ARTICLE IN PRESS

Clinical Nutrition Supplements (2004) 1, 73–80

http://intl.elsevierhealth.com/journals/clnu

Consensus recommendations on the effects and

benefits of fibre in clinical practice
Rémy Meiera, Miquel A. Gassullb,

a
Kantonsspital, Liestal, Switzerland
b
Hospital Germans Trias i Pujol, Badalona, Spain

The consensus meeting generally agreed that:  Dietary fibre has beneficial effects upon intest-
inal function, and should be included in the diet
 Dietary fibre is generally accepted as an im- of all patients at least to the same extent as
portant part of a healthy diet. There is convin- recommended for the general healthy popula-
cing evidence to support the general consensus tion, if there are no contraindications.
that fibre-rich diets—those rich in fruit, vege-  For epidemiological and clinical studies, uniform
tables and whole grains—are generally beneficial definitions of fibre have to be used. In epidemio-
to health. These benefits may not necessarily be logical studies fibre intake has to be assessed by
due to fibre per se, but may reflect the fact that adequate and uniform methods. For clinical
such diets tend to be rich in vitamins, minerals, studies it has always to be considered that fibre
antioxidants and other phytochemicals and are has specific effects on metabolic and on gastro-
low in energy-dense nutrients. A fibre-rich diet intestinal function. For specific diseases, the
may also reflect an otherwise healthy lifestyle. optimal fibre has to be chosen on the basis of
This view represents the basis for the advice their chemical, physical and physiological prop-
contained in national dietary guidelines—that erties.
people should obtain an adequate intake of
dietary fibre. Although there are problems with
Many specific health claims have been made
the methodology in measuring the contents of
regarding fibre. The following sections provide a
fibre in different foodstuffs, the recommended
consensus view based on current available evidence
figures for fibre intake are more than 20 g non-
of the benefits that may be obtained from an
starch polysaccharides (NSP) or more than 25 g of
adequate intake of fibre in normal food or specific
dietary fibre (FAO and WHO).
supplementations in relation to:
 Since the definition of fibre according to its
physiological properties and as functional fibre I. Inflammatory bowel disease (Crohn’s disease,
no longer stands, fibre should be chemically ulcerative colitis and pouchitis)
defined. II. Constipation, diarrhoea and irritable bowel
syndrome
Corresponding author. III. Prevention of colorectal cancer
E-mail addresses: [email protected] (R. Meier), IV. Metabolic effects
[email protected] (M.A. Gassull). V. The use of fibre in enteral nutrition

1744-1161/$ - see front matter & 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.clnu.2004.09.011
 ARTICLE IN PRESS
74 R. Meier, M.A. Gassull

