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INTRODUCTION
Dietary ber intake provides many health benets. A generous intake of dietary ber reduces risk for developing
the following diseases: coronary heart disease,1 stroke,2
hypertension,3 diabetes,4 obesity,5 and certain gastrointestinal disorders.6 Furthermore, increased consumption of dietary ber improves serum lipid
concentrations,7 lowers blood pressure,8 improves blood
glucose control in diabetes,9 promotes regularity,10 aids in
weight loss,11 and appears to improve immune function.12
Unfortunately, most persons in the United States
consume less than half of the recommended levels of
dietary ber daily.13 This results from suboptimal intake
of whole-grain foods, vegetables, fruits, legumes, and
Aliations: JW Anderson is with the Department of Internal Medicine and Nutritional Sciences Program, University of Kentucky, Lexington,
Kentucky, USA. P Baird is with the University of Connecticut, Stamford Campus, Stamford, Connecticut, USA and Westchester Community
College, Valhalla, New York, USA. RH Davis is with the Department of Medicine, University of Florida, Gainesville, Florida, USA. S Ferreri is
with the Division of Pharmacy Practice and Experiential Education, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA. M
Knudtson is with the University of California, Irvine, Irvine, California, USA. A Koraym is with the Ohio State University, Columbus, Ohio,
USA and Wright State University, Dayton, Ohio, USA. V Waters is a Certied Personal Trainer, Los Angeles, California, USA. CL Williams is
with Healthy Directions, Inc., New York, New York, USA.
Correspondence: JW Anderson, University of Kentucky, 913 Taborlake Court, Lexington, KY 40502, USA. E-mail: jwandersmd@aol.com,
Phone: +1-859-269-6642, Fax: +1-859-422-4670.
Key words: coronary heart disease, diabetes, dietary ber, gastrointestinal disorders, obesity
188
doi:10.1111/j.1753-4887.2009.00189.x
Nutrition Reviews Vol. 67(4):188205
Table 1 Dietary ber intake related to relative risk for disease based on estimates from prospective cohort
studies.
Disease
No. of subjects
Relative
95% CI
Reference
(no. of studies)
risk
Coronary heart disease
158,327 (7)
0.71
0.470.95
24
134,787 (4)
0.74
0.630.86
1,2,27,28
Stroke
Diabetes
239,485 (5)
0.81
0.700.93
23
Obesity
115,789 (4)
0.70
0.620.78
64
Table 2 Eects of soluble ber intake on serum LDL-cholesterol values in randomized, controlled clinical trials
with weighted mean changes based on number of subjects.
Fiber
No. of
No. of
Grams/day
Baseline LDL-cholesterol
Weighted
trials
subjects
(median)
net change
Barley b-glucan
9
129
5
4.1
-11.1
Guar gum
4
79
15
4.4
-10.6
HPMC
2
59
5
4.2
-8.5
457
6
4
-5.3
Oat b-glucan
13
Pectin
5
71
15
3.9
-13.0
494
6
3.9
-5.5
Psyllium
9
References are provided as Supporting Information, as noted at the end of this article.
Net changes are treatment change minus placebo change.
Stroke prevalence
Higher intakes of whole grains are associated with a signicant 26% reduction in prevalence of ischemic strokes
(Table 1). Specically, data from four studies2,21,28,29
including over 134,000 individuals indicate that the relative risk for stroke is 0.74 for individuals with the highest
quintile intake of dietary ber or whole grains compared
to those with the lowest quintile intake. Other studies
suggest that fruit and vegetable intake is associated with a
lower risk for ischemic stroke30 and with favorable eects
on the progression of carotid artery atherosclerosis.31
While these studies, like those for CHD, suggest that
dietary ber intake reduces risk of ischemic stroke, prospective RCTs are required to support this hypothesis.
