Hana Koutnikova, PhD

IPA WORLD CONGRESS + PROBIOTA AMERICAS

JUNE 24-26 2019

VANCOUVER, CANADA

Impact of bacterial probiotics on obesity, diabetes, and non-alcoholic fatty liver disease

25 June, 2019

2

DISCLOSUREHANA KOUTNIKOVA IS EMPLOYEE OF DANONE NUTRICIA

RESEARCH

Danone Nutricia Research near Paris is one of

the main Research and Innovation center

serving Danone’s divisions worldwide and

particularly focusing on the Essential Dairy and

Plant-Based and Waters divisions.

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DISEASE BACKGROUNDOBESITY, DIABETES AND NON-ALCOHOLIC FATTY LIVER DISEASE

(NAFLD)

High prevalence

Global health problem

Considerable health care cost

LIFESTYLE CHANGES

management of these tightly-linked

disorders that progress over an

individual’s lifetime.

https://www.worldobesity.org/https://www.diabetesatlas.orgDiehl et al., N Engl J Med. 2017;377(21):2063

Percentage of adults with diabetes

Percentage of adults with obesity Percentage of US adultswith NAFLD

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PROBIOTICS AND THEIR MODE OF ACTION IN METABOLISMMULTIPLE MODES OF ACTION

Sugar digestion and absorption

Incretin secretion

Fat absorption

Gut barrier function

Low-grade inflammation

Bile acid metabolism

Gut microbiota

Short chain fatty acid production

Reproduced from Cani et al., Curr Opin Biotechnol. 2015 Apr;32:21-27.Cerdó et al., Nutrients 2019, 11, 635;Perumpail et al.; Diseases. 2019 Feb 25;7(1).

Proposed role of probiotics in NAFLD

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PROBIOTICS AND METABOLIC DISEASEPROBIOTICS AND (OBESITY OR DIABETES OR NON-ALCOHOLIC FATTY

LIVER DISEASE)

DEFINITION

Live microorganisms which when

administered in adequate amounts

confer a health benefit on the host.

http://www.fao.org/3/a-a0512e.pdf

PROBIOTICS AND OBESITY, DIABETES AND NAFLD

NUMBER OF META-ANALYSES WERE PUBLISHED SINCE OUR PROTOCOL SUBMISSION OF JANUARY 16th

201625 June 2019 6

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OUR QUESTIONSPROTOCOL PROSPERO CRD42016033273

1. What is the effect of probiotics on outcomes related to obesity, diabetes, and NAFLD?

2. Is there effect heterogeneity by gender?

3. Is there effect heterogeneity in the following study populations: normal weight, overweight, obese,

metabolic syndrome, impaired fasting glucose, type 2 diabetes, gestational diabetes, NAFLD?

4. Is there effect heterogeneity by total daily dose, food form and probiotics species?

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INTERVENTION : BACTERIAL PROBIOTICSBACTERIA USED IN FOODS

BIOLOGICAL AGENTS UNDER EFSA QUALIFIED PRESUMPTION OF SAFETY

LIST

Genera

Bifidobacterium

Lactobacillus

Lactococcus

Leuconostoc

Oenococcus

Pediococcus

Propionibacterium

Streptococcus

Condition

Alone or administered with fermentable fibers at a maximum dose of

1.5g/day.

Reproduced from O’Toole et al., Nat Microbiol. 2017 Apr 25;2:17057

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VARIABLES

Body weight (BW)

Body mass index (BMI)

Waist circumference (WC)

Body fat mass (BFM)

Subcutaneous adipose (SAT)

Visceral adipose (VAT)

Fasting glucose (FG)

Glycated haemoglobin (HbA1c)

Insulin (INS)

Homeostatic model of insulin

resistance (HOMA-IR)

Alanine aminotransferase (ALAT)

Aspartate aminotransferase

(ASAT)

Gamma-glutamyl transferase

(GGT)

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STUDY SELECTION AND SEARCH TERMS

