Cancer patients receiving pelvic radiotherapy suffer side effects to the intestine, including diarrhoea and occasionally rectal bleeding, often worsened by chemoradiation. Many pelvic radiotherapy patients receive a form of dietary fibre, psyllium husk, to manage their diarrhoeal symptoms. There is evidence in mice that dietary fibre supplementation can improve tumour response and reduce normal tissue side effects caused by radiation. If this were to be confirmed in humans, it would be a major advance in patient treatment. The investigators will conduct a study in healthy subjects to assess mechanisms and response to dietary fibre.

The investigators will conduct a within-subject diet intervention study on healthy older adults (>60 years old) to determine if a subset of the population are responders to dietary fibre manipulation, using inulin with or without psyllium. This will allow assessment of the physiological impact of dietary fibre. Participants will receive placebo, inulin, or psyllium plus inulin in random order (6 possible combinations) for two weeks each with two-week washout periods.

Baseline faecal microbial activity, short chain fatty acid (SCFA) concentrations, and habitual fibre intake, determined by dietary questionnaires/food diaries will be used to identify individuals in whom dietary fibre manipulation might have a positive impact. Individuals who respond to dietary fibre supplementation may be found to have elevated levels of some SCFAs and significantly increased relative abundance of certain microbiota. Dietary parameters, bacterial relative abundance and SCFA levels will be correlated with plasma cytokine levels.

Of all patients receiving radiotherapy for cancer in 2018 and 2019, 28.6% were treated for a pelvic malignancy. The dose of radiotherapy necessary to cure the tumour often causes side effects in the surrounding healthy tissues, which can significantly impact the patients quality of life. Chemoradiation, the addition of chemotherapy to radiotherapy, improves tumour cure rates by radiosensitising the tumour, but at the expense of worsened normal tissue effects. Most patients over 80 years are unable to tolerate chemoradiation. With an aging population, there is an urgent clinical need to find alternatives to chemoradiation.

A difference in the composition and diversity of the gut microbiota has been found in responders versus non-responders to immunotherapy and in patients experiencing different levels of toxicities following radiotherapy. This indicates that the microbiota could be used to predict, prevent, or treat radiation enteropathy. An often-found side effect in pelvic radiotherapy patients is diarrhoea. Many pelvic radiotherapy patients receive a form of dietary fibre, known as psyllium husk (ispaghula husk or FybogelTM) to manage their diarrhoeal symptoms. Dietary fibres like psyllium and inulin are non-digestible carbohydrates found in fruits, vegetables, whole grains and legumes. They are anaerobically fermented by the gut bacteria, producing SCFAs, including acetate, propionate, and butyrate. SCFAs are the main performers in the interplay between diet, microbiota and health, and have anti-inflammatory and also anti-tumorigenic properties.

A high intake of dietary fibre is proven to decrease the risk of type 2 diabetes, colon cancer and cardiovascular disease by reducing the digestion and absorption of macronutrients and decreasing the contact time of carcinogens with the intestinal lumen. There is emerging evidence that the inclusion of dietary fibre supplements in the diet could modify the tumour response to radiotherapy. If confirmed in humans, this would be a major advance in patient treatment.

In a mouse model of colitis, exhibiting similar acute symptoms to those due to radiotherapy, the addition of psyllium in the diet reduced colonic inflammation and protected intestinal tight junctions. This prevented penetration of luminal inflammatory molecules through the gut wall. In a similar model system, psyllium reduced the severity of colitis in C57BL/6 specific pathogen-free and germ-free mice, via microbiota-dependent and independent mechanisms.

Inulin, another dietary fibre, is rapidly fermented in the proximal large intestine. Here, it selectively increases the growth of the butyrate producer Faecalibacterium prausnitzii and Bifidobacterium spp.. Bifidobacteria are associated with anti-tumour effects and augmented dendritic cell function leading to increased Cytotoxic T-cell (CD8+) priming and accumulation in the tumour microenvironment.

The investigators found promising preliminary data in our mouse studies, indicating that psyllium with inulin enhances tumour control. Immunodeficient mice fed a 10% inulin diet had an improved tumour control following 6 gray (Gy) ionising radiation. Immunocompetent mice showed a delayed tumour growth when receiving psyllium plus inulin when compared to a normal or low fibre diet, accompanied by significantly increased tumour infiltration of cytotoxic T cells. Psyllium plus inulin also significantly increased the percentage of intestinal remaining after 14 Gy compared to a low fibre diet or psyllium alone. A psyllium plus inulin diet also modified intestinal immunity, particularly B cells. Furthermore, in mouse bladder cancer cell UPPL 1591-derived allografts, CD8+ (cytotoxic) T cells scored higher for psyllium and psyllium plus inulin than psyllium plus resistant starch. However, compared to humans, inbred mice are genetically more similar and are held in controlled environmental conditions, so humans are likely to demonstrate more variability in response to dietary fibre intervention.

The investigators will study a group of human participants to assess tolerance and responses to inulin and psyllium plus inulin, in terms of intestinal side effects, significant alterations in the microbiota, levels of SCFAs in plasma and faeces, and plasma inflammatory cytokines. The investigators will also investigate whether responders and non-responders within the study can be identified from baseline dietary information and/or microbial activity (based on faecal SCFA measurements), as an individual's current diet will influence their response to dietary fibre modification.

Inclusion Criteria:

• >60 years old

Exclusion Criteria:

Medication exclusion criteria:

• Oral antibiotic use (within the past 3 months due to impact on gut microbiota).
• Anti-coagulants (Warfarin).
• Carbamazepine (epilepsy)
• Digoxin (heart conditions)
• Mesalazine (gut problems)
• Regular use of anti-constipation medication/laxatives.

Medical exclusion criteria:

• Food allergies, self-reported food sensitivity or intolerance.
• Type 1 or Type 2 diabetes.
• Coeliac disease or gluten intolerance.
• Metformin intake.
• Bowel obstruction
• Muscle weakness of the bowel
• Phenylketonuria.

Other exclusion criteria:

• Anyone with unsuitable veins for blood sampling.
• Anyone with chronic constipation (>3 days without defaecation).
• Anyone who is unable to fluently speak, read and understand English.

No.

The study will be double blind, meaning both the investigator and the participants will not know if the participants are receiving inulin, psyllium plus inulin or the placebo. However, there is some difference in the consistency of the powders. The supplements will be labelled A, B and C by an independent party otherwise not involved in the study, and the investigator and participants will not know which supplement is which letter during the study period.