Flaxseed supplementation in non-alcoholic fatty liver disease: a pilot randomized, open labeled, controlled study

Impact of flaxseed supplementation on lipid profile and liver enzymes in patients with non-alcoholic fatty liver disease: Systematic review and meta-analysis of randomized controlled trials

Since the effects of flaxseed supplementation on lipid profile and liver enzymes are still controversial, a meta-analysis of randomized controlled trials was conducted in the present study to assess the effect of flaxseed supplementation on lipid profile and liver enzymes. The study was designed, conducted, and reported according to the guidelines of the 2020 preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement. A systematic and comprehensive search was performed in several databases from inception up to January 10, 2024. The meta-analysis on the impact of flaxseed supplementation on lipid profile and liver enzymes indicates that the overall effect of flaxseed supplementation on triglycerides, combining different doses, revealed a significant reduction with a WMD of - 230.72 (-53.95, - 27.49) and a P-value of 0.010. High-density lipoprotein (HDL) demonstrated a positive effect, with an overall WMD of 1.82 (0.27, 3.38) and a P-value of 0.021, indicating an increase in HDL levels. The liver enzymes AST and ALT displayed reductions in their levels, with overall WMDs of - 21.18 (-2.95, 0.59) and - 24.83 (-8.74, - 20.91), respectively. Subgroup analysis based on dosage revealed more pronounced reductions in ALT levels for doses below 2000 mg/day. Findings from this study suggest that a flaxseed supplement might be beneficial to modulate the blood lipid profile and liver enzymes.

The effects of flaxseed (Linum usitatissimum) supplementation on anthropometric indices: An updated systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

Flaxseed (Linum usitatissimum) supplementation has shown promise as an anti-obesity agent in various clinical trials, although results have been inconsistent. To provide a more accurate assessment of the impact of flaxseed supplementation on anthropometric indices, a systematic review and meta-analysis was performed.

METHODS

We searched several international databases until August 2023, including Scopus, PubMed, Web of Science, Embase, and Cochrane Library. Weighted mean differences (WMDs) were analyzed using a random-effects model.

RESULTS

Sixty-four trials comprising 72 treatment arms were included. All studies reported the intervention types (Lignans, Whole flaxseed, and Flaxseed oil) and dosage. However, three studies did testing for purity, and 40 studies reported potency. Also, the risk of contamination with heavy metals was not mentioned in studies. Another limitation was the lack of blind evaluation in the studies. According to three trials included in the systematic review, flaxseed did not affect anthropometric indices. Our meta-analysis revealed significant reductions in body weight (WMD = -0.63 kg; 95 % CI: -1.00, -0.27, P < 0.001; I2 = 76.7 %, P < 0.001), body mass index (BMI) (WMD: -0.24 kg/m2, 95 % CI: -0.36, -0.11, P < 0.001; I2 = 78.5 %, P < 0.001) and waist circumference (WC) (WMD: -1.43 cm, 95 % CI: -2.06, -0.80, P < 0.001; I2 = 81.1 %, P < 0.001) following flaxseed supplementation. Subgroup analyses indicated that interventions lasting 10-20 weeks, and studies involving subjects with higher BMI (>30 kg/m2) showed more significant anti-obesity effects. Based on the GRADE evaluation, body weight, BMI, and WC results were considered as moderate-certainty evidence.

CONCLUSION

Our systematic review and meta-analysis suggests that supplementation with flaxseed (Linum usitatissimum) leads to meaningful improvements in body weight, BMI, and WC. Therefore, flaxseed can be considered as an adjunctive therapeutic approach in improving obesity.

Effects of flaxseed supplementation on inflammatory biomarkers: A GRADE-assessed systematic review and meta-analysis of randomized controlled trials

Several studies reported the benefits of flaxseed on inflammatory biomarkers, while others reported conflicting findings. Thus, the aim of this meta-analysis was to assess the impacts of flaxseed on inflammatory biomarkers in adults. Databases including Embase, PubMed, Scopus, and Web of Sciences were searched till February 2024. The 54 RCTs were included in the final analysis, which involved 3000 individuals from 12 countries. Overall, the flaxseed supplementation had a significant reduction in C-reactive protein (CRP) (SMD = -0.46; 95 % CI: -0.70, -0.23, P < 0.001; I2 = 82.9 %, P < 0.001), and interleukin 6 (IL-6) (SMD = -0.64, 95 % CI: -1.13, -0.16, P = 0.010; I2 = 92.7, P < 0.001). Furthermore, flaxseed did not significantly change the concentration of tumor necrosis factor α (TNF-α) (SMD = -0.17; 95 % CI: -0.63, 0.29, P = 0.467; I2 = 92, P < 0.001). Flaxseed supplementation significantly decreased serum concentrations of CRP and IL-6, but not TNF-a. Thus, this meta-analysis suggests that the current evidence supports the potential benefits of flaxseed in managing inflammatory conditions.

Multifunctional role of oral bacteria in the progression of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) encompasses a spectrum of liver disorders of varying severity, ultimately leading to fibrosis. This spectrum primarily consists of NAFL and non-alcoholic steatohepatitis. The pathogenesis of NAFLD is closely associated with disturbances in the gut microbiota and impairment of the intestinal barrier. Non-gut commensal flora, particularly bacteria, play a pivotal role in the progression of NAFLD. Notably, Porphyromonas gingivalis, a principal bacterium involved in periodontitis, is known to facilitate lipid accumulation, augment immune responses, and induce insulin resistance, thereby exacerbating fibrosis in cases of periodontitis-associated NAFLD. The influence of oral microbiota on NAFLD via the "oral-gut-liver" axis is gaining recognition, offering a novel perspective for NAFLD management through microbial imbalance correction. This review endeavors to encapsulate the intricate roles of oral bacteria in NAFLD and explore underlying mechanisms, emphasizing microbial control strategies as a viable therapeutic avenue for NAFLD.

The impact of gut microbiome-targeted therapy on liver enzymes in patients with nonalcoholic fatty liver disease: an umbrella meta-analysis

CONTEXT

Nonalcoholic fatty liver disease (NAFLD) is considered the leading cause of chronic liver disease worldwide. To date, no confirmed medication is available for the treatment of NAFLD. Previous studies showed the promising effects of gut microbiome-targeted therapies; however, the results were controversial and the strength of the evidence and their clinical significance remained unclear.

OBJECTIVES

This umbrella study summarizes the results of meta-analyses investigating the effects of probiotics, prebiotics, and synbiotics on liver enzymes in the NAFLD population.

DATA SOURCE

A comprehensive search of the PubMed, Scopus, Web of Science, and Cochrane Library databases was done up to December 20, 2022, to find meta-analyses on randomized control trials reporting the effects of gut microbial therapy on patients with NAFLD.

DATA EXTRACTION

Two independent investigators extracted data on the characteristics of meta-analyses, and any discrepancies were resolved by a third researcher. The AMSTAR2 checklist was used for evaluating the quality of studies.

DATA ANALYSIS

A final total of 15 studies were included in the analysis. Results showed that microbiome-targeted therapies could significantly reduce levels of alanine aminotransferase (ALT; effect size [ES], -10.21; 95% confidence interval [CI], -13.29, -7.14; P < 0.001), aspartate aminotransferase (AST; ES, -8.86; 95%CI, -11.39, -6.32; P < 0.001), and γ-glutamyltransferase (ES, -5.56; 95%CI, -7.92, -3.31; P < 0.001) in patients with NAFLD. Results of subgroup analysis based on intervention showed probiotics could significantly reduce levels of AST (ES, -8.69; 95%CI, -11.01, -6.37; P < 0.001) and ALT (ES, -9.82; 95%CI, -11.59, -8.05; P < 0.001). Synbiotics could significantly reduce levels of AST (ES, -11.40; 95%CI, -13.91, -8.88; P < 0.001) and ALT (ES, -11.87; 95%CI, -13.80, -9.95; P < 0.001). Prebiotics had no significant effects on AST and ALT levels (ES, -2.96; 95%CI, -8.12, 2.18, P = 0.259; and ES, -4.69; 95%CI, -13.53, 4.15, P = 0.299, respectively).

CONCLUSION

Gut microbiome-targeted therapies could be a promising therapeutic approach in the improvement of hepatic damage in patients with NAFLD. However, more studies are needed to better determine the best bacterial strains, duration of treatment, and optimum dosage of gut microbiome-targeted therapies in the treatment of the NAFLD population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022346998.

