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Journal of the American College of Nutrition, Vol. 20, No. 3, 212-218 (2001)
Published by the American College of Nutrition

Original Research

Potential Antioxidant Effects of Zinc and Chromium Supplementation in People with Type 2 Diabetes Mellitus

Richard A. Anderson, PhD, CNS, FACN, Anne-Marie Roussel, PhD, FACN, Nouri Zouari, MD, PhD, Sylvia Mahjoub, MD, Jean-Marc Matheau and Abdelhamid Kerkeni, PhD

Nutrient Requirements and Functions Laboratory, Beltsville Human Nutrition Research Center, USDA, ARS, Beltsville, MD (R.A.A.)
LBSO, Oxidative Stress Laboratory, Joseph Fourier University, Grenoble (A.M.R.)
Laboratoires Labcatal, Montrouge Cedex (J.M.M.), FRANCE
Service d’Explorations fonctionnelle and Endocrinologie Metabolisme Hopital, Sfax (N.Z.)
Service de Medecine interne, Hopital de Monastir (S.M.)
Laboratoire de Biophysique, Faculté de Médecine (A.K.), Monastir, TUNISIA

Address reprint requests to: Richard A. Anderson, PhD Nutrient Requirements and Functions Laboratory, Bldg 307, Rm 224, Beltsville Human Nutrition Research Center, USDA, ARS, Beltsville, MD 20705. E-mail: anderson{at}307.bhnrc.usda.gov


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Objective: To determine the effects of combined zinc (Zn) and chromium (Cr) supplementation on oxidative stress and glucose homeostasis of people with type 2 diabetes.

Design: Tunisian adult subjects with HbA1C >7.5% were supplemented for 6 months with 30 mg/d of Zn as Zn gluconate or 400 µg/d of Cr as Cr pidolate or combined Zn/Cr supplementation or placebo. The effects of supplementation on plasma zinc (Zn), copper (Cu), selenium (Se), urinary Zn, Cr, plasma thiobarbituric acid reactive substances (TBARS), Cu-Zn superoxide dismutase (SOD) and Se glutathione peroxidase (GPx) in red blood cells, blood lipids and lipoproteins, HbA1C and fasting glucose were measured at the beginning of the study and after six months.

Results: At the beginning of the study, more than 30% of the subjects may have been Zn deficient with plasma Zn values less than 10.7 µmol/L, whereas levels of plasma Cu, Se and antioxidant RBC enzyme activities were in the normal ranges. Following supplementation, there were significant decreases of plasma TBARS in the Cr (13.6%), Zn (13.6%) and Zn/Cr (18.2%) groups with no significant changes in the placebo group. The value for the TBARS of the control healthy Tunisian subjects was 2.08 ± 0.04 µmol/L and that of the Tunisian subjects with diabetes was 3.32 ± 0.05 µmol/L. This difference of 1.24 µmol/L between the control group and the subjects with diabetes was reduced from 36% to 50% in the three supplemented groups. Supplementation did not modify significantly HbA1C nor glucose homeostasis. No adverse effects of Zn supplementation were observed on Cu status, HDL cholesterol nor interactions in Zn or Cr.

Conclusions: These data suggest the potential beneficial antioxidant effects of the individual and combined supplementation of Zn and Cr in people with type 2 DM. These results are particularly important in light of the deleterious consequences of oxidative stress in people with diabetes.

Key words: zinc, chromium, antioxidants, TBARS, lipid peroxidation, glucose homeostasis, trace elements, diabetes


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Oxidative damage due to free radicals is associated with vascular disease in people with type 1 and those with type 2 diabetes mellitus (DM) [1. There are several potential sources of increased free radical production in diabetes including autooxidation of plasma glucose, activation of leucocytes and increased transition metal bioavailability [2. Increased oxidative stress, in relation with glucose autooxidation, is well-documented [3,4. The radical-scavenging antioxidant activity of the serum of people with either type 1 or 2 DM is lower than that of age-matched controls. This may be attributed to lower blood orate, vitamin C or vitamin E [5 or other factors including the trace elements [6. Several reports underlie the key role of micronutrient status in patients with type 1 or 2 DM [7–13.

Recent studies have reported the beneficial effects of supplemental Cr on plasma glucose and related variables of people with type 2 DM and steroid-induced diabetes [11–13. Accompanying these data, there are also suggestive studies to show that Cr also improves cellular antioxidant capacity in rats [14–16. Correction of Zn deficiency in patients with type 1 DM also leads to decreased lipid peroxidation [17 and improvements in glucose homeostasis [18. Therefore, since Cr and Zn act in normalizing glycemia and are postulated to function as antioxidants, a restored Zn and Cr status in people with type 2 DM may counteract the deleterious effects of oxidative stress and help to prevent complications associated with diabetes.

