Effects of Antioxidants (Micronutrients) with Metformin in type 2 Diabetic patients

 

Gozif Mohammed N. Omar1,2*, Fadel Yousif Al-Arabi2,3, Mansour Abdulnabi H. Mehdi2,3, Madhukar M. Fawade1

1Department of Biochemistry, Dr. Babasaheb Ambedkar Marathwada University, Aurangabad 431004, India.

2Department of Biology, Faculty of Education RDFAN, Aden University, Aden-Yemen.

3Dr. Rafiq Zakaria College for Woman, Dr. Babasaheb Ambedkar Marathwada University, Aurangabad, India.

*Corresponding Author E-mail: Gozifalamiriomar@gmail.com

 

ABSTRACT:

Objectives: This study aims to investigate the effect of antioxidants (Micronutrients) with Metformin on the levels of sugar and lipids in type 2 diabetic patients. Methods: The study has been conducted on 32 persons having the disease of type 2 diabetes. The patients were divided randomly into two groups labeled as B and C. All patients in each group have been taking metformin and additional specific treatment has been provided to group B. The samples have been collected before taking medicine (Antioxidants) and after three months of taking it. Blood samples were collected after 12 hours of overnight fasting where blood samples were drawn before and after a meal from the patients to measure levels of the sugar and lipids. The method that has been used for doing these investigations is Kit Spinreact. The results were analyzed statistically. Results: A significant decrease in FBS, PPBS, HbA1c, TC, TG, LDL and VLDL has been observed whereas the results showed increasing significance in HDL level in the patients of group B which received antioxidants (Muvit Gold) and Metformin compared to group C which received Metformin only. In conclusion, the results indicate that daily consumption of supplementary antioxidants (micronutrient) with Metformin leads to improving the level of blood glucose and lipids in patients with Type 2 diabetes and reducing the risk of complications. Hence, the dose of combining micronutrient with metformin can be used in the treatment of Type 2 diabetes by maintaining good glycemic control.

 

KEYWORDS: Type 2 diabetes, Blood sugar, lipid profile, Antioxidants (micronutrients).

 

 


INTRODUCTION:

Diabetes is considered to be one of the most common chronic diseases worldwide. There is a growing scientific and public interest in connecting oxidative stress with a variety of pathological conditions including Diabetes Mellitus (DM) as well as other human diseases.

 

Type 2 diabetes is a progressive condition in which the body becomes resistant to the normal effects of insulin and/or gradually loses the capacity to produce enough insulin in the pancreas. It is associated with modifiable lifestyle risk factors. It also has strong genetic and family-related risk factors1. It makes up about 90% of cases of diabetes with the other 10% due primarily to diabetes mellitus type 1 and gestational diabetes2,3. It is also defined by the complex interaction of various metabolic disorders that include hyperglycemia. Hyperglycemia is a lineament diabetic condition that decreases natural antioxidants and facilitates the production of reactive oxygen species (ROS) which can react with all biological molecules like carbohydrates, proteins, lipids, DNA and exert cytotoxic effects on cellular components4.

 

Antioxidants are natural substances that may prevent or delay cell damage. It is substances that play an important role in protecting cells from the damage caused by free radicals which result from the oxidation process.  In the body, vitamins E and C, antioxidant enzymes, and dietary antioxidants neutralize free radicals and hence control chronic diseases. The antioxidants are either endogenous (in the body) or exogenously obtained (as a part of a diet or as dietary supplements). Endogenous antioxidants play a significant role in keeping optimal cellular functions. However, endogenous antioxidants may not be enough and dietary antioxidants may be required to maintain cellular functions5,6. Antioxidants act as a radical scavenger, hydrogen donor, electron donor, singlet oxygen quencher, peroxide decomposer, an enzyme inhibitor, and metal chelating agents. Both enzymatic and non-enzymatic antioxidants are in the intracellular and extracellular environments to detoxify ROS and RON7,8. Many studies have reported a decrease in concentration of non-enzymatic antioxidants as well as enzymatic antioxidats in type 2 diabetes leading to a product of free radicals.  This leads to the oxidation of carbohydrates, proteins, lipids and nucleic acids 2. There are supplementation studies with vitamin E and zinc and also with vitamin C which found important improvements in serum glucose, total cholesterol, low-density lipoproteins, HbA1c and improved beta-cell function9,10.

