Tag: health and nutrition

Binge Drinking in Adolescents Linked to Changed Composition of Bacteria in the Gut

Posted on by CNP Staff

If we drink multiple alcoholic beverages at once, this will lead to intoxication. But when we sober up, are the alcoholic effects gone or are there changes to our body that linger? A new study by Carbia and colleagues done at the University College Cork in Ireland aimed to identify changes in our body that can be used to detect binge drinking, even before this drinking habit leads to alcohol use disorder. These researchers studied potential links between binge drinking, changes to the gut microbiome, social cognition, and impulsivity. The second goal of the study was to identify the changes in our body that happen when we experience alcohol cravings by examining the associations of the microbiome composition and craving for alcohol.

This study was published in eBioMedicine and explores whether changes in the gut microbiome are associated with cravings for alcohol, and whether alterations in the composition of the gut microbiome due to binge drinking have detrimental effects on cognitive functioning, particularly in relation to social and emotional processing. 

Let’s begin by learning more about binge drinking.

What is binge drinking?

Binge drinking is defined as the consumption of excessive amounts of alcoholic beverages in a short period of time. It is the most frequent type of alcohol misuse during adolescence in Western countries (Carbia et al., 2023), and is most frequent in late adolescence, up to around 24 years of age (Sawyer et al., 2018). Binge drinking is associated with an increased risk of developing alcohol use disorder, but also other types of psychiatric disorders later in life.

The World Health Organization (WHO) defines a binge drinking episode as consuming at least 60 grams of pure alcohol on a single occasion, which leads to a blood alcohol concentration of 0.8 grams/liter or higher (Rolland et al., 2017). A standard shot of whiskey is 1.5 ounces, equaling 42 grams. Given 40% alcohol content, a standard shot of whiskey contains .6 oz or a bit less than 17 grams of alcohol. A binge drinking episode would thus be any single occasion on which a person consumes 4 or more standard shots of whiskey (or of a similar alcoholic beverage) (see Figure 1).

 

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Figure 1. Binge drinking episode per WHO 

 

The microbiome-gut-brain axis 

The human gut microbiome consists of a plethora of microorganisms (predominantly bacteria, but also archaea, viruses, and fungi) that inhabit the human gastrointestinal tract, primarily the colon or large intestine. These microorganisms have co-evolved with the human host over millions of years, forming a complex ecosystem that plays a critical role in human health and disease (Cryan et al., 2019).

The MGBA is a bi-directional communication system existing between our gut, its microbiome, and our brain. This communication system is facilitated by various signaling pathways and molecules which together perform a wide range of functions essential for human health — including digesting complex carbohydrates, producing essential vitamins and nutrients, regulating the immune system, and maintaining the integrity of the intestinal barrier (which serves as a physical and biochemical barrier between the gut and the rest of the body’s organs).

The microbiome gut-brain axis regulates processes beyond the gut, including metabolism, body weight, and brain functions involving mood, emotion, craving, behavior, and cognition. And because this communication system is bidirectional, just as the gut microbiome can influence mood and stress states, mood and stress states can, in turn, influence the gut microbiome — leading to gut dysbiosis, intestinal permeability, and other gut-related health problems (see Figure 2). 

 

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Figure 2. The Microbiome gut-brain axis and stress 

 

The gut microbiome in individuals suffering from binge drinking and alcohol use disorder

Several studies have explored the link between altered gut microbiome in the development of alcohol use disorder and binge drinking in young people (Rodríguez-González et al., 2021; Gorky & Schwaber, 2016). 

In the scope of alcohol use disorder treatment, for example, studies demonstrate that patients who abruptly cease drinking alcohol show increased gut permeability and changes in the composition of their gut microbiome. They also show higher levels of cytokines and cortisol (Adams et al., 2020). The increased levels of cytokines and cortisol in patients’ circulation are associated with the severity of their alcohol use disorder, and the intensity of their craving for alcohol.

Since binge drinking can negatively impact the microbiome-gut-brain axis and contribute to the development of alcohol-related health problems, targeting the gut microbiome holds promise as a potential method for reducing alcohol-related harm in this population.

