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Best Practice & Research Clinical Gastroenterology 30 (2016) 27e37

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Best Practice & Research Clinical


Gastroenterology

Prebiotics: Definition and protective


mechanisms
Rosica Valcheva, PhD, Research Associate *,
Levinus A. Dieleman, PhD, MD, Professor
Department of Medicine, Center of Excellence for Gastrointestinal Inflammation and Immunity Research,
University of Alberta, AB, Canada

abstract
Keywords:
Prebiotics The increase in chronic metabolic and immunologic disorders in the
Definition modern society is linked to major changes in the dietary patterns.
Intestinal microbiota These chronic conditions are associated with intestinal microbiota
Short-chain fatty acids dysbiosis where important groups of carbohydrate fermenting,
short-chain fatty acids-producing bacteria are reduced. Dietary
prebiotics are defined as a selectively fermented ingredients that
result in specific changes in the composition and/or activity of the
gastrointestinal microbiota, thus conferring benefit(s) upon host
health. Application of prebiotics may then restore the gut microbiota
diversity and activity. Unlike the previously accepted prebiotics
definition, where a limited number of bacterial species are involved
in the prebiotic activity, new data from community-wide micro-
biome analysis demonstrated a broader affect of the prebiotics on the
intestinal microbiota. These new findings require a revision of the
current definition. In addition, prebiotics may exert immuno-
modulatory effects through microbiota-independent mechanisms
that will require future investigations involving germ-free animal
disease models.
© 2016 Elsevier Ltd. All rights reserved.

* Corresponding author. Department of Medicine, CEGIIR Group, 7-142 Katz Building, University of Alberta, Edmonton, AB,
T6G 2E1, Canada. Tel.: þ1 7804920019; fax: þ1 7804927593.
E-mail address: valcheva@ualberta.ca (R. Valcheva).

http://dx.doi.org/10.1016/j.bpg.2016.02.008
1521-6918/© 2016 Elsevier Ltd. All rights reserved.
28 R. Valcheva, L.A. Dieleman / Best Practice & Research Clinical Gastroenterology 30 (2016) 27e37

Background

With the industrialization of the farming and food processing industries in the post-Second World
War era the modern society overcame famine and achieved cheaper access to food. Together with
the improved health care the developed countries exemplified increased lifespan and much lower
incidences of mortality caused by infectious diseases. Conversely, chronic endocrine and (auto) immune
disorders such as metabolic syndrome, type 2 diabetes (T2D), cardiovascular disease (CVD), asthma,
allergies, rheumatoid arthritis, multiple sclerosis and inflammatory bowel disease (IBD) are becoming
an increasing burden for the health and social systems and major cause of morbidity and mortality.
Besides the clear evidences from genome-wide association studies regarding the importance of
genetic factors predisposing to the development of these conditions
[1e3], the scientific community unanimously has agreed on the significance of the changing envi-
ronment, including diet, that shapes the human micro-environment and modulates immune response.
Furthermore, the new dietary habits directly affect the intestinal microbiome as shown in
cross-continental population comparative studies using recently developed high-throughput sequencing
techniques [4e6]. The “Western” chronic diseases, such as Type 2 Diabetes mellitus (T2D) and
Inflammatory Bowel Diseases (IBD), are associated with dysbiosis of the intestinal microbiota [7e9]. In
an attempt to control these chronic disease conditions, a modulation of the dietary patterns in general
and modulation of intestinal microbiota in particular was proposed as an
alternative or adjunct to standard medical treatments. As such, probiotic, prebiotic, their combi- nation
(synbiotic) intake or fecal transplantation therapy from healthy donors were shown to be successful
approaches for altering the gut microbiota.

