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Henderson M, Moore SA, Harnois‐Leblanc S, Johnston BC, Fitzpatrick‐Lewis D, Usman AM, Sherifali D, Merdad R, Rigsby AM, Esmaeilinezhad Z, Morrison KM, Hamilton J, Ball GDC, Birken CS. Effectiveness of behavioural and psychological interventions for managing obesity in children and adolescents: A systematic review and meta-analysis framed using minimal important difference estimates based on GRADE guidance to inform a clinical practice guideline. Pediatr Obes 2025; 20:e13193. [PMID: 39823182 PMCID: PMC11803187 DOI: 10.1111/ijpo.13193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 09/18/2024] [Accepted: 09/30/2024] [Indexed: 01/19/2025]
Abstract
OBJECTIVE Conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) of behavioural and psychological interventions for managing paediatric obesity. METHODS Eligible studies, published between 1985 and 2022, included 0 to 18 year olds with outcomes reported ≥3 months post-baseline, including patient-reported outcome measures (PROMs), cardiometabolic and anthropometric outcomes, and adverse events (AEs). We pooled data using a random effects model and assessed certainty of evidence (CoE) related to minimally important difference estimates for outcomes using GRADE. RESULTS We included 73 unique RCTs (n = 6305 participants, 53% female). Intervention types included physical activity (n = 1437), nutrition (n = 447), psychological (n = 1336), technology-based (n = 901) or multicomponent (≥2 intervention types, n = 2184). Physical activity had a small effect on health-related quality of life (HRQoL), varying effects ranging from moderate to very large on blood pressure, lipids and insulin resistance, and a small effect on BMIz. Nutrition had a small effect on lipids, insulin resistance and BMIz. Psychological interventions showed a small effect on HRQoL and triglycerides and moderate benefits on depressive symptoms, while technology interventions showed small benefits on blood pressure and BMIz. Multicomponent interventions had a large benefit on anxiety, small benefit on depressive symptoms, with large to very large benefits on lipids, and small benefits for diastolic blood pressure, insulin resistance and BMIz. AEs were reported infrequently, and when reported, were described as mild. CONCLUSION Physical activity and multicomponent interventions showed improvements in PROMs, cardiometabolic and anthropometric outcomes. Future trials should consistently measure PROMs, evaluate outcomes beyond the intervention period, and study children <6 years of age.
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Affiliation(s)
- M. Henderson
- Sainte‐Justine University Hospital Research CenterUniversité de MontréalMontréalQuebecCanada
- Department of Pediatrics, Faculty of MedicineUniversité de MontréalMontréalQuebecCanada
- Department of Social and Preventive MedicineSchool of Public Health, Université de MontréalMontréalQuebecCanada
| | - S. A. Moore
- School of Health and Human Performance, Faculty of HealthDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Pediatrics, Faculty of MedicineDalhousie UniversityHalifaxNova ScotiaCanada
| | - S. Harnois‐Leblanc
- Sainte‐Justine University Hospital Research CenterUniversité de MontréalMontréalQuebecCanada
- Department of Population MedicineHarvard Pilgrim Health Care Institute and Harvard Medical SchoolBostonMassachusettsUSA
| | - B. C. Johnston
- Department of NutritionCollege of Agriculture and Life Science, Texas A&M UniversityCollege StationTexasUSA
- Department of Epidemiology and BiostatisticsSchool of Public Health, Texas A&M UniversityCollege StationTexasUSA
| | - D. Fitzpatrick‐Lewis
- School of NursingMcMaster UniversityHamiltonOntarioCanada
- McMaster Evidence Review and Synthesis TeamMcMaster UniversityHamiltonOntarioCanada
| | - A. M. Usman
- McMaster Evidence Review and Synthesis TeamMcMaster UniversityHamiltonOntarioCanada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health SciencesMcMaster UniversityHamiltonOntarioCanada
| | - D. Sherifali
- School of NursingMcMaster UniversityHamiltonOntarioCanada
- McMaster Evidence Review and Synthesis TeamMcMaster UniversityHamiltonOntarioCanada
| | - R. Merdad
- Department of Community Medicine, Faculty of MedicineKing Abdulaziz UniversityJeddahSaudi Arabia
| | - A. M. Rigsby
- Department of NutritionCollege of Agriculture and Life Science, Texas A&M UniversityCollege StationTexasUSA
| | - Z. Esmaeilinezhad
- Department of NutritionCollege of Agriculture and Life Science, Texas A&M UniversityCollege StationTexasUSA
| | - K. M. Morrison
- Department of PediatricsMcMaster UniversityHamiltonOntarioCanada
- McMaster Children's HospitalHamiltonOntarioCanada
| | - J. Hamilton
- The Hospital for Sick ChildrenTorontoOntarioCanada
- Department of PediatricsUniversity of TorontoTorontoOntarioCanada
| | - G. D. C. Ball
- Department of Pediatrics, Faculty of Medicine & DentistryCollege of Health Sciences, University of AlbertaEdmontonAlbertaCanada
| | - C. S. Birken
- Department of PediatricsUniversity of TorontoTorontoOntarioCanada
- Child Health Evaluative Sciences, SickKids Research InstituteTorontoOntarioCanada
