The health benefits of anthocyanins: an umbrella review of systematic reviews and meta-analyses of observational studies and controlled clinical trials

Anthocyanins as natural bioactives with anti-hypertensive and atherosclerotic potential: Health benefits and recent advances

BACKGROUND

Hypertension is a highly prevalent chronic metabolic illness affecting individuals of all age groups. Furthermore, it is a significant risk factor for the development of atherosclerosis (AS), as a correlation between hypertension and AS has been observed. However, the effective treatments for either of these disorders appear to be uncommon.

METHODS

A systematic search of articles published in PubMed, Web of Science, ScienceDirect, Scopus, and Google Scholar databases over the last decade was performed using the following keywords: hypertension, AS, anthocyanins, antioxidants, gut microbes, health benefits, and bioactivity.

RESULTS

The available research indicates that anthocyanin consumption can achieve antioxidant effects by inducing the activation of intracellular nuclear factor erythroid 2-related factor (Nrf2) and the expression of antioxidant genes. Moreover, previous reports showed that anthocyanins can enhance the human body's ability to fight against inflammation and cancer through the inhibition of inflammatory factors and the regulation of related signaling pathways. They can also protect the blood vessels and nervous system by regulating the production and function of endothelial nitric oxide synthase (eNOS). Gut microorganisms play an important role in various chronic diseases. Our research has also investigated the role of anthocyanins in the metabolism of the gut microbiota, leading to significant breakthroughs. This study not only presents a unique strategy for reducing the risk of cardiovascular diseases (CVDs) without the need for medicine but also provides insights into the development and utilization of intestinal probiotic dietary supplements.

CONCLUSION

In this review, different in vitro and in vivo studies have shown that anthocyanins slow down the onset and progression of hypertension and AS through different mechanisms. In addition, gut microbial metabolites also play a crucial role in diseases through the gut-liver axis.

The Impact of Cornelian Cherry (Cornus mas L.) on Cardiometabolic Risk Factors: A Meta-Analysis of Randomised Controlled Trials

This meta-analysis aimed to summarise clinical evidence regarding the effect of supplementation with cornelian cherry (Cornus mas L.) on different cardiometabolic outcomes. An extensive literature survey was carried out until 10 April 2024. A total of 415 participants from six eligible studies were included. The overall results from the random-effects model indicated that cornelian cherry supplementation significantly reduced body weight (standardised mean difference [SMD] = -0.27, confidence interval [CI]: -0.52, -0.02, p = 0.03), body mass index (SMD = -0.42, CI: -0.73, -0.12, p = 0.007), fasting blood glucose (SMD = -0.46, CI: -0.74, -0.18, p = 0.001), glycated haemoglobin (SMD = -0.70, CI: -1.19, -0.22, p = 0.005), and HOMA-IR (SMD = -0.89, CI: -1.62, -0.16, p = 0.02), while high-density lipoprotein cholesterol significantly increased (SMD = 0.38, CI: 0.10, 0.65, p = 0.007). A sensitivity analysis showed that cornelian cherry supplementation significantly reduced total plasma triglycerides, total cholesterol, low-density lipoprotein cholesterol, and insulin levels. Cornelian cherry supplementation did not significantly affect waist circumference and liver parameters among the participants. Considering these findings, this meta-analysis indicates that supplementation with cornelian cherry may impact diverse cardiometabolic risk factors among individuals considered to be at a high risk.

Dietary Flavonoids Consumption and Health: An Umbrella Review

SCOPE

The current evidence between dietary flavonoids consumption and multiple health outcomes is inadequate and inconclusive. To summarize and evaluate the evidence for dietary flavonoids consumption and multiple health outcomes, an umbrella review of meta-analyses and systematic reviews is conducted.

