the gastrointestinal (gi) system and gut microbiome in ... · outline • historical link between...

CalliopeHolingue,MPH,PhDCandidate

DepartmentMentalHealth,JohnsHopkinsBloombergSchoolofPublicHealth

DepartmentalSeminar,WednesdayMarch28,2018

Thegastrointestinal(GI)systemandgutmicrobiomeinAutismSpectrumDisorders(ASD)

Outline

•  HistoricallinkbetweenASDandgut,possibleconnections

•  EvidenceforroleofgutmicrobiomeinASD•  MeasurementChallenges•  FutureDirections

‘Alldiseasestartsinthegut’Hippocrates~460-370BC

AutismSpectrumDisorder

DSM-5APA2013

“Autisms”

EytanNisinzweig,ayoungmanwithautism ©EytanArt.com2010

5

GILinkwithAutism

•  LeoKanner1943:6ofthe10childrenwithautism“presentedseverefeedingdifficultyfromthebeginningoflife”

Kanner1943;Goodwinetal1971;D’Eufemiaetal1996;Chaidezetal2014

> >

ASD DD TD

GISymptoms•  MostcommonGIissues(medianacross144autismstudies)–  Constipation(22%)– Diarrhea(23%)– Abdominalpain/discomfort(14%)–  Bloating/flatulence(13%)– Nausea/vomiting(6%)– Anysymptom(47%)

•  Foodsensitivities,preferences,mealtimebehaviors,toiletingproblemsarecommon

Holingueetal2017

Whystudythegutinautism?

•  ComplementaryandAlternativeTreatments/Medicine(CAMs)

Complementary/AlternativeTreatments/Medicine(CAMs)

•  DevelopedoutsideofWesternmainstreammedicine

•  Manyaimto‘healthegut’toprevent/treatASDsymptoms

•  Over70%familiesreportone+CAMs

•  Verylittledataonsafetyorefficacy

Christonetal2010

Whystudythegutinautism?

•  CAMs•  Treatingcomorbidities,improvingqualityoflife

•  Gutasariskfactorfor– ExacerbationofASDsymptoms–  IncidenceofASD

PossibleConceptualDiagram

ASD GIissues

PossibleConceptualDiagram

ASD

Co-occurringconditions

Medications

GIissues

PossibleConceptualDiagram

ASD

Co-occurringconditions

Medications

Diet

GIissues

PossibleConceptualDiagram

Gut ASD

PossibleConceptualDiagram

Gut ASD

DiscomfortDistressPain

PossibleConceptualDiagram

Gut ASD

DiscomfortDistressPain

“Biology”

EvidenceforroleofgutmicrobiomeinASD

TheHumanMicrobiome

“Themicrobiomeisdefinedasthecollectivegenomesofthemicrobes(composedof

bacteria,bacteriophage,fungi,protozoaandviruses)thatliveinsideandonthehuman

body.”

Yang,Joy."TheHumanMicrobiomeProject:Extendingthedefinitionofwhatconstitutesahuman."NationalHumanGenomeResearchInstitute(2012).

Microbe:Microorganisms[e.g.bacteria,virus]Microbiota:MicroorganismsinparticularsiteMicrobiome:Combinedgeneticmaterialofmicroorganismsinparticularenvironment

Thediversityofmicrobesvariesbyanatomicsite

TheHumanMicrobiome

TheHumanMicrobiome

Health,diet,hygiene,genotype… àComposition,complexity,andfunctionofour

microbialcommunities

Rolesofgutmicrobiome

•  Bacteriacommunicatewitheachotherandwithhost(Us!)

•  Producevitaminsandnutrients•  Influencehostgeneexpression,immunecellresponses

•  Regulategutmotility,intestinalbarrierhomeostasis,nutrientabsorption,fatdistribution

•  Gut-braincommunication,brainfunction,behavior

SynergisticRelationship

“Microbiotanormallyhasabalanced

compositionalsignaturethatconfershealthbenefits...

disruptionofthisbalanceconfersdiseasesusceptibility”

Cryan,JohnF.,andTimothyG.Dinan."Mind-alteringmicroorganisms:theimpactofthegutmicrobiotaonbrainandbehaviour."Naturereviewsneuroscience13.10(2012):701-712.

MicrobiomeisDynamic

“…Themicrobiomeisafluctuatingcollectionofgenesandgeneproducts;environmentalperturbations,suchasantibiotictreatmentandinfection,canreadilyalter

themicrobialcompositionandfunctionofeachcommunity…Thehumanmetagenomeisrelatively

plasticormalleable,whichmakesthemicrobiomeanattractivetargetformanipulationbycellorgene

therapy”

Pflughoeft,KathrynJ.,andJamesVersalovic."Humanmicrobiomeinhealthanddisease."AnnualReviewofPathology:MechanismsofDisease7(2012):99-122.

