Figure 1: Major gut flora mediated mechanisms leading to cardiometabolic syndrome. 1. Atherosclerosis pathway depicted by choline conversion to TMA in the gut by microbiota and subsequent conversion to TMAO in liver. Increased TMAO levels lead to macrophage activation and plaque formation. 2. Obesity pathway depicts conversion of carbohydrates to SCFA which enhances gluconeogenesis and lipid accumulation. 3. Insulin resistance pathway is depicted with SCFA mediated endotoxemia with LPS by increased membrane permeability. Macrophage activation is promoted by LPS endotoxemia along with chronic inflammatory state and leads to increased insulin resistance. (Modified: Vinje S, Stroes E, Nieuwdorp M, Hazen SL (2014) The gut microbiome as novel cardiometabolic target: the time has come! Eur Heart J 35: 883-887).