METHODS AND RESULTS

PubMed, Ovid-EMBASE, and the Cochrane Database of Systematic Reviews are searched up to January 2024. The study includes a total of 32 articles containing 24 unique health outcomes in this umbrella review. Meta-analyses are recalculated by using a random effects model. Separate analyses are performed based on the kind of different flavonoid subclasses. The study finds some unique associations such as flavonol and gastric cancer, isoflavone and uterine fibroids and endometrial cancer, total flavonoids consumption and lung cancer, ovarian cancer, and prostate cancer. Overall, the study confirms the negative associations between dietary flavonoids consumption and type 2 diabetes mellitus, cardiovascular diseases, breast cancer, colorectal cancer, lung cancer, and mortality, while positive associations are observed for prostate cancer and uterine fibroids.

CONCLUSION

Although dietary flavonoids are significantly associated with many outcomes, firm generalizable conclusions about their beneficial or harmful effects cannot be drawn because of the low certainty of evidence for most of outcomes. More well-designed primary studies are needed.

Effects of anthocyanin supplementation in diet on glycemic and related cardiovascular biomarkers in patients with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

Purpose

This study is the first systematic review and meta-analysis based on RCTs on the effects of anthocyanins on patients with type 2 diabetes mellitus (T2DM) and the effect on T2DM-related cardiovascular disease.

Methods

RCTs published in English from five electronic databases were evaluated for glycated hemoglobin (HbA1c), fasting blood glucose (FBG), 2-h postprandial blood glucose, fasting insulin, model assessment for insulin resistance, triglycerides (TG), total cholesterol (TC), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, systolic blood pressure, and diastolic blood pressure. The quality of the studies was rated (Cochrane Risk of Bias tool) and weighted mean differences were calculated (DerSimonian-Laird model with random effects). Leave-one-out sensitivity, subgroup, and publication bias analyses were conducted. The strength of the evidence was rated according to the GRADE guidelines.

Results

In all, 13 RCTs were analyzed out of the 239 identified studies, with a duration longer than 4 weeks (703 participants with T2DM). Our findings indicate that a median dose of 320 mg/day anthocyanins, either from fruit extracts or pure supplements, for a median intervention length of 8 weeks significantly reduced HbA1c [Weighted Mean Difference (WMD) -0.31, p = 0.00], FBG (WMD -0.63, p = 0.00), 2-h postprandial glucose (WMD -1.60, p = 0.00), TG (WMD -0.45, p = 0.01), and LDL (WMD -0.26 p = 0.02). However, the effects of anthocyanins on fasting insulin, HOMA-IR, TC, HDL cholesterol, systolic blood pressure, and diastolic blood pressure in patients with T2DM were not statistically significant. Anthocyanins from fruit extracts or powder exhibited a higher reduction of HbA1c compared to pure anthocyanin supplements.

Conclusion

The significant improvements in glycemic parameters and lipid profile, suggest the benefits of anthocyanins, especially from fruit extract or powder, in the management of T2DM, and their ability to delay the onset of lipid disorder-related diseases such as cardiovascular disease associated with T2DM. The mechanism behind this reduction in glycemic markers could be attributed to the antioxidant and anti-inflammatory activity of anthocyanins. Further research with well-designed RCTs is required to determine the optimal dosage of anthocyanins for the treatment of T2DM and to comprehend the consequences.

Health benefits of anthocyanin-containing foods, beverages, and supplements have unpredictable relation to gastrointestinal microbiota: A systematic review and meta-analysis of random clinical trials

