Clinical Trial Details
— Status: Completed
Administrative data
| NCT number |
NCT03950336 |
| Other study ID # |
Pro00090125 |
| Secondary ID |
|
| Status |
Completed |
| Phase |
N/A
|
| First received |
|
| Last updated |
|
| Start date |
February 4, 2020 |
| Est. completion date |
May 17, 2024 |
Study information
| Verified date |
May 2024 |
| Source |
University of Alberta |
| Contact |
n/a |
| Is FDA regulated |
No |
| Health authority |
|
| Study type |
Interventional
|
Clinical Trial Summary
Crohn's disease (CD) is a recurring inflammation of the intestines. The etiology is unknown;
however evidence suggests that it could be a combination of gut microbes, environmental
factors and genetics. CD has a strong genetic component, with up to 12% of patients having
familial history. The Western diet is also thought to increase the risk of developing CD. In
addition up to 20% of healthy first-degree relatives (FRD) of CD patients have increased
small intestinal permeability ("leaky gut"). Previous studies have also shown that the
Western diet can affect the intestinal immune response and normal intestinal barrier
function, as well as alter the gut microbiota. We are interested in looking into whether
beneficial dietary fibers (prebiotics) in combination with a diet low in n-6 polyunsaturated
fatty acids (PUFAs) and high in n-3 PUFAs can protect against the development of CD.
Prebiotics are carbohydrates that cannot be digested by human enzymes and instead feed the
bacteria in the colon that can digest them. Prebiotics occur in different fruits and
vegetables. They have been shown to improve health by positively changing the gut microbes
and their metabolism.
The prebiotic we will be using are β-fructans. β-fructans have been shown to reduce "leaky
gut" and positively impact the intestinal immune system in experimental models and healthy
humans. Diet has been shown to affect the gut microbes, intestinal inflammation development
and the activity of prebiotics. We hypothesize that β-fructans in combination with a diet low
in n-6 PUFAs / high in n-3 PUFAs (similar to a Mediterranean diet) can reduce intestinal
permeability ("leaky gut") in FDR of CD patients, associated with beneficial changes in the
gut microbes.
Participants (FDR of CD patients; 40 total) will be randomized and receive either a 12 g/day
dose of the prebiotic oligofructose-enriched inulin (Prebiotin), or placebo (maltodextrin),
as well as a dietary intervention. In order to control the n-3 and n-6 PUFA intake,
participants will receive nutritional counselling by a registered dietitian. The
Mediterranean diet will have the low n-6 and high n-3 intake ("Low n-6 PUFA"). Participants
in the control diet group will be advised to follow the Canada's Food Guide (CFG)
recommendations. Thus, this placebo-controlled study will involve 2 intervention groups with
20 participants in each group: 1) Prebiotic + Low n-6 PUFA; 2) Placebo + CFG.
Description:
1. Background:
Crohn's disease (CD) is a chronic intestinal inflammation, affecting approximately
130,000 Canadians. Its incidence and prevalence is rising worldwide. The disease
etiology is unknown; however its pathogenesis is thought to be mediated by commensal gut
bacteria, affected by environmental factors in a genetically susceptible host. It is
well established that susceptibility to CD has a strong genetic component with up to 12%
of the patients having family history of inflammatory bowel disease (IBD). Genome-wide
association studies (GWAS) have identified more than 230 single nucleotide polymorphisms
(SNPs) associated with IBD. However the risk-associated SNPs seems to account for only a
portion of the observed IBD heritability, as many healthy individuals and relatives of
Crohn's patients who carry these risk alleles never develop disease.
The gut microbiome, which is also implicated in the CD pathogenesis, also has a certain
degree of inheritance. Up to a third of the intestinal bacteria are heritable, raising
the possibility of specific host genetic variants shaping the individual variability in
microbial profiles. A study with 582 healthy individuals found that a high genetic risk
for IBD was associated with a decrease in the relative abundance of the
butyrate-producing Roseburia. Diet independently can affect the gut microbiome in short-
and long term. Population-based studies in IBD indicate strong association of high
dietary intakes of total fats, n-6 polyunsaturated fatty acids (PUFAs) and meats with
increased risk of IBD, while high intake of fruits and vegetables decrease that risk.
