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Diets high in resistant starch increase plasma levels of trimethylamine-N-oxide, a gut microbiome metabolite associated with CVD risk

  • Nathalie Bergeron (a1) (a2), Paul T. Williams (a3), Regina Lamendella (a4), Nastaran Faghihnia (a1), Alyssa Grube (a4), Xinmin Li (a5), Zeneng Wang (a5), Rob Knight (a6) (a7), Janet K. Jansson (a8), Stanley L. Hazen (a5) and Ronald M. Krauss (a1)...

Production of trimethylamine-N-oxide (TMAO), a biomarker of CVD risk, is dependent on intestinal microbiota, but little is known of dietary conditions promoting changes in gut microbial communities. Resistant starches (RS) alter the human microbiota. We sought to determine whether diets varying in RS and carbohydrate (CHO) content affect plasma TMAO levels. We also assessed postprandial glucose and insulin responses and plasma lipid changes to diets high and low in RS. In a cross-over trial, fifty-two men and women consumed a 2-week baseline diet (41 percentage of energy (%E) CHO, 40 % fat, 19 % protein), followed by 2-week high- and low-RS diets separated by 2-week washouts. RS diets were assigned at random within the context of higher (51–53 %E) v. lower CHO (39–40 %E) intake. Measurements were obtained in the fasting state and, for glucose and insulin, during a meal test matching the composition of the assigned diet. With lower CHO intake, plasma TMAO, carnitine, betaine and γ-butyrobetaine concentrations were higher after the high- v. low-RS diet (P<0·01 each). These metabolites were not differentially affected by high v. low RS when CHO intake was high. Although the high-RS meal reduced postprandial insulin and glucose responses when CHO intake was low (P<0·01 each), RS did not affect fasting lipids, lipoproteins, glucose or insulin irrespective of dietary CHO content. In conclusion, a lower-CHO diet high in RS was associated with higher plasma TMAO levels. These findings, together with the absence of change in fasting lipids, suggest that short-term high-RS diets do not improve markers of cardiometabolic health.

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      Diets high in resistant starch increase plasma levels of trimethylamine-N-oxide, a gut microbiome metabolite associated with CVD risk
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Corresponding author
* Corresponding authors: N. Bergeron, email; R. M. Krauss, email
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1. Koeth, RA, Wang, Z, Levison, BS, et al. (2013) Intestinal microbiota metabolism of l-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med 19, 576585.
2. Wang, Z, Klipfell, E, Bennett, BJ, et al. (2011) Gut flora metabolism of phosphatidylcholine promotes cardiovascular disease. Nature 472, 5763.
3. Koeth, RA, Levison, BS, Culley, MK, et al. (2014) gamma-Butyrobetaine is a proatherogenic intermediate in gut microbial metabolism of l-carnitine to TMAO. Cell Metab 20, 799812.
4. Tang, WH, Wang, Z, Levison, BS, et al. (2013) Intestinal microbial metabolism of phosphatidylcholine and cardiovascular risk. N Engl J Med 368, 15751584.
5. Wang, Z, Tang, WH, Buffa, JA, et al. (2014) Prognostic value of choline and betaine depends on intestinal microbiota-generated metabolite trimethylamine-N-oxide. Eur Heart J 35, 904910.
6. Boutagy, NE, Neilson, AP, Osterberg, KL, et al. (2015) Probiotic supplementation and trimethylamine-N-oxide production following a high-fat diet. Obesity (Silver Spring) 23, 23572363.
7. Miller, CA, Corbin, KD, da Costa, KA, et al. (2014) Effect of egg ingestion on trimethylamine-N-oxide production in humans: a randomized, controlled, dose-response study. Am J Clin Nutr 100, 778786.
8. Rohrmann, S, Linseisen, J, Allenspach, M, et al. (2016) Plasma concentrations of trimethylamine-N-oxide are directly associated with dairy food consumption and low-grade inflammation in a German adult population. J Nutr 146, 283–289.
9. Birt, DF, Boylston, T, Hendrich, S, et al. (2013) Resistant starch: promise for improving human health. Adv Nutr 4, 587601.
10. Abell, GC, Cooke, CM, Bennett, CN, et al. (2008) Phylotypes related to Ruminococcus bromii are abundant in the large bowel of humans and increase in response to a diet high in resistant starch. FEMS Microbiol Ecol 66, 505515.
11. Martinez, I, Kim, J, Duffy, PR, et al. (2010) Resistant starches types 2 and 4 have differential effects on the composition of the fecal microbiota in human subjects. PLoS ONE 5, e15046.
12. Walker, AW, Ince, J, Duncan, SH, et al. (2011) Dominant and diet-responsive groups of bacteria within the human colonic microbiota. ISME J 5, 220230.
13. Wang, Z, Roberts, AB, Buffa, JA, et al. (2015) Non-lethal inhibition of gut microbial trimethylamine production for the treatment of atherosclerosis. Cell 163, 15851595.
