DigestiveandbowelhealthisanimportantpublichealthissueinAustralia.Wehaveanageingpopulationandincreasinglevelsofdigestivehealthproblems,includingcolorectalcancer(CRC),IrritableBowelSyndrome(IBS)andmalabsorptionandmalnutrition.

Colorectal Cancer

ColorectalcancerremainsthemostcommoncancerinAustraliawith30newpatientsdiagnosedeveryday.4outof5patientshavenorecognizableriskfactors.ProfTerryBolinstatedthatdietisimportantanditseemslikelythatfibreandparticularly,resistantstarchintake,influencethegenesisofCRC.HereferredtothelowincidenceofCRCinAfricaandAsiawherestarchintakeishigh.

To further its commitment to improving the digestive health of Australians, Bürgen® Rye initiated an Expert Roundtable discussion, held at CSIRO (Food Futures Centre), Sydney on 12 October 2011. The aim of the full day meeting was to assess the current advice and provide evidence-based, practical and realistic recommendations to assist Australians in managing their digestive and bowel health. The expert participants included:• Prof.TerryBolin,TheGutFoundation

• DrTonyBird,FoodFuturesNationalResearchFlagship,CSIROFoodandNutritionalSciences.

• MsKarenInge,Dietitian,APD&NutritionConsultant

• DrMichaelConlon,FoodFuturesNationalResearchFlagship,CSIROFoodandNutritionalSciences.

• DrTonyHelman,Chairman,NutritionAdvisoryGroup,RACGPandEditorinChief,ArborClinicalNutritionUpdates(Facilitator)

Figure 1: The association between starch intake (g/day) and colon cancer incidence1.

About Colorectal Cancer:

• Itkills12Australianseachday,80Australianseveryweek(morethan4,100perannum).Thisnationaldeathtollleadstheworld

• Bowelcanceristhemostcommoninternalcanceraffectingbothmenandwomen

• Ratesofthediseaseinyoungerpeoplehaveincreasedinthepast10years–67%increasein40-44yearagegroup2

• Almostasmanywomendieofbowelcancerasbreastcancer

• OnlyoneinfourAustraliansareawareofthedeadlyimpactofthedisease

• Awarenessisimportantasthediseaseispreventableandcurableifdetectedearly.

Expert Roundtable Report Diet & Bowel Health

Reference:(TheGutFoundationwww.gutfoundation.com/bowel_cancer_awareness_week)

Australia/USA

India/China

Bowel Health Issues in AustraliaProf Terry Bolin highlighted the most common internal cancer is colorectal cancer and that diet may well be an important factor in its genesis.

Recentevidencesuggeststhatdifferentfibresactthroughdifferentmechanismsandaremoreeffectiveincombinationthanindividuallyforpromotingbowelhealth3.

Combination of Fibres

Soluble fibre Insoluble fibre Resistant starch

Function Viscousfibresslowthetimeittakesforfoodtopassthroughthestomachandsmallintestineresultinginslowerabsorptionofnutrientsandlowercholesterollevels.

Exertsgreatestinfluenceonthelargebowel-helpstonormalizebowelfunction(shortenstransittime,helpsproducelargerandsofterstoolsandincreasesdefecationfrequency).

Starchesthatresistsmallintestinalbreakdownarefermentedbybacteriainthelargebowel,producingshortchainfattyacids(SCFA),whichareimportantforcolonichealth.

Sources Oats,barley,vegetables,lentils,beans(driedorcanned),nuts,seeds,Bürgen®Ryebreadandfruit.

Highfibrewheatbasedcereals,brownriceandpasta,millet,quinoa,bulgarwheat,wholemealandryebreads,Bürgen®Ryebread.

Legumes,wholegrains(e.grye),Bürgen®Ryebread,coldcookedpotatoes,riceandpastaandfirmbananas.

