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Horvath A, Zukauskaite K, Hazia O, Balazs I, Stadlbauer V. Human gut microbiome: Therapeutic opportunities for metabolic syndrome-Hype or hope? Endocrinol Diabetes Metab 2024; 7:e436. [PMID: 37771199 PMCID: PMC10781898 DOI: 10.1002/edm2.436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 06/01/2023] [Accepted: 06/11/2023] [Indexed: 09/30/2023] Open
Abstract
Shifts in gut microbiome composition and metabolic disorders are associated with one another. Clinical studies and experimental data suggest a causal relationship, making the gut microbiome an attractive therapeutic goal. Diet, intake of probiotics or prebiotics and faecal microbiome transplantation (FMT) are methods to alter a person's microbiome composition. Although FMT may allow establishing a proof of concept to use microbiome modulation to treat metabolic disorders, studies show mixed results regarding the effects on metabolic parameters as well as on the composition of the microbiome. This review summarizes the current knowledge on diet, probiotics, prebiotics and FMT to treat metabolic diseases, focusing on studies that also report alterations in microbiome composition. Furthermore, clinical trial results on the effects of common drugs used to treat metabolic diseases are synopsized to highlight the bidirectional relationship between the microbiome and metabolic diseases. In conclusion, there is clear evidence that microbiome modulation has the potential to influence metabolic diseases; however, it is not possible to distinguish which intervention is the most successful. In addition, a clear commitment from all stakeholders is necessary to move forward in the direction of developing targeted interventions for microbiome modulation.
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Affiliation(s)
- Angela Horvath
- Medical University of GrazGrazAustria
- Center for Biomarker Research in Medicine (CBmed)GrazAustria
| | - Kristina Zukauskaite
- Medical University of GrazGrazAustria
- Life Sciences CentreVilnius UniversityVilniusLithuania
| | - Olha Hazia
- Medical University of GrazGrazAustria
- Center for Biomarker Research in Medicine (CBmed)GrazAustria
| | - Irina Balazs
- Medical University of GrazGrazAustria
- Center for Biomarker Research in Medicine (CBmed)GrazAustria
| | - Vanessa Stadlbauer
- Medical University of GrazGrazAustria
- Center for Biomarker Research in Medicine (CBmed)GrazAustria
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Zhang H, Lai J, Zhang L, Zhang W, Liu X, Gong Q, Tian H, Yang M, Yang T, Zhao R, Li D, Huang H, Zhao Y, Yan S, Yu M, Xiyang Y, Shi L, Yang L, Wang L, Chen W, Cao X. The co-regulation of the gut microbiome and host genes might play essential roles in metformin gastrointestinal intolerance. Toxicol Appl Pharmacol 2023; 481:116732. [PMID: 37871735 DOI: 10.1016/j.taap.2023.116732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/14/2023] [Accepted: 10/18/2023] [Indexed: 10/25/2023]
Abstract
Metformin is commonly used, but approximately 20% of patients experience gastrointestinal intolerance, leading to medication discontinuation for unclear reasons and a lack of effective management strategies. In this study, the 18 fecal and blood samples were analyzed using 16S rRNA and mRNA transcriptome, respectively. These samples included 3 fecal and 4 blood from metformin-tolerant T2D patients before and after metformin treatment (T and Ta), 3 fecal and 5 blood from metformin-intolerant T2D patients before and after treatment (TS and TSa), and 6 fecal samples from healthy controls. The results showed that certain anti-inflammatory gut bacteria and gene, such as Barnesiella (p = 0.046), Parabacteroides goldsteinii (p = 0.016), and the gene JUND (p = 0.0002), exhibited higher levels in metformin-intolerant patients, and which decreased after metformin treatment (p < 0.05). This potentially invalidates patients' anti-inflammatory effect and intestinal mucus barrier protection, which may lead to alterations in intestinal permeability, decreased gut barrier function, and gastrointestinal symptoms, including diarrhea, bloating, and nausea. After metformin treatment, primary bile acids (PBAs) production species: Weissella confusa, Weissella paramesenteroides, Lactobacillus brevis, and Lactobacillus plantarum increased (p < 0.05). The species converting PBAs to secondary bile acids (SBAs): Parabacteroides distasonis decreased (p < 0.05). This might result in accumulation of PBAs, which also may lead to anti-inflammatory gene JUND and SQSTM1 downregulated. In conclusion, this study suggests that metformin intolerance may be attributed to a decrease in anti-inflammatory-related flora and genes, and also alterations in PBAs accumulation-related flora. These findings open up possibilities for future research targeting gut flora and host genes to prevent metformin intolerance.
