Effects of Multistrain Probiotics on Metabolic Biomarkers, Inflammation, and Antioxidant System in Patients with Type 2 Diabetes Mellitus: A Prospective Controlled Trial

Effects of Multistrain Probiotics on Metabolic Biomarkers, Inflammation, and Antioxidant System in Patients with Type 2 Diabetes Mellitus: A Prospective Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of Multistrain Probiotics on Metabolic Biomarkers, Inflammation, and Antioxidant System in Patients with Type 2 Diabetes Mellitus: A Prospective Controlled Trial Asli KILAVUZ, Orcun ZORBOZAN, Ilgin YILDIRIM SIMSIR, Nevin TURGAY, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8262784/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 20 You are reading this latest preprint version Abstract Background Recent evidence suggests that the gut microbiota plays a crucial role in the development and progression type 2 diabetes mellitus (T2DM). This study aimed to investigate the effects of multi-strain probiotic supplementation on glucose and lipid metabolism, inflammation, and antioxidant system in patients with T2DM. Methods This prospective controlled clinical trial was conducted at Ege University Faculty of Medicine from July 2020 to June 2023. Participants aged 35–65 years diagnosed with T2DM were allocated sequentially according to order of presentation to either probiotic group (n = 39) or control group (n = 38). The intervention group received a multi-strain probiotic supplement containing Lactobacillus acidophilus , Lactobacillus rhamnosus , Bifidobacterium lactis and Lactobacillus paracasei , twice daily for 12 weeks, while the control group continued standard care. This study evaluated anthropometric measurements, eating attitudes, dietary frequency, quality of life, and physical activity. Biochemical analyses included glycemic control, lipid profiles, inflammation markers (high-sensitivity C-Reactive Protein, Ceruloplasmin), and oxidative stress markers (Malondialdehyde, Glutathione). Results Seventy-seven of the 80 participants completed the study (mean age 55.38 ± 6.40 years, 42.86% female). After 12 weeks a significant within-group decrease in fasting blood glucose (FBG), postprandial blood glucose (PPBG), HbA1c, LDL-C, Non-HDL-C and malondialdehyde in the probiotic group compared to the control group (p < 0.001, p = 0.003, p = 0.004, p = 0.044, p = 0.034, p = 0.001). No significant changes were observed in inflammatory markers or oxidative stress markers’ levels. Anthropometric parameters remained unchanged in both groups. In a two-group comparison, three-month multi-strain probiotic supplementation statistically significantly improved only PPBG in patients with T2DM (p = 0.038). Conclusions Three months of multi-strain probiotic supplementation led to a significant reduction in PPBG levels among patients with T2DM, while FBG, HbA1c, lipid profile parameters, and inflammatory and oxidative stress markers showed improvements that did not reach statistical significance. Trial registration ClinialTrials.gov registration number: NCT07330388. Registered on 23 December 2025. https://clinicaltrials.gov/search?term=NCT07330388 Antioxidant system glycemic control inflammation lipid metabolism probiotics type 2 diabetes mellitus Figures Figure 1 Introduction Type 2 diabetes mellitus (T2DM) prevalence has increased alarmingly due to obesity and sedentary lifestyle trends [ 1 , 2 ]. T2DM causes end-stage renal failure, blindness, and lower limb amputations through progressive atherosclerosis, leading to 3-fold increased cardiovascular events and 2-fold increased cerebrovascular events [ 3 , 4 ]. Recent data suggest that the gut microbiota plays a key role in development and progression of T2DM. This complex ecosystem of at least 10 14 different bacteria affects energy homeostasis through the microorganism-gut-brain axis [ 5 , 6 ]. Gut microbiota changes can alter enteroendocrine signals and gut hormones that regulate β-cell function, insulin secretion, and energy homeostasis [ 7 ]. The gut microbiota can affect the host's inflammation response and energy metabolism, in other words, alteration of the gut microbiota can affect glucose and lipid metabolism and insulin action. One of the most effective methods of maintaining the balance of the gut microbiota is the use of probiotics, defined as live microorganisms that, when given in adequate amounts, show host-specific benefit [ 8 ]. Recently, a growing number of studies have found that probiotics can alter gut flora, improve total cholesterol (Total-C) and Low-Density Lipoprotein Cholesterol (LDL-C) levels [ 9 – 11 ], and reduce blood glucose levels and insulin resistance [ 12 , 13 ]. Nowadays, oxidative stress is also suggested to be a mechanism underlying diabetes and its complications. Antioxidant mechanisms of probiotics include scavenging of reactive oxygen species, metal ion chelation, enzyme inhibition, reduction activity, and inhibition of ascorbate autoxidation [ 14 ]. Modification of gut microflora with probiotics may be seen as a novel tool for the regulation of glucose metabolism and improvement of oxidative stress in T2DM. Increased severity of beta cell dysfunction was positively correlated with increased high-sensitivity C-Reactive Protein (hs-CRP) concentrations [ 15 ]. Although T2DM is recognized as a chronic inflammatory disease, the role of probiotics and prebiotics in its management remains insufficiently explored, and existing evidence regarding their overall efficacy in health and disease is inconsistent [ 16 ]. Regulation of gut microbiota through dietary interventions (e.g., probiotic intake) may be beneficial in reducing inflammation [hs-CRP and Ceruloplasmin (Cp)] and oxidative stress [Glutathione (GSH) and Malondialdehyde (MDA)], as well as regulating glucose and lipid metabolism in T2DM. The aim of this study was to investigate the effects of probiotics on glucose and lipid metabolism, inflammation and antioxidant system in patients with T2DM. Materials and methods Trial design This was a single center, prospective controlled study conducted at the Internal Medicine Outpatient Clinic of Ege University Faculty of Medicine between July 2020 and June 2023. The study included a screening visit, a baseline visit (D0) and one follow-up visit during a 60-days supplementation period. The primary outcomes of the study were defined as the effects of the intervention on inflammatory markers, specifically focusing on a significant decrease in hs-CRP and Cp levels, and oxidative stress markers, including a significant reduction in MDA levels and a significant increase in reduced GSH levels. Secondary outcomes included assessing the glucose metabolism and lipid profile changes, which specifically targeted a significant decrease in Fasting Blood Glucose (FBG), Postprandial Blood Glucose (PPBG), and Glycated Hemoglobin (HbA1c), alongside a reduction in LDL-C and Triglyceride (TG) levels, and an increase in High-Density Lipoprotein Cholesterol (HDL-C) levels. The study adhered to CONSORT guidelines. Trial participants Power analysis was performed and the sample size was calculated as 79 with a statistical power of 80% and an effect size of 0.35. Since two groups were to be studied, 80 patients were planned to participate in the study to equalize the number of participants. This study included adults aged 35–65 years who were diagnosed with T2DM according to American Diabetes Association guidelines, who volunteered to participate in this study. Exclusion criteria were as follows: Use of any systemic antibiotics, multivitamins, minerals, herbal medicines, prebiotic, probiotic and postbiotic supplements in the last 3–6 months, having a diagnosis of any inflammatory bowel disease, severe renal dysfunction or hepatic dysfunction, immunodeficiency diseases, acute infection, rheumatoid arthritis, cancer history, history of alcohol abuse or drug dependence, pregnant or lactating women. Dietary habits, physical activity, and glucose-lowering therapy of the participants were not intervened during the study. Participants were allocated sequentially according to order of presentation (alternate allocation). According to the order of presentation to the outpatient clinic, the first patient who met the inclusion criteria was included in the probiotic group and the second patient who presented to the outpatient clinic was included in the control group. Patients in the intervention group were given a probiotic supplement containing Lactobacillus acidophilus , Lactobacillus rhamnosus , Bifidobacterium lactis and Lactobacillus paracasei , each containing 1.25 billion live microorganisms, without vitamins and minerals, twice a day in addition to their current treatment for 12 weeks (Probiotic group). Patients in the control group were not given any additional treatment and were allowed to continue their routine antidiabetic treatment for 12 weeks (Control group). Participants taking probiotics were instructed to discontinue probiotic intake if they experienced any serious adverse events requiring intervention. The probiotic product was supplied without placebo equivalent, and due to COVID-19-related supply limitations no identical-appearing placebo powder could be obtained. Sociodemographic data and medical data were recorded for all participants. Anthropometric Measurements Body weight, height, waist (WC) and hip circumferences (HC) were collected following the standardized procedures recommended in the World Health Organization Expert Committee Guidelines for physical examination at baseline and after 12 weeks [ 17 ]. Body mass index (BMI) (kg/m 2 ) and waist-to-hip ratio (WHR) (WC/HC) were calculated. A Food Frequency Questionnaire (FFQ) A Food Frequency Questionnaire was employed to determine how often specific food groups or individual food items were consumed. The frequency of consumption was recorded on a daily, weekly, biweekly, or monthly basis, providing insight into participants’ overall dietary patterns. The FFQ is a commonly used tool to assess the relationship between dietary habits and health outcomes and can be adapted in various ways depending on the researcher’s objectives. Food items can be listed individually or grouped according to categories such as full-fat, low-fat, or fat-free options [ 18 ]. The FFQ consisted of 68 individual food items clustered into five main food groups. In this study, the FFQ included five main food groups: dairy products, meat-egg-legumes, fruits and vegetables, cereals, fats and sweets, and beverages. Participants were asked to indicate how often they consumed each item (e.g., 1–2 times daily, 1–3 times weekly, 4–6 times weekly, once every two weeks, once monthly, or never), which enabled the calculation of their food consumption frequency over the past month. The International Physical Activity Questionnaire (IPAQ) When applying the IPAQ, participants were asked about their vigorous physical activity, moderate physical activity, and walking duration in the last seven days. Additionally, the number of days per week they performed these activities and time spent sitting were determined [ 19 ]. The Turkish validity and reliability study of the questionnaire was conducted by Öztürk [ 20 ]. Scoring was calculated as Metabolic Equivalent of Task (MET) scores from the sum of duration and frequency of moderate activity, vigorous activity, and walking [ 21 ]. Categories: • Category I: Inactive individuals ( 3000 MET-min/week) Ferrans and Powers Quality of Life Index© Diabetes Version- III The scale was developed by Ferrans and Powers to measure quality of life in diabetic patients, consisting of 34 satisfaction and 34 importance items. It includes 5 subscales: Total quality of life, Health and Functioning, Social and Economic, Psychological/Spiritual, and Family scores [ 22 ]. Higher scores indicate better quality of life. The Turkish validity study was conducted by Ozer [ 23 ]. Eating Attitudes Test (EAT-26) The EAT-26 was developed for Garner et al.