Prediabetes research studies for holistic treatments

Abstract
A potentially useful approach for drug discovery is to connect gene expression profiles of disease-affected tissues (“disease signatures”) to drug signatures, but it remains to be shown whether it can be used to identify clinically relevant treatment options. We analyzed coexpression networks and genetic data to identify a disease signature for type 2 diabetes in liver tissue. By interrogating a library of 3800 drug signatures, we identified sulforaphane as a compound that may reverse the disease signature. Sulforaphane suppressed glucose production from hepatic cells by nuclear translocation of nuclear factor erythroid 2–related factor 2 (NRF2) and decreased expression of key enzymes in gluconeogenesis. Moreover, sulforaphane reversed the disease signature in the livers from diabetic animals and attenuated exaggerated glucose production and glucose intolerance by a magnitude similar to that of metformin. Finally, sulforaphane, provided as concentrated broccoli sprout extract, reduced fasting blood glucose and glycated hemoglobin (HbA1c) in obese patients with dysregulated type 2 diabetes.

The effect of SFN-containing broccoli sprout extracts was studied in T2D patients
Prompted by these findings in vitro and in vivo, we set out to investigate the effects of SFN on glucose control in T2D patients. SFN has been provided at high concentration as broccoli sprout extracts (BSEs) in several clinical studies for cancer, chronic obstructive pulmonary disease, autism, and inflammatory diseases (www.clinicaltrials.gov) [we used high-performance liquid chromatography (HPLC)–purified SFN at 99.5% in our cell and animal studies, but this has not been used for human studies so far].

Here, we used a dried powder of an aqueous extract of broccoli sprouts, which contains high concentrations of glucoraphanin, the inert glucosinolate precursor of SFN.
Glucoraphanin is converted to SFN by the release of intrinsic sprout myrosinase during chewing and also by human enteric bacteria (37–40). After intake, the plasma concentration of SFN rises within 1 hour with a mean half-life of 1.77 ± 0.13 hours, but SFN exerts a sustained effect on gene expression (41). Renal tubular secretion is suggested to play a major role in the elimination (37). Safety studies using BSE corresponding to 50 to 400 ?mol SFN daily have shown that BSE is well tolerated without clinically significant adverse effects (42–45).
BSEs improves fasting glucose and HbA1c in obese patients with dysregulated T2D
We observed a clear association between HbA1c levels at start of treatment and ?HbA1c in response to BSE treatment (?HbA1c, 0.2 mmol/mol reduction per 1 mmol/mol higher HbA1c at start; P = 0.004, Fig. 4A), whereas there was no association in the placebo group (P = 0.5). There was also an association between BMI and ?HbA1c in BSE-treated patients (?HbA1c, 0.4 mmol/mol reduction per 1 kg/m2 higher BMI; P = 0.015 for the BSE group; not significant for the placebo group).

BSE is most effective in obese patients with dysregulated T2D
Glucose production is exaggerated in dysregulated T2D, which is reflected in the higher fasting blood glucose among the patients with dysregulated T2D in our study (8.6 ± 0.2 in patients with dysregulated T2D versus 7.5 ± 0.2 mM in patients with well-regulated T2D; P = 0.0001). Consequently, BSE reduced fasting glucose in patients with dysregulated T2D but not in patients with well-regulated T2D (P = 0.023). We also observed an association between BMI and BSE-induced change in HbA1c (P = 0.017), and HbA1c was significantly reduced after BSE treatment in obese patients with dysregulated T2D (P = 0.034; Fig. 4B). BSE was more effective in lowering fasting blood glucose in patients with elevated plasma triglyceride concentrations (P = 0.046 for the association between plasma triglycerides at study start and ?glucose; an inverted association was observed in placebo-treated patients; P = 0.008; Fig. 4D). It is also notable that BSE was more effective in lowering fasting blood glucose in patients with high HOMA-IR (P = 0.058 for the association between HOMA-IR and ?glucose; Fig. 4E), and the BSE-induced reduction of HbA1c correlated with high fatty liver index (P = 0.045; Fig. 4F).