Defining prebiotics: (r)evolution in the scientific understanding

The internationally recognized definition of probiotics is live microorganisms that, when


administered in adequate amounts, confer a health benefit on the host. This designation is pretty
straightforward, thus eliminating bacterial products or dead cells that also modulate the immune
response [10,11]. Not that simple is the case with the prebiotics definition. Originally, a prebiotic has been
described as 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 improving host
health [10]. This definition remained virtually unchanged for more than 15 years after its first
introduction in 1995 by Gibson and Roberfroid, thus requiring the selective stimulation of one or a
limited number of microbial genus(era)/species [12]. Following this description, only few compounds of
the carbohydrate group have been considered as prebiotics, most notably short- and long chain b-
fructans [fructo-oligosaccharides (FOS), and inulin], galacto-oligosaccharides (GOS) and lactulose. At
the 6th Meeting of the International Scientific Association of Probiotics and Prebiotics (ISAPP) in 2008
the definition of “dietary prebiotics” was updated as “a selectively fermented ingredient that results in
specific changes in the composition and/or activity of the gastrointestinal microbiota, thus conferring
benefit(s) upon host health” [13]. Based on this definition, prebiotics may exert benefits not only in the
colon, but elsewhere, as in the oral cavity, the urogenital tract and on the skin. With the introduction
of affordable high throughput sequencing in the intestinal micro- biota research, it became evident
that none of the well-accepted prebiotic compounds displays
selectivity, which will be discussed in more detail below. In an effort to meet the newly acquired findings,
Bindels et al. proposed a broader definition of prebiotics that shifted the focus towards ecological and
functional characteristics of the microbiota that are likely more relevant for host physiology, such as
ecosystem diversity, the support of broad consortia of microorganisms and production of short-chain
fatty acids (SCFAs) [14]. As such, a prebiotic is defined as a non-digestible compound that, through its
metabolization by microorganisms in the gut, modulates composition and/or activity of the gut
microbiota, thus conferring a beneficial physiological effect on the host. Besides FOS and GOS, the
authors promoted a fundamental basis for including more compounds in the list of the prebiotics such
as resistant starches, pectin, arabinoxylan, whole grains and non- carbohydrate compounds such as
polyphenols. Whether the understanding on the prebiotic concept will remain in the field of
the pure microbiology or will undergo a revolutionary
R. Valcheva, L.A. Dieleman / Best Practice & Research Clinical Gastroenterology 30 (2016) 27e37 29

development adopting the concept of multiple interactions between host physiology, immunology, gut
microbiota function and food is a matter of consensus between scientists and regulatory agencies. In
this review we will provide evidence that it is time for a new and better definition for prebiotics.

