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Author’s Accepted Manuscript

Prebiotics and synbiotics: Recent concepts in


nutrition

Debapriya Mohanty, Snigdha Misra, Swati


Mohapatra, Priyadarshi Soumyaranjan Sahu

www.elsevier.com/locate/sdj

PII: S2212-4292(17)30845-3
DOI: https://doi.org/10.1016/j.fbio.2018.10.008
Reference: FBIO348
To appear in: Food Bioscience
Received date: 8 November 2017
Revised date: 13 October 2018
Accepted date: 14 October 2018
Cite this article as: Debapriya Mohanty, Snigdha Misra, Swati Mohapatra and
Priyadarshi Soumyaranjan Sahu, Prebiotics and synbiotics: Recent concepts in
nutrition, Food Bioscience, https://doi.org/10.1016/j.fbio.2018.10.008
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Prebiotics and synbiotics: Recent concepts in nutrition

Debapriya Mohanty1, Snigdha Misra2*, Swati Mohapatra3, Priyadarshi Soumyaranjan Sahu4

1
Department of Microbiology, Centre for Post Graduate Studies, Orissa University of
Agriculture and Technology, Bhubaneswar, Odisha 751003, India
2
Division of Nutrition and Dietetics, School of Health Sciences, International Medical
University, 57000, Kuala Lumpur, Malaysia
3
Department of Biotechnology, Amity University (AIMT), Noida, 201313
Uttar Pradesh, India.
4
Division of Pathology, School of Medicine, International Medical University, 57000, Kuala
Lumpur, Malaysia

*Corresponding author: Department of Nutrition and Dietetics, International Medical University,


Kuala Lumpur, Malaysia, Tel: +603 27317608; fax: +603 86567229,
snigdha_misra@imu.edu.my

Abstract
Gut flora have a crucial role in metabolizing various nutritional substrates to maintain human
health. Several studies on prebiotics and symbiotic have reported to be clinically effective in
maintaining the balance of gastrointestinal microbiota to improve health conditions. Therefore,
an optimum balance is required in the intestinal microflora of the host. Under certain stress
conditions, it may be altered which manifests as gut disorders. Prebiotics from food are the
fermentable fiber which selectively feed beneficial bacteria in the intestinal microbiota, to
maintain a healthy microbiome environment. Probiotic foods are supplements with live
microbes, showing immune-supportive effects in the gastrointestinal tract. However, both pre-
and probiotics have been reported to work best in combination. This combined effect of both,

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results in synbiotics. Prebiotic foodstuff remains unaltered in the gastrointestinal tract, as gastric
enzymes cannot act on them. They reach the large intestine intact and are selectively fermented
to give beneficial effects. This review focusses on prebiotic foods, their nutritional value,
characteristics, safe consumption, therapeutic effects and mechanism of action and their role in
synbiotics.

Keywords Prebiotics, synbiotics, therapeutic effects

1. Introduction
There has been a paradigm shift in food culture across the globe. Modernization has led
to transitions in food habits. With an increased consumption of fast foods with decreased
physical activity, there has been a sudden surge in the rise of non-communicable diseases (NCD)
(Prescott, 2014). Particular attention must be drawn to the composition and safety of processed
foods that contribute to NCD. The introduction of prebiotics in processed foods may be a
possible solution. The International Scientific Association for Probiotics and Prebiotics (ISAPP)
defines a prebiotic as “a substrate that is selectively utilized by host microorganisms conferring a
health benefit”. This definition expands the concept of prebiotics to include non-carbohydrate
substances, applications to body sites other than the gastrointestinal tract, and diverse categories
other than food. The consensus definition also applies to prebiotics for use by animals, in which
microbiota-focused strategies to maintain health and prevent disease is equally relevant as
humans (Gibson et al., 2017). Prebiotics are non-active food constituents that moves to the colon
and are selectively fermented. They are colonic foods that enter the large intestine (colon) and
serve as substrates for endogenous colonic bacteria; mostly bifidogenic and lactic acid bacteria in
the gastrointestinal (GI) tract to provide the host with essential nutrients and energy (Gourineni
et al., 2011; Salvini et al., 2011). Prebiotics are often, relatively short chained, low molecular
weight carbohydrates that are not digestible by digestive enzymes in humans; and beneficially
manipulated in the composition and/or activity of colonic microflora. They improve the host’s
health and are antagonistic to pathogenic organisms limiting their proliferation. Thus, the
prebiotic approach uses the administration of non-viable entities. Prebiotics have the ability to