Inflammatory bowel disease Inulin is the only polysaccharide tested in active

Rationale for using fibre in inflammatory inflammatory bowel conditions. It showed a sig-
nificant decrease of intracolonic pH, significant
bowel diseases (IBD)
increase of the concentration of butyrate and a
significant decrease of the number of colonies of
The oligo-polysaccharide components of fibre are
both total Bacteroides and Bacteroides fragilis as
fermented, in different degrees, by colonic anae-
compared to placebo. This was shown over 3 weeks
robic bacteria. This process induces, at least, two
in a cross-over design in a group of patients with
relevant effects in the luminal environment of the
pouchitis, most of them after colectomy for severe
colon: a decrease in pH and the production of
UC. The results showed a significant improvement
short-chain fatty acids (SCFA): acetate, propionate
in disease, endoscopic and histological activity
and butyrate.
indices when inulin was given (Level of evidence
Butyrate is the preferred energy substrate for the
II).
colonocytes. Oxidation of butyrate produces acet-
Plantago ovata has been shown in a multicentre,
yl-Co-A, which is involved in numerous metabolic
randomised, 5-ASA controlled study to be as
pathways in the cell, among them synthesis of
effective as 5-ASA (usual treatment), and both
cholesterol and phospholipids, important elements
treatments together in maintaining UC in remission
of cell membranes, as well as mucus synthesis.
during 1 year (Level of evidence II).
Deficient butyrate oxidation has been described in
So far, on the basis of the actual knowledge,
ulcerative colitis (UC) in vivo, which has been
there is no evidence that fibre has any positive
attributed to the presence of an excessive number
effect in Crohn’s disease. This may be due to the
of sulphate reducing bacteria in the colon in this
fact that most of the known potential therapeutic
condition. This may jeopardise the important
effects are related to the fermentation process,
acetyl-Co-A-dependent metabolic pathways indu-
which mainly takes place in the colon and very
cing changes in cell membrane structure and in
rarely in the small intestine. However, to our
mucus which might favour the triggering and
knowledge, no extensive data regarding the fer-
perpetuation of the inflammatory process. More-
mentation process in colonic Crohn’s are available.
over, butyrate has been shown experimentally to
exert immunomodulatory effects via the inhibition
of the activation of transcription factor NF-kB. What kind of fibre should be used?
Decreasing luminal pH in the colon may induce
changes in microflora, and has been shown experi- Only trials using inulin in pouchitis and P. ovata as
mentally that adding some highly fermentable maintenance treatments in ulcerative colitis have
oligosaccharides to a fermentation system with been published, both showing significant clinical
human luminal colonic contents and faeces in- benefits. It is difficult to extrapolate this concept
creases the number of colonies of Lactobacilli and to that of fermentable fibres, because the meta-
Bifidobacteria and decreases those of Clostridia and bolites produced may vary according to the
Bacteroides. There are no convincing published substrate given and it is not always butyrate. This
studies of other polysaccharides (except inulin) may be influenced by excessive presence of S and N
having prebiotic properties. compounds because of excessive sulphate reducing
bacteria or excessive ingestion, respectively. There
are also no data related to the effect of this
Evidence
unbalanced bacteria in the intestinal lumen on the
effectiveness of the fermentation process and the
Only few clinical data are available on the potential
production of butyrate. The fermentation rate
therapeutic effect of fibre in active ulcerative
along the colon is also of importance. UC is often
colitis and maintenance treatment. In most the
a distal colon disease and a highly fermentable
fermentation-derived metabolite butyrate has
fibre can be fermented in the cecum but cannot
been used as the administered major component.
reach the inflammed areas (this may also apply to
Butyrate has been administered intra-rectally in
inulin).
active distal colitis (and also in radiation proctitis)
in short series of patients with promising results.
Orally administered fibre-polysaccharides have only Recommendation for using fibre in UC
been administered in two studies: as treatment of
active inflammation of the ileo-anal pouch (pou- Although many experimental data suggest a role of
chitis) and as remission maintenance treatment a deficient fibre polysaccharides-metabolite oxida-
in UC. tion and production in the large bowel in the
 ARTICLE IN PRESS
Consensus recommendations 75

pathogenesis of colon inflammation, there is not increases SCFAs, H2, CO2 and biomass. The rate of
enough evidence to support it. fermentation depends on the physico–chemical
The preliminary Japanese data on fermented properties of the fibre. The physiological conse-
barley, the inulin role in pouchitis and even the role quences of fermentation are diverse and several
of P. ovata in the maintenance treatment of UC, have important implications for human diseases. The
although the strongest in the literature, need specific effects of fibre in the large bowel were the
further confirmation (Recommendation B). rational for using fibres in large bowel disorders.

Contraindications for using fibre in IBD Evidence

The major contraindication for the use of fibre in Resistant starch shows some of the attributes of
IBD is the presence of strictures and fistulae, due to non-starch polysaccharides in that it provides
the possibility of mechanic complications. Avoiding substrates for fermentation with the production
of coarse and poorly fermented fibre is mandatory of SCFA and other consequences. Resistant starch
in this situation. Easy fermentable fibre could be increases stool weight on average by 1.5 g/g
considered safer; however, the production of large resistant starch fed and is less effective than raw
quantities of gas proximally to a stricture may bran (7.2 g/g fibre fed), fruit and vegetables (6.0 g/
induce at least very uncomfortable symptoms to g fibre fed) (Level of evidence I).
the patient. There is no data to give evidence- On the other hand, fermentable fibre increase
based recommendations in this subject. SCFA and these can increase colonic sodium and
In active UC poorly fermentable fibre could even water absorption. Soy polysaccharides showed
increase diarrhoea, although data supporting this some beneficial effects in children with acute and
assumption are lacking. antibiotic induced diarrhoea. Furthermore, oral
rehydration solution with partially hydrolysed guar
Areas for future research gum (PHGG) and also starch reaching the colon
showed beneficial effects in children with acute
With the data published so far, research on fibre and chronic diarrhoea or in patients with cholera
and IBD should focus on the following: (Level of evidence I).

