Can Psychobiotics Intake Modulate Psychological Profile and Body

De Lorenzo et al. J Transl Med (2017) 15:135 DOI 10.1186/s12967-017-1236-2 Journal of Translational Medicine

RESEARCH Open Access Can psychobiotics intake modulate psychological profle and body composition of women afected by normal weight obese syndrome and obesity? A double blind randomized clinical trial Antonino De Lorenzo1,8*, Micaela Costacurta2, Giuseppe Merra3, Paola Gualtieri4, Giorgia Cioccoloni4, Massimiliano Marchetti5,6, Dimitrios Varvaras7, Rafaella Docimo2 and Laura Di Renzo1

Abstract Background: Evidence of probiotics efects on gut function, brain activity and emotional behaviour were provided. Probiotics can have dramatic efects on behaviour through the microbiome–gut–brain axis, through vagus nerve. We investigated whether chronic probiotic intake could modulate psychological state, eating behaviour and body composition of normal weight obese (NWO) and preobese–obese (PreOB/OB) compared to normal weight lean women (NWL). Methods: 60 women were enrolled. At baseline and after a 3-week probiotic oral suspension (POS) intake, all subjects underwent evaluation of body composition by anthropometry and dual X-ray absorptiometry, and psychological profle assessment by self-report questionnaires (i.e. EDI-2, SCL90R and BUT). Statistical analysis was carried out using paired t test or a non-parametric Wilcoxon test to evaluate diferences between baseline and after POS intake, one-way ANOVA to compare all three groups and, where applicable, Chi square or t test were used to assess symptoms. Results: Of the 48 women that concluded the study, 24% were NWO, 26% were NWL and 50% were PreOB/OB. Sig- nifcant diferences in body composition were highlighted among groups both at baseline and after a POS (p < 0.05). After POS intake, a signifcant reduction of BMI, resistance, FM (kg and %) (p < 0.05), and a signifcant increase of FFM (kg and %) (p < 0.05) were observed in all subjects in NOW and PreOB/OB. After POS intake, reduction of bacterial overgrowth syndrome (p < 0.05) and lower psychopathological scores (p < 0.05) were observed in NWO and PreOB/ OB women. At baseline and after POS intake, all subjects tested were negative to SCL90R_GSI scale, but after treatment subjects positive to BUT_GSI scale were signifcantly reduced (8.33%) (p < 0.05) compared to the baseline (33.30%). In NWO and PreOB/OB groups signifcant diferences (p < 0.05) in response to the subscales of the EDI-2 were observed. Signifcant improvement of the orocecal transit time was observed (p < 0.05) after POS intake. Fur- thermore, signifcant diferences were observed for meteorism (p < 0.05) and defecation frequency (p < 0.05). Conclusions: A 3-week intake of selected psychobiotics modulated body composition, bacterial contamination, psychopathological scores of NWO and PreOB/OB women. Further research is needed on a larger population and for a longer period of treatment before defnitive conclusions can be made.

*Correspondence: [email protected] 8 Section of Clinical Nutrition and Nutrigenomic, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00136 Rome, Italy Full list of author information is available at the end of the article

© The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. De Lorenzo et al. J Transl Med (2017) 15:135 Page 2 of 12

Trial registration ClinicalTrials.gov Id: NCT01890070 Keywords: NWO syndrome, Probiotic, Psychobiotic, Psychological profle, Body composition

Background depression like behaviors, HPA axis hyperactivity and Te human gut hosts a dynamic and complex microbial abnormal neurochemical changes [9]. ecosystem. It is represented by approximately 1 kg of bac- Gut microbiota seems to have an impact on the sero- teria in the average adult, about the weight of the human tonergic system. In fact, treatment with Lactobacillus brain. It is composed by microorganisms belonging to 14 helveticus in hyperammonemia-treated rats led to an families, 45 genera and 400–500 distinct species, vari- anxiolytic efect and improved cognitive function pos- ously distributed along the entire intestinal tract. Two sibly through a reduction in hippocampal 5-Hydroxy bacterial phylotypes Firmicutes and Bacteroidetes are the Tryptamine (5HT) levels [10]. most abundant bacteria species in the gut [1]. Moreover, a combined treatment with Lactobacillus Te microbiota–gut brain axis, recently termed “psy- helveticus and rhamnosus prevented intestinal perme- chobiota” [2], plays an important role in host physiology, ability alteration caused by stress [11]. as in the regulation of neuroinfammation, neuroendo- Anxiety-like behavior associated with chronic colitis in crine stress response, neurodevelopment and modulation mice was attenuated by B. longum administration, asso- of mood and behavior [3–5], which implicates it in psy- ciated with decreased hippocampal brain-derived neuro- chiatric disorders, such as stress, anxiety and depression. trophic factor (BDNF) mRNA [12, 13]. Nowadays, several studies identify the relationship Although less evidence exists for probiotic actions between gut microbiota and the onset of various dis- on human population, it has been demonstrated that eases, demonstrating the ability of probiotics in control- patients who received a probiotic formulation containing ling infammatory processes, attenuation of metabolic Lactobacillus acidophilus, Lactobacillus casei and Bifdo- dysfunctions, normalization of stress-induced abnormal bacterium bifdum, signifcantly decreased Beck Depres- behaviors, regulation of the hypothalamus–pituitary– sion Inventory (BDI) scores [14]. Moreover, a probiotic adrenal axis (HPA axis) and neuropsychiatric disorders mixture of Lactobacillus helveticus and Bifdobacterium [6–8]. longum and a probiotic-containing milk drink of Lacto- Te evidence of the infammatory state alteration, high- bacillus casei showed positive efects on psychological lighted in schizophrenia, major depressive disorder and distress [15, 16]. bipolar disorder, strongly recalls the microbiota altera- Furthermore, a growing body of scientifc evidence tion, suggesting an important role of the alteration of the supports the notion that the crosstalk between the gut gastrointestinal (GI) system also in neuropsychiatric dis- microbiota, diet and immune system activates mediators orders [8]. and signalling pathways, which infuence the whole body Probiotics can have dramatic efects on behaviour, metabolism and disease [17–19]. Te metabolic activi- through their action on the vagus nerve and on the ties of the gut microbiota play a decisive part in obesity microbiome–gut–brain axis, which constitutes a bidi- because of its role in the improvement of calorie extrac- rectional communication network. Probiotics produce a tion from food, the accumulation of substrates in adipose variety of neurochemicals, analogues of mammalian hor- tissue, like fatty acids, and the utilization of energy and mones, involved in mood and behaviour. Terefore, the nutrients for its growth [20]. visceral messages from the gut can afect brain function Obesity is characterized by a peculiar microbiota and and, vice versa, signals from the brain may afect the sen- the microbiota itself, together with the host genotype sory system and the gut secretion mode. and lifestyle, could contribute to the development of this Te bacteria most commonly exploited as probiotics metabolic dysfunction. Also, a bidirectional association with psychotropic efects in animal models and human between obesity and self-reported or clinical measures of clinical trials have been classifed as “psychobiotics” [2], depression were observed, and body dissatisfaction was and they belong to the Bifdobacterium and Lactobacillus robustly associated as a risk factor for obesity and eating families. disorders [9]. In the last few years, in vivo experiments demonstrated Diferent obese phenotypes have been described based that administration of Bifdobacterium longum 1714 and on body fat composition and distribution, rather than Bifdobacterium breve 1205, Lactobacillus helveticus and the simple increase of body weight, body mass index Lactobacillus plantarum strain PS128 reduce anxiety and (BMI) and genetics [21]: (1) metabolically obese normal weight [22]; (2) metabolically healthy obese [23]; and (3) De Lorenzo et al. J Transl Med (2017) 15:135 Page 3 of 12