Risk factor prevalence
The prevalence of hypertension or dyslipidemia as they
relate to ber intake has not been well characterized. In a
small group of Chinese residents, higher consumption of
oats or buckwheat was associated with signicantly lower
body mass index (BMI), systolic and diastolic blood pressure, and serum LDL-cholesterol and triglyceride values;
serum HDL-cholesterol values were also lower.32 Total
dietary ber intake was associated with signicantly lower
serum LDL-cholesterol values while soluble ber was
associated with lower systolic blood pressure and total
cholesterol values.32 Among French adults, higher intakes
of dietary ber were associated with a lower prevalence of
hypertension and with lower total serum cholesterol and
triglyceride values than were lower intakes.5
Risk factor eects
One of the following major risk factors for CHD is
present in 8090% of patients with the disease: cigarette
smoking, diabetes, dyslipidemia, and hypertension.33
190
Psyllium
Guar
-5
-10
-15
-20
-25
-30
0
12
24
No. of months
-5.5% and -5.2% for psyllium and -5.3% and -5.6% for
oat b-glucan. These analyses indicate that psyllium or oat
b-glucan do not signicantly aect serum HDLcholesterol or triglyceride values.
The limited data available for Konjac mannan (glucomannan) indicates that it has signicant hypocholesterolemic eects.37 Gum arabic (acacia gum),38 partially
hydrolyzed guar gum,39 and methylcellulose40 appear to
have only modest hypocholesterolemic eects.
These short-term studies with mean durations of 48
weeks indicate that the widely used psyllium or oat
b-glucan decrease serum LDL-cholesterol values by
about 5.5%. These reductions would be expected to
reduce the risk for cardiovascular disease by 711%.41 The
best long-term data available for soluble ber are for the
use of psyllium for 6 months and the use of guar for
1224 months (Figure 1). Use of psyllium for 6 months
maintains the LDL-cholesterol reduction of 6.7%42 and
long-term use of guar sustains reductions of LDLcholesterol values of 16.1% at 1 year and 25.6% at 24
months.4345 While the levels of guar used in these studies
may not be practical for widespread use, these data do
indicate that regular use of a soluble ber can sustain
signicant hypocholesterolemic eects for long-term
periods. These changes were maintained without changes
in body weight, HDL-cholesterol, or serum triglyceride
values.45
Blood pressure. Increasing consumption of dietary ber
is often accompanied by a reduction in systolic and diastolic blood pressure. Early studies suggested that highber diets were associated with a signicant reduction in
blood pressure, but these studies were not well-controlled
clinical trials.46,47 The eects of increasing oat ber intake
on blood pressure have been reported in several studies,
with the net results suggesting a modest-to-moderate
Nutrition Reviews Vol. 67(4):188205
glucose and insulin values and increased insulin sensitivity in non-diabetic subjects. Further studies are required
to conrm and extend these observations.
For diabetic subjects, four RCTs including a total of
116 subjects also documented improved glycemic control
and improved insulin sensitivity with ber supplements.
Three used psyllium (10.215 g/d, median 10.2 g/d)7678
and one used guar gum (10 g three times daily).50 After an
average of 10 weeks of treatment, two studies reported
signicant reductions in fasting plasma glucose values
(mean net change, -12.5%). Net postprandial plasma
glucose values were reported to be signicantly decreased
(-4.2%) in one study. Hemoglobin A1c values were signicantly decreased in one study after 8 weeks and the
mean change for two studies was -5.3% below baseline
values. These studies indicate that psyllium intake in
usual doses is accompanied by signicant improvements
in fasting plasma glucose values, and in one study, by
improvements in postprandial glucose concentrations.
Further studies are required to conrm and extend these
observations.
Dietary ber recommendations for diabetic
individuals
General nutrition guidelines for persons with diabetes
from nine inuential international agencies were recently
reviewed and aggregated as Evidence-Based Recommendations.9 The recommendations are as follows: attain
and maintain desirable weight (BMI 25 kg/m2); regulate carbohydrate intake to 5565% of energy; choose
whole grains, legumes, and vegetables; use fruits and
other sources of mono- and disaccharides in moderation;
incorporate GI into exchanges and teaching material; and
regulate other intake levels as follows ber, 2550 g/day
(1525 g/1000 kcal); protein, 1216% of energy; total
fat, <30% of energy; saturated/trans fatty acids, <10% of
energy; monounsaturated fat, 1215% of energy; polyunsaturated fat, <10% of energy; and cholesterol, <200 mg/
day. The practical applications of these recommendations
were recently outlined.79 Because approximately 80% of
type 2 diabetic individuals are obese, weight loss and
management are high priorities for their management.61,62
Because of the benecial eects of increased ber intake
on weight management, increased consumption of highber foods or supplements should be considered.
