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Probiotics Cut Risk for Hepatic Encephalopathy in Half
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Probiotics Cut Risk for Hepatic Encephalopathy in Half

Probiotics Cut Risk for Hepatic Encephalopathy in Half

Daniel M. Keller, PhD
May 01, 2013

AMSTERDAM, the Netherlands — Probiotics were effective in helping to prevent a first episode of overt hepatic encephalopathy in patients with cirrhosis, compared with patients not receiving probiotics, according to a new study.

"The patients in the control group had 2 times the chance of developing overt hepatic encephalopathy in the follow-up period," lead author Manish Lunia, MD, from the G.B. Pant Hospital in New Delhi, India, told delegates here at the International Liver Congress 2013.

It is estimated that hepatic encephalopathy occurs in 30% to 45% of patients with cirrhosis, and the mortality rate is 20% to 30%. Because bacterial overgrowth in the small intestine leads to endotoxemia, the researchers reasoned that probiotics could prevent the condition.

For their open-label, prospective, randomized trial, they enrolled patients 18 to 80 years of age with cirrhosis and no history of overt hepatic encephalopathy. A battery of psychometric tests, the critical flicker frequency test, and the psychometric hepatic encephalopathy score were used to diagnose encephalopathy. Glucose hydrogen breath tests were used to identify small intestinal bacterial overgrowth and lactulose hydrogen breath tests were used to identify orocecal transit time.

Study participants were randomly assigned to the probiotic group (n = 86) or the control group (n = 74). The researchers used the commercially available VSL#3, which is a mixture of nonurease-producing organisms: Streptococcus thermophilus and various species of Bifidobacterium and Lactobacillus (110 billion colony-forming units, 3 times daily).

There were no significant differences between the probiotic and control groups in terms of baseline age (about 44 to 47 years), sex, cause of cirrhosis, proportion of Child–Turcotte–Pugh classes, and model for end-stage liver disease (MELD) score. The groups also did not differ in various baseline laboratory parameters, such as small intestinal bacterial overgrowth (38.4% vs 35.1%) and the proportion of patients with minimal hepatic encephalopathy, defined as a psychometric hepatic encephalopathy score of 5 or lower (48.8% and 44.6%).

Patients were followed monthly for signs of overt hepatic encephalopathy or death (mean follow-up time, 38 to 40 weeks). Every 3 months, they underwent psychometric, arterial ammonia level, critical flicker frequency, glucose hydrogen, and lactulose hydrogen breath tests. Six probiotic patients and 5 control subjects were lost to follow-up.

More patients in the probiotic group than in the control group developed overt hepatic encephalopathy (8.8% vs 20.3%). Kaplan–Meier analysis revealed a hazard ratio for developing overt hepatic encephalopathy of 2.1 (95% confidence interval, 1.31 - 6.53; P < .05). There were fewer deaths in the probiotic group than in the control group (7.5% vs 11.5%).

A significantly greater proportion of patients with Child class B and C cirrhosis than with class A cirrhosis developed overt hepatic encephalopathy, but patients with Child class A and Child class B did not differ from each other (P = .36).


In the probiotic group, there were significant improvements from baseline to 3 months in arterial ammonia (P = .04), small intestinal bacterial overgrowth (P = .006), orocecal transit time (P = .05), psychometric hepatic encephalopathy score (P = .01), critical flicker frequency test (P = .02), and minimal hepatic encephalopathy (P = .001). In the control group, there were no significant differences from baseline in any of these parameters.

Factors significantly associated with the development of overt hepatic encephalopathy were minimal hepatic encephalopathy (adjust odds ratio [aOR], 3.1), Child–Turcotte–Pugh score (aOR, 1.6), small intestinal bacterial overgrowth (aOR, 2.1), and critical flicker frequency (aOR, 1.44).

