Could phthalates exposure contribute to the development of metabolic syndrome and liver disease in humans?

Endocrine disrupting chemicals and obesity prevention: scoping review

INTRODUCTION

Exposure to endocrine disrupting chemicals (EDCs) can result in alterations of natural hormones in the body. The aim of this review article is to highlight the knowledge about EDCs and obesity.

METHODS

A scoping review of the electronic literature was performed using PubMed platform for studies on EDCs and obesity published between the years 2013-2023. A total of 10 systematic reviews and meta-analysis studies met our inclusion criteria on more prominent EDCs focusing mainly on bisphenols, including parabens, triclosan, and phthalates, and their association with obesity.

DESIGN

Scoping review.

RESULTS

EDCs, mostly bisphenols and phthalates, are related to health effects, while there is less information on the impact of parabens and triclosan. A series of negative physiological effects involving obesogenic, diabetogenic, carcinogenic, and inflammatory mechanisms as well as epigenetic and microbiota modulations was related to a prolonged EDCs exposure. A more profound research of particular pollutants is required to illuminate the accelerating effects of particular EDCs, mixtures or their metabolites on the mechanism of the development of obesity.

CONCLUSION

Considering the characteristics of EDCs and the heterogeneity of studies, it is necessary to design specific studies of effect tracking and, in particular, education about daily preventive exposure to EDCs for the preservation of long-term public health.

Environmental endocrine disruptor-induced mitochondrial dysfunction: a potential mechanism underlying diabetes and its complications

Diabetes and its complications significantly affect individuals' quality of life. The etiology of diabetes mellitus and its associated complications is complex and not yet fully understood. There is an increasing emphasis on investigating the effects of endocrine disruptors on diabetes, as these substances can impact cellular processes, energy production, and utilization, ultimately leading to disturbances in energy homeostasis. Mitochondria play a crucial role in cellular energy generation, and any impairment in these organelles can increase susceptibility to diabetes. This review examines the most recent epidemiological and pathogenic evidence concerning the link between endocrine disruptors and diabetes, including its complications. The analysis suggests that endocrine disruptor-induced mitochondrial dysfunction-characterized by disruptions in the mitochondrial electron transport chain, dysregulation of calcium ions (Ca2+), overproduction of reactive oxygen species (ROS), and initiation of signaling pathways related to mitochondrial apoptosis-may be key mechanisms connecting endocrine disruptors to the development of diabetes and its complications.

In silico analysis of endocrine-disrupting potential of triclosan, bisphenol A, and their analogs and derivatives

Owning to the increasing body of evidence about the ubiquitous exposure to endocrine disruptors (EDCs), particularly bisphenol A (BPA), and associated health effects, BPA has been gradually substituted with insufficiently tested structural analogs. The unmanaged excessive use of antimicrobial agents such as triclosan (TCS) during the COVID-19 outbreak has also raised concerns about its possible interferences with hormonal functions. The similarity of BPA and estradiol, as well as TCS and non-steroidal estrogens, imply that endocrine-disrupting properties of their analogs could be predicted based on the chemical structure. Hence, this study aimed to evaluate the endocrine-disrupting potential of BPA substitutes as well as TCS derivatives and degradation/biotransformation metabolites, in comparison to BPA and TCS based on their molecular properties, computational predictions of pharmacokinetics and binding affinities to nuclear receptors. Based on the obtained results several under-researched BPA analogs exhibited higher binding affinities for nuclear receptors than BPA. Notable analogs included compounds detected in receipts (DD-70, BTUM-70, TGSA, and BisOPP-A), along with a flame retardant, BDP. The possible health hazards linked to exposure to TCS and its mono-hydroxylated metabolites were also found. Further research is needed in order to elucidate the health impacts of these compounds and promote better regulation practices.

Associations between exposure to phthalates and liver function among women undergoing assisted reproductive technology

Phthalates can induce hepatotoxicity in animal studies. We aimed to assess the associations of individual and mixture of urinary phthalate metabolites with serum liver function indicators among 764 women undergoing assisted reproductive technology (ART). In linear models, we observed inverse correlations between urinary mono-benzyl phthalate and serum total protein (TP) as well as globulin (β=-0.27 and -0.23, respectively, P<0.05). Additionally, negative associations were identified between mono-isobutyl phthalate and mono-butyl phthalate (MBP) and aspartate aminotransferase-to-alanine transaminase ratio (AST/ALT) (P<0.05). MBP and the sum of all phthalate metabolites (∑all.phth.m) were positively associated with bilirubin, with β ranging from 0.14 to 0.47. Most phthalate metabolites were also positively related to gamma-glutamyl transferase (GGT) (all P<0.05). In Bayesian kernel machine regression models, phthalate mixture was positively associated with bilirubin and GGT, whereas inversely associated with AST/ALT and TP. Our results suggest that phthalate exposure may impair liver function among women undergoing ART.

Phthalate Exposure and Coronary Heart Disease: Possible Implications of Oxidative Stress and Altered miRNA Expression

The relationship between phthalate exposure and coronary heart disease (CHD) is still unclear. This study aimed to investigate the association between phthalate exposure and CHD and determine the possible atherogenic mechanisms of phthalates by assessing oxidative stress and altering miRNA expression. This case-control study included 110 participants (55 CHD patients and 55 healthy controls). The levels of oxidative stress markers, malondialdehyde (MDA), and superoxide dismutase (SOD), and the expression of miRNA-155 (miR-155) and miRNA-208a (miR-208a), were measured and correlated with the urinary mono-2-ethylhexyl phthalate (MEHP). Highly significant differences were detected between the CHD cases and the control group regarding MEHP, MDA, SOD, miR-155, and miR-208a (p-value < 0.001). Spearman correlations revealed a significant positive correlation between MDA and MEHP in urine (P = 0.001 and rs = 0.316) and a significant negative correlation between SOD and MEHP in urine (P < 0.001 and rs = -0.345). Furthermore, significant positive correlations were observed between miR-155 and urinary MEHP (P = 0.001 and rs = 0.318) and miR-208a and urinary MEHP (P < 0.001 and rs = -0.352). This study revealed an association between phthalate exposure, as indicated by urinary MEHP and CHD; altered expression of miR-155 and miR-208a and oxidative stress could be the fundamental mechanisms.