 

Diabetes mellitus is accompanied by increased oxidative stress which is considered an underlying mechanism for inflammation and endothelial dysfunction. It is believed that oxidative stress plays an important role in the development of vascular complications in diabetes particularly. Many researchers have found that the depletion of body antioxidants may raise the risk of complications from diabetes11. Increasing the serum antioxidant percentage has been suggested as a protective measure to decrease the development of complications in diabetes, and after reducing the blood glucose level in the diabetic patient, the lipid profile and oxidation of lipids can be reduced.

 

This study was conducted to evaluate and to measure the effect of antioxidants (Micronutrients) supplemented along with Metformin on levels of fasting blood sugar (FBS), postprandial blood sugar (PPBS), total cholesterol (TC), low- and high-density lipoprotein (LDL and HDL), low- and very low-density lipoprotein (VLDL), triglycerides (TG), and levels of HbA1c in patients with Type 2 diabetes.

 

MATERIALS AND METHODS:

The study was performed in accordance with the principles outlined in the Declaration of Helsinki which have been approved by Dr. Babasaheb Ambedkar Marathwada University, Aurangabad, India, and the Ethics Committee at Halmeen Hospital, and AL-Amal Medical Diagnostic Center in Lahj, Yemen. This study conducted on 32 patients diagnosed with type 2 diabetes. 16 patients were males and the same number was females

 

All patients gave their informed consent before their inclusion in the study. These are patients diagnosed with Type 2 diabetes of age group between 30 and 70 years. Meanwhile, they were depending on Metformin dose so that the treatment was used by having Glucovance manufactured by Merck Sante s.a.s. 2, rue du pressoir Vert 45400 SEMOY- FRANCE.  Each tablet of Glucovance 500mg/2.5mg, contains 500mg Metformin and 2.5mg of glibenclamide. Patients who had fasting blood glucose level >300mg/dl, medical illnesses including metabolic, type 1 diabetes, pregnancy, and age <30 years, and age >70 years were excluded from the study.  Also, patients who had received any antioxidant over the past 3 months were excluded from the study. As well, none of them was a smoker, drinker or had been taking any psychotropic drug.

 

The patients were divided randomly into two groups. These groups were labeled as B and C. Each group had 16 patients. All patients in each group took Metformin but the researcher added a specific treatment for group B without giving any additional treatment to group (C), which was the control group. Meanwhile, patients in group B were given micronutrients (Muvit Gold) dose (a dietary supplement produced by shaphaco pharmaceutical Sana'a, Yemen). The dose Muvit Gold had been given twice a day to Group B for three months. At the same time, all patients received a tablet of Metformin 500 mg twice daily orally with breakfast and dinner. The sample size was calculated with the standard deviation taken from a study and the level of significance at P≤0.05. The drug was given to patients for the duration of one month at a time. Patients were required to return the unused drugs and container during the follow-up treatment, so 95% consumption was considered to be suitable. Drugs were decoded at the end of a trial.

 

After the study performance was over, the subjects were given over to the specialist physician of diet; all patients were maintained on their normal dietary type while reducing their consumption of vitamins rich food during the study. A patient was commanded by a physician to use a basic food list that contained food suitable for diabetic patients. Investigations of values were considered normal in case of; FBS <126mg/dl, TC <200 mg/dl, TG <160mg/dl, HDL-cholesterol 35–55mg/dl, LDL- cholesterol <100mg/dl, and HbA1c 6. Age and sex were examined and recorded.  Then, blood samples were drawn before and after a meal from the patients to measure levels of FBS, PPBS, TC, TG, LDL, VLDL, HDL, and glycated HbA1c. These were measured before the initiation of supplementation with micronutrients. Also, after 3 months of supplementation micronutrients, patients were examined again. For doing these investigations, Kit Spinreact method was used.