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Affiliation(s)
- Huixiang Zhang
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, Yunnan, China; Department of Laboratory Animal Science, Kunming Medical University, Kunming, Yunnan, China
| | - Jiao Lai
- Department of Endocrinology, Qujing NO.1 Hospital of Yunnan Province, Qujing, Yunnan, China
| | - Lihuan Zhang
- Department of Laboratory Animal Science, Kunming Medical University, Kunming, Yunnan, China
| | - Wei Zhang
- Department of Endocrinology, Qujing NO.1 Hospital of Yunnan Province, Qujing, Yunnan, China
| | - Xun Liu
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, Yunnan, China
| | - Qilin Gong
- Department of Endocrinology, Qujing NO.1 Hospital of Yunnan Province, Qujing, Yunnan, China
| | - Hongxi Tian
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, Yunnan, China
| | - Mingzhi Yang
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, Yunnan, China
| | - Tao Yang
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, Yunnan, China
| | - Rui Zhao
- Department of Endocrinology, Qujing NO.1 Hospital of Yunnan Province, Qujing, Yunnan, China
| | - Dongqing Li
- Department of Endocrinology, Qujing NO.1 Hospital of Yunnan Province, Qujing, Yunnan, China
| | - Hehua Huang
- Department of Endocrinology, Qujing NO.1 Hospital of Yunnan Province, Qujing, Yunnan, China
| | - Ya Zhao
- Department of Endocrinology, Qujing NO.1 Hospital of Yunnan Province, Qujing, Yunnan, China
| | - Shan Yan
- Yunnan Key Laboratory of Stem Cell and Regenerative Medicine, Bioengineering Centre, Kunming Medical University, Kunming, Yunnan, China
| | - Ming Yu
- Yunnan Key Laboratory of Stem Cell and Regenerative Medicine, Bioengineering Centre, Kunming Medical University, Kunming, Yunnan, China
| | - Yanbin Xiyang
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, Yunnan, China
| | - Lanlan Shi
- Department of Anatomy, Histology and Embryology, Basic Medical College, Kunming Medical University, Kunming, Yunnan, China
| | - Lirong Yang
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, Yunnan, China; No.1 School of Clinical Medicine, Kunming Medical University, Kunming, Yunnan, China
| | - Limei Wang
- Department of Laboratory Animal Science, Kunming Medical University, Kunming, Yunnan, China.
| | - Weiwen Chen
- Qujing Second People's Hospital of Yunnan Province, Qujing, Yunnan, China.
| | - Xue Cao
- Department of Laboratory Animal Science, Kunming Medical University, Kunming, Yunnan, China; State Key Laboratory for Conservation and Utilization of Bio-Resources in Yunnan, Yunnan University, Kunming, Yunnan, China.
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Foretz M, Guigas B, Viollet B. Metformin: update on mechanisms of action and repurposing potential. Nat Rev Endocrinol 2023:10.1038/s41574-023-00833-4. [PMID: 37130947 PMCID: PMC10153049 DOI: 10.1038/s41574-023-00833-4] [Citation(s) in RCA: 68] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 05/04/2023]
Abstract
Currently, metformin is the first-line medication to treat type 2 diabetes mellitus (T2DM) in most guidelines and is used daily by >200 million patients. Surprisingly, the mechanisms underlying its therapeutic action are complex and are still not fully understood. Early evidence highlighted the liver as the major organ involved in the effect of metformin on reducing blood levels of glucose. However, increasing evidence points towards other sites of action that might also have an important role, including the gastrointestinal tract, the gut microbial communities and the tissue-resident immune cells. At the molecular level, it seems that the mechanisms of action vary depending on the dose of metformin used and duration of treatment. Initial studies have shown that metformin targets hepatic mitochondria; however, the identification of a novel target at low concentrations of metformin at the lysosome surface might reveal a new mechanism of action. Based on the efficacy and safety records in T2DM, attention has been given to the repurposing of metformin as part of adjunct therapy for the treatment of cancer, age-related diseases, inflammatory diseases and COVID-19. In this Review, we highlight the latest advances in our understanding of the mechanisms of action of metformin and discuss potential emerging novel therapeutic uses.