Comparison of phthalate esters (PAEs) in freshwater and marine food webs: Occurrence, bioaccumulation, and trophodynamics

Phthalate esters (PAEs) have received widespread attentions due to their ubiquity in various kinds of matrices and potential biotoxicity. This study systematically compared the concentrations, bioaccumulation, trophodynamics and health risk of PAEs in 25 species (n = 225) collected from a marine (Bohai Bay, BHB) and freshwater environment (Songhua River, SHR), China. Results showed that di-(2-ethylhexyl) phthalate and di-n-butyl phthalate were the predominant PAEs in the organisms from the two aquatic environments. The total concentrations of 6 PAEs in algae and fish from SHR were significantly higher than those from BHB. Two food webs were constructed in BHB and SHR based on the abundance of 15N in the organisms. All the PAEs except dimethyl phthalate exhibited trophic dilution with the trophic magnification factors less than 1. Moreover, an obvious biodilution of PAEs was observed in marine food web compared to freshwater food web. A low health risk of PAEs was found in organisms from both BHB and SHR. However, di-(2-ethylhexyl) phthalate exhibited a potential carcinogenic risk by consumption of some benthos in BHB and fish in SHR. This study provides a valuable perspective for understanding the trophodynamics and health risk of PAEs in marine and freshwater environments.

Telomere length as a modifier in the relationship between phthalate metabolites exposure and glucose homeostasis

Given the rising concern over the potential impact of environmental factors on metabolic heath, we conducted a cross-sectional analysis among 645 adults aged 20 and older in the National Health and Nutrition Examination Survey (NHANES), examining the association between nine phthalate metabolites (Mono-n-butyl phthalate (MBP), Mono-ethyl phthalate (MEP), Mono-(2-ethyl)-hexyl phthalate (MEHP), Mono-benzyl phthalate (MBzP), Mono-n-methyl phthalate (MnMP), Mono-(3-carboxy propyl) phthalate (MCPP), Mono-(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), Mono-(2-ethyl-5-oxohexyl) phthalate (MEOHP), Mono-isobutyl phthalate (MiBP)) and six glucose homeostasis indices (fasting glucose, fasting insulin, hemoglobin A1C (HbA1C), homeostatic model assessment of insulin resistance (HOMA-IR), single Point Insulin Sensitivity Estimator (SPISE), and HOMA-β). Latent Class Analysis identified three phthalate metabolites exposure patterns: high MEP-low MEOHP (n = 282), high MBzP-low MEHHP (n = 214), and high MEHHP, MEOHP (n = 149). The high MBzP-low MEHHP and high MEHHP, MEOHP, versus the high MEP-low MEOHP, exposure groups showed significantly higher levels of fasting insulin (β = 0.126, 95% CI: 0.023-0.228), SPISE (β = 0.091, 95% CI: 0.018-0.164), and HOMA-IR (β = 0.091, 95% CI: 0.018-0.164). In the shorter telomere length group, high MEHHP, MEOHP exposure showed an increase in SPISE levels (β = 0.153, 95% CI: 0.037-0.269), while in the overweight/obese subgroup, high MEHHP, MEOHP exposure was significantly positively associated with HOMA-IR (β = 0.392, 95% CI: 0.150-0.735). Bayesian kernel machine regression analyses showed positive associations between higher combined phthalate exposure and increased glucose homeostasis indices (fasting glucose, HbA1C, fasting insulin, SPISE, and HOMA-IR). The quantile of g-calculation analysis also supported the positive associations with HbA1C, HOMA-IR, and fasting insulin. Our findings indicate that phthalate exposure was positively associated with glucose homeostasis indices, which strengthen the call for proactive measures to reduce phthalate exposure and mitigate potential risks to glucose metabolism.

Phthalate exposure and the metabolic syndrome: A systematic review and meta-analysis

Phthalates are chemicals widely used in plastic-based consumer products, and human exposure is universal. They are classified as endocrine disruptors, and specific phthalate metabolites have been associated with an increased risk of cardiometabolic diseases. The aim of this study was to assess the association between phthalate exposure and the metabolic syndrome in the general population. A comprehensive literature search was performed in four databases (Web of Science, Medline, PubMed, and Scopus). We included all the observational studies that evaluate the association between phthalate metabolites and the metabolic syndrome available until January 31st, 2023. Pooled Odds Ratios (OR) and their 95% confidence intervals were calculated by using the inverse-variance weighted method. Nine cross-sectional studies and 25,365 participants aged from 12 to 80 were included. Comparing extreme categories of phthalate exposure, the pooled ORs for the metabolic syndrome were: 1.08 (95% CI, 1.02-1.16, I2 = 28%) for low molecular weight phthalates, and 1.11 (95% CI, 1.07-1.16, I2 = 7%) for high molecular weight phthalates. For individual phthalate metabolites, the pooled ORs that achieved statistical significance were: 1.13 (95% CI, 1.00-1.27, I2 = 24%) for MiBP; 1.89 (95% CI, 1.17-3.07, I2 = 15%) for MMP in men; 1.12 (95% CI, 1.00-1.25, I2 = 22%) for MCOP; 1.09 (95% CI, 0.99-1.20, I2 = 0%) for MCPP; 1.16 (95% CI, 1.05-1.28, I2 = 6%) for MBzP; and 1.16 (95% CI, 1.09-1.24, I2 = 14%) for DEHP (including ΣDEHP and its metabolites). In conclusion, both low molecular weight and high molecular weight phthalates were associated with an 8 and 11% higher prevalence of the MetS, respectively. The exposure to six specific phthalate metabolites was associated with a higher prevalence of the MetS.

Food contaminants and potential risk of diabetes development: A narrative review

The number of people diagnosed with diabetes continues to increase, especially among younger populations. Apart from genetic predisposition and lifestyle, there is increasing scientific and public concern that environmental agents may also contribute to diabetes. Food contamination by chemical substances that originate from packaging materials, or are the result of chemical reactions during food processing, is generally recognized as a worldwide problem with potential health hazards. Phthalates, bisphenol A (BPA) and acrylamide (AA) have been the focus of attention in recent years, due to the numerous adverse health effects associated with their exposure. This paper summarizes the available data about the association between phthalates, BPA and AA exposure and diabetes. Although their mechanism of action has not been fully clarified, in vitro, in vivo and epidemiological studies have made significant progress toward identifying the potential roles of phthalates, BPA and AA in diabetes development and progression. These chemicals interfere with multiple signaling pathways involved in glucose and lipid homeostasis and can aggravate the symptoms of diabetes. Especially concerning are the effects of exposure during early stages and the gestational period. Well-designed prospective studies are needed in order to better establish prevention strategies against the harmful effects of these food contaminants.