metabolically unhealthy obese or “at risk” obese [24]; (4) and General Hospital Foundation, Catholic University of normal weight obese (NWO) [25]. Sacred Heart, Rome, Italy. Subjects afected by NWO syndrome usually have a Sixty women were enrolled. Subjects were screened for BMI value within the normal range (<25 kg/m2) and, eligibility at frst medical visit and underwent body com- at the same time, high total body fat percentage (TBFat position analysis, psychological profle and eating behav- >30%) and total body lean mass (TBLean) defciency iour assessment by symptom checklist 90 (SCL90R), based on a genetic predisposition. Tey also have high [31] for the evaluation of general psychopathology, body oxidative stress level, early infammatory status and some uneasiness test (BUT), for the evaluation of body image metabolic abnormalities [26–28]. Furthermore, in our perception (IC) [32], and EDI-2, for eating behavior [33], previous study on female subjects afected by NWO syn- in order to test the efcacy of a 3-week administration of drome it was highlighted, not only an increased risk of POS on NWO and preobese–obese (PreOB/OB) com- cardiovascular and metabolic disease, but also a will to pared to normal weight lean women (NWL). control body weight, revealing a suppressed vocation for As the expected weight loss was below 5, according the obesity. In fact, NWO subjects obtained an intermediate Ethical Committee of the University of Rome “Tor Ver- score on the eating disorder inventory-2 (EDI-2), particu- gata”, data from Dual X-ray Absorptiometry (DXA) was larly in terms of body dissatisfaction and drive for thin- used to classifed the subjects. We classifed the subjects ness, between normal weight lean women and pre-obese according to BMI, and TBFat % by DXA into: (a) NWL or obese women [28]. women, with a BMI <25 kg/m2 and TBFat % <30; (b) Up today very few studies demonstrated the benefcial NWO women, with a BMI <25 kg/m2, and TBFat % 30; 2 ≥ efects on the health status of obese subjects with psychi- (c) PreOB/OB women, with a BMI ≥25 kg/m and TBFat atric illnesses and eating disorders of these “mind-alter- % ≥30. ing” probiotics. Lactobacillus appears to reduce body fat Body composition was assessed by Bioelectrical Imped- mass, anxiety and dysphoria, and improves insulin sensi- ance Analysis (BIA) at baseline and after treatment. tivity and glucose tolerance [29, 30]. Forty-eight subjects were eligible for the study and they Nowadays, literature doesn’t report any paper focused were randomly divided into two groups (1:1 ratio). Te on the efectiveness check of treatment with psychobiot- randomization was determined by an external contract ics in NWO syndrome. research organization and coordinated with the Section Given the link among gut microbiota, body composi- of Clinical Nutrition and Nutrigenomic, at the University tion, the risk of eating disorder, anxiety- and depression- of Rome “Tor Vergata”, independently of the investigators. like behaviours, the purpose of the current study was to One intervention group (IG) and one control group test the efcacy of a 3-week administration of a psycho- (CG) were utilized and took daily n.1 bag of POS, or biotic oral suspension (POS), containing Streptococcus n.1 bag of placebo. Te study consists of a 3-week treat- thermophilus, Bifdobacterium animalis subsp. Lactis, ment, with POS or placebo, separated by a 3-week wash Streptococcus thermophiles, Bifdobacterium bifdum, out period, used to avoid additive efects on treatments Lactobacillus delbrueckii spp. Bulgaricus, Lactococcus to follow. After 3 weeks of washout, the IG and CG were lactis subsp. Lactis, Lactobacillus acidophilus, Lactoba- reversed. Te IG and CG arms were double-blinded. cillus plantarum, Lactobacillus reuteri, selected accord- Study period resulted in a total duration of 9 weeks. At ing to literature. Te endpoints of this study were to the beginning and at the end of each arm (±3 days), the evaluate the body composition parameters, the psycho- subjects had to repeat the visit. logical profle, and eating behaviour changes of NWO Subjects were asked to maintain their usual lifestyle and preobese–obese (PreOB/OB) compared to normal habits and to report any illness or abnormality aris- weight lean women (NWL), after POS. ing during the study. At the end of each arm, a clinician assessed any adverse efects from the interventions by Methods going through a checklist of symptoms, including bloat- Clinical study design and subjects ing, fullness or indigestion, altered bowel habit, dizziness Te clinical study was conducted using a randomized, and other symptoms that were possibly associated with double blinded controlled design, between October the interventions. Any adverse efect has been properly 2015 and July 2016, according to the CONSORT fow- reported. chart (Fig. 1). Subjects were consecutively recruited within a program of routine medical check-up at the Exclusion criteria Section of Clinical Nutrition and Nutrigenomic, Depart- Exclusion criteria included age <20 or >65 year, preg- ment of Biomedicine and Prevention of the University nancy, breast-feeding, type 1 diabetes, presence of intes- of Rome “Tor Vergata”, at “Nuova Annunziatella” Clinic, tinal bacterial overgrowth, characterized by high levels De Lorenzo et al. 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Fig. 1 Study Flow Diagram according to Consort, 2010

of hydrogen and methane production in the small bowel, 10 days before enrolment, smoke, drug or alcohol abuse, acute diseases, endocrine disorders, liver, heart or kid- participation in another diet trial. No subjects with ney dysfunctions, history of chronic degenerative or known alterations to intestinal transit following organic infectious diseases, medication, antibiotic therapy until pathologies (abdominal surgery, diabetes mellitus, De Lorenzo et al. J Transl Med (2017) 15:135 Page 5 of 12

scleroderma, hypothyroidism, etc.) were included in the water (ECW), free fat mass (FFM) and fat mass (FM) study. Subjects could not have taken antibiotics or pro- were measured using a BIA phase sensitive system at biotics in the month before the study and were willing to 50 kHz frequency (BIA 101S, Akern/RJL Systems-Flor- avoid use of probiotics for the duration of the study. ence, Italy). Measurements were taken according to Di Renzo et al. Endpoints [35]. Te primary endpoint was the evaluation of body composition changes after POS by anthropometry, DXA, and Dual x‑ray absorptiometry bioimpedentiometry. Te secondary endpoint was the To assess body composition analysis, that give the pos- evaluation of psychological profle by self-report ques- sibility to measure TBFat and TBLean, DXA (i-DXA, GE tionnaires (i.e. EDI-2, SCL90R, and BUT). Te third end- Medical Systems, Milwaukee, WI, USA) evaluation was point was the evaluation of orocaecal transit time and performed at baseline, according to De Lorenzo et al. bacterial overgrowth by lactulose breath test (LBT). [28].

