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Insulin-sensitizing effects of dietary resistant starch and effects on

skeletal muscle and adipose tissue metabolism13


M Denise Robertson, Alex S Bickerton, A Louise Dennis, Hubert Vidal, and Keith N Frayn

KEY WORDS
Ghrelin, lipolysis, short-chain fatty acids, skeletal muscle, insulin sensitivity

be highly effective in delaying the onset of type 2 diabetes (2),


even when compared with pharmacologic agents (3). The results
of controlled intervention studies suggest that certain nutritional
factors are consistently linked to a reduction in insulin sensitivity: low dietary fiber intake, high trans fatty acid intake; and high
saturated fat intake (4). The potential metabolic effects of dietary
fatty acids on insulin sensitivity have been extensively studied
both from observational (5) and mechanistic viewpoints (6). The
effects of dietary fiber, however, remain underdocumented.
Dietary fibers can be classified chemically as either soluble or
insoluble. Soluble fibers have viscous properties within the gastrointestinal tract and cause a well-documented reduction in the
rate of glucose absorption (7) and thus reduce the glycemic excursion after carbohydrate intake. Insoluble fibers, such as resistant starch (RS), are nonviscous and thus have no effect on
glucose absorption, yet they have been shown in short-term human studies (8) to increase insulin sensitivity. Despite epidemiologic evidence linking insoluble fiber intake to a reduced incidence of type 2 diabetes (9 11), the metabolic link between
chronic RS ingestion and insulin sensitivity has yet to be proven
in humans.
One possible mechanism by which dietary RS intake might
modulate insulin sensitivity is through alterations in fatty acid
flux. Fatty acid metabolism is a key feature in determining tissue
insulin sensitivity. Abnormalities in fatty acid storage and lipolysis in insulin-sensitive tissues with increased flux from adipose
to nonadipose tissues such as skeletal muscle may be a critical
event in the development of insulin resistance (12). The direct
effect of RS consumption on fatty acid flux is unknown beyond
studies that have measured fasting triacylglycerol and cholesterol concentrations after RS intervention (7). In isolation, shortchain fatty acids (SCFAs), which are produced during colonic
fermentation of RS, inhibit adipose tissue lipolysis (13), but an in
vivo effect of dietary RS intake has yet to be shown.
1

INTRODUCTION

Type 2 diabetes affects 8% of adults in the United States (1),


and this figure is likely to increase with the growing incidence of
childhood obesity. Although treatments exist to alleviate some of
the complications of diabetes, the preferable long-term strategy
is still to increase tissue insulin sensitivity and thus prevent the
development of overt type 2 diabetes. Recent large-scale studies
clearly showed that lifestyle intervention (diet and exercise) can

From the Oxford Centre for Diabetes, Endocrinology and Metabolism,


University of Oxford, Oxford, United Kingdom (MDR, ASB, ALD, and
KNF) and INSERM U-449/INRA-1235, Lyon, France (HV).
2
Supported by the Biotechnology and Biological Sciences Research
Council (BBSRC), United Kingdom. All test starches were supplied by the
National Starch and Chemical Company.
3
Address reprint requests to KN Frayn, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, OX3 7LJ, United
Kingdom. E-mail: keith.frayn@oxlip.ox.ac.uk.
Received February 28, 2005.
Accepted for publication May 19, 2005.

Am J Clin Nutr 2005;82:559 67. Printed in USA. 2005 American Society for Clinical Nutrition

559

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ABSTRACT
Background: Resistant starch may modulate insulin sensitivity,
although the precise mechanism of this action is unknown.
Objective: We studied the effects of resistant starch on insulin
sensitivity and tissue metabolism.
Design: We used a 4-wk supplementation period with 30 g resistant
starch/d, compared with placebo, in 10 healthy subjects and assessed
the results by using arteriovenous difference methods.
Results: When assessed by euglycemic-hyperinsulinemic clamp,
insulin sensitivity was higher after resistant starch supplementation
than after placebo treatment (9.7 and 8.5 102 mg glucose kg1
min1 (mU insulin/L)1, respectively; P 0.03); insulin sensitivity during the meal tolerance test (MTT) was 33% higher (P 0.05).
Forearm muscle glucose clearance during the MTT was also higher
after resistant starch supplementation (P 0.03) despite lower insulin concentrations (P 0.02); glucose clearance adjusted for insulin was 44% higher. Subcutaneous abdominal adipose tissue nonesterified fatty acid (NEFA; P 0.02) and glycerol (P 0.05)
release were lower with resistant starch supplementation, although
systemic NEFA concentrations were not significantly altered. Shortchain fatty acid concentrations (acetate and propionate) were higher
during the MTT (P 0.05 and 0.01, respectively), as was acetate
uptake by adipose tissue (P 0.03). Fasting plasma ghrelin concentrations were higher with resistant starch supplementation (2769
compared with 2062 pg/mL; P 0.03), although postprandial suppression (40 44%) did not differ significantly. Measurements of
gene expression in adipose tissue and muscle were uninformative,
which suggests effects at a metabolic level. The resistant starch
supplement was well tolerated.
Conclusion: These results suggest that dietary supplementation
with resistant starch has the potential to improve insulin sensitivity.
Further studies in insulin-resistant persons are needed.
Am J
Clin Nutr 2005;82:559 67.

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ROBERTSON ET AL

FIGURE 1. Study protocol for 10 healthy subjects. Study days 1 and 3, hyperinsulinemic-euglycemic clamp; study days 2 and 4, arteriovenous meal
tolerance test. The order of the dietary intervention periods was randomized between subjects.