Association between ultra-processed foods intake with lipid profile: a cross-sectional study

The purpose of this cross-sectional study was to examine the association between ultra-processed foods (UPFs) intake and lipid profile in Iranian people. The study was performed on 236 individuals with the age range of 20-50 years in Shiraz, Iran. Food intakes of the participants were evaluated using a 168-item food frequency questionnaire (FFQ) which was previously validated in Iranian populations. In order to estimate the ultra-processed foods intake, classification of NOVA food group was used. Serum lipids including total cholesterol (TC), triglyceride (TG), high density lipoprotein cholesterol (HDL-C) and low density lipoprotein cholesterol (LDL-C) were measured. The results showed that mean of age and body mass index (BMI) of the participants were 45.98 years and 28.28 kg/m², respectively. Logistic regression was used to evaluation the relation between UPFs intake and lipid profile. Higher UPFs intake was associated with increased OR of TG and HDL abnormality in both crude (OR 3.41; 95% CI 1.58, 7.34; P-trend = 0.001 and OR 2.99; 95% CI 1.31, 6.82; P-trend = 0.010) and adjusted models (OR 3.69; 95% CI 1.67, 8.16; P-trend = 0.001 and OR 3.38 95% CI 1.42, 8.07; P-trend = 0.009). But, there were no association between UPFs intake and other indices of lipid profile. Also, we found significant associations between UPFs intake and dietary nutrient profiles. In conclusion, UPFs consumption could worsen the nutritional profile of the diet and lead to negative changes in some indices of the lipid profile.

Comprehensive investigation of hepatotoxicity of the mixture containing phthalates and bisphenol A

Connections between the mixture containing bis(2- ethylhexyl) phthalate (DEHP), dibutyl phthalate (DBP) and bisphenol A (BPA) and liver injury were explored through in silico investigation and 2 in vivo models. Comparative Toxicogenomics Database (CTD), ShinyGO, ToppCluster and Cytoscape were used for bioinformatic analysis. In vivo subacute study was performed on rats - five groups (n = 6): (1) Control: corn oil, (2) DEHP: 50 mg/kg b.w./day, (3) DBP: 50 mg/kg b.w./day, (4) BPA: 25 mg/kg b.w./day, (5) MIX: DEHP + DBP + BPA. Zebrafish embryos were exposed to the investigated substances in different doses, singularly and combined (binary and ternary mixtures). Liver injury was linked to 75 DEHP, DBP, and BPA genes, mostly connected to inflammation/oxidative stress. In rats, significant alterations in redox status/bioelements and pathohistology were most notable or exclusively present in MIX (probable additive effects). BPA decreased liver area (LA) index in dose-dependent manner. DEHP (< 2 µg/mL) and DBP (≤ 5 µg/mL) reduced LA values, while their higher doses increased LA index. The effect of DBP in binary mixtures led to a lethal outcome at the two highest concentrations, while the hepatotoxicity of DEHP/DBP/BPA mixture was dictated by BPA (confirmed by the benchmark dose analysis).

Comprehensive insight into triclosan-from widespread occurrence to health outcomes

Humans are exposed to the variety of emerging environmental pollutant in everyday life. The special concern is paid to endocrine disrupting chemicals especially to triclosan which could interfere with normal hormonal functions. Triclosan could be found in numerous commercial products such as mouthwashes, toothpastes and disinfectants due to its antibacterial and antifungal effects. Considering the excessive use and disposal, wastewaters are recognized as the main source of triclosan in the aquatic environment. As a result of the incomplete removal, triclosan residues reach surface water and even groundwater. Triclosan has potential to accumulate in sediment and aquatic organisms. Therefore, the detectable concentrations of triclosan in various environmental and biological matrices emerged concerns about the potential toxicity. Triclosan impairs thyroid homeostasis and could be associated with neurodevelopment impairment, metabolic disorders, cardiotoxicity and the increased cancer risk. The growing resistance of the vast groups of bacteria, the evidenced toxicity on different aquatic organisms, its adverse health effects observed in vitro, in vivo as well as the available epidemiological studies suggest that further efforts to monitor triclosan toxicity at environmental levels are necessary. The safety precaution measures and full commitment to proper legislation in compliance with the environmental protection are needed in order to obtain triclosan good ecological status. This paper is an overview of the possible negative triclosan effects on human health. Sources of exposure to triclosan, methods and levels of detection in aquatic environment are also discussed.

The effects of phthalate exposure on metabolic parameters in polycystic ovary syndrome

BACKGROUND-AIM

Phthalates are known as endocrine disrupting chemicals which are present in wide-range of products. The objective of the study was to investigate whether phthalate exposure may attribute to the metabolic syndrome development in women with polycystic ovary syndrome (PCOS).

METHOD

The cross-sectional study involved 60 women in reproductive age with confirmed PCOS. Anthropometric and biochemical measurements were examined together with detected levels of ten phthalate metabolites measured by GC-MS in morning urine samples.

RESULTS

In this study at least one phthalate metabolite was detected in 51.7% of samples. Total phthalate metabolites urine concentrations were positively associated with BMI, waist circumference, waist-to-height-ratio (WtHR), leptin serum levels as well as lipid accumulation product (LAP) and visceral adiposity index (VAI). Mono-methyl-phthalate (MMP) levels was significantly correlated with WtHR, LAP and VAI. Additionally, total phthalate metabolites levels were significantly linked with fasting plasma glucose and HOMA index, whereas MMP concentrations were associated with fasting plasma glucose and insulin levels. Total cholesterol (TC) level was statistically significantly higher among PCOS women with detected phthalate metabolites compared to those without phthalates. The sum of all phthalates was correlated with LDL and triglyceride levels as well as TC/HDL. MMP concentrations were linked positively with TC, LDL and triglyceride levels as well as with TC/HDL. It is noteworthy that MMP concentrations were positively associated with testosterone serum levels while the total phthalate metabolites concentrations were also linked but with moderate significance.

CONCLUSIONS

The increased phthalate metabolites concentrations may interfere with obesity, glucose and lipid impairment in PCOS women. Additionally, testosterone serum levels can be disrupted by MMP.

Endocrine disrupting chemicals: A promoter of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is the most prevalent liver disorder. With the improvement in human living standards, the prevalence of NAFLD has been increasing in recent years. Endocrine-disrupting chemicals (EDCs) are a class of exogenous chemicals that simulate the effects of hormones in the body. There has been growing evidence regarding the potential effects of EDCs on liver health, especially in NAFLD. This paper aims to summarize the major EDCs that contribute to the growing burden of NAFLD and to raise public awareness regarding the hazards posed by EDCs with the objective of reducing the incidence of NAFLD.

