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Intestinal Microbiota and Glycemic Control

Cynthia Lieu, Pharm.D., BCNSPLena Haddad, Ana Barron, Marina Boulos, Laila Fard

University of Southern California, School of PharmacyApril 15, 2018

Objectives

• Describe conditions that influence the composition of the intestinal microbiota

• Discuss the differences in the composition of the intestinal microbiota observed in individuals with and without diabetes

• Discuss interventions that impact glycemic control and diabetes through their effects on microbial balance

• Evaluate prebiotics, probiotics, specific nutrients, and dietary plans that impact glycemic control and diabetes through their effects on the intestinal microbiota

Microbiota

• Variable

– Inter-individual

– Intra-individual

• Predominantly bacteria

• Increased richness & diversity: better health

• Influenced by:

– Mode of birth

– Feeding after birth

– Environment

– Diet

• Influences health

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Intestinal microbiota

• Metabolism of nutrients

• Synthesis of vitamins

• Conversion of bile acids

• Modulation of immune system

• Defense against opportunistic pathogens

• Regulation of intestinal barrier function

• Xenobiotic metabolism

Predominant bacterial phyla in the human body

Phylum Class Examples

Firmicutes Bacilli; Clostridia Lactobacillus; Ruminococcus;Clostridium; Staphylococcus; Enterococcus; Faecalibacterium

Bacteroidetes Bacteroidetes Bacteroides;Prevotella

Proteobacteria Gammaproteobacteria; Betaproteobacteria

Escherichia; Pseudomonas

Actinobacteria Actinobacteria Bifidobacterium; Streptomyces; Nocardia

Pediatrics 2012: 129: 950-960

GI Microbiota: Type 2 Diabetes Mellitus

(T2DM) vs Healthy Individuals

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Overview of Differences in GI Bacteria T2DM vs. Healthy Individuals

Differences in GI Bacteria, T2DM vs. Healthy: Phyla Bacteroidetes and Firmicutes

● T2DM: Significant decrease in number of organisms from Phylum Firmicutes1

● Elevated number of organisms from Phylum Bacteroidetes1

○ Bacteria of this phylum are known to increase after consumption of fatty foods

● Bacteroidetes/Firmicutes (B/F) ratio significantly and positively correlates with reduced glucose tolerance1

1. Larsen N, et al. PLoS ONE. 2010; 5(2): e9085.

Differences in GI Bacteria, T2DM vs. Healthy: Short Chain-Fatty Acid producing bacteria

● T2DM: marked decrease in number of Short-Chain Fatty Acid (SCFA) producing Bacteria, including1,2,3:○ Eubacterium rectale○ Roseburia intestinalis○ Akkermansia muciniphila○ Faecalibacterium prausnitzii

● Short Chain Fatty Acids3,4,5,6

○ Decrease pro-inflammatory cytokine concentration and mucosal inflammation

○ Improve beta cell function○ Stimulate GLP-1 release

1. Qin, et al. Nature. 2012; 490(7418):55-60, 2. Zhang, et al. PLoS ONE. 2013; 8(8):e71108, 3. Sekirov, et al. Physiological Reviews. 2010; 90(3): 859-904, 4. McNeil. AmJClNut. 1984; 39(2): 338-342, 5. Kumar, et al. B J Nutr. 2011; 105: 561-73, 6. Zhao et al. Science. 2018; 359:1151-1156

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Differences in GI Bacteria, T2DM vs. Healthy: SCFA producing bacteria (Akkermansia muciniphila)

● T2DM: Akkermansiamuciniphila, is decreased in GIT1

● A. muciniphila functions in1,2,3:○ Maintaining integrity of the

colon epithelia○ Stimulating production of

anti-inflammatory lipids○ Regulating production of

peptides that are involved in glucose regulation (GLP-1 and GIP)

1. Zhang, et al. PLoS ONE. 2013; 8(8):e71108, 2. Everard, et al. Proceedings of the NAS. 2013; 110(22): 9066-90713. Cani, et al. Frontiers in Microbiology. 2017; 8:1765

Differences in GI Bacteria, T2DM vs. Healthy: Pathogenic Bacteria

● T2DM: increased presence of pathogenic and opportunistic bacteria1

○ Clostridium clusters○ Eggerthella lenta

■ Gram positive organism associated with abdominal sepsis

○ Escherichia coli

1. Qin, et al. Nature. 2012; 490(7418):55-60

Differences in GI Bacteria, T2DM vs. Healthy: Sulfate Reducing Bacteria

● T2DM: increased presence of sulfate reducing bacteria, namely, Desulfovibrio1, 2

