Special Article

Obesity and the gastrointestinal microbiota: a review of

associations and mechanisms
Catherine Graham, Anne Mullen, and Kevin Whelan

The two-way obesity model that considers only the interplay between humans and
their environment has been revised to include the gastrointestinal microbiota.
Notable perturbations in the bacterial communities in obese individuals have been
uncovered. Research is helping to distinguish between the obesogenic mechanisms
attributable to diet and those that may be associated with the microbiota.
Examples include studies in which transplant of the microbiota from murine models
of weight loss (gastric bypass) into germ-free mice resulted in signicant weight
loss. Several mechanisms have been identied that suggest the microbiota may
play a role in obesity development and propagation. There is some evidence from
animal and human studies that the microbiota in the obese harvests energy more
effectively and may manipulate host gene function leading to increased adiposity,
aggravation of inammatory mechanisms, metabolic endotoxemia, and metabolic
dysfunction. Research ndings highlight the potential of the microbiota to inuence
body weight and they allude to its potential therapeutic use in tackling the costly
global epidemic of obesity.

INTRODUCTION THE GASTROINTESTINAL MICROBIOTA

The rise in obesity and the numerous obesity-associated
complications, including diabetes, heart disease, and
stroke, is a major public health issue.1 It is forecasted
that by 2030, there will be a further 65 million obese
adults in the United States alone, where the cost of
treating the complications of obesity are estimated to
increase by US $48 billion to $66 billion per year.1
While the causes of this epidemic are multifactorial,
there is increasing evidence of the interplay between
diet and the gastrointestinal (GI) microbiota in the de-
velopment and propagation of obesity. The aim of this
review is to critically evaluate the studies that investigate
the interactions between the host, diet, and microbiota
and the development of obesity.
The microbiota inhabiting the GI tract comprises 100
trillion microbial cells; this is 10-fold the number of
human cells in the whole body, with 100-fold more
unique genes than the human genome.2 In their study
of 124 people, Qin et al.,2 of the MetaHIT Consortium,
estimated that between 1000 and 1150 bacterial species
were able to colonize the human GI tract, with each
individual harboring at least 160 such species.
Approximately 90% of the GI microbiota belong to
the two main phyla: Firmicutes and Bacteroidetes.
Firmicutes is the largest phylum, with more than 250
genera, including Lactobacillus, Mycoplasma, Bacillus,
and Clostridium, while Bacteroidetes includes around
20 genera, of which the most abundant genus in the

Afliation: C. Graham, A. Mullen, and K. Whelan are with the Diabetes and Nutritional Sciences Division, Faculty of Life Sciences &
Medicine, Kings College London, London, SE1 9NN, UK.
Correspondence: K. Whelan, Diabetes and Nutritional Sciences Division, Faculty of Life Sciences & Medicine, Kings College London, 150
Stamford Street, London, SE1 9NN, UK. E-mail: kevin.whelan@kcl.ac.uk. Phone: 44-20-7848-3858.
Key words: Bacteroidetes, diet, inammation, obesity, metabolic syndrome, microbiota.
C The Author(s) 2015. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For
V
Permissions, please e-mail: journals.permissions@oup.com.