Medical devices as a source of phthalate exposure: a review of current knowledge and alternative solutions

Phthalates are a group of phthalic acid esters used as plasticisers in a large number of products to improve their flexibility, softness, and extensibility. Their wide use in medical devices, however, raises a lot of concern, as they can enter the organism and have toxic effects on human liver, thyroid, kidneys, lungs, reproductive, endocrine, nervous, and respiratory system and are associated with asthma, obesity, autism, and diabetes. The aim of this review is to summarise current knowledge about phthalate migration from medical devices during different medical procedures and possible impact on patient health. It also looks at alternative plasticisers with supposedly lower migration rates and safer profile. Not enough is known about which and how many phthalates make part of medical devices or about the health impacts of alternative plasticisers or their migration rates.

Sex Differences between Urinary Phthalate Metabolites and Metabolic Syndrome in Adults: A Cross-Sectional Taiwan Biobank Study

BACKGROUND

Phthalates are widely used in consumer products, food packaging, and personal care products, so exposure is widespread. Several studies have investigated the association of phthalate exposure with obesity, insulin resistance, and hypertension. However, little is known about the associations of phthalate exposure with sex, age, and menopausal status in metabolic syndrome (MetS). The purpose of this study was to investigate the association between 11 urinary phthalate metabolite concentrations and metabolic syndrome in adults.

METHODS

We conducted a cross-sectional analysis of 1337 adults aged 30-70 years from the Taiwan Biobank 2016-2020. Prevalence odds ratios (POR) and 95% confidence intervals (CIs) were calculated using logistic regression and stratified by sex, age, and menopausal status.

RESULTS

Participants with MetS comprised 16.38%. Higher concentrations of MEP metabolites were associated with more than two- to three-fold increased odds of MetS in males and males ≥ 50 years (adj. POR Q3 vs. Q1 = 2.13, 95% CI: 1.01, 4.50; p = 0.047 and adj. POR Q2 vs. Q1 = 3.11, 95% CI: 0.13, 8.63; p = 0.029). When assessed by menopausal status, postmenopausal females with higher ∑DEHP concentrations had more than nine-fold higher odds of MetS compared with postmenopausal females with the lowest ∑DEHP concentrations (adj. POR Q3 vs. Q1 = 9.58, 95% CI: 1.18, 77.75; p = 0.034).

CONCLUSIONS

The findings suggest differential associations between certain phthalate metabolites and MetS by sex, age, and menopausal status.

Hepatic consequences of a mixture of endocrine-disrupting chemicals in male mice

The global epidemic of metabolic syndrome has been partially linked to ubiquitous exposure to endocrine-disrupting chemicals (EDCs). Although the impacts of exposure to single EDCs have been thoroughly studied, the consequences of simultaneous uncontrolled exposure to multiple EDCs require further investigations. Therefore, in this study, we evaluated how exposure to mixtures containing bisphenol A and seven phthalates impacts liver functions and metabolic homeostasis. Male mice were gavaged with either EDCs at four different dose combinations or corn oil (control) for six weeks. The results showed that exposure to EDCs at the human daily exposure limit had a negligible impact on liver function. However, EDC at ≥ 25 orders of magnitude of human-relevant doses had detrimental impacts on overall liver function, leading to metabolic abnormalities, steatohepatitis, and hepatic fibrosis via the activation of both genomic and non-genomic pathways. The metabolic phenotype was linked to alterations in key genes involved in hepatic lipid and glucose metabolism. In contrast, alterations in cytokine expression, oxidative stress, and apoptosis impacted steatohepatitis and fibrosis. Because EDC exposure does not occur independently, the findings of the combined effects of exposure to multiple EDCs have significant relevance for public health.

Risk of Nonalcoholic Fatty Liver Disease Is Associated with Urinary Phthalate Metabolites Levels in Adults with Subclinical Hypothyroidism: Korean National Environmental Health Survey (KoNEHS) 2012-2014

Nonalcoholic fatty liver disease (NAFLD) is a condition of excess accumulation of fats in the liver. Thyroid dysfunction is commonly observed in adult populations with NAFLD. In subjects with thyroid dysfunction, phthalates, which are chemical compounds widely used to increase the flexibility of various plastic products, may increase the risk of NAFLD prevalence. Therefore, our study aimed to evaluate the relationship between the levels of urinary phthalate metabolites and the risk of NAFLD stratified by the levels of thyroid-stimulating hormone (TSH). Data (n = 2308) were obtained from the Korean National Environmental Health Survey II (2012−2014). Using the hepatic steatosis index, participants were classified into non-NAFLD (<30) and NAFLD (>36) groups. Participants with euthyroidism were defined as 0.45−4.5 mIU/L for serum TSH and normal thyroxine (T4) levels (n = 2125). Subclinical hypothyroidism (SCH) was defined as a higher TSH level (4.5−10 mIU/L) with normal total T4 levels in the serum (n = 183). A multivariate analysis was performed to assess the association of the urinary phthalate concentration with the risk of NAFLD after stratification based on the thyroid hormone levels. The levels of phthalate metabolites in urine were not significantly associated with NAFLD in adults with euthyroidism. However, a significant increased risk of NAFLD in those with SCH was observed in the fourth quartile of mono (2-ethyl-5-hydroxyhexyl) phthalate (odds ratio (OR) 13.59, 95% confidence interval (CI) 12.13−86.44), mono (2-ethyl-5-oxohexyl) phthalate (OR 8.55, 95% CI 1.20−60.53), mono-(2-ethyl-5-carboxypentyl) phthalate (OR 9.06, 95% CI 1.78−45.96), and mono-benzyl phthalate (OR 6.05, 95% CI 1.62−22.54) compared to those of the lowest quartile after being adjusted with covariates. In conclusion, the levels of phthalate metabolites in urine are positively associated with NAFLD in adults with SCH. More experimental studies are needed to clarify the risk of NAFLD caused by phthalate exposure in cases with poor thyroid function.

