Gut microbiota-driven diseases and intervention strategies – lessons from China

Abstract

Complicated relationships exist among lifestyles, gut microbiome (GM), and human health. Lifestyles can modulate the composition and function of GM, hence influencing the development of non-communicable diseases (NCDs). Recently, the socio-economic growth in China has led to the emergence of urbanized lifestyles, including unbalanced eating patterns and a sedentary lifestyle, causing an increased incidence of lifestyle-related NCDs among the Chinese population. In this review, we discussed the impact of lifestyle specific to the Chinese population on the GM and highlighted the mechanistic evidence that the commensals and their metabolites prevent or promote the pathogenesis of common lifestyle-related NCDs in China. Additionally, we described several microbiome-targeted therapies derived from traditional Chinese health practices, including traditional Chinese medicine treatments, the intake of fermented foods and tea, and Tai Chi intervention. In conclusion, we emphasized the significance of lifestyle-induced dysbiosis in the etiology of prevalent NCDs in China and provided relevant solutions, which should offer new insight into the treatment of these diseases to improve the overall health status of Chinese citizens.

Introduction

With economic growth and the acceleration of urbanization and industrialization, China, one of the world’s fastest-growing major economies, has experienced rapid urbanization. The urban population rate increased from 26.4% in 1990 to 60.3% in 2019, and this process is closely linked to environmental pollution, the abuse of antibiotics, urbanized lifestyles (including urban dietary habits and sedentary lifestyles), and early-life exposure to the urban environment^1,2. Epidemiological studies indicate that these urbanization-related changes are closely associated with the pathogenesis of NCDs³. Concurrently, accumulating basic and translational evidence suggests that these factors can significantly affect the composition and function of GM, indicating the potential relationships among urbanization, GM, and the onset and progression of NCDs^4,5. For example, in early 2013, nationwide media reports highlighted severe PM_2.5 (particulate matter with an aerodynamic diameter <2.5 μm)⁶. Epidemiological studies have identified PM_2.5 as a significant risk factor for the T2DM burden, with evidence that PM_2.5 may translocate to the intestine, affect intestinal microbiota, and negatively correlate with α-diversity of GM⁴. Furthermore, the overuse of cesarean delivery in urban China significantly impacts neonates’ first major microbial exposure and colonization^7,8. Studies have shown that vaginally born neonates exhibit higher gut microbial diversity than those born via cesarean section, and this neonatal gut microbiome dysbiosis is closely associated with increased NCDs incidence, particularly asthma^8,9.

Urbanized lifestyles, particularly western dietary patterns and sedentary behaviors, represent key factors influencing the human gut microbiome. Recently, a marked transition in macronutrient intake proportions within Chinese dietary patterns reflects a significant shift toward optimized nutritional balance (Fig. 1A)¹⁰. However, unhealthy lifestyles are still widespread in China. In terms of the Chinese Dietary Guidelines (2022) and Dietary Reference Intakes for China (2023), the intake of five main types of foods (vegetables, whole grains, fruits, soybean products, and milk products) and related dietary nutrients for Chinese residents is lower than the recommended level, and the consumption of animal foods is unbalanced^10,11. Moreover, excessive intake of alcohol and salt, sedentary behaviors, and irregular routines are also critical issues that exist among the Chinese population. Recent studies suggest that the aforementioned lifestyle changes would disrupt the GM symbiosis, which is correlated with the occurrence of various chronic diseases, including gastrointestinal, pulmonary, and breast cancers, as well as inflammatory bowel disease (IBD), cardiovascular disease (CVD), type 2 diabetes mellitus (T2DM), and hypertension (Fig. 2)^12,13. Therefore, this review aims to explore the relationship between gut dysbiosis induced by unhealthy lifestyles and related chronic diseases in China. It provides an overview of the dietary composition and other factors that exert negative impacts on GM. To address this, it is essential to implement microbiota-targeted interventions to maintain a well-balanced gut microbiota, as such a balance is strongly associated with a lower incidence and progression of related NCDs. This approach aligns with evidence linking gut microbiota balance to improved health outcomes, aiming to support the general health of the Chinese population.

Fig. 1. Trends in nutritional energy supply and consumption of key food groups among the Chinese population.

A Trends in the nutritional energy supply ratio within the dietary intake of the Chinese population. B and C Trends in the intake of vegetables, fruits, whole grains, milk and soybean products for Chinese individuals in terms of CHNS 2018. B Changes in the consumption patterns of dark- or light-colored vegetables and fruits among adult residents in China. C The evolving patterns in the consumption level of whole grains, milk, and soybean products among Chinese adult residents. D Trends in the consumption level of animal foods among Chinese adult residents.

Fig. 2. The interplay between lifestyles and GM influences the health of the host.

This figure was created with BioRender.com.

Unhealthy lifestyles in China and their link with gut microbiota

Inadequate intake of vegetables, fruits, whole grains, and soybean products by the Chinese population

The data from the China Health and Nutrition Survey (CHNS) spanning from 2000 to 2018 showed that the consumption of vegetables was still dominated by light-colored vegetables, whereas the intake of dark-colored vegetables was still insufficient (Fig. 1B)¹⁰. As for the fruit intake, it firstly showed an ascending trajectory from 2000 to 2011, followed by a descending trend until 2018. Besides vegetables and fruits, cereal and grains are also indispensable to a balanced diet, yet the Chinese population does not consume enough of them. According to the Scientific Research Report on Dietary Guidelines for Chinese Residents (2021)¹⁴, only 20% of Chinese adults consumed more than 50 g of whole grains per day (mainly corn and foxtail millet). Furthermore, soybean products that are generally regarded as health foods in China are also under-consumed, with 40% of adults abstaining entirely from their consumption (Fig. 1C)¹⁰. Nevertheless, it has been found that inadequate consumption of these four types of foods can lead to a deficient intake of dietary fiber, indigestible carbohydrates, and polyphenols, which are strongly linked to microbiome-linked pathologies. In contrast, diets high in vegetables, fruits, whole grains, and soybean products can rectify this situation, consequently reducing the risks of related diseases (Fig. 3 and Table 1)^15–22.

Fig. 3. The effects of a diet rich in vegetables, fruits, whole grains, and soybean products on metabolic processes in the intestine.

Vegetables, fruits, whole grains, and soybean products offer protection against chronic inflammation through the production of SCFAs. They have been indicated to play crucial roles in inhibiting chronic inflammation by enhancing the autophagy response of Paneth cells, preserving the integrity of the intestinal barrier via the assembly of tight junction proteins, and suppressing tumor cell growth. SCFAs were also reported to influence regulatory T (Treg) cells, T helper 17 (Th17) cells, dendritic cells, and goblet cells. In addition, they could facilitate the recruitment of neutrophils to inflammatory sites, leading to the production of IL-1β and IL-10 and inhibiting pro-inflammatory IL-6, TNF-α, and IFN-γ production. This figure was created with BioRender.com.