Animal studies have described the mechanisms underlying the pathogenesis of high-fat
diets in colitis, including decreased Paneth cell area and less production of
antimicrobial peptides by Paneth cells in the small intestines; reduced goblet cell
number and less secreted mucin by goblet cells in the small intestines; reduced levels
of tight junction proteins as occludin in the ileum, further illustrated by increased
small intestinal permeability; increased IL-6 secretion in colon; and finally expanded
abundance of pathobionts, such as Atopobium and Proteobacteria in stool. This data
suggests that a high-fat diet (as an example of Western diet) has significant effect on
the intestinal immunity and barrier function together with induction of dysbiosis and
pathobiont expansion that can finally predispose to the development of inflammatory
bowel disease.
N-6 PUFAs have been identified as a risk factor for IBD. Canadians currently consume
5-10% dietary energy from n-6 PUFA, due to increased consumption of vegetable oils
recommended by Canada's Food Guide. Meanwhile consumption of n-3 PUFAs (docosahexaenoic
acid and eicosapentaenoic acid) with anti-inflammatory actions, represent only 0.15%
dietary energy. Both n-6 and n-3 PUFAs are precursors of eicosanoids that regulate
inflammation but in polarizing means. N-6 PUFAs, promote the production of
pro-inflammatory series 2 prostaglandins (like prostaglandin E2, PGE2), thromboxanes and
series 4 leukotrienes and also exacerbated murine colitis in several models. In
contrast, n-3 PUFAs have anti-inflammatory properties that lead to the series 3 PGE,
series 5 leukotrienes, and resolvins, which reduce translocation of inflammatory
mediators to the site of injury. However clinical studies have shown conflicting results
on the use of fish oil as source of n-3 PUFAs in IBD. Previously it was shown that fish
oil can cause enrichment with gut pathobionts, and worsened mortality during infectious
colitis in mice when added to n-6 PUFA rich diet, but not if combined with other fatty
acids, revealing the importance of the background diet. Therefore a diet with reduced
n-6 PUFA but higher fibre intake is proposed to be protective in IBD.
Increased small intestinal permeability or so called "leaky gut" has been associated
with many chronic conditions as obesity, type 2 diabetes and IBD. Increased intestinal
permeability is also one of the potential pathogenetic risk factors for CD identified in
up to 20% of our 10 years' longitudinal study population of healthy first-degree
relatives (FDR) of Crohn disease patients. Furthermore, certain diets such as high-fat,
high-glucose or high-fructose diets can also cause barrier dysfunction and increase the
gut permeability, thus increasing the risk of developing metabolic endotoxemia and
chronic intestinal inflammation. In contrast, reducing small intestinal permeability
attenuates experimental colitis. These findings suggest that reduction of the gut
permeability may reduce the risk factors leading to development of CD in FDR of CD
patients.
Studies conducted with animal models and healthy volunteers described reduction of gut
permeability following consumption of β-fructans. However, the prebiotics efficacy in
experimental IBD is also dependent on the background diet composition. We recently found
that β-fructans protective effect in HLA-B27 rat colitis is modulated by n-6 and n-3
PUFAs intake. These data highlight that β-fructan type prebiotics are beneficial, but
also suggest that background dietary lipid composition can modulate clinical outcomes.
Since most Canadians consume a high n-6 / low n-3 PUFAs diet we propose that a
combination of fatty acids including n-3 PUFAs will overpower n-6 PUFAs effect on
β-fructans and (further) improve clinical response.
2. Study Hypothesis and Aims:
Based on the β-fructans efficacy in reducing intestinal permeability and regulating gut
immunity shown in experimental models and clinical studies with healthy participants as well
as the effect of diet on gut microbiome, colitis development and prebiotics activity, we
hypothesize that β-fructans in combination with high n-3 PUFAs/low n-6 PUFAs diet (similar to
a Mediterranean diet) can reduce small intestinal permeability and prevent chronic intestinal
inflammation in FDR of CD patients, associated with improved intestinal microbiota
metabolism.
In order to fulfill this hypothesis the following aims are proposed:
1. To assess if oral administration of β-fructans and dietary changes can improve small
intestinal permeability (measured by urinary excreted lactulose and mannitol) in those
FDRs with abnormal permeability.