Urinary Phthalate Levels in Relation to Obesity among a Sample of Egyptian Children

BACKGROUND: Childhood obesity is considered a risk factor for chronic diseases later in life. Phthalates (phthalate acid esters), predominant constituents of plasticizers, are well-thought-out global environmental contaminants. AIM: This study aims to investigate the relationship between obesity and urinary phthalates in Egyptian children. MATERIALS AND METHODS: This cross-sectional study included 210 children; 71 children were obese. Age ranged between 8.8 and 16 years with a mean of 12.93 ± 1.29 years. Sociodemographic data were collected. Clinical examination included measuring body weight, height, waist and hip circumferences (WC and HC), and calculation of body mass index (BMI). The lipid profile was analyzed. Urine samples were tested for phthalates levels using high-performance liquid chromatography. RESULTS: Urinary phthalates metabolites mono benzyl (MBzP), monobutyl (MBP), monoethyl (MEP), and mono (2ethylhexyl) phthalate (MEHP) were detected in all urinary samples with varying levels. The median concentrations of MBzP, MEHP, MBP, and MEP were 1.4, 54.5, 29.9, and 490 (ng/ml), respectively. In obese children, urinary MBP, MEP, and MEHP demonstrated significantly higher mean levels than in non-obese children. Physical indicators of obesity as body weight, BMI, WC, and HC were significantly positively correlated with urinary levels of MEHP and MEP, while urinary MBzP demonstrated a significant positive association with serum triglycerides levels. CONCLUSION: The present study suggests an association between phthalates exposure and childhood and adolescent adiposity.

Is there a difference in the phthalate exposure between adults with metabolic disorders and healthy ones?

Background/Aim. Phthalates are recognized as endocrine-disrupting compounds and are extensively present in a variety of everyday products. Chronic exposure to phthalates is suspected to be associated with a range of health disorders. The aim of the study was to examine the abundance of phthalate metabolites in the urine samples among adults in the Autonomous Province of Vojvodina, Serbia, and to determine the prevalence of phthalate metabolites in healthy individuals and those with metabolic disorders such as obesity and newly diagnosed type 2 diabetes mellitus (T2DM). Methods. For the study purpose, the first morning urine sample of 308 participants was screened for the presence of 10 phthalate metabolites: mono-ethyl phthalate (MEP), mono-(2-ethylhexyl) phthalate (MEHP), mono-n-butyl phthalate (MBP), mono-iso-allyl phthalate (MiAP), mono-n-allyl phthalate (MnAP), mono-cyclohexyl phthalate (MCHP), mono-benzyl phthalate (MBzP), mono-n-octyl phthalate (MOP), mono-n-propyl phthalate (MPP) and mono-methyl phthalate (MMP). Results. At least one phthalate metabolite was detected in the first morning urine sample in 50.32% of the examined population. The most frequently detected phthalate metabolites were MEP and MEHP. Out of all phthalate-positive participants, 38.3% of them had one, 10.7% had two, while 1.3% of participants had three phthalate metabolites in the first morning urine sample. A significant difference (p < 0.05) between groups was observed on MEP and MMP frequency, while border-line significant difference (p < 0.1) between groups was observed on MEHP and MCHP frequency. Conclusion. In the Vojvodina region, both healthy adults and those with metabolic disorders such as obesity and newly diagnosed T2DM are predominantly exposed to di-ethyl phthalate and di-(2-ethylhexyl)phthalate since MEP and MEHP were the most frequently detected phthalate metabolites. Further re-search is required in order to provide more details of the phthalates influence on the adverse health effects.

Intestinal Barrier and Permeability in Health, Obesity and NAFLD

The largest surface of the human body exposed to the external environment is the gut. At this level, the intestinal barrier includes luminal microbes, the mucin layer, gastrointestinal motility and secretion, enterocytes, immune cells, gut vascular barrier, and liver barrier. A healthy intestinal barrier is characterized by the selective permeability of nutrients, metabolites, water, and bacterial products, and processes are governed by cellular, neural, immune, and hormonal factors. Disrupted gut permeability (leaky gut syndrome) can represent a predisposing or aggravating condition in obesity and the metabolically associated liver steatosis (nonalcoholic fatty liver disease, NAFLD). In what follows, we describe the morphological-functional features of the intestinal barrier, the role of major modifiers of the intestinal barrier, and discuss the recent evidence pointing to the key role of intestinal permeability in obesity/NAFLD.

Associations between urinary phthalate metabolite concentrations and markers of liver injury in the US adult population

BACKGROUND

Phthalates have been largely used for years in varieties of products worldwide. However, research on the joint toxic effect of various phthalates exposure on the liver is lacking.

OBJECTIVES

We aimed to assess exposure to phthalates on liver function tests (LFTs).

METHODS

This analysis included data on 6046 adults (≥20 years old) who participated in a National Health and Nutrition Examination Survey (NHANES) in 2007-2016. We employed linear regression and Bayesian kernel machine regression (BKMR), to explore the associations of urinary phthalate metabolites with 8 indicators of LFTs.

RESULTS

Di(2-ethylhexyl) phthalate (ΣDEHP) was found to be positively associated with serum alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT) and alkaline phosphatase (ALP) (all P _FDR < 0.05). We found significant positive associations of ∑DEHP, mono-ethyl phthalate (MEP) and mono-(carboxyisononyl) phthalate (MCNP) with total bilirubin (TBIL) (all P _FDR < 0.05). ΣDEHP, mono-n-butyl phthalate (MBP), mono-(3-carboxypropyl) phthalate (MCPP) and mono-benzyl phthalate (MBzP) were negatively associated with serum ALB (all P _FDR < 0.05). The BKMR analyses showed a significantly positive overall effect on ALT, AST, ALP and TBIL levels with high concentrations of phthalate metabolites and a significantly negative overall effect on ALB and TP, when all the chemicals at low concentrations.

CONCLUSIONS

Our results add novel evidence that exposures to phthalates might be adversely associated with the indicators of LTFs, indicating the potential toxic effect of phthalate exposures on the human liver.