SUBJECTS AND METHODS

Ten healthy subjects were recruited (6 female).Their ages


ranged from 24 to 61 y (x : 48.5 3.4 y), and their body mass
indexes (BMIs; in kg/m2) ranged from 18.4 to 32.3 (x : 23.4
1.4). The subjects had no history of gastrointestinal, endocrine, or
cardiovascular disease and were currently not taking any prescribed medication (with the exception of hormone replacement
therapy). Habitual diet was assessed by use of 7-d food records
and the US Department of Agriculture database.
General protocol
This was a single-blind, crossover dietary intervention study
in which the subjects visited the metabolic unit for 4 experimental studies over a period of 12 wk, twice for hyperinsulinemiceuglycemic clamps and twice for meal tolerance tests (MTTs;
Figure 1).
The subjects were initially randomly assigned to receive either
Hi-Maize 260 (National Starch and Chemical, Manchester,
United Kingdom) at 50 g/d (30 g type II RS and 20 g rapidly
digestible starch) or Amioca (National Starch and Chemical) at
20 g/d (0 g type II RS and 20 g rapidly digestible starch) for 4 wk
added to their habitual diet, separated by a 4-wk washout period.
The starch was supplied in ready-to-use sachets, and the subjects
were instructed how to incorporate these into everyday foods.
The subjects were then asked to follow their 7-d food record and
to complete new diet diaries (completed during the run-in week)
during each 4-wk intervention to standardize their background
diet. Bowel habit diaries were also completed during each intervention for assessment of tolerance.
At the end of the third week of each 4-wk dietary intervention,
the subjects attended the metabolic unit for a hyperinsulinemiceuglycemic clamp in the fasting state. At the end of the fourth

week, the subjects attended for a full-day MTT with arteriovenous blood sampling across both skeletal muscle and subcutaneous abdominal adipose tissue. The subjects avoided vigorous
exercise and alcohol for 48 h before each test and were provided
with a low-fat, low-fiber evening meal (pasta and tomato sauce)
before each study day to reduce variability (14). This study was
approved by the Oxfordshire Clinical Research Ethics Committee, and all subjects gave written informed consent. For clarity of
presentation in the results and discussion sections, the high-RS
supplement (Hi-Maize 260) will be referred to as RS and the
RS-free supplement (Amioca) as placebo.
Metabolic investigations
Euglycemic-hyperinsulinemic clamp
This was performed as described by DeFronzo et al (15).
Beginning at 0700 after the subjects had fasted for 12 h overnight,
an antecubital vein was cannulated for the infusion of both a 20%
glucose solution and insulin [Actrapid (Novo Nordisk, Bagsvaerd, Denmark) in a solution of 0.9% saline containing 2 mL of
the subjects blood to prevent adhesion of insulin to plastics]. A
hand vein was cannulated retrogradely, and the hand was placed
in a heated box (55 C) for sampling of arterialized blood. After
fasting measurements were made, the insulin infusion was
started at a rate of 35 mU insulin m2 min1. The glucose
concentration of whole blood was measured every 5 min by use
of a glucose analyzer (Hemocue B-glucose analyzer; Hemocue
Ltd, Sheffield, United Kingdom), and the infusion of 20% glucose was adjusted as needed to maintain blood glucose concentrations at 5 mmol/L. Blood was drawn every 10 min during the
clamp for the measurement of plasma insulin, nonesterified fatty
acids (NEFAs), C-peptide, and ghrelin. The insulin infusion was
continued for 120 min to obtain a measure of the rate of insulinstimulated glucose disposal during the last 30 min of the clamp.
Meal tolerance test with tissue-specific arteriovenous
sampling
To assess the metabolism of adipose tissue and skeletal muscle
in vivo in humans, we measured arteriovenous differences across
these tissues. Serial blood samples were taken with the subjects
in the fasting state and for 5 h after a liquid MTT (60 g carbohydrate, 21 g fat, 500 kcal).
Arterialized blood was obtained from a vein draining a heated
hand. Venous blood from muscle was taken from a vein draining

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We showed previously that short-term (24 h) high doses of RS


(60 g/d) significantly elevate postprandial insulin sensitivity,
with lower circulating concentrations of both NEFAs and SCFAs
(8). In the present study, we assessed the effect of a more sustainable dose of RS of 30 g/d for 4 wk to allow the assessment of
longer-term metabolic adaptation to RS. By using an integrative
approach to this nutritional question, we have assessed adaptation to RS intake at the gene-tissue and whole-body levels in
humans.

RESISTANT STARCH AND INSULIN SENSITIVITY

Biochemistry
Whole blood for metabolite and insulin measurement was
collected into heparin-containing syringes (Sarstedt, Leicester,
United Kingdom). Plasma glucose, triacylglycerol (Instrumentation Laboratory, Warrington, United Kingdom), and NEFA
concentrations (Wako Chemicals, Neuss, Germany) were measured enzymatically with an Instrumentation Laboratory Monarch automated analyzer. Whole blood for 3-hydroxybutyrate
and glycerol measurement was deproteinized with 7% (wt:vol)
perchloric acid, and concentrations were measured enzymatically. Metabolites from the placebo and the RS study arms were
analyzed together, and the intra-assay variation was 2.5%.
Concentrations of insulin, C-peptide, and leptin were measured
by radioimmunoassay with commercially available kits (Linco,
St Louis, MO). Blood for total ghrelin analysis was collected into
potassium-EDTA containing 200 Kallikrein inhibiting units
aprotinin/mL (Bayer, Newbury, United Kingdom). For the ghrelin radioimmunoassay (Linco), antibodies were raised against
the C-terminal region (acylated and des-acylated ghrelin) and
showed no detectable cross-reactivity with motilin-related peptide. The sensitivity of this assay was 10 pg/mL. Glucagon-like
peptide 1 (GLP-1) was assayed as described previously (21). The
GLP-1 radioimmunoassay detected changes of 7.5 pmol/L, with
an intraassay CV of 6.1%. The GLP-1 antibody was specific for
the N-terminal amidated GLP-1.
SCFAs were analyzed by gas-liquid chromatography.
Heparin-treated plasma was deproteinized with 16% metaphosphoric acid and denatured for 30 min at 60 C before splitless
injection of 1 L of the supernatant portion onto an FFAP column
(Agilent Technologies, Palo Alto, CA) (22). Measurements were
made with a flame ionization detector, and isovaleric acid was
used as the internal standard.

