1 The E ffects of Potato Starch on Gastrointestinal Function and Symptoms Emily Keeter Food Science and Human Nutrition Department Faculty Adviser Dr. Wendy Dahl email@example.com 1924 NW1st Ave. Gainesville, FL 32603
2 Abstract The gastrointestinal benefits of fiber include stool bulking, increased stool frequency and decreased gastrointestinal transit time. However, Americans are currently consuming less than half of their recommended daily intake of fiber. Foods with added fiber may be needed to c lose the gap between recommendations and current intakes. However, all novel fibers need to be tested for efficacy. The purpose of this study was to determine the effects of resistant potato starch (RS) on stool bulking, daily bowel movement frequency (BMF ) and gastrointestinal symptoms (bloating, flatulence, abdominal cramping, intestinal noises, etc.). Using a randomized, crossover design, healthy adults (n=13) were fed biscotti and Koolaid fortified with a total of 30 g/d RS or similar control foods for 7 days, and commercially available, low fiber meals on days 3 to 7, with a 2 week washout period between treatments. All stools were collected throughout the 5 day dietary intervention. Daily diaries were completed throughout baseline and intervention to determine gastrointe stinal symptoms, daily BMF as well as overall well being. Participant T he study showed no significant difference between the control and RS treatment for gastrointestinal symptoms: bloating ( 0.7 0.8 vs 0.9 0.6; p = 0.47), flatulence ( 2.3 1.6 vs 2.2 1.3; p = 0.42), abdominal cramping ( 0.4 0.7 vs 0.8 0.9; p = 0.72), intestinal noises ( 1.2 0.9 vs 1.1 0.8; p = 0.37), and overall well being ( 0.1 0.1 vs 0.1 0.2; p = 0.65). Daily BMF did not change with the average number of bowel movements per day averaging to 1.1 0.5 for control and 1.1 0.4 for treatment groups. Stool bulking was also not signif icant between t he control (155.3g 46.3g ) and treatment period ( 158.5 g 45.8g ) T he resistant potato starch had no impact on gastrointestinal symptoms or function sug gesting that the proposed fiber may not be resistant. Further research is needed to determine the digestibility of the resistant potat o starch
3 Part 1: Literature Review 1.1 What is fiber and where can it be f ound? pg. 5 1.2 Fiber and Health 1.2.1 Fiber and Cardiovascular Health pg. 6 1.2.2 Fiber and Diabetes pg. 6 1.2.3 Fiber and Weight Loss pg. 7 1.2.4 Fiber and the Gastrointestinal Tract pg. 8 1.3 Resistant Starches pg. 8 1.4 Symptoms of Fermentation pg. 9 Part 2: Research Methods 2.1 Participants pg. 10 2.2 Consent and Preliminary Data pg. 1 1 2.3 Randomization pg. 1 1 2.4 Study Protocol pg. 1 1 Part 3: Results 3.1 Gastrointestinal Symptoms pg. 1 2 3.2 Stool Bulking and Frequency pg. 1 3 Part 4: Discussion pg. 1 3 References pg. 1 5 Table 1 pg.1 7 Table 2 pg. 1 7 Table 3 pg. 1 8 Appendix A pg. 1 9 Appendix B pg. 2 9 Appendix C pg 30
4 Appendix D pg. 3 1 Appendix E pg. 3 2 Appendix F pg. 3 4 Appendix G pg. 3 6
5 Part 1: Literature Review 1.1 What is f iber and where can it be found? In 1987 dietary fiber was defined by the Food and Drug Administration as the part of a plant that could not be digested by the h uman d igestive e nzyme s (IOM, 2001) ; however, the Institute of Medicine formed a panel to develop another definition of fiber. The Institute of Medicine differentiate s between dietary fiber and functional fiber, with functional fiber having favorable physiologic al effects in humans (IOM, 2001) The functional fiber definition includes nondigestible animal carbohydrates, carbohydrates not recovered by alcohol precipitation, but still resistant to the human digestive enzyme (i.e. inulin and oligofructose), nondiges tible mono/disaccharides, lignin, and finally resistant starches (Hollie et al, 2009). In the United States both children and adults currently consume on average less than half of the recommended A dequate I ntake (AI) levels of dietary fiber (Anderson et al, 2009). The IOM state s that the reco mmended intake for fiber is 14 g per 1,000 calories. Therefore, if you consume 2,000 calories per day, your recommended intake (RDA) would be 28 g /day (IMO, 2001) Dietary fiber can be found in fruits, v egetables, legumes, nuts and whole grains which consist of nondigestible carbohydrates and lignin that are intact and intrinsic in plants. F unctional fibers consist of isolated nondigestible carbohydrates that have beneficial physiological effects in human s (IOM, 200 1) The main benefits of