Method for preventing or alleviating symptoms of malabsorption from the gastrointestinal tract

Description of equivalent WO 2004000340 A2

METHOD AND COMPOSITION FOR PREVENTING OR ALLEVIATING SYMPTOMS

OF MALABSORPTION

TECHNICAL FIELD

0004The present invention relates to a method of preventing or alleviating symptoms of malabsorption and to a dietary supplement for use in such a method. The present method comprises enteral administration to a monogastric mammal of a composition that enhances digestion of nutrients in the gastrointestinal tract and is particularly suitable for treating patients suffering from cystic fibrosis, pancreatic insufficiency, coeliac disease, cow's milk protein allergy, small or short bowel syndrome, or small bowel overgrowth.

BACKGROUND OF THE INVENTION

0006A principal function of the gastrointestinal tract is to process and absorb food. The stomach, which is both a storage and digestive organ, works to optimise the conditions for the digestion and absorption of food in the small intestine. Following the stomach and preceding the large bowel (colon) is the small intestine which comprises three regions: the duodenum, jejunum, and ileum. A major function of the small intestine is one of absorption of digested nutrients.

0007The passage of food through the, gastrointestinal tract, which leads to digestion and absorption of the nutrients contained therein, is controlled by a complex system of inhibitory and stimulatory motility mechanisms which are set in motion by the composition of the meal ingested. Specific receptors for fats, and proteins, and the osmolality, acidity and particle size of the meal activate propulsive and inhibitory reactions, which modulate transit and thus absorption.

0008Disruption of the normal digestive and absorptive processes frequently manifests as a variety of syndromes, such as, for example malabsorption, weight loss, diarrhoea, vitamin deficiency, electrolyte imbalance, and the like. The malabsorption syndromes are clinical entities associated with defective absorption of amino acids, sugar, fat, vitamins and minerals. Malabsorption is thus the common denominator in a wide variety of clinical disorders the severity of which covers a broad range and which, when diagnosed, require individual analysis of each patient against the background of the normal process of absorption. Patients with malabsorption syndrome have a difficult time meeting daily nutritional requirements. In patients with malabsoφtion syndrome there generally exists both catabolic and serious nutritional consequences. The efficiency with which nutrients are absorbed (and thus utilised) by the human and animal body depends among other things on the efficiency of digestion. Digestion is inter alia mediated by various enzymes that have specific functions at various locations in the digestive tract. Impairment of digestion, e.g. as a result of diminished intestinal enzyme activity, is one of the prime causes of malabsorption. In the whole process of digestion, which starts in the mouth, the pancreas has an important role. It secretes a juice having two major components, an alkaline fluid and enzymes, into the duodenum. The two components occur in variable proportions depending on the stimuli. The alkaline fluid component, ranging in volume from 200-800 ml/day, has a high concentration of bicarbonate, which neutralises the gastric content entering the duodenum and helps to regulate the pH of the intestinal tract.

0009The enzymes of pancreatic juice are synthesised and secreted by the acinar cells which also secrete a fluid similar in electrolyte composition to an ultrafiltrate of plasma. In intermittent feeders such as man, dog and cat, the volume of the fluid secreted by the acinar cells is very small and it has little effect upon the volume and composition of pancreatic juice flowing in the main pancreatic duct.

0010The pancreatic juice contains four major enzyme groups: lipolytic, proteolytic, amylolytic and nucleic acid splitting enzymes. These pancreatic enzymes, some of them are secreted in multiple forms, possess specifities complementary to the intestinal membrane bound enzymes. Fresh, uncontaminated pancreatic juice is without proteolytic activity because these enzymes are in the form of inactive zymogens. An important fraction of the calcium in pancreatic juice accompanies the enzymes, especially alpha-amylase.

0011Patients suffering from malabsorption as a result of diminished intestinal enzyme activity (e.g. as a result of pancreatic insufficiency), are commonly treated by orally providing one or more digestive enzymes (exocrine pancreas substitution therapy). An important aim of exocrine pancreas substitution therapy is to eliminate the malabsorption and to maintain an adequate nutrition. However it is known that in many patients suffering from pancreatic insufficiency, exocrine pancreas substitution therapy will not restore digestive efficacy to normal levels. As a result, many patients using exocrine pancreas substitution therapy still suffer from symptoms of malabsorption. Malabsorption as a result of impaired digestion may also occur in subjects who do not suffer from pancreatic insufficiency, e.g. in patients suffering from small or short bowel syndrome. In patients suffering from short bowel syndrome the passage of nutrients through the small intestine occurs in such a short time interval that nutrients are only partly digested before they enter the colon. Exocrine pancreas substitution therapy is not effective in such patients and alternative methods of treatment are generally inadequate in enhancing the digestive processes in these patients.

