MINIREVIEW

Probiotics, their health benefits and applications for developing

healthier foods: a review
Ravinder Nagpal1, Ashwani Kumar2, Manoj Kumar3, Pradip V. Behare4, Shalini Jain5 &
Hariom Yadav5
1

Department of Microbiology & Biotechnology, Shaheed Udham Singh College of Research & Technology, Mohali, Punjab, India; 2Department of
Biotechnology, Seth Jai Parkash Mukand Lal Institute of Engineering & Technology, Radaur, Haryana, India; 3Department of Microbiology &
Immunology, National Institute of Nutrition, Hyderabad, India; 4Dairy Microbiology Division, National Dairy Research Institute, Karnal, Haryana,
India; and 5National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA

Correspondence: Ashwani Kumar,

Department of Biotechnology, JMIT, Radaur
135133, Haryana, India. Tel.:
+91 9813968380; fax: +91 1732 283800;
e-mail: [email protected]
Received 5 October 2011; revised 2 May
2012; accepted 4 May 2012.
Final version published online 28 May 2012.
DOI: 10.1111/j.1574-6968.2012.02593.x

MICROBIOLOGY LETTERS

Editor: Hermann Heipieper

Keywords
dairy foods; functional foods; gut microbial
communities; lactic acid bacteria;
lactobacillus; probiotics.

Abstract
In the industrialized world, functional foods have become a part of an everyday
diet and are demonstrated to offer potential health benefits beyond the widely
accepted nutritional effects. Currently, the most important and frequently used
functional food compounds are probiotics and prebiotics, or they are collectively known as synbiotics. Moreover, with an already healthy image, dairy
products appear to be an excellent mean for inventing nutritious foods. Such
probiotic dairy foods beneficially affect the host by improving survival and
implantation of live microbial dietary supplements in the gastrointestinal flora,
by selectively stimulating the growth or activating the catabolism of one or a
limited number of health-promoting bacteria in the intestinal tract, and by
improving the gastrointestinal tracts microbial balance. Hence, the paper
reviews the current scenario of probiotics and their prospective potential applications for functional foods for better health and nutrition of the society.

Introduction
Probiotics are defined as live microorganisms which when
administered in adequate amount confer health benefits to
the host (FAO/WHO, 2002). Alternatively, probiotics have
been defined as live microbial feed supplements that beneficially affect the host animal by improving its intestinal
microbial balance (Fuller, 1989). Probiotics were originally
used to improve the health of both animals and humans
through the modulation of the intestinal microbiota. At
present, several well-characterized strains of Lactobacilli
and Bifidobacteria are available for human use to reduce
the risk of gastrointestinal (GI) infections or treat such
infections (Salminen et al., 2005). Some of the beneficial
effects of probiotic consumption include improvement of
intestinal health by the regulation of microbiota, and stimulation and development of the immune system, synthesizing and enhancing the bioavailability of nutrients, reducing
symptoms of lactose intolerance, and reducing the risk of
certain other diseases (Fig. 1; Kumar et al., 2009a, b, 2010,
FEMS Microbiol Lett 334 (2012) 115

2011a, b; Nagpal et al., 2007, 2010, 2011; Yadav et al.,

2007a, b, 2008). The primary clinical interest in the application of probiotics has been in the prevention of and
treatment for GI infections and diseases (Parvez et al.,
Lactose metabolism
& food digestion

Antibioticassociated
diarrhea

Coronary heart
disease

Oral health

Constipation
& ulcers

Probiotics

Diabetes

Antioxidative
activity

Immune response &

Parasitic infections

B vitamins

Cholesterol
normalization

Urinary tract & upper

respiratory tract
infection

Reduction in
blood pressure

Fig. 1. Projected prospective health attributes of probiotics.

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2006). Gut microbiota deviations have been associated with

enhanced risk of specific diseases; therefore, modulation of
an unbalanced indigenous microbiota forms the rationale
of probiotic therapy (Turnbaugh et al., 2006). Also, the
development of adjuvant or alternative therapies based on
bacterial replacement is becoming important owing to the
rapid emergence of antibiotic-resistant pathogenic strains
and the adverse consequences of antibiotic therapies on the
protective flora, which enhances the risk of infection
(Forestier et al., 2001). However, the use of probiotics
should be further investigated for their benefits and possible side effects, if any. As the knowledge about intestinal
microbiota, nutrition, immunity, and genetics in health
and disease has increased in the past years, such information could certainly help to develop new probiotic strains
with disease-specific functions and could also facilitate the
understanding of when to use probiotics and how they
affect specific pathological states. However, it is important
that the probiotic strains for human use should undergo
animal studies followed by human clinical trials in order to
authenticate the suitability, safety, and benefits of probiotics for human consumption and development of functional
foods.

Properties essential for effective and

successful probiotics
It is of utmost importance that the probiotic strain survives the site where it is presumed to be active. For maximum activity, the strain should be able to proliferate and
colonize at this specific location. Besides, it should also
be tolerated by the immune system. It should not be
pathogenic, allergic, or mutagenic/carcinogenic (Toma &
Pokrotnieks, 2006; Ohashi & Ushida, 2009). Probiotics
for human should have generally regarded as safe status,
with a proven low risk of inducing or being associated
with the etiology of disease. The probiotic organisms
should preferably be of human origin (Collins et al.,
1998), must be able to survive and grow in the in vivo
conditions of the desired site of administration, and thus
must be able to tolerate low pH and high concentration
of both conjugated and deconjugated bile acids. For successful application in foods, the probiotic used should
also be technologically compatible with the foodmanufacturing process. In addition to that, the foods
containing the probiotic bacteria must maintain the characteristic sensory attributes of the traditional food.