The gut microbiome composition might be associated with social behavior

Numerous studies demonstrate that gut microbiota composition appears to be connected to social behavior (Johnson, et. al, 2022; Sylvia, et al., 2018). An experiment where the gut microbiome from patients suffering from alcohol use disorder was transplanted into the guts of mice, showed that this action impaired the sociability of the mice and also lead to certain disturbances in their brain function (Leclercq et al., 2020) such as neuroinflammation (see Figure 3). 

 

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Figure 3. Gut microbiome composition association with social behavior

 

This and other findings have led researchers to postulate that the gut microbiome might play a role in the development of alcohol use disorder, and also in other psychiatric disorders characterized by problems in social cognition and functioning.

 

The gut microbiome might play a role in the development of alcohol use disorder. 

 

The study of young Irish binge drinkers

A 2023 study by Carbia and colleagues aimed to identify early biomarkers of alcohol misuse by exploring the gut microbiome and neurocognitive correlates in young binge drinkers who do not have an alcohol use disorder (Carbia et al., 2023). 

They reasoned that because of the intense development occurring during adolescence, people have increased vulnerability to developing alcohol use disorder (and other psychiatric disorders) during this stage of life. They purport that it is possible that factors creating this vulnerability go beyond the developing brain of a young person and extend to specificities of the gut microorganism composition.

As previously mentioned, these authors wanted to study potential links between binge drinking, changes to the gut microbiome, social cognition, and impulsivity. Social cognition and impulsivity are two cognitive domains most often linked to increase in alcohol drinking. The second goal of the study was to identify the biomarkers of alcohol craving by examining the associations between changes to the microbiome composition and craving for alcohol.

 

Because of the intense development during adolescence, people have increased vulnerability to developing alcohol use disorder (and other psychiatric disorders) during this stage of life. 

 

Study participants and procedure

Study participants were 71 healthy persons, between 18 and 25 years of age, living in Cork, Ireland. Those excluded from the study were prospective participants who never drank alcohol, whose scores on an alcohol use assessment test indicated alcohol use disorder and those who had a family history of alcoholism. Participants were also excluded if they had any other mental disorder, or were using drugs or any medications.

After recruitment, participants underwent a clinical interview in which researchers collected their demographic information, made clinical assessments, and collected a range of other data, such as information about their diets.  During their second visit, participants underwent neuropsychological evaluation and researchers collected their biological samples (saliva, hair, blood, stool). Three months later, participants reported their alcohol use and craving. Participants were paid up to 50 EUR for their participation in the study.

 

It is possible that factors creating vulnerability in young people for alcohol disorders go beyond the developing brain and extend to specificities of the gut microorganism composition.

 

Measures and assessments

In the scope of the study, participants completed assessments of alcohol consumption patterns (the AUDIT questionnaire and the Alcohol Timeline Follow-Back, TFLB), alcohol craving (the Alcohol Craving Questionnaire – Short Form, ACQ), emotional processing (the Emotion Recognition Task, ERT and the Affective Go/No-Go task from the Cambridge Neuropsychological Test Automated Battery, CANTAB), and impulsivity (The Barratt Impulsiveness Scale, BIS-11). 

Researchers also made assessments of participants’ inflammatory markers from blood samples of kynurenine and tryptophan (metabolites suspected to be a part of the microbiome-gut-brain axis communication pathway) and cortisol. Genomic sequencing of the stool samples was conducted for the purposes of identifying composition of the gut microbiome and short-chain fatty acid contents — another suspected component of the microbiome-gut-brain communication axis (see Figure 4).

 

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Figure 4. Research assessment protocol

 

Binge drinkers have higher alcohol cravings and are worse at recognizing emotions.

 

Results showed that participants who had more binge drinking episodes had higher cravings for alcohol. Participants who had a higher number of drinks within a drinking episode were also less able to recognize sadness and disgust. People who drank more were slower to respond when they gave correct answers to these tests. They also scored higher on impulsivity.

