Another study showed that metformin is associated with higher relative abundance of mucin-degrading Akkermansia muciniphila and Bifidobacterium bifidum (43, 48, 49) Both strains protected against NAFLD by activating hepatic FXR, suppressing intestinal FXR expression, modulating the gut microbiota, and improving intestinal mucosal permeability (50). This evidence concerns the gene NR1H4 and metabolic dysfunction-associated steatotic liver disease.