Yoghurt enriched with Lactobacillus acidophilus does not lower blood lipids in healthy men and women with normal to borderline high serum cholesterol levels

European Journal of Clinical Nutrition (1999) 53, 277±280
ß 1999 Stockton Press. All rights reserved 0954±3007/99 $12.00
http://www.stockton-press.co.uk/ejcn
Yoghurt enriched with Lactobacillus acidophilus does not lower
blood lipids in healthy men and women with normal to
borderline high serum cholesterol levels
NM de Roos1*, G Schouten1 and MB Katan1Y2
1Division of Human Nutrition and Epidemiology, Wageningen Agricultural University, The Netherlands; and 2The Wageningen Centre
for Food Sciences
Objective: To investigate whether intake of Lactobacillus acidophilus strain L-1 lowers serum cholesterol in
healthy men and women.
Design: Randomised, placebo-controlled parallel trial.
Setting: Subjects were free-living. Blood sampling and distribution of yoghurts were administered at a local
hospital.
Subjects: Seventy-eight adult men and women with cholesterol levels of 3.9±7.8 mmolaL (mean Æ s.d.,
5.4 Æ 0.7).
Interventions: Subjects consumed 500 mL of control yoghurt daily for two weeks. They were then randomly
allocated to receive 500 mL per day of control yoghurt or of yoghurt enriched with Lactobacillus acidophilus L-1
for another six weeks. The yoghurts were spiked with a trace of lithium; compliance as assessed by plasma
lithium was excellent.
Results: Energy and nutrient intake was constant, and identical for the two groups. Mean body weight was
stable. Baseline blood lipid concentrations in the control and treatment groups were highly similar. The effect of
consumption of Lactobacillus acidophilus L-1 vs control on total cholesterol was 70.02 mmolaL (95% CI,
70.18±0.15) after three weeks and 0.04 mmolaL (95% CI, 70.12±0.20) after six weeks. Serum LDL and HDL-
cholesterol and triacylglycerol levels were also unaffected.
Conclusions: Yoghurt enriched with Lactobacillus acidophilus L-1 does not lower serum cholesterol in men and
women with normal to borderline high cholesterol levels.
Sponsorship: Dutch Dairy Foundation on Nutrition and Health.
Descriptors: lactobacillus acidophilus; blood lipids; yoghurt
Introduction
conversion of cholesterol into bile acids might lower serum
The potential bene®cial effects of the so-called `probiotic'
cholesterol levels.
bacteria has raised much interest (Fuller, 1989; Orrhage et al,
Evidence for a serum cholesterol lowering effect of
1995; Saxelin, 1997) with cholesterol-lowering as a focus of
Lactobacillus acidophilus in humans is sparse. Lin et al,
research (Agerbñk et al, 1995; Richelsen et al, 1996; Lin et al,
1989 found a cholesterol lowering effect of a mixture of
1989; Schaafsma et al, 1998; Mital & Garg, 1995). Commer-
Lactobacillus acidophilus and Lactobacillus bulgaricus in a
cial products with Lactobacillus acidophilus that claim to
16-week parallel, placebo-controlled pilot trial with 38
lower serum cholesterol are marketed by several major dairy
subjects, but no effect in a subsequent 15-week double
companies in Europe (Anonymous, 1996). However, this
blind, cross-over trial with 344 subjects (Lin et al, 1989).
claim is mainly based on in vitro and animal studies. Several
Consumption of yoghurt with Lactobacillus acidophilus in
Lactobacillus acidophilus strains of human origin are able to
a cross-over study with 30 healthy men resulted in 4.4%
remove cholesterol from culture media during growth in the
lower mean cholesterol concentrations than consumption of
presence of bile (Buck & Gilliland, 1994; Gilliland et al,
a placebo (Schaafsma et al, 1998).