Table 1.

The association of diets high in vegetables, fruits, whole grains and soybean products with GM and chronic diseases and related potential mechanisms

Lifestyle	Dietary components	Effects on gut microbiota	Mechanism	Effects on related diseases
Diets high in vegetables, fruits, whole grains, and soybean products	↑ Dietary fiber	↑ Bifidobacterium	High SCFAs production24–26,29,199	↓ CVD ↓ T2DM ↓ IBD ↓ Obesity ↓ GI tumors ↓ Lung cancer ↓ Breast cancer200
		↑ Clostridium
		↑ Eubacterium rectale
		↑ Faecalibacterium prausnitzi
		↑ Lactobacillus
		↑ Lachnospira
		↑ Roseburia
		↑ Prevotella/Bacteroidetes ratio
		↓ Fusobacterium nucleatum	Host immunity regulation: decreased inflammatory cytokine production, suppressed tumor immune escape, promoted natural killer cells or T-cell anti-tumor defense, and inhibition of inflammatory TLR4 signaling30,31
	↑ Indigestible carbohydrates	↓ Firmicutes/Bacteroidetes ratio	High SCFAs production33
		↑ Akkermansia
		↑ Ruminococcus spp.	Not known33,201–203
		↑ Eubacterium rectale
		↑ Actinobacteria
		↑ Bacteroidetes
		↑ Roseburia spp.
		↓ Firmicutes(Clostridium and Enterococcus species)
		↑ Lactobacillus spp.	Bacterial pathogens colonization and growth inhibition through the saccharolytic metabolism pathway34,35
		↑ Bifidobacterium spp.
	↑ Polyphenols	↑ Bifidobacterium	High SCFAs production172,204,205
		↑ Lactobacillus
		↑ Enterococcus
		↑ Faecalibacterium
		↑ Roseburia
		↑ Eubacterium

Insufficient consumption of dietary fiber

The dietary fiber has been found to protect individuals from this kind of chronic inflammation through microbiota-derived short-chain fatty acids (SCFAs) production²³. Studies indicated high intake of dietary fiber was correlated to increased P/B ratio (Prevotella vs. Bacteroides), leading to elevated production of SCFAs^24–26. Then, the higher fecal SCFAs could activate memory T cells and inhibit inflammatory cytokine production, thus contributing to a reduction in CVD, T2DM, or GI tumors^27,28. According to the report on CVD in China (2018), ~290 million Chinese people died from CVD. These cases were related to insufficient intake of vegetables, fruits, whole grains, and soybean products, which are rich in dietary fiber. Furthermore, whole grain intake can cause an increase in different SCFA-producing microbes such as Faecalibacterium prausnitzii (F. prausnitzii) and a corresponding decrease in colorectal cancer (CRC) risk²⁹. It has also been observed that high consumption of fibers can decrease the abundance of Fusobacterium nucleatum, which induces local inflammation, increases inflammatory cytokines, promotes tumor immune escape, and suppresses natural killer cells or T-cell anti-tumor defense to induce colorectal tumor development and metastasis^30,31.

Decreased indigestible carbohydrates consumption

The resistant starch and nonstarch polysaccharides, which are two types of indigestible carbohydrates found abundantly in whole grains, have been suggested to decrease the risk of chronic diseases through promoting the production of SCFAs with the action of GM³². It has been observed that rats fed with unpolished rice and whole wheat diets had higher SCFAs concentration in comparison with those fed with polished rice and refined wheat³³. Besides, large consumption of indigestible carbohydrates, including wheat bran and whole grains, can increase the abundance of “beneficial” bacteria such as Lactobacillus spp. and Bifidobacterium spp., which assist the gut in resisting the pathobionts by inhibiting the colonization and growth of bacterial pathogens through the saccharolytic metabolism pathway^34,35. Furthermore, indigestible carbohydrate consumption is also associated with a decreased ratio of Firmicutes to Bacteroidetes and increased abundance of Actinobacteria or Bacteroidetes. Akkermansia, which is also closely related to the consumption of whole grains, has been discovered to collaborate with Lactobacillus and Coprococcus to ferment indigestible carbohydrates, resulting in the production of a high proportion of beneficial acetic acid. This has been found to be closely related to the integrity of the mucus layer, the body weight, inflammation status, and glucose tolerance of people³³. In terms of CHNS 2018, over 60% of Chinese adult residents did not consume enough whole grains in their daily diets, and only 16.9–21.6% of residents met the recommended daily intake requirement of 50 g of whole grains. Although the Chinese dietary pattern is grain-based, the main type is refined wheat, thus leading to a decreased abundance of Actinobacteria or Bacteroidetes³³.

Insufficient polyphenol intake

Another key category for a positive modulation of GM is polyphenols (flavonoids, stilbenes, lignans, phenolic acids, and secoiridoids), which are abundant in vegetables and soybean products³⁶. Especially, the soy isoflavones contained in soybeans have been reported to prevent specific cancers, including breast cancer, prostate cancer, and colon cancer, through regulating the cell cycle, apoptosis, differentiation, proliferation, growth, and signaling³⁷. Nonetheless, according to the data from CHNS, the intake of soybean products among Chinese residents showed a decreasing trend since 2000. Specifically, the soybean product intake for adults decreased from 14.5 g/d in 2000 to 12.8 g/d in 2018^10,38. The decline in consumption of soybean products may be associated with the increased incidence of specific cancers in China^39–41.

Unbalanced meat and milk intake of Chinese residents

In terms of CHNS (1982–2017), an increasing trend of consumption of animal foods like fish, poultry, eggs, and lean meat had been observed (Fig. 1D)¹⁰. Specifically, the per capita intake of animal foods in China from 2015 to 2017 was 132.7 g, including 24.3 g for fish and shrimp, 72.0 g for red meat (64.3 g for pork), 13.0 g for poultry, and 23.4 g for eggs¹⁰. It is noteworthy that meat consumption is dominated by red meat, and pork stands out as the most frequently consumed one. Additionally, according to the Scientific Research Report on Dietary Guidelines for Chinese Residents (2021), the intake of milk products by Chinese residents has been increasing since 2000. Nevertheless, it was still lower than one tenth of the recommended level (300 g/d), with 27.9 g/d in 2018. It has been found that these two kinds of unbalanced diet patterns can cause excessive harmful compounds intake and specific nutrients deficiency, which are closely associated with GM dysbiosis and chronic disease initiation (Fig. 4 and Table 2)^42–48.

Fig. 4. The effects of a diet rich in red meat on metabolic processes in the intestine.