Intestinal microbiota in health and chronic medical conditions

Human gut harbors trillions of bacterial strains per gram feces collectively called the gut microbiota.
Together, their genome, also known as the microbiome, contains a 100-fold greater number of genes
than the human genome [15]. Intestinal microbiota is composed of several main phyla, such as
Firmicutes, Bacteroidetes, Actinobacteria, Proteobacteria and traces of Verrucomi- crobia, Fusobacteria,
Cyanobacteria and candidate division TM7, majority of which are obligate anaerobes. Every study
reporting the human gut microbiota underlined its uniqueness as highly inter-individual specific. To
make it even more complex, there is no definition what healthy microbiota is. Arumugam et al. first
suggested dividing individuals in enterotypes based on the variations in the levels in one of the three
genera Bacteroides (enterotype 1), Prevotella (enterotype
2) and Ruminococcus (enterotype 3) [16]. Shortly after this report it became evident that the enterotypes
are associated with long-term dietary patterns, particularly protein and animal fat (Bacteroides) versus
carbohydrates intake (Prevotella) [17]. Individuals may fall into one of the enterotypes regardless of their
health status, as shown in 90 patients with atopic dermatitis and 42 healthy controls [18].
Commensal bacteria confer metabolic, protective, and trophic functions to the host through
fermentation of non-digestible carbohydrates, vitamin production, bile acids biotransformation, bar-
rier protection against opportunistic pathogens, control against gut epithelial cell proliferation and
maturation and stimulation of both local and systemic immunity [19e23]. Once the balance between the
intestinal microbiota antigen production and immune cell activation is disrupted in combination with
increased gut permeability, innate and adaptive immune responses are dysregulated towards a chronic
pro-inflammatory response either in the gut (as in IBD) [24] or elsewhere (as in obesity and
T2D) [25]. Gut microbiota-derived metabolites may also be involved in disease pathogenesis as shown
for CVD and non-alcoholic fatty liver diseases through the production of trimethylamine (TMA). This
gas is produced after microbial biotransformation of the dietary lipids choline and phosphatidylcho- line,
and further metabolized by enzymes in the host liver to generate the circulating pro-atherogenic
compound trimethylamine N-oxide (TMAO) [26,27], which also dramatically increases the risk of CVD.
In addition, reduced choline bioavailability results in the accumulation of triglycerides in the liver
associated with hepatic steatosis [28].
In recent years an increasing body of studies report associations between the gut microbiome and
chronic diseases, building the groundwork for a hypothesis that suggests modulation of the intes -
tinal microbiota as the factor linking the environment with host genetics. Table 1 shows a summary
of the microbiota changes detected in important chronic metabolic and immunologic conditions. A
common notion in most of these disorders is reduction in the abundance of short-chain fatty acids-
producing bacteria such as Faecalibacterium prausnitzii and Roseburia e Eubacterium rectale groups. It
has been reported that F. prausnitzii suppresses the production of potent pro-inflammatory cytokines
and/or even induces anti-inflammatory cytokines such as interleukin 10 [29,30]. Recently, Quévrain
et al. were able to isolate and purify protein MAM synthesized by F. prausnitzii that exerted the anti-
inflammatory properties [20,31]. In addition to similar microbial signatures, many of the chronic
conditions display common distinct shifts in the microbiome with respect to function. A meta- genomic
study examining the enzyme biomarkers in obese and IBD microbiome revealed compa-
rable enrichment with enzymes involved in either the phosphotransferase system (PTS) or the nitrate
reductase pathway [32]. Phosphotransferase system is used for sugar transfer into the cell by bacteria
and has been found to be up-regulated following switch to a high-fat/high-sugar “Western diet” in mice
[33]. Recently, a PTS enzyme was found to be a biomarker for IBD [34]. Similarly, nitrate reductase is a
critical component in the conversion of nitrate into nitrite and nitric oxide, and it is not synthesized by
human DNA. Elevated levels of nitric oxide have been associated with both IBD [35] and obesity-induced
insulin resistance [36], as well as other serious carcinogenic and inflammatory
30 R. Valcheva, L.A. Dieleman / Best Practice & Research Clinical Gastroenterology 30 (2016) 27e37

Table 1
Intestinal microbiota changes reported in chronic diseases.
Condition Implicated microbiota Remarks Reference

Obesity Y Bacteroidetes Conflicting data on the Firmicutes/Bacteroidetes ratio [7,72,73]


Y Bifidobacterium spp Overall reduced diversity
Y Faecalibacterium prausnitzii
Y Akkermansia muciniphila
[ Bilophila wadsworthia
Type 2 diabetes Y F. prausnitzii Decreased abundance of butyrate-producing bacteria and [9,74,75]
Y Roseburia e Eubacterium an increase in opportunistic pathogens
rectale
[ Proteobacteria

Chronic kidney Y Lactobacillaceae Increased relative abundance of urease- and uricase-harboring, [76,77]
disease Y Prevotellaceae indole- and p-cresol-forming bacteria
[ Proteobacteria Reduced short-chain fatty acid producing bacteria

Atopic dermatitis [ F. prausnitzii strain L2-6 No difference in the diversity [18]


Enrichment of mucin-degrading and low efficient butyrate
producing F. prausnitzii strain L2-6

Crohn's disease Y F. prausnitzii Overall reduced diversity [78,79]


