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7 Dietary, Functional, and Total Fiber SUMMARY Dietary Fiber consists of nondigestible carbohydrates and lignin that are intrinsic and intact in plants. Functional Fiber consists of isolated, nondigestible carbohydrates that have beneficial physiological effects in humans. Total Fiber is the sum of Dietary Fiber and Functional Fiber. Fibers have different properties that result in different physiological effects. For example, viscous fibers may delay the gastric emptying of ingested foods into the small intestine, result- ing in a sensation of fullness, which may contribute to weight con- trol. Delayed gastric emptying may also reduce postprandial blood glucose concentrations and potentially have a beneficial effect on insulin sensitivity. Viscous fibers can interfere with the absorption of dietary fat and cholesterol, as well as with the enterohepatic recirculation of cholesterol and bile acids, which may result in reduced blood cholesterol concentrations. Consumption of Dietary and certain Functional Fibers, particularly those that are poorly fermented, is known to improve fecal bulk and laxation and ameliorate constipation. The relationship of fiber intake to colon cancer is the subject of ongoing investigation and is currently unresolved. An Adequate Intake (AI) for Total Fiber in foods is set at 38 and 25 g/d for young men and women, respectively, based on the intake level observed to protect against coronary heart dis- ease. Median intakes of Dietary Fiber ranged from 16.5 to 17.9 g/d for men and 12.1 to 13.8 g/d for women (Appendix Table E-4). There was insufficient evidence to set a Tolerable Upper Intake Level (UL) for Dietary Fiber or Functional Fiber. 339
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340 DIETARY REFERENCE INTAKES BACKGROUND INFORMATION Overview Definitions of Fiber A variety of definitions of fiber exist worldwide (IOM, 2001). Some are based solely on one or more analytical methods for isolating fiber, while others are physiologically based. For instance, in the United States fiber is defined by a number of analytical methods that are accepted by the Asso- ciation of Official Analytical Chemists International (AOAC); these methods isolate nondigestible animal and plant carbohydrates. In Canada, how- ever, a formal definition has been in place that recognizes nondigestible food of plant origin—but not of animal origin—as fiber. As nutrition labeling becomes uniform throughout the world, it is recognized that a single definition of fiber may be needed. Furthermore, new products are being developed or isolated that behave like fiber, yet do not meet the traditional definitions of fiber, either analytically or physiologically. Without an accurate definition of fiber, compounds can be designed or isolated and concentrated using available methods without necessarily providing beneficial health effects, which most people consider to be an important attribute of fiber. Other compounds can be developed that are nondigestible and provide beneficial health effects, yet do not meet the current U.S. definition based on analytical methods. For these reasons, the Food and Nutrition Board, under the oversight of the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, assembled a Panel on the Definition of Dietary Fiber to develop a proposed definition of fiber (IOM, 2001). Based on the panel’s deliberations, consideration of public comments, and subsequent modifications, the following definitions have been developed: Dietary Fiber consists of nondigestible carbohydrates and lignin that are intrinsic and intact in plants. Functional Fiber consists of isolated, nondigestible carbohydrates that have beneficial physiological effects in humans. Total Fiber is the sum of Dietary Fiber and Functional Fiber. This two-pronged approach to define edible, nondigestible carbohydrates recognizes the diversity of carbohydrates in the human food supply that are not digested: plant cell wall and storage carbohydrates that predomi- nate in foods, carbohydrates contributed by animal foods, and isolated and low molecular weight carbohydrates that occur naturally or have been synthesized or otherwise manufactured. These definitions recognize a con- tinuum of carbohydrates and allow for flexibility to incorporate new fiber
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341 D IETARY, FUNCTIONAL, AND TOTAL FIBER sources developed in the future (after demonstration of beneficial physi- ological effects in humans). While it is not anticipated that the new defini- tions will significantly impact recommended levels of intake, information on both Dietary Fiber and Functional Fiber will more clearly delineate the source of fiber and the potential health benefits. Although sugars and sugar alcohols could potentially be categorized as Functional Fibers, for la- beling purposes they are not considered to be Functional Fibers because they fall under “sugars” and “sugar alcohols” on the food label. Distinguishing Features of Dietary Fiber Compared with Functional Fiber Dietary Fiber consists of nondigestible food plant carbohydrates and lignin