Chapter 29
Relationship Between Gut Microbiota,
Energy Metabolism, and Obesity
G.J. Bakker* and M. Nieuwdorp**,†,‡
*Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands; **Department of Vascular Medicine,
Academic Medical Center, Amsterdam, The Netherlands; †Department of Internal Medicine, VUmc Diabetes Center, Free University Medical Center,
Amsterdam, The Netherlands; ‡Wallenberg Laboratory, University of Gothenberg, Gothenberg, Sweden
INTRODUCTION
The prevalence of overweight [body mass index (BMI) ≥
25 kg/m2] and obesity (BMI ≥ 30 kg/m2) has been steadily
increasing over the past decades. In 2014, more than 1.9
billion adults worldwide were overweight, of whom over
600 million were obese. Although overweight and obesity
are most prevalent in high-income countries, the rate of
increase has been highest in low- and middle-income coun-
tries, causing experts to term obesity a global epidemic.
As obesity is a major risk factor for a plethora of non-
communicable diseases, including coronary heart disease,
hypertension, stroke, diabetes, and certain types of cancer,
the World Health Organization (WHO) has aimed to halt
the rise of obesity, focusing especially on childhood obesity.
Underlying the development of obesity are genetic fac-
tors and environmental factors, including an increased in-
take of high-fat diets and a sedentary lifestyle. Recently,
there has been increased interest for the role of the gut mi-
crobiota in the development of obesity and its associated
complications.
The intestinal microbiota is a complex organ, consisting
of 1014 bacteria distributed across the entire gut, with the
density lowest in the acidic environment of the proximal in-
testine [approximately 104 colony forming units (CFU)/mL]
and highest in the distal intestine (approximately 1012 CFU/
mL). It has several important functions, including diges-
tion of otherwise indigestible food substrates, production of
hormones, protection against invasive bacterial strains, and
training of the immune system, and these functions differ
based on intestinal segment. In this chapter we will focus on
the mechanisms by which the gut microbiota may influence
energy metabolism. Further research into this area may
contribute to the development of novel therapeutic targets
aimed at preventing obesity and its consequences.
The Microbiota in Gastrointestinal Pathophysiology
Copyright © 2017 Elsevier Inc. All rights reserved.
THE GUT MICROBIOTA EXTRACTS ENERGY
FROM THE DIET
Humans and their gut microbes have evolved to live in a
symbiotic relationship. While our intestines provide a warm,
anaerobic environment with a steady flow of nutrients, the
trillions of microbes living in our gut play a significant role
in digestion and absorption of nutrients. These bacteria help
us to metabolize otherwise indigestible food components
including fibers into energy-rich substrates, such as short-
chain fatty acids (SCFAs) of which butyrate, propionate,
and acetate are the most abundant, and that can be utilized
by the host. Moreover, the gut microbiota promotes absorp-
tion of monosaccharides (Fig. 29.1).
The role of extraction of energy from the food was shown
by early experiments using germ-free mice. These animals
are born and raised in a sterile environment, and thus have
no gut microbiota. Transplanting the gut microbiota from
conventionally raised mice into germ-free recipients result-
ed in an increase in body fat and insulin resistance without
an increase in food consumption [1].
Thus, it was concluded that the gut microbiota helps to
extract energy from food and may be involved in the devel-
opment of obesity. These first experiments led to the gut
microbiota as a whole new field of research. Metagenomic
and biochemical analyses in large cohorts have now estab-
lished a correlation between the obese phenotype and the
composition of the gut microbiota in humans. Specifically,
decreases in the Bacteroidetes phylum and increases in the
Firmicutes and Proteobacteria phyla are associated with
obesity [2]. Moreover, bacterial composition contributes to
variations in lipid metabolism [3].
Further research focuses on interventions aimed at ma-
nipulating the gut microbiota. For example, both mice fed
a high-fed diet and genetically obese ob/ob mice that were
255
256 PART | D Basic Physiologic Effects of Microbiota
FIGURE 29.1  The main ways in which the gut microbiota influences
metabolism.
treated with antibiotics for 4 weeks were partially protected
against the development of metabolic diseases [4].
