Evidence for synergism between chromium and nicotinic acid in the control of glucose tolerance in elderly humans

A Review on the Role of Chromium Supplementation in Ruminant Nutrition-Effects on Productive Performance, Blood Metabolites, Antioxidant Status, and Immunocompetence

With the increase in the global herd, the use of metabolic modifiers has become an important area for many researchers looking for a supraphysiological diet to improve production parameters. For improving the performance of high yielding cows, the optimal balance of all nutrients including microminerals is important. Chromium (Cr) is one of the important micronutrients which plays an important role in metabolism of ruminants. Experimental studies have found that Cr could change performance, immune responses, glucose and fatty acid metabolism, and antioxidant status in dairy cows. In some studies, Cr supplementation improved dry matter intake, milk production, and milk composition of dairy cows in the early, mid, or late stage of lactation. Also, in some studies, performance of growing animal, immune response, and some blood parameters responded positively to Cr supplementation. In conclusion, the effects of Cr supplementation on performance of ruminants are inconsistent; however, its long-term effects on health, productivity, immune system, and antioxidant activity of ruminants still need to be investigated.

Effects of dietary chromium supplementation on muscle and bone mineral interaction in broiler chicken

The study was conducted to ascertain the effects of dietary chromium chloride (CrCl₃·6H₂O) supplementation on mineral interaction in blood serum, leg muscles and bones of broilers at 35^th day of age. For this purpose, ninety male broiler chicks were divided into three groups. One served as control (group I) while, the other two groups were supplemented with CrCl₃ (group II-12.5mg/Kg feed; group III-25mg/Kg feed) from 12 to 28days of age. In serum, Cr concentration remained non-significant however, Zn, and K concentrations decreased (P<0.05) with both levels of Cr-supplementation. Furthermore, in muscles Cr, Cu, Ca and Na levels remained non-significant but concentrations of Zn and K decreased (P<0.05) with feed Cr enrichment. Chromium had a substantial effect on femur and fibula Zn retention with 25mg/Kg feed supplementation while, Cr deposition decreased (P<0.05) in fibula. Femur Ca (P<0.002), Na (P<0.001) and K (P<0.05) retention was inversely proportional to both Cr concentrations in feed. In tibia, Cu and Na concentration decreased (P<0.002) with high dietary Cr supplementation. Fibular Ca and Na concentrations remained significantly (P<0.001) lower in Cr supplemented groups. Bone robusticity index was non-significant but ash to weight ratio of femur, tibia and fibula decreased (P<0.05) in group III. Chromium supplementation has a major effect on serum or muscle Zn and K deposition while bone mineral interaction shows a major thrust on Zn, Ca and Na levels.

Chromium supplements for glycemic control in type 2 diabetes: limited evidence of effectiveness

Some adults with type 2 diabetes mellitus (T2DM) believe that chromium-containing supplements will help control their disease, but the evidence is mixed. This narrative review examines the efficacy of chromium supplements for improving glycemic control as measured by decreases in fasting plasma glucose (FPG) or hemoglobin A1c (HbA1c). Using systematic search criteria, 20 randomized controlled trials of chromium supplementation in T2DM patients were identified. Clinically meaningful treatment goals were defined as an FPG of ≤7.2 mmol/dL, a decline in HbA1c to ≤7%, or a decrease of ≥0.5% in HbA1c. In only a few randomized controlled trials did FPG (5 of 20), HbA1c (3 of 14), or both (1 of 14) reach the treatment goals with chromium supplementation. HbA1c declined by ≥0.5% in 5 of 14 studies. On the basis of the low strength of existing evidence, chromium supplements have limited effectiveness, and there is little rationale to recommend their use for glycemic control in patients with existing T2DM. Future meta-analyses should include only high-quality studies with similar forms of chromium and comparable inclusion/exclusion criteria to provide scientifically sound recommendations for clinicians.