fiber include the gastrointestinal effects o f stool bulking, increased daily bowel movement frequency (BMF) and decreased gastrointestinal transit time (GTT). Depending on the type of fiber, they provide these benefits in different ways. Fermentable fibers, are not digested in the small intestine, but are fermented by bacteria in the colon. Fermentable fibers bulk stools by increas ing the bacterial mass within the colon (Anderson et al 2009 ). Fermentation of fiber results in the production of short chain fatty acids that are absorbed and provide energy. S hort chain fatty acids may modulate glucose and fat metabolism in individuals (Roberfroid, 1993 ). Non fermen table fibers are excreted roughly the same as they were consumed and bulk stool by their water holding ability. 1.2 Fiber and Health 1.2.1 Fiber and Cardiov ascular Health
6 Cardiovascular d isease is one of the number one causes of death in the United States which encompasses stroke, heart attacks, coronary heart disease and hypertension (Anderson et al, 2009) Altho ugh many people do not yet have cardiovascular disease, they have one or more of the risk factors including: physical inactivi ty, smoking, obesit y, older age high blood pressure and central distribution of body fat. After years of research and multiple cohort studies on over 158,000 people, results indicate that coronary heart disease is less likely in individuals with high fiber consumption (Ande rson et al, 2009) Based on the available evidence, t he Food and Drug Administration has approved health claims that soluble fiber provides protection from coronary heart disease (FDA 1997 ). Snchez Muniz described the major effects of fiber within the body to protect against cardiovascular disease include: in creased bile acid synthesis due to increased secretion increased cholesterol synthesis in the l iver, increased bile acid binding and sterol binding decreased lipid emulsification in the small intestine, and increased short chain fatty acid production and fermentation in the large intestine (Snchez Muniz, 2012 ). It can also be speculated that increased fiber intake results in an overall healthier diet due to the foods that contain dietary fiber (i.e. fruits, vegetables legumes and whole grains) Therefore, c onsuming a healthier diet may lead to healthier body weight, decreased blo od pressure and an overall reduction of cardiovascular disease risks. 1.2.2 Fiber and Diabetes Type 2 diabetes is a growing epidemic around the world. According to the American Diabetes Association data from 2010 (release d 2011), 25.8 million Americans have diabetes and 79 million have symptoms of pre diabetes (ADA, 2011) The suggested diet for people with diabetes continues to vary slightly as new information about how certain nutrients effect insulin sensitivity. One suggested diet recommends carbohydrates between 55 65% of total energy, protein 12 16% of energy, BMI<25 kg/ m 2, moderat ion of mono/disaccharides, and fiber between 25 30g/day (Anderson et al, 2009 ).
7 One study performed by Weikert and his team showed that an increase in soluble dietary fiber over a three day period resulted in an improved whole body insulin sensitivity (We ickert et al, 2006 ). Other studies have shown that an increase in dietary fiber provides a decrease in postprandial glycemia and insulinemia (Haub et al, 2012). To assess the best diet options for those with diabetes, Anderson et al combined the results of 11 studies comparing high fiber, moderate carbohydrate diets versus moderate carbohydrate, low fiber diets and 13 studies comparing high fiber, high carbohydrate diets versus low carbohydrate, low fiber diets. There results showed that the high fiber, moderate carbohydrate diet significantly improved glycemic control and decreased fasting serum cholesterol levels. However, the high carbohydrate, high fiber diet yielded even more evidence for lower glucose and lipid levels in partici pants with diabetes. The study classified high carbohydrate as >60% of energy intake and high fiber as >20g/day. There was no real evidence in support a recommendation for insoluble fibers found in the studies (Anderson et al 2004 ). 