Mechanisms underlying immune effects of dietary oligosaccharides1–4
Prescilla V Jeurink, Betty CAM van Esch, Anneke Rijnierse, Johan Garssen, and Le´on MJ Knippels
ABSTRACT
The WHO refers to human milk as the nutritional gold standard for
term infants. Human milk contains many immunomodulatory com-
pounds, including oligosaccharides. Human-milk oligosaccharides
can serve as prebiotics because the nondigestible oligosaccharides
present in human milk show a clear bifidogenic effect on the gut
microbiota. Dietary oligosaccharide structures that have prebiotic
effects similar to human-milk oligosaccharides include galacto-
oligosaccharides, fructo-oligosaccharides, and pectin-derived acidic
oligosaccharides. Both animal studies and human clinical trials
showed that dietary intervention with these dietary oligosaccharides
in early life could lead to the prevention of atopic dermatitis, food
allergy, and allergic asthma. The immune-modulating effects of these
oligosaccharides are likely assisted via alteration of the intestinal
microbiota or in a microbiota-independent manner by direct interac-
tion on immune cells or both. In this review, an overview of the pre-
biotic role of dietary oligosaccharides on the microbiota and the
microbiota-independent immune modulation by these prebiotics is
provided. In addition, recent publications that report on the pathways
by which the oligosaccharides might exert their direct immunomod-
ulatory effect are summarized. Am J Clin Nutr 2013;98
(suppl):572S–7S.
INTRODUCTION
Hippocrates (460–377 BC), considered as the father of West-
ern medicine, stated, “Let medicine be thy food and food be thy
medicine,” which indicates that the medicinal properties of
various nutritional components have been appreciated since
ancient times. Hippocrates also documented medicinal proper-
ties of a powder made from willow bark and leaves containing
salicylic acid, which is now the most well-known painkiller
found in almost every home (aspirin). This shows how nature
delivers a chemical structure for medication such as aspirin. To
date, almost 70% of available drugs originate from chemical
compounds found in vegetables, plants, and fruit. In addition,
there is a large body of evidence that indicates that human health
is also modulated through interactions with microbes present in
the intestine. The beneficial effect of specific microbes was
postulated by the Nobel Prize winner Elie Metchnikoff .100 y
ago. He stated that certain lactic acid bacteria present in yogurt
were beneficial to health and had life-prolonging properties.
This notion has been validated by a broad array of products that
aim to improve human health through direct administration of
prebiotics or probiotics. Generally, prebiotics are described as “a
selectively fermented ingredient that allows specific changes,
both in the composition and/or activity in the gastrointestinal
microflora that confers benefits upon host well-being and
572S Am J Clin Nutr 2013;98(suppl):572S–7S. Printed in USA. Ó 2013 American Society for Nutrition
health” (1), whereas probiotics according to the FAO/WHO are
“live micro-organisms which, when administered in adequate
amounts, confer a health benefit on the host” (2).
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In this review, an overview of the prebiotic role of dietary
oligosaccharides on the microbiota as well as the microbiota-
independent immune modulation by these prebiotics is provided.
In addition, recent publications that report on the pathways by
which pre- and probiotics might exert their immunomodulatory
effect are summarized.
HOST HOMEOSTASIS
The gastrointestinal tract is the largest immune organ in the
body. It contains w65% of the overall immunologic tissues and
#80% of the immunoglobulin-producing tissues of the body.
These immunologic areas in the gastrointestinal tract are in-
volved in managing explicit pathogenic threats and in preventing
the induction of inflammation by damage-associated molecular
patterns. Recently, it has become clear that many gut-related
disorders are correlated with an imbalance in the microbiota and
the immune system. Well-known examples include inflamma-
tory bowel diseases such as Crohn disease and ulcerative colitis
(3, 4). In addition, impaired immune functioning is frequently
associated with irritable bowel syndrome, which is characterized
by the frequent occurrence of gut discomfort symptoms such as
diarrhea, constipation, or bloating (5–7). It is also recognized
that in other disease pathologies such as chronic heart failure
(8), autism (9), allergy (10–12), and HIV (13), the microbiota
and general gut integrity play a role.