Chromium Therapy for Insulin Resistance Associated with HIV-Disease

OBJECTIVE

With the advent of highly active anti-retroviral therapy, HIV disease has become a chronic condition, but with a number of metabolic complications including insulin resistance and diabetes mellitus, dyslipidemia and hypertension and an increased incidence of atherosclerosis. The aim of the current study was to test the safety and efficacy of chromium picolinate for HIV- associated insulin resistance.

MATERIALS/METHODS

The study was a randomized, double-blind, placebo-controlled trial with subjects receiving 500μg of chromium picolinate or placebo twice daily for two months. HIV- infected subjects were selected based on a fasting concentration of plasma glucose greater than 5.5mmol/L or a plasma glucose concentration of greater than 7.7mmol/L (but less than 11mmol/L) 2h after oral ingestion of 75g of glucose. Insulin sensitivity was assessed with a hyper-insulinemic-euglycemic clamp and glucose tolerance was assessed with the oral glucose tolerance test. Subjects were monitored closely for alterations in viral load, CD4+ cells, hemoglobin and hematocrit, kidney and liver function, and fasting lipid profiles.

RESULTS

Forty-three subjects were enrolled and 39 completed the protocol (20 in the chromium-supplemented and 19 in the placebo arm). Following chromium-supplementation, there were no significant changes in either insulin sensitivity or glucose tolerance. There was a significant improvement in serum HDL cholesterol concentration in the group supplemented with chromium.

CONCLUSIONS

Chromium picolinate supplementation at this level was well-tolerated, but overall was not an effective therapy for insulin resistance in these HIV-infected subjects.

Chromium picolinate for insulin resistance in subjects with HIV disease: a pilot study

AIM

Multidrug regimens in HIV disease are associated with an increased incidence of insulin resistance, by as much as 50%. Not only does insulin resistance predisposes subjects to diabetes but also it is associated with the metabolic syndrome and increased risk of cardiovascular disease. Previous studies suggest that chromium picolinate can improve insulin resistance in patients with type 2 diabetes. The objective was to study the efficacy and safety of chromium picolinate as a treatment of insulin resistance in subjects infected with HIV.

METHODS

The ability of chromium picolinate (1000 mug/day) to improve insulin sensitivity, determined with a hyperinsulinaemic-euglycaemic insulin clamp, was determined in eight HIV-positive subjects on highly active antiretroviral therapy.

RESULTS

The mean rate of glucose disposal during the clamp was 4.41 mg glucose/kg lean body mass (LBM)/min (range 2.67-5.50), which increased to 6.51 mg/kg LBM/min (range 3.19-12.78, p = .03), an increase of 25% after 8 weeks of treatment with chromium picolinate. There were no significant changes in blood parameters, HIV viral burden or CD4+ lymphocytes with chromium picolinate treatment. Two subjects experienced abnormalities of liver function during the study. Another subject experienced an elevation in blood urea nitrogen.

CONCLUSIONS

The study shows that chromium picolinate therapy improves insulin resistance in some HIV-positive subjects, but with some concerns about safety in this population.

Effect of chromium supplementation on glucose metabolism and lipids: a systematic review of randomized controlled trials

OBJECTIVE

A systematic review of the effect of chromium supplementation on glucose metabolism and lipid levels.

RESEARCH DESIGN AND METHODS

A literature search was conducted in MEDLINE and the Commonwealth Agricultural Bureau. Eligible studies were English language randomized controlled trials of chromium supplement intake > or = 3 weeks, with > or = 10 participants receiving chromium. All trials with glucose metabolism outcomes and trials of individuals with diabetes or glucose intolerance for lipid outcomes were included. Meta-analyses were performed as appropriate.

RESULTS

Forty-one studies met criteria, almost half of which were of poor quality. Among participants with type 2 diabetes, chromium supplementation improved glycosylated hemoglobin levels by -0.6% (95% CI -0.9 to -0.2) and fasting glucose by -1.0 mmol/l (-1.4 to -0.5) but not lipids. There was no benefit in individuals without diabetes. There were some indications of dose effect and differences among chromium formulations. Larger effects were more commonly observed in poor-quality studies. The evidence was limited by poor study quality, heterogeneity in methodology and results, and a lack of consensus on assessment of chromium status.