Anthocyanins are a type of natural pigment that has numerous health benefits. In recent years, the interaction of anthocyanins with gastrointestinal (GI) microbiota has been presented as a viable paradigm for explaining anthocyanin activities. The current study performed a systematic review and meta-analysis to determine the potential modulation of GI microbiota by anthocyanins in human health improvement. Clinical trials were retrieved from PubMed, Cochrane, Web of Knowledge, China Biology Medicine, China National Knowledge Infrastructure, and ClinicalTrials.gov with no language restrictions. Eight clinical trials (252 participants) were selected from the 1121 identified studies and the relative phylum abundance extracted from the trials was analyzed using a random-effects model. Based on the analysis, anthocyanins had no effect on the relative abundance of Firmicutes (standard mean difference [SMD]: -0.46 [-1.25 to 0.34], P = .26), Proteobacteria (SMD, -0.32 [-0.73 to 0.09], P = .13), nor Actinobacteria (SMD, -0.19 [-0.50 to 0.12], P = 0.24), but influenced the abundance of Bacteroidetes (SMD, 0.84 [0.17 to 1.52], P = .01) when compared with placebo/control. No significant influence on the relative abundance was detected when the data were analyzed following the "posttreatment vs. pretreatment" strategy. Our preliminary analysis revealed that the effects of anthocyanins on human GI microbiota vary between studies and individuals, and at the current stage, the clinical trials regarding the effects of anthocyanin interventions on human GI microbiota are lacking. More trials with larger sample sizes are needed to promote the clinical application of anthocyanins.

Biochar immobilized plant growth-promoting rhizobacteria enhanced the physicochemical properties, agronomic characters and microbial communities during lettuce seedling

Spent mushroom substrate (SMS) is the by-products of mushroom production, which is mainly composed of disintegrated lignocellulosic biomass, mushroom mycelia and some minerals. The huge output and the lack of effective utilization methods make SMS becoming a serious environmental problem. In order to improve the application of SMS and SMS derived biochar (SBC), composted SMS (CSMS), SBC, combined plant growth-promoting rhizobacteria (PGPR, Bacillus subtilis BUABN-01 and Arthrobacter pascens BUAYN-122) and SBC immobilized PGPR (BCP) were applied in the lettuce seedling. Seven substrate treatments were used, including (1) CK, commercial control; (2) T1, CSMS based blank control; (3) T2, T1 with combined PGPR (9:1, v/v); (4) T3, T1 with SBC (19:1, v/v); (5) T4, T1 with SBC (9:1, v/v); (6) T5, T1 with BCP (19:1, v/v); (7) T6, T1 with BCP (9:1, v/v). The physicochemical properties of substrate, agronomic and physicochemical properties of lettuce and rhizospheric bacterial and fungal communities were investigated. The addition of SBC and BCP significantly (p < 0.05) improved the total nitrogen and available potassium content. The 5% (v/v) BCP addiction treatment (T5) represented the highest fresh weight of aboveground and underground, leave number, chlorophyll content and leaf anthocyanin content, and the lowest root malondialdehyde content. Moreover, high throughput sequencing revealed that the biochar immobilization enhanced the adaptability of PGPR. The addition of PGPR, SBC and BCP significantly enriched the unique bacterial biomarkers. The co-occurrence network analysis revealed that 5% BCP greatly increased the network complexity of rhizospheric microorganisms and improved the correlations of the two PGPR with other microorganisms. Furthermore, microbial functional prediction indicated that BCP enhanced the nutrient transport of rhizospheric microorganisms. This study showed the BCP can increase the agronomic properties of lettuce and improve the rhizospheric microbial community.

Are (poly)phenols contained in 100% fruit juices mediating their effects on cardiometabolic risk factors? A meta-regression analysis

Background

The consumption of 100% fruit juices has not been associated with substantial detrimental outcomes in population studies and may even contribute to improving the cardiometabolic profile if included in a healthy balanced diet. The main contributors to such potential beneficial effects include vitamins, minerals, and likely the (poly)phenol content. This study aimed to investigate whether the (poly)phenols contained in 100% fruit juices may mediate their effects on cardiometabolic risk factors based on published randomized controlled trials (RCT).

Methods

A systematic search in PubMed/MEDLINE and Embase, updated till the end of October 2022, was carried out to identify RCT providing quantitative data on (poly)phenol content in 100% fruit juices and used as an intervention to improve cardiometabolic parameters such as blood lipids, glucose, and blood pressure. Meta-regression analysis was performed to calculate the effect of the intervention [expressed as standardized mean difference and 95% confidence intervals (CI)] using the (poly)phenol content as moderator.