Quantitation of messenger RNAs


Concentrations of the messenger RNAs (mRNAs) corresponding to the genes of interest were measured by reverse transcription (RT) followed by real-time polymerase chain reaction
(PCR) with a light cycler (Roche Diagnostics, Meylan, France).
First-strand complementary DNAs (cDNAs) were first synthesized from 500 ng of total RNA in the presence of 100 units of
Superscript II (Invitrogen, Eragny, France) using both random
hexamers and oligo (dT) primers (Promega, Charbonnires,
France). The real-time PCR was performed in a final volume of
20 L containing 5 L of a 60-fold dilution of the RT reaction
medium, 15 L of reaction buffer from the FastStart DNA master
SYBR Green kit (Roche Diagnostics), and 10.5 pmol of the
specific forward and reverse primers (Eurobio, Ler Ulis, France).
Primers were selected to amplify small fragments (80 to 200 bp)
and to hybridize in different exons of the target sequences. For
quantification, a standard curve was systematically generated
with 6 different amounts (150 to 30 000 molecules/tube) of purified target cDNA cloned in the pGEM plasmid (Promega).
Each assay was performed in duplicate. The results are presented
in absolute concentrations, in amol/g of total RNA. Cyclophilin
mRNA levels were measured as the internal standard.
Calculations and statistical analysis
Insulin sensitivity and -cell function were assessed by homeostatic model assessment (HOMA %S and HOMA %B, respectively; 23), hyperinsulinemic-euglycemic clamp [equal to
the glucose infusion rate during steady state (M) divided by the
prevailing plasma insulin concentration (I)], and in the postprandial state during the MTT with the use of a minimal model
approach (24). This approach uses cumulative integrated area
under the curve (AUC) measures of both insulin and glucose
concentrations assuming that the total glucose disposal from the
system after 120 min (or when basal values have been reached)
equals the glucose entering the peripheral circulation, allowing
for first-pass extraction by the liver. The incremental ratio of
C-peptide to insulin over the first 2 h of the study, which is an
index of hepatic insulin extraction, was calculated with the trapezoid method.
During the MTT, adipose tissue blood flow was calculated as
described previously (18). Arteriovenous and venoarterial differences in metabolite concentrations were calculated. Absolute
flux was calculated as the product of the arteriovenous or venoarterial difference and tissue blood or plasma flow as appropriate.
The rate of action of lipoprotein lipase in adipose tissue in vivo
was calculated from triacylglycerol extraction. The rate of action
of hormone-sensitive lipase in adipose tissue in vivo was calculated from the total adipose tissue glycerol release after subtraction of the lipoprotein lipase rate of action (16). Total fatty acid
uptake into muscle was calculated from the rate of triacylglycerol
and NEFA removal across the tissue (16).
All statistical analyses were carried out with SPSS version
12.0.1 for WINDOWS (SPSS Inc, Chicago, IL). Time-course
data were analyzed by repeated-measures analysis of variance
when normally distributed. Postprandial data are also presented
in the tables, text, and figures in summary form, ie, fasting and
AUC [AUC values were calculated by using the trapezoid rule
(25)]. Summary data were analyzed by paired Students t tests.
Partial correlations (controlled for subject) were also performed
between metabolites by using Pearsons correlation. Values of

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the deep tissues of the contralateral forearm. To prevent contamination of the blood from the forearm vein with blood from the
hand, a wrist cuff was inflated to 200 mm Hg for 3 min before the
samples were taken. Venous blood from adipose tissue was obtained from the superficial epigastric vein (16). This vein drains
subcutaneous abdominal adipose tissue with negligible contribution from other tissues (17). Oxygen saturation and ultrasound
were used to assess correct positioning of the cannulae. Simultaneous sampling from 3 sites began at 0700 after the subjects had
fasted for 12 h overnight. Two sets of baseline samples were
taken 30 min apart. Subjects then ingested the test meal as described previously (8), and further blood samples were taken for
5 h after the meal.
Subcutaneous abdominal adipose tissue blood flow was measured by 133Xe washout (18). Forearm muscle blood flow was
assessed by occlusion strain-gauge plethysmography (19).
Skeletal muscle and adipose tissue biopsies were performed
under local anesthesia (1% lignocaine) 5.5 h after the meal.
Subcutaneous abdominal adipose tissue was biopsied with a 12gauge needle, and muscle biopsy samples were taken from the
vastus lateralis muscle by using a percutaneous needle technique.
Samples were snap frozen in liquid nitrogen and stored at 70 C
for later RNA quantification. Total RNA was prepared from the
frozen tissue according to an established procedure (20), with
total RNA solutions stored at 80 C.

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TABLE 1
Anthropometric measurements taken after 4 wk of supplementation with either placebo or resistant starch1

Body weight (kg)


BMI (kg/m2)
Fat mass (kg)2
Lean mass (kg)2
Systolic blood pressure (mm Hg)3
Diastolic blood pressure (mm Hg)3

Placebo

Resistant starch

70.6 3.74
23.7 1.33
19.2 2.05
51.4 3.03
118 3.07
74.4 1.78

71.0 3.88
23.8 1.40
18.5 2.36
52.5 3.08
117 4.08
74.7 3.39

P
NS
NS
NS
0.003
NS
NS

1
All values are x SEM; n 10. All measurements were taken in the morning after the subjects had fasted for 12 h. The placebo contained 0 g resistant
starch and 20 g rapidly digestible starch; the resistant starch supplement contained 30 g resistant starch and 20 g rapidly digestible starch. Comparisons were
made with the paired t test.
2
Measured by using foot-to-hand bioimpedance (Bodystat 1500; Bodystat, Isle of Man, United Kingdom).
3
Mean of 3 readings taken with the subject in a sitting position.