 Optimising the fermentation process in order to

What kind of fibre should be used?
obtain the desirable rate of butyrate production
and maintenance of low pH along all segments of
Several dietary fibres increase stool weight. Raw
the colon.
bran, fruit and vegetables are more effective than
 Minimising the action of substrates limiting the
cooked bran, psyllium, oats, gums and mucilages.
synthesis of butyrate, S and N by decreasing the
Soy polysaccharides and pectin have only a weak
activity of sulphate-reducing bacteria and dimin-
effect. It has to be considered, that within each
ishing the sources of N-compounds.
group of fibre, there is a great variability in
 Evaluating the beneficial synergistic effects of
changing stool weight.
fibre-poly/oligosaccharides and probiotic bacter-
The variability is due in part to the inherent
ia (synbiotic effect) on colonic inflammation.
difference in individual responses and to varying
 Exploring the synbiotic effect in inflammation of
experimental designs, and the fact that in some
the small intestine.
studies uncontrolled diets were used. A major
problem is lack of consistency in methodology for
measurement of dietary fibre. Around 20 different
methods were used in those studies.
Constipation, diarrhoea and irritable
bowel syndrome Recommendation for using fibre in intestinal
diseases
Rationale for using fibre in intestinal
diseases Constipation
Constipation is a symptom/syndrome rather than a
It is well established that dietary fibre reaches the disease. Different patient groups exist and may have
large intestine and exerts specific effects: some different needs, but there is not enough evidence in
type of fibre have more bulking effects and others RCT for recommendations. The populations include
are more fermented. The fermentation process slow transit constipation, outlet obstruction, and
 ARTICLE IN PRESS
76 R. Meier, M.A. Gassull