Psychobiotics oral suspension (POS) and placebo capsules Psychodiagnostic instruments composition Anonymous questionnaires, self-compiled, were given to 1 bag of 3 g psychobiotics oral suspension (POS) con- all subjects for the collection of socio-demographic data. 10 tained: Streptococcus thermophilus SGSt01 (1.5 × 10 Te symptom checklist 90 (SCL90R) [31] was adminis- colony-forming unit CFU), Bifdobacterium animalis tered for the evaluation of general psychopathology, the subsp. Lactis SGB06 (1.5 1010 colony-forming unit body uneasiness test (BUT) for the evaluation of the per- × 10 CFU), Streptococcus thermophiles (1.5 × 10 colony- ception of body image (IC) [32] and the EDI-2, for eat- forming unit CFU), Bifdobacterium bifdum SGB02 ing behavior [33]. Eating behavior was assessed using the (1.5 1010 colony-forming unit CFU), Lactobacillus Italian version of the EDI-2, standardized in an Italian × 10 delbrueckii spp. Bulgaricus DSM 20081 (1.5 × 10 col- population [36]. Te subscales of the EDI-2 include drive ony-forming unit CFU), Lactococcus lactis subsp. Lactis for thinness (DT), bulimia (B), body dissatisfaction (BD), 10 SGLc01 (1.5 × 10 colony-forming unit CFU), Lacto- inefectiveness (I), interceptive awareness (IA), maturity bacillus acidophilus SGL11 (1.5 1010 colony-forming fears (MF), asceticism (A), impulse regulation (IR), social × 10 unit CFU), Lactobacillus plantarum SGL07 (1.5 × 10 insecurity (SI), perfectionism (P) and interpersonal dis- colony-forming unit CFU), Lactobacillus reuteri SGL01 trust (ID). 10 (1.5 × 10 colony-forming unit CFU), maltodextrin from corn, anti-caking agent (silica), casein, lactose and glu- Body uneasiness test (BUT) It is a self-assessment ten <3 ppm LLOQ (lower limit of quantitation) (Biocult scale, used for body image studies and related patholo- strong, HOMEOSYN, Rome, Italy). gies. Beyond the total score, BUT allows to calculate the Te placebo was represented by 3 g of inert material global severity index (GSI) or total average score, which is (four type 00), maltodextrin from corn, anti-caking agent obtained from the sum of clinical scores (BUT a), divided (silica). Te appearance of the placebo was indistinguish- by their number (34). Items number with score ≥1 corre- able in colour, shape, size, packaging, smell, and taste spond to positive symptom total (PST). Te sum of items from that of the probiotic supplement. scores ≥1 divided by PST, produces the positive symptom Both products were provided by HOMEOSYN (Rome, distress index (PSDI) [32]. Italy). Five factors were defned: WP—weight phobia, BIC— body image concerns, A—avoidance, CSM—compulsive Anthropometric measurements self-monitoring, D—depersonalization. In our study, we At T1, after a 12-h overnight fast, all subjects underwent considered as positive for altered perception of body anthropometric evaluation (body weight, height, waist image a GSI score ≥1.2. and hip circumferences), according to standard method [34]. All the individuals were instructed to take of their Symptom check list—revised (SCL90R) It is a general clothes and shoes before undergoing the measurements. evaluation scale of the psychopathology, based on patient’s BMI was calculated using the formula: BMI = body self-evaluation. Tis scale is composed by 90 items, which weight (kg)/height (m)2. investigate the presence of symptoms in the week before the test check. Tese 90 items, which have fve levels Lik- Bioelectrical impedance analysis (BIA) ert answers, have 10 reference factors: (1) somatization Resistance, reactance, impedance, phase angle, total body (Som); (2) obsessive/compulsive (Obs); (3) interpersonal water (TBW), intracellular water (ICW), extracellular sensitivity (Interp Sens); (4) depression (Dep); (5) anxious De Lorenzo et al. J Transl Med (2017) 15:135 Page 6 of 12

(Anx); (6) anger/hostility (Anger Host); (7) phobia (Phob); ECW (%) (Δ% −9.57), ICW (L) (Δ% 11.61), ICW (%) (Δ% (8) psychoticism (Psych); (9) paranoia (Paran); (10) sleep 7.65), TBFat (%) (Δ% 64.97), TBFat (g) (Δ% 125.08), FM disorders. Te score goes from 0 to 4, and a score above 1 (kg) (Δ% 64.32), FM (%) (Δ% 43.35) and FFM (%) (Δ% is an index of pathology [31]. −11.04). Signifcant diferences (p < 0.05) between the NWO and the PreOB/OB groups in terms of weight (Δ% Breath testing and gastrointestinal symptoms 9.40), BMI (Δ% 15.62), Reactance (Ohm), (Δ% 19.73), questionnaire PA (°) (Δ% 20.72), TBW (L) (Δ% −0.60), TBW (%) (Δ% Subjects also completed a questionnaire evaluating gas- −8.27), ECW (L) (Δ% −12.45), ECW (Δ% −11.70), and trointestinal symptoms (meteorism, abdominal pain, def- ICW (L) (Δ% 9.50), ICW (%) (Δ% 9.78), TBFat (%) (Δ% ecation frequency/week). 24.26) and TBFat (g) (Δ% 56.93) were observed (Table 1). Te LBT was performed by administering 20 g lactu- After 3 weeks of POS treatment, a signifcant reduc- lose dissolved in 100 cc water to the subjects. Breath tion of BMI, resistance, reactance, PA, ICW (%), FM (kg samples were obtained by asking the patients to blow into and %) (p < 0.05), and a signifcant increase of TBW (L suitable containers at time 0 (before ingesting the lactu- and %), ECW (L and %), ICW (L), FFM (kg) and FFM (%) lose) and then every 15 min thereafter for the 4 h follow- were observed in NOW population. Furthermore, in Pre- ing lactulose administration. Gas chromatography was obOB group it was highlighted a signifcant reduction of used to assess the presence and quantity of hydrogen in weight, BMI, waist, hip, resistance, ECW (L and %), FM the breath (Quintron Milwaukee, Wisconsin USA). Oro- (kg and %), and a signifcant increase of PA, TBW (%), caecal transit time was calculated for each patient by ICW (L and %), FFM (kg and %) (p < 0.05) (Table 1). constructing the curves of hydrogen in the breath over Signifcant diferences (p < 0.05) were observed among time. Tis therefore showed the time necessary for the the NWL, NWO and PreOB/OB groups in body compo- bolus to reach the caecum [37]. sition parameters after POS treatment (Table 1). At baseline, the total tested sample was negative to Statistical analysis SCL90R_GSI scale and 33.30% of the population was Te statistical analysis was carried out using IBM SPSS positive at BUT_GSI scale (GSI ≥1.2; mean 0.96 ± stand- Statistics for Windows, Version 21.0 (Armonk, NY: IBM ard deviation 0.66). After 3 weeks of POS treatment, all Corp). Data are expressed as mean ± standard devia- population remained negative to SCL90R_GSI scale, tion (SD), and minimum and maximum. A paired t test and the positive to BUT scale was signifcantly reduced or a non-parametric Wilcoxon test were performed to (p < 0.05) at 8.33% (GSI ≥1.2; mean 0.59 ± standard evaluate diferences between baseline and after POS. A deviation 0.52). At baseline, among the 33.3% of the posi- one-way ANOVA was carried out to compare the aver- tive to BUT_GSI and BUT_CSM scale, the 12.5% were age of the responses obtained in all three groups. Where NWL, the 50% were NWO, and 37.55% were PreOB/OB. applicable, the Chi square or Student’s t test were used to After POS treatment only NWO among the 8.33% of the assess symptoms. positive (100%) were identifed. A diference of p < 0.05 was considered signifcant. Te average scores of the various dimensions and the total score of SCL90R scale, BUT_GSI and EDI-2 are rep- Results resented in Table 2. After 3 weeks of POS treatment, in Of the 60 women initially recruited, 8 did not meet inclu- the general population signifcant diferences (p < 0.05) sion criteria, 4 dropped out of the study voluntarily, leav- in terms of the responses to the subscales of the EDI-2 ing a total of 48 subjects for fnal analysis. were observed: −37.98 Δ% of B (baseline, 1.74 ± 3.01; Te characteristics of the study population in terms 3 weeks POS, 1.08 ± 2.06), the −15.95 Δ% of DT (base- of age, weight, height, BMI, body composition and psy- line, 1.74 ± 3.01; 3 weeks POS, 1.08 ± 2.06), the −40.15 chological profle (EDI-2, BUT, and SCL90R) are shown Δ% of I (baseline, 1.74 ± 3.01; 3 weeks POS, 1.08 ± 2.06). in Table 1. In particular, between the NWL and the After POS treatment, in the NWO group signifcant NWO groups, signifcant diferences (p < 0.05), in terms diferences (p < 0.05) in terms of the responses to the of weight (Δ% 14.31), BMI (Δ% 16.95), hip circumfer- subscales of the EDI-2 were observed: −41.94 Δ% of B ence (Δ% 9.4), TBW (%) (Δ% −10.05), TBFat (%) (Δ% (baseline, 0.91 ± 1.64; 3 weeks POS, 0.53 ± 1.16), the 32.77), TBFat (g) (Δ% 43.43), FM (kg) (Δ% 58.59), FM −19.30 Δ% of DT (baseline, 9.29 ± 7.81; 3 weeks POS, (%) (Δ% 39.75) and FFM (%) (Δ% −10.13) were observed. 7.50 ± 7.18), the −50.45 Δ% of I (baseline, 3.26 ± 4.29; Between the NWL and the PreOB/OB there were signif- 3 weeks POS, 1.62 ± 2.85). After 3 weeks of POS treat- cant diferences (p < 0.05) in terms of weight (Δ% 25.06), ment, in the PreOB/OB group signifcant diferences, BMI (Δ% 35.22), waist (Δ% 18.93) and hip circumference (p < 0.05) in terms of responses to the subscales of (Δ% 14.50), PA (°) (Δ%17.46), TBW (%), (Δ% −17.49), the EDI-2, were observed: −31.25 Δ% of B (baseline, De Lorenzo et al. J Transl Med (2017) 15:135 Page 7 of 12

