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Effects of Hydroalcoholic extract of Berberis Integerrima on theanthropometric indices and metabolic profile in active RheumatoidArthritis patients
Naheed Aryaeian, Sara Khorshidi Sedehi, Masoud Khorshidi,Meysam Zarezadeh, AghaFatemeh Hosseini, Farhad Shahram
PII: S0965-2299(19)31492-X
DOI: https://doi.org/10.1016/j.ctim.2020.102331
Reference: YCTIM 102331
To appear in: Complementary Therapies in Medicine
Received Date: 4 October 2019
Revised Date: 16 January 2020
Accepted Date: 27 January 2020
Please cite this article as: Aryaeian N, Sedehi SK, Khorshidi M, Zarezadeh M, Hosseini A,Shahram F, Effects of Hydroalcoholic extract of Berberis Integerrima on the anthropometricindices and metabolic profile in active Rheumatoid Arthritis patients, ComplementaryTherapies in Medicine (2020), doi: https://doi.org/10.1016/j.ctim.2020.102331
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© 2020 Published by Elsevier.
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Effects of Hydroalcoholic extract of Berberis Integerrima on the anthropometric
indices and metabolic profile in active Rheumatoid Arthritis patients
Running title: Berberis Integrima supplementation and Rheumatoid Arthritis
Naheed Aryaeian (Ph.D.)1*, Sara Khorshidi Sedehi (MSc)2, Masoud Khorshidi (Ph.D.)3,4,
Meysam Zarezadeh (Ph.D.)5, AghaFatemeh Hosseini (MSc)6, Farhad Shahram (MD)7**
*1 Department of Nutrition, School of Public Health, Iran University of Medical Sciences,
Tehran, Iran.
2 Department of Nutrition, School of Public Health, Iran University of Medical Sciences,
Tehran, Iran. [email protected].
3 Student Research Committee, Department of Nutrition, School of Public Health, Iran
University of Medical Sciences, Tehran, Iran. [email protected]
4 Pediatric Gastroenterology, Hepatology and Nutrition Research Center, Research
Institute for Children Health, Mofid Children’s Medical Center, Shahid Beheshti
University of Medical Sciences, Tehran, Iran.
5 Department of Clinical Nutrition, Student Research Committee, Nutrition Research
Center, School of Nutrition and Food Sciences, Tabriz University of Medical Sciences,
Tabriz, Iran. [email protected]
6 Department of Biostatistics, School of Public Health, Iran University of Medical
Sciences, Tehran, Iran. [email protected].
7 Rheumatology Research Center, Shariati Hospital, Tehran University of Medical
Sciences, Tehran, Iran. [email protected].
First Correspondence:
*Naheed Aryaeian, Ph.D.
Department of Nutrition,
School of Public Health,
Iran University of Medical Sciences,
Hemmat Broadway, Tehran, Iran
Postal Code: 1449614535
Tel: +982188622706
Fax: +98 21 88622707
Mobile number: 09123093353
Email: [email protected]
Second Correspondence:
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** Farhad Shahram (MD)
Rheumatology Research Center,
Shariati Hospital,
Tehran University of Medical Sciences,
Tehran, Iran
Email: [email protected].
Highlights
• Waist and hip circumference significantly were decreased in the
intervention group.
• Body fat percent, low density lipoprotein levels and systolic blood
pressure significantly were decreased in the intervention group.
• A significant decrease was observed in body fat percent, hip
circumference, fasting blood sugar and high density lipoprotein in the
intervention group compared to the placebo group.
Abstract
Objectives: Since, the main cause of death in Rheumatoid arthritis (RA) patients is the
presence of type 2 diabetes, abnormal increase in blood lipids, blood pressure and obesity,
the aim of this study was to assess the effects of Barberry on the anthropometric indices
and metabolic profile in patients with RA.
Design: present study was a double-blinded, placebo-controlled randomized clinical trial.
Setting: 70 active RA patients were randomly allocated into intervention or placebo
group
Intervention: Participants received 6 capsules of 500 mg barberry extract or placebo for
3 months.
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Main outcome measures: Serum levels of fasting blood sugar (FBS), triglyceride (TG),
LDL cholesterol (LDL-C) and HDL cholesterol (HDL-C), systolic and diastolic blood
pressure and anthropometric factors were assessed at baseline and at the end of the trial.
Results: The results of intervention on 62 patients showed that weight, BMI, and conicity
index increased in both groups, but this was significant only in the placebo group
(p<0.001). Waist and hip circumference were decreased in the intervention group and
increased significantly in the placebo group (p<0.001). Body fat percent (p=0.04), LDL-
C (p=0.05) and SBP (p=0.02) significantly were decreased in the intervention group. The
results showed a significant decrease in body fat percent (p=0.05), hip circumference
(p<0.001), FBS (p=0.03) and HDL-C (p=0.03) in the intervention group compared to the
placebo. Conclusions: Overall, the results of this study demonstrated that the extract of
Berberis Integerrima had beneficial effects on metabolic profile and anthropometric
indices in RA patients.
Keywords: Barberry; Blood glucose; HDL cholesterol; Body Weight; Rheumatoid
Arthritis; Randomized Clinical Trial.