The Role of PNPLA3_rs738409 Gene Variant, Lifestyle Factors, and Bioactive Compounds in Nonalcoholic Fatty Liver Disease: A Population-Based and Molecular Approach towards Healthy Nutrition

This study aimed to investigate the impact of a common non-synonymous gene variant (C>G, rs738409) in patatin-like phospholipase domain-containing 3 (PNPLA3), leading to the substitution of isoleucine with methionine at position 148 (PNPLA3-I148M), on susceptibility to nonalcoholic fatty liver disease (NAFLD) and explore potential therapeutic nutritional strategies targeting PNPLA3. It contributed to understanding sustainable dietary practices for managing NAFLD, recently referred to as metabolic-dysfunction-associated fatty liver. NAFLD had been diagnosed by ultrasound in a metropolitan hospital-based cohort comprising 58,701 middle-aged and older Korean individuals, identifying 2089 NAFLD patients. The interaction between PNPLA3 and lifestyle factors was investigated. In silico analyses, including virtual screening, molecular docking, and molecular dynamics simulations, were conducted to identify bioactive compounds from foods targeting PNPLA3(I148M). Subsequent cellular experiments involved treating oleic acid (OA)-exposed HepG2 cells with selected bioactive compounds, both in the absence and presence of compound C (AMPK inhibitor), targeting PNPLA3 expression. Carriers of the risk allele PNPLA3_rs738409G showed an increased association with NAFLD risk, particularly with adherence to a plant-based diet, avoidance of a Western-style diet, and smoking. Delphinidin 3-caffeoyl-glucoside, pyranocyanin A, delta-viniferin, kaempferol-7-glucoside, and petunidin 3-rutinoside emerged as potential binders to the active site residues of PNPLA3, exhibiting a reduction in binding energy. These compounds demonstrated a dose-dependent reduction in intracellular triglyceride and lipid peroxide levels in HepG2 cells, while pretreatment with compound C showed the opposite trend. Kaempferol-7-glucoside and petunidin-3-rutinoside showed potential as inhibitors of PNPLA3 expression by enhancing AMPK activity, ultimately reducing intrahepatic lipogenesis. In conclusion, there is potential for plant-based diets and specific bioactive compounds to promote sustainable dietary practices to mitigate NAFLD risk, especially in individuals with genetic predispositions.

Polyphenol consumption and Nonalcoholic fatty liver disease risk in adults

In this cross-sectional investigation, the primary objective was to explore the correlation between the consumption of polyphenols and the likelihood of non-alcoholic fatty liver disease (NAFLD) in the adult population participating in the Hoveyzeh cohort. Data from the Hoveyzeh cohort study, part of the Persian Cohort Study, involving 10,009 adults aged 35-70, were analyzed. Exclusions were made for missing data, extreme energy intake, and liver cancer patients. Dietary habits were assessed using a food frequency questionnaire, and polyphenol intake was calculated using the Phenol Explorer database. Logistic regression analyses, adjusted for confounders, were performed to assess the relationship between polyphenol subclasses (total polyphenols, total flavonoids, phenolic acid, and lignin) and NAFLD. Among 9894 participants, those in the highest quintile of total polyphenol (OR 0.65, CI 0.5-0.84; P = 0.007), phenolic acid (OR 0.67, CI 0.52-0.86; P < 0.001), and lignin intake (OR 0.69, CI 0.52-0.87; P = 0.001) demonstrated lower odds of NAFLD compared to the lowest quintile, even after adjusting for confounding factors. However, no significant association was found between total flavonoid intake and NAFLD (OR 1.26, CI 0.96-1.67; P = 0.47). Subgroup analysis indicated a significant inverse association between total polyphenols and NAFLD in women (OR 0.64, CI 0.42-0.93; P = 0.001). Higher intake of total polyphenols, phenolic acid, and lignin was associated with reduced odds of NAFLD among adults in the Hoveyzeh cohort. This suggests that dietary patterns rich in these polyphenols may play a role in mitigating the risk of NAFLD. Further interventional and longitudinal studies are needed to validate these findings and explore potential preventive strategies involving polyphenol-rich diets.

A systematic review and meta-analysis of randomized controlled trials to evaluate plant-based omega-3 polyunsaturated fatty acids in nonalcoholic fatty liver disease patient biomarkers and parameters

CONTEXT

Nonalcoholic fatty liver disease (NAFLD) is prevalent in 25-30% of British and European populations, representing a potential global public health crisis. Marine omega-3 (n-3) polyunsaturated fatty acids offer well-evidenced benefits to NAFLD biomarkers; however, the effect of plant-based n-3 has not been evaluated with a systematic review and meta-analysis.

OBJECTIVE

The review aimed to systematically evaluate the effect of plant-based n-3 supplementation on NAFLD surrogate biomarkers and parameters.

DATA SOURCES

Medline (EBSCO), PubMed, CINAHL (EBSCO), Cochrane Central Register of Controlled Trials, the International Clinical Trials Registry Platform, and Google Scholar databases were searched to identify randomized controlled trials published between January 1970 and March 2022 evaluating the impact of plant-based n-3 interventions on diagnosed NAFLD. The review followed the PRISMA checklist and is PROSPERO registered (CRD42021251980).

DATA EXTRACTION

A random-effects model and generic inverse variance methods synthesized quantitative data, followed by a leave-one-out method for sensitivity analysis. We identified 986 articles; after the application of selection criteria, six studies remained with 362 patients with NAFLD.

RESULTS

The meta-analysis showed that plant-based n-3 fatty acid supplementation significantly reduced alanine aminotransferase (ALT) (mean difference: 8.04 IU/L; 95% confidence interval: 14.70, 1.38; I2 = 48.61%) and plasma/serum triglycerides (44.51 mg/dL; 95% confidence interval: -76.93, -12.08; I2 = 69.93%), alongside body-composition markers in patients with NAFLD (P < 0.05).

CONCLUSION

Plant-based n-3 fatty acid supplementation improves ALT enzyme biomarkers, triglycerides, body mass index, waist circumference, and weight loss when combined with lifestyle interventions to increase physical activity and a calorie-controlled diet. Further research is needed to identify the most effective plant-based n-3 sources in larger numbers of patients with NAFLD over longer study durations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021251980.

A scientifically validated combination of garcinol, curcuminoids, and piperine for mild to moderate nonalcoholic steatohepatitis patients-results from a randomized, double-blind, placebo-controlled study

Background

Garcinol is a naturally occurring compound from the fruit rind of the Garcinia indica, with antioxidant, anti-inflammatory, and anticancer properties. Curcuminoids are the active molecule from the rhizome of Curcuma longa, studied extensively for its health benefits as an anti-inflammatory and antioxidant activities. Non-alcoholic steatohepatitis (NASH) is the progressive form of nonalcoholic steatohepatitis characterized by liver fat and inflammation.

Objective

To evaluate the clinical efficacy and safety of Garcinol, Curcuminoids and piperine (GCP) combination in patients with mild to moderate NASH in a randomized, double-blind, placebo-controlled study.

Methods

The patients received one tablet (450 mg) of GCP containing garcinol-50 mg, curcuminoids -250 mg and piperine 5 mg or a placebo (450 mg of microcrystalline cellulose) twice daily for 90 days. Changes in circulating aspartate aminotransferase (AST), alanine transaminase (ALT) levels, liver stiffness measurement (LSM), and controlled attenuation parameter (CAP) using Fibroscan were compared from baseline to day 90. Anthropometric parameters, serum levels of lipids, Interleukin (IL-6), hsCRP, and adiponectin were estimated. Safety was evaluated by laboratory parameters and by monitoring adverse events.

Results

Seventy-two patients were randomized and 63 (GCP = 32, Placebo = 31) completed the study. The mean age of the patients was 48.3 ± 8.7 years (36 males and 27 females). The mean reduction in AST (U/L) was 9.53 in GCP and 3.16 in placebo (p < 0.001) and that of ALT (U/L) was 13.47 in GCP and 7.43 in Placebo (p = 0.002). The liver stiffness and CAP scores showed a better reduction in GCP (0.56 kPa and 12.38 db/m) compared to placebo (0.064 kPa and 10.42 db/m) p < 0.05. Consequently, the noninvasive Fibroscan-AST (FAST) score reduction was also found to be significant in GCP compared to placebo. Additionally, body weight, lipid levels, hsCRP, and IL-6 in serum decreased, while adiponectin levels increased in GCP-supplemented participants compared to placebo. The combination of garcinol and curcuminoids was well tolerated with no significant changes in hematological and clinical laboratory parameters during the 90-day supplementation.

Conclusion

Our results suggest that GCP could be a possible supplement for the management of NASH.Clinical trial registration: https://clinicaltrials.gov/, identifier CTRI/2019/11/022147.

Pharmacological, nutraceutical, and nutritional properties of flaxseed (Linum usitatissimum): An insight into its functionality and disease mitigation

Flaxseed (Linum usitatissimum L.) is derived from the flax plant, an annual herb. The primary relevance of flaxseed is in the human nutrition sector, where it is emerging as a significant functional food component due to its high level of active chemicals, which have been linked to health benefits. Flaxseed may be consumed in numerous forms, including milled, oil, and bakery items. The phytochemicals that are present in flaxseed have greatly drawn interest as bioactive molecules beneficial for health. It is naturally enriched with alpha-linolenic acid, omega-3 fatty acid, lignin, secoisolariciresinol diglucoside, and fiber which are physiologically active in the protection of some chronic illnesses such as cancer, diabetes, cardiovascular disease, and cerebrovascular stroke. Furthermore, the benefits of flaxseed eating have been demonstrated in the animal nutrition industry, resulting in healthier food from animal origin. In reality, the fatty acid profile of meat and fat in swine and poultry is directly impacted by the source of fat in the diet. Feeding omega-3-enriched diets with flaxseed will improve the omega-3 content in eggs and meat, enriching the products. The current study focuses on the latest evidence on the chemical makeup of flaxseed and its positive benefits.

