FEATURES & INVESTIGATIONS

GUT HEALTH

B
illed in Gut,

Gut health:
the 2015
bestseller, as
‘the body’s
most underrated organ’,

behind the hype the gut is now firmly

in the spotlight.
Emerging evidence
increasingly points
Kefir, kimchi, kombucha – can this new wave of ‘gut-friendly’
to the vital role our
probiotic products really transform your health, or are you just digestive systems
flushing money down the drain? Anna Studman investigates play in maintaining
overall health.
Businesses large
and small have
cottoned on to the
marketing potential.
Whether you’re at
the supermarket or
specialist health food
stores, you may have
seen shelves filling
up with brands flogging
a swathe of ‘gut-
friendly’ products,
many with dubious
or unproven health
benefits, aided by
glowing media
coverage and
opportunistic health
PHOTOGRAPHY: EUGENIO FRANCHI

gurus favouring
pseudoscience
over reality.
Gut health is big
business. The global
market for ‘gut-friendly’
probiotics was
estimated at £35bn in
2017, and is projected
to grow to £50bn by
2022. Some probiotics

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cost more than £1 per pill, no
small sum for a daily dose. But the
simple truth is that while probiotics
can be beneficial for some, most
people don’t need to buy these
expensive supplements.
We’ve consulted leading gut
health experts, and their advice was
unanimous: the best way to boost
your gut health is through a varied
and healthy diet, getting enough
sleep and managing stress.
What is gut health and
why does it matter?
The gut microbiome is a vast ecosystem
of complex organisms that live in our
digestive tract. It’s responsible for
helping us get the most out of our food,
ensuring that it’s properly digested and
nutrients are absorbed. It’s also home
to 70% of our immune system, as well
as trillions of microbes that have an
effect on our health more generally,
including mental health, heart health,
kidney health and more besides.
Probiotic ‘good bacteria’ occur
naturally in your gut and play a
crucial role in this microscopic world.
However, they can be disrupted by
a range of factors, including poor diet,
stress or taking a course of antibiotics.
Probiotic foods and supplements
contain similar bacteria that are
meant to be beneficial to your gut
microbiome, while prebiotics supply
essential nutrients that stimulate
the growth of the ‘good bacteria’
that already exist in your gut.
Digestive differences
When it comes to how exactly to
support our microbiome, things
can get complicated. According to
Our experts
DR MEGAN ROSSI
The Gut Health Doctor,
registered dietitian, research
fellow at King’s College London,
founder of The Gut Health Clinic
DR SAMANTHA GILL
BDA spokesperson, registered
dietitian, research associate
at King’s College London
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Dr Simon Gaisford, professor of
pharmaceutics at UCL, the difficulty
begins with the fact that ‘nobody
knows what a “normal” microbiome
should look like and the diversity
of gut bacteria will always vary from
person to person’.
This makes it hard to establish the
cause and effect between changes
in gut bacteria and health outcomes,
which way around this relationship
works and how it changes between
different gut environments.
The difficulty of establishing
clear, evidence-based advice means
that it’s a field of health advice that
is susceptible to getting lost in
vaguery and nebulous ideas of
holistic wellbeing.
Tailor your treatments
When we asked experts for the
single best thing you can do for your
general gut health, the answer
was pretty simple: aim to include
a variety of fruits, vegetables and
legumes (beans and pulses such
as lentils) in your diet.
If you have ongoing, difficult-
to-treat gut complaints, such as
constipation, diarrhoea or bloating,
you should keep track of your
symptoms in a diary and then see your
GP, who may refer you to a dietitian.
The golden rule – in the absence
of any one-size-fits-all solution – is
to tailor treatment to your specific
symptoms. For example, certain
strains of probiotics have some
evidence of reducing IBS symptoms,
but others don’t. Some treatments
might actively make things worse
– for example, large doses of prebiotics
could trigger IBS symptoms.
CHLOE HALL
British Dietetic Association
(BDA) spokesperson,
community dietitian
PRIYA TEW
BDA media spokesperson,
freelance dietitian and
founder of Dietitian UK
DR SIMON GAISFORD
Professor of pharmaceutics
at University College
London (UCL)
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Prebiotic and probiotic supplements

Do they work?
There’s no overall consensus about
the effectiveness of taking probiotic
supplements. Dr Gaisford says: ‘In
practice, it’s often difficult to define
exactly what the health benefit is.
Specific interactions between a
probiotic and the microbiome may
vary between bacterial species.’
‘In general, though,’ he says,
‘probiotic species, such as
lactobacilli and bifidobacteria, are
thought to produce compounds
called short-chain fatty acids. These
should stimulate growth of the good
bacteria already in the gut and
provide energy to the gut wall.’
The word ‘probiotic’ is not allowed
to appear on products sold within
the EU as no health claims have
been accepted as proven when the
evidence has been assessed by the
European Food Safety Authority
(EFSA). Instead, products are often
marketed in a way that makes them
sound good for you, but without
making reference to a specific health
claim. For instance, the packaging
may say ‘contains healthy bacteria’
or ‘supports your natural flora’.
What are they good for?
While more research is needed for
the EFSA to approve any health
claims linked to probiotics, there
is some evidence that probiotics
can help with IBS symptoms and
antibiotic-associated diarrhoea, but
it’s important to match the bacteria
strain to your specific symptoms.
■ Lactobacillus rhamnosus GG
has some evidence to help prevent
antibiotic-associated diarrhoea.
■ Bifidobacterium lactis has
been linked in some studies to
constipation relief.
■ There is some evidence for
probiotics helping IBS, but it may not
work for everyone. Some products
that have published studies in relation
to IBS include Alflorex, BioKult
Advanced, Symprove and VSL3.
Taking probiotics
Dr Gaisford suggests taking them
on an empty stomach and as a liquid
formulation instead of solid, where
possible, as the bacteria in liquid
probiotics don’t have to rehydrate
in the gut, so may be more effective.

