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Recommendations Summary

CD: Prebiotics or Probiotics 2021

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    CD: Prebiotics or Probiotics Supplementation

    In all individuals with celiac disease following a gluten-free diet, there is insufficient evidence at this time to suggest prebiotics or probiotics supplementation. 

    Rating: Level 2(D)
    Conditional

    • Risks/Harms of Implementing This Recommendation

      Based on limited evidence, very few negative effects in other gastrointestinal conditions after consuming prebiotic or probiotic supplements.

    • Conditions of Application

      For clients with celiac disease interested in using prebiotics or probiotics, please provide guidance as appropriate.  

      Implementation Considerations

      • Use resources in the Nutrition Care Manual to help develop good quality knowledge of foods rich in probiotics (yogurt, kefir) and prebiotics (fructooligosaccharides (FOS) or galactooligosaccharides (GOS)). 
      • The registered dietitian nutritionist should be equipped with a working knowledge of the current definitions of prebiotics and probiotics and identify appropriate food sources that meet these definitions.  https://isappscience.org/for-clinicians/
      • http://www.usprobioticguide.com/

       

    • Potential Costs Associated with Application

      Costs of prebiotics or probiotics can be expensive, and they may not be covered by insurance.

    • Recommendation Narrative

      A total of seven studies and eleven articles were examined that explored the effects of prebiotics/probiotics, compared to a control, on nutrition-related outcomes in patients with celiac disease. Three neutral-quality randomized controlled trials (Drabinska et al, 2018; Quagliariello et al, 2016; Smecuol et al, 2013), three positive-quality randomized controlled trials (Francavilla et al, 2018; Harnett et al, 2016; Olivares et al, 2014) and one negative-quality cross-sectional study (Smecuol et al, 2013) were included. Two included studies were conducted in Italy, two in Argentina, one in Poland, one in Australia, and one in Spain. Four studies included adults with celiac disease and three studies included children with celiac disease as their target population. Sample sizes of participants analyzed ranged from 5 to 55 per group (some studies included additional participant groups not considered for this review). All intervention groups investigated the effect of prebiotics/probiotics compared to a control group, on nutrition-related outcomes among patients with celiac disease. 

      Of the studies that examined the effects of prebiotics/probiotics, compared to a control group, on nutrition-related outcomes in patients with celiac disease, one study and three papers reported on nutrition-related laboratory measures (Drabinska et al, 2018b; Drabinska et al, 2018c; Ferus et al, 2018). Two studies (Drabinska et al, 2019; Olivares et al, 2014) reported on anthropometrics. One study (Francavilla et al, 2018) reported on indicators of quality of life. Seven studies (Drabinska et al, 2018a; Francavilla et al, 2018; Harnett et al, 2016; Olivares et al, 2014; Pinto-Sanchez et al, 2017, Quagliariello et al, 2016; Smecuol et al, 2013) reported on indicators of gastrointestinal health and gastrointestinal symptoms. One study (Drabinska et al, 2019) reported on indicators of bone metabolism. Three studies and four papers (Drabinska et al, 2019; Ferus et al, 2018; Olivares et al, 2014; Smecuol et al, 2013) reported on celiac disease-related antibodies, inflammatory and immunological indicators. 

      Results Overview
      The effects of prebiotics/probiotics, compared to a control group, on nutrition-related laboratory measures among patients with celiac disease are inconclusive. One study reported in three articles (Drabinska et al, 2018b; 2018c; Ferus et al, 2018) concluded that there were significant increases in median plasma vitamin E and D concentrations, as well as urinary excretion of several amino acids, including Alanine, Asparagine, Glutamine, Phenylalanine and alpha-Aminopimelic acid in the group receiving probiotics, but not in the group receiving placebo. The study concluded there were no differences in biochemical blood parameters, such as hemoglobin and hematocrit, or in serum calcium, magnesium, phosphate, total protein or albumin between groups who received probiotic supplementation compared to placebo.

      The effect of prebiotics/probiotics on anthropometrics among patients with celiac disease compared to a control group is inconclusive. While Olivares et al, 2014 concluded that there was a significant difference in height percentile increases between celiac patients who had received probiotics and those who received a placebo, Drabinska et al, 2019 found that there was no difference in height between the group who received a placebo and those who received a probiotic. Both studies investigating height were three months in length, an important consideration for this outcome. Additionally, neither Olivares et al, 2014 nor Drabinska et al, 2019 found significant differences in weight between the group who received a probiotic and the placebo group. 

