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Foreword

The beneficial effects of probiotic foods on human health and nutrition are increasingly recognized by health professionals. Recent scientific work on the properties and functionality of living micro-organisms in food have suggested that probiotics play an important role in immunological, digestive and respiratory functions, and that they could have a significant effect on the alleviation of infectious diseases in children and other high-risk groups. In parallel, the number and type of probiotic foods and drinks that are available to consumers, and marketed as having health benefits, has increased considerably.

In view of this growing popularity of probiotic foods, and the lack of international consensus on the methodology to assess their efficacy and the safety, FAO and WHO initiated work to examine the scientific evidence on the functional and safety aspects of probiotics in food. In particular, an expert consultation on the health and nutritional properties of powder milk with live lactic acid bacteria was convened by FAO and WHO in Cordoba, Argentina in 2001, and an expert working group organized in 2002 to develop guidelines for the evaluation of probiotics in food.

The FAO/WHO consultation in 2001 brought together international scientific experts to evaluate available information on the functional and safety aspects of probiotics in powder milk. The consultation examined available scientific information on the dietary impact of probiotics, evaluated their properties, benefits, safety and nutritional features, and considered their potential adverse effects, taking into consideration work done by national authorities, FAO, WHO and other international organizations and relevant global fora. It reviewed the scientific basis for health claims linked to probiotic foods, considered regulatory needs and discussed strategies for the safety and nutritional assessment of probiotics, taking into account public concerns and food safety evaluation findings. The consultation generated a number of recommendations for further research, as well as priorities for the evaluation of safety and nutritional aspects of probiotics and regulatory requirements.

In follow-up to this consultation, FAO and WHO convened an expert working group to develop Guidelines for the Evaluation of Probiotics in Food. The resulting Guidelines provide a methodology for use in the evaluation of probiotics, and define the criteria and specific levels of scientific evidence needed to make health claims for probiotic foods.

By supporting the development of scientific knowledge on the functional and safety aspects of probiotics, FAO and WHO hope to enhance the overall safety and quality of food for consumers. In particular, it is hoped that the outputs of the FAO/WHO expert consultation and working group on probiotics will be used as a science-based assessment process for managerial decisions on probiotics, and that the Guidelines for the Evaluation of Probiotics in Food will provide a practical model to scientifically evaluate probiotics and be adopted by industry. It is also expected that these outputs will be useful for national work on health and nutrition claims, and as a scientific assessment of a novel food.

Health and Nutrition Properties of Probiotics in Food including Powder Milk with Live Lactic Acid Bacteria

Report of a Joint FAO/WHO Expert Consultation on Evaluation of Health and Nutritional Properties of Probiotics in Food including Powder Milk with Live
Lactic Acid Bacteria

Cordoba, Argentina
1-4 October 2001

The opinions expressed in this report are those of the participants of the Working Group and do not imply any opinion on the part of FAO and WHO

CONTENTS

1.Introduction

2.Background

3.Scope

4.History of Probiotics

5.Guidelines for the Assessment of Probiotic Microorganisms

5.1Selection of probiotic strains for human use

5.2Classification and identification of individual strains

5.3Defining and measuring the health benefits of probiotics

6.Testing methods for establishing health benefits conferred by probiotic microorganisms

7.Safety considerations

7.1Antimicrobial resistance profiles of probiotics

7.2Safety of probiotics in humans

8.Probiotic product specifications, quality assurance and regulatory issues

8.1Regulatory issues

8.2Appropriate labeling

8.3Manufacturing and handling procedures

8.4Prebiotics

9.Post market surveillance

10.Conclusions

11.Recommendations

12.List of abbreviations

13.References

Annex 1: List of Participants

Experts

Authors of working papers

FAO/WHO Secretariat

1.Introduction

A joint Food and Agriculture Organization of the United Nations/World Health Organization (FAO/WHO) Expert Consultation on Health and Nutritional Properties of Powder Milk with Live Lactic Acid Bacteria was held in the Amerian Cordoba Park Hotel, Cordoba, Argentina from 1 to 4 October 2001. The Consultation, which was the first meeting of this group, focused on the evaluation of the scientific evidence available on the properties, functionality, benefits, safety, and nutritional features of probiotic foods. A total of 11 experts from 10 countries participated in the Consultation. The complete list of participants is given in Annex 1.

Mr Juan Schiaretti, Minister of Production of the Province of Cordoba, opened the Consultation. He acknowledged the need for sound scientific evidence to substantiate health benefits associated with probiotic foods. Mr Victor Faraudo, Secretary of Agriculture of the Province of Cordoba; Mr Carlos Debandi, President of the Cordoba Science Agency, and Mr Eduardo Echaniz, Coordinator of the National Codex Committee also gave welcome addresses. Dr Jorgen Schlundt and Dr Maya Pineiro spoke on behalf of the World Health Organization and the Food and Agriculture Organization of the United Nations. In their statements, the importance of probiotics to the health of the human population was indicated, with particular reference to their potential in developing countries.

The Consultation elected Dr Gregor Reid as Chairperson and Dr Catherine Stanton as Rapporteur.

2.Background

The beneficial effects of food with added live microbes (probiotics) on human health, and in particular of milk products on children and other high-risk populations, are being increasingly promoted by health professionals. It has been reported that these probiotics can play an important role in immunological, digestive and respiratory functions and could have a significant effect in alleviating infectious disease in children.

As there are no international consensus on the methodology to assess the efficacy and the safety of these products, at present, it was considered necessary to convene an Expert Consultation to evaluate and suggest general guidelines for such assessments.

The Consultation evaluated the latest information and scientific evidence available on the functional and safety aspects of probiotics, as well as the methodology to assess such aspects, by bringing together worldwide scientific experts in the field.

3.Scope

The Consultation agreed that the scope of the meeting would include probiotics and prebiotics in food, and exclude reference to the term biotherapeutic agents, and beneficial microorganisms not used in food. The Consultation has redefined probiotics for the purpose of this meeting as ‘Live microorganisms which when administered in adequate amounts confer a health benefit on the host’, but restricted its scope to discussion of ‘Live microorganisms which when consumed in adequate amounts as part of food[1] confer a health benefit on the host’. The Consultation agreed that the specific issues related to powder milk could not be discussed without a more general consideration of probiotics in food.

The Consultation agreed to confine its discussion to the following:

a)Properties of probiotic strains and their assessment

b)Probiotic product specifications, quality assurance and regulatory issues

c)Safety and beneficial human health effects

As background to these discussions, the Consultation received background papers and presentations on:

- Taxonomy and physiology of lactic acid bacteria, effects and function on nutrition (Morelli L);

- Technological and commercial applications of lactic acid bacteria; Health and Nutritional Benefits in Dairy Products (Gilliland S);

- Regulatory and clinical aspects of dairy probiotics (Reid G).

The Consultation focused on strains available as probiotics in food. Although the Consultation did not specifically address issues related to genetically modified organisms, the concepts and principles are equally applicable to all probiotics. The potential importance of probiotic strains used in animal feeds as they pertain to human health was recognized.

4.History of Probiotics

The term probiotic is a relatively new word meaning “for life” and it is currently used to name bacteria associated with beneficial effects for humans and animals. The original observation of the positive role played by some selected bacteria is attributed to Eli Metchnikoff, the Russian born Nobel Prize winner working at the Pasteur Institute at the beginning of the last century, who suggested that "The dependence of the intestinal microbes on the food makes it possible to adopt measures to modify the flora in our bodies and to replace the harmful microbes by useful microbes" (Metchnikoff, 1907).

At this time Henry Tissier, a French paediatrician, observed that children with diarrhea had in their stools a low number of bacteria characterized by a peculiar, Y-shaped morphology. These “bifid” bacteria were, on the contrary, abundant in healthy children (Tissier, 1906). He suggested that these bacteria could be administered to patients with diarrhea to help restore a healthy gut flora.

The works of Metchnikoff and Tissier were the first to make scientific suggestions concerning the probiotic use of bacteria, even if the word "probiotic" was not coined until 1960, to name substances produced by microorganisms which promoted the growth of other microorganisms (Lilly and Stillwell, 1965). Fuller (1989), in order to point out the microbial nature of probiotics, redefined the word as "A live microbial feed supplement which beneficially affects the host animal by improving its intestinal balance". A similar definition was proposed by Havenaar and Huis in 't Veld (1992), “a viable mono or mixed culture of bacteria which, when applied to animal or man, beneficially affects the host by improving the properties of the indigenous flora”. A more recent, but probably not the last definition is "live microorganisms, which when consumed in adequate amounts, confer a health effect on the host" (Guarner and Schaafsma, 1998).

It is clear that these definitions have:

1)restricted the use of the word probiotic to products which contain live microorganisms;

2)pointed out the need for providing an adequate dose of probiotic bacteria in order to exert the desirable effects.

The observations of Metchnikoff and Tissier were so appealing that commercial exploitation immediately followed their scientific works. Unfortunately, results were not always positive and most of these observations were anecdotal. The probiotic concept was therefore regarded as scientifically unproven and it received minor interest for decades, with some research involving animal feeding, in order to find healthy substitutes for growth promoting agents. In the last 20 years however, research in the probiotic area has progressed considerably and significant advances have been made in the selection and characterization of specific probiotic cultures and substantiation of health claims relating to their consumption.

Members of the genera Lactobacillus and Bifidobacterium are mainly used, but not exclusively, as probiotic microorganisms and a growing number of probiotic foods are available to the consumer. Some ecological considerations on the gut flora are necessary to understand the relevance, for human health, of the probiotic food concept.

Bacteria are normal inhabitants of humans (as well as the bodies of upper animals and insects) including the gastrointestinal tract, where more than 400 bacterial species are found (reviewed by Tannock, 1999): half of the wet weight of colonic material is due to bacterial cells whose numbers exceed by 10-fold the number of tissue cells forming the human body. Normally the stomach contains few bacteria (10^3 colony forming units per ml of gastric juice) whereas the bacterial concentration increases throughout the gut resulting in a final concentration in the colon of 10^12 bacteria/g. Bacterial colonization of the gut begins at birth, as new-borns are maintained in a sterile status until the delivery begins, and continues throughout life, with notable age-specific changes (Mitsuoka, 1992). Bacteria, forming the so-called resident intestinal microflora, do not normally have any acute adverse effects and some of them have been shown to be necessary for maintaining the well being of their host.

As an example of the beneficial role of intestinal microflora, it is possible to cite what has been referred to as "colonization resistance" or “barrier effect” (van der Waaij et al., 1971; Vollaard and Clasener, 1994) meaning the mechanism used by bacteria already present in the gut to maintain their presence in this environment and to avoid colonization of the same intestinal sites by freshly ingested microorganisms, including pathogens. Therefore, it could be assumed that dietary manipulation of gut microflora, in order to increase the relative numbers of "beneficial bacteria" could contribute to the well being of the host. This was also the original assumption of Metchnikoff who however, cautioned that:

"Systematic investigations should be made on the relation of gut microbes to precocious old age, and on the influence of diets which prevent intestinal putrefaction in prolonging life and maintaining the forces of the body."

