of antibodies against the Salmonella bacteria.  Again, this would indicate that the probiotics stimulate the intestinal immune system to fight harmful intestinal bacteria.

Take Home Message

Be careful about the eggs you consume and make sure you cook them thoroughly. Avoid the runny eggs like poached eggs or eggs that are served sunny-side up. Eggs Benedict with hollandaise sauce is probably not a good idea, at least for now. You may want to consider a bowl of oatmeal until all the bad eggs are recalled.

If you are still concerned about exposure to Salmonella, consider taking a high quality probiotic like EndoMune.

Eat healthy, exercise and live well!
Dr. Hoberman

(1) Guidance for substantiating the evidence for beneficial effects of probiotics: prevention and management of infections by probiotics.Wolvers D, Antoine JM, Myllyluoma E, Schrezenmeir J, Szajewska H, Rijkers GT.J Nutr. 2010 Mar;140(3):

(2) Probiotics have clinical, microbiologic, and immunologic efficacy in acute infectious diarrhea.Chen CC, Kong MS, Lai MW, Chao HC, Chang KW, Chen SY, Huang YC, Chiu CH, Li WC, Lin PY, Chen CJ, Li TY.Pediatr Infect Dis J. 2010 Feb;29(2):135-8.

(3) Clinical evidence for immunomodulatory effects of probiotic bacteria.
Ruemmele FM, Bier D, Marteau P, Rechkemmer G, Bourdet-Sicard R, Walker WA, Goulet O.J Pediatr Gastroenterol Nutr. 2009 Feb;48(2):126-41. Review

(4) Probiotics for treating infectious diarrhoea(Cochrane Review). Reviewers: Allen, Stephen J; Okoko, B; Martinez, Elizabeth G; Gregorio, Germana V; Dans, Leonila F. Review Group: Cochrane Infectious Diseases Group; Cochrane Database of Systematic Reviews; Edited/Substantively amended: 11 November 2008; Edited (no change to conclusions) this issue

(5)McFarland LV: Meta-analysis of probiotics for the prevention of traveler’s diarrhea. Travel Med Infect Dis. 2007;2:97-105

(6) Microbial products from probiotic bacteria inhibit Salmonella enteritidis 857-induced IL-8 synthesis in Caco-2 cells.Malago JJ, Nemeth E, Koninkx JF, Tooten PC, Fajdiga S, van Dijk JE.Folia Microbiol (Praha). 2010 Jul;55(4):401-8. Epub 2010 Aug 3

(7) Anti-infective mechanisms induced by a probiotic Lactobacillus strain against Salmonella enterica serovar Typhimurium LeBlanc Ade M, Castillo NA, Perdigon G.Int J Food Microbiol. 2010 Apr 15;138(3):223-31. Epub 2010 Feb 1.

Tips for Avoiding Foodborne Illness this Summer

School is out, summer is here, and it’s time to make plans for the 4th of July and perhaps a summer vacation.

There following are important reasons to take a good probiotic, like EndoMune during the summer:

  • To lessen the risk of food poisoning
  • To avoid traveler’s diarrhea

Foodborne illness is an ever-present threat that can be prevented with proper care and handling of food products. “It is estimated that between 24 and 81 million cases of foodborne diarrhea disease occur each year in the United States, costing between $5 billion and $17 billion in medical care and lost productivity”.(1)

In the last three years, there have been a number of outbreaks of foodborne illnesses due to Salmonella and E. coli found in contaminated peanut butter, cookie dough, chicken pot pies and beef products.

Friendly Fourth of July Food Reminders

With the 4th of July just around the corner, lots of Americans are planning a picnic or a BBQ.  In fact, the US census department says that one in four Americans will enjoy an outdoor picnic.  The big concern is to keep the cold dishes cold, and the hot foods well cooked(2). Bacteria are killed when the food is heated to 160 degrees or greater, and a temperature less than 40 degrees inhibits the growth of bacteria in refrigerated foods.