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Affiliation(s)
- Marc Foretz
- Université Paris Cité, CNRS, Inserm, Institut Cochin, Paris, France
| | - Bruno Guigas
- Department of Parasitology, Leiden University Medical Center, Leiden, Netherlands
| | - Benoit Viollet
- Université Paris Cité, CNRS, Inserm, Institut Cochin, Paris, France.
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Therapeutic potential of vitamin B 1 derivative benfotiamine from diabetes to COVID-19. Future Med Chem 2022; 14:809-826. [PMID: 35535731 DOI: 10.4155/fmc-2022-0040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Benfotiamine (S-benzoylthiamine-O-monophosphate), a unique, lipid-soluble derivative of thiamine, is the most potent allithiamine found in roasted garlic, as well as in other herbs of the genus Allium. In addition to potent antioxidative properties, benfotiamine has also been shown to be a strong anti-inflammatory agent with therapeutic significance to several pathological complications. Specifically, over the past decade or so, benfotiamine has been shown to prevent not only various secondary diabetic complications but also several inflammatory complications such as uveitis and endotoxemia. Recent studies also demonstrate that this compound could be used to prevent the symptoms associated with various infectious diseases such as HIV and COVID-19. In this review article, the authors discuss the significance of benfotiamine in the prevention of various pathological complications.
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Zhang SS, Zhang NN, Guo S, Liu SJ, Hou YF, Li S, Ho CT, Bai NS. Glycosides and flavonoids from the extract of Pueraria thomsonii Benth leaf alleviate type 2 diabetes in high-fat diet plus streptozotocin-induced mice by modulating the gut microbiota. Food Funct 2022; 13:3931-3945. [PMID: 35289350 DOI: 10.1039/d1fo04170c] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Twenty glycoside derivatives and nine flavonoids from the leaves of Pueraria (P. thomsonii) were isolated by column chromatography and characterized by nuclear magnetic resonance spectroscopy (NMR) and high performance liquid chromatography (HPLC). The contents of twenty glycosides and nine flavonoids from the extract of P. thomsonii leaf (PL) were 173.3 mg g-1 and 134.7 mg g-1, respectively. Two flavonoids with the highest content were robinin (49.28 mg g-1) and puerarin (42.87 mg g-1). Six flavonoids, i.e. puerarin, robinin, rutin, quercetin, quercitrin, and kaempferol showed more inhibitory effects against α-glucosidase than acarbose. PL could effectively increase the level of insulin, decrease the content of fasting blood glucose, reduce lipid accumulation in plasma, ameliorate oxidative injury and inflammation, and relieve liver and kidney damage in diabetic mice. Moreover, PL could increase intestinal probiotics to improve metabolic disorders caused by diabetes and decrease the level of Clostridium celatum to relieve inflammation. This study suggested that PL or its glycoside derivatives and flavonoids regulating glycolipid metabolism and inflammation levels might have the potential to be used to control type 2 diabetes.
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Affiliation(s)
- Shan-Shan Zhang
- College of Chemical Engineering, Department of Pharmaceutical Engineering, Northwest University, 229 Taibai North Road, Shaanxi 710069, China.,College of Food Science and Technology, Northwest University, 229 Taibai North Road, Shaanxi 710069, China.
| | - Niu-Niu Zhang
- College of Food Science and Technology, Northwest University, 229 Taibai North Road, Shaanxi 710069, China.
| | - Sen Guo
- College of Food Science and Technology, Northwest University, 229 Taibai North Road, Shaanxi 710069, China.
| | - Shao-Jing Liu
- College of Chemical Engineering, Department of Pharmaceutical Engineering, Northwest University, 229 Taibai North Road, Shaanxi 710069, China.,College of Pharmacy, Xi'an Medical University, 1 Xinwang Road, Shaanxi 710021, China
| | - Yu-Fei Hou
- College of Food Science and Technology, Northwest University, 229 Taibai North Road, Shaanxi 710069, China.
| | - Shiming Li
- College of Life Sciences, Huanggang Normal University, Hubei 438000, China
| | - Chi-Tang Ho
- Department of Food Science, Rutgers University, 65 Dudley Road, New Brunswick, New Jersey 08901, USA.
| | - Nai-Sheng Bai
- College of Food Science and Technology, Northwest University, 229 Taibai North Road, Shaanxi 710069, China.