 

Biochemical Analysis:

Estimation of glucose level: fasting blood glucose and postprandial blood glucose was measured by Glucose oxidase-peroxidase (GOD-POD) method by using kits (Spinreact). Estimation concentration of total cholesterol (TC) was measured by the cholesterol oxidase- Peroxidase method. It was the estimation of serum triglycerides (TG) by Glycerol-3-oxidase (GPO)- Peroxidase (POD) method. Estimation of serum High-density lipoprotein (HDL) was done by the cholesterol oxidase method using kits (Spinreact). After knowing the results of all the above lipids and lipoproteins, low density lipoprotein cholesterol (LDL-C) and very low-density lipoprotein cholesterol (VLDL-C) were calculated by Friedewalds formula and estimation concentration of glycated hemoglobin (HbA1c) by SD A1c Care.

 

Statistical Analysis:

Results were expressed as ± mean values and standard deviations. Group differences were calculated by SPSS paired t-test. Two-tailed p value was used throughout the analysis, and the p values which were ≤0.05 were judged statistically significant (p≤0.05). IBM SPSS statistical (version 21) was used.

 

RESULT:

It can be seen from Table (1) that the mean age of the patients with diabetes in the experimental group B was (48.50±11.58) years and the control group C (50.00 ±12.18) years; it was not significantly different from each other. In this study, it was found that the participants had an increase in FBG, PPBG, HbA1C, TC, TG, VLDL-C and LDL-C, with a decrease in HDL-C concentrations in type 2 diabetic patients.

 

The results show that there was a statistical significance (p≤0.05) In the experimental group B, there was statistically significant decrease in the levels each of FBS p=0.000, PPBS p=0.000, HbA1c p=0.000, TC p=0.001, TG p=0.028, LDL p=0.000, and VLDL p=0.013, and on the other hand, the results showed an increase in concentrations of HDL as it reached the level which is statistically significant p=0.000 as in (Table 3).  In the control group, the improvement reached the statistically significant level in the levels of FBS p=0.029. Also, in the level of PPBS there was an improvement but it did not reach the level of statistical significance (p≥0.05). At the same time, levels of HbA1c had no improvement after three months of treatment compared to pre-prandial levels. Increasing the level of lipid profile was seen, and it was not a statistically significant level of reduction in HDL so that there was no improvement (Table 2).

 

Moreover, when comparing the effects of medication by using Metformin in the control group, and Metformin with Muvit Gold in the experimental group after 3 months of taking the treatment, the changes from baseline values of these parameters were taken into account. A decrease in levels of fasting blood sugar, postprandial blood glucose, glycosylated hemoglobin and lipid profile (TC, TG, LDL and VLDL) were significant after three months in the experimental group compared to the control group. In contrast, the level of HDL increased significantly in the experimental group compared to the control group.

 

Table 1: Age and distribution

Variables

Age                          

Mal 

Female

Group B

48.50 ± 11.58

8

8

Group C

50.00 ± 12.18

8

8

Values are given as Mean + SD, 32 all groups, group C: control group, group B.

 

Table 2: The effect of Metformin on the levels FBS, PPBS, HbA1c, TC, TG, HDL, LDL, and VLDL in the control group of patients with type 2 diabetes.

Parameter

Before treatment

After treatment

P

FBS

184.06±49.03

174.13±46.60

0.029

PPBS

257.94±46.74

248.63±49.82

0.085

HbA1c

8.98±1.59

8.99±1.48

0.926

TC

174.38±36.91

178.56±44.76

0.345

TG

164.56±63.19

178.25±65.42

0.159

HDL

42.44±7.23

40.56±9.32

0.090

LDL

99.19±39.59

102.13±44.59

0.431

VLDL

31.69±13.09

35.94±13.13

0.065

N= 16 in number, FBS: fasting blood sugar, PPBS: postprandial blood sugar, HbA1c: glycosylated hemoglobin, TC: total cholesterol, TG: Triglyceride, HDL: high density lipoprotein, LDL: low density lipoprotein, VLDL: Very low density, are measured in mg/dL.

 

Table 3: The effect of Metformin with micronutrients (Muvit Gold) on FBS, PPBS, HbA1c, TC, TG, HDL, LDL and VLDL in the experimental group of patients with type 2 diabetes after three months of treatment.

