Effect of starch malabsorption on colonic function and metabolism in humans

The Role of a Colon-in-Continuity in Short Bowel Syndrome

Short bowel syndrome (SBS) is a rare gastrointestinal condition that is defined as having less than 200 cm of remaining small intestine. SBS results from extensive surgical resection and is associated with a high risk for intestinal failure (IF) with a need for parenteral support (PS). Depending on the region of intestinal resection, three different main anatomy types can be distinguished from each other. In this review, we synthesize the current knowledge on the role of the colon in the setting of SBS-IF with a colon-in-continuity (SBS-IF-CiC), e.g., by enhancing the degree of intestinal adaptation, energy salvage, and the role of the microbiota. In addition, the effect of the disease-modifying treatment with glucagon-like peptide-2 (GLP-2) analogs in SBS-IF-CiC and how it differs from patients without a colon will be discussed. Overall, the findings explained in this review highlight the importance of preservation of the colon in SBS-IF.

European guideline on indications, performance, and clinical impact of hydrogen and methane breath tests in adult and pediatric patients: European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Neurogastroenterology and Motility, and European Society for Paediatric Gastroenterology Hepatology and Nutrition consensus

Introduction

Measurement of breath hydrogen (H₂) and methane (CH₄) excretion after ingestion of test‐carbohydrates is used for different diagnostic purposes. There is a lack of standardization among centers performing these tests and this, together with recent technical developments and evidence from clinical studies, highlight the need for a European guideline.

Methods

This consensus‐based clinical practice guideline defines the clinical indications, performance, and interpretation of H₂‐CH₄‐breath tests in adult and pediatric patients. A balance between scientific evidence and clinical experience was achieved by a Delphi consensus that involved 44 experts from 18 European countries. Eighty eight statements and recommendations were drafted based on a review of the literature. Consensus (≥80% agreement) was reached for 82. Quality of evidence was evaluated using validated criteria.

Results

The guideline incorporates new insights into the role of symptom assessment to diagnose carbohydrate (e.g., lactose) intolerances and recommends that breath tests for carbohydrate malabsorption require additional validated concurrent symptom evaluation to establish carbohydrate intolerance. Regarding the use of breath tests for the evaluation of oro‐cecal transit time and suspected small bowel bacterial overgrowth, this guideline highlights confounding factors associated with the interpretation of H₂‐CH₄‐breath tests in these indications and recommends approaches to mitigate these issues.

Conclusion

This clinical practice guideline should facilitate pan‐European harmonization of diagnostic approaches to symptoms and disorders, which are very common in specialist and primary care gastroenterology practice, both in adult and pediatric patients. In addition, it identifies areas of future research needs to clarify diagnostic and therapeutic approaches.

Association between antidiabetic agents use and leukocyte telomere shortening rates in patients with type 2 diabetes

Telomere length and telomere shortening rate (TSR) are accepted indicators of aging in cross-sectional population studies. This study aimed to investigate the potential influence of common antidiabetic agents on telomere length and TSR in patients with type 2 diabetes mellitus (T2DM). Leukocyte telomere length was measured through terminal restriction fragment analysis, and TSR was calculated in 388 T2DM patients. Depending on whether or not they received antidiabetic medication, patients were first divided into a treatment group and a nontreatment group. Treated patients were further subdivided into an acarbose-free group (patients taking antidiabetic agents without acarbose) and an acarbose group (patients using acarbose for more than 3 months). Results showed that untreated patients had higher TSRs than patients on antidiabetic drugs. Interestingly, patients in the acarbose group had significantly higher TSRs than patients in the acarbose-free group. Compared to the nontreatment group, the acarbose group showed better glycemic control of HbA1c, but the TSR was also higher. Our results suggest that antidiabetic treatments without acarbose can slow aging. By contrast, acarbose may accelerate biological aging in patients with T2DM, independently of glycemic control.

Therapeutic potential of α-glucosidase inhibitors in type 2 diabetes mellitus: an evidence-based review

INTRODUCTION

Postprandial hyperglycemia (PPHG) contributes to micro- and macro-vascular complications more than fasting hyperglycemia in patients with type 2 diabetes mellitus. Due to the traditional carbohydrate-rich diet, Asians, particularly Indians and Chinese need agents to control the higher risk of uncontrolled PPHG. Targeting PPHG with α-glucosidase inhibitors (AGIs), either alone or in combination with other oral hypoglycemic agents and insulin, provide overall glycemic control with transient mild gastrointestinal disorders. Treatment with AGIs, especially acarbose, has also shown to provide beneficial effects on lipid levels, blood pressure, coagulation factors, carotid intima-media thickness and endothelial dysfunction. New insights of acarbose therapy obtained like increased activity of gut hormones and improved gut microbiota may explain the benefits on weight, whereas increased production of H2 may explains its cardiovascular benefits to some extent.

AREAS COVERED

A systematic search strategy was developed to identify randomized controlled trials in MEDLINE, PubMed, EMBASE and ongoing trials databases.

EXPERT OPINION

AGIs as a class and acarbose in particular, are most useful in combatting PPHG and glucose variability across the spectrum of diabetes therapy, particularly in Asian patients. Together with their effects on incretin hormones and gut-microbiota AGIs can be considered beyond glycemic control as 'cardio-protective agents.'

Use of an α-Glucosidase Inhibitor and the Risk of Colorectal Cancer in Patients With Diabetes: A Nationwide, Population-Based Cohort Study

OBJECTIVE

Acarbose, an α-glucosidase inhibitor, has been shown to have antineoplastic effects on colorectal cancer in biomarker studies. We assessed the association between acarbose use in patients with diabetes and incident colorectal cancer.

RESEARCH DESIGN AND METHODS

We conducted a nationwide, population-based study using a large cohort with diabetes in the Taiwan National Health Insurance Research Database. Patients with newly diagnosed diabetes (n = 1,343,484) were enrolled between 1998 and 2010. One control subject not using acarbose was randomly selected for each subject using acarbose after matching for age, sex, diabetes onset, and comorbidities. Cox proportional hazards regression with a competing risks analysis was used to calculate the hazard ratios (HRs) and 95% CIs for the association between acarbose use and incident colorectal cancer for each eligible case-control pair (n = 199,296).

