- Email: [email protected]
Effect of green coffee extract supplementation on serum adiponectin concentration and lipid profile in patients with non-alcoholic fatty liver disease: A randomized, controlled trial
Complementary Therapies in Medicine 49 (2020) 102290
Contents lists available at ScienceDirect
Complementary Therapies in Medicine journal homepage: www.elsevier.com/locate/ctim
Effect of green coffee extract supplementation on serum adiponectin concentration and lipid profile in patients with non-alcoholic fatty liver disease: A randomized, controlled trial
T
Samaneh Hosseinabadia, Maryam Rafrafb,*, Somayyeh Asgharib, Mohammad Asghari-Jafarabadic,d, Shohreh Vojouhie a
Students’ Research Committee, Faculty of Nutrition and Food Science, Tabriz University of Medical Sciences, Tabriz, Iran Nutrition Research Center, Faculty of Nutrition and Food Science, Tabriz University of Medical Sciences, Tabriz, Iran Department of Statistics and Epidemiology, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran d Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran e Internists, 22 Bahman Hospital, Neyshabur University of Medical Sciences, Neyshabur, Iran b c
A R T I C LE I N FO
A B S T R A C T
Keywords: Adiponectin Clinical trial Green coffee extract Lipid profile Non-alcoholic fatty liver disease
Objectives: The current study evaluated the effects of green coffee extract (GCE) on serum lipid profile and adiponectin levels in patients with nonalcoholic fatty liver disease (NAFLD). Design: This randomized, double-blind, placebo-controlled clinical trial was conducted on NAFLD patients aged 20–60 years and body mass index (BMI) of 25−35 kg/m2. Setting: Patients were recruited from the Bahman poly-clinic (Neyshabur, Iran) between January and June 2016. Interventions: The study subjects were randomly assigned to receive a daily dose of 400 mg GCE (n = 24) or placebo (n = 24) for eight weeks. Main outcome measures: Serum liver enzyme levels, lipid profile, adiponectin concentrations, and hepatic steatosis grade were measured for all patients at baseline and the end of the trial. Results: GCE supplementation significantly reduced BMI [mean difference (MD): −0.57 and 95 % confidence interval (CI): −0.84 to −0.29, P < 0.001] and increased serum high-density lipoprotein cholesterol (MD: 7.06, 95 % CI: 0.25–13.87, P < 0.05) compared to the control group. Serum total cholesterol decreased significantly within the GCE group (MD: −13.33, 95 % CI: −26.04 to −0.61, P < 0.05). Triglyceride levels reduced significantly in GCE group compared to the placebo group (MD: -37.91; 95 % CI: −72.03 to −3.80; P = 0.03). However, this reduction was not significant when was further adjusted for mean changes in BMI and daily energy intake (MD: -23.43; 95 % CI: −70.92 to 24.06; P = 0.32). Hepatic steatosis grade, liver enzymes, and adiponectin levels did not show significant differences between the two groups after the intervention. Conclusions: GCE supplementation improved serum lipid profile and BMI in individuals with NAFLD. GCE may be useful in controlling NAFLD risk factors.
1. Introduction Nonalcoholic fatty liver disease (NAFLD) is the most common cause of the chronic liver disease1 characterized by the accumulation of fat in more than 5 % of the hepatocytes.2 This disorder represents a histological spectrum ranging from simple hepatic steatosis to nonalcoholic steatohepatitis (NASH) and progression to fibrosis and cirrhosis.3 Various risk factors including abdominal obesity, insulin resistance, dyslipidemia, hypertension, and pro-inflammatory state are associated with NAFLD.4 In the last years, NAFLD has been considered the hepatic
⁎
border of metabolic syndrome, linked to metabolic derangement of patients with this clinical picture.5 Abnormal lipid metabolism and dyslipidemia occurs in 20–80% of NAFLD patients 6 and is characterized by increased serum triglycerides (TG), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C), as well as reduced levels of high-density lipoprotein cholesterol (HDL-C), which are considered strong risk factors for cardiovascular diseases (CVDs) in patients with NAFLD.7 Current therapeutic approaches include strategies that could modify CVD risk factors in these patients.8 To date, there is no specific
Corresponding author at: Nutrition Research Center, Faculty of Nutrition and Food Science, Tabriz University of Medical Sciences, Golgasht Street, Tabriz, Iran. E-mail address: [email protected] (M. Rafraf).
https://doi.org/10.1016/j.ctim.2019.102290 Received 23 September 2019; Received in revised form 17 December 2019; Accepted 24 December 2019 Available online 26 December 2019 0965-2299/ © 2019 Published by Elsevier Ltd.
Complementary Therapies in Medicine 49 (2020) 102290
S. Hosseinabadi, et al.
2.2. Study design
pharmacologic therapy for NAFLD. Lifestyle modification through diet and exercise has been considered to be fundamental for NAFLD management.9 However, adherence to low-calorie diets, weight loss, and subsequent weight maintenance had less long term success in obese participants. Alternative medicine has recently gained interest as a possible therapeutic approach in NAFLD treatment. In the last few years, the effects of bioactive food components especially phytochemicals on NAFLD have received much attention because of their antioxidative, anti-inflammatory, antilipidemic, and anti-adipogenic properties.10 Green coffee is a widely consumed beverage in recent years which contains a complex chemical mixture of polysaccharides, monosaccharides, lipids, sterols, phenolic acids, polyphenols, proteins, free amino acids, vitamins, and minerals.11 Green coffee extract (GCE) is a rich source of bioactive compounds with antioxidant properties such as chlorogenic acid (CGA), diterpenes, and trigonelline.11 Many positive effects of GCE have been attributed to CGA as a main phenolic compound.12 Accumulating experimental evidence has demonstrated that CGA exhibits anti-diabetic, anti-lipidemic, and anti-obesity properties. Some experimental studies have also reported improved adiponectin levels following GCE or CGA administrations.13 Adiponectin is a well-recognized adipokine considering its antiatherogenic, anti-inflammatory and anti-lipidemic properties.14,15 The regulatory effects of adiponectin on lipid metabolism have been shown in some research studies.14–16 In humans, plasma levels of adiponectin are inversely related to body fat mass, body mass index (BMI) and plasma TG and positively correlated with HDL-C concentration.17 It is presumed that the imbalanced production of adiponectin is involved in the pathogenesis of NAFLD.15 Despite the protective effects of coffee toward NAFLD, 18 there is limited research regarding the effects of green coffee on NAFLD features. Moreover, no one has investigated its possible effects on serum adiponectin levels in humans, as indicated in several experimental studies. Thus, the aim of the present study was to evaluate the effects of the green coffee extract on anthropometric measures, liver function, and serum lipid profile and the potential mediating role of adiponectin in this regard in a randomized double-blind controlled trial in patients with NAFLD.
This study was designed as a randomized, double-blind placebocontrolled clinical trial. Fifty patients were randomly assigned to one of two intervention groups using a block randomization procedure of size 4 stratified by age (< 40, > 40 years old), gender (male, female), and BMI (25–30, 30−35 kg/m2). The sequence of the randomization was generated using random allocation software (RAS) and assigning the participants to two groups was conducted by an independent person. The GCE group (n = 24) received two capsules per day each contained 200 mg GCE for eight weeks. The placebo group (n = 24) was given two placebo capsules daily for the same period. The GCE capsules were purchased from Bonyan Salamat Kasra Co., Tehran, Iran which were provided by the hydro-alcoholic extraction of green coffee beans and contained 50 percent (100 mg) CGA as the main ingredient and < 2 % of caffeine. Placebo capsules contained starch and were similar in taste and appearance to the GCE capsules. The medication boxes were labeled as A and B and the researchers and participants were blinded to the allocation until the statistical analyses were completed. Both groups were educated to follow a healthy lifestyle during the study. Patients were excluded if they did not consume more than 10 % of the supplements. They were followed up every two weeks to check the compliance and probable side effects. 2.3. Liver ultrasonography Abdominal ultrasonography (US) was performed in participants after overnight fasting in order to confirm the NAFLD and grading of hepatic steatosis. Each US exam was performed by one expert radiologist using a SonoAce X4 ultrasound system (Medison Inc., Korea). The presence of hepatic steatosis was defined through the ultrasonographic appearance of liver echotexture as compared to the right kidney’s cortex. Visibility and sharpness of the diaphragm and hepatic veins’ clarity were analyzed as well. Based on these parameters, steatosis was graded as mild, moderate, and severe. Mild steatosis was detected by a slightly brighter liver as compared to the renal cortex, clear visualization of diaphragm, and interface of hepatic veins with sharp contours; moderate steatosis was accompanied by a brighter liver with attenuated US beam at deeper parts of the liver, diaphragm, and hepatic veins still visible but with blunted contours; severe steatosis was recognized by a very bright liver with a severe US beam attenuation, not visible diaphragm or hepatic veins. This classification was adopted and already tested by other investigators.20
2. Materials and methods 2.1. Study subjects Patients with NAFLD, aged 20–60 years with body mass index (BMI) ranged 25−35 kg/m2 were recruited from the 22 Bahman poly-clinic (Neyshabur, Iran) between January and June 2016. Subjects were excluded if they were pregnant, breastfeeding, post menopause or professional athletes or had any known documented liver disease (such as hepatitis B, C, and biliary disease) and inherited disorders affecting liver (iron and copper storage disease), history of diagnosed cardiovascular, kidney, diabetes, gastrointestinal, pulmonary and autoimmune diseases, thyroid dysfunction, cancer, and recent surgery. In addition, subjects who used alcohol and cigarettes, nutritional supplements or weight loss diet within the past three months or during the study period as well as some other medications such as corticosteroids, hepatotoxic, anticoagulant, antidiuretic, and lipidlowering were eliminated from the study. The sample size of the study was determined based on the TC level, which obtained from the Roshan et al. study.19 By aiming for a confidence level of 95 %, 80 % power, and two-tailed statistical test, the sample size was computed to be 22 per group. To allow for the anticipated dropout, the sample size was increased to 24 in each group. The research protocol was approved by the Ethics Committee of the Tabriz University of Medical Sciences (IR.TBZMED.REC.1398.918) and was conducted according to the principles of the Declaration of Helsinki. Written informed consent was obtained from all patients.