      There was no impact on prebiotics/probiotics on quality of life among patients with celiac disease compared to a control group. Francavilla et al, 2018 concluded that there was no difference in Irritable Bowel Syndrome Quality of Life scores between patients receiving probiotics and those receiving a placebo. 

      The effect of prebiotics/probiotics on indicators of gastrointestinal health and gastrointestinal symptoms among patients with celiac disease compared to a control is unclear. A variety of indicators were assessed across studies, including fecal microbiota (Drabinska et al, 2018a; Francavilla et al, 2018; Harnett et al, 2016; Quagliariello et al, 2016), intestinal microbiota (Francavilla et al, 2018; Olivares et al, 2014), Gastrointestinal Symptom Rating Scale (GSRS) score (Francavilla et al, 2018; Smecuol et al, 2013), self-reported gastrointestinal symptoms (Olivares et al, 2014), fecal SCFA concentration (Drabinska et al, 2018a), Irritable Bowel Syndrome Severity Scoring System (IBS-SSS) and the Bristol Stool Form Scale (Francavilla et al, 2018). The type of bacteria explored and the findings differed vastly across studies. Drabinska et al, 2018a and Francavilla et al, 2018 noted significant changes in Bifidobacterium counts in fecal samples in the probiotic group compared to the placebo group and Drabinska et al, 2018a additionally noted changes in Lactobacillus between the probiotic and placebo group, with the probiotic group having a lower presence of the bacteria. Harnett et al, 2016 found no changes in Bifidobacteria counts in fecal samples between groups but found differences in Mycoplasma sp. between the group receiving the probiotic and the group receiving the placebo. Olivares et al, 2014 found that B. fragilis bacteria increased significantly in the placebo group compared to the probiotic group in intestinal samples but found no differences in concentrations of other bacteria between groups. Quagliariello et al, 2016 concluded that Firmicutes bacteria in fecal samples were significantly lower in patients in the placebo group compared to the probiotic group. Smecuol et al, 2013 concluded that there were no differences in GSRS between the probiotic and placebo groups after the intervention, while Francavilla et al, 2018 noted significant decreases in GSRS in the probiotic group compared to the placebo group. Pinto-Sanchez et al, 2017 found significant differences in HD-5 and Paneth cell count between the probiotic and placebo groups. Olivares et al, 2014 found significant differences in fecal sIgA concentrations between groups but did not find any differences in self-reported gastrointestinal symptoms. Francavilla et al, 2018 concluded that both BSFS and IBS-SSS scores among those in the probiotics group significantly decreased compared to the placebo group. Drabinska et al, 2018a also noted that total SCFA in the probiotic group was significantly higher than in the placebo group.

      The effect of prebiotics/probiotics on indicators of bone metabolism among patients with celiac disease is inconclusive. While Drabinska et al, 2019 found a significant increase in pyridinoline in the placebo group compared to the probiotic group 3 months after the intervention,  there were no other significant changes in markers of bone metabolism between groups.

      The effect of prebiotics/probiotics on celiac disease-related antibodies, inflammatory and immunological indicators among patients with celiac disease is unclear. Ferus et al, 2018 found no differences in RBC or C-reactive protein levels between the probiotic and placebo groups after the intervention. Smecuol et al, 2013 also found no differences in serum antibody (IgA tTG, IgA DGP) or cytokine (IL-6) concentrations between groups after the intervention. Olivares et al, 2014 and Drabinska et al, 2019 found no differences between the placebo and probiotic group with regards to serum cytokines (such as TNF-α and IL-10) or CD45+ T lymphocytes, including  CD4+ and antigens on lymphocytes, including HLA-DR+, with the exception of Olivares et al, 2014 and CD3+ T-cells, which was found to have reduced significantly amongst the probiotic group compared to the placebo group.

    • Recommendation Strength Rationale

      The evidence supporting the recommendation is based on Grade III /Grade D evidence. 

    • Minority Opinions

      Consensus reached.