doi: 10.1093/nutrit/nuv004
376 Nutrition ReviewsV Vol. 73(6):376385
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human GI tract is Bacteroides.3 The remaining 10% of
the GI microbiota include the gram-positive Actinobac-
teria and the gram-negative Proteobacteria and
Verrucomicrobia.4
Given the large number of species able to colonize
the GI tract, the potential interindividual diversity in
microbiota composition is very large. However, some
species are highly conserved among humans, with 18
core species found in all participants in the MetaHIT
Consortium.2 It is important to highlight that these
were identified through very deep sequencing tech-
niques and that the participants were all from a similar
geographical location (Europe) and, therefore, had been
exposed to similar environmental pressures. Of note, it
has been shown that the microbiota differs markedly
between children from Europe and children from rural
Africa, with greater abundance of Bacteroidetes in the
latter, including many bacteria with genes encoding
polysaccharide digestion; this is likely the result of the
high-fiber diet in rural Africa.5 Therefore, although
there is evidence of some well-conserved core species in
humans, there is capacity for great variation in the
human GI microbiota, and this variation is likely deter-
mined by environmental exposures, including diet.
At birth, the GI tract is colonized with bacteria
from the maternal vaginal tract (for infants delivered
vaginally), and the composition of the microbiota is
then affected by the environment, including diet (e.g.,
breast milk or the ingredients of formula milk).6
Microbiota composition continues to evolve and, by the
age of 3 years, becomes more like that of adults.7
However, not until adulthood does the microbiota
reach its peak complexity in terms of bacterial number
and genetic diversity and stability.8 Microbiota diversity
has been shown to be reduced in older age and is espe-
cially associated with frailty, institutionalization, and
poor nutritional status.9 For example, older people
residing in long-stay institutions had lower proportions
of Firmicutes and higher proportions of Bacteroidetes
compared with community-dwelling older people.9
A recent approach to categorizing the GI
microbiota is based upon microbial community types
(or so-called enterotypes), which are discrete clusters
of bacterial communities in the gut. Enterotypes were
first described by Arumugam et al.,10 who identified
three clusters on the basis of the predominance of
Bacteroides (enterotype 1), Prevotella (enterotype 2),
and Ruminococcus (enterotype 3), while later studies
identified just two enterotypes on the basis of predomi-
nance of Bacteroides and Prevotella.9,11 Subsequent
analysis has demonstrated that enterotypes are not only
the result of the most predominant bacteria in the com-
munity (e.g., Bacteroides, Prevotella) but are also influ-
enced by numerous complex networks of co-occurring
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bacteria typical of that enterotype.12 It is proposed that
different genera either co-occur or avoid each other to
form an enterotype comprising groups of bacteria
cohabiting to create a favorable environment while
making it unfavorable for bacteria of other entero-
types.10 The Human Microbiome Project Consortium
recently analyzed stool samples from 300 healthy indi-
viduals and found that gender was strongly associated
with membership of 1 of 4 microbial community types
(enterotype). Analysis of samples taken at 2 time points
(ranging from 1 month to over 1 year apart) indicated
considerable stability in enterotype membership.12
However, there is no standard methodology for entero-
type determination, and a recent deeper and compre-
hensive analysis of microbial structures has revealed a
gradient based on the abundance of Bacteroides rather
than on distinct clusters.13
Metagenomic analysis has demonstrated wide-
ranging bacterial functions, including fermentation,
adhesion, and digestion of complex sugars, indicating
the possibility that an individuals microbiota might
have a metabolic and functional impact beyond the GI
lumen.2 Furthermore, studies show how the microbiota
can influence xenobiotic metabolism. For example,
some bacteria may play a role in the inactivation of
digoxin (cardiac drug), some may affect the metabolism
of irinotecan (a colorectal cancer drug) and thereby
increase the risk of side-effects, and some may have a
potential role in improving chemotherapy efficacy.14
Given these important functions of the microbiota
metagenome, recent research has focused on the gene
frequency or the gene richness of the GI microbiota
rather than merely the number or proportions of
different taxonomic groups.15 Interestingly, obesity is
associated with low bacterial richness,15 and energy
restriction can increase bacterial richness16; this high-
lights a possible role for the microbiota and its genomic
and metabolic potential in obesity.
Diet and the microbiota
Diet is clearly a major determinant of obesity through
excess energy intake, which increases fat deposition.
Diet is also a primary determinant of GI microbiota
composition. Most high-quality studies use high-
throughput genomic sequencing analysis to measure
microbiota composition, albeit usually in fecal samples
rather than in true luminal samples or mucosal micro-
biota. Dietary information, however, is inevitably less
accurate. Human studies investigating habitual diet
rely upon retrospective recall or prospective dietary
recording. These obstacles can be overcome using
controlled laboratory feeding studies, but these are
377
labor intensive and thus usually small in size, which
limits the application of their findings.
Studies in both animals and humans reveal that
dietary modification results in rapid alterations to
microbiota composition.11,1719 For example, a study
comparing human subjects on animal-based or plant-
based diets for 5 days found changes in microbial diver-
sity occurring within 1 day of the animal-based diet
reaching the distal microbiota.17 The authors speculate
this rapid change following consumption of animal
products may have evolved in humans as a way of opti-
mizing diet flexibility. In a time when meat may have
been eaten seasonally or when available, a GI micro-
biota that could adapt rapidly in response to an occa-
sional change from a herbivorous to a carnivorous diet
might be advantageous to its host.17
Animal studies allow researchers to sidestep the
technical and ethical challenges surrounding studies of
the diet and the GI microbiota and have helped estab-
lish the fundamentals of this field of research. Studies in
gnotobiotic mice indicate that manipulation of dietary
macronutrients accounts for the majority of alterations
to the microbiota.18 Human studies have also made sig-
nificant contributions to the current understanding of
the interactions between diet and microbiota; broadly
speaking, evidence has come from cross-sectional stud-
ies and feeding intervention studies (Table 1).5,11,17,20
Thus far, the most in-depth cross-sectional study
to have investigated diet and microbiota interactions
recruited 98 healthy volunteers and found that
Bacteroides was positively associated with dietary fat
intake and negatively associated with fiber intake,
whereas the opposite was true for Firmicutes and
Proteobacteria.11 Several factors, including red wine
consumption and body mass index (BMI), were found
to correlate with microbiota composition, but not with
enterotype categories,11 suggesting that the enterotype
model cannot encapsulate the dietmicrobiota relation-
ship in its entirety. However, the study by the Human
Microbiome Project Consortium described earlier,
which did not analyze current or recent diet, found that
having been breastfed as an infant was strongly associ-
ated with enterotype membership, implying that dietary
exposure in infancy has a profound and long-lasting
association with GI microbiota development.12
Enterotypes aside, it has been shown that diet-
induced microbiota changes can be broad (e.g., changes
in the ratio of Firmicutes to Bacteroidetes) or specific
to certain groups of bacteria or genera. For example,
a dietary intervention study in mice showed that a

