Effect of herbal medicine Dia-No on clinical and biochemical parameters of metabolic syndrome

Effect of herbal medicine Dia-No on clinical and biochemical parameters of metabolic syndrome RP Agrawal, Jain Shereyans, Chopra Amit Jr, Jhajharia Ashok Diabetes Care and Research Centre, SP Medical College, Bikaner, Rajasthan, India, Pin 334003 Corresponding author: Dr RP Agrawal, 2 Adarsh Colony, Bikaner 334003, Rajasthan, India Ph: 0091 151 2202431 Fax: 0091 151 2202131 Email: drrpagrawal@yahoo.co.in Herbal preparations have attracted attention in the management of metabolic syndrome. Since time immemorial, medicinal plants have been used in virtually all cultures. The traditional herbs require scientific and medical evaluation. Ten classic herbs have been combined in Dia-No, a polyherbal preparation containing water extracts of its ingredients, known for their anti-hyperglycemic and antihyperlipidemic potential. Efficacy of Dia-No on clinical and biochemical parameters of metabolic syndrome was evaluated. Two hundred patients with metabolic syndrome were selected randomly after meeting inclusion and exclusion criteria. The patients were divided into two groups, one group receiving the drug and the other receiving a placebo bearing a distinctive code number. Anthropometric parameters, metabolic profile fasting blood sugar, HbA1c and lipid profiles were performed initially and after 3 months of treatment. Renal, liver function and any untoward effects were noted. After three months of treatment with Dia-No, there was a significant improvement in body mass index (BMI) (25.64±5.12 to 25.46±5.01, p<0.05), systolic blood pressure (135.89±18.48 to 133.60±14.52 mmhg, p<0.05) and fasting blood sugar (221.29±74.16 to 180.14±40.64, p<0.01). There was a significant reduction in HbA1c (9.07±2.04 to 8.47±1.90 %, p<0.01). Changes in triglyceride level, VLDL and LDL were also significant (159.54±28.09 to 148.95±27.07, p<0.01; 31.91±5.81 to 29.87±5.46, p<0.01 and 123.18±29.27 to 119.69±27.14, p<0.05 respectively) after treatment. No adverse effects were observed in this trial. The polyherbal preparation of 10 classic herbs appears to be effective in controlling glycemia and dyslipidemia. Dia-No seems to be a safe drug and an effective oral agent in the management of metabolic syndrome. Key Words: Herbal medicine, metabolic syndrome Introduction Metabolic syndrome is an insulin resistant condition comprising a spectrum of disorders including hyperglycemia, hypertension, dyslipidemia and accelerated cardiovascular disease. The traditional healthcare system of India, Ayurveda, offers a balanced and holistic multimodality approach to treat this disorder. In Ayurveda and Hindu literature (such as Charak Samhita, Madhav Nidan and Astang Sanghra) there are around 600 plants with supposed antidiabetic properties. Only a small number of these have received scientific and medical evaluation. The 20 th century has also seen a revival of more natural medicines as an outcome of increasing disenchantment with conventional medicine. It has been postulated that by utilising natural substances together in their whole form in accurate formulations or in combination, effectiveness will be maximised and side effects minimised. This is contrary to conventional medicine that extracts or synthesises active chemicals that often over time produce side effects. Traditionally Indians have used herbal products for the management of metabolic syndrome but clinical drug trials are lacking. For instance the plant extract guanidine (from Galega officinalis), which lowers blood glucose, prompted the development and use of biguanides, a commonly used oral medication for glycemic control. Despite considerable literature on this, very little work has been done on these parameters. Hence it was planned to study the intervention of a new herbal product Dia-No to see the effect on clinical and biochemical parameters of metabolic syndrome. 113