Comments
In the United States almost half of all individuals have
diabetes, prediabetes, or the metabolic syndrome associated with high risk for the development of diabetes.60
Persons with the highest level of dietary ber consumption, compared to those with the lowest intake, appear to
Nutrition Reviews Vol. 67(4):188205
Control
Fiber
-1
-2
-3
-4
-5
-6
-7
0
12
No. of weeks
Figure 2 Weight
losses
achieved
with
bersupplemented diets versus control diets. Values are
means SEM. Data in 15 studies obtained at 4 and 8 weeks
and additional data in 9 of those studies obtained at 12
weeks. Signicant dierences were seen at 4 weeks
(P = 0.0063) and 8 weeks (P = 0.0088).
compared to those with lower ber intakes. In this analysis of 13 prospective cohort studies with follow-up
periods of 620 years (median 9 years), approximately
725,000 patients were followed and 8,081 cases of colorectal cancer were reported. Persons with the highest
quintile of ber intake had an insignicant 6% reduction
in the development of colorectal cancer. Another recent
prospective cohort study of almost 490,000 persons followed for 5 years noted that total dietary ber intake was
not associated with the development of colorectal cancer,
but persons with the highest quintile for whole-grain
intake had a 14% lower risk for colorectal cancer
(P = 0.01) compared to those in the lowest quintile for
whole-grain intake.91 Thus, the available data do not
provide strong support for the hypothesis that consumption of total dietary ber, cereal ber, and ber from fruits
or vegetables is protective against colorectal cancer, but
whole-grain intake may oer protection.
It is noteworthy that the two available cohort studies
compared persons with low dietary ber intakes (13 g/
day for the lowest quintile) to persons with recommended levels (26 g/day for the highest quintile)91 and
13 g/day (lowest quintile) versus 27 g/day (highest quintile).13 The dietary ber intakes for the lowest quintiles
were less than half the recommended level, while the
individuals in the upper quintile consumed approximately the recommended level of 14 g/1000 kcal/day.5,92
Role of dietary ber in the management of
gastrointestinal disorders
The use of high-ber foods or ber supplements is recommended for a large variety of gut disorders including
the following: GERD, duodenal ulcers, inammatory
bowel disease, irritable bowel syndrome, diverticular
disease, constipation, and hemorrhoids. There are strong
theoretical arguments to support the use of ber in each
condition. Epidemiological data establishing a role for
ber in the prevention of most of these conditions are
limited. Clinical trial data and expert opinions are also
lacking for these very common disorders.
Limited data suggest that individuals with higher
ber intakes have a lower prevalence of GERD.85 Guar
gum and, possibly, other soluble bers are associated with
low levels of gastric acid production, which may protect
from GERD and duodenal ulcer disease.95 The available
evidence strongly indicates that high ber intakes are
associated with lower prevalence of duodenal ulcer
disease than lower ber intakes, and the epidemiological
evidence is moderately well supported by clinical
trials.94
Irritable bowel syndrome is one of the most common
gastrointestinal functional disorders worldwide. It is a
complex disorder with a variety of pathogenetic factors
195
196
Natural
No; mild laxation
100% soluble
Yes
No
Slightly
No data
100% fermentable
No
No data
No data
No data
No data
Natural
Yes
70% soluble
Yes
Yes
Yes
Yes
Partially fermentable
Yes
Yes
Yes
Yes
Yes
Natural/synthetic
FDA approved for laxation
Soluble/insoluble ber
Holds water
Forms a gel
Bulks stools
Traps bile acids
Fermentable
Helps lower blood cholesterol
Helps lower blood pressure
Helps control obesity
Helps lower blood sugar
Helps lower the risk of heart disease
Semisynthetic
Yes
100% soluble
Yes
No
Partially
Yes
No
Minimal
No data
No data
No data
No data
Calcium
polycarbophil
Synthetic
Yes
0% soluble
Yes
Yes
Yes
No data
No
No
No data
No data
No data
No data
Methyl-cellulose
Partially hydrolyzed guar
Inulin
Table 3 Comparison of ber supplement products.