Every year we hear about outbreaks of food poisoning due to contaminated hamburger meat with bacteria like E. coli. The message is to check the temperature of the meat on the grill to insure it has reached at least 160 degrees. Cooked hamburgers with a pink inside could present a problem.

Outbreaks of food poisoning due to potato salad are common. One reported outbreak affected 125 people(3). It is important to avoid allowing any refrigerated salad to be at room temperature for any period of time before serving.

Risk of Traveler’s Diarrhea

Traveling exposes us to the risk of contaminated food and drinks. The risk of traveler’s diarrhea is related to the sanitary practices of storing, preparing and serving the food. Infectious gastroenteritis is a larger problem in less developed countries where running water and refrigeration is a problem.

International travel to exotic locations is becoming more popular. In 2008, one out of five Americans traveled abroad, and 38 million visits were to developing countries where there are significant health risks for travelers.

The rule for avoiding traveler’s diarrhea may be summarized by the CDC-coined phrase, “boil it, cook it, peel it, or forget it.”  The big concerns are salads, unpeeled fruits and vegetables.

EndoMune Can Lessen Risk of Foodborne Illness

So how does a probiotic like EndoMune help to lessen these foodborne illnesses?

There have not been any studies published on the benefits of taking a probiotic and avoiding gastroenteritis during the 4th of July!  But, there are several studies that have found probiotics lessen the risk of traveler’s diarrhea(4). It does make sense that a multispecies probiotic with at least 10 billion bacteria could lessen the risk of developing a foodborne infection. The probiotic bacteria carpet the intestines and produce proteins called bacterocins. The ingested harmful bacteria can’t penetrate the intestinal lining, and they are destroyed by the antibiotic proteins produced by the probiotic bacteria.

There is no guarantee that probiotics will prevent a bout of gastroenteritis, but there is a good chance it will lessen the risk.

Take Home Message

Don’t leave home without your EndoMune whether going to a BBQ or far away country. Have a great summer and remember…

Eat healthy, exercise and live well!
Dr. Hoberman

(1) Bacterial Food PoisoningAl B. Wagner, Jr.Extension Food Technologist Texas Agricultural Extension Service.

(2) Barbecue and food safety.” United States Department of Agriculture. Updated July 2, 2007.

(3) The Middleton outbreak: 125 cases of foodborne salmonellosis resulting from cross-contaminated food items served at a picnic and a smorgasbord.Levy BS, McIntire W, Damsky L, Lashbrook R, Hawk J, Jacobsen GS, Newton B.Am J Epidemiol. 1975 Jun;101(6):502-11

(4) McFarland LV: Meta-analysis of probiotics for the prevention of traveler’s diarrhea.Travel Med Infect Dis. 2007;2:97-105.

Risk of C. Difficile due to Acid Suppression Therapy

Two medical articles(1,2) published last month received a considerable amount of attention; I think they are very pertinent to the discussion of whether to take a probiotic to counter the risks of taking medications for the suppression of gastric acid.

Every day we are bombarded with ads about the benefits of taking medications to lessen the symptoms of heartburn and indigestion. Additionally, the medical profession recommends taking acid suppressive medicines to avoid the development of stomach ulcers as a side effect of taking pain and arthritis drugs like Advil and Aleve.

For years the mainstay of treatment was medications like Tums and Maalox – both antacids. They buffer or neutralize the acid produced by the stomach and are commonly used to relieve heartburn symptoms. Unfortunately, they have been only partially successful.

The pharmaceutical industry has developed better drugs that can lower or prevent acid production by the stomach’s acid producing cells. The most popular and effective of these medications to inhibit gastric acid production are called proton pump inhibitors or PPIs.

Proton pump inhibitors are big business in the United States: “A staggering 113.4 million prescriptions for proton pump inhibitors (PPIs) are filled each year, making this class of drugs, at $13.9 billion in sales, the third highest seller in the United States” (3).