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Introduction:
Rheumatoid arthritis (RA) is an inflammatory and chronic disease affects about 0.5-
1% of world population (1) and it often affects women more than men (2). Although,
there is a wide range of systemic manifestations, the main symptom of the disease is
persistent inflammatory synovitis that usually affects the peripheral joints symmetrically
(3). Patients with RA also have less serum antioxidants, more pro-inflammatory
mediators and lipid peroxidation (4). In RA, persistent inflammation may induce
muscular wasting without thinning. In fact, the reduction of body mass is associated with
the increased fat mass that creates condition said rheumatoid cachexia (RC). Nearly one-
third of all RA patients are affected by RC (5). RC increases protein catabolism and may
cause a change in body composition (6, 7). Moreover, it increases body fat mass and fat
tissue hormones such as leptin, and reduces adiponectin, alters the immune system and
exacerbates autoimmune disease and glucose metabolism (8). In addition, drugs such as
glucocorticoids, which are routinely used in these patients, causes hypertension,
dyslipidemia, hyperglycemia, and obesity (9). In recent years the use of medicinal plants
in RA treatment is expanded due to the vast side effects chemical medications and high
medication cost of this disease. Barberry contains some active components that have
various features such as anti-inflammation (10), antioxidant (11), hypotensive (12),
hypoglycemic (13) and hypocholesterolemic effects (14) and modulate immune system
(15). The fruits of Barberry contain a large amount of vitamin C, glucose, fructose, malic
acid, pectin (16), and berberine. Berberine is one of the main alkaloids of Berberis
Integerrima (18). Many studies showed an increase in mortality and complications of RA
patients compared with healthy people. The main causes of death in RA patients are type
2 diabetes, an abnormal increase in blood lipids, blood pressure, obesity, and smoking
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(19). Also, due to the increased risk of heart disease in RA patients (20) and
corticosteroids consumption, the risk of increasing blood Glucose, hyperlipidemia and
Blood pressure is higher in these patients (21). Thus, this study aimed to investigate the
effect of the Berberis Integerrima extract on the glycemic and lipid profiles, blood
pressure and anthropometric indices specially body weight in patients with RA.
Materials and methods:
We conducted a double-blind, placebo-controlled randomized clinical trial that
registered in the Iranian Registry of Clinical Trials (http://www.irct.ir:
IRCT201409249472N7). The study was conducted in Shariati hospital, Tehran, Iran for
11 months from 23 July 2015 to 20 June 2016. The sample size of n = 35 in each study
group was calculate considering a type 1 error of 5%, power of 80%, and 10% dropout
estimation in each group. We studied 978 patients with rheumatoid arthritis. Among
them, 70 patients with active rheumatoid arthritis were enrolled in the study. The study
was approved by the ethics committee of Iran University of Medical Sciences (code:
25092-93/10/15) and was conducted in accordance with the Declaration of Helsinki. A
written consent was taken from all patients before the intervention. Inclusion criteria
were: diagnosis of rheumatoid arthritis based on American College of Rheumatology
criteria (ACR, 2010) (22), adults older than 18 years, having active RA for at least one
year, lack of diabetes, hypertension, thyroid disorders, kidney failure and liver
dysfunction, non-smoking, non-pregnant and lactating, not taking oral contraceptive
drugs. Exclusion criteria were: taking vitamin and mineral supplements, , acute illness
and sudden infection, immigration, unwillingness to continue the study and any changes
of treatment and drug protocol. Disease activity was confirmed by the Rheumatologist in
accordance with the GPA (Global Physician Assessment) scoring systemthen patients
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were randomly allocated into two groups to receive the extract of black barberry or
Hydroxypropyl methylcellulose (HPMC). At each day of sampling, the first sample was
selected through the sortation and others were decussated in placebo or intervention
groups. Patients, individual researchers and laboratory workers were blinded to treatment
allocation. In this study. Changes in body weight were considered as primary outcome,
while other parameter of anthropometric indices and metabolic profile were considered
as secondary outcomes.
Since hydroalcoholic extraction method (with 30% water and 70% ethanol solvent)
showed the highest yield and the maximum amount of extracted phenol and flavonoids,
it was selected as the extraction method in this study (23). The extraction and
encapsulation process was performed at one of the Iranian herbal supplement companies.
The capsules size was 500 mg, but due to the high adhesion of barberry extract, each
capsule contained 250 mg of barberry extract and 250 mg HPMC and placebo contain
500 mg HPMC. To prepare each capsule, 2.5 g of barberry was used and each patient of
intervention group consumed 1.5 g of barberry extract daily. The lethal dose, 50% (LD50)
of Berberis Integerrima extract was found to be 2500 mg/kg (24), and no side effects were
reported follow the consumption of 3 g of barberry extract daily for 3 months in human
(25). Accordingly, the use of 1.5g barberry extract in our study was completely safe.
Shape and size and color of placebo capsules were similar to barberry extract capsules
and both of them manufactured by Green Plant of Life (Tehran, Iran). The scientific name
of the barberry used in this study was Berberis Integerrima bunge from Berberidaceae
family. The herbarium number that was approved by Tehran University of Medical
Sciences was PMP-658.
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The patients were randomly assigned through permuted blocked randomization to
receive either Berberis Integerrima extract or placebo. Each group consumed 6 capsules
(1500 mg barberry extract and 1500 mg HPMC in intervention group and 3000 mg HPMC
in placebo) for 3 months. Patients were taking two capsules in the morning, two in the
afternoon and two in the evening with or after the meal. All volunteers were advised to
maintain their routine diet habit and do not change physical activity during the study. In
this study, we used per protocol method for dealing with missing data, in which each
patient was asked to return box of supplements, and if less than 80% of the capsules were
used, the individual would be excluded from the study.