Property of active ingredient
Active ingredient
Psyllium husk
Comments
Gastrointestinal disorders such as GERD, IBS, diverticulitis, and constipation are extremely common. Diet
appears to contribute to the symptoms for a large
percentage of persons with these disorders. Considerable
evidence suggests that dietary ber may play a preventive
or ameliorative role for GERD, duodenal ulcers, diverticulitis, constipation, and hemorrhoids. Judicious use of
dietary ber, soluble or insoluble based on the predominant symptoms or stage, may contribute to the management of IBS and be helpful for some individuals with IBD.
The role of inulin-type soluble ber in association with
prebiotics is emerging and has exciting potential for treating inammatory conditions of the gut.
DIETARY FIBER AND THE IMMUNE SYSTEM
The gastrointestinal tract is the largest immune organ for
humans. The gut-associated lymphoid tissue contains
about 60% of all lymphocytes in the body and includes
the Peyers patches and other non-aggregated and intracellular lymphocytes. Optimal function of the gut
immune system is dependent on dietary constituents,
especially prebiotics (substances that stimulate growth of
health-promoting bacteria in the colon).104,105 Most
prebiotics are nondigestible carbohydrates that are fermented in the colon.82 Inulin and other oligofructoses
have been the most extensively studied dietary bers; they
act, in part, to stimulate growth of bidobacteria in the
colon. Bidobacteria and lactobacilli are healthpromoting bacteria that generate short-chain fatty acids
and stimulate the immune system.104 Fairly extensive
animal studies have documented the favorable eect of
inulin on the immune system and preliminary studies in
humans support the hypotheses generated from animal
studies.105 Inulin and oligofructoses are not digested by
pancreatic or brush border enzymes; thus, they enter the
colon virtually intact. In the colon, inulin is fermented
completely by the microbacteria and it promotes the
growth of bidobacteria. Short-chain fatty acids (SCFA)
result from this fermentation process. Other bers are
also fermented to generate SCFA, but the bidobacteria
eects of non-oligofructose bers are not as well characterized. The proposed health benets of bidobacteria
include the following: protection from intestinal infection; lowering of intestinal pH for formation of acids after
assimilation of carbohydrates; reduction of the number of
potentially harmful bacteria; production of vitamins and
antioxidants; activation of intestinal function and assistance in digestion and absorption, especially of calcium;
bulking activity to prevent and treat constipation; stimulation of the immune response; and potential reduction in
the risk for colorectal cancer.104,105
Nutrition Reviews Vol. 67(4):188205
olds, 13.4 g/day for 611 year olds, and 14.6 g/day for
1218-year-old adolescents.124 Common food sources of
ber are yeast bread, ready-to-eat cereal, white potatoes,
dried beans and lentils, tomatoes, and potato chips. In a
study by Hampl et al.,125 children with higher intakes of
dietary ber consumed more breads and cereals, fruits,
vegetables, legumes, nuts, and seeds and had signicantly
higher energy-adjusted intakes of dietary ber, iron, magnesium, and vitamins A, E, and folate, while those with
low ber intakes had signicantly higher energy-adjusted
intakes of fat and cholesterol.
Dietary guidelines
There are several guidelines recommending specic
quantitative ber intakes for children and adolescents,
including the American Academy of Pediatrics guideline,126 Williams Age + 5 guideline,127 the FDA food label
guideline,128 and, most recently, the National Academy of
Sciences 2002 recommendations for adequate intake, or
AI.129 The last recommends a daily intake of 14 grams
per 1000 kcal for all children 1 year of age and older. The
National Academy of Sciences guideline is based on epidemiologic studies of dietary intake levels associated with
reduced risk of coronary heart disease, extrapolating
adult data and applying it to children.130132 For specic
age groups, at estimated mean energy intakes, the recommended AIs for dietary ber intake would be as follows:
13 years, 19 g/d; 48 years, 25 g/d; 913-year-old boys,
31 g/d; 913-year-old girls, 26 g/d; 1418-year-old boys,
38 g/d; and 1418-year-old girls, 26 g/day.