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Altamura S, Lombardi F, Palumbo P, Cinque B, Ferri C, Del Pinto R, Pietropaoli D. The Evolving Role of Neutrophils and Neutrophil Extracellular Traps (NETs) in Obesity and Related Diseases: Recent Insights and Advances. Int J Mol Sci 2024; 25:13633. [PMID: 39769394 PMCID: PMC11727698 DOI: 10.3390/ijms252413633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2024] [Revised: 12/16/2024] [Accepted: 12/18/2024] [Indexed: 01/03/2025] Open
Abstract
Obesity is a chronic, multifactorial disease characterized by persistent low-grade tissue and systemic inflammation. Fat accumulation in adipose tissue (AT) leads to stress and dysfunctional adipocytes, along with the infiltration of immune cells, which initiates and sustains inflammation. Neutrophils are the first immune cells to infiltrate AT during high-fat diet (HFD)-induced obesity. Emerging evidence suggests that the formation and release of neutrophil extracellular traps (NETs) play a significant role in the progression of obesity and related diseases. Additionally, obesity is associated with an imbalance in gut microbiota and increased intestinal barrier permeability, resulting in the translocation of live bacteria, bacterial deoxyribonucleic acid (DNA), lipopolysaccharides (LPS), and pro-inflammatory cytokines into the bloodstream and AT, thereby contributing to metabolic inflammation. Recent research has also shown that short-chain fatty acids (SCFAs), produced by gut microbiota, can influence various functions of neutrophils, including their activation, migration, and the generation of inflammatory mediators. This review comprehensively summarizes recent advancements in understanding the role of neutrophils and NET formation in the pathophysiology of obesity and related disorders while also focusing on updated potential therapeutic approaches targeting NETs based on studies conducted in humans and animal models.
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Affiliation(s)
- Serena Altamura
- Department of Life, Health & Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (S.A.); (F.L.); (P.P.); (B.C.); (C.F.); (R.D.P.)
- Prevention and Translational Research—Dental Clinic, Center of Oral Diseases, 67100 L’Aquila, Italy
| | - Francesca Lombardi
- Department of Life, Health & Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (S.A.); (F.L.); (P.P.); (B.C.); (C.F.); (R.D.P.)
| | - Paola Palumbo
- Department of Life, Health & Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (S.A.); (F.L.); (P.P.); (B.C.); (C.F.); (R.D.P.)
| | - Benedetta Cinque
- Department of Life, Health & Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (S.A.); (F.L.); (P.P.); (B.C.); (C.F.); (R.D.P.)
| | - Claudio Ferri
- Department of Life, Health & Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (S.A.); (F.L.); (P.P.); (B.C.); (C.F.); (R.D.P.)
- Unit of Internal Medicine and Nephrology, San Salvatore Hospital, Center for Hypertension and Cardiovascular Prevention, 67100 L’Aquila, Italy
| | - Rita Del Pinto
- Department of Life, Health & Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (S.A.); (F.L.); (P.P.); (B.C.); (C.F.); (R.D.P.)
- Unit of Internal Medicine and Nephrology, San Salvatore Hospital, Center for Hypertension and Cardiovascular Prevention, 67100 L’Aquila, Italy
| | - Davide Pietropaoli
- Department of Life, Health & Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (S.A.); (F.L.); (P.P.); (B.C.); (C.F.); (R.D.P.)
- Prevention and Translational Research—Dental Clinic, Center of Oral Diseases, 67100 L’Aquila, Italy
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Ren Y, Huang P, Zhang L, Tang YF, Luo SL, She Z, Peng H, Chen YQ, Luo JW, Duan WX, Liu LJ, Liu LQ. Dual Regulation Mechanism of Obesity: DNA Methylation and Intestinal Flora. Biomedicines 2024; 12:1633. [PMID: 39200098 PMCID: PMC11351752 DOI: 10.3390/biomedicines12081633] [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: 06/12/2024] [Revised: 07/15/2024] [Accepted: 07/18/2024] [Indexed: 09/01/2024] Open
Abstract
Obesity is a multifactorial chronic inflammatory metabolic disorder, with pathogenesis influenced by genetic and non-genetic factors such as environment and diet. Intestinal microbes and their metabolites play significant roles in the occurrence and development of obesity by regulating energy metabolism, inducing chronic inflammation, and impacting intestinal hormone secretion. Epigenetics, which involves the regulation of host gene expression without changing the nucleotide sequence, provides an exact direction for us to understand how the environment, lifestyle factors, and other risk factors contribute to obesity. DNA methylation, as the most common epigenetic modification, is involved in the pathogenesis of various metabolic diseases. The epigenetic modification of the host is induced or regulated by the intestinal microbiota and their metabolites, linking the dynamic interaction between the microbiota and the host genome. In this review, we examined recent advancements in research, focusing on the involvement of intestinal microbiota and DNA methylation in the etiology and progression of obesity, as well as potential interactions between the two factors, providing novel perspectives and avenues for further elucidating the pathogenesis, prevention, and treatment of obesity.
