Probiotics are live microorganisms that, when administered in adequate amounts, confer a health benefit on the host.1 Scientific interest in probiotics has been increasing significantly since the beginning of the twenty-first century, due in part to the recent knowledge about the gut microbiota and its role in health and disease, but also due to the growth of the consumption and sales of probiotics. Today, probiotics are available as functional foods or supplements and as medications. The wide variety of commercial products with different presentations (capsules, tablets, envelopes, vials, foods, supplements, milk formulas, etc.) with varying doses and microbial compositions make the choice of a probiotic difficult in clinical practice.2

There are numerous clinical trials, meta-analyses, and systematic reviews that show the beneficial effect of probiotic use in gastrointestinal diseases.3,4 That scientific evidence supports the use of probiotics in the treatment of acute infectious diarrhea,5 in the prevention of antibiotic-associated diarrhea,6 in Clostridium difficile infection,7 in Helicobacter pylori eradication therapy,8–10 in the management of irritable bowel syndrome,11 ulcerative colitis,12 pouchitis,13 and in occult and overt hepatic encephalopathy.14 Other indications for probiotic use in gastroenterology, whose evidence is limited and requires further study, are infantile colic,15 diverticular disease of the colon,16 chronic functional constipation,17 radiation enteritis,18 necrotizing enterocolitis,19 gastrointestinal cancer, and fatty liver disease.20 Different guidelines and consensuses have been published on the use of probiotics in gastroenterology.

There are no studies in Mexico on the pattern of prescription and the clinical use of probiotics by gastroenterologists and specialists in clinical nutrition.

The aim of the present study was to investigate which probiotics are the most widely used, as well as finding out the indications for and recommendations of probiotics by Mexican gastroenterologists and nutritionists.

There were 997 (34.49%) responses to the 2,590 invitations sent requesting participation in the survey. A total of 382 gastroenterologists, 453 nutritionists, and 162 nurses, microbiologists, chemists, and others answered the questionnaire. Of the participants, 300 (30.09%) had no clinical activity or practice related to gastroenterology or nutrition, and so were excluded from the remaining questions of interest for the present study. The final sample consisted of 697 surveyed participants, of which 357 (51.21%) were gastroenterologists and 340 (48.78%) were nutritionists. The demographic data of the participants included in the study are shown in Table 1.

A total of 211 (64.92%) gastroenterologists and 245 (76.08%) nutritionists (p=0.002) knew the definition of probiotics, according to the United Nations Food and Agriculture Organization (FAO). Figure 1 shows the distribution of the frequency with which the survey participants recommended the use of probiotics.

Figure 1.

Frequency of recommendations of probiotics by gastroenterologists and nutritionists.

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The majority of gastroenterologists (56.5%) and only 35.5% of the nutritionists recommended probiotic use because they considered them effective in the treatment of diseases. The majority of the nutritionists (39%) and only 21.5% of gastroenterologists considered probiotics necessary for maintaining a good state of health.

More than 97% of the those surveyed were completely or partially in agreement with the use of probiotics to manage symptoms and gastrointestinal diseases (fig. 2). More than 80% of the survey participants of both groups considered probiotics useful for treating irritable bowel syndrome, acute diarrhea, and antibiotic-associated diarrhea. They did not consider them useful in the treatment of ulcerative colitis, Crohn's disease, pouchitis, radiation enteritis, necrotizing enterocolitis, or infantile colic. The majority of gastroenterologists recommended probiotics for the treatment of pseudomembranous colitis due to Clostridium difficile infection and only 52.04% of the nutritionists considered probiotics useful in that pathology. A total of 83.49% of the nutritionists and 65.01% of the gastroenterologists recommended probiotics for the treatment of chronic constipation.

Figure 2.

Awareness of the evidence that supports the use of probiotics in the different gastrointestinal diseases.

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The most important characteristics considered by the gastroenterologists and nutritionists for prescribing a probiotic are shown in Table 2. The strain tested in a clinical study for the symptom or specific disease was the most important characteristic for prescribing a probiotic for 141 (44.33%) gastroenterologists and 106 (34.30%) nutritionists, with a significant difference between the groups (p=0.010).

More than 97% of those surveyed, from both groups, were in complete or partial agreement that probiotics were safe and did not present a health risk.

The main reason the surveyed participants did not recommend probiotics was cost for 19.7% of the gastroenterologists and 27.6% of the nutritionists, with a significant difference between the groups. Probiotics were not recommended by 18.8% of gastroenterologists because they considered there was not enough scientific evidence to support their use and by 7% because they were unaware of the scientific evidence on probiotic use (Table 3). A total of 147 (50.34%) gastroenterologists and 213 (66.14%) nutritionists stated that they personally consumed probiotics.