CONCLUSIONS

No significant effect of chromium on lipid or glucose metabolism was found in people without diabetes. Chromium supplementation significantly improved glycemia among patients with diabetes. However, future studies that address the limitations in the current evidence are needed before definitive claims can be made about the effect of chromium supplementation.

Chromium picolinate intake and risk of type 2 diabetes: an evidence-based review by the United States Food and Drug Administration

The labeling of both health claims that meet significant scientific agreement (SSA) and qualified health claims on conventional foods and dietary supplements requires pre-market approval by the US Food and Drug Administration (FDA). Approval by the FDA involves, in part, a thorough review of the scientific evidence to support an SSA or a qualified health claim. This article discusses FDA's evidence-based review of the scientific evidence on the role of chromium picolinate supplements in reducing the risk of type 2 diabetes. Based on this evidence-based review, FDA issued a letter of enforcement discretion for one qualified health claim on chromium picolinate and risk of insulin resistance, a surrogate endpoint for type 2 diabetes. The agency concluded that the relationship between chromium picolinate intake and insulin resistance is highly uncertain.

Review article: Obesity, waist-hip ratio and hunter-gatherers

Obesity is a rapidly growing global problem. It is not simply the result of eating too much, and not all types of obesity have the same significance. Obesity is in part genetic, and one particularly important genetic type of obesity is the tendency to 'truncal obesity',-that is, a raised waist-to-hip ratio. Such obesity is powerfully associated not only with a tendency to diabetes, but also to cardiovascular disease, ('Syndrome X'). Interestingly, this is the type of obesity seen in every hunter-gatherer (HG) population around the globe. Such people are intolerant of carbohydrate, especially refined carbohydrate, especially in the excessive amounts typically consumed in affluent societies. In such pure HG communities, rates of diabetes can be as high as 50%, when the 'Western' lifestyle is adopted. Many of us, however, share some of their genes and their carbohydrate intolerance-perhaps as many as 20 or 30% of the world's population. Pregnancy can uncover this characteristic, and obesity and glucose intolerance in pregnancy are rapidly burgeoning problems. Quite contrary to the common nutritional dogma of encouraging regular carbohydrates, it is suggested that pregnant women with a high waist-to-hip ratio should be strongly advised to adhere to a low-glycaemic-index diet. Additionally, many dietary interventions, some of them derived from observation of HG populations, are of proven benefit in reducing the expression of glucose intolerance and may well help in tackling the obesity epidemic.

Chromium as adjunctive treatment for type 2 diabetes

OBJECTIVE

To review the chemistry, pharmacology, efficacy, and safety of trivalent chromium in the treatment of type 2 diabetes and hyperlipidemia.

DATA SOURCES

The English literature was searched from 1966 through May 2002 using MEDLINE, International Pharmaceutical Abstracts, and EMBASE. The key words included chromium, glucose, lipids, and diabetes. Pertinent references from review articles and studies were used as additional sources.

DATA SYNTHESIS

Trivalent chromium is an essential nutrient and has a key role in lipid and glucose metabolism. Supplementation with chromium does not appear to reduce glucose levels in euglycemia. It may, however, have some efficacy in reducing glucose levels in hyperglycemia. The effects of chromium on lipid levels are variable. Chromium in doses <1000 microg/d appears to be safe for short-term administration. Kidney function and dermatologic changes need to be monitored.

CONCLUSIONS

Chromium appears to be a safe supplement and may have a role as adjunctive therapy for treatment of type 2 diabetes. Additional large-scale, long-term, randomized, double-blind studies examining the effect of various doses and forms of chromium are needed.

Glucose and insulin responses to dietary chromium supplements: a meta-analysis

BACKGROUND

Several authors, mostly on the basis of nonrandomized studies, have suggested dietary trivalent chromium supplementation as an attractive option for the management of type 2 diabetes and for glycemic control in persons at high risk of type 2 diabetes.

OBJECTIVE

The study aimed to determine the effect of chromium on glucose and insulin responses in healthy subjects and in individuals with glucose intolerance or type 2 diabetes.