[ 24 ]. The test consists of 26 items, and the total score is between 0–53. A score of 20 and above is defined as “abnormal eating behavior” and a score less than 20 is defined as “normal eating behavior”. The Turkish validity and reliability study was conducted by Erguney-Okumus and Sertel-Berk [ 25 ]. Biochemical measurements Fasting blood samples were collected from the participants at baseline and week 12, following overnight fasting and after 2 hours of satiety. FBG, PPBG, HbA1c, Total-C, LDL-C, HDL-C, TG and hs-CRP were measured using an autoanalyzer. Serum MDA levels were determined by the thiobarbituric acid method [ 26 ], GSH levels by enzymatic recycling method [ 27 ] and Cp levels by colorimetric method [ 27 ] using a microplate reader. Statistical Analysis Statistical analysis was performed using SPSS 25.0 statistical package program. Data from all patients who completed the study were included in the statistical analysis. For descriptive findings, categorical variables were presented as numbers and percentages, and continuous variables were presented as mean, standard deviation, minimum value and maximum value. Kolmogorov-Smirnov normality tests were used to determine whether the data showed normal distribution. Pearson chi-square test was used to analyse categorical variables. Parametric tests (t test in independent groups, t test in dependent groups) were used in the analysis of normally distributed data, and non-parametric tests (Mann-Whitney U test, Wilcoxon Signed Rank Test) were used in the analysis of non-normally distributed data. Statistical significance level was accepted as p < 0.05. Ethical approval This study was approved by the Clinical Research Ethics Committee of Ege University, Faculty of Medicine (Date: 17.04.2018, Number: 18-4.1/67) and conducted in accordance with the principles of the Declaration of Helsinki. Informed consent was obtained from all participants or their legal representatives before the trial commencement. Results A total of 145 subjects were screened for eligibility; of these, 43 did not meet the inclusion criteria, and 22 declined to participate. Of the 80 participants; 40 were allocated sequentially to the probiotic group and 40 were allocated to the control group. The per protocol (PP) population consisted of 80 subjects. In the probiotic group, 39 subjects completed the study, while in the control group, 38 participants completed the study (Total n = 77). The reasons for exclusion from the PP population were one of the following: failure to attend final follow-up visits (n = 3) (Fig. 1). The mean age was 55.38 ± 6.40 years and 42.86% were female. It was confirmed that baseline characteristics were balanced in both groups, except for a higher rate of education in the probiotic group (Table 1). There were no statistically significant differences between the probiotic and control groups across the main food groups assessed (dairy products; meat, eggs, and legumes; fruits and vegetables; bread and cereals; fats, sweets, and beverages) (p >0.05 for all comparisons). No serious adverse reactions were reported in patients in the probiotic group throughout the study. The type and dosage of medications used by all patients during the study were not changed. After 12 weeks, a significant intragroup decrease was seen in FBG, PPBG, HbA1c, LDL-C, Non-HDL-C and MDA levels in the probiotic group compared to the control group (p < 0.001, p = 0.003, p = 0.004, p = 0.044, p = 0.034, p = 0.001) (Table 2). A statistically non-significant within-group increase in serum HDL-C levels was found in both the probiotic group and the control group (Table 2). Within-group comparisons determined that there was no statistically significant change in weight, BMI, WHR in both the control group and the probiotic group after 12 weeks (Table 2). However, comparisons between the two groups after 12 weeks showed that there was no statistically significant change in anthropometric measurements and biochemical data except PPBG levels (p = 0.038) (Table 3). Discussion In the literature, there are many studies showing that probiotic use may affect glucose, lipid metabolism, inflammation, and oxidation process by balancing intestinal microbiota [28]. The present study is, to our knowledge, the first to demonstrate the effects of a multistrain probiotic supplement given over 3-months in the Turkish T2DM population, using inflammation and antioxidant system as the primary endpoint. While the present study is not the first interventional study undertaken on the effects of probiotics in patients with T2DM, which highlighted cardiometabolic benefits in the probiotic group from baseline to 12 weeks. The results of this study revealed that supplementation with probiotics for 12 weeks significantly reduced FBG, PPBG, HbA1c, LDL-C, non-HDL-C, and MDA in the probiotic group compared to the control group in within-group comparisons. However, comparisons between the two groups after 12 weeks revealed a significant reduction in FBG only in the probiotic group. In the present study, no effect of probiotic use on weight loss was observed. Other studies have reported changes in weight, but these usually occurred when probiotics were taken in combination with a hypocaloric diet and/or the use of bioactive compounds [29]; no special diet or bioactive compounds were used in this study. Some studies have shown that probiotics reduce FBG, PPBG, LDL-C, TG levels and increase HDL cholesterol levels [9–13]. Although not the main focus of this study, the effects of probiotics on glycemic control are also noteworthy. In this study, significant decreases in PPBG (p <0.038) levels were observed in the probiotic group. The intervention period of studies evaluating the effects of probiotic use on metabolism in diabetic patients was usually 4-8 weeks. In these studies, FBG, PPBG, insulin, HbA1c, lipid profile and oxidative stress and/or inflammation markers were generally evaluated. Probiotics used in clinical trials were L. acidophilus , Lactobacillus sporogenes , Bifidobacterium bifidum and B. lactis , used alone or in combination [28]. In this study, the probiotic group was given a probiotic supplement consisting of Lactobacillus acidophilus, Lactobacillus rhamnosus, Bifidobacterium lactis, and Lactobacillus paracasei, without vitamins or minerals. In addition, only a few studies have assessed nutrient intake qualitatively and quantitatively, which may affect the interpretation of results. In this study, participants were not given a special diet or exercise program; they were only warned not to consume foods containing probiotics. In this study, probiotics led to significant improvements in glycemic control. While prior research on their effects in T2DM patients has shown mixed outcomes, a recent meta-analyse suggest a modest but greater impact with multi-strain formulations [30]. A recent RCT found no evidence that a 6-week probiotic supplementation improves short-term glycemic control. On the contrary, there was limited evidence suggesting these strains may have a negative impact on glucose homeostasis [31]. Chaithanya et al. found a decrease in PPBG levels in the probiotic group, similar to the present study [32]. Three different meta-analyses over the last five years suggest that probiotic supplementation has a small but significant effect on glycaemic indices [33–35]. However, the magnitude of effect appears to be modulated by baseline BMI, probiotic strain, dosage, duration of intervention, and ethnic background. In this study, consistent with the results of these meta-analyses, a significant decrease in PPBG levels was found in the probiotic group compared to the control group. The present study supports the idea that probiotics improve glycemic control in T2DM patients. In the meta-analysis by G. Li et al., subgroup analysis found that the effect of probiotics on FBG was greater in individuals with higher baseline BMI (≥30.0 kg/m 2 ). Similar to this meta-analysis, the participants in this study had a BMI ≥30.0 kg/m2 at baseline. The use of probiotics may be a promising adjuvant therapy for glycemic control in patients with T2DM. In the study by Andreasen et al., consistent with this study, did blood glucose metabolism parameters decrease more in patients receiving probiotic therapy in addition to their treatment compared to the control group, but this decrease was not statistically significant [36]. In this study, PPBG levels decreased statistically significantly compared to the control group. We cannot exclude the possibility that the difference in PPBG changes between the two groups in this study was due to an unknown bias, leading to a false-positive result. However, the absence of any significant confounding factors in this study suggest that this possibility is unlikely. Although reductions within-group FBG and PPBG were statistically significant, mean values did not achieve ADA glycemic targets (FBG <100 mg/dL; PPBG <140 mg/dL). The observed reductions (-19 mg/dL for FBG and -21 mg/dL for PPBG) may still be clinically relevant, as even modest improvements in glycemic variability and postprandial excursions can lower long-term cardiometabolic risk. However, the magnitude of change suggests that multistrain probiotics should be viewed as an adjunct to, not a replacement for, standard glycemic therapy. In the present study, in within-group comparisons for the probiotic group, more pronounced decreases in Total-C, TG, LDL-C, and non-HDL-C levels were observed compared to the control group. In particular, the decreases in LDL-C and non-HDL-C levels were found to be statistically significant (p=0.044 and p=0.034, respectively). Although an increase in HDL-C was observed within the group, this change was not statistically significant. These findings are consistent with studies in the literature showing the positive effects of probiotics on lipid metabolism. Begley et al. demonstrated that probiotics could affect cholesterol metabolism by regulating the intestinal microbiota [9]. Similarly, two studies have shown that probiotic supplementation can lower Total-C and LDL-C levels[10, 11]. Tonucci et al. reported a decrease in lipid levels in patients using probiotics for T2DM. In this study, a within-group decrease in lipid parameters was also found the probiotic group after 12 weeks [37]. RCTs have demonstrated that a six-week intake of probiotic yogurt can lead to a significant reduction in Total-C [38, 39]. However, data supporting lipid profile improvement in individuals with diabetes remain scarce [40, 41]. A meta-analysis reported that 4-8 weeks of probiotic treatment led to a 4% reduction in Total-C and a 5% reduction in LDL-C in healthy individuals [42]. Another meta-analysis also showed that a significant LDL-C reduction was observed with the use of probiotics [43]. In a RCT conducted in Saudi Arabia, a significant reduction in glucose, TG, Total-C levels were observed in the probiotic group [16] Although several studies have explored the effects of various probiotic strains on hyperglycemia and lipid profiles in patients with T2DM, the results remain inconsistent. Feizollahzadeh et al. found no significant effect on FBG but reported improvements in lipid parameters, including increased HDL and decreased LDL levels in the probiotic group [44]. Another study observed a similar trend for triglycerides, though not statistically significant [45]. In contrast, this study demonstrated non-significant changes in TG, LDL, and HDL levels in both groups, suggesting a limited effect of probiotics on lipid metabolism in this context. The cholesterol-lowering mechanisms of probiotics may include: (1) probiotic bacteria reducing cholesterol absorption by binding cholesterol to cell membranes or taking it into the cell, (2) increasing cholesterol elimination by disrupting the enterohepatic circulation of bile salts through deconjugation of bile salts, and (3) reducing cholesterol synthesis in the liver through production of short-chain fatty acids[9]. The significant decrease in non-HDL-C levels is important in terms of reducing cardiovascular disease risk, as non-HDL-C includes all atherogenic lipoprotein particles. Studies have shown that L. acidophilus reduces MDA in diabetic rats [46], and probiotic yogurt also reduces MDA compared to conventional yogurt [47]. MDA serves as a lipid peroxidation marker associated with diabetic complications, and Lin and Yen demonstrated various antioxidant mechanisms of probiotics [14]. A meta-analysis demonstrated a significant difference in GSH levels between probiotic and control groups; however, considerable statistical heterogeneity was observed, and its sources could not be fully explained [48]. Another meta-analysis showed that 12 weeks of probiotic supplementation in patients with T2DM significantly decreased serum hs-CRP and MDA levels while increasing oxidative markers such as total antioxidant capacity (TAC), nitric oxide, and GSH[49]. In this study, a statistically non-significant within-group decrease in hs-CRP and MDA levels was observed in the probiotic group, and contrary to expectations, a slight within-group decrease in GSH levels was observed in the probiotic group, while a within-group increase was observed in the control group, but these changes were not statistically significant. This unexpected result may be explained by various factors including dietary and lifestyle influences, insufficient study duration to detect significant changes in glutathione metabolism, or the specific probiotic strain composition affecting glutathione pathways. Dyslipidemia, reduced insulin sensitivity, oxidative stress, and systemic inflammation are common in patients with diabetes and contribute to complications such as increased risk of coronary artery disease [50], diabetic retinopathy, neuropathy, nephropathy, and hypertension [51]. The effect of probiotics on high-sensitivity C-reactive protein (hs-CRP), a marker of systemic inflammation, remains controversial. While some studies have reported non-significant reductions in hs-CRP following probiotic supplementation, [45, 52, 53] Asemi et al. found a significant decrease after 8 weeks of probiotic intake[54]. In another study, all inflammatory markers (TNFα, IL-6 and C-reactive protein) showed a significant decrease in the probiotic group, while no significant change was observed in the placebo group [16]. Since Pfützner et al. [15] demonstrated a positive correlation between beta cell dysfunction severity and high hs-CRP concentrations, inflammation control remains important in diabetic patients. In our study, hs-CRP levels showed a non-significant increase in both groups after 12 weeks, suggesting a lack of anti-inflammatory effect. This may be attributed to relatively low baseline hs-CRP levels in our study population, the specific strain composition and dosage used, or an insufficient study duration to detect changes in chronic inflammatory markers. As an acute phase protein and antioxidant enzyme, elevated Cp levels in diabetic patients indicate increased oxidative stress and inflammation. A literature search revealed no studies demonstrating the effect of probiotic use on serum Cp levels in patients with T2DM. However, given the anti-inflammatory effects of probiotics, a decrease in Cp levels in patients using probiotics is expected. In this study also found a greater decrease in Cp levels in