Binge drinking and the gut microbiome

Recent binge drinking episodes were associated with higher microbiome alterations, including changes to how widespread multiple species of bacteria were (referred to as microbial diversity). Higher numbers of drinks per binge drinking session were associated with lower levels of isovalerate, one type of branched-chain saturated fatty acid, thought to be involved in how the gut microbiome interacts with body processes outside the gut. Greater craving for alcohol was found to be associated with reductions in numbers of the gut bacteria Ruthenibacterium lactiformans. It was also associated with changes in levels of a number of compounds thought to be involved in the microbiome-gut-brain axis as well as those involved in the gut-metabolic interactions. Notably, reduced butyrate and inositol synthesis and increased acetate, glutamate, and tryptophan synthesis were associated with higher cravings. 

Let’s see this visually in Figure 5. 

 

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Figure 5.  Link of binge drinking with gut microbiota alteration, craving, and poor emotional processing

 

Conclusion

This study showed that binge drinking, the most common pattern of alcohol misuse in adolescence, is linked with changes to the gut microbiome and specific cognitive impairments. The study also revealed that changes in the gut microbiome are linked with increased cravings for alcoholic beverages. This was shown to happen in participants without alcohol addiction (i.e., before the alcohol use disorder has developed). These findings open the possibility to develop methods for predicting alcohol drinking habits and possibly alcohol-related social functioning impairments by analyzing gut microbiota composition from stool samples. They could also lead to novel dietary or pre/probiotic interventions directed at improving early alcohol-related alterations in the gut microbiota of young drinkers.

More about the gut microbiome and its connection to psychological, cognitive, behavioral and psychosocial functioning and mental health can be found in NP 120 (scheduled to be published in May 2023). NP 120 is part of the Introductory Certificate in Nutritional Psychology through the Center for Nutritional Psychology.  

The paper “The Microbiome-Gut-Brain axis regulates social cognition & craving in young binge drinkers” was authored by Carina Carbia, Thomaz F. S. Bastiaanssen, Luigi Francesco Iannone, Rubén García-Cabrerizo, Serena Boscaini, Kirsten Berding, Conall R. Strain, Gerard Clarke, Catherine Stanton, Timothy G. Dinan, and John F. Cryan.

References

Adams, C., Conigrave, J. H., Lewohl, J., Haber, P., & Morley, K. C. (2020). Alcohol use disorder and circulating cytokines: A systematic review and meta-analysis. Brain, Behavior, and Immunity, 89, 501-512. https://doi.org/10.1016/j.bbi.2020.08.002

Carbia, C., Bastiaanssen, T. F. S., Iannone, F., García-cabrerizo, R., Boscaini, S., Berding, K., Strain, C. R., Clarke, G., Stanton, C., Dinan, T. G., & Cryan, J. F. (2023). The Microbiome-Gut-Brain axis regulates social cognition & craving in young binge drinkers. EBioMedicine, In press), 104442. https://doi.org/10.1016/j.ebiom.2023.104442

Gorky, J., & Schwaber, J. (2016). The role of the gut–brain axis in alcohol use disorders. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 65, 234-241. https://doi.org/10.1016/j.pnpbp.2015.06.013

Johnson, K. V., Watson, K. K., Dunbar, R. I. M., & Burnet, P. W. J. (2022). Sociability in a non-captive macaque population is associated with beneficial gut bacteria. Frontiers in microbiology, 13, 1032495. https://doi.org/10.3389/fmicb.2022.1032495

Leclercq, S., Le Roy, T., Furgiuele, S., Coste, V., Bindels, L. B., Leyrolle, Q., Neyrinck, A. M., Quoilin, C., Amadieu, C., Petit, G., Dricot, L., Tagliatti, V., Cani, P. D., Verbeke, K., Colet, J. M., Stärkel, P., de Timary, P., & Delzenne, N. M. (2020). Gut Microbiota-Induced Changes in β-Hydroxybutyrate Metabolism Are Linked to Altered Sociability and Depression in Alcohol Use Disorder. Cell Reports, 33(2). https://doi.org/10.1016/J.CELREP.2020.108238