in which the plant matrix is largely intact. Specific examples are provided in Table 7-1. Nondigestible means that the material is not digested and absorbed in the human small intestine. Nondigestible plant carbohydrates in foods are usually a mixture of polysaccharides that are integral components of the plant cell wall or intercellular structure. This definition recognizes that the three-dimensional plant matrix is respon- sible for some of the physicochemical properties attributed to Dietary Fiber. Fractions of plant foods are considered Dietary Fiber if the plant cells and their three-dimensional interrelationships remain largely intact. Thus, mechanical treatment would still result in intact fiber. Another distinguish- ing feature of Dietary Fiber sources is that they contain other macronutrients (e.g., digestible carbohydrate and protein) normally found in foods. For example, cereal brans, which are obtained by grinding, are anatomical layers of the grain consisting of intact cells and substantial amounts of starch and protein; they would be categorized as Dietary Fiber sources. TABLE 7-1 Characteristics of Dietary Fiber Characteristic Dietary Fiber Nondigestible animal carbohydrate No Carbohydrates not recovered by alcohol precipitationa Yes Nondigestible mono- and disaccharides and polyols No Lignin Yes Resistant starch Some Intact, naturally occurring food source only Yes Resistant to human enzymes Yes Specifies physiological effect No a Includes inulin, oligosaccharides (3–10 degrees of polymerization), fructans, poly- dextrose, methylcellulose, resistant maltodextrins, and other related compounds.
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342 DIETARY REFERENCE INTAKES Resistant starch that is naturally occurring and inherent in a food or created during normal processing of a food, as is the case for flaked corn cereal, would be categorized as Dietary Fiber. Examples of oligosaccharides that fall under the category of Dietary Fiber are those that are normally constituents of a Dietary Fiber source, such as raffinose, stachyose, and verbacose in legumes, and the low molecular weight fructans in foods, such as Jerusalem artichoke and onions. Functional Fiber consists of isolated or extracted nondigestible carbo- hydrates that have beneficial physiological effects in humans. Functional Fibers may be isolated or extracted using chemical, enzymatic, or aqueous steps. Synthetically manufactured or naturally occurring isolated oligosaccharides and manufactured resistant starch are included in this definition. Also included are those naturally occurring polysaccharides or oligosaccharides usually extracted from their plant source that have been modified (e.g., to a shorter polymer length or to a different molecular arrangement). Although they have been inadequately studied, animal-derived carbohy- drates such as connective tissue are generally regarded as nondigestible. The fact that animal-derived carbohydrates are not of plant origin forms the basis for including animal-derived, nondigestible carbohydrates in the Functional Fiber category. Isolated, manufactured, or synthetic oligosaccharides of three or more degrees of polymerization are considered to be Functional Fiber. Nondigestible monosaccharides, disaccharides, and sugar alcohols are not considered to be Functional Fibers because they fall under “sugars” or “sugar alcohols” on the food label. Also, rapidly changing lumenal fluid bal- ance resulting from large amounts of nondigestible mono- and disaccharides or low molecular weight oligosaccharides, such as that which occurs when sugar alcohols are consumed, is not considered a mechanism of laxation for Functional Fibers. Rationale for Definitions Nondigestible carbohydrates are frequently isolated to concentrate a desirable attribute of the mixture from which it was extracted. Distinguish- ing a category of Functional Fiber allows for the desirable characteristics of such components to be highlighted. In the relatively near future, plant and animal synthetic enzymes may be produced as recombinant proteins, which in turn may be used in the manufacture of fiber-like materials. The definition will allow for the inclusion of these materials and will provide a viable avenue to synthesize specific oligosaccharides and polysaccharides that are part of plant and animal tissues. In summary, one definition has been proposed for Dietary Fiber because many other substances in high fiber foods, including a variety of vitamins and minerals, often have made it difficult to demonstrate a significant
