Higher protein diets consumed ad libitum improve cardiovascular risk markers in children of overweight parents from eight European countries

Dietary strategies to improve early cardiovascular markers in overweight children are needed. We investigated the effect of dietary protein and glycemic index (GI) on cardiovascular markers and metabolic syndrome (MetS) scores in 5- to 18-y-old children of overweight/obese parents from 8 European centers. Families were randomized to 1 of 5 diets consumed ad libitum: high protein (HP) or low protein (LP) combined with high GI (HGI) or low GI (LGI), or a control diet. At 6 centers, families received dietary instruction (instruction centers); at 2 centers, free foods were also provided (supermarket centers). Diet, anthropometry, blood pressure, and serum cardiovascular markers (lipid profile, glucose regulation, and inflammation) were measured in 253 children at baseline, 1 mo, and/or 6 mo. Protein intake was higher in the HP groups (19.9 ± 1.3% energy) than in the LP groups at 6 mo (16.8 ± 1.2% energy) (P = 0.001). The GI was 4.0 points lower (95% CI: 2.1, 6.1) in the LGI compared with the HGI groups (P < 0.001). In the supermarket centers, the HP and LP groups differed more in protein intake than did the groups in the instruction centers (P = 0.009), indicating better compliance. The HP diets evoked a 2.7-cm (95% CI: 0.9, 5.1) smaller waist circumference and a 0.25-mmol/L (95% CI: 0.09, 0.41) lower serum LDL cholesterol compared with the LP diets at 6 mo (P < 0.007). In a separate supermarket center analysis, the HP compared with LP diets reduced waist circumference (P = 0.004), blood pressure (P < 0.01), serum insulin (P = 0.013), and homeostasis model of assessment-insulin resistance (P = 0.016). In the instruction centers, the HP compared with the LP diets reduced LDL cholesterol (P = 0.004). No consistent effect of GI was seen and the MetS scores were not affected. In conclusion, increased protein intake improved cardiovascular markers in high-risk children, particularly in those undergoing most intensive intervention.

A multicentre weight loss study using a low-calorie diet over 8 weeks: regional differences in efficacy across eight European cities

PRINCIPLES

The efficacy of low-calorie diets (LCDs) has not been investigated in large-scale studies or among people from different regions, who are perhaps unaccustomed to such methods of losing weight. The aim of the present study was to investigate changes in obesity measures among overweight/obese adults from eight European cities (from Northern, Central and Southern Europe) during the 8-week LCD phase of the DiOGenes study (2006-2007), a family-based, randomised, controlled dietary intervention.

METHODS

938 overweight/obese adults completed baseline examinations and underwent an 8-week LCD, providing 3.3-4.2 MJ/day to replace all meals. Anthropometric measurements and body composition were assessed at baseline and post-LCD.

RESULTS

773 (82.4%) adults (mean age, 43.1 y) completed the LCD successfully. The highest drop-out rate was observed in Southern (24.9%) and the lowest in Northern (13.3%) European cities. Overall, the LCD induced favourable changes in all outcomes, including an approximate 11.0% reduction in body weight and body fat percentage. Changes in outcomes differed significantly between regions, with North- and Central-European cities generally achieving higher percentage reductions in most anthropometric measurements assessed. Nonetheless, participants in Southern Europe reduced their body fat percentage significantly more than participants in Northern Europe (-11.8 vs. -9.5%, P = 0.017).

CONCLUSIONS

The LCD significantly improved anthropometric and body composition measurements in all cities participating in DiOGenes.

Differences in food consumption according to weight status and physical activity levels among Greek children between 1992/93 and 2006/07

BACKGROUND

There is a lack of data in Greece on trends in food intake according to weight status and physical activity (PA), despite the high prevalence of obesity. The present study aimed to examine differences in these parameters among first-grade children from Crete, Greece, over a 15-year period.

METHODS

Children (aged 5.9-7.6 years) from two representative cross-sectional studies participated during 1992/93 (n = 245) and 2006/07 (n = 257). Estimated 3-day food records were used to assess food consumption and energy-density (ED) [kJ g(-1) (kcal g(-1) )]. Moderate-to-vigorous-PA (MVPA) and cardiorespiratory-fitness were assessed by questionnaires and the 20-m shuttle-run test (20mSRT), respectively.