Dr. Lunia reported that 5 patients with minimal hepatic encephalopathy or 31 patients without minimal hepatic encephalopathy would need to be treated to prevent 1 case of overt hepatic encephalopathy.
null

This study involved patients with a low level of hepatic encephalopathy at worst, and was therefore for prevention, not treatment, session moderator Isabelle Colle, MD, from Gent University in Belgium, who was not involved with the study, told Medscape Medical News. She explained that the use of probiotics is "certainly not" standard for such patients at this point.

She also questioned whether the use of probiotics in these patients is completely benign. "The gut permeability...is increased, so you can imagine that these bacteria can go through the intestine and cause bacterial translocation.... Do you see infections with this treatment?" she asked. It was a short study, and Dr. Lunia did not present any data on infections, Dr. Colle pointed out.

Dr. Lunia and Dr. Colle have disclosed no relevant financial relationships.

International Liver Congress 2013: 48th Annual Meeting of the European Association for the Study of the Liver (EASL). Abstract 78. Presented April 26, 2013.

http://www.medscape.com/viewarticle/803453
45 Comments Post a Comment
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"The researchers used the commercially available VSL#3, which is a mixture of nonurease-producing organisms: Streptococcus thermophilus and various species of Bifidobacterium and Lactobacillus (110 billion colony-forming units, 3 times daily)."

VSL#3 is available at CVS, Walgreens, Rite Aid and many grocery stores that sell vitamins and supplements.

Hector
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Is this why I see objects in my peripheral vision in low light? In bed especially at night, see movements, floating sheet like things some might call them ghosts waving/shimmering to my side. Maybe I need these.
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Thank you so much for this article.  It really helped me quite a bit.
I am grateful to you and Hector for all of the information you share with the rest of us
Dee
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I'm very happy that it helped you.

Good luck,
Mike
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Great article Mike, Thanks. I was doing some research after reading this and found another page that I think is a nice addition to this.

http://www.liversupport.com/wordpress/2009/04/the-high-infection-risk-associated-with-cirrhosis/

In this article though posted in 2009 it is said probiotics can greatly reduce the risk of bacterial infection from ascites (spontaneous bacterial peritonitis).

As always persons with cirrhosis should consult their hepatologist before starting any new medications.

Randy
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Thank you Randy.  After reading Mike's article I am on probiotics.  Of to read yours now :)
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My dad has been on theses probitotics for the last year. It was 1 year ago this week that I was told my dad had less then 6wks to live. His blood work defiantly showed that. We took a different approach to his cirrhosis. We have seen my dad go from near death and in and out of hospitals 5 times last year and bleeding. He could not walk he was blown up and it took 5 of us kids to put him in a blow up raft boat to give him detox baths. We also had him on depends. This man has gone from there to getting himself up out of a real bath tub by himself and  no more depends. I  also own a flower shop and he came in to do deliveries with my mom for mother’s day. He worked 8 hours and was amazing. We know the route that we took might not be for ever one but OMG please people ck into some different things and ck with your dr. My dad turned 78 a couple of months ago. And is living a different life then a year ago. . My dad’s blood work improves ever month. And so does he. I am glad we choose the path that we did. Please belive me it was a rough road to go but the change is amazing.
. I am a daughter that just was not ready to say goodbye to my dad. His life has changed my life also. I go to my dad’s everyday and do a 45 minute treatment on him to keep his blood flowing to all his organs. I also use avocado oil to keep arms and legs soft and smooth so he has no dry skin. This also helps with itching a little.  As of today the only RX med he is on is lactulose the rest are vitamins.  He also eats everything he wants and has no digestion or sodium problems. If you choose to go on probiotics make sure that you get ones safe on the liver. Multi-flora plus   is what we like. My dad will be going for his blood work in the next couple of days. He just had skin cancer surgery yesterday on his head  with over 25 stiches. Today I changed the bandage and they look great! This is something that I would never have done with him 5 months ago where his blood was no high enough nor was he stong enough.  Today  as always I realize what a truly an amazing man he is. And this is where I get my strenght from. I wish everyone a miracle like his.  As always we take one day at a time and breath. Jill
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Jill, of course I'm familiar with your dad's case - and his is really quite a remarkable 'comeback' story.  Thank you so much for continuing to provide this encouragement to us all..!!  My 'lessons learned' from your testimony (and a few other similar ones) are these:
Cirrhosis does not have to be a death sentence!
Every case really IS different!
Attitude IS so vitally important!
There's much that can be done to improve prognosis, often even if the liver has already gone into failure.
It's so important to "keep the blood moving"....with regular exercise and/or by other means (therapeutic massage, acupuncture/acupressure, or whatever works)!
Hopefully many folks - incl. newer ones - will see this and take heart -
You, your dad and family are blessed - and are a blessing!
PD
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Thank you for saying it better then I can. You nailed it! You and Hector are so good at giving great advice. I  could only wish I had your wisdom. My heart goes out to all the families going thru this. I just hope that what we go thru may help someone else. jill
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I loved reading about your Dad. Yours is a very inspiring story.

