Probiotics in dietary guidelines and clinical recommendations outside the European Union

Table 1 Occurrence of yoghurt and/or probiotics as relevant issues in different food-based dietary guidelines

Country	Organization	Document	Yoghurt recommendation	Probiotic recommendation
New Zealand	Ministry of Health	Part 1: New Zealand Food and Nutrition Guidelines[24]	Milk and milk products, including yogurt. Provide energy, protein, fats (mostly saturated), vitamins (riboflavin, B12, A) and minerals (calcium, iodine, phosphorus, zinc). They are important for children and young people to ensure optimal bone health. Reduced or low fat particularly, milk and milk products are the best choices because these foods include less saturated fat, and often more protein and calcium than high-fat alternatives	Not mentioned
Canada	Agriculture and Agri-Food Canada; Health Canada	Probiotics- understanding them will lead to greater use[25]; Canada's Food Guide[26]	Yoghurt (as lower fat milk alternative; milk per se as source of Vitamin D)	Approved by Health Canada as Functional Food with Added Probiotics[27]: Activia® with Bifidobacterium (animalis) lactis DN-173 010; DanActive® with Lactobacillus casei DN-114 001; Yoptimal® and iÖGO ProbioTM with Bifidobacterium lactis BB-12 and Lactobacillus acidophilus LA-5)
United States	United States Department of Agriculture	Dietary Guidelines for Americans, 2010[28]	All milks, including yogurts, frozen yogurts and cheeses. Most choices should be fat-free or low fat. Milk and milk products contribute many nutrients, such as calcium, vitamin D (for products fortified with vita-min D), and potassium, to the diet. Moderate evidence shows that intake of milk and milk products is linked to improved bone health, especially in children and adolescents. Moderate evidence also indicates that intake of milk and milk products is associated with a reduced risk of cardiovascular disease and type 2 diabetes and with lower blood pressure in adults. Choosing fat-free or low-fat milk and milk products provides the same nutrients with less solid fat, and thus, fewer calories. In addition, selecting more milk group intake as fat-free or low-fat fluid milk or yogurt rather than as cheese can increase intake of potassium, vitamin A, and vitamin D and decrease intake of sodium, cholesterol, and saturated fatty acids	Not mentioned
India	National Institute of Nutrition	Dietary Guidelines for Indians[29]	Recommended as curd	Not mentioned
Australia	The Department of Health and Ageing; The Australian Nutrition Foundation;	The Australian Guide to Healthy Eating[30] Australian Dietary Guidelines[31]	Milks, including buttermilk, yoghurt (all yoghurts including reduced fat or full cream-without added sugar), soy yoghurt (calcium fortified), and cheese Milk, cheese and yoghurt provide calcium in a readily absorbable and convenient form. They have various health benefits and are a good source of many nutrients, including calcium, protein, iodine, vitamin A, vitamin D, riboflavin, vitamin B12 and zinc. Avoiding dairy foods and not making suitable alternative choices, such as the ones recommended in this food group, can affect your long-term health	Not mentioned
Brazil	The Ministry of Health	The Food Guide[32]	Milk is an important source of vitamin B2 and main source of calcium in the feed; dairy products such as yoghurt and cottage cheese have the same profile	Not mentioned
China	The Ministry of Health	China's Dietary Guidelines (2007)[33], Chinese Dietary Guidelines[34]	Yogurt, as source of calcium	Not mentioned
Israel	Ministry of Health	The Food Pyramid[35]	Yogurt as source of calcium in the group of protein-rich foods	Not mentioned
Japan	Health and Agriculture ministries	The Food Guide[36]	Yoghurt as a source of calcium	Not mentioned
Mexico	Department of Nutrition and Health Promotion	The Plate of Good Eating[37]	Recommended	Not mentioned
Thailand	Ministry of Public Health[38]		Mentioned in general along with milk	A list of approved microorganisms for food use provided, but no recommendation made.
Turkey	Ministry of Health	Basic Food Groups[39]	Yogurt, cheeses contain important nutrients: proteins, calcium, phosphorus, vitamin B2 (riboflavin) and vitamin B12; eating yogurt and drinking ayran (buttermilk) help in treatment of diarrhea	Not mentioned

All the reviewed countries (except India, which recommends curd) suggest yoghurt in their dietary guidelines. For the time being Canada is the only country mentioning probiotics.

Table 2 Recommendations on probiotics from scientific associations

Scientific society	Area of application	Recommendations
National Institute for Health and Care	Diarrhoea and vomiting in children under 5: NICE guideline[44]	Probiotic specificity for each target should be considered available studies report benefits in reduced duration of diarrhea or stool frequency BUT: published studies have methodological limitations - in specific evaluated probiotics and treatment regimes Many of the studies were conducted in developing countries - response to probiotic therapy may differ Good quality randomized controlled trials should be conducted in the United Kingdom
Excellence (NICE) European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and European Society for Paediatric Infectious Diseases (ESPID)	Evidence-based Guidelines for the Management of Acute Gastroenteritis in Children in Europe[39]	Selected probiotics may reduce the duration and intensity of symptoms Oral rehydration solution with Lactobacillus GG may be beneficial in children with acute gastroenteritis; however, because of insufficient evidence, routine use is not recommended Lactobacillus GG and Saccharomyces boulardii showed benefits in the management of diarrhea but evidence of a lack of risk of antibiotic resistance transfer is required
European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)	Supplementation of infant formula with probiotics and/or prebiotics[45]	Probiotic-supplemented formula: no safety concerns with regard to growth and adverse effects for healthy infants Administration of probiotic-supplemented infant formula during early life does not result in any consistent clinical effects Administration of a few probiotics supplemented to infant or follow-on formulae and given beyond early infancy may have clinical benefits; however there is too much uncertainty to draw reliable conclusions No extrapolation of safety and clinical effects of one probiotic microbe to another ones Generally there is a lack of data on the long-term effects of the administration of formula supplemented with probiotics; would be of particular importance Routine use of probiotic-supplemented formula in infants is not recommended by the Committee