MeasuringtheGutMicrobiome

•  Collectingsamplesoftheactualgutisoftennotfeasibleorethical

•  Moststudiesexaminethefecalmicrobiome

•  DNAisextracted,sequencedtodeterminewhichmicrobesarepresent

EvidenceforroleofgutmicrobiomeinASD

MaternalImmuneActivation

BehavioralAbnormalitiesCorticalpatches

MaternalImmuneActivation

Healthypups

Antibiotic

•  GutbacteriathatinduceTh17cells✔•  Pro-inflammatorystimulus✔•  Pregnancy✔AllrequiredforincreaseinIL-17awhichpromotesMIA-inducedneurodevelopmentalabnormalities

MaternalImmuneActivation

+

SpecificBacteriainMom’sGut

ASDinchild

MaternalImmuneActivation

+

SpecificBacteriainMom’sGut

ASDinchild

?

DissertationAim

AntibioticExposureInPregnantWomen

ASDinoffspring

DissertationAim

AntibioticExposureInPregnantWomen

ASDinoffspringX

MaternalImmuneActivation

ASDhumanmicrobiomestudiesFindingsInconsistent

Clostridium,Sutterella,Lactobacillus,Desulfovibrio

Prevotella,Coprococcus,andVeillonellaceae

Bacteroidetes/Firmicutesratio

Parrachoetal2005;Vuongetal2016;Kangetal2013;Finegoldetal2002;Songetal2004;Williamsetal2012;Wangetal2013;Tomovaetal2014;Williamsetal2011

Reasonsforinconsistenciesacrossstudies

•  Differencesinhowmicrobiomedatawascollected,stored,analyzed

•  Unadjustedconfounding•  HeterogeneityofASD

DissertationAim

ToestimateassociationsofgutmicrobiomesignaturesincludingdiversitymetricsandrelativeabundanceoftaxawithASDco-occurringconditions.

GutmicrobiomeASDco-occurringconditions

•  Recruit30boys3-6yearswithASDfromKennedyKriegerInstitute,CenterforAutismandRelatedDisorders

•  Stoolkit:OmnigeneGut•  Questionnaires:

•  Childbehaviorchecklist•  Theshortsensoryprofile•  GIquestionnaire•  BristolStoolScale

•  SampleswillbeprocessedandsequencedatJHUwith16srRNAtechnology

StatisticalAnalysis

Estimateassociationsbetweenco-occurringissues/behaviorandmicrobialprofiles,withinASD

ExemplarHypotheses:Anxiety~PrevotellawithinASDSomaticComplaints~PrevotellawithinASDSleepproblems~PrevotellawithinASD

MeasurementIssues

•  AssessingGIsymptoms/conditionsinASDischallenging

DissertationAim

Todevelopareliableandvalidquestionnairethatassessesgastrointestinal(GI)symptomsinchildrenwithautismspectrumdisorderforuseinepidemiologicstudies.

StudyPopulation

•  RegistryofparentsofchildwithASDatKennedyKriegerInstitute

•  Havepreviouslyconsentedtobecontactedforresearchpurposes

•  Ages3-18years•  Recruitment,consent,datacollectionwillallhappenonline

Methods•  BaseoffofAutismTreatmentNetworkGI

InventoryandBriefAutismMealtimeBehaviorInventory

•  Focusgroupsandexpertpanel

•  Administerourquestionnaire+childbehaviorchecklist

•  Assesspsychometricperformanceandrevise•  Administertoindependentsample,assess

psychometricperformance

KeyTakeaways

•  GIsymptomsareelevatedinASD•  GIsymptoms/disordersmaybeduetohavingASD

•  GutmayplayaroleincausingASD•  Bothdirectionsarelikelyoccurring,dependsontheindividual

•  Accurate,reliableassessment,diagnosis,treatmentofGIsymptomsinASDiscritical

ImpactandImplications

•  Etiologyofautismandmentalillness

•  Targetforpreventionandtreatment

Futurework

•  Measurementandassessment•  Latentclassesapproachestoidentifying‘subgroups’ofASD

•  Incorporatingmultipledatatypes•  Animalandhumanstudiesshouldinformeachother,informmechanisticwork

Thankyou!!

ThesiscommitteeDaniFallin(Adviser)Li-ChingLeeNoelMuellerSarahMurrayRashelleMusciJayPasricha

FundingPsychiatricEpidemiologyTrainingProgram(PI:PeterZandi)WendyKlagCenterforAutismandDevelopmentalDisabilities

ShamelessPlugs

ShamelessPlugs

Gut-MentalHealthWorkingGroupcholing1@jhu.edu

References(1)•  Kanner,Leo."Autisticdisturbancesofaffectivecontact."Nervouschild2.3(1943):217-250.•  Goodwin,MaryStewart,T.CampbellGoodwin,andMurrayA.Cowen."Malabsorptionandcerebral

dysfunction:amultivariateandcomparativestudyofautisticchildren."JournalofAutismandchildhoodSchizophrenia1.1(1971):48-62.