the probiotic group compared to the control group, but this difference was not statistically significant. Larger sample sizes and longer intervention durations are needed in this regard. Limitations and Strengths of the Study The present study has several limitations. Firstly, dietary habits and physical activity were not controlled, potentially affecting results. Because the FFQ assessed consumption frequency rather than quantitative nutrient intake, we were unable to calculate caloric or macronutrient values. Due to operational constraints during the COVID-19 pandemic, semi-quantitative FFQ or 24-hour dietary recalls could not be applied. Secondly, we did not assess gut microbiota composition directly, limiting our understanding of probiotic mechanisms. Thirdly, A placebo powder identical in appearance was not available from the manufacturer during the COVID-19 period; therefore, the control group continued standard care without additional supplementation. Fourthly, multivariate analysis was not performed due to limited sample size and the risk of overfitting. Baseline characteristics were balanced between groups, reducing major confounding. Additionally, computer-generated randomization was not used, and patient recruitment was delayed due to the COVID-19 pandemic. Despite these limitations, this study has notable strengths including its prospective controlled design, high patient compliance, and comprehensive evaluation of metabolic parameters. To our knowledge, this is among the first studies to comprehensively assess probiotic effects on lipid profile, oxidative stress, and inflammation in T2DM patients. The 12-week intervention period, longer than most comparable studies (4-8 weeks), enhances the significance of our positive findings. Conclusion In conclusion, three months of multi-strain probiotic supplementation significantly reduced PPBG levels in T2DM patients, as well as FBG, HbA1c levels, lipid metabolism parameters, and inflammatory markers and oxidative stress markers, although not statistically significantly. The findings of this study suggest that probiotic supplementation, in addition to standard therapy, may provide metabolic benefits in T2DM patients. However, larger-scale studies with microbiome profiling, dietary monitoring, and longer follow-up are needed to confirm these findings and elucidate the underlying mechanisms. Abbreviations T2DM Type 2 diabetes mellitus WC Waist circumference HC Hip circumference BMI Body mass index WHR Waist-to-hip ratio FFQ A Food Frequency Questionnaire IPAQ The International Physical Activity Questionnaire MET Metabolic Equivalent of Task EAT-26 Eating Attitudes Test FBG Fasting blood glucose PPBG Postprandial blood glucose Total-C Total cholesterol LDL-C LDL cholesterol HDL-C HDL cholesterol TG Triglyceride hs-CRP High-sensitivity C-Reactive Protein MDA Malondialdehyde Cp Ceruloplasmin GSH Glutathione HOMA-IR Homeostasis model of assessment-insulin resistance Declarations Acknowledgments This study was funded and supported by Ege University Scientific Research Projects Unit (Number: TGA-2020-20200). We thank Prof. Dr. Fehmi Akçiçek for academic consultancy and Dr. Nergiz Zorbozan for biochemical analyses. The authors thank iHealth Company for providing the probiotic supplements used in this study. The sponsor had no role in study design, data collection, analysis, interpretation of results, or manuscript preparation. Author Contributions AK, OY, NT, OZ and IYŞ generated the study idea and designed the protocol. AK and OZ contributed to data collection and/or analysis of study outcomes. AK and OZ performed and interpreted the data analysis and drafted the manuscript. AK, NT, OY, IYŞ, and OZ reviewed the manuscript providing substantial academic and/or clinical input. All authors approved the final manuscript. AK is the guarantor of the work and as such had full access to all the data and takes responsibility for the integrity of the data and the accuracy of the data analysis. Funding This study was funded and supported by Ege University Scientific Research Projects Unit (Number: TGA-2020-20200). Data Availability The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Ethics approval and consent to participate The study was completed in compliance with the guidelines of the Helsinki Declaration. The study protocol was reviewed and approved by the Clinical Research Ethics Committee of Ege University Faculty of Medicine (Date: 17.04.2018, Number: 18-4.1/67). Approval for data collection from the administration of hospital has been acquired. All participants reviewed and signed an informed consent form before participation. Consent for publication Not applicable. Competing interests The authors declare no financial or non-financial competing interests. Trial registration ClinialTrials.gov registration number: NCT07330388. Registered on 23 December 2025. https://clinicaltrials.gov/search?term=NCT07330388 References Sullivan PW, Morrato EH, Ghushchyan V, Wyatt HR, Hill JO. Obesity, Inactivity, and the Prevalence of Diabetes and Diabetes-Related Cardiovascular Comorbidities in the U.S., 2000–2002. Diabetes Care. 2005;28:1599–603. https://doi.org/10.2337/diacare.28.7.1599 . Engelgau MM, Geiss LS, Saaddine JB, Boyle JP, Benjamin SM, Gregg EW, et al. The Evolving Diabetes Burden in the United States. Ann Intern Med. 2004;140:945–50. https://doi.org/10.7326/0003-4819-140-11-200406010-00035 . Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, et al. Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach. Diabetes Care. 2012;35:1364–79. https://doi.org/10.2337/dc12-0413 . Choi SH, Chae A, Miller E, Messig M, Ntanios F, DeMaria AN, et al. Relationship Between Biomarkers of Oxidized Low-Density Lipoprotein, Statin Therapy, Quantitative Coronary Angiography, and Atheroma Volume. J Am Coll Cardiol. 2008;52:24–32. https://doi.org/10.1016/j.jacc.2008.02.066 . Hansen AK, Hansen CHF, Krych L, Nielsen DS. Impact of the gut microbiota on rodent models of human disease. World J Gastroenterol. 2014;20:17727–36. https://doi.org/10.3748/wjg.v20.i47.17727 . Bienenstock J, Kunze W, Forsythe P. Microbiota and the gut–brain axis. Nutr Rev. 2015;73:28–31. https://doi.org/10.1093/nutrit/nuv019 . Panwar H, Rashmi HM, Batish VK, Grover S. Probiotics as potential biotherapeutics in the management of type 2 diabetes - prospects and perspectives. Diabetes Metab Res Rev. 2013;29:103–12. https://doi.org/10.1002/dmrr.2376 . Joint, FAO/WHO Working Group. Guidelines for the Evaluation of Probiotics in Food. London, Ontario; 2002. Begley M, Hill C, Gahan CGM. Bile Salt Hydrolase Activity in Probiotics. Appl Environ Microbiol. 2006;72:1729–38. https://doi.org/10.1128/AEM.72.3.1729-1738.2006 . Patel AK, Singhania RR, Pandey A, Chincholkar SB. Probiotic Bile Salt Hydrolase: Current Developments and Perspectives. Appl Biochem Biotechnol. 2010;162:166–80. https://doi.org/10.1007/s12010-009-8738-1 . Guo Z, Liu XM, Zhang QX, Shen Z, Tian FW, Zhang H, et al. Influence of consumption of probiotics on the plasma lipid profile: A meta-analysis of randomised controlled trials. Nutr Metabolism Cardiovasc Dis. 2011;21:844–50. https://doi.org/10.1016/j.numecd.2011.04.008 . Li Z, Yang S, Huang J, Watkins PA, Moser AB, Desimone C, Song XY, Diehl AM. Probiotics and antibodies to TNF inhibit inflammatory activity and improve nonalcoholic fatty liver disease. Hepatology. 2003;37:343–50. https://doi.org/10.1053/jhep.2003.50048 . OZAKI TABUCHIM, TAMURA M, YAMADA A, ISHIDA N, HOSODA T. Antidiabetic Effect of Lactobacillus GG in Streptozotocin-induced Diabetic Rats. Biosci Biotechnol Biochem. 2003;67:1421–4. https://doi.org/10.1271/bbb.67.1421 . Lin M-Y, Yen C-L. Antioxidative Ability of Lactic Acid Bacteria. J Agric Food Chem. 1999;47:1460–6. https://doi.org/10.1021/jf981149l . Pfützner A, Standl E, Strotmann H-J, Schulze J, Hohberg C, Lübben G, et al. Association of high-sensitive C-reactive protein with advanced stage β-cell dysfunction and insulin resistance in patients with type 2 diabetes mellitus. Clin Chem Lab Med (CCLM). 2006;44. https://doi.org/10.1515/CCLM.2006.108 . Sabico S, Al-Mashharawi A, Al-Daghri NM, Wani K, Amer OE, Hussain DS, et al. Effects of a 6-month multi-strain probiotics supplementation in endotoxemic, inflammatory and cardiometabolic status of T2DM patients: A randomized, double-blind, placebo-controlled trial. Clin Nutr. 2019;38:1561–9. https://doi.org/10.1016/j.clnu.2018.08.009 . WHO. Physical Status: The Use of and Interpretation of Anthropometry, Report of a WHO Expert Committee. Geneva, Switzerland: World Health Organization; 1995. RESNICOW YAROCHAL, DAVIS K, DAVIS M, SMITH A, KHAN M. Development of a Modified Picture-Sort Food Frequency Questionnaire Administered to Low-income, Overweight, African-American Adolescent Girls. J Am Diet Assoc. 2000;100:1050–6. https://doi.org/10.1016/S0002-8223(00)00306-0 . MARSHALL CRAIGCL, SJ??STR??M AL, BAUMAN M, BOOTH AE, AINSWORTH ML. International Physical Activity Questionnaire: 12-Country Reliability and Validity. Med Sci Sports Exerc. 2003;35:1381–95. https://doi.org/10.1249/01.MSS.0000078924.61453.FB . Öztürk M. Üniversitede eğitim-öğretim gören öğrencilerde Uluslararası Fiziksel Aktivite anketinin geçerliliği ve güvenirliliği ve fiziksel aktivite düzeylerinin belirlenmesi. Master’s Thesis. Hacettepe University; 2005. Karaca A, Turnagöl HH, ÇALIŞAN BİREYLERDE ÜÇ FARKLI, FİZİKSEL AKTİVİTE ANKETİNİN GÜVENİRLİĞİ VE GEÇERLİĞİ. Spor Bilimleri Dergisi. 2007;18:68–84. Ferrans C, Powers M. Ferrans and Powers Quality of Life Index (QLI). 1984. https://qli.org.uic.edu/ Özer Z. Miyokard Enfarktüsü Geçiren Bireylerde Ferrans ve Powers Yaşam Kalitesi Ölçeği’nin Geçerlilik ve Güvenirlilik Çalışmasının Yapılması. MN Kardiyoloji Dergisi. 2003;10:111–21. Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The Eating Attitudes Test: psychometric features and clinical correlates. Psychol Med. 1982;12:871–8. https://doi.org/10.1017/S0033291700049163 . Ergüney-Okumuş FE, Sertel-Berk HÖ. Yeme Tutum Testi Kısa Formunun (YTT-26) Üniversite Örnekleminde Türkçeye Uyarlanması ve Psikometrik Özelliklerinin Değerlendirilmesi. Psikoloji Çalışmaları / Stud Psychol. 2020;57–78. https://doi.org/10.26650/SP2019-0039 . Jain SK, Ross JD, Levy GJ, Little RL, Duett J. The accumulation of malonyldialdehyde, an end product of membrane lipid peroxidation, can cause potassium leak in normal and sickle red blood cells. Biochem Med Metab Biol. 1989;42:60–5. https://doi.org/10.1016/0885-4505(89)90041-8 . Hellman NE, Gitlin JD. Ceruloplasmin metabolism and function. Annu Rev Nutr. 2002;22:439–58. https://doi.org/10.1146/annurev.nutr.22.012502.114457 . Bordalo Tonucci L, Dos Santos KMO, De Luces Fortes Ferreira CL, Ribeiro SMR, De Oliveira LL, Martino HSD. Gut microbiota and probiotics: Focus on diabetes mellitus. Crit Rev Food Sci Nutr. 2017;57:2296–309. https://doi.org/10.1080/10408398.2014.934438 . Crovesy L, Ostrowski M, Ferreira DMTP, Rosado EL, Soares-Mota M. Effect of Lactobacillus on body weight and body fat in overweight subjects: a systematic review of randomized controlled clinical trials. Int J Obes. 2017;41:1607–14. https://doi.org/10.1038/ijo.2017.161 . Nikbakht E, Khalesi S, Singh I, Williams LT, West NP, Colson N. Effect of probiotics and synbiotics on blood glucose: a systematic review and meta-analysis of controlled trials. Eur J Nutr. 2018;57:95–106. https://doi.org/10.1007/s00394-016-1300-3 . Ivey KL, Hodgson JM, Kerr DA, Lewis JR, Thompson PL, Prince RL. The effects of probiotic bacteria on glycaemic control in overweight men and women: a randomised controlled trial. Eur J Clin Nutr. 2014;68:447–52. https://doi.org/10.1038/ejcn.2013.294 . Chaithanya V, Kumar J, Vajravelu Leela K, Ram M, Thulukanam J. Impact of Multistrain Probiotic Supplementation on Glycemic Control in Type 2 Diabetes Mellitus—Randomized Controlled Trial. Life. 2024;14:1484. https://doi.org/10.3390/life14111484 . Zhong H, Wang L, Jia F, Yan Y, Xiong F, Hidayat K, et al. Effect of Probiotic Fermented Milk Supplementation on Glucose and Lipid Metabolism Parameters and Inflammatory Markers in Patients with Type 2 Diabetes Mellitus: A Meta-Analysis of Randomized Controlled Trials. Biology (Basel). 2024;13:641. https://doi.org/10.3390/biology13080641 . Li G, Feng H, Mao X-L, Deng Y-J, Wang X-B, Zhang Q, et al. The effects of probiotics supplementation on glycaemic control among adults with type 2 diabetes mellitus: a systematic review and meta-analysis of randomised clinical trials. J Transl Med. 2023;21:442. https://doi.org/10.1186/s12967-023-04306-0 . Liang T, Wu L, Xi Y, Li Y, Xie X, Fan C, et al. Probiotics supplementation improves hyperglycemia, hypercholesterolemia, and hypertension in type 2 diabetes mellitus: An update of meta-analysis. Crit Rev Food Sci Nutr. 2021;61:1670–88. https://doi.org/10.1080/10408398.2020.1764488 . Andreasen AS, Larsen N, Pedersen-Skovsgaard T, Berg RMG, Møller K, Svendsen KD, et al. Effects of Lactobacillus acidophilus NCFM on insulin sensitivity and the systemic inflammatory response in human subjects. Br J Nutr. 2010;104:1831–8. https://doi.org/10.1017/S0007114510002874 . Tonucci LB, Olbrich dos Santos KM, Licursi de Oliveira L, Rocha Ribeiro SM, Duarte Martino HS. Clinical application of probiotics in type 2 diabetes mellitus: A randomized, double-blind, placebo-controlled study. Clin Nutr. 2017;36:85–92. https://doi.org/10.1016/j.clnu.2015.11.011 . Ataie-Jafari A, Larijani B, Alavi Majd H, Tahbaz F. Cholesterol-Lowering Effect of Probiotic Yogurt in Comparison with Ordinary Yogurt in Mildly to Moderately Hypercholesterolemic Subjects. Ann Nutr Metab. 