1. Randomized controlled trials

2. Published since 1990

3. Treatment duration of ≥ 14 days

4. Use of probiotics

5. Data on at least one difference between baseline

and end of intervention (irrespective of whether as

primary or secondary criteria)

Obese/ -ity

Diabetic/ -es

Weight, metabolic syndrome

Glucose intolerant, glucose tolerant, glucose

tolerance, glucose intolerance

Insulin resistance, insulin sensitivity

Impaired fasting glucose

Waist circumference

Abdominal adiposity, abdominal obesity, central

obesity, visceral adipose tissue, visceral fat, visceral

adiposity

Fat, fatty liver, non-alcoholic fatty liver

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EXCLUSION CRITERIA AND ASSESSMENT OF STUDY QUALITYPEDRO TOOL - QUALITY SCORE BASED ON 10 FACTORS

Isolated hypercholesterolemia

Alcoholic liver disease

Polycystic ovary syndrome

Children with an age of <3 years

High quality (≥8 points)

Moderate quality (>6 and <8 points)

Low quality (≤6 points)

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EFFECT MEASURE AND DATA SYNTHESIS

Mean difference in absolute change from baseline between the probiotics and control groups

If > 2 measurements during the follow-up: the last pre-intervention and at the end

Missing SE were estimated (Cochrane handbook, assumption of the magnitude of correlation among the repeated outcome measurements)

Coefficients of intrasubject correlation were assumed at intermediate magnitude of 0.5 (plus sensitivity

analyses)

Summary meta-analysis estimates : random effects method (DerSimonian-Laird estimator)

95% confidence interval and p values

Within publication and within study dependence structure (some authors reported multiple trial results investigating

different outcomes in the same study population within the same paper)

To synthesise outcomes separately as separate research questions : not adjustment for multiplicity

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STUDY HETEROGENEITYPEDRO TOOL : QUALITY SCORE BASED ON 10 FACTORS

Low : 0-25%

Intermediate : 25-50%

Moderate : 50-75%

High : ≥75%

Children

Pregnant woman

Gastric surgery

One country (high

preponderance)

Normal weight : NW

Overweight : OW

Obese : OB

Impaired fasting glucose: IFG

Type 2 diabetes: T2DM

Non-alcoholic fatty liver dis:

NAFLD NW : 18.5>BMI<25 kg/m²

OW : 25≥BMI<30 kg/m²

OB : BMI≥30 kg/m²

IFG : 5.6-6.9 mmol/l

T2DM : FG≥7.0 mmol/l or HbA1C≥6.5%

NAFLD : biopsy or ultrasound

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PUBLICATION SEARCH RESULTSMEDLINE, EMBASE AND COCHRANE FROM 1990 TO JUNE 2018

111 DIFFERENT RANDOMIZED COMPARISONS

Variable N°of trials N° of subjects Median

BW 58 3 422 77.4 kg

BMI 68 4 015 28.2 kg/m²

WC 26 1 583 98.8 cm

BFM 27 1 562 27.8 kg

FG 83 5 188 6.1 mmol

HbA1c 28 1 796 6.3

INS 63 3 854 11.0 mU/l

HOMA-IR 52 3 513 3.2

ALAT 26 1 466 38.6 IU/l

ASAT 23 1 340 36.1 IU/l

GGT 14 816 41.5 IU/l

43 trials conducted in Iran

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15OBESITY RELATED VARIABLE RESULTSBODY WEIGHT

RCT Number of trialsn Number of subjects² HeterogeneityI² HeterogeneityP(het) P value

E Estimatelb Lower boundaryub Upper boundaryP P value

FM Fermented milk Y Yogurt

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OBESITY RELATED VARIABLESBODY WEIGHT BW