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343 D IETARY, FUNCTIONAL, AND TOTAL FIBER health benefit specifically attributable to the fiber in foods. Thus, it is difficult to separate out the effect of fiber per se from the high fiber food. Attempts have been made to do this, particularly in epidemiological studies, by controlling for other substances in those foods, but these attempts were not always successful. The advantage, then, of adding isolated non- digestible carbohydrates as a fiber source to a food is that one may be able to draw conclusions about Functional Fiber itself with regard to its physi- ological role rather than that of the vehicle in which it is found. The proposed definitions do not preclude research directed towards the health benefits of Dietary Fiber in foods, but it is not necessary to demonstrate a physiological effect in order for a food fiber to be listed as Dietary Fiber. An important aspect of the recommended definitions is that a sub- stance is required to demonstrate a beneficial physiological effect to be classified as Functional Fiber. Research has shown that extraction or isola- tion of a polysaccharide, usually through chemical, enzymatic, or aqueous means, can either enhance its health benefit (usually because it is a more concentrated source) or diminish the beneficial effect. These recommen- dations should be helpful in evaluating diet and disease relationship studies as it will be possible to classify fiber-like components as Functional Fibers due to their documented health benefits. Although databases are not cur- rently constructed to delineate potential beneficial effects of specific fibers, there is no reason that this could not be accomplished in the future. Examples of Dietary and Functional Fibers As described in the report, Dietary Reference Intakes: Proposed Definition of Dietary Fiber (IOM, 2001), Dietary Fiber includes plant nonstarch poly- saccharides (e.g., cellulose, pectin, gums, hemicellulose, β-glucans, and fibers contained in oat and wheat bran), plant carbohydrates that are not recovered by alcohol precipitation (e.g., inulin, oligosaccharides, and fructans), lignin, and some resistant starch. Potential Functional Fibers for food labeling include isolated, nondigestible plant (e.g., resistant starch, pectin, and gums), animal (e.g., chitin and chitosan), or commercially produced (e.g., resistant starch, polydextrose, inulin, and indigestible dextrins) carbohydrates. How the Definitions Affect the Interpretation of This Report The reason that a definition of fiber is so important is that what is or is not considered to be dietary fiber in, for example, a major epidemiological study on fiber and heart disease or fiber and colon cancer, could deter- mine the results and interpretation of that study. In turn, that would affect recommendations regarding fiber intake. Clearly, the definitions described
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344 DIETARY REFERENCE INTAKES above were developed after the studies cited in this report, which form the basis for fiber intake recommendations. However, that should not detract from the relevance of the recommendations, as the database used to mea- sure fiber for these studies will be noted. For example, most epidemiological studies use the U.S. Department of Agriculture (USDA) database for fiber, along with other databases and data added by the investigators for missing values (Hallfrisch et al., 1988; Heilbrun et al., 1989; Miller et al., 1983; Platz et al., 1997). Such a database represents Dietary Fiber, since Functional Fibers that serve as food ingredients contribute a minor amount to the Total Fiber content of foods. In 1987, the U.S. Food and Drug Administration (FDA) adopted AOAC method 985.29 for regulatory purposes to identify fiber as a mixture of nonstarch poly- saccharides, lignin, and some resistant starch (FDA, 1987). Related methods that isolated the same components as AOAC method 985.29 were developed independently and accepted by AOAC and FDA in subsequent years. These methods exclude all oligosaccharides (3 to 9 degrees of poly- merization) from the definition and include all polysaccharides, lignin, and some of the resistant starch that is resistant to the enzymes (protease, amylase, and amyloglucosidase) used in the AOAC methods. It is these methods that are used to measure the fiber content of foods that is entered into the USDA database. Other epidemiological studies have assessed intake of specific high fiber foods, such as legumes, breakfast cereals, fruits, and vegetables (Hill, 1997; Thun et al., 1992). Intervention studies often use specific fiber supplements such as pectin, psyllium, and guar gum, which would, by the above definition, be considered Functional Fibers if their role in human health is documented. For the above reasons, the type of fiber (Dietary, Functional, or Total Fiber) used in the studies discussed later in this chapter is identified. Description of the Common Dietary and Functional Fibers Below is a description of the Dietary Fibers that are most abundant in foods and the Functional Fibers that are commonly added to foods or pro- vided as supplements. To be classified as a Functional Fiber for food labeling purposes, a certain level of information on the beneficial physiological effects in humans will be needed. For some of the known beneficial effects of Dietary and potential Functional Fibers, see “Physiological Effects of Iso- lated and Synthetic Fibers” and “Evidence Considered for Estimating the Requirement for Dietary Fiber and Functional Fiber.” Cellulose. Cellulose, a polysaccharide consisting of linear β-(1,4)−linked glucopyranoside units, is the main structural component of plant cell walls.
