Best Practice & Research Clinical Gastroenterology

Vol. 18, No. 2, pp. 287 298, 2004

doi:10.1053/ybega.2004.445, available online at http://www.sciencedirect.com

5
Prebiotics
Thea Scantlebury Manning*

BSc, PhD

Research fellow

Glenn R. Gibson

BSc, PhD

Professor and Head of Food Microbial Science Unit

Food Microbial Science Unit, School of Food Biosciences, Reading University, Science and Technology Center, Earley
Gate, Whiteknights Road, Reading RG6 6BZ, UK

In nutritional sciences there is much interest in dietary modulation of the human gut. The
gastrointestinal tract, particularly the colon, is very heavily populated with bacteria. Most bacteria
are benign; however, certain gut species are pathogenic and may be involved in the onset of acute
and chronic disorders. Bifidobacteria and lactobacilli are thought to be beneficial and are
common targets for dietary intervention.
Prebiotic is a non-viable food ingredient selectively metabolized by beneficial intestinal
bacteria. Dietary modulation of the gut microflora by prebiotics is designed to improve health by
stimulating numbers and/or activities of the bifidobacteria and lactobacilli. Having an optimal gut
microflora can increase resistance to pathogenic bacteria, lower blood ammonia, increase
stimulation of the immune response and reduce the risk of cancer. This chapter examines how
prebiotics are being applied to the improvement of human health and reviews the scientific
evidence behind their use.
Key words: prebiotic; oligosaccharides; gut microflora; bifidobacteria; lactobacilli functional
food.

Biological functions of the human large intestine include waste storage (and its
excretion) and the absorption of water as well as essential minerals. However, because
of a slow transit time, near-neutral pH and high substrate availability, the colon harbours
a very complex and diverse bacterial microflora.1 The microflora in the human large
intestine is thought to compromise about 95% of total cells in the body, representing
1012 cells/g dry weight contents, making the organ a highly specialized and active area of
the body. Through the activities of the resident microflora, the colon plays a major role
in host nutrition and welfare.2 Dietary modulation of the human gut flora can be of
some benefit to health. In recent years, the functional food concept has moved towards
the situation whereby improved gut (microbial) functionality is the main current driving
force. The colon is by far the most intensely populated region of the gastrointestinal
tract and is therefore a major target for dietary intervention.
* Corresponding author. Tel.: 44-118-935-7220; Fax: 44-118-935-7222.
E-mail address: t.m.scantleburymanning@reading.ac.uk (T. S. Manning).
1521-6918/$ - see front matter Q 2003 Elsevier Ltd. All rights reserved.