Potential attributes and benefits of

probiotics
It is now an established fact that the indigenous microbial
communities is host specific, location specific, very com 2012 Federation of European Microbiological Societies
Published by Blackwell Publishing Ltd. All rights reserved

R. Nagpal et al.

plex in composition and has beneficial properties to the

host. However, it is not precisely known which species of
microorganisms play the principal part in these beneficial
properties. Some major health benefits of probiotics and
their proposed mechanisms are illustrated in Table 1.
Several probiotic bacteria have been introduced in the
market, and the range of products in which probiotic
bacteria are added is increasing (Table 2). Some of the
major health attributes of probiotics are discussed in the
following sections.
Antimicrobial properties

The intestinal microbial community is a complex ecosystem, and introducing new organisms into this highly
competitive environment is difficult. Thus, organisms that
can produce a product that inhibits the growth of existing organisms have a characteristic advantage. The ability
of probiotics to establish in the GI tract is enhanced by
their ability to eliminate competitors. Some antimicrobials with producer organisms are enlisted in Table 3. In
different studies on humans and animals, beneficial
microorganisms are used to improve the colonization
resistance on body surfaces, such as GI, the urogenital,
and the respiratory tract. Bifidobacteria produce acetic
and lactic acids in a molar ratio of 3 : 2 (Desjardins &
Roy, 1990). Lactobacillus acidophilus and Lactobacillus
casei produce lactic acid as the main end product of fermentation. In addition to lactic and acetic acids, probiotic organisms produce other acids, such as hippuric and
citric acid. Lactic acid bacteria also produce hydrogen
peroxide, diacetyl, and bacteriocin as antimicrobial substances. These inhibitory substances create antagonistic
environments for foodborne pathogens and spoilage
organisms. Yoghurt bacteria are reported to produce bacteriocin against probiotic bacteria and vice versa (Dave &
Shah, 1997).
Anticarcinogenic properties

Goldin & Gorbach (1980) reported that the introduction

of L. acidophilus into the diet lowers the incidence of
chemically induced colon tumors in rats. Later, the same
authors also suggested that diet and antibiotics can lower
the generation of carcinogens in the colon and reduce
chemically induced tumors (Goldin & Gorbach, 1984).
These effects appear to be mediated through the intestinal
microbial communities. A possible mechanism for these
anticancer effects relies on inhibiting intestinal bacterial
enzymes that convert procarcinogens to more proximal
carcinogens (Kumar et al., 2011a, b). This approach can
be expanded in the future by testing probiotics for their
ability to inhibit the growth of organisms normally found
FEMS Microbiol Lett 334 (2012) 115

Probiotics and human health

Table 1. Health benefits of probiotic bacteria to the host, and

speculated mechanisms involved
Health benefits

Proposed mechanisms involved

Resistance to enteric
pathogens

Antagonism activity
Adjuvant effect increasing
antibody production
Systemic immune effect
Colonization resistance
Limiting access of enteric
pathogens (pH, bacteriocins/defensins,
antimicrobial peptides, lactic acid
production, and toxic oxygen
metabolites)
Bacterial lactase acts on lactose in the
small intestine
Lactobacilli influence the activity of
overgrowth flora, decreasing toxic
metabolite production
Normalization of a small bowel
microbial community
Antibacterial characteristics
Strengthening of nonspecific and
antigen-specific defense against
infection and tumors
Adjuvant effect in antigen-specific
immune responses
Regulating/influencing Th1/Th2 cells,
production of anti-inflammatory
cytokines
Decreased release of toxic N-metabolites
Antimutagenic activity
Detoxification of carcinogenic
metabolites
Alteration in pro-cancerous enzymatic
activity of colonic microorganisms
Stimulation of immune function
Influence on bile salt concentration
Increased bifidobacterial cell counts
and shift from a preferable proteinto carbohydrate-metabolizing microbial
community, less toxic and for
putrefactive metabolites, improvements
of hepatic encephalopathy after the
administration of bifidobacteria and
lactulose
Prevention of antigen translocation into
blood stream
Prevent excessive immunologic responses
to increased amount of antigen
stimulation of the gut
Assimilation of cholesterol by bacterial cell
Alteration in the activity of BSH enzyme
Antioxidative effect
Bacterial peptidase action on milk
protein results in antihypertensive
tripeptides
Cell wall components act as ACE
inhibitors

Aid in
lactose digestion
Small bowel bacterial
overgrowth

Immune system
modulation

Anticolon
cancer effect

Decreased
detoxification/
excretion
of toxic
microbial
metabolites

Allergy

Blood lipids,
heart disease
Antihypertensive
effect

FEMS Microbiol Lett 334 (2012) 115

Table 1. Continued
Health benefits

Proposed mechanisms involved

Urogenital Infections

Adhesion to urinary and vaginal tract cells

Competitive exclusion
Inhibitor production (H2O2, biosurfactants)
Competitive colonization
Inhibition of growth and adhesion to
mucosal cells, decrease in gastric H. pylori
concentration
Competitive exclusion or inhibition of ureaseproducing gut flora
Production of butyric acid neutralizes the
activity of dietary carcinogens

Infection caused by
Helicobacter pylori

Hepatic
encephalopathy
Neutralization
of dietary
carcinogens
NEC
(necrotic
inflammation
of the distal
small intestine)
Rotaviral
gastroenteritis
Inflammatory bowel
diseases, type
I diabetes
Crohns disease

Caries gingivitis

Enhanced nutrient
value

Decrease in TLRs and signaling molecules

and increase in negative regulations
Reduction in the IL-8 response

Increased IgA response to the virus

Enhancement of mucosal barrier function

Reduction in proinflammatory cytokines

including TNFa, reduction in the number of
CD4 cells as well as TNFa expression among
intraepithelial lymphocytes
Reduction in gingivitis by L. reuteri, affects
on streptococcus mutants, colonization of
the teeth surface by lactobacilli
Less carries after the ingestion of living or
oral vaccination with heat-killed lactobacilli
Vitamin and cofactor production

in the flora that have high activities of enzymes such as

b-glucuronidase (Reddy, 1999), nitroreductase, azoreductase, and b-glycosidase or the capability for nitrosation.
The sixth most commonly diagnosed cancer in the
world is hepatitis B virus. Consumption of foods, contaminated with aflatoxins, is also established causes of
liver cancer. Aflatoxin B1 (AFB1) causes characteristic
genetic changes in the p53 tumor suppressor gene and ras
protooncogenes. Some probiotic bacterial strains have
been successfully shown to bind and neutralize AFB1 in
vivo and thus reduce the bioabsorption of the toxin from
the gut (Haskard et al., 2000; Kumar et al., 2011a, b).
Addition of probiotic Bifidobacterium longum to the diet
of rats has been shown to exert a strong antitumor activity on colonic mucosa by reducing the expression level of
ras-p21 expression and cell proliferation (Reddy, 1998).
Lactobacillus GG administration determined the up- and
downregulation of 334 and 92 genes, respectively, by
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Table 2. Some
industries