Recommendations for increasing dietary ber intake
in childhood emphasize greater consumption of berrich fruits, vegetables, legumes, cereals, and whole-grain
products. In addition, ber supplements may be prescribed as an adjunct to the dietary treatment of constipation, hypercholesterolemia, and obesity. Since dietary
ber increases water retention in the colon, resulting in
bulkier, softer stools, recommendations for water intake
should be increased commensurate with increases in
dietary ber. The Institute of Medicine recommends the
following daily levels of adequate total water intake for
children and adolescents: 13 years, 1.3 L; 48 years,
1.7 L; 913-year-old boys, 2.4 L; 913-year-old girls,
2.1 L; 1418-year-old boys, 3.3 L; and 1418-year-old
girls, 2.3 L.133
Comments
Adequate intake of dietary ber has been associated with
a variety of health benets in childhood. These include
promotion of normal gastrointestinal function, especially
laxation; prevention and treatment of childhood obesity;
maintenance of normal blood glucose values; sustaining
Nutrition Reviews Vol. 67(4):188205
intake (1.5 g/day) were modest, increases in fruit and vegetable intake were statistically signicant (+1.3 servings/
day) and intake of grains decreased (-0.4 servings/day).
Of additional interest, there were no signicant dierences in rates of CHD or stroke events or deaths between
the two groups.143
The observations from the Womens Health Initiative143 and recent observations by the FDA indicate that
consumers are not as eective in modifying dietary habits
as they try to be. The ndings of FDAs latest survey on
health and nutrition underscore that while US consumers
have good health intentions, this does not carry through
to their dietary habits.144 These reports suggest that the
recommendations of health advisory groups, which focus
almost exclusively on foods, may have a low probability of
empowering the general population to achieve recommended goals. Furthermore, these dietary guidelines may
not empower the average consumer to reduce risk for
CHD, stroke, hypertension, diabetes, or obesity. Clearly,
there are strong implications for strengthening educational initiatives beyond guidelines for consumers and
health professionals. These initiatives should be focused,
positive, and achievable. These suggestions go beyond
education; there is a strong cost-eect component to consider. Any tool that will contain the costs for reducing the
risks and complications of CHD, diabetes, and obesity
and for improving immune function should receive a
high priority.
There do not appear to be any prospective, longterm studies evaluating ber supplements related to
disease (e.g., diabetes) or outcomes (e.g., CHD or stroke).
The majority of evidence related to clinical markers such
as serum lipoprotein changes,7 weight loss,11 improved
glycemic control in diabetes,77 improved gastrointestinal
function,10 and enhanced immune function104 has been
documented with ber supplements rather than with
high-ber foods. Because serum LDL-cholesterol values
appear to be the most specic marker for risk for CHD
events and death, it seems likely that reductions of serum
LDL-cholesterol values with ber supplements would
reduce risk for CHD. While most ber supplements
(such as psyllium) do not have the array of protective
phytochemicals that oatbran provides,64 reductions of
LDL-cholesterol values by 6% are nevertheless likely to
reduce risk for CHD by 712% by either intervention.41
Likewise, since the clinical trial data clearly indicate that
a variety of ber supplements signicantly enhance
weight loss, whereas the data for high-ber foods are
inconclusive, until better strategies for empowering overweight individuals to increase their intake of high-ber
foods are found, it seems reasonable to recommend a
practical use of ber supplements twice or three times
daily for individuals engaged in a weight-reduction
eort.
199
Currently available over-the-counter ber supplements are summarized in Table 3.145 These products are
available in a variety of dosage forms such as multidose
containers of powdered ber, capsules, or caplets. Inulin
and psyllium are natural products that are packaged
without chemical modication.145 Wheat dextrin, a newly
available supplement, is a natural resistant starch (class 3
or RS3) extracted from cooked and cooled wheat our.17
Guar gum is a natural product that is produced from the
seed of the guar plant; it is hydrolyzed to a smaller
molecular size to produce partially hydrolyzed guar
gum.146 Methylcellulose is a semisynthetic product produced by methylating a natural product (cellulose), and
calcium polycarbophil is a synthetic product. Fiber
supplements are most commonly used to promote laxation. Calcium polycarbophil, methylcellulose, and psyllium have FDA approval for laxation.145 Inulin also has
modest fecal-bulking eects.105 Psyllium is the only ber
supplement that has clearly documented cholesterollowering properties147 and has a health claim with respect
to CHD.36 Psyllium or other soluble ber supplements
have been associated with reduced blood pressure52 as
well as improved glycemia and insulin sensitivity in
individuals without diabetes,71 and improved glycemia
control in persons with diabetes.77 Inulin is emerging as
the best-documented prebiotic and stimulus for immune
function with other soluble bers such as oat and barley
b-glucans sharing this function.104 Overall, these active
ber supplements appear to promote a number of the
specic health benets similar to those provided by highber foods. Current scientic evidence suggests that the
use of ber supplements to complement dietary ber
intake from foods would provide protection from CHD,
improve insulin sensitivity and glycemia, enhance intestinal function and stimulate immune function.
