1. FMT: Can we cure obesity and insulin resistance?
Max Nieuwdorp MD PhD
Internist-endocrinologist
Dept of Vascular Medicine Amsterdam
Wallenberg Laboratory, Gothenberg, Sweden
session Panacea or Pandora’s Box 17th august 2014: am
20 minutes

2. Disclosure slide Scientific advisory board Seres Health
Founder Caelus pharmaceuticals

3. Take home message
Decreased butyrate producing bacteria in obesity associated with malign obesity and insulin resistance
FMT incudes changes in (small) iIntestinal microbiota and affects insulin resistance (but it is not a panancea)
Using FMT as a working model can derive novel probiotics on top of current treatment for insulin resistance

4. Intestinal microbiota in obesity and MetSyn

5. Benign vs malign obesity
66% metabolically healthy obese
34% insulin resitance and DM2
Low grade inflammation involved
Samocha-bonet et al, obesity Reviwws 2014.

6. Gut microbiota and obesity/type 2 diabetes mellitus
Qin, Nature 2012
Le Chatelier, Nature 2013
Karlsson, Nature 2013
Ridaura, Science 2013

7. Diagnostic and clinical value of gut microbiota composition in Dm2
Reduced short-chain fatty acid butyrate producers (Roseburia species and Faecalibacterium prausnitzii) in DM2
Enrichment of Lactobacillus gasseri and Streptococcus mutans in fecal sample has predictive value for developing insulin resistance
Karlsson, Nature 2013

8. Results of these cohort based studies using fecal samples
F prausznitzii lower
Ruminococcus lower
Smits/Nieuwdorp, Gastroenterology 2013 [in press]

9. Major disadvantages of current fecal sample centered approach
1. Small intestine is more involved
in metabolism than the colon
2. Association is not causality!
3. Sequencing vs culturing bacteria

10. pH dictates bacterial survival and gutmicrobiota composition
Hartstra/nieuwdorp, Diabetes Care 2014.

11. Koch’s postulates for causality
The microorganism must be identified/isolated from a diseased organ(ism).
The microorganism should be associated with disease (association/intervention).
The cultured microorganism should induce beneficial or adverse effects when introduced into an organism (inoculation).

12. Manipulating gut microbiota by fecal transplant

13. Effects of fecal transplantations in clostridium difficile diarroea
Van Nood, NEJM 2013

14. Gutmicrobiota Diversity in Cdiff After FMT
Correction of Low Diversity of Patients by Transplantation
Diverse Community Stably Maintained for Over 2 Months

15. FMT Randomized controlled trials performed at AMC
Since 1958 casereport by Eiseman, at least 4500 patients treated worldwide with donor feces (since 2007 at AMC),
RCT superiority of fecal Tx in clostridium difficile diarrhea and MetSyn
At AMC ongoing/finished RCT’s for:
-IBD (Colitis ulcerosa, TURN trial)
- insulin resistance
-NAFLD/NASH
Long term side effects not seen yet
Smits/Nieuwdorp, Gastroenterology 2013 [in press]; van Nood/Nieuwdorp, NEJM 2013

16. No effect on weight 6 weeks after lean donor FMT
No adverse effects!
No effect on weight 6 weeks after lean donor FMT
A.Vrieze, Gastroenterology 2012

17. Effect donor faeces on periferal insulin sensitivity
A.Vrieze, Gastroenterology 2012

18. Fecal gut microbiota composition Gutmicrobiota diversity increased
F prausznitzii higher
Ruminococcus higher
A.Vrieze, Gastroenterology 2012

19. Small intestinal gut microbiota composition
A.Vrieze, Gastroenterology 2012

20. Koch’s postulates Fecal transplant doesn’t induce a definate cure!
The cultured microorganism should induce beneficial or adverse effects when introduced into a healthy organism (3rd postulate)
Concentrations of Eubacterium hallii in small intestinal biopsies correlated significantly with improved insulin sensitivity upon lean donor Fecal Tx
Eiseman (Surgery 1958)