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improve the survival, growth, metabolism and beneficial health activities of probiotics in the
digestive system (Sekhon et al., 2010).
The synergistic combination of prebiotics and probiotics found in products such as foods,
drugs, and supplements is known as “Synbiotics” (live cells of the useful microbes/probiotics
and a selective substrate/prebiotic). In other words, synbiotics is defined as “a combination of
probiotics and prebiotics that beneficially affects the host by improving the survival and
implementation of live microbial dietary supplements in the GI tract”. Synbiotics have a greater
efficacy, as compared to either probiotic or prebiotic used in isolation. Functional petit-Suisse
cheese and ice creams supplemented with L. casei and 2.5% inulin are effective synbiotic
products (Criscio et al., 2010). Various combinations of synbiotics show therapeutic effects
against diseases, like gastrointestinal diseases, respiratory infections, hypercholesterolemia,
atopic dermatitis, allergy, diabetes, liver diseases and cancer (Ogawa et al., 2006; Passeron et al.,
2006; Cazzola et al., 2010; Ooi et al., 2010; Rayes et al., 2012; Dinleyici et al., 2013).

2. Sources of prebiotics
Legumes, fruits and vegetables, such as wheat, oatmeal, barley, navy beans, white beans,
black beans, lentils, kidney beans, chickpeas, tomatoes, onions, garlic, chicory, greens, leeks,
shallots, asparagus, spinach, Jerusalem artichokes, bananas and berries are rich in prebiotic
fibers. (Crittenden and Payne, 2008). Generally, the beneficial prebiotic agents are categorized as
polyols (sugar alcohols), oligosaccharides and soluble fiber (Table 1).
2.1. Polyols
Xylitol, sorbitol, mannitol, lactulose and lactilol are widely used prebiotic polyols (Venter, 2007;
Spindler-Vesel et al., 2007).
2.2. Oligosaccharides
Oligosaccharides are the combinations of sugars with a different degree of polymerization and
considered as major sources of prebiotics. They are non-digestible; hence, are available for
hydrolysis by hydrolytic enzymes in the colon and favor the growth of beneficial bacteria over
that of harmful ones. Examples of prebiotic oligosaccharides are; fructo-oligosaccharides
(FOS), galacto-oligosaccharides (GOS), soy-oligosaccharides (SOS), isomalto-oligosaccharides
(IMO), oligosaccharides (OS), transgalacto-oligosaccharides, xylo-oligosaccharides (XOS),
inulins, raffinose lactosucrose, palatinose, oligofructose (OF), galactosyl lactose and

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pyrodextrins (Venter, 2007; Spindler-Vesel et al., 2007; Al-Sheraji et al., 2013). FOS are found
in plants such as onion, garlic, asparagus, chicory, sugar beet, tomatoes, banana, Jerusalem
artichoke, honey, wheat, oat, barley and soybean asparagus whereas human milk and cow’s milk
are the major sources of GOS (Alander et al., 2001). XOS are found in fermented foods such as
fruits, vegetables, milk, honey and wheat bran. Additionally, miso, soy, sauce, sake, sugarcane
juice and honey are foods containing IMO and isomaltulose in abundance. Inulin is a blend of
fructan chains widely distributed in various plant species, e.g., garlic, onion, asparagus, chicory,
artichoke and wheat. The majority of inulin commercially available today is extracted from
chicory roots. Inulin and OF have a specific chemical structure which is metabolized as dietary
fibers in the human body showing the same beneficial dietary fiber effects (Al-Sheraji et al.,
2013).
2.3. Fibers
Although all prebiotics are fiber, not all fibers are prebiotics. The grains, legumes, flours,
potatoes, vegetables and fruits are the most popular sources of dietary fiber. Dietary fibers are
non-digestible carbohydrates, mainly, several non-starch polysaccharides such as cellulose,
dextrins, pectins, beta-glucans, waxes, and lignin. They show similar physiological effects on
human health as that of inulin-type fructans (Slavin, 2008; Napolitano et al., 2009). Therefore,
dietary fibers are a good source of prebiotics. The classification of the dietary fibers is presented
in Table 2.
2.4. Other food supplements with prebiotic properties
Some novel sources of food supplements are capable of stimulating the growth of beneficial
microflora in the GIT and as effective prebiotic sources. Examples of the novel sources of
prebiotics, in the microbiome environment in human intestines are: Lupin kernel fiber, a
legume-derived food (Smith et al., 2006); aqueous extracts of blueberry, selenium-containing
green tea (SGT) and China green tea (CGT) (Molan et al., 2009a; 2009b); Indian mulberry
(Yang et al., 2011b); mushrooms (Synytsya et al., 2009); dragon fruit (Wichienchot et al., 2010)
and Yacon root (Ojansivu et al., 2011). Lupin kernel fiber enhances the growth of
Bifidobacterium spp. by suppressing the levels of the Clostridia, e.g., C. ramosum, C. spiroforme
and C. cocleatum (Smith et al., 2006). The aqueous extract of blueberry and SGT modulated the
activity L. rhamnosus and Bifidobacterium breve in addition to having higher DPPH free-radical
scavenging activity (Molan et al., 2009a; 2009b).

