Calliope Holingue, MPH, PhD Candidate Department Mental Health, Johns Hopkins Bloomberg School of Public Health Departmental Seminar, Wednesday March 28, 2018 The gastrointestinal (GI) system and gut microbiome in Autism Spectrum Disorders (ASD)
CalliopeHolingue,MPH,PhDCandidate
DepartmentMentalHealth,JohnsHopkinsBloombergSchoolofPublicHealth
DepartmentalSeminar,WednesdayMarch28,2018
Thegastrointestinal(GI)systemandgutmicrobiomeinAutismSpectrumDisorders(ASD)
Outline
• HistoricallinkbetweenASDandgut,possibleconnections
• EvidenceforroleofgutmicrobiomeinASD• MeasurementChallenges• FutureDirections
‘Alldiseasestartsinthegut’Hippocrates~460-370BC
AutismSpectrumDisorder
DSM-5APA2013
“Autisms”
EytanNisinzweig,ayoungmanwithautism ©EytanArt.com2010
5
GILinkwithAutism
• LeoKanner1943:6ofthe10childrenwithautism“presentedseverefeedingdifficultyfromthebeginningoflife”
Kanner1943;Goodwinetal1971;D’Eufemiaetal1996;Chaidezetal2014
> >
ASD DD TD
GISymptoms• MostcommonGIissues(medianacross144autismstudies)– Constipation(22%)– Diarrhea(23%)– Abdominalpain/discomfort(14%)– Bloating/flatulence(13%)– Nausea/vomiting(6%)– Anysymptom(47%)
• Foodsensitivities,preferences,mealtimebehaviors,toiletingproblemsarecommon
Holingueetal2017
Whystudythegutinautism?
• ComplementaryandAlternativeTreatments/Medicine(CAMs)
Complementary/AlternativeTreatments/Medicine(CAMs)
• DevelopedoutsideofWesternmainstreammedicine
• Manyaimto‘healthegut’toprevent/treatASDsymptoms
• Over70%familiesreportone+CAMs
• Verylittledataonsafetyorefficacy
Christonetal2010
Whystudythegutinautism?
• CAMs• Treatingcomorbidities,improvingqualityoflife
• Gutasariskfactorfor– ExacerbationofASDsymptoms– IncidenceofASD
PossibleConceptualDiagram
ASD GIissues
PossibleConceptualDiagram
ASD
Co-occurringconditions
Medications
GIissues
PossibleConceptualDiagram
ASD
Co-occurringconditions
Medications
Diet
GIissues
PossibleConceptualDiagram
Gut ASD
PossibleConceptualDiagram
Gut ASD
DiscomfortDistressPain
PossibleConceptualDiagram
Gut ASD
DiscomfortDistressPain
“Biology”
EvidenceforroleofgutmicrobiomeinASD
TheHumanMicrobiome
“Themicrobiomeisdefinedasthecollectivegenomesofthemicrobes(composedof
bacteria,bacteriophage,fungi,protozoaandviruses)thatliveinsideandonthehuman
body.”
Yang,Joy."TheHumanMicrobiomeProject:Extendingthedefinitionofwhatconstitutesahuman."NationalHumanGenomeResearchInstitute(2012).
Microbe:Microorganisms[e.g.bacteria,virus]Microbiota:MicroorganismsinparticularsiteMicrobiome:Combinedgeneticmaterialofmicroorganismsinparticularenvironment
Thediversityofmicrobesvariesbyanatomicsite
TheHumanMicrobiome
TheHumanMicrobiome
Health,diet,hygiene,genotype… àComposition,complexity,andfunctionofour
microbialcommunities
Rolesofgutmicrobiome
• Bacteriacommunicatewitheachotherandwithhost(Us!)
• Producevitaminsandnutrients• Influencehostgeneexpression,immunecellresponses
• Regulategutmotility,intestinalbarrierhomeostasis,nutrientabsorption,fatdistribution
• Gut-braincommunication,brainfunction,behavior
SynergisticRelationship
“Microbiotanormallyhasabalanced
compositionalsignaturethatconfershealthbenefits...
disruptionofthisbalanceconfersdiseasesusceptibility”
Cryan,JohnF.,andTimothyG.Dinan."Mind-alteringmicroorganisms:theimpactofthegutmicrobiotaonbrainandbehaviour."Naturereviewsneuroscience13.10(2012):701-712.
MicrobiomeisDynamic
“…Themicrobiomeisafluctuatingcollectionofgenesandgeneproducts;environmentalperturbations,suchasantibiotictreatmentandinfection,canreadilyalter
themicrobialcompositionandfunctionofeachcommunity…Thehumanmetagenomeisrelatively
plasticormalleable,whichmakesthemicrobiomeanattractivetargetformanipulationbycellorgene
therapy”
Pflughoeft,KathrynJ.,andJamesVersalovic."Humanmicrobiomeinhealthanddisease."AnnualReviewofPathology:MechanismsofDisease7(2012):99-122.
MeasuringtheGutMicrobiome
• Collectingsamplesoftheactualgutisoftennotfeasibleorethical
• Moststudiesexaminethefecalmicrobiome
• DNAisextracted,sequencedtodeterminewhichmicrobesarepresent
EvidenceforroleofgutmicrobiomeinASD
MaternalImmuneActivation
BehavioralAbnormalitiesCorticalpatches
MaternalImmuneActivation
Healthypups
Antibiotic
• GutbacteriathatinduceTh17cells✔• Pro-inflammatorystimulus✔• Pregnancy✔AllrequiredforincreaseinIL-17awhichpromotesMIA-inducedneurodevelopmentalabnormalities
MaternalImmuneActivation
+
SpecificBacteriainMom’sGut
ASDinchild
MaternalImmuneActivation
+
SpecificBacteriainMom’sGut
ASDinchild
?