1.2.3 Fiber and Weight Los s It is well known that the United States is currently facing an obesity epidemic in children and adults. The Center for Disease Control and Prevention states that in 2009 2010 approximately one third of all US adults were obese, and almost 17% of adolesce nts (Ogden et al 2012) It has long been speculated that fiber has the ability to produce higher post meal satiety, which in turn decreases hunger and decreases caloric intake to aid in weight loss or management (Howarth et al, 2001) Fiber may aid in weight lo ss by delaying gastric emptying and therefore enhances satiety Dietary fiber may also have protective benefits against the development of obesity (Anderson et al, 2009 ). In studies comparing the hunger and satiety between meals on high fiber versus control, high fiber has shown a decrease in hunger and increase satiety (Howarth et al, 2001 ) Fiber is thought to have this effect through a multitude of ways. One way is by in creasing the chewing time required. Foods high in fiber require more effort to chew, which increases satiation by slowing the rate of eating. Increased
8 chew time also increases water binding/ absorption which leads to stomach distention. When the stomach i s distended it triggers the feeling of fullness (Howarth et al 2001 ). Another method fiber implores to decease hunger, is in its ability to lower the energy density of foods. Fiber has a low energy content per unit weight due to the fact that roughly 60% of fiber is not fermented. This fact makes fiber a beneficial addition to the diet because it significantly lowers the energy density. In addition, both soluble and insoluble fibers bind to water causing the energy density to weight ratio to decrease even more ( Howarth et al, 2001 ). 1.2.4 Fiber and the Gastrointestinal Tract There are a few studies examining the benefits of fiber to prevent the occurrence of intestinal disorders such as colon cancer, Celiac Disease, Crohn s Disease, Irritable Bowel Syndrome (IBS) and Peptic Ulcer Disease (PUD) Spiller and Freeman present hypotheses as to how fiber may prevent colon cancer by affecting colon carcinogenesis. and f c ration of intestinal microbial flora either quantitatively 1981 ). The most common consensus remains in that dietary fiber works to prevent/ease the symptoms of gastrointestinal disorders. An increase in soluble fibe r correlates with lower levels of gastric acid which benefits patients with gastrointestinal reflux disorder (GERD) (Anderson et al, 2009) Constipation is the most common GI disorder and can be best prevented by an intake of insoluble fibers. Insoluble f ibers add bulk to the diet and are not broken down within the intestinal tract. This aids in preventing constipation by speeding up transit time. 1.3 Resistant Starches (RS)
9 Englyst et al first defined RS in whole plant cells or within the food matrix and some starch granules that have not been fully gelatinized, are hydrolyzed only very amylase and therefor e et al 1996 ). There are f ive primary types of RS ; however, type 2 3 and 4 are the most frequently studied (Haub et al 2012 ). All of the resistant starches undergo a certain extent of breakdown depending on amylase levels According to Cummings et al, resistant starches m a y resi st breakdown due to a few different reasons. The first explanation of resistance to digestion is the physical entrapment in food; second, the structure of the granules; third, retrogradation through food processing (Cumming s et al 1996 ). The resistant starches are differentiated by their makeup. Resistant starch 1 (RS1) is an inaccessible starch, RS2 is native granular starch with ungelatinized granules, RS3 is a retrograde amylase, and RS4 is chemically modified for indigestibility (Mart inez et al 2010 ). RS1 can be found in whole or partly milled grains, seeds, legumes and pasta. RS2 is found in raw potatoes, green bananas, and high amylase starches. RS3 is in cooked/ cooled potatoes, bread and cornflakes. RS4 is found in fibre drinks an d foods with modified starches (Nugent, 2005 ). Once the RS is consumed it escapes digestion in the small intestine and then affects the la rge bowel function. Roughly 10% may be excreted in the stools (Cummings et al 1996 ). Studies done on rats have shown that RS aid in lipid and glucose metabolism as well as the reduction of LDL, HDL, IDL, VLDL, and triglyceride levels (Nugent, 2005 ). 1.4 Symptoms of Resistant Starch Most fibers are known to create gastrointestinal symptoms with their consumption. These symptoms may include: flatulence, bloating, cramping, abdominal pain, gas, and increased daily BMF Although these are common symptoms associated with the consumption of fiber, there have been a multitude of studies testing the severity of the sympto ms against the amount consumed or the type of fiber consumed.