Red meat can promote carcinogenesis by accelerating DNA damage, gene mutations, and epithelial hyperproliferation or hyperplasia. This can be attributed to the production of carcinogenic compounds, including 2-amino-3-methyl-3H-imidazo[4,5-f]quinoline (IQ), 2-amino-3,6-dihydro-3-methyl-7H-imidazo(4,5)-fquinoline-7-one (HOIQ), and NOCs. Besides, excessive consumption of cooked red meat increases the abundance of mucin-degrading bacteria and sulfate-reducing bacteria, further contributing to the risk of tumorigenesis. Dietary red meat has also been identified to contribute to chronic inflammation by increasing the binding of GM-produced lipopolysaccharides (LPS) with chylomicrons before entering the bloodstream. This is facilitated by an elevation in pro-inflammatory bacteria levels and a reduction in anti-inflammatory bacteria levels. This figure was created with BioRender.com.

Table 2.

The association of diets high in red meat with GM and chronic diseases and related potential mechanisms

Lifestyle	Dietary components	Effects on gut microbiota	Mechanism	Effects on related diseases
Diets high in red meat	↑ HCA (PHIP)	↓ Lactobacillus	Not known51–53	↑ CRC ↑ T2DM ↑ Obesity ↑ Gastric cancer ↑ Esophageal cancer206
		↑ Clostridiaceae and Prevotellaceae UCG-001
	↑ HCA (HOIQ)	Not known	IQ → HOIQ with the action of GM, providing genetoxin57
	↑ PAH (BaP)	↑ Pro-inflammatory bacteria: Alcaligenaceae, Bacteroideceae, Erysipelotrichaceae, Paraprevotellaceae, Porphyromonadaceae and Turicibacter	Not known42
		↓ Anti-inflammatory bacteria: Lactobacillaceae, Lachnospiraceae, Ruminococcaceae, and Verrucomicrobiaceae
		↓ Roseburia, Ruminococcus, Blautia, Dialister, Coprococcus, Megasphaera, Eubacerium and Anaerostipes	Low SCFAs production54
	↑ Heme	Not known	GM promoted the generation of thiobarbituric acid reactive substances and lipoperoxidation57,58.
		↑ Enterobacteria	Not known57
		↓ Lactobacilli
		↑ Bacteroides fragilis and Escherichia coli	Promotion of epithelial hyperproliferation and hyperplasia59
		↑ Sulfate-producing mucin-degrading bacteria (such as Akkermansia)	Thinning of the intestinal mucus layer46
		↑ NOC-producing bacteria: Escherichia, Pseudomonas, Proteus, Klebsiella, and Neisseria	Underlying NOCs-carcinogenesis association60
		↑ Escherichia-Shigella	Not known61
	↑ TMA/TMAO	Not known	Modulated GM induces TMA/TMAO production, leading to a higher risk of atherosclerosis62
		↑ Hungatella hathewayi, Clostridium asparagiforme, and Klebsiella oxytoca	Not known27
		↑ Escherichia coli	Induction of pro-inflammatory and oncogenic mediators production68
	↑ Cholesterol	↑ Enterobacteriaceae	Increased colonic oxygen level and TMA/TMAO production, thus inducing metabolic disease72
		↑ Bacteroides, Clostridium, and Lactobacillus	Abnormal bile acid metabolism73
		Not known	GM produced LPS with chylomicrons entering the bloodstream47

Excessive heterocyclic aromatic amines and polycyclic aromatic hydrocarbons intake

In 2020, China accounted for 28.8% of global new CRC cases and 30.6% of related deaths, which highlighted the significant impact of this disease in the country⁴⁹. One of the main causes of this situation is overconsumption of the heterocyclic aromatic amines (HCAs) and polycyclic aromatic hydrocarbons (PAH), which are derived from meat during the high-temperature cooking process^50,51. 2-amino-1-methyl-6-phenylimidazo [4,5-b] pyridine (PHIP), as a major type of HCA in cooked meat, has been observed to increase the abundance of Clostridiaceae and Prevotellaceae UCG-001, leading to the increased CRC risk^52,53. Meanwhile, PHIP can induce a decrease in beneficial GM, like Lactobacillus, which is responsible for reducing the genotoxicity of this compound⁵¹. Polycyclic aromatic hydrocarbons (PAHs), another type of harmful compounds in cooked meat, have also been shown to induce CRC-related GM changes. Specifically, it can increase the number of pro-inflammatory bacteria, including Alcaligenaceae, Bacteroideceae, Erysipelotrichaceae, Paraprevotellaceae, Porphyromonadaceae and Turicibacter, and reduce the number of anti-inflammatory bacteria, such as Lactobacillaceae, Lachnospiraceae, Ruminococcaceae, and Verrucomicrobiaceae⁴². Furthermore, it has also been observed that there is a negative relationship between PAH level and the abundance of SCFAs-producing bacteria⁵⁴. Thus, excessive consumption of HCAs and PAHs caused by improperly cooked meat intake may explain higher CRC risk among the Chinese population.

High intake of heme iron

In 2023, total pork production of China is estimated at ~58 million tons, with a per capita pork consumption exceeding 27 kg⁵⁵. However, in comparison with white meat, red meat contains a higher level of heme iron, which has been indicated to induce carcinogenesis through several GM-modulated pathways⁵⁶. It has been found that rats fed with diets rich in heme iron would promote thiobarbituric acid reactive substances production due to GM modulation, which correlates with colorectal carcinogenesis risk^57,58. Similarly, it has also been observed that a certain amount of heme iron contained in diets could increase the growth of Gram-negative Enterobacteria and inhibit the growth of Gram-positive Lactobacilli in the feces of rats, which led to increased CRC risk⁵⁷. Besides, heme-fed rodents also showed carcinogenesis-related epithelial hyperproliferation and hyperplasia with an increased number of Bacteroides fragilis and Escherichia coli⁵⁹. Another study also showed an elevated number of the N-nitroso compounds (NOCs) producing bacteria in rats that consumed heme iron, and those produced bacterial metabolites had been found to be closely associated with carcinogenesis⁶⁰. Hence, an unbalanced red meat intake leading to excessive heme iron consumption may constitute an additional significant risk factor for heightened cases of cancer in China. Notably, higher heme iron intake has also been linked to an increase in the abundance of pathogenic bacteria, such as Escherichia–Shigella. These bacteria have been reported to be enriched in obese individuals⁶¹, thereby underlying the potential association between excessive heme iron intake due to red meat consumption and higher obesity rate in the Chinese population (Fig. S1).

