Prebiotics in Reducing Inflammation and Clinical Endpoints in Ulcerative Colitis (PRInCE-UC)

This dietary intervention study will be carried out in a double-blind, cross-over manner, whereby 44 participants with mild to moderately active UC will be asked to consume an appropriate dose of the candidate prebiotic (2'-Fucosyllactose, a human milk oligosaccharide) for 28 days followed by a 28 day feeding period with an equivalent placebo (maltodextrin), or vice versa. Prebiotics are generally available in sachet form and participants will be instructed on how to take them each day.

Volunteer bowel habit, symptom scoring and quality of life: During supplementation and washout periods, the volunteers will be sent questionnaires to record their bowel habit, use of medication and adverse events. Volunteers will record the number of bowel movements per day, Bristol stool scale scores and any symptoms of bloating or abdominal discomfort (rated as none, mild, moderate or severe). Validated scoring systems will be used, namely the Simple Clinical Colitis Activity Index (SCCAI), a marker of clinical activity, and the IBD-Control questionnaire which is the International Consortium for Health Outcomes Measurement measure of choice for assessing disease-specific quality of life in IBD.

Selectivity index: The impact of prebiotic feeding upon relative numbers of potentially health promoting Bifidobacterium, Roseburia, Faecalibacteria and Lactobacilli (beneficial), upon numbers of commensal Eubacterium spp., Atopobium spp. and upon numbers of potentially detrimental members of the gut microflora namely Escherichia coli, proteolytic Bacteroides spp. and the Clostridium perfringens/histolyticum group will be determined within the faecal microflora. Moreover, functional capacity of the microbiome and the impact on the host metabolic phenotype will be determined by 1H-Nuclear Magnetic Resonance (NMR) spectroscopy-based metabonomics. These global profiles contain information relating directly to microbial metabolic processes, trans- genomic interactions as well as host endogenous metabolism. Through application of this top-down systems biology approach, biochemical responses of the host and microbiota to prebiotic exposure can be characterised.

Gut microbiota composition studies: Fluorescent in situ hybridisation (FISH) will be used to identify and enumerate principal anaerobic bacteria in the human studies, and flow cytometry will enable high throughput and sensitivity. In addition, a full qualitative assessment of community structure through a metagenomic approach using high capacity sequencing (454 pyrosequencing or similar) will be applied.

1H-NMR spectroscopy-based metabolic profiling studies: In this proposal, 1H-NMR spectroscopy will be applied to characterise global metabolic signatures from biological samples collected throughout the human trials, using standard one-dimensional NMR experiments. Gut microbiology and metabonomic data will be integrated using data fusion techniques (for example, bidirectional partial least squares multi-block data analysis) to generate mechanistic understanding of system-level changes and optimise extraction of clinically relevant molecular information. It is anticipated that this analysis will provide a measure of how prebiotic based intervention during the clinical trial has affected the human metabonome in a manner closer to 'health.'

Immunological assessments: Blood and faecal specimens will be used to determine immune cell counts and phenotypes. These data will show immunological status of the patients at any particular time of the trial - including inflammatory issues.

Immune cell subsets interacting with antigen presentation cell populations: The investigators will compare antigen-presentation by differentiated cell types (professional and stromal) and the extent to which they interact with effector T-cell subsets. It is likely that initial presentation of antigen to the immune system will differ between these groups and quantifying these interactions using 4-colour fluorescence immunohistology will provide mechanistic information of these processes and the progression of the UC disease state.

Data collected will be bacterial community profiles, immunological markers, blood/serum measurements, volunteer questionnaires, NMR-based metabonomic data, microbial end products and patient symptoms. These data will mostly be numerical and in the form of Excel spreadsheets, but will also include spectra data files, raw sequence files and food diary records (MS word/REDCap). Software for data analysis will be SAS (Statistical Analysis Software). Only the metabonomic NMR spectroscopy and microbial sequencing data files will generate moderately large data volumes. The investigators will identify community standards for data formatting for eventual deposit in data repositories.