Rodríguez-González, A., Vitali, F., Moya, M., De Filippo, C., Passani, M. B., & Orio, L. (2021). Effects of Alcohol Binge Drinking and Oleoylethanolamide Pretreatment in the Gut Microbiota. Frontiers in Cellular and Infection Microbiology, 1134. https://doi.org/10.3389/fcimb.2021.731910

Rolland, B., Chazeron, I. de, Carpentier, F., Moustafa, F., Viallon, A., Jacob, X., Lesage, P., Ragonnet, D., Genty, A., Geneste, J., Poulet, E., Dematteis, M., Llorca, P. M., Naassila, M., & Brousse, G. (2017). Comparison between the WHO and NIAAA criteria for binge drinking on drinking features and alcohol-related aftermaths: Results from a cross-sectional study among eight emergency wards in France. Drug and Alcohol Dependence, 175, 92–98. https://doi.org/10.1016/J.DRUGALCDEP.2017.01.034

Sawyer, S. M., Azzopardi, P. S., Wickremarathne, D., & Patton, G. C. (2018). The age of adolescence. The Lancet Child & Adolescent Health, 2(3), 223–228. https://doi.org/10.1016/S2352-4642(18)30022-1

Sylvia, K. E., & Demas, G. E. (2018). A gut feeling: Microbiome-brain-immune interactions modulate social and affective behaviors. Hormones and behavior, 99, 41–49. https://doi.org/10.1016/j.yhbeh.2018.02.001

 

Why are Hyper-Palatable Foods so Alluring? New Type of Brain Cell Lends Insight

Posted on by CNP Staff

Our food preferences have changed significantly over the last decade, with processed, hyperpalatable foods being increasingly available and consumed. A substantial percentage of foods in the US food system (62%) is considered to be hyperpalatable, including foods not previously conceptualized as hyperpalatable, such as foods labeled “reduced” or “low fat” and sauces, trail mixes, vegetables cooked in creams, etc. (Fazzino et al., 2019).

 

Sixty-two percent of the foods in the US food system may be hyperpalatable, including foods not previously conceptualized as hyperpalatable.

 

We know that the highly palatable sensations and interoceptive experiences associated with these foods can activate the brain’s reward system, providing us with an experience of pleasure and reward. Activation of the reward system occurs in other activities such as achieving a goal or engaging in addictive behaviors like substance abuse. In truth, there are many factors involved in our choosing of highly palatable foods, including the availability of these foods, and the social environment in which we live.

Have you ever wondered why hyperpalatable foods are so desirable, and why they have been increasingly making it into our shopping carts despite the knowledge that they lack nutrients? Certainly, it is because hyperpalatable foods are cheap, convenient, and taste good, not to mention they give you a rewarding and memorable experience. However, what you might not know is that there’s a type of neuron in our brain that influences our dietary intake patterns.

In truth, many factors influence our dietary intake behavior and food cravings (learn more in NP 110) – both of which are important topics in the study of the diet-mental health relationship (DMHR) and within nutritional psychology. In this article, we focus on the new discovery of a type of brain cell (neuron) which may play a role in our desire to consume these highly processed foods.

 

Neurotensin neurons are a new structure that might impact our eating behavior.

 

Alessandro Furlan and his research team explored a new structure within the brain that can modulate dietary intake behavior and increase our preference for fatty foods. This structure is a group of neurons called neurotensin neurons, located in a part of the amygdala known as the interstitial nucleus of the posterior limb of the anterior commissure (IPAC) (Furlan et al., 2022). Let’s uncover the crucial role of these neurotensin neurons within the IPAC and see what Furlan and his team discovered about their role in orchestrating our dietary intake behaviors and metabolic health.

 

Activation of neurotensin neurons can promote hedonic feeding and weight gain.

 

This experiment consisted of four steps. First, they examined how activation of the neurotensin neurons can change the food behavior of the animals (i.e., whether they will be more interested in palatable food). They then examined how different foods can activate neurotensin neurons (i.e., fat vs. water). They also tested whether these cells play a role in food-seeking behavior by testing whether they are activated by merely food stimuli. Finally, they examined how inhibiting these cells can alter the food behavior of animals. 