DESIGN

The study design was a systematic review and meta-analysis of randomized clinical trials (RCTs).

RESULTS

The authors identified 20 reports of RCTs assessing the effect of chromium on glucose, insulin, or glycated hemoglobin (Hb A(1c)). This review summarizes data on 618 participants from the 15 trials that reported adequate data: 193 participants had type 2 diabetes and 425 were in good health or had impaired glucose tolerance. The meta-analysis showed no association between chromium and glucose or insulin concentrations among nondiabetic subjects. A study of 155 diabetic subjects in China showed that chromium reduced glucose and insulin concentrations; the combined data from the 38 diabetic subjects in the other studies did not. Three trials reported data on Hb A(1c): one study each of persons with type 2 diabetes, persons with impaired glucose tolerance, and healthy subjects. The study of diabetic subjects in China was the only one to report that chromium significantly reduced Hb A(1c).

CONCLUSIONS

Data from RCTs show no effect of chromium on glucose or insulin concentrations in nondiabetic subjects. The data for persons with diabetes are inconclusive. RCTs in well-characterized, at-risk populations are necessary to determine the effects of chromium on glucose, insulin, and Hb A(1c).

Serum chromium does not predict glucose tolerance in late pregnancy

BACKGROUND

Chromium is an essential element in human nutrition. Serum concentrations of chromium are not well characterized during pregnancy or in gestational diabetes mellitus.

OBJECTIVE

The objective of this study was to determine whether low plasma chromium concentrations (< or =3 nmol/L) are associated with altered glucose, insulin, or lipid concentrations during pregnancy.

DESIGN

The study was conducted prospectively and took place at the medical obstetric clinic of a tertiary referral hospital. Seventy-nine women with abnormal results of a 50-g glucose challenge test in the third trimester of pregnancy were studied. All women had a formal 75-g oral-glucose-tolerance test, and fasting insulin, lipid, and chromium concentrations were determined. Chromium was measured by graphite furnace atomic absorption spectrometry.

RESULTS

The median chromium concentration was 2 nmol/L (95% CI: 0, 12). There were no significant differences in age, plasma glucose, insulin, lipids, calculated insulin resistance, or calculated ss cell function between women with normal and those with abnormal (< or =3 nmol/L) chromium concentrations.

CONCLUSIONS

Plasma chromium during pregnancy does not correlate with glucose intolerance, insulin resistance, or serum lipids. Plasma chromium concentrations may not accurately reflect tissue stores of chromium. Several trials showed a beneficial effect of chromium supplementation on glucose tolerance, insulin, and lipids. A method for assessing body chromium stores is required to allow further study.

Chromium as a supplement

Chromium (Cr) is an essential mineral element that has received considerable public attention. The suggestion that Cr intake is generally low has generated interest regarding the purported beneficial effects of Cr supplementation on biological function and health of animals and humans. This review briefly describes key aspects of Cr nutritional status and evaluates the effects of Cr supplementation on various components of biological function, body composition, and health. A novel biological role of Cr in regulation of insulin function is described. Although promising results of Cr supplementation are presented, the considerable challenge of developing methods for routine assessment of Cr nutriture in humans remains.

Chromium, glucose intolerance and diabetes

Within the last 5 years chromium (Cr) has been shown to play a role in glucose intolerance, Type 2 diabetes mellitus (Type 2 DM), and gestational diabetes. In addition, diabetes and the neuropathy of a patient on home parenteral nutrition were alleviated when supplemental Cr was added to total parenteral nutrition (TPN) solutions. In a study conducted in China that has been supported by studies in the United States, supplemental Cr as Cr picolinate improved the blood glucose, insulin, cholesterol, and hemoglobin A1C in people with Type 2 DM in a dose dependent manner. Follow-up studies of > 1 year have confirmed these studies. The requirement for Cr is related to the degree of glucose intolerance: 200 microg/day of supplemental Cr is adequate to improve glucose variables of those who are mildly glucose intolerant. However, people with more overt impairments in glucose tolerance and diabetes usually require more than 200 microg/day. Daily intake of 8 microg of Cr per kg body weight was also more effective than 4 microg/kg in women with gestational diabetes. The mechanism of action of Cr involves increased insulin binding, increased insulin receptor number, and increased insulin receptor phosphorylation. In summary, supplemental Cr has been shown to have beneficial effects without any documented side effects on people with varying degrees of glucose intolerance ranging from mild glucose intolerance to overt Type 2 DM.