CONCLUSION
A high level of ber intake has health-protective eects
and disease-reversal benets. Persons who consume generous amounts of dietary ber, compared to those who
have minimal ber intake, are at lower risk for developing
CHD, stroke, hypertension, diabetes, obesity, and certain
gastrointestinal diseases. Increasing the intake of highber foods or ber supplements improves serum lipoprotein values, lowers blood pressure, improves blood
glucose control for diabetic individuals, aids weight loss,
and improves regularity. Emerging research indicates that
intake of inulin and certain soluble bers enhances
immune function in humans. Dietary ber intake also
provides health benets for children and the recommended acceptable intakes for children above the age of 1
year are 14 g/1000 kcal, which is the same as for adults.
The recommended acceptable intakes of dietary ber for
200
received research funding from Cargill, Health Management Resources (HMR) Weight Management Program,
and the High Carbohydrate, Fiber (HCF) Nutrition
Research Foundation.
P Baird serves as Vice Chair of the National Fiber
Council.
RH Davis is a member of the National Fiber Council,
the National Heartburn Alliance, and has been a consultant to Procter and Gamble, and TAP Pharmaceuticals.
S Ferreri, M Knudtson, A Koraym, and V Waters are
members of the National Fiber Council.
CL Williams is a member of the National Fiber
Council, member of the McNeil Splenda Scientic Advisory Board, and consultant for the American Beverage
Association.
SUPPORTING INFORMATION
Additional Supporting Information may be found in the
online version of this article:
Table S1. Eects of soluble ber intake on serum LDLcholesterol values in randomized, controlled clinical trials
with weighted mean changes based on number of
subjects.
Please note: Wiley-Blackwell is not responsible for the
content or functionality of any supporting materials
supplied by the authors. Any queries (other than missing
material) should be directed to the corresponding author
for the article.
REFERENCES
1. Liu S, Stampfer MJ, Hu FB, et al. Whole-grain consumption
and risk of coronary heart disease: results from the Nurses
Health study. Am J Clin Nutr. 1999;70:412419.
2. Steen LM, Jacobs DR Jr, Stevens J, Shahar E, Carithers T,
Folsom AR. Associations of whole-grain, rened grain, and
fruit and vegetable consumption with risks of all-cause mortality and incident coronary artery disease and ischemic
stroke: the Atherosclerosis Risk in Communities (ARIC)
Study. Am J Clin Nutr. 2003;78:383390.
3. Whelton SP, Hyre AD, Pedersen B, Yi Y, Whelton PK, He J.
Eect of dietary ber intake on blood pressure: a metaanalysis of randomized, controlled clinical trials. J Hypertens. 2005;23:475481.
4. Montonen J, Knekt P, Jarvinen R, Aromaa A, Reunanen A.
Whole-grain and ber intake and the incidence of type 2
diabetes. Am J Clin Nutr. 2003;77:622629.
5. Lairon D, Arnault N, Bertrais S, et al. Dietary ber intake and
risk factors for cardiovascular disease in French adults. Am J
Clin Nutr. 2005;82:11851194.
6. Petruzziello L, Iacopini F, Bulajic M, Shah S, Costamagna G.
Review article: uncomplicated diverticular disease of the
colon. Aliment Pharmacol Ther. 2006;23:13791391.
7. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterollowering eects of dietary ber: a meta-analysis. Am J Clin
Nutr. 1999;69:3042.
8. Keenan JM, Pins JJ, Frazel C, Moran A, Turnquist L. Oat ingestion reduces systolic and diastolic blood pressure in patients
with mild or borderline hypertension: a pilot trial. J Fam
Practice. 2002;51:369375.
9. Anderson JW, Randles KM, Kendall CWC, Jenkins DJA. Carbohydrate and ber recommendations for individuals with
diabetes: a quantitative assessment and meta-analysis of
the evidence. J Am Coll Nutr. 2004;23:517.