RESULTS

There were 1,332 incident cases of colorectal cancer in the cohort with diabetes during the follow-up period of 1,487,136 person-years. The overall incidence rate was 89.6 cases per 100,000 person-years. Patients treated with acarbose had a 27% reduction in the risk of colorectal cancer compared with control subjects. The adjusted HRs were 0.73 (95% CI 0.63-0.83), 0.69 (0.59-0.82), and 0.46 (0.37-0.58) for patients using >0 to <90, 90 to 364, and ≥365 cumulative defined daily doses of acarbose, respectively, compared with subjects who did not use acarbose (P for trend < 0.001).

CONCLUSIONS

Acarbose use reduced the risk of incident colorectal cancer in patients with diabetes in a dose-dependent manner.

Differential effects of feeding fermentable carbohydrate to growing pigs on performance, gut size and slaughter characteristics

Thirty-five gilts grown between 18 and 55 kg live weight were used to examine the effects of feeding fermentable carbohydrate on voluntary food intake, performance, carcass characteristics, and large intestinal growth. Five diets were used. The first diet contained steam-flaked sorghum and a supplement based on animal protein sources and 40 g/kg soya-bean meal (diet SAP). Using this diet as a base, three other diets contained either (i) guar gum, a source of soluble non-starch polysaccharide (NSP) (diet SAP + S-NSP), (ii) Novelose™, a source of resistant starch (RS) (diet SAP + RS), and (Hi) a combination of both S-NSP and RS (diet SAP + S-NSP + RS). The final diet (diet WBL) was based on wheat, barley and Australian sweet lupins. Diets (i), (ii) and (Hi) were formulated such that the concentrations of soluble NSP, oligosaccharide and RS were similar to those contained in diet WBL. There was no relationship (F > 0·05) between voluntary food intake and indices of hind-gut fermentation, although pigs given diets SAP + S-NSP and SAP + S-NSP + RS took longer to reach the slaughter weight of 55 kg (F < 0·001) and converted food less efficiently than pigs given other diets (F < 0·001). An increased intake of S-NSP (R2 = 0·842, P < 0·05) and S-NSP + RS (R2 = 0·805, F < 0·05) was positively correlated to an increased (empty) weight of the large intestine. A significant negative relationship (R2 = 0·78, F < 0·05) existed between the daily intake of S-NSP + RS and dressing proportion, such that each gram increase caused a 0·25 g/kg decrease in the dressing proportion of pigs. No such relationships existed between the daily intake of soluble NSP, insoluble NSP, or RS (P > 0·05) with dressing proportion. These data suggest that the sources of fermentable carbohydrate used in this study, i.e. soluble NSP and RS, may not significantly depress voluntary food intake but can affect performance and have a significant effect on large intestinal growth and dressing proportion.

Effects of isomalt consumption on gastrointestinal and metabolic parameters in healthy volunteers

The polyol isomalt (Palatinit®) is a well established sugar replacer. The impact of regular isomalt consumption on metabolism and parameters of gut function in nineteen healthy volunteers was examined in a randomised, double-blind, cross-over trial with two 4-week test periods. Volunteers received 30 g isomalt or 30 g sucrose daily as part of a controlled diet. In addition to clinical standard diagnostics, biomarkers and parameters currently discussed as risk factors for CHD, diabetes or obesity were analysed. Urine and stool Ca and phosphate excretions were measured. In addition, mean transit time, defecation frequency, stool consistency and weight were determined. Consumption of test products was affirmed by the urinary excretion of mannitol. Blood lipids were comparable in both phases, especially in volunteers with hyperlipidaemia, apart from lower apo A-1 (P=0·03) for all subjects. Remnant-like particles, oxidised LDL, NEFA, fructosamine and leptin were comparable and not influenced by isomalt. Ca and phosphate homeostasis was not affected. Stool frequency was moderately increased in the isomalt phase (P=0·006) without changes in stool consistency and stool water. This suggests that isomalt is well tolerated and that consumption of isomalt does not impair metabolic function or induce hypercalciuria. In addition, the study data indicate that isomalt could be useful in improving bowel function.

Faecal bacterial mass and energetic losses in healthy humans and patients with a short bowel syndrome

OBJECTIVE

In addition to non-digested nutrients, human stools contain endogenous substrates, among which bacteria are a major component, whose growth may be stimulated when more dietary nutrients are available for bacterial fermentation, as in patients with malabsorption syndrome. We assessed the energy content and composition of both stools and faecal bacteria in healthy volunteers and patients with a short bowel and colon in continuity (SBC). Our goal was to clarify the magnitude of error introduced by the faecal bacteria in the measurement of the digestibility of ingested energy and nutrients.

SUBJECTS AND METHODS

We studied six healthy volunteers and six patients with a SBC under free oral intake. The bacterial mass of stools was isolated. In the bacterial fractions and fresh stools, calorie, fat, nitrogen and short-chain fatty acid contents were determined. The Wilcoxon signed rank or the Mann-Whitney tests were used for comparison.

RESULTS

In healthy volunteers and patients with SBC, faecal bacterial mass accounted for 44 and 35% of faecal dry weight, and contained 50 and 34% of total faecal energy. In healthy volunteers, the apparent digestibilities when corrected by bacterial constituents (88-97% according to nutrients) were significantly higher than the apparent non-corrected digestibilities (84-94%). In patients with SBC, the corrected apparent digestibilities (69-89% according to nutrients) were significantly higher than the apparent non-corrected digestibilities (54-83%).

CONCLUSION

The error introduced by the faecal bacterial fraction when assessing the extent of nutrient digestibility is small in healthy volunteers; it is more pronounced in patients with SBC, reaching 18% for the digestibility of ingested fat.