There are 5 medications in this class of drugs which we all know thanks to the television ads: Prilosec, Prevacid, Protonix, Aciphex and the most famous – the purple capsule – Nexium.

What is the Concern with PPI Medications?

Since their introduction in 1998, there has been a progressive increase in intestinal infections with the bacterium called Clostridium difficile (C. difficile).

C. difficile causes a severe diarrhea and life threatening colitis. Roughly 3-5% of the healthy adult population has this bacterium in their intestines. These individuals do fine until they are given an antibiotic for an infection like pneumonia or sinusitis. The antibiotic wipes out the healthy intestinal bacteria which then allows the C. difficile to multiple and produce a toxin that causes a serious colitis. In addition, hospitalized patients are at risk of acquiring this bacterium from contaminated bed rails and other surfaces(4).

Risks of Acid Suppression Therapy

There has been an increasing rate and severity of C. difficile infections in hospitalized patients. Acid suppressive therapy has been suggested as a risk factor. The articles previously mentioned studied the risk of hospitalized patients taking PPI’s and developing C. difficile infections. The first study(1) found a 70% increased risk of a C. difficile infection in patients taking a PPI versus patients not receiving a PPI.

The second article(2) studied the risk of recurrent C. difficile infections in hospitalized patients taking PPIs. These patients had been successfully treated for a C. difficile infection.  There is a known recurrent rate of 20% after treatment. The concern was if PPIs could increase the risk of recurrent infections. The study found that recurrent C. difficile infection rate was 42% higher in those patients receiving PPIs vs. patients not receiving PPIs.

The exact reason why PPIs increase the risk for C. difficile infection is unknown. One potential mechanism has to do with the ability of gastric acid to destroy harmful bacteria. It is known that the stomach acid is the first defense against ingested harmful bacteria in contaminated drinks and foods. The harmful bacteria are destroyed by the stomach acid and never have an opportunity to invade the intestines.

Experimental studies in mice and hamsters have shown an increase in susceptibility to C. difficile infections when the stomach acid is suppressed(5). In addition, other studies have found that humans are more susceptible to other intestinal infections when the gastric acid is suppressed.

Based on a number of reports(6), there is reason to believe that probiotics may help to lessen the risk of C. difficile infections in patients taking PPIs. Probiotics have been shown to produce proteins that destroy harmful bacteria. In addition, they interact with the intestinal immune system to stimulate the immune reaction against harmful bacteria.

Take Home Message

Consider taking a high quality probiotic like EndoMune if you are going to be on long-term PPIs. If someone needs to be hospitalized, consider taking a probiotic to lessen the risk of acquiring a C. difficile infection, especially if PPIs and/or antibiotics are prescribed.

Thank you for your interest in EndoMune.

Eat healthy, exercise and live well!
Dr. Lawrence Hoberman

(1) Arch Intern Med. 2010 May 10;170(9):784-90.Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection.Howell MDNovack VGrgurich PSoulliard DNovack LPencina MTalmor D

(2) Arch Intern Med. 2010 May 10;170(9):772-8.Proton pump inhibitors and risk for recurrent Clostridium difficile infection.Linsky AGupta KLawler EVFonda JRHermos JA.

(3) Arch Intern Med. 2010 May 10;170(9):747-8.Failing the acid test: benefits of proton pump inhibitors may not justify the risks for many users.Katz MH.

(4) Am J Infect Control. 2010 Jan 31. [Epub ahead of print]Significant impact of terminal room cleaning with bleach on reducing nosocomial Clostridium difficile.Hacek DMOgle AMFisher A,Robicsek APeterson LR.

(5) Microbiol Immunol. 2007;51(12):1209-14.Comparative role of antibiotic and proton pump inhibitor in experimental Clostridium difficile infection in mice.Kaur SVaishnavi CPrasad KKRay P,Kochhar R.

(6) Am J Gastroenterol. 2006 Apr;101(4):812-22.Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease.McFarland LV.