In Tunisia, the incidence of type 2 DM is approximately 10%, with a high incidence of oxidative complications such as retinopathies, glomerulopathies and vascular complications. Therefore, this multicenter study was conducted in Tunisia, under the auspices of UNESCO, and aimed to investigate the effects of individual and combined Zn and Cr supplementation on variables associated with glucose metabolism and oxidative stress.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Subjects
Volunteers were adult males and females less than 65 years old with diabetes for at least five years exhibiting fasting glucose > 8 mmol/L and HbA1C > 7.5%. Key exclusion criteria included pregnant and lactating women, people receiving trace element supplements in the previous three months, people with gastric or diuretic treatment, patients with acute renal failure (creatinine <120 µmol/L) and patients with a recent surgery or acute infection. Patients were enrolled from June to March from the Departments of Endocrinology of Sfax and Monastir Hospitals. The study received the agreement of the Tunisian Health Department and approval of the United States Department of Agriculture Research Service Human Studies Review Board. Patients were informed of the purposes of the study, were free to ask questions throughout the study and signed an informed consent form witnessed by one of the investigators.

The study design was randomized, double blind and placebo controlled. Subjects, n = 110, were divided randomly into four groups and supplemented daily with either 30 mg of Zn as Zn gluconate, 400 µg of Cr as Cr pidolate (tris(2-pyrrolidine-5-carboxylato)chromium III), 30 mg of Zn and 400 µg of Cr or placebo. Zinc gluconate, Cr pidolate and placebo capsules were provided by Labcatal Pharmaceutical (7 Rue Roger Salengro, 92541 Montrouge Cedex, France). Each month, the volunteers received the daily doses for one month, and they were asked to return the non-used supply after one month to help measure their compliance. Subjects were also asked questions regarding any possible side effects and degree of compliance. Sixty healthy Tunisian adults, age and gender matched, composed the control group for plasma TBARS.

Analysis
Blood samples were drawn after an overnight fast at the beginning of the study and after six months of daily supplementation. Urine samples were collected in 4 L brown plastic containers (Fisher Scientific, Pittsburgh, PA). Aliquot samples were dispensed into Falcon polypropylene tubes (Falcon, Oxnard, CA) and stored at -20°. All the samples were run prior to the breaking of the code which was not available to the investigators until completion of all the samples. Urinary Cr was analyzed using graphite furnace atomic absorption [19. Urinary Zn was determined by flame atomic absorption spectrometry using a Perkin-Elmer 5000 spectrometer on acidified urine samples. An in-house control urine sample, whose Cr concentration had been verified by two independent methods, was assayed at least two times daily as an internal check on the accuracy of the urinary Cr [20. Plasma Zn and Cu were determined by flame atomic absorption spectrometry [21,22 and plasma Se using electrothermal atomic absorption spectrophotometry [23. Red blood cell Se GPx activity was measured by a modified Gunzler method [24, and Cu-Zn SOD activity was evaluated by the method of Marklund and Marklund [25. SeronormR Trace Element (Nycomed, Oslo, Norway) and an in-house pool of human erythrocytes and plasma were used as internal quality controls. Plasma TBARS were determined as described [26, using the fluorimetric determination of malondialdehyde (MDA)-TBA (thiobarbituric acid) complex after extraction with n-butanol (Sobioda MDA fluorimetry kit, Grenoble, France). Since the plasma MDA fluorimetric determination may also form a variety of chromogens other than the MDA-TBA adduct by reacting with substances such as amino acids or sugars, we verified every fifth sample, using the TBA test followed by HPLC separation as described by Richard et al. [27. The correlation coefficient between the two methods was 0.85 (p<0.001). Lipids, lipoproteins, HbA1C and fasting blood glucose were measured using routine laboratory methods.

Statistics
Statistical analyses of the data were performed by analysis of variance. Individual means comparisons were identified with Duncan’s Multiple Range Test (SAS, SAS Institute, Cary, NC). Statistical significance was set at p<0.05. Values are mean ± SEM.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
As shown in Table 1, at the beginning of the study, the groups were similar based upon age, duration of diabetes, weight, BMI, fasting glucose, HbA1C, insulin, cortisol, total cholesterol and HDL cholesterol. Following six months of supplementation, there were no statistical changes in any of these variables. HbA1c decreased from 8.9 ± 0.4% to 7.7 ± 0.3% following six months of Zn supplementation, from 8.4 ± 0.2% to 7.4 ± 0.26% in the Cr group and from 9.0 ± 0.3% to 8.1 ± 0.3% in the Zn/Cr group, but decreases were not significant at p < 0.05.