288 T. S. Manning and G. R. Gibson

The gut microflora ferments a range of substances, mainly provided by the diet, that
cannot be digested by the host in the small intestine and are available for fermentation by
the colonic microflora. These include resistant starch, non-starch polysaccharides
(dietary fibre), oligosaccharides, proteins, amino acids, etc. In a typical adult, about 100 g
of food ingested each day reaches the large intestine and is therefore susceptible to
fermentation by the gut flora. The two main types of anaerobic fermentation that are
carried out in the gut are saccharolytic and proteolytic. The main end-products of
carbohydrate metabolism are the short-chain fatty acids (SCFAs), principally acetate,
propionate and butyrate. These may be further metabolized systemically or locally to
provide energy generation for the host. The end-products of proteolytic fermentation
include phenolic compounds, amines and ammonia, all of which are toxic. The proximal
colon (right side) is essentially a site of saccharolytic fermentation, whereas the more
distal (left side) sees a depletion of available carbohydrate and more protein metabolism.
Dietary modulation of the human gut microflora is a popular area of the nutritional
sciences. This is driven by the fact that the gastrointestinal tract, particularly the colon,
is very heavily colonized and that the composition of the flora can be modulated.
Undoubtedly, certain gut species are pathogenic and may be involved in the onset of
acute and chronic disorders. However, bifidobacteria and lactobacilli are considered to
be examples of health-promoting constituents of the microflora. Lactobacilli may aid
digestion of lactose in lactose-intolerant individuals, reduce constipation and infantile
diarrhoea, help resist infections such as salmonellae, prevent travellers diarrhoea and
help to relieve irritable bowel syndrome (IBS).3 Bifidobacteria are thought to stimulate
the immune system, produce B vitamins, inhibit pathogen growth, reduce blood
ammonia and blood cholesterol levels, and help to restore the normal flora after
antibiotic therapy.4 Health-promoting effects of the microflora may include immunostimulation, improved digestion and absorption, vitamin synthesis, inhibition of the
growth of potential pathogens, cholesterol reduction and lowering of gas distension.4
Harmful effects are carcinogen production, intestinal putrefaction, toxin formation,
diarrhoea/constipation, liver damage and intestinal infection. Bifidobacteria and
lactobacilli are therefore common targets for dietary intervention that improves health.
GENERAL ASPECTS OF PREBIOTICS
Dietary modulation of the human gut flora has been carried out for many years. In
humans, there are positive aspects to the gut fermentation. For instance, bifidobacteria
and lactobacilli may help to reduce the risk of disease for the reasons given above.2,5
The definitive health outcomes, and their mechanisms of effect, are being gradually
uncovered and there is currently much interest in increasing numbers and activities of
these bacteria in the large gut, preferably at the expense of more harmful species.
One approach whereby commensal bifidobacteria and/or lactobacilli are selectively
promoted by the intake of certain non-viable substrates, is known as prebiotics. Gibson
and Roberfroid4 first described a prebiotic as a non-digestible food ingredient that
beneficially affects the host by selectively stimulating the growth and/or activity of one
or a limited number of bacteria in the colon, and thus improves host health. As diet is
the main factor controlling the intestinal microflora it is possible to modulate the
composition of the microflora through foods. A prebiotic substrate is selectively
utilized by beneficial components of the indigenous gut flora but does not promote
potential pathogens such as toxin-producing clostridia, proteolytic bacteroides and
toxigenic Escherichia coli. In this manner, a healthier microflora composition is obtained
whereby the bifidobacteria and/or lactobacilli become predominant in the intestine

Prebiotics 289

and exert possible health-promoting effects. For a dietary substrate to be classed as a

prebiotic, at least three criteria are required: (1) the substrate must not be hydrolysed
or absorbed in the stomach or small intestine, (2) it must be selective for beneficial
commensal bacteria in the colon such as the bifidobacteria, (3) fermentation of the
substrate should induce beneficial luminal/systemic effects within the host.
A range of substrates of dietary origin, or produced by the host, are available for
fermentation by the colonic microflora. Through diet, resistant starch (RS) is the most
quantitatively important.6 Non-starch polysaccharides (NSP) form the next largest
contribution and include plant-derived substrates such as pectin, cellulose, hemicellulose, guar and xylan. Sugars and oligosaccharides such as lactose, lactulose,
raffinose, stachyose and fructo-oligosaccharides (FOS) also escape absorption in the
small intestine and are metabolized by species of colonic bacteria. Mucin glycoproteins,
which are produced by goblet cells in the colonic epithelium, are predominant
endogenous substances fermented in the colon. Related mucopolysaccharides such as
chondroitin sulphate and heparin, and pancreatic and bacterial secretions, are also
available for the intestinal microflora.7 Finally, proteins and peptides originating in the
diet, in pancreatic secretions or produced by bacteria are also available8, although to a
lesser extent than the carbohydrates.
The premise behind prebiotics is therefore to stimulate certain indigenous bacteria
resident in the gut rather than introducing exogenous species as is the case with
probiotics. Ingesting a diet containing non-digestible carbohydrates that are selectively
fermented by indigenous beneficial bacteria is the prebiotic principle. Any dietary
component that reaches the colon intact is a potential prebiotic; however, most of the
interest in the development of prebiotics is aimed at non-digestible oligosaccharides.
It may be possible to take in prebiotics more naturally through the diet. Many fruit
and vegetables contain prebiotic oligosaccharides such as FOS. Examples are onion,
garlic, banana, asparagus, leek, Jerusalem artichoke, chicory. However, the probable
situation is that levels in these foods are too low to exert any significant effect. Our
(unpublished) data indicate that at least 4 g/days but more preferably 8 g/days of FOS
would be needed to significantly (ca. one log10 value) elevate bifidobacteria in the
human gut. Hence, there exists much value in the approach of fortification of commonly
ingested foodstuffs with prebiotics.
As the majority of bacteria resident in the gut microflora are present in the colon,
prebiotics are usually directed towards lower gut bacteriology. As mentioned, current
prebiotics seem to be mainly confined to oligosaccharides that are non-digestible in the
upper gut, and confer the degree of fermentation selectivity that is required, for
example, specifically towards bifidobacteria.
Oligosaccharides are sugars consisting of between approximately two and 20
saccharide units, i.e. they are short-chain polysaccharides. Apart from those, which
occur naturally in fruits and vegetables, and are extractable, others can be commercially
produced through the hydrolysis of polysaccharides (e.g. dietary fibres, starch) or
through enzymatic generation. The following oligomers have been suggested as having
prebiotic potential9:

Lactulose
Fructo-oligosaccharides
Galacto-oligosaccharides
Soybean oligosaccharides
Lactosucrose
Isomalto-oligosaccharides

290 T. S. Manning and G. R. Gibson

Gluco-oligosaccharides
Xylo-oligosaccharides
Palatinose
Structurefunction relationships
The prebiotic properties of carbohydrates are likely to be influenced by the following
factors:
Monosaccharide composition
Recognized prebiotics are built primarily from glucose, galactose, xylose and fructose.
The prebiotic potential of oligosaccharides composed of other monosaccharides is not
known at the present time.
Glycosidic linkage
The linkage between the monosaccharide residues is a crucial factor in determining
both selectivity of fermentation and digestibility in the small intestine. Fermentation of
FOS prebiotics is selective because of a cell-associated b-fructofuranosidase in the
bifidobacteria.
Molecular weight
Polysaccharides are generally not prebiotic in their metabolism but oligosaccharides
are.10 Inulin has the highest molecular weight, but most of the carbohydrate in inulin has
a degree of polymerization less than 25, with an average of about DP 14.11 The effect of
molecular weight on prebiotic properties can be seen from the fact that xylan is not
selective whereas xylo-oligosaccharides are thought to be.12,13 Similar effects occur
with pectin.14,15
Increased molecular weight
Most current prebiotics are of relatively small DP, the exception being inulin. It is
thought that the oligosaccharides must be hydrolysed by cell-associated bacterial
glycosidases prior to uptake of the resultant monosaccharides. It is, therefore,
reasonable to assume that the longer the oligosaccharide the slower the fermentationand hence the further the prebiotic effect will penetrate more effectively
throughout the colon. For example, long-chain inulin may exert a prebiotic effect in
more distal colonic regions compared with the lower-molecular-weight FOS, which
may be more quickly fermented in the saccharolytic proximal bowel.
Potential food applications
The current concept of a prebiotic is an oligosaccharide that is selectively fermented by
bifidobacteria and lactobacilli.4 Due to the difficulties of characterizing the colonic
microflora at the species level, virtually all of the data on prebiotic properties of
oligosaccharides are on microflora changes at the genus level. It may, however, be
desirable to develop prebiotics which are targeted at particular species of

Prebiotics 291

Bifidobacterium and Lactobacillus. Such targeted prebiotics might be considered for

several applications, as follows.
Synbiotics with defined health benefits
Many probiotic strains have been developed to have particular health benefits, such as
immune stimulation or anti-pathogen activity. In addition, commercial probiotic strains
are selected for their survival characteristics such as resistance to acid and bile, and
their ability to be freeze-dried.16,17 Availability of prebiotics specifically targeted at
these strains (not just genus-level changes) would enable the development of synbiotic
versions with enhanced survivability in the gut.
Infant formulae
It has long been thought that the gut flora of the breast-fed infant is dominated by
bifidobacteria and that this is not the case for formula-fed infants.18,19 This is seen to be
one reason for the improved resistance to infection that the latter group experiences. If
prebiotics could be developed with particular selectivity towards those bifidobacteria
that are present in the guts of breast-fed infants, a new range of synbiotic formula foods
could be envisaged.
Functional foods for the elderly
Above the age of about 55 60 years, faecal bifidobacterial counts have been shown to
markedly decrease compared to those of younger people.20,21 This decrease in
bifidobacteria is a cause for concern as the natural elderly gut flora may have become
compromised through reduced bifidobacterial numbers, resulting in a diminished ability
to resist colonization with invading pathogens. Prebiotics may be potentially utilized as a
dietary intervention in the attempt to restore the microflora (i.e. bifidobacteria)
balance of the gut in the elderly population concurrently with indirectly providing antipathogenic protection.
As prebiotics exploit the use non-viable dietary components to improve gut health,
the range of foods into which they can be added is much wider than that for probiotics,
where culture viability needs to be maintained. This has the advantage that heat stability,
or exposure to oxygen is not an issue. As such, virtually any carbohydrate containing
food is susceptible to supplementation. Potential applications for prebiotics as food
ingredients to improve the gastrointestinal health of the consumer are listed below:

Beverages and fermented milks

Health drinks
Bakery products
Table spreads
Sauces
Infant formulae and weaning foods
Cereals
Biscuits
Confectionery, cakes, desserts
Snack bars
Soups

292 T. S. Manning and G. R. Gibson

Salad dressings
Dairy products
HEALTH-RELATED ASPECTS AND APPLICATIONS
At present, most prebiotics are selected on the basis of their ability to promote the growth
of lactic-acid-producing microorganisms. Fructo-oligosaccharides, lactulose and glucooligosaccharides (GOS) are all popular prebiotics. In Europe, most success has been gained
with FOS. In human studies, after a short feeding period, FOS stimulate bifidobacteria in the
lower gut.22 Similarly, lactulose is an efficient prebioticas demonstrated through the use
of molecular probes in a human volunteer trial.23 In Europe, FOS, GOS and lactulose have
been shown to be prebiotics, as evidenced by their ability to change the gut flora
composition after a short feeding period.9 The Japanese market is more widespread. A
recent volunteer trial was carried out at the University of Reading.23 Here, shortbread
containing 7 g/day FOS was fed to human subjects and the effects upon faecal bacteria
determined as compared to a placebo (FOS not added). The nature of the trial was a crossover approach in that volunteers took active and placebo shortbread but neither they nor
the investigators were aware of which was ingested. Moreover, the bacteriology was
carried out using a (culture-independent) probing approach that relied upon differences in
16SrRNA profiles for the confirmation of identity. The data clearly showed that the use of
FOS exerted a profound effect upon bifidobacteria.
A number of benefits can be ascribed to prebiotic intake.9 However, some areas of
interest are described below.
Protection against colon cancer
Many common diseases of the human large bowel arise in the distal colon, particularly
colonic cancer.24 Prebiotics have been postulated to be protective against the
development of colon cancer.25 29 The second most prevalent cancer in humans is
colon cancer30; in addition, it is thought that tumours arise 100 times more often in the
large intestine compared to the small intestine.31 For this reason, many researchers
believe that the colonic microflora has an important role to play in the development of
bowel cancer.32 It is known that several species of bacteria commonly found in the
colon produce carcinogens and tumour promoters from the metabolism of food
components. Interest in a diet-mediated intervention towards colon cancer arises due
to the slow, progressive nature of the disease and the fact that we can influence colonic
microbiology by diet. There have been several studies on the use of prebiotics in cancer
prevention, mainly focusing on animal models.
It is thought that prebiotics may protect against development of colon cancer
through at least two mechanisms:
(i)

Production of protective metabolites. Butyrate is a common fermentation end

product and is known to stimulate apoptosis in colonic cancer cell lines and it is
also the preferred fuel for healthy colonocytes.33,34 For these reasons, it is
generally believed that it is desirable to increase the level of butyrate formed in the
large gut. Some prebiotics are known to have this effect14,35, although it must be
borne in mind that lactobacilli and bifidobacteria do not produce butyrate. Known
butyrate producers in the gut are clostridia and eubacteria.6 Development of
prebiotics which stimulate (benign) eubacteria but not (toxic) clostridia would be a
desirable enhancement.