2.4. Anthropometric parameters, dietary intake, and physical activity level assessment Anthropometric parameters including body weight and height were measured at baseline and the end of the trial. Body weight was recorded in light clothing and no shoes to the nearest 0.5 kg, using a scale (Seca, Hamburg, Germany). Height was measured without shoes, using a mounting tape with a precision of 0.1 cm. BMI calculated as the weight (kg) divided by the square of the height (m). Daily dietary intake data were collected by 3-day food records (2 weekdays and 1 weekend day) at baseline and end of the study. Dietary data were analyzed by using Nutritionist 4 software (First Databank Inc., Hearst Corp., San Bruno, CA, USA). Physical activity was assessed by the International Physical Activity Questionnaire at the beginning and 8th week.21 2.5. Biochemical measurements Venous blood samples (5 ml) were collected from each subject after 12-h overnight fasting at the baseline and eight weeks after the intervention. The serum was separated from whole blood by centrifugation and stored at -70 °C until analysis. Blood samples were analyzed at the 2
Complementary Therapies in Medicine 49 (2020) 102290
S. Hosseinabadi, et al.
Drug Applied Research Center (Tabriz University of Medical Sciences, Tabriz, Iran). Serum TG, TC, and HDL-C concentrations were determined by enzymatic colorimetric assay method (Pars Azmoon Inc. kit, Tehran, Iran). LDL-C was obtained using the Friedewald calculation.22 Serum adiponectin concentrations were determined using an enzyme-linked immunosorbent assay (ELISA) kit (Mediagnost, Germany). Serum Alanine transaminase (ALT) and aspartate transaminase (AST) were measured by photometric assay (Pars Azmoon Inc. kit, Tehran, Iran).
Table 1 Baseline characteristics of the study patients.
2.6. Statistical analysis All statistical tests were performed using SPSS18 software (SPSS Inc., IL, Chicago, USA). Kolmogorov–Smirnov test was used to determine the normality of the variables. Comparisons of baseline characteristics were performed using Student’s t-test and the chi-squared test for quantitative and qualitative variables, respectively. Paired t-test and sign test were applied for within-group comparisons (after supplementation compared to the baseline). The effect of the intervention was investigated by ANCOVA test adjusting for baseline values and other potential confounders. P < 0.05 was considered to be statistically significant. 3. Results
Variables
Control (n = 23)
GCE (n = 21)
P-value
Age (y)* Sex, n (%) Male Female PAL, n (%) light moderate vigorous Dietary intakes* Energy (kcal/day) Carbohydrate (g/day) Protein (g/day) Total fat (g/day) Educational status, n (%) Illiterate High school Diploma Academic Marital status, n (%) Single Married Employment, n (%) Employed Unemployed
41.13 (8.47)
41.14 (7.87)
0.99† 0.98‡
12 (52.2 %) 11 (47.8 %)
11 (52.4 %) 10 (47.6 %)
10 (43.5 %) 2 (8.5 %) 11 (49.0 %)
5 (24.0 %) 8 (38.0 %) 8 (38.0 %)
2315.00 (469.37) 254.04 (75.35) 68.73 (15.77) 116.32 (23.62)
2325.95 (326.88) 253.19 (54.19) 71.32 (22.45) 116.09 (20.15)
1 4 9 9
(4.3 %) (17. 4 %) (39.1 %) (39.1 %)
0 (0 %) 2 (9.5 %) 8 (38.1 %) 11 (52.4 %)
8 (34.8 %) 15 (65.2 %)
5 (23.8 %) 16 (76.2 %)
19 (82.6 %) 4 (17.4 %)
16 (76.2 %) 5 (23.8 %)
0.07‡
0.93† 0.96† 0.66† 0.97† 0.74‡
0.52‡
0.72‡
GCE: green coffee extract; PAL: physical activity level. * Data are expressed as mean (standard deviation). † Independent sample t-test. ‡ Fisher’s exact test.
3.1. General characteristics A total of 48 patients were enrolled in the study and 44 patients (21 in the GCE group and 23 in the placebo group) completed the intervention. The reasons for the loss to follow up are described in the study flow diagram (Fig. 1). During the trial period, no subject reported any adverse event.
Baseline characteristics of the study patients are presented in Table 1. There were no significant differences in sex, age, physical activity levels, and educational, marital, and employment status between
Fig. 1. Study flow diagram. 3
Complementary Therapies in Medicine 49 (2020) 102290
S. Hosseinabadi, et al.
Table 2 Anthropometric measurements and liver steatosis grades of the study patients at baseline and after 8-wk intervention. Variables Weight (kg)
BMI (kg/m2)
Grade of liver steatosis (0/1/2/3)£
Before After MD (%95 CI) P-value§ Before After MD (%95 CI) P-value§ Before After
Control (n = 23)
GCE (n = 21)
P-value
83.97 (10.59) 83.60 (11.06) −0.36 (-0.91 to 0.17) 0.17 30.51 (2.81) 30.37 (2.96) −0.13 (-0.32 to 0.04) 0.14 0/15/7/1 1/14/7/1
85.95 (11.76) 84.30 (12.17) −1.64 (-2.11 to -1.18) < 0.001 30.14 (2.60) 29.54 (2.59) −0.57 (-0.84 to -0.29) < 0.001 0/12/8/1 1/12/8/0
0.56† < 0.001‡ 0.65† < 0.001‡ 0.31€ 0.76€
Data are expressed as mean (standard deviation). BMI: body mass index, GCE: green coffee extract, MD (%95 CI): mean difference (%95 confidence interval). † Independent sample t-test. ‡ Analysis of covariance (ANCOVA) adjusted for baseline values and mean changes of daily energy intake. § Paired t-test. £ Number of patients in each grade according to ultrasound assay. € Fisher’s exact test.
4. Discussion
the two groups at baseline. No significant changes were seen in patients’ physical activity level throughout the study within or between the two groups (P > 0.05). The mean reported dietary intakes demonstrated no significant differences in calorie and macronutrient intakes between the two groups at the beginning of the study. There was not also any difference in dietary intake between the study groups at the end of the trial.
The current findings indicated that supplementation with 400 mg of GCE in patients with NAFLD for eight weeks, significantly reduced BMI and increased serum HDL-C levels in the intervention group compared to the control. TC and TG concentrations decreased considerably through the study, which were not albeit significantly different from the control group after adjusting for potential confounders. There was no significant improvement in circulating adiponectin following the intervention. It has been known that consumption of GCE exhibits anti-obesity and anti-lipogenic effects by several mechanisms. GCE and its main phenolic compound CGA reduce fat absorption through the inhibition of pancreatic lipase activity. Downregulating fatty acid biosynthesis and enhancing fatty acid oxidation are other possible mediated pathways by this phytochemical component.23–27 Acetyl-CoA carboxylase (ACC) is a vital enzyme required for free fatty acid synthesis in the liver. AMP-activated protein kinase (AMPK) phosphorylation inactivates ACC and leads to inhibition of de novo synthesis of fatty acids and cholesterol while enhancing fatty acid oxidation. Phosphorylation of AMPK augmented in GCE and CGA treated animals.23 GCE and its metabolites also up-regulate the lipid oxidation-related genes, like peroxisome proliferator-activated receptor α (PPARα) and carnitine palmitoyltransferase-1 (CPT-1) and down-regulate the lipogenic factors such as sterol regulatory element binding proteins (SREBPs) and PPARγ 28,29 which all result in decreased serum lipid profile and fat accumulation in the adipose tissue and liver. A recent meta-analysis of three trials reported significant decreases in weight and BMI of GCE-treated groups as compared with the placebo.30 Some previous studies have also shown anti-obesity potential of phenolic phytochemicals in NAFLD.31–35 The beneficial effects of GCE on lipid profiles in NAFLD patients in the present study are in line with the results of some previous clinical trials. In a recent study by Alhamhany et al., significant improvement in serum lipid profile of obese subjects were observed after six weeks of 1000 mg green coffee supplementation.36 Haidari et al. reported a significant reduction in serum TC, LDL-C, and free fatty acid (FFA) concentrations in healthy obese women with 400 mg GCE supplementation during eight weeks.37 Shahmohammadi et al. also found reduced serum levels of TG, TC, and FFA with administrating 1000 mg/day GCE in NAFLD patients in eight weeks.38 However, Roshan et al. did not find any significant changes in the serum lipid profile of patients with metabolic syndrome by using 400 mg of GCE during eight weeks.19 Taken together, although human studies have so far been less consistent, rodent studies have generally found a promising effect of green coffee and its components on serum lipid levels. Choi et al. reported that GCE decreased plasma TC and LDL-C levels while increased plasma HDL-C
3.2. Hepatic steatosis and anthropometric measurements Liver steatosis grade, weight, and BMI were not significantly different between the study groups at baseline (Table 2). Liver steatosis grade did not show significant changes in any of the groups at the end of the intervention. Significant decreases in mean weight (mean difference [MD]: -1.64; 95 % confidence interval [CI]: -2.11 to -1.18; P < 0.001) and BMI (MD: -0.60; 95 % CI: -0.77 to -0.42; P < 0.001) were observed in the GCE group after the intervention compared to the baseline values. Results of analysis of covariance adjusted for energy intake and baseline values also demonstrated a significant difference in weight (MD: -1.73; 95 % CI: -2.44 to -1.01 kg; P < 0.001) and BMI (MD: -0.57; 95 % CI: -0.84 to -0.29 kg; P < 0.001) in GCE group compared to the placebo group at the end of the study.