Linseed oil attenuates fatty liver disease in mice fed a high-carbohydrate diet

The impact of linseed oil as a lipid source on liver disease induced by a high-carbohydrate diet (HCD) was evaluated. Adult male Swiss mice received an HCD containing carbohydrates (72.1%), proteins (14.2%), and lipids (4.0%). The Control HCD group (HCD-C) received an HCD containing lard (3.6%) and soybean oil (0.4%) as lipid sources. The L10 and L100 groups received an HCD with 10 and 100% linseed oil as lipid sources, respectively. A group of mice were euthanized before receiving the diets (day 0) and the remaining groups after 56 days of receiving the diets (HCD-C, L10, and L-100 groups). Morphological and histopathological analyses, as well as collagen deposition were evaluated. Perivenous hepatocytes (PVH) of the HCD-C group were larger (P<0.05) than periportal hepatocytes (PPH) in the median lobe (ML) and left lobe (LL). There was a greater (P<0.05) deposition of type I collagen in PPH (vs PVH) and in the ML (vs LL). The ML exhibited a higher proportion of apoptotic bodies, inflammatory infiltrate, and hepatocellular ballooning. All these alterations (hepatocyte size, deposition of type I collagen, apoptotic bodies, inflammatory infiltrate, and hepatocellular ballooning) induced by HCD were prevented or attenuated in L10 and L100 groups. Another indicator of the beneficial effects of linseed oil was the lower (P<0.05) number of binucleated hepatocytes (HCD-C vs L10 or L100 group). In general, the L100 group had greater effects than the L10 group. In conclusion, linseed oil impedes or reduces the liver injury progression induced by an HCD.

Pomegranate (Punica granatum L.) peel extract ameliorates metabolic syndrome risk factors in patients with non-alcoholic fatty liver disease: a randomized double-blind clinical trial

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) is a metabolic syndrome (MS)-related liver disorder that has an increasing prevalence. Thus, the aim of our study is to evaluate the effects of pomegranate peel extract (PP) supplementation on hepatic status and metabolic syndrome risk factors.

METHODS

In phase one, the hydro-alcoholic extraction of the peel of 750 kg of pomegranate (Punica granatum L.) was performed by the soaking method. Then, in phase two, NAFLD patients received 1500 mg of placebo (n = 37) or pomegranate peel capsules (n = 39) with a 500-kcal deficit diet for 8 weeks. Gastrointestinal intolerance, dietary intake, lipid and glycemic profiles, systolic and diastolic blood pressure, body composition, insulin resistance indexes, and elastography-evaluated NAFLD changes were followed.

RESULTS

The mean age of participants was 43.1 ± 8.6 years (51.3% female). Following the intervention, the mean body weight (mean changes: -5.10 ± 2.30 kg), waist circumference (-7.57 ± 2.97 cm), body mass index (-1.82 ± 0.85 kg/m2), body fat index (-1.49 ± 0.86), and trunk fat (- 3.93 ± 3.07%), systolic (-0.63 ± 0.29 cmHg) and diastolic (-0.39 ± 0.19 cmHg) blood pressure, total cholesterol (-10.51 ± 0.77 mg/dl), triglyceride (-16.02 ± 1.7 mg/dl), low-density lipoprotein cholesterol (-9.33 ± 6.66 mg/dl; all P < 0.001), fat free mass (- 0.92 ± 0.90 kg; P < 0.003), and fasting blood sugar (-5.28 ± 1.36 mg/dl; P = 0.02) decreased significantly in PP in contrast to the placebo group in the raw model and when adjusted for confounders. Also, high-density lipoprotein cholesterol (5.10 ± 0.36 mg/dl), liver steatosis and stiffness (- 0.30 ± 0.17 and - 0.72 ± 0.35 kPa, respectively, all P < 0.001) improved in the PP group. However, fasting insulin (P = 0.81) and homeostatic model assessment for insulin resistance (HOMA-IR) (P = 0.93) were not significantly different when comparing two groups during the study in the raw and even adjusted models.

CONCLUSION

In conclusion, 1500 mg pomegranate peel extract along with a weight-loss diet improved metabolic syndrome risk factors and reduced hepatic steatosis in patients with NAFLD after 8 weeks.

Flaxseed Reduces Cancer Risk by Altering Bioenergetic Pathways in Liver: Connecting SAM Biosynthesis to Cellular Energy

This article illustrates how dietary flaxseed can be used to reduce cancer risk, specifically by attenuating obesity, type 2 diabetes, and non-alcoholic fatty liver disease (NAFLD). We utilize a targeted metabolomics dataset in combination with a reanalysis of past work to investigate the "metabo-bioenergetic" adaptations that occur in White Leghorn laying hens while consuming dietary flaxseed. Recently, we revealed how the anti-vitamin B6 effects of flaxseed augment one-carbon metabolism in a manner that accelerates S-adenosylmethionine (SAM) biosynthesis. Researchers recently showed that accelerated SAM biosynthesis activates the cell's master energy sensor, AMP-activated protein kinase (AMPK). Our paper provides evidence that flaxseed upregulates mitochondrial fatty acid oxidation and glycolysis in liver, concomitant with the attenuation of lipogenesis and polyamine biosynthesis. Defatted flaxseed likely functions as a metformin homologue by upregulating hepatic glucose uptake and pyruvate flux through the pyruvate dehydrogenase complex (PDC) in laying hens. In contrast, whole flaxseed appears to attenuate liver steatosis and body mass by modifying mitochondrial fatty acid oxidation and lipogenesis. Several acylcarnitine moieties indicate Randle cycle adaptations that protect mitochondria from metabolic overload when hens consume flaxseed. We also discuss a paradoxical finding whereby flaxseed induces the highest glycated hemoglobin percentage (HbA1c%) ever recorded in birds, and we suspect that hyperglycemia is not the cause. In conclusion, flaxseed modifies bioenergetic pathways to attenuate the risk of obesity, type 2 diabetes, and NAFLD, possibly downstream of SAM biosynthesis. These findings, if reproducible in humans, can be used to lower cancer risk within the general population.

Effect of a moderately carbohydrate-restricted diet on liver enzymes, steatosis and fibrosis in normal-weight individuals with non-alcoholic fatty liver disease: study protocol for a parallel randomised controlled clinical trial

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) is a hepatic condition that is considerably prevalent across the world. Dietary intakes, in which macronutrient composition is precisely planned, might be able to reduce inflammation, steatosis and fibrosis among patients with NAFLD. A moderately carbohydrate restricted diet with weight loss has been demonstrated to improve liver fat content among overweight or obese patients. However, there is no information about the appropriateness of such a restriction, without weight loss, in normal-weight patients. This randomised clinical trial will be aimed at assessing the effect of moderate carbohydrate restriction on liver enzymes, liver steatosis and fibrosis in normal-weight patients with NAFLD.

METHODS AND ANALYSIS

This randomised controlled clinical trial will be conducted to evaluate the impact of a moderately carbohydrate restricted diet on liver enzymes, steatosis and fibrosis in 52 eligible normal-weight individuals with NAFLD. Transient elastography and controlled attenuation parameter with FibroScan will be applied to diagnose NAFLD. After individual matching based on body mass index, age and sex, patients will be randomly assigned to receive a moderately carbohydrate restricted diet or an isocaloric diet without carbohydrate restriction for 12 weeks. The primary and secondary outcomes in this study will be liver function indices, including liver steatosis and fibrosis, metabolic parameters and anthropometric measures. All these variables will be assessed at study baseline and postintervention.

ETHICS AND DISSEMINATION

The present clinical trial study was accepted by the ethics committee of TUMS (Tehran University of Medical Sciences) (code: IR.TUMS.MEDICINE.REC.1400.116).

TRIAL REGISTRATION NUMBER

IRCT20210119050086N1.

Nutraceutical approaches to non-alcoholic fatty liver disease (NAFLD): A position paper from the International Lipid Expert Panel (ILEP)

Non-Alcoholic Fatty Liver Disease (NAFLD) is a common condition affecting around 10-25% of the general adult population, 15% of children, and even > 50% of individuals who have type 2 diabetes mellitus. It is a major cause of liver-related morbidity, and cardiovascular (CV) mortality is a common cause of death. In addition to being the initial step of irreversible alterations of the liver parenchyma causing cirrhosis, about 1/6 of those who develop NASH are at risk also developing CV disease (CVD). More recently the acronym MAFLD (Metabolic Associated Fatty Liver Disease) has been preferred by many European and US specialists, providing a clearer message on the metabolic etiology of the disease. The suggestions for the management of NAFLD are like those recommended by guidelines for CVD prevention. In this context, the general approach is to prescribe physical activity and dietary changes the effect weight loss. Lifestyle change in the NAFLD patient has been supplemented in some by the use of nutraceuticals, but the evidence based for these remains uncertain. The aim of this Position Paper was to summarize the clinical evidence relating to the effect of nutraceuticals on NAFLD-related parameters. Our reading of the data is that whilst many nutraceuticals have been studied in relation to NAFLD, none have sufficient evidence to recommend their routine use; robust trials are required to appropriately address efficacy and safety.