Furlan found many things in their study, including:

  • Activation of neurotensin neurons can promote hedonic feeding. Hedonic feeding and hunger involve the consumption of food uniquely because of its rewarding properties (pleasure) rather than eating for homeostatic energy balance (Monteleone, 2012). 
  • When rats had their neurotensin neurons activated, they exhibited increased dietary intake. The effect was more pronounced for more palatable high-fat diets than for chow.
  • When mice were fed with either fat or water, they found that immediately following ingestion, neurotensin neurons were more strongly activated by fat than by water in a concentration-dependent manner. 
  • They also tried to see the effect when they compared two palatable foods (with one of them being more palatable). They found that these cells were activated by sucrose more than by sucralose (a palatable, sweet food but non-caloric sugar analog).
  • Neurotensin neurons can be activated by sensory cues that anticipate meals (i.e., odors). This means that they also play a role in food-seeking behaviors.

As shown in Figure 1, these findings show that neurotensin neurons are not only influenced by the type of food consumed (i.e., highly palatable), but that they also activate our response to food stimuli, and their activity is scaled by the palatability of food. They affect our hedonic feeding behavior and increase our intake of highly palatable foods.

%learn about nutrition mental health %The Center for Nutritional Psychology Figure 1. Summary of how neurotensin neurons can affect our food behavior

 

When neurotensin neurons are inhibited, the preference for highly palatable food decreases.

 

Conversely, acute inhibition of neurotensin neurons reduces feeding on a high-fat diet in sated mice and reduces feeding in hungry mice. In addition, prolonged inactivation of neurotensin neurons leads to a dramatic increase in aerobic locomotion and long-term weight loss.

The inactivation of these cells protected mice from obesity and the long-term negative consequences of chronic feeding. Mice who had their neurotensin neurons inhibited exhibited higher energy expenditure, higher lipid oxidation rate, low blood sugar levels, and engaged in more activity. A summary of the research findings by Furlan and his team is shown in Figure 2.

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Figure 2. Summary of findings by Furlan and his team

 

What are the implications of this in everyday life?

The desire to consume highly palatable foods more frequently than healthier, nutrient-dense foods is a major cause of the current obesity pandemic. Exercise programs are known to be the first-line intervention when treating obesity, however, body weight is often restored through metabolic processes (Petridou et al., 2019).

Because these neurons seem to play a crucial role in promoting metabolic responses via behavior alteration, this knowledge may play a critical therapeutic role in future obesity interventions. Inhibiting these neurons can change our food choices, promote long-term weight loss, and protect us from obesity. Neurotensin neurons can be a piece of the puzzle in unraveling the complex mechanisms underlying our feeding behavior and metabolic health.

Of course, this research is not free of limitations. The main limitation is that this study was a mouse study, and it takes time to do translational research on human subjects. Furthermore, because this was found in animals, this does not necessarily mean that studies on human subjects would come up with the same findings.

Conclusion

The amygdala is a complex neurological structure that helps us to regulate our emotions. It is not surprising that this structure may play a role in dietary intake behavior. The discovery of neurotensin neurons in this area of the brain can contribute to our understanding the behavioral aspects of obesity and support the development of novel interventions for treating obesity. While more research is needed, this new insight makes critical strides in our understanding of the alure of hyperpalatable foods.

More about the science of the Diet-Behavior relationship can be found in NP 110: Introduction to Nutritional Psychology Methods.