Table 1 Comparison of body composition parameters of normal weight lean, normal weight obese and pre-obese/obese groups between baseline and after 3 weeks POS treatment NWL NWO PreobOB Baseline POS Baseline POS Baseline POS

Age (years) 30.18 2.04 (28.00–33.00) 40.00 12.56 (27.00–56.00) 33.57 10.57 (24.00–50.00) ± ± ± Height (cm) 164.64 4.03 (160.00–170.00) 162.90 6.60 (154.00–168.00) 158.33 1.86 (155.60–160.00) ± ± ± Weight (kg) 55.55 4.65¤,° 54.84 5.63Ϫ,ϣ 63.50 3.97¥ 63.10 3.27 69.47 6.07 63.35 0.16b (50.50–62.50)± (49.20–63.00)± (59.00–68.30)± (59.00–66.60)± (63.80–78.00)± (63.20–63.50)± BMI (kg/m2) 20.47 1.04¤,° 20.49 1.40Ϫ,ϣ 23.94 0.93¥ 23.80 0.84a,Ϭ 27.68 1.92 25.78 0.48b (19.48–22.41)± (18.98–22.59)± (22.74–24.88)± (22.92–24.88)± (25.56–30.47)± (25.32–26.23)± Waist (cm) 67.41 4.22 67.98 4.60Ϫ,ϣ 74.25 5.08 75.33 4.70 80.17 8.02 73.75 2.35b (64.50–75.00)°± (63.80–75.00)± (69.50–79.00)± (70.00–81.00)± (73.00–91.00)± (71.50–76.00)± Hip (cm) 94.09 4.57 ¤,° 93.23 4.35 Ϫ,ϣ 103.25 5.61¥ 101.00 3.72Ϭ 107.73 0.54 106.75 0.78b (87.00–97.00)± (87.50–97.00)± (98.00–108.50)± (98.00–106.00)± (107.00–108.20)± (106.00–± 107.50) Resistance (Ohm) 595.89 85.36 598.33 69.50 ϣ 576.67 55.46 567.00 53.60a 565.13 35.34 523.00 24.02b (501.00–735.00)± (497.00–690.00)± (526.00–650.00)± (513.00–636.00)± (526.00–611.00)± (500.00–± 546.00) Reactance (Ohm) 66.00 12.24 65.89 8.46 61.33 7.74¥ 59.67 8.75a,Ϭ 73.43 9.54 69.50 6.79 (56.00–87.00)± (56.00–73.00)± (53.00–71.00)± (51.00–71.00)± (66.00–89.00)± (63.00–76.00)± PA (°) 6.30 0.35° 6.29 0.46ϣ 6.13 0.89¥ 6.03 0.97a,Ϭ 7.40 0.59 7.55 0.37b (5.90–6.80)± (5.70–6.80)± (5.30–7.30)± (5.10–7.30)± (6.70–8.30)± (7.20–7.90)± TBW (L) 31.80 2.83 31.66 3.00 33.13 2.50¥ 33.40 2.56a 32.93 0.36 33.35 1.10 (29.10–36.60)± (29.70–36.90)± (31.10–36.50)± (31.10–36.80)± (32.60–33.50)± (32.30–34.40)± TBW (%) 57.92 4.19¤,° 57.82 3.19 52.10 1.37¥ 52.90 2.01a 47.79 4.30 52.65 1.83b (50.80–61.30)± (52.40–60.40)± (50.30–53.40)± (50.60–55.30)± (42.00–52.60)± (50.90–54.40)± ECW (L) 14.11 1.33 14.07 1.39 15.10 2.01¥ 15.37 2.18a,Ϭ 13.22 0.74 13.20 0.84b (12.40–16.10)± (12.60–16.10)± (12.50–17.10)± (12.50–17.40)± (12.10–14.00)± (12.40–14.00)± ECW (%) 44.42 1.38° 43.93 2.64ϣ 45.53 3.93¥ 45.87 4.29a,Ϭ 40.17 2.02 39.50 1.36b (42.50–46.00)± (40.80–47.20)± (40.40–49.30)± (40.30–50.10)± (37.10–42.60)± (38.20–40.80)± ICW (L) 17.66 1.63° 17.59 1.86ϣ 18.00 1.45¥ 18.03 1.47a, Ϭ 19.71 0.63 20.15 0.26b (16.70–20.50)± (16.20–20.80)± (16.10–19.40)± (16.10–19.40)± (18.90–20.60)± (19.90–20.40)± ICW (%) 55.58 1.38° 55.62 1.91ϣ 54.50 3.91¥ 54.12 4.37a,Ϭ 59.83 2.02 60.61 1.37b (54.00–57.50)± (52.92–57.58)± (50.70–59.60)± (49.85–59.81)± (57.40–62.90)± (59.30–61.92)± TBFat (%) 26.55 2.83¤,° – 35.25 1.44¥ – 43.80 0.00 – (24.10–29.00)± (33.90–36.60)± (43.80–43.80)± TBFat (kg) 15.15 0.01¤,° – 21.73 1.73¥ – 34.10 0.00 – (15.14–15.16)± (20.11–23.34)± (34.10–34.10)± TBLean (kg) 40.17 5.98 – 37.61 0.57 – 41.26 0.00 – (34.99–45.35)± (37.08–38.14)± (41.26–41.26)± FM (kg) 11.35 2.86¤,° 11.80 3.12c,Ϫ,ϣ 18.00 1.64 17.27 1.80a 18.65 0.99 16.95 0.99b (8.10–15.10)± (8.10–16.00)± (15.90–19.70)± (15.80–19.70)± (17.70–19.60)± (16.00–17.90)± FM (%) 20.30 4.06¤,° 21.05 4.43c,Ϫ,ϣ 28.37 2.09 27.57 2.58a 29.10 1.36 26.70 1.46b (16.10–26.40)± (16.50–27.80)± (26.90–31.20)± (25.00–30.90)± (27.80–30.40)± (25.30–28.10)± FFM (kg) 44.23 3.57 43.75 4.06 45.50 3.25 45.83 3.32a 45.50 0.63 46.40 0.84b (42.20–50.00)± (41.10–50.30)± (43.10–49.90)± (43.20–50.30)± (44.90–46.10)± (45.60–47.20)± FFM (%) 79.70 4.06¤,° 78.95 4.43c,Ϫ,ϣ 71.63 2.09 72.43 2.58a 70.90 1.36 73.30 1.46b (73.60–83.90)± (72.20–83.50)± (68.80–73.10)± (69.10–75.00)± (69.60–72.20)± (71.90–74.70)±