The composition and development of the intestinal microbiota
in infants are influenced by genetic factors, exposure to microbes,
and mode of delivery but also to a large extent by the composition
of human milk, which also contributes to the maturation of the
infants’ immune system (14–16). Clinical data show that
1
From the Danone Research–Centre for Specialised Nutrition, Immunol-
ogy Platform, Wageningen, Netherlands (PVJ, BCAMvE, AR, JG, and
LMJK), and Utrecht Institute for Pharmaceutical Sciences, Faculty of Sci-
ence, Utrecht University, Utrecht, Netherlands (PVJ, BCAMvE, AR, JG, and
LMJK).
2
Presented at the symposium “Bringing Science to Early Life Nutrition”
held in Utrecht, Netherlands, 25 October 2011.
3
Supported by the non-profitable Dutch Top Institute Pharma Grant of the
project “Immune Modulation and Tolerance Induction, Prevention, and In-
hibition of Inflammatory Diseases (T1-214).”
4
Address correspondence to PV Jeurink, Danone Research–Centre for
Specialised Nutrition, PO Box 7005, 6700 CA Wageningen, Netherlands.
E-mail: prescilla.jeurink@danone.com.
First published online July 3, 2013; doi: 10.3945/ajcn.112.038596.
 IMMUNE EFFECTS OF OLIGOSACCHARIDES
breastfed children have high numbers of the health-promoting
lactobacilli and bifidobacteria, whereas children that are bottle-
fed with a cow-milk formula have significantly lower numbers
of these intestinal bacteria (17). This large impact of human
milk on an infant’s microbiota is important to reestablish the
immunologic balance that is skewed during pregnancy to avoid
rejection of the fetus by the mother’s body (15) and to set the
metabolic homeostasis (16).
HUMAN MILK
The WHO refers to human milk as the nutritional gold standard
for term infants. From a nutritional point of view, human-milk
compounds are therefore interesting targets for immunomodu-
latory research. Several studies have shown the antiinfective
properties of human milk, which reduces the incidence of gas-
trointestinal and nonenteric infections in infants (15). In addition
to these antiinfective properties, antiinflammatory properties of
human milk have been described (15). This is mainly of im-
portance during the bacterial colonization of the mucosal surfaces
of newborns. For example, in the skin and gut, large quantities of
microbial components are in direct contact with the sterile ne-
onate. Coordination of the inflammatory response occurring after
this first contact is vital. The epithelial layer, together with the
intraepithelial and immune-competent cells in the lamina propria,
is the most important player in regulating the recognition of
microorganisms and the maintenance of gut homeostasis. As
described in more detail by Oozeer et al (14) elsewhere in this
supplement, this gut-ecophysiology is important for metabolic,
immunologic, and even neurologic development, which em-
phasizes the diverse activity of human-milk compounds.
Human milk contains many immunomodulatory compounds,
including IgG, IgM, and isoforms of immunoglobulins (secretory
IgA), nucleotides, specific amino acids (taurine, polyamines),
PUFAs (EPA, DHA), monoglycerides, leuric acid, linoleic acid,
cytokines and chemokines, soluble receptors (CD14, Toll-like
receptor 2), antibacterial proteins/peptides (lactoferrin, lyso-
syme, b-lactoglobulin, casein), intact immune cells, and car-
bohydrates. Carbohydrates in human milk, such as lactose,
glycoconjugates, and oligosaccharides, display a multifunctional
activity spectrum as described in detail by Stahl (18) elsewhere
in this supplement. In addition to being an energy source, hu-
man-milk oligosaccharides (HMOS)5 can also serve as pre-
biotics because the nondigestible HMOS present in human milk
show a clear bifidogenic effect on the gut microbiota. However,
the HMOS composition of human milk cannot be generalized
because the mother’s secretor status and Lewis blood type de-
termine the fucosylation pattern and thereby the types of HMOS
present in human milk. Furthermore, Albrecht et al indicated
that the composition of human milk shows considerable differ-
ences in the carbohydrate content during different phases of
lactation (19). The literature on the effect of maternal diet on the
nutrient composition of human milk is scarce, although it has
5
Abbreviations used: AOS, acidic oligosaccharides; DC, dendritic cell; dp,
degree of polymerization; FOS, fructo-oligosaccharides; Foxp3, forkhead box
p3; GOS, galacto-oligosaccharides; HMOS, human-milk oligosaccharides;
lcFOS, long-chain fructo-ligosaccharides; MLN, mesenteric lymph node;
pAOS, pectin-derived acidic oligosaccharides; scGOS, short-chain galacto-
oligosaccharides; Th, helper T cell; Treg, regulatory T cell.