Unnecessary trimethylamine and trimethylamine N-oxide consumption

Precursors to GM-mediated formation of trimethylamine (TMA) and trimethylamine N-oxide (TMAO) are choline and carnitine, which can be found in red meat, eggs, and fish⁶². It has been found that diabetic patients and obese people have higher levels of TMAO than their healthy counterparts^63,64. Notably, there was an exponential rise in the total incidence rate of diabetes in China, escalating from 1.29% in 1980–1984 to 14.92% in 2015–2019⁶⁵. This trend suggests TMAO may potentially be responsible for the elevated incidence rates associated with diabetes in China. In addition, high TMAO intake due to choline and carnitine consumption may possibly cause other chronic diseases with higher incidence rates in China, such as CVD and CRC⁶⁶. It was reported that the composition of cecal microbiota changed after mice were supplemented with choline and carnitine. These changes could cause the production of TMA or TMAO, which has been associated with a higher risk of atherosclerosis⁶². Additionally, two bacterial genes that regulate TMA synthesis, including choline TMA-lyase (CutC) and choline TMA-lyase-activating enzyme (CutD), have been found to be highly expressed in CRC patients⁶⁷. The intestinal flora associated with sequence variants of cutC has been identified to encompass Hungatella hathewayi, Clostridium asparagiforme, Klebsiella oxytoca, and Escherichia coli²⁷. Particularly, some strains of Escherichia coli can survive in macrophages and induce pro-inflammatory and oncogenic mediators, which in turn promote the development of CRC⁶⁸.

Increased intake of cholesterol

According to data from the United States Department of Agriculture, the amount of meat consumed by Chinese people each year was double that of the American people, and is estimated to continue increasing in the next few decades⁶⁹. Pork, as the most frequently consumed meat in China, has been discovered to contain high levels of cholesterol, ranging from 56 to 113 mg per 100 g of cooked meat⁷⁰. It has been shown that excessive intake of red meat associated with increased consumption of cholesterol could induce the development of cancers, including CRC. This can be attributed to the impact of cholesterol on the formation of the colon cell membrane and its role in cell proliferation⁷¹. In addition, cholesterol has also been found to increase colonic oxygen level and intensify the growth of Enterobacteriaceae, resulting in the bacterial metabolite TMAO production. Subsequently, heightened blood TMAO level triggers the initiation of inflammation⁷². In addition, frequent pork intake leading to high cholesterol consumption has also been linked with nonalcoholic steatohepatitis, as it induced increased abundance of Bacteroides, Clostridium, and Lactobacillus, leading to the abnormal bile acid metabolism⁷³. Hence, high intake of pork and cholesterol may also represent a potential risk factor for the occurrence of this disease among the Chinese population.

Insufficient intake of milk and milk products

Long-term inadequate intake of milk and milk products has been shown to correlate with calcium deficiency¹⁰. According to the results of the China National Nutrition Surveys, the nutrition status of calcium within the Chinese population was in a terrible situation. The average dietary intake of calcium in China was less than 500 mg/d, a level significantly below the recommended level in Dietary Reference Intakes for China^11,74. It has been reported that milk products can be a good source to provide necessary nutrients such as protein and calcium. Moreover, they have been shown to improve the host health through modulating GM (Table S1)^75,76. It has been found that the consumption of fermented milk can promote the synthesis of beneficial metabolites like butyrate through increasing the abundance of Bifidobacterium⁷⁷. At the same time, fermented milk intake can decrease the levels of specific pathobionts such as Bilophila wadsworthia and Clostridium sp. HGF_2, along with concurrent anti-inflammatory effects⁷⁸. Besides, the intake of yogurt containing Bifidobacterium longum BB536 can suppress the population of Bacteroides fragilis, accompanied by corresponding decreases in endotoxin production and endotoxinemia-related inflammatory responses⁷⁹. It has also been found that yogurt consumption can improve the situation of children who are infected with Helicobacter pylori by inducing an increase in the ratio of Bifidobacterium spp./Escherichia coli⁸⁰.

Excessive alcohol consumption of Chinese individuals

China has a longstanding tradition of alcohol consumption. With a huge demand for alcoholic drinks, China’s alcohol industry is experiencing sustained and robust growth. According to the statistics, during the period from the second quarter of 2021 to the first quarter of 2022, the e-commerce sales of Chinese white spirits surpassed 30 billion yuan, with beer sales also exceeding 2.7 billion yuan. This suggested alcohol drinking behavior is becoming more and more common in Chinese society⁸¹. The monitoring results in 2015–2017 showed that male and female drinkers in China overdosed on alcohol at 56.8% and 27.8%, respectively. Moreover, Drink Moderately and Live a Happy Life (2023) reveals a discernible trend wherein the frequency of alcohol consumption is positively correlated with an escalating proportion of Chinese males, indicating a gradual rise in male residents engaging in alcohol consumption. Conversely, the opposite trend is observed among females in China^14,82. The difference in the drinking rate between Chinese men and women may be due to the social tradition in China, also referred to as the drinking table culture. In this drinking table culture, Chinese adult male residents play a dominant role, and they engage in more socializing and business-related drinking activities. Thus, Chinese males tend to consume more alcohol compared with females, and they are more prone to developing a beer belly. In this context, male subjects are more likely to suffer from increased risk of alcohol-related diseases such as liver diseases, CVD, and GI cancers.

Chinese residents obtained a higher attributable fraction than most of the other populations for alcohol-related cancer. In terms of data from the Global Burden of Disease Study, the age-adjusted prevalence of liver cancer in China was 29.55/100,000 cases in 1999. However, that number substantially increased in the following 2 decades, reaching 60.04/100,000 cases in 2016⁸³. In 2020, China had the largest number of liver cancer cases in the world. Furthermore, the pooled prevalence of alcoholic liver disease (ALD) kept increasing from 5.1% in the early 2000s to 12.9% in the mid-2010s for Chinese adult males and from 0.2% to 2.9% for Chinese adult females⁸⁴. It has been indicated that ethanol intake can modulate GM, thereby affecting SCFAs levels in the gut. Specifically, alcohol consumption has been discovered to decrease the abundance of butyrate-producing Clostridiales order, resulting in the reduced level of SCFAs, including propionate and isobutyrate⁸⁵. Additionally, it has been observed that alcoholic subjects exhibited higher gut permeability, characterized by a diminished level of Clostridia and Ruminococcaceae (Ruminococcus, Faecalibacterium, Subdoligranulum, Oscillibacter, and Anaerofilum) and an elevated abundance of Dorea (Lachnospiraceae), Blautia, and Megasphaera⁸⁶. In addition to colonic dysbiosis, alcohol abuse has also been linked to gut mucosal inflammation. The process initiates with heightened gut-derived pathogen-associated molecular patterns and elevated intestinal permeability following ethanol consumption. Subsequently, bacteria translocate from the intestinal lumen to portal blood, exposing the liver parenchyma to LPS. After that, LPS stimulates related immune receptors, such as Toll-like receptors and CD14, triggering the activation of associated hepatic cells and production of pro-inflammatory mediators, including reactive oxygen species (ROS), leukotrienes, chemokines, and cytokines (Table S2)⁸⁷. Hence, one of the key steps to mitigate the incidence of Chinese higher alcohol related disease is to regulate and control the level of ethanol consumption within the Chinese population.