Thank you for sharing.

Mike
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Good articles, Mike and Randy.
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Great news all. I'm watching this post just to have a reminder to read it again. These are amazing stories. What inspiration. I'm actually a little teary now thinking that the worst does NOT have to happen. xo Karen:)
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Hi I came across this old but good thread, regarding probiotic, prebiotics, etc. hope it helps someone. I actually have two but can only cut and paste one at a time :)

http://www.medhelp.org/posts/Hepatitis-C/anti-fibrotic-diet-info/show/443382
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here is the second one, really interesting, I sure do miss HR
http://www.medhelp.org/posts/Hepatitis-C/prebioticsprobiotics/show/379137
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I took this excerpt from HR's post in the above link for anyone who may not be up to searching.HR points out that not all probiotics are created equal and having wasted a bit of money, I wanted to underscore that.

"There are many offerings of "probiotic bacteria"  by the supplement industry, they are difficult to judge. In this situation those where university or governmental funded research has provided useful publications to support them could be selected. In that sense Lactobacillus GG has been well researched.
Since those are real live organisms, they need to be treated with care until use and the quality in their production seems important. As such products that are individually sealed in aluminum blister packages and are stored in
the refrigerator until use probably deserve more confidence. If the bacteria that you swallow are dead, they are useless."

Thanks Mike and Dee (and HR:) )

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Hi I used to be able to buy mine from the pharmacy, they were refrigerated, then they stopped, wonder where I could get some.

That was a good catch Rivil.  I did not see that.  All I saw, in my book, was the bifidum bacterium was the most effective for those with liver disease

My best to you
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Hi looked up the align I was telling you about that my doctor recommended, it has live probiotics and is only one with bifidum infantis (sp)
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Thanks Dee. :-)
I will look for Align. The print is so small on those bottles, I get dizzy trying to read the ingredients.
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Already have HE, take Xifaxin and Lactulose, so probably should consult hepa before embarking on this input to my body. Also, I worked in a non regulated 'health products" industry, selling pills and potions over the internet and to stores. These products didn't do anything, they aren't regulated by the FDA and are made under questionable circumstances. I have also worked in an FDA regulated industry as a QE and the difference in requirements in night/day, FDA products actually have to prove they do what they say. Where does this probiotic formulation that's sold without a prescription fit in?
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Hi it is actually a substance that is in yogurt and other fermented foods.
It is a friendly flora that is good for our digestion.  It kills of the bad and feeds the good so to speak.
I have taken it for 20 years off and on and find it really helps me
It does not mean it will help everyone but the article was really helpful to me
Good luck
Dee
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Thank you for this article, I can not believe the difference in just a couple of days.
I have taken the acidolphilus for 20 years for various problems.
I just bought some probiotics and the difference is night and day.
I really appreciate you posting this

Thanks again
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Which product have you been using?
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Hi it is called Ultimate Flora, I picked it up at Walmart.  I had been using Align for about a month as a doctor had recommended, then when Rivil said something about live, I went looking :)

It is working really well
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p.s. there are a few kinds, it is the one with 15 Billion strains.
There is another one I found on Amazon (our favorite place ha ha) and it has
30 billion but is much more expensive.  There is also one for seniors however we are not there yet :)

I was wondering if one could take the better probiotic for a while and then lower to something cheaper.