RESULTS

In 2006/07, compared to 1992/93, both sexes had a significantly higher intake of dairy products and snacks (P < 0.001), a lower intake of cereals (P < 0.001) and higher cardiorespiratory fitness levels (P < 0.001). Among girls, fruit/vegetable consumption was higher (P < 0.05), although legume intake was lower (P < 0.005). Among overweight/obese (OW/OB) children, ED significantly decreased (P < 0.05) and the mean consumption of fruits/vegetables was higher (P < 0.001). The percentage of OW/OB boys was significantly higher (P < 0.001); however, MVPA was significant higher in this group compared to 1992/93 (P < 0.001). During the two time-periods, active children in 2006/07 appeared to have a lower ED than active ones in 1992/93 (P < 0.001).

CONCLUSIONS

Several differences in food intake were observed among first-grade children of Crete between 1992/93 and 2006/07, as characterised by significant increases in the consumption of dairy products and snacks and a decrease in the intake of cereals, among both sexes. Future school-based interventions in this population should emphasise the need to increase fruit/vegetable, unrefined cereal and legume consumption.

Analyses of single nucleotide polymorphisms in selected nutrient-sensitive genes in weight-regain prevention: the DIOGENES study

BACKGROUND

Differences in the interindividual response to dietary intervention could be modified by genetic variation in nutrient-sensitive genes.

OBJECTIVE

This study examined single nucleotide polymorphisms (SNPs) in presumed nutrient-sensitive candidate genes for obesity and obesity-related diseases for main and dietary interaction effects on weight, waist circumference, and fat mass regain over 6 mo.

DESIGN

In total, 742 participants who had lost ≥ 8% of their initial body weight were randomly assigned to follow 1 of 5 different ad libitum diets with different glycemic indexes and contents of dietary protein. The SNP main and SNP-diet interaction effects were analyzed by using linear regression models, corrected for multiple testing by using Bonferroni correction and evaluated by using quantile-quantile (Q-Q) plots.

RESULTS

After correction for multiple testing, none of the SNPs were significantly associated with weight, waist circumference, or fat mass regain. Q-Q plots showed that ALOX5AP rs4769873 showed a higher observed than predicted P value for the association with less waist circumference regain over 6 mo (-3.1 cm/allele; 95% CI: -4.6, -1.6; P/Bonferroni-corrected P = 0.000039/0.076), independently of diet. Additional associations were identified by using Q-Q plots for SNPs in ALOX5AP, TNF, and KCNJ11 for main effects; in LPL and TUB for glycemic index interaction effects on waist circumference regain; in GHRL, CCK, MLXIPL, and LEPR on weight; in PPARC1A, PCK2, ALOX5AP, PYY, and ADRB3 on waist circumference; and in PPARD, FABP1, PLAUR, and LPIN1 on fat mass regain for dietary protein interaction.

CONCLUSION

The observed effects of SNP-diet interactions on weight, waist, and fat mass regain suggest that genetic variation in nutrient-sensitive genes can modify the response to diet. This trial was registered at clinicaltrials.gov as NCT00390637.

Effects of Weight Loss and Long-Term Weight Maintenance With Diets Varying in Protein and Glycemic Index on Cardiovascular Risk Factors

Background—

We sought to separately examine the effects of either weight loss or diets varying in protein content and glycemic index without further changes in body weight on cardiovascular risk factors within the Diet, Obesity, and Genes study (DiOGenes).

Methods and Results—

DiOGenes is a pan-European controlled dietary intervention study in 932 overweight adults who first lost body weight on an 8-week low-calorie diet and were then randomized to 1 of 5 ad libitum diets for 26 weeks. The diets were either high or low protein or high or low glycemic index in 4 combinations or control. Weight loss (−11.23 kg; 95% confidence interval, −11.54 to −10.92; P <0.001) reduced high-sensitivity C-reactive protein (−1.15 mg/L; 95% confidence interval, −1.30 to −0.41; P <0.001), low- and high-density lipoprotein cholesterol, triglycerides, and blood pressure. During the 26-week weight maintenance period in the intention-to-treat analysis, the further decrease of high-sensitivity C-reactive protein blood levels was −0.46 mg/L greater (95% confidence interval, −0.79 to −0.13) in the groups assigned to low-glycemic-index diets than in those on high-glycemic-index diets ( P <0.001). Groups on low-protein diets achieved a −0.25 mg/L greater reduction in high-sensitivity C-reactive protein (95% confidence interval, −0.59 to −0.17) than those on high-protein diets ( P <0.001), whereas lipid profiles and blood pressure were not differently affected.