Excessive sodium intake of Chinese population

In China, the consumption of salt has a long history. As early as the Yan and Huang era, Chinese residents started to add salt to their diets, and salty taste was considered the foremost of the five flavors (spicy, sour, sweet, bitter, and salty). Many Chinese traditional distinctive dishes are created by using salt as a crucial seasoning, such as cured meats and pickled vegetables. Thus, for most Chinese residents, salt is an essential part of their daily diets. However, the alarming issue is that the daily intake of salt by Chinese people (more than 10 g/d) far exceeds the level recommended by the WHO at 5 g/d^14,88,89. In terms of statistics, 76.7% of Chinese residents consume more than 5 g/d in their daily diets. Moreover, the proportion of urban residents who consume more than 5 g/d is 72.3%, lower than that of rural residents¹⁰. A similar situation where salt was overconsumed in daily diets once occurred in Japan, leading to the highest incidence of stroke worldwide in 1950.

The negative impacts of overconsumption of salt are gradually becoming apparent in China as well. About 2.6 million Chinese people died from CVD, and an increasing number of Chinese residents over 40 years old were diagnosed with hypertension¹⁴. It has been found that high salt diets (HSDs) play an important role in the modulation of the gut-immune axis to induce these diseases (Table S3). HSDs have been indicated to reduce the abundance of Lactobacillus spp. in the human gut and increase the number of T-helper cells, resulting in elevated blood pressure. Furthermore, a decreased number of Lactobacillus spp. has also been shown to inhibit the generation of fecal tryptophan metabolite indole-3-lactic acid (ILA), which is closely associated with abnormal autoimmunity of the central nervous system⁹⁰. HSDs have also been suggested to disturb the lipoprotein transportation and the equilibrium between oxidative stress and the antioxidant system to cause diseases. This process initiates with the interaction between GM and gut epithelia that leads to the production of ROS. Then, the generated ROS can induce mitochondrial dysfunction, causing the generation of inflammatory cytokines and bacterial metabolites such as LPS and hydrogen sulfide. These changes finally contribute to hepatic damage and liver diseases⁹¹. Hence, it is imperative for Chinese residents to actively diminish their daily salt intake to mitigate the incidence of salt-related diseases and improve their health status.

Less individuals in China engage in physical activities

With the modernization and urbanization of China, more and more Chinese people are involved in a sedentary lifestyle. According to the Scientific Research Report on Dietary Guidelines for Chinese Residents (2021), the amount of occupational, domestic, transportation and leisure physical activities of Chinese adult residents had been consistently declining in the past 30 years (Fig. S2)^10,92,93. Moreover, the average daily energy consumption had decreased by nearly 80 kcal for Chinese males and by nearly 65 kcal for Chinese females. Meanwhile, Chinese individuals were spending more time in screens, with 3 h for average daily leisure screen time¹⁴. It is common that people who have a sedentary lifestyle (due to having a lower metabolic rate) are more likely to gain weight and become overweight or obese compared with individuals who exercise regularly. This negative outcome has been observed in some countries, such as America and some European countries.

There is a discernible trend of rising chronic disease prevalence within the younger Chinese population in recent years. According to the data reported by the National Health Commission of China, 25% of Chinese adult residents suffer from hypertension, and 40% of them have dyslipidemia. It has been indicated this terrible situation is closely associated with the sedentary lifestyle and unhealthy dietary habits of Chinese younger generation. Statistics show there is a significant decrease in physical activity ability of the young generation, as evidenced by a target group index of 122.0⁹⁴. Concurrently, the majority of young Chinese individuals prefer to eat takeout foods (mainly energy-dense, high-saturated-fat, and high-sodium foods), which have been closely associated with obesity when compared to nutritionally balanced diets. Consequently, this positive energy balance may contribute to a significant increase in obesity rates among young adults in China¹⁴. Nevertheless, it has been found that an increase in physical activity can regulate GM, leading to an improvement in the host immunity (Table S4). Although some studies showed that long-term exercise did not affect the α and β diversity of GM composition, it increased the abundance of F. prausnitzii (spp.), Roseburia hominis (spp.), Akkermansia, Bifidobacterium, Bacteroides, Prevotella, Eubacterium, Ruminococcus, Lactobacillus, Blautia wexlerae, Eubacterium hallii, Parabacteroides, Phascolarctobacterium, Oscillibacter, and Bilophila⁹⁵. For the temporary physical activity, it has also been identified to increase the number of Dorea, Anaerofilum, and Akkermansia and decrease the abundance of Porphyromonadaceae, Odoribacter, Desulfovibrionaceae, and Enterobacteriaceae in obese subjects. Those changes in GM have been indicated to be closely associated with improving the host immunity through the production of SCFAs and anti-inflammatory modulators, combined with the reduction of oxygen tension and pro-inflammatory cytokines generation⁹⁶. Therefore, it is essential for the Chinese population to formulate a personalized exercise regimen, incorporate diversification in exercise modalities, and judiciously plan the temporal allocation of activities. These strategic approaches aim to mitigate the elevated obesity rate, consequently diminishing the susceptibility to obesity-associated chronic diseases, including cancers, T2DM, liver diseases, and CVD⁹⁷.

Microbiome-targeted therapies derived from Chinese traditional health practices

Traditional Chinese medicine treatment

Traditional Chinese medicine (TCM), which is a fundamental aspect of complementary and alternative medicine, has been utilized for millennia in China and its neighboring regions due to its efficacy in the therapy of human diseases. Recently, complementary and alternative therapies have been increasingly accepted, and traditional Chinese medicine, which is one of these therapies, is extensively recognized throughout South Asia and has greater global popularity^98–100. Research indicates the pharmacological efficacy of traditional Chinese medicine is significantly reliant on the biotransformation conducted by gut microbiota^101–105. In comparison to the primary medications, the metabolites generated by gut microbiota exhibit enhanced pharmacological action and facilitate absorption^106,107. Furthermore, various elements of TCM can supply specific intestinal flora with nutrients, hence influencing the composition of the host’s intestinal microbiota^101,102.