Association between phthalate exposure and insulin resistance: a systematic review and meta-analysis update

An update on systematic review and meta-analysis was performed to explore effects of phthalate exposure on insulin resistance. A systematic literature search was performed in MEDLINE, Web of Science, and CNKI until March 2021. A conceptual framework was constructed to guide the organization and presentation of results. Besides, beta coefficients with corresponding confidence intervals were extracted from the most adjusted models. Extracted beta coefficients were transformed into correlation, and z Fisher transformation of correlation with the corresponding standard error was included in meta-analysis. Subgroup analyses were performed by age (adult vs. adolescent) and sex (female vs. male) of participants and site of study (America and Europe vs. Asia) to explore potential sources of heterogeneity. Nineteen literatures with 12,533 participants reporting on the association of exposure to specific phthalates and insulin resistance were selected. The majority of included studies revealed positive relationships of insulin resistance with different phthalate metabolites exposure. Meta-analyses were performed on 16 studies. Exposure to MnBP, MBzP, MCPP, MEHP, MEOHP, MEHHP, ∑DEHP, and high-molecular weight phthalate (∑HMWP) was associated with the increase of the homeostasis model assessment of insulin resistance (HOMA-IR) index. The results of sensitivity analyses stratified by age, sex, and site of study remained stable, suggesting the robustness of these meta-analyses. Most of heterogeneity in sensitivity analyses decreased to moderate or low degree. Exposure to MnBP, MBzP, MCPP, MEHP, MEOHP, MEHHP, ∑DEHP, and ∑HMWP was associated with the increased risk of HOMA-IR. Age, sex, and site of study might provide limited source of heterogeneity.

Effects of Mono-2-ethylhexyl Phthalate on the Neural Transmission of PNs in Drosophila Antennal Lobe

Long-term exposure to different types of chemicals is hazardous to human health. Di(2-ethylhexyl) phthalate (DEHP) could exert pleiotropic deleterious effects on nervous systems. Mono(2-ethylhexyl) phthalate (MEHP), as one of the most toxic metabolites of DEHP, may have similar effects on nervous systems. However, no effects of MEHP on neural circuits have been reported. To uncover the regulation of MEHP on neural transmission, the functional changes of neural excitability and synaptic plasticity of projection neurons (PNs) have been assessed. In the current study, we recorded the action potentials (APs), stimulate action potentials (sti-APs), mini excitement postsynaptic current (mEPSC), calcium currents, and sodium currents from PNs of isolated whole brain of Drosophila model utilizing patch clamp recordings. We found that MEHP-300 (at the concentration of 300 μM), but not MHEP-100 (at the concentration of 100 μM), significantly decreased the frequency and amplitude of APs. Besides, the amplitude and anti-amplitude of sti-APs were reduced with the application of MEHP-300. Meanwhile, MEHP-300 reduced the frequency of mEPSC, but not the amplitude. Furthermore, MEHP-300 reduced the peak current densities of sodium and calcium channels. Therefore, our results indicated that MEHP could alter the neural excitability and synaptic plasticity of PNs by inhibiting the ion channels activities, revealing the potential modulation of MEHP on neural transmission of PNs.

Phthalates exposure is associated with non-alcoholic fatty liver disease among US adults

PURPOSE

Non-alcoholic fatty liver disease (NAFLD) has become the most common liver disease in the western countries. We aimed to ascertain the relationship of urinary phthalates concentrations with presence of NAFLD among US adults.

METHODS

A cross-sectional analysis of data from National Health and Nutrition Examination Survey (NHANES) during 2003-2016 was performed. NAFLD was predicted by Hepatic Steatosis Index (HSI) and US Fatty Liver Index (US FLI), respectively. The logistic regression models were conducted to evaluate associations of urinary phthalates with NAFLD by adjustment for other covariates.

RESULTS

Of the 4206 participants (mean age 47.99 years old; 50.06% men), risk of suspected NAFLD was increased in those with higher concentrations of urinary phthalates. The results of multivariate models suggested that urinary phthalate metabolites MEOHP (odds ratio [OR] = 1.56, 95% confidence interval [CI] = 1.08-2.24), MEHHP (OR = 1.55, 95% CI = 1.09-2.21), MECPP (OR = 1.44, 95% CI = 1.06-1.95) and the mixtures of nine phthalates (OR = 1.58, 95%CI = 1.18-2.11) were positively related to NAFLD defined by HSI; the similar significant associations were observed for MEHHP (OR = 1.98, 95% CI = 1.32-2.97) when NAFLD was determined based upon US FLI ≥30. In subgroup analyses, the positive associations of urinary phthalates concentrations with NAFLD risk remained robust both in males and females, whereas only in individuals aged <60 years.

CONCLUSIONS

Phthalates exposure was independently associated with NAFLD both in males and females, regardless of being defined using HSI or US FLI.

High Consumption of Ultra-Processed Food is Associated with Incident Dyslipidemia: A Prospective Study of Older Adults

BACKGROUND

Ultra-processed food (UPF) consumption has been associated with higher cardiovascular disease (CVD) and mortality risks.

OBJECTIVES

The aim of this study was to assess the relationship between UPF consumption and incident dyslipidemia in older adults, where evidence is limited.

METHODS

We studied a prospective cohort of 1082 community-dwelling adults in Spain, older than 60 (mean age, 68 ± 6 years old). Participants (52% were women) were recruited between 2008-10 and followed up to 2015. At baseline, food intake data were collected using a validated computerized face-to-face dietary history. UPFs were identified according to the nature and extent of their industrial processing (NOVA classification). Triglycerides, HDL cholesterol, and LDL cholesterol were measured in fasting plasma samples collected at baseline and at follow-up. Statistical analyses were performed with logistic regression adjusted for the main potential confounders.

RESULTS

Among those free of corresponding dyslipidemia at baseline, and after a follow-up of between 5 to 7 years, 60 (out of 895) developed incident hypertriglyceridemia (≥150 mg/dL), 112 (out of 878) had low HDL cholesterol (<40 in men/<50 mg/dL in women), and 54 (out of 472) had high LDL cholesterol (>129 mg/dL). The mean percentage of UPF consumption was 19% ± 11% of total energy intake. Those in the highest versus the lowest tertile of energy intake from UPFs had more than twice the odds of incident hypertriglyceridemia (OR, 2.66; 95% CI: 1.20-5.90; P-trend, 0.011) or low HDL cholesterol (OR, 2.23; 95% CI: 1.22-4.05; P-trend, 0.012). UPF consumption was not associated with high LDL cholesterol plasma concentrations.

CONCLUSIONS

Although UPF consumption in Spain was low among older adults, high consumption of UPFs was clearly associated with incident dyslipidemia. The increase in CVD risk recently found to be associated with UPF consumption might be mediated by these atherogenic lipid abnormalities.