treatment related constipation (e.g. opiates in may benefit from fibre; however side-effects (e.g.
cancer patients). At present, the evidence is bloating) may override its benefits. Some fibre
insufficient to suggest guidelines for treatment of sources (e.g. PHGG) may be better tolerated than
constipation in the different groups of patients. others, but there are insufficient data on which to
Overall, there is convincing data to show that make recommendations.
fibre results in a modest increase in bowel move-
ment frequency (on average plus 1.4–1.5 bowel Contraindications of using fibre
movements per week) (Recommendation A).
Fibres improve symptoms such as pain and stool There are no real contraindication to use dietary
consistency, but there are no long-term data fibre and functional fibre in constipation and
available. In regard to which fibre sources are most irritable bowel syndrome. To overcome bloating
effective, there are insufficient data available to and flatulence as a fermentation consequence, it
make evidence-based recommendations. Increase has been suggested that the co-administration of
in stool weight and altered transit times may not probiotics can be helpful, but there are no data
fully reflect symptom relief and patient satisfac- available so far to recommend this.
tion. Patient’s tolerance of fibres (particularly in
regard to the amount/volume of fibre) is impor- Areas for future research
tant.
Dietary fibre (raw bran, fruit and vegetables) is  There appears to be paucity of research into
of potential benefit in many circumstances, and is treatment of constipation. Future trials are
often used in self-care. There are numerous data, required comparing different dietary fibre and
but most are from uncontrolled studies and thus not additional fibre (e.g. PHGG) alone or in combina-
applicable to evidence based guidelines. Lifestyle tion with probiotics to assess clinical effective-
factors, patient’s preferences and tolerance of ness and cost-effectiveness.
fibre are important facts to consider.  The efficacy of PHGG and resistant starch should
be investigated in acute and chronic diarrhoea in
Diarrhoea combination with probiotics.
There are problems in regard to definition and  For all kind of irritable bowel syndrome the
quantification of diarrhoea—the opinions differ combination of different pre- and probiotics
from patients to nurses, doctors and relatives. A seems to be a reasonable approach for future
common physiological definition would be based on research. These trials should be placebo-con-
daily stool weight exceeding 200 g. Clinical defini- trolled and lasting at least 12 weeks with a
tions would reflect a change in consistency and control period of 4 weeks after treatment stop.
frequency. Diarrhoea is commonly regarded as
more than three loose stools per day. There are
not enough data to say which types of fibre might
be of benefit in different types of diarrhoea. Prevention of colorectal cancer
Owing to the lack of data, no specific recom-
mendations about the benefit of fibre in diarrhoea Rationale to consider an anti-carcinogenic
can be given in general. The only data available effect of fibre
regarding a beneficial effect of fibre on diarrhoea
are those showing a significant effect of PHGG and The physical effects of fibre on stool mass and
resistant starch in an oral rehydration solution in transit time were considered for many years as the
children with acute and chronic diarrhoea and in preventive mechanism of colorectal cancer. The
patients with cholera (Recommendation A). actual knowledge suggests that this claimed effect
could be achieved through the metabolites pro-
Irritable bowel syndrome (IBS) duced by the action of bacteria on the complex
Fibre is generally recommended in IBS, but there is carbohydrates reaching the colon. The best-studied
little evidence to support its use. Patients with anti-neoplastic effect of these metabolites is that
predominant constipation may benefit, although of butyrate. This compound interacts with mutated
data supporting its use are mostly on bowel APC, modulates p53 (both suppressor genes),
frequency and not on bloating or pain relief. There inhibits the activity of the transcription factors
is a lack of long-term data. (such as NF-kB) controlling cell division and
Overall, therefore, the benefits of fibre in decreases the apoptotic rate, probably by mod-
patients with irritable bowel syndrome are unpro- ulating the activity of caspases. Hence, butyrate
ven despite many trials. Some of these patients gives the immature cells a survival advantage.
 ARTICLE IN PRESS
Consensus recommendations 77

Evidence When considering recommendations it has to be

taken into account whether the intervention is in a
A metanalysis pooling the data of the results of the high-risk individual. An individual that has already
best 13 case–control studies provided substantive developed large adenomas in the colon has a high
evidence that the intake of fibre-rich foods was risk of developing cancer because genetic mutations
inversely correlated to the risk of cancer of both may have already taken place and the effect of
colon and rectum. It was estimated that the risk of major changes in the diet on adenoma development
colorectal cancer in the US population could be may need longer than 5–19 years to show-up.
reduced by 31% with increasing and average of However, major recommendations in the diet early
13 g/day in fibre intake from food sources (Level of in life might be beneficial in the future. In fact the
evidence I). intake of high fibre diet is recommended from
The relationship of fibre intake to colon cancer is childhood onwards in the general population. It is
the subject of ongoing investigation and currently advised to consume preferentially fibre-rich foods
unresolved. In fact, various cohort studies showed like vegetables, fruits and whole grains. These may
conflicting results, but the large European Prospec- also include other protective substances. In addition
tive Investigation into Cancer and Nutrition (EPIC it has to be considered that fibre is not an isolated
study) has clearly shown that dietary fibre in food substrate within the diet and the diet is also related
inversely correlated to the incidence of large bowel to lifestyle.
cancer: the protective effect was higher for the
left side of the colon and lower for the rectum Contraindications of using fibre in the
(Level of evidence I). prevention of colorectal cancer
Polyp recurrence intervention trials using fibre
over 3–4 years failed to show any significant effect. There are no contraindications for a fibre rich diet
However, the type and source of fibre in the diet for primary or secondary prevention of adenoma
was not fully evaluated in these studies. In and colorectal cancer. There is no evidence against
addition, and of utmost importance, these inter- the use of high fibre diet in childhood.
vention studies were performed in high-risk popu-
lations who had already developed adenomas, i.e. Areas for future research for the use of fibre
precursors of cancer.
in colorectal cancer prevention