Effect of Dietary Intervention, with or without Cointerventions, on Inflammatory Markers in Patients with Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis

Nonalcoholic fatty liver disease (NAFLD) encompasses a spectrum of disease from simple steatosis to nonalcoholic steatohepatitis, with inflammatory cytokines and adipokines identified as drivers of disease progression. Poor dietary patterns are known to promote an inflammatory milieu, although the effects of specific diets remain largely unknown. This review aimed to gather and summarize new and existing evidence on the effect of dietary intervention on inflammatory markers in patients with NAFLD. The electronic databases MEDLINE, EMBASE, CINAHL, and Cochrane were searched for clinical trials which investigated outcomes of inflammatory cytokines and adipokines. Eligible studies included adults >18 y with NAFLD, which compared a dietary intervention with an alternative diet or control (no intervention) group or were accompanied by supplementation or other lifestyle interventions. Outcomes for inflammatory markers were grouped and pooled for meta-analysis where heterogeneity was allowed. Methodological quality and risk of bias were assessed using the Academy of Nutrition and Dietetics Criteria. Overall, 44 studies with a total of 2579 participants were included. Meta-analyses indicated intervention with an isocaloric diet plus supplement was more effective in reducing C-reactive protein (CRP) [standard mean difference (SMD): 0.44; 95% CI: 0.20, 0.68; P = 0.0003] and tumor necrosis factor-alpha (TNF-α) (SMD: 0.74; 95% CI: 0.02, 1.46; P = 0.03) than an isocaloric diet alone. No significant weighting was shown between a hypocaloric diet with or without supplementation for CRP (SMD: 0.30; 95% CI: -0.84, 1.44; P = 0.60) and TNF-α (SMD: 0.01; 95% CI: -0.43, 0.45; P = 0.97). In conclusion, hypocaloric and energy-restricted diets alone or with supplementation, and isocaloric diets with supplementation were shown to be most effective in improving the inflammatory profile of patients with NAFLD. To better determine the effectiveness of dietary intervention alone on a NAFLD population, further investigations of longer durations, with larger sample sizes are required.

Comparisons of the effects of different flaxseed products consumption on lipid profiles, inflammatory cytokines and anthropometric indices in patients with dyslipidemia related diseases: systematic review and a dose-response meta-analysis of randomized controlled trials

BACKGROUND

Flaxseed is widely used as a functional food for its rich sources of linolenic acid, lignans and dietary fibers in the world. This systematic review and dose-response meta-analysis on randomized controlled trials (RCTs) is first to evaluate effects of different flaxseed products (whole flaxseed, oil and lignans) on lipid profiles, inflammatory and anthropometric parameters in patients with dyslipidemia related diseases.

METHODS

Literature search was performed in PubMed, Embase, Cochrane Central, Scopus, and Web of Science from the inception dates to January, 2020. Weighted mean differences with the 95% confidence interval (CI) were pooled using fix or random-effects models.

RESULTS

Thirty-one RCTs involving 1,698 participants were included. The present meta-analysis revealed that flaxseed consumption had an overall beneficial effect on serum TC, LDL-C, TG, apo B and IL-6 in patients with dyslipidemia related diseases, but not on apo A, HDL-C, hs-CRP, CRP and anthropometric indices. However, different flaxseed products showed obviously different effects. Whole flaxseed supplementation significantly reduced TC (- 11.85 mg/dl, 95% CI - 20.12 to - 3.57, P = 0.005), LDL-C (- 10.51 mg/dl, 95% CI - 14.96 to - 6.06, P < 0.001), TG (- 19.77 mg/dl, 95% CI - 33.61 to - 5.94, P = 0.005), apolipoprotein B (- 5.73 mg/dl, 95% CI - 7.53 to - 3.93, P < 0.001), TC/HDL-C (- 0.10, 95% CI - 0.19 to - 0.003, P = 0.044) and weight (- 0.40 kg, 95% CI - 0.76 to - 0.05, P = 0.027); Lignans supplementation significantly reduced TC (- 17.86 mg/dl, P = 0.004), LDL-C (- 15.47 mg/dl, P < 0.001) and TC/HDL-C (- 0.45, P = 0.04). Although flaxseed oil supplementation had no such lowering-effect on lipid, meta-analysis revealed its lowering-effect on IL-6 (- 0.35 pg/ml, P = 0.033) and hs-CRP (- 1.54 mg/l, P = 0.004). Subgroup analysis revealed that whole flaxseed decreased TC, LDL-C and TG levels irrespective of country and the intervention time prescribed, but was more pronounced when the dose of whole flaxseed was ≤ 30 g/day (TC: WMD - 13.61 mg/mL; LDL-C: WMD - 10.52 mg/mL; TG: WMD - 23.52 mg/mL), rather not a dose > 30 g/day. Moreover, a linear relationship between dose of whole flaxseed and absolute changes in C-reactive protein (P = 0.036) and a nonlinear relationship between with IL-6 (P < 0.001) were detected.

CONCLUSIONS

Flaxseed intervention suggested the positive effects on lipid profiles, inflammatory cytokines and anthropometric indices in patients with dyslipidemia related diseases. Of these, whole flaxseed and lignans play an important role in reducing blood lipid, while flaxseed oil mainly plays in anti-inflammatory. Lipid- and weight-lowering was significant when whole flaxseed was consumed at doses < 30 mg/d, for lipid status with mixed dyslipidemia and patients with BMI > 25.

Flaxseed Powder Attenuates Non-Alcoholic Steatohepatitis via Modulation of Gut Microbiota and Bile Acid Metabolism through Gut-Liver Axis

Non-alcoholic steatohepatitis (NASH) is gradually becoming one of the most common and health-endangering diseases; therefore, it is very important to prevent the occurrence of NASH and prevent simple non-alcoholic fatty liver (NAFL) from further developing into NASH. We fed mice a high-fat diet (HFD, 60% fat) for 14 weeks to induce NAFL and then fed different doses of flaxseed powder (low (10%), middle (20%), and high (30%)) to the mice for 28 weeks. After the animal experiment, we analyzed fecal bile acid (BA) profiles of the HFD mice, flaxseed-fed (FLA-fed) mice, and control mice with a normal diet (10% fat) using a targeted metabolomics approach, and we analyzed the gut microbiota at the same time. We also investigated the mechanistic role of BAs in NASH and identified whether the altered BAs strongly bind to colonic FXR or TGR5. In the present study, we found that 28-week FLA treatment notably alleviated NASH development in NAFL model mice fed with an HFD, and the beneficial effects may be attributed to the regulation of and improvement in the gut flora- and microbiota-related BAs, which then activate the intestinal FXR-FGF15 and TGR5-NF-κB pathways. Our data indicate that FLA might be a promising functional food for preventing NASH through regulating microbiomes and BAs.

Nutritional supplementation for nonalcohol-related fatty liver disease: a network meta-analysis

BACKGROUND

The prevalence of non-alcohol-related fatty liver disease (NAFLD) varies between 19% and 33% in different populations. NAFLD decreases life expectancy and increases risks of liver cirrhosis, hepatocellular carcinoma, and the requirement for liver transplantation. Uncertainty surrounds relative benefits and harms of various nutritional supplements in NAFLD. Currently no nutritional supplement is recommended for people with NAFLD.

OBJECTIVES

• To assess the benefits and harms of different nutritional supplements for treatment of NAFLD through a network meta-analysis • To generate rankings of different nutritional supplements according to their safety and efficacy SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, the World Health Organization International Clinical Trials Registry Platform, and trials registers until February 2021 to identify randomised clinical trials in people with NAFLD.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or status) for people with NAFLD, irrespective of method of diagnosis, age and diabetic status of participants, or presence of non-alcoholic steatohepatitis (NASH). We excluded randomised clinical trials in which participants had previously undergone liver transplantation.

DATA COLLECTION AND ANALYSIS

We performed a network meta-analysis with OpenBUGS using Bayesian methods whenever possible and calculated differences in treatments using hazard ratios (HRs), odds ratios (ORs), and rate ratios with 95% credible intervals (CrIs) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance.