0012Thus, despite the tremendous amount of research that has been undertaken to elucidate the role of nutrition and absorption in gastrointestinal disorders, few methods currently exist that offer adequate solace for patients suffering from these disorders, in particular patients suffering from malabsorption as a result of impaired intestinal digestion. Thus, a need exists for new methods and nutritional compositions that can effectively be employed to improve digestion and subsequent absorption of ingested nutrients.

SUMMARY OF THE INVENTION

0014The inventors have found that symptoms of malabsorption in monogastric mammals which is caused by impaired intestinal digestion may effectively be alleviated or prevented by enterally administering an effective amount of one or more strains of the genus Propionibacterium and/or a prebiotic that stimulates gastrointestinal activity of Propionibacterium.

0015Propionibacterium is found in rumen and intestine of ruminants (cattle, sheep), where it plays apart in the formation of fatty acids, particularly propionic and acetic acids. Propionibacterium is responsible for the conversion of lactate, which arises from various fermentations in the rumen, to predominantly propionate. Under anaerobic conditions, members of the genus Propionibacterium ferment glucose, sucrose, lactose and pentoses, as well as lactate, malate, glycerol and other substrates to propionic acid. The catabolism of hexoses proceeds via the fructose-bisphosphate pathway. Although the inventors do not wish to be bound by theory, it is believed that in the anaerobic intestinal environment Propionibacterium is capable of fermenting nutrients, which the mammal is unable to (enzymatically) digest and/or absorb, to propionic acid (or propionate). Propionic acid is readily absorbed in the intestine, following which it can be used as an energy source. Thus, the enteral administration of Propionibacterium enables the mammal to recover a larger fraction of its total energy intake in the form of ingested food. Similarly, because Propionibacterium naturally occur in the intestinal microflora, the enteral administration of a prebiotic that enhances the intestinal activity of Propionibacterium maybe used to achieve the same effect. Since the digestion and absorption of various nutrients is strongly interrelated, the enteral administration of Propionibacterium and/or the prebiotic is also believed to improve the mammal's capability of satisfying its needs for certain essential nutrients.

0016Other micro-organisms, such as those belonging to the genus Lactobacillus and Enterococcus, are known to also have the capability to ferment nutrients to short chain fatty acids within the intestinal tract. However, the inventors have found that Propionibacterium offers several important advantages over these other micro-organisms.

0017It was found that, unlike micro-organisms such as Lactobacillus and Enterococcus and Bifidobacterium which are also capable of fermenting nutrients to short chain fatty acids, Propionibacterium ferments nutrients to propionic acid without simultaneously producing substantial amounts of methane. Whereas Propionibacterium only produce propionic acid, all other foodgrade micro-organisms produce lactate and/or acetate which are easily converted to methane. This means that, in comparison to these other micro-organisms, Propionibacterium will give rise to significantly less flatulence and bloating, h addition, it is important to note that fermentative production of methane is associated with less energy yield for the mammal, meaning that Propionibacterium is capable of providing more energy sources for the mammal from the same substrate than these other micro-organisms.

0018Thus, the present method of enteral administration to monogastric mammals of Propionibacterium and/or a prebiotic that stimulates gastrointestinal activity of Propionibacterium is a very effective method for treating or preventing symptoms of malabsorption caused by impaired intestinal digestion as the method is particularly effective in enhancing energy recovery from ingested nutrients and does not suffer from unpleasant side-effects such as flatulence and bloating.