To evaluate the compliance, patients were asked to bring the supplements container.
In order to ensure from adherence, patients received regular phone calls as a reminder of
supplement intake. For control the confounding effect of diet, dietary intake was
evaluated using a 24-hour food recall (two weekdays and one weekend) by a specialist at
the beginning and at the end of the study. Nutritionist 4 software (USA) was used to
analyses energy, macronutrients, and micronutrients intake at baseline and at the end of
trial. Also, for control the physical activity, as a confounding factor, International
Physical Activity Questionnaire (IPAQ), was used before and after the intervention.
To measure body composition, body composition scale (ebody) was used (Beurer BF54,
Germany). In this instrument, at first, the gender, age in year, height in centimeters and
the amount of physical activity were entered in scale. Then weight as a main outcome of
this study in kilograms (with an accuracy of 100 g), Body mass index (BMI), and body
fat percent (with an accuracy of 0.1 percent) shown on the digital board of scale. Height
measured using a stadiometer attached to the wall with an accuracy of 0.5 cm and without
shoes. Waist and hip circumference were measured using a non-elastic measuring tape.
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Blood pressure in the sitting position after 10 minutes of resting was measured at the
beginning and end of the study using a mercuric barometric measurement from the right
hand of the patients. Conicity index also is known as an important indicator of the
anthropometric data is associated with waist circumference and abdominal obesity. It
calculates using the following formula:
𝐶𝑜𝑛𝑖𝑐𝑖𝑡𝑦 𝐼𝑛𝑑𝑒𝑥 =Waist circumference(m)
0.109 ∗ √𝐻𝑒𝑖𝑔ℎ𝑡(𝑚)
𝑊𝑒𝑖𝑔ℎ𝑡(𝑘𝑔)
At baseline and at the end of 3-months intervention, 10 ml fasting blood sample
was taken. Measurement of blood glucose and lipid profile factors was done in Nutrition
Laboratory of Iran University of Medical Sciences by using BT1500 auto-analyzer and
enzymatic kits (Pars Azmun, Tehran, Iran). Throughout the study, all measurements were
performed by one person and the questionnaires were completed by a questioner.
Statistical Analysis
The Kolmogorov-Smirnov Shapiro-Wilk test was used to control the normal
distribution of variables. To compare the quantitative variables between two groups
Independent samples t-test and Mann-Whitney U test was used for variables with normal
and abnormal distribution, respectively. Also, for the quantitative variables before and
after the intervention within each group, paired t-test and Wilcoxon test was used.
Qualitative variables were analyzed by Chi-square, Fisher and McNemar test. P value <
0.05 was considered statistically significant. All statistical analyses were done using the
SPSS version 16.
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Results:
From 70 patients that participated in the study, four patients in the intervention
group (one due to irregular use of supplements, one due to unwillingness to cooperate,
one due to heartburn and one due to don’t come on time), and four in the placebo group
(one person due to unwillingness to cooperate, one due to heartburn and two people due
to don’t come on time) were excluded. Finally, this 3-months study completed with 62
patients (Figure 1). Characteristics of participants in the intervention and placebo groups
at baseline are presented in Table 1. Comparing data showed no significant differences in
the glucocorticoid intake, age, weight, height, duration of disease, sex and physical
activity level between the two groups at the beginning of the intervention. All patients
had active rheumatoid arthritis of varying degrees according to the GPA scores performed
by the rheumatologist and there was no difference between the two groups (Table
1).Statistical analysis of energy, macronutrients and micronutrients intake showed no
significant difference between the two groups at the beginning and at the end of the study,
and within each group (Table 2).
Table 3 shows mean and standard deviation of anthropometric indices. The results
showed that weight and BMI were increased in both groups, but the increase was
significant only in the placebo group (p<0.001) and the difference between the two groups
were not significant before and after the intervention. Findings showed that body fat
percent significantly was decreased in Berberis Integerrima group (35.02±7.40 versus
33.98±7.81 percent, p=0.04) and increased in the placebo group. The mean difference in
body fat percent between the two groups was statistically significant at the end of the
study (p=0.05). The findings showed that waist circumference partially reduced in
intervention group and significantly increased in the placebo group (89.87±11.81 vs.
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91.52±11.12 cm, p<0.001). The results of the study revealed that the average hip
circumference was decreased in the intervention group and increased in the placebo
group, but these changes were significant only in the placebo group (p<0.001). The hip
circumference was partially decreased in intervention group and significantly increased
in placebo group (p<0.001) at the end of supplementation. No significant change was
observed on waist-to-hip ratio at the end of the study in both groups. Conicity index was
increased in both groups after intervention and the increase was significant only in the
placebo group (p<0.001).
A significant decrease has been observed in systolic blood pressure in intervention
group at the end of study (p=0.02), however, no significant difference was observed on
diastolic blood pressure. The difference in systolic and diastolic blood pressure between
the two groups was not significant. Regarding the effect of Berberis Integerrima extract
on FBS, the findings showed that after the intervention, FBS significantly was decreased
in the intervention group at the end of study (101.76±24.61 vs. 86.86±17.35 mg/dl,
p=0.02). The differences in FBS between the two intervention and placebo groups was
significant following supplementation (-14.89±30.02 vs. 10.54±36.52 mg/dl, p=0.03)
(Table 4).