What kind of fibre should be used?  The adenoma-carcinoma sequence provides a

unique human model for studying the potential
In view of the poor experimental evidences, no anti-proliferative effects of fibre. These studies
specific recommendations can be given in order to should have, at least, an observational period
prevent colorectal cancer. In this sense it is worth- between 5 and 10 years, because of the
while to consider the findings of the EPIC study, which prolonged interval between early adenoma for-
has shown that the total intake of fibre-rich foods mation and carcinoma (about 10 years).
inversely correlated to the incidence of large bowel  There is an important need to incorporate early
cancer. No source of fibre was significantly more pre-neoplastic markers in the fibre-cancer-inter-
protective than another. Fruits and soluble fibre vention studies.
showed a modest effect on distal colonic adenoma  Future studies should incorporate the evaluation
formation, but this effect could not be demonstrated of the potential synergistic anti-carcinogenic
with cereals, vegetables and non-soluble fibre. effect of fibre, other nutrients and some drugs.

Recommendations for using fibre for the

Metabolic effects
prevention of colorectal cancer
Rationale for using fibre for metabolic
The review of controlled clinical trials reveals that control
the role of dietary fibre as an anti-carcinogenic
agent is, at best equivocal. This is due to the fact The ingestion of certain types of fibre (i.e. viscous
that many studies show important methodological fibre) can have a mild cholesterol-lowering effect,
problems (mainly difficulties with the food fre- which is attributable to the increased viscosity of
quency questionnaires, quantitative and qualita- intestinal contents slowing ileal bile acid uptake
tive heterogeneity in the dietary intakes, and lack and enhancing fecal bile acid loss, thus promoting
of prospective data). hepatic cholesterol catabolism. The increased
 ARTICLE IN PRESS
78 R. Meier, M.A. Gassull

viscosity of chyme also reduces the rate of present this best sums up our knowledge of the
intestinal glucose uptake and subsequent insulin topic.
response.
Soluble (viscous) fibre (guar gum, pectin, psy- Recommendation for using fibre in
llium) has a cholesterol-lowering effect in both cardiovascular protection
healthy and hyperlipidaemic subjects. According to
one limited meta-analysis, for each 1 g of soluble Regular intake of viscous fibre or psyllium shows
fibre added to the diet, total cholesterol is lowered beneficial effects on blood cholesterol, LDL-cho-
by 0.045 mmol/l and LDL-cholesterol is lowered by lesterol and reduces postprandial glucose levels
0.057 mmol/l. Others have shown greater effects. and insulin response. (Recommendation A)
There is no significant effect on HDL-cholesterol or Viscous fibres have demonstrated benefits in lipid
triglycerides. For other sources of soluble fibre metabolism and glycaemic control; nevertheless,
(e.g. fructo-oligosaccharides) there is a lack of there are no data from randomised controlled trials
consistent evidence for effects on blood lipids. with hard end points to indicate a clear benefit in
Insoluble fibre (wheat bran, cellulose) has no effect terms of prevention of CHD and diabetes.
on blood cholesterol. Regular fibre intake has shown beneficial effects
In short-term randomised feeding trials, guar on CHD, but fibre is only one factor of many dietary
gum, pectin, and the laxative fibre psyllium reduce components, which affect the risk. (Recommenda-
blood glucose levels by 29–44%. Slowing starch tion A)
digestion or modifying other factors such as lipid
and protein content of the meal and thus slowing
gastric emptying reduces the postprandial glycae- Contraindications for adding fibre to the diet
mic and insulin responses. However, there is only
limited evidence of long-term improvement of There are no contraindications for using fibre to
metabolic control of diabetes with high fibre further the beneficial effects of healthy diets. In
intakes. diabetic patients, long-term studies using soluble
fibre may be associated with a number of problems
of acceptability, dose, and side effects.
Evidence of a protective against coronary
heart disease and diabetes Areas for future research
Meta-analyses of prospective observational studies  Short-term studies in acute critically ill patients
suggest a protective effect of dietary fibre and/or using different soluble (viscous) fibre in enteral
whole grain cereals against coronary heart disease nutrition to control hyperglycaemia looking on
(level of evidence III). On the other hand, refined morbidity and mortality should be done (see also
cereals lack a protective effect. chapter V).
Pooled data from prospective studies suggests  Long-term studies in enterally fed, insulin de-
that dietary fibre and/or whole grain cereals may pendent patients using different types of fibre to
have a protective effect against type 2 diabetes control blood glucose levels, insulin and lipids on
(level of evidence III). Fruit and vegetables, nuts, long-term complications (e.g. micro- and macro-
legumes, and plant-based diets in general have a vascular diseases) would be important.
similar beneficial effect in cohort studies.  Clearly defined fibre should be used in long-term
There is a need for randomised clinical trials to studies using hard endpoints (e.g. prevention of
confirm the protective effects of high-fibre diets. acute coronary heart disease or re-infarction
rates).
What kind of fibre should be used?

