Bariatric Times

JUN 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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P O T L I G H T o n N U T R I T I O N S S UPPLEMENT TO BARIATRIC TIMES VOLUME 14, NUMBER 6 • JUNE 2017 • SUPPLEMENT A Tackling Body Weight Regulation Through Targeted Probiotics The Clinical Issue: Weight Loss Maintenance and Patterns of Regain Weight loss surgery has led to tremendous weight loss success. 1 Obesity is a chronic progressive disease, and patients may experience recidivism and need continued support to maintain their weight loss post-surgery. 1 Weight loss and weight maintenance support needs can also be observed in the nonsurgical patient population with obesity. The health records of 176,495 men and women with obesity were examined over more than nine years and revealed that only 1 in 8 men and 1 in 7 women with body mass indices (BMIs) greater than 40kg/m 2 successfully lost five percent total body weight. The odds of achieving normal body weight were 1 in 1,290 for men and 1 in 677 for women with BMIs greater than 40kg/m 2 . Eighty-six percent of men and 85 percent of women who initially achieved a reduction in their BMI showed subsequent increase, 2 highlighting the chronic nature of obesity. Adaptive changes that occur in weight loss, such as changes in metabolic rate and changes in secretion of gut peptides that promote feeling of satiety (e.g., glucagon- like peptide 1 [GLP-1]), pose challenges for maintenance. 5 As outlined by The Obesity Society, 6 weight regulation is multifaceted and involves various external environmental aspects, as well as internal factors, such as genetics, physiology, and the microbiome. The Microbiome and Body Weight Regulation—What is the Evidence? The Human Microbiome Project characterized the intestinal microbiome as a complex eco-system colonized by over 100 trillion microorganisms. Communication networks between the intestine and other organs (e.g., gut-brain, gut-liver axes) enable the microbiome to influence health. 7 Although a "healthy" microbiome has been difficult to precisely identify, microbial dysbiosis—defined as a n imbalance within the microbiome—has been linked to numerous diseases, including obesity. Microbiome transfer studies show that obesity can be transferred through the microbiome. Reports of weight gain in individuals receiving microbiome samples from individuals with overweight during treatment for Clostridium difficile infection have been published, 8 and we await results from larger studies. Transfer of an obese microbiome sample into mice induces significant body weight and fat gain, a result not seen with transfer of a lean sample. 9 Reduced intestinal microbial diversity—defined as reduced variety in microbiota—is seen in obesity and has been linked with greater BMI and visceral fat 10 and more marked weight gain over time. 11 The numbers of specific microbiota have also been shown to vary in obesity. A meta-analysis reported that certain microbiota are increased in obesity, whereas others, including members of the Bifidobacterium genus, are reduced. 1 2 Functional differences leading to increased energy-harvesting ability in obesity, as well as differences in gut peptide expression, have also been proposed (Figure 1). 13 Weight Management in the Era of Precision Probiotics According to research by the World Health Organization and the Food and Agriculture Organization of the United Nations (FAO), probiotics are live microorganisms which, when administered in adequate amounts, alter the microbiota and may confer beneficial health effects, but not all probiotics are the same. The health benefits of probiotics are genus, species, and strain specific, and clinical trials on specific probiotic strains and doses for the outcome of interest are required prior to selection. 14,15 In recent years, several probiotic strains with relevance to body weight regulation have entered the research arena. Of these, Bifidobacteria animalis lactis 420 (B420) currently shows greatest promise. B420 is clinically effective in body weight and fat regulation and contributes to body weight maintenance. B420 is increased in feces following s upplementation, indicating survival through the gastrointestinal tract. 16 The complete genome sequence has been characterized—a factor important for quality assessment. 17 More recently, this probiotic strain has been shown to be robust enough for manufacture, making it relevant for practice and not purely a research tool. Tracking B420 in the literature tells an interesting story about its development. Supplementing animal models of obesity with B420 resulted in reduced body weight and body fat mass gain compared with placebo. 18 Investigators also found that increased GLP-1 when combined with dietary fiber is one potential mechanism of action. 18 Additionally, a protection against high-fat, diet-induced bacterial translocation and circulating lipopolysaccharide (LPS), a cell wall component of certain bacteria, have also been reported. 19 Bacterial translocation and low-grade increases in LPS—termed metabolic endotoxemia—have been associated with adverse metabolic outcomes, food intake, and body fat regulation. 19–22 In late 2016, clinical data highlighting B420 efficacy were published. 16 This randomized, controlled, double-blind study in individuals with overweight and obesity was designed to test the impact of B420 (10 billion live cells/day; n=55) or placebo control (n=57) on body weight and fat variables over six months. No changes to food intake or activity patterns were recommended, and the study assessed the impact of B420 as the primary intervention. At six months, BMI and total fat mass were significantly lower in the B420 group compared to placebo. Trunk fat mass was significantly lower in the B420 group compared to the placebo control group at six months, and this was reflected in a significantly lower waist circumference in the B420 group. Overall, the data showed a pattern of superior body weight and body fat regulation over time in the B420 group, with these variables increasing over the intervention period in the placebo group. by Annalouise O'Connor, PhD Dr. O'Connor is a member of the research and development team at Metagenics and Bariatric Advantage.

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