This prudent statement can still be regarded today as an invitation to scientists to investigate the probiotic bacteria in more depth and with care.

5.Guidelines for the Assessment of Probiotic Microorganisms

In order to assess the properties of probiotics, the Consultation suggested that the following guidelines be used. For use in foods, probiotic microorganisms should not only be capable of surviving passage through the digestive tract but also have the capability to proliferate in the gut. This means they must be resistant to gastric juices and be able to grow in the presence of bile under conditions in the intestines, or be consumed in a food vehicle that allows them to survive passage through the stomach and exposure to bile. They are Gram positive bacteria and are included primarily in two genera, Lactobacillus and Bifidobacterium (Holzapel et al., 1998; Klein et al., 1998).

5.1Selection of probiotic strains for human use

Probiotics must be able to exert their benefits on the host through growth and/or activity in the human body (Collins et al., 1998; Morelli, 2000). However, it is the specificity of the action, not the source of the microorganism that is important. Indeed, it is very difficult to confirm the source of a microorganism. Infants are born with none of these bacteria in the intestine, and the origin of the intestinal microflora has not been fully elucidated. It is the ability to remain viable at the target site and to be effective that should be verified for each potentially probiotic strain.

There is a need for refinement of in vitro tests to predict the ability of probiotics to function in humans. The currently available tests are not adequate to predict the functionality of probiotic microorganisms in the intestine.

5.2Classification and identification of individual strains

Classification is the arranging of organisms into taxonomic groups (taxa) on the basis of similarities or relationships. Nomenclature is the assignment of names to the taxonomic groups according to rules. Identification is the process of determining that a new isolate belongs to one of the established, named taxa.

The Consultation recommended that probiotics be named according to the International Code of Nomenclature to ensure understanding on an international basis. The Consultation strongly urged that for the sake of full disclosure, probiotic strains be deposited in an internationally recognized culture collection.

Since probiotic properties are strain related, it is suggested that strain identification (genetic typing) be performed, with methodology such as pulse field gel electrophoresis (PFGE). It is recommended that phenotypic tests be done first, followed by genetic identification, using such methods as DNA/DNA hybridization, 16S RNA sequencing or other internationally recognized methods. For the latter, the RDP (ribosomal data base project) should be used to confirm identity (www.cme.msu.edu/RDP/).

5.3Defining and measuring the health benefits of probiotics

A number of health effects are associated with usage of probiotics. There are differing degrees of evidence supporting the verification of such effects and the Consultation recognizes that there are reports showing no clinical effects of certain probiotic strains in specific situations (Andersson et al. 2001). While a rigorous review of each topic was not within the scope of the Consultation, an attempt was made to provide guidelines on parameters for measuring health benefits.

The use of probiotic microorganisms to confer health benefits on the host must indicate the dosage regimens and duration of use as recommended by the manufacturer of each individual strain or product based upon scientific evidence, and as approved in the country of sale. While this practice is not currently in place, the Consultation strongly recommended that each product should indicate the minimum daily amount required for it to confer specific health benefit(s). Such evidence should, where possible result from in vitro, animal (where appropriate) and human studies. Examples have been cited below to illustrate studies on specific strains and clinical outcomes. In doing so, the emphasis should not be on one particular strain being termed as superior to another, rather that the benefit conferred and the methods used to obtain and measure said benefits are of most importance.

5.3.1  Disorders associated with the gastrointestinal tract

5.3.1.1 Prevention of diarrhea caused by certain pathogenic bacteria and viruses

Infectious diarrhea is a major world health problem, responsible for several million deaths each year. While the majority of deaths occur amongst children in developing countries, it is estimated that up to 30% of the population even in developed countries are affected by foodborne diarrhea each year. Probiotics can potentially provide an important means to reduce these problems. It should be noted that some of the studies referenced below utilize probiotics administered in a non-food form.

The strongest evidence of a beneficial effect of defined strains of probiotics has been established using Lactobacillus rhamnosus GG and Bifidobacterium lactis BB-12 for prevention (Saavedra et al., 1994; Szajewska et al., 2001) and treatment (Isolauri et al., 1991; Guarino et al., 1997; Majamaa et al., 1995; Shornikova et al., 1997; Perdone et al., 1999; Guandalini et al., 2000) of acute diarrhea mainly caused by rotaviruses in children.

In addition to rotavirus infections, many bacterial species cause death and morbidity in humans. There is good in vitro evidence that certain probiotic strains can inhibit the growth and adhesion of a range of enteropathogens (Coconnier et al., 1993, 1997; Hudault et al., 1997; Gopal et al., 2001; Bernet Camard et al., 1997), and animal studies have indicated beneficial effects against pathogens such as Salmonella (Ogawa et al., 2001; Shu et al., 2000). There is evidence from studies on travelers’ diarrhea, where some of the causative pathogens have been presumed to be bacterial in nature, that benefits can accrue with probiotic administration (Hilton et al., 1997).

It is important to note that probiotic therapy of acute diarrhea should be combined with rehydration if available. Current WHO recommendations state that clinical management of acute diarrhea should include replacement of fluid and electrolytes losses along with nutritional support (WHO, 1995). Oral rehydration salts (ORS) have been widely used in such disease management, and it is within this context that the combination therapy with probiotics is hereby advocated. Effects such as probiotic restoration of the non-pathogen dominated intestinal microflora secondary to infection, maintaining mucosal integrity and improving electrolyte balance could have a significant impact on programmes of treatment and prevention of acute diarrhea in developing countries.

A major problem associated with antibiotic treatment is the appearance of diarrhea, often caused by Clostridium difficile. This organism is not uncommon in a healthy intestinal tract, but the disruption of the indigenous microflora by antibiotics leads to an abnormal elevation of their numbers, and subsequent symptoms related to toxin production. The rationale therefore to use probiotics is that in such patients, administration of exogenous commensal microorganisms (that is probiotics) is required to restore the microflora to one that more closely reflects the normal flora prior to antibiotic therapy. Some open ended studies have indeed shown that this approach can alleviate the signs and symptoms of C. difficile infection (Gorbach et al., 1987; Biller et al., 1995; Bennet et al., 1986). With respect to antibiotic-associated diarrhea, probiotics have proved useful as a prophylactic regimen, and potentially they can also be used to alleviate the signs and symptoms once antibiotic induced diarrhea has occurred (Arvola et al., 1999; Vanderhoof et al., 1999; Armuzzi et al., 2001). It must be recognized that evidence for therapeutic effects against C. difficile, and other disorders has been obtained using certain probiotic strains, such as L. rhamnosus GG. It is important to note that such effects may also be conferred by other strains, but scientific evidence may not yet be available or the microorganisms involved may not be included in the scope of this Consultation.

5.3.1.2 Helicobacter pylori infection and complications

A new development for probiotic applications is activity against Helicobacter pylori, a Gram negative pathogen responsible for type B gastritis, peptic ulcers and gastric cancer. In vitro and animal data indicate that lactic acid bacteria can inhibit the growth of the pathogen and decrease urease enzyme activity necessary for the pathogen to remain in the acidic environment of the stomach (Midolo et al., 1995; Kabir et al., 1997; Aiba et al., 1998; Coconnier et al., 1998). Human data is limited, but there is some evidence of an effect induced by L. johnsonii La1 (Michetti et al., 1999). In terms of measuring probiotic effects, feasible end points include the suppression of the infection (which may be reversible upon cessation of treatment), combination treatment with antibiotics leading to fewer side effects such as acid reflux, and lower risk of recurrent infection (Michetti et al., 1999; Canducci et al., 2000; Felley et al., 2001). Placebo-controlled trials are needed before specific claims can be made for probiotic anti-Helicobacter pylori benefits in humans with respect to prevention and treatment. Such studies are warranted given the preliminary evidence to support these effects.

5.3.1.3 Inflammatory diseases and bowel syndromes

Inflammatory bowel diseases, such as pouchitis and Crohn’s disease, as well as irritable bowel syndrome, may be caused or aggravated by alterations in the gut flora including infection (Shanahan, 2000). These are new avenues of investigation, although it is premature to state a firm action of probiotics in these conditions. Some studies support the potential role of probiotics in therapy and prophylaxis and illustrate that combinations of strains may have a role to play in remediation (Gionchetti et al., 2000; Gupta et al., 2000). The intestinal microflora likely plays a critical role in inflammatory conditions in the gut, and potentially probiotics could remediate such conditions through modulation of the microflora. Clinical and mechanistic studies are urgently required to better understand the interface between the microbes, host cells, mucus and immune defenses, and to create efficacious interventions. Such studies should include molecular examination of the intestinal (not only fecal) flora and long-term (5-10 years) effects of probiotic microorganisms.

5.3.1.4 Cancer

There is some preliminary evidence that probiotic microorganisms can prevent or delay the onset of certain cancers. This stems from the knowledge that members of the gut microflora can produce carcinogens such as nitrosamines. Therefore, administration of lactobacilli and bifidobacteria could theoretically modify the flora leading to decreased β-glucuronidase and carcinogen levels (Hosada et al., 1996). Furthermore, there is some evidence that cancer recurrences at other sites, such as the urinary bladder can be reduced by intestinal instillation of probiotics including L. casei Shirota (Aso et al., 1995). In vitro studies with L. rhamnosus GG and bifidobacteria and an in vivo study using L. rhamnosus strains GG and LC-705 as well as Propionibacterium sp. showed a decrease in availability of carcinogenic aflatoxin in the lumen (El-Nezami et al., 2000; Oatley et al., 2000). However, it is too early to make definitive clinical conclusions regarding the efficacy of probiotics in cancer prevention.

The Consultation was not convinced that there is sufficient proof of a correlation between probiotics and specific anti-cancer effects, and urged that extensive studies are required. Such studies must utilize internationally recognized markers for cancer, or risk of cancer, and evaluate such markers and presence of carcinogenic lesions or tumors over a suitably long period of time for prevention of primary cancer, and reduction of the incidence of recurrences.

5.3.1.5 Constipation

The ability of probiotic therapy to alleviate constipation (difficulty in passing stool, excessive hardness of stool, slow transit through the bowel) is debatable, but may be a feature of selected strains. Randomized placebo controlled efficacy studies aimed at exploring these effects are strongly recommended.

5.3.2  Mucosal immunity

The innate and adaptive immune systems are the two compartments traditionally described as important for the immune response. Macrophages, neutrophils, natural killer (NK) cells and serum complement represent the main components of the innate system, in charge of the first line of defence against many microorganisms. However, there are many agents that this system is unable to recognize. The adaptive system (B and T cells) provide additional means of defence, while cells of the innate system modulate the beginning and subsequent direction of adaptive immune responses. Natural killer cells, including gamma/delta T cells, regulate the development of allergic airway disease, suggesting that the interleukins play an important role. Intravenous, intraperitoneal and intrapleural injection of L. casei Shirota into mice significantly increased NK activity of mesenteric node cells but not of Peyer's patch cells or of spleen cells (Matsuzaki and Chin, 2000), supporting the concept that some probiotic strains can enhance the innate immune response.