Colonic health: fermentation and short chain fatty acids

Interest has been recently rekindled in short chain fatty acids (SCFAs) with the emergence of prebiotics and probiotics aimed at improving colonic and systemic health. Dietary carbohydrates, specifically resistant starches and dietary fiber, are substrates for fermentation that produce SCFAs, primarily acetate, propionate, and butyrate, as end products. The rate and amount of SCFA production depends on the species and amounts of microflora present in the colon, the substrate source and gut transit time. SCFAs are readily absorbed. Butyrate is the major energy source for colonocytes. Propionate is largely taken up by the liver. Acetate enters the peripheral circulation to be metabolized by peripheral tissues. Specific SCFA may reduce the risk of developing gastrointestinal disorders, cancer, and cardiovascular disease. Acetate is the principal SCFA in the colon, and after absorption it has been shown to increase cholesterol synthesis. However, propionate, a gluconeogenerator, has been shown to inhibit cholesterol synthesis. Therefore, substrates that can decrease the acetate: propionate ratio may reduce serum lipids and possibly cardiovascular disease risk. Butyrate has been studied for its role in nourishing the colonic mucosa and in the prevention of cancer of the colon, by promoting cell differentiation, cell-cycle arrest and apoptosis of transformed colonocytes; inhibiting the enzyme histone deacetylase and decreasing the transformation of primary to secondary bile acids as a result of colonic acidification. Therefore, a greater increase in SCFA production and potentially a greater delivery of SCFA, specifically butyrate, to the distal colon may result in a protective effect. Butyrate irrigation (enema) has also been suggested in the treatment of colitis. More human studies are now needed, especially, given the diverse nature of carbohydrate substrates and the SCFA patterns resulting from their fermentation. Short-term and long-term human studies are particularly required on SCFAs in relation to markers of cancer risk. These studies will be key to the success of dietary recommendations to maximize colonic disease prevention.

Abdominal bloating

Abdominal bloating is a common and significant clinical problem that remains to be scientifically addressed. Bloating is one of the most bothersome complaints in patients with various functional gut disorders. However, in the current standard classification, abdominal bloating is merely regarded as a secondary descriptor, which masks its real clinical effect. Four factors are involved in the pathophysiology of bloating: a subjective sensation of abdominal bloating, objective abdominal distention, volume of intra-abdominal contents, and muscular activity of the abdominal wall. The primer to elicit subjective bloating may be any of the other 3 factors, or the sensation may be related to distorted perception. All of these mechanisms may play an independent role or may be interrelated. Gas transit studies have evidenced that patients with bloating have impaired reflex control of gut handling of contents. Segmental pooling, either of gas or of solid/liquid components, may induce a bloating sensation, particularly in patients with altered gut perception. Furthermore, altered viscerosomatic reflexes may contribute to abdominal wall protrusion and objective distention, even without major intra-abdominal volume increment. Bloating probably is a heterogeneous condition produced by a combination of pathophysiological mechanisms that differ among individual patients and that in most cases are subtle and undetectable by conventional methods. Further advances in the pathophysiology and clinical forms of bloating are warranted to develop mechanistic strategies rather than the current empiric treatment strategies for comprehensive and effective management of this problem.

The pathogenesis of bloating and visible distension in irritable bowel syndrome

Abdominal bloating is a relevant, troublesome, and poorly understood clinical problem. Despite its clinical importance, bloating remains substantially ignored, without proper clinical classification, known pathophysiology, and effective treatment. It is not even clear to what extent the complaints of individual patients correlate with objective evidence of abdominal distension, and this uncertainly regarding the subjective or objective origin of the complaints further adds to confusion. This article proposed a framework for investigating bloating, considering key factors potentially involved in its pathophysiology: distorted sensation, physical abdominal expansion, and abdominal wall dystony. Some data indicate that patients complaining of bloating have impaired transit and tolerance of intestinal gas loads. The problem does not seem to be too much gas,however, but rather abnormal responses to gas. Furthermore, abnormal control of abdominal muscle activity in these patients may contribute to objective distension. Bloating, like many other abdominal symptoms,probably represents a heterogeneous condition produced by a combination of pathophysiological mechanisms that differ among individual patients,resulting in a polymorphic clinical presentation.

Heat moisture treatment of high amylose cornstarch increases its resistant starch content but not its physiologic effects in rats

To examine whether the physiologic effects of high amylose cornstarch (HACS) are affected by gelatinization or heat moisture treatment, male rats were fed for 21 d a fiber-free purified diet containing 40 g/100 g gelatinized normal cornstarch (G-CS), HACS, gelatinized high amylose cornstarch (G-HACS) or heat moisture-treated HACS (HMCS). Dietary fiber (DF) content in G-HACS was 87% lower than that in HACS. The apparent starch and protein digestibilities were higher in the G-HACS group than in the HACS group. Fecal wet weight and fecal bile acid excretion were lower in the G-HACS group than in the HACS group. The cecal tissue weight, cecal surface area, cecal content weight and cecal pH were lower in the G-HACS group than in the HACS group. The cecal n-butyric acid and succinic acid concentrations were higher and lower, respectively, in the G-HACS group than in the HACS group. The plasma cholesterol and triacylglycerol concentrations did not differ between the G-HACS group and the HACS group. On the other hand, the DF content in HMCS was 330% higher than that in HACS, but the HMCS and HACS groups generally did not differ except in cecal surface area. Dietary starch did not affect fecal moisture, fecal neutral sterol (cholesterol + coprostanol) excretion, liver cholesterol level, total short-chain fatty acid (SCFA) concentration or apparent Ca, Fe, Mg and Zn absorptions. These results show that the heat moisture treatment of HACS for the most part does not alter its physiologic effects despite the greater DF content.

Short-chain fatty acids and human colonic function: roles of resistant starch and nonstarch polysaccharides

Resistant starch (RS) is starch and products of its small intestinal digestion that enter the large bowel. It occurs for various reasons including chemical structure, cooking of food, chemical modification, and food mastication. Human colonic bacteria ferment RS and nonstarch polysaccharides (NSP; major components of dietary fiber) to short-chain fatty acids (SCFA), mainly acetate, propionate, and butyrate. SCFA stimulate colonic blood flow and fluid and electrolyte uptake. Butyrate is a preferred substrate for colonocytes and appears to promote a normal phenotype in these cells. Fermentation of some RS types favors butyrate production. Measurement of colonic fermentation in humans is difficult, and indirect measures (e.g., fecal samples) or animal models have been used. Of the latter, rodents appear to be of limited value, and pigs or dogs are preferable. RS is less effective than NSP in stool bulking, but epidemiological data suggest that it is more protective against colorectal cancer, possibly via butyrate. RS is a prebiotic, but knowledge of its other interactions with the microflora is limited. The contribution of RS to fermentation and colonic physiology seems to be greater than that of NSP. However, the lack of a generally accepted analytical procedure that accommodates the major influences on RS means this is yet to be established.