Fecal microbiota transplant (FMT) in mice showed that
obesity can be transmitted, indicating a causal relationship
between the gut microbiota and development of obesity. FMT
studies may also be used as a way of finding new correlations.
For example, in a randomized controlled trial, allogenic FMT
from lean donors increased insulin sensitivity in metabolic
syndrome patients in comparison to autologous FMT [5].
The allogenic group had several species-level differences
in gut microbiota composition, providing novel correlations
between microbiota composition and insulin sensitivity. If
specific strains can be correlated to clinical parameters, this
could result in novel therapeutic targets. Thus, beneficial bac-
teria may be given to patients as a dietary supplement (i.e.,
probiotics). On the other hand, targeting specific harmful
bacteria, for example, by using vaccination could be an excit-
ing new strategy to treat or even prevent metabolic disease.
REGULATION OF FAT STORAGE
THROUGH PRODUCTION OF
SHORT-CHAIN FATTY ACIDS
Apart from direct energy harvesting from the diet, the gut
microbiota is involved in energy expenditure via a number
of different mechanisms, most importantly via the produc-
tion of SCFAs. Complex carbohydrates or fibers, such as
cellulose, resistant starch, and inulin, cannot be degraded by
human enzymes. Instead, they are metabolized by intestinal
bacteria into absorbable SCFAs, mainly butyrate (±15%),
propionate (±25%), and acetate (±60%) in a process called
fermentation. These SCFA not only serve as energy sub-
strates for microbes and host tissues, but also serve as signal-
ing molecules to have a profound effect on host metabolism.
Butyrate is the primary energy substrate for colonic epi-
thelium. Moreover, it has a trophic effect on the mucosa and
stimulates intestinal mucus production, leading to improved
gut barrier function. Apart from these direct effects on the
colon, it has several beneficial metabolic effects, including
increased insulin sensitivity and reduced adipose tissue in-
flammation. Differences in butyrate production are thought
to play a role in metabolic regulation. For example, lower
fecal concentrations of the butyrate-producing Roseburia
and Faecalibacterium prausnitzii was highly discriminant
of prevalent type 2 diabetes [6,7]. Moreover, the improve-
ment in insulin sensitivity seen in metabolic syndrome pa-
tients after lean donor FMT was coupled with increases in
butyrate-producing Roseburia and Eubacterium hallii [5].
The beneficial properties of butyrate have led to several
studies involving oral administration of either sodiumbutyr-
ate or probiotics containing bacteria that are known to pro-
duce butyrate, with promising results in animal studies [8].
Trials in humans are still ongoing at this moment.
The other SCFAs also have several effects on metabo-
lism. For example, propionate and acetate are important
substrates for gluconeogenesis and lipogenesis, respec-
tively. Propionate improves insulin sensitivity and inhibits
hepatic gluconeogenesis from lactate [9].
The SCFAs also control colonic gene expression by in-
hibiting histone deacetylases (HDAC). Moreover, SCFAs
bind to the G-protein coupled receptors GPR41 and GPR43
(also known as FFAR3 and FFAR 2, respectively), which
results in increased expression of peptide YY (PYY), an en-
teroendocrine hormone that inhibits gut motility, increases
intestinal transit time, and decreases appetite [10]. Binding
to these G-protein coupled receptors also induces GLP-1
secretion, another enteroendocrine hormone that improves
insulin sensitivity and decreases appetite. Interestingly,
supplementation with prebiotics blunted the overexpression
of GPR43 in high-fat fed mice, resulting in lower fat mass
[11]. Thus, the production of SCFAs by the gut microbiota
is an important source of energy from the diet as well as an
important mediator in gut motility, appetite, and the regula-
tion of fat storage.