R. Nagpal et al.

commercial

probiotic

strains

used

by

various

Table 3. Antimicrobial substances produced by probiotic bacteria

(Fuller, 1992)

Strains

Source

Probiotic

Compound

L. acidophilus LA-1
L. paracasei CRL 431
B. lactis Bb-12
L. casei Shirota
B. breve strain Yakult
L. acidophilus SBT-2062
B. longum SBT-2928

Chr. Hansen (Horsholm,

Denmark)

Lactobacillus GG

Wide-spectrum
antibiotic
Acidolin, Acidophilin,
Lactocidin, Lactocin B
Bulgarican

L. acidophilus R0011
L. rhamnosus R0052
L. acidophilus NCFM
L. acidophilus DDS-1
L. casei DN014001
(Immunitas)
L. fermentum RC-14
L. rhamnosus GR-1
L. johnsonii La1
(same as Lj1)
L. plantarum 299V
L. Rhamnosus 271
L. reuteri SD2112
(same as MM2)
L. rhamnosus GG
L. rhamnosus LB21
Lactococcus lactis L1A
L. salivarius UCC118
B. longum BB536

L. delbrueckii subsp.
bulgaricus 2038
L. acidophilus LB
L. paracasei F19
L. crispatus CTV05
L. casei DN 114
S. boulardii
B. lactis HN019 (DR10)

L. acidophilus
Yakult (Tokyo, Japan)
Snow Brand Milk
Products Co., Ltd (Tokyo,
Japan)
Institut Rosell (Montreal,
Canada)
Rhodia, Inc. (Madison,
WI)
Nebraska Cultures, Inc.
(Lincoln, NE)
Danone Le PlessisRobinson (Paris, France)
Urex Biotech Inc.
(London, Ontario,
Canada)
Nestle (Lausanne,
Switzerland)
Probi AB (Lund,
Sweden)
BioGaia (Raleigh, NC)
Valio Dairy (Helsinki,
Finland)
Essum AB (Umea,
Sweden)
University College
(Cork, Ireland)
Morinaga Milk
Industry Co., Ltd
(Zama-City, Japan)
Meiji Milk Products
(Tokyo, Japan)
Lacteol Laboratory
(Houdan, France)
Arla Dairy
(Stockholm, Sweden)
Gynelogix, Boulder, CO
Danone, Paris, France
Biocodex Inc.
(Seattle, WA)
New Zealand
Dairy Board

affecting the expression of genes involved in immune

response and inflammation [transforming growth factorbeta (TGF-b) and tumor necrosis factor (TNF) family
members, cytokines, nitric oxide synthase 1, defensin
alpha-1], apoptosis, cell growth and cell differentiation
(cyclins and caspases, oncogenes), cellcell signaling
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L. delbrueckii ssp.
bulgaricus
L. plantarum
L. brevis
L. reuteri
L. sake L45, L.
sake Lb706
L. johnsonii
L. helveticus
L. cremoris
Lactococcus lactis
Pediococcus
pentosaceous,
P. acidilactis
S. thermophilus
Enterococcus
faecium DPC1146

Lactolin
Lactobacillin, Lactobrevin
Reuterin
Lactocin S, Sakacin A
Lactocin F
Helveticin J
Diplococin
Nisin, Lactostrepsin,
Lactocin, Lacticin
Pediocin

Streptophilin
Enterocin 1146

(intracellular adhesion molecules and integrins), cell

adhesion (cadherins), signal transcription and transduction (Caro et al., 2005).
Probiotics have also been found by several researchers
to decrease fecal concentrations of enzymes (glycosidase,
B-glucuronidase, azoreductase, and nitroreductase) and
secondary bile salts and reduce the absorption of harmful
mutagens that may contribute to colon carcinogenesis
(Rafter, 1995). Normal intestinal flora can influence carcinogenesis by producing enzymes (glycosidase, B-glucuronidase, azoreductase, and nitroreductase) that transform
precarcinogens into active carcinogens (Goldin, 1990;
Pedrosa et al., 1995). Lactobacillus acidophilus and L. casei supplementation in humans helped to decrease the
levels of these enzymes (Lidbeck et al., 1991). In mice,
these bacterial enzymes were suppressed with the administration of Lactobacillus GG (Drisko et al., 2003). Several
mechanisms have been proposed as to how lactic acid
bacteria may inhibit colon cancer, which includes enhancing the hosts immune response, altering the metabolic
activity of the intestinal microbial communities, binding
and degrading carcinogens, producing antimutagenic
compounds, and altering the physiochemical conditions
in the colon (Hirayama & Rafter, 2000; Kumar et al.,
2011a, b). Oral administration of LAB has been shown to
effectively reduce DNA damage, induced by chemical carcinogens, in gastric and colonic mucosa in rats (Li & Li,
FEMS Microbiol Lett 334 (2012) 115

Probiotics and human health

2003). By comet assay, L. acidophilus, Lactobacillus gasseri,

Lactobacillus confusus, Streptococcus thermophilus, Bifidobacterium breve, and B. longum were antigenotoxic
toward N-nitro-N-nitrosoguanidine (MNNG; Pool-Zobel
et al., 1996). These bacteria were also protective toward 1,
2-dimethylhydrazine (DMH)-induced genotoxicity. Metabolically active L. acidophilus cells, as well as an acetone
extract of the culture, prevented MNNG-induced DNA
damage, while heat-treated L. acidophilus was not antigenotoxic. Azomethane-induced colon tumor development was also suppressed with a decrease in colonic
mucosal cell proliferation and tumor ornithine decarboxylase and ras-p21 activities (Hirayama & Rafter, 2000).
There was a report on the antitumorigenic activity of the
prebiotic inulin, enriched with oligofructose, in combination with the probiotics Lactobacillus rhamnosus and Bifidobacterium lactis in the azoxymethane (AOM)-induced
colon carcinogenesis rat model (Femia et al., 2002). Other
lactic acid bacteria have also shown the ability to lower
the risk of colon cancer; however, the relationship
between enzyme activity and cancer risk needs further
investigation.
Immunologic enhancement

