Full text of DOI:10.1111/j.1365-2621.2002.tb08754.x

JFS: Sensory and Nutritive Qualities of Food
Consumer Attitudes Toward
Use of Probiotic Cultures
C.M. BRUHN, J.C. BRUHN, A. COTTER, C. GARRETT, M. KLENK, C. POWELL, G. STANFORD, Y. STEINBRING, AND E. WEST
ABSTRACT: Some probiotic cultures appear to modulate the immune system, improve lactose intolerance, resolve
some bacterial and viral diarrheal diseases, reduce symptoms associated with inflammatory bowel disease, lower
blood cholesterol, and protect against some cancers. Focus groups were used to determine consumer familiarity
with probiotic bacteria and response to benefits, information source, potential health claims, and dietary sources.
Some consumers were skeptical that probiotic cultures could be effective. Information is more credible if it is
consistent with existing beliefs and endorsed by recognized health experts. Consumers aware of “friendly bacteria”
in yogurt were more likely to accept the potential benefits of probiotic cultures than consumers unaware of benefi-
cial bacteria. Some consumers were so sensitive to the risks of pathogenic bacteria that the concept of beneficial
bacteria was not credible.
Keywords: probiotics, cultures, yogurt, consumer attitudes
Introduction
ers 1996). Probiotics appear to influence a variety of other condi-
ROBIOTIC CULTURES ARE LIVE MICROBIAL FOOD INGREDIENTS THAT tions, including reducing ill effects from radioactive isotopes
P
have beneficial effects on human health (Salminen and oth- (Henriksson and others 1995; Korschunov and others 1996;
ers 1988). Bacterial cultures have long been used in dairy prod- Salminen and others1988) and reducing the effects of endotox-
ucts to develop a distinctive flavor and increase shelf life. In emia associated with alcoholic liver disease (Nanji and others
some regions of the world, human longevity is attributed to con- 1994).
sumption of cultured dairy products (Bibel 1988). Interest in
Although the number of studies identifying these beneficial
these cultures has increased in recent years as research has veri- effects is impressive, additional verification is needed. Results
fied the effect of specific strains of Lactobacillus and Bifidobacte- were not always consistent, studies used different probiotic
rium on human health (Sanders 1999; Sanders 2000).
strains, and the length of dietary intervention and exposure lev-
The benefits of consuming probiotic cultures have been dem- els varied. Identification of strains that are most effective in pro-
onstrated in several areas (Sanders 1999; Sanders and Klaen- moting these health-enhancing properties is ongoing. The
hammer 2001; Hamburger and others 1997). Some cultures have amount and frequency of consumption necessary to obtain ben-
been shown to reduce lactose intolerance. Animal models and eficial effects is under investigation.
human studies have found that probiotic bacteria are able to en-
Although structure/function statements about gastrointesti-
hance nonspecific and specific immune responses by activating nal tract health, immune function, or improved digestion are
macrophages, increasing levels of cytokines, increasing natural permitted on probiotic dietary supplement labels as long as they
killer cell activity, and increasing levels of immunoglobulins. Pro- are truthful and not misleading, they are seldom found on food
biotic bacteria have been shown to decrease the incidence, dura- products (Sanders 1998). The United States Food and Drug Ad-
tion, and severity of some bacterial and viral diarrheal disease ministration (FDA) regulations permit promotion of health en-
and reduce symptoms associated with some inflammatory bowel hancing properties on food labels or in advertising material (Mc-
disease. Probiotic bacteria may be able to counteract mutagenic Namara 1998). Consumers indicated an interest in receiving
and genotoxic effects in the colon and other organ sites. Addi- information about the health benefits of food. In a nationwide
tionally, probiotic bacteria or their byproducts appear to de- survey, 78% of consumers said they were interested in receiving
crease cancer cell proliferation. Preliminary research in the area information about food that boosts the immune system, 77%
of food allergies indicates that probiotics may suppress milk-in- were interested in information about food that reduces the risk
duced immune inflammatory response (Pessi and others 1998; of disease, and 53% were interested in information about active
Isolauri 1996). Some probiotic bacteria, or their end products, cultures in yogurt (Health Focus 2001). This project was under-
may inhibit H. pylori infection associated with chronic gastritis, taken to assess relative consumer interest in health enhancing
peptic ulcers, and the risk of gastric cancer (Coconnier and others properties of probiotics, identify factors which increase credibili-
1
998; Kabir and others 1997; Midolo and others 1995). Vaginal ty of health related messages, and identify the consumer’s pre-
health has been correlated with oral consumption of certain pro- ferred sources of information.