TCMs have been proposed to enhance glucose and lipid homeostasis by altering the composition and metabolic output of the gut microbiota¹⁰⁸. For instance, Tong et al. discovered that a particular herbal formulation composed of 8 herbs, including Rhizoma anemarrhenae, Momordica charantia, Coptis chinensis, Salvia miltiorrhiza, red yeast rice, Aloe vera, Schisandra chinensis, and dried ginger, ameliorated T2DM with hyperlipidemia by increasing the populations of short-chain fatty acids producing gut bacteria and anti-inflammatory species, including Blautia and Faecalibacterium spp., via the action of its major bioactive ingredients, including mangiferin and berberine¹⁰⁹. Moreover, polysaccharides from Plantago asiatica, anthraquinone-glycoside (RAGP) derived from rhubarb, berberine, and the Linggui Zhugan formula (comprising Poria, Ramulus cinnamomi, Rhizoma atractylodis macrocephalae, and Glycyrrhizae radix) can promote SCFAs production and increase Lactobacillus populations, which correlates with improving insulin sensitivity^110–115. The Huang-Lian-Jie-Du-Decoction (composed of Coptidis rhizoma, Scutellariae radix, Phellodendri cortex, and Gardeniae fructus) has been shown to increase the population of anti-inflammatory microorganisms such as Parabacteroides and ameliorate hyperglycemia, although the exact bioactive components underlying these beneficial effects remain unclear¹¹⁶. Berberine from Coptis chinensis and baicalin from Radix scutellariae water extract can increase the population of bacteria with bile salt hydrolase activity (e.g., Lactobacillus), thereby facilitating bile acid metabolism^117,118. TCMs can modulate the structure and function of gut microbiota. Particularly, it can increase the number of advantageous bacteria. A double-blinded clinical study by Xu et al. demonstrated that Gegen Qinlian Decoction, a traditional Chinese herbal formulation (containing Radix puerariae, Radix scutellariae, Rhizoma coptidis, and honey-fried Licorice root), enhanced the abundance of Faecalibacterium, Gemmiger, Bifidobacterium, and Lachnospiraceae incertae sedis via the action of its major active component, berberine¹¹⁹. Xiexin Tang (composed of Rhei rhizome, Scutellaria radix and Coptidis rhizome) has been shown to increase SCFAs production and elevate the mRNA levels and activities of essential SCFA-synthesizing enzymes^120,121. Additionally, it has also been indicated that TCMs can reduce the quantity of detrimental germs. For example, RAGP, berberine, and dietary fiber from bitter melon powder have been shown to diminish the population of LPS-producing bacteria (e.g., Desulfovibrio), thereby decreasing LPS levels and alleviating metabolic endotoxemia^{110,114,122–128}. Salidroside from Rhodiola rosea L. reduces the prevalence of pro-inflammatory microorganisms, such as Proteobacteria, which strongly correlates with mitigating inflammation¹²⁹.

TCMs can enhance intestinal barrier function by augmenting the population of mucin-degrading bacteria and modulating the expression of tight junction and adhesion proteins. Hydroxysafflor yellow A from Carthamus tinctorius significantly increases villus height and crypt depth in the small intestine and upregulates the expression of the key tight junction protein zonula occludens-1 (ZO-1), thereby significantly enhancing intestinal barrier integrity. These effects are mediated via gut microbiota modulation¹³⁰. Mannoglucan from Hirsutella sinensis mycelium and polysaccharides from Polygonatum kingianum significantly upregulate the expression of tight junction proteins, with changed microbiota composition contributing to improved metabolic function^{110,131–133}. TCMs can regulate inflammatory responses by inhibiting inflammation-related signaling pathways and reducing the expression of inflammatory factors in a GM-dependent manner. Furthermore, their modulation of macrophage polarization to enhance insulin sensitivity may also be regulated by GM and its metabolites¹²³. TCMs have also been proven to modulate the gut-brain axis through their impact on GM. Specifically, they regulate the number of SCFA-producing bacteria and promote the secretion of gut hormones, thus influencing satiety and appetite. These microbial-dependent signals subsequently affect the expression of hypothalamic neurons, such as NPY/AgRP and POMC/CART, which are closely associated with insulin sensitivity and blood homeostasis^126,134,135. It has also been suggested that TCMs modulate bile acid metabolism by altering the bile salt-hydrolyzing gut microbiota. They govern the conversion of cholesterol to bile acids and the reabsorption of bile acids, thereby improving metabolism^116,124,136. Research indicates that TCMs can also influence the tryptophan metabolism pathway through the modulation of gut microbiota composition¹³⁷.

Although this review centers on the beneficial effects of traditional Chinese medicine on human health via modulating the gut microbiota, it is crucial to recognize the potential toxic effects of TCM. Adachi et al. discovered that treatment with indigo naturalis can exacerbate oxazolone-induced colitis by modifying the composition of the gut microflora, although it can alleviate oxazolone-induced dermatitis¹³⁸. Another crucial aspect that requires consideration is that TCMs can be transformed by the intestinal flora into metabolites with diverse toxicities. For instance, a study demonstrated that genipin, which is toxic to HepG2 cells, can be formed subsequent to the metabolism of geniposide by the GM¹³⁹. Therefore, for the more effective utilization of TCMs in treating gut dysbiosis-induced diseases, it is essential to take the toxicity of TCMs into account.

Intake of fermented foods

Fermented foods are characterized as foods or beverages produced by controlling the proliferation of microbes and transforming food constituents via enzymatic processes¹⁴⁰. Traditionally, food fermentation was considered a preservation technique in China, since the metabolites produced by microbes could diminish the danger of contamination by pathogenic microbes. Currently, fermentation is used not only to enhance the flavor and texture of food but also to provide significant health advantages. In China, frequently consumed fermented foods can be categorized into different groups based on raw/non-fermented food substrate, including cereals-based ferments (like vinegar, “Baijiu” and “mijiu” made from rice, barley and sorghum wheat), vegetable-based ferments (like “pao-tsai” and “suan-tsai” made from napa cabbage), soybean-based ferments (like soy sauce, “douchi”, “furu” and “doubanjiang” made from soybeans), milk-based ferments (like yogurt made from cow’s milk) and other fermented foods (like “pidan” made from eggs from ducks and “kombucha” made from black tea)^141–145. Numerous studies indicate that fermented foods can confer health advantages and mitigate disease by influencing gut microbiota. For instance, An et al. found that douchi can improve diabetes and hyperlipidemia by modulating the composition and diversity of intestinal bacteria¹⁴⁶. Research also suggests that changing gut microbiota in soy yogurt contributes to gastrointestinal health¹⁴⁷.