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Xiang K, Zhang JJ, Xu YY, Zhong X, Ni J, Pan HF. Genetically Predicted Causality of 28 Gut Microbiome Families and Type 2 Diabetes Mellitus Risk. Front Endocrinol (Lausanne) 2022; 13:780133. [PMID: 35185792 PMCID: PMC8851667 DOI: 10.3389/fendo.2022.780133] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/04/2022] [Indexed: 12/12/2022] Open
Abstract
Mounting evidence indicates that gut microbiome may be involved in the pathogenesis of type 2 diabetes mellitus (T2DM). However, there is no consensus on whether there is a causal link between gut microbiome and T2DM risk. In the present study, the Mendelian randomization (MR) analysis was performed to investigate whether gut microbiome was causally linked to T2DM risk. The single nucleotide polymorphisms (SNPs) that were significantly related to exposure from published available genome-wide association study (GWAS) were selected as instrumental variables (IVs). The robust methods including inverse variance weighting (IVW), MR Egger, and weighted median were conducted to infer the causal links. Mendelian randomization pleiotropy residual sum and outlier (MR-PRESSO) and MR-Egger regression were used to test whether there was horizontal pleiotropy and identify outlier SNPs. The estimates of IVW suggested that Streptococcaceae (odds ratio (OR) = 1.17, 95% confidence interval (CI), 1.04-1.31, p = 0.009) was associated with higher risk of T2DM in European population. In Asian population, the MR IVW estimates revealed that there was a causal link between Acidaminococcaceae and T2DM risk (OR = 1.17, 95% CI, 1.04-1.31, p = 0.008). There was no evidence of notable heterogeneity and horizontal pleiotropy. However, after false discovery rate (FDR) correction, the causal link between gut microbiome and T2DM was absent (FDR, p > 0.05). In summary, using genetic instruments, this study does not find evidence of association between the 28 gut microbiome families and T2DM risk. However, Streptococcaceae and Acidaminococcaceae may have a borderline positive correlation with T2DM risk.
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Affiliation(s)
- Kun Xiang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China
| | - Jing-Jing Zhang
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei, China
| | - Yuan-Yuan Xu
- Department of Outpatient Wound Care Center, 901 Hospital of Joint Logistics Support Force of People Liberation Army, Hefei, China
| | - Xing Zhong
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jing Ni
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China
- *Correspondence: Hai-Feng Pan, ; Jing Ni,
| | - Hai-Feng Pan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China
- *Correspondence: Hai-Feng Pan, ; Jing Ni,
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Zhao Q, Shi J, Chen S, Hao D, Wan S, Niu H, Zhang Y. Salidroside Affects Gut Microbiota Structure in db/db Mice by Affecting Insulin, Blood Glucose and Body Weight. Diabetes Metab Syndr Obes 2022; 15:2619-2631. [PMID: 36060789 PMCID: PMC9438798 DOI: 10.2147/dmso.s372192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/05/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The purpose of this study was to investigate the regulatory effect of salidroside on the intestinal flora of mice with type 2 diabetes (T2DM) and its protective effect in the body. PATIENTS AND METHODS We acclimated 8-week-old mice for 7 days, divided them into 4 groups, and continued dosing for 8 weeks. We recorded weekly blood glucose levels and body weight for each mouse. After the completion of the feeding cycle, the 16S rRNA of the intestinal flora in the mice was sequenced, and the insulin and C-peptide levels in each group of mice were measured. Four samples were taken from each group for liver and kidney section staining. RESULTS Our results showed that gut microbiota diversity and function were significantly different between the diabetic mice and healthy mice and that insulin levels, body weight, and blood glucose levels could significantly influence gut microbiota changes at the genus level. The gut microbiota diversity and function of db/db mice were also altered after salidroside administration. Salidroside could attenuate inflammatory damage, lipid accumulation and inflammatory changes in the diabetic liver, as well as diabetic kidney damage. Candidatus arthromitus and Odoribacter are important species of the microbiota during diabetes and may serve as potential therapeutic targets. CONCLUSION Our investigation of the associated pathological conditions and fecal microbiota in db/db mice provides new insights into the pathogenesis of T2DM and provides implications for the diagnosis and treatment of T2DM.