P 0.05 were taken as significant. Values in the text are displayed as means with ranges or SEMs. Gene expression data
were analyzed by using the nonparametric Wilcoxons test to
compare mRNA levels between the placebo and RS diets.

0.003) averaging 1.1 kg (0.6 1.6 kg) over the 4-wk period of RS
supplementation (Table 1).
Glucose metabolism and insulin sensitivity

The inclusion of an additional 30 g RS/d in the diet was well


tolerated [mean fiber intake increased from 17.5 g/d (range:
14.6 21.3 g/d) to 46.5 g/d]. There was no significant effect of the
RS supplement on stool frequency; adverse gastrointestinal
symptoms (abdominal pain, flatulence, bloating, and constipation) were reported with a mean frequency of 1.0 (range: 0 1)
incident per month on the placebo treatment compared with 3.0
(range: 0 5) incidents per month with the RS supplement (P
0.05). Mean daily macronutrient intake as assessed by 7-d food
records was 17.5 g dietary fiber (Association of Official Analytical Chemists classification), 256 g carbohydrate, 57.8 g fat, and
7.76 MJ/d during the placebo intervention and 47.9 g dietary
fiber, 266 g carbohydrate, 62 g fat, and 7.9 MJ/d during the RS
intervention. There was no significant difference in reported
food intake between the 2 supplementation periods and no subsequent change in either body weight or BMI (Table 1). There
was a small but significant increase in lean body mass (P

TABLE 2
Indexes of insulin sensitivity after 3 or 4 wk of a highresistant starch (RS) supplement (30 g RS/d) or placebo (0 g RS/d)1
Placebo
Hyperinsulinemic-euglycemic clamp (week 3)
M/I
MTT (week 4)
HOMA %S
HOMA %B
Fasting plasma glucose (mmol/L)
Plasma glucose AUC (mmol 300 min/L)
Fasting plasma insulin (pmol/L)
Plasma insulin AUC (pmol 300 min/L)
C-peptide/insulin AUC
Oral SI
Total glucose uptake by AT (mol/100 mL tissue)

8.5 10

Resistant starch
3

8.7 10

77.4 5.55
128 9.21
5.04 0.118
1890 27.7
79.8 16.0
63 000 10 600
6.08 0.523
1.36 103 1.9 104
54.4 62.5

9.7 10

P
2

1.09 10

76.75 6.72
138 8.83
5.06 0.139
1830 28.9
84 17.4
55 200 10 500
7.48 0.734
1.82 103 3.6 104
141 59.3

0.027

NS
NS
NS
NS
NS
0.024
0.034
0.050
0.007

All values are x SEM; n 10. The total uptake of glucose across adipose tissue (AT) is the arteriovenous difference times the AT plasma flow calculated
as an area under the curve (AUC) between 0 and 300 min. M/I, glucose infusion rate during steady state (mg kg1 min1) divided by the prevailing plasma
insulin concentration (mU insulin/L); MTT, meal tolerance test; HOMA S and HOMA B, insulin sensitivity and cell function, respectively, assessed
by homeostatic model assessment; SI, insulin sensitivity assessed during the meal tolerance test [(dL kg1 min1)/(U/mL)]. Comparisons were made with
the paired t test.
1

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There was no significant effect of RS supplementation on


either -cell function or fasting insulin sensitivity (23; Table 2)
when measured by HOMA. During the hyperinsulinemiceuglycemic clamp study, insulin sensitivity was significantly
higher (P 0.027) after RS intake than with placebo. Oral insulin
sensitivity (incorporating the effects of the gastrointestinal tract)
was also significantly higher after RS supplementation (P
0.05). The postprandial insulin concentration was significantly
lower after RS supplementation (Figure 2) and the molar ratio of
C-peptide to insulin was significantly higher, which indicated
increased hepatic insulin extraction.
During the MTT, insulin sensitization was noted in both skeletal muscle and adipose tissue after the RS supplement. Muscle
glucose clearance was significantly higher despite lower prevailing insulin concentrations (Figure 2C). The mean glucose clearance per pmol/L insulin, averaged across the study period, was
43.9% higher after RS intake than after the placebo (P 0.013).
A similar trend was observed for adipose tissue, with glucose
uptake being higher by almost 3-fold (Table 2; P 0.007). There

RESULTS

RESISTANT STARCH AND INSULIN SENSITIVITY

563

FIGURE 2. Mean (SEM) plasma glucose and insulin concentrations


and skeletal muscle glucose clearance after a meal tolerance test (dashed line)
in healthy subjects after a 4-wk intervention of 30 g resistant starch (RS)/d (E)
compared with placebo (F). n 10. There was no significant difference in
the plasma glucose response between the treatments. The plasma insulin
response, however, was significantly (P 0.024) lower after the RS intervention, and muscle glucose clearance was significantly (P 0.027) higher
(repeated-measures ANOVA).