A number of studies have been performed in vitro and in animals (Gill et al., 2000) which clearly show that probiotic strains can modify immune parameters. Correlating these findings with events taking place in the human body is still somewhat unclear, but evidence is mounting that such effects occur. In a series of randomized, double blind, placebo controlled clinical trials, it was demonstrated that dietary consumption of B. lactis HN019 and L. rhamnosus HN001 resulted in measurable enhancement of immune parameters in the elderly (Arunachalam et al., 2000; Gill et al., 2001; Sheih et al., 2001).

Probiotic modulation of host immunity is a very promising area for research. Supportive data is emerging, such as those carried out in humans showing that probiotic microorganisms can enhance NK cell activity in the elderly (Gill et al., 2001) and nonspecific host defenses can be modulated (Donnet-Hughes et al., 1999; Perdigon et al., 1999).

There is a need to specify whether the activities being advocated are designed to operate in otherwise healthy people or subjects with known diseases. Some of the critical factors involved in the host’s defenses have been identified and include the induction of mucus production or macrophage activation by lactobacilli signaling (Mack et al., 1999; Miettinen et al., 2000), stimulation of sIgA and neutrophils at the site of probiotic action (for example the gut), and lack of release of inflammatory cytokines or stimulation of elevated peripheral immunoglobulins (Kaila et al., 1992; Gardiner et al., 2001). It is also recognized that in some situations, stimulation of factors such as inflammatory cytokines may confer health benefits on the host.

Future studies should focus on the effect in humans, and elucidate the mechanisms of action within systems which simulate the in vivo situation, and link this to bacterial and human genomics.

5.3.3  Allergy

In a double-blind, randomized, placebo-controlled trial, L. rhamnosus GG was given to pregnant women for four weeks prior to delivery, then to newborns at high risk of allergy for six months with the result that there was a significant reduction in early atopic disease (Kalliomaki et al., 2001). This study illustrates the potential for probiotic microorganisms to modulate the immune response and prevent onset of allergic diseases. In other clinical studies with infants allergic to cow’s milk, atopic dermatitis was alleviated by ingestion of probiotic strains L. rhamnosus GG and B. lactis BB-12 (Majamaa and Isolauri, 1996; 1997; Isolauri et al., 2000). The precise mechanisms have not been elucidated, but the premise is based upon the ability of lactobacilli to reverse increased intestinal permeability, enhance gut-specific IgA responses, promote gut barrier function through restoration of normal microbes, and enhance transforming growth factor beta and interleukin 10 production as well as cytokines that promote production of IgE antibodies (Kalliomaki et al., 2001; Isolauri, 2001). Whether T-helper-1 (TH1) is enhanced and/or T-helper-2 (TH2) dominance is reduced remains to be determined, as do the time-points of these types of events. Certain microorganisms can contribute to the generation of counter-regulatory T-helper cell immune responses, indicating that use of specific probiotic microorganisms could redirect the polarized immunological memory to a healthy one (McCracken and Lorenz, 2001).

5.3.4  Cardiovascular disease

There is preliminary evidence that use of probiotic lactobacilli and metabolic byproducts potentially confer benefits to the heart, including prevention and therapy of various ischemic heart syndromes (Oxman et al., 2001) and lowering serum cholesterol (De Roos and Katan, 2000). While the Consultation believes these findings to be important, more research and particularly human studies are required before it can be ascertained that probiotics confer health benefits to the cardiovascular system.

5.3.5  Urogenital tract disorders

Excluding sexually transmitted diseases, almost all infections of the vagina and bladder are caused by microorganisms that originate in the bowel. There is a strong correlation between presence of commensals, particularly lactobacilli in the vagina with health, and an absence of these microorganisms in patients with urogenital infections. Disruption of the normal vaginal flora is caused by broad-spectrum antibiotics, spermicides, hormones, dietary substances and factors not, as yet, fully understood. There is some evidence that probiotic microorganisms delivered as foods and topical preparations have a role in preventing urogenital tract disorders. The criteria for selection of effective probiotic strains have been proposed (Reid and Bruce, 2001) and should include verification of safety, colonization ability in the vagina and ability to reduce the pathogen count through competitive exclusion of adherence and inhibition of pathogen growth.

5.3.5.1 Bacterial vaginosis

Bacterial vaginosis (BV) is a disease of unknown etiology resulting from the overgrowth of various anaerobic bacterial species and associated with the disappearance of lactobacilli, which dominate the normal vagina. Many women with BV are asymptomatic yet are at risk of more serious complications such as endometriosis, pelvic inflammatory disease and complications of pregnancy including pre-term labour. There is some clinical evidence to suggest that oral and vaginal administration of lactobacilli can eradicate asymptomatic (Reid et al., 2001a; 2001b) and symptomatic BV (Hilton et al., 1995; Sieber and Dietz, 1998). Oral administration of Lactobacillus acidophilus and yogurt has been used in the prevention and therapy of candidal vaginitis, although no efficacy data have yet been generated (Hilton et al., 1992). The necessity for the lactobacilli to produce hydrogen peroxide has been proposed, but given that these microorganisms are more prone to being killed by spermicides, the combination of two or more strains, one of which produces hydrogen peroxide and others which resists spermicidal killing, may prove to be more therapeutic.

5.3.5.2 Yeast vaginitis

Yeast vaginitis is a very common ailment, often precipitated by antibiotic use, exposure to spermicides or hormonal changes as yet not fully understood. Unlike BV and urinary tract infection, yeast vaginitis is not necessarily due to loss of lactobacilli. Few Lactobacillus strains are able to inhibit the growth and adhesion of Candida albicans or other Candida species, and there is no solid evidence to indicate that intravaginal administration of lactobacilli can eradicate yeast infection. However, there is some evidence to suggest that lactobacilli ingestion and vaginal use can reduce the risk of recurrences (Hilton et al., 1992; 1995) and further studies are warranted since this disease is widespread and debilitating.

5.3.5.3 Urinary tract infections

Several hundred million women are affected by urinary tract infection (UTI) annually. Uropathogenic Escherichia coli originating in the bowel is the responsible agent in up to 85% of cases. Asymptomatic bacteruria is also a common finding in women, and sometimes it is followed by symptomatic UTI. There is evidence, including randomized controlled data to suggest that once weekly vaginal capsules of freeze dried Lactobacillus strains GR-1 and B-54 (Reid et al., 1995) prepared with addition of skim milk, and once daily oral capsule use of Lactobacillus strains GR-1 and RC-14 (Reid et al., 2001b), can result in the restoration of a lactobacilli dominated vaginal flora and lower risk of UTI recurrences. By creating a lactobacilli barrier in the vagina, it is believed that fewer pathogens can ascend into the bladder, thereby blocking the infectious process.

5.3.6  Use of probiotics in otherwise healthy people

Many probiotic products are used by consumers who regard themselves as being otherwise healthy. They do so on the assumption that probiotics can retain their health and well being, and potentially reduce their long-term risk of diseases of the bowel, kidney, respiratory tract and heart. Several points need to be made on this assumption and its implications. The Consultation recognized that the use of probiotics should not replace a healthy lifestyle and balanced diet in otherwise healthy people.

Firstly, there is no precise measure of “health” and subjects may actually have underlying and undetectable diseases at any given time. Secondly, no studies have yet been undertaken which analyse whether or not probiotic intake on a regular basis helps retain life-long “health” over and above dietary, exercise and other lifestyle measures. One study of day care centres in Finland showed that probiotic use reduced the incidence of respiratory infections and days absent due to ill health (Hatakka et al., 2001). The Consultation would like studies to be done to give credibility to the perception that probiotics should be taken on a regular basis by healthy men, women and children. Such studies should be multi-centred and require randomization on the basis of age, gender, race, nutritional intake, education, socio-economic status and other parameters.

It is currently unclear as to the impact of regular probiotic intake on the intestinal microflora. For example, does it lead to the depletion or loss of commensal microorganisms which otherwise have beneficial effects on the host? While there is no indication of such effects, the issue needs to be considered. Furthermore, the concept of restoring a normal balance assumes that we know what the normal situation in any given intestinal tract comprises. It was deemed important by the Consultation to further study the various contributions of gut microorganisms on health and disease. Another point worthy of note is that, to date, the ingestion of probiotic strains has not led to measurable long-term colonization and survival in the host. Invariably, the microorganisms are retained for days or weeks, but no longer (Tannock et al., 2000). Thus, use of probiotics likely confers more transient than long-term effects, and so continued intake appears to be required.

In newborn children, where a commensal flora has not yet been established, it is feasible that probiotic microorganisms could become primary colonizers that remain long-term, perhaps even for life. While such probiotic usage can prevent death and serious morbidity in premature, low birth weight infants (Hoyos, 1997), the alteration of flora in healthy babies is a more complex situation. Just so, an implication of the Human Genome Project is that selected probiotics may be used at birth to create a flora that improves life-long health. These issues are very important for the future, and will require full discussion including human ethical considerations.

6.Testing Methods for Establishing Health Benefits Conferred by Probiotic Microorganisms

Proper in vitro studies should establish the potential health benefits of probiotics prior to undertaking in vivo trials. Tests such as acid and bile tolerance, antimicrobial production and adherence ability to human intestinal cells should be performed depending on the proposed health benefit (Collins et al., 1998; Havenaar and Huis in’t Veld, 1992).

In order to ascertain that a given probiotic can prevent or treat a specific pathogen infection, a clinical study must be designed to verify exposure to the said pathogen (preventive study), or that the infecting microorganism is that specific pathogen (treatment study). If the goal is to apply probiotics in general to prevent or treat a number of infectious gastroenteritis or urogenital conditions, the study design must define the clinical presentation, symptoms and signs of infection, and include appropriate controls.

For in vivo testing, randomized double blind, placebo controlled human trials should be undertaken to establish the efficacy of the probiotic product. The Consultation recognized that there is a need for human studies in which adequate numbers of subjects are enrolled to achieve statistical significance (Andersson et al., 2001). It would be preferable to have such findings corroborated by more than one independent center. For some foods, it may be difficult to separate a probiotic effect from an effect related to the general product characteristics of the food. Therefore, it is essential that proper controls be included in these human trials. Furthermore, data obtained with one specific probiotic food cannot be extrapolated to other foods containing that particular probiotic strain or to other probiotic microorganisms.

With respect to measuring the health benefits in human studies, consideration should be given to clinically relevant outcomes in the population being studied. For diarrheal studies, this might be preventing death in some countries, while in others it might be prevention of a defined and statistically significant weight loss, decreased duration of watery/liquid stools, and faster recovery to normal health, as measured by restoration of normal bowel function and stool consistency.