Beneficial health effects of low-digestible carbohydrate consumption

Low-digestible carbohydrates represent a class of enzyme-resistant saccharides that have specific effects on the human gastrointestinal tract. in the small bowel, they affect nutrient digestion and absorption, glucose and lipid metabolism and protect against known risk factors of cardiovascular disease. In the colon they are mainly degraded by anaerobic bacteria in a process called fermentation. As a consequence, faecal nitrogen excretion is enhanced, which is used clinically to prevent or treat hepatic encephalopathy. Low-digestible carbohydrates are trophic to the epithelia of the ileum and colon, which helps to avoid bacterial translocation. Short-chain fatty acids are important fermentation products and are evaluated as new therapeutics in acute colitis. They are considered in the primary prevention of colorectal cancer. The bifidogenic effect of fructo-oligosaccharides merits further attention, Unfermented carbohydrates increase faecal bulk and play a role in the treatment of chronic functional constipation, symptomatic diverticulosis and, possibly, the irritable bowel syndrome. In conclusion, low-digestible carbohydrates may play a role in the maintenance of human digestive health. However, the strength of evidence differs between disease entities.

Hydroxypropyl-distarch phosphate from Tapioca starch reduces zinc and iron absorption, but not calcium and magnesium absorption, in rats

Male rats were fed a fiber-free, purified diet containing either gelatinized tapioca starch that was not modified chemically (TS, 50 g/kg diet) or gelatinized chemically modified tapioca starch (CMS, 50 g/kg) for 21 d. TS was used as the control. The six kinds of gelatinized hydroxypropyl distarch phosphate (HDP) from tapioca with two different degrees of substitution (DS) and three different degrees of cross-linking (DC) were used as CMS sources. The wet weight and moisture of fecal output of the rats fed HDP with higher DS were 100 and 20% greater than that in the control rats, respectively. The weights of cecal wall and cecal contents were also 30 and 50% higher in the rats fed HDP with higher DS than those in the control rats. The pH of the cecal contents was more acidic in the rats fed HDP with higher DS than that in the control rats. Fecal excretion of bile acids was 40% higher in the rats fed HDP with higher DS than in the control rats. These effects of HDP were only slightly affected by the DC. The plasma cholesterol concentration was 16% lower in the rats fed HDP with higher DS and highest DC than in the control rats. The concentrations of liver lipids and plasma triglycerides and the cecal pool of organic acids were not affected by diet. The apparent absorptions of Ca and Mg were not affected by diet, but those of Zn and Fe were 75 and 70% lower in the rats fed HDP with higher DS than in the control rats. These results suggest that the physiological effects of HDP depend on the DS but not on the DC.

Changes to the quantity and processing of starchy foods in a western diet can increase polysaccharides escaping digestion and improve in vitro fermentation variables

This study investigated how readily achievable changes to the quantity and processing of starchy foods in a typical Western diet: (1) were reflected in levels of resistant starch (RS) and NSP excreted from the small intestine; and (2) more favourable profiles of butyrate, NH3 and phenol production. Two diets, a low-starch diet (LSD) and a high-starch, low-fat diet (HSLFD) were compared. The LSD with 20% total energy (%E) from starch was based on a 'typical' Australian diet, while the HSLFD (40%E as starch) was the same Australian diet modified by an increased content of legumes, starchy foods and coarsely-ground cereals and by a reduced fat content. Four subjects with iliostomies consumed each diet for 2 d, with ileal effluent collection on the second day. On the HSLFD compared with the LSD, RS in ileal effluent increased from from 0.49 to 1.7 g/MJ per d (P < 0.005) while ileal NSP excretion increased from 2.0 to 3.3 g/MJ per d (P < 0.05). Ileal effluents obtained after each diet were incubated for 24 h in vitro with a human faecal innoculum. After fermentation, ileal effluent from the HSLFD produced more butyrate relative to other short-chain fatty acids (17.5 v. 15.8 molar %, P < 0.005) and less phenol (2.3 v. 5.7 mg/l, P < 0.05) and NH3 (20.3 v. 23.1 mmol/l, P < 0.005) than the LSD diet. The HSLFD also generated a lower pH (6.15 v. 6.27, P < 0.05). On a wt/wt basis, RS was 2.3-fold higher in the HSLFD effluent while NSP did not increase, suggesting that the change in RS largely contributed to the fermentation effects. Changes in in vitro variables when the HSLFD ileal effluent was ground before fermentation indicated the importance of physical structure in determining ileal excretion of RS. We conclude that: (1) readily achievable modifications to the amount and processing of starchy foods in an Australian diet would produce potential benefits for in vitro fermentation variables; and (2) the physical structure of grains and cereals is important in determining access by colonic bacteria to a carbohydrate substrate.

Digestion of carbohydrate from white beans (Phaseolus vulgaris L.) in healthy humans

Resistant starch (RS) is thought to be present in large amounts in legume seeds; however, it has never been quantified in healthy humans. RS from cooked (atmospheric pressure) white beans was quantified in humans and pigs, and characterized to explain its low digestibility. Six human volunteers were intubated to collect ileal digesta after an experimental meal composed of orange juice, butter and 167 g beans (dry matter basis). The reliability of the intubation method was examined in a pig study in which it was compared with another collection method, ileal cannulation. Chemical analyses, microscopy and size exclusion chromatography were performed on human and pig digesta. The pig study showed that the intubation method may underestimate the quantity of RS. However, no chemical/physical difference was observed between the RS collected by the two techniques. In the human study, 16.5 +/- 1.3% (11.3 g) of the ingested starch was recovered as RS. The microscopy of the digesta showed that part of the RS was enclosed in the cell walls. Although the RS was composed mainly of alpha-glucan molecules with a degree of polymerization (DP) 40 to 60, oligosaccharides and large molecules of DP > 400 were also present. Retrogradation was not found to be the main factor responsible for starch malabsorption. We conclude that white beans may contain a large amount of RS formed mainly by partially degraded molecules protected by the cell walls during their transit through the gut.