No severe adverse effects of BSE were reported
Most patients tolerated the BSE well. Eight patients receiving BSE and seven patients receiving placebo reported gastrointestinal side effects such as loose stools and flatulence, typically present during the first few days of the treatment period, after which these symptoms disappeared. Ten BSE-treated and five placebo-treated patients reported mild respiratory infections, and there were also a few other reported adverse events, including orthopedic ailments, most likely unrelated to the study compound (table S5). Of the 103 patients, 6 (5 with BSE and 1 with placebo) discontinued the study because of nausea (2 patients), headache (1 patient), glucose above 15 mM (one of the exclusion criteria; 1 patient), hospital visit for suspected ileus (later successfully treated; 1 patient), and depression (1 patient on placebo) (table S6).
DISCUSSION
Together, our data show that SFN reduces glucose production, partly via NRF2 translocation and decreased expression of key gluconeogenetic enzymes, and that highly concentrated SFN administered as BSE improves fasting glucose and HbA1c in obese patients with dysregulated T2D. BSE was well tolerated, and SFN reduced glucose production by mechanisms different from that of metformin. SFN also protects against diabetic complications such as neuropathy, renal failure, and atherosclerosis in animal models because of its antioxidative effects (49–52).
Our data suggest that BSE has a direct effect on gluconeogenesis rather than hepatic insulin sensitivity, but the degree of IR may still influence the efficacy of BSE via altered constitutive NRF2 activity. It has been shown that insulin signaling activates NRF2 via phosphatidylinositide 3-kinase (53). Moreover, studies in cardiomyocytes have shown that NRF2 is activated at the early stages of T2D to protect against increased reactive oxygen species but is reduced at later stages of the disease (54). This is further supported by observations of reduced NRF2 expression in animals with IR (55, 56) and hepatic steatosis (27, 28).
It is not surprising that BSE was most effective in obese patients with dysregulated T2D. First, our animal experiments showed an effect of SFN on glucose control in metabolically dysregulated animals on a HFD but not in metabolically well-regulated animals on a low-fat diet. Second, gluconeogenetic rate was correlated with body weight in mice with diet-induced diabetes, and SFN reduced gluconeogenetic rate specifically in the heaviest mice. Third, hepatic glucose production is often exaggerated in patients with high HbA1c, whereas patients with low HbA1c primarily have an impairment of peripheral glucose uptake (47). Fourth, it has been shown that hepatic glucose production is increased particularly in obese T2D patients, potentially via elevated free fatty acids (34–36).
There is abnormal regulation of hepatic glucose production early in the development of T2D, but it is typically compensated for by increased insulin secretion (57). SFN has been shown to protect from pancreatic ? cell damage in animals (58). We observed no changes in insulin secretion, measured as HOMA-B and insulinogenic index, and BSE did not affect fasting glucose or HbA1c in well-regulated T2D patients. However, we observed that SFN prevented the development of hyperglycemia in diet-challenged rats, and it would be of interest to longitudinally study the long-term effects of BSE on glucose production and insulin secretion capacity in prediabetic individuals.
Glitazones and metformin were not ranked particularly high in the drug comparisons, suggesting that they do not affect the hepatic gene coexpression network that was associated with hyperglycemia in this case but exert their effects via other pathways. It is not entirely surprising because these drugs have different mechanisms of action from that of SFN.
It has been demonstrated that 1% [DCCT (Diabetes Control and Complications Trial) units] decrease of HbA1c corresponds to 37% reduced risk of microvascular complications (59). BSE treatment reduced HbA1c from 57.1 mmol/mol (or 7.38%) to 53.4 mmol/mol (or 7.04%) in obese patients with dysregulated T2D. The patients thereby reached the 7% treatment goal recommended by the American Diabetes Association (60), which is likely to represent a clinically meaningful effect.
Although the effect of BSE on glucose production was abolished in vitro when the conversion of glucoraphanin to SFN was prevented, we cannot fully determine that SFN explains the effect of BSE given to patients. High doses of BSE cannot yet be recommended to patients as a drug treatment but would require further studies, including data on which groups of patients would potentially benefit most from it. Finally, the findings provide support for using disease signatures based on coexpression networks to interrogate drug signatures, thereby using the large public repositories of gene expression data, as one of many strategies for repurposing compounds of immediate clinical relevance.

Delphinidin anthocyanins have previously been associated with the inhibition of glucose absorption. Blood glucose lowering effects have been ascribed to maqui berry (Aristotelia chilensis) extracts in humans after boiled rice consumption. In this study, we aimed to explore whether a standardized delphinidin-rich extract from maqui berry (Delphinol) affects glucose metabolism in prediabetic humans based on glycemia and insulinemia curves obtained from an oral glucose tolerance test (OGTT) after a challenge with pure glucose. Volunteers underwent four consecutive OGTTs with at least one week washout period, in which different doses of Delphinol were administered one hour before glucose intake. Delphinol significantly and dose-dependently lowered basal glycemia and insulinemia. Lower doses delayed postprandial glycemic and insulinemic peaks, while higher doses reversed this tendency. Glycemia peaks were dose-dependently lowered, while insulinemia peaks were higher for the lowest dose and lower for other doses. The total glucose available in blood was unaffected by treatments, while the total insulin availability was increased by low doses and decreased by the highest dose. Taken together, these open exploratory results suggest that Delphinol could be acting through three possible mechanisms: by inhibition of intestinal glucose transporters, by an incretin-mediated effect, or by improving insulin sensitivity.