0019The present method is of general benefit to monogastric mammals who are malnutritioned, or at risk of becoming malriutritioned as a result of malabsoφtion. It is of crucial importance for such mammals to recover as much energy as possible from ingested nutrients. The present invention enables enhanced energy recovery from ingested nutrients, which is advantageous to any mammal suffering from malabsoφtion as a result of impaired enzymatic or fermentative intestinal digestion, even if such malabsoφtion is not caused by maldigestion. DETAILED DESCRIPTION OF THE INVENTION

0020Consequently, one aspect of the invention relates to a method of preventing or alleviating symptoms of malabsoφtion in a monogastric mammal which malabsoφtion is caused by impaired fermentative intestinal digestion, said method comprising the enteral administration to said mammal of an effective amount of one or more strains of the genus Propionibacterium and/or a prebiotic that stimulates gastrointestinal activity of Propionibacterium.

0021The term "monogastric mammal" encompasses all mammals that do not belong to the group of polygastric mammals. Important representatives of the group of polygastric mammals are ruminants such as cattle. Typical examples of monogastric mammals include humans, pigs, dogs and cats. The term "enteral administration" includes oral and rectal administration. The term

0022"oral administration" also encompasses tube feeding. Preferably, the present method employs oral administration.

0023The term "malabsoφtion" refers to a condition of defective intestinal absoφtion of amino acids, peptides, sugar, fat, vitamins and/or minerals. Preferably, malabsoφtion is defined more narrowly as defective intestinal absoφtion of amino acids peptides, degradation products of carbohydrates and/or degradation products of fart.

0024The effectiveness of the present method is dependent on the amount of Propionibacterium cells and/or prebiotic administered as well as on the status of the Propionibacterium cells. In a particularly preferred embodiment metabolically active cells of Propionibacterium are administered m a daily amount of at least 10 cells. More preferably metabolically active cells are administered in a daily amount of at least 10⁸ cells, most preferably of at least 10⁹ cells. Here the term "daily amount" refers to the average daily amount. The term "metabolically active" refers to the capability of the cells to convert ingested nutrients to propionic acid. In general, the prebiotic will be administered in a daily amount of at least 0.5 g, preferably in a daily amount of at least 1 g, most preferably of at least 5 g. The daily administered amount of prebiotic will usually not exceed 50 g. Preferably said amount will not exceed 30 g. The prebiotic used in accordance with the present invention is preferably selected from the group consisting of mono-, oligo-, polysaccharides and combinations thereof.

0025In a very preferred embodiment of the invention, the present method comprises the co- administration of Propionibacterium and the prebiotic. This particular embodiment not only offers the advantage that it introduces one or more metabolically active strains of

0026Propionibacterium into the intestine but, in addition, it stimulates metabolic activity and even proliferation of these strains at the cost of other, less desirable, micro-organisms present in the intestinal microflora.

0027The inventors have discovered that the impact of the present method on the ratio of propionate to acetate found in the faeces of the mammal is a reliable indicator of the effectiveness of the present method. High priopionate to acetate ratios generally correspond with high energy recovery and little methane production as such a high ratio is indicative of high intestinal activity of Propionibacterium, relative to the intestinal activity of other microorganisms. The ratio in which propionate and acetate occur in faeces may be influenced effectively by the administration of a suitable prebiotic, i.e. a substrate for Propionibacterium. The terms "propionate" and "acetate" as used in this document encompass both the free acid and the salt forms of these substances.

0028In order to establish whether or not a component can suitably be used as a prebiotic in the present method a relatively simple in vitro test can be applied. This method is described in detail in appendix I. hi a particularly preferred embodiment, the prebiotic used in accordance with the invention yields a propionate to acetate ratio which is at least 25% higher than that observed for a glucose control in the aforementioned in vitro incubation test. More preferably said ratio is at least 50% higher and most preferably it is at least 75% higher than the same ratio observed for the glucose control.

0029In the present method, the frequency of administration may suitably vary from 4 times daily to once a week. Preferably the frequency is between 3 times a day and once every 3 days. Most preferably the frequency of administration is once or twice daily. The present method is particularly effective when it comprises uninterrupted administration of Propionibacterium and/or the prebiotic during a period of at least 1 week, more preferably of at least 3 weeks.