Results are expressed in mean value standard deviation, and minimum and maximum for each parameter. Values of p < 0.05 are considered signifcant ± BMI body mass index, ECW extracellular water, FM fat mass, FFM fat free mass, ICW intracellular water, NWL normal weight lean, NWO normal weight obese, PA phase angle, PreOB/OB preobese–obese, TB total body, TBW total body water a NWO T0 vs T1 p < 0.05; b PreOB/OB T0 vs T1 p < 0.05 c NWL T0 vs T1. For Anova-test at baseline p < 0.05; ¤ NWL vs NWO p < 0.05; ¥ NWO vs PreOB/OB p < 0.05; ° NWL vs PreOB/OB p < 0.05. Anova-test after POS p < 0.05; Ϫ NWL vs NWO p < 0.05; Ϭ NWO vs PreOB/OB p < 0.05; ϣ NWL vs PreOB/OB p < 0.05 De Lorenzo et al. J Transl Med (2017) 15:135 Page 8 of 12

Table 2 Comparison of psychometric parameters of normal weight lean, normal weight obese and pre-obese/obese groups of women between baseline and after 3 weeks POS treatment NWL NWO PreobOB Baseline POS Baseline POS Baseline POS

EDI-2_DT 2.89 4.63 2.94 4.40 5.26 6.33 5.09 6.08 8.41 7.58 8.50 7.84 (0.00–20.00)± (0.00–19.00)± (0.00–21.00)± (0.00–20.00)± (0.00–18.00)± (0.00–19.00)± EDI-2_B 1.00 2.45 0.39 1.24 0.91 1.64 0.53 1.16a 3.64 4.12 2.50 2.89b (0.00–10.00)± (0.00–5.00)± (0.00–7.00)± (0.00–5.00)± (0.00–16.00)± (0.00–10.00)± EDI-2_BD 5.28 6.09 4.94 6.01 9.29 7.81 7.50 7.18a 14.09 6.35 11.91 5.76b (0.00–23.00)± (0.00–23.00)± (0.00–27.00)± (0.00–25.00)± (2.00–24.00)± (0.00–20.00)± EDI-2_I 1.39 2.20 1.22 1.90 3.26 4.29 1.62 2.85a 5.82 4.92 3.68 4.51b (0.00–6.00)± (0.00–5.00)± (0.00–17.00)± (0.00–10.00)± (1.00–19.00)± (0.00–16.00)± EDI-2_P 3.83 3.54 3.61 3.16 4.85 3.00 4.74 2.99 3.36 3.67 3.32 3.81 (0.00–14.00)± (0.00–13.00)± (0.00–11.00)± (0.00–12.00)± (0.00–14.00)± (0.00–15.00)± EDI-2_ID 2.33 2.47 2.06 2.39 3.53 3.55 3.47 3.67 3.68 3.37 3.59 3.45 (0.00–9.00)± (0.00–9.00)± (0.00–16.00)± (0.00–17.00)± (0.00–10.00)± (0.00–10.00)± EDI-2_IA 3.61 3.96 3.22 3.61 4.47 5.93 4.41 6.03 5.36 5.02 5.27 4.73 (0.00–12.00)± (0.00–11.00)± (0.00–23.00)± (0.00–24.00)± (0.00–16.00)± (0.00–15.00)± EDI-2_MF 7.89 5.14 7.67 4.98 5.76 3.24 5.59 3.28 5.50 4.59 5.45 4.27 (1.00–21.00)± (1.00–20.00)± (0.00–14.00)± (0.00–15.00)± (1.00–20.00)± (1.00–19.00)± EDI-2_A 3.50 2.46 3.56 2.50 3.53 1.97 3.38 1.97 4.50 2.09 4.27 2.07 (0.00–8.00)± (0.00–9.00)± (0.00–7.00)± (0.00–8.00)± (1.00–8.00)± (0.00–7.00)± EDI-2_IR 1.61 2.48 1.67 2.28 3.50 3.86 3.68 4.09 2.32 2.92 2.27 2.81 (0.00–9.00)± (0.00–8.00)± (0.00–14.00)± (0.00–15.00)± (0.00–9.00)± (0.00–9.00)± EDI-2_SI 2.39 2.17 2.33 2.00 4.03 3.38 3.94 3.20 4.00 3.41 3.91 3.38 (0.00–7.00)± (0.00–6.00)± (0.00–15.00)± (0.00–14.00)± (0.00–14.00)± (0.00–15.00)± SCL90R_Som 0.67 0.12 0.30 0.15c 0.61 0.35 0.28 0.11a 0.87 0.63 0.42 0.26b (0.50–0.83)± (0.08–0.50)± (0.33–1.08)± (0.17–0.42)± (0.08–1.67)± (0.17–0.67)± SCL90R_Obs Comp 0.81 0.36 0.37 0.13c 0.60 0.23 0.27 0.10a 0.46 0.34 0.20 0.00b (0.50–1.30)± (0.30–0.60)± (0.30–0.80)± (0.20–0.40)± (0.20–1.00)± (0.20–0.20)± SCL90R_Interp Sens 0.75 0.41 0.22 0.23c 0.56 0.09 0.26 0.11a 0.45 0.29 0.56 0.00b (0.22–1.33)± (0.00–0.56)± (0.44–0.67)± (0.11–0.33)± (0.11–0.89)± (0.56–0.56)± SCL90R_Dep 0.70 0.35 0.27 0.26c 0.18 0.04 0.26 0.10 0.52 0.67 0.23 0.24 (0.38–1.31)± (0.00–0.69)± (0.15–0.23)± (0.15–0.38)± (0.08–1.62)± (0.00–0.46)± SCL90R_Anx 0.56 0.34 0.17 0.15 0.30 0.22 0.31 0.14 0.66 0.42 0.08 0.08b (0.12–1.00)± (0.10–0.43)± (0.04–0.57)± (0.21–0.50)± (0.03–1.19)± (0.00–0.16)± SCL90R_Anger Host 0.50 0.22 0.20 0.07c 0.39 0.16 0.17 0.14a 0.78 0.49 0.17 0.17b (0.17–0.67)± (0.17–0.33)± (0.17–0.50)± (0.00–0.33)± (0.00–1.33)± (0.00–0.33)± SCL90R_Phob 0.10 0.17 0.06 0.13 0.33 0.19 0.19 0.07a 0.37 0.56 0.07 0.07b (0.00–0.43)± (0.00–0.29)± (0.14–0.57)± (0.14–0.29)± (0.00–1.29)± (0.00–0.14)± SCL90R_Paran 0.82 0.63 0.31 0.27c 0.17 0.25 0.00 0.00a 0.39 0.32 0.17 0.17b (0.00–1.67)± (0.00–0.67)± (0.00–0.50)± (0.00–0.00)± (0.00–0.83)± (0.00–0.33)± SCL90R_Psych 0.26 0.18 0.06 0.08 0.26 0.17 0.15 0.13a 0.34 0.40 0.08 0.08b (0.10–0.60)± (0.00–0.18)± (0.11–0.49)± (0.00–0.31)± (0.00–0.98)± (0.00–0.16)± SCL90R_GSI 0.58 0.23 0.23 0.07c 0.45 0.20 0.25 0.02a 0.54 0.38 0.24 0.12b (0.29–0.92)± (0.17–0.32)± (0.23–0.69)± (0.22–0.27)± (0.14–1.13)± (0.13–0.36)± BUT_GSI 0.55 0.43 0.39 0.43c 1.11 0.66 0.79 0.64 1.08 0.69 0.54 0.41b (0.09–1.21)± (0.12–1.15)± (0.24–1.71)± (0.15–1.62)± (0.41–2.09)± (0.15–0.94)± BUT_WP 0.93 0.82 0.79 1.05 1.96 1.17 1.42 1.27 1.97 0.60 1.13 0.65b (0.13–2.38)± (0.13–2.63)± (0.38–2.88)± (0.38–3.13)± (1.13–2.75)± (0.50–1.75)± BUT_BIC 0.58 0.62 0.37 0.56c 1.48 0.85 1.00 0.78 1.27 1.20 0.67 0.58b (0.11–1.56)± (0.00–1.33)± (0.44–2.44)± (0.22–2.00)± (0.11–3.00)± (0.11–1.22)± BUT_A 0.18 0.20 0.04 0.07c 0.28 0.22 0.11 0.16a 0.13 0.14 0.17 0.17b (0.00–0.50)± (0.00–0.17)± (0.00–0.50)± (0.00–0.33)± (0.00–0.33)± (0.00–0.33)± BUT_CSM 0.71 0.48 0.57 0.30 1.06 0.67 0.89 0.87 0.99 0.73 0.33 0.35b (0.00–1.33)± (0.17–1.00)± (0.17–1.67)± (0.00–2.00)± (0.17–1.83)± (0.00–0.67)± De Lorenzo et al. J Transl Med (2017) 15:135 Page 9 of 12