14. Behall, KM, Scholfield, DJ & Canary, J (1988) Effect of starch structure on glucose and insulin responses in adults. Am J Clin Nutr 47, 428432.
15. Behall, KM & Howe, JC (1995) Effect of long-term consumption of amylose vs amylopectin starch on metabolic variables in human subjects. Am J Clin Nutr 61, 334340.
16. Behall, KM, Scholfield, DJ, Yuhaniak, I, et al. (1989) Diets containing high amylose vs amylopectin starch: effects on metabolic variables in human subjects. Am J Clin Nutr 49, 337344.
17. Raben, A, Tagliabue, A, Christensen, NJ, et al. (1994) Resistant starch: the effect on postprandial glycemia, hormonal response, and satiety. Am J Clin Nutr 60, 544551.
18. Sands, AL, Leidy, HJ, Hamaker, BR, et al. (2009) Consumption of the slow-digesting waxy maize starch leads to blunted plasma glucose and insulin response but does not influence energy expenditure or appetite in humans. Nutr Res 29, 383390.
19. Bravata, DM, Wells, CK, Concato, J, et al. (2004) Two measures of insulin sensitivity provided similar information in a U.S. population. J Clin Epidemiol 57, 12141217.
20. Chiu, S, Williams, PT, Dawson, T, et al. (2014) Diets high in protein or saturated fat do not affect insulin sensitivity or plasma concentrations of lipids and lipoproteins in overweight and obese adults. J Nutr 144, 17531759.
21. Demarquoy, J, Georges, B, Rigault, C, et al. (2004) Radioisotopic determination of l-carnitine content in foods commonly eaten in Western countries. Food Chem 86, 137142.
22. Behall, KM & Hallfrisch, J (2002) Plasma glucose and insulin reduction after consumption of breads varying in amylose content. Eur J Clin Nutr 56, 913920.
23. Ratnayake, WS & Jackson, DS (2009) Starch gelatinization. Adv Food Nutr Res 55, 221268.
24. Wang, Z, Levison, BS, Hazen, JE, et al. (2014) Measurement of trimethylamine-N-oxide by stable isotope dilution liquid chromatography tandem mass spectrometry. Anal Biochem 455, 3540.
25. Friedewald, WT, Levy, RI & Fredrickson, DS (1972) Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem 18, 499502.
26. Rifai, N & King, ME (1986) Immunoturbidimetric assays of apolipoproteins A, AI, AII, and B in serum. Clin Chem 32, 957961.
27. Smith, SJ, Cooper, GR, Henderson, LO, et al. (1987) An international collaborative study on standardization of apolipoproteins A-I and B. Part I. Evaluation of a lyophilized candidate reference and calibration material. Clin Chem 33, 22402249.
28. Caulfield, MP, Li, S, Lee, G, et al. (2008) Direct determination of lipoprotein particle sizes and concentrations by ion mobility analysis. Clin Chem 54, 13071316.
29. Caporaso, JG, Lauber, CL, Walters, WA, et al. (2012) Ultra-high-throughput microbial community analysis on the Illumina HiSeq and MiSeq platforms. ISME J 6, 16211624.
30. Caporaso, JG, Kuczynski, J, Stombaugh, J, et al. (2010) QIIME allows analysis of high-throughput community sequencing data. Nat Methods 7, 335336.
31. Bennett, BJ, de Aguiar Vallim, TQ, Wang, Z, et al. (2013) Trimethylamine-N-oxide, a metabolite associated with atherosclerosis, exhibits complex genetic and dietary regulation. Cell Metab 17, 4960.
32. Seldin, MM, Meng, Y, Qi, H, et al. (2016) Trimethylamine N-oxide promotes vascular inflammation through signaling of mitogen-activated protein kinase and nuclear factor-kappaB. J Am Heart Assoc 5, e002767.
33. Zhu, W, Gregory, JC, Org, E, et al. (2016) Gut microbial metabolite TMAO enhances platelet hyperactivity and thrombosis risk. Cell 165, 111–124.
34. Shih, DM, Wang, Z, Lee, R, et al. (2015) Flavin containing monooxygenase 3 exerts broad effects on glucose and lipid metabolism and atherosclerosis. J Lipid Res 56, 2237.
35. Miao, J, Ling, AV, Manthena, PV, et al. (2015) Flavin-containing monooxygenase 3 as a potential player in diabetes-associated atherosclerosis. Nat Commun 6, 6498.
36. Ze, X, Duncan, SH, Louis, P, et al. (2012) Ruminococcus bromii is a keystone species for the degradation of resistant starch in the human colon. ISME J 6, 15351543.
37. Macfarlane, GT & Englyst, HN (1986) Starch utilization by the human large intestinal microflora. J Appl Bacteriol 60, 195201.
38. Craciun, S & Balskus, EP (2012) Microbial conversion of choline to trimethylamine requires a glycyl radical enzyme. Proc Natl Acad Sci U S A 109, 2130721312.