Conclusions—

This large-scale intervention study clearly separates weight loss from dietary composition–related effects. Low-glycemic-index carbohydrates and, to a lesser extent, low-protein intake may specifically reduce low-grade inflammation and associated comorbidities in overweight/obese adults.

Clinical Trial Registration—

http://www.clinicaltrials.gov . Unique identifier: NCT00390637.

Presence of metabolic syndrome and cardiovascular risk factors in adolescents and University students in Crete (Greece), according to different levels of snack consumption

The aim of this study was to investigate the presence of cardiovascular and metabolic syndrome (MetSyn) risk factors in adolescents and University students in Crete (Greece), according to different levels of snack consumption. 237 adolescents (14.2-16.3 years) and 196 University students (19.5-31.5 years) participated during 2002/3 and 2004/5. Dietary intake (24-h dietary recalls), cardiorespiratory fitness, smoking habits, time spent watching television, anthropometric, blood pressure and biochemical measurements were assessed in all subjects. Adolescents consumed snacks more often than University students (62% vs. 49.5%, P < 0.05) and had significantly higher total energy intake (8629 vs. 7641 kJ, P < 0.05) and energy intake from snacks (2537 vs. 1767 kJ, P < 0.001). Snack consumers had higher energy intake than non-consumers in both groups. No relationship was found between snack consumption and MetSyn risk factors, cardiorespiratory fitness and smoking. However, University students who consumed snacks had 15.36 times higher risk of having ≥ 2 MetSyn risk factors than adolescent snack consumers, had considerably higher LDL-cholesterol levels, total: HDL-cholesterol ratio and watched more television than non-consumers. These findings emphasize the need for developing effective nutrition interventions to promote healthier snack choices in adolescents and young adults with characteristics similar to our sample, in order to prevent cardiovascular risk later in adulthood.

Predictors of weight loss maintenance and attrition during a 6-month dietary intervention period: results from the DiOGenes study

There is a need to develop tools to predict individual weight loss maintenance and attrition prognosis. We aimed to identify predictors of weight loss maintenance outcome and attrition in subjects from eight European countries in the DiOGenes project. A total of 932 overweight/obese subjects (body mass index: 27-42 kg m(-2) ) were enrolled in an 8-week low-calorie diet (LCD). The 776 subjects (83%) who achieved at least 8% reduction in their initial body weight were randomized into five dietary arms varying in protein content and glycemic index for a 6-month weight maintenance period. Baseline characteristics, weight loss at weeks 1, 3 and 8 of LCD were assessed as predictors of weight loss maintenance and attrition using multivariate regression and correlation models. The multivariate model showed that the 6-month weight loss maintenance was predicted by: 7.889 - 0.343 × weight loss at week 3 + 1.505 × weight loss at week 8 + 2.422 × gender (0 = male and 1 = female gender) (R(2)  = 51%, P = 0.0001). A greater weight loss at week 8 was associated with a lower attrition during the subsequent 6-month dietary intervention period (OR = 0.92, 95% CI: 0.88-0.97, P = 0.001). Furthermore, the men showed an increased likelihood for attrition during the dietary intervention period (OR = 1.54, 95% CI: 1.07-2.20, P = 0.02). A greater weight loss during 8 weeks of LCD and female gender predict better 6-month weight maintenance of weight loss, whereas the baseline characteristics did not predict outcome. Attrition could be strongly predicted by gender and weight loss during LCD.

Secular changes in anthropometric measurements and blood pressure in children of Crete, Greece, during 1992/93 and 2006/07

OBJECTIVES

To examine secular changes in anthropometric measurements and blood pressure (BP) in 1st-grade children in Crete, Greece, during 1992/93 and 2006/07.

METHODS

Children (aged 5.7-7.8 years) from two representative cross-sectional cohorts participated during 1992/93 (n=606) and 2006/07 (n=361). Body weight, body-mass-index (BMI), waist circumference (WC), waist-to-hip (WHpR) and waist-to-height (WHtR) ratios, BP, 20 m-shuttle-run test (20 mSRT), and moderate-to-vigorous-physical-activity (MVPA) were assessed.