MAIN RESULTS

We included in the review a total of 202 randomised clinical trials (14,200 participants). Nineteen trials were at low risk of bias. A total of 32 different interventions were compared in these trials. A total of 115 trials (7732 participants) were included in one or more comparisons. The remaining trials did not report any of the outcomes of interest for this review. Follow-up ranged from 1 month to 28 months. The follow-up period in trials that reported clinical outcomes was 2 months to 28 months. During this follow-up period, clinical events related to NAFLD such as mortality, liver cirrhosis, liver decompensation, liver transplantation, hepatocellular carcinoma, and liver-related mortality were sparse. We did not calculate effect estimates for mortality because of sparse data (zero events for at least one of the groups in the trial). None of the trials reported that they measured overall health-related quality of life using a validated scale. The evidence is very uncertain about effects of interventions on serious adverse events (number of people or number of events). We are very uncertain about effects on adverse events of most of the supplements that we investigated, as the evidence is of very low certainty. However, people taking PUFA (polyunsaturated fatty acid) may be more likely to experience an adverse event than those not receiving an active intervention (network meta-analysis results: OR 4.44, 95% CrI 2.40 to 8.48; low-certainty evidence; 4 trials, 203 participants; direct evidence: OR 4.43, 95% CrI 2.43 to 8.42). People who take other supplements (a category that includes nutritional supplements other than vitamins, fatty acids, phospholipids, and antioxidants) had higher numbers of adverse events than those not receiving an active intervention (network meta-analysis: rate ratio 1.73, 95% CrI 1.26 to 2.41; 6 trials, 291 participants; direct evidence: rate ratio 1.72, 95% CrI 1.25 to 2.40; low-certainty evidence). Data were sparse (zero events in all groups in the trial) for liver transplantation, liver decompensation, and hepatocellular carcinoma. So, we did not perform formal analysis for these outcomes. The evidence is very uncertain about effects of other antioxidants (antioxidants other than vitamins) compared to no active intervention on liver cirrhosis (HR 1.68, 95% CrI 0.23 to 15.10; 1 trial, 99 participants; very low-certainty evidence). The evidence is very uncertain about effects of interventions in any of the remaining comparisons, or data were sparse (with zero events in at least one of the groups), precluding formal calculations of effect estimates. Data were probably because of the very short follow-up period (2 months to 28 months). It takes follow-up of 8 to 28 years to detect differences in mortality between people with NAFLD and the general population. Therefore, it is unlikely that differences in clinical outcomes are noted in trials providing less than 5 to 10 years of follow-up.

AUTHORS' CONCLUSIONS

The evidence indicates considerable uncertainty about effects of nutritional supplementation compared to no additional intervention on all clinical outcomes for people with non-alcohol-related fatty liver disease. Accordingly, high-quality randomised comparative clinical trials with adequate follow-up are needed. We propose registry-based randomised clinical trials or cohort multiple randomised clinical trials (study design in which multiple interventions are trialed within large longitudinal cohorts of patients to gain efficiencies and align trials more closely to standard clinical practice) comparing interventions such as vitamin E, prebiotics/probiotics/synbiotics, PUFAs, and no nutritional supplementation. The reason for the choice of interventions is the impact of these interventions on indirect outcomes, which may translate to clinical benefit. Outcomes in such trials should be mortality, health-related quality of life, decompensated liver cirrhosis, liver transplantation, and resource utilisation measures including costs of intervention and decreased healthcare utilisation after minimum follow-up of 8 years (to find meaningful differences in clinically important outcomes).

Effect of Portulaca Oleracea (purslane) extract on liver enzymes, lipid profile, and glycemic status in nonalcoholic fatty liver disease: A randomized, double-blind clinical trial

Purslane (Portulaca oleracea L.) is the richest green leafy vegetable source of omega-3, especially alpha linolenic acid (ALA). Experimental studies have shown beneficial effects of purslane extract on liver enzymes. The aim of the present study was to examine the effect of purslane hydroalcohoic extract in patients with non-alcoholic fatty liver disease (NAFLD). In a randomized double-blinded clinical trial, 74 patients were randomly assigned to receive either 300 mg purslane extract or placebo capsules for 12 weeks. Compared with baseline, alanine aminotransferase (ALT) (-9 [-17, 0.50] mg/dl; p = .007), aspartate aminotransferase (AST) (-4 [-10, -0.50] mg/dl; p = .001), gamma glutamyltransferase (GGT) (-6.21 ± 9.85 mg/dL; p < .001), fasting blood glucose (FBG) (-8 [-11, -1.50] mg/dl; p < .001) insulin resistance (-0.95 ± 2.23; p = .020), triglyceride (-20 [-67.50, 3.50] mg/dl; p = .010), and low-density lipoprotein cholesterol (LDL-C) (-5 [-12, -1] mg/dl; p < .001) decreased significantly in the purslane group. At the end of study, no significant changes were observed in liver steatosis grade, insulin, liver enzymes, total bilirubin, lipid profile, and blood pressure between the two groups. The findings of our study show that purslane extract at the dose of 300 mg/day for 12 weeks has no significant effects on liver enzymes, lipid profile, and glycemic indices in patients with NAFLD.

The effects of flaxseed supplementation on metabolic syndrome parameters, insulin resistance and inflammation in ulcerative colitis patients: An open-labeled randomized controlled trial

The present study aimed to evaluate the efficacy of flaxseed supplementation in the management of metabolic syndrome (MetS)-related parameters among the patients with mild-to-moderate ulcerative colitis (UC). A randomized controlled clinical trial was conducted on 70 patients with UC. Participants were randomized in the intervention group, which received 30 g/day ground flaxseed powder or control group. Anthropometric and biochemical variables were assessed at the beginning and end of 12 weeks of intervention. Of the 70 patients enrolled in this study, 64 subjects were included in the final analysis. From baseline to 12 weeks' intervention, flaxseed supplementation resulted in a significant reduction in the serum concentration of insulin (p < .001), HOMA-IR (p < .001), triglyceride (p = .001), total cholesterol (p < .001), and significant increase in the serum levels of HDL (p = .008). Also, we found a significant improvement in the SCCAI score (p < .001), TNF-α (p = .03), and CRP (p < .001) following the flaxseed supplementation. However, we not observed any significant differences between two groups regarding the body weight, BMI, waist circumferences, systolic, and diastolic blood pressure (p > .05). Overall, 12 weeks of flaxseed supplementation resulted in greater improvement in the some MetS-related parameters.

Effect of dietary intervention, with or without co-interventions, on inflammatory markers in patients with nonalcoholic fatty liver disease: a systematic literature review

CONTEXT

Nonalcoholic fatty liver disease (NAFLD) represents a spectrum of liver disorders, ranging from simple steatosis to nonalcoholic steatohepatitis (NASH), with inflammation acting as a key driver in its pathogenesis and progression. Diet has the potential to mediate the release of inflammatory markers; however, little is known about the effects of various diets.

OBJECTIVE

This systematic review aimed to evaluate the effect of dietary interventions on cytokines and adipokines in patients with NAFLD.

DATA SOURCES

The electronic databases MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched for clinical trials investigating dietary interventions, with or without supplementation, on cytokines and adipokines in NAFLD patients.

DATA EXTRACTION

Basic characteristics of populations, dietary intervention protocol, cytokines, and adipokines were extracted for each study. Quality of evidence was assessed using the American Dietetic Association criteria.

DATA ANALYSIS

Nineteen studies with a total of 874 participants were included. The most frequently reported inflammatory outcomes were C-reactive protein (CRP), tumor necrosis factor alpha (TNF-α), interleukin 6 (IL-6), adiponectin, and leptin. Hypocaloric, isocaloric, or low-fat diets significantly (P < 0.05) lowered levels of CRP, TNF-α, and adiponectin. The addition of nutraceutical or pharmacological supplementation to dietary interventions appeared to elicit additional benefits for all of the most frequently reported inflammatory markers.

CONCLUSIONS

Hypo- or isocaloric diets alone, or with co-interventions that included a nutraceutical or pharmacological supplementation, appear to improve the inflammatory profile in patients with NAFLD. Thus, anti-inflammatory diets may have the potential to improve underlying chronic inflammation that underpins the pathophysiological mechanisms of NAFLD. In the absence of any known liver-sensitive markers, the use of cytokines and adipokines as a surrogate marker of liver disease should be further investigated in well-controlled trials.

Combination therapy of flaxseed and hesperidin enhances the effectiveness of lifestyle modification in cardiovascular risk control in prediabetes: a randomized controlled trial

BACKGROUND

Regarding the increasing prevalence of cardiometabolic abnormalities, and its association with non-communicable chronic diseases, providing preventive and therapeutic strategies is a priority. A randomized placebo-controlled study was conducted to assess the effects of combination therapy of milled brown flaxseed and hesperidin during lifestyle intervention on controlling cardiovascular risk in prediabetes.

METHODS

A total of forty-eight subjects were randomly assigned to receive lifestyle intervention plus combination therapy of brown flaxseed (30 g milled) and hesperidin (two 500 mg capsules) or lifestyle modification alone for 12 weeks. Changes from baseline in anthropometric measures, lipid profile and atherogenic indices, glucose homeostasis parameters, and inflammatory biomarkers was assessed as a primary end point.

RESULTS

Anthropometric data comparison between the two groups showed a significant reduction in weight (p = 0.048). Waist circumference reduction was about twice that of the control group (- 6.75 cm vs - 3.57 cm), but this difference was not statistically significant. Comparison of blood pressure changes throughout the study indicated a greater reduction in blood pressure in the intervention group rather than control group (- 5.66 vs. - 1.56 mmHg, P = 0.049). Improvements of lipid profile and atherogenic indices, glucose homeostasis parameters, and inflammatory biomarkers in flaxseed-hesperidin group was significantly more than the control group after 12 weeks of intervention (p < 0.05).