Although it is known that certain probiotics can elicit beneficial effects (as discussed in Section 5), little is known about the molecular mechanisms of the benefits reported (Andersson et al., 2001). The mechanisms may vary from one probiotic to another (for the same benefit via different means) and the mechanism may be a combination of events, thus making this a very difficult and complex area. It could involve the production of a specific enzyme(s) or metabolite(s) that act directly on the microorganism(s), or the probiotic could also cause the body to produce the beneficial action.

Examples of possible probiotic mechanisms of action, in the control of intestinal pathogens include:

- Antimicrobial substance production

- Competitive exclusion of pathogen binding

- Competition for nutrients

- Modulation of the immune system

The Consultation proposes that clear experiments (in vitro and/or in vivo) should be designed at the molecular level to elucidate the mechanisms of probiotic beneficial effects. Appropriate experiments including genetic analysis to elucidate the mechanism of actions should be performed.

Probiotic bacteria containing β-galactosidase can be added to food to improve lactose maldigestion (Kim and Gilliland, 1983). However, a similar health effect is also observed for lactose fermenting starter bacteria such as L. delbrueckii. ssp. bulgaricus and S. thermophilus in fermented milk products like yogurt (Kim and Gilliland, 1984; Kolars et al., 1984). These traditional starters are not considered probiotics since they lack the ability to proliferate in the intestine (Klein et al., 1998).

7.Safety Considerations

7.1Antimicrobial resistance profiles of probiotics

As with any bacteria, antibiotic resistance exists among some lactic acid bacteria, including probiotic microorganisms (Salminen et al., 1998). This resistance may be related to chromosomal, transposon or plasmid located genes. However, insufficient information is available on situations in which these genetic elements could be mobilized and it is not known if situations could arise where this would become a clinical problem.

There is concern over the use in foods of probiotic bacteria that contain specific drug resistance genes. Bacteria, which contain transmissible drug resistance genes, should not be used in foods. Currently, no standardized phenotypic methods are available which are internationally recognized for lactobacilli and bifidobacteria (non-pathogens). The Consultation recognizes the need for the development of standardized assays for the determination of drug insensitivity or resistance profiles in lactobacilli and bifidobacteria.

The Consultation is aware that plasmids exist in lactobacilli and bifidobacteria, especially in strains isolated from the intestine, which have genes encoding antibiotic resistance. Due to the relevance of this problem, it is suggested that further research be done relating to the antibiotic resistance of lactobacilli and bifidobacteria.

When dealing with selection of probiotic strains, it is recommended that probiotic bacteria should not harbour transmissible drug resistance genes encoding resistance to clinically used drugs. Research is required relating to the antibiotic resistance of lactobacilli and bifidobacteria and the potential for transmission of genetic elements to other intestinal and/or foodborne microorganisms.

7.2Safety of probiotics in humans

In terms of safety of probiotics, the Consultation believes that a set of general principles and practical criteria need to be generated to provide guidelines as to how any given potential probiotic microorganism can be tested and proven to have a low risk of inducing or being associated with the etiology of disease, versus conferring a significant health benefit when administered to humans. These guidelines should recognize that some species may require more vigorous assessment than others. In this respect, the evaluation of safety will require at least some studies to be performed in humans, and should address aspects of the proposed end use of the probiotic strain.

Information acquired to date shows that lactobacilli have a long history of use as probiotics without established risk to humans, and this remains the best proof of their safety (Naidu et al., 1999; Saxelin et al., 1996). Also, no pathogenic or virulence properties have been found for lactobacilli, bifidobacteria or lactococci (Aguirre and Collins, 1993). Having stated that, the Consultation acknowledges that under certain conditions, some lactobacilli strains have been associated with adverse effects, such as rare cases of bacteremia (Saxelin et al., 1996). However, a recent epidemiological study of systematically collected lactobacilli bacteremia case reports in one country has shown that there is no increased incidence or frequency of bacteremia with increased usage of probiotic lactobacilli (Salminen et al., 2001).

It is also acknowledged that some members of lactic acid bacteria, such as enterococci may possess virulence characteristics. For this and other reasons, the Consultation recommends that Enterococcus not be referred to as a probiotic for human use. The rationale is based upon:

1. Strains can display a high level of resistance to vancomycin (Shlaes et al., 1989; Eaton and Gasson, 2001; Lund and Edlund, 2001), or can acquire such resistance. If this resistance is present, transfer to other microorganisms may occur and this could enhance the pathogenesis of such recipients (Noble et al., 1992; Leclercq and Courvalin, 1997).

2. Certain strains of vancomycin resistant enterococci are commonly associated with nosocomial infections in hospitals (Leclercq and Courvalin, 1997; Woodford et al., 1995).

The Consultation recognizes that some strains of Enterococcus display probiotic properties, and may not at the point of inclusion in a product display vancomycin resistance. However, the onus is on the producer to prove that any given strain cannot acquire or transfer vancomycin resistance or be virulent and induce infection.

8.Probiotic Product Specifications, Quality Assurance and Regulatory Issues

8.1Regulatory issues

Government regulations differ among countries, however 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. These are differentiated from drugs in a number of ways, especially with respect to claims. Drugs are allowed to claim effectiveness in the treatment, mitigation or cure of a disease, whereas foods, feed additives and dietary supplements can only make general health claims.

In order to understand where probiotic products currently fall in terms of regulatory agencies, and the claims that can be made with their use, the following US example is provided (www.fda.gov). Consumers are permitted access to products ingested as pills, capsules, tablets and liquids, or in capsules sold in health food stores or via the internet.

-A ‘health claim’ is defined as “a statement, which characterizes the relationship of any substance to a disease or health-related condition, and these should be based upon well-established, generally accepted knowledge from evidence in the scientific literature and/or recommendations from national or international public health bodies. Examples include ‘protects against cancer’.

-A structure/function claim is defined as “a statement of nutritional support that describes the role of a nutrient or dietary ingredient to affect the structure or functioning of the human body, or characterizes the documented mechanism by which a nutrient or dietary ingredient acts to maintain such structure or function. Examples include ‘supports the immune system’. Claims that substances can treat, diagnose, cure or prevent a disease are not structure/function claims.

The Consultation recommends that disease reduction claims be permitted for specific probiotics if these have been demonstrated using guidelines outlined in this report.

The new paradigm of risk analysis is making its way into regulatory food safety and focuses on a functional separation of the science-based risk assessment and risk management. However, the issue of communication is now also considered an important integrated part of risk analysis. Communication includes exchange between assessors and managers and two-way interaction with other interested parties. Within this concept, the transparency of the decision making process for food safety regulatory action is emphasized, as well as the importance of providing a vehicle for consumers and others to participate in the development process. Therefore communication efforts relative to the use of probiotics should be considered as an integrated part of the development of regulatory initiatives.

8.2Appropriate labelling

To clarify the identity of a probiotic present in the food, the Consultation recommends that the microbial species be stated on the label. If a selection process has been undertaken at the strain level, the identity of the strain should also be included, since the probiotic effect seems to be strain specific.

There is a need to accurately enumerate the probiotic bacteria in food products in order to include them on the label. The label should state the viable concentration of each probiotic present at the end of shelf life (Reid et al., 2001c).

8.3Manufacturing and handling procedures

To ensure that any given culture maintains the beneficial properties, the stock culture should be maintained under appropriate conditions and be checked periodically for strain identity and probiotic properties. Furthermore, viability and probiotic activity must be maintained throughout processing, handling and storage of the food product containing the probiotic, and verified at the end of shelf-life.

Adequate quality assurance programmes should be in place. Good manufacturing practices should be followed in the manufacture of probiotic foods. The Consultation recommends that the Codex General Principles of Food Hygiene and Guidelines for Application of HACCP (CAC, 1997) be followed.

8.3.1.  Powdered milk products

Since a purpose of this Consultation was to address the health and nutritional properties of milk powder with live lactic acid bacteria, it was considered necessary to further address the issue in this report. Methods of production of dried probiotic powders should be such that adequate numbers of viable probiotic bacteria are maintained in the dried powder following manufacture, and also retention/stability of probiotic properties should be ensured throughout shelf-life.

The Consultation agreed that there is not adequate information available on the stability of probiotics in powdered milk and little information is available on the issue of probiotic quality following spray drying. Cell damage and loss of viability of the probiotic culture occur during the spray drying process (Daemen and van der Stege, 1982; Gardiner et al., 2000). Thus improvements in spray drying methods are necessary to ensure better survival, including the use of protective agents which have been shown to enhance survival of lactobacilli (Prajapati et al., 1986; Selmer-Olsen et al., 1999) and environmental adaptation (Desmond et al., 2001). Probiotic stability during powder storage is inversely related to storage temperature (Gardiner et al., 2000), and methods have to be identified to address this. Although not published in the literature, certain companies producing starter cultures have the technology to produce freeze dried lactic acid bacteria including probiotics that are ‘stabilized’ and thus retain a high level of viability during drying and storage. The incorporation of such dried cultures into powdered milk may be the method of choice for preparing powdered milk products containing probiotics. However, research is needed including storage testing to confirm the feasibility of such a process.

Careful consideration should be given to factors such as the following, with respect to viability of the probiotic:

- Drying method

- Type of packaging

- Size of packaging

- Storage conditions (temperature, humidity, etc.)

- Powder milk quality (Standard reference)

- Rehydration procedure

- Handling of rehydrated product

8.4Prebiotics

Prebiotics as an area is distinct from probiotics and therefore, will not be covered in detail in this report. The Consultation recognizes both the potential benefits of prebiotics with respect to probiotics, in addition to their ability to stimulate indigenous beneficial bacteria in the host.

Prebiotics are generally defined as ‘nondigestible food ingredients that beneficially affect the host by selectively stimulating the growth and/or activity of one or a limited number of bacterial species already established in the colon, and thus in effect improve host health’ (Gibson and Roberfroid, 1995).

The concept of prebiotics essentially has the same aim as probiotics, which is to improve host health via modulation of the intestinal flora, although by a different mechanism. However, there are some cases in which prebiotics may be beneficial for the probiotic, especially with regard to bifidobacteria, that is the synbiotic concept. Synbiotics are defined as ‘mixtures of probiotics and prebiotics that beneficially affect the host by improving the survival and implantation of live microbial dietary supplements in the gastrointestinal tract of the host’ (Andersson et al., 2001). If a synbiotic relationship is intended, then it should be verified scientifically, following the guidelines outlined in Section 5 of this report.

9.Post Market Surveillance

The Consultation recommends that probiotic producers, medical professionals and public health officers consider some form of system to monitor the health outcomes of long-term probiotic administration. This is suggested as a means to gain insight into potential side effects as well as assess long-term benefits. A necessary prerequisite for surveillance is a proper trace-back system.