biotic-containing products (Hallen and others 1992; Hilton and
others 1992; Hilton and others 1995). Consumption of fermented
milk products by hypercholesterolemic individuals has resulted
in a significant lowering of total cholesterol and low-density lipo-
Methods
ROUP DISCUSSIONS (FOCUS GROUPS) WERE USED TO MEASURE
G
consumer attitudes since this method permits free expres-
protein cholesterol (Taylor and Williams 1998). Daily consump- sion of ideas within a structured question format. Questions ad-
tion of food products derived from probiotic culture could also dressed participants’ use of nutritional labeling, awareness of
contribute to blood pressure control (Takano 1998; Hata and oth- health claims on labels, familiarity with Lactobacillus or Bifidobac-
©
2002 Institute of Food Technologists
Vol. 67, Nr. 5, 2002—JOURNAL OF FOOD SCIENCE 1969

Consumer attitudes toward probiotic cultures . . .
terium, interest in potential benefits of food which contains the thought of eating bacteria. These individuals viewed both
these bacteria, response to potential label statements, credibili- the words “culture” and “bacteria” with concern and distaste.
ty of product endorsements, and appropriate price for probiotic Those who had a course in bacteriology recalled unpleasant
products. The discussion of benefits was limited to lowering odors and plates with mounds of growth. Even those who lacked
blood cholesterol and thereby guarding against heart disease, these classroom experiences were conscious of the need for good
decreasing the risk of certain cancers, enhancing the immune sanitary practices and could not envision bacteria as “friendly.”
system and thereby increasing resistance to illness, and reduc-
ing lactose intolerance.
Consumers were overwhelmed when they heard that specific
probiotic bacteria might lower blood cholesterol, decrease inci-
Focus group findings are not quantitative, but rather reflect dence of some cancers, and enhance the immune system so peo-
the range of attitudes likely to be encountered in the market- ple would be more resistant to illness. Although each benefit was
place (Krueger 1994). To explore the range of consumer attitudes, considered valuable, people noted that the potential to influ-
efforts were made to recruit men and women of Caucasian, Lati- ence cancer or heart disease was not unique to probiotic cultures.
no, Asian, and African heritage. Participants were advised that Several commented that many foods protect against heart dis-
they would share their ideas on a food-related topic and receive a ease and cancer, thus probiotic cultures could only be added to a
$
30 honorarium for participating in a discussion that would last long list of other items. People also felt these benefits were pri-
no more than 2 h.
marily important to those at highest risk for these diseases be-
cause of family history, life style, or age. Several consumers had
family or friends who suffered from cancer. They saw cancer as a
Results
ITH THE ASSISTANCE OF UNIV. OF CALIFORNIA COOPERATIVE Ex- complex set of catastrophic diseases that arose unexpectedly.
tension Advisors, consumers from Southern, Central, and Conducting further research to verify the effectiveness of probi-
Northern California were identified to participate in a 2 h discus- otic cultures in protecting against cancer was a priority for them.
sion. Consumers were recruited through announcements in
Strengthening the immune system was seen as important to
W
newspapers, business offices located near the Cooperative Ex- all people at any age. Participants believed this benefit would
tension office, and service organizations. Nine discussion groups help the body resist a multitude of illnesses and diseases. They
ranging in size from 8 to 17 people, average size 11, took place in saw this as a powerful benefit for their children or grandchildren
the summer of 1998 with a total of 100 people (28 men and 72 as well as for themselves. Typical comments included, “If you
women) of Caucasian, Latino, Asian, and African heritage. The have a good immune system, it will protect you against the oth-
age of participants ranged from the twenties to over 60, with ers [diseases],” “Improving your immune system improves the
most in the 40 to 50 age group.
quality of life today,” and “In our culture, immune system prob-
Most consumers said they examined the nutritional label lems are becoming an even greater issue. They contribute to
when they purchased a food for the first time. Some only exam- many (conditions) we don’t even realize.” Some asked if a
ined nutritional labels when they were looking for a certain type strengthened immune system would protect against HIV and
of food or if they were especially focused on nutrition. Others ac- AIDS.
knowledged that they are not interested in nutrition label infor-
Some participants were pessimistic and thought probiotic cul-
mation.