0030Examples of prebiotics that may advantageously be employed in the present method, because they are good sources of propionate, include inuline; modified inuline; hydrolysed inuline; fructo-oligosaccharides; galactomannan (e.g. guar gum) and hydrolysates thereof; arabinogalactan (e.g. gum acacia) and hydrolysates therof; trans-galacto-oligosaccharides; rhamnose; pectin and pectin hydrolysates; resistant starch and hydrolysates thereof; indigestible dextrin and hydrolysates thereof; indigestible polydextrose; beta-glucan and hydrolysates thereof; and combinations of these oligo- and polysaccharides. Preferably, the prebiotic is selected from the group consisting of inuline; modified inuline; hydrolysed inuline; fructo-oligosaccharides; arabinogalactan and hydrolysates therof; resistant starch; indigestible dextrin; indigestible polydextrose; and combinations thereof. More preferably, the prebiotic is selected from the group consisting of inuline; modified inuline; hydrolysed inuline; fructo-oligosaccharides; arabinogalactan and hydrolysates thereof; resistant starch; indigestible dextrin and combinations thereof. Most preferably, the prebiotic is selected from the group consisting of inuline, arabinogalactan, resistant starch, indigestible dextrin and combinations thereof.

0031Screening studies conducted by applicant using the method described in Appendix 1 showed that the following carbohydrates are particularly suitable prebiotics:

0032<img file="WO2004000340A2_D0001.tif" />

0033For nutritional purposes, starch can be classified into three categories: rapidly digestible, slowly digestible and resistant starch. Resistant starches pass the small intestines without being digested or absorbed. Subsequently, in the large intestine, the resistant starch can be broken down by fermentation to short chain fatty acids, carbon dioxide, hydrogen and methane. There are four types of resistant starches:

00341. physically inaccessible starches that are locked away within cell walss such as those found in partially milled grains, seeds and legumes

00352. native resistant starch granules like those typically found in bananas, raw potatoes and high amylase maize starch

00363. retrograded crystalline non-granular starch, like starch found in cooked and cooled, potatoes, bread crusts, cornflakes and retrograded high amylase maize starch 4. specific chemically modified or repolymerised starch such as chain linked altered dextrins (see article by M. Croghan in Functional Foods &amp; Nutraceuticals; September/October 2001)

0037In another preferred embodiment of the invention Propionibacterium is administered in the form of viable cells, i.e. cells that are capable of replication. The present method advantageously comprises the enteral administration of one or more viable strains of the genus Propionibacterium in a daily amount of at least 10⁶ CFU, preferably of at least 10⁸ CFU, most preferably of at least 10⁹ CFU.

0038Examples of species of Propionibacterium that may suitably be employed in the present process include P. freudenreichii, spp freudenreichii or spp shermanii; P. jensenii; P. acidipropionici and P. microaerophilus.

0039The present method advantageously comprises the enteral co-administration of one or more metabolically active homofermentative strains of the genus Lactococcus or Lactobacillus, preferably in a daily amount of at least 10⁶ cells. Homofermentative strains of the genus Lactococcus or Lactobacillus are capable of anaerobic fermentation of nutrients to lactic acid and, unlike heterofermentative strains, produce virtually no carbon dioxide. The co-administration of the genus Lactococcus and 'or Lactobacillus offers the advantage that even higher energy recovery rates can be achieved as the latter strains are particularly efficient in fermenting certain nutrients such as lactose. The fermentation products of Lactococcus and/or Lactobacillus, especially lactate, may suitably serve as a substrate for the Propionibacterium strain(s).

0040The strains of the genus Lactobacillus are preferably selected from the group consisting of L. casei, L. plantarum, L. sake, L. salivarius, L. acidophilus, L. crispatus, L. johnsonii, L. gasseri, L. delbrueckii, L. jensenii, L. curvatus, L. helveticus, L. amilophilus, L. amylovorus and L. rhamnosus.

0041Another genus of micro-organisms that may advantageously be co-administered with Propionibacterium is Bifidobacterium. Bifidobacterium is highly efficient in degrading (hydrolysing) complex carbohydrates which may subsequently be fermented by Propionibacterium and/or Lactococcus /Lactobacillus. Consequently, in a preferred embodiment, the present method comprises the enteral co-administration of one or more metabolically active strains of the genus Bifidobacterium, preferably in a daily amount of at least 10⁶ cells, more preferably in a daily amount of at least 10⁸ cells.

0042The present method may suitably be used to treat patients suffering from various forms of malabsoφtion. The method is particularly effective for treating patients who suffer from malabsoφtion caused by impaired enzymatic or fermentative intestinal digestion. Best results are obtained in patients suffering from some form of pancreatic insufficiency or short bowel syndrome.