DrBirdhighlightedadietrichinarangeoffibrescanhelppreventandmanagecommonintestinalproblemslikeconstipation,haemorrhoidsanddiverticulardisease.Carefuluseofdietaryfibre(solubleorinsoluble,basedonthesymptoms),canalsohelptomanageirritablebowelsyndrome(IBS)andinflammatoryboweldisease4,5,6.

NHMRC Nutrient Reference Values for Dietary Fibre*

Men aged 19+ Women aged 19+

Adequate Intake (AI) 30g/day 25g/day

AIsincluderesistantstarch,thefirstglobalofficialrecommendation.TheAIwassetatthemediandietaryfibreintakeforthepopulation.

Suggested Dietary Targets (SDTs)

38g/day 28g/day

Levelsbasedonupperlevel90thcentileofintakeforreductionincoronaryheartdiseaserisk(notforCRC).

Upper limit Not set Not set

Noevidencethathighintakewouldproducesubstantialdeleteriouseffects.

The Australian Paradox: Comparatively High Fibre Intakes, High Rates of Colorectal Cancer

Dietaryfibrehasahighlevelofconsumerrecognitionanditsimportanceforgoodhealthiswellestablishedandaccepted7.AveragefibreintakesofadultsinAustraliaareformen~27g/dandforwomen~21g/d.Theselevelsarehighbyinternationalstandards-almosttwicethatoftheUS&UK.“OurdietaryfibreintakeisapproachingtheNHMRCtargetsandhasbeenatthislevelforthepasttwodecades.Paradoxically,bowelcancerratesremainstubbornlyhigh”,statedDrTonyBird.

Fibre intakes are too low, particularly resistant starch intakes

DrBirdisconcernedthatAustraliansarenotconsumingtherightamountandcombinationoffibre,particularlyresistantstarch.Recommendedresistantstarchintakesshouldbearound20gaday,whichisalmostfourtimesgreaterthanatypicalwesterndietcurrentlyprovides8.

Internationalcomparativestudiesshowstrongercorrelationsbetweenbowelcancerandstarch(andthusresistantstarch)intakethanwithdietaryfibre1.

Thestronginverseassociationbetweenstarchandbowelcancercorrespondswiththehypothesisthatfermentationofresistantstarchinthecolonisapotentialmechanismforbowelcancerpreventionviatheproductionofshortchainfattyacids,inparticularbutyrate.

“Although dietary fibre intakes seem to be reaching targets, more than 60% of the population, do not consume adequate amounts of fibre, particularly young women and food avoiders (those who avoid carbohydrates, gluten, wheat and other grains)”, –DrTonyBird.

(*NHMRC.NutrientReferenceValuesforAustraliaandNewZealand.Canberra:CommonwealthofAustralia,2006)

“CSIRO clinical trials have provided more than 40g of fibre per day, yet there were no significant differences in abdominal discomfort between the high fibre and the low fibre groups”, – DrTonyBird.

The role of dietary fibre in digestive healthDr Tony Bird highlighted the public health focus for fibre needs to evolve from general basic advice for people to ‘eat more fibre’ to a stronger emphasis on specifically consuming a diverse range of fibres for maintaining digestive health.

Wholegrainryeishighinfibreandcontainsadiverserangeoffibressuchasarabinoxylans,fructans,beta-glucanandresistantstarch.Manyofthesefibresarehighlyfermentableinthelargebowel,makingwholegrainryebeneficialforbowelhealth.

AnewstudybyCSIRO9addstothegrowingbodyofevidencethatryeisbeneficialforbowelhealth.Thestudywasacrossoverdesigninwhichtheeffectofconsuming4or5slicesdailyofeitherBürgen®Ryeorawhitebread(control)respectivelyforfourconsecutiveweekswascompared.

TwentyhealthyhumanscompletedthestudyandtherewasnodifferenceinabdominaldiscomfortwhenconsumingthewhitebreadorBürgen®Ryebread,whichwasselfreportedusingagastrointestinalqualityoflifeindex.Bürgen®Ryeelicitedanumberofchangesconsideredbeneficialtobowelhealth:• increasedfaecalbulkandlowered

faecalpHcomparedtowhitebread• significantlyincreasedlevelsof

acetate,butyrateandtotalSCFA• significantlyincreasedfaecal

concentrationsandexcretionofammonia(toxin)

• significantlyincreasednumbersofFaecalibacteriumprausnitziiandRuminococcusbromii,whicharepotentiallybeneficialbacteriaandmayfacilitatebutyrateproduction.