1985; Walker & Gilliland, 1993). The mechanism of action is
We investigated whether Lactobacillus acidophilus low-
probably that the bacteria deconjugate bile acids which, when
ered serum cholesterol in a placebo-controlled, double-
deconjugated, coprecipitate with cholesterol at a pH ` 5.5
blind study with healthy volunteers. We chose volunteers
(Gilliland et al, 1985; Klaver & Van der Meer, 1993; Tahri et
with normal to borderline-high serum cholesterol levels
al, 1995). If this also occurs in vivo, such coprecipitation
because this is the target group for these yoghurts and
might increase faecal excretion of bile acids and cholesterol.
because most dietary components that can lower serum
It is thought that the liver will compensate for the loss of bile
cholesterol do so also in normocholesterolaemic subjects
acids by converting cholesterol into new bile acids. This
(Lu et al, 1997; Pelletier et al, 1995). We chose a treatment
period of six weeks because the same period or shorter was
chosen in previous studies (Agerbñk et al, 1995; Lin et al,
*Correspondence: Dr NM de Roos, Wageningen Agricultural University,
1989; Schaafsma et al, 1998). To our knowledge every
Division of Human Nutrition and Epidemiology, Bomenweg 2, 6703 HD
dietary component that lowers cholesterol does so within
Wageningen, The Netherlands.
six weeks. We chose the maximum dose that could be
Received 7 August 1998; revised 13 November 1998; accepted
16 November 1998
given in a yoghurt.

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Lactobacillus acidophilus L-1 does not lower blood lipids
NM de Roos et al
278
Subjects and methods
Compliance
Prior approval for this study was obtained from the Medical
Lithium chloride (250 mmol) was added to the yoghurt
Ethical Committee of the Department of Human Nutrition,
(500 mL) as a marker (Sanchez-Castillo et al, 1987).
Wageningen Agricultural University. All volunteers gave
Toxic effects of lithium below the therapeutic dose have
their written informed consent. Volunteers who completed
not been reported (Amdisen, 1977; Lehmann, 1994). The
the study received a ®nancial reward.
two serum samples of week three were pooled for lithium
analysis, and so were the two samples of week six.
Serum samples were deproteinised by mixing ®ve parts
Subjects
with one part of 20% (wav) trichloroacetic acid. Lithium
Eligible for the study were healthy men and women
concentrations in deproteinised serum samples were mea-
between 18 and 65 y old who were free of heart disease,
sured by atomic absorption spectrophotometry (Miller et al,
diabetes, liver or kidney disease, and did not use any
1989).
medications known to affect blood lipid metabolism.
Subjects recorded missed supplements, illness, and use
Ninety-nine volunteers were screened and 85 were
of medications in a diary.
enrolled. Volunteers with a serum total cholesterol concen-
tration higher than 8 mmolaL or a triacylglycerol concen-
tration higher than 4 mmolaL were excluded. We made sure
Statistical analyses
that at least 50% of the enrolled volunteers had serum
The two-sample t-test was used to compare changes in the
cholesterol levels over 5 mmolaL, the cut-off value for mild
acidophilus group with changes in the control group.
hypercholesterolaemia in the Netherlands (Anonymous,
1992). Three subjects dropped out because of vacations,
two because of illness, one because she could not eat all the
yoghurt and one because of gastrointestinal complaints.
Results
The study was completed by 39 subjects in each of the two
test groups.
Each of the two test groups consisted of 11 men and 28
women with a mean age of 40 y and on average normal
body weights and serum cholesterol values (Table 1).