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  		Table 1. Baseline Characteristics of Subjects

 
At the beginning of the study, plasma Zn, Cu and Se were similar in all the groups (Table 2). More than 30% of the subjects exhibited plasma Zn levels below the cut off of 10.7 µmol/L, which is considered to be at risk of Zn deficiency. Following Zn supplementation, none of the subjects displayed plasma Zn values below 10.7 µmol/L (Fig. 1). Plasma Zn increased from 11.3 ± 0.18 to 13.7 ± 0.20 µmol/L in the group receiving supplemental Zn for six months and from 11.0 ± 0.15 to 13.2 ± 0.20 µmol/L in the Zn/Cr group (Table 2). There were no significant differences in the placebo group, and the incidence of Zn deficiency was similar at the beginning and end of the study (Fig. 2). Plasma Se levels and Cu levels were adequate and were not altered by Zn or Cr supplementation (Table 2).


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  		Table 2. Supplementation Effects on Plasma Zn, Cu and Se and Urinary Zn and Cr

 


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  		Fig. 1. Increases in plasma zinc of subjects with type 2 diabetes mellitus following daily supplementation with 30 mg of Zn as Zn gluconate for six months. Individual bars denote number of subjects with plasma zinc values in the designated intervals.

 


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  		Fig. 2. Plasma zinc distribution of the placebo group at the onset of the study and after six months. Individual bars denote number of subjects with plasma zinc values in the designated intervals.

 
Urinary Cr was similar in all groups at the beginning of the study and increased several-fold following Cr and Zn/Cr supplementation (Table 2). There were also much smaller increases in the urinary losses of Cr in the Zn supplemented and in the placebo groups. The distribution of the urinary Cr/creatinine values for the placebo group is shown in Fig. 3. At the six-month time point, there were several subjects with basal urinary Cr/creatinine values greater than 0.45 ng/mg creatinine while there were only two at the onset of the study (Fig. 3). Similar results were observed in the Zn supplemented group (data not shown). There was negligible Cr in the Zn and placebo capsules. Urinary Zn losses were similar at the onset of the study and were not altered by supplementation (Table 2).



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  		Fig. 3. Urinary chromium losses of the placebo group at the onset of the study and after six months. Individual bars denote the number of subjects with chromium losses in the designated intervals.

 
Plasma TBARS in subjects with type 2 DM (Table 3) were significantly higher than those measured in control adult Tunisians (2.08 ± 0.04 µmol/L). After six months of supplementation, a significant decrease (p<0.001) in plasma lipid peroxidation was observed in all the supplemented groups (Table 3). Plasma TBARS decreased 13.6% in the group receiving Zn alone (3.32 ± 0.06 vs. 2.87 ± 0.08 µmol/L), 13.6% in the Cr group (3.31 ± 0.06 vs. 2.86 ± 0.08 µmol/L) and 18.2% in Cr/Zn group (3.47 ± 0.05 vs. 2.84 ± 0.07 µmol/L). There were no significant changes in the placebo group (3.18 ± 0.05 vs. 3.04 ± 0.07 µmol/L). Antioxidant metalloenzyme activities, Cu-Zn SOD and Se GPx, were not altered (Table 3) and were comparable to those previously described in European adults, using the same method of determination [28.


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  		Table 3. Effects of 6 Months of Supplementation on Plasma TBARS and Antioxidant RBC Enzymes

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
In people with diabetes, the vulnerability to oxidative damage may be partly attributed to lower antioxidant micronutrient status including trace elements. Impairments of Cr [9,29 and Zn [10,30–32 status have been reported as aggravating factors in the progression of diabetes. The objective of this study was to determine the effects of combined Zn and Cr supplementation on oxidative stress and glucose homeostasis in people with type 2 DM. At the onset of our study, plasma TBARS were significantly elevated in people with type 2 DM compared with control apparently healthy subjects (3.32 ± 0.05 vs. 2.08 ± 0.04 µmol/L), thus confirming that lipid peroxidation increases in people with diabetes [33–35. This difference of 1.24 µmol/L between the control group and the subjects with diabetes was reduced from 36% to 50% in the three supplemented groups. The source of the lipid peroxides is postulated to be the end products from membrane damage which are elevated in people with diabetes. These elevated levels of peroxides could result from the hyperglycemic state in relation with autooxidation of plasma glucose and other small autooxidizable molecules [36 and are associated with poor metabolic control of plasma glucose [37.