2009;54:22–7. https://doi.org/10.1159/000203284 . Anderson JW, Gilliland SE. Effect of Fermented Milk (Yogurt) Containing Lactobacillus Acidophilus L1 on Serum Cholesterol in Hypercholesterolemic Humans. J Am Coll Nutr. 1999;18:43–50. https://doi.org/10.1080/07315724.1999.10718826 . Moroti C, Souza Magri LF, de Rezende Costa M, Cavallini DC, Sivieri K. Effect of the consumption of a new symbiotic shake on glycemia and cholesterol levels in elderly people with type 2 diabetes mellitus. Lipids Health Dis. 2012;11:29. https://doi.org/10.1186/1476-511X-11-29 . Ejtahed HS, Mohtadi-Nia J, Homayouni-Rad A, Niafar M, Asghari-Jafarabadi M, Mofid V, et al. Effect of probiotic yogurt containing Lactobacillus acidophilus and Bifidobacterium lactis on lipid profile in individuals with type 2 diabetes mellitus. J Dairy Sci. 2011;94:3288–94. https://doi.org/10.3168/jds.2010-4128 . Agerholm-Larsen L, Bell M, Grunwald G, Astrup A. The effect of a probiotic milk product on plasma cholesterol: a meta-analysis of short-term intervention studies. Eur J Clin Nutr. 2000;54:856–60. https://doi.org/10.1038/sj.ejcn.1601104 . DiRienzo DB. Effect of probiotics on biomarkers of cardiovascular disease: implications for heart-healthy diets. Nutr Rev. 2014;72:18–29. https://doi.org/10.1111/nure.12084 . Feizollahzadeh S, Ghiasvand R, Rezaei A, Khanahmad H, Sadeghi A, Hariri M. Effect of Probiotic Soy Milk on Serum Levels of Adiponectin, Inflammatory Mediators, Lipid Profile, and Fasting Blood Glucose Among Patients with Type II Diabetes Mellitus. Probiotics Antimicrob Proteins. 2017;9:41–7. https://doi.org/10.1007/s12602-016-9233-y . Firouzi S, Majid HA, Ismail A, Kamaruddin NA, Barakatun-Nisak M-Y. Effect of multi-strain probiotics (multi-strain microbial cell preparation) on glycemic control and other diabetes-related outcomes in people with type 2 diabetes: a randomized controlled trial. Eur J Nutr. 2017;56:1535–50. https://doi.org/10.1007/s00394-016-1199-8 . Harisa GI, Taha EI, Khalil AF, Salem M. Oral administration of Lactobacillus acidophilus restores nitric oxide level in diabetic rats. Aust J Basic Appl Sci. 2009;3:2963–9. Ejtahed HS, Mohtadi-Nia J, Homayouni-Rad A, Niafar M, Asghari-Jafarabadi M, Mofid V. Probiotic yogurt improves antioxidant status in type 2 diabetic patients. Nutrition. 2012;28:539–43. https://doi.org/10.1016/j.nut.2011.08.013 . Dai Y, Quan J, Xiong L, Luo Y, Yi B. Probiotics improve renal function, glucose, lipids, inflammation and oxidative stress in diabetic kidney disease: a systematic review and meta-analysis. Ren Fail. 2022;44:862–80. https://doi.org/10.1080/0886022X.2022.2079522 . Zheng HJ, Guo J, Jia Q, Huang YS, Huang W-J, Zhang W, et al. The effect of probiotic and synbiotic supplementation on biomarkers of inflammation and oxidative stress in diabetic patients: A systematic review and meta-analysis of randomized controlled trials. Pharmacol Res. 2019;142:303–13. https://doi.org/10.1016/j.phrs.2019.02.016 . Shim U, Lee H, Oh J-Y, Sung Y-A. Sleep Disorder and Cardiovascular Risk Factors among Patients with Type 2 Diabetes Mellitus. Korean J Intern Med. 2011;26:277. https://doi.org/10.3904/kjim.2011.26.3.277 . White JR. Economic considerations in treating patients with type 2 diabetes mellitus. Am J Health-System Pharm. 2002;59. https://doi.org/10.1093/ajhp/59.suppl_9.S14 . suppl_9:S14–7. Mazloom Z, Yousefinejad A, Dabbaghmanesh MH. Effect of probiotics on lipid profile, glycemic control, insulin action, oxidative stress, and inflammatory markers in patients with type 2 diabetes: a clinical trial. Iran J Med Sci. 2013;38:38–43. Mohamadshahi M, Veissi M, Haidari F, Shahbazian H, Kaydani G-A, Mohammadi F. Effects of probiotic yogurt consumption on inflammatory biomarkers in patients with type 2 diabetes. Bioimpacts. 2014;4:83–8. https://doi.org/10.5681/bi.2014.007 . Asemi Z, Zare Z, Shakeri H, Sabihi S, Esmaillzadeh A. Effect of Multispecies Probiotic Supplements on Metabolic Profiles, hs-CRP, and Oxidative Stress in Patients with Type 2 Diabetes. Ann Nutr Metab. 2013;63:1–9. https://doi.org/10.1159/000349922 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 16 Mar, 2026 Reviewers agreed at journal 15 Mar, 2026 Reviewers agreed at journal 15 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviews received at journal 13 Mar, 2026 Reviewers agreed at journal 13 Mar, 2026 Reviewers agreed at journal 13 Mar, 2026 Reviewers agreed at journal 12 Mar, 2026 Reviewers agreed at journal 27 Feb, 2026 Reviewers agreed at journal 27 Feb, 2026 Reviews received at journal 26 Feb, 2026 Reviewers agreed at journal 25 Feb, 2026 Reviewers agreed at journal 24 Feb, 2026 Reviewers agreed at journal 24 Feb, 2026 Reviewers agreed at journal 24 Feb, 2026 Reviewers invited by journal 24 Feb, 2026 Editor assigned by journal 19 Feb, 2026 Editor invited by journal 06 Feb, 2026 Submission checks completed at journal 10 Jan, 2026 First submitted to journal 10 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8262784","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":596834792,"identity":"a10048d8-a07d-4f07-a278-07df69a6e6dd","order_by":0,"name":"Asli KILAVUZ","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYFAC5oYDDAckZMDsDxAhAwJaGMFaeMDMGXAtCfi1MDAcYABrYeYhRgt//8HGAwxnLHj4Z+QYf7apqJVjYG/eJsH44x5OLRI3EoEOuyHBI3Ejx8A458xxYwaeY2USDAnFuK25AfLLB6BfzpwxSM5tO5bYIJFjBtSC22Xy5w9CtMgDtRy2/HesvkH+DX4tBgegDjM43mPYzNhQk8AgwYNfiyHILwlnJHgMj7cVM/YcO2DYxpNWbJGQhluL3PnDhz98OFYnJ3eYefOHHzV18vzshzfe+GCDWwsYIEkfZmBDEyEI6khQOwpGwSgYBSMFAAAbZFV9ihSKMgAAAABJRU5ErkJggg==","orcid":"","institution":"Ege Üniversitesi Tıp Fakültesi Hastanesi","correspondingAuthor":true,"prefix":"","firstName":"Asli","middleName":"","lastName":"KILAVUZ","suffix":""},{"id":596834793,"identity":"81422ad0-39bd-465c-bb52-525415f7e9fc","order_by":1,"name":"Orcun ZORBOZAN","email":"","orcid":"","institution":"Bakırçay Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Orcun","middleName":"","lastName":"ZORBOZAN","suffix":""},{"id":596834794,"identity":"5d061b87-c533-4a12-8e4b-86c5477fabaa","order_by":2,"name":"Ilgin YILDIRIM SIMSIR","email":"","orcid":"","institution":"Ege Üniversitesi Tıp Fakültesi Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"Ilgin","middleName":"YILDIRIM","lastName":"SIMSIR","suffix":""},{"id":596834795,"identity":"85b89fbb-48d1-456f-a696-591af80e2772","order_by":3,"name":"Nevin TURGAY","email":"","orcid":"","institution":"Ege Üniversitesi Tıp Fakültesi Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"Nevin","middleName":"","lastName":"TURGAY","suffix":""},{"id":596834797,"identity":"cbb3d518-eb98-4e7a-9ead-c88b087e552a","order_by":4,"name":"Ozlem YILMAZ","email":"","orcid":"","institution":"Ege Üniversitesi Tıp Fakültesi Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"Ozlem","middleName":"","lastName":"YILMAZ","suffix":""}],"badges":[],"createdAt":"2025-12-02 16:38:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8262784/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8262784/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103599630,"identity":"f5c55145-44be-40e0-bfa1-866713588553","added_by":"auto","created_at":"2026-02-27 13:51:38","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30954,"visible":true,"origin":"","legend":"\u003cp\u003eThe CONSORT diagram shows the participants' flow through each stage of the clinical trial.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8262784/v1/86f9fec91740509753e0d49e.jpeg"},{"id":104399152,"identity":"73910083-984e-4209-960d-a141142d1ef0","added_by":"auto","created_at":"2026-03-11 12:04:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":692582,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8262784/v1/9bc0b009-b176-4958-93ee-c9374da2df30.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of Multistrain Probiotics on Metabolic Biomarkers, Inflammation, and Antioxidant System in Patients with Type 2 Diabetes Mellitus: A Prospective Controlled Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eType 2 diabetes mellitus (T2DM) prevalence has increased alarmingly due to obesity and sedentary lifestyle trends [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. T2DM causes end-stage renal failure, blindness, and lower limb amputations through progressive atherosclerosis, leading to 3-fold increased cardiovascular events and 2-fold increased cerebrovascular events [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent data suggest that the gut microbiota plays a key role in development and progression of T2DM. This complex ecosystem of at least 10\u003csup\u003e14\u003c/sup\u003e different bacteria affects energy homeostasis through the microorganism-gut-brain axis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Gut microbiota changes can alter enteroendocrine signals and gut hormones that regulate β-cell function, insulin secretion, and energy homeostasis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The gut microbiota can affect the host's inflammation response and energy metabolism, in other words, alteration of the gut microbiota can affect glucose and lipid metabolism and insulin action. One of the most effective methods of maintaining the balance of the gut microbiota is the use of probiotics, defined as live microorganisms that, when given in adequate amounts, show host-specific benefit [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Recently, a growing number of studies have found that probiotics can alter gut flora, improve total cholesterol (Total-C) and Low-Density Lipoprotein Cholesterol (LDL-C) levels [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and reduce blood glucose levels and insulin resistance [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Nowadays, oxidative stress is also suggested to be a mechanism underlying diabetes and its complications. Antioxidant mechanisms of probiotics include scavenging of reactive oxygen species, metal ion chelation, enzyme inhibition, reduction activity, and inhibition of ascorbate autoxidation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eModification of gut microflora with probiotics may be seen as a novel tool for the regulation of glucose metabolism and improvement of oxidative stress in T2DM. Increased severity of beta cell dysfunction was positively correlated with increased high-sensitivity C-Reactive Protein (hs-CRP) concentrations [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough T2DM is recognized as a chronic inflammatory disease, the role of probiotics and prebiotics in its management remains insufficiently explored, and existing evidence regarding their overall efficacy in health and disease is inconsistent [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegulation of gut microbiota through dietary interventions (e.g., probiotic intake) may be beneficial in reducing inflammation [hs-CRP and Ceruloplasmin (Cp)] and oxidative stress [Glutathione (GSH) and Malondialdehyde (MDA)], as well as regulating glucose and lipid metabolism in T2DM. The aim of this study was to investigate the effects of probiotics on glucose and lipid metabolism, inflammation and antioxidant system in patients with T2DM.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTrial design\u003c/h2\u003e \u003cp\u003eThis was a single center, prospective controlled study conducted at the Internal Medicine Outpatient Clinic of Ege University Faculty of Medicine between July 2020 and June 2023. The study included a screening visit, a baseline visit (D0) and one follow-up visit during a 60-days supplementation period. The primary outcomes of the study were defined as the effects of the intervention on inflammatory markers, specifically focusing on a significant decrease in hs-CRP and Cp levels, and oxidative stress markers, including a significant reduction in MDA levels and a significant increase in reduced GSH levels. Secondary outcomes included assessing the glucose metabolism and lipid profile changes, which specifically targeted a significant decrease in Fasting Blood Glucose (FBG), Postprandial Blood Glucose (PPBG), and Glycated Hemoglobin (HbA1c), alongside a reduction in LDL-C and Triglyceride (TG) levels, and an increase in High-Density Lipoprotein Cholesterol (HDL-C) levels.\u003c/p\u003e \u003cp\u003e The study adhered to CONSORT guidelines.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTrial participants\u003c/h3\u003e\n\u003cp\u003ePower analysis was performed and the sample size was calculated as 79 with a statistical power of 80% and an effect size of 0.35. Since two groups were to be studied, 80 patients were planned to participate in the study to equalize the number of participants.\u003c/p\u003e \u003cp\u003e This study included adults aged 35\u0026ndash;65 years who were diagnosed with T2DM according to American Diabetes Association guidelines, who volunteered to participate in this study. Exclusion criteria were as follows: Use of any systemic antibiotics, multivitamins, minerals, herbal medicines, prebiotic, probiotic and postbiotic supplements in the last 3\u0026ndash;6 months, having a diagnosis of any inflammatory bowel disease, severe renal dysfunction or hepatic dysfunction, immunodeficiency diseases, acute infection, rheumatoid arthritis, cancer history, history of alcohol abuse or drug dependence, pregnant or lactating women. Dietary habits, physical activity, and glucose-lowering therapy of the participants were not intervened during the study.