573S
been suggested that maternal factors such as diet have a larger
influence on human-milk composition in later lactation stages
than in the first few months (20).
MICROBIOTA-INDEPENDENT IMMUNE MODULATION
Apart from their prebiotic effect related to microbiota changes,
HMOS can act as receptor analogs to inhibit the adhesion of
pathogens on the epithelial surface (21). There is increasing
evidence that HMOS act directly on the immune system, most
likely via specific sugar receptors on immune cells (22–25).
HMOS have been shown to interfere with in vitro leukocyte
recruitment to sites of inflammation and to inhibit cell-cell in-
teractions of lymphocytes via selectins (24), whereas other
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HMOS inhibit adhesion to endothelial cells and leukocyte roll-
ing (22). Moreover, oligosaccharides have been shown to in-
terfere with T helper (Th)1/Th2 skewing in cord blood–derived
mononuclear cells (more interferon-g producing CD4+ T cells)
and to affect the Th2-type immune response of allergen-specific
T cells from peanut-allergic individuals (24, 25). These publi-
cations support the in vitro evidence for epithelial transport of
HMOS (24). Interestingly, Naarding et al (23) showed that
HMOS are able to bind specifically to the lectin receptor DC-
SIGN [dendritic cell (DC)–specific intercellular adhesion mol-
ecule-3-grabbing non-integrin] expressed by DCs. DC-SIGN
interacts with a variety of pathogens, including HIV-1, and
binding of HMOS inhibited the transfer of HIV-1 to CD4+ T
lymphocytes. The above-described data suggest that oligosac-
charides act systemically and are thereby modulating the im-
mune response in a microbiota-independent manner.
DIETARY OLIGOSACCHARIDES WITH FUNCTIONS
SIMILAR TO HMOSs
In human milk, the proportion of prebiotic carbohydrates is
substantial [12–15 g/L (26)], whereas prebiotic oligosaccharides
in cow milk are present only in trace amounts. In addition, the
HMOS composition is very complex because .200 different
HMOS structures have been determined (26). The HMOS
structures are often divided into 2 main categories: neutral and
acidic oligosaccharides (27). Within the neutral core structures
and fucosylated carbohydrates, 4 molecular masses represent
#70% of the total molecules, including isomeres of lacto-N-
tetraose, lacto-N-neotetraose, lacto-n-hexaose , monofucosyl-
lacto-N-hexaose, and difucosyl lacto-N-hexaose (26). The acidic
oligosaccharides (AOS) contain sialic acids or sulfate groups,
are present in human milk in relatively low amounts (1.5–3.3
g/L), and mainly consist of 5-N-acetyl-neuraminic acid (28).
Oligosaccharide structures that display prebiotic effects sim-
ilar to HMOS include galacto-oligosaccharides (GOS), fructo-
oligosaccharides (FOS), and AOS. Several types of GOS with
different chemical characteristics are used in immunomodulatory
research. GOS produced by glycosylation of lactose, by using
b-galactosidase enzymes, is usually referred to as b-linked GOS
(29). Short-chain GOS (scGOS) has not been studied widely
with respect to its immunomodulating effects as a single dietary
agent. Although antiallergic and antiinflammatory effects were
described for a-GOS (30, 31) and raffinose (31, 32), more work
is needed to clarify the effects of GOS and compare these
with similar effects of other (nondigestible) oligosaccharides.
574S JEURINK ET AL
Definitions of fructans, such as various types of FOS and inulin,
vary widely in the literature. Most described experiments were
performed with unprocessed chicory inulin or fructans derived
from chicory inulin. Unprocessed chicory inulin is mainly
composed of fructans with a degree of polymerization (dp)
ranging from 2 to 60, ending with a terminal glucose monomer.
Partially hydrolyzed inulin (short-chain FOS) has a typical dp
range of 2–8, and there are more molecules that end without
a terminal glucose monomer compared with inulin. The physical
removal of short-chain fructans from chicory inulin (33, 34)
leads to a mixture of fructans with terminal glucose monomers
and an approximate average dp of 22 [long-chain FOS (lcFOS)].
To stimulate the entire microbiota, a great variation of oli-
gosaccharide structures is needed, because HMOS comprise
many different oligosaccharides. Therefore, AOS such as
methylated pectin–derived AOS (pAOS) are under investigation
(35, 36). The addition of pAOS facilitates the required oligo-
saccharide diversity, because it is known that AOS act very
specifically to their acidity, enabling them to interact with sur-
faces and to prevent the adhesion of pathogens on the intestinal
epithelium.