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Affiliation(s)
- Qin Zhao
- Biobank, Hospital of Chengdu Office of People’s Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, Sichuan Povince, People’s Republic of China
| | - Jing Shi
- Biobank, Hospital of Chengdu Office of People’s Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, Sichuan Povince, People’s Republic of China
| | - Siyuan Chen
- Biobank, Hospital of Chengdu Office of People’s Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, Sichuan Povince, People’s Republic of China
| | - Doudou Hao
- Biobank, Hospital of Chengdu Office of People’s Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, Sichuan Povince, People’s Republic of China
| | - Sha Wan
- Biobank, Hospital of Chengdu Office of People’s Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, Sichuan Povince, People’s Republic of China
| | - Haomeng Niu
- Medical School, Tibet University, Lhasa, Tibet Autonomous Region, People’s Republic of China
| | - Yongqun Zhang
- Biobank, Hospital of Chengdu Office of People’s Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, Sichuan Povince, People’s Republic of China
- Correspondence: Yongqun Zhang, Biobank, Hospital of Chengdu Office of People’s Government of Tibetan Autonomous Region (Hospital.C.T.), No. 20 Ximianqiao Road, Chengdu, Sichuan Povince, 610041, People’s Republic of China, Tel +86-28-85593218, Fax +86 28-85558071, Email
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Hata S, Nakajima H, Hashimoto Y, Miyoshi T, Hosomi Y, Okamura T, Majima S, Nakanishi N, Senmaru T, Osaka T, Okada H, Ushigome E, Hamaguchi M, Asano M, Yamazaki M, Fukui M. Effects of probiotic Bifidobacterium bifidum G9-1 on the gastrointestinal symptoms of patients with type 2 diabetes mellitus treated with metformin: An open-label, single-arm, exploratory research trial. J Diabetes Investig 2021; 13:489-500. [PMID: 34665938 PMCID: PMC8902400 DOI: 10.1111/jdi.13698] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/28/2021] [Accepted: 10/14/2021] [Indexed: 12/20/2022] Open
Abstract
Aims/Introduction Metformin is associated with the risk of gastrointestinal complications, and probiotic Bifidobacterium bifidum G9‐1 (BBG9‐1) can improve the symptoms of diarrhea. This study aimed to clarify the effects of probiotic BBG9‐1 on the gastrointestinal symptoms of type 2 diabetes mellitus patients using metformin. Materials and methods In this open‐label single‐arm exploratory study, 40 patients (mean age 64.0 ± 9.4 years) were given probiotic BBG9‐1 for 10 weeks. Changes in the gastrointestinal symptom rating scale total score, which was the primary end‐point, gastrointestinal symptom rating scale subscale scores, glycated hemoglobin levels and gut microbiota after the administration of probiotic BBG9‐1 were evaluated by the Student's t‐test. Results The gastrointestinal symptom rating scale total score significantly improved (from 2.02 ± 0.51 to 1.59 ± 0.43, change, −0.43 ± 0.49, P < 0.001). Furthermore, all gastrointestinal symptom rating scale subscale scores, including diarrhea (from 2.32 ± 1.14 to 1.89 ± 0.99, change, −0.42 ± 0.95, P = 0.007) and constipation (from 3.00 ± 1.16 to 2.20 ± 1.07, change, −0.80 ± 1.19, P < 0.001), scores also significantly improved. However, the glycated hemoglobin levels did not change (from 7.0 ± 0.7 to 7.0 ± 0.6%, change, 0.0 ± 0.4, P = 0.91). The relative abundance of the genus Sutterella decreased by the use of probiotic BBG9‐1 (from 0.011 ± 0.009 to 0.008 ± 0.006, change, −0.003 ± 0.006, P = 0.002). Conclusions Type 2 diabetes mellitus patients treated with metformin showed significant improvement in all gastrointestinal symptom rating scores after using probiotic BBG9‐1 without changing the glucose control. This study showed the potential usefulness of probiotic BBG9‐1 for improving gastrointestinal symptoms, including constipation and diarrhea, in type 2 diabetes mellitus patients treated with metformin.
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Affiliation(s)
- Shinnosuke Hata
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hanako Nakajima
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshitaka Hashimoto
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomoki Miyoshi
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yukako Hosomi
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takuro Okamura
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Saori Majima
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naoko Nakanishi
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takafumi Senmaru
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takafumi Osaka
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroshi Okada
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Emi Ushigome
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahide Hamaguchi
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Mai Asano
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Yamazaki
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Michiaki Fukui
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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