•  d'Eufemia,P.,etal."Abnormalintestinalpermeabilityinchildrenwithautism."ActaPaediatrica85.9(1996):1076-1079.

•  Chaidez,Virginia,RobinL.Hansen,andIrvaHertz-Picciotto."Gastrointestinalproblemsinchildrenwithautism,developmentaldelaysortypicaldevelopment."Journalofautismanddevelopmentaldisorders44.5(2014):1117-1127.

•  Holingue,Calliope,etal."Gastrointestinalsymptomsinautismspectrumdisorder:Areviewoftheliteratureonascertainmentandprevalence."AutismResearch(2017).

•  Christon,LillianM.,VirginiaH.Mackintosh,andBarbaraJ.Myers."Useofcomplementaryandalternativemedicine(CAM)treatmentsbyparentsofchildrenwithautismspectrumdisorders."ResearchinAutismSpectrumDisorders4.2(2010):249-259.

•  Yang,Joy."TheHumanMicrobiomeProject:Extendingthedefinitionofwhatconstitutesahuman."NationalHumanGenomeResearchInstitute(2012).

•  Cryan,JohnF.,andTimothyG.Dinan."Mind-alteringmicroorganisms:theimpactofthegutmicrobiotaonbrainandbehaviour."Naturereviewsneuroscience13.10(2012):701-712.

•  Pflughoeft,KathrynJ.,andJamesVersalovic."Humanmicrobiomeinhealthanddisease."AnnualReviewofPathology:MechanismsofDisease7(2012):99-122.

References(2)•  Kim,Sangdoo,etal."Maternalgutbacteriapromoteneurodevelopmentalabnormalitiesinmouseoffspring."Nature

549.7673(2017):528.•  ParrachoHMRT,BinghamMO,GibsonGR,McCartneyAL.Differencesbetweenthegutmicrofloraofchildrenwithautistic

spectrumdisordersandthatofhealthychildren.JMedMicrobiol.2005;54(10):987–91.•  VuongHE,HsiaoEY.Emergingrolesforthegutmicrobiomeinautismspectrumdisorder.BiolPsychiatry.Elsevier;2016;•  KangDW,ParkJG,IlhanZE,WallstromG,LaBaerJ,AdamsJB,etal.ReducedIncidenceofPrevotellaandOtherFermentersin

IntestinalMicrofloraofAutisticChildren.PLoSOne.2013;8(7).•  FinegoldSM,MolitorisD,SongY,LiuC,VaisanenM-L,BolteE,etal.Gastrointestinalmicroflorastudiesinlate-onsetautism.

ClinInfectDis.OxfordUniversityPress;2002;35(Supplement1):S6–16.•  SongY,LiuC,FinegoldSM.Real-TimePCRQuantitationofClostridiainFecesofAutisticChildrenReal-TimePCRQuantitation

ofClostridiainFecesofAutisticChildren.ApplEnviromentalMicrobiol.2004;70(11):6459–6465.•  WilliamsBL,HornigM,ParekhT,LipkinWI.ApplicationofnovelPCR-basedmethodsfordetection,quantitation,and

phylogeneticcharacterizationofSutterellaspeciesinintestinalbiopsysamplesfromchildrenwithautismandgastrointestinaldisturbances.MBio.AmSocMicrobiol;2012;3(1):e00261-11.

•  WangL,ChristophersenCT,SorichMJ,GerberJP,AngleyMT,ConlonMa.IncreasedabundanceofSutterellaspp.andRuminococcustorquesinfecesofchildrenwithautismspectrumdisorder.MolAutism[Internet].2013;4(1):42.Availablefrom:MolecularAutism

•  TomovaA,HusarovaV,LakatosovaS,BakosJ,VlkovaB,BabinskaK,etal.GastrointestinalmicrobiotainchildrenwithautisminSlovakia.PhysiolBehav[Internet].ElsevierInc.;2015;138:179–87.Availablefrom:http://dx.doi.org/10.1016/j.physbeh.2014.10.033

•  WilliamsBL,HornigM,BuieT,BaumanML,ChoPaikM,WickI,etal.Impairedcarbohydratedigestionandtransportandmucosaldysbiosisintheintestinesofchildrenwithautismandgastrointestinaldisturbances.PLoSOne.2011;6(9).

•  Buie,Timothy,etal."Evaluation,diagnosis,andtreatmentofgastrointestinaldisordersinindividualswithASDs:aconsensusreport."Pediatrics125.Supplement1(2010):S1-S18.