Table 2 continued NWL NWO PreobOB Baseline POS Baseline POS Baseline POS BUT_D 0.13 0.10 0.00 0.00c 0.13 0.20 0.13 0.20 0.57 0.75 0.10 0.10b (0.00–0.20)± (0.00–0.00)± (0.00–0.40)± (0.00–0.40)± (0.00–1.80)± (0.00–0.20)±

Results are expressed in mean value standard deviation, and minimum and maximum for each parameter. Values of p < 0.05 are considered signifcant ± A asceticism, A avoidance, Anger Host anger/hostility, Anx anxious, B bulimia, BD body dissatisfaction, BIC body image concerns, BMI body mass index, BUT body uneasiness test, CSM compulsive self-monitoring, D depersonalization, Dep depression, DT drive for thinness, EDI-2 eating disorder inventory-2, GSI global severity index, I inefectiveness, IA interoceptive awareness, IC body image, ID interpersonal distrust, IG intervention group, Interp Sens interpersonal sensitivity, IR impulse regulation, MF maturity fears, NWL normal weight lean, NWO normal weight obese, Obs obsessive/compulsive, P perfectionism, Paran paranoia, Phob phobia, POS probiotic oral suspension, PreOB/OB preobese–obese, PSDI positive symptom distress index, PST positive symptom total, Psych psychoticism, SCL90R symptom checklist 90, SI social insecurity, Som somatization, WP weight phobia a NWO T0 vs T1 p < 0.05; b PreOB/OB T0 vs T1 p < 0.05; c NWL T0 vs T1

3.64 ± 4.12; 3 weeks POS, 2.50 ± 2.89), the −15.48 Δ% of probiotic infuences the secretion of molecules on which DT (baseline, 14.09 ± 6.35; 3 weeks POS, 11.91 ± 5.76), depend anxiety and depression, and simultaneously the −36.72 Δ% of I (baseline, 5.82 ± 4.92; 3 weeks POS, afects neuroendocrine response to stress. 3.68 ± 4.51) (Table 2). Recent data show the strong correlation between dys- A signifcant improvement of the orocaecal transit time biosis and a variety of conditions such as obesity, aller- and gastrointestinal symptoms were observed (p < 0.05) gies, autoimmune disorders, Irritable Bowel Syndrome, after 3 weeks of POS treatment respect to placebo. More- Infammatory Bowel Disease and psychiatric disorders over, signifcant diferences were observed for meteorism [39, 40]. Bifdobacterium and Atopobium were signif- (p < 0.05) and defecation frequency (p < 0.05) (data not cantly less abundant in obese animals compared to the show). non-obese rats, in conjunction with signifcantly higher levels of the Clostridium cluster XIVa and Lactobacil- Discussion lus group [41]. In the meantime, Cani et al. reported a Te link between the “somatic” and “mental” is undeni- reduction in the Clostridium cluster XIVa (Clostridium ably a subject that has fascinated through the years and coccoides) group, along with lower Bifdobacterium and until the present day many artists and philosophers. Also Bacteroides levels in mice fed high-fat diet. An increase researchers and scientists daily make their contribution of Firmicutes levels was observed in high-fat fed mice, to reveal this chimera showing a complex but fascinating while Bacteroides phylum decreased overtime in obese harmonic unit. animals [42]. Angelakis et al. [43], highlighted elevated Te gut–microbiota–brain axis includes the central levels of Bacteroidetes phylum, a strong abundance of the nervous system, neuroendocrine and neuro-immune sys- Firmicutes phylum and elevated concentrations of Lac- tem, the sympathetic and parasympathetic arms of the tobacilli in the gut microbiota of obese and overweight autonomic nervous system, the enteric nervous system adults compared to lean individuals. Moreover, the sup- and, most importantly, the intestinal microbiota [38]. plementation with lactic acid bacteria brought to weight Some bacteria within the human gastrointestinal tract modifcation, suppression of the neuroendocrine stress have the capacity to produce many neurotransmitters response and relieved abdominal dysfunction [44, 45]. and neuromodulators, such as norepinephrine, serotonin, Consistent with these considerations, it has been pre- dopamine, acetylcholine, histamine and gamma-amin- pared a new formulation of POS, containing diferent obutyric acid [7]. Due to these new evidences about the strain of bacteria, i.e. Streptococcus thermophiles, Bif- fundamental role of gut microbiota in the alteration of dobacterium animalis subsp. Lactis, Streptococcus ther- immune, neural and endocrine pathways, the so-called mophiles, Lactobacillus bulgaricus, Lactococcus lactis “gut–brain axis” is acquiring new signifcance, even if the subsp. Lactis, Lactobacillus acidophilus, Lactobacillus 10 communication routes are not yet defned [38]. plantarum, Lactobacillus reuteri, for a total of 120 × 10 From clinical experience and from the literature it is colony-forming unit CFU. clear the importance of “personalization” of treatment, We tested the efectiveness of this new POS formula- also respect to the individuals we have in care, taking tion, having two main purposes: (1) to investigate the into account body composition, gut microbiota, feed- correlation between body composition and the presence ing behaviour, attitude towards food and the presence of of psychological disorders and psychopathological symp- emotional states that may infuence them. Te intake of toms in people afected by NWO syndrome and obesity De Lorenzo et al. J Transl Med (2017) 15:135 Page 10 of 12