Parameter

Before treatment

After treatment

P

FBS

213.31±62.44

170.63±43.23

0.000

PPBS

282.88±77.89

234.31±52.42

0.000

HbA1c

9.39±1.23

8.15±1.07

0.000

TC

187.00±35.73

168.06±38.39

0.000

TG

182.94±70.50

170.38±63.09

0.028

HDL

39.75±3.97

44.31±4.39

0.000

LDL

110.63±40.12

89.94±41.28

0.000

VLDL

36.81±13.73

34.06±12.74

0.013

N= 16 in number, FBS: fasting blood sugar, PPBS: postprandial blood sugar, HbA1c: glycosylated hemoglobin, TC: total cholesterol, TG: Triglyceride, HDL: high density lipoprotein, LDL: low density lipoprotein, VLDL: Very low densities lipoprotein, are measured in mg/dL.

 

Fig. 1: Levels of improvement are shown the mean values of FBS: Fasting blood sugar, PPBS: Postprandial blood sugar, HbA1c: Glycosylated hemoglobin, TC: Total cholesterol, TG: Triglyceride, HDL: High-density lipoprotein, LDL: Low-density lipoprotein, VLDL: Very low-density lipoprotein before (red bars) and after (green bars) supplementation/treatment with doses of micronutrients (Muvit Gold).

 

DISCUSSION:

The results of this study showed low level of improvement at the significant level P≤0.05 in the FBG, PPBG, HbA1c, TC, TG, LDL and VLDL and an increase in HDL level of the diabetes patients which reached the significance level when taking antioxidants compared with the stage before taking antioxidants (micronutrients (Muvit Gold)) supplementation along with Metformin in patients of type 2 diabetes. Up to my knowledge, this is the first study related to the role of antioxidants and their effects on all the above parameters after the use of Muvit Gold (micronutrients) with Metformin. The results of this study are in agreement with previously published data showing improvement in glycemic control with micronutrients (Vitamin supplementation and Minerals) together or separately. In this study, patients received Muvit Gold in addition to Metformin which is the first-line drug for the treatment of Type 2 diabetes. The results led to show a beneficial effect in the group which used micronutrients (Muvit Gold) with Metformin better than the second group which used only Metformin.

 

It is well known from previous studies that there is an increased production of damaging free radicals in Type 2 diabetes patients. Glucose auto-oxidation, protein glycosylation, in a formation of the polyol pathway, and advanced glycation end products are involved in the generation of oxidative stress, which are involved in the origin of both Type 1 and 2 diabetes12. The imbalance between the reactive types and the antioxidants leads to the production of oxidative stress which causes the development of the condition to diabetes where antioxidants work a chain-breaking mechanism by which the primary antioxidant donates an electron to the free radical present in the systems13. The second mechanism involves the removal of ROS/reactive nitrogen species initiators (secondary antioxidants) by quenching chain-initiating catalyst. Antioxidants may exert their effect on biological systems by different mechanisms including electron donation, metal ion chelation, co-antioxidants, or by gene expression regulation. Hence there are beneficial effects of antioxidant on the complications of diabetes in which oxidative stress is reduced; and diabetes and its complications are relieved14.

 

The first important observation of the studies was a significant reduction in FBS, PPBS, HbA1c, TC, TG, and LDL, in varying periods when adding multivitamins to the experimental groups either combined or single. A similar finding is reported by various studies.  Prajapat et al.,15 in a report study, found that combined doses [500mg/day twice] for four months, of vitamin E and C in addition to the normal food, improved the plasma glucose and lipid profile in patients with type 2 diabetes. Dakhale et al.,16 indicated that after treatment with vitamin C along with Metformin compared to placebo with Metformin, FBS, PPBS, and HbA1c levels showed a significant improvement after 12 weeks of treatment with vitamin C. Also, the results of the present study agree with the study conducted by Gunasekara et al.,17 where effective changes were observed in the improvement of the patients' glycemic control in response to zinc and other multivitamin along with mineral supplementation.