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345 D IETARY, FUNCTIONAL, AND TOTAL FIBER Humans lack digestive enzymes to cleave β-(1,4) linkages and thus cannot absorb glucose from cellulose. Powdered cellulose is a purified, mechani- cally disintegrated cellulose obtained as a pulp from wood or cotton and is added to food as an anticaking, thickening, and texturizing agent. Dietary cellulose can be classified as Dietary Fiber or Functional Fiber, depending on whether it is naturally occurring in food (Dietary Fiber) or added to foods (Functional Fiber). Chitin and Chitosan. Chitin is an amino-polysaccharide containing β-(1,4) linkages as is present in cellulose. Chitosan is the deacetylated product of chitin. Both chitin and chitosan are found in the exoskeletons of arthropods (e.g., crabs and lobsters) and in the cell walls of most fungi. Neither chitin nor chitosan is digested by mammalian digestive enzymes. Chitin and chitosan are primarily consumed as a supplement and poten- tially can be classified as Functional Fibers if sufficient data on physiological benefits in humans are documented. β-Glucans. β-glucans are homopolysaccharides of branched glucose resides. These β-linked D-glucopyranose polymers are constituents of fungi, algae, and higher plants (e.g., barley and oats). Naturally occurring β-glucans can be classified as Dietary Fibers, whereas added or isolated β-glucans are potential Functional Fibers. Gums. Gums consist of a diverse group of polysaccharides usually iso- lated from seeds and have a viscous feature. Guar gum is produced by the milling of the endosperm of the guar seed. The major polysaccharide in guar gum is galactomannan. Galactomannans are highly viscous and are therefore used as food ingredients for their thickening, gelling, and stabi- lizing properties. Gums in the diet can be classified as Dietary or Functional Fibers. Hemicelluloses. Hemicelluloses are a group of polysaccharides found in plant cell walls that surround cellulose. These polymers can be linear or branched and consist of glucose, arabinose, mannose, xylose, and galact- uronic acid. Dietary hemicelluoses are classified as Dietary Fibers. Inulin, Oligofructose, and Fructooligosaccharides. Inulin and oligofructose are naturally occurring in a variety of plants. Most of the commercially available inulin and oligofructose is either synthesized from sucrose or extracted and purified from chicory roots. Oligofructose is also formed by partial hydrolysis of inulin. Inulin is a polydisperse β-(2,1)-linked fructan with a glucose molecule at the end of each fructose chain. The chain length is usually 2 to 60 units, with an average degree of polymerization of
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346 DIETARY REFERENCE INTAKES ten. The β-(2,1) linkage is resistant to enzymatic digestion. Synthetic oligofructose contains β-(2,1) fructose chains with and without terminal glucose units. The chain ranges from two to eight monosaccharide residues. Synthetic fructooligosaccharides have the same chemical and structural composition as oligofructose, except that the degree of polymerization ranges from two to four. Because many current definitions of dietary fiber are based on methods involving ethanol precipitation, oligosaccharides and fructans that are endogenous in foods, but soluble in ethanol, are not analyzed as dietary fiber. Thus, the USDA database does not currently include these fiber sources. With respect to the definitions outlined in this chapter, the naturally occurring fructans that are found in plants, such as chicory, onions, and Jerusalem artichoke, would be classified as Dietary Fibers; the synthesized or extracted fructans could be classified as Func- tional Fibers when there are sufficient data to show positive physiological effects in humans. Lignin. Lignin is a highly branched polymer comprised of phenyl- propanoid units and is found within “woody” plant cell walls, covalently bound to fibrous polysaccharides (Dietary Fibers). Although not a carbo- hydrate, because of its association with Dietary Fiber, and because it affects the physiological effects