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Affiliation(s)
- Yi Ren
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (Y.R.); (P.H.); (L.Z.); (Y.-F.T.); (S.-L.L.); (Z.S.); (H.P.); (Y.-Q.C.); (J.-W.L.); (W.-X.D.); (L.-J.L.)
- Children’s Brain Development and Brain Injury Research Office, The Second Xiangya Hospital of Central South University, Changsha 410011, China
- Department of Pediatrics, Haikou Hospital of the Maternal and Child Health, Haikou 570100, China
- Department of Children’s Healthcare, Hainan Modern Women and Children’s Medical, Haikou 570100, China
| | - Peng Huang
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (Y.R.); (P.H.); (L.Z.); (Y.-F.T.); (S.-L.L.); (Z.S.); (H.P.); (Y.-Q.C.); (J.-W.L.); (W.-X.D.); (L.-J.L.)
- Children’s Brain Development and Brain Injury Research Office, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Lu Zhang
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (Y.R.); (P.H.); (L.Z.); (Y.-F.T.); (S.-L.L.); (Z.S.); (H.P.); (Y.-Q.C.); (J.-W.L.); (W.-X.D.); (L.-J.L.)
- Children’s Brain Development and Brain Injury Research Office, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Yu-Fen Tang
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (Y.R.); (P.H.); (L.Z.); (Y.-F.T.); (S.-L.L.); (Z.S.); (H.P.); (Y.-Q.C.); (J.-W.L.); (W.-X.D.); (L.-J.L.)
- Children’s Brain Development and Brain Injury Research Office, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Sen-Lin Luo
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (Y.R.); (P.H.); (L.Z.); (Y.-F.T.); (S.-L.L.); (Z.S.); (H.P.); (Y.-Q.C.); (J.-W.L.); (W.-X.D.); (L.-J.L.)
- Children’s Brain Development and Brain Injury Research Office, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Zhou She
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (Y.R.); (P.H.); (L.Z.); (Y.-F.T.); (S.-L.L.); (Z.S.); (H.P.); (Y.-Q.C.); (J.-W.L.); (W.-X.D.); (L.-J.L.)
- Children’s Brain Development and Brain Injury Research Office, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Hong Peng
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (Y.R.); (P.H.); (L.Z.); (Y.-F.T.); (S.-L.L.); (Z.S.); (H.P.); (Y.-Q.C.); (J.-W.L.); (W.-X.D.); (L.-J.L.)
- Children’s Brain Development and Brain Injury Research Office, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Yu-Qiong Chen
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (Y.R.); (P.H.); (L.Z.); (Y.-F.T.); (S.-L.L.); (Z.S.); (H.P.); (Y.-Q.C.); (J.-W.L.); (W.-X.D.); (L.-J.L.)
- Children’s Brain Development and Brain Injury Research Office, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Jin-Wen Luo
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (Y.R.); (P.H.); (L.Z.); (Y.-F.T.); (S.-L.L.); (Z.S.); (H.P.); (Y.-Q.C.); (J.-W.L.); (W.-X.D.); (L.-J.L.)
- Children’s Brain Development and Brain Injury Research Office, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Wang-Xin Duan
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (Y.R.); (P.H.); (L.Z.); (Y.-F.T.); (S.-L.L.); (Z.S.); (H.P.); (Y.-Q.C.); (J.-W.L.); (W.-X.D.); (L.-J.L.)
- Children’s Brain Development and Brain Injury Research Office, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Ling-Juan Liu
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (Y.R.); (P.H.); (L.Z.); (Y.-F.T.); (S.-L.L.); (Z.S.); (H.P.); (Y.-Q.C.); (J.-W.L.); (W.-X.D.); (L.-J.L.)
- Children’s Brain Development and Brain Injury Research Office, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Li-Qun Liu
- Department of Pediatrics, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (Y.R.); (P.H.); (L.Z.); (Y.-F.T.); (S.-L.L.); (Z.S.); (H.P.); (Y.-Q.C.); (J.-W.L.); (W.-X.D.); (L.-J.L.)
- Children’s Brain Development and Brain Injury Research Office, The Second Xiangya Hospital of Central South University, Changsha 410011, China
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Luzzi A, Briata IM, Di Napoli I, Giugliano S, Di Sabatino A, Rescigno M, Cena H. Prebiotics, probiotics, synbiotics and postbiotics to adolescents in metabolic syndrome. Clin Nutr 2024; 43:1433-1446. [PMID: 38704983 DOI: 10.1016/j.clnu.2024.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 12/06/2023] [Accepted: 04/19/2024] [Indexed: 05/07/2024]
Abstract
The prevalence of childhood and adolescent obesity has globally reached alarming dimensions and many adolescents affected by obesity already present one or more obesity-related comorbidities. In recent years, emerging evidence supporting the role of gut microbiota in the pathophysiology of metabolic diseases has been reported and the use of prebiotics, probiotics, synbiotics and postbiotics as a strategy to manipulate gut microbiota has become popular. The aim of this review is to explore the relationship between gut microbiota and metabolic syndrome in adolescents and to discuss the potential use of prebiotics, probiotics, synbiotics and postbiotics for the prevention and treatment of this clinical picture in adolescence. According to the most recent literature, prebiotics, probiotics and synbiotics have no clear effect on MetS, but a possible modulation of anthropometric parameters has been observed after synbiotic supplementation. Only one study has examined the role of postbiotics in alleviating metabolic complications in children with obesity but not in adolescents. More extensive research is needed to support the conclusions drawn so far and to develop effective microbiome-based interventions that may help improving the quality of life of children and adolescents exposed to the increasing prevalence of MetS.
