REvIEWS

Dietary fibre in gastrointestinal health

and disease
Samantha K. Gill, Megan Rossi, Balazs Bajka and Kevin Whelan ✉
Abstract | Epidemiological studies have consistently demonstrated the benefits of dietary fibre
on gastrointestinal health through consumption of unrefined whole foods, such as wholegrains,
legumes, vegetables and fruits. Mechanistic studies and clinical trials on isolated and extracted
fibres have demonstrated promising regulatory effects on the gut (for example, digestion and
absorption, transit time, stool formation) and microbial effects (changes in gut microbiota
composition and fermentation metabolites) that have important implications for gastrointestinal
disorders. In this Review, we detail the major physicochemical properties and functional
characteristics of dietary fibres, the importance of dietary fibres and current evidence for
their use in the management of gastrointestinal disorders. It is now well-​established that
the physicochemical properties of different dietary fibres (such as solubility, viscosity and
fermentability) vary greatly depending on their origin and processing and are important
determinants of their functional characteristics and clinical utility. Although progress in
understanding these relationships has uncovered potential therapeutic opportunities for
dietary fibres, many clinical questions remain unanswered such as clarity on the optimal
dose, type and source of fibre required in both the management of clinical symptoms and the
prevention of gastrointestinal disorders. The use of novel fibres and/or the co-​administration
of fibres is an additional therapeutic approach yet to be extensively investigated.

The term ‘dietary fibre’ was first coined in 1953, and from
the 1970s onwards attempts to provide formal defini-
tions have continued in light of the growing evidence of
its associated health benefits1,2. In 2009, following nearly
20 years of discussions, the World Health Organization
and Codex Alimentarius provided a globally dis-
seminated and updated definition (Box 1). Analytical
methods to quantify dietary fibre have evolved alongside
the updated definitions, although data derived from these
updated methods are not comprehensively available
in all food composition databases (Box 1).
Investigating the health effects of fibre is complicated
by variations in the interventions. Studies can investi-
gate synthetic fibres consisting of only one type of mol-
ecule (for example, fructo-​oligosaccharides), extracted
fibres from naturally occurring plant sources consist-
ing of one, or a limited number of fibres (for example,
alginate or psyllium), single foods containing a limited
number of naturally occurring fibres that are intrinsic
King’s College London, and intact in plant cells (such as prunes or wholegrain
Department of Nutritional
Sciences, London, UK.
cereals), and high-​fibre diets consisting of a wide range of
✉e-​mail: kevin.whelan@ different naturally occurring fibres from a wide range
kcl.ac.uk of different foods. The variations in fibre interventions
https://doi.org/10.1038/ have created numerous challenges in interpreting and
s41575-020-00375-4 applying the findings. Firstly, in vitro and animal studies
have frequently used synthetic or extracted fibres in
supplemental form, but whose physicochemical char-
acteristics such as molecular weight and bioaccessibility
might be different when consumed as whole foods and
as part of diets that can affect their functional properties,
and secondly because high-​fibre foods and diets contain
other nutrients and food components (such as vitamins
and polyphenols) that could be beneficial to health and,
therefore, identifying the effect of fibre alone can be
challenging.
Dietary fibre has been shown in an extensive num-
ber of epidemiological and interventional studies to
have important associations with the development and
management of various diseases and with mortality. For
example, in 2015, the Scientific Advisory Committee on
Nutrition (SACN)3 in the UK performed meta-​analyses
of epidemiological studies of fibre in the prevention of
disease, and showed that for each increase in dietary
fibre intake from food of 7 g per day there was a statisti-
cally significantly reduced risk of cardiovascular disease
(relative risk (RR) 0.91, 95% CI 0.88–0.94; P < 0.001),
haemorrhagic plus ischaemic stroke (RR 0.93, 95% CI
0.88–0.98; P = 0.002), colorectal cancer (CRC; RR 0.92,
95% CI 0.87–0.97; P = 0.002), rectal cancer (RR 0.91,
95% CI 0.86–0.97; P = 0.007) and diabetes (RR 0.94,