Chromium picolinate modulates rat vascular smooth muscle cell intracellular calcium metabolism

We have previously shown that insulin attenuates vasoconstriction, accelerates both vascular relaxation and [Ca2+]i recovery from pressor agonist-induced Ca2+ loads, and stimulates Ca2+-ATPase gene expression in rat and human vascular smooth muscle cells (VSMC). Moreover, these functions are impaired in VSMC from both insulin resistant and insulinopenic rats, suggesting that hypertension in insulin resistant states may result, in part, from impaired insulin-regulation of VSMC Ca2+ transport. Accordingly, we have now evaluated the effect of improving cellular insulin sensitivity with chromium picolinate (CrPic) on regulation of VSMC Ca2+ transport. Cultured VSMC from rats were grown from passage to confluence in the presence or absence of 1 micromol/L CrPic, maintained in a quiescent medium for 24 h and incubated with or without insulin (10(-8) mol/L) for the final 2 h. Cells were then harvested and RNA and protein extracted for Northern and Western blot analysis, respectively. Insulin caused a significant stimulation of plasmalemmal Ca2+-ATPase mRNA and protein (P < 0.05). A comparable stimulation of the mRNA and protein levels was caused by CrPic in the absence of insulin (P < 0.05), while the CrPic + insulin treatment caused a greater percentage stimulation of the Ca2+-ATPase mRNA level than either separate treatment (P < 0.05). Fluorometric analysis of the rate of [Ca2+]i recovery following stimulation with arginine vasopressin support these findings: insulin caused an 83% increase, CrPic caused a 35% increase and insulin + CrPic caused a 133% increase in [Ca2+]i recovery rate. These data suggest that CrPic may be an effective modality to reduce VSMC [Ca2+]i loads and thereby reduce peripheral vascular resistance in insulin resistant states.

Chromium as an essential nutrient for humans

Chromium is an essential nutrient required for sugar and fat metabolism. Normal dietary intake of Cr for humans is suboptimal. The estimated safe and adequate daily dietary intake for Cr is 50 to 200 microg. However, most diets contain less than 60% of the minimum suggested intake of 50 microg. Insufficient dietary intake of Cr leads to signs and symptoms that are similar to those observed for diabetes and cardiovascular diseases. Supplemental Cr given to people with impaired glucose tolerance or diabetes leads to improved blood glucose, insulin, and lipid variables. Chromium has also been shown to improve lean body mass in humans and swine. Response to Cr is dependent upon form and amount of supplemental Cr. Chromium is a nutrient; therefore, it will only be of benefit to those who are marginally or overtly Cr deficient. Trivalent Cr has a very large safety range and there have been no documented signs of Cr toxicity in any of the nutritional studies at levels up to 1 mg per day.

Effect of chromium nicotinic acid supplementation on selected cardiovascular disease risk factors

The effects of daily supplemental chromium (200 micrograms) complexed with 1.8 mg nicotinic acid on plasma glucose and lipids, including total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides, were assessed in 14 healthy adults and 5 adults with noninsulin-dependent diabetes mellitus (NIDDM) using a double-blind crossover study with 8-wk experimental periods. Eight of the 14 healthy subjects and all 5 subjects with NIDDM also underwent an oral glucose tolerance test with assessment of 90 min postprandial plasma glucose and insulin concentrations. No statistically significant effects of chromium nicotinic acid supplementation were found on plasma insulin, glucose, or lipid concentrations, although chromium nicotinic acid supplementation slightly lowered fasting plasma total and LDL cholesterol, triglycerides, and glucose concentrations, and 90-min postprandial glucose concentrations in individuals with NIDDM.