\u003c/p\u003e \u003cp\u003eParticipants were allocated sequentially according to order of presentation (alternate allocation). According to the order of presentation to the outpatient clinic, the first patient who met the inclusion criteria was included in the probiotic group and the second patient who presented to the outpatient clinic was included in the control group. Patients in the intervention group were given a probiotic supplement containing \u003cem\u003eLactobacillus acidophilus\u003c/em\u003e, \u003cem\u003eLactobacillus rhamnosus\u003c/em\u003e, \u003cem\u003eBifidobacterium lactis\u003c/em\u003e and \u003cem\u003eLactobacillus paracasei\u003c/em\u003e, each containing 1.25\u0026nbsp;billion live microorganisms, without vitamins and minerals, twice a day in addition to their current treatment for 12 weeks (Probiotic group). Patients in the control group were not given any additional treatment and were allowed to continue their routine antidiabetic treatment for 12 weeks (Control group). Participants taking probiotics were instructed to discontinue probiotic intake if they experienced any serious adverse events requiring intervention. The probiotic product was supplied without placebo equivalent, and due to COVID-19-related supply limitations no identical-appearing placebo powder could be obtained. Sociodemographic data and medical data were recorded for all participants.\u003c/p\u003e\n\u003ch3\u003eAnthropometric Measurements\u003c/h3\u003e\n\u003cp\u003eBody weight, height, waist (WC) and hip circumferences (HC) were collected following the standardized procedures recommended in the World Health Organization Expert Committee Guidelines for physical examination at baseline and after 12 weeks [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Body mass index (BMI) (kg/m\u003csup\u003e2\u003c/sup\u003e) and waist-to-hip ratio (WHR) (WC/HC) were calculated.\u003c/p\u003e\n\u003ch3\u003eA Food Frequency Questionnaire (FFQ)\u003c/h3\u003e\n\u003cp\u003eA Food Frequency Questionnaire was employed to determine how often specific food groups or individual food items were consumed. The frequency of consumption was recorded on a daily, weekly, biweekly, or monthly basis, providing insight into participants\u0026rsquo; overall dietary patterns. The FFQ is a commonly used tool to assess the relationship between dietary habits and health outcomes and can be adapted in various ways depending on the researcher\u0026rsquo;s objectives. Food items can be listed individually or grouped according to categories such as full-fat, low-fat, or fat-free options [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The FFQ consisted of 68 individual food items clustered into five main food groups. In this study, the FFQ included five main food groups: dairy products, meat-egg-legumes, fruits and vegetables, cereals, fats and sweets, and beverages. Participants were asked to indicate how often they consumed each item (e.g., 1\u0026ndash;2 times daily, 1\u0026ndash;3 times weekly, 4\u0026ndash;6 times weekly, once every two weeks, once monthly, or never), which enabled the calculation of their food consumption frequency over the past month.\u003c/p\u003e\n\u003ch3\u003eThe International Physical Activity Questionnaire (IPAQ)\u003c/h3\u003e\n\u003cp\u003eWhen applying the IPAQ, participants were asked about their vigorous physical activity, moderate physical activity, and walking duration in the last seven days. Additionally, the number of days per week they performed these activities and time spent sitting were determined [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The Turkish validity and reliability study of the questionnaire was conducted by \u0026Ouml;zt\u0026uuml;rk [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Scoring was calculated as Metabolic Equivalent of Task (MET) scores from the sum of duration and frequency of moderate activity, vigorous activity, and walking [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Categories:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Category I: Inactive individuals (\u0026lt;\u0026thinsp;600 MET-min/week)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Category II: Minimum active individuals (600\u0026ndash;3000 MET-min/week)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Category III: Very active individuals (\u0026gt;\u0026thinsp;3000 MET-min/week)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFerrans and Powers Quality of Life Index\u0026copy; Diabetes Version- III\u003c/h2\u003e \u003cp\u003eThe scale was developed by Ferrans and Powers to measure quality of life in diabetic patients, consisting of 34 satisfaction and 34 importance items. It includes 5 subscales: Total quality of life, Health and Functioning, Social and Economic, Psychological/Spiritual, and Family scores [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Higher scores indicate better quality of life. The Turkish validity study was conducted by Ozer [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEating Attitudes Test (EAT-26)\u003c/h3\u003e\n\u003cp\u003eThe EAT-26 was developed for Garner et al.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The test consists of 26 items, and the total score is between 0\u0026ndash;53. A score of 20 and above is defined as \u0026ldquo;abnormal eating behavior\u0026rdquo; and a score less than 20 is defined as \u0026ldquo;normal eating behavior\u0026rdquo;. The Turkish validity and reliability study was conducted by Erguney-Okumus and Sertel-Berk [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eBiochemical measurements\u003c/h3\u003e\n\u003cp\u003eFasting blood samples were collected from the participants at baseline and week 12, following overnight fasting and after 2 hours of satiety. FBG, PPBG, HbA1c, Total-C, LDL-C, HDL-C, TG and hs-CRP were measured using an autoanalyzer. Serum MDA levels were determined by the thiobarbituric acid method [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], GSH levels by enzymatic recycling method [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and Cp levels by colorimetric method [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] using a microplate reader.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using SPSS 25.0 statistical package program. Data from all patients who completed the study were included in the statistical analysis. For descriptive findings, categorical variables were presented as numbers and percentages, and continuous variables were presented as mean, standard deviation, minimum value and maximum value. Kolmogorov-Smirnov normality tests were used to determine whether the data showed normal distribution. Pearson chi-square test was used to analyse categorical variables. Parametric tests (t test in independent groups, t test in dependent groups) were used in the analysis of normally distributed data, and non-parametric tests (Mann-Whitney U test, Wilcoxon Signed Rank Test) were used in the analysis of non-normally distributed data. Statistical significance level was accepted as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Clinical Research Ethics Committee of Ege University, Faculty of Medicine (Date: 17.04.2018, Number: 18-4.1/67) and conducted in accordance with the principles of the Declaration of Helsinki. Informed consent was obtained from all participants or their legal representatives before the trial commencement.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 145 subjects were screened for eligibility; of these, 43 did not meet the inclusion criteria, and 22 declined to participate. \u0026nbsp;Of the 80 participants; 40 were allocated sequentially to the probiotic group and 40 were allocated to the control group. \u0026nbsp;The per protocol (PP) population consisted of 80 subjects. In the probiotic group, 39 subjects completed the study, while in the control group, 38 participants completed the study (Total n = 77). The reasons for exclusion from the PP population were one of the following: failure to attend final follow-up visits (n = 3) (Fig. 1). The mean age was 55.38 \u0026plusmn; 6.40 years and 42.86% were female. It was confirmed that baseline characteristics were balanced in both groups, except for a higher rate of education in the probiotic group (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere were no statistically significant differences between the probiotic and control groups across the main food groups assessed (dairy products; meat, eggs, and legumes; fruits and vegetables; bread and cereals; fats, sweets, and beverages) (p \u0026gt;0.05 for all comparisons). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo serious adverse reactions were reported in patients in the probiotic group throughout the study. The type and dosage of medications used by all patients during the study were not changed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter 12 weeks, a significant intragroup decrease was seen in FBG, PPBG, HbA1c, LDL-C, Non-HDL-C and MDA levels in the probiotic group compared to the control group (p \u0026lt; 0.001, p = 0.003, p = 0.004, p = 0.044, p = 0.034, p = 0.001) (Table 2).\u003c/p\u003e\n\u003cp\u003eA statistically non-significant within-group increase in serum HDL-C levels was found in both the probiotic group and the control group (Table 2).\u003c/p\u003e\n\u003cp\u003eWithin-group comparisons determined that there was no statistically significant change in weight, BMI, WHR in both the control group and the probiotic group after 12 weeks (Table 2).\u003c/p\u003e\n\u003cp\u003eHowever, comparisons between the two groups after 12 weeks showed that there was no statistically significant change in anthropometric measurements and biochemical data except PPBG levels (p = 0.038) (Table 3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the literature, there are many studies showing that probiotic use may affect glucose, lipid metabolism, inflammation, and oxidation process by balancing intestinal microbiota [28]. The present study is, to our knowledge, the first to demonstrate the effects of a multistrain probiotic supplement given over 3-months in the Turkish T2DM population, using inflammation and antioxidant system as the primary endpoint. While the present study is not the first interventional study undertaken on the effects of probiotics in patients with T2DM, which highlighted cardiometabolic benefits in the probiotic group from baseline to 12 weeks. The results of this study revealed that supplementation with probiotics for 12 weeks significantly reduced FBG, PPBG, HbA1c, LDL-C, non-HDL-C, and MDA in the probiotic group compared to the control group in within-group comparisons. However, comparisons between the two groups after 12 weeks revealed a significant reduction in FBG only in the probiotic group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the present study, no effect of probiotic use on weight loss was observed. Other studies have reported changes in weight, but these usually occurred when probiotics were taken in combination with a hypocaloric diet and/or the use of bioactive compounds [29]; no special diet or bioactive compounds were used in this study.\u003c/p\u003e\n\u003cp\u003eSome studies have shown that probiotics reduce FBG, PPBG, LDL-C, TG levels and increase HDL cholesterol levels [9\u0026ndash;13]. Although not the main focus of this study, the effects of probiotics on glycemic control are also noteworthy. In this study, significant decreases in PPBG (p \u0026lt;0.038) levels were observed in the probiotic group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe intervention period of studies evaluating the effects of probiotic use on metabolism in diabetic patients was usually 4-8 weeks. In these studies, FBG, PPBG, insulin, HbA1c, lipid profile and oxidative stress and/or inflammation markers were generally evaluated. Probiotics used in clinical trials were \u003cem\u003eL. acidophilus\u003c/em\u003e, \u003cem\u003eLactobacillus sporogenes\u003c/em\u003e, \u003cem\u003eBifidobacterium bifidum\u003c/em\u003e and \u003cem\u003eB. lactis\u003c/em\u003e, used alone or in combination [28]. In this study, the probiotic group was given a probiotic supplement consisting of \u003cem\u003eLactobacillus acidophilus, Lactobacillus rhamnosus, Bifidobacterium lactis, and Lactobacillus paracasei,\u003c/em\u003e without vitamins or minerals. In addition, only a few studies have assessed nutrient intake qualitatively and quantitatively, which may affect the interpretation of results. In this study, participants were not given a special diet or exercise program; they were only warned not to consume foods containing probiotics.\u003c/p\u003e\n\u003cp\u003eIn this study, probiotics led to significant improvements in glycemic control. While prior research on their effects in T2DM patients has shown mixed outcomes, a recent meta-analyse suggest a modest but greater impact with multi-strain formulations [30]. A recent RCT found no evidence that a 6-week probiotic supplementation improves short-term glycemic control. On the contrary, there was limited evidence suggesting these strains may have a negative impact on glucose homeostasis [31]. Chaithanya et al. found a decrease in PPBG levels in the probiotic group, similar to the present study [32].\u003c/p\u003e\n\u003cp\u003eThree different meta-analyses over the last five years suggest that probiotic supplementation has a small but significant effect on glycaemic indices [33\u0026ndash;35]. However, the magnitude of effect appears to be modulated by baseline BMI, probiotic strain, dosage, duration of intervention, and ethnic background. In this study, consistent with the results of these meta-analyses, a significant decrease in PPBG levels was found in the probiotic group compared to the control group. The present study supports the idea that probiotics improve glycemic control in T2DM patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the meta-analysis by G. Li et al., subgroup analysis found that the effect of probiotics on FBG was greater in individuals with higher baseline BMI (\u0026ge;30.0 kg/m\u003csup\u003e2\u003c/sup\u003e). Similar to this meta-analysis, the participants in this study had a BMI \u0026ge;30.0 kg/m2 at baseline. The use of probiotics may be a promising adjuvant therapy for glycemic control in patients with T2DM.