tures were unnecessary. Typical comments included, “If you
When asked if they had noticed health or nutrition claims on have a good general diet and you exercise, you should be getting
foods, many consumers reported seeing statements describing all the normal vitamins. I don’t see that all this is necessary,” and,
constituents a food did not have, such as “Fat Free,” “Cholesterol “If you have a healthy diet with fresh foods, chances are you are
Free,” or “No MSG.” The most commonly recalled positive claim already getting natural bacteria.”
was related to dietary fiber. Regarding health claims, some had
seen endorsements from the American Heart Association. Quak- Communicating benefits
er Oats and Cheerios were referred to as “heart healthy.” One
Multiple channels were suggested to convey benefits to the
person made a general statement that the cultures in yogurt are public. People looked to their favorite television or radio pro-
healthful.
grams for information. The national news, Discovery Channel,
Dr. Dean Edell (a physician with a syndicated call-in show) and
Oprah were frequently mentioned. People also looked for infor-
Response to probiotic cultures
When specifically asked, familiarity with Lactobacillus, Bifido- mation in magazines, especially Reader’s Digest, health maga-
bacterium, or the general concept of cultures in yogurt varied zines, and assorted magazines in the doctors’ waiting rooms.
from knowledgeable and believing, to unaware, to repulsed. Some received health-related newsletters, such as Tufts Univ.
Many who consume yogurt had heard of the bacteria and be- Health and Nutrition Letter. Younger consumers said that they
lieved yogurt helps prevent yeast infections and replenishes gut looked for information on the Internet. Hispanic consumers com-
flora, especially after taking antibiotics. Some consumers also mented on the need to have information in Spanish. Word of
mentioned that yogurt helps digest protein while others be- mouth was cited as a common and useful means to receive infor-
lieved it helps with lactose intolerance. Acidophilus milk or acido- mation; many people said they placed great faith in information
philus supplements, as well as yogurt, were identified as offering from people who used and benefited from a particular product. A
these benefits. Some were vaguely aware of digestion benefits typical comment was, “Use all these methods and a consistent
while others were not at all familiar with these bacteria or the po- message. Tell me 1 thing 10 times, then I get it.”
tential benefits of consumption. Among those unaware, some
ate yogurt because they liked it while others did not like yogurt appear on the food label, and believed credibility was enhanced
and never consumed it.
if the statement was reviewed and approved by FDA. Further en-
People felt information describing potential benefits should
In each focus group, there were some consumers who said dorsement by recognized health authorities such as the Ameri-
they had heard of Salmonella and other harmful bacteria, saw can Cancer Society, the National Academy of Science, or the U.S.
advertisements about antibacterial soap, and were repelled by Surgeon General increased the perception of credibility. Many
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970 JOURNAL OF FOOD SCIENCE—Vol. 67, Nr. 5, 2002

Consumer attitudes toward probiotic cultures . . .
also commented that additional information such as the number as possible. Dairy products were frequently mentioned because
of studies completed, the number of persons studied, the name of the historic use of probiotics in this food group. As long as
of universities conducting the research, and the degree of bene- there are no ill effects from high consumption, people suggested
fit would convey the strength of the science behind the stated putting probiotic cultures in milk, cheese, and ice cream.
health claims.
In each focus group, consumers noted that labels must state
Those consumers who purchased from health food stores the quantity and frequency of recommended consumption.
were less interested in FDA approval and more focused on com- Some who consumed yogurt for health benefits said they never
ments from providers of alternative medicine. Because of long- knew how active the bacteria were, or if they were getting
term interactions at health food stores, they thought that infor- enough. Providing probiotics in both supplement and food prod-
mation provided by store clerks and electronic and published uct forms allowed the consumers to adjust their consumption to
resources available in these settings was reliable, but they were obtain probiotic benefits without radically changing their food
skeptical of information provided by “big business.” They be- habits. People also wanted to know if there are any foods that
lieved that information other than the required Nutrition Facts should not be consumed at the same time as probiotic cultures.
was most likely promotional and not grounded in sound re- They were also interested if there were foods that should be con-
search. While some felt FDA approval increased reliability of a sumed with the cultures to enhance their viability. Finally, they
health claim, others commented that it takes too long for FDA to wanted to know if there were possible ill effects from over-con-
review studies, and many previously approved products have sumption, and if so, what amount was too much.