was no significant relation between insulin sensitization with the


RS supplement and BMI.
Fatty acid metabolism
There was no significant effect of RS intake on either fasting
triacylglycerol or NEFA concentrations. During the MTT, however, the postprandial output of both NEFAs and glycerol from
adipose tissue was significantly lower with RS supplementation
(Figure 3). The decreased NEFA output from adipose tissue
reflected a significant postprandial reduction in the rate of action
of hormone-sensitive lipase, the enzyme responsible for the mobilization of stored triacylglycerol (from 128 48 to 55 36
nmol 100 mL tissue1 min1; P 0.046). There was no
significant effect of RS intake on plasma triacylglycerol (data not
shown) despite a significant reduction in the calculated rate
of action of lipoprotein lipase (from 188 39 to 114 29

nmol 100 mL tissue1 min1; P 0.026). Although the release


of NEFAs from adipose tissue was lower, the arterialized NEFA
concentration and the total uptake of fatty acids by muscle were
unchanged by supplementation (data not shown).
Short-chain fatty acids
Systemic concentrations of both acetate and propionate were
higher after RS supplementation than with placebo (Table 3 and
Figure 4), although no significant effect of supplementation was
seen on plasma butyrate. During the MTT, there was significant
net uptake of SCFAs across both muscle and adipose tissue after
both the placebo and the RS-supplemented diets. The uptake of
acetate was significant after both the placebo (P 0.009 across
muscle; P 0.037 across fat) and the high-RS diet (P 0.002
across muscle; P 0.004 across fat). (The P values refer to
whether we were able to measure significant uptake by the tissues; comparisons of uptake between the dietary periods are
given in Table 3.) However, propionate uptake was significant
only after the high-RS diet (P 0.006 across muscle; P 0.027
across fat). Butyrate uptake was not significant. Acetate uptake
increased after RS supplementation across both tissues: as a
function of increased plasma concentration (adipose tissue) and
as increased fractional extraction (skeletal muscle) (Table 3).

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FIGURE 3. Mean (SEM) nonesterified fatty acid (NEFA) and glycerol


release from subcutaneous adipose tissue (AT) after a meal tolerance test
(dashed line) in healthy subjects after a 4-wk intervention of 30 g resistant
starch (RS)/d (E) compared with placebo (F). n 8. The release of both
NEFAs (P 0.019) and glycerol (P 0.046) from AT was significantly
lower after the RS intervention (repeated-measures ANOVA).

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ROBERTSON ET AL

TABLE 3
Plasma acetate and propionate concentrations and flux rates after 4 wk of a highresistant starch (RS) supplement (30 g RS/d) or placebo (0 g RS/d)1

Plasma acetate
Fasting (mol/L)
AUC (mol 300 min/L)
Fractional extraction across muscle (%)
Net uptake by muscle (nmol/100 g tissue)
Fractional extraction across AT (%)
Net uptake by AT (nmol/100 mL tissue)
Plasma propionate
Fasting (mol/L)
AUC (mol 300 min/L)
Fractional extraction across muscle (%)
Net uptake by muscle (nmol/100 g tissue)
Fractional extraction across AT (%)
Net uptake by AT (nmol/100 mL tissue)

Placebo

Resistant starch

212 23.7
53 800 4260
15.7 4.33
14 600 4400
8.62 2.88
8200 2890

217 18.2
69 200 5970
24.2 3.68
25 900 5900
14.6 2.34
18 200 3640

NS
0.037
0.05
0.064
NS
0.034

5.74 1.26
1490 155
25.2 12.8
846 453
14.1 9.05
791 424

9.09 2.48
2690 320
39.3 7.98
1100 310
35.3 13.5
1530 495

NS
0.012
NS
NS
0.048
NS

Propionate was present at much lower concentrations and had a


higher fractional extraction across adipose tissue after the RS
supplement (Table 3).

FIGURE 4. Mean (SEM) arterialized short-chain fatty acid concentrations after a meal tolerance test (at time 0) in healthy subjects after a 4-wk
intervention of 30 g resistant starch (RS)/d (E) compared with placebo (F).
n 10. Repeated-measures ANOVA showed significant effects of the RS
intervention for both acetate (P 0.048) and propionate (P 0.009), with
a significant effect of time after meal for acetate (P 0.036) but not for
propionate (P 0.069).

Hormones
RS supplementation resulted in a significant increase in fasting plasma ghrelin concentrations, although the degree of postprandial suppression during the MTT (40 44%) remained unchanged (Figure 5). The postprandial AUC for ghrelin was
significantly correlated with both BMI (r 0.523, P 0.021)
and M/I (r 0.496, P 0.03). There was no significant effect of
RS supplementation on plasma leptin or GLP-1 concentrations
(data not shown).

FIGURE 5. Mean (SEM) plasma ghrelin concentrations after a meal


tolerance test (dashed line) in healthy subjects after a 4-wk intervention of
30 g resistant starch (RS)/d (E) compared with placebo (F). n 10.
Repeated-measures ANOVA showed a significant effect of the RS intervention (P 0.027).

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1
All values are x SEM; n 10 for muscle and n 8 for adipose tissue (AT). The fractional extraction across both muscle and AT is calculated as the
arteriovenous difference across the individual tissue divided by the arterialized concentration and is expressed as a percentage. The total uptake of fatty acid
across tissue is the arteriovenous difference across the individual tissue times the tissue plasma flow calculated as an area under the curve (AUC) between 0
and 300 min. Comparisons were made with the paired t test.

RESISTANT STARCH AND INSULIN SENSITIVITY

Gene expression
In adipose tissue, there was no significant change in the expression of the following genes after RS supplementation: hexokinase II, CD36, lipoprotein lipase, peroxisome proliferator
activated receptor , phosphatidyl-inositol-3 kinase, glucose
transporter 4, or leptin. There was, however, significantly greater
expression of hormone-sensitive lipase (35.7 5.5 to 45.8 7.7
amol/g total RNA; P 0.036) and lower expression of insulin
receptor substrate 1 (11.2 1.5 to 8.8 1.4 amol/g total RNA;
P 0.016) after RS supplementation than with placebo. In skeletal muscle samples, however, there was no significant effect of
dietary period on the expression of any of the genes measured
(hexokinase II, CD36, lipoprotein lipase, insulin receptor substrate 1, phosphatidyl-inositol-3 kinase, or glucose transporter 4;
data not shown).