Dia-No is a polyherbal preparation of water extracts of 10 classic herbs combined in a fibre base. All the ingredients of Dia-No have been known in Indian traditional medicine for their antihyperglycemic potential. Many of these also possess antihyperlipidemic and antioxidant activity. Ten ingredients of the polyherbal Dia-No S. No. Botanical name Common % Hindi name English name Concentration Part Used 01 Syzigium cumini Jamun Jamun 20 Seed 02 Trigonella foenum- Seed Fenugreek Methi 14 graecum 03 Azadirachta indica Neem Neem 07 Leaf 04 Emblica officinalis Indian gooseberry Aonla 10 Fruit 05 Cassia auriculata Cassia Tarwar 07 Flower 06 Gymnema sylvestre Gymnema Gurmar 20 Leaf 07 Tribulus terristris Caltrops Gokharu 07 Fruit 08 Andrographis paniculata Andrographis Kalmegh 05 Leaf 09 Pterocarpus marsupium Pilfar Vijaysar 05 Heart wood 10 Momordica charantia Bittergourd Karela 05 Fruit Methods Design of study Randomised double blind placebo controlled study. Selection of patients Two hundred patients with metabolic syndrome were selected randomly from outdoor and indoor patients of the Associated Group of Hospitals, SP Medical College, Bikaner. Procedure and motive of the study were explained to the patients and informed consent was taken. Approval was obtained by the Ethics Committee, SP Medical College and Associated Group of Hospitals, Bikaner. Metabolic syndrome was diagnosed by NCEP ATP guidelines: 140/ 90 mmhg Waist Males >102 cm Circumference Females > 88 cm Triglycerides >150 mg/dl HDL Cholesterol Males < 40 mg/dl Females <50 mg/dl Fasting Plasma Glucose >110 mg/dl Patients meeting inclusion criteria were stabilised by standard diet and exercise for one month. These patients were divided into two groups randomly. One group received drug A and another group received drug B. Exclusion criteria Patients suffering from liver disease, arthritis, pulmonary tuberculosis, malabsorption or alcoholism were excluded from the study. Patients taking insulin, lipid lowering drugs, anti hypertensive agents or weight reduction drugs were not included. The medications offered to the patients were given in identical packs bearing a distinctive code number. Depending on the specific code number the patients received either Dia-No or placebo. A specific member of the research project was responsible for the distribution of the drug or placebo. Another member of the team, who was completely blinded to the drug status performed clinical and biochemical investigations. Patients visits were scheduled weekly and 20 tablets were provided on each visit. Patients were instructed to take one tablet daily after lunch and dinner. On every office visit patient compliance was checked by counting remaining tablets. All the data along with code numbers was submitted to the statistician and after decoding, the patients were divided into group I (placebo) and group II (Dia-No). Patients were examined for: waist circumference: body circumference measured midway between the iliac crest and lowest rib blood pressure: by sphygmomanometer fasting blood sugar: by glucose oxidase method lipid profile: by auto analyser HbA 1 c: by DS5 Drew Scientific machine (ion exchange chromatography). Blood samples were taken after 8 hours of fasting. For side effect profile, besides clinical examination, liver function tests and renal functional tests were performed. 114

Statistical analysis The data is expressed as mean ± SD; statistical analysis is performed according to intention to treat analysis. Analysis is performed by using SPSS version 10.0 computer software. Results The demographic and clinical profiles of both the groups (drug and placebo) were studied for different variables in the beginning of study and there was no significant difference in baseline characteristics (table 1). The mean BMI in the treatment group decreased from 25.64±5.12 to 25.46±5.01, (p<0.05). Improvement in systolic blood pressure from 135.89±18.48 to 133.60±14.52 mmhg was significant at p<0.05 level after treatment with Dia- No. The mean fasting blood sugar and HbA 1 c in the treatment group improved from a value of 221.29±74.16mg/dl and 9.07±2.04% to 180.14±40.64mg/dl and 8.47±1.90% respectively (p<0.01). Improvements in mean serum cholesterol and HDL were insignificant while the significant changes in triglycerides (159.54±28.09 to 148.95±27.07, p<0.01), VLDL (31.91±5.81 to 29.87±5.46, p<0.01) and LDL (123.18±29.27 to 119.69±27.14, p<0.05) were observed in the Dia- No treated group. There was no statistically significant difference in the blood urea (28.80±6.24 to 28.10±8.65mg/dl), serum