Making sense of probiotic label jargon

■ Strain of bacteria: This is the first thing you should check.
Before you take it, see whether it has been tested in a human
clinical trial. You can look up bacterial strains and the
corresponding evidence on usprobioticguide.com.
■ Number of bacteria: The range in billions of bacteria between
different probiotic supplements can seem baffling – from
100 million to more than a trillion. However, more is not
necessarily better. It comes back to choosing the dose
that has shown demonstrable results in humans.

Fermented food and drink

Fermented drinks, such as
kombucha (a slightly sour, fizzy
flavoured drink made from
sweetened tea and bacterial
cultures) and foods such as miso,
kimchi and sauerkraut, are enjoying
a wave of popularity in the Western
world thanks to their association
with ‘positive digestive health’.
Do they work?
Consuming fermented products
for their health benefits is rooted
in ancient eating practices, but
which makes it difficult to standardise
and replicate results in studies.
Fermented products can contain
a wide variety of bacteria and
minerals that contribute to gut
diversity. However, Priya Tew,
a registered dietitian, warns that
‘it’s hard to know what bacteria is
in these foods and what bacteria
your body needs, so it’s worth
experimenting by including a range
of these foods in your diet’.
What to watch out for
PHOTOGRAPHY: EUGENIO FRANCHI

Dr Rossi notes that ‘the scientific Dr Samantha Gill, a registered

evidence for fermented foods is
rather limited’. This isn’t necessarily
because they aren’t beneficial, but
because the studies haven’t been
done. The microbes in fermented
food are different in every batch,
dietitian, cautions that fermented
foods such as kimchi and miso
can be high in salt, and not all
fermented food contains live
bacteria. Check the label for
‘contains live cultures’.

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Probiotic yoghurt drinks

Do they work?
Probiotic yoghurt drinks such
as Actimel and Yakult, along
with live yoghurt, have been
supermarket staples for many
years and, as such, have a little
more research behind them than
a lot of fermented food options.
Activia has been shown
to help relieve constipation,
*250ml of plain milk has 12g of naturally occurring sugar (lactose).
What about kefir?
Kefir – a traditional Eastern
fermented milk product available
as both a drink and yoghurt – is
also growing in popularity, with
brands such as Biotiful and Yeo
Kefir popping up in the dairy
aisle at major supermarkets.
As with other fermented
foods, there isn’t currently robust

and there are some studies evidence of clinical benefits

linking Actimel with the
prevention of antibiotic-
associated diarrhoea. However,
in both cases the evidence
has not been deemed strong
enough to be authorised by
the EU register on nutrition
and health claims.
Be aware, as Tew points
out, that ‘some products only
have one strain of bacteria
in them, so will have limited
clinical effectiveness beyond
milder symptoms’. Most will have
more, but check the label.
and there’s no way of knowing
exactly what’s in it or in what
concentrations. Kefir products
usually contain a broader range
of probiotic bacteria than
yoghurt-based drinks, though.
What to watch out for
Look out for the sugar content: a
250ml bottle of flavoured Biotiful
Kefir contains 14g of sugar*, which
is nearly half the recommended
daily sugar intake. Actimel has
11g and Yakult contains almost
9g of sugar in one little bottle.