As shown in Table 5, there were no significant differences in mean serum TC, TG,
LDL-C, and HDL-C levels between the intervention and placebo groups at the baseline.
After the intervention, a significant increase in serum HDL-C levels was observed in the
intervention compared to the placebo (65.97±11.43 vs. 57.55±13.88 mg/dl, p=0.03).
Comparing intra-group difference with paired t-test showed no significant changes in TC,
TG and HDL-C levels in the two groups, but LDL-C levels (p=0.05) were significantly
decreased in the intervention group.
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Discussion
In this 3-months study, we demonstrated that in rheumatoid arthritis patients who
consumed glucocorticoids, although weight and BMI, and Conicity index increased in
both groups after supplementation, in the group consuming 1500 mg of Berberis
Integerrima extract daily this increase was minor and insignificant, whereas in the placebo
group it was increased significantly. Body fat percentage was significantly decreased in
the intervention group compared to the placebo group. There was a significant increase
in waist and hip circumference in the placebo group and an insignificant decrease in the
intervention group. Some studies showed the positive effects of barberry extract or its
compounds such as berberine on weight and BMI loss (26). Cachexia in patients with
rheumatoid arthritis is a common disorder, followed by reducing energy consumption and
percentage of body fat and muscle catabolism increases (7). One of the main reasons is
due to the increase in the production of inflammatory cytokines, including interleukin-1β
and TNF-α. These two pro-inflammatory factors interact with each other and cause
imbalance between protein synthesis and protein degradation in RA patients and cause
muscle loss and fat accumulation (7, 27). As an anti-inflammatory agent, berberine
decreases the accumulation of fat and loss of muscle tissue by reducing NF-κB activity
and consequently reducing TNF-α gene expression (28). Berberine is one of the most
important components that increases expression of UCP2 (Uncoupling protein2) (29).
UCP2 protein is in the inner mitochondrial membrane that reduces reactive oxygen
species (ROS) production in fat tissue (30). Also, Berberine reduces oxidative stress by
reducing the expression of NADPH oxidase that is the source of ROS in the cells (31).
Since the NADPH oxidase increasing is associated with obesity, it can explain the
beneficial effects of berberine on obesity (32). Moreover, Studies have shown that
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berberine prevents the conversion of pre-adipocytes into mature adipocytes in cell culture
and prevents the enlargement of fat cells, reduces leptin and inflammatory responses in
fat cells (33). Thus, berberine has a potential role in reducing body weight, visceral fat
and central obesity. In addition, all participants in our study had active rheumatoid
arthritis and chronically were using glucocorticoids, and their increased waist
circumference and weight might be a side effect of these medications, partly controlled
by the supplementation with berberine (34).
The result of this study showed that FBS was decreased in the intervention group
and increased in the placebo group and the difference of FBS between the two groups
was significant at the end of the intervention. The result of many studies, like; Wei et
al.,(35) Moazzi et al.,(36) Shidfar et al.,(25) are similar to our result. Most studies have
shown the effect of berberine on reducing blood glucose in diabetic patients, but its effect
on blood glucose in other diseases requires a wider research. Wie and his colleagues
demonstrated that barberine reduces blood sugar levels due to a decrease in GLUT4 gene
expression (37). Also, barberine reduces blood sugar levels by activating AMP-activated
protein kinase in the cell and reducing the activity of sucrose and α-glucosidase in the
intestine (38). The average levels fasting blood glucose in RA patients are higher than the
normal population due to the intake of glucocorticoids. In this study, we observed a
decrease in blood glucose in the intervention group.
Following supplementation, the systolic blood pressure was significantly
decreased in the intervention group and diastolic blood pressure remained unchanged. It
should be noted that the values of blood pressure in this study were in the normal ranges.
The findings of Perez-Rubio et al., study indicated a positive effect of 3 months berberine
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supplementation (1500 mg daily) on blood pressure (39). In the study of Golzarand et al.,
black barberry had no effect on systolic and diastolic blood pressure that is probably due
to the low amount of barberry consumption (40). The results of animal studies showed
that berberine decreases blood pressure by inhibiting ACE (41). Moreover, the results of
the studies have shown that berberine increases the production of NO and cyclic
guanosine monophosphate (cGMP) as a major causes of vasodilatation. Therefore, it
appears that the blood pressure lowering effect of berberine is mediated by the ACE and
NO / cGMP pathways (41).
Following intervention serum LDL-C levels were significantly decreased. TC
decreased in both groups, but it wasn’t statistically significant. TG was decreased in the
intervention group and increased in the placebo group, however, the changes were not
significant. The difference in HDL-C levels between the two groups was significant at
the end of the intervention. It should be noted that RA patients have normal lipid profile.
Many studies showed the positive effect of berberine on lipid profile (35, 42, 43). In the
study by Shidfar et al., barberry extract consumption significantly decreased the serum
TG and TC levels, at the end of the study in the intervention group. However, there was
no significant change in HDL-C levels, which is probably due to low amounts of barberry
or low levels of effective compounds in the extract (25). Studies have shown that
berberine improves hyperlipidemia by stimulating the oxidation of fatty acids and
restoring metabolic programs through the activity of liver and muscle AMPK (44).
Berberine also seems to carry out its effect to lower cholesterol by increasing the
expression of the LDL-C receptor (35).
We suggest assessing the effect of Berberine on RMR (Resting Metabolic Rate) by
colorimetric assay, and using a high accuracy method such as DXA (Dual x-ray
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absorptiometry) for body composition analysis in the further study. As limitations, we
were unable to conduct study with larger sample size due to the financial constraints.