of Dietary Fiber, lignin is classified as a Dietary Fiber if it is relatively intact in the plant. Lignin isolated and added to foods could be classified as Functional Fiber given sufficient data on positive physi- ological effects in humans. Pectins. Pectins, which are found in the cell wall and intracellular tissues of many fruits and berries, consist of galacturonic acid units with rhamnose interspersed in a linear chain. Pectins frequently have side chains of neutral sugars, and the galactose units may be esterified with a methyl group, a feature that allows for its viscosity. While fruits and veg- etables contain 5 to 10 percent naturally occurring pectin, pectins are industrially extracted from citrus peels and apple pomace. Isolated, high methoxylated pectins are mainly added to jams due to their gelling prop- erties with high amounts of sugar. Low methoxylated pectins are added to low-calorie gelled products, such as sugar-free jams and yogurts. Thus, pectins in the diet are classified as Dietary and/or Functional Fiber. Polydextrose. Polydextrose is a polysaccharide that is synthesized by random polymerization of glucose and sorbitol. Polydextrose serves as a bulking agent in foods and sometimes as a sugar substitute. Polydextrose is not digested or absorbed in the small intestine and is partially fermented in the large intestine, with the remaining excreted in the feces. Polydextrose
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347 D IETARY, FUNCTIONAL, AND TOTAL FIBER can potentially be classified as a Functional Fiber when sufficient data on physiological benefits in humans are documented. Psyllium. Psyllium refers to the husk of psyllium seeds and is a very viscous mucilage in aqueous solution. The psyllium seed, also known as plantago or flea seed, is small, dark, reddish-brown, odorless, and nearly tasteless. P. ovata, known as blond or Indian plantago seed, is the species from which husk is usually derived. P. ramosa is known as Spanish or French psyllium seed. Psyllium, also known as ispaghula husk, may be classified as a Functional Fiber. Resistant Dextrins. Indigestible components of starch hydrolysates, as a result of heat and enzymatic treatment, yield indigestible dextrins that are also called resistant maltodextrins. Unlike gums, which have a high viscosity that can lead to problems in food processing and unpleasant organoleptic properties, resistant maltodextrins are easily added to foods and have a good mouth feel. Resistant maltodextrins are produced by heat/acid treat- ment of cornstarch, followed by enzymatic (amylase) treatment. The average molecular weight of resistant maltodextrins is 2,000 daltons and consists of polymers of glucose containing α-(1-4) and α-(1-6) glucosidic bonds, as well as 1-2 and 1-3 linkages. Resistant dextrins can potentially be classified as Functional Fibers when sufficient data on physiological benefits in humans are documented. Resistant Starch. Resistant starch is naturally occurring, but can also be produced by the modification of starch during the processing of foods. Starch that is included in a plant cell wall and thus physically inaccessible to α-amylase is called RS1. Native starch that can be made accessible to the enzyme by gelatinization is called RS2. Resistant starch that is formed during processing is called RS3 or RS4 and is considered to be fiber that is isolated rather than intact and naturally occurring. RS3 (retrograded starch) is formed from the cooking and cooling or extrusion of starchy foods (e.g., potato chips and cereals). RS4 (chemically modified starch) includes starch esters, starch ethers, and cross-bonded starches that have been produced by the chemical modification of starch. RS3 and RS4 are not digested by mammalian intestinal enzymes and are partly fermented in the colon (Cummings et al., 1996; Englyst et al., 1992). Resistant starch is estimated to be approximately 10 percent (2 to 20 percent) of the amount of starch consumed in the Western diet (Stephen et al., 1983). Thus, RS1 and RS2 are classified as Dietary Fibers, and RS3 and RS4 may be classified as Functional Fibers.