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3. Characteristics of beneficial prebiotics
The prebiotic activity reflects the ability of a given substrate to support the growth of
probiotics. Both in vitro and in vivo methods are available to show this resistance in the
candidate prebiotic. Thus, stimulation of probiotic activities has been identified as one of the
characteristics of beneficial prebiotic selection (Seifert and Watzl, 2007; Wang, 2009). The
characteristics of beneficial prebiotics are summarized in Table 3.

4. Prebiotics in daily foods


Prebiotics show several nutritional characteristics. They can be incorporated into food to
enhance the growth of microflora in the GI tract thereby improving the quality of foods.
Prebiotics provide more freshness in food and keeps them moist for a long time (Wichienchot et
al., 2010). They can be formulated either as a powder or syrup and marketed as supplements or
incorporated into food products (e.g., yogurts and breads). Breast milk naturally contains
prebiotics (oligosaccharides) at a level of 10-12 g/l that favor the growth of bifidobacteria in the
colon of infants (Rao et al., 2009). Prebiotic functional food products includes biscuit, cakes,
sauces, breads, pasta, snack foods, dietetic products, frozen yoghurt, custard, desserts, table-top
sweetener, candies, soft drinks, fruit juices, lactic acid bacteria drinks, coffee and beverages
(Douglas and Sanders, 2008). The global demand of prebiotics has grown appreciably over the
last 10 years to approximately 500,000 t per annum.
The addition of prebiotics such as OF to yogurt not only increases the beneficial bacteria
in the small intestine, but also reduces its caloric value. OF is much more soluble, sweeter and
has fewer calories compared to native inulin and can be used for partial sucrose replacement. It
neither crystallizes nor precipitates and does not leave a dry or sandy sensation in the mouth,
appearing to have a similar viscosity as sucrose. Furthermore, it is heat stable and can be used in
food processing up to approximately 140 0C (Cruz et al., 2013).
Sheep milk ice cream is an interesting food matrix appreciated by people worldwide
(Balthazar et al., 2017). It has a great nutritional value due to its high proteins, lipids, minerals,
and essential vitamins content. It can be used in the manufacture of cheese, yogurt and ice-
cream. Nevertheless, sheep milk contains high levels of saturated fats, which may be detrimental

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for cardiovascular health. Replacement of sheep milk fat by prebiotics to manufacture sheep milk
ice cream can be an effective alternative to improve the nutritional and physiological aspects due
to its low caloric value and functionality provided by prebiotics (Balthazar et al., 2017). Thus,
the demand for functional dairy products has led to the reduction and replacement of fat content
by prebiotic fibers in the formulations. The supplementation with prebiotic dietary OS can add
value to the product by providing a functional appeal.

4.1. Commercially available prebiotic products


Some prebiotic containing foods available in the market include Ensure® Plus Fibre
(USA), Chicory root inulin powder (USA), Prebiotin powder (USA), Fiber Gummies Sugar-Free
Prebiotic (USA) and MSPrebiotic® (Canada).

Prebiotin, a prebiotic fiber powder is rich in OF and inulin. It stimulates the growth of
beneficial bacteria throughout the colon. MSPrebiotic® is 70% dietary fiber, which is a simple
and easy solution to bridge the fiber gap. It promotes regularity, maintains heart health, and
reduces inflammation.

Prebiotics offer a double benefit: an improved organoleptic quality and a better-balanced


nutritional composition. A prebiotic oat bran added to a dairy fruit beverage has been well
accepted by consumers (Guergoletto et al., 2010). Beneo offers a wide variety of products
which includes Orafti® GR. It is a granulated inulin powder, used in baked products, beverages,
breakfast cereals and cereal bars, candy, chocolate, dairy alternatives, dairy products, dry mixes,
fillings, frozen desserts, fruit preparations, meat products, soups and sauces, and table spreads.
Inulin improves the intestinal flora, helps in weight management and increases calcium
absorption (Guergoletto et al., 2010; Keenan et al., 2011).

Buckwheat diet (Prestamo et al., 2003), a cake containing barley β-glucan (Mitsou et al., 2010),
peach-flavored yogurt containing a prebiotic (Gonzalez et al., 2011), drinkable yogurt with

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prebiotics, e.g., soluble corn fiber, polydextrose and chicory inulin (Allgeyer et al., 2010)
showed beneficial health effects. Some other examples are shown in Table 4.