10 In a study done by Martinez, Jaehyoung and Duffy comparing crackers with RS 2 to crackers with RS 4 it was det ermined that resistance starches at 33g/day were well tolerated (Martinez et al, 201 0 ). To determine this, a weekly symptoms diary was completed by participants rating symptoms 1 (best) to 5 (worse) in the categories of bowel movement, stool consistency, discomfort, flatulence, abdominal pain and bloating. Flatulence showed a significant difference between RS2 and RS4 compared to the control group, but still tolerated by participants. Another study done by Maki, Reeves Sanders and Kaden demonstrated the positive beneficial symptoms provided by RS specifically RS3 (high amylase cornstarch) Adding 25g/day of RS3 in the diets of healthy adults provided an enhanced laxation effect (roughly 20% more) In increa se of fecal weight was also observed (Maki et al 2009 ). It was determined that after bowel regularity is ac hieved, 1 to 3 bowel movements per day, any additional dietary fiber does not contribute to regularity, but simply increases each individual stool weight (Maki et al 2009 ). Based on the known information of fiber and resistant starches, the purpose of this study was to determine the effects of resistant potato starch (RS) on stool bulking, daily bowel movement frequency (BMF) and gastrointestinal symptoms (bloating, flatulence, abdominal cramping, intestinal noises, etc.). The goal was to discover wheth er or not potato RS had the ability to increase stool bulking and frequency without causing any adverse GI symptoms. Part 2: Research Methods 2.1 Participants Staff and students aged between 18 and 65 years old w ere recruited via University of Florida lis tservs (e.g., department, club, organization, college, academic advising), social networks (e.g., Facebook, MySpace), flyers, posters and announcements. Interested volunteers had to be willing to complete daily questionnaires, provide a social security nu mber to receive payment, have internet access for the duration of the study, and be willing to eat the study foods for two periods of seven days.
11 Study volunteers were excluded if they had a physician diagnosed gastrointestinal disease or disease, short bowel disease, ileostomy, colostomy constipation, or diverticular disease), ha d a f ood allergy, or t ook dietary supplements (e.g. prebiotic and fiber supplements). Individual s with a high fiber intake (>20g/d) i.e. vegetarians and those determined to have a high fiber intake by food frequency (Block Fruit/Vegetable/ Fiber Screener http: //nutritionquest.com/assessment/list of questionnaires and screeners/), were excluded from study participation. 2.2 Consent and Preliminary Data Interested participants were instructed to contact the study coordinator (via study phone) and were read the inclusion/ exclusion criteria. Participants who indicated they met the inclusion/exclusion criteria were then scheduled for a consenting appointment. T hirteen participants were consented for the study. Study participants were asked to complete seven days of online 24 hour dietary recalls (ASA24, National Cancer Institute http://riskfactor.cancer.gov/tools/instruments/asa24 /) prior to the sta rt of the study to determine usual energy intake of participants Two baseline stools were collected along wi th height, weight and demographic information. 2.3 Randomization A 2 phase prospective, randomized, crossover design was used. Although, blinding is difficult to achieve in fiber studies, control low fiber foods similar to the resistant starch ( RS ) fortif ied foods were provided during the control period. Each treatment (control or RS was provided for 7 days separated by a 2 week washout period. Thirteen (male n=6 and female n=7 ) participants received a maximum of 30 g/d of RS and control through the provis ion of biscotti and Koolaid. In addition, the study participants received commercially available, pre prepared, lower fiber meals for five days (M F) during each treatment period. A total of 14 days were spent participating in the study. 2.4 Study Protocol
12 Informed consent was obtained and each participant was informed of the s tudy p rotocol prior to the start of the study. Study volunteers were provided study foods on a daily basis through the Clinical Lab in the Food Science and Human Nutrition bui lding. Weekend foo ds were provided on Fridays. Study volunteers during the treatment week ate biscotti and Koolaid fortified with RS as snacks during the day as well as pre prepared low fiber meals. Participants in the control group were given a similar biscotti or Koolaid without the added RS and the same instructions. After the first treatment period, a two week washout period preceded the next treatment. Participants were required to provide complete stool collections for 5 days throughout each of the two 7 d ay treatment periods. Participants were provided with coolers for transit. Total 3 day fecal collections were weighed. Participants w ere randomly assigned a st udy number depending on the order that they were consented into the study Daily diaries w e re complete d to determine gastrointestinal symptoms (gas, bloating, diarrhea etc), bowel movement times and frequency, measures of well being, as well as diet and stool collection compliance throughout the study. (no Participants were also asked to complete one week of pre baseline ASA 24 hr rec alls. The study coordinators monitor ed subject compliance on a daily basis and, if necessary, contact ed the study volunteers via phone o r email to remind them to complete their daily diaries and stool collections. Part 3: Results 3.1 Gastrointestinal Symptoms scores were analyzed. Individual scores for bloating, flatulence, abdominal cramping, intestinal noises, and other, were then averaged for each individual in both t he control and treatment group. Finally, the individual averages for the control and treatment group were averaged together to determine an overall average score for all of the gastrointestinal symptoms for each group. The two averages (control group and t reatment group) for each symptom were then compared using the T test and determining the P value.