The distinction between soluble and insoluble fibre

may not be helpful. Physical characteristics, The use of fibre in enteral nutrition
including viscosity may be more worthwhile to-
gether with the digestion characteristics of the Rationale for using fibre in enteral nutrition
whole food. However, as mentioned above, to
assess purity, it is recommended to address dietary Feeding the gut to maintain gut physiology,
carbohydrates by their chemical structure. improving gastrointestinal tolerance (e.g. preven-
Recommendations to the general public should tion of diarrhoea) and glycaemic control in glucose
be based on a prudent, vegetable-rich diet. At intolerant patients should be the major endpoints.
 ARTICLE IN PRESS
Consensus recommendations 79

In acute disease, the use of fermentable fibre Fermentable and viscous fibres (e.g. oat b-
would appear to be the best way to achieve this. glucan) are effective for glycaemic control, but
Chronic patients requiring long-term enteral nutri- the available studies make it difficult to ascertain
tion may also need bulking fibre to maintain normal to what extent fibre supplementation contributes
bowel function (e.g. preventing constipation). to the beneficial effects of the diabetes formulas
Thus, some kind of fibre should be provided to (No recommendation).
most (if not all) patients receiving enteral nutri- Short-term studies showed that soy polysacchar-
tion, but the fibre need to pass the enteral tubes ides or soy polysaccharides combined with oat
without blocking. fibre, increased daily stool weight and frequency.
There is only one pilot study showing a beneficial
Evidence effect of adding soy polysaccharides to control
bowel habits in patients on long-term enteral
The available clinical studies using fibre in enteral feeding (Recommendation C).
nutrition have yielded divergent results.
There is evidence that: Contraindications for adding fibre to enteral
nutrition
 PHGG is effective in reducing enteral nutrition
associated diarrhoea in patients after surgery Contraindications for adding fibre to enteral nutri-
and in critically ill-patients (Level of evidence tion include intestinal or colonic strictures (e.g.
I). IBD), fistulae (liquid fibre could be used, but there
 Soy polysaccharides, or soy polysaccharide com- is no data on this topic) and gastroparesis (except
bined with oat fibre are effective to increase when post pyloric access could be reached).
daily stool weight and frequency in individuals on However, the level of evidence for this recommen-
enteral feedings, but the effect of fibre was dation is poor.
studied in small group of patients during short
periods (Level of evidence III). Areas for future research
 Supplementation of soy polysaccharides
(20–30 g/l in enteral solution) showed a signifi-  Future research should seek to confirm that
cant increase in stool weight during one year of including fibre in enteral nutrition is beneficial
enteral feeding in 11 patients (Level of evidence for gut function. Work should also be directed at
III). identifying the best type of fibre for different
conditions, for instance in the ICU (trauma,
burns, sepsis and surgery) for specific diseases
(gastrointestinal disease, cancer, diabetes) and
What kind of fibre should be used? for long-term use.
 Additional work should also explore the synergis-
For enteral nutrition in acute illness (intensive tic effects of fibre/pre- and probiotics. It is
care, perioperatively) fermentable fibre (e.g. suggested that the effect of individual fibre
PHGG) can be recommended. Hydrolysis appears preparation should be tested in each condition.
to be a conditio sine qua non for incorporating fibre This would allow better definition of the optimal
into enteral formulas. This process alters the fibre fibre mixture to be used in future enteral
in the way that some of its properties are lost formulas.
(particularly viscosity and bulking effects) but they  There is need for larger trials with clinical
are still fermented (e.g. PHGG). relevant primary end-points; both in short-term
For patients with chronic illness requiring long- enteral nutrition in acute patients and in long-
term enteral nutrition, both non-fermentable fibre term conditions.
(bulking fibre, e.g. soy polysaccharide) and fer-
mentable fibre (e.g. PHGG) may be appropriate.
Consensus conference panel
Recommendation for using fibre in enteral
nutrition Chairmen