5. Safety of prebiotic consumption


Inulin and OF are natural food ingredients present in edible plants and in the traditional
diets. Several studies have reported that FOS are neither mutagenic nor carcinogenic. Generally,
prebiotics are assumed safe as they are found in natural foods. However, animal and human trials
have reported that the ensuing gastrointestinal symptoms are dose dependent; and animal model
experiments have been carried out to identify possible intolerance of beneficial prebiotics (Den
Hond et al., 2000). Daily ingestion of 2 g/day of XOS, 10 g/day of GOS and at least 4 g FOS/day
are required to raise the bifidobacteria levels in the human gut (Manning and Gibson, 2004).
Prebiotics consumed in doses higher than the normal level (approximately 20 g/day) may cause
some side effects like increased gas production, abdominal bloating or diarrhea (Tuohy et al.,
2003).

6. Mechanisms of action of prebiotics


The putative mechanisms of prebiotics may follow different modes; such as direct and
indirect modes (Figure 1). In the indirect mode, prebiotics provide nutrients and nourishment to
the gut flora for their natural growth, thereby conferring health benefits. On other hand, prebiotic
may directly be responsible for inhibiting several pathogenic bacteria, cancer inhibition,
cholesterol removal, reduction of cardiovascular disease, prevention of obesity and constipation
(Patel and Goyal, 2012; Al-Sheraji et al., 2013). Several prebiotics and their health promoting
effects are summarized in Table 5.

7. Therapeutic effects of prebiotics

7.1. Improvement of gut health


Prebiotic supplementations modulate the gut microbiota. The immune responses in the gut and
its associated lymphoid tissue (GALT) enhances the cytokine production and other immune
functions (Patel and Goyal, 2012). Inulin, FOS, and arabino galactans are therapeutic nutritional
preparations which support optimum gut function, and favor the proliferation of normal bacterial

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flora (Bodera, 2008). Passariello et al (2011) evaluated the efficacy of zinc and prebiotics (FOS
and XOS) fortified oral rehydration solutions (ORS) for treatment of diarrhea among children
over 72 h. They reported that a zinc and prebiotic combination reduced the duration of diarrhea
in patients by stimulating water and electrolyte re-absorption across gut mucosa and inhibited the
pathogens.
7.2. Antipathogenic effect
The potential use of prebiotics has been reported in experimental and animal studies, with
respect to gastrointestinal infections. They have an ability to protect against a variety of potential
pathogenic bacteria, such as Salmonella enterica serovar typhimurium (S. Typhimurium) ,
Listeria monocytogenes and Escherichia coli by following several mechanisms such as
production of inhibitory factors (bacteriocin, short chain fatty acid (SCFA)), colonization
resistance and competitive exclusion (Vamanu and Vamanu, 2010; Licht et al., 2012; Patel and
Goyal, 2012).
Vamanu and Vamanu (2010) studied the effect of prebiotics, e.g., inulin from chicory and
dahlia, raffinose and lactulose on the synthesis of bacteriocins from Lactobacillus paracasei
CMGB16 strain. They observed a significant increase of the activity of the bacteriocin when the
media was supplemented with inulin, lactulose and raffinose (after 25 - 96 h). Prebiotic sorbitol
has a positive influence on bacteriocin production from Pediococcus acidilactici LAB 5 isolated
from meat (Mandal et al., 2009).
Prebiotics improve the growth and functions of colonic microbiota during their
fermentation. Lactates, SCFA such as acetate, propionate and butyrate are the end products of
metabolized prebiotics. SCFA have an important role in the mechanism responsible for
inhibiting enteropathogens by lowering the pH of GI tract. This low pH may reduce the peptide
degradation. The toxic compounds like ammonia, amines, and phenolic compounds are acted
upon by bacterial enzymes to prevent their harmful effects. SCFA stimulates the growth of
colonic crypt cells, decreases the risk of mutations in the intestine, helps in protein synthesis
resulting in increased microbial biomass (Fooks and Gibson 2002; Cavaglieri et al., 2003; Coles
et al., 2005). SCFAs can bind G-protein coupled receptor 41 (Gpr41), a strong regulator of host
energy balance whose effects are dependent upon the gut microbiota (Samuel et al., 2008).
Generally, butyrate is an energy source for colonocytes and can also maintain a normal