Probiotics Shed Light on Obesity and Diabetes

Keeping up with the latest scientific developments on probiotics and human health is becoming very challenging because every month there are new and very exciting findings.

Recently, there have been several reports on how intestinal bacteria play a role in nutrition, obesity and diabetes.

Here are a few of the results of those studies:

  1. Patients who received probiotics after gastric bypass surgery lost more weight than those who received a placebo (1).
  2. Women who took probiotics starting in the first trimester of pregnancy were less likely at one year postpartum to have central or abdominal obesity as compared to the control group who did not take a probiotic (2).
  3. In a study of overweight adolescents who went on a weight loss diet, those who were successful at losing weight had a healthy change in the composition of the intestinal bacteria (3).

These and others studies in humans and animals have discovered that our intestinal bacteria affect the amount of calories we extract from the food we eat, and how we store or use those calories. The studies further suggest that obese and lean people have different intestinal bacterial flora.

Probiotics’ Regulation of Obesity and Type 2 Diabetes

There are ongoing scientific investigations aimed at determining how the gut bacteria participate in the regulation of our weight and the development of obesity and Type 2 diabetes.

In a series of experiments, it was found that mice fed a normal diet had 40% higher body fat content than germ-free mice fed a similar diet (4). The bacteria in the colon, particularly Bifidobacteria, can metabolize certain starches in our diet that we can’t digest otherwise. These extra calories harvested by the bacteria contribute to our net calorie balance. A mere 1-2% increase in calorie absorption on a daily basis can add up to many extra pounds over a year.

These studies are a little confusing. If a healthy gut flora includes Bifidobacteria, why don’t the lean individuals who have more of the Bifidobacteria gain weight?

Scientists are trying to sort out these conflicting results. To understand how the good bacteria can help control weight gain, it is important to briefly review a little biochemistry.

Whole grain foods contain starches that are resistant to digestion in the small intestines. These starches enter the colon where they are used as fuel by Bifidobacteria and Lactobacillus. The bacteria break the starches down and produce short chain fatty acids (SCFA) by a process called fermentation. The SCFA are absorbed in the colon and contribute to the calories in the diet. But the SCFA also have other effects.

One proposed mechanism is that the short chain fatty acids produced by the Bifidobacteria stimulate the release of intestinal hormones that slow the stomach emptying after a meal (5). This results in a sense of fullness or satiety with less calorie intake; it takes less to fill you up. It may be that people with the healthy bacteria who consume whole grain foods don’t eat as much.

In addition, the healthy bacteria in lean individuals suppress the proliferation of a group of bacteria called “gram negative bacteria.” Gram negative bacteria can produce a substance called lipopolysaccharide (LPS) that causes the liver to convert ingested carbohydrate calories into fat instead of burning the calories as an energy source (6). The fat is then stored in our adipose or fat tissues.

Finally, LPS has been shown to lessen our cells’ sensitivity to the insulin our pancreas produces (6). This can result in Type 2 diabetes. Studies have shown that modifying the bacterial content of the intestines can lessen the production of LPS and the potential for developing diabetes.

The evidence indicates that the gut bacteria composition can be different between healthy individuals and those who are obese and have Type 2 diabetes. The challenge is how to manipulate the intestinal bacteria to lessen these metabolic disorders.

Take home message.  Eat whole grain foods, avoid high fatty diets and consider a probiotic like EndoMune. You may just avoid weight gain and the risk of developing diabetes.

