Probiotics and Antibiotic-Associated Diarrhea

Antibiotics, used in the treatment of bacterial infections, are one of the most commonly prescribed medications in the world. A common side effect when taking antibiotics is antibiotic-associated diarrhea (AAD). This occurs in up to 25% of people taking antibiotics.

Why do antibiotics cause gastrointestinal problems? In addition to killing bacteria that cause illness, antibiotics also kill the beneficial bacteria that inhabit the bowel. A decrease in these good bacteria may lead to digestive problems, such as diarrhea, gas, and cramping. Another adverse effect from a reduction in good bacteria is that harmful bacteria are allowed to multiply and take their place. One of the most serious of these harmful bacterial is called Clostridium difficile. Overgrowth of these particular bacteria has been responsible for numerous hospitalizations and even deaths.

What are probiotics? Probiotics are live bacteria that are the same or similar to the good bacteria that live in the human body. They occur naturally in such foods as yogurt, buttermilk, and fermented foods, such as sauerkraut. Probiotics are also available as nutritional supplements. When ingested, probiotics take up residence in the intestines and are thought to provide a number of health benefits.

How do probiotics help to prevent AAD? A number of studies have demonstrated that probiotics, in particular products containing Lactobacillus, are effective in preventing AAD. They have specifically been shown to reduce the risk of developing Clostridium-associated diarrhea by up to 64%. They also appear to be helpful in reducing the incidence of other antibiotic-related side effects, such as gas and cramping. Probiotics are thought to work by replacing the beneficial bacteria that were killed during antibiotic treatment. It is conceivable that probiotics may one day be routinely coupled with a prescription for an antibiotic.

Where are probiotics obtained? Probiotics are considered to be dietary supplements and their sale is not under the regulation of the U.S. Food and Drug Administration (FDA). Probiotic manufacturers are responsible for seeing that they contain the purported types and amounts of bacteria, are safe, and achieve their advertised claims. Probiotics are marketed primarily as oral products such as capsules and in yogurt cultures and are sold in most grocery and health food stores. Activa yogurt, Nature's Bounty Extra Strength Probiotic Acidophilus, Truebiotics by One-a-day, and Naked Juice Probiotics are a few of the commercial preparations of probiotics available.

Do probiotics have other uses? In addition to preventing AAD, probiotics are also used in the treatment or prevention of other medical conditions such as recurrent urinary tract infections, irritable bowel syndrome and yeast infections. Since probiotic bacteria are already a normal part of the human flora, they are generally considered to be safe with very few side effects. People with an impaired immune system or who are severely debilitated, however, are advised to avoid taking them.

What's so bad about sugary drinks?

Sugar-sweetened beverages (SSBs) are those that contain added caloric sweeteners such as sucrose, high-fructose corn syrup, or fruit-juice concentrates. They include soft drinks, fruit drinks, sports drinks, sweetened iced tea, and lemonade. Findings from multiple scientific studies show a positive association between greater intakes of sugar sweetened beverages and weight gain in both children and adults. They may also increase risk of developing Type 2 diabetes mellitus and cardiovascular disease.

And the problem doesn't lie with SSBs alone. Quick, can you tell which has more sugar, a glass of cranberry juice or a cup of coffee with 2 packets of sugar? If you guessed the coffee, you'd be wrong since the cranberry juice has over 5 times as much sugar! The amount of sugar reported in 12 ounces of other popular drinks may surprise you too. In some cases, the beverages listed below are sweetened with added sugars, in other instances, as with orange juice, the beverage is naturally high in sugar:

• Coca-Cola® Classic---10 teaspoons of sugar (146 calories)
  
• Minute Maid® Orange Juice---10 teaspoons of sugar (165 calories)
  
• POM Wonderful® 100% Pomegranate Juice---14 teaspoons of sugar (240 calories)
  
• Sunny D® Tangy Original Style---10 teaspoons or sugar (180 calories)
  
• Welch's® 100% Grape Juice---15 teaspoons of sugar (255 calories)
  
• Red Bull®---10 teaspoons of sugar (165 calories)

What is the significance of all this? As mentioned previously, there is a strong relationship between the consumption of sugary drinks and the development of obesity, type 2 diabetes, and heart disease. Let's look at the connection between sugary drinks and these conditions further.

Obesity: The rising consumption of SSBs in the U.S. is a major contributor to the obesity epidemic. These beverages add calories to the diet without providing a significant amount of nutrients. Drinking a single sugar-sweetened soft drink per day could add up to 55,000 calories over the course of a year. If this added caloric load is not accompanied by an equal amount of energy expenditure through activity or exercise, it does little but contribute to weight gain. At approximately 100 calories burned per mile of walking, this would mean that you would have to walk an additional 550 miles over the course of a year to prevent these calories from being converted to fat.

Diabetes: Several studies have shown that SSBs contribute to the development of type 2 diabetes. The reason for this is not due to sugar itself, but rather to the weight gain from excessive calories in these drinks. A study involving over 90,000 female nurses found that drinking one or more servings a day of sugar-sweetened beverages resulting in a doubling of the likelihood for developing Type 2 diabetes.