Table 1 Summary of human studies investigating the association between diet and the gastrointestinal microbiota
Reference No. of subjects Method
De Filippo 30 Stool samples obtained from 15 healthy chil-
et al. (2010)5 dren from a rural village in Burkina Faso
and 15 healthy children from Florence,
Italy (16 y of age). Microbiota analyzed
using 16 S rDNA sequencing. SCFA also
measured
Wu et al. 98 (observational) Nutrients in long-term habitual diet (as-
(2011)11 10 (intervention) sessed by FFQ) were compared with GI
microbiota of 98 healthy subjects. Then, a
10-d controlled feeding study was con-
ducted in 10 healthy subjects randomized
to a high-fat/low-ber or low-fat/high--
ber diet
David et al. 10 6 male and 4 female volunteers aged
(2014)17 2133 y with a BMI of 1932 kg/m2 each
consumed equicaloric plant-based and an-
imal-based diets for 5 d. Weight was mea-
sured and stool samples collected daily;
eating habits were observed 4 d prior to
diet and 6 d afterwards.
Walker et al. 14 14 overweight men were given several pre-
(2011)20 cisely controlled diets successively over
10 wk: control, high-resistant starch, non-
starch polysaccharides, and a nal 3-wk
weight-loss diet. Fecal samples collected
twice weekly.
Abbreviations: BMI, body mass index; FFQ, food frequency questionnaire; GI, gastrointestinal; SCFA, short-chain fatty acids.
Result
African children (with high ber intakes)
had lower numbers of Firmicutes than
European children, higher numbers of
Bacteroidetes, a high number of
Prevotella and Xylanibacter, and higher
concentrations of SCFA
Enterotypes were associated with many
nutrients and food components in the
habitual diet. In the feeding study,
changes in GI microbiota composition
were detectable within 24 h, but entero-
types remained unchanged
Change in GI microbiota occurred 1 d after
the animal-based diet reached the distal
gut and reverted back to original struc-
ture 2 d after this diet ended. Animal-
based diet increased the abundance of
bile-tolerant bacteria and decreased lev-
els of Firmicutes that metabolize dietary
plant polysaccharides.
Increase in specic bacterial groups oc-
curred rapidly after dietary change and
was reversed rapidly by the subsequent
diet. No signicant effect of diet on
Bacteroidetes, Firmicutes, Actinobacteria,
or Proteobacteria proportions. Dietary
nondigestible carbohydrate produced
marked changes in the microbiota, but
this was dependent upon initial compo-
sition of individuals microbiota.