10.Conclusions

1. The experts agreed that adequate scientific evidence exists to indicate that there is potential for the derivation of health benefits from consuming food containing probiotics. However, it was felt that additional research data are needed to confirm a number of these health benefits in humans, applying a systematic approach and following the guidelines for the assessment of probiotics suggested in this report.

2. There is good evidence 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.

3. The health benefits for which probiotics can be applied include conditions such as gastrointestinal infections, certain bowel disorders, allergy, and urogenital infections, which afflict a large portion of the world’s population. The application of probiotics to prevent and treat these disorders should be more widely considered by the medical community.

4. In addition, there is emerging evidence to indicate that probiotics can be taken by otherwise healthy people as a means to prevent certain diseases and modulate host immunity.

5. The regulatory status of probiotics as a component in food is currently not established on an international basis. In only a few countries, regulatory procedures are in place or sufficiently developed to enable probiotic products to be allowed to describe specific health benefits.

11. Recommendations

1. Potential probiotic strains must be identified by methods including internationally accepted molecular techniques and named according to the International Code of Nomenclature, and strains should preferably be deposited in a reputable internationally recognized culture collection.

2. In order to be termed a probiotic, the probiotic microorganism must be able to confer defined health benefits on the host, as outlined in Section 5 of this Report, in the actual product vehicle that will be made available to humans.

3. There is a need for refinement of in vitro and in vivo tests to better predict the ability of probiotic microorganisms to function in humans.

4. There is a need for more statistically significant efficacy data in humans.

5. Good manufacturing practices must be applied with quality assurance, and shelf-life conditions established, and labeling made clear to include minimum dosage and verifiable health claims.

6. The regulatory status of probiotics as a component in food has to be established on an international level.

7. The Consultation recommends that a regulatory framework be established to better address issues related to probiotics including efficacy, safety, labelling, fraud and claims.

8. Probiotic products shown to confer defined health benefits on the host should be permitted to describe these specific health benefits.

9. Surveillance systems, including trace-back and post marketing surveillance, should be put in place to record and analyze any adverse events associated with probiotics in food. Such systems could also be used to monitor the long-term health benefits of probiotic strains.

10. Efforts should be made to make probiotic products more widely available, especially for relief work and populations at high risk of morbidity and mortality.

11. Further work is needed to address criteria and methodologies for probiotics.

12.List of Abbreviations

BV

Bacterial Vaginosis

CAC

Codex Alimentarius Commission

DNA

Deoxyribonucleic Acid

FAO

Food and Agriculture Organization of the United Nations

HACCP

Hazard Analysis Critical Control Point System

IgE

Immunoglobulin E

NK cells

Natural killer cells

ORS

Oral Rehydration Salts

PFGE

Pulse Field Gel Electrophoresis

RDP

Ribosomal Database Project

RNA

Ribonucleic Acid

sIgA

Secretory Immunoglobulin A

TH1

T helper lymphocytes 1

TH2

T helper lymphocytes 2

UTI

Urinary Tract Infection

WHO

World Health Organization

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69. Mitsuoka T (1992): Intestinal flora and ageing. Nutr Rev, 50: 438-46.

70. Morelli L (2000): In vitro selection of probiotic lactobacilli: A critical appraisal. Curr Issues Intestinal Microbiol, 1: 59-67.

71. Naidu AS, Biblack WR, Clemens RA (1999): Probiotic spectra of lactic acid bacteria (LAB). Crit Revs Food Sci & Nutr, 39: 13-126.

72. Noble WC, Virani Z, Cree RG (1992): Co-transfer of vancomycin and other resistance genes from Enterococcus faecalis NCTC 12201 to Staphylococcus aureus. FEMS Microbiol Lett, 72: 195-8.

73. Oatley JT, Rarick MD, Ji GE, Linz JE (2000): Binding of aflatoxin B1 to bifidobacteria in vitro. J Food Prot, 63: 1133-6.

74. Ogawa M, Shimizu K, Nomoto K, Takahashi M, Watanuki M, Tanaka R, Tanaka T, Hamabata T, Yamasaki S, Takeda Y (2001): Protective effect of Lactobacillus casei strain Shirota on Shiga toxin-producing Escherichia coli O157:H7 infection in infant rabbits. Infect Immun, 69: 1101-8.

75. Oxman T, Shapira M, Klein R, Avazov N, Rabinowitz B (2001): Oral administration of Lactobacillus induces cardioprotection. J Altern Complement Med, 7(4): 345-354.

76. Perdigon G, Vintini E, Alvarez S, Medina M, Medici M (1999): Study of the possible mechanisms involved in the mucosal immune system activation by lactic acid bacteria. J. Dairy Sci, 82(6): 1108-14.

77. Perdone CA, Bernabeu AO, Postaire ER, Bouley CF, Reinert P (1999): The effect of supplementation by Lactobacillus casei (strain DN-114 001) on accute diarrhea in children attending day care centers. Int J Clin Pract, 53: 179-184.

78. Prajapati JB, Shah RK, Dave JM (1986): Nutritional and therapeutic benefits of a blended spray dried acidophilus preparation. Aust J Dairy Technol, 42: 17-21.

79. Reid G, Bruce AW (2001): Selection of Lactobacillus strains for urogenital probiotic applications. J Infect Dis, 183(S1): S77-80.

80. Reid G, Bruce AW, Taylor M (1995): Instillation of Lactobacillus and stimulation of indigenous organisms to prevent recurrence of urinary tract infections. Microecol Ther, 23: 32-45.

81. Reid G, Bruce AW, Fraser N, Heinemann C, Owen J, Henning B (2001a): Oral probiotics can resolve urogenital infections. FEMS Microbiol Immunol, 30: 49-52.

82. Reid G, Beuerman D, Heinemann C, Bruce AW (2001b): Effect of oral probiotic Lactobacillus therapy on the vaginal flora and susceptibility to urogenital infections. FEMS Immunol Med Microbiol, (in press).

83. Reid G, Zalai C, Gardiner G (2001c): Urogenital lactobacilli probiotics, reliability and regulatory issues. J. Dairy Sci, 84(E Suppl): E164-169.

84. Saavedra JM, Bauman NA, Oung I, Perman JA, Yolken RH (1994): Feeding of Bifidobacterium bifidum and Streptococcus thermophilus to infants in hospital for prevention of diarrhea and shedding of rotavirus. Lancet, 344: 1046-9.

85. Salminen S, von Wright A, Morelli L, Marteau P, Brassart D, de Vos WM, Fonden R, Saxelin M, Collins K, Mogensen G, Birkeland SE, Mattila-Sandholm T (1998): Demonstration of safety of probiotics -A review. Int J Food Microbiol, 44(1-2): 93-106.

86. Salminen MK, Järvinen A, Saxelin M, Tynkkynen S, Rautelin H, Valtonen V (2001): Increasing consumption of Lactobacillus GG as a probiotic and the incidence of lactobacilli bacteraemia in Finland. Clin Microbiol Infect, 7: (Suppl 1) 802.

87. Saxelin M, Rautelin H, Salminen S, Mäkelä, PH (1996): The safety of commercial products with viable Lactobacillus strains. Infect Dis Clin Pract, 5(5): 331-335.

88. Selmer-Olsen E, Sorhaug T, Birkeland SE, Pehrson R (1999): Survival of Lb. helveticus entrapped in calcium alginate in relation to water content, storage and rehydration. J Ind Microbiol Biotech, 23: 79-85.

89. Shanahan F (2000): Probiotics and inflammatory bowel disease: Is there a scientific rationale? Inflamm Bowel Dis, 6: 107-15.

90. Shlaes DM, Al-Obeid S, Shlaes JH, Boisivon A, Williamson R (1989): Inducible, transferable resistance to vancomycin in Enterococcus faecium, D399. Antimicrob Chemother, 23: 503-8.

91. Sheih YH, Chiang BL, Wang LH, Chuh LK and Gill HS (2001): Systemic immunity-enhancing effect in healthy subjects following dietary consumption of the lactic acid bacterium Lactobacillus rhamnosus HN001. J Am Coll Nutr, 20: 149-156.

92. Shornikova AV, Isolauri E, Burkanova L, Lukovnikova S, Vesikari T (1997). A trial in the Karelian Republic of oral rehydration and Lactobacillus GG for treatment of acute diarrhea. Acta Paediatr, 86: 460-5.

93. Shu Q, Lin H, Rutherfurd KJ, Fenwick SG, Prasad J, Gopal PK, Gill HS (2000): Dietary Bifidobacterium lactis HN019 enhances resistance to oral Salmonella typhimurium infection in mice. Microbiol. Immunol, 44: 213 – 222.

94. Sieber R, Dietz UT (1998): Lactobacillus acidophilus and yogurt in the prevention and therapy of bacterial vaginosis. Int Dairy J, 8: 599-607.

95. Szajewska H, Kotowska M, Mrukowicz JZ, Armanska M, Mikolajczyk W (2001): Efficacy of Lactobacillus GG in prevention of nosocomial diarrhea in infants. J Pediatr, 138(3): 361-365.

96. Tannock GW (1999): Analysis of the intestinal microflora: A renaissance. Antonie van Leenwenhoek, 76: 265-278.

97. Tannock GW, Munro K, Harmsen HJ, Welling GW, Smart J, Gopal PK (2000): Analysis of fecal microflora of human subjects subjects consuming a probiotic product containing Lactobacillus rhamnosus DR20. Appl Environ Microbiol, 66: 2578-2588.

98. Tissier H (1906) : Traitement des infections intestinales par la méthode de la flore bactérienne de l'intestin. CR.Soc Biol, 60 : 359-361.

99. Vanderhoof JA, Whitney DB, Antonson DL, Hanner TL, Lupo JV, Young RJ (1999): Lactobacillus GG in the prevention of antibiotic-associated diarrhea in children. J Pediatr, 135: 564-568.

100. van der Waaij D, Berghuis-de Vries JM, Lekkerkerk–van der Wees, JEC (1971): Colonization resistance of the digestive tract in conventional and antibiotic-treated mice. J Hyg (Lond), 69: 405-11.

101. Vollaard EJ, Clasener HA (1994): Colonization resistance. Antimicrob Agents Chemother, 38: 409-14.

102. WHO (1995): The treatment of diarrhea - A manual for physicians and other senior health workers. WHO/CDR/95.3

103. Woodford N, Johnson AP, Morrison D, Speller DC (1995): Current perspectives on glycopeptide resistance. Clin Microbiol Rev, 8: 585-615.

[1] Water is included as a food

Annex 1

List of Participants

EXPERTS

ARAYA, Magdalena

Institute of Nutrition and Food Technology (INTA)

Macul 5540 – Macul

Santiago

CHILE

Tel: +56 2 678 1468

Fax: +56 2 221 4030

E-mail: maraya@uec.inta.uchile.cl

GOPAL, Pramod

Senior Research Scientist

New Zealand Dairy Research Institute

Palmerston North

NEW ZEALAND

Tel: +64 6 350 4600

Fax: +64 6 356 1476

E-mail: pramod.gopal@nzdri.org.nz

LINDGREN, Sven E.