\u003c/p\u003e\n\u003cp\u003eIn the study by Andreasen et al., consistent with this study, did blood glucose metabolism parameters decrease more in patients receiving probiotic therapy in addition to their treatment compared to the control group, but this decrease was not statistically significant [36].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eIn this study,\u0026nbsp;PPBG levels decreased statistically significantly compared to the control group. We cannot exclude the possibility that the difference in PPBG changes between the two groups in this study was due to an unknown bias, leading to a false-positive result. However, the absence of any significant confounding factors in this study suggest that this possibility is unlikely.\u003c/p\u003e\n\u003cp\u003eAlthough reductions within-group FBG and PPBG were statistically significant, mean values did not achieve ADA glycemic targets (FBG \u0026lt;100 mg/dL; PPBG \u0026lt;140 mg/dL). The observed reductions (-19 mg/dL for FBG and -21 mg/dL for PPBG) may still be clinically relevant, as even modest improvements in glycemic variability and postprandial excursions can lower long-term cardiometabolic risk. However, the magnitude of change suggests that multistrain probiotics should be viewed as an adjunct to, not a replacement for, standard glycemic therapy.\u003c/p\u003e\n\u003cp\u003eIn the present study, in within-group comparisons for the probiotic group, more pronounced decreases in Total-C, TG, LDL-C, and non-HDL-C levels were observed compared to the control group. In particular, the decreases in LDL-C and non-HDL-C levels were found to be statistically significant (p=0.044 and p=0.034, respectively). Although an increase in HDL-C was observed within the group, this change was not statistically significant. These findings are consistent with studies in the literature showing the positive effects of probiotics on lipid metabolism. Begley et al. demonstrated that probiotics could affect cholesterol metabolism by regulating the intestinal microbiota [9]. Similarly, two studies have shown that probiotic supplementation can lower Total-C and LDL-C levels[10, 11].\u003c/p\u003e\n\u003cp\u003eTonucci et al. reported a decrease in lipid levels in patients using probiotics for T2DM. In this study, a within-group decrease in lipid parameters was also found the probiotic group after 12 weeks [37]. RCTs have demonstrated that a six-week intake of probiotic yogurt can lead to a significant reduction in Total-C [38, 39]. However, data supporting lipid profile improvement in individuals with diabetes remain scarce [40, 41]. A meta-analysis reported that 4-8 weeks of probiotic treatment led to a 4% reduction in Total-C and a 5% reduction in LDL-C in healthy individuals [42]. Another meta-analysis also showed that a significant LDL-C reduction was observed with the use of probiotics [43].\u0026nbsp; In a RCT conducted in Saudi Arabia, a significant reduction in glucose, TG, Total-C levels were observed in the probiotic group [16]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough several studies have explored the effects of various probiotic strains on hyperglycemia and lipid profiles in patients with T2DM, the results remain inconsistent. Feizollahzadeh et al. found no significant effect on FBG but reported improvements in lipid parameters, including increased HDL and decreased LDL levels in the probiotic group [44]. Another study observed a similar trend for triglycerides, though not statistically significant [45]. In contrast, this study demonstrated non-significant changes in TG, LDL, and HDL levels in both groups, suggesting a limited effect of probiotics on lipid metabolism in this context.\u003c/p\u003e\n\u003cp\u003eThe cholesterol-lowering mechanisms of probiotics may include: (1) probiotic bacteria reducing cholesterol absorption by binding cholesterol to cell membranes or taking it into the cell, (2) increasing cholesterol elimination by disrupting the enterohepatic circulation of bile salts through deconjugation of bile salts, and (3) reducing cholesterol synthesis in the liver through production of short-chain fatty acids[9]. The significant decrease in non-HDL-C levels is important in terms of reducing cardiovascular disease risk, as non-HDL-C includes all atherogenic lipoprotein particles.\u003c/p\u003e\n\u003cp\u003eStudies have shown that \u003cem\u003eL. acidophilus\u003c/em\u003e reduces MDA in diabetic rats [46], and probiotic yogurt also reduces MDA compared to conventional yogurt [47]. MDA serves as a lipid peroxidation marker associated with diabetic complications, and Lin and Yen demonstrated various antioxidant mechanisms of probiotics [14].\u003c/p\u003e\n\u003cp\u003eA meta-analysis demonstrated a significant difference in GSH levels between probiotic and control groups; however, considerable statistical heterogeneity was observed, and its sources could not be fully explained [48]. Another meta-analysis showed that 12 weeks of probiotic supplementation in patients with T2DM significantly decreased serum hs-CRP and MDA levels while increasing oxidative markers such as total antioxidant capacity (TAC), nitric oxide, and GSH[49]. In this study, a statistically non-significant within-group decrease in hs-CRP and MDA levels was observed in the probiotic group, and contrary to expectations, a slight within-group decrease in GSH levels was observed in the probiotic group, while a within-group increase was observed in the control group, but these changes were not statistically significant. This unexpected result may be explained by various factors including dietary and lifestyle influences, insufficient study duration to detect significant changes in glutathione metabolism, or the specific probiotic strain composition affecting glutathione pathways.\u003c/p\u003e\n\u003cp\u003eDyslipidemia, reduced insulin sensitivity, oxidative stress, and systemic inflammation are common in patients with diabetes and contribute to complications such as increased risk of coronary artery disease [50], diabetic retinopathy, neuropathy, nephropathy, and hypertension [51]. The effect of probiotics on high-sensitivity C-reactive protein (hs-CRP), a marker of systemic inflammation, remains controversial. While some studies have reported non-significant reductions in hs-CRP following probiotic supplementation, [45, 52, 53] Asemi et al. found a significant decrease after 8 weeks of probiotic intake[54]. In another study, all inflammatory markers (TNF\u0026alpha;, IL-6 and C-reactive protein) showed a significant decrease in the probiotic group, while no significant change was observed in the placebo group [16].\u0026nbsp;Since Pf\u0026uuml;tzner et al. [15] demonstrated a positive correlation between beta cell dysfunction severity and high hs-CRP concentrations, inflammation control remains important in diabetic patients. In our study, hs-CRP levels showed a non-significant increase in both groups after 12 weeks, suggesting a lack of anti-inflammatory effect. This may be attributed to relatively low baseline hs-CRP levels in our study population, the specific strain composition and dosage used, or an insufficient study duration to detect changes in chronic inflammatory markers.\u003c/p\u003e\n\u003cp\u003eAs an acute phase protein and antioxidant enzyme, elevated Cp levels in diabetic patients indicate increased oxidative stress and inflammation. \u0026nbsp;A literature search revealed no studies demonstrating the effect of probiotic use on serum Cp levels in patients with T2DM. However, given the anti-inflammatory effects of probiotics, a decrease in Cp levels in patients using probiotics is expected. In this study also found a greater decrease in Cp levels in the probiotic group compared to the control group, but this difference was not statistically significant. Larger sample sizes and longer intervention durations are needed in this regard.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations and Strengths of the Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study has several limitations. Firstly, dietary habits and physical activity were not controlled, potentially affecting results. Because the FFQ assessed consumption frequency rather than quantitative nutrient intake, we were unable to calculate caloric or macronutrient values. Due to operational constraints during the COVID-19 pandemic, semi-quantitative FFQ or 24-hour dietary recalls could not be applied. \u0026nbsp;Secondly, we did not assess gut microbiota composition directly, limiting our understanding of probiotic mechanisms. Thirdly, A placebo powder identical in appearance was not available from the manufacturer during the COVID-19 period; therefore, the control group continued standard care without additional supplementation. Fourthly, multivariate analysis was not performed due to limited sample size and the risk of overfitting. Baseline characteristics were balanced between groups, reducing major confounding. Additionally, computer-generated randomization was not used, and patient recruitment was delayed due to the COVID-19 pandemic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite these limitations, this study has notable strengths including its prospective controlled design, high patient compliance, and comprehensive evaluation of metabolic parameters. To our knowledge, this is among the first studies to comprehensively assess probiotic effects on lipid profile, oxidative stress, and inflammation in T2DM patients. The 12-week intervention period, longer than most comparable studies (4-8 weeks), enhances the significance of our positive findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, three months of multi-strain probiotic supplementation significantly reduced PPBG levels in T2DM patients, as well as FBG, HbA1c levels, lipid metabolism parameters, and inflammatory markers and oxidative stress markers, although not statistically significantly. The findings of this study suggest that probiotic supplementation, in addition to standard therapy, may provide metabolic benefits in T2DM patients. However, larger-scale studies with microbiome profiling, dietary monitoring, and longer follow-up are needed to confirm these findings and elucidate the underlying mechanisms.\u003c/p\u003e"},{"header":"Abbreviations ","content":"\u003cp\u003eT2DM\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003eType 2 diabetes mellitus\u003c/p\u003e\n\u003cp\u003eWC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Waist circumference\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHC\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003eHip circumference\u003c/p\u003e\n\u003cp\u003eBMI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Body mass index\u003c/p\u003e\n\u003cp\u003eWHR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Waist-to-hip ratio\u003c/p\u003e\n\u003cp\u003eFFQ\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;A Food Frequency Questionnaire\u003c/p\u003e\n\u003cp\u003eIPAQ\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;The International Physical Activity Questionnaire\u003c/p\u003e\n\u003cp\u003eMET\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Metabolic Equivalent of Task\u003c/p\u003e\n\u003cp\u003eEAT-26 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Eating Attitudes Test\u003c/p\u003e\n\u003cp\u003eFBG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Fasting blood glucose\u003c/p\u003e\n\u003cp\u003ePPBG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Postprandial blood glucose\u003c/p\u003e\n\u003cp\u003eTotal-C\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Total cholesterol\u003c/p\u003e\n\u003cp\u003eLDL-C\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;LDL cholesterol\u003c/p\u003e\n\u003cp\u003eHDL-C\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;HDL cholesterol\u003c/p\u003e\n\u003cp\u003eTG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Triglyceride\u003c/p\u003e\n\u003cp\u003ehs-CRP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;High-sensitivity C-Reactive Protein\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMDA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Malondialdehyde\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCp\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Ceruloplasmin\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGSH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Glutathione\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHOMA-IR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Homeostasis model of assessment-insulin resistance\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded and supported by Ege University Scientific Research Projects Unit (Number: TGA-2020-20200). We thank Prof. Dr. Fehmi Ak\u0026ccedil;i\u0026ccedil;ek for academic consultancy and Dr. Nergiz Zorbozan for biochemical analyses. The authors thank iHealth Company for providing the probiotic supplements used in this study. The sponsor had no role in study design, data collection, analysis, interpretation of results, or manuscript preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAK, OY, NT, OZ and IYŞ generated the study idea and designed the protocol. AK and OZ contributed to data collection and/or analysis of study outcomes. AK and OZ performed and interpreted the data analysis and drafted the manuscript. AK, NT, OY, IYŞ, and OZ reviewed the manuscript providing substantial academic and/or clinical input. All authors approved the final manuscript. AK is the guarantor of the work and as such had full access to all the data and takes responsibility for the integrity of the data and the accuracy of the data analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded and supported by Ege University Scientific Research Projects Unit (Number: TGA-2020-20200).