There have been several reports indicating that lactobacilli

used in dairy products can enhance the immune response
of the host. Organisms that have been identified as having
this property are B. longum, L. acidophilus, L. casei subsp.
rhamnosum, and Lactobacillus helveticus (Isolauri, 2001).
However, prospective probiotics should be tested in the
future for the enhancement of the immunologic response.
The measurements that should be considered are lymphocyte proliferation, interleukins 1, 2, and 6, TNF, prostaglandin E production, and serum total protein, albumin,
globulin, and gamma interferon. The intrinsic properties
of lactobacilli to modulate the immune system make
them attractive for health applications. Enhanced phagocytic activity of granulocytes, cytokine excretion in lymphocytes, and increased immunoglobulin-secreting cells
in blood are typical responses to probiotics, all of which
are indicative of changes in the immune system. An
inflammatory immune response produced cytokine-activated monocytes and macrophages, causing the release of
cytotoxic molecules capable of lysing tumor cells in vitro
(Philip & Epstein, 1986). The inflammatory cytokines
IL-1 and TNF-a exerted cytotoxic and cytostatic effects
on neoplastic cells in in vitro models (Raitano & Kore,
1993). Aatourri et al. (2002) observed increased lymphocyte proliferation in the spleen, peripheral blood, and
Peyers patches and also increased IFN-c production in
Peyers patches and spleen of rats fed yogurt containing
L. bulgaricus 100158 and S. thermophilus 001158. Because
FEMS Microbiol Lett 334 (2012) 115

immune function declines with age, enhancing immunity

in the elderly with probiotics would be of particular use
(Gill & Rutherfurd, 2001). Regardless of the mechanisms
involved, probiotics cultures have been shown to stimulate both nonspecific immunity and specific immunity.
Possible stimulation of an immune response by probiotic
bacteria may explain potential therapeutic and prophylactic applications of such cultures in the treatment for
infections and carcinogenesis.
Enhancement of short-chain fatty acid
production

Because the improved intestinal microbial communities

with probiotics primarily involve the stimulation of intestinal fermentation, the stimulation of short-chain fatty
acid (SCFA) production is one of the essential factors for
the beneficial effects exerted by probiotics. A significant
increase in indigenous lactobacilli in the large intestine as
a result of probiotic Lactobacillus has been reported
(Tsukahara & Ushida, 2001). Although increases in lactobacilli stimulate lactate production, lactate does not accumulate in the large intestine, except in those patients with
short bowel syndrome and dyspeptic diarrhea (Tsukahara
& Ushida, 2001). Rather, lactate is normally metabolized
to acetate, propionate, or butyrate by lactate-utilizing bacteria (Bourriaud et al., 2005; Belenguer et al., 2006). Lactate-utilizing bacteria from the human flora have been
previously identified as belonging to the Clostridia cluster
XIVa, based on their 16S rRNA gene sequences (Duncan
et al., 2004). The increase in fecal SCFA by probiotic Lactobacillus would be due to this mechanism (Tsukahara
et al., 2006). In fact, the oral administration of the lactate-utilizing
and
butyrate-producing
bacterium,
Megasphaera elsdenii, with Lactobacillus plantarum has
been shown to increase the butyrate production in the
large intestine (Tsukuhara et al., 2002). Thus, the administration of probiotics with other lactate-utilizing bacteria,
butyrate-producing bacteria, in particular, could be a
more effective way to achieve maximum health benefits.
Antiatherogenic and cholesterol-lowering
attributes of probiotics

Coronary heart diseases and cardiovascular diseases

(CVD), major causes of most death in adults, are conditions in which the main coronary arteries supplying the
heart are no longer able to supply sufficient blood and oxygen to the heart muscle (myocardium). Although low-fat
diets offer an effective means of reducing blood cholesterol
concentrations, these appear to be less effective, largely due
to poor compliance, attributed to low palatability and
acceptability of these diets by the consumers. Therefore,
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attempts have been made to identify other dietary components that can reduce blood cholesterol levels. Individuals
with CVD and those with a higher risk of developing the
condition are treated in a number of ways to help lower
their LDL cholesterol and triacylglycerol (TAG) concentrations while elevating their high-density lipoprotein cholesterol. The role of fermented milk products as
hypocholesterolemic agents in human nutrition is still
equivocal, as the studies performed have been of varying
quality, and statistically analysis with incomplete documentation being the major limitation of most studies.
However, since 1974 when Mann & Spoerry (1974) showed
an 18% fall in plasma cholesterol levels after feeding
45 liters of fermented milk per day for 3 weeks to Maasai
warriors, there has been a considerable interest in the effect
of probiotics on human lipid metabolism. Supplementation of diet with dairy products fermented with LAB has
the potential to reduce serum cholesterol levels in humans
and animals (Pulusoni & Rao, 1983). A significant decrease
in serum cholesterol level in rats fed milk fermented with
L. acidophilus has been reported (Grunewald, 1982). Mann
(1977) showed that large dietary intake of yogurt lowered
the cholesterolemia in humans.
Experiments by Gilliland et al. (1985) have shown that
dietary elevation of plasma cholesterol levels can be prevented by the introduction of a L. acidophilus strain that is
bile resistant and assimilates cholesterol. These findings
were supported by Pereira & Gibson (2002) who demonstrated that probiotic strains were able to assimilate cholesterol in the presence of bile into their cellular membranes.
Results, however, were influenced greatly by the bacterial
growth stage, and inoculum using resting cells did not interact with cholesterol as also shown by studies conducted by
Dambekodi & Gilliland (1998). St-Onge et al. (2000) extensively reviewed the existing studies from animal and human
studies which detected that moderate cholesterol lowering
was attributable to the consumption of fermented products
containing probiotic bacteria. Studies by Gopal et al. (1996)
also showed cholesterol removal by Bifidobacterium spp.
and L. acidophilus. The possible mechanisms of action of
probiotics are cholesterol assimilation by bacteria, deconjugation of bile salts, cholesterol binding to bacterial cell walls,
and reduction in cholesterol biosynthesis (Pulusoni & Rao,
1983; Pereira & Gibson, 2002).
Probiotics in diabetes and obesity