Nature Reviews | Gastroenterology & Hepatology

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Key points
• Dietary fibre has been shown to have a number of important associations with the
development and management of various diseases and with mortality in
epidemiological and interventional studies.
• Dietary fibre has physicochemical characteristics (for example, solubility, viscosity,
fermentability) that determine its functionality in the gastrointestinal tract, including
its effects on, for example, micronutrient availability, gut transit time, stool formation
and microbial specificity.
• Current dietary fibre recommendations are often limited and conflicting, and fail
to provide specific types and doses in the treatment of gastrointestinal disorders
including irritable bowel syndrome, inflammatory bowel disease, diverticular disease
and functional constipation.
• Future research that considers the influence of differing physicochemical
characteristics on functionality will potentially maximize the effect of clinically
meaningful symptom improvement in gastrointestinal disorders.
95% CI 0.90–0.97; P = 0.001). In 2019, a meta-​analysis of
185 epidemiological cohort studies including just under
135 million person-​years echoed these findings, showing
that risk reduction is greatest when dietary fibre intake
from food is between 25 g per day and 29 g per day. This
higher fibre intake was associated with reduced risk of
all-​cause mortality (RR 0.85, 95% CI 0.79–0.91) and
mortality from coronary heart disease (RR 0.69, 95% CI
0.60–0.81) and cancer (RR 0.87, 95% CI 0.79–0.95), and
with lower incidence of coronary heart disease (RR 0.76,
95% CI 0.69–0.83), stroke (RR 0.78, 95% CI 0.69–0.88),
type 2 diabetes mellitus (RR 0.84, 05% CI 0.78–0.90)
and CRC (RR 0.84, 95% CI 0.78–0.89)4 compared with
lower fibre intake. Both observational analyses highlight
the critical importance of the quantity of fibre required
to elicit health benefits5,6. These well-​established asso-
ciations between dietary fibre intake and health have
resulted in the majority of countries recommending
a daily intake for adults of 25–35 g per day. Despite
this recommendation, the average intake of dietary
fibre by adults worldwide remains low, typically under
20 g per day7.
As well as disease prevention, dietary fibre has the
potential to be used as a therapeutic intervention, in par-
ticular for disorders of the gastrointestinal tract. National
and international guidelines provide some recommen-
dations in relation to dietary fibre in the treatment of
gastrointestinal disorders such as irritable bowel syn-
drome (IBS)8,9, inflammatory bowel disease (IBD)10 and
diverticular disease11,12, and in the management of spe-
cific gastrointestinal symptoms such as constipation12,13.
However, these recommendations are often limited, fail-
ing to provide specifics in terms of the type and dose of
fibre, and are sometimes even conflicting. The limited
number and quality of studies as well as the variations
in the fibre interventions (including fibre type, source,
dose and duration of treatment) represent key challenges
to providing recommendations for the therapeutic use
of dietary fibre in the treatment of gastrointestinal dis-
orders. The potential of dietary fibre for gastrointesti-
nal health and as a therapeutic agent in gastrointestinal
disorders is attributed to its effect on nutrient diges-
tion and absorption, improving glycaemic and lipae-
mic responses, regulating plasma cholesterol through
limiting bile salt resorption, influencing gut transit,
and microbiota growth and metabolism. Mechanistic
research has highlighted the diverse physico­chemical
characteristics of different dietary fibres, such as
solubility, viscosity and fermentability, all of which
determine their function in the upper and lower
gastrointestinal tracts.
The aim of this Review is to discuss the physicochem-
ical and functional characteristics of dietary fibres and
the effect of these factors on the clinical application of
fibre in the management of gastrointestinal disorders,
with a focus on studies in humans wherever possible.
Physicochemical characteristics
The majority of dietary fibres are the structural polysac-
charide components of plant cell walls (Fig. 1; Table 1).
Cell walls contain multiple polysaccharides and the
complexity in elucidating their functions results from
the variety of sources and their functions within the
cell. This aspect is most evident in the variation in their
molecular structure, which includes the composition
of the polymer subunits, but also extends to the poly-
mer linkages and side-​chains (esterification)14. These
differences in molecular structure of dietary fibres can
substantially alter their physicochemical properties
and their behaviour in the gastrointestinal tract. For
example, their resistance to intestinal digestion can
result from the spatial orientation of polymer subunits,
branching, or the presence of side-​chains15.
Food processing provides an additional level of com-
plexity. Indeed, both milling and cooking can also be
important determinants of the physicochemical char-
acteristics of dietary fibres, improving starch digesti-
bility and degradation of plant-​derived compounds16.
However, some digestible polysaccharides can also
be classified as dietary fibre due to their inaccessibil-
ity to digestive enzymes within the food matrix, such
as type 1 resistant starch (RS-1; as in whole grains) or
type 3 resistant starch (RS-3; retrograded), in which
resistance can be conferred following cooking and
cooling17. The consequence of these small variations in
structure is that dietary fibres can have very different
physicochemical characteristics (for example, viscos-
ity and fermentability) that influence their functional
effects (such as gut transit time or the microbiota) in
the gastrointestinal tract.
Fibre solubility. Solubility refers to the extent to which
dietary fibres can dissolve in water. Unlike insoluble
fibres that remain as discrete particles, soluble fibres
have a high affinity for water18. In cases in which it is
necessary to divide the dietary fibre content into soluble
and insoluble fibre fractions, the enzymatic–gravimetric
assay is often used for routine analysis (Association of
Official Analytical Chemists method 2011.25).
Examples of carbohydrate polymers whose structure
affects their solubility are starch (amylose and amylo­
pectin) and cellulose. The former is composed of
α-​glucose monomers and the latter β-​glucose. The cor-
responding secondary structures result in starch being
soluble (most of which is digested in the small intestine)
and cellulose being insoluble (and therefore classified as
dietary fibre)18. However, although β-​glucose monomer
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linkages can result in β(1,4)-​cellulose being insoluble,
they can result in β(1,3)(1,4)-​glucan (mixed linkages
in β-​glucan) being soluble19. Similarly, branching of the
polymer structure, such as in amylopectin, β-​glucan
or inulin, can also affect solubility. Interestingly, the
branching in amylopectin can result in increased solu-
bility, whereas branching in β-​glucan decreases solubility.
Additionally, some fibres, such as pectin or methyl cellu-
lose, contain side-​chains along the polymer that provide
resistance to digestion20 whilst also increasing solubility21.
The majority of current evidence has focused on solu-
bility as a characteristic of fibre in relation to its effect on
the upper gastrointestinal tract through the regulation of
gastric emptying and nutrient absorption. Indeed, early
in vitro studies of isolated fibres allowed the distinction
between those that primarily affect small intestinal lipid
and glucose absorption and those that primarily affect
colonic function such as stool bulking and reduced tran-
sit time (insoluble fibres such as cellulose, wheat bran
and lignin)22. Thus, classifying fibres based upon solubil-
ity was for many decades used to allude to differentiation
of their functional properties. However, in 2003 the Food
and Agriculture Organization of the United Nations
proposed that these conventionally classified terms
relating to solubility should be phased out for a num-
ber of reasons23. Firstly, measuring and classifying fibre
solubility in vitro is method-​dependent. Secondly, the
varying pH conditions within the gastrointestinal tract
(such as stomach versus colon) and between individuals
Box 1 | Definition of dietary fibre and approaches to its chemical analysis
Dietary fibre definition
• Dietary fibre as defined by the World Health Organization and Codex Alimentarius
(collection of internationally recognized standards, guidelines and codes of practice)
includes all carbohydrates that are neither digested nor absorbed in the small intestine
and have a degree of polymerization (DP) of ten or more monomeric units205,206.
• The Codex Alimentarius dietary fibre definition has been adopted by many countries
and this has encouraged international consistency in nutrition labelling, food
composition tables and published research.
• There is flexibility in the definition enabling regional authorities to include
carbohydrates with a DP of three to nine monomeric units in the fibre definition.
Subsequently, the European Food Safety Authority (EFSA)5 and the FDA6 adopted the
wider definition of dietary fibre to include all carbohydrates that are neither digested
nor absorbed in the small intestine and have a DP of three or more monomeric units.
• Both EFSA and the FDA specify that synthetic and extracted fibres that are not
intrinsic to plant cells must also demonstrate physiological effects to human health
prior to being declared a dietary fibre.
• Codex-​defined fibre includes non-​starch polysaccharides such as cellulose,
hemicelluloses and pectins, resistant starch and non-​digestible oligosaccharides such
as inulin and oligofructose, as well as lignins. Thus, foods high in dietary fibre include
wholegrains, legumes, vegetables, fruits, nuts and seeds.
Dietary fibre analysis
• Analytical methods to quantify dietary fibre have evolved alongside the updated
definitions.
• The Association of Official Analytical Chemists (AOAC) method (2011.25) is
considered the most reflective of the current Codex definition, capturing and
enabling quantification of most dietary fibre entities, including total dietary fibre and
its insoluble and soluble fractions by an enzymatic–gravimetric assay, and molecular
weight by size exclusion chromatography or high-​performance liquid chromatography.
• Some food databases still include some fibre values derived from outdated AOAC
methods that do not reflect current Codex fibre definitions.
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might affect fibre solubility in vivo24,25. Thirdly, solubil-
ity alone does not predict the physiological effects of
fibre and, therefore, its functional properties. For exam-
ple, both psyllium (soluble) and cellulose (insoluble)
have been shown to improve glycaemic control, transit
time and stool output, albeit via different mechanisms.
Glycaemic control in humans is improved by psyllium26
through a mechanism involving increased viscosity of
intestinal contents, whereas in rats, cellulose has been
shown to affect glycaemia via inhibition of starch diges-
tion by binding α-​amylase27, thereby reducing glucose
absorption28.
A further challenge to the use of fibre solubility as an
indicator of functionality is that, in reality, whole fibrous
foods are often a complex mix of soluble and insoluble
fibres (for example, resistant starch, hemicelluloses, cel-
lulose and lignin) and, therefore, simultaneously exert
different physiological effects in the gastrointestinal
tract. For example, apples contain soluble (pectins) and
insoluble (cellulose) fibre fractions. It has been suggested
that the effects of both soluble (that is, swelling via water
absorption) and insoluble (that is, bulking) fibres in