RESULTS

There was a significant increase (P<0.01) in body weight (+10.2% and +6.7%), BMI (+6.9% and +4.0%), WC (+5.6% and +5.1%), WHpR (+3.0% and +3.4%), and WHtR (+4.2% and +3.8%), for boys and girls, respectively, and in the proportion of overweight/obese boys (19.4% vs. 33.7%; P<0.001) between 1992/93 and 2006/07. Both genders had decreased BP measurements in 2006/07 compared to 1992/93 (P<0.001). In both periods, BP was higher in obese compared to overweight and normal children (P<0.001), but there was no relationship between BP and physical activity (PA).

CONCLUSIONS

A substantial decrease in BP was observed in Cretan children over a 15-year period, despite a concurrent increase in obesity and anthropometric indices. This may be attributed to lifestyle and dietary changes and does not support the hypothesis that the obesity epidemic in children has resulted in proportionate increases in BP levels.

Diets with high or low protein content and glycemic index for weight-loss maintenance

BACKGROUND

Studies of weight-control diets that are high in protein or low in glycemic index have reached varied conclusions, probably owing to the fact that the studies had insufficient power.

METHODS

We enrolled overweight adults from eight European countries who had lost at least 8% of their initial body weight with a 3.3-MJ (800-kcal) low-calorie diet. Participants were randomly assigned, in a two-by-two factorial design, to one of five ad libitum diets to prevent weight regain over a 26-week period: a low-protein and low-glycemic-index diet, a low-protein and high-glycemic-index diet, a high-protein and low-glycemic-index diet, a high-protein and high-glycemic-index diet, or a control diet.

RESULTS

A total of 1209 adults were screened (mean age, 41 years; body-mass index [the weight in kilograms divided by the square of the height in meters], 34), of whom 938 entered the low-calorie-diet phase of the study. A total of 773 participants who completed that phase were randomly assigned to one of the five maintenance diets; 548 completed the intervention (71%). Fewer participants in the high-protein and the low-glycemic-index groups than in the low-protein-high-glycemic-index group dropped out of the study (26.4% and 25.6%, respectively, vs. 37.4%; P=0.02 and P=0.01 for the respective comparisons). The mean initial weight loss with the low-calorie diet was 11.0 kg. In the analysis of participants who completed the study, only the low-protein-high-glycemic-index diet was associated with subsequent significant weight regain (1.67 kg; 95% confidence interval [CI], 0.48 to 2.87). In an intention-to-treat analysis, the weight regain was 0.93 kg less (95% CI, 0.31 to 1.55) in the groups assigned to a high-protein diet than in those assigned to a low-protein diet (P=0.003) and 0.95 kg less (95% CI, 0.33 to 1.57) in the groups assigned to a low-glycemic-index diet than in those assigned to a high-glycemic-index diet (P=0.003). The analysis involving participants who completed the intervention produced similar results. The groups did not differ significantly with respect to diet-related adverse events.

CONCLUSIONS

In this large European study, a modest increase in protein content and a modest reduction in the glycemic index led to an improvement in study completion and maintenance of weight loss. (Funded by the European Commission; ClinicalTrials.gov number, NCT00390637.).

Longer breastfeeding is associated with increased lower body explosive strength during adolescence

Our aim in this study was to examine the association between breastfeeding duration and cardiorespiratory fitness, isometric strength, and explosive strength during adolescence. A total of 2567 adolescents (1426 girls) from the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) cross-sectional study aged 12.5-17.5 y were included. Information about duration of any and exclusive breastfeeding was obtained retrospectively by means of a parental questionnaire. The 20-m shuttle run, handgrip strength, and standing long jump tests were used to assess physical fitness. Significant differences among the categories of breastfeeding duration were tested using ANCOVA after adjusting for a set of potential confounders: gestational and current age, birth weight, sexual maturation, fat mass, fat-free mass, maternal education, parental weight status, country, smoking behavior, and days of vigorous physical activity. Longer breastfeeding (either any or exclusive) was associated with a higher performance in the standing long jump test in both boys and girls (P < 0.001), regardless of fat mass, fat-free mass, and the rest of potential confounders. In adolescents who were breastfed for 3-5 mo or ≥6 mo, the risk of having a standing long jump performance below the 5th percentile was reduced by half compared with those who were never breastfed [odds ratio (OR) = 0.54, 95% CI = 0.30-0.96, P < 0.05; and OR = 0.40, 95% CI = 0.22-0.74, P < 0.01, respectively). These findings suggest a role of breastfeeding in determining lower body explosive strength during adolescence.