BACTERIAL TRANSLOCATION
CONTRIBUTES TO OBESITY AND
ASSOCIATED DISORDERS THROUGH
LOW-GRADE INFLAMMATION
Obesity and type 2 diabetes mellitus (T2DM), a condi-
tion strongly associated with obesity, are characterized by
chronic low-grade systemic inflammation. Especially vis-
ceral adipose tissue inflammation is strongly associated
with insulin resistance. Although the triggering factor for
the inflammatory response is still unknown, it is now gen-
erally accepted that translocation of intestinal bacteria into
 Relationship Between Gut Microbiota, Energy Metabolism, and Obesity Chapter | 29
blood and visceral adipose tissue is an important underlying
mechanism in the development of obesity and T2DM.
Translocation of intestinal bacteria encompasses a broad
spectrum of mechanisms. Thus, whole bacteria or their me-
tabolites may cross the intestinal barrier and enter the blood
stream. For example, bacterial lipopolysaccharide (LPS), a
component of the cell wall of Gram-negative bacteria, is a
strong inducer of the innate immune system cascade that
drives an inflammatory response; LPS binding protein can
be readily measured in plasma as marker of translocation
and has been associated with development of metabolic
syndrome and type 2 diabetes [12].
Another way of measuring translocation of inflammation-
inducing bacteria is direct measurement of LPS. Indeed, sev-
eral studies showed plasma LPS, also called endotoxin, to be
associated with insulin resistance. Moreover, chronic infusion
with LPS causes inflammation and insulin resistance in mice
[13]. Interestingly, both LPS and bacterial DNA have been
shown in visceral adipose tissue of obese mice [14], suggest-
ing that bacterial translocation might occur in specific organs
where (dead) bacteria drive a local inflammatory response.
The ability of the gut wall to prevent bacterial transloca-
tion is termed gut barrier function. Increased intestinal per-
meability resulting from a decrease in gut barrier function
can be measured in a variety of ways. For example, patholog-
ic examination of intestinal mucosa may reveal a decrease in
tight junction proteins. Moreover, an Ussing chamber may
be used to quantify the passage of ions, nutrients, or drugs
across intestinal epithelium. However, routinely sampling
multiple mucosal biopsies may be too invasive to be used on
large scale in mechanistic clinical trials. Another functional
way of testing intestinal permeability in vivo is oral inges-
tion of oligosaccharides of different sized, such as mannitol
and saccharose followed by determination of urinary excre-
tion. The ratio of urinary excretion of these saccharides re-
flects permeability of the intestinal wall. Unfortunately, the
clinical significance and reproducibility of measuring intes-
tinal permeability with these small molecules is currently
unknown. Although mono- or disaccharides may readily
pass the mucosa under some circumstances, it is unknown
to what extend this also applies to bacteria or LPS. Alterna-
tively, direct measurement of bacterial DNA may be used
to measure bacterial translocation. Importantly, bacterial
DNA isolated from blood or visceral adipose tissue can be
sequenced to determine which specific bacterial strains are
involved in translocation. Although not yet widely adopted,
this approach may lead to novel therapeutic targets for obe-
sity and T2DM including vaccination and phage therapy.
Although bacterial translocation is a well established
and often described concept, interestingly it is largely un-
known where translocated bacteria cross the intestinal wall.
One possibility is the colon, where the concentration of
bacteria is up to 100 times higher than in the small intes-
tine. However, the colon is relatively metabolically inactive.
257
Conversely, in the duodenum a plethora of metabolic ac-
tivities are regulated. Moreover, the absorption of food par-
ticles in the small intestine may present an opportunity for
pathogens to cross the intestinal wall.
Dietary intake is an important determinant of gut micro-
biota composition. After consuming a diet high in fat and
low in fibers, large shifts in gut microbiota composition can
be seen within 24 h [15]. While excessive fat intake is a
clear risk factor for a variety of inflammatory diseases, in-
cluding obesity and T2DM, the exact mechanisms linking
diet-induced changes in gut microbiota composition to in-
creased bacterial translocation and inflammation are largely
unknown. However, ingestion of a high-fat meal leads to
a systemic inflammatory response. Considering that LPS
has a high affinity for chylomicrons, derived from dietary
fatty acids and transported through the intestinal wall, it is
hypothesized that bacterial translocation can be induced by
uptake of dietary lipids. This hypothesis is supported by in
vivo and in vitro studies that showed that chylomicron for-
mation promotes intestinal LPS absorption and that plasma
LPS levels correlate to postprandial triglycerides changes.