CONCLUSION

Our results indicate that co-administration of flaxseed and hesperidin as an adjunct to lifestyle modification program is more effective than lifestyle modification alone in the metabolic abnormalities remission of prediabetic patients.

TRIAL REGISTRATION

 The trial was registered with ClinicalTrials.gov, number NCT03737422. Registered 11 November 2018. Retrospectively registered, https://clinicaltrials.gov/ct2/results?cond=&term=NCT03737422&cntry=&state=&city=&dist= .

The effects of sumac (Rhus coriaria L.) powder supplementation in patients with non-alcoholic fatty liver disease: A randomized controlled trial

BACKGROUND

In recent years, great attention has been paid to the role of herbal medicine in the management of non-alcoholic fatty liver disease (NAFLD). Sumac (Rhus coriaria L.) is a popular herb which contains major bioactive compounds known for a variety of health benefits. This study aimed to assess the effects of sumac powder supplementation on hepatic fibrosis and some metabolic markers in patients with NAFLD.

METHODS

Eighty-four patients diagnosed with NAFLD were included in this randomized double-blind placebo-controlled clinical trial. They were randomly assigned to receive 2000 mg per day sumac powder (n = 42) or placebo (n = 42) for 12 weeks. Also, both groups received a 500-calories deficit diet plan. Hepatic fibrosis and liver enzymes (ALT and AST) as well as fasting blood sugar (FBS), serum insulin, HbA1c, HOMA-IR (insulin resistance index), QUICKI (insulin sensitivity index), malondialdehyde (MDA), and high sensitivity C-reactive protein (hs-CRP) were measured at baseline and the end of trial.

RESULTS

Eighty patients completed the trial. After 12-weeks of intervention, subjects in the sumac group showed a greater decrease in hepatic fibrosis and liver enzymes as well as FBS, serum insulin, HbA1c, HOMA-IR, MDA, and hs-CRP, compared to the placebo (P-value < 0.05); while the QUICKI was significantly higher in the sumac group at the end of intervention.

CONCLUSION

Daily intake of 2000 mg sumac powder along with a low-calorie diet for 12 weeks was beneficial for the management of NAFLD.

The effects of Bacillus coagulans supplementation in patients with non-alcoholic fatty liver disease: A randomized, placebo-controlled, clinical trial

BACKGROUND

The aim of this study was to evaluate the effects of supplementation with 10⁹ spores of Bacillus coagulans (GBI-30) plus inulin in patients with non-alcoholic fatty liver disease (NAFLD).

METHODS

In a randomized, double-blind, placebo-controlled clinical trial, fifty three patients with NAFLD were randomly assigned to receive either a synbiotic or a placebo capsule for 12 weeks. The primary outcome was reduction in steatosis score in Fibroscan exam.

RESULTS

At the end of study, serum alanine aminotransferase and γ glutamine transaminase decreased significantly more in synbiotic group compared to placebo group (p = 0.001, and p = 0.004, respectively). Synbiotic supplementation significantly reduced serum tumor necrosis factor-α (p = 0.03) and nuclear factor-κB activity (p = 0.04). Moreover, hepatic steatosis reduced significantly more in synbiotic group compared to placebo group (p < 0.001).

CONCLUSION

Our results indicate that 12 weeks supplementation with B. coagulans plus inulin is beneficial for treatment of NAFLD and its related inflammation without any significant effects on related cardiovascular risk factors.

CLINICAL TRIALS

This trial was registered at irct.ir with number of IRCT20100524004010N23.

The efficacy of flaxseed and hesperidin on non-alcoholic fatty liver disease: an open-labeled randomized controlled trial

BACKGROUND/OBJECTIVES

Non-alcoholic fatty liver disease (NAFLD) is growing in prevalence globally and no definitive evidence for any approved pharmacological approaches for patients with NAFLD has been found yet. This study was aimed to assess the clinical effects of flaxseed and hesperidin in patients with NAFLD.

SUBJECTS/METHODS

In this randomized, controlled, clinical trial, one hundred eligible patients with NAFLD were enrolled and randomly assigned to four dietary intervention groups including lifestyle modification program (control), lifestyle modification program with 30 g whole flaxseed powder, lifestyle modification program with 1 g hesperidin supplementation, and lifestyle modification program with combination of 30 g flaxseed and 1 g hesperidin (flax-hes) for 12 weeks. The changes in anthropometric parameters, metabolic profiles of glucose and lipids, inflammatory biomarkers and hepatic steatosis and fibrosis were evaluated.

RESULTS

After the 12-week dietary interventions, significant reductions in body mass index, glucose hemostasis parameters and hepatic steatosis were observed in all groups. Repeated measures analysis of variance revealed a significant effect for time relative to almost all paraclinical parameters. Post hoc analysis with Bonferroni correction revealed that the three intervention groups experienced significant decreases in plasma levels of alanine aminotransferase, indices of insulin resistance and insulin sensitivity, fasting glucose and fatty liver index compared to control (p < 0.008).

CONCLUSIONS

In conclusion, our study confirmed that hesperidin and flaxseed supplementation improved glucose and lipid metabolism, while reduced inflammation and hepatic steatosis (controlled attenuation parameter) in NAFLD patients. The synergistic effects of their combination were observed on plasma glucose concentration and HOMA-IR.

Flaxseed for Health and Disease: Review of Clinical Trials

BACKGROUND

Flaxseed (Linum usitatissimum) is an oil-based seed that contains high amounts of alpha-linolenic acid, linoleic acid, lignans, fiber and many other bioactive components which is suggested for a healthier life. Nowadays, flaxseed is known as a remarkable functional food with different health benefits for humans and protects against cardiovascular disease, diabetes, dyslipidemia, obesity and altogether metabolic syndrome.

METHODS

To review the bioactive components of flaxseed and their potential health effects, PubMed and Scopus were searched from commencement to July 2019. Keywords including: "flaxseed", "Linum usitatissimum", "metabolic syndrome", "obesity", "inflammation", "insulin resistance", "diabetes", "hyperlipidemia" and "menopause" were searched in the databases with varying combinations.

CONCLUSION

Consumption of flaxseed in different forms has valuable effects and protects against cardiovascular disease, hypertension, diabetes, dyslipidemia, inflammation and some other complications. Flaxseed can serve as a promising candidate for the management of metabolic syndrome to control blood lipid levels, fasting blood sugar, insulin resistance, body weight, waist circumference, body mass and blood pressure.

Energy-dense nutrient-poor snacks and risk of non-alcoholic fattyliver disease: a case-control study in Iran

OBJECTIVE

The purpose of the present study was to determine the association between energy-dense nutrient-poor snacks intake and the risk of non-alcoholic fatty liver disease (NAFLD) in Iranian adults. For this purpose, a total of 143 cases with a newly confirmed diagnosis of NAFLD and 471 controls free of the disease were studied. Dietary intake was assessed using a food frequency questionnaire.

RESULTS

The percentage of calories from total energy-dense nutrient-poor snacks was 6.08% and 5.04%, in patients and controls, respectively (P = 0.036). Compared with subjects in the lowest quartile of total energy-dense nutrient-poor snacks intake, the risk of NAFLD for those in the top quartile of consumption increased by about two times, in both crude (OR: 1.94; 95% CIs 1.16-3.26; P for trend = 0.015) and adjusted (OR: 2.27; 95%CIs 1.19-4.31; P for trend = 0.001) models. The relative odds of NAFLD increased significantly in the fourth quartile of dietary cake and biscuit (OR: 1.21, P for trend = 0.037) and soft drinks (OR: 1.64, P for trend = 0.005) intake compared with the lowest corresponding quartiles, after adjustment for age, sex, body mass index, physical activity, alcohol, energy intake. Our results indicate that there might be a moderate positive association between energy-dense nutrient-poor snacks intake and risk of NAFLD.

Flaxseed oil in the context of a weight loss programme ameliorates fatty liver grade in patients with non-alcoholic fatty liver disease: a randomised double-blind controlled trial

Long-chain n-3 fatty acids have been shown to regulate lipid metabolism and reduce fat accumulation in the liver. This trial investigated the effect of flaxseed oil, as a rich source of α-linolenic acid, on fatty liver and cardiometabolic risk factors in patients with non-alcoholic fatty liver disease (NAFLD). The randomised, double-blind, controlled trial was performed on sixty-eight NAFLD patients who were divided into flaxseed (n 34) and sunflower (n 34) oil groups. Patients were given a hypoenergetic diet (−2092 kJ/d) and 20 g/d of the corresponding oil for 12 weeks. Fatty liver grade, liver enzymes and cardiometabolic parameters were determined. The intention-to-treat approach was used for data analysis. Fatty liver grade significantly decreased in both groups (−0·68 in flaxseed v. −0·29 in sunflower, P = 0·002). Alanine aminotransferase and aspartate aminotransferase decreased in both groups (P < 0·01). Also, significant reduction was observed in blood glucose (P = 0·005) and fat mass (P = 0·01) in the flaxseed and muscle mass (P = 0·01) in the sunflower group. However, none of these alterations was significantly different between the groups. Weight, waist circumference and blood pressure were significantly decreased in both groups but only weight change was significantly different between the groups (P = 0·01). IL-6 did not significantly change in either group but showed a significant between-group difference (P = 0·03). Overall, the results showed that in the context of a low-energy diet and moderate physical activity, flaxseed oil may benefit NAFLD patients to improve fatty liver grade, weight and IL-6 compared with sunflower oil.