Eat healthy and live well.
Lawrence J Hoberman, MD


(1) Probiotics Improve Outcomes After Roux-en-Y Gastric Bypass Surgery: A Prospective Randomized Trial: Woodard G, Encarnacion B, Downey J, et al:J Gastrointest Surg. 2009 Apr 18

(2) Probiotics May Help Ward Off Obesity, Laitinen K:  Study In Pregnant Women. European Association for the Study of Obesity; Presented 2009 May 8

(3) Interplay Between Weight Loss and Gut Microbiota Composition in Overweight AdolescentsSantacruz A, Marcos A, Wärnberg J, Martí A, Martin-Matillas M, Campoy C, Moreno LA, Veiga O, Redondo-Figuero C, Garagorri JM, Azcona C, Delgado M, García-Fuentes M, Collado MC, Sanz Y. Obesity (Silver Spring). 2009 Apr 23

(4) The gut microbiota as an environmental factor that regulates fat storage. Backhed F, Ding H, Wang
T, et al. Proc Natl Acad Sci U S A. 2004 Nov 2;101(44):15718-15723

(5)Oligofructose and long-chain inulin:influence on the gut microbial ecology of rats associated with a human faecal flora. Kleessen B, Hartmann L, Blaut M.  Br J Nutr. 2001;86(2):291-300

(6) Metabolic endotoxemia initiates obesity and insulin resistance. Cani PD, Amar J, Iglesias MA, et al
Diabetes. 2007 Jul;56(7):1761-1772. Epub 2007 Apr 24.


An Expert’s take on Traveler’s Diarrhea

Now that it is getting close to summer, folks are starting to consider vacation travel plans. This newsletter will discuss options for staying healthy when traveling outside the United States to developing countries.

I would like to review the updated recommendations in preventing and treating Traveler’s diarrhea (TD).

Overview: Among travel-related illnesses, acute diarrhea is the most common disorder. A study of Americans visiting developing countries found that 46% acquired diarrhea (1). Destination is the most significant risk factor for developing diarrhea. Areas with highest risk are developing countries in Latin America, the Middle East, Africa and South Asia.

Definition: Traveler’s diarrhea is defined as three or more unformed stools per 24 hours starting during or shortly after a period of foreign travel with at least one of the following symptoms: fever, nausea, vomiting, or abdominal cramps. Most episodes last 3-4 days without therapy, but some infections can cause severe diarrhea and dehydration requiring hospitalization and IV fluids.

Etiology: The cause of TD is exposure to food and water that has been contaminated with fecal matter due to poor sanitary and public health conditions.

The organisms that cause the diarrhea are bacteria, viruses and parasites. Studies have found that bacteria like E. Coli, Shigella and Campylobacteria account for 80% of the episodes (2). Parasites and viruses are less common causes although there have been a number of outbreaks on cruise ships due to viruses (3).

Prevention: Travelers are advised to ”boil it, cook it, peel it, or forget it.” Unfortunately, despite pre-travel advice, many travelers still develop diarrhea even when avoiding high risk foods. The general recommendations include avoid raw vegetables, fruits that you have not peeled, unpasteurized dairy products, cooked food not served steaming and tap water, including ice. Although it smells and looks great…don’t eat food from street vendors!

Drug prophylaxis: There have been a number of studies evaluating different medications taken on a daily basis in order to prevent the development of diarrhea.

Antibiotics: It is not generally recommended to prescribe antibiotics as a prophylaxis to prevent TD as it can lead to drug resistant organisms (4). In immuno-compromised individuals or those with serious health issues, use of prophylactic antibiotics may be beneficial. Taking daily antibiotics like ciprofloxin (Cipro) 500mg, or levofloxacin (Levaquin) 500mg have been used successfully to prevent bacterial diarrhea in 90% of those treated (5).

Rifaximin (Xifaxan) is a non-absorbable antibiotic that has also been shown to lessen the risk of TD in 75% of those taking a single 200mg dose daily. However, the antibiotic does not protect against invasive bacteria like Samonella.

Bismuth subsalicylate: Pepto-Bismo provides a protection rate of 60% when given as two tablets 4 times daily (6). It does cause the tongue and stool to turn black and can cause ringing in the ears. It is not recommended to use this regimen for more than 3 weeks.