 

Lipids are important for a variety of different functions. However, persistently high lipids can have detrimental effects on health and is a risk factor for a disease process called atherosclerosis. This can ultimately lead to pain, reduced function, and even death. In the present study, high levels of TC, TG, LDL, and VLDL with low HDL were showed in diabetics. Also, it has been showed that there was a low improvement at the significant level in the lipids level when taking antioxidants compared with the stage before taking antioxidants. The present finding is in line with the study of Errikson, and Kohvakka18. The proposed significant decrease in lipids was observed by using 2gm of vitamin C for 90 days. In another study, Paolisso and Giugliano19 demonstrated that vitamin E has led to improvement in plasma level and lipids. Afkhami-Ardekani and Shojaoddiny-Ardekani10 in their clinical trials showed a significant improvement in lipids levels after the usage of 1000mg of vitamin C in type 2 diabetic patients. The present finding is also in line with the study of Gunasekara et al.,20 in which treatment with multivitamin-mineral with or without zinc, resulted in improvement of lipids levels. The present finding is also in line with the study of Gillani et al.,21 where the trial concluded that ascorbic acid with metformin resulted in a significant decrease in lipids.

 

The increases in levels of cholesterol occur when the cells of the body stop responding properly to the insulin. This is called insulin resistance or syndrome. Insulin resistance causes higher levels of insulin, free fatty acids, and blood sugar22. Insulin plays an important role in the metabolism of lipid apart from its regulation of carbohydrate metabolism. Insulin is potent inhibitor lipolysis since it inhibits the activity of hormone-sensitive lipases in adipose tissue. Also, insulin acts on inhibiting the reductase enzyme of Hydroxymethylglutary-COA (HMG-COA) which participates in catabolism of mevalonic acid and the formation of cholesterol23.

 

Antioxidants play an important role in reducing free radicals in cells that improve insulin resistance by improving endothelial function and lowering oxidative stress. Also, Vitamin C plays an important role in several metabolic functions such as the conversion of cholesterol to bile acids and the conversion of the amino acid to the neurotransmitter, serotonin that is leading to decrease cholesterol. Vitamin C deficiency especially, and other antioxidants, might lead to weakness in the transport of long-chain fatty acids into the mitochondria and raise triglyceride synthesis in patients24. Studies have also ascribed a role to vitamin A in energizing the antioxidant enzyme functions in the body. Moreover, a relationship has been found between diabetes and deficient vitamin A levels indicating vitamin A supplementation may have a role in T2DM biology25.

 

According to previous findings, single vitamin or mineral, and a low single dose at the same time did not cause significant benefits in all cases and all parametric (glucose and lipid profile) in diabetes patients, but increased dose causes significant benefits. In the present study, combined micronutrients (Muvit Gold) twice daily for 3 months caused a significant decrease in FBG, PPBG, HbA1c, TC, TG, LDL and VLDL and a significant increase in HDL level after treatment by Muvit Gold supplementation along with Metformin in patients of type 2 diabetes.

 

CONCLUSION:

Supplementary antioxidant of the micronutrient (Muvit Gold)) twice daily with Metformin for 3 months period was well tolerated and devoid of any side effects. It has led to an improvement in that it caused a decrease in FBG, PPBG, HbA1c, TC, TG, LDL and VLDL and a significant increase in HDL level after treatment for the Type 2 diabetes which makes it useful therapy in the treatment and improvement of Type 2 diabetic patients.

 

REFERENCE:

1.      Bellamy L, Casas J P, Hingorani A D, Williams, D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. The Lancet. 2009; 373(9677): 1773-1779.

2.      American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010; 33(Suppl 1): S62.

3.      World Health Organization. WHO report on the global tobacco epidemic, 2013: enforcing bans on tobacco advertising, promotion and sponsorship. World Health Organization. 2013.

4.      Dincer Y, Akcay T, Alademir Z, Ilkova H. Effect of oxidative stress on glutathione pathway in red blood cells from patients with insulin-dependent diabetes mellitus. Metabolism-Clinical and Experimental. 2002; 51(10): 1360-1362.

5.      Omar Gm, Al-Arabi Fy, Mehdi Ma, Fawade Mm. Antioxidant Effect of Vitamins Combined A, C, And E Dose on Type 2 Diabetic Patients. Asian J Pharm Clin Res. 2019;12(4):51-4.

6.      Rahman K. Studies on free radicals, antioxidants, and co-factors. Clinical Interventions in Aging. 2007; 2(2): 219.

7.      Frei B, Stocker R, Ames B N. Antioxidant defenses and lipid peroxidation in human blood plasma. Proceedings of the National Academy of Sciences. 1988; 85(24): 9748-9752.