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colonocyte population, preventing mutations. Thus, it functions as a primary protective factor
against colonic disorders (Vernazza et al., 2006).
Some prebiotics (GOS) showed an anti-adhesive effect on harmful microbes in the GI
tract. OS acts as a molecular receptor decoy that can competitively inhibit bacterial adhesion and
also as a repressor of virulence factors by repressing the gene expression in some
enteropathogens. They can adhere to the binding sites of bacteria on the enterocyte surface
resulting in blocking the adhesion of pathogenic bacteria to intestinal epithelial cells (Shoaf et
al., 2006). Certain milk-derived OS structurally resemble the saccharide containing glycoproteins
that many pathogens bind to, in the intestinal cells. These may act as a receptor analogue and
thereby inhibit infection, if the pathogenic cell binds to the oligosaccharides rather than to host
cell receptors. Several studies with different preparations of GOS consistently show that, in vitro,
the prebiotic has the potential to reduce adherence of enteropathogenic E. coli, as well as
Salmonella to epithelial cell lines. Also non-milk derived prebiotics have been shown to inhibit
infection though direct interaction with the pathogen. Pectins and pectic OS were reported to
reduce the activity of shiga like toxins produced by E. coli O157:H7, likely by inhibiting binding
of the toxin (Licht et al., 2012). Evidence shows an improved efficacy of zinc and prebiotics
(FOS and XOS) fortified ORS for treatment of diarrhea in children (Passariello et al., 2011).
FOS is reported to be effective in preventing relapse of C. diffecile associated diarrhea (Saad et
al., 2013). Earlier studies have demonstrated that prebiotics also exert their effect beyond the GI
tract (Lenoir-Wijnkoop et al., 2007).
7.3. Anti-cancerous effect
Prebiotics have a protective effect against carcinogens involved in colon cancer (Hsu et al.,
2004). SCFA, such as propionate, has an anti-inflammatory effect on colon cancer cells. Butyrate
obtained from fermentation of GOS regulates the apoptosis and reduces metastasis in colon cell
lines. It also protects the body from carcinogens by enhancing expression of enzymes involved in
detoxification (Nurmi et al., 2005; Pool-Zobel, 2005; 2007). Butyrate suppressed the expression
of transcription factor NF-jB in HT-29 cell lines, whereas acetate increased the peripheral blood
antibody production and natural killer cells (NK) activity in cancer patients (Macfarlane et al.,
2008; Patel and Goyal, 2012).

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7.4. Immune-modulatory effect
Prebiotics have an important role in modulating the immune system and enhancing host defences
(Lomax and Calder, 2008; Macfarlane et al., 2008). Vos et al. (2010) studied the immune-
modulatory effect of specific prebiotic OS, e.g., GOS, FOS and pectin-derived acidic OS. The
administration of prebiotics enhanced the production of anti-inflammatory cytokines by
suppressing pro-inflammatory cytokines that led to a decrease in overall gut inflammation
(Schiffrin et al., 2007; Vulevic et al., 2008; Patel and Goyal, 2012).

7.5. Prevention of cardiovascular diseases


Dietary fibers as short-chain FOS, whole grains and soy foods enriched with prebiotics reduced
the risk of coronary heart disease. Regular intake of such prebiotics increased the plasma ferulic
acid concentration, induced satiety, reduced the low-density lipoprotein cholesterol and increased
high-density lipoprotein. Prebiotics also improved glucose homeostasis and lowered the risk of
obesity and cardiovascular diseases (Harris and Kris-Etherton, 2010; Hess et al., 2011; Wong et
al., 2010). FOS is also reported to be effective against hyperlipidaemia. This action is due to the
inhibition of a lipogenic enzyme in the liver that may be a result of the action of propionate
produced from the fermentation of prebiotics by gut bacteria (Al-Sheraji et al., 2013).
7.6. Promotes absorption of minerals
Prebiotics have an important role in cancer prevention. These processes include the induction of
apoptosis, a process which is deactivated in cancer cells which would normally lead to their
elimination and an increase in the immunogenicity of cancer cells due to an increase in the
expression of cell surface proteins. Prebiotics such as FOS and GOS increased calcium and
magnesium absorption and acted as a laxative. In human studies, 15 g per day of OF or 40 g of
inulin per day increased the apparent calcium absorption. Magnesium absorption is increased
following ingestion of FOS (Al-Sheraji et al., 2013).

8. Efficacy of prebiotics in humans and animals


Several studies have shown protective effects of prebiotics in experimental animals
infected with typical food borne bacteria including Salmonella, E. coli and L. monocytogenes.
Besides, a number of controlled or placebo-controlled intervention studies reported the effect of

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prebiotic carbohydrates on infectious diseases in human subjects. Some of these studies are
summarized in Table 6.

The action of prebiotics improved in the presence of probiotics. Probiotics are live
microorganisms when administered in adequate amount and have conferred health benefits.
Hence, both probiotics and the prebiotics work together to prevent any altered health condition.

Synbiotics
Synbiotics are essentially a synergistic combination of probiotics and prebiotics, with
therapeutic effects. Prebiotics promote the growth of probiotics in the colon. Hence, synbiotics
are essential for good colonic health, prevention of disease, and/or as alternatives for reducing
the risk associated with diseases.