The effect of protein and glycemic index on children's body composition: the DiOGenes randomized study

OBJECTIVE

To investigate the effect of protein and glycemic index (GI) on body composition among European children in the randomized, 6-month dietary intervention DiOGenes (diet, obesity, and genes) family-based study.

PATIENTS AND METHODS

In the study, 827 children (381 boys and 446 girls), aged 5 to 18 years, completed baseline examinations. Families with parents who lost ≥ 8% of their weight during an 8-week run-in low-calorie diet period were randomly assigned to 1 of 5 ad libitum diets: low protein (LP)/low glycemic index (LGI); LP/high GI (HGI); high protein (HP)/LGI; HP/HGI; and control diet. The target difference was 15 GI U between the LGI/HGI groups and 13 protein percentage points between the LP/HP groups. There were 658 children examined after 4 weeks. Advice on food-choice modification was provided at 6 visits during this period. No advice on weight loss was provided because the focus of the study was the ability of the diets to affect outcomes through appetite regulation. Anthropometric measurements and body composition were assessed at baseline, week 4, and week 26.

RESULTS

In the study, 465 children (58.1%) completed all assessments. The achieved differences between the GI and protein groups were 2.3 GI U and 4.9 protein percentage points, respectively. The LP/HGI group increased body fat percentage significantly more than the other groups (P = .040; partial η(2) = 0.039), and the percentage of overweight/obese children in the HP/LGI group decreased significantly during the intervention (P = .031).

CONCLUSIONS

Neither GI nor protein had an isolated effect on body composition. However, the LP/HGI combination increased body fat, whereas the HP/LGI combination was protective against obesity in this sample of children.

Developing a methodology for assigning glycaemic index values to foods consumed across Europe

There is growing evidence that the glycaemic index (GI) of the diet is important with respect to body weight and metabolic disease risk. However, research is limited by the paucity of GI values for commonly consumed carbohydrate-rich foods in European countries. A new methodology has been developed for consistent assignment of GI values to foods across five European databases used in the Diogenes intervention study. GI values were assigned according to five decreasing levels of confidence (1) Measured values for specific foods; (2) Published values from published sources; (3) Equivalent values where published values for similar foods existed; (4) Estimated values assigned as one of three values representing low/medium/high GI ranges and (5) Nominal values assigned as 70, where no other value could be assigned with sufficient confidence. GI values were assigned to 5105 foods. In food records collected at baseline, the contribution to carbohydrate intake of foods assigned levels 1-2 ranged from 16% to 43% depending on country, and this increased to 53-81% including level 3 foods. The degree of confidence to assigned GI values differed across Europe. This standardized approach of assigning GI values will be made available to other researchers to facilitate further investigation into the effects of dietary GI on health.

Biomarker evaluation of Greek adolescents' exposure to secondhand smoke

Exposure to secondhand smoke (SHS) is a significant threat to public health, and represents a danger for both the development and health status of children and adolescents. Taking the above into account, our aim was to quantify Greek adolescents' exposure to SHS using serum cotinine levels. During 2006, 341 adolescents aged 13-17 were randomly selected from high schools in Heraklion and agreed to participate as part of the European Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study. Blood samples were drawn from a random sample of 106 adolescents, while serum cotinine/nicotine concentrations were measured by Gas Chromatography-Mass Spectrometry (GC-MS). The mean levels of serum cotinine and nicotine were calculated at 1.60 +/- 2.18 ng/mL and 4.48 +/- 4.00 ng/mL, respectively, while 97.7% of the non-smoker adolescents were found to have measureable levels of serum cotinine indicating exposure to SHS. The analysis revealed that their paternal (p = .001) and maternal smoking habits (p = .018) as also the existence of a younger brother or sister (p = .008) were the main modifiers of SHS exposure during adolescence. Conclusively, almost all of the measured Greek adolescents were exposed to SHS, even when their parents were non-smokers. This finding indicates the need for both community and school-based educational programmes as also the implementation of a comprehensive ban on smoking in public places.