0043The enteral administration of Propionibacterium can provide a remedy for defective intestinal absoφtion of amino acids, peptides, sugars, fat, vitamins and/or minerals. The present method is particularly effective for treating mammals suffering from malabsoφtion of lipids and/or carbohydrates. A crucial benefit of the present method is that it enhances the energy that the treated mammal can derive from ingested nutrients, especially ingested carbohydrate material. The symptoms of malabsoφtion treated by the present method may be associated with a variety of disorders. The present method is very suitable for treating patients who suffer from malabsoφtion which is associated with a disorder selected from the group consisting of cystic fibrosis, pancreatic insufficiency, pancreatitis, diseases accompanied by villous atrophy (e.g. caused by coeliac disease, cow's milk protein allergy, chain disease, and inflammatory or infectious diseases), small or short bowel syndrome, malabsoφtion of mono- and disaccharides, and small bowel (bacterial) overgrowth. The method of the invention is particularly suitable for treating or preventing symptoms of malabsoφtion in patients suffering from a disorder selected from the group consisting of cystic fibrosis, pancreatic insufficiency, pancreatitis or small or short bowel syndrome. Cystic fibrosis is an inherited disease of the exocrine glands and exocrine sweat glands which primarily affects the digestive and respiratory systems. This disease is usually characterised by chronic respiratory infections, pancreatic insufficiency, abnormally viscid mucuous secretions and premature death. The main clinical effects of cystic fibrosis are observed in evidence of respiratory tract involvement and pancreatic insufficiency characterised by failure to grow despite an excellent appetite, frequent foul stools and abnormal pancreatic function tests.

0044Short bowel syndrome generally refers to a condition in which less than 150 cm of remaining small bowel is associated with a massive loss of absoφtive capacity. It is characterised by severe diarrhoea and malabsoφtion. Patients with short bowel syndrome often experience malabsoφtion of protein, carbohydrate and fat resulting in calorie depletion and steatorrhea.

0045The most important therapeutic objective in the management of short bowel is to maintain the patient's nutritional status. By necessity, it is achieved primarily by parenteral nutrition support in the early postoperative period. Enteral nutrition support can be started early after operation when the ileus has resolved. Maximisation of enteral absoφtion of nutrients is important for long-term survival. Generally, such maximisation requires that the enteral intake greatly exceed the absoφtive needs to ensure that the nutritional requirements are met. Another aspect of the invention relates to a dietary supplement comprising at least 10⁶ metabolically active cells of the genus Propionibacterium, at least 0.5 g of a prebiotic that yields a propionate to acetate ratio which is at least 25% higher than that observed for a glucose control in an in vitro incubation test as defined appendix I, and a nutritionally acceptable carrier. The dietary supplement may suitably contain at least 0.5 g of a prebiotic as described herein before. Preferably the amount of prebiotic contained in the supplement is at least 1 g, more preferably at 5 g. Usually the amount of prebiotic in a daily unit dosage of the supplement will not exceed 50 g, preferably it will not exceed 30 g.

0046Yet another aspect of the invention relates to a dietary supplement comprising at least 10⁶ metabolically active cells of the genus Propionibacterium, at least 10⁶ metabolically active homofermentative cells of the genus Lactobacillus and a nutritionally acceptable carrier.

0047A further aspect of the invention is concerned with a dietary supplement comprising at least 10⁶ metabolically active cells of the genus Propionibacterium, at least 10 metabolically active cells of the genus Bifidobacterium and a nutritionally acceptable carrier. As explained before, the combination of. Propionibacterium with Lactobacillus and/or

0048Bifidobacterium strains offers the advantage that it enables very high energy recovery rates. Particularly high energy recovery rates may be achieved by including metabolically active cells of both. Lactobacillus and Bifidobacterium. Consequently, in a preferred embodiment, the supplement additionally contains at least 10⁶ metabolically active cells of the genus Bifidobacterium and at least 10⁶ metabolically active cells of the genus Lactobacillus.