Foods with synbiotic effects


The best food for infants providing a synbiotic effect is breast milk. Breast milk contains
prebiotics in the form of OS and lactic acid bacteria (LAB) as probiotics. Hence, breast milk is a
synbiotic food conferring a wide range of health benefits to infants (Heyman and Menard, 2002).
Of late, prebiotics are being introduced in infant formulas with a combination of milk derived OS
and B. lactis, which protects children from diarrhea (Sazawal et al., 2004).
Resistant starch consumption is associated with several health benefits, such as,
cholesterol- and triglyceride-lowering effects, positive impact on glucose homeostasis,
increasing satiety, and potential effects on the treatment of chronic kidney disease. Green
bananas are rich in indigestible carbohydrates, especially dietary fiber, and resistant starch
(approximately 40.9–58.5%). This has led to the commercial production of green banana flour
(GBF). Fermented milk containing organic banana flour can maintain viable lactic acid and
probiotic cultures (>6 log CFU/g) with resistant starch (3.0–10.3 g/100 g). The addition of 3%
w/v GBF led to an increase in post acidification, proteolysis, and concentrations of lactic acid
and acetic acid. However, it improved the fatty acid profile (increasing long-chain fatty acids,
such as oleic, linoleic, and alinolenic) and contributed to the appearance of volatile compounds
(esters, ketones, and carboxylic acids) with positive impact on the flavor and aroma acceptance

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of the products. GBF is an alternative ingredient in fermented milk formulations, contributing as
a functional food, particularly as a synbiotic product (Batista et al 2017).

Plum juice is formulated by using different strains of probiotics (Lactobacillus


kefiranofaciens, Candida kefir and Saccharomyces boluradii) with OS resulting in a synbiotic
product. These formulated foods showed antibacterial activity against diarrhea-causing
pathogens such as E. coli, Vibrio cholerae, Salmonella paratyphi A, Shigella dysenteriae and
Staphylococcus aureus (Sheela and Suganya, 2012). L. acidophilus, L. rhamnosus,
Bifidobacterium bifidum, Bifidobacterium longum and Enterococcus faecium were effective in
acute watery diarrhea patients in the presence of FOS (Dinleyici et al., 2013). Inflammatory
bowel syndrome, bloating and constipation can be treated using L. acidophilus with prebiotic
plant fiber (Young and Cash, 2006).
Studies have shown that pancreatitis can be cured by using synbiotics supplement; a combination
of 4 probiotic strains, i.e., L. acidophilus, L. rhamnosus, B. bifidum, and B. longum and 4
different prebiotics, i.e., inulin, β-glucan, resistant starch, and pectin (Banks and Freeman, 2006;
Forsmark et al., 2007; Olah et al., 2007). Short bowel syndrome is caused by complete
dysfunction of a large segment of the bowel or the surgical removal of the small intestine
(malabsorption disorder) (Damaraju et al., 2010). It can be treated using a synbiotic preparation
(B. breve and L. casei and GOS) which suppresses pathogenic microbes, increases weight of
patients, improves fecal content and pre-albumin concentrations (Kanamori et al., 2004).
Synbiotic formulations are useful in the alteration of fecal bacterial composition and the
enhancement of functionality of epithelial barriers. It is also highly recommended for the
alleviation of periodontal disorders and for reduction of allergic conditions in children (Devkar et
al., 2012). L. rhamnosus GG and LC705 and Bifidobacterium breve Bb99 along with prebiotic
GOS are effective against respiratory infections (Parracho et al., 2007). Furthermore, synbiotics
may be useful in the treatment of winter depression, which includes gastroenteritis, common
cold, strep throat, influenza and respiratory tract infections by significantly reducing systemic
production of Th2 cytokines in the allergic patients. Bifidobacterium brevem16V with GOS and
Lactobacillus helveticus R0052 with FOS may be specifically helpful in these conditions
(Bengmark et al., 2001; Van de Pol et al., 2010).

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A combination of Bifidobacterium lactis HN019 and prebiotic oligosaccharide reduced
the incidences of dysentery episodes, pneumonia, and respiratory infection in lowering childhood
morbidities (Sazawal et al., 2010). Progressive studies in the field of synbiotics established that
the use of a combined supplement of Lactobacillus plantarum299 and fiber prevents bacterial
infections after liver transplantation and enhanced liver function capacity (Rayes et al., 2012).
Synbiotic 2000, L. rhamnosus GG and Bifidobacteria subsp. lactis and OF-enriched inulin are
efficient synbiotics against colon cancer (Cazzola et al., 2010) whereas L. acidophilus CHO-220
and inulin together show advantageous health effects on hyperlipidaemia (Ooi et al., 2010).

Conclusion

This review presents the therapeutic properties of prebiotics and synbiotics, showing their
efficacy in the systemic health, metabolism and immune system. Identification of the prebiotic
coupled with the potent probiotic will result in effective synbiotics. Potential advantages of using
prebiotics and synbiotics from a health standpoint, includes partial replacement of antibiotic
growth promoters. Prebiotics, especially inulin-type fructans (also synbiotics) are good
candidates to be classified as functional food ingredients. However, to affirm the findings of this
review more clinical trials are suggested.

Conflicts of interest and financial disclosures: The authors declare no conflict of interest.