Results

A total of 39 articles on RCT investigating the effects of 100% fruit juices on cardiometabolic risk factors reporting data on total (poly)phenol and anthocyanin content were included in the analysis. Total (poly)phenol content was substantially unrelated to any outcome investigated. In contrast, each 100 mg per day increase in anthocyanins was related to 1.53 mg/dL decrease in total cholesterol (95% CI, -2.83, -0.22, p = 0.022) and 1.94 mg/dL decrease in LDL cholesterol (95% CI, -3.46, -0.42, p = 0.012). No other potential mediating effects of anthocyanins on blood triglycerides, glucose, systolic and diastolic pressure were found, while a lowering effect on HDL cholesterol after excluding one outlier study was observed.

Discussion

In conclusion, the present study showed that anthocyanins may mediate the potential beneficial effects of some 100% fruit juices on some blood lipids. Increasing the content of anthocyanins through specific fruit varieties or plant breeding could enhance the health benefits of 100% fruit juices.

One-Week Elderberry Juice Treatment Increases Carbohydrate Oxidation after a Meal Tolerance Test and Is Well Tolerated in Adults: A Randomized Controlled Pilot Study

Obesity in the United States continues to worsen. Anthocyanin-rich fruits and vegetables provide a pragmatic dietary approach to slow its metabolic complications. Given American diet patterns, foods with high anthocyanin content could address dose-response challenges. The study objective was to determine the effect of 100% elderberry juice on measures of indirect calorimetry (IC) and insulin sensitivity/glucose tolerance in a placebo-controlled, randomized, crossover pilot study. Overweight and obese adults were randomized to a 5-week study which included 2 1-week periods of twice-daily elderberry juice (EBJ) or sugar-matched placebo consumption separated by a 3-week washout period. Following each 1-week test period, IC and insulin sensitivity/glucose tolerance was measured with a 3 h meal tolerance test (MTT). Treatment differences were tested with linear mixed modeling. A total of 22 prospective study volunteers (18 F/4 M) attended recruitment meetings, and 9 were analyzed for treatment differences. EBJ was well tolerated and compliance was 99.6%. A total of 6 IC measures (intervals) were created, which coincided with 10-20 min gaseous samplings in-between MTT blood samplings. Average CHO oxidation was significantly higher during the MTT after 1-week EBJ consumption (3.38 vs. 2.88 g per interval, EBJ vs. placebo, p = 0.0113). Conversely, average fat oxidation was significantly higher during the MTT after 1-week placebo consumption (1.17 vs. 1.47 g per interval, EBJ vs. placebo, p = 0.0189). This was in-line with a significantly lower average respiratory quotient after placebo treatment (0.87 vs. 0.84, EBJ vs. placebo, p = 0.0114). Energy expenditure was not different. There was no difference in serum glucose or insulin response between treatments. This pilot study of free-living volunteers describes significant change in IC but not insulin sensitivity with an EBJ intervention. Controlled feeding and increased sample size will help determine the utility of EBJ on these outcomes.

Elderberry Extracts: Characterization of the Polyphenolic Chemical Composition, Quality Consistency, Safety, Adulteration, and Attenuation of Oxidative Stress- and Inflammation-Induced Health Disorders