Comprehensive Insight from Phthalates Occurrence: From Health Outcomes to Emerging Analytical Approaches

Phthalates are a group of chemicals used in a multitude of important industrial products (e.g., medical devices, children's toys, and food packages), mainly as plasticizers to improve mechanical properties such as flexibility, transparency, durability, and longevity of polyvinyl chloride (PVC). The wide occurrence of phthalates in many consumer products, including foods (e.g., bottled water, soft drinks, wine, milk, and meat) brings that most people are exposed to phthalates every day, which raises some concerns. Adverse health outcomes from phthalates exposure have been associated with endocrine disruption, deformities in the human reproductive system, increased risk of preterm birth, carcinogen exposure, among others. Apprehension related to the health risks and ubiquitous incidence of phthalates in foods inspires the development of reliable analytical approaches that allow their detection and quantification at trace levels. The purpose of the current review is to provide information related to the presence of phthalates in the food chain, highlighting the health risks associated with their exposure. Moreover, an overview of emerging extraction procedures and high-resolution analytical approaches for a comprehensive quantification of phthalates is presented.

Representative Bacillus sp. AM1 from Gut Microbiota Harbor Versatile Molecular Pathways for Bisphenol A Biodegradation

Human gut microbiota harbors numerous microbial species with molecular enzymatic potential that impact on the eubiosis/dysbiosis and health/disease balances. Microbiota species isolation and description of their specific molecular features remain largely unexplored. In the present study, we focused on the cultivation and selection of species able to tolerate or biodegrade the endocrine disruptor bisphenol A (BPA), a xenobiotic extensively found in food plastic containers. Chemical xenobiotic addition methods for the directed isolation, culturing, Whole Genome Sequencing (WGS), phylogenomic identification, and specific gene-encoding searches have been applied to isolate microorganisms, assess their BPA metabolization potential, and describe encoded catabolic pathways. BPA-tolerant strains were isolated from 30% of infant fecal microbial culture libraries analyzed. Most isolated strains were phylogenetically related to the operational taxonomic group Bacillus amyloliquefaciens spp. Importantly, WGS analysis of microbial representative strain, Bacillus sp. AM1 identified the four complete molecular pathways involved on BPA degradation indicating its versatility and high potential to degrade BPA. Pathways for Exopolysaccharide (EPS) and Polyhydroxyalkanates (PHA) biopolymer synthesis were also identified and phenotypically confirmed by transmission electronic microscopy (TEM). These microbial biopolymers could generally contribute to capture and/or deposit xenobiotics.

Enhancing the activity and thermal stability of a phthalate-degrading hydrolase by random mutagenesis

Our previous work has reported that EstJ6 was a phthalate-degrading hydrolase. In the study, a random mutant library was constructed by two rounds of error-prone PCR, three mutants (ET1.1, ET2.1, and ET2.2) with enhanced hydrolytic activity against dibutyl phthalate (DBP) were obtained. The best mutant ET2.2, accumulated three amino acid substitutions (Thr91Met, Ala67Val, and Val249Ile) and exhibited 2.8-fold increase enzyme activity and 2.3-fold higher expression level. Meanwhile, compared with EstJ6, ET2.2 showed over 50% improvement in thermostability (at 50 °C for 1 h) and 1.2-fold increase in 50% methanol tolerance. Kinetic parameters analysis revealed that the Km value for ET2.2 decreased by 60% and the kcat/Km value increased by 166%. The molecular docking indicated that the shortening of hydrogen bond between Ser146-OH and DBP-CO, which may led to an increase in enzyme activity and catalytic efficiency, the enhancement of hydrophobicity of hydrophobic pocket was related to the improvement of organic solvents tolerance, and three hydrophobic amino acid substitutions Thr91Met, Ala67Val, and Val249Ile facilitated to improve the thermal stability and organic solvents tolerance. These results confirmed that random mutagenesis was an effective tool for improving enzyme properties and lay a foundation for practical applications of phthalate-degrading hydrolase in biotechnology and industrial fields.

The Assessment of the Sewage and Sludge Contamination by Phthalate Acid Esters (PAEs) in Eastern Europe Countries

Phthalate acid esters (PAEs) are widely used as raw materials for industries that are well known for their environmental contamination and toxicological effects as “endocrine disruptors”. The determining of PAE contamination was based on analysis of dimethyl phthalate (DMP), diethyl phthalate (DEP), dipropyl phthalate (DPP), dibutyl phthalate (DBP), diisobutyl phthalate (DiBP), dicyclohexyl phthalate (DCHP) and di(2-ethylhexyl) phthalate (DEHP) in wastewater and sediment samples collected from city sewer systems of Lithuania and Poland, and Denmark for comparison. The potential PAE sources as well as their concentrations in the wastewater were analyzed and discussed. The intention of the study was to determine the level and key sources of pollution by phthalates in some Eastern European countries and to reveal the successful managerial actions to minimize PAEs taken by Denmark. Water and sludge samples were collected in 2019–2020 and analyzed by gas chromatography-mass spectrometry. The highest contamination with phthalates in Lithuania can be attributed to DEHP: up to 63% of total PAEs in water samples and up to 94% of total PAEs in sludge samples, which are primarily used as additive compounds to plastics but do not react with them and are gradually released into the environment. However, in water samples in Poland, the highest concentration belonged to DMP—up to 210 μg/L, while the share of DEHP reached 15 μg/L. The concentrations of priority phthalate esters in the water samples reached up to 159 μg/L (DEHP) in Lithuania and up to 1.2 μg/L (DEHP) in Denmark. The biggest DEHP concentrations obtained in the sediment samples were 95 mg/kg in Lithuania and up to 6.6 mg/kg in Denmark. The dominant compounds of PAEs in water samples of Lithuania were DEHP > DEP > DiBP > DBP > DMP. DPP and DCHP concentrations were less than 0.05 μg/L. However, the distribution of PAEs in the water samples from Poland was as follows: DMP > DEHP > DEP > DBP, and DiBP, as well as DPP and DCHP, concentrations were less than 0.05 μg/L. Further studies are recommended for adequate monitoring of phthalates in wastewater and sludge in order to reduce or/and predict phthalates’ potential risk to hydrobiots and human health.