3.3. Biochemical parameters Table 3 shows the biochemical characteristics of patients throughout the study. There were no significant differences in serum lipid profile, liver enzymes, and adiponectin levels between the two groups at the baseline. Following the intervention, significant decreases in serum levels of TC were observed in the GCE group compared to the baseline values (MD: -13.33; 95 % CI: -26.04 to -0.61; P = 0.04). Besides, serum LDL-C declined considerably in the intervention group compared to the baseline (MD: -12.03; 95 % CI: -24.85 to 0.77; P = 0.06). Results of the analysis of covariance adjusted for the baseline values showed a significant decrease in TG levels in the GCE group compared to the placebo group at the end of the study (MD: -37.91; 95 % CI: -72.03 to -3.80; P = 0.03). However, this reduction was not significant when was further adjusted for mean changes in BMI and daily energy intake (MD: -23.43; 95 % CI: -70.92 to 24.06; P = 0.32). A significant increase in serum concentrations of HDL-C was observed in the intervention compared to the placebo group adjusted for baseline values and mean changes in BMI and daily energy intake (MD: 7.06; 95 % CI: 0.25–13.87; P = 0.042). Serum levels of ALT, AST, LDL-C, TC, and adiponectin showed no significant differences between the two groups at the end of the study (P > 0.05). 4
Complementary Therapies in Medicine 49 (2020) 102290
S. Hosseinabadi, et al.
Table 3 Biochemical parameters of the study patients at baseline and after the 8-wk intervention. Variables ALT (IU/L)
AST (IU/L)
TG (mg/dl)
TC, (mg/dl)
LDL-C (mg/dl)
HDL-C (mg/dl)
Adiponectin (μg/ml)
Before After MD (95 %CI), Before After MD (95 %CI), Before After MD (95 %CI), Before After MD (95 %CI), Before After MD (95 %CI), Before After MD (95 %CI), Before After P-value§
P-value§
P-value§
P-value§
P-value§
P-value§
P-value§
Control (n = 23)
GCE (n = 21)
P-value
36.56 (19.19) 37.04 (19.99) 0.47 (-3.71 to 4.67), 0.81 30.00 (9.39) 32.13 (11.14) 2.13 (-1.76 to 6.02), 0.26 176.95 (91.36) 190.13 (97.30) 13.17 (-8.74 to 35.08), 0.22 211.47 (42.68) 200.86 (40.19) −10.60 (-23.66 to 2.44), 0.10 124.29 (38.48) 111.54 (32.84) −11.63 (-26.17 to 2.90), 0.11 52.17 (14.24) 51.30 (13.41) −0.86 (-5.04 to 3.30), 0.67 7.42 (4.13) 6.49 (3.14) −0.93 (-1.97 to 0.09), 0.07
43.85 (25.82) 44.52 (30.08) 0.66 (-10.99 to 12.32), 0.90 35.71 (22.63) 32.66 (16.74) −3.04 (-11.94 to 5.84), 0.48 187.04 (106.04) 159.14 (74.96) −27.90 (-61.92 to 6.11), 0.10 231.66 (43.70) 218.33 (38.52) −13.33 (-26.04 to -0.61), 0.04 138.25 (29.55) 127.92 (30.87) −12.03 (-24.85 to 0.77), 0.06 55.04 (10.03) 58.47 (8.71) 3.42 (-0.53 to 7.38), 0.08 6.89 (3.90) 6.79 (4.46) −0.1 (-0.77 to 0.57), 0.75
0.29† 0.26‡ 0.27† 0.86‡ 0.73† 0.32‡,₤ 0.13† 0.36‡ 0.12† 0.33‡ 0.44† 0.04‡ 0.66† 0.30‡
Data are expressed as mean (standard deviation). ALT: alanine aminotransferase, AST: aspartate aminotransferase, TG: triglyceride, TC: total cholesterol, LDL-C: low-density lipoprotein cholesterol, HDL-C: highdensity lipoprotein cholesterol, GCE: green coffee extract, MD (%95CI): mean difference (%95 confidence interval). † Independent sample t-test. ‡ Analysis of covariance (ANCOVA) adjusted for the baseline values and mean changes of BMI and daily energy intake. ₤ P < 0.05 when adjusted for the baseline values. § Paired t-test.
levels in the mice fed a high-fat diet (HFD).13 In another study, GCE decreased plasma LDL-C and TC and increased HDL-C concentrations in HFD induced obese mice.39 In addition, CGA administration reduced lipids, lipoproteins, and lipid metabolizing enzymes such as 3-hydroxy 3-methylglutaryl coenzyme A reductase and increased lipoprotein lipase and lecithin cholesterol acyltransferase activities in the streptozotocin (STZ)-nicotinamide induced diabetic rats.40 It should be considered that the effect of GCE on lipid parameters would probably be influenced by the baseline metabolic characteristics of the study subjects. Most of the patients in our study had elevated levels of TC at baseline. However, the mean TG and LDL-C levels were below the borderline values of 200 mg/dl and 130 mg/dl, respectively, which could affect the efficacy of the intervention. In addition, the effect of GCE on TG levels may be mediated through reducing weight which such association was observed in the current study after additional adjustment for BMI changes. Overall, despite the considerable improvements in lipid parameters in the current trial, more studies are required to confirm the beneficial effect of GCE on lipid metabolism. Hepatic enzyme levels including ALT and AST did not change significantly throughout the study in any of the study groups. Some rodent studies illustrated the reduced serum levels of ALT and AST by GCE and CGA administration. Xu et al. reported that CGA administration suppressed serum AST and ALT in a mice model with tetrachloro-1,4benzoquinone (TCBQ) induced acute liver injury.41 Some of the hepatoprotective effects of CGA are attributed to its antioxidant and antiinflammatory actions.41,42 It is well established that oxidative stress is involved in the pathogenesis of NAFLD 43 and disease progression from simple steatosis to steatohepatitis and liver damage.44 It has been shown that CGA is an effective antioxidant that alleviates the oxidative reactions and protects the liver from oxidative stress-induced injuries by up-regulating the expression of antioxidant enzymes and by preventing the lipid peroxidation.45 Shahmohammadi et al. demonstrated alleviated serum ALT levels following 1 g/day of GCE supplementation in individuals with NAFLD.38 The findings may vary among different research studies which might be related to different dosage uses of GCE or baseline metabolic characteristics of the study patients.
Hepatic steatosis also did not show significant improvement by GCE supplementation. However, some animal studies indicated favorable effects of green coffee or CGA on hepatic fat accumulation.13,23,42,46,47 It was demonstrated that CGA may reduce liver fat content through PPARα facilitated hepatic FFA drainage pathway.28,48 Peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α) is a versatile transcriptional coactivator and indicates important roles in hepatic fatty acid oxidation. CGA restored PGC-1α mRNA levels that were suppressed in mice with lipopolysaccharide-induced liver injury.42 Possible impacts of GCE on hepatic steatosis in NAFLD patients require further studies using different doses and durations of GCE supplementation. More precise methods of assessing steatosis changes such as Fibroscan are needed to evaluate clinical outcomes. In our study, serum adiponectin levels were not affected by GCE consumption. To our knowledge, this study is the first to evaluate the effects of GCE on adiponectin levels in NAFLD patients. In a study on obese women, 400 mg/day of GCE supplementation combined with dietary energy restriction, significantly increased plasma adiponectin levels.37 Previous animal studies indicated that treatment with GCE or CGA improved adiponectin levels or adiponectin gene expression.13,24,29 Choi et al. reported an enhanced plasma concentration of adiponectin by GCE treatment in a dose-dependent manner in HFDinduced obese mice. Gene expression levels of adiponectin were also upregulated by GCE.13 In the study by Cho et al. CGA increased plasma adiponectin levels but caffeic acid did not alter plasma adiponectin concentration in HFD-induced obese mice.24 Adiponectin levels in human serum normally range between 5 and 30 μg/mL.49 In the present study, the mean baseline levels of this hormone were in the normal range in both groups, so non-significant changes in this variable would be expected to some extent. On the other hand, it seems that the dose and duration of GCE supplementation in our study were not adequate to induce significant alters in adiponectin levels. More research is warranted to explore this topic further. It should be noted that daily energy and macronutrient intakes and physical activity levels of our study subjects did not change significantly in any of the groups throughout the study. Thus, detected 5
Complementary Therapies in Medicine 49 (2020) 102290
S. Hosseinabadi, et al.
biochemical results of this study could not be affected by these variables. The main strength of our study is the randomized, placebo-controlled design and stratification by age, gender, and BMI, which eliminates inter-individual differences. However, it had some limitations such as short intervention time and using a fixed dose of the supplement. Therefore, the results of the current study are not generalizable to other studies concerning different dosages and durations of GCE supplementation in NAFLD.
9. 10.
11.
12.
5. Conclusion
13.
The results of this study indicated hopeful effects of GCE supplementation on serum lipid profile and BMI in patients with NAFLD. These findings support the consumption of GCE, as a part of an integrated approach to NAFLD management. Further studies are needed to provide enough evidence on the probable effect of green coffee on preventing NAFLD development and/or progression.
14.
15. 16.
17.
Sources of financial support
18.
Research Vice-Chancellor of Tabriz University of Medical Sciences, Tabriz, Iran (grant number: 5/d/25969)
19.
CRediT authorship contribution statement Samaneh Hosseinabadi: Conceptualization, Investigation, Data curation. Maryam Rafraf: Supervision, Conceptualization. Somayyeh Asghari: Project administration, Visualization, Writing - original draft, Writing - review & editing. Mohammad Asghari-Jafarabadi: Methodology, Software, Formal analysis, Validation. Shohreh Vojouhi: Resources.
20.
Declaration of Competing Interest
23.
21.
22.
24.
None. 25.
Acknowledgments
26.
We thank The Research Vice-Chancellor of Tabriz University of Medical Sciences (Tabriz, Iran) for financial support (grant number: 5/ d/25969) and all of the patients who participated in this study. It should be noted that the financial sponsor of the study had no involvement in the study design, in the collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. This article was written based on the data set of the MSc thesis (NO. A/30) registered at Tabriz University of Medical Sciences, Iran.
27.
28.
29.
30.