○ These bacteria form Hydrogen Sulfide (H2S)■ Cytotoxic to GI mucosal

cells ■ Decrease colonic

secretions■ Decrease ulcer wound

healing■ Decrease release of GLP-1

1. Delzenne, et al. Diabetologia. 2015; 58(10):2206-2217,2. Karlsson, et al. Nature. 2013; 498(7452): 99-103

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T2DM: An Overview● T2DM: characterized by elevated plasma glucose,

deficit in secretion/action of insulin and incretins, and low level inflammation1,2

○ Moderate excess in systemic cytokine levels1

○ Cytokines activate Toll-like Receptors on peripheral tissues ■ Results in phosphorylation of proteins

regulating normal signaling through the insulin receptor1

■ Leads to peripheral insulin resistance

1. Moreno-Indias, et al. Frontiers in Microbiology. 2014; 5:190. 2. Shoelson, SE. J Clin Invest. 206; 116(8):2308-2318

T2DM: An Overview...continued● Key molecule involved in triggering inflammation →

Lipopolysaccharide (LPS)1

● Phylum Bacteroidetes: increased in those with T2DM

● LPS from these Gram negative organisms is shed

○ LPS translocates across the intestinal mucosa and triggers release of pro-inflammatory cytokines

○ Innate inflammatory process is triggered ■ Leads to the beta cell damage and insulin resistance

1. Moreno-Indias, et al. Frontiers in Microbiology. 2014; 5.

How does dysbiosis inside the intestine affect health/disease pathogenesis? A possible mechanism

● T2DM: increased intestinal permeability○ Impairment of tight junctions1

○ Results in translocation of bacterial endotoxin (LPS) paracellularly1

○ Mechanism producing low grade inflammation characteristic of T2DM1

● Modulating gut microbiota composition with prebiotics:1

○ Improved gut permeability○ Decreased inflammation○ Improved glucose tolerance

1. Han JL, Lin HL. 2014. World J Gastroenterol. 2014; 20(47):17737-45.

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Drugs & the microbiota

Alterations in intestinal microbiota:

How medications used to treat T2DM affect the microbiota

Metformin

Known MOA1

Activates AMPK

↓ glucose production in the liver

↑ insulin sensitivity

Enhancesglucose utilization

Mouse studies:

There may be more

Metforminmodulates the

gut microbiota towards a more beneficial state

1. Rotella et al. Curr Diabetes Rev 2006; 2(3): 307-315

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Akkermansia spp. population in lean vs obese mice1

Lean Mouse Obese/T2DM Mouse

Greater abundance of Akkermansia spp.

Decreased abundance of Akkermansia spp.

Presence of Akkermansia spp. inversely correlates with body weight in rodents & humans1

VS

1. Everard et al. Proc Natl Acad Sci U S A 2013; 110(22): 9066-9071.

Effect of Metformin on the gut microbiota of HFD-fed diabetic mice1

High Fat Diet (HFD)-fed, diabetic mouse

Metformin

↑ abundance of Akkermansia spp1,2

Correlated with improved metabolic parameters:- Amelioration of glucose intolerance1

- Reversed metabolic endotoxemia & insulin resistance3

1. Shin et al. Gut. 2014; 63: 727-7352. Lee et al. Appl Environ Microbiol 2014; 80(19): 5935-59433. Everard et al. Proc Natl Acad Sci U S A 2013; 110(22): 9066-9071

Significance:These findings suggest that:

Aside from its well-know MOA,

metformin may also be achieving its efficacy via its

modulation of the gut microbiota towards a more beneficial state

Pharmacologic manipulation of the

gut microbiota in favor of

Akkermansia spp. may be a potential

treatment for T2DM1.