10. Cummings JH. The eect of dietary ber on fecal weight and
composition. In: Spiller G, ed. Dietary Fiber in Human Nutrition. Boca Raton, FL: CRC Press; 2001:183252.
11. Birketvedt GS, Shimshi M, Erling T, Florholmen J. Experiences with three dierent ber supplements in weight
reduction. Med Sci Monit. 2005;11:1518.
12. Watzl B, Girrbach S, Roller M. Inulin, oligofructose and
immunomodulation. Br J Nutr. 2005;93(Suppl 1):S49
S55.
13. Park Y, Hunter DJ, Spiegelman D, et al. Dietary ber intake
and risk of colorectal cancer: a pooled analysis of prospective cohort studies. JAMA. 2005;294:28492857.
14. Jones JR, Lineback DM, Levine MJ. Dietary reference intakes:
implications for ber labeling and consumption: a summary
of the International Life Sciences Institute North American
Fiber Workshop, June 12, 2004. Washington, DC. Nutr Rev.
2006;64:3138.
15. US Department of Agriculture (USDA), US Department of
Health and Human Services. Dietary Guidelines for Americans. Washington, DC: USDA; 2005.
16. DeVries JW, Rader JI. Historical perspective as a guide for
identifying and developing applicable methods for dietary
ber. J AOAC Int. 2005;88:13491366.
17. Witwer RS. Natural resistant starch in glycemic management: from physiological mechanisms to consumer communications. In: Pasupuleti VK, Anderson JW, eds.
Nutraceuticals, Glycemic Health and Type 2 Diabetes. Ames,
Iowa: Blackwell Publishing Professional; 2008:401438.
18. American Heart Association. Cardiovascular Disease Statistics. 2008. Available at: www.americanheart.org/
presenter.jhtml?identier=4478. Accessed 6 May 2008.
19. Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC.
Primary prevention of coronary heart disease in women
through diet and lifestyle. New Engl J Med. 2000;343:1622.
20. Kris-Etherton PM, Etherton TD, Carlson J, Gardner C. Recent
discoveries in inclusive food-based approaches and dietary
patterns for reduction in risk for cardiovascular disease. Curr
Opin Lipidol. 2002;13:397407.
21. Liu S, Manson JE, Stampfer MJ, et al. Whole grain consumption and risk of ischemic stroke in women: a prospective
study. J Amer Med Assoc. 2000;284:15341540.
22. Merchant AT, Hu FB, Spiegelman D, Willett WC, Rimm EB,
Ascherio A. Dietary ber reduces peripheral arterial disease
risk in men. J Nutr. 2003;133:36583663.
23. Anderson JW, Conley SB. Whole grains and diabetes. In:
Marquart L, Jacobs DR Jr, McIntosh GH, Poutanen K,
Reicks M, eds. Whole Grains and Health. Ames, Iowa: Blackwell Publishing Professional; 2007:2945.
24. Anderson JW. Whole grains and coronary heart disease: the
whole kernel of truth. Am J Clin Nutr. 2004;80:14591460.
25. Anderson JW, Johnstone BM, Cook-Newell ME. Metaanalysis of eects of soy protein intake on serum lipids in
humans. New Engl J Med. 1995;333:276282.
26. Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle
changes reverse coronary heart disease? The Lifestyle Heart
Trial. Lancet. 1990;336:129133.
201
27. Burr ML, Fehily AM, Gilbert JF. Eects of changes in fat, sh
and bre on death and myocardial reinfarction: Diet and
Reinfarction Trial (DART). Lancet. 1989;2:757761.
28. Ascherio A, Rimm EB, Hernan MA, et al. Intake of potassium,
magnesium, calcium, and ber and risk of stroke among US
men. Circulation. 1998;98:11981204.
29. Mozaarian D, Kumanyika SK, Lemaitre RN, Olson JL,
Burke GL, Siscovick DS. Cereal, fruit, and vegetable ber
intake and the risk of cardiovascular disease in elderly individuals. JAMA. 2003;289:16591666.
30. Johnsen SP, Overvad K, Stripp C, Tjonneland A, Husted SE,
Sorensen HT. Intake of fruit and vegetables and the risk of
ischemic stroke in a cohort of Danish men and women. Am
J Clin Nutr. 2003;78:5764.