References 1. Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-meta‐analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016;64:73–84. 2. Birkenfeld AL, Shulman GI. Nonalcoholic fatty liver disease, hepatic insulin resistance, and type 2 diabetes. Hepatology. 2014;59:713–723. 3. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of non‐alcoholic fatty liver disease: Practice Guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology. 2012;55:2005–2023. 4. Hurjui DM, Niţă O, Graur LI, et al. The pathogenesis of non-alcoholic fatty liver disease is closely related to the metabolic syndrome components. Rom J Diabetes Nutr Metab Dis. 2012;19:311–321. 5. Abenavoli L, Milic N, Di Renzo L, Preveden T, Medić-Stojanoska M, De Lorenzo A. Metabolic aspects of adult patients with nonalcoholic fatty liver disease. World J Gastroenterol. 2016;22:7006–7016. 6. Chatrath H, Vuppalanchi R, Chalasani N, eds. Dyslipidemia in patients with nonalcoholic fatty liver disease. Seminars in liver disease. NIH Public Access; 2012. 7. Byrne CD, Targher G. NAFLD: A multisystem disease. J Hepatol. 2015;62:S47–64. 8. Gaggini M, Morelli M, Buzzigoli E, DeFronzo R, Bugianesi E, Gastaldelli A. Non-
31.
32.
33.
34.
35.
36.
6
alcoholic fatty liver disease (NAFLD) and its connection with insulin resistance, dyslipidemia, atherosclerosis and coronary heart disease. Nutrients. 2013;5:1544–1560. Gossard AA, Lindor K. Current therapies for nonalcoholic fatty liver disease. Drugs Today. 2011;47:915–922. Bagherniya M, Nobili V, Blesso CN, Sahebkar A. Medicinal plants and bioactive natural compounds in the treatment of non-alcoholic fatty liver disease: A clinical review. Pharmacol Res. 2018;130:213–240. Jeszka-Skowron M, Sentkowska A, Pyrzyńska K, De Peña MP. Chlorogenic acids, caffeine content and antioxidant properties of green coffee extracts: Influence of green coffee bean preparation. Eur Food Res Technol. 2016;242:1403–1409. Nuhu AA. Bioactive micronutrients in coffee: Recent analytical approaches for characterization and quantification. ISRN Nutr. 2014;2014:384230. Choi B-K, Park S-B, Lee D-R, et al. Green coffee bean extract improves obesity by decreasing body fat in high-fat diet-induced obese mice. Asian Pac J Trop Med. 2016;9:635–643. Mirza M. Obesity, visceral fat, and NAFLD: Querying the role of adipokines in the progression of nonalcoholic fatty liver disease. ISRN Gastroenterol. 2011;2011:592404. Finelli C, Tarantino G. What is the role of adiponectin in obesity related non-alcoholic fatty liver disease? World J Gastroenterol. 2013;19:802–812. Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-Meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016;64:73–84. Baratta R, Amato S, Degano C, et al. Adiponectin relationship with lipid metabolism is independent of body fat mass: Evidence from both cross-sectional and intervention studies. J Clin Endocrinol Metab. 2004;89:2665–2671. Marventano S, Salomone F, Godos J, et al. Coffee and tea consumption in relation with non-alcoholic fatty liver and metabolic syndrome: A systematic review and meta-analysis of observational studies. Clin Nutr. 2016;35:1269–1281. Roshan H, Nikpayam O, Sedaghat M, Sohrab G. Effects of green coffee extract supplementation on anthropometric indices, glycaemic control, blood pressure, lipid profile, insulin resistance and appetite in patients with the metabolic syndrome: A randomised clinical trial. Br J Nutr. 2018;119:250–258. van Werven JR, Marsman HA, Nederveen AJ, et al. Assessment of hepatic steatosis in patients undergoing liver resection: Comparison of US, CT, T1-weighted dual-echo MR imaging, and point-resolved 1H MR spectroscopy. Radiology. 2010;256:159–168. Moghaddam MB, Aghdam FB, Jafarabadi MA, Allahverdipour H, Nikookheslat SD, Safarpour S. The Iranian Version of International Physical Activity Questionnaire (IPAQ) in Iran: Content and construct validity, factor structure, internal consistency and stability. World Appl Sci. 2012;18:1073–1080. Hirany S, Li D, Jialal I. A more valid measurement of low-density lipoprotein cholesterol in diabetic patients. Am J Med. 1997;102:48–53. Ong KW, Hsu A, Tan BKH. Anti-diabetic and anti-lipidemic effects of chlorogenic acid are mediated by AMPK activation. Biochem Pharmacol. 2013;85:1341–1351. Cho A-S, Jeon S-M, Kim M-J, et al. Chlorogenic acid exhibits anti-obesity property and improves lipid metabolism in high-fat diet-induced-obese mice. Food Chem Toxicol. 2010;48:937–943. Dellalibera O, Lemaire B, Lafay S. Svetol, green coffee extract, induces weight loss and increases the lean to fat mass ratio in volunteers with overweight problem. Phytotherapie. 2006;4:194–197. Shimoda H, Seki E, Aitani M. Inhibitory effect of green coffee bean extract on fat accumulation and body weight gain in mice. BMC Complement Altern Med. 2006;6:1–9. Sudeep H, Venkatakrishna K, Patel D, Shyamprasad K. Biomechanism of chlorogenic acid complex mediated plasma free fatty acid metabolism in rat liver. BMC Complement Altern Med. 2016;16:274. Shu-Yuan L, Chang C-Q, Fu-Ying M, Chang-Long Y. Modulating effects of chlorogenic acid on lipids and glucose metabolism and expression of hepatic peroxisome proliferator-activated receptor-α in golden hamsters fed on high fat diet. Biomed Environ Sci. 2009;22:122–129. Zhang L, Chang C, Liu Y, Chen Z. Effect of chlorogenic acid on disordered glucose and lipid metabolism in db/db mice and its mechanism. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2011;33:281–286. Onakpoya I, Terry R, Ernst E. The use of green coffee extract as a weight loss supplement: A systematic review and meta-analysis of randomised clinical trials. Gastroenterol Res Pract. 2011;2011. Chen I-J, Liu C-Y, Chiu J-P, Hsu C-H. Therapeutic effect of high-dose green tea extract on weight reduction: A randomized, double-blind, placebo-controlled clinical trial. Clin Nutr. 2016;35:592–599. Ekhlasi G, Shidfar F, Agah S, Merat S, Hosseini AF. Effects of pomegranate and orange juice on antioxidant status in non-alcoholic fatty liver disease patients: A randomized clinical trial. Int J Vitam Nutr Res. 2016;14:1–7. Asghari S, Rafraf M, Farzin L, Asghari-Jafarabadi M, Ghavami S-M, Somi M-H. Effects of pharmacologic dose of resveratrol supplementation on oxidative/antioxidative status biomarkers in nonalcoholic fatty liver disease patients: A randomized, doubleblind, placebo-controlled trial. Adv Pharm Bull. 2018;8:307–317. Chang H-C, Peng C-H, Yeh D-M, Kao E-S, Wang C-J. Hibiscus sabdariffa extract inhibits obesity and fat accumulation, and improves liver steatosis in humans. Food Funct. 2014;5:734–739. Asghari S, Asghari-Jafarabadi M, Somi M-H, Ghavami S-M, Rafraf M. Comparison of calorie-restricted diet and resveratrol supplementation on anthropometric indices, metabolic parameters, and serum Sirtuin-1 levels in patients with nonalcoholic fatty liver disease: A randomized controlled clinical trial. J Am Coll Nutr. 2018;37:223–233. Alhamhany NN, Alassady EH. Does green coffee has a positive effect on body mass
Complementary Therapies in Medicine 49 (2020) 102290
S. Hosseinabadi, et al.
37.
38.
39.
40.
41.
42. 43.
and non‐alcoholic steatohepatitis. Aliment Pharmacol Ther. 2008;28:2–12. 44. Takaki A, Kawai D, Yamamoto K. Multiple hits, including oxidative stress, as pathogenesis and treatment target in non-alcoholic steatohepatitis (NASH). Int J Mol Sci. 2013;14:20704–20728. 45. Koriem KM, Soliman RE. Chlorogenic and caftaric acids in liver toxicity and oxidative stress induced by methamphetamine. J Toxicol. 2014;2014:583494. 46. de Sotillo DVR, Hadley M. Chlorogenic acid modifies plasma and liver concentrations of: Cholesterol, triacylglycerol, and minerals in (fa/fa) Zucker rats. J Nutr Biochem. 2002;13(12):717–726. 47. Ma Y, Gao M, Liu D. Chlorogenic acid improves high fat diet-induced hepatic steatosis and insulin resistance in mice. Pharm Res. 2015;32:1200–1209. 48. Li SY, Chang CQ, Ma FY, Yu CL. Modulating effects of chlorogenic acid on lipids and glucose metabolism and expression of hepatic peroxisome proliferator-activated receptor-alpha in golden hamsters fed on high fat diet. Biomed Environ Sci. 2009;22:122–129. 49. Nabavi S, Rafraf M, M-h Somi, Homayouni-Rad A, Asghari-Jafarabadi M. Probiotic yogurt improves body mass index and fasting insulin levels without affecting serum leptin and adiponectin levels in non-alcoholic fatty liver disease (NAFLD). J Funct Foods. 2015;18:684–691.