Like HMOS, scGOS and lcFOS can complete the entire
gastrointestinal passage because they are detectable in the feces
of infants fed scGOS+lcFOS-supplemented formula (37). Several
clinical trials showed that feeding infants a formula supple-
mented with a specific mixture of scGOS (Vivinal GOS) and
lcFOS (Beneo HP) (ratio of 9:1; Immunofortis) resulted in an
intestinal microbiota similar to that found in breastfed infants—
ie, higher amounts of Bifidobacterium and Lactobacillus species
(17, 38, 39). Term infants who were fed a formula containing
pAOS with or without scGOS+lcFOS showed no differences in
growth, crying, vomiting, and regurgitation patterns compared
with the placebo group (35). Also in preterm infants, enteral
supplementation of a prebiotic mixture consisting of scGOS
+lcFOS+pAOS lowered the stool pH and stool viscosity with
a trend toward a higher stool frequency (40). The effects of
dietary oligosaccharides in infant formula on the microbiota and
their influence on human health are extensively described by
Oozeer et al (14) in this supplement issue.
The first postnatal year of life seems to be a key period for
programming the immune system. Feeding (ie, human milk) and
other factors to which a newborn is subjected (ie, antibiotics)
may have an influence on the indigenous gut microbiota, in-
testinal epithelial integrity, and the immune system. It is fur-
thermore known that infants are more prone to develop Th2
disorders, which might be partly associated with the immature
gut. Therefore, an imbalance in the immune system can lead to
immunologic disorders, with allergies and atopic dermatitis as
the most prevalent disorders (36). Chicken egg (4–5%), cow
milk (2–3%), and peanut (.1%) are the 3 most important di-
agnosed food allergies in young children (41, 42). Although it is
established that there is a strong genetic influence in the de-
velopment of food hypersensitivity, the answer to the question
of which factors are responsible for the rising number of al-
lergic children might also lie in the changing westernized
lifestyle, nutritional habits, higher consumption of food pre-
servatives and additives, environmental conditions, and air
pollution (43). Furthermore, the antigen type and dose, and the
age at which the first exposure occurs, are all mentioned as key
players in the subsequently evoked immune response (44). In
case of food allergy, the allergic response most likely occurs
because of either a failure in establishing oral tolerance or
a breakdown of existing tolerance. In addition, food allergy and
eczema are strongly correlated in children ,1 y of age, and
approximately one-third of them display atopic dermatitis
symptoms as a consequence of sensitization to food allergens
(45–47). Food allergens can exaggerate these atopic dermatitis
symptoms by activation of Th2 cells in the skin because the
gastrointestinal DCs are able to transport the allergen to the
skin where they can degranulate mast cells (48).
A large, prospective, randomized, double-blind, placebo-
controlled study in which healthy infants received a mixture of
scGOS+lcFOS+pAOS (ratio of 9:1:2) showed prevention of the
development of atopic dermatitis (49). Moreover, infants who
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were fed with scGOS+lcFOS (ratio of 9:1) showed increased
fecal secretory IgA, suggesting a positive effect on the immune
system (11). The direct beneficial effect on the immune system
was also shown in a study in infants at risk (ie, a family history of
atopy). In this study by Moro et al (50), the at-risk infants re-
ceived a hydrolyzed formula either supplemented with the scGOS
+lcFOS mixture or not supplemented during the first 6 mo of life.
The data indicate that the incidence of atopic dermatitis and
infectious diseases was reduced in infants who received the
prebiotic mixture during these first 6 mo (50). This protection
lasted, because the early-life intervention with these prebiotics
also resulted in significantly lower allergic symptoms at 24 mo of
age (51). Even after 5 y, preliminary observations in a subset
indicated that scGOS+lcFOS consumption early in life has
a protective effect on atopic dermatitis and allergic rhinitis (52). It
is therefore suggested that intervention with prebiotics early in
life induces a prolonged preventive effect on the development of
atopic disorders.