creatinine (0.97±0.37 to 0.95±0.25 mg/dl) and serum bilirubin (0.76 ± 1.15 to 0.75±1.15 g/dl) after drug treatment (table 2). There was no significant difference in any parameter in the placebo group except in fasting blood sugar and HbA 1 c levels. In this group fasting blood sugar increased from 237.78±74.83 mg/dl to 259.45±68.80 mg/dl (p<0.01) while HbA 1 c raised levels from 8.66±1.80 to 9.10±1.68% (p<0.01) (table 3). In both the groups during the three months duration there were no noticeable side effects. Table 4 shows significant effects of Dia-No on three out of five parameters of metabolic syndrome: systolic blood pressure, fasting blood sugar and triglycerides level. There was mild nausea, vomiting or epigastric pain in two patients initially but these symptoms subsided without any intervention or withdrawal of the drug (table 5). Table 1 Baseline characteristics Group I (n = 89) Group II (n = 94) Mean SD Mean SD t p Age (yrs) 52.81 10.30 51.85 11.77 0.59 0.19 Sex (M/F) 31 F : 58 M 49 F : 45 M - - BMI 25.88 4.37 25.64 5.12 0.24 0.78 Waist Circumference 89.34 10.79 85.71 14.36 1.96 0.09 Systolic 137.07 17.22 135.89 18.48 0.44 0.57 (mmhg) Diastolic 85.93 11.95 84.04 12.19 2.23 0.06 Glycemic Control FBS(mg/dl) 237.78 74.83 221.29 74.16 1.73 0.08 HbA1c(%) 8.66 1.80 9.07 2.04 1.57 0.19 Serum cholesterol 188.70 34.43 190.07 35.26 0.26 0.77 Triglycerides Lipid Profile 169.42 46.14 159.54 28.09 1.73 0.09 (mg/dl) HDL 45.26 9.27 44.70 24.72 0.21 0.76 VLDL 34.28 12.10 31.91 5.81 1.74 0.09 LDL 122.11 25.10 123.18 29.27 0.26 0.74 B. urea (mg/dl) Renal Function 29.33 5.72 28.80 6.24 0.31 0.79 S. Creatinine (mg/dl) 0.99 0.30 0.97 0.37 0.51 0.58 S. Bilirubin (mg/dl) 0.70 0.45 0.76 1.15 1.50 0.19 LFT SGOT (IU/L) 25.15 6.54 24.50 7.28 0.62 0.49 SGPT (IU/L) 24.07 5.31 25.29 7.63 1.27 0.98 Group I = Control group Group II = Study group 115

Table 2 Comparison of parameters before and after treatment in Dia-No treated group Before Treatment After Treatment Mean SD Mean SD t p BMI 25.64 5.12 25.46 5.01 2.46 0.02 Waist Circumference 85.71 14.36 85.69 13.81 >0.05 NS Systolic 135.89 18.48 133.60 14.52 2.22 0.03 (mmhg) Diastolic 84.04 12.19 82.81 11.61 1.07 0.29 Glycemic Control FBS(mg/dl) 221.29 74.16 180.14 40.64 7.21 0.00 HbA1c(%) 9.07 2.04 8.47 1.90 6.46 0.00 Serum cholesterol 190.07 35.26 187.86 32.68 1.32 0.19 Triglycerides 159.54 28.09 148.95 27.07 9.30 0.00 Lipid Profile HDL 44.70 24.72 45.82 10.36-0.53 0.60 (mg/dl) VLDL 31.91 5.81 29.87 5.46 7.77 0.00 LDL 123.18 29.27 119.69 27.14 2.11 0.04 Renal Function B urea (mg/dl) 28.80 6.24 28.10 8.65 2.37 0.42 S. Creatinine (mg/dl) 0.97 0.37 0.95 0.26 2.40 0.59 S. Bilirubin 0.76 1.15 0.75 1.15 0.82 0.41 LFT SGOT (IU/L) 24.50 7.28 23.90 6.09 1.48 0.14 SGPT (IU/L) 25.29 7.63 26.71 17.20-0.82 0.42 Table 3 Comparison of parameters before and after treatment in control group Before Treatment After Treatment Mean SD Mean SD t p BMI 25.88 4.37 26.01 5.38-0.34 0.74 Waist Circumference 0.9340 0.07 0.9343 0.07 0.08 0.94 Systolic 137.07 17.22 139.20 16.84-1.02 0.31 (mmhg) Diastolic 85.93 11.95 87.89 12.20-1.32 0.19 Glycemic Control FBS(mg/dl) 237.78 74.83 259.45 68.80-4.63 0.00 HbA1c(%) 8.66 1.80 9.10 1.68-4.72 0.00 Serum cholesterol 188.70 34.43 191.07 30.39-1.57 0.12 Triglycerides 169.42 46.14 171.01 39.38-1.07 0.29 Lipid Profile HDL 45.26 9.27 44.31 10.38 1.87 0.07 (mg/dl) VLDL 34.28 12.10 34.62 11.57-1.17 0.25 LDL 122.11 25.10 123.29 24.85-0.72 0.47 Renal Function B urea (mg/dl) 29.33 5.72 30.81 6.22-7.60 0.31 S. Creatinine (mg/dl) 0.99 0.30 1.00 0.20-0.51 0.61 S. Bilirubin 0.70 0.45 0.71 0.45-1.00 0.32 LFT SGOT (IU/L) 25.15 6.54 25.75 8.10 8.64 0.52 SGPT (IU/L) 24.07 5.31 24.67 6.13 4.54 0.06 Table 4 Effect of Dia-No on all parameters of metabolic syndrome Waist circumference 0 month Mean SD 85.71 14.36 3 months Mean SD 85.69 13.81 p- value 0.98 Blood pressure (mmhg) Systolic Diastolic 135.89 84.04 18.48 12.19 133.60 82.81 14.52 11.61 0.03 0.29 Fasting Blood Sugar (mg/dl) Triglycerides 221.29 159.54 74.16 28.09 180.1 148.95 40.6 27.07 0.00 0.00 HDL 44.70 24.72 45.82 10.36 0.60 116