Funding was not required for this paper.

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Table 1 Source and classification of prebiotics
Class of prebiotic Types of prebiotics Food sources
1. Polyols (sugar alcohols) Lactulose Lactose (milk)

Xylitol, sorbitol, mannitol,


lactilol

2. Oligosaccharides FOS Asparagus, sugar


beet, garlic, chicory,
onion, Jerusalem
artichoke, wheat,
honey, banana,
barley, tomato and
rye

GOS Human’s milk and


cow’s milk

XOS Bamboo shoots,


fruits, vegetables,
milk,
honey and wheat
bran

Isomalto-oligosaccharides Miso, soy, sauce,


sake, all starchy
food

Raffinose oligosaccharides Seeds of legumes,


lentils, peas, beans,
chickpeas, mallow
composite, and
mustard

Soy-oligosaccharides Soybean

Isomaltulose Honey, sugarcane


juice

Arabinoxylooligosaccharides Wheat bran

Inulins Garlic, onion,


asparagus, chicory,
artichoke and wheat
Soligosaccharides, OF,

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galactosyl lactose and
pyrodextrinsare

Fibers Cellulose, dextrins, pectins, Grains, legumes,


beta-glucans, waxes, and lignin, flours, potatoes,
inulin-type fructans vegetables and fruits

Others Legume-derived food Lupin kernel fiber

Aqueous extract of blueberry, Selenium-


containing green tea
(SGT) and China
green tea
Indian mulberry, mushrooms
dragon fruit and Yacon root

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Table 2 Classification of dietary fibers
Category Examples
Dietary fiber Lignin, cellulose, β-glucans, hemicelluloses, pectins and gums
Functional fiber Fructooligosaccharides polydextrose, isolated gums
Soluble fibers Pectin, β –glucans, gums, wheat dextrin and psyllium
Insoluble fibers Cellulose, lignin
Fermentable fibers Pectin, inulin, β –glucans
Non-fermentable Cellulose, lignin
fibers
Viscous fibers Pectins, β-glucans, psyllium, glucomannan

(Source: Slavin et al., 2009)

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Table 3 Characteristics of beneficial prebiotics
Criteria
1. Must be edible parts of plants
2. Should be carbohydrates comprising of a mixture of oligosaccharides/ and
polysaccharides
3. Must be resistant to gastric acidity and hydrolysis by mammalian digestive enzymes
4. Should not get absorbed in the upper part of the gastrointestinal tract
5. Must encourage beneficial luminal/systemic effects within the host by fermentation
6. Should not be metabolized by the host
7. Should selectively stimulate the growth and/or activity of health promoting intestinal
bacteria and probiotic strains to become metabolically active
8. Must be beneficial to the host health
9. Must be excreted as such in the urine

(Source: Seifert and Watzl, 2007)

30
Table 4 Examples of commercially available prebiotic supplements

Produc Manufacturer Prebiotics Health concern Contraindication


t & Country fiber
1 Ensure Abbott Mixed fiber and  Malnutrition  Not
. ® Plus Nutrition, FOS  Constipation or recommended
Fibre Columbus, OH diarrhoea for children
(USA)  Neurological 
disorders  Unsuitable for
 Anorexia or poor people with
appetite galactosaemia
 Pre- and post-
operative conditions

2 Ensure Abbott 2g of FOS per  Provides nutrition  Unsuitable for


. ® Nutrition, 200 ml and hydrates people children under 1
TwoCal Columbus, OH at risk year of age
(USA) of malnutrition  Unsuitable for
people with
galactosaemia

3 Chicory Jetsu, Inulin  Nourishes the gut  Oral intake of


. root bacteria chicory during
inulin p (USA)  Improves digestion pregnancy may
owder  Relieves result in
constipation miscarriage.
 Unsuitable for
diabetics
and patients
with gallstone
4 Prebioti Prebiotin, OF -Enriched-  Benefits the entire
. n (USA) Inulin length of the colon
Prebioti  Supports digestive -
c Fiber and immune systems
Powder  Increases calcium
absorption

5 Fiber BeLive, Inulin  Improves digestive


. Gummi (USA) and Chicory function -
es root  Controls blood
Sugar- sugar
Free
Prebioti  Lowers LDL
c cholesterol
 Promotes healthy

31
weight

6 Jarrow Jarrow, Combination  Supports the growth -


. Formul Los of XOS and of Bifidobacteria
as Angeles, CA GOS and Lactobacilli
Prebioti (USA)  Supports intestinal
cs XOS and immune
plus function
GOS

Table 5 Mechanisms of action of prebiotics


Prebiotic Health benefits Mechanism of actions
1. Fructo-oligosaccharides 1. Antipathogenic effect A. Inhibits of human and animal