The role of gut flora in the pathology of insulin resistance

(type 2 diabetes) and obesity has been well documented
by Ley et al. (2005). Animal and human studies have suggested that gut flora enhances the body weight gain and
increases the insulin resistance, and these phenotypes are
transmittable with gut flora during the implantation stud 2012 Federation of European Microbiological Societies
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R. Nagpal et al.

ies of microbiota from obese to normal and germ-free

mice (Ley et al., 2006; Turnbaugh et al., 2006). The
mechanisms associated with gut floramediated pathology
of obesity and diabetes are through (1) increased energy
harvest, (2) increased blood LPS levels (endotoxemia),
and (3) low-grade inflammation (Delzenne et al., 2011).
Therefore, modulation of gut flora has been considered as
a potential target to treat against obesity and diabetes.
Probiotics are novel gut flora modulators, and their role
in the prevention of and treatment for diabetes and obesity has been implicated in recent past by Yadav et al.
(2007a, b, 2008). Yadav et al. (2007b, 2008) suggested
that probiotic-supplemented fermented milk product
called dahi (yogurt) dramatically suppressed diet-induced
insulin resistance and protected from streptozotocininduced diabetes in animal models. It was also observed
that probiotic dahi suppressed the diabetes progression
and its complication through enhancing antioxidant system (Yadav et al., 2008). Though, the actual link between
probiotic-mediated pathology of obesity and diabetes has
been debated on the basis of farm animals data (Raoult,
2008; Delzenne & Reid, 2009; Ehrlich, 2009). In relation
to these controversies, Bifidobacteria, one of the important classes of probiotic organisms, have been found to
be decreased in overweight women in comparison with
normal weight women (Santacruz et al., 2009). Recent
studies have suggested that probiotic-based selective
strains of Lactobacilli and Bifidobacteria show beneficial
effects on obesity and type-2 diabetes (Aronsson et al.,
2010). Andreasen et al. (2010) reported that L. acidophilus decreased the insulin resistance and inflammatory
markers in human subjects. More recently, Vajro et al.
(2011) and others (Kang et al., 2010; An et al., 2011;
Chen et al., 2011; Naito et al., 2011) showed that feeding
of specific strains of Lactobacilli and Bifidobacteria ameliorate the progression of obesity and diabetes, suggesting
that probiotic-mediated modulation of gut flora can be a
potential therapy against obesity and diabetes. Although
animal studies have shown promising results in probioticmediated suppression of obesity and diabetes, very few
studies in humans showed the significant effects. Hence,
it is required to conduct well-designed studies for examining the efficacy of probiotic-based formulation in the
treatment for obesity and diabetes. Also, the mechanism
(s) of action for probiotic-based formulation is not completely understood; therefore, future studies should also
be focused on describing the probiotic actiontargeted
molecules and organs in physiologic models.
Other potential benefits

Certain functional foods containing probiotic provide

preformed lactase to gut and allow better digestion of
FEMS Microbiol Lett 334 (2012) 115

Probiotics and human health

lactose. The regulatory role of probiotics in allergic disease was demonstrated by a suppressive effect on lymphocytes proliferation and interleukin-4 generation in vitro
(Sutas et al., 1996). Subsequently, the immune inflammatory responses to dietary antigens in allergic individuals
were shown to be alleviated by probiotics, this being
partly attributable to enhance the production of antiinflammatory cytokines (Pessi et al., 2000) and transferring growth factor-b (Haller et al., 2000). Probiotic bacteria also possess prophylactic and therapeutic properties.
Other potential benefits include protection against vaginal
or urinary tract infections, reduction in ulcers and intestinal tract infections, increased nutritional value, maintenance of mucosal integrity, reduction in catabolic
products eliminated by kidney and liver, stimulation of
repair mechanism of cells, breaking down and rebuilding
hormones, relieving anxiety and depression, formation,
maintenance, or reconstruction of a well-balanced indigenous intestinal and/or respiratory microbial communities,
inhibiting decalcification of the bones in elderly people,
and synthesis of vitamins and predigestion of proteins.

Molecular characterization of probiotics

marker genes and surface layer protein
(SlpA)
In view of high stakes involved in the exploration of their
commercial value, particularly in the booming functional/
health food market, the correct identification of probiotic
cultures has become extremely important to rule out the
possibility of false claims and to resolve disputes concerning their identity in probiotic preparations (Mohania
et al., 2008). The phylogenetic information encoded by
16S rRNA gene has enabled the development of molecular biology techniques, which allow the characterization
of the whole human gut microbiota (Lawson, 1999).
These techniques have been used in monitoring the specific strains as they have high discriminating power.
Numerous molecular techniques have been exploited for
the identification of various putative probiotic marker
genes such as bile salt hydrolase (BSH), mucus-binding
protein (mub), fibronectin-binding protein (fbp) for the
screening of probiotic strains.
Bile salt hydrolase (BSH) gene