index and lipid profile in a sample of obese people. J Pharm Sci Res. 2018;10:627–630. Haidari F, Samadi M, Mohammadshahi M, Jalali MT, Engali KA. Energy restriction combined with green coffee bean extract affects serum adipocytokines and the body composition in obese women. Asia Pac J Clin Nutr. 2017;26:1048–1054. Shahmohammadi HA, Hosseini SA, Hajiani E, Malehi AS, Alipour M. Effects of green coffee bean extract supplementation on patients with non-alcoholic fatty liver disease: A randomized clinical trial. Hepat Mon. 2017;17:e12299. Setyono J, Nugroho DA, Mustofa M, Saryono S. The effect of orlistat, green coffee bean extract, and its combinations on lipid profile and adiponectin levels. J Ners. 2017;9:26–34. Karthikesan K, Pari L, Menon V. Antihyperlipidemic effect of chlorogenic acid and tetrahydrocurcumin in rats subjected to diabetogenic agents. Chem Biol Interact. 2010;188:643–650. Xu D, Hu L, Xia X, et al. Tetrachlorobenzoquinone induces acute liver injury, upregulates HO-1 and NQO1 expression in mice model: The protective role of chlorogenic acid. Environ Toxicol Phar. 2014;37:1212–1220. Xu Y, Chen J, Yu X, et al. Protective effects of chlorogenic acid on acute hepatotoxicity induced by lipopolysaccharide in mice. Inflamm Res. 2010;59:871–877. Younossi Z. Review article: Current management of non‐alcoholic fatty liver disease
7
Contents lists available at ScienceDirect
Complementary Therapies in Medicine journal homepage: www.elsevier.com/locate/ctim
Effect of green coffee extract supplementation on serum adiponectin concentration and lipid profile in patients with non-alcoholic fatty liver disease: A randomized, controlled trial
T
Samaneh Hosseinabadia, Maryam Rafrafb,*, Somayyeh Asgharib, Mohammad Asghari-Jafarabadic,d, Shohreh Vojouhie a
Students’ Research Committee, Faculty of Nutrition and Food Science, Tabriz University of Medical Sciences, Tabriz, Iran Nutrition Research Center, Faculty of Nutrition and Food Science, Tabriz University of Medical Sciences, Tabriz, Iran Department of Statistics and Epidemiology, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran d Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran e Internists, 22 Bahman Hospital, Neyshabur University of Medical Sciences, Neyshabur, Iran b c
A R T I C LE I N FO
A B S T R A C T
Keywords: Adiponectin Clinical trial Green coffee extract Lipid profile Non-alcoholic fatty liver disease
Objectives: The current study evaluated the effects of green coffee extract (GCE) on serum lipid profile and adiponectin levels in patients with nonalcoholic fatty liver disease (NAFLD). Design: This randomized, double-blind, placebo-controlled clinical trial was conducted on NAFLD patients aged 20–60 years and body mass index (BMI) of 25−35 kg/m2. Setting: Patients were recruited from the Bahman poly-clinic (Neyshabur, Iran) between January and June 2016. Interventions: The study subjects were randomly assigned to receive a daily dose of 400 mg GCE (n = 24) or placebo (n = 24) for eight weeks. Main outcome measures: Serum liver enzyme levels, lipid profile, adiponectin concentrations, and hepatic steatosis grade were measured for all patients at baseline and the end of the trial. Results: GCE supplementation significantly reduced BMI [mean difference (MD): −0.57 and 95 % confidence interval (CI): −0.84 to −0.29, P < 0.001] and increased serum high-density lipoprotein cholesterol (MD: 7.06, 95 % CI: 0.25–13.87, P < 0.05) compared to the control group. Serum total cholesterol decreased significantly within the GCE group (MD: −13.33, 95 % CI: −26.04 to −0.61, P < 0.05). Triglyceride levels reduced significantly in GCE group compared to the placebo group (MD: -37.91; 95 % CI: −72.03 to −3.80; P = 0.03). However, this reduction was not significant when was further adjusted for mean changes in BMI and daily energy intake (MD: -23.43; 95 % CI: −70.92 to 24.06; P = 0.32). Hepatic steatosis grade, liver enzymes, and adiponectin levels did not show significant differences between the two groups after the intervention. Conclusions: GCE supplementation improved serum lipid profile and BMI in individuals with NAFLD. GCE may be useful in controlling NAFLD risk factors.
1. Introduction Nonalcoholic fatty liver disease (NAFLD) is the most common cause of the chronic liver disease1 characterized by the accumulation of fat in more than 5 % of the hepatocytes.2 This disorder represents a histological spectrum ranging from simple hepatic steatosis to nonalcoholic steatohepatitis (NASH) and progression to fibrosis and cirrhosis.3 Various risk factors including abdominal obesity, insulin resistance, dyslipidemia, hypertension, and pro-inflammatory state are associated with NAFLD.4 In the last years, NAFLD has been considered the hepatic
⁎
border of metabolic syndrome, linked to metabolic derangement of patients with this clinical picture.5 Abnormal lipid metabolism and dyslipidemia occurs in 20–80% of NAFLD patients 6 and is characterized by increased serum triglycerides (TG), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C), as well as reduced levels of high-density lipoprotein cholesterol (HDL-C), which are considered strong risk factors for cardiovascular diseases (CVDs) in patients with NAFLD.7 Current therapeutic approaches include strategies that could modify CVD risk factors in these patients.8 To date, there is no specific
Corresponding author at: Nutrition Research Center, Faculty of Nutrition and Food Science, Tabriz University of Medical Sciences, Golgasht Street, Tabriz, Iran. E-mail address: [email protected] (M. Rafraf).
https://doi.org/10.1016/j.ctim.2019.102290 Received 23 September 2019; Received in revised form 17 December 2019; Accepted 24 December 2019 Available online 26 December 2019 0965-2299/ © 2019 Published by Elsevier Ltd.
Complementary Therapies in Medicine 49 (2020) 102290
S. Hosseinabadi, et al.
2.2. Study design
pharmacologic therapy for NAFLD. Lifestyle modification through diet and exercise has been considered to be fundamental for NAFLD management.9 However, adherence to low-calorie diets, weight loss, and subsequent weight maintenance had less long term success in obese participants. Alternative medicine has recently gained interest as a possible therapeutic approach in NAFLD treatment. In the last few years, the effects of bioactive food components especially phytochemicals on NAFLD have received much attention because of their antioxidative, anti-inflammatory, antilipidemic, and anti-adipogenic properties.10 Green coffee is a widely consumed beverage in recent years which contains a complex chemical mixture of polysaccharides, monosaccharides, lipids, sterols, phenolic acids, polyphenols, proteins, free amino acids, vitamins, and minerals.11 Green coffee extract (GCE) is a rich source of bioactive compounds with antioxidant properties such as chlorogenic acid (CGA), diterpenes, and trigonelline.11 Many positive effects of GCE have been attributed to CGA as a main phenolic compound.12 Accumulating experimental evidence has demonstrated that CGA exhibits anti-diabetic, anti-lipidemic, and anti-obesity properties. Some experimental studies have also reported improved adiponectin levels following GCE or CGA administrations.13 Adiponectin is a well-recognized adipokine considering its antiatherogenic, anti-inflammatory and anti-lipidemic properties.14,15 The regulatory effects of adiponectin on lipid metabolism have been shown in some research studies.14–16 In humans, plasma levels of adiponectin are inversely related to body fat mass, body mass index (BMI) and plasma TG and positively correlated with HDL-C concentration.17 It is presumed that the imbalanced production of adiponectin is involved in the pathogenesis of NAFLD.15 Despite the protective effects of coffee toward NAFLD, 18 there is limited research regarding the effects of green coffee on NAFLD features. Moreover, no one has investigated its possible effects on serum adiponectin levels in humans, as indicated in several experimental studies. Thus, the aim of the present study was to evaluate the effects of the green coffee extract on anthropometric measures, liver function, and serum lipid profile and the potential mediating role of adiponectin in this regard in a randomized double-blind controlled trial in patients with NAFLD.
This study was designed as a randomized, double-blind placebocontrolled clinical trial. Fifty patients were randomly assigned to one of two intervention groups using a block randomization procedure of size 4 stratified by age (< 40, > 40 years old), gender (male, female), and BMI (25–30, 30−35 kg/m2). The sequence of the randomization was generated using random allocation software (RAS) and assigning the participants to two groups was conducted by an independent person. The GCE group (n = 24) received two capsules per day each contained 200 mg GCE for eight weeks. The placebo group (n = 24) was given two placebo capsules daily for the same period. The GCE capsules were purchased from Bonyan Salamat Kasra Co., Tehran, Iran which were provided by the hydro-alcoholic extraction of green coffee beans and contained 50 percent (100 mg) CGA as the main ingredient and < 2 % of caffeine. Placebo capsules contained starch and were similar in taste and appearance to the GCE capsules. The medication boxes were labeled as A and B and the researchers and participants were blinded to the allocation until the statistical analyses were completed. Both groups were educated to follow a healthy lifestyle during the study. Patients were excluded if they did not consume more than 10 % of the supplements. They were followed up every two weeks to check the compliance and probable side effects. 2.3. Liver ultrasonography Abdominal ultrasonography (US) was performed in participants after overnight fasting in order to confirm the NAFLD and grading of hepatic steatosis. Each US exam was performed by one expert radiologist using a SonoAce X4 ultrasound system (Medison Inc., Korea). The presence of hepatic steatosis was defined through the ultrasonographic appearance of liver echotexture as compared to the right kidney’s cortex. Visibility and sharpness of the diaphragm and hepatic veins’ clarity were analyzed as well. Based on these parameters, steatosis was graded as mild, moderate, and severe. Mild steatosis was detected by a slightly brighter liver as compared to the renal cortex, clear visualization of diaphragm, and interface of hepatic veins with sharp contours; moderate steatosis was accompanied by a brighter liver with attenuated US beam at deeper parts of the liver, diaphragm, and hepatic veins still visible but with blunted contours; severe steatosis was recognized by a very bright liver with a severe US beam attenuation, not visible diaphragm or hepatic veins. This classification was adopted and already tested by other investigators.20
2. Materials and methods 2.1. Study subjects Patients with NAFLD, aged 20–60 years with body mass index (BMI) ranged 25−35 kg/m2 were recruited from the 22 Bahman poly-clinic (Neyshabur, Iran) between January and June 2016. Subjects were excluded if they were pregnant, breastfeeding, post menopause or professional athletes or had any known documented liver disease (such as hepatitis B, C, and biliary disease) and inherited disorders affecting liver (iron and copper storage disease), history of diagnosed cardiovascular, kidney, diabetes, gastrointestinal, pulmonary and autoimmune diseases, thyroid dysfunction, cancer, and recent surgery. In addition, subjects who used alcohol and cigarettes, nutritional supplements or weight loss diet within the past three months or during the study period as well as some other medications such as corticosteroids, hepatotoxic, anticoagulant, antidiuretic, and lipidlowering were eliminated from the study. The sample size of the study was determined based on the TC level, which obtained from the Roshan et al. study.19 By aiming for a confidence level of 95 %, 80 % power, and two-tailed statistical test, the sample size was computed to be 22 per group. To allow for the anticipated dropout, the sample size was increased to 24 in each group. The research protocol was approved by the Ethics Committee of the Tabriz University of Medical Sciences (IR.TBZMED.REC.1398.918) and was conducted according to the principles of the Declaration of Helsinki. Written informed consent was obtained from all patients.