Heart Disease:: Obesity and diabetes are well known risk factors for the development of heart disease. Since sugary drinks can contribute to the development of both of these, it stands to reason that heart disease risk would increase also. In fact, a study that followed over 40,000 men over 20 years found that those who drank one can of a sugary beverage per day had a 20% higher risk of having a heart attack or dying from a heart attack than men who rarely consumed sugary drinks. A similar association between the consumption of SSBs and heart disease was noted in the study of female nurses mentioned previously. In addition to the excess calories from sugar drinks, there is also concern that the high glycemic load and inflammatory factors associated with these beverages may contribute to the higher risk of heart disease.

The good news is that studies have also demonstrated that reducing sugary drink consumption can lead to better weight control among those who are overweight. By addressing obesity, the risks for developing diabetes and heart disease will go down also. While meeting constitutional opposition, efforts to reduce "supersizing" of soft drinks in New York State is an attempt to decrease the number of empty calories from SSBs. New labeling practices indicating the amount of exercise necessary to "burn" excess calories from sugary drinks is another way to encourage healthier beverage choices.

Heel Pain: Stone bruise, Bone Spur, or Something Else?

A great deal of heel pain is attributed to self-diagnosed causes, such as a heel spur or stone bruise, but a more common explanation is an inflammatory condition known as plantar fasciitis. The structure affected, the plantar fascia, is a ligament that connects the heel to the front of the foot and serves to support the arch of the foot The most common symptoms associated with plantar fasciitis are:

• Pain on the bottom of the foot toward the front of the heel.
  
• Pain when taking the few steps after getting out of bed in the morning or after a period of rest such as sitting in a chair.
  
• Heel pain that is worse after, instead of during, exercise or activity.
  

What causes plantar fasciitis? The function of the plantar fascia is to absorb the stress and impact placed on the feet when walking or running. With injury or overuse, the plantar fascia can be torn or damaged. Examples of how this could occur are when someone has to be on their feet for long periods of time while working or when someone is increasing their mileage while training for a marathon. Inflammation, the body's natural response to injury, sets in following the injury, leading to the classic symptoms of plantar fasciitis. Besides activity, other predisposing factors in the development of plantar fasciitis include flat feet, high arches, weight gain, and shoes that lack proper support.

Aren't heel spurs and plantar fasciitis the same thing? Approximately 10% of people with plantar fasciitis do develop heel spurs. These result from calcium deposits related to chronic inflammation. Most people with plantar fasciitis, however, do not have heel spurs, and many people with heel spurs seen on x-ray do not have plantar fasciitis. In any case, treatment of plantar fasciitis is directed toward the inflammation and predisposing factors, rather than toward the spur itself.

How is plantar fasciitis treated? The great majority of people with plantar fasciitis can be treated conservatively, that is, without surgery. The following are the most commonly employed self-care measures:

• Rest. Discomfort should be your guide in this regard. You should decrease or stop activities that are painful. If running causes pain, you may be able to walk or cycle instead. If this is an occupational injury, a temporary reassignment to a job that does not require as much time on the feet may be necessary. 
• Non-steroidal anti-inflammatory medications (NSAIDs), such as ibuprofen or naproxen, help to reduce inflammation and pain associated with plantar fasciitis. Generally, it is best to take the NSAIDs on a regular basis (2 to 4 times a day depending on the medication) but limit its use to a couple of weeks.
  
• Application of ice helps to reduce pain and inflammation. It is especially beneficial after activity or being on your feet. Typically an ice pack is applied to the heel region for 20 minutes or so. This can be done several times a day.
  
• Heel and foot stretching exercises. Tight hamstring muscles and heel cords often set the stage for the development of plantar fasciitis. Stretches, as described in this link, help to stretch these muscles and tendons, relieving tension on the plantar fascia. Stretching should be started once the pain has begun to resolve and is best performed several times each day.
  
• Silicone heel pads or heel cups can help by cushioning and redistributing pressure over the painful region of the heel. Off-the-shelf arch supports (shoe inserts) may also be helpful, particularly when flat feet have contributed to the development of the fasciitis.

While most people will improve with some combination of the above, a few will require more aggressive treatment. Physician-guided options beyond these self-care measures include: a) cortisone injection in the region of the plantar fascia attachment to the heel, b) iontophoresis, a physical therapy modality that uses electrical current to deliver cortisone to the inflamed fascia, c) nighttime splints that stretch the plantar fascia while sleeping, and d) extracorporeal shockwave therapy that uses high-energy shockwave impulses to stimulate healing of damaged plantar fascia tissue. Surgery to release the plantar fascia is rarely required, and is usually reserved for those in whom the above treatments were unsuccessful.

Pets and our Health--The Good, the Bad, the Ugly: Part 2

Last week we looked at "good" aspects of pet ownership, ways that pets can contribute to our health and well-being. This week, we'll look at animals that many authorities consider to be inappropriate as pets. We'll also consider some of the illnesses that can be transmitted from animals to humans.