The effects of flaxseed supplementation on metabolic status in women with polycystic ovary syndrome: a randomized open-labeled controlled clinical trial

BACKGROUND

Polycystic Ovary Syndrome (PCOS) is known as the most common endocrine disorder of women in reproductive ages. With the increasing prevalence of PCOS in different countries, the use of herbal medicine as an alternative treatment is growing in these patients. This study aimed to evaluate the effects of flaxseed powder supplementation on metabolic biomarkers of patients with PCOS.

METHODS

This randomized open-labeled controlled clinical trial was conducted on 41 patients with PCOS. The participants were randomized to take either flaxseed powder (30 g/day) plus lifestyle modification or only lifestyle modification for 12 weeks. Anthropometric and biochemical evaluations were performed for all patients at the beginning and end of the study.

RESULTS

The flaxseed group showed a significant reduction in body weight, insulin concentration, Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), Triglycerides (TG), high-sensitivity C-Reactive Protein (hs-CRP), and leptin and an increase in Quantitative Insulin-Sensitivity Check Index (QUICKI), High Density Lipoprotein (HDL), and adiponectin compared to the baseline (p < 0.05). Flaxseed supplementation also led to a significant reduction in insulin concentration, HOMA-IR, TG, hs-CRP, Interleukin 6 (IL- 6), and leptin and an increase in QUICKI, HDL, and adiponectin compared to the control group (p < 0.05). No significant changes were observed in other parameters.

CONCLUSIONS

Flaxseed supplementation plus lifestyle modification was more effective compared to lifestyle modification alone in biochemical and anthropometric variables in patients with PCOS.

TRIAL REGISTRATION

The trial protocol was approved by the Ethics Board at Ahvaz Jundishapur University of Medical Sciences and was registered at Iranian Registry of Clinical Trials (code: IRCT20120704010181N11).

Effects of Flaxseed Interventions on Circulating Inflammatory Biomarkers: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

There have been various clinical studies on the effect of flaxseed-derived products on circulating inflammatory biomarkers, but the findings from these are contradictory. The aim of the present study was to clarify any association. A comprehensive literature search was conducted from inception to May 2018. From the eligible trials, 32 articles describing studies conducted on adults aged 18-70 y were selected for the meta-analysis. Meta-analyses using the random-effects model were performed to investigate the data and results showed significant effects of flaxseed intake on circulating high-sensitivity CRP (hs-CRP) [weighted mean difference (WMD) = -0.75; 95% CI: -1.19, -0.30; P < 0.001] and TNFα (WMD = -0.38; 95% CI: -0.75,-0.01; P = 0.04). However, no significant changes were found in IL6 concentration (WMD = -0.24; 95% CI: -0.70, 0.21; P = 0.28) and C-reactive protein (CRP) (WMD = -0.34; 95% CI:-0.89, 0.20; P = 0.22). Moreover, by eliminating 1 of the studies from the sensitivity analysis, changes in IL6 concentration were significant (WMD = -0.44; 95% CI: -0.81, -0.08). The changes in inflammatory biomarkers were dependent on study design (parallel or crossover), supplement type (flaxseed, flaxseed oil, or lignan), study quality (high or low), and participants' age and BMI. According to this meta-analysis, flaxseed significantly reduced circulating concentrations of hs-CRP and TNFα, but did not affect IL6 and CRP. Further research is needed to examine the effect of different doses and long-term benefits of flaxseed and its derivatives on inflammatory factors.

Polyphenol intakes and risk of impaired lipid profile, elevated hepatic enzymes and nonalcoholic fatty liver disease

Purpose

Polyphenols are plant-derived bioactive compounds with some known hepato-protective effects. The purpose of this study is to evaluate the association between polyphenol consumption and risk of nonalcoholic fatty liver disease (NAFLD) and its related conditions such as impaired lipid profile and elevated hepatic enzymes.

Design/methodology/approach

A total of 196 NAFLD patients and 803 controls were enrolled in this case-control study. Biochemical and anthropometric measurements as well as polyphenol consumption during the previous year were assessed.

Findings

In unadjusted model, participants who consumed the third and fourth quartiles of polyphenols intake were less likely to have NAFLD in comparison to those who consumed the first quartile [odds ratio, OR: 0.48; 95 per cent confidence interval, CI: (0.30-0.77) and OR: 0.62; 95 per cent CI: (0.40-0.96), respectively]. In separate analysis of genders, this effect was seen only in male participants [OR: 0.29; 95 per cent CI: (0.14-0.58) and OR: 0.21; 95 per cent CI (0.10-0.42), respectively], and the association remained significant after adjustment for energy, body mass index, age and smoking.

Originality/value

Higher total polyphenol intake is associated with a decreased risk of NAFLD. Prospective studies are needed to confirm these results.

Association Between Index of Nutritional Quality and Nonalcoholic Fatty Liver Disease: The Role of Vitamin D and B Group

BACKGROUND

Numerous studies have revealed that diet has been considered as an important pathogenic factor for nonalcoholic fatty liver disease (NAFLD). The Index of Nutritional Quality (INQ) is a method of quantitative and qualitative evaluation of single foods and diets, which has special significance in recognizing clinical nutritional problems.

MATERIALS AND METHODS

This study included 295 patients with NAFLD and 704 controls. The dietary intake was assessed through a valid and reliable food frequency questionnaire. INQ was calculated from the questionnaire data and was compared between the 2 groups.

RESULTS

The controls had higher INQ of vitamin D, vitamin E, thiamin, riboflavin, niacin, vitamin B12; biotin, pantothenic acid, magnesium and zinc compared to the patients with NAFLD. After controlling for several covariates, positive associations were observed between NAFLD risk and INQs of riboflavin (OR_riboflavin = 0.49, 95% confidence interval [CI]: 0.28-0.78; OR_biotin = 0.35, 95% CI: 0.18-0.76; OR_pantothenic = 0.28, 95% CI: 0.12-0.64; OR_magnesium = 0.28, 95% CI: 0.11-0.75; OR_zinc = 0.15 95% CI: 0.05-0.42).

CONCLUSIONS

Findings of the present study suggest that subjects who follow a more healthy and nutrient-rich diet, especially in terms of vitamins D, B1, B2, B12, B3 and zinc, are at a lower risk of NAFLD compared to those who consume unhealthy and nutrient-poor diet.

Hesperidin improves hepatic steatosis, hepatic enzymes, and metabolic and inflammatory parameters in patients with nonalcoholic fatty liver disease: A randomized, placebo-controlled, double-blind clinical trial

This study aimed to evaluate the effects of hesperidin on nonalcoholic fatty liver disease (NAFLD) characteristics. In this randomized, double-blind, controlled clinical trial, 50 NAFLD patients were supplemented with either 1-g hesperidin capsule or identical placebo capsule for 12 weeks. During the intervention, both groups were advised to follow healthy lifestyle habits including dietary and physical activity recommendations. At the end of the study, hesperidin supplementation, compared with placebo, was associated with a significant reduction in alanine aminotransferase (p = .005), γ-glutamyltransferase (p = .004), total cholesterol (p = .016), triglyceride (p = .049), hepatic steatosis (p = .041), high-sensitivity C-reactive protein (p = .029), tumor necrosis factor-α, and nuclear factor-κB (NF-κB). In conclusion, our results indicate that hesperidin supplementation accompanied with lifestyle modification is superior to lifestyle modification alone in management of NAFLD at least partially through inhibiting NF-κB activation and improving lipid profile. Further studies with higher dose of hesperidin are required to find the optimal dose.

What are the main areas of focus to prevent or treat non-alcoholic fatty liver disease?

Recently, a growing body of information has accumulated to suggest that nutritional status and food compounds impact on the development or progression of non-alcoholic fatty liver disease (NAFLD). The best strategy to prevent and treat NAFLD is to modify diet and lifestyle by maintaining a healthy weight, following a well-balanced diet with appropriate energy intake and increasing physical activity or strength training. Here we review the literatures and discuss existing and potential therapeutic strategies for the prevention and management of NAFLD, emphasizing the description of nutritional status and its clinical impact on the outcomes of NAFLD.