DissertationAim
AntibioticExposureInPregnantWomen
ASDinoffspring
DissertationAim
AntibioticExposureInPregnantWomen
ASDinoffspringX
MaternalImmuneActivation
ASDhumanmicrobiomestudiesFindingsInconsistent
Clostridium,Sutterella,Lactobacillus,Desulfovibrio
Prevotella,Coprococcus,andVeillonellaceae
Bacteroidetes/Firmicutesratio
Parrachoetal2005;Vuongetal2016;Kangetal2013;Finegoldetal2002;Songetal2004;Williamsetal2012;Wangetal2013;Tomovaetal2014;Williamsetal2011
Reasonsforinconsistenciesacrossstudies
• Differencesinhowmicrobiomedatawascollected,stored,analyzed
• Unadjustedconfounding• HeterogeneityofASD
DissertationAim
ToestimateassociationsofgutmicrobiomesignaturesincludingdiversitymetricsandrelativeabundanceoftaxawithASDco-occurringconditions.
GutmicrobiomeASDco-occurringconditions
• Recruit30boys3-6yearswithASDfromKennedyKriegerInstitute,CenterforAutismandRelatedDisorders
• Stoolkit:OmnigeneGut• Questionnaires:
• Childbehaviorchecklist• Theshortsensoryprofile• GIquestionnaire• BristolStoolScale
• SampleswillbeprocessedandsequencedatJHUwith16srRNAtechnology
StatisticalAnalysis
Estimateassociationsbetweenco-occurringissues/behaviorandmicrobialprofiles,withinASD
ExemplarHypotheses:Anxiety~PrevotellawithinASDSomaticComplaints~PrevotellawithinASDSleepproblems~PrevotellawithinASD
MeasurementIssues
• AssessingGIsymptoms/conditionsinASDischallenging
DissertationAim
Todevelopareliableandvalidquestionnairethatassessesgastrointestinal(GI)symptomsinchildrenwithautismspectrumdisorderforuseinepidemiologicstudies.
StudyPopulation
• RegistryofparentsofchildwithASDatKennedyKriegerInstitute
• Havepreviouslyconsentedtobecontactedforresearchpurposes
• Ages3-18years• Recruitment,consent,datacollectionwillallhappenonline
Methods• BaseoffofAutismTreatmentNetworkGI
InventoryandBriefAutismMealtimeBehaviorInventory
• Focusgroupsandexpertpanel
• Administerourquestionnaire+childbehaviorchecklist
• Assesspsychometricperformanceandrevise• Administertoindependentsample,assess
psychometricperformance
KeyTakeaways
• GIsymptomsareelevatedinASD• GIsymptoms/disordersmaybeduetohavingASD
• GutmayplayaroleincausingASD• Bothdirectionsarelikelyoccurring,dependsontheindividual
• Accurate,reliableassessment,diagnosis,treatmentofGIsymptomsinASDiscritical
ImpactandImplications
• Etiologyofautismandmentalillness
• Targetforpreventionandtreatment
Futurework
• Measurementandassessment• Latentclassesapproachestoidentifying‘subgroups’ofASD
• Incorporatingmultipledatatypes• Animalandhumanstudiesshouldinformeachother,informmechanisticwork
Thankyou!!
ThesiscommitteeDaniFallin(Adviser)Li-ChingLeeNoelMuellerSarahMurrayRashelleMusciJayPasricha
FundingPsychiatricEpidemiologyTrainingProgram(PI:PeterZandi)WendyKlagCenterforAutismandDevelopmentalDisabilities
ShamelessPlugs
ShamelessPlugs
References(1)• Kanner,Leo."Autisticdisturbancesofaffectivecontact."Nervouschild2.3(1943):217-250.• Goodwin,MaryStewart,T.CampbellGoodwin,andMurrayA.Cowen."Malabsorptionandcerebral
dysfunction:amultivariateandcomparativestudyofautisticchildren."JournalofAutismandchildhoodSchizophrenia1.1(1971):48-62.
• d'Eufemia,P.,etal."Abnormalintestinalpermeabilityinchildrenwithautism."ActaPaediatrica85.9(1996):1076-1079.
• Chaidez,Virginia,RobinL.Hansen,andIrvaHertz-Picciotto."Gastrointestinalproblemsinchildrenwithautism,developmentaldelaysortypicaldevelopment."Journalofautismanddevelopmentaldisorders44.5(2014):1117-1127.
• Holingue,Calliope,etal."Gastrointestinalsymptomsinautismspectrumdisorder:Areviewoftheliteratureonascertainmentandprevalence."AutismResearch(2017).
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• Yang,Joy."TheHumanMicrobiomeProject:Extendingthedefinitionofwhatconstitutesahuman."NationalHumanGenomeResearchInstitute(2012).
• Cryan,JohnF.,andTimothyG.Dinan."Mind-alteringmicroorganisms:theimpactofthegutmicrobiotaonbrainandbehaviour."Naturereviewsneuroscience13.10(2012):701-712.
• Pflughoeft,KathrynJ.,andJamesVersalovic."Humanmicrobiomeinhealthanddisease."AnnualReviewofPathology:MechanismsofDisease7(2012):99-122.
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