Lack of measurement of the bioactive factors of berberine in the blood which could
determine its bioavailability also was one the limitations. besides, since the participants
in the study were overweight on average, having a normal weight group would allow the
interpretation of the results.
In conclusion, daily consumption of 3000 mg barberry extract for 3 months in active RA
patients, significantly decreased body fat, FBS, and increased HDL levels. Following
supplementation, barberry prevented weight gain and decreased body mass in comparison
with placebo. The current findings demonstrated that barberry might have beneficial
effects in modulating some major comorbidities in patients with RA. The efficacy of this
compound, with especial focus on inflammation, should be further investigated as an
adjuvant therapy in RA.
Author contributions:
Naheed Aryaeian: designed and supervised the study, participated in the presentation of
the results, drafting and review of the manuscript.
Sara Khorshidi Sedehi: Participated in writing proposal, sampling, and filling the
questionnaires and data collection.
Farhad Shahram: Clinical assessment of RA patients, determined the disease activity
and participated in review of the manuscript.
Masoud Khorshidi: participated in writing and review of the manuscript.
Meysam Zarezadeh: participated in writing and review of the manuscript.
AghaFatemeh Hosseini: participating in statistical Analysis.
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Declaration of interest
All authors declare no conflict of interest.
Acknowledgment
This study was supported by the Iran University of Medical Sciences Grant 25092. We
are thankful for the cooperation of the staff of green plants of life factory for preparation
of supplements and placebos for this research. We also would like to show our gratitude
to the participants of the study and Rheumatology Research Center Tehran University of
Medical Sciences for participating in the patinet selection phase.
References
1. Mikuls TR. Co-morbidity in rheumatoid arthritis. Best practice & research Clinical rheumatology. 2003;17(5):729-52. 2. Keane A, Woods R, Dowding V, Roden D, Barry C. Anticardiolipin antibodies in
rheumatoid arthritis. Rheumatology. 1987;26(5):346-50. 3. Raut VV, Cullen J, Cathers G. Hearing loss in rheumatoid arthritis. Journal of
Otolaryngology. 2001;30 (5.) 4. Hitchon CA, El-Gabalawy HS. Oxidation in rheumatoid arthritis. Arthritis Res Ther.
2004;6(6):265. 5. Santo RC, Fernandes KZ, Lora PS, Filippin LI, Xavier RM. Prevalence of rheumatoid
cachexia in rheumatoid arthritis: a systematic review and meta‐analysis. Journal of cachexia, sarcopenia and muscle. 2018;9(5):816-25. 6. Rall L, Roubenoff R. Rheumatoid cachexia: metabolic abnormalities, mechanisms and
interventions. Rheumatology. 2004;43(10):1219-23. 7. Walsmith J, Roubenoff R. Cachexia in rheumatoid arthritis. International journal of
cardiology. 2002;85(1):89-99. 8. de Heredia FP, Gómez-Martínez S, Marcos A. Obesity, inflammation and the immune
system. Proceedings of the Nutrition Society. 2012;71(2):332-8. 9. Schäcke H, Döcke W-D, Asadullah K. Mechanisms involved in the side effects of
glucocorticoids. Pharmacology & therapeutics. 2002;96(1):23-43. 11. Shamsa F, Ahmadiani A, Khosrokhavar R. Antihistaminic and anticholinergic activity of
barberry fruit (Berberis vulgaris) in the guinea-pig ileum. Journal of ethnopharmacology. 1999;64(2):161-6. 11. Hadaruga DI, Hadaruga NG, Bandur GN, Rivis A, Costescu C, Ordodi VL, et al. Berberis
vulgaris extract/β cyclodextrin nanoparticles synthesis and characterization. Rev Chim (Bucharest). 2010;61:669-75. 12. Fatehi M, Saleh TM, Fatehi-Hassanabad Z, Farrokhfal K, Jafarzadeh M, Davodi S. A
pharmacological study on Berberis vulgaris fruit extract. Journal of ethnopharmacology. 2005;102(1):46-52.