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Affiliation(s)
- Alessia Luzzi
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; Post Graduate Course in Food Science and Human Nutrition, Università Statale di Milano, 20122 Milan, Italy; Clinical Nutrition Unit, Department of General Medicine, ICS Maugeri IRCCS, 27100 Pavia, Italy.
| | - Irene Maria Briata
- Post Graduate Course in Food Science and Human Nutrition, Università Statale di Milano, 20122 Milan, Italy; Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy.
| | - Ilaria Di Napoli
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy.
| | - Silvia Giugliano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, 20072, Italy.
| | - Antonio Di Sabatino
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy; First Department of Internal Medicine, Fondazione IRCCS San Matteo, 27100 Pavia, Italy.
| | - Maria Rescigno
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, 20072, Italy; IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy.
| | - Hellas Cena
- Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; Clinical Nutrition Unit, Department of General Medicine, ICS Maugeri IRCCS, 27100 Pavia, Italy.
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Duan Y, Wang L, Ma Y, Ning L, Zhang X. A meta-analysis of the therapeutic effect of probiotic intervention in obese or overweight adolescents. Front Endocrinol (Lausanne) 2024; 15:1335810. [PMID: 38352715 PMCID: PMC10861773 DOI: 10.3389/fendo.2024.1335810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/08/2024] [Indexed: 02/16/2024] Open
Abstract
Background & aims Existing evidence on the possible effects of probiotics on obese or overweight adolescents has not been fully established. Therefore, the aim of this study was to explore the effects of probiotic supplementation on anthropometric indices, inflammatory markers and metabolic indices in obese or overweight adolescents. Methods The literature up to March 2023 related to probiotic intervention in obese or overweight adolescents was searched and screened from multiple databases, including the CNKI(China national knowledge infrastructure), CBM(Chinese biomedical literature database), PubMed, EmBase, and Cochrane library databases. All randomized controlled trials using probiotic supplements in obese or overweight adolescents were included in this systematic review and meta-analysis. Results A total of 8 studies that met the inclusion criteria were included in this study. There were 201 cases in the experimental group (probiotic treatment) and 190 cases in the control group. Compared to the control group, probiotic intervention in adolescents resulted in a decrease in body mass index, fasting blood glucose and C-reactive protein with WMD(Weighted mean difference) and 95% CI of -2.53 (-4.8 to -0.26) kg/m2, -0.80 (-1.13 to -0.47) mol/L and -0.24 (-0.43 to -0.05) mg/L, respectively. No significant changes were found in weight, waist circumference, waist-to-hip ratio, insulin, Homeostatic Model Assessment of insulin resistance, interleukin 6, tumor necrosis factor alpha and so on; however, an unfavorable elevated effect in total cholesterol, triglycerides, and low-density lipoproteins was detected with WMD and 95% CI of 0.06 (0.02 to 0.09) mmol/L, 0.18 (0.14 to 0.21) mmol/L, and 0.19 (0.18 to 0.20) mmol/L, respectively. Conclusion According to our results, probiotic supplementation was beneficial in managing metabolic indicators such as fasting blood glucose, body mass index and inflammation-related C-reactive protein in overweight or obese adolescents. Further large scale studies are warranted to confirm present findings and to identify the effects and mechanisms to provide more precise evidence for clinical intervention. Systematic review registration doi: 10.37766/inplasy2024.1.0081, identifier INPLASY202410081.