Sauerkraut, which is a traditional fermented cuisine originating from China, is produced by mixing shredded cabbage with 2.3–3.0% salt and allowing natural fermentation by Leuconostoc spp., Lactobacillus spp., and Pediococcus spp.¹⁴⁸. Nielsen et al. investigated the impact of sauerkraut on individuals with irritable bowel syndrome (IBS) and discovered, compared with baseline, a significant reduction in the IBS-Severity Scoring System in both groups with daily consumption of 75 g either pasteurized (control) or unpasteurized (intervention) sauerkraut, although there were no differences in symptoms between these two groups. Moreover, 16S rRNA sequencing revealed a significant increase in sauerkraut-associated lactic acid bacteria, specifically L. plantarum and L. brevis, in the microbiota composition of the intervention group compared to the control group¹⁴⁹. Dojiang and furu are two kinds of ancient Chinese fermented foods with a rich historical background. Xinyu et al. discovered that the composition of intestinal microbiota altered following the administration of these two fermented meals to rats. The abundance of Firmicutes markedly diminished in the doujiang group at the phylum level. The abundances of Lactobacillus and Bifidobacterium considerably increased at the genus level in both doujiang and furu groups. Differential examination of KEGG metabolic pathways indicated that the intake of doujiang and furu dramatically enhanced secondary bile acid biosynthesis while diminishing flagellar assembly and bacterial chemotaxis pathways, potentially impacting the metabolic function of the gut microbiota¹⁵⁰.

However, another study in Chinese participants suggested that higher intake of sauerkraut may be associated with adverse health outcomes in gastrointestinal cancers. This case-control study found that the highest quintile of sauerkraut intake, compared to the lowest quintile, was associated with an increased risk of laryngeal cancer^151,152. One possible mechanism involves the high salt content of sauerkraut, although another two studies of dietary risk factors for laryngeal cancer found no associations with salt-preserved vegetables^153–156. Conversely, the high potassium content of sauerkraut is hypothesized to counteract the hypertensive effects of added salt¹⁵⁷.

Tea consumption

China is home to an abundance of tea varieties, including Biluochun, Longjing, Dahongpao, Tieguanyin, and more. It has been suggested that tea comprises a diverse array of components, including polyphenols, terpenoids, glycosides, purine (xanthine) alkaloids, amino acids, and carbohydrates; however, their concentrations fluctuate depending on the production method. Among them, tea polyphenols (TPP) have been reported to be the principal contributors to the health benefits of green tea¹⁵⁸. Unlike unfermented tea (green tea), other fermented teas, such as black tea, exhibit reduced polyphenol concentration and increased polysaccharide level. Tea is widely recognized for its advantageous benefits on human health, including the prevention of cancer, cardiovascular illnesses, obesity, metabolic syndrome, and other diseases^159–167. Recent research indicates that consumption of tea or TPP may affect the composition of gut microbiota, providing health benefits^168–170. Jin et al. evaluated alterations in the human intestinal microbiota of 10 participants consuming green tea in place of water for 10 days. The findings indicated that the intake of green tea, which acted as a prebiotic, could improve the colonic environment by elevating the number of Bifidobacterium species¹⁷¹. Yuan et al. investigated the impact of green tea liquid (GTL) on the intestinal and oral microbiome in healthy participants aged 27–50 years and found that the administration of GTL could change both the oral and gut microbes¹⁷².

Tea polyphenols have been suggested to influence the composition of gut microbiota. They can not only enhance beneficial bacteria such as Bifidobacterium and Lactobacillus, but also diminish potentially harmful bacteria like Prevotella and Bacteroides^172–174. After the intake of tea polyphenols, there is a reduction in the Firmicutes to Bacteroidetes ratio in the gut, which correlates with improvements in obesity and metabolic syndrome (MS)¹⁶⁹. It has been found that tea polyphenols can influence intestinal barrier integrity. For instance, one study showed that TPP could improve intestinal barrier function and diminish intestinal permeability, hence reducing the entry of pathogens and toxins into the bloodstream and attenuating inflammatory responses via GM modulation¹⁷⁵. Tea polyphenols can also prevent or alleviate symptoms of IBD by mitigating inflammatory responses, such as diminishing pro-inflammatory cytokines and inhibiting the NF-κB signaling pathway, which are influenced by GM¹⁷⁶. TPP also improves energy metabolism and the progression of metabolic syndrome by modifying GM-derived metabolites such as SCFAs, bile acids, and amino acids, which results in weight reduction, amelioration of dyslipidemia, and reduction of blood glucose levels¹⁷⁷.

However, emerging evidence suggests that green tea interventions modulate microbial ecosystems in a context-dependent manner. In a healthy volunteer intervention trial, green tea supplementation did not significantly alter salivary microbiota α-diversity at low taxonomic levels. Although the mechanism underlying the lack of α-diversity changes in salivary microbiota remains unclear, such changes may become apparent with higher doses and/or longer durations of GTL¹⁷². Additionally, Janssens et al. conducted a 12-week human intervention in which 58 subjects received or did not receive green tea. The study reported no significant differences in gut microbiome composition between baseline and after 12 weeks of tea consumption. Nonetheless, this phylogenetic analysis was limited to the phylum level, and potential differences at lower taxonomic levels may have been overlooked¹⁷⁸.

Fitness Tai Chi intervention

Traditional Chinese Medicine fitness, such as Tai Chi and Qigong, mixes the principles of traditional Chinese philosophy with the foundational traditional Chinese medicine health preservation theories, resulting in a comprehensive regimen of exercises that integrates fitness with relaxation. There has been an increasing number of publications regarding the application of traditional Chinese medicine fitness to improve health through regulating gut flora. For instance, in a randomized controlled experiment, researchers investigated the effects of exercise or Tai Chi on ameliorating internet addiction disease (IAD) through the modulation of GM and found that Tai Chi could markedly alleviate fatigue symptoms and diminish the prevalence of Erysipelotrichia; however, this intervention did not lead to a reduction in scores on the internet addiction test¹⁷⁹. Moreover, Tai Chi may promote beneficial changes in GM and metabolite profiles by regulating the hypothalamic–pituitary–adrenal (HPA) axis¹⁸⁰. It demonstrates a particular efficacy in significantly increasing the abundance of probiotics, such as Bifidobacterium and Lactobacillus¹⁸¹. Furthermore, Tai Chi can also improve cardiorespiratory fitness through its modulatory effects on GM¹⁸⁰. Matsumoto et al. propose that Tai Chi may enhance gut immune function by augmenting butyrate-producing bacteria¹⁸². Furthermore, Tai Chi enhances the quantity of regulatory T-cells and augments cell-mediated immunity¹³⁵. Consistent Tai Chi practice for 12 weeks enhances the ratio of CD4⁺/CD8⁺ and CD4⁺CD25⁺ regulatory T cells, while also improving helper T cell functionality in individuals with type 2 diabetes¹⁸³. A 16-week Tai Chi regimen also reduces the complement regulatory protein (CD55) in T cell immunity among post-surgical lung cancer survivors¹⁸⁴.