Akkermansia spp. has a potential

role as a probiotic with antidiabetic

effects.1

*These were findings from mouse studies;

still need human studies

1. Shin et al. Gut. 2014; 63: 727-735

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Effect of Liraglutide on the microbiota of hyperglycemic mice1

Hyperglycemic mouse

Liraglutide

Changed overall structure of mouse’s microbiota by leading to:

↓ obesity-related phylotypes

↑ lean-related phylotypesAND

May be reason behind Liraglutide’s weight loss effect1

1. Wang et al. Sci Rep. 2016; 6: 33251

Effect of Saxagliptin on the microbiota of hyperglycemic mice1

In T2DM:

Bacteroides

Firmicutes

Decreased F to B ratio1

(Dysbiosis)

Saxagliptinadministration to

hyperglycemic mice

↑ F to B ratio1

(possibly correcting some of

the dysbiosis characteristic of

T2DM)

1. Wang et al. Sci Rep. 2016; 6: 33251

Effect of Sitagliptin on the microbiota of obese & T2DM rats1

Obese/T2DM Rat

Sitagliptin

↑ Roseburia1

(SCFA-producing bacteria)

↑ Bifidobacterium1

Improved insulin

sensitivity2

Improved glucose tolerance

& low-grade inflammation3,4

1. Yan et al. J Diabetes Res 2016; 2016: Article ID 20931712. Karlsson et al. Nature 2013; 498(7452): 99-1033. Cani. Gut.2009; 58(8): 1091-11034. Cani. Diabetologia 2008; 51: S34-S35

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Alterations in intestinal microbiota:

How medications that affect the gut microbiota may impact the risk of

T2DM/Obesity

Effect of antibiotics on the gut microbiota: overview

Antibiotics

Marked short-term

disturbances in the human gut

microbiota

Often incompleterecovery of gut

flora to its initial composition.1-4

Linked with development of obesity &

T2DM5-7

Use in children

associated with obesity later in life6

Significantly reduce

bacterial diversity in

the gut8

Broad > Narrow-spectrum8

1. Panda et al. PLoS One 2014; 9(4): e954762. Jernberg et al. ISME J 2007; 1: 56-663. Jakobsson et al. PLoS One 2010; 593); e98364. Dethlefsen et al. Proc Natl Acad Sci U S A 2010; 108 Suppl 1: 4554-45615. Thuny et al. PLoS One 2010; 5(2): e90746. Bailey et al. JAMA Pediatr 2014; 168(11): 1063-10697. Mikkelsen et al. J Clin Endocrinol Metab 2015; 100: 3633-36408. Czaja et al. Nutrition Health Food Sci 2017; 5(4): 1-21

Intestinal bacterial diversity in obese vs lean individuals1

Obese

Low intestinal bacterial diversity

VS

1. Le Chatelier et al. Nature 2013; 500: 541-546

Lean

Greater intestinal bacterial diversity

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Low vs high

bacterial richness:

More marked overall adiposity, insulin resistance & dyslipidemia

More pronounced

inflammatory phenotype1

Low gut bacterial

richnessRisk factor for progression to

adiposity-associated co-morbidities:

obesity & T2DM1

Intestinal bacterial diversity in obese vs lean individuals1

1. Le Chatelier et al. Nature 2013; 500: 541-546

Broad-spectrum antibiotic use &its connection to obesity1

↑ use of broad-spectrum antibiotics may be contributing to obesity trends

Ceftriaxone(broad-spectrum Abx)

Amoxicillin(narrow-spectrum Abx)

Weak correlation with obesity rateStrong correlation

with obesity rate

Significantly ↓ bacterial diversity in the gut

1. Czaja et al. Nutrition Health Food Sci. 2017; 5(4): 1-21

Antibiotic use in childhood &obesity later in lifeVarious observational studies:

Abx use in children associated with obesity later in life

Exposure to broad-spectrum

abx at ages 0-23 months is associated with early childhood

obesity; not with narrow1

Abx exposure during the

first 12 months was associated with ↑ed BMI

in boys aged 5–8 years3

Early-life abx use was associated with a 20%

increased risk of being

overweight at age 7 years2

1. Bailey et al. JAMA Pediatr 2014; 168(11): 1063-10692. Ajslev et al. Int J Obes (Lond) 2011; 35(4); 522-5293. Murphy et al. Int J Obes (Lond) 2014; 38: 1115-1119

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Conclusion● Overall, these studies highlight the importance of implementing

more restricted use of antimicrobial agents

● Antibiotic use may damage the gut flora and lead to dysbiosisthat may contribute to the development of obesity & T2DM

● Implementation of appropriate antibiotic stewardship programs is critical, and ensures that that:○ Broad-spectrum antibiotics are only used when absolutely

necessary○ Regimens are promptly de-escalated when cultures and

sensitivities (C&S) are available○ Duration of therapy with broad-spectrum agents is limited

Food & the microbiota

Different Diets & the Microbiota

1.Kim, et al., Environ Microbiol Rep, 2013, 5: 765-7752.Fallucca, et al., Diabetes Metab Res Rev, 2014, 30: 48-54 3.Xiao, et al., Microbiol Ecol, 2014, 87: 357-367