Y Roseburia spp Decreased abundance of butyrate-producing bacteria and
Y Dialister spp an increase in opportunistic pathogens
Y Coprococcus spp
[ Enterobacteriaceae
[ Rumonococcus gnavus
Ulcerative colitis Y F. prausnitzii Reduced biodiversity [59,80,81]
Y Roseburia spp Reduced abundance of butyrate-producing bacteria and
Y Eubacterium rectale et rel. an increase in opportunistic pathogens
[ Fusobacterium spp

Irritable bowel Y Bifidobacterium spp Overall reduced diversity [82,83]


syndrome Y Faecalibacterium spp
[ Veillonellaceae
[ Enterobacteriaceae

Colorectal cancer Y Roseburia spp Reduced biodiversity [84]


Y Lachnospiraceae Reduced abundance of butyrate-producing bacteria and
[ Bacteroides/Prevotella an increase in opportunistic pathogens
[ Enterococcus spp
[ Escherichia/Shigella
[ Streptococcus spp

effects [37]. Metagenomic sequencing studies have the power to identify functional shifts even at strain
level as in the case with mucin-degrading low efficient butyrate-producing F. prausnitzii strain L2-6
associated with atopic dermatitis [18]. Thus more metagenomic studies comparing the microbiome of
different chronic conditions need to be carried out. Such studies may support the vision of gut
microbiota modulation as a new clinical practice. Finally, metagenomic studies may propose the
introduction of personalized treatments that will be based not on the disease pheno- type, but on
metabolic biomarkers.

Compositional shifts in the gut microbiota following prebiotic ingestion

Given that prebiotics are non-digestible, but fermentable substrates, the most obvious effect is their
ability to alter the intestinal microbiota composition toward enrichment with microbial groups that are
able to use the prebiotics as energy source in their fermentation processes. Most of the studies related
to the effects of prebiotics on the gut microbiota in the past have been focused on the stimulation of
bifidobacteria and lactobacilli, which are often employed as probiotics [38,39]. However, with the
recently developed next-generation sequencing and DNA-microarrays techniques that enable a
community-wide analysis of the gut microbiota, the strict bifidogenic effect of known prebiotics, such as
inulin and galacto-oligosaccharides, was challenged. For example in an in vitro experiment Scott et al.
showed that all tested strains
R. Valcheva, of F. prausnitzii,
L.A. Dieleman / Best Practice & Researchspp,
Roseburia Eubacterium
Clinical spp,
Gastroenterology 30 (2016) 27e37 31
32 R. Valcheva, L.A. Dieleman / Best Practice & Research Clinical Gastroenterology 30 (2016) 27e37

Anaerostipes caccae, Coprococcus spp, Anaerostipes hadrum, Bifidobacterium spp and Bacteroides spp
were able to grow well on short-chain FOS (sc-FOS) indicating that this prebiotic is not a particularly
selective growth substrate [40]. With the increase of the complexity of the fructan substrate, from sc-
FOS to long-chain inulin, the range of bacteria able to ferment the carbohydrates was reduced as
none of the tested Bifidobacterium strains grew on dahlia inulin (degree of polymerization ~25). In
vivo feeding experiments with rodent models further confirmed a broad effect of the prebiotic FOS on
the intestinal microbiota. In a study with genetically obese mice Everard et al. identi fied both
increase and reduction in the abundance of 102 taxa in the fecal microbiota following 8 weeks of
feeding with diet containing 5% FOS [41]. However, in human studies the global effect of prebiotics
on the intestinal microbiota is not so well understood. Just few studies reported data generated from
high-throughput sequencing analysis (Table 2) and yet the detected shifts in the fecal microbiota of
the participants showed bigger complexity, when compared to studies employing targeted phylo -
genetic approach. Besides bifidobacteria, FOS and GOS repeatedly increase the abundance of F.
prausnitzii [42e45]. In an in vitro study Rios-Covain et al. demonstrated that F. prausnitzii and B.
adolescentis exist in synergy in presence of FOS, as both of them were able to metabolize the sub- strate,
however F. prausnitzii became more efficient in presence of acetate produced by B. adolescentis [46]. This
study thus provided mechanistic insights supporting the in vivo observations for simul- taneous
stimulation of bifidobacteria and F. prausnitzii by prebiotics.
Microbiota changes after fermentable fiber ingestion do not guarantee beneficial health impact. For
example soluble dextrin fibers from corn led to a significant increase in the relative abundance of
Porphyromonadaceae and Prevotellaceae together with decreases in Lactobacillaceae, Incertae Sedis XIV,
Lachnospiraceae, and Ruminococcaceae in IL-10 deficient mice [47]. Feeding this fiber induced lower
colonic secretion of pro-inflammatory and immunoregulatory cytokines, including interleukin-12
heterodimer p70 (IL12p70), IL-6 and chemokine ligand 1 (CXCL1), however these animals had no
improvement in histological colonic inflammation. Therefore, not every fiber can be classified as
prebiotic. Besides the non-digestibility by the host enzymes and the fermentability by the gut
microbiota, prebiotics must fulfill the requirement of providing health benefit(s) for the host, which
should be demonstrated in a scientific matter [48].