the ileum might activate the ileal brake (negative feed-
back mechanism that results in inhibition of gastro­
intestinal motility and secretion) via mediators such as
glucagon-​like peptide 1 (GLP1) and GLP2 according to
animal research29. Nonetheless, although solubility per se
is a poor indicator of physiological function in isolation,
it has a profound effect on other factors that have since
gained recognition for their specific physiological and
microbial actions in the gastrointestinal tract such as
viscosity and fermentability.
Fibre viscosity. Viscosity is the degree of resistance
to flow. It is generally associated with soluble dietary
fibres (such as gums, pectins, β-​glucans and psyllium)
and relates to the ability of a fibre, when hydrated, to
thicken in a concentration-​dependent manner30. Some
forms of fibre, such as pectins, have the capacity to form
gel networks. In the gastrointestinal tract, this process
can begin in the mouth and continues throughout the
digestive tract31. There are several physicochemical char-
acteristics that contribute to the viscosity potential of
fibre, including the length and structure of the polymer
as well as its charge. These factors affect the ‘type’ of gel
formed and the critical concentration required for the
formation of a viscoelastic gel. Broadly, viscous fibres
can be categorized into two groups: random coil poly-
saccharides and ordered assembly polymers. Random
coil polysaccharides increase viscosity through entan-
glement, thereby restricting the flow of the surround-
ing solvent32. Examples include the neutral polymers
β-​glucans, psyllium and guar galactomannan, in which
generally the longer the polymer (that is, the higher
the molecular weight), the greater the entanglement
that occurs and, therefore, the lower the concentration
required to increase viscosity33. By contrast, ordered
assembly polymers, such as some pectins and alginate,
form a gel network in the presence of divalent ions (that
is, Ca2+)33. Increasing gut luminal viscosity has been sug-
gested to have multiple health benefits. Consumption of
viscous dietary fibre has been shown to alter transit time
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Starch granules
Cooked starches Raw starches
Gelatinized (soluble) Ungelatinized (insoluble)
Digested Resistant starch
• RS-1: whole or partially milled
• RS-2: granules (high amylose)
• RS-3: retrograded (cooked and cooled)
• RS-4: chemically modified
• RS-5: starch–lipid complexes
Fig. 1 | physicochemical characteristics of dietary fibre and their location within the plant cell. Polysaccharides that
contribute to the dietary fibre definition can be divided into two broad categories: non-​starch polysaccharides that are a
main component of plant cell walls, and resistant starch (RS), the plant’s energy store and a major carbohydrate source in
the human diet. Their chemical structure, interactions with other cell wall components, food processing and digestion can
all influence their solubility, viscosity and fermentability.
in the upper gut, including decreasing gastric emptying
rate and modulating small intestinal transit34. Increased
luminal viscosity has been suggested to play a part in
major regulatory effects of dietary fibre consumption,
including delaying digestion, decreasing postprandial
glycaemia35 and lipaemia36–38 and increasing satiety in
humans39. The effect of the viscoelastic properties
in the small intestine are less well defined, particularly
as the effect of digestive secretions that dilute luminal
contents are difficult to replicate and test in vivo. Indeed,
a study investigating the effects of simulated gastric and
small intestine digestion in vitro on the thickening abil-
ity of six soluble fibres from different sources found
substantial differences in their viscosity profiles. For
example, xanthan gum retained viscosity more than all
the other fibres40.
Viscosity remains the accepted model for the
cholesterol-​lowering capacity of β-​glucan. Increased
luminal viscosity decreases diffusion of bile salts,
preventing their resorption in the distal ileum 41.
Malabsorbed primary bile salts entering the colon can
be de-​conjugated by bacterial hydrolases to produce
secondary bile acids, which have been shown to increase
the risk of CRC through induction of epithelial cell
hyperproliferation and increased oxidative DNA dam-
age in vitro42. Although the mechanism remains unclear,
as does the interaction between bile acids and dietary
fibre43, this elevated CRC risk is not observed in vivo.
Cell wall
Soluble fibres Insoluble fibres
• Pectin • Cellulose
• β-Glucan • Hemicellulose
• Galactomannan • Lignin
Indeed there is substantial epidemiological evidence
suggesting the opposite: that diets high in fibre are pro-
tective against CRC in humans44. Additionally, in vitro
studies have suggested that dietary fibres (for example,
rice bran fibre, cellulose) might interact with digestive
enzymes, inhibiting the rate of nutrient digestion27,45,46.
An additional mechanism has been proposed, whereby
an interaction between dietary fibres and the mucus
layer results in localized increases in viscosity adjacent
to the brush border in pigs47,48 regulating nutrient dif-
fusion across it. In the colon, increases in luminal vis-
cosity and water-​holding capacity can in turn influence
colonic bulk and transit time. The colonic contrac-
tions moving luminal content between compartments
might also reduce localized viscosity by shear thinning
and alter colonic transit, particularly with fibres that
are able to form disordered networks when hydrated
(such as pectins). The consequences of these changes
are likely to influence the extent of fermentation occur-
ring in the colon, indeed with greater understanding of
the physico­chemical properties, it might be possible to
affect microbiome composition49.
There are several mathematical equations and mod-
els, as well as rheological measurements to determine
the viscosity of a solution. While the two most common
analytical techniques of rheometry (measures the flow
of a fluid) and viscometry (measures the viscosity of a
fluid) are effective at determining viscosity of isolated
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fibre solutions, their validity in vivo remains equivocal as specialist primary degraders known as ‘keystone species’
intestinal luminal contents are extremely heterogeneous have been identified within the large intestine57. These
and the effect of muscular contractions, peristalsis and species have a superior ability to degrade certain dietary
mixing in the gastrointestinal tract cannot be replicated fibres and release energy on which other bacterial com-
in vitro. munities depend. For example, Ruminococcus bromii
has been shown to specifically degrade certain types of
Fibre fermentability. Observational studies have con- resistant starch57.
sistently shown differences in faecal microbiota com- Examples of fermentable fibres include inulin-​type
position between industrialized and rural populations. fructans, galacto-​oligosaccharides and resistant starch
These differences have been attributed to differences (Table 1). All natural plant fibres have some degree of
in the typical westernized diet consisting of foods that fermentability, even cellulose and lignin (low ferment-
are highly refined and low in dietary fibre, particularly ability), with only synthesized fibres such as methyl-
fermentable fibre50–55. Unlike mammalian cells, some cellulose being completely non-​fermentable58 (Table 1).
species of the gut microbiota possess enzymes able to Fibre fermentability has traditionally been assessed
hydrolyse the chemical bonds within some dietary fibres using in vitro fermentation models of the digestive tract.
within plant-​based foods56. Interestingly, a number of Although this technique provides valuable mechanistic
insights into fermentation patterns and behaviour of dif-
ferent dietary fibres, the findings are not always reflected
Table 1 | physicochemical characteristics of common dietary fibres in vivo. For example in vitro models have indicated that
psyllium is moderately fermented, whereas in vivo
Fibre type Common sources physicochemical characteristicsa
studies have demonstrated that it is poorly fermented59.
solubility Viscosity Fermentability This discrepancy is probably because the dilution and
Cellulose All green plant cell Insoluble Non-​viscous Low high-​speed mechanical blending that occurs in vitro
walls destroys the gel network, artificially exposing the fibres
Lignins All green plant cell Insoluble Non-​viscous Low to enzymatic degradation. In vivo methods of measur­ing
walls fibre fermentability include quantification of short-​chain
Arabinoxylans Wheat, psylliumb Low to Medium Highb fatty acids (SCFAs) in stools and hydrogen breath test-
medium ing, although these also have limited interpretability,
β-​Glucans Oat, barley, fungi Low to Medium to High and breath testing in particular is subject to limited
medium high reproducibility60. Advances in MRI have enabled meas-
Galactomannans Guar gum, fenugreek Medium Medium to High urement of colonic gas volumes in response to differ-
to high high ent fibres in humans61,62. Although still in its infancy
Pectins Fruits, vegetables, High Medium to High in terms of quantifying fermentation, MRI overcomes
legumes high many of the limitations of the other methods and can
non-​invasively and simultaneously assess the water con-
Inulin Cereals, fruits, Medium Low to high High
vegetables to high tent of the small intestine, colonic volumes and colonic
gas volume63.
Galacto-​ Pulses (e.g. beans, High Low High
oligosaccharides peas, lentils) Greater intake of dietary fibre, particularly from
foods high in the fermentable fibres, has been associ-
Dextrins Cereals (e.g. wheat High Non-​viscous High ated with higher stool SCFA concentrations in adults64.
dextrins) to low
SCFAs have a number of key roles in the gastrointestinal
Alginate Seaweed High High Low tract. Animal studies have shown that SCFAs affect gas-
Methylcellulose Synthesized High High Non-​ trointestinal motility by stimulating colonic contractile
fermentable activity through increasing the number of excitatory
Resistant Starch cholinergic neurons65. SCFAs also have a mediatory role,
RS-1 (physically Whole grains, Insoluble Non-​viscous High bridging communication between the mucosal micro-
inaccessible) legumes, raw fruits, biota and the mucosal immune system, with preclini-
vegetables cal evidence suggesting notable anti-​inflammatory and
RS-2 (starch Cereals, raw Low Non-​viscous High immunomodulatory effects with relevance to inflam-
conformation) legumes, raw fruits, matory disorders of the gut66. For example, SCFAs can
vegetables influence intestinal adaptive immune responses through
RS-3 Cooking and cooling Low Non-​viscous High direct regulation of the size and function of the regu-
(retrograded) of any starch source to low latory T cell pool, including proliferative capacity and
RS-4 (chemically Synthesized (e.g. Low to Low to High gene expression in mice67. In animal studies, SCFAs have
modified) acylated starches) high medium also been implicated in maintaining intestinal barrier
RS-5 (starch– Synthesized Low Low Low integrity68 and regulating appetite via several mech-
lipid complex) (e.g. amylose anisms including the stimulation of gluconeogenesis
and stearic acid) in the liver69. Furthermore, SCFAs indirectly maintain
a
Physicochemical characteristics are not distinct entities but represent a continuum or gastrointestinal homeostasis via the reduction in lumi-
gradient, and will vary depending on botanical origin, chemical structure and molecular nal pH 70, which could be important in preventing
weight, or whether the fibres are isolated or part of the cell wall matrix (Fig. 1). bDue to their
structural features, wheat and psyllium sources of arabinoxylans are considered of only low colonization and inhibiting growth of acid-​sensitive
fermentability. enteropathogens (Fig. 2).