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Affiliation(s)
- Yuanqing Duan
- Department of Endocrinology, The Second Affiliated Hospital of Shandong First Medical University, Taian, Shandong, China
| | - Lanping Wang
- Department of Operating Room, The Second Affiliated Hospital of Shandong First Medical University, Taian, Shandong, China
| | - Yan Ma
- Department of Endocrinology, The Second Affiliated Hospital of Shandong First Medical University, Taian, Shandong, China
| | - Lei Ning
- Department of Case Room, The Second Affiliated Hospital of Shandong First Medical University, Taian, Shandong, China
| | - Xinhuan Zhang
- Department of Endocrinology, The Second Affiliated Hospital of Shandong First Medical University, Taian, Shandong, China
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Carson MD, Westwater C, Novince CM. Adolescence and the Microbiome: Implications for Healthy Growth and Maturation. THE AMERICAN JOURNAL OF PATHOLOGY 2023; 193:1900-1909. [PMID: 37673331 PMCID: PMC10699129 DOI: 10.1016/j.ajpath.2023.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 09/08/2023]
Abstract
The gut microbiota was initially thought to develop into a stable, adult-like profile during early postnatal life. The formation of the gut microbiota during early life has been shown to contribute to healthy growth and has lifelong implications for host health. Adolescence, the developmental period between childhood and adulthood, is a critical window for healthy growth and maturation. The composition of the gut microbiota in adolescents is distinct from that of children and adults, which supports the premise that the gut microbiota continues to develop during adolescence toward an adult-like profile. Research has begun to shift its focus from understanding the gut microbiome at the extremes of the life span to evaluating the importance of the gut microbiome during adolescence and its role in healthy development. This article provides an overview of adolescent development, host-microbiota interactions, and experimental models used to discern effects of gut microbiota on health and disease. Herein, the role of the gut microbiota is reviewed as it relates to adolescent: i) brain development, cognition, and behavior; ii) metabolism and adiposity; and iii) skeletal growth and bone mass accrual. Future directions are addressed, including omics investigations defining mechanisms through which the gut microbiota influences adolescent development. Furthermore, we discuss advancing noninvasive interventions targeting the adolescent gut microbiota that could be employed to support healthy growth and maturation.
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Affiliation(s)
- Matthew D Carson
- Departments of Oral Health Sciences, College of Dental Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Caroline Westwater
- Departments of Oral Health Sciences, College of Dental Medicine, Medical University of South Carolina, Charleston, South Carolina; Department of Microbiology and Immunology, College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Chad M Novince
- Departments of Oral Health Sciences, College of Dental Medicine, Medical University of South Carolina, Charleston, South Carolina; Division of Endocrinology, Department of Pediatrics, College of Medicine, Medical University of South Carolina, Charleston, South Carolina; Division of Periodontics, Department of Stomatology, College of Dental Medicine, Medical University of South Carolina, Charleston, South Carolina.
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Borka Balas R, Meliț LE, Lupu A, Lupu VV, Mărginean CO. Prebiotics, Probiotics, and Synbiotics-A Research Hotspot for Pediatric Obesity. Microorganisms 2023; 11:2651. [PMID: 38004665 PMCID: PMC10672778 DOI: 10.3390/microorganisms11112651] [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: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023] Open
Abstract
Childhood obesity is a major public health problem worldwide with an increasing prevalence, associated not only with metabolic syndrome, insulin resistance, hypertension, dyslipidemia, and non-alcoholic fatty liver disease (NAFLD), but also with psychosocial problems. Gut microbiota is a new factor in childhood obesity, which can modulate the blood lipopolysaccharide levels, the satiety, and fat distribution, and can ensure additional calories to the host. The aim of this review was to assess the differences and the impact of the gut microbial composition on several obesity-related complications such as metabolic syndrome, NAFLD, or insulin resistance. Early dysbiosis was proven to be associated with an increased predisposition to obesity. Depending on the predominant species, the gut microbiota might have either a positive or negative impact on the development of obesity. Prebiotics, probiotics, and synbiotics were suggested to have a positive effect on improving the gut microbiota and reducing cardio-metabolic risk factors. The results of clinical trials regarding probiotic, prebiotic, and synbiotic administration in children with metabolic syndrome, NAFLD, and insulin resistance are controversial. Some of them (Lactobacillus rhamnosus bv-77, Lactobacillus salivarius, and Bifidobacterium animalis) were proven to reduce the body mass index in obese children, and also improve the blood lipid content; others (Bifidobacterium bifidum, Bifidobacterium longum, Lactobacillus acidophilus, Lacticaseibacillus rhamnosus, Enterococcus faecium, and fructo-oligosaccharides) failed in proving any effect on lipid parameters and glucose metabolism. Further studies are necessary for understanding the mechanism of the gut microbiota in childhood obesity and for developing low-cost effective strategies for its management.
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Affiliation(s)
- Reka Borka Balas
- Department of Pediatrics I, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, Gheorghe Marinescu Street, No. 38, 540136 Târgu Mureș, Romania; (R.B.B.); (C.O.M.)
| | - Lorena Elena Meliț
- Department of Pediatrics I, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, Gheorghe Marinescu Street, No. 38, 540136 Târgu Mureș, Romania; (R.B.B.); (C.O.M.)
| | - Ancuța Lupu
- Department of Pediatrics, University of Medicine and Pharmacy Gr. T. Popa Iași, Universității Street No 16, 700115 Iași, Romania; (A.L.); (V.V.L.)
| | - Vasile Valeriu Lupu
- Department of Pediatrics, University of Medicine and Pharmacy Gr. T. Popa Iași, Universității Street No 16, 700115 Iași, Romania; (A.L.); (V.V.L.)
| | - Cristina Oana Mărginean
- Department of Pediatrics I, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, Gheorghe Marinescu Street, No. 38, 540136 Târgu Mureș, Romania; (R.B.B.); (C.O.M.)