0049In order to achieve good results within a short time frame, it is preferred to incoφorate at least 10⁸ metabolically active cells of Propionibacterium and at least 10⁸ metabolically active cells of Lactobacillusmd/or at least 10⁸ metabolically active cells of Bifidobacterium. The invention is illustrated by means of the following examples. EXAMPLES

0050Example 1

0051A powdered product, packed in a sachet containing 85 g, to be made up with whole milk. For children of 1-5 years of age 54 sachet is made up with 240 ml milk. For children of 5-10 years 1 sachet is made up with 240 ml milk. Servings: 1 per day. For children of 10 years and upward 1-2 servings a day are recommended.

0052Several flavours may be used, for instance vanilla, strawberry, orange, lemon, mocha or chocolate. (This is also true for most of the other examples) Per sachet the composition is as follows:

0053- Energy: 1831 kJ

0054- Protein: 4 g

0055- Carbohydrate 55 g, of which sugars are 20.1 g

0056- Fat 21 g of which saturated fat 9 g - Sodium 119 mg

0057- Potassium 485 mg

0058- Calcium 111 mg

0059- Phosphorous 340 mg

0060- Magnesium 12 mg - Propionibacterium freudenreichiispp freudenreichii: 10⁹ cells

0061- Lactobacillus rhamnosus: 10 cells

0062- Resistant starch or inulin: 1 g

0063- Moisture

0064Example 2

0065A powder that can be easily incoφorated into an infant milk formula, moist food or a liquid by sprinkling on the recommended amount, and subsequent stirring. It is recommended to paste with a small amount of liquid/water before adding in order to ensure thorough mixing. Dose ranges from 1 g to 10 g/100 ml liquid and should be gradually increased. The powder is packed in cans in aluminum foil. The composition per 100 g of powder is as follows:

0066- Energy 2000 kJ

0067- Protein 0 g - Carbohydrate 69.1 g ; sugars 6.2 g and oligosaccharides 5 g (TOS + inulin ratio 9/1 w/w)

0068- Fat 21.2 g of which saturated 13.8 g monounsaturated 2.6 g, and polyunsaturated 4.8 g

0069- Fat contains 35% medium chain triglycerids

0070- Minerals 20 mg Na, 5 mg K, 20 mg Cl, 5 mg and 5 mg P - Propionibacterium acidpropioni: 10⁹ cells

0071- Lactobacillus rhamnosus: 10⁹ cells

0072- Bofidobacterium bifidum 10 cells

0073Example 3 Powder, packed in cans or sachets, used to fortify drinks and foods. Also to be used in tube and sip feeds. Can be mixed with water to form a bland tasting, high energy liquid. Paste the powder with a small amount of water than add the remaining water, stir briskly with a fork. Once prepared, store in refrigerator for maximally 12 h.

0074To be introduced into the diet gradually: 1 to 10 gr per 100 ml drink or food Composition per 100 g:

0075- Energy 1940 kJ

0076- Carbohydrate 70 g of which 4.8 g sugar

0077- Fat: 22 g of which saturated 17.8 g, monounsaturated 0.7 g and polyunsaturated 2.5 g

0078- Fat is present in the form of 83% MCT and 17% LCT - 30 mg Na, 3.7 mg K, 50 mg Cl

0079- Propionibacterium freudenreichii spp shermanii: 10⁸ cells

0080- Lactobacillus casei: 5.10⁹ cells

0081- Inulin 5 g

0082Example 4

0083Powder, packed in cans or sachets, used to fortify drinks and foods, especially LMF for children older than 6 months. Powder is packed in sachets of 132 g, or in 200 g cans. To be introduced into the diet gradually, 1-10 g/ 100 ml drink or food. Composition per 100 g - Energy 1615 kJ

0084- Carbohydrates 95 g of which 6.7 sugar

0085- Propionibacterium jensenii 10⁹

0086- Bifidobacterium longum or Bifidobacterium breve: 10 10 Example 5

0087Ready to eat, snack sized chunky bar, in the flavour natural or strawberry. Composition per 100 g

0088- Energy 2477 kJ

0089- Protein: less than 0.05 g

0090- Carbohydrate: 47.36 g (sugar)

0091- Fat 47.36 g of which saturated 28.9 g, monounsaturated 16.3 g, polyunsaturated 2.2 g

0092- Propionibacterium freudenreichii spp freudenreichii: 2.10⁷ cells

0093- Guar gum: 8 g

0094Example 6

0095Powder in can. Dose 50 g/day for children, 100 g/day for adults. 5 g per spoon. Sprinkle mix to moist food or liquid. Composition per 100 g:

0096- Energy 1615 kJ - Carbohydrates 95 g of which 1.9 g glucose, 4.3 g maltose and 88.8 g polysaccharide including 10 g inulin

0097- Propionibacterium acidipropioni: 10⁹ cells

0098- Lactobacillus acidophilus: 10 cells

0099Example 7

0100Powder, packed in cans or sachets. To be applied as tube or sip feeding. 430 g plus 1700 water or 650 g/1700 ml for an energy rich enteral feeding. First the powder should be mixed with a small amount of water, to ensure good mixing. The powder should be prepared shortly before application or should be stored in the refrigerator for maximally 3 h. Composition per 100 g:

0101- Energy 1990 kJ

0102- Protein 18.8 g (casein)

0103- Carbohydrates 57.5 g of which glucose 1.5, maltose 14 g and polysaccharides 42 g

0104- Fat 18.3 g of which saturated 4.3 g, monounsaturated 5.8 g and polyunsaturated 8.1 g - Na 375 mg, K 630 mg, Cl 585 mg, Ca 235 mg, P 235 mg, Mg 94 mg

0105- Trace elements

0106- Vitamins

0107- Propionibacterium freudenreichii sp shermanii: 10⁸ cells Example 8

0108Powder in a can or sachet. 30 g per serving. Sprinkle on food or moist food or liquid. Mix or stir. Composition per 100 g: - Energy 1879 kcal

0109- Protein 30 g

0110- Carbohydrates 48 g of which 0.2 g glucose, 35.3 g lactose, 3.9 g maltose, 7.3 polysaccharide

0111- Fat 15 g of which saturated 7.9 g, monounsaturated 6.2 g, and polyunsaturated 0.94 g - Minerals, trace elements, vitamins

0112- P. jensenii: 10¹⁰ cells

0113- L. rhamnosus: 10¹⁰ cells

0114Example 9 Supplement: Powder in a gelatine capsule, tablet or sachet. 0.5 g powder per capsule or tablet. Dose: 2 capsules a day. Not to be ingested together with hot drinks. Composition of capsule/tablet:

0115- L. rhamnosus 10¹⁰ cells

0116- P. freudenreichii 10 cells - B. bifidum cells 10⁹ cells

0117- 0.4 g rhamnose (Sachets contain 1.9 g rhamnose)

0118Example 10

0119Supplement: Capsule, tablet or powder in a sachet. Composition capsule/tablet: - Lactobacillus. rhamnosus 10⁹ cells

0120- Propionibacterium. jensenii 10⁹ cells

0121- Lactococcus. lactis ssp cremoris 10 cells

0122- Streptococcus, thermophilus ssp salivarius 10⁹ cells

0123- Bifidobacterium. bifidum 10⁹ cells - Lactobacillus fermentum 10⁹ cells

0124- 0.5 g guar gum (Sachets contain 1.9 g guar gum) APPENDIX I - Protocol for fermentation in dialysis tubes

0125Materials

0126<img file="WO2004000340A2_D0002.tif" /> Methods

0127Preservation

0128The fresh faeces are mixed with the preservative medium and can be preserved in this form for several hours at 4°C.

0129Faecal suspension

0130The preserved solution of faeces is centrifuged at 13,000 φm for 15 minutes. The supernatant is removed and the faeces are mixed with the McBain and MacFarlane medium in a weight ration of 1 : 5.

0131Fermentation

0132- Combine 15 ml of the faecal suspension with 500 mg glucose or prebiotic in a bottle and mix thoroughly - Bring 15 ml of the resulting suspension in a dialysis tube and remove air

0133- Put the dialysis tube in a 250 ml bottle filled with 250 ml of the buffered medium

0134- Close the bottles well and incubate at 37°C

0135- Take a samples from the medium with a hypodermic syringe after 24 and 48 hours (± 1 ml) and immediately put it on ice to stop fermentation

0136Determination ofthepriopionate to acetate ratio

0137Prepare the samples for gaschromatographic analysis (including methylation of the acids present therein) and determine the relative amounts of propionate and acetate found in each of the prebiotic samples as well as the glucose sample. Calculate the propionate:acetate ratio for each sample and compare the ratios obtained for the prebiotic samples with the ratio observed for the glucose sample.