BODY MASS INDEX BMI

BODY FAT MASS BFM

WAIST CIRCUMFERENCE WC

Robust effect estimates

Small effect size

IN OVERWEIGHT, significant effects with

probiotics

IN OBESE, effects were non-significant

ALL STUDIES ALL

NORMAL WEIGHT NW

OVERWEIGHT OW

OBESE OB

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DIABETES RELATED VARIABLESFASTING GLUCOSE FG

GLYCATED HAEMOGLOBIN HbA1c

INSULIN INS

INSULIN RESISTANCE HOMA-

IR

Effect estimates were non-significant upon

excluding studies conducted in Iran

Small effect size

IN DIABETICS, significant effects with

probiotics

ALL STUDIES ALL

IMPAIRED FASTING GLUCOSE IFG

TYPE 2 DIABETES T2DM

/9

/7

/8

/6

The meta-analysis did not explore the contribution of the Iranian studies in different study populations

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NAFLD RELATED VARIABLES

ALANINE AMINOTRANSFERASE

ALAT

ASPARTATE AMINOTRANSFERASE ASAT

GAMMA-GLUTAMYL TRANSFERASE GGT

Effect estimates were non-significant upon

excluding studies conducted in Iran

Small effect size

IN NAFLD, significant effects on ALAT and

ASAT

ALL STUDIES ALL

NON-ALCOHOLIC FATTY LIVER DISEASE

NAFLD

The meta-analysis did not explore the contribution of the Iranian studies in different study populations

/8

/7

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SPECIES SUBGROUP ANALYSISEFFECT WITH A SINGLE BACTERIAL SPECIES ON ALL ANTHROPOMETRIC VARIABLES.

EFFECTS ON AN INCREASED NUMBER OF OUTCOMES WITH THREE OR MORE SPECIES

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LIMITATIONSFUNNEL PLOT

• Integration of both exploratory and secondary

outcomes, 43 trials conducted in one country,

trials with small sample size, heterogeneous

study populations, incomplete information

on drug treatment, dietary and physical

activity records.

• For some trials, parameters necessary for the

estimation of effect sizes were unknown

• Non-published results from studies that did

not show significant results.

• Evidence of publication bias for FG, HbA1c,

INS, ALAT, ASAT and GGT

FG HbA1c

ALAT ASAT

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CONCLUSIONTHE INTAKE OF BACTERIAL PROBIOTICS RESULTED IN MINOR BUT CONSISTENT IMPROVEMENTS IN

SEVERAL METABOLIC RISK FACTORS IN SUBJECTS WITH METABOLIC DISEASES

• Probiotics consumption improves OBESITY

related variables with small effect sizes.

• Body weigh loss in OVERWEIGHT (0.94 kg,

1.2%) is below the clinically meaningful

threshold.

• Probiotics consumption improves DIABETES

related variables with small effect sizes and the

effect is influenced by Iranian studies.

• HbA1c reduction (0.28) in DIABETICS is

promisingly close to medical nutrition therapy

(0.5–2 pp).

• Probiotics consumption improves NAFLD

related variables with small effect sizes and the

effect is influenced by Iranian studies.

• Liver enzymes reduction in NAFLD subjects is

promising although the number of trials is

small.

25 June, 2019PRESENTATION TITLE IN CALIBRI BOLD

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PERSPECTIVESELECT THE PROBIOTICS STRAINS NOT ONLY FOR THEIR CAPACITY TO COMPLY WITH FOOD

GRADE STATUS

BUT ALSO

FOR THEIR CAPACITY TO SURVIVE THROUGH GASTROINTESTINAL TRACT (ASSUMING THIS IS

REQUIRED)

AND AFFECT RELEVANT BIOLOGICAL TARGET(S).

What are theunderlying mechanisms?

How can multispecies mixes be optimised to

induce synergistic effects?

Can probiotics become part of standard dietary

recommendations for obesity, diabetes and NALFD

management?

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ACKNOWLEDGEMENTS

BERND GENSER, PhD

MILENA MONTEIRO-SEPULVEDA,

PhD

JEAN-MICHEL FAURIE, PhD

SALWA RIZKALLA, MD, PhD

JÜRGEN SCHREZENMEIR, MD

KARINE CLÉMENT, MD, PhD

MURIELLE GAGNEAU

AGNÈS MEUNIER

MARION GENSER

QUENTIN DORNIC

KEVIN J CARROLL

TIMOTHY SWARTZ