Bacteria ferment dietary fibers through cross-feeding processes

Cross-feeding between diverse functional groups of bacteria during dietary carbohydrates


fermentation are well documented. For example, in in vitro study strains of Eubacterium hallii and
Anaerostipes caccae failed to grow on starch in pure cultures, but in co-culture with B. adolescentis these
lactate utilizing strains were able to produce butyrate [49]. Similarly, xylan fermentation is accom-
panied by interspecies H2 transfer between H2-producing cellulolytic species and hydrogenotrophic
microorganisms (methanogen and acetogen) in the human gut. In particular, xylan-degrading Rose- buria
intestinalis efficiently degraded xylan into butyrate and H 2, whereas H2-utilyzing Methano- brevibacter
smithii and Ruminococcus hydrogenothrophicus further metabolized H2/CO2 into methane or acetate,
respectively. Interestingly the secondary acetate was then metabolized by the primary cellu- lolytic
Roseburia intestinalis strain, leading to a higher net production of butyrate, thus efficiently closing the
cycle of H2 utilization [50].

Effect of the prebiotic dose on the microbiota compositional and functional shifts

Besides the chemical structure, the prebiotic dose is another important factor which can influence
fiber (including prebiotics) fermentation. For example, in most animal studies the applied dose of
prebiotics is 10e20% of the total food intake [51e53]. In human studies the tested daily doses vary in
the range 5e20 g (Table 2) which represents 1e4% of the total food intake (estimations based on World
Health Organization recommended daily food intake of ~500 g). Therefore, data from animal studies
cannot be directly translated into human physiology. In addition, it can be predicted that the larger the
prebiotic dose, the more diverse bacterial groups are affected (Table 2). Recent work from our own
laboratory with patients with active ulcerative colitis (UC) treated with 7.5 g/day or 15 g/day of inulin
type b-fructans for 9 weeks revealed a dose-dependent effect of the prebiotic mixture on the disease
R. Valcheva, L.A. Dieleman / Best Practice & Research Clinical Gastroenterology 30 (2016) 27e37 33

Table 2
Bacterial groups in human feces affected by fiber treatment.