8.      Omar G M N, Al-arabi F Y, Mehdi M A H, Fawade M M. Management of diabetes and its complications through the role of antioxidants: Review. RESEARCH REVIEW International Journal of Multidisciplinary. 2019; 3(9): 519-26.

9.      Paolisso G, D'Amore A, Galzerano D, Balbi V, Giugliano D, Varricchio M, D'Onofrio F. Daily vitamin E supplements improve metabolic control but not insulin secretion in elderly type II diabetic patients. Diabetes Care. 1993; 16(11): 1433-1437.

10.    Afkhami-Ardekani M, Shojaoddiny-Ardekani A. Effect of vitamin C on blood glucose, serum lipids & serum insulin in type 2 diabetes patients. Indian Journal of Medical Research. 2007; 126(5):471.

11.    Cade W T. Diabetes-related microvascular and macrovascular diseases in the physical therapy setting. Physical Therapy. 2008; 88(11): 1322-1335.

12.    Omar G M N, Al-arabi F Y, Mehdi M A H, Fawade M M. Antioxidant effect of vitamins combined a, c, and e dose on type 2 diabetic patients. Asian Journal of Pharmaceutical and Clinical Research. 2019; 12(4): 51-54.

13.    Lobo V, Patil A, Phatak A, Chandra N. Free radicals, antioxidants and functional foods: impact on human health. Pharmacognosy Reviews. 2010; 4(8): 118.

14.    Srivatsan R, Das S, Gadde R, Manoj K K, Taduri S, Rao N, Balakumaran T A. Antioxidants and lipid peroxidation status in diabetic patients with and without complications. 2009.

15.    Prajapat R, Bhattacharya I, Jakhalia A. Combined effect of vitamin C and E dose on type 2 diabetes patients. Adv in Diabetes and Metabolism. 2017; 5(2): 21-5.

16.    Dakhale G N, Chaudhari H V, Shrivastava M. Supplementation of vitamin C reduces blood glucose and improves glycosylated hemoglobin in type 2 diabetes mellitus: a randomized, double-blind study. Advances in Pharmacological Sciences. 2011.

17.    Gunasekara P, Hettiarachchi M, Liyanage C, Lekamwasam S. Effects of zinc and multimineral vitamin supplementation on glycemic and lipid control in adult diabetes. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2011; 4:53.

18.    Eriksson J, Kohvakka A. Magnesium and ascorbic acid supplementation in diabetes mellitus. Annals of Nutrition and Metabolism. 1995; 39(4): 217-223.

19.    Paolisso G, Giugliano D. Oxidative stress and insulin action: is there a relationship. Diabetologia. 1996; 39(3): 357-363.

20.    Gunasekara P, Hettiarachchi M, Liyanage C, Lekamwasam S. Effects of zinc and multimineral vitamin supplementation on glycemic and lipid control in adult diabetes. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2011; 4: 53.

21.    Gillani S W, Sulaiman S A S, Abdul M I M, Baig M R. Combined effect of metformin with ascorbic acid versus acetyl salicylic acid on diabetes-related cardiovascular complication; a 12-month single blind multicenter randomized control trial. Cardiovascular Diabetology. 2017; 16(1): 103.

22.    Cahova M, Vavřínková H, Kazdova L. Glucose-fatty acid interaction in skeletal muscle and adipose tissue in insulin resistance. Physiological Research. 2007; 56(1):1-15.

23.    Goodman, L. S. Goodman and Gilman's the Pharmacological Basis of Therapeutics New York: McGraw-Hill. 1996; 1549.

24.    Dai S, McNeill J H. Ascorbic acid supplementation prevents hyperlipidemia and improves myocardial performance in streptozotocin-diabetic rats. Diabetes Research and Clinical Practice. 1995; 27(1): 11-18.

25.    Iqbal S, Naseem I. Role of vitamin A in type 2 diabetes mellitus biology: effects of intervention therapy in a deficient state. Nutrition. 2015; 31(7-8): 901-907.

 

 

 

 

Received on 14.04.2020            Modified on 08.06.2020

Accepted on 02.07.2020         © RJPT All right reserved

Research J. Pharm. and Tech. 2021; 14(4):1923-1927.

DOI: 10.52711/0974-360X.2021.00340