ThisstudysupportspreviousresearchconductedbyCSIROshowingthattheconsumptionofryefoods(includingBürgen®Ryebread)improvedmarkersofbowelandmetabolichealthinoverweightmiddle-agedmen10.

The role of gut microbiota in maintaining gastrointestinal health – current understanding and challenges

DrConlondiscussedthisevolvingareaofnutritionscience.Thegutmicrobiotafermentcarbohydratesandproteinsthatreachthelargebowelandcancontributetothebenefitsobtainedfromconsumptionofwholegrains.Dietaryfibrescanincreasemicrobialgrowthandmassinthelargebowel(contributingtofaecalbulking),dilutepotentiallytoxicproductssuchasammonia,phenolsandhydrogensulphidethatcanresultfromproteinfermentationandreducetheirimpactonguttissues.Also,fibreswhicharefermentedbythebacteriainthelargebowelleadtotheproductionofshortchainfattyacids(SCFA),primarilyacetate,butyrateandpropionate,whichhavemultiplebeneficialeffectsoncolonictissuesandlowerluminalpH,providinganenvironmentmoreconducivetogrowthofbeneficialbacteria.

Bread Type in CSIRO Research Project

Resistant Starch g/100g

Total Dietary Fibre g/100g

Bürgen®Rye

4.7 8.4

Sunblest®White

0.9 3.7

Benefits of Rye:

• Highfibrewholegrainandcontainsadiverserangeoffibres• Improvesbowelfunction• Effectivestoolbulkingagent

• Increasesbutyrateproduction• Promotesfaecalexcretionofpotentialtoxins(foregammonia)• ReducesfaecalpH

“There are about 10 times as many bacteria in the large bowel as cells in our body”

Beneficial bacteria

DrConlonrevealed“thereislimitedknowledgeaboutthebacteriathatliveinthelargebowelyetwedoknowthereareapproximately10timesasmanybacteriainthelargebowelascellsinourbodyandweallhaveourowndistinctgut

microbiota”.Inclinicalstudies,improvedgastrointestinalhealthmaynottranslatetoobviouschangesinthegutmicrobiota.“Specific,possiblysmall,changesmaygoundetected,”hestated.

Are dietary fibres prebiotics?

AcurrentdefinitionofaprebioticsetbytheInternationalScientificAssociationforProbioticsandPrebioticsisa“selectivelyfermentedingredientthatresultsinspecificchangesinthecompositionand/oractivityofthegastrointestinalmicrobiota,thusconferringbenefit(s)uponhosthealth”.IntherecentstudybyCSIRO,Bürgen®Ryebreadincreasednumbersofpotentiallyhelpfulbacteriathatfacilitatecarbohydratefermentationandbutyrateproduction(e.gR.bromiiandF.prausnitzii)butdidnotincreaselactobacilliandbifidobacteria.DrConlonbelievesthatafocusonlactobacilliandbifidobacteriaindefiningaprebioticislikelytobetoonarrowandpossiblyirrelevanttoadulthealth. The challenge – there is a current limited understanding of gut microbiota (types and activities) that limit our ability to determine which microorganisms should be used as markers of bowel or digestive health.

Large Bowel Microbiology:• Anaerobicenvironment• Mostmicrobes:

− Difficulttoculture− Uncharacterised

• Microbesfacilitatefermentationofcolonicsubstratesandareintegraltocolorectalhealth

(NB:Numbersareapproximateandcanvary)

1010

102-3

105-8

1012

Gastrointestinal Tract Microbiology

Rye & Gastrointestinal HealthDr Michael Conlon presented the results of a recent CSIRO study which examined the bowel health benefits of consuming Bürgen® Rye Bread and revealed the implications of a narrow definition for prebiotics.