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Diet
Obesity and weight loss associated
with altered microbiota
Gastrointesnal
Obesity
microbiota
Microbiota alter colonic energy
harvest, host gene expression and
increase host inammaon
Figure 1 Related mechanisms involved in the interactions
among dietary intake, the gastrointestinal microbiota, and
obesity
high-fat diet reduced the numbers of Eubacterium
rectaleClostridium coccoides group and Bifidobacteria
while simultaneously inducing inflammatory activity,
fat mass, and insulin resistance.21 The GI microbiota
has also been shown to influence energy harvest from
the diet, introducing the concept of an association
between microbiota and obesity.19 The interaction
between diet, the microbiota, and obesity is a mutually
dependent, rather than a unidirectional, relationship
(Figure 1).
The microbiota, obesity and weight loss
The cross-sectional study of Arumugan et al.10 analyzed
human fecal metagenomes and identified 12 microbial
genes that correlated with age and BMI. In particular,
there was a strong correlation between a high BMI and
microbial genetic markers for adenosine triphosphatase
complexes, indicative of a greater energy-harvesting
capability and hinting at the potential of using these
microbial genomes as markers of obesity disposition in
the future.10
A number of observational studies have reported
greater abundance of Firmicutes and lower abundance
of Bacteroidetes (and, therefore, a higher Firmicutes-
to-Bacteroidetes ratio) in obese humans compared with
their lean counterparts,22,23 whereas other studies have
failed to show such differences, with no explanation for
the inconsistent findings.24,25 Obesity has also been
associated with lesser diversity of the microbiota.26 The
findings from observational studies are also supported
by a number of dietary intervention studies that have
investigated the effect of energy restriction and subse-
quent weight loss on the GI microbiota in the obese.
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Some intervention studies report a reduction in
Firmicutes numbers and an increase in Bacteroidetes
numbers (and, therefore, a lowering in the Firmicutes-
to-Bacteroidetes ratio) during dietary energy restriction
and weight loss,22 although others report no such
change.20,25
Rather than investigate the effect of dietary inter-
vention on the microbiota, Cotillard et al.16 investigated
the impact of dietary change on microbial genes, sorting
a human study population into those with a microbiota
of low gene count (LGC) (<480 000 genes) and those
with a microbiota of high gene count (HGC). This study
found a greater difference in GI microbiota when com-
paring LGC and HGC individuals than when compar-
ing lean and obese individuals. Crucially, gene richness
of the LGC group increased significantly following a
6-week energy-restricted, high-protein diet. LGC status,
rather than obesity, the study concluded, may be a
better marker for pathology.16
The effect of surgically induced weight loss on the
GI microbiota has been investigated in murine models.
A study of mice that had undergone Roux en-Y gastric
bypass (RYGB) surgery reported a considerable increase
in numbers of Verrucomicrobia and Gammaproteobac-
teria within 1 week compared with mice without an
RYGB.27 Interestingly, the modified microbiotas of
RYGB mice were not directly comparable with those
found in formerly obese people who had lost weight
through an energy-restricted diet, demonstrating that
RYGB may create a unique set of selective pressures on
the GI microbiota. When the microbiotas from the
RYGB mice were transplanted into germ-free mice,
greater weight loss and less fat mass were observed
compared with findings in germ-free mice transplanted
with microbiotas from mice without an RYGB. Weight
loss in the mice colonized with microbiotas from the
RYGB mice occurred in conjunction with reductions in
energy harvest (lower cecal short-chain fatty acids
[SCFAs]) and altered lipid metabolism.27 Interestingly,
the RYGB mice lost 29% of their initial body weight,
while those colonized with bacteria from RYBG mice
lost only 5% body weight, a significant yet notably lower
amount.27 This suggests that, following RYBG surgery,
other factors besides the modified microbiota account
for the difference in weight loss between the two
groups, e.g., the change in acid exposure to the proxi-
mal small bowel, nutrient malabsorption, and possible
intestinal dysmotility.28
The effect of surgically induced weight loss on the
microbiota of humans has also been investigated. In a
study of obese humans undergoing RYGB, Kong et al.29
reported an increase in microbiota diversity, with 58
previously undetectable genera colonizing the gut fol-
lowing surgery, more than one-third of which belonged
379
to Proteobacteria. Again, changes in diet may be partly
responsible for the microbiota changes, with RYGB
having been shown to reduce fat intake and increase
polysaccharide intake, the latter being associated with
increased microbiota diversity.29 However, the study
also found changes in the gene expression of host white
adipose tissue that were associated with changes in bac-
terial genera.29 Approximately half of the associations
between changes in GI microbiota and changes in white
adipose tissue gene expression following RYGB were
independent of the change in energy intake, suggesting
that weight loss following RYGB is not simply the result
of reductions in energy intake but also the result of an
interplay between microbiota and host biology.29
The effect of dietary-induced and surgically induced
weight loss on the GI microbiota has been investigated
in a range of human studies (Table 2).15,16,22,24,25,29
Many studies, though not all, provide evidence of an
association between the GI microbiota and obesity.
The interaction between the GI microbiota, the diet, and
obesity makes it problematic to demonstrate whether
differences in microbiotas are a cause of obesity or
merely a consequence of obesity or altered dietary intake
(Figure 1).
Metabolic mechanisms of the microbiota in obesity
The GI microbiota influences numerous host functions
through a range of mechanisms, suggesting the
microbiota may have a role, at least in part, in the
development or propagation of obesity. The host
microbiotadiet relationship is intricate, and the
processes involved are intimately connected (Figure 2).