Of course health is more important, I could always cut something else out :)
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Thank you so much for your recommendation. I see it on Amazon and will get it next month
Dee
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Thank you so much for sharing your wonderful story.  It is so inspiring.
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Quality of Probiotic Supplements Questioned

People who take supplements that are supposed to contain beneficial bacteria (probiotics) may not be getting their money’s worth, according to a study presented by researchers from Bastyr University (Kenmore, WA) at an American Public Health Association meeting. The finding that some of these products do not contain viable bacteria or are contaminated with other potentially harmful bacteria raises concerns about the safety and efficacy of these products.

The intestinal tract contains billions of beneficial bacteria that perform various necessary functions, such as aiding in the digestion and absorption of food and protecting the body against microorganisms that can cause infection. While there are dozens of different types of friendly bacteria, Lactobacillus acidophilus, L. bulgaricus, L. thermophilus, L. reuteri, and Bifidobacterium bifidum are some of the more common strains found in the gut. Studies suggest that taking supplements containing these bacteria can help boost immune function and prevent or relieve certain health conditions including irritable bowel syndrome, vaginal yeast infections, and traveler’s diarrhea. However, commercially available probiotic products that do not contain what they are purported to contain will not deliver these benefits.

According to this new report, laboratory testing of 12 refrigerated and 8 non-refrigerated, randomly selected probiotic supplements obtained from different health food stores revealed that only one product contained the same bacteria as those listed on the label. Many of the refrigerated products had some beneficial bacteria, but contained fewer species of organisms than the label claimed. More than 30% of all supplements were contaminated with other microorganisms and 50% of the non-refrigerated products were completely dead. Dead probiotics have no impact on improving intestinal function or restoring the balance of normal intestinal flora.

The deficiencies found in these probiotic supplements may be due to poor manufacturing processes, poor quality control, or other environmental factors that cause the bacteria to deteriorate. While some probiotics are stable at room temperature, most require refrigeration to maintain live cultures. The findings in the new study suggest that many probiotic supplements will provide no benefit due to lack of viable organisms and may cause infection if contaminated with organisms that cause disease. However, no reports have been published linking a probiotic supplement to an intestinal infection. It is unclear at this point whether there are any adverse effects from the bacterial contaminants found in probiotic supplements.

Despite the quality-control concerns with probiotic supplements, many of the available products appear to be safe and effective in clinical practice. The one product that contained exactly what was listed on the label was Lactobacillus GG, a specific strain of beneficial bacteria. Studies have shown that Lactobacillus GG is useful in treating acute and chronic intestinal infections, preventing eczema in children, and stimulating the immune system.

Choosing a probiotic supplement can be difficult since it is not possible to know whether the product contains live cultures at the time of purchase. Selecting a refrigerated product may be more beneficial, since they were found to be more likely to contain live bacteria. If taking a particular product does not appear to be effective, some physicians recommend trying another product before discontinuing the treatment altogether. Probiotics may also be found in some cultured dairy products, such as some yogurt products and some types of milk. However, people with a dairy allergy or lactose intolerance may prefer taking a supplement. Some physicians recommend taking a supplement that contains 3 to 5 billion live organisms per day in between meals.

Darin Ingels, ND, MT (ASCP), received his bachelor’s degree from Purdue University and his Doctorate of Naturopathic Medicine from Bastyr University in Kenmore, WA. Dr. Ingels is the author of The Natural Pharmacist: Lowering Cholesterol (Prima, 1999) and Natural Treatments for High Cholesterol (Prima, 2000). He currently is in private practice at New England Family Health Associates located in Southport, CT, where he specializes in environmental medicine and allergies. Dr. Ingels is a regular contributor to Healthnotes and Healthnotes Newswire.