Jour
nal P
re-p
roof
17
13. Yin J, Xing H, Ye J. Efficacy of berberine in patients with type 2 diabetes mellitus. Metabolism. 2008;57(5):712-7. 14. Hu Y, Ehli EA, Kittelsrud J, Ronan PJ, Munger K, Downey T, et al. Lipid-lowering effect of
berberine in human subjects and rats. Phytomedicine. 2012;19(10):861-7. 15. Yang Y, Qi J, Wang Q, Du L, Zhou Y, Yu H, et al. Berberine suppresses Th17 and dendritic
cell responses. Investigative ophthalmology & visual science. 2013;54(4):2516-22. 16. Joshi V. Some plants used in ayurvedic and homoeopathic medicine. Journal of
Pharmacognosy and Phytochemistry. 2013;2 (1.) 17. Javadzadeh SM, Ebrahimi A. The traditional uses and pharmacological effects of
different parts Berberis Vulgaris (berberine) in Iran .Scientia. 2013;1(2):61-6. 18. Azimi G, Hakakian A, Ghanadian M, Joumaa A, Alamian S. Bioassay-directed isolation of
quaternary benzylisoquinolines from Berberis integerrima with bactericidal activity against Brucella abortus. Research in Pharmaceutical Sciences. 2018;13(2):149-58. 19. Goodson NJ, Wiles NJ, Lunt M, Barrett EM, Silman AJ, Symmons DP. Mortality in early
inflammatory polyarthritis: cardiovascular mortality is increased in seropositive patients. Arthritis & Rheumatism. 2002;46(8):2010-9. 21. Pasceri V, Yeh ET. A tale of two diseases: atherosclerosis and rheumatoid arthritis. Am
Heart Assoc; 1999. 21. Lu M-C, Yan S-T, Yin W-Y, Koo M, Lai N-S. Risk of rheumatoid arthritis in patients with
type 2 diabetes: a nationwide population-based case-control study. PLoS One. 2014;9(7):e101528. 22. Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham III CO, et al. 2010
rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis & Rheumatism. 2010;62(9):2569-81. 23. Garmus TT, Kopf SF, Paula JT, Aguiar AC, Duarte GH, Eberlin MN, et al. ETHANOLIC AND
HYDROALCOHOLIC EXTRACTS OF PITANGA LEAVES (Eugenia uniflora L.) AND THEIR FRACTIONATION BY SUPERCRITICAL TECHNOLOGY. Brazilian Journal of Chemical Engineering. 2019;36(2):1041-51. 24. Bayani M, Ahmadi-hamedani M, Jebelli Javan A. Phytochemical and antioxidant
activities of Berberis integerrima and Berberis vulgaris and pharmacological effects of the more active species on alloxan-induced diabetic rats انیگ یپژوهش یعلم فصلنامه. . ییدارو اه
2116;3(59:)111-21. 25. Shidfar F, Ebrahimi SS, Hosseini S, Heydari I, Shidfar S, Hajhassani G. The effects of
Berberis vulgaris fruit extract on serum lipoproteins, apoB, apoA-I ,homocysteine, glycemic control and total antioxidant capacity in type 2 diabetic patients. Iranian journal of pharmaceutical research: IJPR. 2012;11(2):643. 26. SalehZadeh H, Iloun kashkooliR R, Najafi SS, Hosseini Asl MK, Hamedi A, Kalateh Sadati
A. The effect of Berberis vulgaris extract on blood pressure and weight of the patients suffered from Non-alcoholic Fatty Liver Disease. Journal of Research Development in Nursing & Midwifery. 2013;10:21-7. 27. Metsios GS, Stavropoulos-Kalinoglou A, Douglas KM ,Koutedakis Y, Nevill AM, Panoulas
VF, et al. Blockade of tumour necrosis factor-α in rheumatoid arthritis: effects on components of rheumatoid cachexia. Rheumatology. 2007;46(12):1824-7.
82. Wang Y-X, Liu L, Zeng Q-X, Fan T-Y, Jiang J-D, Deng H-B, et al .Synthesis and identification of novel Berberine derivatives as potent inhibitors against TNF-α-induced NF-κB activation. Molecules. 2017;22(8):1257. 29. Liu L, Liu J, Gao Y, Yu X, Xu G, Huang Y. Uncoupling protein‐2 mediates the protective
action of berberine against oxidative stress in rat insulinoma INS‐1 E cells and in diabetic mouse islets. British journal of pharmacology. 2014;171(13):3246-54.
Jour
nal P
re-p
roof
18
31. Robson-Doucette CA, Sultan S, Allister EM, Wikstrom JD, Koshkin V, Bhattacharjee A, et al. β-cell uncoupling protein 2 regulates reactive oxygen species production, which influences both insulin and glucagon secretion. Diabetes. 2011;60(11):2710-9. 31. Paul M, Hemshekhar M, Kemparaju K, Girish KS. Berberine mitigates high glucose-
potentiated platelet aggregation and apoptosis by modulating aldose reductase and NADPH oxidase activity. Free radical biology & medicine. 2019;130:196-205. 32. Sahin K, Orhan C, Tuzcu M, Sahin N, Ozdemir O, Juturu V. Ingested capsaicinoids can
prevent low-fat-high-carbohydrate diet and high-fat diet-induced obesity by regulating the NADPH oxidase and Nrf2 pathways. Journal of inflammation research. 2017;10:161-8. 33. Choi B-H, Ahn I-S, Kim Y-H, Park J-W, Lee S-Y, Hyun C-K, et al. Berberine reduces the
expression of adipogenic enzymes and inflammatory molecules of 3T3-L1 adipocyte. Experimental & molecular medicine. 2006;38(6):599. 34. Berthon BS, MacDonald-Wicks LK, Wood LG. A systematic review of the effect of oral
glucocorticoids on energy intake, appetite, and body weight in humans. Nutrition research (New York, NY). 2014;34(3):179-90.
