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Wu Q, Kan J, Cui Z, Ma Y, Liu X, Dong R, Huang D, Chen L, Du J, Fu C. Understanding the nutritional benefits through plant proteins-probiotics interactions: mechanisms, challenges, and perspectives. Crit Rev Food Sci Nutr 2024:1-19. [PMID: 38922612 DOI: 10.1080/10408398.2024.2369694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
The nutritional benefits of combining probiotics with plant proteins have sparked increasing research interest and drawn significant attention. The interactions between plant proteins and probiotics demonstrate substantial potential for enhancing the functionality of plant proteins. Fermented plant protein foods offer a unique blend of bioactive components and beneficial microorganisms that can enhance gut health and combat chronic diseases. Utilizing various probiotic strains and plant protein sources opens doors to develop innovative probiotic products with enhanced functionalities. Nonetheless, the mechanisms and synergistic effects of these interactions remain not fully understood. This review aims to delve into the roles of promoting health through the intricate interplay of plant proteins and probiotics. The regulatory mechanisms have been elucidated to showcase the synergistic effects, accompanied by a discussion on the challenges and future research prospects. It is essential to recognize that the interactions between plant proteins and probiotics encompass multiple mechanisms, highlighting the need for further research to address challenges in achieving a comprehensive understanding of these mechanisms and their associated health benefits.
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Affiliation(s)
- Qiming Wu
- Nutrilite Health Institute, Shanghai, China
| | - Juntao Kan
- Nutrilite Health Institute, Shanghai, China
| | - Zhengying Cui
- Department of Food Science and Technology, National University of Singapore Suzhou Research Institute, Suzhou, China
| | - Yuchen Ma
- Department of Food Science and Technology, National University of Singapore Suzhou Research Institute, Suzhou, China
| | - Xin Liu
- Department of Food Science and Technology, National University of Singapore Suzhou Research Institute, Suzhou, China
| | - Ruifang Dong
- Department of Food Science and Technology, National University of Singapore Suzhou Research Institute, Suzhou, China
| | - Dejian Huang
- Department of Food Science and Technology, National University of Singapore Suzhou Research Institute, Suzhou, China
- Department of Food Science and Technology, National University of Singapore, Singapore
| | - Lin Chen
- School of Chemistry, Chemical Engineering and Biotechnology, Nanyang Technological University, Singapore
| | - Jun Du
- Nutrilite Health Institute, Shanghai, China
| | - Caili Fu
- Department of Food Science and Technology, National University of Singapore Suzhou Research Institute, Suzhou, China
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2
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Lee MC, Hsu YJ, Chen MT, Kuo YW, Lin JH, Hsu YC, Huang YY, Li CM, Tsai SY, Hsia KC, Ho HH, Huang CC. Efficacy of Lactococcus lactis subsp. lactis LY-66 and Lactobacillus plantarum PL-02 in Enhancing Explosive Strength and Endurance: A Randomized, Double-Blinded Clinical Trial. Nutrients 2024; 16:1921. [PMID: 38931275 PMCID: PMC11206817 DOI: 10.3390/nu16121921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/14/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
Probiotics are posited to enhance exercise performance by influencing muscle protein synthesis, augmenting glycogen storage, and reducing inflammation. This double-blind study randomized 88 participants to receive a six-week intervention with either a placebo, Lactococcus lactis subsp. lactis LY-66, Lactobacillus plantarum PL-02, or a combination of both strains, combined with a structured exercise training program. We assessed changes in maximal oxygen consumption (VO2max), exercise performance, and gut microbiota composition before and after the intervention. Further analyses were conducted to evaluate the impact of probiotics on exercise-induced muscle damage (EIMD), muscle integrity, and inflammatory markers in the blood, 24 and 48 h post-intervention. The results demonstrated that all probiotic groups exhibited significant enhancements in exercise performance and attenuation of muscle strength decline post-exercise exhaustion (p < 0.05). Notably, PL-02 intake significantly increased muscle mass, whereas LY-66 and the combination therapy significantly reduced body fat percentage (p < 0.05). Analysis of intestinal microbiota revealed an increase in beneficial bacteria, especially a significant rise in Akkermansia muciniphila following supplementation with PL-02 and LY-66 (p < 0.05). Overall, the combination of exercise training and supplementation with PL-02, LY-66, and their combination improved muscle strength, explosiveness, and endurance performance, and had beneficial effects on body composition and gastrointestinal health, as evidenced by data obtained from non-athlete participants.