Probiotics: A statistical analysis of 12 control trials found that 85% of TD cases were prevented by probiotics (6). The dosage of probiotic bacteria given and the type of organisms varied. It is difficult to generalize that all probiotics are effective. The analysis did find that probiotics containing lactobacillus and Bifidobacteria strains were effective. Also, probiotics containing a yeast, Saccharomyces boulardii, lessened the risk of TD (6).

Probiotics are a more natural approach to prophylaxis. The bacteria colonize the intestines and prevent the pathogenic bacteria from successfully producing harmful toxins and invading the mucosa.


Generally, traveler’s diarrhea is a self-limited illness without fever lasting several days. Unfortunately, it is not possible to determine after the first loose stool the length and severity of the illness. Having diarrhea while on vacation or on a business trip can be very disruptive to planned activities. There are several recommendations:

  • Start an antibiotics if the there are 3 or more loose stools in an eight hour period. The drug of choice is still Cipro 500 mg twice daily for 3 days. If there is no fever or blood in the stools, an alternative antibiotic is Rifaximin 200 mg three times daily for 3 days.
  • There are areas (e.g., Thailand) where the bacteria are resistant to Cipro type medication; in these areas, Azithromycin (Zithromax) is recommended 500mg once daily for 3 days.
  • To lessen the diarrhea and cramps, Pepto Bismo 1 oz (2 tbsp) every half hour for a total of 8 doses (16 tbsps) in eight hours. Pepto Bismo eases the cramps, nausea and diarrhea without any serious side effects.
  • Another medication used to lessen diarrhea and cramps is loperamide or Imodium. Take a loading dose (4 mg) after the first loose stool and then 2mg after every loose stool for a total of 8 doses (16 mg) in 24 hours. This will ease the symptoms of diarrhea and help prevent dehydration. A warning though: do not take Imodium if there is fever or blood in the stool. Imodium slows the motility of the colon and can possibly make an invasive infection worse.
  • Rehydration packets like CeraLyte electrolyte packets can be added to water to help maintain hydration. Otherwise, replace fluids with plenty of water and replace lost electrolytes using foods like broth and saltine crackers.

Final Recommendation

  • If traveling to a developing country, access the CDC webpage for information on immunizations and other health questions.
  • Contact your physician regarding prescriptions for the antibiotics to take if you develop TD. It is important to start therapy on a timely basis. Trying to obtain medical care and medicines while traveling delays treatment and medications purchased abroad may be substandard.
  • Take a good probiotic like EndoMune on a daily basis. Start 2-3 days before you travel. In general, good probiotics should be refrigerated. Studies have shown that EndoMune will survive at room temperature for months. It is best not to store probiotics in temperatures greater than 85 degrees for prolonged periods.

Finally, I hope all your travels are joyful, safe, and healthy. Don’t forget to pack your camera…and some EndoMune.

Eat healthy, exercise and live well!!
Dr. Hoberman

(1) Hill DR: Occurrence and self-treatment of diarrhea in a large cohort of Americans traveling to developing countries. Am J Trop Med Hyg 2000;62:585-9.

(2) Steffen R, Sack RB:Epidemiology. In: Ericsson CD, DuPont HL, Steffen R, eds. Travelers’ diarrhea; Hamilton, Ont.: BC Decker, 2003: 112-23

(3) Chapin AR, Carpenter CM, Dudley WC, et al: Prevalence of norovirus among visitors from the United States to Mexico and Guatemala who experienced traveler’s diarrhea. J Clin Microbiol 2005;43:1112-1117.

(4) Centers for Disease Control:

(5) Rendi-Wagner P, Kollaritsch H. Drug prohylaxis for traveler’s diarrhea. Clin Inft. Dis 2002;34:628-33.

(6) Steffen R, Heusser R, DuPont HL: Prevention of travelers’ diarrhea by nonantibiotic drugs. Rev Infect Dis; 1986;8(suppl 2);S151-9.

(7) McFarland LV: Meta-analysis of probiotics for the prevention of traveler’s diarrhea. Travel Med Infect Dis. 2007;2:97-105.

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