Elderberry is highly reputed for its health-improving effects. Multiple pieces of evidence indicate that the consumption of berries is linked to enhancing human health and preventing or delaying the onset of chronic medical conditions. Compared with other fruit, elderberry is a very rich source of anthocyanins (approximately 80% of the polyphenol content). These polyphenols are the principals that essentially contribute to the high antioxidant and anti-inflammatory capacities and the health benefits of elderberry fruit extract. These health effects include attenuation of cardiovascular, neurodegenerative, and inflammatory disorders, as well as anti-diabetic, anticancer, antiviral, and immuno-stimulatory effects. Sales of elderberry supplements skyrocketed to $320 million over the year 2020, according to an American Botanical Council (ABC) report, which is attributable to the purported immune-enhancing effects of elderberry. In the current review, the chemical composition of the polyphenolic content of the European elderberry (Sambucus nigra) and the American elderberry (Sambucus canadensis), as well as the analytical techniques employed to analyze, characterize, and ascertain the chemical consistency will be addressed. Further, the factors that influence the consistency of the polyphenolic chemical composition, and hence, the consistency of the health benefits of elderberry extracts will be presented. Additionally, adulteration and safety as factors contributing to consistency will be covered. The role of elderberry in enhancing human health alone with the pharmacological basis, the cellular pathways, and the molecular mechanisms underlying the observed health benefits of elderberry fruit extracts will be also reviewed.

Dietary Intake of Anthocyanidins and Renal Cancer Risk: A Prospective Study

Evidence on the association between anthocyanidin intake and renal cancer risk is limited. The aim of this study was to assess the association of anthocyanidin intake with renal cancer risk in the large prospective Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. The cohort for this analysis consisted of 101,156 participants. A Cox proportional hazards regression model was used to estimate the hazard ratios (HRs) and the 95% confidence intervals (CIs). A restricted cubic spline model with three knots (i.e., 10th, 50th, and 90th percentiles) was used to model a smooth curve. A total of 409 renal cancer cases were identified over a median follow-up of 12.2 years. In the categorical analysis with a fully adjusted model, a higher dietary anthocyanidin consumption was associated with a lower risk of renal cancer (HR_Q4vsQ1: 0.68; 95% CI: 0.51-0.92; p for trend < 0.010). A similar pattern was obtained when anthocyanidin intake was analyzed as a continuous variable. The HR of one-SD increment in the anthocyanidin intake for renal cancer risk was 0.88 (95% CI: 0.77-1.00, p = 0.043). The restricted cubic spline model revealed a reduced risk of renal cancer with a higher intake of anthocyanidins and there was no statistical evidence for nonlinearity (p for nonlinearity = 0.207). In conclusion, in this large American population, a higher dietary anthocyanidin consumption was associated with a lower risk of renal cancer. Future cohort studies are warranted to verify our preliminary findings and to explore the underlying mechanisms in this regard.

Behind the Scenes of Anthocyanins-From the Health Benefits to Potential Applications in Food, Pharmaceutical and Cosmetic Fields

Anthocyanins are widespread and biologically active water-soluble phenolic pigments responsible for a wide range of vivid colours, from red (acidic conditions) to purplish blue (basic conditions), present in fruits, vegetables, and coloured grains. The pigments' stability and colours are influenced mainly by pH but also by structure, temperature, and light. The colour-stabilizing mechanisms of plants are determined by inter- and intramolecular co-pigmentation and metal complexation, driven by van der Waals, π-π stacking, hydrogen bonding, and metal-ligand interactions. This group of flavonoids is well-known to have potent anti-inflammatory and antioxidant effects, which explains the biological effects associated with them. Therefore, this review provides an overview of the role of anthocyanins as natural colorants, showing they are less harmful than conventional colorants, with several technological potential applications in different industrial fields, namely in the textile and food industries, as well as in the development of photosensitizers for dye-sensitized solar cells, as new photosensitizers in photodynamic therapy, pharmaceuticals, and in the cosmetic industry, mainly on the formulation of skin care formulations, sunscreen filters, nail colorants, skin & hair cleansing products, amongst others. In addition, we will unveil some of the latest studies about the health benefits of anthocyanins, mainly focusing on the protection against the most prevalent human diseases mediated by oxidative stress, namely cardiovascular and neurodegenerative diseases, cancer, and diabetes. The contribution of anthocyanins to visual health is also very relevant and will be briefly explored.