Hydroxypropyl-modified potato starch increases fecal bile acid excretion in rats

The effects of hydroxypropyl potato starches (HPS) of three different degrees of substitution (DS) on concentration of plasma cholesterol, apparent digestibility of protein, fecal excretion of bile acids, fecal output and cecal pool of organic acids such as acetic, propionic, butyric, lactic and succinic acid were studied in rats in Experiment 1. In Experiment 2, the effects of hydroxypropyl distarch phosphate (HDP) of three different degrees of cross-linking (DC) on the same indexes were studied. Gelatinized potato starch that was not modified chemically (PS) was used as a control. Rats were fed a fiber-free, purified diet containing either HPS, HDP or PS (100 g/kg) for 21 d. In each experiment, fecal output was greater and fecal excretion of bile acids was higher in rats fed the HPS diets with higher DS and the HDP diets compared with control rats fed the PS diet. Apparent protein digestibility in rats fed the HPS diets with higher DS and the HDP diets with higher DC was lower than that in control rats fed the PS diet. The pool size of cecal organic acids was not affected by diet. In Experiment 1, apparent protein digestibility, fecal output and fecal bile acids excretion were significantly correlated with DS (r = -0.994, P = 0.0059; r = 0.976, P = 0.0236; and r = 0.899, P = 0.0077, respectively). The plasma cholesterol concentration was significantly lower in rats fed the HPS diets than in control rats fed the PS diet. The HPS diets resulted in higher proportions of propionic acid, lactic acid and succinic acid and a lower proportion of n-butyric acid than the PS diet. In Experiment 2, apparent protein digestibility was significantly correlated with DSP (r = 0.996, P = 0.0028), which was inversely related to DC. The HDP diets did not affect the plasma cholesterol concentration. The HDP diets resulted in higher proportions of acetic acid, lactic acid and succinic acid and a lower proportion of n-butyric acid than the PS diet. These results suggest that the physiological effects of chemically modified starches are affected by the type of modification.

In vitro fermentation of high-amylose cornstarch by a mixed population of colonic bacteria

BACKGROUND

Malabsorbed starch is probably the most important substrate for bacterial fermentation in the human large intestine. Fermentability of starch may depend on the composition of the colonic flora and its adaptation to the substrate supply.

METHODS

Ten healthy volunteers were fed a controlled diet containing either 7.0 to 8.3 or 50.7 to 59.7 g/d of resistant starch (Hylon VII) for 4 weeks. At the end of each diet period, fecal starch concentrations were measured. Fecal samples were incubated in 48-hour batch cultures containing 10 g/L Hylon VII or digestible Lintner's starch. Bacterial breakdown of starch and short-chain fatty acid concentrations were measured at 0, 3, 6, 12, 24, and 48 hours.

RESULTS

Fecal starch concentrations were higher during the Hylon VII period (35.7 +/- 16 vs 8.9 +/- 3.3 mg/g). Starch was fermented rapidly and completely in vitro in all but two subjects. Fermentability of resistant starch was comparable to that of digestible starch. No differences were found between the dietary periods. Fermentation of resistant starch produced higher rates of n-butyrate. Two subjects had substantially higher fecal starch concentrations. In vitro starch breakdown in these subjects was slow and incomplete.

CONCLUSIONS

Fermentation of resistant starch by the colonic microflora was rapid and complete in 8 of 10 subjects. No adaptation of the fermentation capacity was observed after 4 weeks of dietary resistant starch supplementation. Fermentation of resistant starch increased the proportion of n-butyrate in vitro. In two subjects, fecal starch concentrations were substantially higher than in the other subjects and in vitro starch fermentation was slow and incomplete.

Metabolic consequences of total colectomy

Colectomy is performed for inflammatory bowel disease, familial polyposis syndrome and colorectal carcinoma. Surgical procedures are ileostomy with or without pouch, ileorectal anastomosis or ileal pouch-anal anastomosis. One of the major functions of the intact large intestine is to absorb water and electrolytes. After colectomy, as much as 400-1000 ml of nearly isotonic ileostomy fluid may be excreted, resulting in a chronic salt and water depletion. This is compensated for by an activation of the renin-angiotensin-aldosterone system. Reduced urine volumes may cause kidney stones. Both dehydration and renal sodium retention are probably less frequent in patients with ileal pouch-anal anastomosis. Absorption of nutrients in general is not impaired by colectomy. The large intestine salvages energy from malabsorbed organic matter through absorption of the short-chain fatty acids produced in bacterial fermentation. In ileostomy patients, fermentation is negligible, which leads to a significant loss of energy in the ileostomy fluid. Pouches are colonized by a bacterial flora similar to colonic bacteria. In these patients conservation of energy from malabsorbed substrate may be similar to healthy subjects. Resection of ileum and bacterial colonization may lead to malabsorption of vitamin B12 and bile acids. The latter may cause increased incidence of biliary cholesterol stones. Pouchitis is a frequent problem which may be caused by a deficiency of short-chain fatty acids and glutamine in the pouch contents. It is concluded that although the colon is not essential as a digestive organ in man, colectomy results in a number of metabolic changes. The ileal pouch-anal anastomosis may in part substitute for the functions of the large intestine.