21. Manipulating gutmicrobiota by Eubacterium hallii : effect on insulin resistance

22. Eubacterium hallii belongs to Firmicutes phylum (spore former)
Anaerobic gram positive lactate-utilizing SCFA butyrate- producing bacterial strain
Can produce butyrate at pH 5-6 (small intestine) as well as at pH 6-7 (colon)
Sensitive to vancomycine

23. Studyprotocol I Db/db male mice (8 weeks old), n=8 per group
Daily gavage (100ul/mouse) with E. Hallii (stored in 10% glycerol at -80C), gavage within 1 hour after thawing for 4 weeks with: -10^6 CFU/ml
- 10^8 CFU/ml
- 10^10 CFU/ml
- placebo (dissolvens = 10% glycerol)

24. Insulin tolerance test (insulin sensitivity)
E. Hallii normalises insulin sensitivity (ITT) compared to placebo
Udayappan/Manneras, submitted

25. Gutmicrobiota analyses: Ehallii treatment significantly increases Ehallii in cecum
Mean ±SEM

26. Studyprotocol II
Db/db male mice (8 weeks old), n=7-9 per group (Gothenborg university, Sweden)
Daily gavage (100ul/mouse) with alive or heat inactivated E. Hallii 10x6CFU/ (stored in 10% glycerol at -80C), gavage within 1 hour after thawing for 4 weeks followed by:
-48h in Metabolic cages (Somedic cages)
- hyperinsulinemic normoglycemic clamp

27. Effect E. Halli on food intake and bodyweight
Udayappan/Manneras, submitted

28. 10^8 E.hallii treatment significantly increases E.halli in cecum
P<0.05
Udayappan/Manneras, submitted

29. Active E. Hallii treatment significantly increases verruco bacteria, cyanobacteria, deferribacteres and fusobacteria
* Significant p<0.05
Mann Whitney U
Cyanobacteria: p=0.015(2-tailed), .007 (1-tailed)
Deferribacteres: p=0.028 (2-tailed), (1-tailed)
Fusobacteria: p=0.028 (2-tailed), (1-tailed)
Verrucomicrobia: p=0.028 (2-tailed), (1-tailed)
Red: E hallii 10x8CUF
Green: plaecbo

30. Resting energy increased upon E. hallii
TEE was determined, using Weir's equation: (3.9 × VO2) + (1.1 × VCO2)
Udayappan/Manneras, submitted
Mean ±SEM

31. Insulin sensitivity (clamp) increased upon E. hallii*
Peripheral insulin sensitivity
Udayappan/Manneras, submitted

32. E. hallii increases fecal secondary bile acids
Mean ±SEM

33. Ehallii treatment: effect on fecal SCFA
P<0.05
Mean ±SEM

34. E.Halli as novel therapeutic in in insulin resistance?
Has beneficial effects on insulin sensitivity
Potential mechanism via bileacids and brown fat (Increased Energy Expenditure)
Human intervention phase 1 dosefinding trial with E.hallii curently ongoing at AMC
Eubacterium hallii
De Vos WM and Nieuwdorp M. Nature 2013; 498(7452):48-9

35. Take home message
Decreased butyrate producing bacteria in obesity associated with malign obesity and insulin resistance
FMT incudes changes in (small) iIntestinal microbiota and affects insulin resistance (but it is not a panancea)
Using FMT as a working model can derive novel probiotics on top of current treatment for insulin resistance

36. Acknowledgments Ruud Kootte MD Fleur van der Valk, MD
Erik Stroes
AMC
Willem de Vos
WUR/Helsinki
Fredrik backhed
Gothenborg
Hans Romijn
AMC
Ruud Kootte MD
Fleur van der Valk, MD
Pim Gilijamse, MD
Loek Smits, MD
Sophie Bernelot Moens, MD
Mara Sandberg, MD
Kristien Bouter, MSc
Pieter de Groot, MD
Annick Hartstra MD
Han Levels PhD
Geesje Dallinga, PhD
Alinda Schimmel, Bsc I
Anne Vrieze
MD PhD
AMC
Shanti Udayappan
Mireille Serlie MD PhD
AMC
Louise Manneras