Study design
Blood lipid concentrations remained stable in the control
After a two-week run-in period, in which the subjects added
group and were unaffected by consumption of Lactobacillus
500 mL of control yoghurt to their daily diet, subjects were
acidophilus L-1 (Table 2). The net effect of consumption of
strati®ed according to sex, age and LDL-cholesterol. Sub-
Lactobacillus acidophilus L-1, computed as the difference in
jects in each stratum were randomly allocated to receive
change in blood lipid concentrations between acidophilus
either control or Lactobacillus acidophilus yoghurt for six
group and control group, was close to zero (Figure 1). We did
weeks. Venous blood samples were taken after an overnight
not perform separate analyses for men and women because
fast at the end of the run-in period and at three and six
our study was not designed to do this. Mean changes in blood
weeks after the start of the test-period. Blood samples were
lipids, however, were almost identical in men and women.
taken twice in each week at an interval of 2±4 d, which
Twenty-one subjects in the control group and 21 sub-
amounted to a total of six blood samples during the study.
jects in the acidophilus group had initial serum cholesterol
levels greater than 5.2 mmolaL (200 mgadL, mean
5.7 Æ 0.4 mmolaL), the cut-off value for borderline high
Yoghurts
blood cholesterol in the USA (Anonymous, 1993). Lacto-
The control yoghurt was a non-fat yoghurt with a starter
bacillus acidophilus had no effect on serum cholesterol
culture of Streptococcus thermophilus. The test yoghurt
levels in this subgroup either: the net effect on total
was control yoghurt enriched with Lactobacillus acidophi-
cholesterol was an elevation of 0.01 mmolaL (95% CI,
lus L-1. The yoghurt was made once a week (NIZO, the
70.19±0.21) after three weeks and 0.08 mmolaL (95%
Netherlands) and was given fresh, not pasteurised. Subjects
CI, 70.12±0.29) after six weeks. Effects on other blood
were instructed to take 200 mL of the yoghurt directly after
lipids were even smaller (data not shown).
breakfast and 300 mL directly after dinner.
Changes in body weight were negligible; the mean
Samples of both yoghurts were analysed on Rogosa
difference in weight change between the acidophilus and
medium every week. Levels of Lactobacillus acidophilus
control group was 0.04 kg (95% CI, 70.37±0.44) at week
ranged from 4.8 6 109 to 2.7 6 1010 colony forming units
three and 0.21 kg (95% CI, 70.35±0.78) at week six.
per 500 mL.
Measurements
Blood samples were allowed to clot at room temperature
Table 1 Mean ( Æ s.d.) baseline characteristics of 78 subjects who
and were centrifuged for 10 min at 1500 6 g. Serum
completed a six-week study into the effect of consumption of
Lactobacillus acidophilus L-1 on serum cholesterol concentrations
samples were stored at 780C.
Serum lipids were measured or computed as described
Treatment
previously (Siedel et al, 1983; Warnick et al, 1982;
Sullivan et al, 1985), with an intra-run coef®cient of
Characteristic
Control
Lactobacillus acidophilus L-1
variance of 2.6% and an inter-run coef®cient of variance
Menawomen (number)
11a28
11a28
of 3.8%.
Age (y)
39.9 Æ 8.7
39.8 Æ 8.4
Body weight was measured with subjects clothed but
Body mass index (kgam2)
24.2 Æ 3.0
23.9 Æ 2.6
Total cholesterol (mmolaL)
5.4 Æ 0.7
5.3 Æ 0.8
without shoes. We used a single 24 h recall method to
estimate energy and macronutrient intake in all subjects.
Conversion factors: cholesterol, 5mmolaL ? 193mgadL.

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Lactobacillus acidophilus L-1 does not lower blood lipids
NM de Roos et al
Table 2 Blood lipid concentrations after the two-week run-in period and
279
(Buck & Gilliland, 1994). Our study, however, shows
after three and six weeks of consumption of control yoghurt or yoghurt
that daily consumption of yoghurt enriched with a high
enriched with Lactobacillus acidophilus L-1
dose of Lactobacillus acidophilus L-1 for a period of six
Treatment
weeks does not lower blood lipid concentrations in men and
women with normal to borderline high serum cholesterol
Lactobacillus
Control
acidophilus L-1
levels. The 95% con®dence intervals for the net effect of
the acidophilus yoghurt on serum LDL levels make any
Sample
(mmolaL)
change of more than 0.15 mmolaL (4.7%) unlikely.