Cellular Antioxidant Effect of an Aronia Extract and Its Polyphenolic Fractions Enriched in Proanthocyanidins, Phenolic Acids, and Anthocyanins

Oxidative stress and chronic inflammation contribute to some chronic diseases. Aronia berries are rich in polyphenols. The aim of the present study was to characterize the cellular antioxidant effect of an aronia extract to reflect the potential physiological in vivo effect. Cellular in vitro assays in three cell lines (Caco-2, HepG2, and SH-SY5Y) were used to measure the antioxidant effect of AE, in three enriched polyphenolic fractions (A1: anthocyanins and phenolic acids; A2: oligomeric proanthocyanidins; A3: polymeric proanthocyanidins), pure polyphenols and microbial metabolites. Both direct (intracellular and membrane radical scavenging, catalase-like effect) and indirect (NRF2/ARE) antioxidant effects were assessed. AE exerted an intracellular free radical scavenging activity in the three cell lines, and A2 and A3 fractions showed a higher effect in HepG2 and Caco-2 cells. AE also exhibited a catalase-like activity, with the A3 fraction having a significant higher activity. Only A1 fraction activated the NRF2/ARE pathway. Quercetin and caffeic acid are the most potent antioxidant polyphenols, whereas cyanidin and 5-(3',4'-dihydroxyphenyl)-γ-valerolactone showed the highest antioxidant effect among polyphenol metabolites. AE rich in polyphenols possesses broad cellular antioxidant effects, and proanthocyanidins are major contributors. Polyphenol metabolites may contribute to the overall antioxidant effect of such extract in vivo.

Should We ‘Eat a Rainbow’? An Umbrella Review of the Health Effects of Colorful Bioactive Pigments in Fruits and Vegetables

Health promotion campaigns have advocated for individuals to ‘eat a rainbow’ of fruits and vegetables (FV). However, the literature has only focused on individual color pigments or individual health outcomes. This umbrella review synthesized the evidence on the health effects of a variety of color-associated bioactive pigments found in FV (carotenoids, flavonoids, betalains and chlorophylls), compared to placebo or low intakes. A systematic search of PubMed, EMBASE, CINAHL and CENTRAL was conducted on 20 October 2021, without date limits. Meta-analyzed outcomes were evaluated for certainty via the GRADE system. Risk of bias was assessed using the Centre for Evidence-Based Medicine critical appraisal tools. A total of 86 studies were included, 449 meta-analyzed health outcomes, and data from over 37 million participants were identified. A total of 42% of health outcomes were improved by color-associated pigments (91% GRADE rating very low to low). Unique health effects were identified: n = 6 red, n = 10 orange, n = 3 yellow, n = 6 pale yellow, n = 3 white, n = 8 purple/blue and n = 1 green. Health outcomes associated with multiple color pigments were body weight, lipid profile, inflammation, cardiovascular disease, mortality, type 2 diabetes and cancer. Findings show that color-associated FV variety may confer additional benefits to population health beyond total FV intake.

Anthocyanins in Chronic Diseases: The Power of Purple

Anthocyanins are mainly purple-coloured phenolic compounds of plant origin that as secondary metabolites are important in plant survival. Understanding their health benefits in humans requires sourcing these unstable compounds in sufficient quantities at a reasonable cost, which has led to improved methods of extraction. Dark-coloured fruits, cereals and vegetables are current sources of these compounds. The range of potential sustainable sources is much larger and includes non-commercialised native plants from around the world and agri-waste containing anthocyanins. In the last 5 years, there have been significant advances in developing the therapeutic potential of anthocyanins in chronic human diseases. Anthocyanins exert their beneficial effects through improvements in gut microbiota, oxidative stress and inflammation, and modulation of neuropeptides such as insulin-like growth factor-1. Their health benefits in humans include reduced cognitive decline; protection of organs such as the liver, as well as the cardiovascular system, gastrointestinal tract and kidneys; improvements in bone health and obesity; and regulation of glucose and lipid metabolism. This review summarises some of the sources of anthocyanins and their mechanisms and benefits in the treatment of chronic human diseases.