In addition to the effect on the allergic response, van Hoffen
et al (53) showed that scGOS+lcFOS supplementation of high-
risk infants reduced the total immunoglobulin response, modu-
lating the allergic response away from the symptom-inducing
IgE, whereas the vaccination response to DTP (diphtheria, tet-
anus, and polio) remained equally effective. Several other studies
also showed a reduced incidence of infections in combination
with a reduction in allergic disease outcomes after supplemen-
tation with scGOS+lcFOS-containing nutrition (54–56). In HIV-
1–infected individuals who were not receiving highly active
antiretroviral therapy, dietary scGOS+lcFOS+pAOS application
resulted in increased bifidobacteria amounts; reduced numbers
of Clostridium histolyticus, Eubacterium rectale, and Clostrid-
ium coccoides; reduced CD4+ T cell activation; and improved
natural killer cell cytotoxicity (57).
ROLE OF REGULATORY T CELLS IN IMMUNE
RESPONSES
The maintenance of a proper balance within the immune re-
sponses requires a well-orchestrated regulation. In food allergy,
the subtle balance between hypersensitivity and oral tolerance is
arranged by regulatory cells, including IL-10–producing Tr1
cells, natural killer T cells, and transforming growth factor
b–producing Th3 cells (58–60). Moreover, naturally occurring
CD4+CD25+Foxp3+ regulatory T cells (Tregs) have shown their
importance in the maintenance of peripheral tolerance and the
suppression of CD4+ and CD8+ T cell proliferation (61, 62).
 IMMUNE EFFECTS OF OLIGOSACCHARIDES
Interestingly, these Tregs can be generated de novo in, eg, the
intestinal mucosa (63). Approximately 5–10% of the CD4+ T
cell population are regulatory T cells, and most of them display
the transcription factor forkhead box p3 (Foxp3). Foxp3 is
considered to be a necessary gene for Treg generation and
maintenance (63). However, naturally occurring Tregs are
plastic, which means that they are capable of losing Foxp3 and
their regulatory function and, conversely, capable of acquiring
various effector functions (64). In addition to their crucial role in
oral tolerance development, Tregs are also increasingly prom-
inent in vaccine strategies because they serve to limit activation,
trafficking, and/or effector functions of both CD4+ and CD8+ T
cells (65, 66). During a primary immune response, the expansion
and attraction of conventional and Treg populations occur in
synchrony (67). More important, the relative accumulation of
Tregs at peak response significantly exceeds that of conventional
T cells, reflecting an extensive relation between Tregs and
conventional T cells, which control the magnitude of the re-
sponse (68). Little is known about the intracellular factors and
external cues for the differentiation and function of distinct Treg
populations. Recently, it has been shown that both Foxp3 as well
as T-bet (a transcription factor both necessary and sufficient for
Th1 differentiation) act jointly within Tregs to produce unique
functional outcomes in Th1 type of inflammation (69), sug-
gesting the possibility of specific immune response–related Treg
development.
The effects of scGOS+lcFOS have also been studied exten-
sively in mouse models for influenza vaccination (70), allergic
asthma (71), and cow milk allergy (12). Although the influenza-
specific vaccination response and fecal bifidobacteria and
lactobacilli proportions in scGOS+lcFOS-fed mice were signifi-
cantly enhanced, dietary intervention with scGOS+lcFOS+pAOS
was even more effective (72). Moreover, van’t Land et al (73)
showed that dietary scGOS1lcFOS1pAOS clearly induces
a more pronounced Th1 responsiveness, as shown by increased
Influenza-specific, delayed-type hypersensitivity responses and
T-bet expression levels. Furthermore, CD25+ Tregs played
a prominent role in the development of prebiotic scGOS+lcFOS
+pAOS-induced immune modulation toward enhanced Th1
vaccine responsiveness, because in vivo depletion of CD25+ cells
completely diminished scGOS+lcFOS+pAOS-induced immune
modulation toward control levels.