Prebiotics 293

(ii) Subversion of colonic metabolism away from protein and lipid metabolism. It is
possible that prebiotics would induce a shift in bacterial metabolism in the colon
towards more benign end products. An obvious target would be to shift the
metabolism of clostridia and bacteroides away from proteolysis to a saccharolysis.
Lactic acid bacteria are believed to have inhibitory effects on several bacteria that
produce carcinogenic enzymes and are themselves non-producers. Moreover,
prebiotics may indirectly modify the activities of enzymes produced by the lactic acid
bacteria that are involved in carcinogenesis, such as azoreductases, nitroreductases, bglucuronidase, etc.36
To date, few prebiotics have been evaluated in animal and human trials. Inulin, for
instance has been shown to inhibit the formation of aberrant crypt foci in rats.26 Human
studies are low in number and tend to focus on faecal markers of carcinogenesis rather
than being epidemiological in nature. FOS, GOS and resistant starch have all been
investigated in this regard. FOS has been found to reduce genotoxic enzymes
concomitant with increasing bifidobacteria27, and resistant starch has been found to
reduce sterols, secondary bile acids and genotoxic enzymes, although no microbiological studies were performed.29 However, a recent study on GOS found no
significant changes in bifidobacteria or in markers of carcingenesis37. At first sight these
results mightseem curious, as GOS are known prebiotics.38 However, the starting
populations of bifidobacteria in the volunteers were rather high (9.2 9.4 log). It has
been noted previously39 that the magnitude of the response to prebiotics by
bifidobacteria depends on the starting levels. It is apparent that we currently have an
inadequate knowledge of the effects of various prebiotics upon the risk of colon cancer;
more studies are needed to address this. Development of prebiotics with the goal of
reducing biomarkers of cancer would, however, be very desirable.

Effects on pathogens
Good evidence for the success of prebiotics lies in their ability to improve resistance to
pathogens by increasing bifidobacteria and lactobacilli. Lactic-acid-excreting microorganisms are known for their inhibitory properties.40 In humans, viruses, protozoa, fungi
and bacteria can all cause acute gastroenteritis. Metabolic end-products, such as acids
excreted by these microorganisms, may lower the gut pH to levels below those at
which pathogens are able effectively to compete. Also, many lactobacilli and
bifidobacterial species are able to excrete natural antibiotics, which can have a broad
spectrum of activity. For the bifidobacteria, some species are able to exert antimicrobial
effects on various Gram-positive and Gram-negative intestinal pathogens.41 A recent
study in mice has shown that FOS and inulin protected against enteric and systemic
pathogens and tumour inducers.42 This includes the verocytotoxin strain of Escherichia
coli O157:H7 and campylobacters.
A rational way to reduce the food-poisoning burden may be fortify certain
components of the intestinal flora such that it becomes much more resistant to
invasion. This is achievable through the use of prebiotics that target bifidobacteria
and/or lactobacilli. Taking this further, some other gut-related conditions more chronic
than acute gastroenteritis, additionally labeled microbiological pathogens, may also be
susceptible to prevention or treatment by altering the gut flora. Examples would
include ulcerative colitis, bowel cancer, peptic ulcers, pseudomembranous colitis and
Candida-induced conditions.

294 T. S. Manning and G. R. Gibson

Improved calcium absorption

There has been increasing interest in recent years in the possibility of increasing mineral
(particularly calcium) absorption through the consumption of prebiotics. Although the
small intestine is the principal site of calcium absorption in humans, it is thought that
significant amounts are absorbed throughout the length of the gut, consequently,
maximizing of colonic effects is desirable.
Several mechanisms have been postulated for increased calcium absorption induced
by prebiotics.43 They include the following. (i) Fermentation of prebiotics such as inulin
results in a significant production of SCFA, leading to a reduction in lumenal colonic pH.
This is likely to increase calcium solubility and overall levels in the gut. (ii) Phytate
(myoinositol hexaphosphate) is a component of plants that reaches the colon largely
intact.44 It also forms stable, insoluble complexes with divalent cations, such as calcium,
rendering them unavailable for transport. Fermentation results in bacterial metabolism
of phytate, thereby liberating calcium. (iii) It is postulated that a calcium exchange
mechanism operates in the colon. In this system, SCFAs enter the colon in a protonated
form and then dissociate in the intracellular environment. The liberated proton is then
secreted into the lumen in exchange for a calcium ion. Numerous animal studies have
indicated that prebiotics increase absorption of calcium from the colon and decreased
losses from bone tissue.45 However, very few human studies have been carried out. In
one study, the feeding of 40 g inulin/day for 28 days to nine healthy subjects resulted in a
significant increase in calcium absorption.46 A lower dose, 15 g inulin, FOS or GOS/day,
when fed to 12 healthy subjects for 21 days, resulted in no significant effect on
absorption of calcium or iron.47 In a later study, 12 adolescent boys (aged 14 16) were
fed 15 g FOS/day for 9 days in a placebo-controlled trial against sucrose.48 The data
showed a 10.8% increase in calcium balance with no significant effect on urinary
excretion.
Effects on blood lipids
There is interest in the food industry in developing functional foods to modulate blood
lipids such as cholesterol and triglycerides. It is widely believed that elevated
cholesterol levels in the blood represent a risk factor for coronary heart disease, with
low-density lipoproteins (LDL) being of most concern.49 There is also evidence that
lactic acid bacteria may be able to reduce total and LDL cholesterol levels. The
mechanisms by which lactic acid bacteria, and hence, indirectly, prebiotics, influence
blood lipids are not clearly understood at the present time. It is possible that some
lactic acid bacteria may be able to assimilate cholesterol directly.49,50 There is evidence
that FOS decrease the de novo synthesis of triglycerides by the liver. The means by
which this occurs is not fully understood but the effect appears be exerted at the
transcriptional level. It is also possible that prebiotics (such as inulin) can modulate
insulin-induced inhibition of triglyceride synthesis.50 Human studies on the lipidlowering properties of prebiotics when consumed at a realistic (tolerable) dose are,
however, contradictory and the role in lipid reduction remains to be confirmed.51
Immunological effects
Lactic acid bacteria are thought to stimulate both non-specific host defence
mechanisms and certain types of cell involved in the specific immune response.