The Bad-Inappropriate Pets: According to the American Academy of Pediatrics (AAP), all of these are considered to be inappropriate as pets for kids under age 5:

• Reptiles (turtles, snakes, lizards, iguanas)
• Rodents (hamsters, gerbils, guinea pigs, chinchillas, hedgehogs, prairie dogs, mice, rats)
• Amphibians (frogs, toads, salamanders)
• Ferrets
• Baby poultry (chicks, ducklings, goslings, turkeys)
• Monkeys
• Illegal exotic animals

AAP concerns include the potential for these animals to bite, trigger allergies, or spread disease and infection. Likewise, even though veterinary science is dedicated to the care of all animals, a policy statement from the American Veterinary Medical Association (AVMA) states that it "has concerns about animal welfare, husbandry, infectious diseases, public health and safety, and environmental impacts relative to ownership of wild animal species and their hybrids." A specific concern of the AVMA is that people may find that they are unable to care for a wild species with the possibility that the animal will become neglected or released into the environment.

The Ugly-Human illnesses related to animal contact: The following are illnesses that can spread from infected animals to humans. Fortunately, these diseases occur infrequently, and are more likely to occur from exposure to feral animals or those animals considered to be less appropriate as pets.

Toxoplasmosis is a parasitic disease that is of particular concern in pregnant women. If the disease spreads from an infected mother to her fetus, there is the potential for developmental malformations or miscarriage. Toxoplasmosis can be passed to people from contaminated cat feces, so pregnant women are advised to avoid cleaning cat litter boxes or coming in contact with dirt where cats may have been. Most people who get toxoplasmosis do not get sick, but some people will get swollen glands, muscle aches and feel as though they have the "flu". Others who are more likely to get sick with toxoplasmosis include young children, organ transplant patients, people with HIV/AIDS and people getting treatment for cancer.

Rabies is a rare disease caused by the rabies virus. People think of dog bites being a common method of contracting this disease, but actually, most cases of rabies are due to bites from wild animals, especially raccoons, skunks, bats, foxes, and coyotes. In recent years, most of the cases of human rabies attributed to dog bites in Americans were contracted in foreign countries. The reduced prevalence of rabies in pets can primarily be attributed to mandatory vaccination policies in this country. It can take several weeks for symptoms to develop following exposure, but once they do, the disease is usually fatal. Early signs include fever or headache, which can progress to neurological symptoms such as confusion or agitation.

Cat scratch disease is a bacterial disease that can develop as a result of being bitten or scratched by a cat. Swelling of the lymph nodes, especially those around the head, neck, and upper limbs, is a common feature of this illness. People with cat scratch disease may also develop fever, headache, fatigue, and poor appetite. Kittens are more likely to carry the bacteria, so avoiding any activity that may lead to cat scratches and bites is important in preventing the occurrence of this disease. Cat bites or scratches should be addressed immediately and by washing with soap and water. Should signs of an infection develop (swelling, redness, drainage, etc.) medical attention for the consideration of antibiotic treatment should be sought.

Leptospirosis is a bacterial disease that is spread through the urine of infected animals. Many animals including cattle, pigs, horses, dogs, rodents, and wild animals can harbor these bacteria without showing any signs of the disease. Humans are usually exposed to the bacteria through contact with water, soil, or food contaminated with the urine of infected animals. Initial symptoms in humans include fever, chills, headache, muscle aches, vomiting, and diarrhea.

Salmonellosis is a diarrheal disease caused by the bacterium Salmonella. Salmonella is most commonly transmitted through contaminated food, but it can also be spread by a number of animals including reptiles (turtles, snakes, and lizards), amphibians (frogs and toads), and poultry (chicks, chickens, ducks ducklings, geese, turkeys), "pocket pets" (guinea pigs and hamsters), dogs, cats and birds (including pet and wild birds). This illness, which can include diarrhea, fever, and stomach pain, typically resolves on its own after a week. The best ways of preventing salmonellosis are to avoid handling or touching high-risk animals (e.g., turtles, water frogs, chicks, ducklings, etc.) and to wash hands thoroughly after touching potentially infected animals.

Psittacosis also known as ornithosis or parrot fever is an infection caused by a Chlamydia bacterium. Psittacosis is usually spread by inhaling dust from dried droppings from birdcages and by handling infected birds in slaughterhouses. All birds can potentially carry the bacterium, although pet birds (parrots, parakeets, macaws, and cockatiels) and poultry (turkeys and ducks) are most frequently involved in transmission to humans. Symptoms in humans include fever, chills, headache, muscle aches, and a dry cough with evidence of pneumonia on x-ray. Antibiotics such as tetracycline or doxycycline are often prescribed for treating infected people.

Most people would agree that the benefits of having a companion animal, particularly dogs or cats, far outweigh the potential risks. It is important, however, to understand that some pets are more appropriate than others and that even appropriate pets can harbor disease-producing organisms. Conscientious pet care, including providing all appropriate immunizations, is the best way to minimize the risk of contracting animal-borne diseases.