Digestivehealthisadominanthealthissueinconsumers’mindsnowandinthefuture.Today’sconcernsareabout‘feelinggood’anddealingwithflatulence,bloating,indigestionandconstipationcomparedtofutureconcerns,whicharefocusedaroundmoreseriousconditionssuchasstomachulcersandgastritis.Interestingly,preventionofbowelcancerisnota‘topofmind’healthissue.

Consumersrecognisethatdietisakeyplayerindigestivehealthandhaveahighwillingnesstotreatwithfood.Generally,consumersprefertoeattheirwaytohealthbyincreasingtheirintakeofhealthyfoodsratherthaneatinglessofthefoodsthattheylikethatmaynotbeashealthy.(ADANutritionandyoutrends2011)

“Consumers know ‘fibre keeps you regular’ but have limited awareness of the types of fibre and the health benefits”.

Socialresearchhasfoundconsumersswitchoffwithwordssuchas‘bowel’and‘constipation’preferringpositivemessageslike‘helpstokeepyourdigestivesystemhealthy’or‘helpskeepyouregular’.

Karenrecommendedweget‘backtobasics’andhelpconsumersunderstandwhatis‘normal’.Inarecentradiointerviewondigestivehealth,KarenpointedoutthedownloadoftheBristolstoolchartontheradiostationswebsitereceivedmorehitsthananyothernewsfeatured.

Thisclearlyindicatespeopleareafterthistypeofinformationbuttooembarrassedtoask–weneedtomakethisreadilyavailable.

TheBristolStoolChartclassifiestheformofhumanstoolsintosevencategories.Types1and2indicateconstipation,with4and5beingthe“idealstools”,and6–7tendingtowardsdiarrhoea12.

Type 2

Type 1

Type 3

Type 4

Type 5

Type 6

Type 7

Separate hard lumps, like nuts(hard to pass)

Sausage-shaped but lumpy

Like a sausage but with cracks on the surface

Like a sausage or snake, smooth and soft

Soft blobs with clear-cut edges

Fluffy pieces with ragged edges, a mushy stool

Watery, no solid pieces.Entirely Liquid

Bristol Stool Chart

Consumer InsightsKaren Inge encouraged health professionals to look outside clinical guidelines when educating Australians on bowel and digestive issues. ‘Beating the bloat’ is the hot button in digestive wellbeing but is talking about it sexy?

Recommendations: Key Issues

ThePaneldiscussionfocusedoncurrentknowledgeonfibreandbowelhealthandthepracticalimplicationsoftheroundtablepresentations.

General Recommendations• Target high risk consumers:

− RestrictiveEaters–particularlythoseonlowcarborhighproteindiets

− FoodAvoiders–thoseonGlutenFreeorWheat-FreeDiets(self-prescribedandmedicallydiagnosed)

− OlderAustralians

− PeoplewithCoeliacDisease

− Breakfastskippers

• Address misconceptions and misunderstandings:

− Educateoncombinationoffibres,recommendedlevelsandrichsources–withafocusonincreasingintakesofresistantstarchandwholegrains

− Wheatandglutenavoiders–educateontheimportanceoffibreinmaintainingbowelhealth

− Normalgutandbowelfunction–BristolStoolChart(indicates7typesofstoolswithType4and5beingmostoptimal).Thiscouldbeausefulcommunicationtooltoeducatepeopleonnormalbowelhealthandtoassistinassessingthetypeoffibreintakeimportantforimprovingbowelhabits(suchas,howtogetfroma1toa4).

− Thereisaneedforevidence-basedinformationandpracticaltipsonthecombinationoffibresinmanagingdigestiveandbowelhealth.ThesecommunicationmaterialswouldbeusefulresourcesforDietitians,GPs,PracticeNursesandGastroenterologistsandeasilyaccessibleonline.

Health Professional Recommendations

• Informhealthprofessionalson‘newnews’relatedtocombinationofdietaryfibresforbowelhealthandtheneedtofocusonincreasingresistantstarchintake.