EXPERT VIEW both ways. Emerging research

STRESS
& YOUR GUT
Dr Megan Rossi, founder
of The Gut Health Clinic
Stress has
been shown
to significantly
impact the
health of your
gut. This is due to the two-way
relationship between the gut
and the brain, known as the
‘gut/brain axis’.
Scientific research in
this area is still in the early
stages, but the gut and
brain appear to communicate
via three pathways: the
nervous system, the immune
system and the blood. When
we feel stressed or tired, this
can trigger gut symptoms
– that’s why you find your
stomach tied up in knots
when you’re feeling nervous
or anxious. But this works
suggests that when we don’t
nurture our gut health, this
may have an impact on mental
health, too.
Healthy gut,
healthy mind
There is growing evidence
for the benefits of mindfulness
in destressing a stressed gut.
In fact, short daily sessions
of mindfulness have shown
impressive benefits on gut
symptoms after just eight
weeks. Sleep is also an
important lifestyle factor for
reducing stress. Lack of sleep
has been shown to negatively
impact gut health.
Dietary diversity, based
on a Mediterranean diet
high in fibre and full of
wholegrains, nuts, seeds,
legumes, veg, fruit and
extra virgin olive oil has also
been shown to considerably
improve people’s mental
health after 12 weeks.
Gut health: the five biggest
misconceptions
What happens when a complex
and evolving field of science
collides with a surge of health
hype and media coverage?
A lot of nuance gets lost,
misinformation abounds and
fad cures crop up everywhere,
from the pharmacy to your
local supermarket.
We asked leading experts
for some of the most influential
and persistent myths about
gut health. Here are five of
the biggest ones:
MYTH: Excluding
1 certain types of food,
such as dairy and gluten,
is the answer.
Exclusionary diets have gained
steam over the past few years,
but are unlikely to be suitable for
most people, unless you have
a diagnosed medical condition
such as lactose intolerance or
coeliac disease. Dr Rossi points
out that ‘cutting out any food
group unnecessarily can impact
your gut microbes and decrease
gut microbe diversity’. It can also
lead to nutritional deficiencies.
MYTH: Looking after
2 your gut is as simple
as taking probiotics.
Different probiotic strains have
differing levels of effectiveness
depending on your symptoms.
The jury is out on whether there
is any benefit to taking probiotics
if you’re generally in good health.
MYTH: Gut health
3 remedies work in the
same way for everyone.
Everyone’s gut is different, so
something that your neighbour
claims to be a miracle cure
might well be a waste of
money for you.

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Misleading marketing
Under EU regulations, food and drink
products aren’t allowed to claim to treat or
cure a health issue. But many get around this
by using vague marketing buzzwords which
don’t have any objective scientific meaning.
There are more than 250 non-authorised
claims for probiotic products on the EU
Register for nutrition and health claims, such
as ‘bio-live’, ‘supporting the immune system’
and ‘promoting gut health’. Some product
claims relate to other ingredients with proven
benefits, such as calcium and vitamin B6, but
we think some brands are breaking the rules.
OptiBac uses the word probiotic on its labels,
which is a non-authorised claim. Biotiful Kefir
refers to ‘gut-friendly cultures’, Kombucha Kat
to ‘beneficial’ bacteria and Lo Bros Kombucha
to ‘gut-loving cultures’, which we think would
fall into the same category.
Biotiful, Kombucha Kat and Lo Bros insist
they are compliant with EU regulations
– arguing that they don’t make specific health
claims, but refer to the bacteria that goes into
the products. OptiBac told us that OptiBac
Probiotics is a brand name which under EU
regulations can continue to be marketed until
2022, by which time they are committed to
removing this wording.

Good gut food: what to eat

Rather than rely on supplements, you should aim to include a range of prebiotic,
probiotic and fibrous foods in your diet. Variety is key, but make sure you introduce
food that you are unfamiliar with gradually to avoid any side effects.

PREBIOTIC FOODS FIBRE PROBIOTIC FOODS

MYTH: You need to
4 buy special probiotic
products to support your gut.
There might be a glut of new
products and supplements vying
for your attention, but including
more plant-based food into your
diet is a much simpler solution.
Cooking with frozen fruit and
veg, and tinned legumes, is
a good cheap way to feed your
gut without blowing your budget
in the health food aisle.
These will help the This aids digestion and These include strains
good bacteria in your healthy bowel movements. of good bacteria.
gut to thrive. Good natural sources: Good natural sources:
Good natural sources: Fruit and veg, especially berries, Live yoghurt,
Bananas, apples, onions, pears, oranges, peas, beans, fermented food and
garlic, leeks, chicory, broccoli, carrots, sweetcorn drinks (eg kefir).
asparagus, oats and and potatoes. Plus wholegrain
barley, flax seeds, cocoa. bread, oats and barley.
Don’t forget the fibre There is strong evidence that eating lots
It’s not as trendy as some of the new gut of fibre lowers the risk of heart disease, stroke,
health products, but most of us could type 2 diabetes, bowel cancer and more. It also
probably do with adding more fibre to our helps you feel fuller for longer, and can aid
diet. It’s thought that we need to consume digestion and preventing constipation. Many
around 30g of fibre per day, but the average fibrous foods are also prebiotic, making these
Brit consumes an estimated 18g a day. choices a win-win for digestive health.

MYTH: changing your

5 diet or taking probiotics
will yield immediate results.
Introducing a sudden change
to your gut – even if it’s
something healthy such as
eating more fibre – can initially
disrupt your microbiome and
produce side effects such as
gas and bloating. Introduce
any changes gradually.
THE BOTTOM LINE FIND OUT MORE
We’re becoming increasingly aware of the importance Other useful contacts
of the gut to our overall health, but knowing which gut health ● Information on probiotics
interventions to choose and which to avoid is a minefield. and prebiotics:
The basic rules are to eat a varied diet full of plant-based foods isappscience.org
● The NHS guide to food for
and to allow for gradual change – embracing trial and error. If digestion: nhs.uk/live-well/
considering probiotic supplements, do your research and tailor eat-well/good-foods-to-
them to your specific symptoms. If in doubt, consult your GP. help-your-digestion

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