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Kilic Yildirim G, Dinleyici M, Vandenplas Y, Dinleyici EC. Effects of synbiotic supplementation on intestinal microbiota composition in children and adolescents with exogenous obesity: (Probesity-2 trial). Gut Pathog 2023; 15:36. [PMID: 37474971 PMCID: PMC10360342 DOI: 10.1186/s13099-023-00563-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023] Open
Abstract
INTRODUCTION Gut microbiota manipulation may be a potential therapeutic target to reduce host energy storage. There is limited information about the effects of probiotics/synbiotics on intestinal microbiota composition in children and adolescents with obesity. The objective of this randomized double-blind placebo-controlled trial was to test the effects of a multispecies synbiotic on intestinal microbiota composition in children and adolescents with exogenous obesity. METHOD Children with exogenous obesity were managed with a standard diet and increased physical activity and were randomly allocated into two groups at a ratio of 1:1; the 1st group received synbiotic supplementation (probiotic mixture including Lactobacillus acidophilus, Lacticaseibacillus. rhamnosus, Bifidobacterium bifidum, Bifidobacterium longum, Enterococcus faecium (total 2.5 × 109 CFU/sachet) and fructo-oligosaccharides (FOS; 625 mg/sachet) for 12 weeks; the 2nd group received placebo once daily for 12 weeks. Fecal samples were obtained before and at the end of the 12-week intervention to characterize the changes in the gut microbiota composition. Detailed metagenomic and bioinformatics analyses were performed. RESULTS Before the intervention, there were no significant differences in alpha diversity indicators between the synbiotic and placebo groups. After 12 weeks of intervention, the observed taxonomic units and Chao 1 were lower in the synbiotic group than at baseline (p < 0.001 for both). No difference for alpha diversity indicators was observed in the placebo group between baseline and 12 weeks of intervention. At the phylum level, the intestinal microbiota composition of the study groups was similar at baseline. The major phyla in the synbiotic group were Firmicutes (66.7%) and Bacteroidetes (18.8%). In the synbiotic group, the Bacteroidetes phylum was higher after 12 weeks than at baseline (24.0% vs. 18.8%, p < 0.01). In the synbiotic group, the Firmicutes/Bacteroidetes ratio was 3.54 at baseline and 2.75 at 12 weeks of intervention (p < 0.05). In the placebo group, the Firmicutes/Bacteroidetes ratio was 4.70 at baseline and 3.54 at 12 weeks of intervention (p < 0.05). After 12 weeks of intervention, the Firmicutes/Bacteroidetes ratio was also lower in the synbiotic group than in the placebo group (p < 0.05). In the synbiotic group, compared with the baseline, we observed a statistically significant increase in the genera Prevotella (5.28-14.4%, p < 0.001) and Dialister (9.68-13.4%; p < 0.05). Compared to baseline, we observed a statistically significant increase in the genera Prevotella (6.4-12.4%, p < 0.01) and Oscillospira (4.95% vs. 5.70%, p < 0.001) in the placebo group. In the synbiotic group, at the end of the intervention, an increase in Prevotella, Coprococcus, Lachnospiraceae (at the genus level) and Prevotella copri, Coprococcus eutactus, Ruminococcus spp. at the species level compared to baseline (predominance of Eubacterium dolichum, Lactobacillus ruminis, Clostridium ramosum, Bulleidia moorei) was observed. At the end of the 12th week of the study, when the synbiotic and placebo groups were compared, Bacteroides eggerthi species were dominant in the placebo group, while Collinsella stercoris species were dominant in the synbiotic group. CONCLUSION This study is the first pediatric obesity study to show that a synbiotic treatment is associated with both changes intestinal microbiota composition and decreases in BMI. Trial identifier: NCT05162209 (www. CLINICALTRIALS gov).
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Affiliation(s)
- Gonca Kilic Yildirim
- Faculty of Medicine, Pediatrics Nutrition and Metabolism Unit, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Meltem Dinleyici
- Faculty of Medicine, Department of Social Pediatrics, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Yvan Vandenplas
- Vrije Unversiteit Brussel, UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | - Ener Cagri Dinleyici
- Faculty of Medicine, Department of Pediatrics, Eskisehir Osmangazi University, Eskisehir, TR-26040, Turkey.
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9
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Fiore G, Magenes VC, DI Profio E, Milanta C, Calcaterra V, Diamanti A, Campoy C, Zuccotti G, Verduci E. Gut microbiota in obesity and related comorbidities in children and adolescents: the role of biotics in treatment. Minerva Pediatr (Torino) 2022; 74:632-649. [PMID: 35708037 DOI: 10.23736/s2724-5276.22.06964-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Obesity is a complex pathology, globally spread, with a multifactorial pathogenesis, strictly linked with lifestyle, hormones, genetic and epigenetic factors. Evidence supports that obesity, and its comorbidities, are related to changes in gut microbiota, partially responsible of the modulation of energy metabolism. EVIDENCE ACQUISITION Pediatric obesity has been associated with lower bacterial diversity and differences in composition of the gut microbiota, also varying according to the metabolic status of obese subjects. Indeed, differences in distributions and activity of microorganisms in the gut of metabolically healthy and unhealthy obese children have been highlighted. EVIDENCE SYNTHESIS Based on human studies, this review aims to discuss gut microbiota alterations in obese children and adolescents and its role in obese-related complications. Moreover, the role of biotics (probiotics, prebiotics, synbiotics and -marginally- postbiotics) has been analyzed as modulator of obesity-related dysbiosis. CONCLUSIONS As a conclusion, a deeper knowledge about biotic mechanisms of action would be of great interest to implement the clinical care of children and adolescents with obesity and related comorbidities.