BSH, an intracellular enzyme found commonly in certain

intestinal bacteria, plays a vital role. BSH catalyzes the
hydrolysis of glycine- or taurine-conjugated bile acids
into the amino acid residue and deconjugated bile acid.
The ability of probiotic strains to hydrolyze bile salts has
often been included among the criteria for the selection
of probiotic strain, and a number of BSHs have been
FEMS Microbiol Lett 334 (2012) 115

identified and characterized. It has been investigated that

Lactobacillus isolates of human origin along with Bifidobacterium also possess bsh homologs in their genome.
Sequence analysis of these bsh homologs establishes intraspecies heterogeneity and interspecies homogeneity, which
might be due to the horizontal transfer of bsh gene from
one species to other. With the completion of some probiotic genome projects, analyses of sequenced probiotic
(Lactobacilli and Bifidobacteria) strains reveal that many
possess more than one bsh homolog and each BSH may
respond to different types of bile or perhaps different
length of exposure to bile. Therefore, BSH activity by a
probiotic bacterium may be a desirable property because
it could maximize its prospects of survival in hostile environment of GI tract and hence can be used as one of the
potential markers for the screening of probiotic strains.
Because large amounts of deconjugated bile salts may
have undesirable effects for the human host, concerns
may arise over the safety of administering a BSH-positive
probiotic strain. However, the bacterial genera that would
most likely to be used as probiotics (Lactobacilli and Bifidobacteria) are not capable of dehydroxylating deconjugated bile salts, and so the majority of the breakdown
products of BSH activity by a probiotic strain may be
precipitated and excreted in feces. Hence, the ability of
probiotic strains to hydrolyze conjugated bile salts has
often been included among the criteria for probiotic
strain selection (FAO/WHO, 2002).
Mucus-binding protein (Mub), Fibronectinbinding protein (FbpA), and surface layer
protein (SlpA)

Roos & Jonsson (2002) identify the mub gene encoding

mucus-binding protein in Lactobacillus reuteri ATCC
53608 (strain 1023). Using the immunoglobulin G (IgG)
fraction of an antiserum against cell surface proteins of
L. reuteri ATCC 53608 (strain 1023), they screened a
phage library and identified a number of clones that were
reactive with the antiserum and adhered to mucus. Subcloning resulted in the identification of the mub gene,
encoding a very large sortase-dependent protein (SDP)
with a highly repetitive structure (3000 residues).
Domains with the two main types of repeats, that is,
Mub1 and Mub2, were shown to adhere to mucus after
recombinant expression in Escherchia coli. In another
L. reuteri strain, 100-23, a similar approach using an antiserum against the surface proteins was used to identify
the lsp (large cell surface protein) gene, which encodes a
high molecular mass cell wall protein, Lsp (Walter et al.,
2005). Mutational analysis showed a reduced ecological
performance of the lsp mutant in the murine gastro
intestinal tract (GIT). Boekhorst et al. (2005) performed
2012 Federation of European Microbiological Societies
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an in silico search for potential mucus-binding proteins

present in several publicly available databases. They
reported that a total of 48 proteins containing at least one
MUB domain were identified in 10 lactic acid bacterial
species. Callanan et al. (2008) reported that these mucusbinding proteins are involved mainly in GIT colonization
as observed from the genome sequence of the dairy isolate
L. helveticus DPC4571. A striking difference between the
various mucus-binding proteins is the number of repeats
of the MUB domain, and it might be interesting to investigate whether the number of repeats correlates with the
capacity of binding to mucus (Boekhorst et al., 2006).
Buck et al. (2005) reported the genes encoding FbpA,
Mub, and SlpA all contribute to the ability of L. acidophilus NCFM to adhere to Caco-2 cells in vitro, confirming
that adhesion is determined by multiple factors. mub and
fbpA mutations resulted in 65% and 76% decreases in
adherence, respectively. In a similar study, VanPijkeren
et al. (2006) mined the genome of L. salivarius UCC118
for the presence of sortase gene homologs and genes
encoding SDPs. The sortase gene srtA was deleted, three
genes encoding SDPs (large surface protein lspA, lspB,
and lspD) were disrupted, and the capacity of adherence
of these mutants to HT-29 and Caco-2 cells was investigated. Both the srtA and the lspA mutant showed a significant decrease in adherence. While the adherence of the
srtA mutant was on average 50% of wild-type levels, the
lspA mutant adhered at around 65%, only slightly better
than the Sortase srtA mutant, indicating that LspA plays a
key role in adherence to these intestinal cells.

Mechanism of action of probiotics

Probiotic bacteria have multiple and diverse influences on
the host. Different organisms can influence the intestinal
luminal environment, epithelial and mucosal barrier function, and the mucosal immune system. The numerous cell
types affected by probiotics involve epithelial cells, dendritic cells, monocytes/macrophages, B cells, T cells. There
are significant differences between probiotic bacterial genera and species. These differences may be due to various
mechanism of action of probiotics. It is crucial that each
strain be tested on its own or in products designed for a
specific function. Molecular research on these probiotics
pays attention to these strain-specific properties. Different
probiotic strains have been associated with different
effects related to their specific capacities to express particular surface molecules or to secrete proteins and metabolites directly interacting with host cells.
The effectiveness of probiotics is related to their ability
to survive in the acidic and alkaline environment of gut
as well as their ability to adhere and colonize the colon.
The mechanisms for the improved mucosal barrier are
2012 Federation of European Microbiological Societies
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R. Nagpal et al.

achieved by providing a means of limiting access, with

respect to pH, redox potential, hydrogen sulfide production, and antimicrobial compounds/molecules, to enteric
pathogens or by several interrelated system such as
mucous secretion, chloride and water secretion, and binding together of epithelial cells. Hydrogen peroxide in
combination with lactoperoxidasethiocyanate milk system exerts a bactericidal effect on most pathogens (Kailasapathy & Chin, 2000). Bacillus clausii constitute < 1% of
gut microbial communities, stimulate CD4 proliferation,
and produce bacteriocins to limit the growth of potential
pathogens. Microbial communities also enhance nutritive
value by producing several enzymes for the fermentation
of nondigestible dietary residue and endogenously
secreted mucus (Roberfroid et al., 1995) and help in
recovering lost energy in form of short-chain fatty acids.
They also have a role in the synthesis of vitamins (Conly
et al., 1994) and in the absorption of calcium, magnesium, and iron (Younes et al., 2001). Some examples of
host benefit and suspected mechanism have been summarized in Table 1.