31. Wu H, Dwyer KM, Fan Z, Shircore A, Fan J, Dwyer JH. Dietary
ber and progression of atherosclerosis: the Los Angeles
Atherosclerosis Study. Am J Clin Nutr. 2003;78:10851091.
32. He J, Klag MJ, Whelton PK, et al. Oats and buckwheat intakes
and cardiovascular disease risk factors in an ethnic minority
of China. Am J Clin Nutr. 1995;61:366372.
33. Greenland P, Knoll MD, Stamler J, et al. Major risk factors as
antecedents of fatal and nonfatal coronary heart disease
events. J Amer Med Assoc. 2003;290:891897.
34. Butt MS, Shahzadi N, Sharif MK, Nasir M. Guar gum: a miracle
therapy for hypercholesterolemia, hyperglycemia and
obesity. Crit Rev Food Sci Nutr. 2007;47:389396.
35. US Department of Health and Human Services FaDA. Health
claims: oats and coronary heart disease nal rule. Fed
Regist. 1997;62:35833601.
36. US Department of Health and Human Services FaDA.
Health claims: soluble ber from certain foods and coronary
heart disease nal rule. Fed Regist. 1998;63:8103
8121.
37. Chen HL, Sheu WH, Tai TS, Liaw YP, Chen YC. Konjac supplement alleviated hypercholesterolemia and hyperglycemia
in type 2 diabetic subjects a randomized double-blind
trial. J Am Coll Nutr. 2003;22:3642.
38. Haskell WL, Spiller GA, Jensen CD, Ellis BK, Gates JE. Role of
water-soluble dietary ber in the management of elevated
plasma cholesterol in healthy subjects. Am J Cardiol. 1992;
69:433439.
39. Yamada K, Tokunaga Y, Ikeda A, et al. Dietary eect of guar
gum and its partially hydrolyzed product on the lipid
metabolism and immune function of Sprague-Dawley rats.
Biosci Biotechnol Biochem. 1999;63:21632167.
40. Anderson JW, Gilinsky NH, Deakins DA, et al. Hypocholesterolemic eects of dierent bulk-forming hydrophilic bers as
adjuncts to dietary therapy in mild to moderate hypercholesterolemia. Arch Intern Med. 1991;151:15971602.
41. Katan MB, Grundy SM, Jones P, Law M, Miettinen T,
Paoletti R. Ecacy and safety of plant stanols and sterols in
the management of blood cholesterol levels. Mayo Clin
Proc. 2003;78:965978.
42. Anderson JW, Davidson MH, Blonde L, et al. Long-term
cholesterol-lowering eects of psyllium as an adjunct to
diet therapy in the treatment of hypercholesterolemia. Am J
Clin Nutr. 2000;71:14331438.
43. Tuomilehto J, Silvasti M, Aro A, et al. Long term treatment of
severe hypercholesterolemia with guar gum. Atherosclerosis. 1988;72:157162.
44. Simons LA, Gayst S, Balasubramaniam S, Ruys J. Long-term
treatment of hypercholesterolaemia with a new palatable
formulation of guar gum. Atherosclerosis. 1982;45:101
108.
202
203
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.
120.
204
121.
122.
123.
124.
125.
126.
127.
128.
129.
130.
131.
132.
133.
134.
135.
136.
137.
138.
139. Pereira MA, Jacobs DR, Slattery ML, et al. The association
between whole grain intake and fasting insulin in a bi-racial
cohort of young adults: the CARDIA study. CVD Prev.
1998;1:231242.
140. Stevens J, Ahn K, Juhaer I, Houston D, Stean L, Couper D.
Dietary ber intake and glycemic index and incidence of
diabetes in African-American and white adults. Diabetes
Care. 2002;25:17151721.
141. Lichtenstein AH, Appel LJ, Brands M, et al. Diet and lifestyle
recommendations revision 2006: a scientic statement from
the American Heart Association Nutrition Committee. Circulation. 2006;114:8296.
142. American Diabetes Association. Nutrition principles and recommendations in diabetes. Diabetes Care. 2004;27(Suppl):
S36S46.
143. Howard BV, Van Horn L, Hsia J, et al. Low-fat dietary pattern
and risk of cardiovascular disease: the Womens Health
144.
145.
146.
147.
205