The compliance of the subjects, checked by addition of a
Total cholesterol
Run-in
5.19 Æ 0.74
5.12 Æ 0.72
Week 3
5.27 Æ 0.74
5.19 Æ 0.74
trace of lithium to the yoghurts, was excellent. Weight
Week 6
5.12 Æ 0.69
5.10 Æ 0.74
changes were negligible and background food intake was
HDL-cholesterol
Run-in
1.51 Æ 0.40
1.40 Æ 0.32
the same for the two groups.
Week 3
1.53 Æ 0.44
1.43 Æ 0.35
Week 6
1.54 Æ 0.41
1.40 Æ 0.35
Choice of subjects with normal to borderline high serum
LDL-cholesterol
Run-in
3.12 Æ 0.80
3.20 Æ 0.68
Week 3
3.17 Æ 0.82
3.26 Æ 0.68
cholesterol levels
Week 6
3.04 Æ 0.80
3.18 Æ 0.69
We do not think that the absence of an effect of the
Triacylglycerol
Baseline
1.22 Æ 0.52
1.13 Æ 0.66
Lactobacillus acidophilus in our study was due to low
Week 3
1.22 Æ 0.51
1.10 Æ 0.57
initial cholesterol levels in our subjects. Feeding studies
Week 6
1.17 Æ 0.54
1.11 Æ 0.54
with fatty acids (Lu et al, 1997; Perez-Jimenez et al, 1995;
Values are means Æ s.d. of 39 subjects in the control group and 39 subjects in
Abbey et al, 1994; Cobb & Risch, 1993; Chan et al, 1991),
the Lactobacillus acidophilus L-1 group. Conversion factors: Cholesterol,
fat restriction (Lefevre et al, 1997; Jenkins et al, 1997;
5mmolaL ? 193mgadL; Triacylglycerol 1mmolaL ? 88.6mgadL.
Miller et al, 1998; Schaefer et al, 1995), psyllium (Ganji &
Kies, 1996), or phytosterols (Pelletier et al, 1995), have
shown that serum total cholesterol can be reduced in
subjects with comparable or even lower mean serum
Mean intake of total energy, macronutrients, ®bre and
cholesterol levels. Also, the subgroup with a mean total
cholesterol as measured by 24 h recall was not different
cholesterol level of 5.7 mmolaL (220 mgadL) did not
between the test groups.
respond to Lactobacillus acidophilus either. It is unlikely
Compliance, de®ned as a rise in serum lithium of at least
that patients with borderline high blood cholesterol will
three times the baseline value, was excellent. Mean serum
bene®t from consumption of Lactobacillus acidophilus.
lithium levels at three and six weeks were about 6.5-fold
higher than baseline values. Two subjects from the
Choice and dosage of probiotic strain
acidophilus group had an increase from baseline of less
It is possible that the strain we used in our study is not the
than a factor three: one of them at week three and six, the
most potent strain for cholesterol reduction. However, the
other only at week six. Excluding these subjects from the
strain used in this present study had the highest ability to
analysis did not affect the outcome of the study.
remove cholesterol from a medium in vitro (Buck &
Gilliland, 1994; Gilliland et al, 1985; Walker &
Gilliland, 1993).
Discussion
The dose we gave, 109±1010 colony-forming units per
Lactobacillus acidophilus is the best studied of the `pro-
day, was up to 1000 times higher than that of previous
biotic' cholesterol-lowering bacteria (Lin et al, 1989;
studies aimed at cholesterol-lowering (Agerbñk et al, 1995;
Schaafsma et al, 1998; Harrison & Peat, 1975; Khedkar
Lin et al, 1989; Schaafsma et al, 1998; Harrison & Peat,
et al, 1993; de Rodas et al, 1996). Of all the Lactobacillus
1975; Khedkar et al, 1993). It is not possible to incorporate
acidophilus-strains the L-1 strain, used in commercial
larger amounts into yoghurts or similar foods.
products in the Netherlands, is thought to be one of
the most effective strains to lower serum cholesterol
Length of treatment period
After a run-in period of two weeks we measured serum
cholesterol after three and six weeks of treatment to
measure short-term as well as long-term effects. Although
we cannot exclude an effect of Lactobacillus acidophilus
after a longer treatment period, we are not aware of any
dietary component that has no effect for up to six weeks
and then starts to lower serum cholesterol after more than
six weeks.