Prospective applications of probiotics in

developing healthful foods
A growing public awareness of diet-related health issues
and mounting evidence regarding health benefits of probiotics have increased consumers demand for probiotic
foods. A number of food products including yoghurt, frozen fermented dairy deserts, spray-dried milk powder,
cheeses, ice cream, freeze-dried yoghurt (Nagpal et al.,
2007; Kumar et al., 2009a; Nagpal & Kaur, 2011), and
fruit juices (Nagpal et al., 2012) have been suggested as
delivery vehicles for probiotic to consumer. It has been
suggested that approximately 109CFU per day of probiotic microorganisms is necessary to elicit health effects.
Based on the daily consumption of 100 g or mL of probiotic food, it has been suggested that a product should
contain at least 107 cells per g or mL of a food, a level
that was also recommended in Japan (Ross et al., 2002).
The most popular food delivery systems for probiotic
have been fermented milk and yoghurt. A few studies
have shown that many commercial yoghurt products have
failed to successfully deliver the required level of viable
cells of probiotic bacteria (Dave & Shah, 1997). Cheeses
have a number of advantages over fresh fermented products (such as yoghurt) as a delivery system for viable probiotic to GI tract. Cheeses tend to have a higher pH and
more solid consistency where the matrix of the cheese
and its relatively high fat content may offer protection to
probiotic bacteria during passage through the GI tract.
Cheese also has high buffering capacity than yoghurt
(Gardiner et al., 1998). Overall, the major points to be
FEMS Microbiol Lett 334 (2012) 115

Probiotics and human health

addressed while incorporating probiotics into foods are

the selection of a compatible probiotic strain/food type
combination; using food processing conditions that are
compatible with probiotic survival; ensuring that the food
matrix supports probiotic growth (if fermentation is
required); selecting a product matrix, packaging, and
environmental conditions to ensure adequate probiotic
survival over the products supply chain and during shelf
storage; and finally ensuring that addition of the probiotic does not adversely impact on the taste and texture of
the product.

Carriers for probiotics

Probiotics are normally added to foods as a part of the fermentation process. The emphasis for prolonged survival of
probiotics in the food matrix has resulted in the alteration
in the functionality and efficacy of the food product. In
order to exert health benefits, probiotic bacteria must
remain viable in the food carriers and survive the harsh
condition of GI tract, with a minimum count of
106 CFU g 1. The nature of food carrier can affect the stability of the probiotic microorganisms during GI transit.
Although dairy-based products are suggested to be the
main carriers for the delivery of probiotics, other nondairybased products such as soy and fruits can be exploited as a
potential carrier of probiotic microorganisms because of
the increasing demand for new flavor and taste among con-

sumers. A brief idea about the variety of products that serve

as carriers for probiotics is given in Table 4.

Legislation and safety regarding

probiotics
The regulatory status of probiotics as a component in food
has to be established on an international level. A regulatory
framework should be established to better address probiotic issues, including efficacy, safety, labeling, fraud, and
claims. Probiotic products shown to confer defined health
benefits on the host should be permitted to describe these
specific health benefits. Surveillance systems (trace-back,
postmarketing) should be put in place to record and analyze adverse events associated with probiotics in food and
monitor long-term health benefits. Probiotic products
should be made more widely available, especially for relief
work and to populations at high risk of morbidity and
mortality. Foods that could be regarded as functional foods
are subject to regulations drawn up for other food groups.
The US Food and Drug Administration (FDA) defined
four food categories: conventional foods, constituting the
largest category and including articles of food and drink
that do not fall into the other three categories such as foods
for special dietary use; medical foods; and dietary supplements. According to Berner & ODonnell (1998), it is possible to envision functional foods in any of the categories
of foods and supplements mentioned above. From a

Table 4. Details of the products that serve as carriers for probiotics

Carrier

Products

Probiotics

References

Dairy based

Sweet-acidophilus milk
Ice cream
Whey drink
Whey cheese

L. gasseri
L. johnsonii
L. casei
B. animalis, L. acidophilus,
L. brevi, L. paracasei
L. acidophilus, L. casei,
Bifidobacterium
L. casei
L. acidophilus, L. casei, B. bifidum
Lactobacillus, Bifidobacterium,
Streptococcus thermophilus
L. acidophilus
L. acidophilus, L. casei,
Bifidobacterium
L. acidophilus., L. gasseri
L. plantarum
L. casei A4, L. delbrueckii D7
L. plantarum, L. acidophilus
L. plantarum, L. casei, L. delbrueckii
L. casei, L. rhamnosus GG,
L. paracasei, L. acidophilus LA39
B. lactis Bb-12, B. bifidum B7.1, B3.2
L. plantarum, L. acidophilus

Usman & Hosono (1999)

Alamprese et al. (2002)
Drgalic et al. (2005)
Madudeira et al. (2005)

Natural-set yogurt

Soy based

Low-fat cheddar cheese

Yogurt
Soymilk
Soy cream cheese
Soymilk

Juice based

Soymilk
Soymilk
Tomato juices
Cabbage juices
Beet juice
Orange and pineapple juice
Carrot juice
Tomato, orange, and grape juice

FEMS Microbiol Lett 334 (2012) 115

Donkor et al. (2007)

Sharp et al. (2008)
Sendra et al. (2008)
Donkor et al. (2007)
Liong et al. (2009)
Yeo & Liong (2010)
Ewe et al. (2010)
Bao et al. (2011)
Yoon et al. (2004)
Yoon et al. (2005)
Yoon et al. (2006)
Sheehan et al. (2007)
Kun et al. (2008)
Nagpal et al. (2012)