Alan R. Gaby, MD, an expert in nutritional therapies, testified to the White House Commission on CAM upon request in December 2001. Dr. Gaby served as a member of the Ad-Hoc Advisory Panel of the National Institutes of Health Office of Alternative Medicine. He is the author of Preventing and Reversing Osteoporosis (Prima, 1994), and co-author of The Natural Pharmacy, 2nd Edition (Healthnotes, Prima, 1999), the A–Z Guide to Drug-Herb-Vitamin Interactions (Healthnotes, Prima, 1999), Clinical Essentials Volume 1 and 2 (Healthnotes, 2000), and The Patient’s Book of Natural Healing (Prima, 1999). A former professor at Bastyr University of Natural Health Sciences, in Kenmore, WA, where he served as the Endowed Professor of Nutrition, Dr. Gaby is the Chief Medical Editor for Healthnotes, Inc.
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I just remember that HepatitisResearcher  once said that lactulose could be used as a preventative...probiotic

I just started using Ultimate Flora which starts out with 15 billion strains.  The difference between this and what I was taking is amazing.
I am going to try the one referenced in the article when I have the $.  It is shipped cold

McKansas, thank you for the article, very helpul
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I just started using Ultimate Flora which starts out with 15 billion strains.  The difference between this and what I was taking is amazing.
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I have noticed a big difference too. Thanks Dee.
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Are you both experiencing a reduction in the symptoms of a hepatic encephalopathy? Or what specific benefits are you both experiencing?

Randy

P.s. sorry I haven't been in the group much lately we just had a new house built and it's going to be a while before they can get cable ran back to us here for Internet. So its just me and my smartphone and it's not very smart lol
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Hi Randy, glad your posting I was starting to worry!! Well this probiotic stuff is tricky as you've probably read the posts. I'm currently taking A formula with:

5 billion organisms per capsule
Derived from 8 strains
Jarro-Dophilus   EPS
They are in blister packs that do not require refrigeration.
PROD # 103020

I've looked up the product Dee is taking. It's derived from 10 strains/15 billion cultures per capsule. Renew Life is the maker.
I'm also going to try the one Hector mentions above, that's the one the research was done on. Point is I'm trying to get the cost down with the highest quality product.

The benefits I have received from taking 2-4 capsules a day are more energy. I'm still not a good candidate to measure by as I'm only 39 days post treatment. But I guess that the energy came on the heels of starting that protocol I have to think its helping. Hope someone will post there specific benefits especially if they are experiencing HE. That was your original question, lol!  Good luck!!   Kitty





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Hi Dee! By chance can you please post the PRODUCT/ITEM # on the box of Ultimate Flora. Thank You!!     Kitty
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Hi Randy,
Though the op was about taking probiotics for HE, I do not take them for that. I have had serious digestive problems since becoming cirrhotic and they help with that. I have also adjusted my diet and between the two, am feeling more energy and less digestive discomfort.

Missed you, glad you are back. :)
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Hi I bought the Ultimate Flora 15 billion from Amazon, I will get you the number, it was in a yellow bottle.  I was using Align, and while that helped this UF has helped my digestion tremendously in just a few days and I feel clearer in my my thoughts than I have in a while. I also have more energy and I am happy which I have not been in years.
I have been trying to recover from tx for HCV and I have cirrhosis.
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Hi I don't have the box but the yellow bottle of Ultimate Flora 15 Billion live cultures per capsule made by Renew Life has a bar code 31257 15864 on it.
I looked up the the other one and it is just too expensive.
Money is very tight for me so I have thought that once I finish the Ultimate Flora I may try to maintain with another less expensive item.
This UF was $18 for 30.  Not a lot but per pill much more expensive than the Walmart brand of Align I was taking.
A nutritionist on Amazon felt that Align had too many fillers...sugar so she recommended Natren which is supposed to be delivered cold and then refrigerated.
It is expensive as well....the search continues.
Gosh Mike, did  you think your article would create such a buzz? :)
Thanks again
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Hi I went to Amazon and could not find the yellow bottle but found this

http://www.amazon.com/Renew-Life-Ultimate-Critical-Billion/dp/B000CMKC5Y/ref=sr_1_cc_1?s=aps&ie=UTF8&qid=1372082202&sr=1-1-catcorr&keywords=ultimate+flora