Swedish National Food Administration

Hamnesplanaden 5 75126 Uppsala

SWEDEN

Tel: +46 181 75606

Fax: +46 181 05848

E-mail: svli@slv.se

LODI, Roberta

Consiglio Nazionale delle Ricerche

Via Celoria 2

20133 Milano

ITALY

Tel: +39 02 583 56685

Fax: +39 02 583 56687

E-mail: R.Lodi@area.mi.cnr.it

OLIVER, Guillermo

CERELA

Chacabuco 145

(4000) Tucuman

ARGENTINA

Tel: +54 0381 4311720/4310465

Fax: +54 0381 4310465

E-mail: guillermo_oliver@hotmail.com

SAXELIN, Maija-(Liisa)

Valio Ltd.

Meijeritie 4A

00039 Helsinki,

FINLAND

Tel: +35 810 3813111

Fax: +35 810 3813019

E-mail: maija.saxelin@valio.

SERVIN, Alain L.

Faculty of Pharmacy Paris XI

Research Unit INSERM 510

Châtenay – Malabry 92296

FRANCE

Tel: +33 1 46 83 56 61

Fax: +33 1 46 83 55 28

STANTON, Catherine (Rapporteur)

Teagasc, Dairy Products Research Center

Moorepark,

Fermoy, Co. Cork

IRELAND

Tel: +353 25 42442

Fax: +353 25 42340

E-mail: cstanton@moorepark.teagasc.ie

AUTHORS OF WORKING PAPERS

GILLILAND, Stanley E.

Oklahoma State University

Food and Agricultural Products Research and Technology Center

148 FAPC, Stillwater

Oklahoma 74078-6055

USA

Tel: +1 405 744 6071

Fax: +1 405 744 6313

E-mail: seg@okstate.edu

MORELLI, Lorenzo

Istituto di Microbiologia UCSC

Vía Emilia Parmense 84

29100 Piacenza

ITALY

Tel: +39 0523 599248

Fax: +39 0523 599246

E-mail: morelli@pc.unicatt.it

REID, Gregor (Chairperson)

Lawson Health Research Institute

268 Grosvenor St.

London, Ontario N6A 4V2

CANADA

Tel: +1 519 646 6100 65256

Fax: +1 519 646 6110

E-mail: gregor@uwo.ca

FAO/WHO SECRETARIAT

PINEIRO, Maya

Food Quality and Standards

Food and Nutrition Division

FAO

Via Delle Terme di Caracalla

Rome 00100

ITALY

Tel: +39 06 570 53308

Fax: +39 06 570 54593

E-mail: maya.pineiro@fao.org

SCHLUNDT, Jorgen

Food Safety Programme

WHO

20 Avenue Appia

Ch-1211 Geneva 27

SWITZERLAND

Tel: +41 22 791 3445

Fax: +41 22 791 4807

E-mail: schlundtj@who.int

Guidelines for the Evaluation of Probiotics in Food

Report of a Joint FAO/WHO Working Group on Drafting Guidelines for the Evaluation of Probiotics in Food

London, Ontario, Canada
30 April - 1 May 2002

The opinions expressed in this report are those of the participants of the Working Group and do not imply any opinion on the part of FAO and WHO

CONTENTS

1.Introduction

2.Scope

3.Guidelines for Probiotic

3.1Genus/species/strain

3.2In vitro tests to screen potential probiotics

3.3Safety considerations: Requirements for proof that a probiotic strain is safe and without contamination in its delivery form

3.4In vivo studies using animals and humans

3.5Health claims and labelling

4.Recommendations

5.List of abbreviations

6.References

Annex 1: List of Participants

Experts

FAO/WHO Secretariat

1.Introduction

The Joint FAO/WHO Expert Consultation on Evaluation of Health and Nutritional Properties of Probiotics in Food held in Córdoba, Argentina from 1 to 4 October, 2001 recognized that there is a need for guidelines to set out a systematic approach for the evaluation of probiotics in food leading to the substantiation of health claims. Consequently, a Working Group was convened by FAO/WHO to generate guidelines and recommend criteria and methodology for the evaluation of probiotics, and to identify and define what data need to be available to accurately substantiate health claims. The aims of the Working Group were to identify and outline the minimum requirements needed for probiotic status. Consequently, guidelines were prepared to meet this objective.

2.Scope

The report of the Joint FAO/WHO Expert Consultation on Evaluation of Health and Nutritional Properties of Probiotics in Food addressed probiotics in food, and excluded reference to the term biotherapeutic agents, and beneficial microorganisms not used in food (http://www.fao.org/ag/AGN/Probio/probio.htm). The Working Group adopted the same scope as the Expert Consultation, and specifically excluded genetically modified organisms (GMOs).

3.Guidelines for Probiotics

In order to claim that a food has a probiotic effect, the guidelines set forth in this report should be followed. A scheme outlining these guidelines for the evaluation of probiotics for food use is shown in Fig. 1. This was the basis for discussions and details are specified in the following sections of this report.

3.1.Genus/species/strain

It was recognized that it is necessary to know the genus and species of the probiotic strain. The current state of evidence suggests that probiotic effects are strain specific. Strain identity is important to link a strain to a specific health effect as well as to enable accurate surveillance and epidemiological studies. A possible exception is the ability in general of S. themophilus and L. delbrueckii ssp. bulgaricus to enhance lactose digestion in lactose intolerant individuals. In this case, or in other cases where there is suitable scientific substantiation of health benefits that are not strain specific, individual strain identity is not critical.

Speciation of the bacteria must be established using the most current, valid methodology. It is recommended that a combination of phenotypic and genetic tests be used.

Nomenclature of the bacteria must conform to the current, scientifically recognized names. Protracted use of older or misleading nomenclature is not acceptable on product labels. The use of incorrect names does not properly identify the probiotic bacterium in the product and forces consumers and regulatory agencies to make assumptions about the identity of the real bacterium being sold. Current nomenclature can be retrieved as follows:

- Approved Lists of Bacterial Names (Int. J. Syst. Bacteriol, 1980,30:225-420) also available in http://www.bacterio.cict.fr/

- Validation Lists, published in the International Journal of Systematic and Evolutionary Microbiology (or International Journal of Systematic Bacteriology, prior to 2000)

DNA-DNA hybridization is the reference method to specify that a strain belongs to a species; however, as it is time consuming and beyond the resources of many laboratories, requiring a large collection of reference strains, the use of DNA sequences encoding 16S rRNA is suggested as a suitable substitute. In this case, it is recommended that this genotypic technique be combined with phenotypic tests for confirmation.

Patterns generated from the fermentation of a range of sugars and final fermentation products obtained from glucose utilization are key phenotypes that should be investigated for identification purposes.

Strain typing has to be performed with a reproducible genetic method or using a unique phenotypic trait. Pulsed Field Gel Electrophoresis (PFGE) is the gold standard. Randomly Amplified Polymorphic DNA (RAPD) can also be used, but is less reproducible. Determination of the presence of extrachromosomal genetic elements, such as plasmids can contribute to strain typing and characterization.

It is recommended that all strains be deposited in an internationally recognized culture collection.

3.2.In vitro tests to screen potential probiotics

In vitro tests are critical to assess the safety of probiotic microbes (see Section 3.3).

In addition, in vitro tests are useful to gain knowledge of strains and the mechanism of the probiotic effect. However, it was noted that the currently available tests are not fully adequate to predict the functionality of probiotic microorganisms in the human body. It was also noted that in vitro data available for particular strains are not sufficient for describing them as probiotic. Probiotics for human use will require substantiation of efficacy with human trials. Appropriate target-specific in vitro tests that correlate with in vivo results are recommended. For example, in vitro bile salts resistance was shown to correlate with gastric survival in vivo (Conway et al., 1987). A list of the main currently in vitro tests used for the study of probiotic strains is shown in Table 1. All of these tests require validation, however, with in vivo performance.

3.3.Safety considerations: Requirements for proof that a probiotic strain is safe and without contamination in its delivery form

Historically, lactobacilli and bifidobacteria associated with food have been considered to be safe (Adams & Marteau, 1995). Their occurrence as normal commensals of the mammalian flora and their established safe use in a diversity of foods and supplement products worldwide supports this conclusion. However, probiotics may theoretically be responsible for four types of side-effects (Marteau, 2002):

1. Systemic infections

2. Deleterious metabolic activities

3. Excessive immune stimulation in susceptible individuals

4. Gene transfer

Documented correlations between systemic infections and probiotic consumption are few and all occurred in patients with underlying medical conditions. The following is a list (including some microbes used in non-food applications) of infections reported to be associated (although not necessarily proven) with the consumption of commercial products:

- Two cases of L. rhamnosus traced to possible probiotic consumption (Rautio et al., 1999; Mackay et al., 1999).

- Thirteen cases of Saccharomyces fungemia due to vascular catheter contamination (Hennequin et al., 2000).

- Bacillus infections linked to probiotic consumption include three reports (Spinosa et al., 2000; Oggioni et al., 1998; Richard et al., 1988) detailing seven cases of B. subtilis bacteremia, septicemia and cholangitis, all in patients with underlying disease.

No cases of infections from Bifidobacterium have been reported. Enterococcus is emerging as an important cause of nosocomial infections and isolates are increasingly vancomycin resistant. The Working Group recognizes that some strains of Enterococcus display probiotic properties, and may not at the point of inclusion in a product display vancomycin resistance. However, the onus is on the producer to prove that any given probiotic strain is not a significant risk with regard to transferable antibiotic resistance or other opportunistic virulence properties.

In recognition of the importance of assuring safety, even among a group of bacteria that is Generally Recognized as Safe (GRAS), the Working Group recommends that probiotic strains be characterized at a minimum with the following tests:

1. Determination of antibiotic resistance patterns;

2. Assessment of certain metabolic activities (e.g., D-lactate production, bile salt deconjugation);

3. Assessment of side-effects during human studies;

4. Epidemiological surveillance of adverse incidents in consumers (post-market);

5. If the strain under evaluation belongs to a species that is a known mammalian toxin producer, it must be tested for toxin production. One possible scheme for testing toxin production has been recommended by the EU Scientific Committee on Animal Nutrition (SCAN, 2000);

6. If the strain under evaluation belongs to a species with known hemolytic potential, determination of hemolytic activity is required.

Assessment of lack of infectivity by a probiotic strain in immunocompromized animals would add a measure of confidence in the safety of the probiotic.

3.4. In vivo studies using animals and humans

In some cases, animal models exist to provide substantiation of in vitro effects and determination of probiotic mechanism. Where appropriate, the Working Group encourages use of these prior to human trials.

The principal outcome of efficacy studies on probiotics should be proven benefits in human trials, such as statistically and biologically significant improvement in condition, symptoms, signs, well-being or quality of life; reduced risk of disease or longer time to next occurrence; or faster recovery from illness. Each should have a proven correlation with the probiotic tested.