13 The P value for each symptom was <0.05, concluding that all comparisons were not significant. The control and treatment means for each symptom are found in Ta ble 1 3.2 Stool Bulking and Frequency Based on the average weight of stool in the control group and the average weight of stool in the treatment group (Table 2) it can be concluded that 30g/day of potato RS does not increase st ool bulk The total numbe r of stool samples provided as well for the control and treatment groups (Table 2) was the exact same number (control, 1.1 0.5; treatment, 1.1 0.4 stools/day ) resulting in the conclusion that 30 g/day of potato RS d oes not increase daily BMF Part 4: Discussion A dding 30g/day of potato RS to diets did not increase the daily BMF or contribute to stool bulking. However, 30g/day of potato RS wa s well tolerated by individuals with no significant changes in gastrointestinal symptoms. Both the contr ol group and the treatment periods presented negligible gastrointestinal symptoms. Resistant starches are known to increase fecal bulkin g, as well as increase daily BMF The increase in stool bulking is caused by increasing the bacterial mass within the stool sample. An increase in bacterial mass is caused in large part by the resistant starch escaping digestion in the small intestine and then causing bacterial fermentation in the colon. This bacterial fermentation increases the bacterial mass within the stool prior to excretion. Due to the fact that our potato RS did not cause any increase in fecal bulking, it is hypothesized that the potato starch evaluated in this study did not escape digestion in the small intestine and therefore did not cause bacterial fermentation within the colon. Another product of fermentation in the colon is increased microbial activity. This increase in microbial activity can cause a mild laxat ive effect, which can increase daily BMF (Maki et al, 2009) Our research results show no increase in daily BMF between the control and treatment groups This data support the conclusion that there is no fermentation occurring in the colon due to the proposed RS
14 The data collected in this study supports the conclusio n that the potato RS used, was not in fact a resistant starch. With such a large consumption of a have been a significan t impact on fecal bulk.
15 References Anderson, James W., Pat Baird, Richard H. Davis Jr., Stefanie Ferreri, Mary Knudtson, Ashraf Koryam, et al. 2009. Health Benefits of Dietary Fiber. Nutrition Reviews 67.4: 188 205. Hollie A. Grabitske MS, RD & Joanne L. Slavin PhD, RD. 2009. Gastrointestinal Effects of Low Digestible Carbohydrates. Critical Reviews in Food Science and Nutrition. 49:4, 327 360. IOM. 2001. Dietary Reference Intakes: Proposed Definitions of Dietary Fiber. National Academy of Sciences, Washington, D.C. Jenkins, David J.A., and Cyril W.C. Kendall. 2000. Resistant Starches. Current Opinion in Gastroenterolgy 16:178 183. Roberfroid,M. 1993. Dietary fiber, inulin, and oligofructose: A review comparing their physiological effects. Critical Reviews in Food Science and Nutrition. 33:2, 103 148. Ludwig, David S., Mark A. Pereira, Candyce H. Kroenke, Joan E. Hilner, Linda Van Horn, et al.1999. Dietary Fiber, Weight Gain, and Cardiovascular Disease Risk Factors in Young Adults. Journal of the American Medical Association 282.16: 1539 1546. Snchez Muniz, F.J. 2012. Dietary Fibre and Cardiovascular Health. Nutricion Hospitalaria 27.1: 31 45. Weickert MO, Mohlig M, Schofl C, et al. 2006. Cereal fiber improves whole body insulin sensitivity in overweight and obese women. Diabetes Care.29:775 780. Anderson, James W., Kim M. Randles, Cyril W.C. Kendall, et al. 2004. Carbohydrate and Fiber Recommendations for Individuals with Diabetes: A Quantitative Assessment and Meta Analysis of the Evidence. Journal of the American Colle ge of Nutrition 23.4: 5 17. Howarth, Nancy, Edward Saltzman, and Susan B. Roberts. 2001. Dietary Fiber and Weight Regulation. Nutrition Reviews 59.5: 129 139. Spiller, Gene A., and Hugh J. Freeman. 1981. Recent Advances in dietary fiber and colorectal diseases. American Journal of Clinical Nutrition 34: 1145 1152. McDonald, Jane, Diane Pirhonen, and Mary Ann Rangam. 1983. High Fiber Diets: Their Role in Gastrointestinal Disorders. Can. Fam. Physician 29: 1632 1638. Haub, Mark A. Julie A. Louk, and Tara C. Lopez. 2012. Novel Resistant Potato Starches on Glycemia and Satiety in Humans. Journal of Nutrition and Metabolism 1 4. Englyst, Hans, Susan Kingman, Geoffery Hudson, and John Cummings.1996. Measurement of resistant starch in vitro and in vivo. British Journal of Nutrition 75. 749 755. Cummings, John, Emily Beatty, Susan Kingman, et al.1996. Digestion and physiological properties of resistant starch in the human large bowel. British Journal of Nutrition 75: 132 747. Martinez, Ines, J aehyoung Kim, Patrick Duffy, et al. 2012. Resistant Starches Types 2 and 4 Have Differential Effects on the Composition of the Fecal Microbiota in Human Subjects. Plos One 5.11: 1 11.