Maybe I bought the yellow bottle from Walmart.or they are out of it on amazon...can I still use brain fog?:)

One thing to watch out for is the herkmier response.  As the good bacteria replaces the bad, some people will feel as if they are getting the flu, the best thing to do in this case it to back off...drink more water.. etc. The best way to take acidolphilus or probiotics is to start out slow.  i.e. I have taken just the acidolphilus for many many years due to yeast/thrush problems.  I just started the probiotics when I read this article so started out with Walmart version of Align.  Align is recommended by many doctors.
It seemed to work ok.  Then Rivil said something about live so I found these Ultimate Flora which start out with 15 billion as of manufacturing date.
I can tell these are superior to what I was taking.

So sorry for all the posts.  I "talk" too much :)
Dee
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Me again...:)
I have a book called Nutritional Healing.  I can look up the problem and it will tell me which nutrients I need.  They are graded from essential to helpful
For cirrhosis it says essential

Liquid Kyolic with B1 and B12  - an excellent liver detoxifier
Phosphatidyl choline               - for fatty liver
Primrose oil or Total EFA         - to prevent imbalance of fatty acids
Vitamin B                               - necessary for proper digestion/absorbtion
Bifido Factor from Natren         - repairs liver cells and aids healing
Kyo-Dophilus            - human cultured flore from small intestine to improve assimilation
Garlis                      - detoxifies the liver and bloodstream
enzymes that act to inhibit inflammation
Larginine to detox ammonia a by-product of protein digestion

I hope this helps someone
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I've had 2 of those books. It was my bible back in the late 80s. After reading your post ill find my book. Mine is about 16 years old. Maybe I'll buy a new one. Lol!  

Thanks for bar code!    Kitty
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Hey there!  Glad it could help, yes this is my 4th edition, I may need a new one myself :)
My Mom used one by a Ms Davis, can't remember what it was called exactly though she also wrote a book "feed our kids right" in addition to the one I can not think of :)
Gosh, now I will go search
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Oy I remembered! Eureka!  Who's got brain fog? ha ha

It was Let's get well by Adelle Davis from 1965
It was so informative, it is relevant for today.
Great book on deficiencies, symptoms and what we can do about it. :)
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OMG yes, Let's Eat Right to Keep Fit and others. She made a huge impression on me at the time.  I've got to review her books again. All physical and mental conditions could be better managed with the correct nutrition.
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Adelle Davis that was my sisters guru!!! Ha!! That's a blast from a past. She was ahead of her time. She was so good for that era of when all junk food came out middle 60s/70s.
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I agree about Adelle Davis, she helped my Mom and I very much back in the last 70's
I went searching for her book and found one from a later time.  I think another author joined with her.

I also wanted to mention that if your diet does not include many raw food, fresh fruit or veggies, digestive enzymes in supplement can really help.
The body can't survive without enzymes and co enzymes.  In addition to digestive enzymes are systemic enzymes for the body.

Thank you all for your responses, really good thread.
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Hi I wanted to come back to say I did really well for about 2 weeks or so on the Ultimate Probiotics, I felt great.  Then last Thursday I had the worst pain in my stomach, it has taken til today for me to feel human again :)

I think I did too much too fast so have stopped the UP and will try again at a lower dosage.  I went back to the Align (Walmart's Brand) and will continue that for a while.

Thank you
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As I mentioned the Ultimate Flora caused problems for me.  I just found some information about it and felt I should share it.
I think I am sick from it
http://www.ehow.com/info_7945270_ultimate-flora-side-effects.html

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