2. To assess which protective mechanisms are associated with the permeability changes such
as alterations in circulating zonulin, glucagone-like peptide 2 (GLP-2) and plasma
endotoxin, as well as changes in gut microbiota composition and short chain fatty acid
production.
3. Study Design:
Participants (first degree relatives of CD patients; 40 total) will be randomized to receive
either β-fructans (12 grams daily dose of Prebiotin®, oligofructose-enriched inulin in ratio
1:1, equivalent to Orafti®Synergy1, supplied by Jackson GI Medical), or placebo (digestible
maltodextrin, 5 grams daily dose, isocaloric to 12 g/d Prebiotin®) as well as dietary
intervention. In order to control n-3 and n-6 PUFAs intake, participants will receive
nutritional counselling by a registered dietitian. The Mediterranean diet pattern (MDP) (also
called below "Low n-6 PUFA diet") with increased n-3 PUFA, saturated fatty acids (SFA) and
monounsaturated fatty acids (MUFA) and reduced n-6 PUFAs food intake will be adopted as
suitable low n-6 PUFA diet. Participants who will not be assigned to "Low n-6 PUFA diet" will
be advised to follow Canada's Food Guide recommendations ("Control diet"). Thus this
placebo-controlled study will involve 2 intervention groups with 20 participants in each arm:
1) Prebiotin + "Low n-6 PUFA Diet"; 2) Placebo + Control Diet
The intestinal permeability will be evaluated using lactulose/mannitol ratio (at weeks 0 and
6), as well as serum/plasma markers for intestinal permeability including zonulin,
glucagone-like peptide 2 (GLP-2) and lipopolysaccharides (LPS) (weeks 0 and 6). We will also
study the effect of prebiotic product and diet on fecal microbiota composition and activity
(as fecal short-chain fatty acids and bile acids) (weeks 0 and 6). Attention will also be
paid to the safety and tolerability of these prebiotics in FDR using questionnaires related
to adverse events/dyspepsia and gastrointestinal habits (weeks 0, 3, and 6).
Since diet is also part of the intervention study and thought to play role in the intestinal
permeability and prebiotic activity, all participants will receive dietary counselling and
will be expected to adhere to recommended diet. Long-term dietary intake correlates with the
bacteria taxa in the individual, so is important to quantify this prior to the dietary
intervention. Participants will complete the on-line version of the Canadian Diet History
Questionnaire II (C-DHQ II) which is a food frequency questionnaire to assess their pre-study
diet (habitual diet) over the past year. In order to assess compliance to the diets the
participants will complete the Canadian adaptation of the Automated Self-Administered 24-hour
(ASA24-Canada-2016) which is a validated 24 hours dietary recall. The research dietitian will
review recalls and provide feedback to participants based on results - in order to support
changes to the diets. Additionally, participants will complete the Mediterranean Dietary
Serving Score (MDSS). The MDSS is a validated instrument used to measure MDP adherence based
on the consumption of food servings and food groups. The ASA-24 and MDSS will be completed at
0, 3 and 6 weeks of the study.
The study will be for 6 weeks from baseline where study participants will receive prebiotics
treatment or placebo (maltodextrin) in addition to dietary counselling and intervention.
Oral intake of oligofructose-enriched inulin in a rat model of colitis as well in ulcerative
colitis (UC) patients was able to increase fecal bifidobacteria and increase potentially
protective butyrate-producing bacteria and their butyrate production in the colon and to
alter cytokine production in the colon to favour a more anti-inflammatory profile. In the
current proposed study we will assess if such microbiota changes driven by prebiotics and
diet will also be associated with reduction of small intestinal permeability in the healthy
population at risk for CD development. We will therefore measure small intestinal
permeability at the start and at the end of the study, as well as collect stool, blood/serum
and urine specimen throughout the trial.
Increased small intestinal permeability can also be caused by some broadly used medications
such as nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin and ibuprofen.
Virtually all studies agree that all conventional NSAIDs increase intestinal permeability in
the human within 24 h of ingestion and that this is equally evident when they are taken long
term. In order to control for this confounding factor, we will exclude individuals who take
NSAIDs on daily basis. In addition, we will request participants to stop taking NSAIDs 1 week
before the screening permeability test.