2.4. Anthropometric parameters, dietary intake, and physical activity level assessment Anthropometric parameters including body weight and height were measured at baseline and the end of the trial. Body weight was recorded in light clothing and no shoes to the nearest 0.5 kg, using a scale (Seca, Hamburg, Germany). Height was measured without shoes, using a mounting tape with a precision of 0.1 cm. BMI calculated as the weight (kg) divided by the square of the height (m). Daily dietary intake data were collected by 3-day food records (2 weekdays and 1 weekend day) at baseline and end of the study. Dietary data were analyzed by using Nutritionist 4 software (First Databank Inc., Hearst Corp., San Bruno, CA, USA). Physical activity was assessed by the International Physical Activity Questionnaire at the beginning and 8th week.21 2.5. Biochemical measurements Venous blood samples (5 ml) were collected from each subject after 12-h overnight fasting at the baseline and eight weeks after the intervention. The serum was separated from whole blood by centrifugation and stored at -70 °C until analysis. Blood samples were analyzed at the 2
Complementary Therapies in Medicine 49 (2020) 102290
S. Hosseinabadi, et al.
Drug Applied Research Center (Tabriz University of Medical Sciences, Tabriz, Iran). Serum TG, TC, and HDL-C concentrations were determined by enzymatic colorimetric assay method (Pars Azmoon Inc. kit, Tehran, Iran). LDL-C was obtained using the Friedewald calculation.22 Serum adiponectin concentrations were determined using an enzyme-linked immunosorbent assay (ELISA) kit (Mediagnost, Germany). Serum Alanine transaminase (ALT) and aspartate transaminase (AST) were measured by photometric assay (Pars Azmoon Inc. kit, Tehran, Iran).
Table 1 Baseline characteristics of the study patients.
2.6. Statistical analysis All statistical tests were performed using SPSS18 software (SPSS Inc., IL, Chicago, USA). Kolmogorov–Smirnov test was used to determine the normality of the variables. Comparisons of baseline characteristics were performed using Student’s t-test and the chi-squared test for quantitative and qualitative variables, respectively. Paired t-test and sign test were applied for within-group comparisons (after supplementation compared to the baseline). The effect of the intervention was investigated by ANCOVA test adjusting for baseline values and other potential confounders. P < 0.05 was considered to be statistically significant. 3. Results
Variables
Control (n = 23)
GCE (n = 21)
P-value
Age (y)* Sex, n (%) Male Female PAL, n (%) light moderate vigorous Dietary intakes* Energy (kcal/day) Carbohydrate (g/day) Protein (g/day) Total fat (g/day) Educational status, n (%) Illiterate High school Diploma Academic Marital status, n (%) Single Married Employment, n (%) Employed Unemployed
41.13 (8.47)
41.14 (7.87)
0.99† 0.98‡
12 (52.2 %) 11 (47.8 %)
11 (52.4 %) 10 (47.6 %)
10 (43.5 %) 2 (8.5 %) 11 (49.0 %)
5 (24.0 %) 8 (38.0 %) 8 (38.0 %)
2315.00 (469.37) 254.04 (75.35) 68.73 (15.77) 116.32 (23.62)
2325.95 (326.88) 253.19 (54.19) 71.32 (22.45) 116.09 (20.15)
1 4 9 9
(4.3 %) (17. 4 %) (39.1 %) (39.1 %)
0 (0 %) 2 (9.5 %) 8 (38.1 %) 11 (52.4 %)
8 (34.8 %) 15 (65.2 %)
5 (23.8 %) 16 (76.2 %)
19 (82.6 %) 4 (17.4 %)
16 (76.2 %) 5 (23.8 %)
0.07‡
0.93† 0.96† 0.66† 0.97† 0.74‡
0.52‡
0.72‡
GCE: green coffee extract; PAL: physical activity level. * Data are expressed as mean (standard deviation). † Independent sample t-test. ‡ Fisher’s exact test.
3.1. General characteristics A total of 48 patients were enrolled in the study and 44 patients (21 in the GCE group and 23 in the placebo group) completed the intervention. The reasons for the loss to follow up are described in the study flow diagram (Fig. 1). During the trial period, no subject reported any adverse event.
Baseline characteristics of the study patients are presented in Table 1. There were no significant differences in sex, age, physical activity levels, and educational, marital, and employment status between
Fig. 1. Study flow diagram. 3
Complementary Therapies in Medicine 49 (2020) 102290
S. Hosseinabadi, et al.
Table 2 Anthropometric measurements and liver steatosis grades of the study patients at baseline and after 8-wk intervention. Variables Weight (kg)
BMI (kg/m2)
Grade of liver steatosis (0/1/2/3)£
Before After MD (%95 CI) P-value§ Before After MD (%95 CI) P-value§ Before After
Control (n = 23)
GCE (n = 21)
P-value
83.97 (10.59) 83.60 (11.06) −0.36 (-0.91 to 0.17) 0.17 30.51 (2.81) 30.37 (2.96) −0.13 (-0.32 to 0.04) 0.14 0/15/7/1 1/14/7/1
85.95 (11.76) 84.30 (12.17) −1.64 (-2.11 to -1.18) < 0.001 30.14 (2.60) 29.54 (2.59) −0.57 (-0.84 to -0.29) < 0.001 0/12/8/1 1/12/8/0
0.56† < 0.001‡ 0.65† < 0.001‡ 0.31€ 0.76€
Data are expressed as mean (standard deviation). BMI: body mass index, GCE: green coffee extract, MD (%95 CI): mean difference (%95 confidence interval). † Independent sample t-test. ‡ Analysis of covariance (ANCOVA) adjusted for baseline values and mean changes of daily energy intake. § Paired t-test. £ Number of patients in each grade according to ultrasound assay. € Fisher’s exact test.
4. Discussion
the two groups at baseline. No significant changes were seen in patients’ physical activity level throughout the study within or between the two groups (P > 0.05). The mean reported dietary intakes demonstrated no significant differences in calorie and macronutrient intakes between the two groups at the beginning of the study. There was not also any difference in dietary intake between the study groups at the end of the trial.
The current findings indicated that supplementation with 400 mg of GCE in patients with NAFLD for eight weeks, significantly reduced BMI and increased serum HDL-C levels in the intervention group compared to the control. TC and TG concentrations decreased considerably through the study, which were not albeit significantly different from the control group after adjusting for potential confounders. There was no significant improvement in circulating adiponectin following the intervention. It has been known that consumption of GCE exhibits anti-obesity and anti-lipogenic effects by several mechanisms. GCE and its main phenolic compound CGA reduce fat absorption through the inhibition of pancreatic lipase activity. Downregulating fatty acid biosynthesis and enhancing fatty acid oxidation are other possible mediated pathways by this phytochemical component.23–27 Acetyl-CoA carboxylase (ACC) is a vital enzyme required for free fatty acid synthesis in the liver. AMP-activated protein kinase (AMPK) phosphorylation inactivates ACC and leads to inhibition of de novo synthesis of fatty acids and cholesterol while enhancing fatty acid oxidation. Phosphorylation of AMPK augmented in GCE and CGA treated animals.23 GCE and its metabolites also up-regulate the lipid oxidation-related genes, like peroxisome proliferator-activated receptor α (PPARα) and carnitine palmitoyltransferase-1 (CPT-1) and down-regulate the lipogenic factors such as sterol regulatory element binding proteins (SREBPs) and PPARγ 28,29 which all result in decreased serum lipid profile and fat accumulation in the adipose tissue and liver. A recent meta-analysis of three trials reported significant decreases in weight and BMI of GCE-treated groups as compared with the placebo.30 Some previous studies have also shown anti-obesity potential of phenolic phytochemicals in NAFLD.31–35 The beneficial effects of GCE on lipid profiles in NAFLD patients in the present study are in line with the results of some previous clinical trials. In a recent study by Alhamhany et al., significant improvement in serum lipid profile of obese subjects were observed after six weeks of 1000 mg green coffee supplementation.36 Haidari et al. reported a significant reduction in serum TC, LDL-C, and free fatty acid (FFA) concentrations in healthy obese women with 400 mg GCE supplementation during eight weeks.37 Shahmohammadi et al. also found reduced serum levels of TG, TC, and FFA with administrating 1000 mg/day GCE in NAFLD patients in eight weeks.38 However, Roshan et al. did not find any significant changes in the serum lipid profile of patients with metabolic syndrome by using 400 mg of GCE during eight weeks.19 Taken together, although human studies have so far been less consistent, rodent studies have generally found a promising effect of green coffee and its components on serum lipid levels. Choi et al. reported that GCE decreased plasma TC and LDL-C levels while increased plasma HDL-C
3.2. Hepatic steatosis and anthropometric measurements Liver steatosis grade, weight, and BMI were not significantly different between the study groups at baseline (Table 2). Liver steatosis grade did not show significant changes in any of the groups at the end of the intervention. Significant decreases in mean weight (mean difference [MD]: -1.64; 95 % confidence interval [CI]: -2.11 to -1.18; P < 0.001) and BMI (MD: -0.60; 95 % CI: -0.77 to -0.42; P < 0.001) were observed in the GCE group after the intervention compared to the baseline values. Results of analysis of covariance adjusted for energy intake and baseline values also demonstrated a significant difference in weight (MD: -1.73; 95 % CI: -2.44 to -1.01 kg; P < 0.001) and BMI (MD: -0.57; 95 % CI: -0.84 to -0.29 kg; P < 0.001) in GCE group compared to the placebo group at the end of the study.