In conclusion, bacterial translocation could represent
a very interesting direction for future therapies, especially
if specific bacterial strains are found to be more prone to
translocation. For example, targeted vaccination against
those strains, replenishing gut microbiota balance by pro- or
prebiotics, or targeting molecular pathways may be devel-
oped in the coming years. However, at this point the cau-
sality of specific intestinal microbial strains in obesity and
T2DM is not yet proven.
THE ANGPTL4 AND AMPK PATHWAYS
ARE INVOLVED IN FAT STORAGE
IN GERM-FREE MICE
Angiopoietin-like factor IV (ANGPTL4), previously known
as fasting-induced adipose factor, is a circulating enzyme
produced by the intestine, liver, and adipose tissue that inhib-
its lipoprotein lipase (LPL) activity. Colonizing germ-free
mice with a gut microbiota of conventionally raised mice
(also known as “conventionalization”) does not only lead to
an increase in fat mass, but also results in a decrease in in-
testinal expression of ANGPTL4, resulting in increased LPL
activity in adipose tissue. Thus, inhibition of ANGPTL4 has
been proposed as another mechanism by which the gut mi-
crobiota may stimulate accumulation of adipose tissue.
The ANGPTL4 hypothesis has been supported by sev-
eral experiments. For example, Lactobacillus paracasei in-
duced an upregulation of ANGPTL4 in colonic epithelial
cells, while oral inoculation of germ-free mice with this
bacterium resulted in increased circulating levels of ANG-
PTL4. Moreover, germ-free ANGPTL4-knockout was able
to contain the same amount of total body fat as convention-
alized mice [1].
258 PART | D Basic Physiologic Effects of Microbiota
Another pathway that has been proposed to play a role
in fat storage involves phosphorylated AMP-activated pro-
tein kinase (AMPK), an enzyme that stimulates fatty acid
oxidation. Germ-free mice that are resistant to diet-induced
obesity have increased skeletal muscle and hepatic AMPK.
Moreover, they have increased expression of the downstream
targets of AMPK that are involved in fatty acid oxidation.
Despite these interesting early findings, similar experi-
ments investigating these pathways have not reproduced
consistent results [16]. Moreover, most of these experi-
ments were done in germ-free mice. Thus, while the ANG-
PTL4 and AMPK theories are supported by some evidence,
it is unclear to what extend the findings apply to physiologi-
cal circumstances in humans.
THE GUT MICROBIOTA PRESENTS
AN IMPORTANT HOPE FOR FUTURE
TREATMENT OPTIONS IN OBESITY
In summary, the gut microbiota plays an important role in
energy homeostasis through several mechanisms, most im-
portantly energy extraction from the diet and regulation of fat
storage through SCFAs. Moreover, accumulating evidence
strongly suggests bacterial translocation and systemic inflam-
mation to be associated with obesity and insulin resistance.
Nevertheless, it should be emphasized that there are still
many unknown gaps. Importantly, while many differences
in gut microbiota composition between obese and lean hu-
mans have been characterized, it is unclear to what extend
these differences have a causal origin. Moreover, the impact
of different interventions on the gut microbiota is unclear in
many cases. Much research has been performed in animals,
and the relevance to human metabolism has to be further
explored in human trials.
Although the gut microbiota is certainly not the only
factor in weight gain and the development of metabolic
disease, it represents an important novel therapeutic target.
Manipulation of the gut microbiota through various inter-
ventions, such as probiotics, prebiotics, or fecal transplanta-
tion may yield novel insights into the link between the gut
microbiota and disease (Fig. 29.2).
FIGURE 29.2  Interventions aimed at the gut microbiota that may be
investigated in future research.
Moreover, with more and more research investigating
the role of intestinal microbes in the onset of disease, future
treatments could be directed at specific bacterial strains.
Thus, further exploring the exciting avenues that were in-
vestigated in the past years could help fight the growing
population of obese patients.
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