DISCUSSION

by 200% after RS supplementation. The metabolic fate of this


additional glucose is at present unclear.
A novel aspect of the present study was the direct measurement of SCFA uptake into both skeletal muscle and adipose
tissue. After RS supplementation, the peripheral concentrations
of both acetate and propionate were increased, as was the rate of
uptake into the specific tissues. SCFAs were recently shown to
bind to the G protein coupled receptors GPR41 and GPR43,
which have been isolated from both adipose tissue (30) and
skeletal muscle (31). The function of these receptors is at present
ill defined, but they have been proposed to trigger leptin release
from adipocytes. Despite significantly higher SCFA concentrations, no significant change in plasma leptin or leptin mRNA was
found after RS supplementation. SCFAs have been shown to
inhibit adipose tissue lipolysis in vivo (13, 32) and thus may
contribute to the observed reduction in lipolysis. However, this
has never been reported physiologically after fiber intake. We
found no relation between NEFA release from adipose tissue and
SCFA concentrations, so additional mechanisms may be involved. The fate of the SCFAs taken up into skeletal muscle is
likely to be rapid oxidation (33). The accumulation of acetyl CoA
from acetate may result in acetylation of the carnitine pool, thus
limiting the availability of free carnitine (34) and potentially
reducing fatty acid transport into the mitochondria for oxidation.
Increased muscle insulin sensitivity could therefore be partly
explained by the increased muscle uptake of SCFAs.
An interesting observation was the increase in the circulating
concentration of total ghrelin after RS supplementation. This
result is counterintuitive from what we know about the satiating
effects of RS (35, 36) and the appetite-stimulating effects of
ghrelin (37). Perhaps the systemic concentration of ghrelin is
more relevant in determining its peripheral actions, independent
of those induced within the hypothalamus. Elevations in plasma
ghrelin have been linked to increased insulin sensitivity in numerous studies (38 40), although debate still exists as to the
mechanism. It is hypothesized that the hyperinsulinemia of insulin resistance down-regulates ghrelin release and thus that elevated ghrelin is merely a consequence of the low insulin concentrations. In the present study, fasting ghrelin concentrations
were significantly elevated with no significant change in fasting
insulin concentrations, and thus it is doubtful that this mechanism
is in place. Ghrelin has been shown to inhibit lipolysis, stimulate
lipogenesis, and stimulate the expression of peroxisome proliferator activated receptor in vitro (41), which potentially influence insulin sensitivity in vivo. The lack of a change in fatty acid
uptake into muscle in our study implies that any insulinsensitizing effects of ghrelin are independent of those induced in
adipose tissue. Ghrelin may have direct insulin-sensitizing effects on skeletal muscle. Muscle expresses the putative ghrelin
receptor GHS-R1b (42), although a function for this receptor
remains to be described. It is perhaps more likely that the skeletal
muscle ghrelin receptor is a protein independent of either GHSR1a or 1b (43), such as the fatty acid translocase protein CD36/
FAT, as has been shown in cardiac muscle (44). If elevated
plasma ghrelin concentrations are partly responsible for the
insulin-sensitizing effects of RS, then the link between fermentation in the colon and ghrelin production from the stomach
warrants further investigation.
Increases in systematic SCFA concentrations have been
shown to augment the expression of functional proteins within
the intestine (45), potentially because of the ability of SCFAs to

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We used an integrative approach to study the metabolic effects


of RS intake and obtained novel data concerning the function of
individual tissues (adipose tissue and skeletal muscle) in vivo in
humans after a period of dietary supplementation. In an earlier
short-term study (60 g RS for 24 h) (8), we found RS intake to
increase insulin sensitivity at the whole-body level and to increase hepatic insulin clearance, a finding that was corroborated
in the present study when RS was included in the diet at more
physiologic levels (30 g RS/d for 4 wk). We have now shown
insulin sensitization at the whole-body level assessed by both the
hyperinsulinemic-euglycemic clamp and the MTT methods. In
addition, we showed a reduction in adipose tissue lipolysis and an
increase in the insulin sensitivity of skeletal muscle glucose
clearance. These effects of RS may be due to changes in the
peripheral metabolism of SCFAs or in the secretion of ghrelin.
The concept that dietary fibers induce insulin sensitization by
reducing the plasma NEFA concentration (26 28) and thus that
they serve as a signal between adipose tissue and muscle has not
been supported by conclusive in vivo data. Through direct measurement of tissue metabolic flux rates, we have been able to
show the metabolic changes induced by fermentable fiber at both
the whole-body and the tissue level.
Adipose tissue lipolysis, as assessed by the calculated rate of
action of hormone-sensitive lipase, was significantly lower after
RS supplementation than with placebo. Hormone-sensitive
lipase is suppressed by insulin after meals, yet we observed lower
insulin during the RS study, and thus the results are not consistent
with adipose tissue simply responding to concentrations of insulin. To suppress lipolysis, only small excursions in the plasma
insulin concentration are required, and this may explain why the
maximal effects of RS supplementation were not evident until the
late postprandial period when insulin concentrations were low.
Insulin-mediated skeletal muscle glucose clearance (glucose
clearance/plasma insulin concentration) was significantly higher
after RS supplementation. However, we found no direct link
between a reduced rate of fatty acid release from adipose tissue
and the increased muscle insulin sensitivity, because the skeletal
muscle uptake of total fatty acids was unchanged. We cannot,
however, exclude the possibility that changes in NEFA flux may
influence insulin sensitization in other organs, such as the liver
(29). Adipose tissue itself is also an important site for maintaining glucose homeostasis, with total glucose removal increasing

565

566

ROBERTSON ET AL

We thank Jenny Currie and Sandra Ellis for technical assistance and all the
volunteers for giving their time so freely.
MDR was involved in designing the protocol, recruiting volunteers, conducting much of the practical work, and writing the first draft of the paper.
ASB and ALD were involved in managing the clinical studies; HV conducted
the studies of gene expression; and KNF helped to design the study and write
the paper. All authors helped to refine the paper. None of the authors had
personal or financial conflicts of interest.