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Small intestine
↑ Water binding
↑ Viscosity → ↓ Glucose Microbial growth
and lipid absorption rate
Fibre
Phytate Bile acids
Iron ↓ Reabsorption
↓ Gluconeogenesis
Intestinal
epithelial
cell
Dendritic
cell
T cell
Immunomodulation
Fig. 2 | Mechanisms by which different dietary fibres affect the gastrointestinal tract. There are several mechanisms
by which the physicochemical characteristics (solubility, viscosity and fermentability) of dietary fibre might affect its
functional properties in the gastrointestinal tract including influencing glucose and lipid absorption, contributing to stool
output (frequency, consistency and weight) and stimulating changes in microbial composition and metabolite production
including the production of short-​chain fatty acids (SCFAs).
Many factors can affect the rate, site and extent of
fibre fermentation, including the composition of the
microbiota (degradation capacity) with different micro-
organisms shown to preferentially metabolize different
fibres71 and the availability of other substrates (that is,
proteins that have escaped digestion)72. Nonetheless, the
key factor influencing fibre fermentability is thought to
be its physicochemical characteristics (for example, sol-
ubility, viscosity, accessibility). This has been shown in
an in vitro fermentation study using healthy human stool
samples from three donors to investigate the effect of
15 dietary fibres on SCFA production. Despite marked
inter-​individual differences in gut microbiota composi-
tion between donors, SCFA production (concentrations
and proportions) from the different fibres was reproduc-
ible between samples. More specifically, rhamnose pro-
duced the highest proportion of propionate followed by
galactomannans, whereas fructans and other α-​glucans
and β-​g lucans produced the highest proportion of
butyrate73.
The effect of fermentable fibres on SCFA produc-
tion has been consistently shown in vitro74–77. By con-
trast, interpretation of human interventional studies is
somewhat limited given that approximately 95% of
SCFAs are absorbed by colonocytes, and therefore fae-
cal SCFA concentrations only represent ~5% of the total
SCFAs produced. Thus, faecal SCFAs better reflect the
dynamic processes of both SCFA production and SCFA
absorption, the former being affected by fibre source,
Large intestine
Ca2+
↑ Stool bulk
↑ Solubility
↓ pH
SCFA ↓ pH
• Acetate Inhibit
pathogens
• Propionate
• Butyrate
Supports
tight
junction
Large fibre integrity
particles
↑ Colonic muscular contraction
Liver
colonic transit time and the gut microbiota and the latter
being greatly affected by colonic transit time78.
Reducing fermentable fibre intake might reduce bac-
terial diversity. Several animal studies have shown that
gut microbiota deprived of fermentable fibres shift to
degrading and extracting alternative energy from the
glycoprotein-​rich mucus layer that acts as a protec-
tive and mechanical barrier to pathogens79,80. Indeed,
reduced availability of fermentable fibres leads to a
thinner mucus layer81–83, which in turn might compro-
mise intestinal epithelial integrity and increase pathogen
susceptibility. Reduced availability of fermentable fibres
also causes a shift from a stable microbial intestinal
environment to one that is temporarily or permanently
altered, often characterized by reduced bacterial diver-
sity and richness, a state that is commonly referred to as
dysbiosis84. A dysbiotic intestinal environment is a com-
mon feature of a number of gastrointestinal disorders;
for example, decreases in abundance of bifidobacteria85,86
and Firmicutes87–89 have been commonly observed in
cohorts of people with IBS and IBD, respectively.
The food matrix. The nature of the food matrix in which
a dietary fibre is delivered will markedly influence the
extent of its physiological function. More specifically,
the particle size and integrity of the plant cell walls
affects the dissolution of soluble fibre90. This process
has the potential to substantially affect luminal viscosity
and reduce the rate of fermentation. Furthermore, the
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cell wall integrity can also encapsulate the intracellular
starch91, therefore reducing digestion by endogenous
enzymes and increasing the substrate available for
microbial fermentation (RS-1; Fig. 1).
Particle size can influence fibre fermentation,
although to date, the majority of research has been con-
ducted in vitro, with limited translational research inves-
tigating the effects in humans. Reduced particle size of
fibres has been associated with increased SCFA concen-
trations in an in vitro fermentation system with human
faecal inoculum92, suggesting greater bacterial fermen-
tation. This outcome is likely to have been due to the
fact that smaller particles have a greater external surface
area exposed to bacterial enzymes. Similarly, the physical
act of chewing and grinding high-​fibre foods can have a
notable role in particle size kinetics by increasing surface
area and total pore volume as well as structural modifi-
cation. For example, reducing the particle size of coconut
residue from 1,127 μm to 550 μm led to an increase in
hydration properties, including water-​holding, retention
and swelling capacity93. Equally, in human studies, the
physical and mechanical effects of large and/or coarse
insoluble fibre particles on the colonic mucosa has been
shown to stimulate the secretion of water and mucus
into the lumen, contributing to stool output (that is,
consistency and weight)94,95.
Porosity determines the degree to which enzymes or
bacteria can diffuse into particles, which can substan-
tially influence the fermentability of a fibre. Low porosity
of a food matrix can result from maintenance of cell wall
structures in the small intestine and, therefore, inability
of digestive enzymes to access intracellular starch, lead-
ing to increased RS-1, as is the case, for example, with
whole chickpeas17. Low porosity of a food matrix in the
large intestine can also impede fermentative degradation
in humans96. Dietary fibre preparations high in insoluble
fibres such as cellulose are likely to have low porosity,
whereas those high in soluble fibres such as pectin have
high porosity, and these differences in the porosity of
fibres contribute to differences in their fermentability
(Table 1).
Functional characteristics of fibre
Micronutrient bioavailability. Dietary fibre can influ-
ence nutrient bioavailability beyond merely limit-
ing micronutrient accessibility within a food matrix.
Cereals containing dietary fibre (such as wheat) are a
vital source of non-​haem iron; however, other cereal
components (for example, bran fractions) contain con-
comitant factors such as phytate that reduce absorption
of iron, zinc and calcium97. Additionally, in wheat, the
aleurone contains the majority of the iron, but is encap-
sulated by the cell walls (predominantly dietary fibre)98.
Studies have shown that micro-​milling to disrupt these
structures results in increased mineral bioavailability
in vitro99. In contrast to iron, several studies in humans
have shown that consumption of specific fibres, such
as fructans100 and galacto-​oligosaccharides101, could
increase absorption of dietary calcium. Based on exper-
imental findings, the proposed mechanism involves
decreased colonic pH resulting from SCFA produc-
tion, which in turn can increase calcium solubility,
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thereby increasing passive transport of calcium across
the intestine.
The influence of dietary fibre consumption on vita-
min absorption remains unclear. Several studies have
demonstrated that some fibres improve absorption
of some water-​soluble and fat-​soluble vitamins102,103,
whereas others have shown no effect104. For example,
a study in African Americans has shown that fibre can
enhance the net colonic bacterial biosynthesis of B vita-
mins such as folate105, whereas other studies in women
have shown increased faecal excretion of vitamins
following dietary fibre consumption106. The variety of
fibre sources with varying physico-​chemical properties
demonstrates that further work is required.
Gut transit time. Abnormal whole-​gut transit times are
found in some gastrointestinal disorders, which some
types of fibre could normalize. For example, evidence
from animal models demonstrates that, as found in rats,
fermentable fibres can indirectly modulate contractile
activity via production of SCFAs107, whereas, as found
in dogs, non-​fermentable fibres might contribute to
stool weight that increases colonic volume and, there-
fore, stimulates contractility108. Indeed, a systematic
review and meta-​analysis in healthy populations found