Fiber Study design Dose/ Method of Stimulated bacterial Reduced bacterial Reference
Period detection taxa taxa

Inulin þ FOS Open labeled 20 g/day DGGE Bifidobacterium [85]


N ¼ 17 healthy 4 weeks longum
subjects Bifidobacterium
adolescentis

Inulin þ FOS Open labeled 7.5 g/day 16S rDNA Feacalibacterium spp. [42]
N ¼ 25 ulcerative or pyrosequencing Bifidobacterium spp.
colitis patients 15 g/day Roseburia sp
9 weeks

Inulin Placebo controlled 10 g/day qPCR Bifidobacterium sp [43]


crossover 16 days F. prausnitzii
N ¼ 12 healthy
subjects
Inulin Double-blind placebo 16 g/day; HITChip Firmicutes Bacteroidetes [44]
controlled 3 months Bifidobaterium spp Bacteroides
N ¼ 30 obese women F. prausnitzii intestinalis
Lactobacillus spp. Bacteroides
vulgatus
Propionibacterium

Agave inulin Double-blind placebo 5 g/day or 16S rDNA Actinobacteria Desulfovibrio ssp [86]
controlled 7.5 g/day Illunina Bifidobacterium spp Ruminococcus ssp
N ¼ 29 healthy 3 weeks sequencing Lachnobacterium
subjects per dose ssp
GOS Single-blind crossover 2.5 g/day 16S rDNA Bifidobacteriaceae Bacteroidaceae [45]
N ¼ 18 healthy 5.0 g/day pyrosequencing F. prausnitzii Coprococcus
subjects 10 g/day comes
3 weeks
per dose
GOS Placebo controlled 7.5 g/day; I-Chip Bifidobacterium spp [87]
N ¼ 12 healthy 12 days and qPCR B. longum
subjects B. thermophilum
treated
with amoxicillin
for 5 days

GOS Double-blind placebo 5.5 g/day; FISH Bifidobacterium spp. [88]


controlled cross-over 10 weeks Bacteroides-Prevotella
N ¼ 40 healthy elderly group
subjects Atopobium spp.

RS4 Double-blind 33 g/day 16S rDNA Bacteroidetes Firmicutes [89]


crossover 3 weeks pyrosequencing Porphyromonadaceae Ruminococcaceae
N ¼ 10 healthy Parabacteroides F. prausnitzii
subjects distasonis Dorea ssp
Actinobacteria
Bifidobacteriaceae
B. adolescentis
Clostridium
clostridioforme
Polydextrose Double-blind placebo 21 g/day Whole-genome Bacteroidetes Firmicutes [57]
controlled crossover 3 weeks shotgun Porphyromonadaceae Lachnospiraceae
N ¼ 21 healthy pyrosequencing Eubacteriaceae
subjects Coriobacteriaceae

Soluble Double-blind placebo 21 g/day Whole-genome Bacteroidetes Firmicutes [57]


Corn Fiber controlled crossover 3 weeks shotgun Porphyromonadaceae Ruminococcaceae
N ¼ 21 healthy pyrosequencing Lachnospiraceae
subjects Eubacteriaceae
Coriobacteriacea

DGGE e denaturing gradient gel electrophoresis; FISH e fluorescent in situ hybridization; FOS e fructooligosaccharides; GOS e
galactoologisaccharides; HITChip e Human Intestinal Tract Chip; I-Chip e Intestinal Chip; qPCR e quantitative PCR; RS e
resistant starch; RS4 e resistant starch type 4.
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R. Valcheva, L.A. Dieleman / Best Practice & Research Clinical Gastroenterology 30 (2016) 27e37 35

activity, fecal microbiota shifts and production of short-chain fatty acids [42]. The low dose of 7.5 g/day
b-fructans increased F. prausnitzii relative abundance, however this treatment failed to demonstrate
health benefits for the patients. In contrast, a dose of 15 g/day of the prebiotics shifted the fecal
microbiota towards a FOS-induced co-metabolism between Bifidobacterium sp. and Roseburia sp., and
also showed significant increase in the total short-chain fatty acids (SCFA), butyrate and acetate pro-
duction and significant reduction in the disease activity in the UC patients. Morel et al. also showed that
a-GOS decreased plasma lipopolysaccharide (LPS) concentrations in a dose-dependent fashion in a
study with overweight adults treated with 6e18 g of a-GOS for 14 days [54].