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Affiliation(s)
- Giulia Fiore
- Department of Pediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Vittoria C Magenes
- Department of Pediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Elisabetta DI Profio
- Department of Pediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Chiara Milanta
- Department of Pediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Valeria Calcaterra
- Department of Pediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy.,Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Antonella Diamanti
- Unit of Hepatology Gastroenterology and Nutrition, Bambino Gesù Children's Hospital, Rome, Italy
| | - Cristina Campoy
- Centre of Excellence for Pediatric Research EURISTIKOS, Department of Pediatrics, University of Granada, Granada, Spain
| | - Gianvincenzo Zuccotti
- Department of Pediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy.,L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.,Pediatric Clinical Research Center Fondazione Romeo ed Enrica Invernizzi, University of Milan, Milan, Italy
| | - Elvira Verduci
- Department of Pediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy - .,Department of Health Sciences, University of Milan, Milan, Italy
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10
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Calcaterra V, Verduci E, Vandoni M, Rossi V, Fiore G, Massini G, Berardo C, Gatti A, Baldassarre P, Bianchi A, Cordaro E, Cavallo C, Cereda C, Bosetti A, Zuccotti G. The Effect of Healthy Lifestyle Strategies on the Management of Insulin Resistance in Children and Adolescents with Obesity: A Narrative Review. Nutrients 2022; 14:4692. [PMID: 36364954 PMCID: PMC9657567 DOI: 10.3390/nu14214692] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 10/29/2022] [Accepted: 11/04/2022] [Indexed: 11/07/2023] Open
Abstract
Childhood obesity is characterized by an increased risk of several metabolic derangements including insulin resistance (IR). The strongest recommendations to prevent obesity and related complications are a balanced and adequate diet and practicing physical activity from early childhood. In this review, we propose to present the effects of healthy lifestyle strategies, including physical exercise and dietary approaches, on the management of IR and related metabolic derangements. All types of exercise (aerobic, resistance and combined training) effectively reduce IR in pediatric patients with obesity; it seems that aerobic and combined training stimulate greater improvements in IR compared to resistance training. Balanced normocaloric or hypocaloric dietary approaches are also valid strategies to address IR; it is not possible to assess the long-term impact of varying macronutrients on cardiometabolic risk. The glycemic index/load evaluation is a useful dietary approach to glucose metabolism control. Similarly, they should adopt the principle of the Mediterranean diet. Randomized studies with longer monitoring are needed to define the benefits of nutritional supplementation on IR. Considering that healthy style acquisition could track to later ages, programs of healthy lifestyle starting with children offer a better preventive strategy to preserve metabolic control and children's health.
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Affiliation(s)
- Valeria Calcaterra
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Elvira Verduci
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
- Department of Health Sciences, University of Milano, 20142 Milan, Italy
| | - Matteo Vandoni
- Laboratory of Adapted Motor Activity (LAMA), Department of Public Health, Experimental Medicine and Forensic Science, University of Pavia, 27100 Pavia, Italy
| | - Virginia Rossi
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Giulia Fiore
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Giulia Massini
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Clarissa Berardo
- Department of Biomedical and Clinical Science, University of Milano, 20157 Milan, Italy
| | - Alessandro Gatti
- Laboratory of Adapted Motor Activity (LAMA), Department of Public Health, Experimental Medicine and Forensic Science, University of Pavia, 27100 Pavia, Italy
| | - Paola Baldassarre
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Alice Bianchi
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Erika Cordaro
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Caterina Cavallo
- Laboratory of Adapted Motor Activity (LAMA), Department of Public Health, Experimental Medicine and Forensic Science, University of Pavia, 27100 Pavia, Italy
- LUNEX International University of Health, Exercise and Sports, 50, Avenue du Parc des Sports, 4671 Differdange, Luxembourg
| | - Cristina Cereda
- Neonatal Screening and Metabolic Disorders Unit, V. Buzzi Children’s Hospital, 20154 Milan, Italy
| | - Alessandra Bosetti
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Gianvincenzo Zuccotti
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science, University of Milano, 20157 Milan, Italy
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11