Probiotics have been tested for an impact on a variety of clinical conditions (see Expert Consultation Report, Section 5.3). Standard methods for clinical evaluations are comprised of Phase 1 (safety), Phase 2 (efficacy), Phase 3 (effectiveness) and Phase 4 (surveillance). Phase 1 studies focused on safety are discussed in Section 3.3 above. Phase 2 studies, generally in the form of randomized, double blind, placebo-controlled (DBPC) design, measure efficacy compared with placebo. In addition, phase 2 studies measure adverse effects. A general recommendation for the testing of probiotic foods is that the placebo would be comprised of the food carrier devoid of the test probiotic. Sample size needs to be calculated for specific endpoints. Statistically significant differences must apply to biologically relevant outcomes.

Probiotics delivered in food generally are not tested in Phase 3 studies, which are concerned with comparison with a standard therapy. When a claim is made for a probiotic altering a disease state, the claim should be made based on sound scientific evidence in human subjects.

In Phase 2 and 3 studies, the Working Group recognizes the value of validated quality of life assessment tools.

It is recommended that human trials be repeated by more than one Center for confirmation of results.

No adverse effects related to probiotic administration should be experienced when food is considered. Adverse effects should be monitored and incidents reported.

The Working Group recommends that information accumulated to show that a strain(s) is a probiotic, including clinical trial evidence be published in peer-reviewed scientific or medical journals. Furthermore, publication of negative results is encouraged as these contribute to the totality of the evidence to support probiotic efficacy.

Further information on the generation and use of clinical information to substantiate health effects can be found at www.ftc.gov/bcp/conline/pubs/buspubs/dietsupp.htm#IIb

3.5Health claims and labelling

Currently in most countries, only general health claims are allowed on foods containing probiotics. The Working Group recommends that specific health claims on foods be allowed relating to the use of probiotics, where sufficient scientific evidence is available, as per the guidelines set forth in this report. Such specific health claims should be permitted on the label and promotional material. For example, a specific claim that states that a probiotic ‘reduces the incidence and severity of rotavirus diarrhea in infants’ would be more informative to the consumer than a general claim that states ‘improves gut health’. This would better comply with Codex General Guidelines on Claims (CAC/GL 1-1979 (Rev. 1-1991) to avoid misleading information.

It is recommended that it be the responsibility of the product manufacturer that an independent third party review by scientific experts in the field be conducted to establish that health claims are truthful and not misleading.

The Working Group recommends that the following information be described on the label:

- Genus, species and strain designation. Strain designation should not mislead consumers about the functionality of the strain

- Minimum viable numbers of each probiotic strain at the end of the shelf-life

- The suggested serving size must deliver the effective dose of probiotics related to the health claim

- Health claim(s)

- Proper storage conditions

- Corporate contact details for consumer information

4.Recommendations

1. Adoption of the definition of probiotics as ‘Live microorganisms which when administered in adequate amounts confer a health benefit on the host’.

2. Use and adoption of the guidelines in this report should be a prerequisite for calling a bacterial strain ‘probiotic’.

3. Regulatory framework to allow specific health claims on probiotic food labels, in cases where scientific evidence exists, as per the guidelines set forth in this report.

4. Promotion of these guidelines at an international level.

5. Good manufacturing practices (GMP) must be applied in the manufacture of probiotic foods with quality assurance, and shelf-life conditions established.

6. Further development of methods (in vitro and in vivo) to evaluate the functionality and safety of probiotics.

5.List of Abbreviations

CAC/GL

Codex Alimentarius Commission/General Guidelines on Claims

DBPC

Double blind, randomized, placebo-controlled

DNA

Deoxyribonucleic Acid

FAO

Food and Agriculture Organization of the United Nations

GMO

Genetically Modified Organism

GMP

Good manufacturing practices

GRAS

Generally Recognized as Safe

PFGE

Pulsed Field Gel Electrophoresis

RNA

Ribonucleic Acid

RAPD

Randomly Amplified Polymorphic DNA

SCAN

EU Scientific Committee on Animal Nutrition

WHO

World Health Organization

6.References

1. Adams MR, Marteau P (1995): On the safety of lactic acid bacteria. Int J Food Micro, 27: 263-264.

2. Conway PL, Gorbach SL, Goldin BR (1987): Survival of lactic acid bacteria in the human stomach and adhesion to intestinal cells. J Dairy Sci, 70: 1-12.

3. Hennequin C, Kauffmann-Lacroix C, Jobert A, Viard JP, Ricour C, Jacquemin JL, Berche P (2000): Possible role of catheters in Saccharomyces boulardii fungemia. Eur J Clin Microbiol Infect Dis, 19: 16-20.

4. Mackay AD, Taylor MB, Kibbler CC, Hamilton-Miller JMT (1999): Lactobacillus endocarditis caused by a probiotic organism. Clin Microbiol Infect, 5: 290-292.

5. Marteau P (2002): Safety aspects of probiotic products. Scand J Nutr, (In Press).

6. Oggioni MR, Pozzi G, Balensin PE, Galieni P, Bigazzi C (1998): Recurrent septicemia in an immunocompromised patient due to probiotic strains of Bacillus subtilis. J Clin Microbiol, 36: 325-326.

7. Rautio M, Jousimies-Somer H, Kauma H, Pietarinen I, Saxelin M, Tynkkynen S, Koskela M (1999): Liver abscess due to a Lactobacillus rhamnosus strain indistinguishable from L. rhamnosus strain GG. Clin Infect Dis, 28: 1159-60.

8. Richard V, Auwera P, Snoeck R, Daneau D, Meunier F (1988): Nosocomial bacteremia caused by Bacillus species. Eur J Clin Microbiol Infect Dis, 7: 783-785.

9. SCAN (2000): Report of the Scientific Committee on Animal Nutrition on the Safety of Use of Bacillus Species in Animal Nutrition. European Commission Health & Consumer Protection Directorate-General. > http://europa.eu.int/comm/food/fs/sc/scan/out41.pdf

10. Spinosa MR, Wallet F, Courcol RJ, Oggioni MR (2000): The trouble in tracing opportunistic pathogens: cholangitis due to Bacillus in a French hospital caused by a strain related to an Italian probiotic? Microb Ecol Health Dis, 12: 99-101.

Annex 1

List of Participants

EXPERTS

ARAYA, Magdalena, Institute of Nutrition and Food Technology (INTA),

Macul 5540 – Macul, Santiago, Chile

Tel: +56 2 678 1468

Fax: +56 2 221 4030

E-mail: maraya@uec.inta.uchile.cl

MORELLI, Lorenzo, Istituto di Microbiologia UCSC,

Vía Emilia Parmense 84, 29100 Piacenza, Italy

Tel: +39 0523 599248

Fax: +39 0523 599246

E-mail: morelli@pc.unicatt.it

REID, Gregor, Lawson Health Research Institute,

268 Grosvenor St, London, Ontario N6A 4V2, Canada (Chairperson)

Tel: +1 519 646 6100 x 65256

Fax: +1 519 646 6110

E-mail: gregor@uwo.ca

SANDERS, Mary Ellen, Dairy and Food Culture Technologies,

7119 S. Glencoe Ct., Centennial, CO 80122, USA

Tel: +1 303 793 9974

Fax: +1 303 771 6201

E-mail: mesanders@msn.com

STANTON, Catherine, Teagasc, Dairy Products Research Centre, Moorepark, Fermoy,

Co Cork, Ireland (Rapporteur)

Tel: +353 25 42442

Fax: +353 25 42340

E-mail: cstanton@moorepark.teagasc.ie

FAO/WHO SECRETARIAT

PINEIRO, Maya, Food Quality and Standards, Food and Nutrition Division, FAO,

Via Delle Terme di Caracalla, Rome 00100, Italy

Tel: +39 06 570 53308

Fax: +39 06 570 54593

E-mail: maya.pineiro@fao.org

BEN EMBAREK, Peter, Food Safety Program, WHO,

20, Avenue Appia, CH-1211 Geneva 27, Switzerland

Tel: +41 22 791 42 04

Fax: +41 22 791 48 07

E-mail: benembarekp@who.int

FAO TECHNICAL PAPERS

FAO FOOD AND NUTRITION PAPERS

1/1

Review of food consumption surveys 1977 – Vol. 1. Europe, North America, Oceania, 1977 (E)

1/2

Review of food consumption surveys 1977 – Vol. 2. Africa, Latin America, Near East, Far East, 1979 (E)

2

Report of the joint FAO/WHO/UNEP conference on mycotoxins, 1977 (E F S)

3

Report of a joint FAO/WHO expert consultation on dietary fats and oils in human nutrition, 1977 (E F S)

4

JECFA specifications for identity and purity of thickening agents, anticaking agents, antimicrobials, antioxidants and emulsifiers, 1978 (E)

5

JECFA – guide to specifications, 1978 (E F)

5 Rev. 1

JECFA – guide to specifications, 1983 (E F)

5 Rev. 2

JECFA – guide to specifications, 1991 (E)

6

The feeding of workers in developing countries, 1976 (E S)

7

JECFA specifications for identity and purity of food colours, enzyme preparations and other food additives, 1978 (E F)

8

Women in food production, food handling and nutrition, 1979 (E F S)

9

Arsenic and tin in foods: reviews of commonly used methods of analysis, 1979 (E)

10

Prevention of mycotoxins, 1979 (E F S)

11

The economic value of breast-feeding, 1979 (E F)

12

JECFA specifications for identity and purity of food colours, flavouring agents and other food additives, 1979 (E F)

13

Perspective on mycotoxins, 1979 (E F S)

14

Manuals of food quality control:

14/1

Food control laboratory, 1979 (Ar E)

14/1 Rev. 1

The food control laboratory, 1986 (E)

14/2

Additives, contaminants, techniques, 1980 (E)

14/3

Commodities, 1979 (E)

14/4

Microbiological analysis, 1979 (E F S)

14/5

Food inspection, 1981 (Ar E) (Rev. 1984, E S)

14/6

Food for export, 1979 (E S)

14/6 Rev. 1

Food for export, 1990 (E S)

14/7

Food analysis: general techniques, additives, contaminants and composition, 1986 (C E)

14/8

Food analysis: quality, adulteration and tests of identity, 1986 (E)

14/9

Introduction to food sampling, 1988 (Ar C E F S)

14/10

Training in mycotoxins analysis, 1990 (E S)

14/11

Management of food control programmes, 1991 (E)

14/12

Quality assurance in the food control microbiological laboratory, 1992 (E F S)

14/13

Pesticide residue analysis in the food control laboratory, 1993 (E F)

14/14

Quality assurance in the food control chemical laboratory, 1993 (E)

14/15

Imported food inspection, 1993 (E F)

14/16

Radionuclides in food, 1994 (E)

14/17

Unacceptable visible can defects – a pictorial manual, 1998 (E F S)

15

Carbohydrates in human nutrition, 1980 (E F S)