However, emerging evidence suggests other exercise modalities also positively regulate gut microbial ecology. For example, rugby, a type of high-intensity exercise training, significantly altered gut microbiota (22 phyla). Among these, the phylum Bacillota and Faecalibacterium prausnitzii were particularly enriched in rugby athletes, which have been associated with favorable health outcomes, including longevity and metabolic health. Additionally, rugby athletes also exhibited an increased abundance of gut bacteria with high biosynthetic activity¹⁸⁵. Moderate-intensity exercise training, such as a half-marathon, also modified GM composition. Namely, it significantly increased 20 bacterial clades while decreasing 7 taxa, and the top 4 enriched genera were Pseudobutyrivibrio, Coprococcus 2, Collinsella, and Mitsuokella, whereas Bacteroides coprophilus showed the most pronounced decrease¹⁸⁶. Petersen et al. demonstrated that cycling, an endurance activity, influenced GM composition in both professional cyclists and amateurs¹⁸⁷. Participants spending more than 11 h per week on training exhibited increased Prevotella abundance and elevated levels of branched-chain amino acids, which may be attributed to the significant correlation between Prevotella and metabolic pathways involved in carbohydrate and amino acid metabolism, particularly branched-chain amino acids biosynthesis¹⁸⁸. Moreover, those cyclists also showed increased Akkermansia and decreased Bacteroides¹⁸⁹. Notably, in comparison with other exercise patterns, mind-body exercises such as Tai Chi, incorporating deep breathing and meditation, exert unique regulatory effects. For instance, Tai Chi, as a low-intensity exercise, is suitable for individuals with mild-to-moderate obesity and middle-aged or elderly populations by aiding blood pressure control, bone mineral density maintenance, and glycemic regulation^190–193. Although there are general health benefits, uncertainties remain regarding the effect of Tai Chi on opportunistic pathogens such as Enterococcus and Enterobacteriaceae¹⁸¹. Furthermore, Tai Chi’s therapeutic effects on metabolic parameters in T2DM management appear inconsistent. A meta-analysis by Xia et al. indicated significant reductions in fasting blood glucose and HbA1c compared with inactive controls, yet no significant effects for Yang-style Tai Chi, the simplified 24-form practice, or interventions shorter than 12 weeks¹⁹⁴. Qin et al. further found Tai Chi’s superiority over a passive control group in reducing BMI, but not more effective than other aerobic exercises such as walking or dancing. Specifically, no interventional benefits of Tai Chi were observed for waist-to-hip ratio¹⁹⁵. Given that GM plays a central role in glucose homeostasis and adiposity regulation, these metabolic findings are likely not independent of microbial modulation^196–198. The observed heterogeneity may thus reflect differences in Tai Chi styles and control group selection bias, as well as variations in GM-mediated responses, underscoring the need for mechanistic studies linking Tai Chi, GM, and NCDs outcomes^194,195.

In conclusion, substantial data indicates significant effects of therapies based on traditional Chinese health practices in altering the composition and function of intestinal flora, with such alterations correlated with improved host health outcomes (Fig. 5). Thus, the scientific dissemination of traditional Chinese medicine, Chinese fermented foods, tea, and Tai Chi, which rooted in Chinese local lifestyles, may hold substantial importance as a prevalent intervention strategy for the prevention and improvement of lifestyle-related chronic diseases.

Fig. 5. Some reported functional attributes associated with microbiota-targeted therapeutics in enhancing human health.

This figure was created with BioRender.com.

Conclusion and perspectives

Over the past few decades, although the dietary structure in China has been continuously improving, the diet quality of the majority of residents remains suboptimal. In view of the rising morbidity and mortality of NCDs resulting from long-term dietary irrationality, the WHO published “Saving Lives with Less: A Strategic Response to Non-Communicable Diseases”, in which reducing unhealthy diets was listed as one of the WHO’s most cost-effective interventions for the prevention and control of NCDs. Even though some studies have indicated that the gut microbiota changes induced by short-term dietary interventions appear to be temporary, it should not be overlooked that habitual diets have more profound effects on the modulation of gut microbiota, with such modulation being strongly associated with health promotion. For example, chronic red meat consumption has been linked to increased colonization of Bacteroides fragilis and Escherichia–Shigella, both of which are associated with obesity. Additionally, excessive alcohol consumption increases the colonization density of Helicobacter pylori, the strongest known risk factor for gastric cancer. Therefore, it is imperative for Chinese individuals to embrace healthier lifestyles to mitigate the risk of NCDs stemming from microbiota dysbiosis. Specifically, Chinese residents should adhere to a diet primarily centered around cereals, eat more dark-colored vegetables, fruits, milk, soybean products, white meat, fish and shrimp, while refraining from too much red or processed meat consumption. Moreover, moderation in the consumption of oil, salt, and alcohol is recommended. Finally, cultivating a more active routine with increased physical activities is encouraged to counteract sedentary habits. Additionally, personalized therapies tailored for the Chinese population represent an effective and health-conscious approach to modulating gut microbiota, which significantly influences overall health outcomes. For instance, optimized administration of TCMs has been shown to improve insulin sensitivity by promoting SCFAs production and increasing Lactobacillus populations. Furthermore, habitual tea consumption has been demonstrated to alleviate obesity and metabolic syndrome through reducing the Firmicutes/Bacteroidetes ratio. While the effects of these traditional Chinese therapies on gut microbiota and their metabolites, as well as their role in health modulation, are well-established, further research is required to elucidate the interactions between such interventions and gut microbiota, especially for clarifying the exact regulatory mechanisms underpinning discrepancies across study results and enabling more robust interpretation of conflicting findings. Upon resolution of the aforementioned issues, it is anticipated that enhancing gut microbiota and its metabolites through lifestyle adjustments and the application of traditional Chinese therapies may serve as a more effective method for promoting overall public health in the future.

Author contributions

Y.Y.Z.: Writing—original draft, funding acquisition, investigation, methodology, supervision, and visualization. T.G.: Writing—original draft, data curation, formal analysis, and visualization. C.Z.Y.: Funding acquisition and project administration. W.Y.Y.: Data curation. G.J.Y.: Data curation. D.X.: Funding acquisition. Y.Y.C.: Investigation. Y.X.: Investigation. E.I.: Project administration. A.C.: Project administration. L.N.R.: Funding acquisition, project administration, and supervision. W.H.L.: Funding acquisition, project administration, and supervision.

Data availability

No datasets were generated or analyzed during the current study.

Competing interests

The authors declare no competing interests.

Supplementary information

The online version contains supplementary material available at 10.1038/s41538-025-00610-9.