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Gur M, Zuckerman-Levin N, Masarweh K, Hanna M, Laghi L, Marazzato M, Levanon S, Hakim F, Bar-Yoseph R, Wilschanski M, Bentur L. The effect of probiotic administration on metabolomics and glucose metabolism in CF patients. Pediatr Pulmonol 2022; 57:2335-2343. [PMID: 35676769 PMCID: PMC9796051 DOI: 10.1002/ppul.26037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 05/23/2022] [Accepted: 06/08/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Cystic fibrosis (CF)-related diabetes (CFRD) affects 50% of CF adults. Gut microbial imbalance (dysbiosis) aggravates their inflammatory response and contributes to insulin resistance (IR). We hypothesized that probiotics may improve glucose tolerance by correcting dysbiosis. METHODS A single-center prospective pilot study assessing the effect of Vivomixx® probiotic (450 billion/sachet) on clinical status, spirometry, lung clearance index (LCI), and quality of life (QOL) questionnaires; inflammatory parameters (urine and stool metabolomics, blood cytokines); and glucose metabolism (oral glucose tolerance test [OGTT]), continuous glucose monitoring [CGM], and homeostasis model assessment of IR (HOMA-IR) in CF patients. RESULTS Twenty-three CF patients (six CFRD), mean age 17.7 ± 8.2 years. After 4 months of probiotic administration, urinary cysteine (p = 0.018), lactulose (p = 0.028), arabinose (p = 0.036), mannitol (p = 0.041), and indole 3-lactate (p = 0.046) significantly increased, while 3-methylhistidine (p = 0.046) and N-acetyl glutamine (p = 0.047) decreased. Stool 2-Hydroxyisobutyrate (p = 0.022) and 3-methyl-2-oxovalerate (p = 0.034) decreased. Principal component analysis, based on urine metabolites, found significant partitions between subjects at the end of treatment compared to baseline (p = 0.004). After 2 months of probiotics, the digestive symptoms domain of Cystic Fibrosis Questionnaire-Revised improved (p = 0.007). In the nondiabetic patients, a slight decrease in HOMA-IR, from 2.28 to 1.86, was observed. There was no significant change in spirometry results, LCI, blood cytokines and CGM. CONCLUSIONS Changes in urine and stool metabolic profiles, following the administration of probiotics, may suggest a positive effect on glucose metabolism in CF. Larger long-term studies are needed to confirm our findings. Understanding the interplay between dysbiosis, inflammation, and glucose metabolism may help preventing CFRD.
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Affiliation(s)
- Michal Gur
- Pediatric Pulmonary Institute and CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Nehama Zuckerman-Levin
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Pediatric Diabetes Unit, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Kamal Masarweh
- Pediatric Pulmonary Institute and CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Moneera Hanna
- Pediatric Pulmonary Institute and CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Luca Laghi
- Department of Agricultural and Food Sciences, University of Bologna, Cesena, Italy.,Interdepartmental Centre for Industrial Agrofood Research, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Massimiliano Marazzato
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Shir Levanon
- Pediatric Pulmonary Institute and CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Fahed Hakim
- Pediatric Pulmonary Institute and CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ronen Bar-Yoseph
- Pediatric Pulmonary Institute and CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Michael Wilschanski
- Department of Pediatric Gastroenterology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Lea Bentur
- Pediatric Pulmonary Institute and CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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12
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Li D, Li Y, Yang S, Lu J, Jin X, Wu M. Diet-gut microbiota-epigenetics in metabolic diseases: From mechanisms to therapeutics. Biomed Pharmacother 2022; 153:113290. [PMID: 35724509 DOI: 10.1016/j.biopha.2022.113290] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/26/2022] [Accepted: 06/09/2022] [Indexed: 11/02/2022] Open
Abstract
The prevalence of metabolic diseases, including obesity, dyslipidemia, type 2 diabetes mellitus (T2DM), and non-alcoholic fatty liver disease (NAFLD), is a severe burden in human society owing to the ensuing high morbidity and mortality. Various factors linked to metabolic disorders, particularly environmental factors (such as diet and gut microbiota) and epigenetic modifications, contribute to the progression of metabolic diseases. Dietary components and habits regulate alterations in gut microbiota; in turn, microbiota-derived metabolites, such as short-chain fatty acids (SCFAs), are influenced by diet. Interestingly, diet-derived microbial metabolites appear to produce substrates and enzymatic regulators for epigenetic modifications (such as DNA methylation, histone modifications, and non-coding RNA expression). Epigenetic changes mediated by microbial metabolites participate in metabolic disorders via alterations in intestinal permeability, immune responses, inflammatory reactions, and insulin resistance. In addition, microbial metabolites can trigger inflammatory immune responses and microbiota dysbiosis by directly binding to G-protein-coupled receptors (GPCRs). Hence, diet-gut microbiota-epigenetics may play a role in metabolic diseases. However, their complex relationships with metabolic diseases remain largely unknown and require further investigation. This review aimed to elaborate on the interactions among diet, gut microbiota, and epigenetics to uncover the mechanisms and therapeutics of metabolic diseases.
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Affiliation(s)
- Dan Li
- Guang'an men Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China.
| | - Yujuan Li
- Guang'an men Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China.
| | - Shengjie Yang
- Guang'an men Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China.
| | - Jing Lu
- Guang'an men Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China.
| | - Xiao Jin
- Guang'an men Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China.
| | - Min Wu
- Guang'an men Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China.
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