that transit time decreased in a dose-​dependent man-
ner by 0.78 h per additional 1 g per day of wheat fibre109.
Additionally, wheat fibre particle size has been shown
to influence stool output, whereby coarse wheat fibre
resulted in higher stool weight (mean 219.4 g per day)
than fine wheat fibre (199 g per day) in one study of
21 healthy humans110.
In the 1970s and 1980s, studies measuring gut transit
time using radio-​opaque markers and scintigraphy
showed that dietary fibre interventions reduce gut transit
time in humans111–114. One study in healthy humans
showed a decrease in transit time with wheat bran sup-
plementation from 70 h to approximately 46 h (ref.115).
Insoluble, poorly fermented fibres (for example, wheat
bran) have a greater effect on reducing gut transit time
in healthy individuals and to a lesser extent in those
with constipation116 than fermentable fibres that do not
remain physically intact throughout the colon.
More recently, studies investigating the use of a wire-
less motility capsule that measures, among other things,
transit time have been reported. Transit times measured
with this device correlate with those obtained using
radio-​opaque markers and scintigraphy117,118 and the
device has been shown to provide a more practical and
less invasive method for determining gastric emptying
time and whole gut transit time. For example, one con-
trolled crossover trial in healthy individuals with back-
ground fibre intakes of 14–15 g per day who consumed
an additional 9 g per day of wheat bran or a low-​fibre
control diet for 3 days found that whole-​gut transit time
and colonic transit time were lower in those receiving
wheat bran supplementation than in those receiving the
control diet (−8.9 h and −10.8 h, respectively)119.
Stool forming. For a dietary fibre to exert effects on stool
output (that is, frequency, consistency and weight), it
must possess certain physical characteristics. Wheat bran
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supplementation has been shown to increase stool fre-
quency from 1 per day to 1.5 per day115, although the
type of bowel movement (complete or spontaneous) was
not reported, whereas further studies in healthy humans
have shown that supplementation with a cellulose–
pectin combination120 or psyllium121 and high-​f ibre
breakfast cereals122 increase stool frequency.
Both soluble, viscous fibres and insoluble, non-
viscous fibres can contribute to improvements in stool
consistency and stool weight (bulk). Soluble, viscous
fibres (for example, psyllium) with a high water-​holding
capacity that are resistant to fermentation and form a
viscoelastic substance in the gastrointestinal tract, con-
tribute to softening hard stool and increasing stool bulk,
making them easier to pass123,124. These properties also
assist with diarrhoea by firming loose stools and slow-
ing transit time125–127. By contrast, insoluble, non-​viscous
fibres (for example, coarse wheat bran) can contribute to
improvements in stool consistency and stool weight via
the mechanical stimulation of the intestinal mucosa95,128.
Previous studies in adults with self-​reported constipa-
tion have shown improvements in stool consistency
with increased consumption of rye bread129 and fibre
bread130. Theoretically, fermentable fibres might con-
tribute, in part, to stool weight via increasing microbial
mass, but the effect size is limited compared with that
of non-​fermentable fibres. For example, results from
six trials showed that RS-2 supplementation increased
stool weight (+38 g per day, 95% CI 23–53 g per day;
P < 0.001) at doses ranging from +21.5 to +37 g per day3.
A review of interventional trials investigating outcomes
in healthy humans concluded that fermentability deter-
mines the role of fibre in total stool weight, with less
fermentable fibres from cereals contributing most to
stool weight131.
Microbial specificity (prebiotics). Some fermentable
fibres are also classed as prebiotics, a term whose defi-
nition has been updated to “a substrate that is selectively
utilized by host microorganisms conferring a health
benefit”132. Examples of prebiotic fibres include the
inulin-​type fibres and galacto-​oligosaccharides.
Prebiotic fibres are known for their rapid fermenta-
tive capacity and subsequent release of SCFAs, in par-
ticular acetate, but selectively stimulate the growth of
only a specific range of genera and/or species (that is,
Bifidobacterium and Lactobacillus)133–135. This selectiv-
ity is due to specific gene clusters within the bacterial
genome that dictate the saccharolytic enzymes they
produce and their phenotypic ability to selectively
metabolize the prebiotic substrate136,137.
The first landmark study demonstrating the prebio­
tic effect in eight healthy volunteers found that supple-
mentation with 15 g per day of oligofructose or inulin
increased luminal bifidobacterial levels by almost one
log10 (ref.138). Subsequent research has demonstrated a
dose-​dependent effect on luminal Bifidobacterium levels
of oligofructose121 and galacto-​oligosaccharides139 sup-
plementation. Published in 2018, a systematic review
and meta-​analysis of 64 randomized controlled trials
(RCTs) in humans demonstrated that fibre, and in par-
ticular fructans and galacto-​oligosaccharides and other
candidate prebiotic fibres, increases the abundance of
Bifidobacterium and Lactobacillus species133.
However, large inter-​individual variability in
gut microbiota responses to dietary fibre have been
reported140–144. A crossover RCT in 34 healthy partici-
pants found that those with a habitually high dietary fibre
intake had a greater gut microbial response to pre­biotics
(that is, increases in abundance of Bifidobacterium and
Faecalibacterium, and decreases in Coprococcus, Dorea
and Ruminococcus) compared with those with habitu-
ally low dietary fibre intake, suggesting that individuals
following a habitual high-​fibre diet are more likely to
benefit from an inulin-​type fructan prebiotic145.
Dietary fibre in gut disorders
Given the substantial inter-​c ondition and inter-
individual variability in response to dietary fibre, there
remains the complex challenge of unravelling which
fibres are most appropriate for which gastrointestinal
disorders. Consideration of the diverse physicochem-
ical characteristics of fibre and how these translate to
functional characteristics is fundamental to optimizing
any clinical benefit (Fig. 3). Consideration should also
be given to maintaining the balance between optimiz-
ing symptom benefit (that is, management and main-
tenance) and limiting symptom exacerbation (that
is, tolerance). The manipulation of dietary fibre is a
common approach in clinical practice for many gastro­
intestinal disorders and is commonly recommended as
first-​line therapy in the management of several gastro­
intestinal symptoms (Table 2), despite the limited num-
ber of RCTs across gastrointestinal disorders, all of
which used heterogeneous methodologies (for example,
fibre type, amount, duration).
Irritable bowel syndrome. IBS is a functional gastroin-
testinal disorder characterized by recurrent abdominal
pain and change in stool habit (that is, constipation, diar-
rhoea or both), often alongside abdominal bloating and
distension146. The mechanisms underpinning IBS symp-
toms include visceral hypersensitivity, and alterations in
gut–brain interactions, immune activation, gut motil-
ity and the gut microbiota. Since the revised Rome IV
criteria were introduced in 2016, estimated worldwide
prevalence of IBS has decreased from 11.7% (Rome III)
to 5.7% (Rome IV)147.
Guidelines for fibre consumption in individuals
with IBS vary. The National Institute for Health and
Care Excellence8 in the UK recommends that resistant
starch intake should be reduced, whereas the World
Gastroenterology Organization Global Guidelines148
suggest that fibre-​rich foods or fibre supplements (for
example, psyllium) should be encouraged and that insolu
ble fibres that might exacerbate symptoms should be
limited.
To date, a number of systematic reviews and meta-
analyses have concluded that some fibres are beneficial in
reducing IBS symptoms and improving stool frequency
and consistency, although results are inconsistent with
wide variation in responses149–151. Benefits seem to be
limited to soluble fibre (RR of having continued symp-
toms after supplementation 0.83, 95% CI 0.73–0.94)152,
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Physicochemical Physicochemical
• Medium solubility • Soluble
• Medium viscosity • Viscous
• Low fermentability • Fermentable
• e.g. Psyllium • e.g. Pectin,
Functional galactomannan
• Nutrient bioavailability Functional
• Faster transit • Nutrient bioavailability
• Water holding • SCFA production