Role of the short-chain fatty acids in the prebiotics activity

As discussed above, prebiotics as fermentable fibers may stimulate microorganisms other than the
classic “probiotics” through cross-feeding. The primary products of the fiber, including prebiotics,
fermentation are the linear (SCFA) acetate (mainly produced by bifidobacteria), butyrate (mainly
produced by Lachnospiraceae and Ruminococcaceae) and propionate (produced by propionibacteria and
Bacteroidetes) [55]. Acetate is metabolized in muscles, kidney, heart and brain; propionate is cleared by
liver and suppresses the cholesterol synthesis; whereas butyrate acts at the colon. In addition to
increased short-chain fatty production [55e57], prebiotic fermentation leads to reduced fecal pH and
reduced production of putrefactive compounds, such as ammonia, phenol, indole and branched-chain
fatty acids [58].
It is well documented that in some chronic inflammatory diseases such as IBD, the fecal butyrate
levels are reduced [59]. Moreover, butyrate oxidation is impaired in the colonic mucosa of patients with
IBD, likely due to malfunctioning butyrate transport into epithelial cells during colonic inflammation
[60]. Therefore, prebiotics that particularly aim to improve butyrate production are thought to be
beneficial in reducing colonic inflammation. Butyrate is mainly produced from complex carbohydrates
via pyruvate and acetyl-coenzyme A (CoA) pathway, although production from amino acids via glu-
tarate, 4-aminobutyrate, and lysine pathways is also present in the gut [61]. This short chain fatty acid
has multiple functions in the colon. Butyrate is a major energy source for colonocytes [62] and lack of
bio-available butyrate may lead to energy deprivation and autophagy as observed in IBD. Butyrate is part
of a class of epigenetic substances known as histone deacetylase inhibitors (HDACi). Research on HDACi
may offer new cancer therapies as well as cancer chemoprevention [63]. Butyrate also inhibits
the production of pro-inflammatory cytokines, such as interferon-a (INF-a) and IL-2 in rat mesenteric
lymph nodes [64], the chemokine CXCL-8 (IL-8) in Caco-2 cells [65] and tumor necrosis factor a (TNF-a)
in monocytes [66]. Butyrate may also reduce inflammation by inhibiting nuclear factor kB (NFkB)
activation and by increasing the levels of its cytoplasmic inhibitor (IKB), thereby reducing the pro-
duction of pro-inflammatory chemokines and cytokines [64,67]. In addition, SCFA may regulate fat and
glucose metabolism [68].

Immunomodulatory effects of prebiotics independent of gut microbiota

Recently it was shown that non-digestible oligosaccharides (FOS and GOS) act as Toll-like Receptor
4 (TLR4) ligands both in epithelial cells and monocytes, thus upregulating cytokine secretion [69,70]. As
such, modulation of inflammation could be due to direct effects of fibers on the host immunity which
process seems to precede the microbiota changes. Feeding both germ-free and conventionalized mice
resistant starch type 2 or type 4, added to a Western diet, improved their index of insulin resistance,
confirming the existence of microbiome-independent mechanisms [71]. Some authors refer to these
mechanisms as non-prebiotic effects of the dietary fibers [14], with which conclusion we do not agree.
In order to fully understand the role of the microbiota-independent immunomodulatory effects of the
prebiotics on the host health, more studies with gnotobiotic animal models are required. These should
not exclude more complex machinery of interactions between the fiber prebiotics, in- testinal microbiota
and host physiology and immune system.
36 R. Valcheva, L.A. Dieleman / Best Practice & Research Clinical Gastroenterology 30 (2016) 27e37

Practice points

Research agenda

Conflict of interest

No conflict of interest has been declared by the authors.

Acknowledgment

Dr. L. Dieleman receives funding from the Canadian Institutes for Health Research (CIHR) (CIHR MOP
130368) and Alberta Innovates Bio Solutions (AgFC/MULTI 2012Q007R/QFH11046).

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