• EncouragetheuseoftheBristolStoolChartasamarkerofgoodbowelhealthandtomonitordietarychanges(e.g.movingfroma‘1or2’toa‘4or5’)

• Detailedandinformativemessagesaddressingkeyissuesfor‘atriskgroups’,andgastrointestinaldiseasesarerequiredforconsumersandpatients.

• Advisepatientstomakegradualchangestotheirdietaryfibreintakeandtodrinkenoughwater.Forexample,graduallyoveraweekchangetoahighfibrebreakfastcerealandtheninweek2,changetoawholegrainbreadlikeRyebread.

• Practicalconsumer-friendlyguidelinesonhowtomeetrecommendedfibreintakesfromavarietyofsourcesneedtobedeveloped.

Research recommendations

• Specificguidelinesonthemixoffibresforpreventivehealtharerequired.

• CurrentconsumptiondataonfibreintakesincludingresistantstarchisrequiredforAustralianadults.

• Up-to-datefoodcompositiondatabaseincludingthetypesoffibreinfoodsisrequired.

• Officialdietaryfibreandresistantstarchrecommendationsneedtobereviewedasthecurrentadequateintakes(25-30g/day)reflectthecurrentlowintakesofresistantstarchintheAustralianpopulation.Recommendationsforspecifictargetgroupsmaybenecessary,e.g.byage,lifestage,gender,pre-andpost-menopauseandrace.

• Exploreimplicationsoffoodavoidanceandfaddietsonfibreintakesandbowelhealth.

• Moreresearchtoconfirmnon-invasivebiomarkersofbowelhealth-whichtypeoffibreorbacteriaisimportantformaintainingbowelhealth.

• Isthereanupperintakelimitoffibreisolatesthatcouldbeproblematic?Moreinformationonwithinandbetweenindividualresponsestodietaryfibres.

Recommendations

Key messages

• Combinationsofdietaryfibreareessentialforbowelhealth-therearethreemajortypesoffibreanditisimportanttoconsumealltypesoffibrefromawidevarietyoffoods.

• Internationalcomparativestudiesshowstrongercorrelationsbetweenbowelcancerandresistantstarchintakethanwithdietaryfibre.

• Australianfibreintakeshavebeenincreasingoverthelasttwentyyears,yetcolorectalcancerratesremainstubbornlyhigh.

• Atleast60%ofAustraliansarenotgettingenoughfibreandthemajorityarenotgettingenoughdiversityinfibreintake,especiallyresistantstarch.

• MedianvaluesarenotappropriateasabasisforAdequateIntake(AI)recommendationswherethepopulationconsumeslowlevelsofresistantstarchandhasahighincidenceofchronicdisease.ReliablecontemporaryfibreintakedataarerequiredandofficialAIrecommendationsneedtobereviewed(aspercurrentreviewofNRV’s).

• Ryeisahighfibrewholegrainandcontainsadiverserangeoffibres,includingresistantstarch.RecentresearchconductedbyCSIROonBürgen®Ryebreadaddstothegrowingbodyofevidencethatryeisbeneficialforbowelanddigestivehealth.

• Thereisacurrentlimitedunderstandingofgutmicrobiota,thereforeresearchoutcomesshouldbefocusedonimprovedbowelfunctionasopposedtoanincreaseinspecificbacteria(bifidobacteriaandlactobacilli).

• Consumersneedtobebetterinformedaboutdigestiveandbowelhealth.Misconceptionsaboutgrainfoodsneedtobeaddressedandcommunicationsneedtobetargetedto‘atrisk’groups(e.g.dieters,foodavoiders(gluten-freeorwheat-free)andolderAustralians).

• Consumersneedtoknowwhat’snormalintermsofbowelfunctionandwhattoaimfore.g.a‘4’onBristolStoolChart.

• ‘Notallfibreiscreatedequal’.Healthprofessionalsneedtoaddresscurrentmisconceptionsaboutfibre-richgrainfoodsinthedietastheyareessentialforprovidingtheoptimalcombinationoffibresfordigestiveandbowelhealth.