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348 DIETARY REFERENCE INTAKES Physiology of Absorption, Metabolism, and Excretion By definition, Dietary Fiber and Functional Fiber are not digested by mam- malian enzymes. Therefore, they pass into the large intestine relatively intact. Along the gastrointestinal tract, properties of fiber result in differ- ent physiological effects. Effect on Gastric Emptying and Satiety Consumption of viscous fibers delays gastric emptying (Low, 1990; Roberfroid, 1993) and expands the effective unstirred layer, thus slowing the process of absorption once in the small intestine (Blackburn et al., 1984). This in turn can cause an extended feeling of fullness (Bergmann et al., 1992). A slower emptying rate means delayed digestion and absorp- tion of nutrients (Jenkins et al., 1978; Ritz et al., 1991; Roberfroid, 1993; Truswell, 1992), resulting in decreased absorption of energy (Heaton, 1973). For example, Stevens and coworkers (1987) showed an 11 percent reduction in energy intake with psyllium gum intake. Postprandial glucose concentration in the blood is thus lower after the consumption of viscous fiber than after consumption of digestible carbohydrate alone (Benini et al., 1995; Holt et al., 1992; Leathwood and Pollet, 1988). The extended presence of nutrients in the upper small intestine may promote satiety (Sepple and Read, 1989). Fermentation Fibers may be fermented by the colonic microflora to carbon dioxide, methane, hydrogen, and short-chain fatty acids (primarily acetate, propi- onate, and butyrate). Foods rich in hemicelluloses and pectins, such as fruits and vegetables, contain Dietary Fiber that is more completely ferment- able than foods rich in celluloses, such as cereals (Cummings, 1984; Cummings and Englyst, 1987; McBurney and Thompson, 1990). There appears to be no relationship between the level of Dietary Fiber intake and fermentability up to very high levels (Livesey, 1990). Resistant starch is highly fermentable (van Munster et al., 1994). Butyrate, a four-carbon, short-chain fatty acid, is the preferred energy source for colon cells (Roediger, 1982), and lack of butyrate production, absorption, or metabo- lism is thought by some to contribute to ulcerative colitis (Roediger, 1980; Roediger et al., 1993). Others have suggested that butyrate may be protec- tive against colon cancer (see “Dietary Fiber and the Prevention of Colon Cancer”). However, the relationship between butyrate and colon cancer is controversial and the subject of ongoing investigation (Lupton, 1995).
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349 D IETARY, FUNCTIONAL, AND TOTAL FIBER Contribution of Fiber to Energy When a metabolizable carbohydrate is absorbed in the small intestine, its energy value is 16.7 kJ/g (4 kcal/g); when fiber is anaerobically fer- mented by colonic microflora in the large intestine, short-chain fatty acids (e.g., butyrate, acetate, and propionate) are produced and absorbed as an energy source. Once absorbed into the colon cells, butyrate can be used as an energy source by colonocytes (Roediger, 1982); acetate and propionate travel through the portal vein to the liver, where propionate is then utilized by the liver. Acetate can be metabolized peripherally. A small proportion of energy from fermented fiber is used for bacterial growth and mainte- nance, and bacteria are excreted in feces, which also contain short-chain fatty acids (Cummings and Branch, 1986). Differences in food composi- tion, patterns of food consumption, the administered dose of fiber, the metabolic status of the individual (e.g., obese, lean, malnourished), and the digestive capability of the individual influence the digestible energy consumed and the metabolizable energy available from various dietary fibers. Because the process of fermentation is anaerobic, less energy is recovered from fiber than the 4 kcal/g that is recovered from carbohy- drate. While it is still unclear as to the energy yield of fibers in humans, current data indicate that the yield is in the range of 1.5 to 2.5 kcal/g (Livesey, 1990; Smith et al., 1998). Physiological Effects of Isolated and Synthetic Fibers This section summarizes the fibers for which there is a sufficient data- base that documents their beneficial physiological human effects, which is the rationale for categorizing them as Functional Fibers. It is important to note that discussions on the potential benefits of what might eventually be classified as Functional Fibers should not be construed as endorsements of those fibers. While plant-based foods are a good source of Dietary Fiber, isolated or synthetic fibers have been developed for their use as food ingredients and because of their beneficial role in human health. In 1988 Health Canada published guidelines for what they considered to be “novel fiber sources” and food products containing them that could be labeled as a source of fiber in addition to those included in their 1985 definition (Health Canada, 1988). The rationale for these guidelines was that there were safety issues unique to novel sources of fiber, and if a product was represented as containing fiber, it should have the beneficial physiological effects associated with dietary fiber that the public expects. The guidelines indicated that both safety and efficacy of the fiber source had to be estab- lished in order for the product to be identified as a source of dietary fiber in Canada, and this had to be done through experiments using humans.