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Affiliation(s)
- Mon-Chien Lee
- Graduate Institute of Sports Science, National Taiwan Sport University, Taoyuan 333325, Taiwan; (M.-C.L.); (Y.-J.H.)
- Center for General Education, Taipei Medical University, Taipei 110301, Taiwan
| | - Yi-Ju Hsu
- Graduate Institute of Sports Science, National Taiwan Sport University, Taoyuan 333325, Taiwan; (M.-C.L.); (Y.-J.H.)
| | - Mu-Tsung Chen
- Committee on General Studies, Shih Chien University, Taipei City 104, Taiwan;
| | - Yi-Wei Kuo
- Functional R&D Department, Research and Design Center, Glac Biotech Co., Ltd., Tainan City 744, Taiwan; (Y.-W.K.); (J.-H.L.); (Y.-Y.H.); (C.-M.L.); (H.-H.H.)
| | - Jia-Hung Lin
- Functional R&D Department, Research and Design Center, Glac Biotech Co., Ltd., Tainan City 744, Taiwan; (Y.-W.K.); (J.-H.L.); (Y.-Y.H.); (C.-M.L.); (H.-H.H.)
| | - Yu-Chieh Hsu
- Research Product Department, Research and Design Center, Glac Biotech Co., Ltd., Tainan City 744, Taiwan; (Y.-C.H.); (S.-Y.T.); (K.-C.H.)
| | - Yen-Yu Huang
- Functional R&D Department, Research and Design Center, Glac Biotech Co., Ltd., Tainan City 744, Taiwan; (Y.-W.K.); (J.-H.L.); (Y.-Y.H.); (C.-M.L.); (H.-H.H.)
| | - Ching-Min Li
- Functional R&D Department, Research and Design Center, Glac Biotech Co., Ltd., Tainan City 744, Taiwan; (Y.-W.K.); (J.-H.L.); (Y.-Y.H.); (C.-M.L.); (H.-H.H.)
| | - Shin-Yu Tsai
- Research Product Department, Research and Design Center, Glac Biotech Co., Ltd., Tainan City 744, Taiwan; (Y.-C.H.); (S.-Y.T.); (K.-C.H.)
| | - Ko-Chiang Hsia
- Research Product Department, Research and Design Center, Glac Biotech Co., Ltd., Tainan City 744, Taiwan; (Y.-C.H.); (S.-Y.T.); (K.-C.H.)
| | - Hsieh-Hsun Ho
- Functional R&D Department, Research and Design Center, Glac Biotech Co., Ltd., Tainan City 744, Taiwan; (Y.-W.K.); (J.-H.L.); (Y.-Y.H.); (C.-M.L.); (H.-H.H.)
- Research Product Department, Research and Design Center, Glac Biotech Co., Ltd., Tainan City 744, Taiwan; (Y.-C.H.); (S.-Y.T.); (K.-C.H.)
| | - Chi-Chang Huang
- Graduate Institute of Sports Science, National Taiwan Sport University, Taoyuan 333325, Taiwan; (M.-C.L.); (Y.-J.H.)
- Tajen University, Pingtung 907101, Taiwan
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3
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Gross KN, Harty PS, Krieger JM, Mumford PW, Sunderland KL, Hagele AM, Kerksick CM. Milk or Kefir, in Comparison to Water, Do Not Enhance Running Time-Trial Performance in Endurance Master Athletes. Nutrients 2024; 16:717. [PMID: 38474845 DOI: 10.3390/nu16050717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/21/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024] Open
Abstract
This study compared flavored kefir (KFR) and flavored milk (MLK) as a recovery drink in endurance master athletes. Using a randomized, placebo-controlled, non-blinded crossover design, 11 males and females completed three testing visits whilst acutely ingesting either KFR, MLK, or water as a placebo (PLA). KFR supplementation occurred for 14 days before the KFR-testing day, followed by a 3-week washout period. Testing visits consisted of an exhausting-exercise (EE) bout, a 4-h rest period where additional carbohydrate feeding was provided, and a treadmill 5 km time trial (TT). The Gastrointestinal Symptom Rating Scale (GSRS) survey was assessed at four timepoints. Blood was collected at baseline and after the TT and was analyzed for I-FABP levels. No significant difference (PLA: 33:39.1 ± 6:29.0 min, KFR: 33:41.1 ± 5:44.4 min, and MLK: 33:36.2 ± 6:40.5 min, p = 0.99) was found between the groups in TT performance. The KFR GSRS total score was significantly lower than the PLA after EE (p = 0.005). No differences in I-FABP were observed between conditions. In conclusion, acute KFR supplementation did not impact TT performance or I-FABP levels but may have reduced subjective GI symptoms surrounding exercise when compared to MLK or PLA.