39. Zhu, Y, Jameson, E, Crosatti, M, et al. (2014) Carnitine metabolism to trimethylamine by an unusual Rieske-type oxygenase from human microbiota. Proc Natl Acad Sci U S A 111, 42684273.
40. Romano, KA, Vivas, EI, Amador-Noguez, D, et al. (2015) Intestinal microbiota composition modulates choline bioavailability from diet and accumulation of the proatherogenic metabolite trimethylamine-N-oxide. MBio 6, e02481.
41. Singh, J, Dartois, A & Kaur, L (2010) Starch digestibility in food matrix: a review. Trends Food Sci Technol 21, 168180.
42. Robertson, MD, Bickerton, AS, Dennis, AL, et al. (2005) Insulin-sensitizing effects of dietary resistant starch and effects on skeletal muscle and adipose tissue metabolism. Am J Clin Nutr 82, 559567.
43. Maki, KC, Pelkman, CL, Finocchiaro, ET, et al. (2012) Resistant starch from high-amylose maize increases insulin sensitivity in overweight and obese men. J Nutr 142, 717723.
44. Heijnen, ML, van Amelsvoort, JM, Deurenberg, P, et al. (1996) Neither raw nor retrograded resistant starch lowers fasting serum cholesterol concentrations in healthy normolipidemic subjects. Am J Clin Nutr 64, 312318.
45. Jenkins, DJ, Vuksan, V, Kendall, CW, et al. (1998) Physiological effects of resistant starches on fecal bulk, short chain fatty acids, blood lipids and glycemic index. J Am Coll Nutr 17, 609616.
46. Noakes, M, Clifton, PM, Nestel, PJ, et al. (1996) Effect of high-amylose starch and oat bran on metabolic variables and bowel function in subjects with hypertriglyceridemia. Am J Clin Nutr 64, 944951.
47. Krauss, RM, Blanche, PJ, Rawlings, RS, et al. (2006) Separate effects of reduced carbohydrate intake and weight loss on atherogenic dyslipidemia. Am J Clin Nutr 83, 10251031; quiz 1205.
48. Dreon, DM, Fernstrom, HA, Miller, B, et al. (1994) Low-density lipoprotein subclass patterns and lipoprotein response to a reduced-fat diet in men. FASEB J 8, 121126.
49. Dreon, DM, Fernstrom, HA, Williams, PT, et al. (1997) LDL subclass patterns and lipoprotein response to a low-fat, high-carbohydrate diet in women. Arterioscler Thromb Vasc Biol 17, 707714.
50. Dreon, DM, Fernstrom, HA, Williams, PT, et al. (1999) A very low-fat diet is not associated with improved lipoprotein profiles in men with a predominance of large, low-density lipoproteins. Am J Clin Nutr 69, 411418.
51. LeCheminant, JD, Smith, BK, Westman, EC, et al. (2010) Comparison of a reduced carbohydrate and reduced fat diet for LDL, HDL, and VLDL subclasses during 9-months of weight maintenance subsequent to weight loss. Lipids Health Dis 9, 54.
52. Sacks, FM, Carey, VJ, Anderson, CA, et al. (2014) Effects of high vs low glycemic index of dietary carbohydrate on cardiovascular disease risk factors and insulin sensitivity: the OmniCarb randomized clinical trial. JAMA 312, 25312541.
53. Heijnen, ML, van den Berg, GJ & Beynen, AC (1996) Dietary raw versus retrograded resistant starch enhances apparent but not true magnesium absorption in rats. J Nutr 126, 22532259.
54. Park, OJ, Kang, NE, Chang, MJ, et al. (2004) Resistant starch supplementation influences blood lipid concentrations and glucose control in overweight subjects. J Nutr Sci Vitaminol (Tokyo) 50, 9399.
55. Wang, S & Copeland, L (2013) Molecular disassembly of starch granules during gelatinization and its effect on starch digestibility: a review. Food Funct 4, 15641580.
56. Yadav, BS, Sharma, A & Yadav, RB (2009) Studies on effect of multiple heating/cooling cycles on the resistant starch formation in cereals, legumes and tubers. Int J Food Sci Nutr 60, Suppl. 4, 258272.
57. Englyst, H, Wiggins, HS & Cummings, JH (1982) Determination of the non-starch polysaccharides in plant foods by gas-liquid chromatography of constituent sugars as alditol acetates. Analyst 107, 307318.
58. Wu, Y, Qian, Y, Pan, Y, et al. (2015) Association between dietary fiber intake and risk of coronary heart disease: a meta-analysis. Clin Nutr 34, 603611.
59. Solanky, KS, Bailey, NJ, Beckwith-Hall, BM, et al. (2005) Biofluid 1H NMR-based metabonomic techniques in nutrition research – metabolic effects of dietary isoflavones in humans. J Nutr Biochem 16, 236244.
60. Barton, S, Navarro, SL, Buas, MF, et al. (2015) Targeted plasma metabolome response to variations in dietary glycemic load in a randomized, controlled, crossover feeding trial in healthy adults. Food Funct 6, 29492956.
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