35. Wei J, Wu J, Jiag J. Clinical study on improvement of typeⅡdiabetes mellitus complicated with fatty liver treated by berberine. Chinese J Integ Tradition West Med Liver Dis. 2004;6:334-6. 36. Moazezi Z, Qujeq D. Berberis fruit extract and biochemical parameters in patients with
type II diabetes. Jundishapur journal of natural pharmaceutical products. 2014;9 (2.) 37. Zhang W, Xu Y-c, Guo F-j, Ye M, Li M-l. Anti-diabetic effects of cinnamaldehyde and
berberine and their impacts on retinol-binding protein 4 expression in rats with type 2 diabetes mellitus. Chinese Medical Journal. 2008;121(21):2124-8. 38. Zhang Y, Li X, Zou D, Liu W, Yang J, Zhu N, et al. Treatment of type 2 diabetes and
dyslipidemia with the natural plant alkaloid berberine. The Journal of Clinical Endocrinology & Metabolism. 2008;93(7):2559-65. 39. Perez-Rubio KG, Gonzalez-Ortiz M, Martinez-Abundis E, Robles-Cervantes JA, Espinel-
Bermudez MC. Effect of berberine administration on metabolic syndrome, insulin sensitivity, and insulin secretion. Metabolic syndrome and related disorders. 2013;11(5):366-9. 41. Golzarand M, Ebrahimi-Mamaghani M, Arefhosseini S, Asgarzadeh AA. Effect of
processed Berberis vulgaris in apple vinegar on blood pressure and inflammatory markers in type 2 diabetic patients. Journal of Diabetes and Metabolic Disorders. 2008;7:3. 41. Kang DG, Sohn EJ, Kwon EK, Han JH, Oh H, Lee HS. Effects of berberine on angiotensin-
converting enzyme and NO/cGMP system in vessels. Vascul Pharmacol. 2002;39(6):281-6. 42. Derosa G, Bonaventura A, Bianchi L, Romano D, Fogari E, Maffioli P. Effects of Berberis
aristata/Silybum marianum association on metabolic parameters and adipocytokines in overweight dyslipidemic patients .Journal of biological regulators and homeostatic agents. 2013;27(3):717-28. 43. Farhadi A, Gavadifar K. Effects of Berberise Vulgaris fruit extract on blood cholesterol
and triglyceride in hyperlipidemic patients. Koomesh. 2008:211-5. 44. Kim WS, Lee YS ,Cha SH, Jeong HW, Choe SS, Lee M-R, et al. Berberine improves lipid
dysregulation in obesity by controlling central and peripheral AMPK activity. American Journal of Physiology-Endocrinology and Metabolism. 2009;296(4):E812-E9.
Figure 1. Flow diagram of the study
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Table 1: Participant characteristics in the extract of Berberis Integrima and placebo groups
before supplementation (Mean±SD)
p-
value¶,
£
HPMC
(n=31)
Berberis Integrima extract
(n=31)
0.59 47.1±10.75 48.61±11.69 Age (years)
0.24 74.68±15.05 70.44±13.19 Body weight
(kg)
0.98 1.59±0.07 1.59±0.08 Height(m)
0.30 29.46±5.70 27.90±6.06 BMI (kg/m2)
Jour
nal P
re-p
roof
20
0.36 13.84±17.98 10.61±8.40 Duration of
RA(years)
1.00
28(90.3)
3(9.7)
28(90.3)
3(9.7)
Sex
Female (%)
Male (%)
0.39
21(67.7)
8(25.8)
2(6.5)
20(64.5)
6(19.3)
5 (16.1)
Physical
activity
Light (%)
Moderate (%)
Severe (%)
0.37 7.42±4.35 8.36±4.21 Glucocorticoid
s (mg per day)
0.87 Sever
e
Moderat
e
Mild Non
activ
e
Severe Moderat
e
Mild Non
activ
e
GPA n(%)
3(9.7) 18(58) 10(32.3
)
0(0) 5(16.2
)
17(54.8) 9(29
)
0(0)
¶ P-value (age, body weight, height, BMI and duration of RA) calculated by Independent sample t-test. £ P-value (sex and physical activity) calculated by fisher-test. SD, Standard Deviation; HPMC,
Hydroxypropyl Methylcellulose; n, number of patients; BMI, Body Mass Index; RA, rheumatoid arthritis;
GPA, Global Physician Assessment
Table2. Glucocorticoids, energy, macronutrients and some micronutrients intake in
the extract of Berberis Integrima and placebo groups before and after intervention
(Mean±SD)
p-value¶,$ HPMC
(n=31)
Berberis Integrima extract
(n=31)
0.21
0.13
1395.90±447.90
1313.8±555.46
0.36
1508.87±226.24
1490.81±325.35
0.52
Energy(Kcal)
Before
After
p‡
0.23
0.13
69.18±7.60
68.17±11.80
0.67
67.02±9.54
64.10±9.49
0.20
Carbohydrate (%)
Before
After
p‡
0.84
0.14
14.23±3.82
13.5±5.10
0.51
14.42±3.49
15.24±4.16
0.40
Protein (%)
Before
After
p‡
0.12
0.16
16.49±5.64
18.13±10.83
0.42
19.67±9.90
21.80±9.62
0.38
Fat (%)
Before
After
p‡
0.94
0.08
102.84±129.70
70.65±74.36
68.28±34.64
68.48±26.65
Vitamin C(mg)
Before
After
Jour
nal P
re-p
roof
21
0.20 0.89 p†
0.07
0.83
0.55±0.75
0.36±0.63
0.10
0.61±1.23
0.83±1.06
0.40
Vitamin D(μg)
Before
After
p†
0.61
0.42
6.27±3.24
5.79±2.76
0.46
5.90±2.42
6.26±1.67
0.32
Zinc(mg)
Before
After
p‡
0.41
0.07
0.03±0.04
0.04±0.05
0.93
0.03±0.03
0.04±0.05
0.22
Selenium(mg)
Before
After
p†
SD, standard deviation; HPMC, Hydroxypropyl methylcellulose; n, number of patients. ¶ P-value (energy,
carbohydrate, protein, fat, and zinc) calculated by Independent sample t-test between two groups. $ P-value
(vitamin C, vitamin D, and selenium) calculated by Mann-Whitney between two groups.