16 Nugent, A.P. 2005. Health properties of resistant starch. British Nut rition Foundation 30.1: 27 54. Stewart, Maria, Soma Nikhanj, Derek Timm, et al. 2012. Evaluation of the Effect of Four Fibers on Laxation, Gastrointestinal Tolerance and Serum Markers in Healthy Humans. Annals of Nutrition and Metabolism 56: 91 98. Maki, Kevin C., Lisa M. Sanders, Matthew S. Reeves, Valerie N. Kaden, et al.2009. Beneficial effects of resistant starch on laxation in healthy adults. International Journal of Food Sciences and Nutrition 60.S4: 296 305. Ogden, Cynthia L., Margaret D. C arroll, Brian K. Kit, et al. "Prevalence of Obesity in the United States, 2009 2010." National Center for Health Statistics Data Brief 82. (2012): 1 8. Web. 12 Feb. 2013. . "Diabetes Statistics." Americ an Diabetes Association American Diabetes Association, 26 Jan 2011. Web. 12 Feb 2013. . "Â§ 101.81 Health claims: Soluble fiber from certain foods and risk of coronary heart disease (CHD).." U.S. Food and Drug Administration Electronic Code of Federal Regulations, 8 Feb 2013. Web. 12 Feb 2013. . Instit ute of Medicine; Food and Nutrition Board. Dietary Reference Intakes: energy, carbohydrates, fiber, fat, fatty acids, cholesterol, protein and amino acids. Washington (DC): National Academies Press; 2005.
17 Table 1: Gastrointestinal Symptom Scores (1= Very Mild, 10= Very Severe) based on Daily Questionnaire Scores of Participants Control Mean (n=13) Treatment Mean (n=13) P Value Flatulence 2.3 2.2 NS Bloating 0.72 0.94 NS Intestinal Noises 1.2 1.1 NS Abdominal Cramping 0.37 0.85 NS Overall Well being 0.055 0.10 NS Table 2: Stool Averages and Stool Frequency for both Control and Treatment Groups Control Average #stools/day Treatment Average #stools/day Control Average Weight of Stool Treatment Average Weight of Stool St. Deviation Between Stool Averages RS39 2 1.6 138.71g 146.49g 5.50 RS40 1.8 2 135.12g 151.67g 11.7 RS41 1.6 0.8 139.49g 163.43g 16.9 RS42 0.4 0.8 186.95g 170.73g 11.5 RS43 1 0.8 214.22g 189.2g 17.7 RS44 1 0.8 209.08g 134.58g 52.7 RS45 1 1.2 93.38g 104.83g 8.10 RS46 1.4 2 145.70g 184.08g 27.1 RS47 0.8 0.8 99.85g 153.78g 38.1
18 RS48 0.8 0.8 144.18g 126.9g 12.2 RS49 0.6 1 247.73g 135.22g 79.5 RS50 1 1 218.7g 286.96g 48.3 RS51 1 0.8 134.84g 96.9g 26.8 Total Average 14.4 14.4 155.32g 158.49g 2.24 Table 3: Participant Demographic Table N=13 (6 male, 7 female) Average St. Deviation Height 182.05 cm 5.586 Pre treatment Weight 70.8 kg 6.3639 Treatment Weight 71.75 kg 6.0104 BMI 21.48 0.5515 Age 21.5 yrs 0.7071
19 Appendix A
29 Appendix B
30 Appendix C
31 Appendix D
32 Appendix E
34 Appendix F
36 Appendix G