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411 D IETARY, FUNCTIONAL, AND TOTAL FIBER Jenkins DJA, Wolever TMS, Leeds AR, Gassull MA, Haisman P, Dilawari J, Goff DV, Metz GL, Alberti KGMM. 1978. Dietary fibres, fibre analogues, and glucose tolerance: Importance of viscosity. Br Med J 1:1392–1394. Jenkins DJA, Wolever TMS, Collier GR, Ocana A, Rao AV, Buckley G, Lam Y, Mayer A, Thompson LU. 1987. Metabolic effects of a low-glycemic-index diet. Am J Clin Nutr 46:968–975. Jenkins DJA, Vuksan V, Kendall CWC, Würsch P, Jeffcoat R, Waring S, Mehling CC, Vidgen E, Augustin LSA, Wong E. 1998. Physiological effects of resistant starches on fecal bulk, short chain fatty acids, blood lipids and glycemic index. J Am Coll Nutr 17:609–616. Jenkins DJA, Kendall CWC, Vuksan V, Vidgen E, Parler T, Faulkner D, Mehling CC, Garsetti M, Testolin G, Cunnane SC, Ryan MA, Corey PN. 2002. Soluble fiber intake at a dose approved by the US Food and Drug Administration for a health claim of health benefits: Serum lipid risk factors for cardiovascular disease assessed in a randomized controlled crossover trial. Am J Clin Nutr 75:834–839. Jennings CD, Boleyn K, Bridges SR, Wood PJ, Anderson JW. 1988. A comparison of the lipid-lowering and intestinal morphological effects of cholestyramine, chitosan, and oat gum in rats. Proc Soc Exp Biol Med 189:13–20. Jie Z, Bang-Yao L, Ming-Jie X, Hai-Wei L, Zu-Kang Z, Ting-Song W, Craig SAS. 2000. Studies on the effects of polydextrose intake on physiologic function in Chinese people. Am J Clin Nutr 72:1503–1509. Judd PA, Truswell AS. 1981. The effect of rolled oats on blood lipids and fecal steroid excretion in man. Am J Clin Nutr 34:2061–2067. Kang JY, Doe WF. 1979. Unprocessed bran causing intestinal obstruction. Br Med J 1:1249–1250. Kato I, Akhmedkhanov A, Koenig K, Toniolo PG, Shore RE, Riboli E. 1997. Pro- spective study of diet and female colorectal cancer: The New York University Women’s Health Study. Nutr Cancer 28:276–281. Kay RM, Truswell AS. 1977. Effect of citrus pectin on blood lipids and fecal steroid excretion in man. Am J Clin Nutr 30:171–175. Kelsay JL, Behall KM, Prather ES. 1978. Effect of fiber from fruits and vegetables on metabolic responses of human subjects. I. Bowel transit time, number of defecations, fecal weight, urinary excretions of energy and nitrogen and appar- ent digestibilities of energy, nitrogen, and fat. Am J Clin Nutr 31:1149–1153. Key TJA, Thorogood M, Appleby PN, Burr ML. 1996. Dietary habits and mortality in 11,000 vegetarians and health conscious people: Results of a 17 year follow up. Br Med J 313:775–779. Khaw K, Barrett-Connor E. 1987. Dietary fiber and reduced ischemic heart disease mortality rates in men and women: A 12-year prospective study. Am J Epidemiol 126:1093–1102. Kirby RW, Anderson JW, Sieling B, Rees ED, Chen W-JL, Miller RE, Kay RM. 1981. Oat-bran intake selectively lowers serum low-density lipoprotein cholesterol concentrations of hypercholesterolemic men. Am J Clin Nutr 34:824–829. Kleessen B, Sykura B, Zunft HJ, Blaut M. 1997. Effects of inulin and lactose on fecal microflora, microbial activity, and bowel habit in elderly constipated persons. Am J Clin Nutr 65:1397–1402. Klurfeld DM. 1992. Dietary fiber-mediated mechanisms in carcinogenesis. Cancer Res 52:2055S–2059S. Knekt P, Steineck G, Järvinen R, Hakulinen T, Aromaa A. 1994. Intake of fried meat and risk of cancer: A follow-up study in Finland. Int J Cancer 59:756–760.
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