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Affiliation(s)
- Kristen N Gross
- Exercise and Performance Nutrition Laboratory, College of Science, Technology and Health, Lindenwood University, St. Charles, MO 63301, USA
| | - Patrick S Harty
- Exercise and Performance Nutrition Laboratory, College of Science, Technology and Health, Lindenwood University, St. Charles, MO 63301, USA
| | - Joesi M Krieger
- Exercise and Performance Nutrition Laboratory, College of Science, Technology and Health, Lindenwood University, St. Charles, MO 63301, USA
| | - Petey W Mumford
- Exercise and Performance Nutrition Laboratory, College of Science, Technology and Health, Lindenwood University, St. Charles, MO 63301, USA
| | - Kyle L Sunderland
- Exercise and Performance Nutrition Laboratory, College of Science, Technology and Health, Lindenwood University, St. Charles, MO 63301, USA
| | - Anthony M Hagele
- Exercise and Performance Nutrition Laboratory, College of Science, Technology and Health, Lindenwood University, St. Charles, MO 63301, USA
| | - Chad M Kerksick
- Exercise and Performance Nutrition Laboratory, College of Science, Technology and Health, Lindenwood University, St. Charles, MO 63301, USA
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4
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Gross K, Santiago M, Krieger JM, Hagele AM, Zielinska K, Scheiman J, Jäger R, Kostic A, Kerksick CM. Impact of probiotic Veillonella atypica FB0054 supplementation on anaerobic capacity and lactate. iScience 2024; 27:108643. [PMID: 38222109 PMCID: PMC10784697 DOI: 10.1016/j.isci.2023.108643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/28/2023] [Accepted: 12/01/2023] [Indexed: 01/16/2024] Open
Abstract
Seven healthy, physically active men (n = 3) and women (n = 4) (30.7 ± 7.5 years, 172.7 ± 8.7 cm, 70.4 ± 11.6 kg, 23.6 ± 4.1 kg/m2, 49.2 ± 8.4 mL/kg/min) supplemented for 14 days with a placebo (PLA) or 1 × 1010 CFU doses of the probiotic Veillonella atypica FB0054 (FitBiomics, New York, NY). Participants had safety panels, hemodynamics, lactate, and anaerobic capacity assessed. Stool samples were collected to evaluate for metagenomic and metabolomic changes. Exhaustion times were not different between groups, whereas anaerobic capacity tended to shorten with PLA (61.14 ± 72.04 s; 95% CI: -5.49, 127.77 s, p = 0.066) with no change with VA (13.29 ± 100.13 s, 95% CI: -79.32, 105.89 s, p = 0.738). No changes in lactate, hemodynamics, or bacterial community changes were observed, whereas 14 metabolites exhibited differential expression patterns with VA supplementation. In conclusion, VA maintained exercise performance that tended to decline in PLA. Supplementation was well tolerated with no changes in safety markers or reported adverse events.