Table 2 Summary of human studies investigating the interplay between the gastrointestinal microbiota and weight loss
or obesity
Reference
Schwiertz et al. (2009)24
Le Chatelier et al. (2013)15
Duncan et al. (2008)25
Cotillard et al. (2013)16
Ley et al. (2006)22
Kong et al. (2013)29
Abbreviations: GI, gastrointestinal; HGC, high gene count; LGC, low gene count; PCR, polymerase chain reaction; SCFA, short-chain fatty
acids.
No. of Method
subjects
98 30 lean, 35 overweight, and 33 obese
subjects consumed Western diet. Stool
samples analyzed for microbiota using
real-time PCR. Concentrations of SCFA in
stool analyzed
292 GI microbial composition measured in 123
nonobese and 169 obese Danish individ-
uals. 1 stool sample was taken from sub-
jects following an overnight fast; DNA was
extracted and sequenced
70 Major bacterial groups were monitored in 33
obese and 14 nonobese subjects during
weight-maintaining conditions and also in
23 obese males on 2 different 4-wk
weight-loss diets
49 Obese or overweight subjects were sub-
jected to a 6-wk energy-restricted high-
protein diet, then a 6-wk weight-mainte-
nance diet. Stool samples were collected
and food intake, physical activity, and clin-
ical characteristics measured at baseline,
6 wk, and 12 wk
12 Obese subjects were assigned fat- or carbo-
hydrate-restricted energy-restricted diet.
Stool samples were analyzed for GI micro-
biota using 16 S rDNA sequencing over a
1-y period
30 Obese women underwent gastric bypass sur-
gery, resulting in signicant weight loss.
Stool and white adipose tissue samples
taken at baseline and 3 mo
postoperatively
Result
Contrary to most ndings, overweight and
obese subjects had greater numbers of
Bacteroidetes. Total SCFA concentrations
were >20% higher in obese than in lean
volunteers
2 groups were identied according to lev-
els of bacterial richness: LGC, <480,000
genes, and HGC, with an average of
380 000640 000 genes or 40% more
than LGCs. LGC subjects had greater
overall adiposity, insulin resistance, and
dyslipidemia and a more inammatory
phenotype than HGC subjects
No evidence that the proportions of
Bacteroidetes and Firmicutes were associ-
ated with human obesity
18 LGC and 27 HGC individuals identied
with an average of 379 436 and 561 499
genes, respectively. The LGC group pre-
sented phenotypes that expose them to
an increased risk of obesity-associated
comorbidities. After intervention with an
energy-restricted diet, gene richness in-
creased signicantly in the LGC group
Obese subjects had higher numbers of
Firmicutes, lower numbers of
Bacteroidetes, and higher
Firmicutes:Bacteroidetes ratios. Weight
loss resulted in reduction in Firmicutes
and increase in Bacteroidetes, irrespec-
tive of diet type
58 initially undetectable genera were de-
tected postoperatively in all patients. A
signicant increase in the number of as-
sociations between GI microbiota and
gene expression was detected
postoperatively

380 Nutrition ReviewsV Vol. 73(6):376385

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 Diet High fat diet
Mechanism pathways
Ecient energy harvest
Gastrointesnal microbiota Gram nega ve bacteria Host gene funcon and
increased adiposity
Pro-inammatory

Host gene suppression

Host gene suppression
mechanisms

SCFA Lipopolysaccharide

Colonocytes
metabolize SCFA
as energy source Chylomicrons

Mucin TLR4
Lumen producon
Gpr41
Enterocytes Gpr43 Fiaf Tight juncons

Vagal aerent
neuron
De novo triglyceride Triglycerol storage Gut permeability Plasma LPS Lepn resistance
synthesis Lipoprotein lipase Unresponsive to CCK
Lepn/PYY expression
Translocaon CD4 + IL-6

Metabolic Hyperphagia
endotoxemia
Weight gain

Cytokines Inammaon Weight gain

Figure 2 Potential mechanisms of the relationship between the gastrointestinal microbiota and obesity. The interplay between dietary
intake and the gastrointestinal microbiota strikes a metabolic balance in the host. Some animal studies and a small number of human studies
demonstrate alterations in this metabolic balance that are hypothesized to be linked to obesity. For example, some studies show that a high-
fat diet favors gram-negative bacteria, while others show that a high-fat diet may lead to raised serum LPS concentrations, which could lead
to inammation and weight gain. In contrast, some studies have shown that microbiota-derived SCFAs stimulate satiety hormones such as
leptin and PYY.
Abbreviations: CCK, cholecystokinin; Fiaf, fasting-induced adiposity factor; IL-6, interleukin 6; LPS, lipopolysaccharide; PYY, polypeptide YY;
SCFA, short-chain fatty acids.

Efficient energy harvest. The majority of nutrients are Compared with their lean counterparts who con-
absorbed in the small intestine, yet up to 15% of the sume a Western diet, overweight and obese humans
monosaccharides, disaccharides, and polysaccharides have higher fecal concentrations of SCFAs.24,33 In one
consumed are not absorbed.30 This potential energy human study, fecal SCFA concentrations were 20%
source is salvaged by the colonic microbiota, compo- higher in obese than in lean volunteers, in particular for
nents of which ferment these carbohydrates to provide propionate and butyrate, which therefore act as addi-
energy to support microbial metabolism while produc- tional energy sources for the host.24
ing SCFAs that are then absorbed and metabolized The observation of higher concentrations of SCFAs
as an energy source by the host colonocytes.31 in the obese may not be causal. For example, the differ-
Metagenomic screening has revealed that SCFA synthe- ences could merely reflect the differences in the GI
sis genes are commonly expressed by the GI microbiota, microbiota populations already described, particularly
suggesting carbohydrate fermentation is a central func- since Bacteroides and Prevotella, known to produce
tion.2 The most predominant SCFA is acetate, followed propionate, may be found in greater abundance in the
by propionate and then butyrate in a molar ratio of obese.24 It has also been argued that the elevation of
57:22:21, which together account for up to 95% of the luminal SCFAs is due not to greater SCFA production
SCFA content of the GI tract.32 (and, therefore, more efficient energy harvest) but to