Prebiotics 295

The result is often increased phagocytic activity and/or elevated immunological

molecules such as secretory IgA, which may affect pathogens such as salmonellae and
rotavirus. Most attention in this respect has been diverted towards the intake of
probiotics (lactic acid bacteria)52,53 and interactions between cell wall components and
immune cells. As prebiotics serve a similar end point to lactic acid bacteria (i.e.
improved composition of the gut microflora) similar effects may occur through their
intake. A recent animal study have shown that prebiotics had an effect on immune
functions.54

Practice points
health-promoting effects of the microflora may include immunostimulation,
improved digestion and absorption, vitamin synthesis, inhibition of the growth
of potential pathogens, cholesterol reduction and lowering of gas distension
harmful effects of microflora are carcinogen production, intestinal putrefaction,
toxin formation, diarrhoea/constipation, liver damage and intestinal infection
a prebiotic is a non-digestible food ingredient that beneficially affects the host
by selectively stimulating the growth and/or activity of one or a limited number
of bacteria in the colon (i.e. bifidobacteria and lactobacilli), and thus improves
the hosts health
prebiotics have been postulated to be protective against the development of
colon cancer
evidence supports the ability of prebiotics to improve resistance to pathogens
by increasing bifidobacteria and lactobacilli
numerous animal studies have indicated that prebiotics increase absorption of
calcium from the colon and decreased losses from bone tissue
evidence of the ability of prebiotics to lower lipids remains controversial
prebiotics may have an effect on immune functions

Research agenda
If progress in the use of dietary intervention directed towards particular gut
bacteria is to be exploited, a sound research base is required. Some areas of
interest may include:
the application of advanced molecular procedures that help to identify the gut
microbial diversity as well as allow effective tracking of changes in microflora in
response to diet (it is likely that a large number of gut bacteria have not hitherto
been characterized, and culture-independent methodologies may help to
overcome this)
the prebiotic potential of dietary ingredients, an identification of those
foodstuffs that can be fortified and the optimal dose required
a definition of prebiotics which act at the species level and have a high degree of
selectivity and contain multiple biological activities
whether certain target groups are more susceptible to the approach (elderly,
weaning stage, formula-fed infants, hospitalized patients)
a determination of the health consequences that are associated with
modulation of the gut flora

296 T. S. Manning and G. R. Gibson

SUMMARY
The microflora of the gastrointestinal tract is key for nutrition and health of the host.
Modulation of the microflora can occur through diets that contain prebiotics. The
approach of using diet to induce microbial change offers a very straightforward
approach towards improved health. In terms of new developments, it is important that
the definitive health bonuses associated with prebiotic intake be determined. This is
especially relevant given the broad applicability of their use. It is likely that prevention of
acute gastroenteritis through fortification of certain components of the gut microflora
is an important aspect. Moreover, improved protection from more chronic gut
disorders that have been associated with bacteria (inflammatory bowel disease, colon
cancer, irritable bowel syndrome) may also be possible. It may also be the case that
certain target populations, such as infants, the elderly and hospitalized persons, are
more susceptible to the approach. The health benefits that have been suggested are
varied but also very important. In addition to good human volunteer studies we also
need to enhance our mechanistic understanding of the health effects of prebiotics.

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