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Affiliation(s)
- Kristen Gross
- Exercise and Performance Nutrition Laboratory, Kinesiology Department, College of Science, Technology, and Health, Lindenwood University, St. Charles, MO, USA
| | | | - Joesi M. Krieger
- Exercise and Performance Nutrition Laboratory, Kinesiology Department, College of Science, Technology, and Health, Lindenwood University, St. Charles, MO, USA
| | - Anthony M. Hagele
- Exercise and Performance Nutrition Laboratory, Kinesiology Department, College of Science, Technology, and Health, Lindenwood University, St. Charles, MO, USA
| | - Kinga Zielinska
- FitBiomics, Inc, New York City, NY, USA
- Ludwig Institute for Cancer Research, University of Oxford, Oxford, UK
| | | | | | - Alex Kostic
- FitBiomics, Inc, New York City, NY, USA
- Department of Microbiology, Harvard Medical School, Boston, MA, USA
- Section on Pathophysiology and Molecular Pharmacology, Joslin Diabetes Center, Boston, MA, USA
| | - Chad M. Kerksick
- Exercise and Performance Nutrition Laboratory, Kinesiology Department, College of Science, Technology, and Health, Lindenwood University, St. Charles, MO, USA
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Garvey SM, Emami NK, Guice JL, Sriranganathan N, Penet C, Rhoads RP, Spears JL, Dalloul RA, El-Kadi SW. The Probiotic Bacillus subtilis MB40 Improves Immunity in a Porcine Model of Listeriosis. Microorganisms 2023; 11:2110. [PMID: 37630670 PMCID: PMC10458092 DOI: 10.3390/microorganisms11082110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Probiotics for humans and direct-fed microbials for livestock are increasingly popular dietary ingredients for supporting immunity. The aim of this study was to determine the effects of dietary supplementation of Bacillus subtilis MB40 (MB40) on immunity in piglets challenged with the foodborne pathogen Listeria monocytogenes (LM). Three-week-old piglets (n = 32) were randomly assigned to four groups: (1) basal diet, (2) basal diet with LM challenge, (3) MB40-supplemented diet, and (4) MB40-supplemented diet with LM challenge. Experimental diets were provided throughout a 14-day (d) period. On d8, piglets in groups 2 and 4 were intraperitoneally inoculated with LM at 108 CFU/mL per piglet. Blood samples were collected at d1, d8, and d15 for biochemical and immune response profiling. Animals were euthanized and necropsied at d15 for liver and spleen bacterial counts and intestinal morphological analysis. At d15, LM challenge was associated with increased spleen weight (p = 0.017), greater circulating populations of neutrophils (p = 0.001) and monocytes (p = 0.008), and reduced ileal villus height to crypt depth ratio (p = 0.009), compared to non-challenged controls. MB40 supplementation reduced LM bacterial counts in the liver and spleen by 67% (p < 0.001) and 49% (p < 0.001), respectively, following the LM challenge, compared to the basal diet. MB40 supplementation was also associated with decreased circulating concentrations of monocytes (p = 0.007). Altogether, these data suggest that MB40 supplementation is a safe and well-tolerated approach to enhance immunity during systemic Listeria infection.
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Affiliation(s)
- Sean M. Garvey
- Department of Research and Development, BIO-CAT, Inc., Troy, VA 22974, USA
| | - Nima K. Emami
- School of Animal Sciences, Virginia Tech, Blacksburg, VA 24061, USA
| | - Justin L. Guice
- Department of Research and Development, BIO-CAT, Inc., Troy, VA 22974, USA
| | | | - Christopher Penet
- Department of Research and Development, BIO-CAT, Inc., Troy, VA 22974, USA
| | - Robert P. Rhoads
- School of Animal Sciences, Virginia Tech, Blacksburg, VA 24061, USA
| | - Jessica L. Spears
- Department of Research and Development, BIO-CAT Microbials, LLC, Shakopee, MN 55379, USA
| | - Rami A. Dalloul
- Department of Poultry Science, University of Georgia, Athens, GA 30602, USA
| | - Samer W. El-Kadi
- School of Animal Sciences, Virginia Tech, Blacksburg, VA 24061, USA
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6
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Longo M, Jericó D, Córdoba KM, Riezu-Boj JI, Urtasun R, Solares I, Sampedro A, Collantes M, Peñuelas I, Moreno-Aliaga MJ, Ávila MA, Pierro ED, Barajas M, Milagro FI, Dongiovanni P, Fontanellas A. Nutritional Interventions with Bacillus coagulans Improved Glucose Metabolism and Hyperinsulinemia in Mice with Acute Intermittent Porphyria. Int J Mol Sci 2023; 24:11938. [PMID: 37569315 PMCID: PMC10418637 DOI: 10.3390/ijms241511938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 08/13/2023] Open
Abstract
Acute intermittent porphyria (AIP) is a metabolic disorder caused by mutations in the porphobilinogen deaminase (PBGD) gene, encoding the third enzyme of the heme synthesis pathway. Although AIP is characterized by low clinical penetrance (~1% of PBGD mutation carriers), patients with clinically stable disease report chronic symptoms and frequently show insulin resistance. This study aimed to evaluate the beneficial impact of nutritional interventions on correct carbohydrate dysfunctions in a mouse model of AIP that reproduces insulin resistance and altered glucose metabolism. The addition of spores of Bacillus coagulans in drinking water for 12 weeks modified the gut microbiome composition in AIP mice, ameliorated glucose tolerance and hyperinsulinemia, and stimulated fat disposal in adipose tissue. Lipid breakdown may be mediated by muscles burning energy and heat dissipation by brown adipose tissue, resulting in a loss of fatty tissue and improved lean/fat tissue ratio. Probiotic supplementation also improved muscle glucose uptake, as measured using Positron Emission Tomography (PET) analysis. In conclusion, these data provide a proof of concept that probiotics, as a dietary intervention in AIP, induce relevant changes in intestinal bacteria composition and improve glucose uptake and muscular energy utilization. Probiotics may offer a safe, efficient, and cost-effective option to manage people with insulin resistance associated with AIP.