respect to normal lean individual; (2) to check whether evidence that POS therapy improves the psychological the intake of POS could change all the examined parame- state, reducing the positivity to BUT (−24.90%) and ters, in order to make an early diagnosis and to block any the alteration of body image perception, as demon- nascent development of a psychopathological disorder, strated by the signifcant reduction in the subscales of taking into account all its future consequences. the EDI-2 responses both in NWO than in PreOB/OB In the present study, the cut-of point of total body fat (−41.94 Δ% of B, the −19.30 Δ% of DT, the −50.45 Δ% was 30% [46]; the analysis of anthropometric and body of I in NWO; −31.25 Δ% of B, the −15.48 Δ% of DT in composition values showed 24% of NWO, 26% of NWL PreOB/OB). and 50% of PreOB/OB women. In particular, between the It has been demonstrated that the oral administra- NWL versus the NWO group, were highlighted several tion of the probiotic Bifdobacterium longum NCC3001 signifcant diferences (p < 0.05), like weight, BMI, hip (Morinaga, Japan) is able to prevent the anxiety-like circumference, TBW (%), TBFat (% and g), FM (kg and behavior associated with gut infammation in animals %) and FFM (%), as well as in NWL versus the PreOB/OB with an intact vagus nerve [51], as did Lactobacillus group, in terms of weight, BMI, waist and hip circumfer- rhamnosus and Lactobacillus hilgardii [52]. Lactobacillus ence, PA (°), TBW (%), ECW (%), ICW (L and %), TBFat reuteri prevented the physiological signs of visceral pain, (% and g), FM (kg and %) and FFM (%) (p < 0.05). with a reduction in cardio-autonomic response [53], and Moreover, signifcant diferences (p < 0.05) between Bifdobacterium lactis decreased visceral hypersensitiv- the NWO and the PreOB/OB groups in terms of weight, ity when colorectal distention occurred in the context of BMI, Reactance, PA, TBW (L and %), ECW (L and %), psychological stress. ICW (L and %), TBFat (% and g) were observed. Hence, the lactulose passes intact the stomach and As a challenge in the development of efective strate- small intestine, and reaches the caecum, where the bac- gies to prevent the increased prevalence of obesity, teria (normally present in the colon fora) break it down, data reported in this study highlight the efcacy of the leading to the production of hydrogen. Part of the hydro- POS treatment on body composition in subjects with gen that forms is absorbed by the intestinal mucous and more than 30% of total body fat, given the considerable therefore enters the bloodstream before being released improvement of BMI, FM (kg and %), hydration status at the pulmonary alveoli and expired. By evaluating the as TBW, ECW and ICW, and FFM (p < 0.05) in NWO time at which hydrogen appears in the breath, we are group, as well as the improvement of weight, BMI, waist, indirectly able to determine orocaecal transit time [35]. hip, resistance, PA, TBW, ICW ECW, FM, and FFM in After POS treatment, a reduction of bacterial overgrowth the PreobOB group (p < 0.05), suggesting a safe and efec- (p < 0.05) was observed in NWO and PreOB/OB when tive intervention for general population, with substantial compared to controls. After POS therapy, a statistically benefts to public health. signifcant improvement was seen in the intestinal transit Many neurotransmitters and neuromodulators time in all subjects. An increase in the number of weekly secreted by bacteria are able to modulate the state of the defecations and a reduction of meteorism in subjects host mood: gamma-aminobutyric acid is produced by afected by constipation were recorded. certain Lactobacillus and Bifdobacterium species; norepinephrine is released by Escherichia, Bacillus and Sac- Conclusions charomyces spp.; 5 Hydroxy Triptamine is released by A 3-week intake of selected probiotics, by modulat- Candida, Streptococcus, Escherichia and Enterococcus ing body composition, bacterial contamination, psy- spp.; dopamine is produced by Bacillus and acetylcholine chopathological scores and eating behaviour of women by Lactobacillus [47]. Dinan et al. have reported that pro- afected by NWO syndrome and obesity, ofers a tracta- biotic Bifdobacterium infantis 35624 has shown to have ble approach to problems related to obesity, psychologi- an antidepressant action in preclinical models of depres- cal state and unhealthy eating. One improvement of this sion acting as a psychobiotic with a mental health beneft study may be to extend the administration period of POS, [48]. Gut composition is afected also by the resilience as probiotics need several weeks to proliferate. to environmental stress, impairing the cortisol awaking Despite the limitations of our study, related to the study response and emotional reaction in healthy subjects [49]. design and the low sample size, our results highlighted On the other hand, it has been shown that psychological that this new formulation of POS may possibly have stress itself leads to dysbiosis [50, 51], turning in a vicious potential as a therapeutic strategy for prevention and/ circle. or treatment of certain eating behaviour disorders and Our results seem to confrm the high prevalence anxiety-like conditions, to avoid a worsening of the psy- of body image disorders in NWO and PreoOB/OB chiatric symptomatology, the establishment of a global patients. According to literature data, we provided the functional impairment of the subject and to improve the De Lorenzo et al. J Transl Med (2017) 15:135 Page 11 of 12