 

References

Fazzino, T. L., Rohde, K., & Sullivan, D. K. (2019). Hyper-palatable foods: Development of a quantitative definition and application to the US Food System Database. Obesity, 27(11), 1761–1768. https://doi.org/10.1002/oby.22639

Furlan, A., Corona, A., Boyle, S., Sharma, R., Rubino, R., Habel, J., Gablenz, E. C., Giovanniello, J., Beyaz, S., Janowitz, T., Shea, S. D., & Li, B. (2022). Neurotensin neurons in the extended amygdala control dietary choice and energy homeostasis. Nature Neuroscience, 25(11), 1470–1480. https://doi.org/10.1038/s41593-022-01178-3

Monteleone, P., Piscitelli, F., Scognamiglio, P., Monteleone, A. M., Canestrelli, B., Di Marzo, V., & Maj, M. (2012). Hedonic eating is associated with increased peripheral levels of ghrelin and the endocannabinoid 2-arachidonoyl-glycerol in healthy humans: a pilot study. The Journal of Clinical Endocrinology and Metabolism, 97(6), E917–E924. https://doi.org/10.1210/jc.2011-3018

Petridou, A., Siopi, A., & Mougios, V. (2019). Exercise in the management of obesity. Metabolism: Clinical and Experimental, 92, 163–169. https://doi.org/10.1016/J.METABOL.2018.10.009

 

 

Eating Fermented Foods with Live Microbes May Improve Dietary Health

Posted on by CNP Staff

Fermented foods—like kimchi and yogurt—and probiotic supplements have been associated with improved metabolic health and, consequently, stronger immunity and reduced risk against various cancers (Savaiano et al., 2021; Wastyk et al., 2021). What these foods and supplements have in common is the presence of living microorganisms (Montville, 2004; Jeddi et al., 2014; Ziyaina et al., 2018). In fact, raw and unpeeled fruits and vegetables, dairy, and certain proteins contain dietary microbes that have been demonstrated to benefit human health (Roselli et al., 2021; Marco et al., 2022). 

Note: this article/study does not specifically explore beneficial or pathogenic microbes; rather, the authors are interested in determining how many “live” microbes are found in foods within the Western diet. To do this, they used preexisting data to estimate microbial content by classifying the foods eaten by participants as low, medium, or high amounts.

 

Raw and unpeeled fruits and vegetables, dairy, and certain proteins contain dietary microbes that have been demonstrated to benefit human health.

 

However, compared to other macronutrients such as carbohydrates, fats, and proteins which are reported on nutrition fact labels and databases, it is not clear how much of the Western diet is actually composed of foods containing live dietary microbes and, moreover, the percentage of U.S. adults and children who consume them. Addressing this knowledge gap is not only imperative in establishing safe daily intake values of live microbes but also encourages further clinical studies to investigate the long-term health benefits they may provide.

To quantify the level of microbes across food groups and the proportion of U.S. residents that ingest them, Marco et al. conducted a 2022 study that analyzed published dietary data from the National Health and Nutrition Examination Survey (NHANES), an ongoing study led by the CDC’s National Center for Health Statistics. NHANES study participants are selected through statistical sampling and information is collected through both in-home interviews and physical examinations at designated health centers. 

For their retrospective analysis, Marco et al. used 24-hour dietary recall results obtained from 74,466 adults and children, dating from 2001 to 2018. Their study aimed to use pre-existing data to estimate the general amounts of microbes contained in food items reported in the NHANES study, classify each item as low-, medium-, or high-microbial content, and, ultimately, approximate the percentage of U.S. adults and children who consume these live microbes.

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Figure 1. Representative image depicting the approximate levels of live microbes across different food groups and the increasing U.S. dietary intake of medium to medium-high levels of microbes from 2001 to 2018 (based on Marco et al., J Nutr, 2022).

 

They estimated that processed foods (which are usually pasteurized to remove harmful microbes), meats, seafood (raw and cooked), and peeled fresh fruits and vegetables contained low levels of microbes. Fruit juices, unpeeled fruits and vegetables (skin is still on, so microbes can live on the surface), and fermented foods like sauerkraut, miso, and kimchi have medium levels. Fermented and cultured dairy products like milk, yogurt, sour cream, and cheese were classified as high (Figure 1). 

 

Processed foods (which are usually pasteurized to remove harmful microbes), meats, seafood (raw and cooked), and peeled fresh fruits and vegetables contained low levels of microbes.