MEHP/ethanol co-exposure favors the death of steatotic hepatocytes, possibly through CYP4A and ADH involvement

Liver steatosis has been associated with various etiological factors (obesity, alcohol, environmental contaminants). How those factors work together to induce steatosis progression is still scarcely evaluated. Here, we tested whether phthalates could potentiate death of steatotic hepatocytes when combined with ethanol. Pre-steatotic WIF-B9 hepatocytes were co-exposed to mono (2-ethylhexyl) (MEHP, 500 nM; main metabolite of di (2-ethylhexyl) phthalate or DEHP) and ethanol (5 mM) for 5 days. An increased apoptotic death was detected, involving a DNA damage response. Using 4-Methypyrazole to inhibit ethanol metabolism, and CH-223191 to antagonize the AhR receptor, we found that an AhR-dependent increase in alcohol dehydrogenase (ADH) activity was essential for cell death upon MEHP/ethanol co-exposure. Toxicity was also prevented by HET0016 to inhibit the cytochrome P450 4A (CYP4A). Using the antioxidant thiourea, a role for oxidative stress was uncovered, notably triggering DNA damage. Finally, co-exposing the in vivo steatosis model of high fat diet (HFD)-zebrafish larvae to DEHP (2.56 nM)/ethanol (43 mM), induced the pathological progression of liver steatosis alongside an increased Cyp4t8 (human CYP4A homolog) mRNA expression. Altogether, these results further emphasized the deleterious impact of co-exposures to ethanol/environmental pollutant towards steatosis pathological progression, and unraveled a key role for ADH and CYP4A in such effects.

Liver Steatosis, Gut-Liver Axis, Microbiome and Environmental Factors. A Never-Ending Bidirectional Cross-Talk

The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing worldwide and parallels comorbidities such as obesity, metabolic syndrome, dyslipidemia, and diabetes. Recent studies describe the presence of NAFLD in non-obese individuals, with mechanisms partially independent from excessive caloric intake. Increasing evidences, in particular, point towards a close interaction between dietary and environmental factors (including food contaminants), gut, blood flow, and liver metabolism, with pathways involving intestinal permeability, the composition of gut microbiota, bacterial products, immunity, local, and systemic inflammation. These factors play a critical role in the maintenance of intestinal, liver, and metabolic homeostasis. An anomalous or imbalanced gut microbial composition may favor an increased intestinal permeability, predisposing to portal translocation of microorganisms, microbial products, and cell wall components. These components form microbial-associated molecular patterns (MAMPs) or pathogen-associated molecular patterns (PAMPs), with potentials to interact in the intestine lamina propria enriched in immune cells, and in the liver at the level of the immune cells, i.e., Kupffer cells and stellate cells. The resulting inflammatory environment ultimately leads to liver fibrosis with potentials to progression towards necrotic and fibrotic changes, cirrhosis. and hepatocellular carcinoma. By contrast, measures able to modulate the composition of gut microbiota and to preserve gut vascular barrier might prevent or reverse NAFLD.

Critical Review on the Presence of Phthalates in Food and Evidence of Their Biological Impact

Phthalates are a huge class of chemicals with a wide spectrum of industrial uses, from the manufacture of plastics to food contact applications, children's toys, and medical devices. People and animals can be exposed through different routes (i.e., ingestion, inhalation, dermal, or iatrogenic exposure), as these compounds can be easily released from plastics to water, food, soil, air, making them ubiquitous environmental contaminants. In the last decades, phthalates and their metabolites have proven to be of concern, particularly in products for pregnant women or children. Moreover, many authors reported high concentrations of phthalates in soft drinks, mineral waters, wine, oil, ready-to-eat meals, and other products, as a possible consequence of their accumulation along the food production chain and their accidental release from packaging materials. However, due to their different physical and chemical properties, phthalates do not have the same human and environmental impacts and their association to several human diseases is still under debate. In this review we provide an overview of phthalate toxicity, pointing out the health and legal issues related to their occurrence in several types of food and beverage.

Endocrine Disruptors in Food: Impact on Gut Microbiota and Metabolic Diseases

Endocrine disruptors (EDCs) have been associated with the increased incidence of metabolic disorders. In this work, we conducted a systematic review of the literature in order to identify the current knowledge of the interactions between EDCs in food, the gut microbiota, and metabolic disorders in order to shed light on this complex triad. Exposure to EDCs induces a series of changes including microbial dysbiosis and the induction of xenobiotic pathways and associated genes, enzymes, and metabolites involved in EDC metabolism. The products and by-products released following the microbial metabolism of EDCs can be taken up by the host; therefore, changes in the composition of the microbiota and in the production of microbial metabolites could have a major impact on host metabolism and the development of diseases. The remediation of EDC-induced changes in the gut microbiota might represent an alternative course for the treatment and prevention of metabolic diseases.

Metabolically Healthy Obesity-Heterogeneity in Definitions and Unconventional Factors

The concept of heterogeneity among obese individuals in their risk for developing metabolic dysfunction and associated complications has been recognized for decades. At the origin of the heterogeneity idea is the acknowledgement that individuals with central obesity are more prone to developing type 2 diabetes and cardiovascular disease than those with peripheral obesity. There have been attempts to categorize subjects according to their metabolic health and degree of obesity giving rise to different obese and non-obese phenotypes that include metabolically unhealthy normal-weight (MUHNW), metabolically healthy obese (MHO), and metabolically unhealthy obese (MUO). Individuals belonging to the MHO phenotype are obese according to their body mass index although exhibiting fewer or none metabolic anomalies such as type 2 diabetes, dyslipidemia, hypertension, and/or unfavorable inflammatory and fribinolytic profiles. However, some authors claim that MHO is only transient in nature. Additionally, the phenotype categorization is controversial as it lacks standardized definitions possibly blurring the distinction between obesity phenotypes and confounding the associations with health outcomes. To add to the discussion, the factors underlying the origin or protection from metabolic deterioration and cardiometabolic risk for these subclasses are being intensely investigated and several hypotheses have been put forward. In the present review, we compare the different definitions of obesity phenotypes and present several possible factors underlying them (adipose tissue distribution and cellularity, contaminant accumulation on the adipose tissue, dysbiosis and metabolic endotoxemia imposing on to the endocannabinoid tone and inflammasome, and nutrient intake and dietary patterns) having inflammatory activation at the center.

The Intricate Relationship between Type 2 Diabetes Mellitus (T2DM), Insulin Resistance (IR), and Nonalcoholic Fatty Liver Disease (NAFLD)

Nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus (T2DM) remain as one of the most global problematic metabolic diseases with rapidly increasing prevalence and incidence. Epidemiological studies noted that T2DM patients have by two-fold increase to develop NAFLD, and vice versa. This complex and intricate association is supported and mediated by insulin resistance (IR). In this review, we discuss the NAFLD immunopathogenesis, connection with IR and T2DM, the role of screening and noninvasive tools, and mostly the impact of the current antidiabetic drugs on steatosis liver and new potential therapeutic targets.