↑ Viscosity
Physicochemical
• Insoluble Physicochemical
• Non-viscous • Soluble
• Non-fermentable • Non-viscous
• e.g. Cellulose in wheat • Fermentable

ty
bran

ili
• e.g. Inulin, GOS

ab
t
Functional

en
Functional

rm
• Faster transit • SCFA production

Fe
• Stool bulking • Prebiotic

↑
↑ Solubility

Fig. 3 | spectrum of physicochemical characteristics of dietary fibre. The physicochemical characteristics of fibre
(solubility, viscosity and fermentability) form a continuum and work in concert to determine its functional properties in the
gastrointestinal tract. The combination of these three physicochemical characteristics determines the functional effects
of fibres in the gut. For example, fibres in the left-​hand, bottom, near corner (insoluble, non-​viscous, non-​fermentable) have
functions relating to gut transit time; fibres in the right-​hand, bottom, far corner (soluble, non-​viscous, fermentable)
have functions relating to microbiome and fermentation; and fibres in the right-​hand, top, far corner (soluble, viscous,
fermentable) have functions relating to microbiome, fermentation and nutrient bioavailability. Fibres in intermediate
positions would be predicted to have intermediate functional properties. GOS, galacto-​oligosaccharides; SCFA,
short-​chain fatty acid.

compared with other fibres such as bran (RR 0.90, 95%
CI 0.79–1.03). The ongoing changes in diagnostic cri-
teria (for example, Rome Criteria for IBS), and lack of
standardization in outcome measures between studies
presents major challenges when attempting to com-
pare findings of previous studies. Further rigorous and
long-​term RCTs are required, and there is an urgent
need to assess the different functionalities of dietary
fibres in subgroups of individuals with IBS (for exam-
ple, specifically those with constipation-​predominant
IBS or diarrhoea-​predominant IBS) to enable a better
understanding of its therapeutic potential. Interestingly,
a three-​period, crossover mechanistic study revealed
that despite similar physiological responses to prebio­
tics between patients with IBS and healthy individuals
as controls, only those with IBS experienced symptoms
when challenged with 40 g of fructose or inulin whereas
the healthy controls did not, suggesting that visceral
hypersensitivity to colonic gas is involved in the induc-
tion of symptoms, rather than excessive gas production
per se153.
A limited number of clinical trials investigating
prebiotic supplementation (for example, oligofructose,
fructo-​oligosaccharide and β-​galacto-​oligosaccharides)
ranging from 3.5 g per day to 20 g per day over 4–12 weeks
have been conducted in IBS populations, with mixed
results154–157. A systematic review and meta-​analysis pub-
lished in 2019 of 11 RCTs including 729 patients showed
that although the abundance of bifidobacteria increased
following prebiotic supplementation, there were no
differences in response rates, or severity of abdominal
pain, bloating, flatulence or quality of life158. Notably,
subgroup analysis showed improvement in flatulence
with lower prebiotic doses (≤6 g per day; standardized
mean difference (SMD) −0.35, 95% CI −0.71 to 0.00;
P = 0.05) and non-​inulin-​type fructans (for example,
galacto-​oligosaccharide, guar gum: SMD −0.34, 95% CI
−0.66 to −0.01; P = 0.04). Although little current evidence
exists for the use of prebiotics in IBS management158,159,
emerging evidence suggests that second-​generation can-
didate prebiotics such as pectin and partially hydrolysed
guar gum have bifidogenic properties160 with potential
therapeutic use in IBS161, possibly due to their viscosity
characteristics and, therefore, slower fermentation rate.
Inflammatory bowel disease. IBD encompasses Crohn’s
disease and ulcerative colitis, both chronic, relapsing
gastrointestinal disorders of which the pathogenesis
remains incompletely understood, although a dysreg-
ulated mucosal inflammatory response in genetically
susceptible individuals is responsible for the initiation
and maintenance of IBD162. This process involves altera-
tions in immunological factors (for example, T and B cell
regulation) and microbial factors (for example, diversity
and functionality of bacteria such as Faecalibacterium
prausnitzii)163. The prevalence of IBD exceeds 0.3%
across North America, Oceania and Europe164. The goal
of IBD treatment is to halt disease progression, main-
tain remission and prevent recurrence of inflammatory
episodes.
There continues to be debate on the clinical benefits
of dietary fibre in IBD165 despite plausible mechanisms
for its therapeutic potential, including the production of
SCFAs (particularly butyrate) that could attenuate intes-
tinal inflammation through upregulation or downregu-
lation of cytokine expression (for example, IL-10, IFNγ

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Table 2 | Guidelines and recommendations for the use of fibre in gastrointestinal disorders
Gastrointestinal Dietary fibre recommendations level of evidence
disorder
IBS-​C Soluble fibre in supplement form (e.g. psyllium, methylcellulose, Meta-​analyses of RCTs
partially hydrolysed guar gum)8,12,148–150
Adjust fibre intake according to symptoms including adding naturally Professional consensus
occurring sources (e.g. oats or linseeds)8
Ground linseeds (6–24 g per day); increase gradually over a 3-​month Small number of RCTs
period9
IBS-​D Reduce intake of insoluble fibre, such as wholemeal or high-​fibre flour Systematic review
and breads, cereals high in bran, and whole grains such as brown rice8 of RCTs
Soluble fibre in supplement form (e.g. psyllium)148,150,204 Meta-​analyses of RCTs
Adjust fibre intake according to symptoms 8
Professional consensus
Inflammatory Encourage a varied diet to meet energy and nutrient requirements, Professional consensus
bowel disease including dietary fibre, including a wide variety of fruit and vegetables,
cereals, grains, nuts and seeds10
Consider limiting fibre and fibrous foods in patients with strictures12 Professional consensus
Dietary fibre should not be restricted, unless intestinal obstruction12 Professional consensus
Ulcerative colitis might be more amenable to fibre supplement Systematic review
interventions than Crohn’s disease165 of RCTs
Diverticular Low-​fibre diet during active diverticulitis to ‘minimize irritation’12 Professional consensus
disease
High-​fibre diet from mixed sources to prevent diverticulitis Observational studies
and professional
consensus
Functional Encourage gradual increases (weeks rather than days) in fibre (or by Meta-​analyses of RCTs
constipation adding fibre supplements) to minimize gastrointestinal discomfort
including bloating and flatulence aiming for 20–30 g per day, being
aware that beneficial effects might be seen after several weeks12,13
Encourage whole-​fibre foods with additional components Small number of RCTs and
with laxating effects (e.g. sorbitol) such as prunes or apricots13 professional consensus
High-​dose psyllium (>15 g/day)124 Meta-​analysis of RCTs
Guidelines are based upon research and professional consensus, but frequently the evidence is not from high-​quality clinical trials.
IBS-​C, irritable bowel syndrome with constipation; IBS-​D, irritable bowel syndrome with diarrhoea; RCTs, randomized controlled
trials.