3.3. Biochemical parameters Table 3 shows the biochemical characteristics of patients throughout the study. There were no significant differences in serum lipid profile, liver enzymes, and adiponectin levels between the two groups at the baseline. Following the intervention, significant decreases in serum levels of TC were observed in the GCE group compared to the baseline values (MD: -13.33; 95 % CI: -26.04 to -0.61; P = 0.04). Besides, serum LDL-C declined considerably in the intervention group compared to the baseline (MD: -12.03; 95 % CI: -24.85 to 0.77; P = 0.06). Results of the analysis of covariance adjusted for the baseline values showed a significant decrease in TG levels in the GCE group compared to the placebo group at the end of the study (MD: -37.91; 95 % CI: -72.03 to -3.80; P = 0.03). However, this reduction was not significant when was further adjusted for mean changes in BMI and daily energy intake (MD: -23.43; 95 % CI: -70.92 to 24.06; P = 0.32). A significant increase in serum concentrations of HDL-C was observed in the intervention compared to the placebo group adjusted for baseline values and mean changes in BMI and daily energy intake (MD: 7.06; 95 % CI: 0.25–13.87; P = 0.042). Serum levels of ALT, AST, LDL-C, TC, and adiponectin showed no significant differences between the two groups at the end of the study (P > 0.05). 4
Complementary Therapies in Medicine 49 (2020) 102290
S. Hosseinabadi, et al.
Table 3 Biochemical parameters of the study patients at baseline and after the 8-wk intervention. Variables ALT (IU/L)
AST (IU/L)
TG (mg/dl)
TC, (mg/dl)
LDL-C (mg/dl)
HDL-C (mg/dl)
Adiponectin (μg/ml)
Before After MD (95 %CI), Before After MD (95 %CI), Before After MD (95 %CI), Before After MD (95 %CI), Before After MD (95 %CI), Before After MD (95 %CI), Before After P-value§
P-value§
P-value§
P-value§
P-value§
P-value§
P-value§
Control (n = 23)
GCE (n = 21)
P-value
36.56 (19.19) 37.04 (19.99) 0.47 (-3.71 to 4.67), 0.81 30.00 (9.39) 32.13 (11.14) 2.13 (-1.76 to 6.02), 0.26 176.95 (91.36) 190.13 (97.30) 13.17 (-8.74 to 35.08), 0.22 211.47 (42.68) 200.86 (40.19) −10.60 (-23.66 to 2.44), 0.10 124.29 (38.48) 111.54 (32.84) −11.63 (-26.17 to 2.90), 0.11 52.17 (14.24) 51.30 (13.41) −0.86 (-5.04 to 3.30), 0.67 7.42 (4.13) 6.49 (3.14) −0.93 (-1.97 to 0.09), 0.07
43.85 (25.82) 44.52 (30.08) 0.66 (-10.99 to 12.32), 0.90 35.71 (22.63) 32.66 (16.74) −3.04 (-11.94 to 5.84), 0.48 187.04 (106.04) 159.14 (74.96) −27.90 (-61.92 to 6.11), 0.10 231.66 (43.70) 218.33 (38.52) −13.33 (-26.04 to -0.61), 0.04 138.25 (29.55) 127.92 (30.87) −12.03 (-24.85 to 0.77), 0.06 55.04 (10.03) 58.47 (8.71) 3.42 (-0.53 to 7.38), 0.08 6.89 (3.90) 6.79 (4.46) −0.1 (-0.77 to 0.57), 0.75
0.29† 0.26‡ 0.27† 0.86‡ 0.73† 0.32‡,₤ 0.13† 0.36‡ 0.12† 0.33‡ 0.44† 0.04‡ 0.66† 0.30‡
Data are expressed as mean (standard deviation). ALT: alanine aminotransferase, AST: aspartate aminotransferase, TG: triglyceride, TC: total cholesterol, LDL-C: low-density lipoprotein cholesterol, HDL-C: highdensity lipoprotein cholesterol, GCE: green coffee extract, MD (%95CI): mean difference (%95 confidence interval). † Independent sample t-test. ‡ Analysis of covariance (ANCOVA) adjusted for the baseline values and mean changes of BMI and daily energy intake. ₤ P < 0.05 when adjusted for the baseline values. § Paired t-test.
levels in the mice fed a high-fat diet (HFD).13 In another study, GCE decreased plasma LDL-C and TC and increased HDL-C concentrations in HFD induced obese mice.39 In addition, CGA administration reduced lipids, lipoproteins, and lipid metabolizing enzymes such as 3-hydroxy 3-methylglutaryl coenzyme A reductase and increased lipoprotein lipase and lecithin cholesterol acyltransferase activities in the streptozotocin (STZ)-nicotinamide induced diabetic rats.40 It should be considered that the effect of GCE on lipid parameters would probably be influenced by the baseline metabolic characteristics of the study subjects. Most of the patients in our study had elevated levels of TC at baseline. However, the mean TG and LDL-C levels were below the borderline values of 200 mg/dl and 130 mg/dl, respectively, which could affect the efficacy of the intervention. In addition, the effect of GCE on TG levels may be mediated through reducing weight which such association was observed in the current study after additional adjustment for BMI changes. Overall, despite the considerable improvements in lipid parameters in the current trial, more studies are required to confirm the beneficial effect of GCE on lipid metabolism. Hepatic enzyme levels including ALT and AST did not change significantly throughout the study in any of the study groups. Some rodent studies illustrated the reduced serum levels of ALT and AST by GCE and CGA administration. Xu et al. reported that CGA administration suppressed serum AST and ALT in a mice model with tetrachloro-1,4benzoquinone (TCBQ) induced acute liver injury.41 Some of the hepatoprotective effects of CGA are attributed to its antioxidant and antiinflammatory actions.41,42 It is well established that oxidative stress is involved in the pathogenesis of NAFLD 43 and disease progression from simple steatosis to steatohepatitis and liver damage.44 It has been shown that CGA is an effective antioxidant that alleviates the oxidative reactions and protects the liver from oxidative stress-induced injuries by up-regulating the expression of antioxidant enzymes and by preventing the lipid peroxidation.45 Shahmohammadi et al. demonstrated alleviated serum ALT levels following 1 g/day of GCE supplementation in individuals with NAFLD.38 The findings may vary among different research studies which might be related to different dosage uses of GCE or baseline metabolic characteristics of the study patients.
Hepatic steatosis also did not show significant improvement by GCE supplementation. However, some animal studies indicated favorable effects of green coffee or CGA on hepatic fat accumulation.13,23,42,46,47 It was demonstrated that CGA may reduce liver fat content through PPARα facilitated hepatic FFA drainage pathway.28,48 Peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α) is a versatile transcriptional coactivator and indicates important roles in hepatic fatty acid oxidation. CGA restored PGC-1α mRNA levels that were suppressed in mice with lipopolysaccharide-induced liver injury.42 Possible impacts of GCE on hepatic steatosis in NAFLD patients require further studies using different doses and durations of GCE supplementation. More precise methods of assessing steatosis changes such as Fibroscan are needed to evaluate clinical outcomes. In our study, serum adiponectin levels were not affected by GCE consumption. To our knowledge, this study is the first to evaluate the effects of GCE on adiponectin levels in NAFLD patients. In a study on obese women, 400 mg/day of GCE supplementation combined with dietary energy restriction, significantly increased plasma adiponectin levels.37 Previous animal studies indicated that treatment with GCE or CGA improved adiponectin levels or adiponectin gene expression.13,24,29 Choi et al. reported an enhanced plasma concentration of adiponectin by GCE treatment in a dose-dependent manner in HFDinduced obese mice. Gene expression levels of adiponectin were also upregulated by GCE.13 In the study by Cho et al. CGA increased plasma adiponectin levels but caffeic acid did not alter plasma adiponectin concentration in HFD-induced obese mice.24 Adiponectin levels in human serum normally range between 5 and 30 μg/mL.49 In the present study, the mean baseline levels of this hormone were in the normal range in both groups, so non-significant changes in this variable would be expected to some extent. On the other hand, it seems that the dose and duration of GCE supplementation in our study were not adequate to induce significant alters in adiponectin levels. More research is warranted to explore this topic further. It should be noted that daily energy and macronutrient intakes and physical activity levels of our study subjects did not change significantly in any of the groups throughout the study. Thus, detected 5
Complementary Therapies in Medicine 49 (2020) 102290
S. Hosseinabadi, et al.
biochemical results of this study could not be affected by these variables. The main strength of our study is the randomized, placebo-controlled design and stratification by age, gender, and BMI, which eliminates inter-individual differences. However, it had some limitations such as short intervention time and using a fixed dose of the supplement. Therefore, the results of the current study are not generalizable to other studies concerning different dosages and durations of GCE supplementation in NAFLD.
9. 10.
11.
12.
5. Conclusion
13.
The results of this study indicated hopeful effects of GCE supplementation on serum lipid profile and BMI in patients with NAFLD. These findings support the consumption of GCE, as a part of an integrated approach to NAFLD management. Further studies are needed to provide enough evidence on the probable effect of green coffee on preventing NAFLD development and/or progression.
14.
15. 16.
17.
Sources of financial support
18.
Research Vice-Chancellor of Tabriz University of Medical Sciences, Tabriz, Iran (grant number: 5/d/25969)
19.
CRediT authorship contribution statement Samaneh Hosseinabadi: Conceptualization, Investigation, Data curation. Maryam Rafraf: Supervision, Conceptualization. Somayyeh Asghari: Project administration, Visualization, Writing - original draft, Writing - review & editing. Mohammad Asghari-Jafarabadi: Methodology, Software, Formal analysis, Validation. Shohreh Vojouhi: Resources.
20.
Declaration of Competing Interest
23.
21.
22.
24.
None. 25.
Acknowledgments
26.
We thank The Research Vice-Chancellor of Tabriz University of Medical Sciences (Tabriz, Iran) for financial support (grant number: 5/ d/25969) and all of the patients who participated in this study. It should be noted that the financial sponsor of the study had no involvement in the study design, in the collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. This article was written based on the data set of the MSc thesis (NO. A/30) registered at Tabriz University of Medical Sciences, Iran.
27.
28.
29.
30.
References 1. Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-meta‐analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016;64:73–84. 2. Birkenfeld AL, Shulman GI. Nonalcoholic fatty liver disease, hepatic insulin resistance, and type 2 diabetes. Hepatology. 2014;59:713–723. 3. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of non‐alcoholic fatty liver disease: Practice Guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology. 2012;55:2005–2023. 4. Hurjui DM, Niţă O, Graur LI, et al. The pathogenesis of non-alcoholic fatty liver disease is closely related to the metabolic syndrome components. Rom J Diabetes Nutr Metab Dis. 2012;19:311–321. 5. Abenavoli L, Milic N, Di Renzo L, Preveden T, Medić-Stojanoska M, De Lorenzo A. Metabolic aspects of adult patients with nonalcoholic fatty liver disease. World J Gastroenterol. 2016;22:7006–7016. 6. Chatrath H, Vuppalanchi R, Chalasani N, eds. Dyslipidemia in patients with nonalcoholic fatty liver disease. Seminars in liver disease. NIH Public Access; 2012. 7. Byrne CD, Targher G. NAFLD: A multisystem disease. J Hepatol. 2015;62:S47–64. 8. Gaggini M, Morelli M, Buzzigoli E, DeFronzo R, Bugianesi E, Gastaldelli A. Non-
31.