The hypothesis for the cholesterol lowering effect of
Lactobacillus acidophilus L-1 is based on its ability to
deconjugate bile acids in vitro. At a pH lower than 5.5
deconjugated bile acids and cholesterol coprecipitate and
are excreted in faeces (Klaver & Van der Meer, 1993).
However, the neutral to alkaline pH of the small intestine
makes precipitation of cholesterol and deconjugated bile
Figure 1 Net effects (means and 95% con®dence intervals) on blood
acids in vivo unlikely. Indeed, consumption of a fermented
lipid concentrations of daily consumption of yoghurt enriched with
dairy product containing Lactobacillus acidophilus did not
Lactobacillus acidophilus L-1 for six weeks. Net effects were computed
as changes in blood lipid concentrations in the acidophilus group (39
increase the relative amount of deconjugated bile salts in
subjects) minus changes in the control group (39 subjects).
faeces of 8 ileostomy patients (Marteau et al, 1995).

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Lactobacillus acidophilus L-1 does not lower blood lipids
NM de Roos et al
280
Conclusions
Lefevre M, Ginsberg HN, Kris-Etherton PM, Elmer PJ, Stewart PW,
Ershow A, Pearson TA, Roheim PS, Ramakrishnan R, Derr J, Gordon
Yoghurt containing Lactobacillus acidophilus strain L-1
DJ & Reed R (1997): ApoE genotype does not predict lipid response to
did not lower blood lipids in men and women with normal
changes in dietary saturated fatty acids in a heterogeneous normolipi-
and borderline high blood cholesterol. Claims to such an
demic population. The DELTA Research Group. Dietary Effects on
effect would not be justi®ed. More in general, claims made
Lipoproteins and Thrombogenic Activity. Arterioscler. Thromb. Vasc.
Biol. 17, 2914±2923.
by commercial producers that probiotic yoghurts lower
Lehmann K (1994): Endogenous lithium levels. Pharmacopsychiatry 27,
serum cholesterol in man should not be based solely on
130±132.
in vitro and animal studies but should be supported by
Lin SY, Ayres JW, Winkler W & Sandine WE (1989): Lactobacillus
proper randomised trials in man.
effects on cholesterol: In vitro and in vivo results. J. Dairy Res. 72,
2885±2899.
Lu Z, Hendrich S, Shen N, White PJ & Cook LR (1997): Low linolenate
Acknowledgements ÐWe thank the Dutch Dairy Foundation on Nutrition
and commercial soyabean oils diminish serum HDL cholesterol in
and Health for funding this study. We are greatly indebted to our
young free-living adult females. J. Am. Coll. Nutr. 16, 562±569.
volunteers for taking part in this study and to staff and personnel of the
Marteau P, Gerhardt MF, Myara A, Bouvier E, Trivin F & Rambaud J-C
Hofpoort Hospital in Woerden, the Netherlands, for screening the volun-
(1995): Metabolism of bile salts by alimentary bacteria during transit in
teers and for taking blood samples. We would like to thank Jeanne de
the human small intestine. Microb. Ecol. Health Dis. 8, 151±157.
Vries for advising us about the 24 h recalls. Finally we thank Robert
Miller M, Teter B, Dolinar C & Georgopoulos A (1998): An NCEP II diet
reduces postprandial triacylglycerol in normocholesterolemic adults. J.
Hovenier, Frans Schouten and Rijkelt Beumer for analysing blood and
Nutr. 128, 582±586.
yoghurt samples.
Miller NL, Durr JA & Alfrey AC (1989): Measurement of endogenous
lithium levels in serum and urine by electrothermal atomic absorption
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