Tables 3 and 4 show the commercial probiotic products most recommended by the gastroenterologists and nutritionists, respectively. In addition, the percentage of surveyed participants that had knowledge of the probiotic strain contained in the recommended product were shown, as well as the percentage of surveyed participants that knew the commercial product but not the probiotic strain it contained, and the percentage of participants that knew neither the probiotic strain nor the commercial product. When the matrix question of the name of the commercial product and the matrix question of the probiotic strain were matched, no commercial product reached more than 80% of knowledge of the probiotic strain it contained.

In our study, we found that the majority of the gastroenterologists and nutritionists surveyed recommend the use of probiotics. The gastroenterologists consider probiotics useful in the treatment of gastrointestinal diseases and the nutritionists use them to prevent disease or maintain a good state of health. The results also showed that more than half of the participants surveyed consumed probiotics themselves. Those data suggest that the concept that probiotics are beneficial in relation to states of health and disease has spread among healthcare professionals. That could be due to an increase in the marketing and sales of probiotics worldwide and to a significant increase in the scientific evidence that supports the use of probiotics under conditions of health and disease.1,2 However, our results clearly show that both the gastroenterologists and nutritionists recommend commercial products with probiotics without taking the concept of strain specificity and clinical indication into account. In over 80% of the products recommended, the gastroenterologists and nutritionists did not know the probiotic strain it contained. That undesirable prescription pattern could cause therapeutic failure with probiotics.

In the present study, we found that the majority of the survey participants recommended the use of probiotics in infectious diarrhea and antibiotic-associated diarrhea. That result concurs with different controlled clinical trials and meta-analyses that have shown that probiotics are effective in those two conditions, with very good quality of evidence.5,6 Studies on the use of probiotics for treating C. difficile infection have demonstrated that some probiotic strains help prevent the infection, but do not cure it.21,22 Half of the gastroenterologists surveyed recommended probiotics in cases of said infection. With respect to irritable bowel syndrome and chronic constipation, probiotics have shown a beneficial effect, but the scientific evidence in those disorders is of moderate-to-low quality.23–25 The majority of the participants surveyed recommended the use of probiotics in irritable bowel syndrome and chronic constipation. In contrast, the gastroenterologists and nutritionists did not prescribe probiotics in ulcerative colitis, Crohn's disease, diverticulosis, radiation enteritis, or infantile colic. Those findings suggest that there is a partial lack of knowledge in the gastroenterology and nutrition communities about the scientific evidence and clinical guidelines published on the use of probiotics in different gastrointestinal conditions.

Regarding the safety of probiotics, almost all the participants surveyed considered probiotics to be safe. Even though the literature contains reports of a very limited number of cases of bacteremia due to Lactobacilli, and fungemia due to yeasts, in patients with central vein catheters or that are immunosuppressed, in general, probiotics are recognized to be a safe therapeutic tool, with no major adverse events.26

One of the limitations of our study was the low response rate to the online survey (30%), which did not allow us to generalize the conclusions to the entire population of gastroenterologists and nutritionists in Mexico. Another was the fact that the questionnaire was not internally and externally validated. Nevertheless, a considerable number of gastroenterologists and nutritionists were surveyed, and an attempt was made to include the most relevant items in the questionnaire to become aware of the probiotic prescription pattern.

We conclude that gastroenterologists and nutritionists in Mexico understand the concept of probiotics and the majority consider them to be beneficial under conditions of health and disease. However, there is a partial lack of knowledge of the scientific evidence and clinical guidelines on the efficacy of probiotics in digestive disorders. Products with probiotics are recommended without knowing the probiotic strains they contain. Programs of continuous medical education and diffusion of the clinical guidelines are required for the appropriate use of probiotics in Mexico.

No financial support was received in relation to this study/article.

Miguel A. Valdovinos Díaz is a Member of the Advisory Board of Biocodex, Sanofi, Menarini, Mayoly-Spindler, and Takeda. He is a Speaker for Takeda, Ferrer, Sanofi, Menarini, Mayoly-Spindler, Columbia, Biocodex, and Carnot.

Ana Teresa Abreu y Abreu is a Member of the Advisory Board of the Sanofi, Takeda, and Mayoly-Spindler laboratories. She is a Speaker for Takeda, Sanofi, Mayoly-Spindler, Alfa Wassermann, Carnot, and Biocodex.

Luis Raúl Valdovinos García declares that he has no conflict of interest.