Dietary scGOS+lcFOS+pAOS was also investigated in an
experimental allergic asthma model in mice (71) and showed
a significant suppression of ovalbumin-induced airway in-
flammation and hyperresponsiveness. A similar allergy-reducing
effect of pAOS was observed in a model for cow-milk allergy to
whey, in which the severity of allergic symptoms, as determined
by a strongly reduced acute allergic skin response, in mice fed
the prebiotic diet during whey sensitization was ameliorated
(74). This reduced allergic skin response was accompanied by
a slight reduction in Th2-type Ig concentrations (whey-specific
IgE and IgG1) and unaltered high concentrations of Th1-type
IgG2a. Because naturally occurring or de novo–induced CD25+
Tregs are important for the acquisition of oral tolerance (61–
63), the contribution of these cells to the protective effect of the
prebiotic diet was studied by transferring spleen cells. The
beneficial diet-induced reduction in the allergic response was
transferable, and ex vivo depletion of CD25+ cells from the
transferred spleen cells abolished this effect (74). Similar re-
575S
sults were obtained in a study that used another cow-milk
protein, casein. Dietary scGOS+lcFOS+pAOS before and dur-
ing oral casein sensitization showed a strong reduction in the
allergic effector response compared with allergic control mice,
which could be abrogated by in vivo depletion of CD25+ Tregs
(75). Overall, these results indicate active regulation of the
mucosal immune response that occurs on sensitization with
casein or whey as a consequence of dietary intervention with
scGOS+lcFOS+pAOS.
Flinterman et al (76) showed that there is a considerable
chance of developing acute allergic reactions to cow milk after its
elimination in children with atopic eczema dermatitis syndrome
who previously did not experience problems after cow-milk
intake. A possible explanation for this was published by van Esch
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(77) who showed in a mouse model for cow-milk allergy that
partial and not extensive whey hydrolysates retained the putative
capacity to prevent allergic symptoms when given orally before
sensitization. In addition, the protective effects coincided with
elevated numbers of Tregs in the intestine and could be adop-
tively transferred by using mesenteric lymph node (MLN) cells.
In a subsequent study, they postulated that unique mucosal
CD103+ DCs, present in the lamina propria and MLNs, and
capable of sensing external stimuli present in the gastrointestinal
tract, possess the capability to induce Tregs that are responsible
for the above-described tolerance induction. Because systemic
oral tolerance to food antigens may be generated via the in-
duction of Tregs in the MLNs by antigen-presenting migratory
DCs arriving from the intestinal mucosa, the effect of dietary
scGOS+lcFOS+pAOS intervention in a cow-milk allergy model
on CD103+ DCs and CD4+CD25+Foxp3+ Tregs in MLN cells
was investigated. It was shown that scGOS+lcFOS+pAOS could
improve the tolerizing capacity of a partial whey hydrolysate,
and improved tolerance response coincided with increased per-
centages of CD11c+CD103+ DCs and Foxp3+ Tregs in MLN
cells (78).
CONCLUSIONS
In this review, the prebiotic function of dietary oligosaccha-
rides was compared with the functionality of HMOS. Both animal
studies and human clinical trials show that dietary intervention
with oligosaccharides in early life could lead to the prevention of
atopic dermatitis, food allergy, and/or allergic asthma. It is
thought that the immune-modulating effects of these oligosac-
charides are mediated via modification of the intestinal micro-
biota and/or in a microbiota-independent manner by direct
interaction on immune cells. These direct “pharmaceutical
properties” of oligosaccharides are very promising and should
be studied further. Because most studies to date are performed in
a preventive setup (ie, applying the prebiotics before induction
of the disease), studies investigating treatment protocols are
required to establish the capacity of oligosaccharides to reduce,
eg, established allergies. Moreover, the studies on the role of
Tregs indicate that dietary intervention induces Tregs that are (at
least in large part) responsible for the abrogation of allergic
symptoms and tolerance induction. In addition to the role in the
reduction of Th2-mediated allergic responses, Tregs also play
a prominent role in the development of prebiotic-induced
immune modulation toward enhanced Th1 Influenza-specific-
vaccination response.
576S JEURINK ET AL
We acknowledge Paul Vos, Belinda van’t Land, and Bastiaan Schouten for
their expertise in prebiotics. The non-profitable Dutch Top Institute Pharma
is acknowledged for providing assistance in the public-private partnership
project “Immune Modulation and Tolerance Induction, Prevention, and In-
hibition of Inflammatory Diseases (T1-214)” and for funding part of the
work described.
The authors’ responsibilities were as follows—BCAMvE and AR: con-
tributed equally to the review of the manuscript. JG is head of the Division of
Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of
Science at the Utrecht University; and LMJK is Group Leader of Immunol-
ogy at Danone Research–Centre for Specialised Nutrition. All authors, as
indicated by the affiliations, are part of a strategic alliance between Utrecht
University and Danone Research–Centre for Specialised Nutrition. JG and
BCAMvE are partly employed and AR, LK, and PJ fully employed by
Danone Research.
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