Fecal short-chain fatty acids in patients with diarrhea-predominant irritable bowel syndrome: in vitro studies of carbohydrate fermentation

Colonic bacterial production of short-chain fatty acids (SCFA) plays an important role in the salvage of unabsorbed carbohydrate and in colonic absorption of electrolytes and water. The objective of this study was to determine whether patients with diarrhea-predominant irritable bowel syndrome (DP-IBS) have a different pattern and rate of fermentation of carbohydrate and fiber to SCFA compared with controls. Fecal homogenates from 10 patients with DP-IBS and 10 age-matched controls were studied. SCFA were measured by gas chromatography in baseline fecal samples and in fecal homogenates in an in vitro anaerobic fermentation system after incubation with no additional substrate, lactulose, potato starch, citrus pectin, and hemicellulose over a 24-hour period. Net SCFA production rates were calculated for the first 6 h of the incubation period. Patients with DP-IBS had a consistently different pattern of less total SCFA, a lower percentage of acetate (p < 0.05), and a higher proportion of n-butyrate (p < 0.05) than controls. In stool homogenates from both controls and DP-IBS patients, lactulose fermentation resulted in the highest rate of SCFA production followed by pectin, starch, and hemicellulose. However, at all time points, the fecal homogenates from controls generated a higher concentration of total SCFA, acetate, and propionate with all substrates tested. SCFA production rates were higher in controls incubated with lactulose, starch, and hemicellulose. The fecal SCFA profile of patients with DP-IBS is characterized by lower concentrations of total SCFA, acetate, and propionate and a higher concentration and percentage of n-butyrate. Fecal flora from these patients produced less SCFA in an in vitro fermentation system in response to incubations with various carbohydrates and fibers. Differences in SCFA production by colonic bacterial flora in patients with DP-IBS may be related to the development of gastrointestinal symptoms.

Digestion and physiological properties of resistant starch in the human large bowel

The digestion of four sources of resistant starch (RS) has been studied in twelve healthy volunteers who ate controlled diets for 15 d periods. RS from potato, banana, wheat and maize (17-30 g/d) was compared with a starch-free diet, a diet containing wheat starch that was fully digested in the small intestine, and with 18.4 g NSP from brand/d. RS increased stool wet weight by 1.6 g/d per g RS fed for potato, 1.7 for banana, 2.5 for wheat and 2.7 for maize, but this was significantly less than bran NSP at 4.9 g/g. RS was extensively digested in twenty-seven of thirty-four diet periods but five subjects were unable to break down one or two of the RS sources. Faecal N and energy excretion were increased. RS decreased NSP breakdown and RS2 (resistant starch granules) tended to prolong transit time. All forms of RS increased faecal total short-chain fatty acid excretion. RS2 (from potato and banana) gave greater proportions of acetate in faeces, and RS3 (retrograded starch from wheat and maize) more propionate. We have concluded that RS2 and RS3 are broken down in the human gut, probably in the colon although in 26% of cases this breakdown was impaired. RS exerts mild laxative properties, predominantly through stimulation of biomass excretion but also through some sparing of NSP breakdown.

Bacterial adaptation in patients with short bowel and colon in continuity

BACKGROUND & AIMS

Long-term carbohydrate malabsorption in patients with short bowel and colon in continuity (SBC) could result in a more efficient fermentation. The bacterial fermentation capacity in patients with SBC was assessed.

METHODS

Eleven fasting patients with SBC ingested 60 g lactulose with 10 g polyethylene glycol. Stool specimens were analyzed. Patients were compared with 8 normal subjects who ingested 60 g lactulose on two occasions, separated by 8 days during which 20 g lactulose was taken twice daily. Moreover, the daily amount of bacteria excreted in stools was measured in 6 patients with SBC and 6 normal subjects.

RESULTS

Despite fast transit time, patients fermented more lactulose and hexoses and had a higher activity of beta-galactosidase in stools than nonadapted normal subjects (P < 0.01); these parameters were roughly similar in patients and adapted normal subjects. The fecal output of short-chain fatty acids was significantly lower in patients than in nonadapted normal subjects (P < 0.03). Patients excreted a significantly greater amount of bacteria in stools than normal subjects (P < 0.05).

CONCLUSIONS

In patients with SBC, the capacity of bacterial flora to ferment lactulose and fecal bacterial mass is spontaneously increased, suggesting that hyperfermentation may affect other carbohydrates. Moreover, hyperfermentation is associated with efficient removal of extra short-chain fatty acids from fecal water.

Influence of starch fermentation on bile acid metabolism by colonic bacteria

Secondary bile acids (BA) may be involved in the pathogenesis of colorectal cancer. In vivo, starch malabsorption has been shown to reduce fecal excretion of secondary BA. The present in vitro study was performed to investigate the effect of starch fermentation on BA metabolism by colonic bacteria. Fecal samples of healthy volunteers were incubated in anaerobic batch cultures for 48 hours with the primary bile acids cholic (0.6 g/l) and chenodeoxycholic acid (0.4 g/l). Media were starch free or enriched with starch (10 g/l). The pH was controlled and held at 6 or 7. In the starch-free incubations, secondary BA were rapidly formed, and degradation of primary to secondary BA was complete within 24 hours. The formation of secondary BA was partially inhibited by the addition of starch to the media. This effect was stronger at pH 6 than at pH 7. Starch was rapidly and completely fermented. In conclusion, this study showed that formation of secondary BA by fecal bacteria is inhibited when starch is simultaneously fermented, an effect that is mainly, but not completely, explained by reduction of pH.

Effect of resistant starch on colonic fermentation, bile acid metabolism, and mucosal proliferation

Resistant starch is by definition that part of starch that escapes digestion in the small bowel. Cecal fermentation of resistant starch into short-chain fatty acids will result subsequently in a decrease in pH. Thus, resistant starch may have the same effect on colonic luminal contents and mucosa as some fiber components. We studied the effects of adding 45 g native amylomaize (Hylon-VII) to a standardized diet in 14 healthy volunteers on fermentation and colonic mucosal proliferation. Hylon-VII is a high amylose maize starch, containing 62% resistant starch. During amylomaize consumption, breath hydrogen excretion rose 85% and fecal short chain fatty acid output increased 35% (P < 0.01). Excretion of primary bile acids increased and the soluble deoxycholic acid concentration decreased by 50% (P = 0.002). Subsequently, cytotoxicity of the aqueous phase of feces--as measured on a colon cancer cell line--decreased (P = 0.007). Colonic mucosal proliferation in rectal biopsies (proliferating cell nuclear antigen immunostaining) decreased from 6.7 to 5.4% (P = 0.05). We speculate that resistant starch consumption decreases colonic mucosal proliferation as a result of the decreased formation of cytotoxic secondary bile acids, which is possibly mediated through acidification of the large bowel by production of short-chain fatty acids.