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381
greater SCFA excretion as a mechanism to actually avoid
additional energy harvest and, thus, limit further weight
gain.33 This hypothesis is difficult to test in humans be-
cause fecal SCFA concentrations are the result of the dy-
namic processes of both colonic production and colonic
absorption and are, therefore, not an accurate reflection
of the production of SCFAs in the gut.31,32
Indeed, SCFAs may have numerous independent
effects on the development of obesity. The presence of
the microbiota and SCFAs stimulate de novo hepatic
triglyceride synthesis.34 Acetate and propionate, in par-
ticular, stimulate adipogenesis in white adipose tissue.
This has been demonstrated in both a mouse adipocyte
cell line and mouse adipose tissue in primary culture.35
Acetate, propionate, and butyrate are ligands for the G
proteincoupled receptors Gpr43 and Gpr41. These two
receptors are expressed in adipocytes, epithelial cells,
and endocrine cells, and both express the satiety hor-
mone polypeptide YY (PYY) and increase intestinal
motility, while Gpr41 also expresses leptin.35 When
germ-free mice are colonized with SCFA-producing
bacteria, their body weight and body fat increase.
However, in Gpr41/ mice, this does not occur, sug-
gesting that weight gain occurs via Gpr41 stimulation.
Gpr41 sensitivity to propionate is greater than it is to
butyrate which is greater than to acetate.36
While Gpr41 activates adipocytes to express leptin,
both Gpr41 and Gpr43 promote PYY production.37
Inactivation of Gpr41 in Gpr41/ mice results in de-
creased PYY expression and increased intestinal motil-
ity, reducing both energy harvest from diet and hepatic
lipogenesis.38 Gpr41 has, therefore, been identified as a
possible regulator of energy balance for the host.39
In contrast, SCFA production may also stimulate
satiation though PYY production. Acetate has been
shown to cause an anorectic effect by working directly
on the hypothalamus.40 Therefore, the role of SCFAs in
body weight regulation involves a number of opposing
mechanisms.
Host gene function and increased adiposity. Some com-
ponents of the GI microbiota are able to suppress the
expression of host genes for proteins such as fasting-
induced adiposity factor (Fiaf, also known as angiopoie-
tin-like protein 4) and tight junction proteins expressed
in the intestinal epithelia.41 Fiaf plays a central role in
triglyceride metabolism.42 This glycoprotein inhibits
lipoprotein lipase (LPL) production in adipose tissue
and modulates fatty acid oxidation in both adipocytes
and skeletal muscle.4 Conversely, its suppression by
specific components of the GI microbiota increases LPL
activity in adipocytes and promotes liver-derived
triglycerol storage in host fat cells.34 Through its Fiaf-
suppressing role, components of the GI microbiota
382
might potentially stimulate host weight gain by impair-
ing triglyceride metabolism and promoting fat storage.
Current understanding of the role of the interac-
tion between microbiota, host gene expression, and adi-
posity in the development of obesity has been aided by
the use of mice reared in a germ-free environment and
lacking a GI microbiota. One study showed how, unlike
colonized mice, germ-free mice do not experience the
same weight gain when exposed to a Western-style diet
(high fat, high sugar).43 This can be explained by a num-
ber of mechanisms, including increased fat metabolism,
lower fat storage, and lower sugar absorption.44 First,
germ-free mice have higher levels of circulating Fiaf,
resulting in lower LPL activity and, therefore, reduced
fat storage. Second, muscle and hepatic concentrations
of phosphorylated adenosine monophosphateactivated
protein kinase, key to the b-oxidation pathway, are
high.44 Third, germ-free mice have been shown to have
lower monosaccharide uptake from the gut compared
with colonized mice.43
The very presence of the GI microbiota has been
shown to promote host fat storage. When germ-free
mice become colonized with bacteria, both body weight
and fat mass have been shown to increase.43 LPL activ-
ity stimulates triacylglycerol release from circulating
lipoproteins in both adipose tissue and muscle.45
Furthermore, germ-free Fiaf/ mice have the same
amount of body fat as their colonized counterparts,
demonstrating the role of Fiaf in metabolism and fat
storage as well as in the mediation of microbial energy
storage.39
Despite these potential mechanisms through which
germ-free mice might be protected from diet-induced
weight gain, another study was unable to reproduce
these findings, demonstrating that a Western-style diet
led to significant weight gain in germ-free mice.46
Proinflammatory mechanisms. Inflammation is strongly
associated with obesity and is detected in weight gain
prone ratsfed a high-fat diet. de La Serre et al.47 mea-
sured ileal inflammation, intestinal permeability, and
activity of intestinal alkaline phosphatase, an enzyme
that detoxifies lipopolysaccharide (LPS), in rats fed
either a high-fat or a low-fat diet. Half of the rats