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REFERENCES
1. Harris MI. Diabetes in America: epidemiology and scope of the problem.
Diabetes Care 1998;suppl 3:C11 4.
2. Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2
diabetes mellitus by changes in lifestyle among subjects with impaired
glucose tolerance. N Engl J Med 2001;344:134350.
3. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the
incidence of type 2 diabetes with lifestyle intervention or metformin.
N Engl J Med 2002;346:393 403.
4. Parillo M, Riccardi G. Diet composition and the risk of type 2 diabetes:
epidemiological and clinical evidence. Br J Nutr 2004;92:719.
5. Rivellese AA, Lilli S. Quality of dietary fatty acids, insulin sensitivity
and type 2 diabetes. Biomed Pharmacother 2003;57:84 87.
6. McGarry JD, Dobbins RL. Fatty acids, lipotoxicity and insulin secretion.
Diabetologia 1999;42:128 38.
7. Jenkins DJA, Kendall CWC, Axelsen M, Augustin LSA, Vuksan V.
Viscous and nonviscous fibres, nonabsorbable and low glycaemic index
carbohydrates, blood lipids and coronary heart disease. Curr Opin Lipidol 2000;11:49 56.
8. Robertson MD, Currie JM, Morgan LM, Jewell DP, Frayn KN. Prior
short-term consumption of resistant starch enhances postprandial insulin
sensitivity in healthy subjects. Diabetologia 2003;46:659 65.
9. Salmeron J, Ascherio A, Rimm EB. Dietary fiber, glycaemic load, and
risk of NIDDM in men. Diabetes Care 1997;20:54550.
10. Salmeron J, Manson JE, Stampfer MJ, Colditz GA, Wing AL, Willett
WC. Dietary fiber, glycaemic load and risk of non-insulin dependent
diabetes mellitus in women. JAMA 1997;277:4727.
11. Ylonen K, Saloranta C, Kronberg-Kippila C, Groop L, Aro A, Virtanen

27.
28.

29.

30.

31.

32.

33.

34.

35.

SM. Associations of dietary fiber with glucose metabolism in nondiabetic relatives of subjects with type 2 diabetes; the Botnia Dietary Study.
Diabetes Care 2003;26:1979 85.
McGarry JD. Banting Lecture 2001: dysregulation of fatty acid metabolism in the etiology of type 2 diabetes. Diabetes 2002;51:718.
Crouse JR, Gerson CD, DeCarli LM, Lieber CS. Role of acetate in the
reduction of plasma free fatty acids produced by ethanol in man. J Lipid
Res 1968;9:509 12.
Robertson MD, Henderson RA, Vist GE, Rumsey RDE. Extended effect
of evening meal carbohydrate-to-fat ratio on fasting and postprandial
substrate metabolism. Am J Clin Nutr 2002;75:50510.
DeFronzo RA, Tobin J, Andres R. Glucose clamp technique: a method
for quantifying insulin secretion and resistance. Am J Physiol 1979;237:
E214 23.
Frayn KN, Coppack SW. Assessment of white adipose tissue metabolism by measurement of arteriovenous differences. Methods Mol Biol
2001;155:269 79.
Frayn KN, Coppack SW, Humphreys SM, Whyte PL. Metabolic characteristics of human adipose tissue in vivo. Clin Sci 1989;76:509 16.
Larsen OA, Lassen NA, Quaade F. Blood flow through human adipose
tissue determined with radioactive xenon. Acta Physiol Scand 1966;66:
337 45.
Rdegran G. Limb and skeletal muscle blood flow measurements at rest
and during exercise in human subjects. Proc Nutr Soc 1999;58:88798.
Chomczynski P, Sacchi N. Single-step method of RNA isolation by acid
guanidinium-thiocyanate-phenol-chloroform extraction. Ann Biochem
1987;162:156 9.
Kreyman B, Williams G, Ghatei MA, Bloom SR. Glucagon-like peptide
1: a physiological incretin in man. Lancet 1987;8571:1300 4.
Brighenti F. Simple method for quantitative analysis of short chain fatty
acids in serum by gas-liquid chromatography. In: Guillon F, Abraham G,
Amado R, et al, eds. Plant polysaccharides in human nutrition: structure,
function, digestive fate and metabolic affects. Nantes, France: INRA,
1997:114 9.
Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF,
Turner RC. Homeostasis model assessment: insulin resistance and -cell
function from fasting plasma glucose and insulin concentrations in man.
Diabetologia 1985;28:4129.
Caumo A, Bergman RN, Cobelli C. Insulin sensitivity from meal tolerance tests in normal subjects: a minimal model index. J Clin Endocrinol
Metab 2000;85:4396 402.
Matthews JNS, Altman DG, Campbell MJ, Royston P. Analysis of serial
measurements in medical research. BMJ 1990;300:230 5.
Wolever TM, Brighenti F, Royall D, Jenkins AL, Jenkins DJ. Effect of
rectal infusion of short chain fatty acids in human subjects. Am J Gastroenterol 1989;84:102733.
Venter CS, Vorster HH. Possible metabolic consequence of fermentation in the colon for humans. Med Hypotheses 1989;29:161 66.
Anderson JW, Bridges SR. Short-chain fatty acid fermentation products
of plant fiber affect glucose metabolism of isolated rat hepatocytes. Proc
Soc Exp Biol Med 1984;177:372 6.
Kim SP, Ellmerer M, Van Citters GW, Bergman RN. Primacy of
hepatic insulin resistance in the development of the metabolic syndrome induced by an isocaloric moderate-fat diet in the dog. Diabetes
2003;52:2453 60.
Xiong Y, Miyamoto N, Shibata K, et al. Short chain fatty acids stimulate
leptin production in adipocytes through the G protein-coupled receptor
GPR41. Proc Natl Acad Sci U S A 2004;100:104550.
Bonini JA, Andersen SM, Steiner DF. Molecular cloning and tissue
expression of a novel orphan G protein-coupled receptor from rat lung.
Biochem Biophys Res Commun 1997;234:190 3.
Yki-Jarvinen H, Koivisto VA, Ylinkahri R, Taskinen MR. Acute effects
of ethanol and acetate on glucose kinetics in normal subjects. Am J
Physiol 1988;254:E175 80.
Akanji AO, Bruce MA, Frayn KN. Effect of acetate infusion on energy
expenditure and substrate oxidation rates in non-diabetic and diabetic
subjects. Eur J Clin Nutr 1989;43:10715.
Randle PJ, Garland PB, Hales CN, Newsholme EA. The glucose fattyacid cycle. Its role in insulin sensitivity and the metabolic disturbances
of diabetes mellitus. Lancet 1963;1:7859.
Jenkins DJA, Vuksan V, Kendall CWC, et al. Physiological effects of
resistant starches on fecal bulk, short chain fatty acids, blood lipids and
glycemic index. J Am Coll Nutr 1998;17:609 16.