Effect of an alpha-glucosidase inhibitor on intestinal fermentation and faecal lipids in diabetic patients

Eight non-insulin-dependent diabetes mellitus patients, in whom oral hypoglycaemic agents were not effective, were treated with an alpha-glucosidase inhibitor, AO-128 (0.9 mg/day) for 6 months. After 6 months of treatment there was a statistically significant decrease in the blood glucose level 1 and 2 h postprandially. The 2 h blood glucose level was also significantly reduced after 2 months' treatment. The insulin and HbA1c levels after 2 and 6 months' treatment were lower than those before administration. Faecal weight, the frequency of bowel movements, the ratio of hydroxy fatty acids to total fatty acids, and faecal short-chain carboxylic acid content were all increased significantly during treatment. The initially hard stools became normal or soft, although no actual diarrhoea developed. Both faecal bile-acid excretion and the ratio of primary bile acids to total bile acids were increased significantly after 2 months, but they showed some recovery towards the pretreatment levels after 6 months' treatment. There was no distinct change in neutral sterol and fatty acid excretion. Breath hydrogen excretion showed a slight increase after treatment. These results suggest that intestinal fermentation was promoted and the intestinal transit time was shortened by AO-128 administration.

Protective mechanisms of dietary fibers in nutritional carcinogenesis

Fibers in foods are complex carbohydrates. There are several types of fiber, but, for the purpose of mechanistic insight into their mode of protective action in carcinogenesis, classification into two broad types, soluble and insoluble fibers, is warranted. Soluble fibers are present in fruits, vegetables, and certain grains like oats. This type of fiber undergoes metabolism in the small intestine and especially in the large intestine through bacterial enzymes, converting it to products that increase stool size only moderately. But, they have appreciable effects in modifying the metabolism of colon carcinogens like azoxymethane to yield detoxified products and, thus, reducing colon carcinogenesis. In contrast, insoluble fibers present in sizeable amounts in bran cereals, like wheat or rice, are not significantly metabolized by enzymes in the intestinal flora. Such fibers increase stool size substantially through several mechanisms, including higher water retention. The larger bulk dilutes carcinogens, especially tumor promoters such as secondary bile acids, resulting in lower risk of colon cancer in animals and in humans. Evidence in animal models and in humans also indicates that fiber may lower the risk of breast cancer, possibly via an endocrine mechanism. Based on these concepts, increased intake of total fiber, but especially of wheat bran cereal fiber, to yield a daily stool in adults of about 200 grams can significantly reduce the risk of colon cancer and, to a lesser but definite extent, of breast cancer. Thus, adequate fiber intake from cereals, fruits, and vegetables can help prevent important types of human cancer.

Effects of acarbose on starch hydrolysis. Study in healthy subjects, ileostomy patients, and in vitro

The effect of acarbose on hydrolysis of a pure starch meal was investigated in normal subjects and ileostomy patients by means of 13CO2 breath tests and blood glucose levels as parameters of absorption, and of H2 breath tests, serum acetate levels, and ileal loss of carbohydrate as parameters of malabsorption. Additional information on the effect of acarbose on alpha-amylase activity was obtained by in vitro experiments. Acarbose (200 and 400 mg) significantly delayed starch absorption. Serum acetate was found to be a less sensitive marker of malabsorption than breath H2 excretion. After intake of 50 g starch plus 400 mg acarbose, 23-71% of the starch load was lost in the ileostomy effluent, for a large part as starch. This suggests that acarbose considerably inhibits alpha-amylase, and not only brush-border enzymes. In vitro experiments confirm that an inhibition of two thirds of alpha-amylase activity can be expected from pharmacologically used doses of acarbose.

Effect of short-chain fatty acids on the human colonic mucosa in vitro

Fermentable dietary fiber components are known to stimulate colonic crypt proliferation. As these compounds are rapidly degraded to short-chain fatty acids (SCFAs) by the anaerobic microflora, the hypothesis was tested that this trophic effect of fiber may be mediated by SCFAs. Biopsies were taken from normal cecal mucosa of 45 individuals during routine colonoscopy. They were incubated for 3 hours with sodium salts of SCFAs at physiological concentrations (three SCFAs = acetate 60 mmol/L + propionate 25 mmol/L + butyrate 10 mmol/L; acetate 60 mmol/L; propionate 25 mmol/L; butyrate 10 mmol/L) or equimolar NaCl (control). Cell proliferation was measured autoradiographically by subsequent pulse labeling with [3H]thymidine (1 hour). The labeling index (number of labeled cells divided by the total number of cells) was computed for the crypt as a whole and for five equal crypt compartments (compartment 1 = crypt base, compartment 5 = crypt surface). Cecal crypt proliferation was raised significantly in all incubation experiments with SCFAs. Butyrate (10 mmol/L, increase + 89%) and propionate (25 mmol/L, + 70%) were as effective in stimulating proliferation as the combination of three SCFAs (+103%), although the effect of acetate (+31%) was minor. Increasing the butyrate concentration to 25 mmol/L or 60 mmol/L did not result in a further increase of cell labeling. SCFAs stimulated proliferation in the basal three crypt compartments only. An expansion of the proliferative zone to compartments 4 and 5 was not observed. SCFAs, especially butyrate and propionate, are luminal trophic factors for the cecal epithelium.(ABSTRACT TRUNCATED AT 250 WORDS)

Colonic fermentation of potato starch after a freeze-thaw cycle

To estimate colonic carbohydrate fermentation following a potato meal, 13 healthy volunteers consumed 375 g potatoes containing 60 g starch on three different occasions in random order: (A) potatoes boiled and consumed fresh at 60 degrees C; (B) potatoes boiled, frozen, thawed and consumed at 20 degrees C; and (C) potatoes boiled, frozen, thawed, reheated to 90 degrees C, and consumed at 60 degrees C. End-expiratory breath hydrogen (H2) was measured every 15 min for 10-14 hr with a selective electrochemical cell. The extent of colonic carbohydrate fermentation (AUC = area under the breath H2 concentration vs time curve) in experiment B was significantly higher (+186%, P less than 0.002) than in experiment A. The breath hydrogen AUC in experiment C was higher than in experiment A (+48%, P less than 0.04) but lower than in experiment B (-94%, P less than 0.003). It is suggested that structural alterations of the starch molecule occur during freezing, thawing, and reheating and alter the availability of carbohydrates for fermentation by colonic anaerobes.