been recalled. These consumers also did not trust the American
Study participants recognized that adding something new to
Medical Association’s safety evaluations. They believe that the existing products would entail a price increase, but they would
Association and individual doctors are biased due to financial prefer not to pay a premium for probiotic-enriched foods. Others
profits they receive from pharmaceutical sales. Many of these in- countered that this was not realistic. These consumers noted
dividuals placed greater confidence in holistic doctors and chiro- that they were already paying a premium for vitamins and other
practors than in mainstream medical doctors.
health aids. Some consumers saw the use of health enhancing
Participants were asked to respond to statements that con- probiotic cultures as an opportunity for the dairy industry to re-
veyed the potential beneficial effects of probiotics on the im- ward loyal customers who have been choosing dairy products all
mune system and cancer, and in preventing heart disease. In their lives. People believed if probiotic cultures were truly as
general, consumers preferred statements that used simple beneficial as stated, they should be available in all products
terms. The structure/function claim, “Improves gastrointestinal without additional cost.
tract health” was rejected because people did not like the term
When asked for a final message, consumers noted that taste
“gastrointestinal.” They did not want to think of the gastrointes- is a primary consideration. Comments included, “Be sure it
tinal tract when shopping for food. Similarly, “Guards against doesn’t taste bad,” and, “Lots of times when they make things
foodborne illness” was not appealing because it was viewed as healthy, it tastes unappealing.” Several women noted that put-
too technical and people did not want to think about foodborne ting probiotic cultures in commonly consumed foods would allow
illness or diarrhea when buying food. In contrast, positive terms them to subtly provide these benefits to their husbands and
that referred more generally to the natural systems were accept- children. Several had noted that some men refuse to take care of
able. “Strengthens the body’s immune system” was universally themselves, and that children don’t always follow good dietary
endorsed.
habits. People urged that consuming probiotic cultures be de-
Consumers were sensitive to statements that may promise scribed as a preventive practice. Even if healthful foods cost
too much regarding the ability of probiotics to help prevent can- more today, consuming them would save on health costs in the
cer and heart disease. “Reduces incidence of cancer” was consid- future.
ered both too broad and too absolute. “Helps reduce incidence
Discussion
of certain types of cancer,” or “May reduce incidence of cancer”
were much more acceptable because they did not promise abso-
lute reduction. People expected to be able to read additional ma-
terial that stated what types of cancer were affected. Similarly, theless, attitudes expressed by the 100 participants in this study
claims such as, “May reduce blood cholesterol” were acceptable reflect trends observed in other studies. Consumers check nutri-
because they do not overstate the benefits of consuming probi- tional labels when first purchasing items and expect the informa-
ROJECTIONS OF THIS STUDY’S RESULTS TO NATIONWIDE STATISTICS
P
are not an appropriate use of focus group research. Never-
otic cultures.
tion to be truthful (Bender and Derby 1992; Rodolfo and others
998; Buzby and Ready 1996). They also rely on mass media for
information, are more likely to trust information provided by rec-
1
Marketplace application
Consumers would like the option of obtaining probiotic cul- ognized health groups, and are more likely to believe a message
tures in foods or supplements. Those who preferred a supple- if there is scientific consensus on the issue (Hoban and Kendall
ment valued the control of taking the product at a specific dose 1992; Bruhn and others 1992). Label information should use lay
and frequency. Others pointed out that supplements would add terminology and describe how consumers should use a product
to food costs, would require people to remember to consume to most greatly benefit from it (National Institute of Nutrition
them, and may be difficult for those uncomfortable swallowing 1999).
pills.
Products containing probiotics are common in Japan and Eu-
Those who preferred a food source considered food more con- rope (Sanders 1999). A review of the yogurt market in Europe
venient than dietary supplements. They also asserted that food shows that probiotic yogurts constitute 13% of the market in the
vehicles for probiotics should diversify beyond yogurt. Even United Kingdom and Germany, and 20% of the market in Den-
those who liked yogurt were not sure they wanted to eat it daily, mark (Fonden and others 1999). A survey of food manufacturers,
and those who did not like yogurt were not prepared to eat it at retailers, and ingredient producers conducted by Leatherhead
all. People suggested adding probiotic cultures to as many foods Research in the United Kingdom projects about a 60% growth in
Vol. 67, Nr. 5, 2002—JOURNAL OF FOOD SCIENCE 1971

Consumer attitudes toward probiotic cultures . . .
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4
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C
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