“…The approach adopted in this study provides an opportunity to generate new hypotheses on metabolic pathway perturbation. One can indeed hypothesize that the metabolites involved in metabolic pathways identified in this study in fact act as signaling molecules [or account for lack of these (e.g., in HBR, NBR)] involved in the PlanHab symptoms as detailed in Figure 1 : insulin resistance, low-grade inflammation, different mitochondrial function, miRNA expression in large muscles, differences in lipid oxidation, mood changes, and depression ( Debevec et al, 2014a , 2016b ; Rittweger et al, 2016 ; Simpson et al, 2016 ; Sket et al, 2017a , b , 2018 ; Strewe et al, 2017 , 2018 ; Stavrou et al, 2018a , b ; Supplementary Table 1 ). In addition to those listed above, groups of metabolites identified in this study were also associated with: (i) the chronic obstructive pulmonary disease (COPD) ( Adamko et al, 2015 ; Za̧bek et al, 2015 ) and included metabolites such as 3-hydroxyisovalerate, 2-hydroxyisobutyrate, creatinine, formate, taurine, urea, choline, isoleucine, pantothenate, valine, and its degradation to beta-aminoisobutyric acid during metabolism of branched-chain amino acids suggest increased catabolism associated with COPD; (ii) cardiovascular disease as a results of associated chain of events such as tissue hypoxia (gut ischemia) due to reduced oxidative phosphorylation and energy production that lead to pulmonary hypertension, systemic inflammatory responses, and increased risk of cardiovascular disease, type 2 diabetes, depression, and osteoporosis ( Jones, 2014 ).…”