Starch malabsorption and stool excretion are influenced by the menstrual cycle in women consuming low-fibre Western diets

The objectives of the study were to determine whether the follicular (F; days 6-11) and luteal (L; days 16-21) phases of the menstrual cycle were associated with changes in starch malabsorption, stool bulking, stool mucinase, and beta-glucuronidase activities in 10 women (24.1 +/- 0.7 years old) eating a standardized low-fibre diet. Starch malabsorption, measured by breath hydrogen excretion after a breakfast of pureed chickpea (days 10 and 20) versus 10 g lactulose (days 11 and 21), decreased from 9.7 +/- 1.8 g/50 g starch ingested (F) to 6.6 +/- 1.8 g/50 g starch ingested (L) (P less than 0.05). Stool wet weight decreased from 84.5 +/- 10.1 g/day (F) to 52.2 +/- 5.8 g/day (L) (P less than 0.002). Stool dry weight decreased from 20.2 +/- 1.9 g/day (F) to 14.2 +/- 1.1 g/day (L) (P less than 0.006). Stool nitrogen excretion decreased from 1.81 +/- 0.19 g/day (F) to 0.82 +/- 0.06 g/day (L) (P less than 0.006). Stool mucinase and beta-glucuronidase activities were unaffected by the menstrual cycle. These results indicate that women eating low-fibre Western diets may be more prone to constipation during the luteal phase of the menstrual cycle.

Intestinal absorption of free oral hyperalimentation in the very short bowel syndrome

Ten adult ambulatory patients with the nonactive digestive disease short bowel syndrome were prospectively studied to quantitatively assess their free oral intake and their net digestive absorption of total calories, fat, protein, and carbohydrate during a 3-day period at least 6 months after a resection. The remaining portions of small bowel had a mean length of 75 cm (range, 0-200 cm); the remaining colon lengths had a mean of 67% of normal (range, 0%-100%). The experimental diets were formulated according to a home dietary inquiry. During the study period, pooled intakes and digestive losses were measured for total calories, fat, and protein using the bomb calorimetry, Van de Kamer, and Kjeldahl techniques, respectively. The ingested diet provided 58 +/- 14 kcal.kg-1.day-1 (mean +/- SD) and consisted of 46% carbohydrate, 31% fat, and 23% protein. Net digestive absorption was 67% +/- 12% for total calories, 79% +/- 15% for carbohydrate, 52% +/- 16% for fat, and 61% +/- 19% for protein. The larger net digestive absorption of carbohydrate (P less than or equal to 0.004) compared with fat and protein suggests salvage of colonic cholesterol in short bowel syndrome patients. It is concluded that these patients with the short bowel syndrome adapted to a hypercaloric, hyperprotein diet to compensate for increased fecal losses and that this hyperphagia does not seem to have impaired their net digestive absorption.

Impact of dietary cereal on nutrient absorption and fecal nitrogen loss in formula-fed infants

STUDY OBJECTIVE

To determine the capacity of infants to digest and absorb rice cereal and to determine the effect of cereal feeding on total energy and nitrogen absorption.

SETTING

Subject's residences and the Texas Children's Hospital Clinical Research Center, Houston.

PATIENTS

Eight healthy 1-month-old bottle-fed infants.

INTERVENTIONS

Infants were fed their usual formula for 3 days. For the subsequent 6 days, they received 4 gm of rice cereal, labeled with carbon 13, per 30 ml of the formula.

MEASUREMENTS AND MAIN RESULTS

Fecal balance studies were performed for a 72-hour period while the infants received only formula and again during the last 3 days of cereal feeding. Breath samples for hydrogen measurement were collected before and after the cereal feeding. Nutrient intake was measured and stools were analyzed for 13C abundance, energy, nitrogen, fiber content, and bacterial mass. Cereal absorption was 88 +/- 9% (mean +/- SD). Despite a significant increase in energy and nitrogen intake from cereal feeding, the coefficient of absorption fell (energy: 97% to 90%, p = 0.048; nitrogen: 94% to 74%, p = 0.009). Fecal dry weight increased after the cereal feeding (p = 0.004), primarily as a result of a sevenfold increase in fecal bacterial mass (p = 0.002). Fecal nitrogen increased primarily because of incorporation of nitrogen into bacteria. No differences were detected in breath hydrogen as a consequence of formula feeding versus formula-cereal feeding.

CONCLUSIONS

Although cereal was relatively well-absorbed in this group of infants and increased their intakes of energy and nitrogen, it did not increase the coefficients of energy and nitrogen absorption. Cereal feeding increased fecal bacterial mass and bacterial nitrogen.

Severe short bowel syndrome with a surgically reversed small bowel segment

We report a case of short bowel syndrome (60 cm of jejunum anastomosed to the left colon) with reversal of the distal 15 cm of jejunum in a 21-year-old man. The nutritional absorptive capacity and digestive motility was studied for 18 months postoperatively. His absorptive capacity reached subnormal values allowing him oral nutritive autonomy and normal social life. The results of the manometric study suggested that the reversed segment delayed intestinal transit time. The prolonged contact of the chyme with the intestinal absorptive mucosa possibly increased its absorptive capacity. Our data and the literature reports suggest that reversal of a bowel loop could help wean patients from their dependence on parenteral nutrition.

Effects of the glucosidase inhibitor acarbose in patients with liver cirrhosis

In this preliminary study, we examined the effects of acarbose and placebo together with a standardized breakfast on blood glucose levels, on breath hydrogen excretion and on plasma insulin and glucagon levels; in addition, the effects on fasting blood levels of metabolites were studied following an evening meal with acarbose or placebo. Acarbose significantly reduced blood glucose levels in 10 patients with alcoholic cirrhosis following a meal containing 100 g of carbohydrate. There were no significant changes in plasma insulin after breakfast but glucagon levels were increased at 1 h after the meal. Breath hydrogen excretion did not change significantly. Acarbose given with a late evening snack reduced fasting beta-hydroxybutyrate levels the next morning in these cirrhotic patients.