Panel Discussion: Getting the focus back on fibre and bowel health – what needs to be done?All participating experts agreed on the need to clear up the current confusion about diet and bowel health and communicate positive evidence-based messages about the beneficial role of fibre-rich grain foods and the combination of fibres needed for bowel health.

References:1.CassidyA,BinghamSA,CummingsJH.Starchintakeandcolorectalcancerrisk–aninternationalcomparison.BrJCancer199469:937-942.2.DavisDM,MarcetJE,FrattiniJC,etal.IsIttimetolowertherecommendedscreeningageforcolorectalcancer?JournalAmericanCollegeofSurgery.2011;213:352-362.3.BirdAR,VuaranM,CrittendenR,HayakawaT,PlaynMJ,BrownILandToppingDL.Comparativeeffectsofahigh-amylosestarchandafructooligosaccharideonfecalbifidobacterianumbersandshort-chainfattyacidsinpigsfedBifidobacteriumanimalis.DigestiveDiseasesandSciences.2009;54:947-954.4.AndersonJW,BairdP,DavisJrRH,FerreriS,KnudtsonM,KoraymA,WatersVandWilliamsCL.Healthbenefitsofdietaryfiber.NutritionReviews.2009;67(4):188–205.5.PositionoftheAmericanDieteticAssociation:HealthImplicationsofDietaryFiber.JAmDietAssoc.2008;108:1716-17316.TheGutFoundation(Australia).Dietaryfibreandhealth,2005.PreparedbyTerryBolin,AlistairCowen,MelvynKorman,RosemaryStanton.7.MohrP,QuinnS,MorellM,ToppingD.EngagementwithdietaryfibreandreceptivenesstoresistantstarchinAustralia.PublicHealthNutrition2010;13:1915-19228.BaghurstPA,BaghurstKI,RecordSJ.Dietaryfibre,non-starchpolysaccharidesandresistantstarch-areview.FoodAust.1996;48(Suppl):S3-S35.9.ConlonM&BirdAR.StudyonthePrebioticPotentialofBürgen®Rye.2011:CSIROReport.10.McIntoshetal.Whole-grainryeandwheatfoodsandmarkersofbowelhealthinoverweightmiddle-agedmen.AmJClinNutr2003;77:967-974.11.Abelletal.PhylotypesrelatedtoRuminococcusbromiiareabundantinthelargebowelofhumansandincreaseinresponsetoadiethighinresistantstarch.FEMSMicrobiolEcol.2008;66:505-515.12.LewisSJ,HeatonKW.Stoolformscaleasausefulguidetointestinaltransittime.Scand.J.Gastroenterol.1997;32(9):920–4

®GoGrainsHealth&Nutrition.Trademarkusedunderlicense.Allrightsreserved.January2012

Food Serving Size Resistant Starch (g)

Oatmeal 1cup,cooked 0.5g1

Barley,pearl ¾cup,cooked 2.8g1

Bürgen®RyeBread 2slices,100g 4.7g2

Pasta,cold(insalad) 1cup 1.4g1

Lentils ¾cup,cooked 5.0g1

Potato,cold(insalad) 1-2”diameter 1.0g1

Navybeans ½cup,cooked 3.8g1

Foods with Moderate to High Resistant Starch Content - Aim for 20g resistant starch per day for bowel health

References:1MurphyM,EnvironInternationalCorporation.BirkettA.BarndtR.PreliminaryestimatesofresistantstarchintheUnitedStates,2006.2ConlonM&BirdT.StudyonthePrebioticPotentialofBürgen®Rye.2011:inpress)

For patient resources and facts sheets visit visit www.burgen.com.au/healthcareprofessional

Bürgen®iscommittedtoprovidinghealthprofessionalsandallAustralianswithspeciallydevelopedinformation,publicationsandresourcestokeepyouup-to-dateontheroleofBürgen®breadinhealthandwellbeing.

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