and IL-1β) by colonic epithelial cells according to in vitro
data67,166,167. A number of studies have found alterations
in the gut microbiota (for example, reduced abundance
of Bifidobacterium and Faecalibacterium prausnitzii) in
patients with Crohn’s disease that might be amenable to
prebiotic fibre supplementation168,169. Previous studies
have generally found lower stool SCFA concentrations
in patients with IBD than in healthy individuals170–172,
suggesting a reduced fermentative capacity and an
impairment in SCFA production in this patient group.
Collectively, it is conceivable that fibre (dietary or sup-
plement form) might prevent IBD, maintain or restore
intestinal epithelial integrity in IBD, although studies
in humans of fibre in the prevention, maintenance and
treatment of IBD are extremely limited165.
In terms of the risk of developing IBD, a prospective
cohort study in 170,776 women in the Nurses’ Health
Cohort Study followed up over 26 years identified 269
and 338 cases of Crohn’s disease and ulcerative colitis,
respectively173. Compared with women with the lowest
energy-​adjusted dietary fibre intake, intake in the high-
est quintile (median of 24.3 g per day) was associated
with a 40% reduction in risk of Crohn’s disease (hazard
ratio for Crohn’s disease, 0.59, 95% CI 0.39–0.90), but
not ulcerative colitis173. On the contrary, a meta-​analysis
of 14 case–control studies found an association between
higher intakes of vegetables and lower risk of ulcerative
colitis (OR 0.71, 95% CI 0.58–0.88), but not Crohn’s
disease (OR 0.66, 95% CI 0.40–1.09), whereas a higher
consumption of fruit was associated with lower risk
of both ulcerative colitis (OR 0.69, 95% CI 0.49–0.96)
and Crohn’s disease (OR 0.57, 95% CI 0.44–0.74)174.
However, a large prospective study including 401,326
participants recruited from across eight European coun-
tries found no associations between intakes of total fibre
or fibre from specific sources and the development of
IBD175; however, this study was in a population of peo-
ple recruited in their middle age, beyond the age at
which IBD commonly develops (mean age at recruit-
ment 49.6–51.6 years, range 20–80 years). Furthermore,
given the nature of these observational studies, recall
bias is likely.
Only a limited number of clinical trials investigating
the use of fibre in the maintenance and treatment of IBD
have been undertaken, and they have been summarized
in a systematic review165. For maintenance of remission,
of the four studies included in patients with ulcerative
colitis (n = 213), two found positive effects on disease
activity: one larger RCT found continued remission at
12 months across all groups (psyllium versus mesalamine

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versus psyllium plus mesalamine), whereas a smaller
unblinded RCT found a lower rate of treatment failure
at 12 months for psyllium plus mesalamine (28%) ver-
sus mesalamine alone (35%). Four studies in patients
with Crohn’s disease (n = 465) found equivalence in
the number of patients with deteriorating disease at
24 months between the high-​fibre group (mean intake
27 g per day) and the low-​fibre group (mean intake 15 g
per day), one study found negative outcomes in patients
consuming a high-​fibre diet (33.4 ± 1.8 g per day, of
which 2.9 ± 0.3 g per day was from raw fruit and vegeta-
bles) with markedly higher treatment failure and shorter
time to relapse (1.4 versus 2.8 months) than patients
consuming a low-​fibre exclusion diet165. By contrast, an
observational cohort study in 1,619 patients with IBD
found that a higher fibre intake was associated with
reduced risk of flare in those with Crohn’s disease
(adjusted OR 0.58, 95% CI 0.37–0.90), but not in those
with ulcerative colitis (adjusted OR 1.82, 95% CI 0.92–
3.60), although intakes were measured using a 26-​item
self-​reported, retrospective dietary survey176. For treat-
ment of active disease, the systematic review included
five trials in patients with ulcerative colitis (n = 114) and
showed positive effects of fibre (for example, germinated
barley, combined oligofructose–inulin) on disease activ-
ity. Although five trials in patients with Crohn’s disease
(n = 193) showed no positive effect of fibre, three studies
showed equivalent effects of a high-​fibre diet compared
with another dietary intervention in cohorts with active,
inactive or mixed disease stages165.
Collectively, based on these results, although there
is limited evidence for the value of dietary fibre in the
maintenance or treatment of IBD, dietary fibre should
not be unnecessarily restricted in patients with IBD,
unless intestinal strictures are present and there is risk
of obstruction. Overall, the results suggest that ulcerative
colitis might be more amenable to dietary fibre inter-
ventions than Crohn’s disease, potentially due to the
formation of SCFAs at the site of disease165. Historically,
it has been common in clinical practice to recommend
reducing high-​fibre foods during relapse, although this
practice is not evidence-​based, and patients should be
monitored in regard to their tolerance to fibre during
both remission and relapse.
Diverticular disease. Diverticular disease refers to
herniation of the mucosa and submucosa through the
muscular layer of the colonic wall177. The pathogenesis
of diverticular disease relates to colonic smooth muscle
overactivity, thickening of the colonic wall and/or genet-
ics, in addition to lifestyle factors such as fibre intake
and physical activity, although associations remain
inconsistent178. The incidence of diverticular disease is
highest in economically developed countries with cases
continuing to increase, and is strongly associated with
age, with a prevalence of 5% in those under 40 years
and up to 65% in those over 65 years179. Although the
majority of patients with diverticular disease remain
asymptomatic (~80%), inflammation of a diverticulum
presents as diverticulitis that can vary in duration and
severity, but can be complicated by fistulae, abscesses,
obstruction and perforation180.
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A prospective cohort study in 46,295 men investigat-
ing the risk of developing diverticular disease, found a
positive association between a Western dietary pattern
and an increased risk of diverticulitis, in particular,
a higher consumption of red meat and lower consump-
tion of dietary fibre181. Similar results were found in the
Million Women Study including 690,075 women in
the UK whereby the relative risk of diverticular disease
for a 5 g per day greater fibre intake was 0.86 (95% CI
0.84–0.88). Notably, the source of fibre seemed to influ-
ence disease risk whereby an additional 5 g per day of
fibre from fruit (RR 0.81, 95% CI 0.77–0.86; P < 0.01) or
cereals (RR 0.84, 95% CI 0.81–0.88; P < 0.01) was associ-
ated with significant reductions in risk, an additional 5 g
per day of fibre from vegetables was not associated with
risk (RR 1.03, 95% CI 0.93–1.14; P = 0.634) whereas an
additional 1 g per day of fibre from potatoes was asso-
ciated with a greater risk (RR 1.04, 95% CI 1.02–1.07;
P = 0.002)182. By contrast, one observational case–control
study in 2,104 participants undergoing colonoscopy
found that a high-​fibre diet was not protective against
diverticular disease183; in fact, those with the highest
quartile of fibre intake showed an increased prevalence
of diverticular disease (prevalence ratio 1.30, 95% CI
1.13–1.50). However, it is important to note that dietary
intake was measured up to 12 weeks following colon­
oscopy and it is not possible to exclude alterations in diet
as a consequence, rather than a cause, of the diverticular
disease diagnosis. Overall, a meta-​analysis of five pro-
spective cohort studies (19,282 cases, 865,829 partici-
pants) found a reduced risk of diverticular disease, with
a relative risk of 0.74 (95% CI 0.71–0.78) for every addi-
tional 10 g per day of total fibre intake184. Again, the level
of protection varied with the fibre source, with an addi-
tional 10 g per day of fibre from fruit providing the great-
est protection (RR 0.56, 95% CI 0.37–0.84), followed by
cereals (RR 0.74, 95% CI 0.67–0.81) and vegetables (RR
0.80, 95% CI 0.45–1.44)184. The proposed mechanisms
by which fibre reduces the risk of diverticular disease
include increased stool bulk, decreased colonic pressure
and therefore reduced herniation.
In terms of fibre being used in the management of
acute diverticulitis, there is no consensus on fibre intake.
Some guidelines suggest a low-​fibre diet to ‘minimize
irritation’12 and a gradual increase to 20–30 g per day
through diet or as fibre supplements once inflammation
has resolved185. These recommendations are often used
in clinical practice, although they are based on physio-
logical rationale or uncontrolled studies, and not robust
clinical trials. A systematic review published in 2018 rec-
ommended that patients with uncomplicated diverticu-
litis should be placed on a liberalized diet (for example,
solid food, no bowel rest or nil by mouth), as opposed
to dietary restrictions, and a high-​fibre diet that meets
individualized nutrient requirements, with or without
fibre supplementation. However, it was recognized that
recommendations were based on a limited number of
low-​quality studies186.
In terms of fibre being used in the management
of uncomplicated diverticular disease, a systematic
review from 2012 (ref.187) found only three RCTs of
sufficient quality, although they yielded inconsistent
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findings188–190. In 2019, a systematic review of nine con-
trolled or uncontrolled trials in patients with asymp-
tomatic or symptomatic uncomplicated diverticular
disease identified only one study investigating the effect
of a high-​fibre diet with bran on the risk of developing
diverticulitis, but this study did not have a control group
against which to compare the risk191. In the remaining
studies, fibre supplementation improved stool weight
(mean difference, MD, +42 g per day; P < 0.00001) but
did not affect gastrointestinal symptoms (SMD −0.13;
P = 0.16) or gut transit time (MD −3.70; P = 0.32)191.
Overall, in those with diverticular disease there is lim-
ited evidence for an effect of fibre in preventing acute
diverticulitis.
Functional constipation. Functional constipation is
one of the most common functional bowel disorders
and is characterized by symptoms of difficult or infre-
quent stool passage, or incomplete defaecation, with-
out structural cause146. Unlike IBS in which abdominal
pain must be present, functional constipation does
not have abdominal pain as a predominant symptom,
and although not considered to be a serious condition,
it can lead to complications such as faecal impaction,
bowel perforation and haemorrhoids146, and the symp-
toms experienced are varied and place a burden on the
patient192. At present, there are limited data available on
the pathophysiology of functional constipation, although
lifestyle factors, including low fibre intake and low levels
of physical activity are associated with the presence of
constipation and may play a role in its aetiology192. The
majority of studies have focused on chronic constipa-
tion, the estimated global prevalence of which is 14%123,
although variations in symptoms used in self-​reporting
constipation result in varying numbers presenting to
their doctor193.
A number of large cohort studies have shown
positive associations between high intakes of dietary
fibre and stool frequency194,195. A systematic review
and meta-​analysis of seven RCTs concluded that fibre
is effective in treating chronic constipation in adults
compared with placebo. For example, fibre (dietary;
for example, wheat bran) and in supplement form (for
example, psyllium) including prebiotics (for example,
inulin) was associated with increased stool frequency
(SMD 0.39, 95% CI 0.03–0.76; P = 0.03) and more
normalized stool consistency (SMD 0.35, 95% CI
0.04–0.65; P = 0.02). In particular, subgroup analysis
suggested that a high dose (>15 g per day) of psyllium
was the most effective in increasing stool frequency
and improving stool consistency124. However, fibre
can induce other gastrointestinal symptoms such as
flatulence (compared with placebo: SMD 0.56, 95%
CI 0.12–1.00; P = 0.01). This meta-​analysis further
highlights the importance of choosing fibres with the
most appropriate physicochemical characteristics to
provide the preferred functional benefit. For exam-
ple, non-​v iscous, highly fermentable fibres such as
prebiotic fibres (inulin and galacto-​oligosaccharides)
did not consistently have any benefit over placebo in
increasing stool frequency and stool consistency. This
is because these fibres are almost completely fermented
in the colon so that and their water‐holding capacity is
lost. By contrast, viscous and poorly fermented fibres
such as psyllium retain their physicochemical charac-
teristics (such as high-​water holding and gel-​forming
capacity) throughout the gastrointestinal tract 59.
Indeed, although insoluble fibres containing large
and/or coarse particles can provide a regulatory
benefit94,196, there are fibres (wheat dextrin and finely
ground wheat bran) that have been shown to contribute
only to the dry mass of stool, resulting in decreased
stool water content and a constipating effect, potentially
exacerbating symptoms in those with constipation197.
This finding might, in part, explain the disparities in
the findings of previous studies showing laxative effects
of insoluble fibre198.
The effect of different quantities of different fibres
on health have been previously highlighted3. One review
that summarized the research of Burkitt, who advocated
the intake of >50 g per day of dietary fibre for preven-
tion of chronic disease (for example, colon cancer)199,
noted that fibre intakes of >35 g per day seem to be
more effective in reducing chronic disease than lower
intakes. Moreover, it has been suggested that the mini-
mal effects of fibre supplementation on health outcomes
shown in many of the intervention trials in humans to
date could simply reflect the insufficient quantity of fibre
supplement provided in these studies199.
Future research
Fibre co-​administration. Currently, extracted and
isolated fibres (such as inulin or psyllium) from vari-
ous sources are commonly added to food products to
enrich the fibre content, in order to assist people in
achieving the dietary recommendations for dietary fibre.
It is plausible that co-​administration of different
fibres (for example, combined isolated fibres) might
provide a ‘dual treatment’ by driving different func-
tionalities that target separate gastrointestinal features
(that its, the correction of dysbiosis, and normalization
of stool form and transit time), potentially maximizing
the effect of clinically meaningful symptom improve-
ment. Yet, to date, there is limited research in the area
of co-​administration. A 3-​week randomized crossover
block design study in 19 healthy volunteers found that
wheat bran plus resistant starch (12 g per day and 22 g
per day, respectively) produced greater benefits (such
as increased stool output, reduced transit time, reduced
faecal pH (a proxy for luminal pH, for which lower
values are associated with the suppression of potentially
pathogenic microorganisms), and increased concentra-
tions of acetate and butyrate) than wheat bran (12 g per
day) alone200. Furthermore, a study in animals demon-
strated that wheat bran combined with resistant starch
versus wheat bran alone can shift fermentation distally,
thus potentially improving the luminal environment and
providing protective effects further along the colon201.
In addition, an in vitro study using faecal microbiota
from healthy donors to compare degradation profiles of
single fibres (arabinoxylan, chondroitin sulfate, galac-
tomannan, polygalacturonic acid, xyloglucan) versus
a combination of these showed slower utilization of
some soluble dietary fibres when present in a mixture,
www.nature.com/nrgastro
 Reviews