The results of this study corroborate our previous data demonstrating that, in people with type 1 DM receiving similarly 30 mg of Zn as Zn gluconate for three months, there is also a decreased lipid peroxidation and an improvement in antioxidant status [17. The potential antioxidant effects of Zn in diabetes [38 could be related to several mechanisms. It has been suggested that Zn metallothionein complexes in the islet cells provide protection against immune-mediated free-radical attack. Zinc could act also in protecting sulfhydryl groups against oxidation and participate in the inhibition of the free radical production in Haber Weiss cycle by competing with transition metals.

The mechanism by which Cr acts as an antioxidant is still not totally understood. Increased formation of lipid peroxidation products is associated with insulin perturbations [39,40. Chromium, which decreases circulating insulin, might lessen lipid peroxidation through the glucose/insulin system. Chromium, like vitamin E, also protects rats from oxidative damage related to carbon tetrachloride [14. Chromium decreased lipid peroxidation in isolated rat hepatocytes [15, and there is an association between age-related accumulation of lipofuscin that can be reversed by common antioxidants and/or Cr [41. In hypertensive rats receiving Cr as polynicotinate, hepatic and renal TBARS were also reduced [15. Most of the Cr nutrition studies have focused on the role of Cr in preventing insulin resistance; however, in the light of our results, interactions among insulin sensitizers and antioxidants should also be evaluated as suggested by Preuss [42.

In this study, in contrast to some previous studies involving Cr supplementation [9,11,43,44, decreases in fasting insulin were not significant. It may be that the improvements in the antioxidant defense mechanisms of the body are more sensitive than those for changes in total glucose or insulin concentrations. There may be improvements in insulin sensitivity that are associated with improved antioxidant status that precede changes in insulin concentrations. The amount of Cr used in this study may have been adequate to lead to improved antioxidant status, but not adequate to meet the requirements for measurable changes in the glucose/insulin system. Discrepancy in response to Cr is dependent upon the form of Cr (pidolate vs. picolinate), duration of diabetes and status of subjects, including dietary habits.

During this study, urinary Cr losses were almost double in the placebo and Zn supplemented groups at the end of the study compared with those at the onset of the study. We have not observed such changes in any of our previous studies involving non-supplemented subjects. The Cr intake of the subjects appeared to increase during the study, and dietary Cr intake studies need to be completed to determine foods that are high in Cr in these subjects.

Insulin resistance is associated with increased lipid peroxidation and free radical formation. Formation of TBARS is an indirect measure of lipid peroxidation, and increased formation of TBARS is associated with insulin perturbations. In this study, Cr and Zn elicited lower levels of plasma TBARS. Therefore, studies reporting effects of Cr and Zn on the glucose/insulin system may also be consistent with effects on free radical production. Further studies are needed to confirm these results.


   CONCLUSIONS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
These data suggest the potential beneficial antioxidant effects of individual and combined Zn and Cr supplementation in people with type 2 DM. Neither adverse effects of Zn supplementation on Cu status and HDL cholesterol, nor interaction of Zn nor Cr on absorption were observed. These results are particularly important in light of the deleterious consequences of oxidative stress in people with diabetes.


   ACKNOWLEDGMENTS
 
We would like to thank Noella A Bryden, Marilyn M Polansky, Michel Seve and MarieJeanne Richard for their excellent technical assistance.


   FOOTNOTES
 
This work was carried out under the auspices of Trace Element Institute for UNESCO, Lyon, France, and supported in part by grants from the Diabetes Action Foundation, Washington, DC, and Labcatal Pharmaceutical, Montrouge Cedex, France.

Received December 5, 2000. Revised March 26, 2001. Accepted March 26, 2001.


   REFERENCES
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 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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W. T. Cefalu, Z. Q. Wang, X. H. Zhang, L. C. Baldor, and J. C. Russell
Oral Chromium Picolinate Improves Carbohydrate and Lipid Metabolism and Enhances Skeletal Muscle Glut-4 Translocation in Obese, Hyperinsulinemic (JCR-LA Corpulent) Rats
J. Nutr., June 1, 2002; 132(6): 1107 - 1114.
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