Downloaded from ajcn.nutrition.org by guest on April 15, 2014

mediate the release of glucagon-like peptide 2 (GLP-2) (46) or


gastrin (47). We suggest that increased peripheral concentrations
of SCFA [not colonic SCFAs (48)], either directly or indirectly
via GLP-2 or gastrin, are linked to ghrelin release. However,
more work is needed to clarify the link between colonic fermentation and gastric ghrelin. In contrast with the results of animal
studies, the present RS intervention did not increase plasma concentrations of GLP-1. In terms of systemic effects, GLP-1 is an
important incretin; however, tissue-specific studies in humans
have clearly shown that GLP-1 does not directly inhibit adipose
tissue lipolysis when measured by microdialysis (49) and so the
change observed in adipose tissue function would not be predicted to be dependent on GLP-1. The measurement of gene
regulation after RS intake is novel, yet, unlike pharmacologic
interventions (50), the increased uptake of glucose into skeletal
muscle could not be explained by changes in expression of the
key genes involved in either insulin signaling or glucose uptake.
This does not, however, exclude the possibility that gene expression in other tissues such as the gastrointestinal tract contributes
to the metabolic changes observed.
In conclusion, RS intake increases insulin sensitivity in noninsulin-resistant subjects by changing both adipose tissue and
skeletal muscle metabolism. This is potentially due to elevations
in the systemic concentrations of both ghrelin and SCFAs. RS
intake at this dose (30 g/d) was well tolerated and thus could have
beneficial effects for the treatment of insulin-resistant persons or
those with type 2 diabetes. This would require further investigation.

RESISTANT STARCH AND INSULIN SENSITIVITY


36. Tapsell. Diet and the metabolic syndrome: where does resistant starch fit
in? J AOAC Int 2004;87:756 60.
37. Halford JC, Cooper GD, Dovey TM. The pharmacology of human appetite suppression. Curr Drug Targets 2004;5:221 40.
38. Ikezaki A, Hosada H, Ito K, et al. Fasting ghrelin levels are negatively
correlated with insulin resistance and PAI-1 but not with leptin in obese
children and adolescents. Diabetes 2002;51:3408 11.
39. Poykko S, Ukkola O, Kauma H, Savolainin MJ, Kesaniemi YA. Ghrelin
Arg51Gln mutation is a risk factor for type 2 diabetes and hypertension
in a random sample of middle aged subjects. Diabetologia 2003;46:
455 8.
40. Pagotto U, Gambineri A, Vicennati V, Heiman ML, Tschop M, Pasquali
R. Plasma ghrelin, obesity and the polycystic ovary syndrome: correlation with insulin resistance and androgen levels. J Clin Endocrinol Metab
2002;87:56259.
41. Choi K, Roh SG, Hong YH, et al. The role of ghrelin and growth hormone
secretagogues receptor on rat adipogenesis. Endocrinology 2003;144:
754 9.
42. Gnanapavan S, Kola B, Bustin SA, et al. The tissue distribution of the
mRNA of ghrelin and subtypes of its receptor, GHS-R in humans. J Clin
Endocrinol Metab 2002;87:2988 91.
43. Pierno S, de Luca A, Desaphy JF, et al. Growth hormone secretagogues

44.
45.
46.
47.
48.
49.
50.

567

modulate the electrical and contractile properties of rat skeletal muscle


through a ghrelin-specific receptor. Br J Pharmacol 2003;139:575 84.
Bodart V, Febbraio M, Demers A, et al. CD36 mediates the cardiovascular action of growth hormone-releasing peptides in the heart. Circ Res
2002;90:844 9.
Tappenden KA, Albin DM, Bartholome AL, Mangian HF. Glucagonlike peptide 2 and short chain fatty acids: a new twist on an old story. J
Nutr 2003;133:371320.
Tappenden KA, McBurney MI. Systemic short chain fatty acids rapidly
alter gastrointestinal structure, function and expression of early response
genes. Dig Dis Sci 1998;43:1526 36.
Reilly KJ, Frankel WL, Bain AM. Colonic short chain fatty acids mediate jejunal growth by increasing gastrin. Gut 1995;37:81 6.
Anini Y, Fu-Cheng X, Cuber JC, Kervran A, Chariot J, Roz C. Comparison of the postprandial release of peptide YY and proglucagonderived peptides in the rat. Pflugers Arch 1999;438:299 306.
Bertin E, Arner P, Bolinder J, Hagstrom-Toft E. Action on glucagon and
glucagon-like peptide 1 (736) amide on lipolysis in human subcutaneous adipose tissue. J Clin Endocrinol Metab 2001;86:1229 34.
Sreekumar R, Halvatsiotis P, Schimke JC, Nair KS. Gene expression
profile in skeletal muscle of type 2 diabetes and the effect of insulin
treatment. Diabetes 2002;51:191320.

Downloaded from ajcn.nutrition.org by guest on April 15, 2014