quality of life of patients. Moreover, these results high- Ethics approval and consent to participate This study was approved by the Institutional Review Board of University of light the need for a more detailed psychiatric evaluation Rome “Tor Vergata”, Nuova Annunziatella” Clinic and General Hospital Founda- of subjects with an alteration of body image perception, tion, Catholic University of Sacred Heart. even when this alteration does not ft into a previous pat- Study design was clearly written in lay person language and provided to each study subject. All participants recruited in the study authorized their tern referred as eating disorder. participation by reading and signing the informed consent, conducted in Further research is needed on a larger population and accordance with the provisions of the ethics committee and with the Helsinki for a longer period of treatment with a controlled trial Declaration of 1975 as revised in 1983. The participants received no fnancial compensation or gifts. before defnitive conclusions can be made. Funding Supported by grants from Ministry of Agriculture, Food and Forestry (D.M.: Abbreviations 2017188 03/24/2011). A: asceticism; A: avoidance; Anger Host: anger/hostility; Anx: anxious; B: bulimia; BCM: body cell mass; BCMI: body cell mass index; BD: body dissatisfaction; BIC: body image concerns; BMI: body mass index; BUT: body uneasiness Publisher’s Note test; CFU: colony-forming unit; CG: control group; CSM: compulsive self- Springer Nature remains neutral with regard to jurisdictional claims in pub- monitoring; D: depersonalization; Dep: depression; DT: drive for thinness; DXA: lished maps and institutional afliations. dual X-ray absorptiometry; ECW: extracellular water; EDI-2: eating disorder inventory-2; GI: gastrointestinal; GSI: global severity index; I: inefectiveness; Received: 24 March 2017 Accepted: 1 June 2017 IA: interoceptive awareness; IC: body image; ICW: intracellular water; ID: interpersonal distrust; IG: intervention group; Interp Sens: interpersonal sensitivity; IR: impulse regulation; LBT: lactulose breath test; LPL: lipoprotein lipase; LPS: lipopolysaccharide; MF: maturity fears; NS: not signifcant; NWL: normal weight lean; NWO: normal weight obese; Obs: obsessive/compulsive; P: perfectionism; PA: phase angle; Paran: paranoia; PBF: body fat percentage; Phob: phobia; References POS: probiotic oral suspension; PreOB/OB: preobese–obese; PSDI: positive 1. Dethlefsen L, Eckburg PB, Bik EM, Relman DA. Assembly of the human symptom distress index; PST: positive symptom total; Psych: psychoticism; intestinal microbiota. Trends Ecol Evol. 2006;21:517–23. SCL90R: symptom checklist 90; SI: social insecurity; Som: somatization; TBBone: 2. Dinan TG, Stanton C, Cryan JF. Psychobiotics: a novel class of total body bone; TBFat: total body fat; TBLean: total body lean; TBW: total body psychotropic. Biol Psychiatry. 2013;74(10):720–6. doi:10.1016/j. water; WP: weight phobia. biopsych.2013.05.001. 3. Diaz Heijtz R, Wang S, Anuar F, Qian Y, Bjorkholm B, Samuelsson A, et al. Authors’ contributions Normal gut microbiota modulates brain development and behavior. Proc The authors’ responsibilities were as follows: ADL had primary responsibility for Natl Acad Sci USA. 2011;108(7):3047–52. the fnal content; SG, GM, GC, MM: performed the experiments, and collected 4. Neufeld KA, Kang N, Bienenstock J, Foster JA. Efects of intestinal micro- the data; PG, analyzed the data; LDR drafted the manuscript, and designed the biota on anxiety-like behavior. Commun Integr Biol. 2011;4(4):492–4. study. ADL, MC, GM, PG, GC, MM, DV, RD, LDR contributed to the interpretation 5. Cryan JF, Dinan TG. Mind-altering microorganisms: the impact of the data and revision of the manuscript. All authors read and approved the of the gut microbiota on brain and behaviour. Nat Rev Neurosci. fnal manuscript. 2012;13(10):701–12. 6. Liu YW, Su YW, Ong WK, Cheng TH, Tsai YC. Oral administration of Author details Lactobacillus plantarum K68 ameliorates DSS induced ulcerative colitis in 1 Section of Clinical Nutrition and Nutrigenomic, Department of Biomedi- BALB/c mice via the anti-infammatory and immunomodulatory activi- cine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy. ties. Int Immunopharmacol. 2011;11:2159–66. 2 Department of Experimental Medicine and Surgery, University of Rome “Tor 7. Moloney RD, Desbonnet L, Clarke G, Dinan TG, Cryan JF. The microbiome: Vergata”, Rome, Italy. 3 Emergency Department, “A. Gemelli” General Hospital stress, health and disease. Mamm Genome. 2014;25:49–74. Foundation, Catholic University of Sacred Heart, 00168 Rome, Italy. 4 PhD 8. Mangiola F, Ianiro G, Franceschi F, Fagiuoli S, Gasbarrini G, Gasbarrini A. School of Applied Medical‑Surgical Sciences, University of Rome “Tor Vergata”, Gut microbiota in autism and mood disorders. World J Gastroenterol. 00133 Rome, Italy. 5 USL 1 UmbriaCastiglione del Lago, 06061 Perugia, Italy. 2016;22:361–8. 6 Department of Surgical Sciences, University Hospital “Umberto I”, “Sapienza” 9. Liu YW, Liu WH, Wu CC, Juan YC, Wu YC, Tsai HP, Wang S, Tsai YC. Psycho- University of Rome, 00161 Rome, Italy. 7 Department of Experimental Medicine tropic efects of Lactobacillus plantarum PS128 in early life-stressed and and Surgery, University of Rome Tor Vergata, 00133 Rome, Italy. 8 Section naïve adult mice. Brain Res. 2016;1631:1–12. of Clinical Nutrition and Nutrigenomic, Department of Biomedicine and Pre- 10. Luo J, Wang T, Liang S, Hu X, Li W, Jin F. Ingestion of Lactobacillus strain vention, University of Rome Tor Vergata, Via Montpellier 1, 00136 Rome, Italy. reduces anxiety and improves cognitive function in the hyperammonemia rat. Sci China Life Sci. 2014;57(3):327–35. Acknowledgements 11. Ait-Belgnaoui A, Durand H, Cartier C, Chaumaz G, Eutamene H, Ferrier L, We are indebted to all the subjects who volunteered in the study. We also et al. Prevention of gut leakiness by a probiotic treatment leads to attenu- thank the entire medical team from the Section of Clinical Nutrition and ated HPA response to an acute psychological stress in rats. Psychoneu- Nutrigenomic, University of Rome Tor Vergata, Rome, Emergency Department, roendocrinology. 2012;37(11):1885–95. “A. Gemelli” General Hospital Foundation, Catholic University of Sacred Heart, 12. Bercik P, Park AJ, Sinclair D, Khoshdel A, Lu J, Huang X, et al. The and Nuova Annunziatella” Clinic for their technical assistance in conducting anxiolytic efect of Bifdobacterium longum NCC3001 involves vagal the clinical aspects of this study. This study was supported by grants from pathways for gut–brain communication. Neurogastroenterol Motil. Ministry of Agriculture, Food and Forestry (D.M.; 2017188). 2011;23(12):1132–9. 13. Bercik P, Verdu EF, Foster JA, Macri J, Potter M, Huang X, et al. Chronic Competing interests gastrointestinal infammation induces anxiety-like behavior and The authors declare that they have no competing interests. alters central nervous system biochemistry in mice. Gastroenterology. 2010;139(6):2102–2112.e1. Availability of data and materials 14. Akkasheh G, Kashani-Poor Z, Tajabadi-Ebrahimi M, Jafari P, Akbari H, The datasets used and/or analyzed during the current study are available from Taghizadeh M, et al. Clinical and metabolic response to probiotic the corresponding author on reasonable request. administration in patients with major depressive disorder: a randomized, double-blind, placebo-controlled trial. Nutrition. 2016;32(3):315–20. De Lorenzo et al. J Transl Med (2017) 15:135 Page 12 of 12

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