Table 5 Side effect of profile of Dia-No (n = 94) Discussion Side Effect n Nausea 2 Vomiting 1 Loss of appetite 2 Burning epigastrium 1 Liver dysfunction 0 Renal dysfunction 0 All the ingredients of Dia-No are known in the Indian traditional system of medicine for their antihyperglyemic and antihyperlipidemic potential. These components have been demonstrated to have beneficial effects in animal and human studies individually as well as in combination. In this study the mean BMI and systolic blood pressure decreased significantly in the treatment group. Kochhar et al (2005) have reported a significant decrease in weight and BMI in overweight subjects due to oral administration of Syzigium, Momordica and Trigonella seed (equal parts 2 g/day) for three months. Reductions in systolic and diastolic blood pressure were also observed in these diabetic subjects. The significant fall in fasting blood sugar and HbA 1 c may be attributed to the hypoglycemic potential of some of ingredients of Dia-No. Dixit et al (1986) treated both normoglycemic and alloxan induced hyperglycemic rats with neem oil at a dose of 200 mg/kg orally. It produced a significant lowering of blood glucose. The decrease was more pronounced in mildly hyperglycemic rats. The result could be attributed to several mechanisms including increased peripheral glucose utilization, increased release of insulin and/or inhibition of the proximal tubular reabsorption mechanism for glucose in kidney. The hypoglycemic effect of Syzigium seed on alloxan induced diabetic rats was observed in a study (Prince et al 2004). Researchers have demonstrated evidence of insulinotropic and antidiabetic properties of 4-hydroxyisoleucine isolated from fenugreek seeds in a glucose dependent manner (Sauvaire 1998). Yu et al (2000) observed oral administration of Andrographis decreased plasma glucose concentration in streptozotocin induced diabetic rats. Effects of the aqueous leaf extract of Gymnema on streptozotocin induced diabetic rats were observed for blood glucose homeostasis. In the diabetic rats fasting glucose levels returned to normal within 20 days of oral administration (Shanmugasundaram 1990). Kimura (2006) noted that gymnemic acid IV isolated from Gymnema sylvestris leaves has antisweet antihyperglycemic effects. In a comparative study on diabetic rats, the extract of Cassia flowers was found better than glibenclamide (600 µg/kg body weight) for HbA 1C and cholesterol levels (Pari 2002). It was suggested that the possible mechanism by which Cassia brings about its antihyperglycemic action may be potentiation of pancreatic secretion of insulin from β-cells of islets or due to enhanced transport of blood glucose to peripheral tissues. Saravanan and Pari (2005) have studied the antihyperglycemic, antiperoxidative and antihyperlipidemic activity of a polyherbal formulation containing 10 medicinal plants including nine used in Dia-No. Results indicated that treatment with glibenclamide and the polyherbal drug were comparable resulting in significant reduction of blood glucose and tissue lipids. Lipid peroxide formation clearly showed an antihyperlipidemic and antiperoxidative effect of the herbal formulation. In a clinical trial on normal and hypercholesterolemic men, oral administration of Emblica officinalis fruit demonstrated a decrease in total serum cholesterol levels (Jacob 1988). Chopra and Simon (2000) have shown that use of Emblica powder decreases serum LDH cholesterol levels and reduces fat deposits. Sodium-orthovanadate (SOV) and seed powder of Trigonella foenum graecum (TSP) besides being a potential hypoglycemic agent has been shown to ameliorate altered lipid metabolism during diabetes. Alloxan induced diabetic rats showed significant increase in blood glucose, total lipids, triglycerides and total cholesterol. SOV and TSP administration to diabetic animals prevented the development of hyperglycemia and alteration in lipid profile in plasma and tissues and maintained it near normal. Maximum prevention was observed in the combined treatment with lower dose of SOV (0.2%) (Yadev 2004). One study demonstrated that Pterocarpus marsupium may lower blood lipid levels. The use of an extract produced a reduction in serum triglycerides, total cholesterol, low density lipoproteins (LDL) and very low density lipoproteins (VLDL) cholesterol (Jahromi 1993). 117