 

While their study attempted to categorize different food groups based on their microbial content through previous studies and expert opinions, Marco et al. recognize that their findings are limited by possible biases and inaccuracies in how items were classified. Nevertheless, after quantifying the levels of microbes across different foods in the Western diet, the authors approximated that greater than 50% of U.S. adults and children eat medium to medium-high amounts of live microbes, with this being an increasing trend over an 18-year period (Marco et al., 2022). 

Out of all food groups categorized, fruits, vegetables, and fermented dairy constituted the majority of live microbes in the U.S. diet based on the study’s classification system. Despite the numerous approaches and regulatory guidelines implemented to clean fruits and vegetables for human consumption, Marco et al. report them to be a notable source of microbes that can actually be providing key nutrients such as calcium, fiber, and potassium, which are lacking in the diets of adults and children (USDA and USDHHS, 2020). 

 

Out of all food groups categorized, fruits, vegetables, and fermented dairy constituted the majority of live microbes in the U.S. diet. 

 

This result is not surprising but underscores the need for further research on the validity of the study’s approach and the significance of these microbes on fruits and vegetables. In comparison, the authors expected fermented dairy products to be the major source of microbes as the process of fermentation—in which foods composed of carbohydrates convert to alcohol or organic acids used in various cuisines—relies on the biological activities of microorganisms. Ultimately, Marco et al. presented interesting results that provide a foundation for future research to better explore the relationship between the consumption of live microbes and dietary health outcomes. 

 

References

Jeddi, M. Z., Yunesian, M., Gorji, M. E., Noori, N., Pourmand, M. R., & Khaniki, G. R. (2014). Microbial evaluation of fresh, minimally-processed vegetables and bagged sprouts from chain supermarkets. Journal of health, population, and nutrition, 32(3), 391–399.

Marco, M. L., Hutkins, R., Hill, C., Fulgoni, V. L., Cifelli, C. J., Gahche, J., Slavin, J. L., Merenstein, D., Tancredi, D. J., & Sanders, M. E. (2022). A Classification System for Defining and Estimating Dietary Intake of Live Microbes in US Adults and Children. The Journal of nutrition, nxac074. Advance online publication. https://doi.org/10.1093/jn/nxac074 

Montville, R., & Schaffner, D. W. (2004). Statistical distributions describing microbial quality of surfaces and foods in food service operations. Journal of food protection, 67(1), 162–167. https://doi.org/10.4315/0362-028x-67.1.162 

Roselli, M., Natella, F., Zinno, P., Guantario, B., Canali, R., Schifano, E., De Angelis, M., Nikoloudaki, O., Gobbetti, M., Perozzi, G., & Devirgiliis, C. (2021). Colonization Ability and Impact on Human Gut Microbiota of Foodborne Microbes From Traditional or Probiotic-Added Fermented Foods: A Systematic Review. Frontiers in nutrition, 8, 689084. https://doi.org/10.3389/fnut.2021.689084 

Savaiano, D. A., & Hutkins, R. W. (2021). Yogurt, cultured fermented milk, and health: a systematic review. Nutrition reviews, 79(5), 599–614. https://doi.org/10.1093/nutrit/nuaa013 

U.S. Department of Agriculture and U.S. Department of Health and Human Services (2020). Dietary Guidelines for Americans, 2020-2025. 9th Edition. Available at DietaryGuidelines.gov.

Wastyk, H. C., Fragiadakis, G. K., Perelman, D., Dahan, D., Merrill, B. D., Yu, F. cactusmeraviglietina.it B., Topf, M., Gonzalez, C. G., Van Treuren, W., Han, S., Robinson, J. L., Elias, J. E., Sonnenburg, E. D., Gardner, C. D., & Sonnenburg, J. L. (2021). Gut-microbiota-targeted diets modulate human immune status. Cell, 184(16), 4137–4153.e14. https://doi.org/10.1016/j.cell.2021.06.019 

Ziyaina, M., Govindan, B. N., Rasco, B., Coffey, T., & Sablani, S. S. (2018). Monitoring Shelf Life of Pasteurized Whole Milk Under Refrigerated Storage Conditions: Predictive Models for Quality Loss. Journal of food science, 83(2), 409–418. https://doi.org/10.1111/1750-3841.13981 

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