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Affiliation(s)
- Miriam Longo
- Hepatology: Porphyrias & Carcinogenesis Laboratory, Solid Tumors Program, CIMA-University of Navarra, 31008 Pamplona, Spain; (M.L.); (D.J.); (K.M.C.); (A.S.); (M.A.Á.)
- Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (E.D.P.); (P.D.)
| | - Daniel Jericó
- Hepatology: Porphyrias & Carcinogenesis Laboratory, Solid Tumors Program, CIMA-University of Navarra, 31008 Pamplona, Spain; (M.L.); (D.J.); (K.M.C.); (A.S.); (M.A.Á.)
| | - Karol M. Córdoba
- Hepatology: Porphyrias & Carcinogenesis Laboratory, Solid Tumors Program, CIMA-University of Navarra, 31008 Pamplona, Spain; (M.L.); (D.J.); (K.M.C.); (A.S.); (M.A.Á.)
| | - José Ignacio Riezu-Boj
- Center for Nutrition Research, Department of Nutrition, Food Sciences and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (J.I.R.-B.); (M.J.M.-A.); (F.I.M.)
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (M.C.); (I.P.)
| | - Raquel Urtasun
- Biochemistry Area, Department of Health Science, Public University of Navarre, 31008 Pamplona, Spain; (R.U.); (M.B.)
| | - Isabel Solares
- Rare Disease Unit, Internal Medicine Department, Clinica Universidad de Navarra, 31008 Pamplona, Spain;
| | - Ana Sampedro
- Hepatology: Porphyrias & Carcinogenesis Laboratory, Solid Tumors Program, CIMA-University of Navarra, 31008 Pamplona, Spain; (M.L.); (D.J.); (K.M.C.); (A.S.); (M.A.Á.)
| | - María Collantes
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (M.C.); (I.P.)
- MicroPET Research Unit, CIMA-CUN, 31008 Pamplona, Spain
- Nuclear Medicine-Department, CUN, 31008 Pamplona, Spain
| | - Ivan Peñuelas
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (M.C.); (I.P.)
- MicroPET Research Unit, CIMA-CUN, 31008 Pamplona, Spain
- Nuclear Medicine-Department, CUN, 31008 Pamplona, Spain
| | - María Jesús Moreno-Aliaga
- Center for Nutrition Research, Department of Nutrition, Food Sciences and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (J.I.R.-B.); (M.J.M.-A.); (F.I.M.)
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (M.C.); (I.P.)
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Matías A. Ávila
- Hepatology: Porphyrias & Carcinogenesis Laboratory, Solid Tumors Program, CIMA-University of Navarra, 31008 Pamplona, Spain; (M.L.); (D.J.); (K.M.C.); (A.S.); (M.A.Á.)
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (M.C.); (I.P.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Elena Di Pierro
- Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (E.D.P.); (P.D.)
| | - Miguel Barajas
- Biochemistry Area, Department of Health Science, Public University of Navarre, 31008 Pamplona, Spain; (R.U.); (M.B.)
| | - Fermín I. Milagro
- Center for Nutrition Research, Department of Nutrition, Food Sciences and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; (J.I.R.-B.); (M.J.M.-A.); (F.I.M.)
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (M.C.); (I.P.)
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Paola Dongiovanni
- Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (E.D.P.); (P.D.)
| | - Antonio Fontanellas
- Hepatology: Porphyrias & Carcinogenesis Laboratory, Solid Tumors Program, CIMA-University of Navarra, 31008 Pamplona, Spain; (M.L.); (D.J.); (K.M.C.); (A.S.); (M.A.Á.)
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain; (M.C.); (I.P.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
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