The beneficial effect of this polyherbal preparation may be attributed to the components of Dia-No. The antihyperglycemic, antihyperlipidemic and antioxidant activity of this drug may be due to the combined or individual effect of its ingredients. The possible mechanisms involved may include: 1. Protection, stimulation and regeneration of β- cells, which confer insulinotropic properties. 2. Possible effect on insulin resistance by reducing adiposity. 3. Dietary fibre helps in the management of metabolic abnormalities. 4. Enhanced transport of blood glucose to peripheral tissues and increased peripheral glucose utilisation. 5. Glucose uptake inhibitory or glycosidase inhibitory effects. 6. Antioxidant effects by inhibiting oxidative stress. Biological antioxidant enzymes directly scavenge free radicals and prevent their conversion to toxic products. 7. Increased glucose metabolism and beneficial hypotryglyceridemic effect. As there is no such study of poly herbs available for comparison, the dose of ingredients has been calculated on previous knowledge. This may be a limiting factor and can be modified according to the results for a future plan. It can be concluded that DIA-NO, the polyherbal preparation of traditional medicinal plants, is an effective measure in controlling glycemia and dyslipidemia. It appears to be a safe and effective oral agent able to bring about favourable and significant changes in clinical and biochemical parameters of metabolic syndrome. References Chopra D, Simon D. 2000. The Chopra Centre Herbal Handbook. New York: Three Rivers Press. Dixit VP, Sinha R, Tank R. 1986. Effect of Neem seed oil on the blood glucose concentration of normal and alloxan diabetic rats. J Ethnopharmacol 17;95-8. Jacob A, Pandey M, Kapoor S, Saroja R. 1988. Effect of the Indian gooseberry (amla) on serum cholesterol levels in men aged 35-55 years. Eur J Clin Nutr 42;939-44. Jahromi MA, Ray AB. 1993. Antihyperlipidemic effect of flavonoids from pterocarpus marsupium. J Nat Prod 56;989-94. Kimura I. 2006. Medical benefits of using natural compounds and their derivatives having multiple pharmacological actions. Yakugaku Zasshi 126;133-43. Kochhar A, Nagi M, Sachdeva R. 2005. Impact of nutrition counselling and supplementation of medicinal plants on the anthropometry and blood pressure of the diabetic subjects. J Hum Ecol 18;235-8. Pari L, Latha M. 2002. Effect of Cassia auriculata flowers on blood sugar levels, serum and tissue lipids in streptozotocin diabetic rats. Singapore Med J 43;617-21. Prince PS, Kamalakkannan N, Menon VP. 2004. Antidiabetic and antihyperlipidaemic effect of alcoholic Syzigium cumini seeds in alloxan induced diabetic albino rats. J Ethnopharmacol 91;209-13. Saravanan R, Pari L. 2005. Antihyperlipidemic and antiperoxidative effect of Diasulin, a polyherbal formulation in alloxan induced hyperglycemic rats. BMC Comp Alt Med 22;5-14. Sauvaire Y, Petit P, Broca C et al. 1998. 4- Hydroxyisoleucine: a novel amino acid potentiator of insulin secretion. Diabetes 47; 206-10. Shanmugasundaram ER, Gopinath KL, Radha, Shanmugasundaram K, Rajendran VM. 1990. Possible regeneration of the islets of Langerhans in streptozotocin-diabetic rats given Gymema sylvestre leaf extracts. J Ethnopharmacol 30;265-79. Yadav UC, Moorthy K, Baquer NZ. 2004. Effects of sodium orthovanadate and Trigonella foenumgraecum seeds on hepatic and renal lipogenic enzymes and lipid profile during alloxan diabetes. J Bioscience 29;81-91. Yu BC, Hung CR, Chen WC, Cheng JT. 2000. Antihyperglycemic effect of andrographolide in streptozotocin-induced diabetic rats. Planta Med 69;1075-9. Ready to use Packs Tubes for creams or ointments in ready to use packs of 100 in 30ml 50ml and 100ml. Less expensive than jars or bottles Over 90% of the product in a tube can be easily dispensed and applied The tube is recyclable (given an established recycle stream) Easy to label and fill and seal with our starter kit Eliminates breakages of glass jars A syringe can easily be inserted into the nozzle for a measured dose as directed Market studies have confirmed consumers prefer tubes! They're easy to store, easy to use, portable and durable. Filling starter kits including sealing machine available. Online: www.weltrade.com.au Fax: 07 3337 9841 Email: sales@weltrade.com.au Phone: 07 5559 2923 WELTRADE Order now with free delivery 118