16

Analysis of food consumption survey data for developing countries, 1980 (E F S)

17

JECFA specifications for identity and purity of sweetening agents, emulsifying agents, flavouring agents and other food additives, 1980 (E F)

18

Bibliography of food consumption surveys, 1981 (E)

18 Rev. 1

Bibliography of food consumption surveys, 1984 (E)

18 Rev. 2

Bibliography of food consumption surveys, 1987 (E)

18 Rev. 3

Bibliography of food consumption surveys, 1990 (E)

19

JECFA specifications for identity and purity of carrier solvents, emulsifiers and stabilizers, enzyme preparations, flavouring agents, food colours, sweetening agents and other food additives, 1981 (E F)

20

Legumes in human nutrition, 1982 (E F S)

21

Mycotoxin surveillance – a guideline, 1982 (E)

22

Guidelines for agricultural training curricula in Africa, 1982 (E F)

23

Management of group feeding programmes, 1982 (E F P S)

23 Rev. 1

Food and nutrition in the management of group feeding programmes, 1993 (E F S)

24

Evaluation of nutrition interventions, 1982 (E)

25

JECFA specifications for identity and purity of buffering agents, salts; emulsifiers, thickening agents, stabilizers; flavouring agents, food colours, sweetening agents and miscellaneous food additives, 1982 (E F)

26

Food composition tables for the Near East, 1983 (E)

27

Review of food consumption surveys 1981, 1983 (E)

28

JECFA specifications for identity and purity of buffering agents, salts, emulsifiers, stabilizers, thickening agents, extraction solvents, flavouring agents, sweetening agents and miscellaneous food additives, 1983 (E F)

29

Post-harvest losses in quality of food grains, 1983 (E F)

30

FAO/WHO food additives data system, 1984 (E)

30 Rev. 1

FAO/WHO food additives data system, 1985 (E)

31/1

JECFA specifications for identity and purity of food colours, 1984 (E F)

31/2

JECFA specifications for identity and purity of food additives, 1984 (E F)

32

Residues of veterinary drugs in foods, 1985 (E/F/S)

33

Nutritional implications of food aid: an annotated bibliography, 1985 (E)

34

JECFA specifications for identity and purity of certain food additives, 1986 (E F)

35

Review of food consumption surveys 1985, 1986 (E)

36

Guidelines for can manufacturers and food canners, 1986 (E)

37

JECFA specifications for identity and purity of certain food additives, 1986 (E F)

38

JECFA specifications for identity and purity of certain food additives, 1988 (E)

39

Quality control in fruit and vegetable processing, 1988 (E F S)

40

Directory of food and nutrition institutions in the Near East, 1987 (E)

41

Residues of some veterinary drugs in animals and foods, 1988 (E)

41/2

Residues of some veterinary drugs in animals and foods. Thirty-fourth meeting of the joint FAO/WHO Expert Committee on Food Additives, 1990 (E)

41/3

Residues of some veterinary drugs in animals and foods. Thirty-sixth meeting of the joint FAO/WHO Expert Committee on Food Additives, 1991 (E)

41/4

Residues of some veterinary drugs in animals and foods. Thirty-eighth meeting of the joint FAO/WHO Expert Committee on Food Additives, 1991 (E)

41/5

Residues of some veterinary drugs in animals and foods. Fortieth meeting of the Joint FAO/WHO Expert Committee on Food Additives, 1993 (E)

41/6

Residues of some veterinary drugs in animals and foods. Forty-second meeting of the Joint FAO/WHO Expert Committee on Food Additives, 1994 (E)

41/7

Residues of some veterinary drugs in animals and foods. Forty-third meeting of the Joint FAO/WHO Expert Committee on Food Additives, 1994 (E)

41/8

Residues of some veterinary drugs in animals and foods. Forty-fifth meeting of the Joint FAO/WHO Expert Committee on Food Additives, 1996 (E)

41/9

Residues of some veterinary drugs in animals and foods. Forty-seventh meeting of the Joint FAO/ WHO Expert Committee on Food Additives, 1997 (E)

41/10

Residues of some veterinary drugs in animals and foods. Forty-eighth meeting of the Joint FAO/WHO Expert Committee on Food Additives, 1998 (E)

41/11

Residues of some veterinary drugs in animals and foods. Fiftieth meeting of the Joint FAO/WHO Expert Committee on Food Additives, 1999 (E)

41/12

Residues of some veterinary drugs in animals and foods. Fifty-second meeting of the Joint FAO/WHO Expert Committee on Food Additives, 2000 (E)

41/13

Residues of some veterinary drugs in animals and foods. Fifty-forth meeting of the Joint FAO/WHO Expert Committee on Food Additives, 2000 (E)

41/14

Residues of some veterinary drugs in animals and foods. Fifty-eighth meeting of the Joint FAO/WHO Expert Committee on Food Additives, 2002 (E)

41/15

Residues of some veterinary drugs in animals and foods. Sixtieth meeting of the Joint FAO/WHO Expert Committee on Food Additives, 2003 (E)

41/16

Residues of some veterinary drugs in animals and foods. Monographs prepared by the sixty-second meeting of the Joint FAO/WHO Expert Committee on Food Additives, 2004 (E)

42

Traditional food plants, 1988 (E)

42/1

Edible plants of Uganda. The value of wild and cultivated plants as food, 1989 (E)

43

Guidelines for agricultural training curricula in Arab countries, 1988 (Ar)

44

Review of food consumption surveys 1988, 1988 (E)

45

Exposure of infants and children to lead, 1989 (E)

46

Street foods, 1990 (E/F/S)

47/1

Utilization of tropical foods: cereals, 1989 (E F S)

47/2

Utilization of tropical foods: roots and tubers, 1989 (E F S)

47/3

Utilization of tropical foods: trees, 1989 (E F S)

47/4

Utilization of tropical foods: tropical beans, 1989 (E F S)

47/5

Utilization of tropical foods: tropical oil seeds, 1989 (E F S)

47/6

Utilization of tropical foods: sugars, spices and stimulants, 1989 (E F S)

47/7

Utilization of tropical foods: fruits and leaves, 1990 (E F S)

47/8

Utilization of tropical foods: animal products, 1990 (E F S)

48

Number not assigned

49

JECFA specifications for identity and purity of certain food additives, 1990 (E)

50

Traditional foods in the Near East, 1991 (E)

51

Protein quality evaluation. Report of the Joint FAO/WHO Expert Consultation, 1991(E F)

52/1

Compendium of food additive specifications – Vol. 1, 1993 (E)

52/2

Compendium of food additive specifications – Vol. 2, 1993 (E)

52 Add. 1

Compendium of food additive specifications – Addendum 1, 1992 (E)

52 Add. 2

Compendium of food additive specifications – Addendum 2, 1993 (E)

52 Add. 3

Compendium of food additive specifications – Addendum 3, 1995 (E)

52 Add. 4

Compendium of food additive specifications – Addendum 4, 1996 (E)

52 Add. 5

Compendium of food additive specifications – Addendum 5, 1997 (E)

52 Add. 6

Compendium of food additive specifications – Addendum 6, 1998 (E)

52 Add. 7

Compendium of food additive specifications – Addendum 7, 1999 (E)

52 Add. 8

Compendium of food additive specifications – Addendum 8, 2000 (E)

52 Add. 9

Compendium of food additive specifications – Addendum 9, 2001 (E)

52 Add. 10

Compendium of food additive specifications – Addendum 10, 2002 (E)

52 Add. 11

Compendium of food additive specifications – Addendum 11, 2003 (E)

52 Add. 12

Compendium of food additive specifications – Addendum 12, 2004 (E)

52 Add. 13

Compendium of food additive specifications – Addendum 13, 2005 (E)

53

Meat and meat products in human nutrition in developing countries, 1992 (E)

54

Number not assigned

55

Sampling plans for aflatoxin analysis in peanuts and corn, 1993 (E)

56

Body mass index – A measure of chronic energy deficiency in adults, 1994 (E F S)

57

Fats and oils in human nutrition, 1995 (Ar E F S)

58

The use of hazard analysis critical control point (HACCP) principles in food control, 1995 (E F S)

59

Nutrition education for the public, 1995 (E F S)

60

Food fortification: technology and quality control, 1996 (E)

61

Biotechnology and food safety, 1996 (E)

62

Nutrition education for the public – Discussion papers of the FAO Expert Consultation, 1996 (E)

63

Street foods, 1997 (E/F/S)

64

Worldwide regulations for mycotoxins 1995 – A compendium, 1997 (E)

65

Risk management and food safety, 1997 (E)

66

Carbohydrates in human nutrition, 1998 (E S)

67

Les activités nutritionnelles au niveau communautaire – Expériences dans les pays du Sahel, 1998 (F)

68

Validation of analytical methods for food control, 1998 (E)

69

Animal feeding and food safety, 1998 (E)

70

The application of risk communication to food standards and safety matters, 1999 (Ar C E F S)

71

Joint FAO/WHO Expert Consultation on Risk Assessment of Microbiological Hazards in Foods, 2004 (E F S)

72

Joint FAO/WHO Expert Consultation on Risk Assessment of Microbiological Hazards in Foods – Risk characterization of Salmonella spp. in eggs and broiler chickens and Listeria monocytogenes in ready-to-eat foods, 2001 (E F S)

73

Manual on the application of the HACCP system in mycotoxin prevention and control, 2001 (E F S)

74

Safety evaluation of certain mycotoxins in food, 2001 (E)

75

Risk assessment of Campylobacter spp. in broiler chickens and Vibrio spp. in seafood, 2003 (E)

76

Assuring food safety and quality – Guidelines for strengthening national food control systems, 2003 (E F S)

77

Food energy – Methods of analysis and conversion factors, 2003 (E)

78

Energy in human nutrition. Report of a Joint FAO/WHO/UNU Expert Consultation, 2003 (E). Issued as No. 1 in the FAO Food and Nutrition Technical Report Series entitled Human energy requirements, Report of a Joint FAO/WHO/UNU Expert Consultation, 2004 (E)

79

Safety assessment of foods derived from genetically modified animals, including fish, 2004 (E)

80

Marine biotoxins, 2004 (E)

81

Worldwide regulations for mycotoxins in food and feed in 2003, 2004 (C E F S)

82

Safety evaluation of certain contaminants in food, 2005 (E)

83

Globalization of food systems in developing countries: impact on food security and nutrition, 2004 (E)

84

The double burden of malnutrition – Case studies from six developing countries, 2006 (E)

85

Probiotics in food – Health and nutritional properties and guidelines for evaluation, 2006 (E)

Availability: May 2006

Ar – Arabic

C – Chinese

E – English

F – French

P – Portuguese

S – Spanish

Multil – Multilingual

*          Out of print

**        In preparation

The FAO Technical Papers are available through the authorized FAO Sales Agents or directly from Sales and Marketing Group, FAO, Viale delle Terme di Caracalla, 00100 Rome, Italy.