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10

R. Nagpal et al.

legislative standpoint, probiotic-containing foods could fit

into several of the four categories of foods described by the
FDA; however, there is no explicit recognition of any
health benefits of probiotic-, prebiotic-, or culture-added
dairy foods in the United States.
Government regulations regarding safety assessment
differ among countries, and the status of probiotics as a
component in food is currently not established on an
international basis. For the most part, probiotics come
under food and dietary supplements because most are
delivered by mouth as foods and, as such, are allowed to
make only general health claims. The factors that must be
addressed in the evaluation of safety of probiotics include
pathogenicity, infectivity, and virulence factors comprising toxicity, metabolic activity, and the intrinsic properties of the microorganisms. Donohue & Salminen (1996)
provided some methods for assessing the safety of lactic
acid bacteria through the use of in vitro studies, animal
studies, and human clinical studies and indicated that
some current probiotic strains are reported to fulfill the
required safety standards. Salminen & Marteau (1997)
also proposed studies on intrinsic properties, pharmacokinetics, and interactions between the host and probiotics
as means to assess the safety of probiotics. It was recognized that there is a need to accurately enumerate the
probiotic bacteria in food products to include them on a
label and that proper manufacture and handling procedures be employed to ensure the maintenance of viability
and probiotic activity through processing, handling, and
storage of probiotic foods, including powdered milk
products. Good evidence exists that specific strains of
probiotics are safe for human use and able to confer
some health benefits on the host, but such benefits cannot be extrapolated to other strains without experimentation. As there has been an increased influx of probiotic
products in the Indian market during the last decade,
therefore an initiative was taken by the Indian Council of
Medical Research and Department of Biotechnology,
Government of India, to formulate guidelines for the regulation of probiotic products in the country (Ganguly
et al., 2011), defining a set of parameters required for a
product/strain to be termed as probiotic. These include
the identification of the strain, in vitro screening for probiotic characteristics, and in vivo animal and human studies to establish efficacy, requirements for labeling of the
probiotic products with strain specification, viable numbers at the end of shelf-life, storage conditions, etc., so as
to help the consumers to safeguard their awareness.

Genetic manipulation offers the potential to enhance the

existing probiotic properties of an organism or to load an
organism with probiotic properties (Steidler, 2003). Elucidation of mechanisms of activity of a probiotic could
enable the manipulation of organisms to create specific
and targeted probiotics. Although consumer resistance to
genetically modified organisms is such that GMO probiotic
foods are unlikely in the near future, potential clinical
applications to ameliorate or prevent chronic intractable
diseases may be more readily accepted. For instance, Steidler (2003) treated mice with genetically modified Lactococcus lactis to deliver mouse cytokine IL-10 at the
intestinal mucosa to prevent colitis, demonstrating that
probiotics can be designed to produce potent bioactive
chemicals. Braat et al. (2006) also constructed a biologically contained L. lactis to produce human IL-10 and treated Crohns disease patients with this GM L. lactis in a
phase-1 placebo-uncontrolled trial. A decrease in disease
activity was observed with minor adverse effects, and containment of the organism was achieved through its dependency on thymidine for growth and IL-10 production.

Validation of health claims

Synbiotics

To validate or substantiate a health-related claim, the

proposed relationship between the product and the

Another possibility of gut microbial community management

is the use of synbiotics, where probiotics and prebiotics

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health-related end point should be identified, and appropriate measurements of both should be indicated. The
interests of patients and consumer involvement are
becoming integral part of clinical development and
should be taken into consideration. For regulatory purposes, health-related claims require sound evidence from
all available sources. Positive evidence should not be outweighed by negative evidence, and sufficient evidence
based on human experience should be available to support the safety and efficacy, including pre- and postmarketing experience. The greater the consistency of evidence
from different sources, the stronger the evidence will be.
The Nutrition Labeling and Education Act of 1990 gives
the US Food and Drug Administration (FDA) the authority
to regulate health claims on food labels. These claims
describe the link between specific nutrients or substances in
food, and a particular disease or health-related condition.
The process of reviewing the scientific evidence of health
claims involves the following steps: define the substance
disease relationship that is the subject of the claim, identify
relevant studies, classify the studies, rate the studies on the
basis of quality, rate the studies on the basis of the strength
of their body of evidence, and report the studies rank order.

Future prospects: toward genetically

modified designer probiotics

FEMS Microbiol Lett 334 (2012) 115

11

Probiotics and human health

are used in combination. A prebiotic is a nondigestible

food ingredient that beneficially affects the host by selectively stimulating the growth and/or activity of one or a
limited number of bacteria in the colon, thus improving
the host health (Gibson & Roberfroid, 1995). The combination of suitable probiotics and prebiotics enhances the
survival and activity of the organism. The combination of
prebiotic and probiotic has synergistic effects because in
addition to promoting the growth of existing strains of
beneficial bacteria in the colon, synbiotics also act to
improve the survival, implantation, and growth of newly
added probiotic strains. The synbiotic concept has been
widely used by European dairy drink and yoghurt manufacturers such as Aktifit (Emmi, Switzerland), Proghurt
(Ja Naturlich Naturprodukte, Austria), Vifit (Belgium,
UK), and Fysiq (the Netherlands; Niness, 1999). The
combination of Bifidobacterium and oligofructose was
reported to synergistically improve colon carcinogenesis
in rats compared to when both were given individually
(Gallaher & Khil, 1999). Another study reported that a
synbiotic containing Pediococcus pentoseceus, Leuconostoc
mesenteroides, Lactobacillus paracasei, and L. plantarum
with four fermentable fibers namely b-glucan, inulin, pectin, and resistant starch reduced the occurrence of postoperation infections from 48% to 13% in 66 liver
transplant patients (Rayes et al., 2005). Most of the
claims on benefits of different synbiotics are on general
health (Gibson & Roberfroid, 1995). There have yet been
any clinical trials on suitable combinations of synbiotics
that specifically target reduction in serum cholesterol level
in animals and humans. Bifidobacteria and Lactobacilli are
the most frequent target organisms for prebiotics.
Although there is growing interesting development of
new functional foods with synbiotics, the concept of synbiotics has been studied to a limited extent and needs
further investigations. Only a few human studies have
been carried out on the effectiveness of synbiotics (Morelli et al., 2003).

Conclusion
There are evidences from well-conducted clinical trials of
beneficial health effects from probiotics in a range of clinical conditions. The concept of synbiotics has recently
been proposed to characterize health-enhancing food and
supplements used as functional food ingredients in
humans, and with the advent of the functional food concept, it is clear that there is an important niche for these
probiotic-based approaches. Although from the ongoing
research, more of promising potential health effects of
probiotics are being observed, more standardized and verifiable clinical studies are needed to demonstrate the
safety, efficacy, and limitations of a putative probiotic, to
FEMS Microbiol Lett 334 (2012) 115

determine effects on the immune system in healthy and

diseased individuals and effects of long-term consumption, and to resolve whether it is superior to existing
therapies. Also, the prospect of GM probiotics targeted
for clinical conditions demands a rigorous safety strategy
to prevent spread into the environment and dissemination of the genetic modification.

Acknowledgements
The authors report no conflicts of interest.

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