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Strict Vegetarian Diet

Kim et al., Environ Microbiol Rep 2013; 5(5): 765-775

Food supplements & the microbiota

1.Suez et al., Nature, 2014, 514: 181-1862.Gomes et al., British Jour Nutri, 2015, 114: 1756-17653.Feng et al., PLoS ONE, 2015, 10: e0125952

Artificial sweeteners

Suez et al., Nature, 2014, 514: 181-186

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Food supplements & the microbiota... continued

1. Zhu et al., Intern Journ Food Sci & Nutr, 2016, 67: 686-6952. Roopchand et al., Diabetes, 2015, 64: 2847-2858

Conclusions

• Diets that are low in calorie and high in fiber are most influential in improving glucose intolerance

• Try to avoid consistently using artificial sweeteners, especially saccharin (Sweet’N Low)

• Calcium, chromium malate, bitter melon, and dietary polyphenols can benefit an individual with T2DM

Prebiotics/Probiotics & the microbiota

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Good Sources of Probiotics & Prebiotics

1. Le Barz M et al. Diabetes Metab J. 2015;39:291-3032. Gibson GR et al. Nutr. Res. Rev.2004;17:259–275

Effects of Prebiotics

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1. Dehghan P et al. Nutrition. 2014;30(4):418-423

2. Gibb RG et al. Am J Clin Nutr. 2015, 102: 1604-16133. Maki KC et al. J Nutr. 2012;142(4):717–234. Maziarz MP et al. Nutrition Journal. 2017;16(1)

Effects of Probiotics

VSL #3• 8 beneficial lactic acid bacteria1

– B. longum, B. infantis, B. breve, L. acidophilus, L. casei, L. delbrueckii ssp. bulgaricus, L. plantarum and Streptococcus salivarius ssp. thermophilus

• ↓ inflammatory mediators: TNF-alpha, IL-6, and hs-CRP1

– Compromise intestinal integrity– Complicate metabolic diseases

• Prevented ↑ in serum insulin concentration and rise in insulin resistance1

1. Jafarnejad S et al. Journal of Nutrition and Metabolism. 2016;1-8

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1. Asemi Z et al. Annals of Nutrition and Metabolism. 2013;63(1-2):1-92. Simon M et al. Diabetes Care. 2015; 38: 1827-18343. Everard A et al. mBio. 2014;5(3)4. He C, Shan Y, Song W. Nutrition Research. 2015; 35:361-367.

Fecal microbiota transplantation (FMT)

• Transfer of intestinal microbiota

• From healthy donor to patient

• To introduce or restore a stable microbial community in the gut

• Manipulation of altered intestinal microbiota

• Reinstall depleted bacterial species associated with disease

Xu, et al. World J Gastroenterol 2015; 21(1): 102-111

FMT: potential for increasing insulin sensitivity

• Double blind, randomized controlled trial

• 18 M, metabolic syndrome

• Half received fecal microbiota infusion from lean male donors (allogenic group), vs self-collected feces (control)

• After 6-wk infusion of microbiota from lean donors, marked increase:

– Insulin sensitivity

– Levels of butyrate-producing intestinal microbiota

• No significant changes found in control group

Vrieze, et al. Gastroenterology 2012; 143: 913-916

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FMT: potential for increasing insulin sensitivity

• 38 M, metabolic syndrome, BMI ≥ 30

• Fecal microbiota infusion from lean M donors, BMI < 25 (allogenic), vs own (autologous = control)

• 18 wks after FMT: microbiota similar to baseline; no significant effects on insulin sensitivity; no wt change

• 6 wks after FMT: responders vs non-responders

– Altered microbiota composition

– Peripheral & hepatic insulin sensitivity increased

– Significant increase in Akkermansia muciniphila

– Metabolic response dependent on decreased fecal microbial diversity at baseline

Knotte, et al. Cell Metab 2017; 26(4): 611-619.e6

Thank You!

Ana BarronUSC School of PharmacyEmail: anabarro@usc.edu

Marina BoulosUSC School of Pharmacy Email: marinabo@usc.edu

Laila FardUSC School of PharmacyEmail: lfard@usc.edu

Speaker Contact Information:

Lena HaddadUSC School of PharmacyEmail: lenahadd@usc.edu

Cynthia L. Lieu, Pharm.D, BCNSPUSC School of PharmacyOffice: (323) 442-1472Email: CLLLieu@usc.edu