† P-value (vitamin C, vitamin D, and selenium) calculated by Wilcoxon test for before and after the
intervention within each group. ‡ P-value (energy, carbohydrate, protein, fat, and zinc) calculated by the
paired-t test for before and after the intervention within each group.
Table3. Weight, BMI, body fat percent, waist circumference, hip circumference, waist-to-
hip ratio, and Conicity index in the extract of Berberis Integrima and placebo groups before
and after intervention )Mean±SD)
p¶ HPMC
(n=31)
Berberis Integrima extract
(n=31)
0.24
0.15
0.23
74.68±15.05
76.57±15.53
1.92±2.29 < 0.001***
70.44±13.19
71.27±13.40
0.90±4.04 0.27
Weight (Kg)
Before
After
Difference p‡
0.30
0.24
0.49
29.46±5.70
30.23±5.90
0.76±0.95
< 0.001***
27.90±6.06
28.42±6.26
0.51±1.77
0.11
BMI
Before
After
Difference
p‡
0.97
0.45
0.05*
35.08±7.52
35.45±7.43
0.37±2.89
0.48
35.02±7.40
33.98±7.81
-1.03±2.77
0.04*
Body fat percent
Before
After
Difference
p‡
0.71
0.37 0.17
89.87±11.81
91.52±11.12 1.64±2.78
< 0.001***
88.64±13.96
88.58±14.44 -0.06±6.27
0.95
Waist circumference
Before
After Difference
p‡
0.14
0.59
< 0.001***
107.55±10.75
109.55±10.75
2.00±2.50
< 0.001***
105.90±13.56
105.12±12.84
-0.77±4.70
0.36
Hip circumference
Before
After
Difference
p‡
Jour
nal P
re-p
roof
22
0.99
0.76
0.69
0.83±0.06
0.83±0.05
-0.00±0.02
0.99
0.83±0.04
0.83±0.05
0.00±0.05
0.67
Waist-to-hip ratio
Before
After
Difference
p‡
0.50
0.28
0.13
56.77±12.50
58.52±12.37
1.74±2.22
< 0.001***
54.57±13.30
54.93±13.83
0.35±4.51
0.66
Conicity index Before
After
Difference
p‡ *p< 0.05, ***p<0.001. SD, standard deviation; HPMC, Hydroxypropyl methylcellulose; n, number of
patients. ¶ P-value calculated by Independent sample t-test between two groups. ‡ P-value calculated by the
paired-t test for before and after the intervention within each group.
Table4. Systolic and diastolic blood pressure and FBS level in the extract of Berberis Integrima and
placebo groups before and after the intervention (Mean ± SD)
$ p HPMC
(n=31)
Berberis Integrima extract
(n=31)
0.36
0.04*
0.76
12.16±1.38
11.74±1.50
- 0.48±1.31
0.06
12.56±1.29
12.05±0.48
- 0.51±1.15
0.02*
Systolic blood pressure
(mmHg)
Before
After
Difference
p†
0.76
0.98
0.50
7.79±1.13
7.81±1.22
0.00±1.31
0.97
7.77±1.08
7.94±0.44
0.16±0.93
0.33
Diastolic blood pressure
(mmHg)
Before
After
Difference
p†
0.21
<0.001***
0.03*
104.56±21.62
115.12±40.93
10.54±36.52
0.41
101.76±24.61
86.86±17.35
-14.89±30.02
0.02*
Fasting blood sugar (mg/dl)
Before
After
Difference
p† *p< 0.05, ***p<0.001. SD, standard deviation; HPMC, Hydroxypropyl methylcellulose; n, number of
patients. $ P-value calculated by Mann-Whitney between two groups. † P-value calculated by Wilcoxon
test for before and after the intervention within each group.
Table 5. TC, TG, LDL- cholesterol and HDL- cholesterol levels in the extract of Berberis Integrima,
and placebo groups before and after the intervention (Mean±SD)
p¶ HPMC
(n=31)
Berberis Integrima extract
(n=31)
0.21
0.20
0.93
200.66±35.69
195.03±35.44
- 5.62±20.54
0.15
188.61±37.85
182.32±41.51
- 6.29±40.56
0.39
Total cholesterol (mg/dl)
Before
After
Difference
p‡
0.31
134.68±58.32
119.52±56.71 Triglyceride (mg/dl)
Before
Jour
nal P
re-p
roof
23
0.27
0.79
134.93±65.11
0.25±35.36
0.97
116.77±62.00
- 2.74±48.68
0.75
After
Difference
p‡
0.48
0.90
0.32
113.43±28.01
109.73±37.22
-3.70±24.46
0.41
119.16±34.62
108.71±27.78
-10.45±28.56
0.05*
LDL cholesterol(mg/dl)
Before
After
Difference
p‡
0.46
0.01**
0.03*
59.23±13.69
57.55±13.88
-1.67±6.20 0.14
61.87±14.24
65.97±11.43
4.10±13.54 0.10
HDL cholesterol(mg/dl)
Before
After
Difference
p‡ p<0.01. SD, standard deviation; HPMC, Hydroxypropyl methylcellulose; n, number of patients. **p< 0.05, *
t -value calculated by the paired-P ‡test between two groups. -value calculated by Independent sample t-P ¶
test for before and after the intervention within each group.
Jour
nal P
re-p
roof