expressed the obesity-prone phenotype and the other
half the obesity-resistant phenotype, but only the
obesity-prone rats had ileal inflammation.47
The bacterial components of gram-negative bacte-
ria, such as LPS, appear to trigger inflammation in the
host as part of an innate immune response. In some
studies, weight gain has been shown to follow LPS-
induced inflammation.48 One experiment showed simi-
lar weight gain in mice after 4 weeks of infusion with
low doses of LPS compared with 4 weeks of a high-fat
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R
diet.21 CD14 is an immunoprotein responsible for the
inflammatory reaction to LPS. When CD14/ rats
were infused with LPS, no weight gain occurred, indi-
cating the role of LPS-induced inflammation in weight
gain.21 In much the same way, Toll-like receptor 4
(TLR4)-deficient mice are protected from high fat
dietinduced obesity and insulin resistance because the
ligation of LPS with TLR4 activates innate inflamma-
tory responses.49 Because this LPS recognition occurs
constantly, there is always the potential for an inflam-
matory response. Silencing TLR4 has been shown to
protect the host from obesity.49
These animal studies have established the connec-
tion between inflammation and weight gain.
Interestingly, the delivery of bacterial products such as
LPS exerts inflammatory effects similar to those of a
high-fat diet.21 LPS, an endotoxin, may enter the host
bloodstream via the lymph through integration into
chylomicrons.50 Human studies show that chylomicron
formation increases following a high-fat meal, resulting
in greater LPS transport than that following a low-fat
meal.50 When plasma LPS concentrations are raised, so
too are markers of inflammation, such as CD14 and in-
terleukin-6.51 A diet consistently high in fat, therefore,
would lead to greater levels of LPS entering the
peripheral circulation and subsequent LPS-induced
inflammation.
Raised serum LPS concentrations are a hallmark of
metabolic endotoxemia. The consequent low-grade sys-
temic inflammation has been implicated in the develop-
ment of both atherosclerosis and type II diabetes.21
While metabolic endotoxemia is aggravated by both a
high-fat diet and LPS-producing bacteria, only one of
these needs to be removed to observe a reduction in
inflammation. Endotoxemia is found in mice consum-
ing a high-fat diet; however, when mice on the same
diet were given ampicillin and neomycin to alter the GI
microbiota, endotoxemia was reduced and glucose tol-
erance improved.52
Although the actions of LPS are proinflammatory,
some microbial activity is immunoregulatory. In addi-
tion to harvesting additional energy for the host, some
SCFAs also reduce inflammation.53 Many bacteria pro-
duce butyrate from fermentation of dietary polysaccha-
ride, including the Eubacterium rectaleClostridium
coccoides group and Faecalibacterium prausnitzii.54,55
Butyrate inhibits lymphocyte proliferation and two key
drivers of inflammation: interleukin-2 and interferon-
c.53 Conversely, acetate and propionate raise inter-
feron-c levels, although the overall effect of these 3
SCFAs is immunoregulatory.53
The role of the gram-negative bacterial product
LPS in inflammation, adiposity, and obesity contrasts
with some observations that obese humans have
Nutrition ReviewsV Vol. 73(6):376385
R
more Firmicutes (generally gram-positive) and fewer
Bacteroidetes (gram-negative) than lean humans.22,23
However, Prevotellaceae (a subgroup of Bacteroidetes) is
a ready source of bacterial LPS and has recently been
shown to be significantly enriched in obese subjects.28
Raised serum levels of LPS are associated with obe-
sity through other mechanisms. Vagal afferent neurons
of diet-induced obese rats become leptin resistant, and
LPS is believed to play a role in the development of this
resistance.56 Leptin resistance can lead to both hyper-
phagia and weight gain, potentially further increasing
fat intake and raising LPS and inflammation.57 By in-
ducing hyperphagia in its host, the microbiota is com-
pounding both the inflammatory and obesity processes.
The more permeable the hosts GI tract, the less
effective it is as a barrier to LPS. Cani et al.21 note that
increased gut permeability is a second hallmark of met-
abolic endotoxemia and is also associated with the
microbiota. The microbiota present following a high-fat
diet reduces expression of host genes that code for ZO-
1 and occludin, which are tight junction proteins essen-
tial for normal GI integrity.58 When the GI epithelium
is compromised, whole bacteria and their products may
be able to cross it and enter the bloodstream. Bacterial
translocation has been shown to be higher in mice fed a
high-fat diet than in those fed standard chow and, inter-
estingly, can be reversed through the use of a specific
probiotic bacteria.59 Intestinal permeability is also
greatly increased following antibiotic treatment but can
be restored to normal levels.21
Mucus is a key component of a robust GI epithelial
barrier, making it less permeable to bacteria. Mucus is