Follow-up of a web-based tailored intervention promoting the Mediterranean diet in Scotland

OBJECTIVE

To assess the impact of a 3-month follow-up of a 6-month quasi-experimental study conducted to evaluate a web-based, tailored-feedback intervention promoting four key components of the Mediterranean diet.

METHODS

Fifty-three (intervention) and nineteen (control) healthy females, 25-55 years, employed at two Universities in Glasgow, Scotland, between 2003 and 2004 participated. Participants received tailored dietary and psychosocial feedback and Internet education, or minimal dietary feedback and general healthy-eating brochures, respectively. Dietary intake using 7d-estimated food diaries and blood lipids were assessed at baseline, 6 (post-test) and 9 months (follow-up).

RESULTS

Intention-to-treat analyses for between-group comparisons over time showed that the intervention group had increased their vegetable intake over 9 months and had more favourable levels of HDL-cholesterol and ratio of total:HDL-cholesterol over the 9-month assessment, compared with the control group. Within-group comparisons showed that, except for fruit consumption, the intervention group sustained their dietary improvement at 9 months, compared with baseline.

CONCLUSION

This intervention proved successful at sustaining most of the favourable dietary and blood lipid profile changes achieved over the 6-month intervention at the 3-month follow-up.

PRACTICE IMPLICATIONS

This intervention can be effective in promoting a Mediterranean-style diet in work settings.

Serum C-reactive protein at admission predicts in-hospital mortality in medical patients

BACKGROUND

Previous studies have examined the role of inflammatory markers in patients with coronary heart disease, stroke, chronic renal failure and other selected patient populations. The aim of this study was to assess the clinical utility of serum C-reactive protein (CRP) at admission in predicting outcome in hospitalized medical patients.

METHODS

All patients admitted to our medical department were eligible to be included in the study. At the time of admission, demographic and clinical information was obtained. CPR was measured within 12 h of hospitalization. The results were analyzed using Cox proportional hazards multiple regression model.

RESULTS

Three hundred eighty-two patients were included in the study (186 males and 196 females). Age (mean+/-standard deviation) was 70.8+/-15.7 years. Serum CRP [median (interquartile range) at admission was 29.7 mg/l (6.6-114.3). Serum CRP at admission was independently associated with in-hospital death. Levels above 120 mg/l increased the probability of fatal outcome three fold (hazard ratio=2.98, 95% confidence interval: 1.35-6.58). In patients older than 80 years, CRP at admission was a stronger predictor of in-hospital death (hazard ratio=5.41, 95% confidence interval: 1.38-21.26).

CONCLUSIONS

Serum CRP at admission is an independent predictor of mortality in hospitalized patients, particularly in the elderly. Admission CRP higher than 120 mg/l was associated with increased probability of in-hospital death (three fold in the overall population and five fold in the elderly subgroup) compared with lower levels.

Hormone therapy alters the composition of the vaginal microflora in ovariectomized rats

The aim of the present study was to evaluate the alterations that may take place in the bacterial genital tract flora in the absence of ovarian hormones. The role of hormone replacement therapy was also assessed. For this purpose, various bacteria were identified from the vaginal flora of ovariectomized and sham operated female rats, following the Bergey's manual criteria. The data of this study showed that substantial differences exist in the vaginal bacterial microflora between ovariectomized and normal cyclic rats. Ovariectomy was associated with a lower total bacterial load that may be due mainly to the absence of Lactobacillus. Anaerobic bacteria were also absent. Streptococcus and Enterococcus were also not favored in an environment lacking the ovarian hormones. In contrast, C. perfringens, Bacteroides, S. epidermidis, and S. aureus were detected in high numbers in ovariectomized rats. In terms of the impact of hormone replacement therapy on vaginal flora, only estradiol (EE2) restored Lactobacillus levels in ovariectomized rats, whereas all hormonal schemes used brought Streptococcus, Clostridium lec (-), and C. perfringens, the spore and vegetative forms, close to those detected in normal cyclic female rats. In conclusion, ovarian hormones appeared to be regulatory factors that favor the presence of a broad variety of bacteria, which are members of the normal genital tract flora. On the other hand, ovariectomy modifies the vaginal microbial profile, and hormone replacement therapy based mainly on schemes containing EE2 could alleviate this disturbance.