To prevent enteral nutrition induced diarrhoea in Rémy Meier

post surgical- and in critical ill-patients supple- University Hospital, Liestal (Switzerland)
menting enteral nutrition with PHGG is effective Miquel Angel Gassull
(Recommendation A). Hospital Germans Trias I Pujol, Badalona (Spain)
 ARTICLE IN PRESS
80 R. Meier, M.A. Gassull

Lecturers Andrea Pezzana, Ospidale Giovanni, Torino (Italy)

Joanne L. Slavin, University of Minnesota, St. Paul
Ingvar Bosaeus (USA)
Sahlgrenska University Hospital, Gothenburg III Prevention of colorectal cancer
(Sweden) Chairmen: Wolfgang Scheppach, University of
Eduard Cabré Wuerzburg, Wuerzburg (Germany), John Rom-
Hospital Germans Trias I Pujol, Badalona (Spain) beau, Hospital of the University of Pennsylvania,
John Cummings Philadelphia (USA)
Ninewells Hospital and Medical School, Dundee Carlo Pedrolli, Ospedale S. Chiara, Trento (Italy)
(UK) Barbara Schneeman, University of California,
Glenn Gibson Davis (US)
The University of Reading (UK) Paul AM van Leeuwen, Free University Hospital,
Heinz-Herbert Homann Amsterdam (The Netherlands)
University Hospital Bergmannsheil, Ruhr-University IV Metabolic effects
(Bochum) Chairman: Emilio Ros, Hospital Clı́nic I Provin-
David Jenkins cial, Barcelona (Spain)
St. Michael’s Hospital, Toronto, Ontario (Canada) Henrik Andersson, Sahlgrenska University Hospi-
John Rombeau tal, Goteborg (Sweden)
Hospital of the University of Pennsylvania, Phila- Peter Ballmer, Kantonsspital, Winterthur (Swit-
delphia (USA) zerland)
Wolfgang Scheppach Maria Ermelinda Camilo, Faculdade de Medicina
University of Wuerzburg, Wuerzburg (Germany) de Lisboa, Lisboa (Portugal)
Jordi Salas, Universitat Rovira i Virgili, Reus,
Tarragona (Spain)
V The use of fibre in enteral nutrition
Workshop groups and Participants
Chairman: Eduard Cabré, Hospital Germans Trias
I Inflammatory bowel disease I Pujol, Badalona (Spain)
Chairmen: John Cummings, Ninewells Hospital Stig Bengmark, University College London (UK)
and Medical School, Dundee (UK), Glenn Gibson, Cécile Chambrier, Hôpital Edouard Herriot, Lyon
The University of Reading (UK) (France)
Lisbeth Mathus-Vliegen, Academisch Medisch Luiza Kent-Smith, Facüldade de Ciencias da
Centrum, Amsterdam (Netherlands) Nutricao, Porto (Portugal)
Alberto Miján de la Torre, Hospital General Reto Stocker, University Hospital Zurich (Swit-
Yagüe, Burgos (Spain) zerland)
Ana Ma Pita, Ciutat Sanitària de Bellvitge,
% de Llobregat, Barcelona (Spain)
Hospitalet Scientific Coordination
II Constipation, diarrhoea and irritable bowel Mireia Morera, MD, Medical Affairs, Novartis
syndrome Medical Nutrition, Barcelona (Spain)
Chairman: Ingvar Bosaeus, Sahlgrenska Univer-
sity Hospital, Gothenburg (Sweden) This Consensus was reached after discussion
Philippe Ducrotte, CHU Charles Nicolle, Rouen within the groups and the general group of chair-
(France) men, lecturers and participants.