32.
33.
34.
35.
36.
6
alcoholic fatty liver disease (NAFLD) and its connection with insulin resistance, dyslipidemia, atherosclerosis and coronary heart disease. Nutrients. 2013;5:1544–1560. Gossard AA, Lindor K. Current therapies for nonalcoholic fatty liver disease. Drugs Today. 2011;47:915–922. Bagherniya M, Nobili V, Blesso CN, Sahebkar A. Medicinal plants and bioactive natural compounds in the treatment of non-alcoholic fatty liver disease: A clinical review. Pharmacol Res. 2018;130:213–240. Jeszka-Skowron M, Sentkowska A, Pyrzyńska K, De Peña MP. Chlorogenic acids, caffeine content and antioxidant properties of green coffee extracts: Influence of green coffee bean preparation. Eur Food Res Technol. 2016;242:1403–1409. Nuhu AA. Bioactive micronutrients in coffee: Recent analytical approaches for characterization and quantification. ISRN Nutr. 2014;2014:384230. Choi B-K, Park S-B, Lee D-R, et al. Green coffee bean extract improves obesity by decreasing body fat in high-fat diet-induced obese mice. Asian Pac J Trop Med. 2016;9:635–643. Mirza M. Obesity, visceral fat, and NAFLD: Querying the role of adipokines in the progression of nonalcoholic fatty liver disease. ISRN Gastroenterol. 2011;2011:592404. Finelli C, Tarantino G. What is the role of adiponectin in obesity related non-alcoholic fatty liver disease? World J Gastroenterol. 2013;19:802–812. Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-Meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016;64:73–84. Baratta R, Amato S, Degano C, et al. Adiponectin relationship with lipid metabolism is independent of body fat mass: Evidence from both cross-sectional and intervention studies. J Clin Endocrinol Metab. 2004;89:2665–2671. Marventano S, Salomone F, Godos J, et al. Coffee and tea consumption in relation with non-alcoholic fatty liver and metabolic syndrome: A systematic review and meta-analysis of observational studies. Clin Nutr. 2016;35:1269–1281. Roshan H, Nikpayam O, Sedaghat M, Sohrab G. Effects of green coffee extract supplementation on anthropometric indices, glycaemic control, blood pressure, lipid profile, insulin resistance and appetite in patients with the metabolic syndrome: A randomised clinical trial. Br J Nutr. 2018;119:250–258. van Werven JR, Marsman HA, Nederveen AJ, et al. Assessment of hepatic steatosis in patients undergoing liver resection: Comparison of US, CT, T1-weighted dual-echo MR imaging, and point-resolved 1H MR spectroscopy. Radiology. 2010;256:159–168. Moghaddam MB, Aghdam FB, Jafarabadi MA, Allahverdipour H, Nikookheslat SD, Safarpour S. The Iranian Version of International Physical Activity Questionnaire (IPAQ) in Iran: Content and construct validity, factor structure, internal consistency and stability. World Appl Sci. 2012;18:1073–1080. Hirany S, Li D, Jialal I. A more valid measurement of low-density lipoprotein cholesterol in diabetic patients. Am J Med. 1997;102:48–53. Ong KW, Hsu A, Tan BKH. Anti-diabetic and anti-lipidemic effects of chlorogenic acid are mediated by AMPK activation. Biochem Pharmacol. 2013;85:1341–1351. Cho A-S, Jeon S-M, Kim M-J, et al. Chlorogenic acid exhibits anti-obesity property and improves lipid metabolism in high-fat diet-induced-obese mice. Food Chem Toxicol. 2010;48:937–943. Dellalibera O, Lemaire B, Lafay S. Svetol, green coffee extract, induces weight loss and increases the lean to fat mass ratio in volunteers with overweight problem. Phytotherapie. 2006;4:194–197. Shimoda H, Seki E, Aitani M. Inhibitory effect of green coffee bean extract on fat accumulation and body weight gain in mice. BMC Complement Altern Med. 2006;6:1–9. Sudeep H, Venkatakrishna K, Patel D, Shyamprasad K. Biomechanism of chlorogenic acid complex mediated plasma free fatty acid metabolism in rat liver. BMC Complement Altern Med. 2016;16:274. Shu-Yuan L, Chang C-Q, Fu-Ying M, Chang-Long Y. Modulating effects of chlorogenic acid on lipids and glucose metabolism and expression of hepatic peroxisome proliferator-activated receptor-α in golden hamsters fed on high fat diet. Biomed Environ Sci. 2009;22:122–129. Zhang L, Chang C, Liu Y, Chen Z. Effect of chlorogenic acid on disordered glucose and lipid metabolism in db/db mice and its mechanism. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2011;33:281–286. Onakpoya I, Terry R, Ernst E. The use of green coffee extract as a weight loss supplement: A systematic review and meta-analysis of randomised clinical trials. Gastroenterol Res Pract. 2011;2011. Chen I-J, Liu C-Y, Chiu J-P, Hsu C-H. Therapeutic effect of high-dose green tea extract on weight reduction: A randomized, double-blind, placebo-controlled clinical trial. Clin Nutr. 2016;35:592–599. Ekhlasi G, Shidfar F, Agah S, Merat S, Hosseini AF. Effects of pomegranate and orange juice on antioxidant status in non-alcoholic fatty liver disease patients: A randomized clinical trial. Int J Vitam Nutr Res. 2016;14:1–7. Asghari S, Rafraf M, Farzin L, Asghari-Jafarabadi M, Ghavami S-M, Somi M-H. Effects of pharmacologic dose of resveratrol supplementation on oxidative/antioxidative status biomarkers in nonalcoholic fatty liver disease patients: A randomized, doubleblind, placebo-controlled trial. Adv Pharm Bull. 2018;8:307–317. Chang H-C, Peng C-H, Yeh D-M, Kao E-S, Wang C-J. Hibiscus sabdariffa extract inhibits obesity and fat accumulation, and improves liver steatosis in humans. Food Funct. 2014;5:734–739. Asghari S, Asghari-Jafarabadi M, Somi M-H, Ghavami S-M, Rafraf M. Comparison of calorie-restricted diet and resveratrol supplementation on anthropometric indices, metabolic parameters, and serum Sirtuin-1 levels in patients with nonalcoholic fatty liver disease: A randomized controlled clinical trial. J Am Coll Nutr. 2018;37:223–233. Alhamhany NN, Alassady EH. Does green coffee has a positive effect on body mass
Complementary Therapies in Medicine 49 (2020) 102290
S. Hosseinabadi, et al.
37.
38.
39.
40.
41.
42. 43.
and non‐alcoholic steatohepatitis. Aliment Pharmacol Ther. 2008;28:2–12. 44. Takaki A, Kawai D, Yamamoto K. Multiple hits, including oxidative stress, as pathogenesis and treatment target in non-alcoholic steatohepatitis (NASH). Int J Mol Sci. 2013;14:20704–20728. 45. Koriem KM, Soliman RE. Chlorogenic and caftaric acids in liver toxicity and oxidative stress induced by methamphetamine. J Toxicol. 2014;2014:583494. 46. de Sotillo DVR, Hadley M. Chlorogenic acid modifies plasma and liver concentrations of: Cholesterol, triacylglycerol, and minerals in (fa/fa) Zucker rats. J Nutr Biochem. 2002;13(12):717–726. 47. Ma Y, Gao M, Liu D. Chlorogenic acid improves high fat diet-induced hepatic steatosis and insulin resistance in mice. Pharm Res. 2015;32:1200–1209. 48. Li SY, Chang CQ, Ma FY, Yu CL. Modulating effects of chlorogenic acid on lipids and glucose metabolism and expression of hepatic peroxisome proliferator-activated receptor-alpha in golden hamsters fed on high fat diet. Biomed Environ Sci. 2009;22:122–129. 49. Nabavi S, Rafraf M, M-h Somi, Homayouni-Rad A, Asghari-Jafarabadi M. Probiotic yogurt improves body mass index and fasting insulin levels without affecting serum leptin and adiponectin levels in non-alcoholic fatty liver disease (NAFLD). J Funct Foods. 2015;18:684–691.
index and lipid profile in a sample of obese people. J Pharm Sci Res. 2018;10:627–630. Haidari F, Samadi M, Mohammadshahi M, Jalali MT, Engali KA. Energy restriction combined with green coffee bean extract affects serum adipocytokines and the body composition in obese women. Asia Pac J Clin Nutr. 2017;26:1048–1054. Shahmohammadi HA, Hosseini SA, Hajiani E, Malehi AS, Alipour M. Effects of green coffee bean extract supplementation on patients with non-alcoholic fatty liver disease: A randomized clinical trial. Hepat Mon. 2017;17:e12299. Setyono J, Nugroho DA, Mustofa M, Saryono S. The effect of orlistat, green coffee bean extract, and its combinations on lipid profile and adiponectin levels. J Ners. 2017;9:26–34. Karthikesan K, Pari L, Menon V. Antihyperlipidemic effect of chlorogenic acid and tetrahydrocurcumin in rats subjected to diabetogenic agents. Chem Biol Interact. 2010;188:643–650. Xu D, Hu L, Xia X, et al. Tetrachlorobenzoquinone induces acute liver injury, upregulates HO-1 and NQO1 expression in mice model: The protective role of chlorogenic acid. Environ Toxicol Phar. 2014;37:1212–1220. Xu Y, Chen J, Yu X, et al. Protective effects of chlorogenic acid on acute hepatotoxicity induced by lipopolysaccharide in mice. Inflamm Res. 2010;59:871–877. Younossi Z. Review article: Current management of non‐alcoholic fatty liver disease
7