Chromium, glucose tolerance, and diabetes

Chromium functions in maintaining normal glucose tolerance primarily by regulating insulin action. In the presence of optimal amounts of biologically active chromium, much lower amounts of insulin are required. Glucose intolerance, related to insufficient dietary chromium, appears to be widespread. Improved chromium nutrition leads to improved sugar metabolism in hypoglycemics, hyperglycemics, and diabetics.

Chromium in the elderly

Several studies indicate that glucose tolerance improves and lipid levels decline in the elderly after supplementation with Cr-rich brewer's yeast or inorganic Cr. Other studies report equivocal results or no changes. Interpretation of these investigations is hampered by 1. Lack of a marker to identify Cr-deficient people 2. Artifactually high levels of dietary and body Cr, owing to inadequate analytic techniques and 3. The interplay of chronic health problems, medications, institutionalization, and dietary practices. Investigators have studied the effects of aging on Cr in the body. In the rat, tissue retention of 51Cr decreases, and organ distribution changes with age. In humans, plasma Cr levels of healthy elderly subjects are not different from those of young adults. There is no evidence of malabsorption in aged humans or animals. Nevertheless, higher urinary Cr losses are reported in elderly people. These data suggest that Cr retention may decrease with aging and that aging may alter Cr metabolism. Diets of many healthy elderly people contain less than 30 micrograms Cr. Two elderly men living under controlled conditions maintained Cr balance with 37 micrograms/d. However, these levels may be insufficient during the stresses and illnesses associated with aging.

The management of diabetes mellitus in older individuals

Nearly 50% of individuals with type II diabetes mellitus are over the age of 65 years. There are numerous reasons to maintain blood glucose levels below 11.1 nmol/L (200 mg/dl) in older persons, and there are a number of changes often seen with advancing age that persons, and there are a number of changes often seen with advancing age that may interfere with the management of diabetes mellitus, e.g. hypodipsia, anorexia, visual disturbance, altered renal and hepatic function, depression, impaired basoreceptor response and multiple medications. Hyperglycaemia appears to produce cognitive impairment which may lead to poor compliance. It is often difficult to manipulate diet in older people, and in fact dietary changes can lead to severe protein energy malnutrition. High maximum voluntary oxygen intake has been correlated with increased glucose disposal, but there is little evidence that physical exercise can improve diabetic control in the elderly. Oral sulphonylurea hypoglycaemic agents are extremely useful in the treatment of diabetes in these patients, but it should be remembered that they are more liable to develop hypoglycaemia than are younger diabetics. The role of metformin in the management of older diabetic patients is poorly studied. Many older persons can cope well with insulin therapy, but those with visual disturbances often make errors when drawing up insulin and require special attention. Combination therapy of insulin with oral hypoglycaemic agents is not recommended in this group of patients, and serum fructosamine is preferred to glycated haemoglobin to monitor control. Successful management of elderly diabetic patients thus requires an interdisciplinary team approach.

Prostaglandins, brown fat and weight loss

In obesity, a situation is created in which energy intake exceeds energy expenditure. The three components of energy expenditure are resting metabolism, physical activity, and thermogenesis. Increasing attention is being paid to the role of impaired energy expenditure in obesity. Evidence indicates that impairment in activity of the sympathetic nervous system, which stimulates thermogenic processes, contributes to the etiology of obesity. In addition, insulin resistance, a well-recognized metabolic consequence of obesity, appears to interfere with feeding-related, insulin-mediated increases in thermogenesis in brown adipose tissue. This thermogenic defect results in reduced energy buffering by brown adipose tissue leading to deficient energy expenditure and an increased efficiency in weight gain. A unique weight loss program, The Princeton Metabolic Diet Program, is presented. The Program stimulates metabolism by stimulating the sympathetic nervous system and correcting insulin resistance, thereby enhancing thermogenesis in brown adipose tissue. Methods include: 1) alternating diet composition and caloric intake and, 2) the use of nutritional metabolic stimulants. This type of non-toxic therapy, directed at correcting biochemical defects, will enhance metabolic mechanisms and induce weight loss.