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was completed in compliance with the guidelines of the Helsinki Declaration. The study protocol was reviewed and approved by the Clinical Research Ethics Committee of Ege University Faculty of Medicine (Date: 17.04.2018, Number: 18-4.1/67). Approval for data collection from the administration of hospital has been acquired. All participants reviewed and signed an informed consent form before participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no financial or non-financial competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinialTrials.gov registration number: NCT07330388. Registered on 23 December 2025. https://clinicaltrials.gov/search?term=NCT07330388\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSullivan PW, Morrato EH, Ghushchyan V, Wyatt HR, Hill JO. Obesity, Inactivity, and the Prevalence of Diabetes and Diabetes-Related Cardiovascular Comorbidities in the U.S., 2000\u0026ndash;2002. Diabetes Care. 2005;28:1599\u0026ndash;603. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2337/diacare.28.7.1599\u003c/span\u003e\u003cspan address=\"10.2337/diacare.28.7.1599\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEngelgau MM, Geiss LS, Saaddine JB, Boyle JP, Benjamin SM, Gregg EW, et al. The Evolving Diabetes Burden in the United States. Ann Intern Med. 2004;140:945\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7326/0003-4819-140-11-200406010-00035\u003c/span\u003e\u003cspan address=\"10.7326/0003-4819-140-11-200406010-00035\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, et al. Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach. Diabetes Care. 2012;35:1364\u0026ndash;79. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2337/dc12-0413\u003c/span\u003e\u003cspan address=\"10.2337/dc12-0413\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi SH, Chae A, Miller E, Messig M, Ntanios F, DeMaria AN, et al. Relationship Between Biomarkers of Oxidized Low-Density Lipoprotein, Statin Therapy, Quantitative Coronary Angiography, and Atheroma Volume. J Am Coll Cardiol. 2008;52:24\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jacc.2008.02.066\u003c/span\u003e\u003cspan address=\"10.1016/j.jacc.2008.02.066\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHansen AK, Hansen CHF, Krych L, Nielsen DS. Impact of the gut microbiota on rodent models of human disease. World J Gastroenterol. 2014;20:17727\u0026ndash;36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3748/wjg.v20.i47.17727\u003c/span\u003e\u003cspan address=\"10.3748/wjg.v20.i47.17727\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBienenstock J, Kunze W, Forsythe P. Microbiota and the gut\u0026ndash;brain axis. Nutr Rev. 2015;73:28\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/nutrit/nuv019\u003c/span\u003e\u003cspan address=\"10.1093/nutrit/nuv019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanwar H, Rashmi HM, Batish VK, Grover S. Probiotics as potential biotherapeutics in the management of type 2 diabetes - prospects and perspectives. Diabetes Metab Res Rev. 2013;29:103\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/dmrr.2376\u003c/span\u003e\u003cspan address=\"10.1002/dmrr.2376\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoint, FAO/WHO Working Group. Guidelines for the Evaluation of Probiotics in Food. London, Ontario; 2002.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBegley M, Hill C, Gahan CGM. Bile Salt Hydrolase Activity in Probiotics. Appl Environ Microbiol. 2006;72:1729\u0026ndash;38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1128/AEM.72.3.1729-1738.2006\u003c/span\u003e\u003cspan address=\"10.1128/AEM.72.3.1729-1738.2006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel AK, Singhania RR, Pandey A, Chincholkar SB. Probiotic Bile Salt Hydrolase: Current Developments and Perspectives. Appl Biochem Biotechnol. 2010;162:166\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12010-009-8738-1\u003c/span\u003e\u003cspan address=\"10.1007/s12010-009-8738-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuo Z, Liu XM, Zhang QX, Shen Z, Tian FW, Zhang H, et al. Influence of consumption of probiotics on the plasma lipid profile: A meta-analysis of randomised controlled trials. Nutr Metabolism Cardiovasc Dis. 2011;21:844\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.numecd.2011.04.008\u003c/span\u003e\u003cspan address=\"10.1016/j.numecd.2011.04.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Z, Yang S, Huang J, Watkins PA, Moser AB, Desimone C, Song XY, Diehl AM. Probiotics and antibodies to TNF inhibit inflammatory activity and improve nonalcoholic fatty liver disease. Hepatology. 2003;37:343\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1053/jhep.2003.50048\u003c/span\u003e\u003cspan address=\"10.1053/jhep.2003.50048\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOZAKI TABUCHIM, TAMURA M, YAMADA A, ISHIDA N, HOSODA T. Antidiabetic Effect of Lactobacillus GG in Streptozotocin-induced Diabetic Rats. Biosci Biotechnol Biochem. 2003;67:1421\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1271/bbb.67.1421\u003c/span\u003e\u003cspan address=\"10.1271/bbb.67.1421\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin M-Y, Yen C-L. Antioxidative Ability of Lactic Acid Bacteria. J Agric Food Chem. 1999;47:1460\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1021/jf981149l\u003c/span\u003e\u003cspan address=\"10.1021/jf981149l\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePf\u0026uuml;tzner A, Standl E, Strotmann H-J, Schulze J, Hohberg C, L\u0026uuml;bben G, et al. Association of high-sensitive C-reactive protein with advanced stage β-cell dysfunction and insulin resistance in patients with type 2 diabetes mellitus. Clin Chem Lab Med (CCLM). 2006;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1515/CCLM.2006.108\u003c/span\u003e\u003cspan address=\"10.1515/CCLM.2006.108\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSabico S, Al-Mashharawi A, Al-Daghri NM, Wani K, Amer OE, Hussain DS, et al. Effects of a 6-month multi-strain probiotics supplementation in endotoxemic, inflammatory and cardiometabolic status of T2DM patients: A randomized, double-blind, placebo-controlled trial. Clin Nutr. 2019;38:1561\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.clnu.2018.08.009\u003c/span\u003e\u003cspan address=\"10.1016/j.clnu.2018.08.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Physical Status: The Use of and Interpretation of Anthropometry, Report of a WHO Expert Committee. Geneva, Switzerland: World Health Organization; 1995.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRESNICOW YAROCHAL, DAVIS K, DAVIS M, SMITH A, KHAN M. Development of a Modified Picture-Sort Food Frequency Questionnaire Administered to Low-income, Overweight, African-American Adolescent Girls. J Am Diet Assoc. 2000;100:1050\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0002-8223(00)00306-0\u003c/span\u003e\u003cspan address=\"10.1016/S0002-8223(00)00306-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMARSHALL CRAIGCL, SJ??STR??M AL, BAUMAN M, BOOTH AE, AINSWORTH ML. International Physical Activity Questionnaire: 12-Country Reliability and Validity. Med Sci Sports Exerc. 2003;35:1381\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1249/01.MSS.0000078924.61453.FB\u003c/span\u003e\u003cspan address=\"10.1249/01.MSS.0000078924.61453.FB\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Ouml;zt\u0026uuml;rk M. \u0026Uuml;niversitede eğitim-\u0026ouml;ğretim g\u0026ouml;ren \u0026ouml;ğrencilerde Uluslararası Fiziksel Aktivite anketinin ge\u0026ccedil;erliliği ve g\u0026uuml;venirliliği ve fiziksel aktivite d\u0026uuml;zeylerinin belirlenmesi. Master\u0026rsquo;s Thesis. Hacettepe University; 2005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaraca A, Turnag\u0026ouml;l HH, \u0026Ccedil;ALIŞAN BİREYLERDE \u0026Uuml;\u0026Ccedil; FARKLI, FİZİKSEL AKTİVİTE ANKETİNİN G\u0026Uuml;VENİRLİĞİ VE GE\u0026Ccedil;ERLİĞİ. Spor Bilimleri Dergisi. 2007;18:68\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrans C, Powers M. Ferrans and Powers Quality of Life Index (QLI). 1984. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://qli.org.uic.edu/\u003c/span\u003e\u003cspan address=\"https://qli.org.uic.edu/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Ouml;zer Z. Miyokard Enfarkt\u0026uuml;s\u0026uuml; Ge\u0026ccedil;iren Bireylerde Ferrans ve Powers Yaşam Kalitesi \u0026Ouml;l\u0026ccedil;eği\u0026rsquo;nin Ge\u0026ccedil;erlilik ve G\u0026uuml;venirlilik \u0026Ccedil;alışmasının Yapılması. MN Kardiyoloji Dergisi. 2003;10:111\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarner DM, Olmsted MP, Bohr Y, Garfinkel PE. The Eating Attitudes Test: psychometric features and clinical correlates. Psychol Med. 1982;12:871\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S0033291700049163\u003c/span\u003e\u003cspan address=\"10.1017/S0033291700049163\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErg\u0026uuml;ney-Okumuş FE, Sertel-Berk H\u0026Ouml;. Yeme Tutum Testi Kısa Formunun (YTT-26) \u0026Uuml;niversite \u0026Ouml;rnekleminde T\u0026uuml;rk\u0026ccedil;eye Uyarlanması ve Psikometrik \u0026Ouml;zelliklerinin Değerlendirilmesi. Psikoloji \u0026Ccedil;alışmaları / Stud Psychol. 2020;57\u0026ndash;78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.26650/SP2019-0039\u003c/span\u003e\u003cspan address=\"10.26650/SP2019-0039\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJain SK, Ross JD, Levy GJ, Little RL, Duett J. The accumulation of malonyldialdehyde, an end product of membrane lipid peroxidation, can cause potassium leak in normal and sickle red blood cells. Biochem Med Metab Biol. 1989;42:60\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/0885-4505(89)90041-8\u003c/span\u003e\u003cspan address=\"10.1016/0885-4505(89)90041-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHellman NE, Gitlin JD. Ceruloplasmin metabolism and function. Annu Rev Nutr. 2002;22:439\u0026ndash;58. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1146/annurev.nutr.22.012502.114457\u003c/span\u003e\u003cspan address=\"10.1146/annurev.nutr.22.012502.114457\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBordalo Tonucci L, Dos Santos KMO, De Luces Fortes Ferreira CL, Ribeiro SMR, De Oliveira LL, Martino HSD. Gut microbiota and probiotics: Focus on diabetes mellitus. Crit Rev Food Sci Nutr. 2017;57:2296\u0026ndash;309. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10408398.2014.934438\u003c/span\u003e\u003cspan address=\"10.1080/10408398.2014.934438\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrovesy L, Ostrowski M, Ferreira DMTP, Rosado EL, Soares-Mota M. Effect of Lactobacillus on body weight and body fat in overweight subjects: a systematic review of randomized controlled clinical trials. Int J Obes. 2017;41:1607\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/ijo.2017.161\u003c/span\u003e\u003cspan address=\"10.1038/ijo.2017.161\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNikbakht E, Khalesi S, Singh I, Williams LT, West NP, Colson N. Effect of probiotics and synbiotics on blood glucose: a systematic review and meta-analysis of controlled trials. Eur J Nutr. 2018;57:95\u0026ndash;106. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00394-016-1300-3\u003c/span\u003e\u003cspan address=\"10.1007/s00394-016-1300-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIvey KL, Hodgson JM, Kerr DA, Lewis JR, Thompson PL, Prince RL. The effects of probiotic bacteria on glycaemic control in overweight men and women: a randomised controlled trial. Eur J Clin Nutr. 2014;68:447\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/ejcn.2013.294\u003c/span\u003e\u003cspan address=\"10.1038/ejcn.2013.294\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaithanya V, Kumar J, Vajravelu Leela K, Ram M, Thulukanam J. Impact of Multistrain Probiotic Supplementation on Glycemic Control in Type 2 Diabetes Mellitus\u0026mdash;Randomized Controlled Trial. Life. 2024;14:1484. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/life14111484\u003c/span\u003e\u003cspan address=\"10.3390/life14111484\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhong H, Wang L, Jia F, Yan Y, Xiong F, Hidayat K, et al. Effect of Probiotic Fermented Milk Supplementation on Glucose and Lipid Metabolism Parameters and Inflammatory Markers in Patients with Type 2 Diabetes Mellitus: A Meta-Analysis of Randomized Controlled Trials. Biology (Basel). 2024;13:641. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/biology13080641\u003c/span\u003e\u003cspan address=\"10.3390/biology13080641\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi G, Feng H, Mao X-L, Deng Y-J, Wang X-B, Zhang Q, et al. The effects of probiotics supplementation on glycaemic control among adults with type 2 diabetes mellitus: a systematic review and meta-analysis of randomised clinical trials. J Transl Med. 2023;21:442. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12967-023-04306-0\u003c/span\u003e\u003cspan address=\"10.1186/s12967-023-04306-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiang T, Wu L, Xi Y, Li Y, Xie X, Fan C, et al. Probiotics supplementation improves hyperglycemia, hypercholesterolemia, and hypertension in type 2 diabetes mellitus: An update of meta-analysis. Crit Rev Food Sci Nutr. 2021;61:1670\u0026ndash;88. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10408398.2020.1764488\u003c/span\u003e\u003cspan address=\"10.1080/10408398.2020.1764488\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndreasen AS, Larsen N, Pedersen-Skovsgaard T, Berg RMG, M\u0026oslash;ller K, Svendsen KD, et al. Effects of Lactobacillus acidophilus NCFM on insulin sensitivity and the systemic inflammatory response in human subjects. Br J Nutr. 2010;104:1831\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S0007114510002874\u003c/span\u003e\u003cspan address=\"10.1017/S0007114510002874\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTonucci LB, Olbrich dos Santos KM, Licursi de Oliveira L, Rocha Ribeiro SM, Duarte Martino HS. Clinical application of probiotics in type 2 diabetes mellitus: A randomized, double-blind, placebo-controlled study. Clin Nutr. 2017;36:85\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.clnu.2015.11.011\u003c/span\u003e\u003cspan address=\"10.1016/j.clnu.2015.11.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtaie-Jafari A, Larijani B, Alavi Majd H, Tahbaz F. Cholesterol-Lowering Effect of Probiotic Yogurt in Comparison with Ordinary Yogurt in Mildly to Moderately Hypercholesterolemic Subjects. Ann Nutr Metab. 2009;54:22\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1159/000203284\u003c/span\u003e\u003cspan address=\"10.1159/000203284\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson JW, Gilliland SE. Effect of Fermented Milk (Yogurt) Containing Lactobacillus Acidophilus L1 on Serum Cholesterol in Hypercholesterolemic Humans. J Am Coll Nutr. 1999;18:43\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/07315724.1999.10718826\u003c/span\u003e\u003cspan address=\"10.1080/07315724.1999.10718826\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoroti C, Souza Magri LF, de Rezende Costa M, Cavallini DC, Sivieri K. Effect of the consumption of a new symbiotic shake on glycemia and cholesterol levels in elderly people with type 2 diabetes mellitus. Lipids Health Dis. 2012;11:29. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1476-511X-11-29\u003c/span\u003e\u003cspan address=\"10.1186/1476-511X-11-29\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEjtahed HS, Mohtadi-Nia J, Homayouni-Rad A, Niafar M, Asghari-Jafarabadi M, Mofid V, et al. Effect of probiotic yogurt containing Lactobacillus acidophilus and Bifidobacterium lactis on lipid profile in individuals with type 2 diabetes mellitus. J Dairy Sci. 2011;94:3288\u0026ndash;94. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3168/jds.2010-4128\u003c/span\u003e\u003cspan address=\"10.3168/jds.2010-4128\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgerholm-Larsen L, Bell M, Grunwald G, Astrup A. The effect of a probiotic milk product on plasma cholesterol: a meta-analysis of short-term intervention studies. Eur J Clin Nutr. 2000;54:856\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/sj.ejcn.1601104\u003c/span\u003e\u003cspan address=\"10.1038/sj.ejcn.1601104\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiRienzo DB. Effect of probiotics on biomarkers of cardiovascular disease: implications for heart-healthy diets. Nutr Rev. 2014;72:18\u0026ndash;29. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/nure.12084\u003c/span\u003e\u003cspan address=\"10.1111/nure.12084\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeizollahzadeh S, Ghiasvand R, Rezaei A, Khanahmad H, Sadeghi A, Hariri M. Effect of Probiotic Soy Milk on Serum Levels of Adiponectin, Inflammatory Mediators, Lipid Profile, and Fasting Blood Glucose Among Patients with Type II Diabetes Mellitus. Probiotics Antimicrob Proteins. 2017;9:41\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12602-016-9233-y\u003c/span\u003e\u003cspan address=\"10.1007/s12602-016-9233-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFirouzi S, Majid HA, Ismail A, Kamaruddin NA, Barakatun-Nisak M-Y. Effect of multi-strain probiotics (multi-strain microbial cell preparation) on glycemic control and other diabetes-related outcomes in people with type 2 diabetes: a randomized controlled trial. Eur J Nutr. 2017;56:1535\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00394-016-1199-8\u003c/span\u003e\u003cspan address=\"10.1007/s00394-016-1199-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarisa GI, Taha EI, Khalil AF, Salem M. Oral administration of Lactobacillus acidophilus restores nitric oxide level in diabetic rats. Aust J Basic Appl Sci. 2009;3:2963\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEjtahed HS, Mohtadi-Nia J, Homayouni-Rad A, Niafar M, Asghari-Jafarabadi M, Mofid V. Probiotic yogurt improves antioxidant status in type 2 diabetic patients. Nutrition. 2012;28:539\u0026ndash;43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nut.2011.08.013\u003c/span\u003e\u003cspan address=\"10.1016/j.nut.2011.08.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDai Y, Quan J, Xiong L, Luo Y, Yi B. Probiotics improve renal function, glucose, lipids, inflammation and oxidative stress in diabetic kidney disease: a systematic review and meta-analysis. Ren Fail. 2022;44:862\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/0886022X.2022.2079522\u003c/span\u003e\u003cspan address=\"10.1080/0886022X.2022.2079522\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng HJ, Guo J, Jia Q, Huang YS, Huang W-J, Zhang W, et al. The effect of probiotic and synbiotic supplementation on biomarkers of inflammation and oxidative stress in diabetic patients: A systematic review and meta-analysis of randomized controlled trials. Pharmacol Res. 2019;142:303\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.phrs.2019.02.016\u003c/span\u003e\u003cspan address=\"10.1016/j.phrs.2019.02.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShim U, Lee H, Oh J-Y, Sung Y-A. Sleep Disorder and Cardiovascular Risk Factors among Patients with Type 2 Diabetes Mellitus. Korean J Intern Med. 2011;26:277. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3904/kjim.2011.26.3.277\u003c/span\u003e\u003cspan address=\"10.3904/kjim.2011.26.3.277\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite JR. Economic considerations in treating patients with type 2 diabetes mellitus. Am J Health-System Pharm. 2002;59. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/ajhp/59.suppl_9.S14\u003c/span\u003e\u003cspan address=\"10.1093/ajhp/59.suppl_9.S14\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. suppl_9:S14\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMazloom Z, Yousefinejad A, Dabbaghmanesh MH. Effect of probiotics on lipid profile, glycemic control, insulin action, oxidative stress, and inflammatory markers in patients with type 2 diabetes: a clinical trial. Iran J Med Sci. 2013;38:38\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohamadshahi M, Veissi M, Haidari F, Shahbazian H, Kaydani G-A, Mohammadi F. Effects of probiotic yogurt consumption on inflammatory biomarkers in patients with type 2 diabetes. Bioimpacts. 2014;4:83\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5681/bi.2014.007\u003c/span\u003e\u003cspan address=\"10.5681/bi.2014.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsemi Z, Zare Z, Shakeri H, Sabihi S, Esmaillzadeh A. Effect of Multispecies Probiotic Supplements on Metabolic Profiles, hs-CRP, and Oxidative Stress in Patients with Type 2 Diabetes. Ann Nutr Metab. 2013;63:1\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1159/000349922\u003c/span\u003e\u003cspan address=\"10.1159/000349922\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Antioxidant system, glycemic control, inflammation, lipid metabolism, probiotics, type 2 diabetes mellitus","lastPublishedDoi":"10.21203/rs.3.rs-8262784/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8262784/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRecent evidence suggests that the gut microbiota plays a crucial role in the development and progression type 2 diabetes mellitus (T2DM). This study aimed to investigate the effects of multi-strain probiotic supplementation on glucose and lipid metabolism, inflammation, and antioxidant system in patients with T2DM.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis prospective controlled clinical trial was conducted at Ege University Faculty of Medicine from July 2020 to June 2023. Participants aged 35\u0026ndash;65 years diagnosed with T2DM were allocated sequentially according to order of presentation to either probiotic group (n\u0026thinsp;=\u0026thinsp;39) or control group (n\u0026thinsp;=\u0026thinsp;38). The intervention group received a multi-strain probiotic supplement containing \u003cem\u003eLactobacillus acidophilus\u003c/em\u003e, \u003cem\u003eLactobacillus rhamnosus\u003c/em\u003e, \u003cem\u003eBifidobacterium lactis\u003c/em\u003e and \u003cem\u003eLactobacillus paracasei\u003c/em\u003e, twice daily for 12 weeks, while the control group continued standard care. This study evaluated anthropometric measurements, eating attitudes, dietary frequency, quality of life, and physical activity. Biochemical analyses included glycemic control, lipid profiles, inflammation markers (high-sensitivity C-Reactive Protein, Ceruloplasmin), and oxidative stress markers (Malondialdehyde, Glutathione).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSeventy-seven of the 80 participants completed the study (mean age 55.38\u0026thinsp;\u0026plusmn;\u0026thinsp;6.40 years, 42.86% female). After 12 weeks a significant within-group decrease in fasting blood glucose (FBG), postprandial blood glucose (PPBG), HbA1c, LDL-C, Non-HDL-C and malondialdehyde in the probiotic group compared to the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, p\u0026thinsp;=\u0026thinsp;0.003, p\u0026thinsp;=\u0026thinsp;0.004, p\u0026thinsp;=\u0026thinsp;0.044, p\u0026thinsp;=\u0026thinsp;0.034, p\u0026thinsp;=\u0026thinsp;0.001). No significant changes were observed in inflammatory markers or oxidative stress markers\u0026rsquo; levels. Anthropometric parameters remained unchanged in both groups. In a two-group comparison, three-month multi-strain probiotic supplementation statistically significantly improved only PPBG in patients with T2DM (p\u0026thinsp;=\u0026thinsp;0.038).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThree months of multi-strain probiotic supplementation led to a significant reduction in PPBG levels among patients with T2DM, while FBG, HbA1c, lipid profile parameters, and inflammatory and oxidative stress markers showed improvements that did not reach statistical significance.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eClinialTrials.gov registration number: NCT07330388. Registered on 23 December 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://clinicaltrials.gov/search?term=NCT07330388\u003c/span\u003e\u003cspan address=\"https://clinicaltrials.gov/search?term=NCT07330388\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e","manuscriptTitle":"Effects of Multistrain Probiotics on Metabolic Biomarkers, Inflammation, and Antioxidant System in Patients with Type 2 Diabetes Mellitus: A Prospective Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 13:51:34","doi":"10.21203/rs.3.rs-8262784/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-16T09:01:05+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"265152758811990549488417386102996912257","date":"2026-03-16T00:32:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280154052195396395684722813205221450145","date":"2026-03-15T11:03:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140954359448298873444454569729026346922","date":"2026-03-15T01:55:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-13T11:59:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196208520214359327618293588088559897535","date":"2026-03-13T09:07:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"32989105529513149551306765350843205185","date":"2026-03-13T07:29:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319442495523525995482151573620513317399","date":"2026-03-13T00:18:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7715787925029260660668706893075040696","date":"2026-02-27T13:18:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276594905473982812064228977429845076273","date":"2026-02-27T05:15:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-27T04:00:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"279197326441647724759150974140371355227","date":"2026-02-25T10:03:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317448830306024105002403190699390718365","date":"2026-02-25T02:13:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284748505640664323344135608055610251178","date":"2026-02-24T20:23:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8226660481456091778301509667848635627","date":"2026-02-24T20:19:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-24T20:17:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-19T06:24:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-06T13:44:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-10T22:05:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nutrition","date":"2026-01-10T22:00:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"09d30b56-baca-4161-a2e8-8c22d7af4ddb","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T16:54:26+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 13:51:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8262784","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8262784","identity":"rs-8262784","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}