secreted by goblet cells as mucin 2 (MUC-2), the outer
layer of which is extensively populated with bacteria.58
The SCFAs acetate and butyrate stimulate mucin
release. When butyrate is added to goblet cell lines,
MUC-2 expression is increased 23-fold,60 demonstrat-
ing that bacterial products stimulate the host to produce
a mucus layer to protect against translocation.
Potential future application of microbiotaobesity
interactions
The observations that aspects of the microbiota are
associated with body weight, combined with plausible
physiological mechanisms to link the microbiota with
body weight, raise the possibility that approaches to
modifying the microbiota may assist in the prevention
or management of overweight and obesity. Although
detailed examination is outside the purpose of this
review, some preliminary studies have investigated the
impact of probiotics and prebiotics, as well as other
microbiota-modifying interventions, on appetite and
body weight.
383
 A randomized controlled trial of a probiotic
(Lactobacillus rhamnosus CGMC1.3724) compared with
placebo in obese people undergoing moderate energy
restriction found no impact on weight loss at 12 weeks,
although there was significantly greater weight loss
among females in the probiotic group (4.4 kg) com-
pared with females in the placebo group (2.6 kg).61
Meanwhile, a study in nonobese humans reported that
prebiotic inulin/oligofructose increased GLP-1 and
PYY concentrations.62 However, despite GLP-1 concen-
trations strongly correlating with markers of prebiotic
fermentation, it has not been possible to demonstrate
that prebiotic-induced changes in microbiota per se are
the cause of the reductions in appetite.62 Furthermore,
although a recent meta-analysis of randomized con-
trolled trials confirmed that prebiotic supplementation
increased satiety in healthy adults, the impact on dietary
energy intake and body weight was equivocal.63
In terms of dietary modifications, evidence that an
energy-restricted, high-protein diet resulted in signifi-
cant weight loss in overweight and obese people while
increasing microbiota gene richness has been described
previously.16 Research is required to investigate whether
(as-yet undefined) dietary components that increase
microbiota gene richness may augment weight loss
without drastic energy restriction. Finally, in a random-
ized controlled trial in obese subjects with metabolic
syndrome, fecal microbiota transplant from lean donors
did not result in significant weight loss, though it did
increase insulin sensitivity compared with autologous
transplant.64
Further research is required to investigate the
effect of microbiota-modifying interventions on body
weight to determine the usefulness of these measures
in the prevention or management of overweight and
obesity.
CONCLUSION
There is now considerable evidence to suggest the GI
microbiota is altered in obesity. While diet wields a
large influence on body weight, the microbiota is inte-
gral to the host metabolic response. There is some evi-
dence to suggest the microbiota in obese individuals
harvests energy more effectively and may manipulate
host gene function; this has been shown in some animal
studies to be associated with increased adiposity, meta-
bolic endotoxemia, and metabolic dysfunction. With
lower bacterial diversity in the GI tract of the obese,
there is a reduced ability of the microbiota to normalize,
particularly while the diet remains obesogenic.
The extent to which alterations in the microbiota
are a cause or a consequence of weight gain or weight
loss is difficult to elucidate in humans because of the
384
complex multidirectional interactions among diet, the
microbiota, and obesity (Figure 1). However, if the
microbiota plays even a minor role in influencing body
weight, then there is potential to prevent or manage
obesity through modulation of the GI microbiota. What
remains clear, however, is that diet, particularly its en-
ergy content, remains a central factor in obesity
development.
Acknowledgments
Author contributions C.G. developed the idea for the re-
view, undertook the literature search, and wrote the
manuscript; A.M. developed the initial idea for the re-
view, developed the manuscript structure, co-supervised
the literature search, and commented critically
on manuscript drafts; K.W. developed the initial
idea for the review, developed the manuscript structure,
co-supervised the literature search, commented criti-
cally on the manuscript drafts, and is corresponding
author.
Funding/support. No external funding or nonfinancial
support was provided for the writing of this
manuscript.
Declaration of interest. K.W. has previously received re-
search funding, speakers honoraria, or consulting fees
from a range of research and charitable bodies, includ-
ing the Broad Medical Research Program, Crohns and
Colitis UK, Core UK, and the National Institute of
Health Research, as well as industry bodies that include
the Californian Dried Prune Board, Clasado
Biosciences, Danone, Nestle, Nutricia, and Yakult.
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