The links between the gut microbiome and non-alcoholic fatty liver disease (NAFLD)

NAFLD is currently the main cause of chronic liver disease in developed countries, and the number of NAFLD patients is growing worldwide. NAFLD often has similar symptoms to other metabolic disorders, including type 2 diabetes and obesity. Recently, the role of the gut microbiota in the pathophysiology of many diseases has been revealed. Regarding NAFLD, experiments using gut microbiota transplants to germ-free animal models showed that fatty liver disease development is determined by gut bacteria. Moreover, the perturbation of the composition of the gut microbiota has been observed in patients suffering from NAFLD. Numerous mechanisms relating the gut microbiome to NAFLD have been proposed, including the dysbiosis-induced dysregulation of gut endothelial barrier function that allows for the translocation of bacterial components and leads to hepatic inflammation. In addition, the various metabolites produced by the gut microbiota may impact the liver and thus modulate NAFLD susceptibility. Therefore, the manipulation of the gut microbiome by probiotics, prebiotics or synbiotics was shown to improve liver phenotype in NAFLD patients as well as in rodent models. Hence, further knowledge about the interactions among dysbiosis, environmental factors, and diet and their impacts on the gut-liver axis can improve the treatment of this life-threatening liver disease and its related disorders.

Impact of Nutritional Changes on Nonalcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) is a major global health threat due to its growing incidence and prevalence. It is becoming the leading cause of liver disease in addition to its strong association with cardio-metabolic disease. Therefore, its prevention and treatment are of strong public interest. Therapeutic approaches emphasize lifestyle modifications including physical activity and the adoption of healthy eating habits that intend to mainly control body weight and cardio-metabolic risk factors associated with the metabolic syndrome. Lifestyle interventions may be reinforced by pharmacological treatment in advanced stages, though there is still no registered drug for the specific treatment of NAFLD. The purpose of this review is to assess the evidence available regarding the impact of dietary recommendations against NAFLD, highlighting the effect of macronutrient diet composition and dietary patterns in the management of NAFLD.

Rates of and Factors Associated With Placebo Response in Trials of Pharmacotherapies for Nonalcoholic Steatohepatitis: Systematic Review and Meta-analysis

BACKGROUND & AIMS

It is important to know the extent of the placebo effect in designing randomized controlled trials for patients with nonalcoholic steatohepatitis (NASH), to accurately calculate sample size and define treatment endpoints.

METHODS

We performed a systematic review and meta-analysis of the placebo groups from randomized controlled trials of adults with NASH that provided histologic and/or magnetic resonance image-based assessments. We identified trials through a comprehensive search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus, from each database's inception through January 2, 2018.

RESULTS

We identified 39 randomized controlled trials, comprising 1463 patients who received placebo. Histologic assessment data (the nonalcoholic fatty liver disease activity scores, NAS) were available from 956 patients; magnetic resonance spectroscopy data were available from 295 patients and magnetic resonance proton density fat fraction measurements from 61 patients. Overall, 25% of patients given placebo had an improvement in NAS by 2 or more points (95% CI, 21%-29%) with a small amount of heterogeneity (I₂ = 27%). There were improvements by at least 1 point in steatosis scores of 33% ± 3% of patients, in hepatocyte ballooning scores of 30% ± 3% of patients, in lobular inflammation scores of 32% ± 3% of patients, and in fibrosis scores of 21% ± 3% of patients, with a moderate amount of heterogeneity among trials (I₂ range, 51%-63%). Patients given placebo had a statistically significant improvement in NAS (by 0.72 ± 0.19), with a large amount of heterogeneity (I₂ = 96%). Univariate and multivariate meta-regression showed that trials with a higher baseline NAS, those conducted in South America, and those in which patients had a decrease in body mass index, were associated with greater improvements in NAS among patients given placebo. Patients given placebo had significant reductions in intrahepatic triglyceride, measured by magnetic resonance spectroscopy (by 1.45% ± 0.54%) with moderate heterogeneity (I₂ = 40%), and in magnetic resonance proton density fat fraction (by 2.43 ± 0.89), without heterogeneity (I₂ = 0). Mean serum levels of alanine and aspartate aminotransferases decreased significantly (by 11.7 ± 3.8 U/L and 5.9 ± 2.1 U/L, respectively; P < .01 for both).

CONCLUSIONS

In a meta-analysis of randomized controlled trials of NASH, patients given placebo have significant histologic, radiologic, and biochemical responses. The placebo response should be considered in designing trials of agents for treatment of NASH.

Inflammatory markers response to citrulline supplementation in patients with non-alcoholic fatty liver disease: a randomized, double blind, placebo-controlled, clinical trial

Objectives

The aim of this study was to investigate the effects of citrulline (Cit) supplementation on inflammatory markers and liver histopathology in patients with non-alcoholic fatty liver disease (NAFLD). In this clinical trial, fifty NAFLD patients were assigned to receive 2 g/day Cit or placebo for 3 months.

Results

At the end of study, serum high sensitive C-reactive protein (hs-CRP) and activity of nuclear factor kappa B (NF-κB) were reduced in Cit group significantly more than placebo group (P-value = 0.02 and < 0.01 respectively). Serum concentrations of tumor necrosis factor-α (TNF-α) was reduced in Cit group significantly more than placebo after adjusting for levels of baseline (P-value < 0.001). Moreover, Cit supplementation decreased serum alanine aminotransferase (ALT) and hepatic steatosis significantly (P = 0.04). Anthropometric measurements and hepatic enzymes did not change significantly in any group (P ≥ 0.05). In conclusion, our results showed that 12 weeks supplementation with 2 g/day Cit improved inflammatory markers in patients with NAFLD. Further studies with longer period of supplementation and different dosages of Cit are needed to be able to conclude.

Trial registration IRCT201703194010N18 on 2017-10-13

Legume intake and risk of nonalcoholic fatty liver disease

BACKGROUND

It is known that diet plays a pivotal role in the pathogenesis and management of nonalcoholic fatty liver disease (NAFLD); however, the knowledge on the role of different food groups such as legumes is not enough.

METHODS

We designed this study to assess the relationship between legume intake and risk of NAFLD in framework of a case-control study among Tehrani adults. One hundred and ninety-six newly diagnosed patients with NAFLD and 803 controls were studied, and their dietary intake was assessed using a valid and reliable food frequency questionnaire. Conditional logistic regression was used to determine the odds ratio (OR) of NAFLD per increase of one serving/week dietary legumes, lentil, and beans adjusting for potential confounders.

RESULTS

In energy-adjusted model, greater intake of legumes, lentils, and beans was associated with a lower risk of NAFLD. These risk associations remained significant after adjusting for all known risk factors of NAFLD. OR of NAFLD in adjusted models for higher dietary intake of legumes, lentils, and beans were 0.73 (0.64-0.84), 0.61 (0.46-0.78), and 0.35 (0.17-0.74), respectively.

CONCLUSION

Our findings suggest that higher intake of total legumes (beans, lentils, and peas) was associated with lower risk of NAFLD.

The effects of curcumin supplementation on liver enzymes, lipid profile, glucose homeostasis, and hepatic steatosis and fibrosis in patients with non-alcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a major global health problem. The most common cause of death in these patients is due to cardiovascular disorders. The aim of this study was to examine the effects of curcumin supplementation on cardiovascular risk factors in patients with NAFLD.

METHODS AND MATERIALS

In this randomized, placebo-controlled, clinical trial, fifty two patients with NAFLD were randomly assigned to receive life style recommendations plus either 1500 mg curcumin or placebo for 12 weeks. Anthropometric indices, blood lipid profile, insulin resistance, as well as hepatic steatosis and fibrosis scores were measured at the beginning and the end of the study, and compared between and within groups.

RESULTS

Hepatic fibrosis, serum cholesterol, glucose and alanin aminotransferase (ALT) reduced significantly only in curcumin group (p < 0.05). Anthropometric indices, blood lipid profile, insulin resistance, and hepatic steatosis decreased significantly in both groups (p < 0.05), without any significant difference between two groups.

CONCLUSION

Our results showed that daily intake of 1500 mg curcumin plus weight loss is not superior to weight loss alone in amelioration of cardiovascular risk factors in patients with NAFLD. Further studies with different dosages of curcumin are needed to be able to conclude about the effects of this dietary supplement on cardiovascular risk factors and NAFLD characteristics.

The potential protective influence of flaxseed oil against renal toxicity induced by thioacetamide in rats

The present study was aimed to evaluate the influence of flaxseed oil on renal toxicity induced by thioacetamide in male rats. The animals were distributed into four groups. Rats of the first group were served as control. Rats of the second group were exposed to thioacetamide. Rats of the third group were treated with flaxseed oil and thioacetamide. Rats of the fourth group were treated with flaxseed oil. Significant increases of blood creatinine and uric acid were observed in TAA-treated rats after three weeks. In thioacetamide group, the levels of serum creatinine, blood urea nitrogen and uric acid were significantly elevated after six weeks. Histopathologically, the renal sections from thioacetamide-treated rats showed severe alterations in the structure of renal corpuscles including a degeneration of glomeruli and Bowman's capsules. Administration of flaxseed oil protects the observed biochemical and histopathological alterations induced by thioacetamide exposure. Hence, the results of this study suggest that flaxseed oil protects against thioacetamide-induced renal injury and the protective influence of flaxseed oil may be attributed to its antioxidant role.