32
(FOS) pathogens by following
competitive exclusion
B. Increases SCFA such as
acetate, propionate and butyrate in
the large bowel
C. Reduces damage of ulcerative
colitis

2. Improvement of gut A. Simulates lactobacilli and


health bifidobacteria

3. Immune modulatory A. Modulates the immune


effect responses in the gut associated
lymphoid tissue (GALT)
B. Enhances the production of
anti-inflammatory cytokines
C. Increases the activity of natural
killer cells and peripheral blood
antibody production

4. Reduction of A. Increases the plasma ferulic


cardiovascular diseases acid concentration thereby
lowering the glucose and lipid
levels
B. Induces satiety and reduces low
density lipoprotein and increases
high-density lipoprotein
cholesterol
3. Mineral absorption A. Stimulates intestinal calcium
and magnesium absorption

2. Galacto- 1. Antipathogenic effect A. It decreases diarrhea


oligosaccharides (GOS) 2.Improvement of gut A. Major source of energy for
health colonocytes and helps maintain
a healthy epithelium
3. Reduction of A. Reduces LDL-cholesterol
cardiovascular diseases
4. Anti-cancerous effect A. Induces apoptosis
B. Increases the immunogenicity
of cancer
cells due to an increase in the
expression of cell surface proteins
5. Mineral absorption A. Stimulates intestinal Calcium
and Magnesium absorption

3. Manno- 1. Improvement of gut A. Simulates beneficial gut flora

33
oligosaccharides health

4. Xylo-oligosaccharides 1. Antipathogenic effect A. Increases SCFA


(XOS) 2. Improvement of gut A. Simulates growth of
health bifidobacteria

5. Trans-galactooligo 1.Prevents and reduce A. Relieves from inflammatory


Saccharides (TGOS) Gastrointeritis bowel disease
2. Improvement of gut A. Simulates positive microflora
health composition and immune response
in elderly

6. Arabinoxylo- 1. Improvement of gut A. Simulates lactobacilli and


oligosaccharides health bifidobacteria and other positive
microflora composition
2.Anti-cancerous effect A. Effect on colonic cancer lesions

7. Inulin 1.Reduces A. Relieves from colitis


Gastrointeritis
2. Improvement of gut B. Simulates lactobacilli and
health bifidobacteria
3. Mineral absorption C. Stimulates intestinal calcium
and magnesium absorption

(Source: Saad et al., 2013; Al-Sheraji et al., 2013)

Table 6 Efficacy of prebiotics in animals and humans


a. Animal studies
Host Challenge Prebiotic Treatment Effects

34
treatment period
Mice Candida Inulin 6 wk  Lowered densities of C.
albicans
or before challenge albicans in the small intestine
L.
monocytogenes, FOS in intervention groups
S.Typhimurium
 Lowered mortality from L.
monocytogenes in mice fed
FOS and especially inulin
 Lowered mortality from S.
typhimurium in mice fed
inulin
Rats S. enteritidis FOS , 2 wk  Enhanced translocation
lactulose, before challenge of Salmonella
resistant
starch, wheat
fibers or
cellulose
Rats S. enteritidis FOS 2 weeks  Increased translocation of
before challenge Salmonella
Guine L. Either XOS, 3 weeks  Lowered prevalence of
monocytogenes
a pigs GOS before Listeria in intestinal samples
(mix of 3
strains), challenge and in liver, spleen and
oral infection
mesenteric lymph nodes
(Source: Licht et al., 2012)

b. Human studies
Type of Challenge Prebiotic Treatment Effects
study treatment period
Prospective, Infants with Mixture of short- First 6  Reduced in number of
parental
randomized, chained GOS months infectious episodes and
history of atopy
double- and long-chained of life in the incidence of

35
blind, FOS recurring infections
placebo- during first 6 months of
controlled life
study
Double- Healthy infants FOS In diet for  Decreased in pathogenic
aged
blind 21 days clostridia and lower
7-19
placebo incidence of diarrhea
controlled during supplementation

Double- Healthy adults GOS In diet for  Lowered the duration of


traveling
blind 1 week traveler’s diarrhea.
to countries
placebo- with a high pre-travel  Decreased the abdominal
risk of travelers
controlled, and during pain and better
diarrhea
randomized travel assessment of overall life
(minimum 2 quality.
weeks)
A double- healthy Transgalactoolig 10 weeks  Relieved of
osaccharides
blind, elderly subjects inflammatory bowel
(TGOS)
placebo- disease and increasing
controlled, gut bifidobacteria
crossover
study  Simulation of positive
microflora composition
and immune response in
elderly

Double- Healthy men FOS 2 weeks  Increased LAB and


blind, lactic acid in gut
placebo-
controlled
cross-over

36
study

(Source: Licht et al., 2012)

37
Figure 1 Legend: Schematic representation of direct and indirect mechanism of action by the
prebiotics on host health

38

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