suggesting that this strategy could be used as a means of Conclusions

delivering fibres to the more distal regions of the colon202.
Further research is required to determine whether fibre
combinations might be efficacious in the management
of gastrointestinal and other disorders. As our under-
standing of the physicochemical characteristics of
dietary fibre advances, co-​administration of known
fibres with different functional characteristics is likely
to offer greater therapeutic utility.
Natural fibres. Natural sources of dietary fibre are
increasingly used as they often contain many differ-
ent fibres. For this reason, they might hold some of the
benefits of co-​administration, have synergistic effects
and offer diverse functional characteristics that could
offer therapeutic potential in the management of a
range of gastrointestinal disorders. Examples of novel
plant-​based fibres include prickly pear, galactoman-
nan, plantain peel, ivy gourd, Gnetum africanum, yacon
root, Moringa oleifera, which have unique combinations
of different fibres and are rich sources of other bioac-
tive compounds, such as polyphenols, that have poten-
tial anti-​inflammatory and antibacterial properties203.
However, there are a limited number of studies of natural
fibres in the management of gastrointestinal disorders.
Manipulating and/or increasing fibre intake is a promising
therapeutic strategy in the prevention and management
of many gastrointestinal disorders. Physicochemical
characteristics such as solubility, viscosity and fermen­
tability drive different functionalities in the gastro­
intestinal tract, and therefore underpin their therapeutic
potential. Current guidelines and recommendations
reflect earlier studies that have used a wide range of die-
tary fibres with different physicochemical and functional
characteristics. The lack of consistency and reporting of
these characteristics in studies to date has limited the
clinical utility of dietary fibre for managing gastrointes-
tinal disorders. There is an urgent need for well-​designed
RCTs to determine which physicochemical character-
istics, and therefore which fibre sources, and in what
doses and durations are optimal for clinically mean-
ingful gastrointestinal health benefits. The utility of
co-​administration of different fibres with differing
physiological effects, or novel, naturally occurring die-
tary fibres with dual physiological properties has yet to
be explored and holds promise as a therapeutic strategy
across several gastrointestinal disorders.
Published online xx xx xxxx

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Acknowledgements
The authors acknowledge research funding from the Medical
Research Council investigating the effect of fibre on the gut
(MR/N029097/1).
Author contributions
All authors researched data for the article, contributed to
discussion and reviewed/edited the manuscript before
submission. S.K.G. and K.W. wrote the article.
Competing interests
The authors have received research grants related to dietary
fibre from government agencies including the Medical
Research Council and commercial funders including Clasado
Biosciences, Danone, Nestec, Almond Board of California and
the International Nut and Dried Fruit Council.
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