Background:
The aim of this paper is to evaluate the efficacy and safety of DLBS3233, a novel bioactive fraction derived from Cinnamomum burmanii and Lagerstroemia speciosa, in improving insulin resistance and preserving?-cell performance in patients with impaired glucose tolerance (IGT). PATIENTS AND
METHODS:
Eighty adult subjects with IGT, defined as 2-hour postprandial glucose level of 140-199 mg/dL, were enrolled in this two-arm, 12-week, double-blind, randomized, placebo-controlled preliminary study. Eligible subjects were randomly allocated to receive either DLBS3233 at a dose of 50-100 mg daily or placebo for 12 weeks. The study mainly assessed the improvement of homeostatic model-assessed insulin resistance (HOMA-IR), the 15-minute and 2-hour plasma insulin levels, and the oral disposition index.
Results:
After 12 weeks, DLBS3233 improved insulin resistance better than placebo as reflected by a reduced HOMA-IR (-27.04%±29.41% vs -4.90%±41.27%, P=0.013). The improvement of the first- and second-phase insulin secretion was consistently greater in DLBS3233 group than placebo group (-144.78±194.06 vs -71.21±157.19, P=0.022, and -455.03±487.56 vs -269.49±467.77, P=0.033, respectively). Further, DLBS3233 also significantly better improved oral disposition index than placebo. No serious hypoglycemia, edema, or cardiovascular-related adverse events were found in either groups.
Conclusion:
This study has shown that DLBS3233 at the dose of 50-100 mg once daily was well tolerated, and promisingly efficacious in improving insulin sensitivity as well as preserving?-cell performance in subjects with IGT.

Background:
Bisphenol A (BPA) is a widely used chemical in the manufacture of polycarbonate plastics and epoxy resins. Recent animal studies have suggested that BPA exposure may have a role in the development of weight gain, insulin resistance, pancreatic endocrine dysfunction, thyroid hormone disruption, and several other mechanisms involved in the development of diabetes. However, few human studies have examined the association between markers of BPA exposure and diabetes mellitus.
METHODS:
We examined the association between urinary BPA levels and diabetes mellitus in the National Health and diet therapyal Examination Survey (NHANES) 2003-2008. Urinary BPA levels were examined in quartiles. The main outcome of interest was diabetes mellitus defined according the latest American Diabetes Association guidelines.
Results:
Overall, we observed a positive association between increasing levels of urinary BPA and diabetes mellitus, independent of confounding factors such as age, gender, race/ethnicity, body mass index, and serum cholesterol levels. Compared to quartile 1 (referent), the multivariate-adjusted odds ratio (95% confidence interval) of diabetes associated with quartile 4 was 1.50 (1.05-2.14) (p-trend = 0.03). The association was present among normal-weight as well as overweight and obese subjects.Conclusions:Urinary BPA levels are found to be associated with diabetes mellitus independent of traditional diabetes risk factors. Future prospective studies are needed to confirm or disprove this finding.

Background:
Data on the effects of coenzyme Q10 (CoQ10) supplementation on metabolic profiles among subjects with polycystic ovary syndrome (PCOS) are scarce. OBJECTIVE:
This study was done to evaluate the effects of CoQ10 supplementation on glucose metabolism and lipid profiles in subjects with PCOS. DESIGN, PATIENTS AND MEASUREMENTS: This randomized double-blind, placebo-controlled trial was conducted on 60 women diagnosed with PCOS. Subjects were randomly assigned into two groups to intake either 100 mg CoQ10 supplements (N=30) or placebo (N=30) per day for 12 weeks. Markers of insulin metabolism and lipid profiles were assessed at first and 12 weeks after the intervention.
Results:
After 12 weeks of intervention, compared to the placebo, subjects who CoQ10 supplements had significantly decreased fasting plasma glucose (-0.24±0.51 vs. +0.01±0.44 mmol/L, P=0.04), serum insulin concentrations (-7.8±14.4 vs. +6.0±15.0 pmol/L, P

Background:
It is hypothesized that dietary supplementation with Fenugreek modulates glucose homeostasis and potentially prevents diabetes mellitus in people with prediabetes. The objective of present study is to determine whether Fenugreek can prevent the outcome of T2DM in non diabetic people with prediabetes.
METHODS:
A 3-year randomized, controlled, parallel study for efficacy of Fenugreek (n?=?66) and matched controls (n?=?74) was conducted in men and women aged 30-70 years with criteria of prediabetes. Fenugreek powder, 5 g twice a day before meals, was given to study subjects and progression of type 2 diabetes mellitus (T2DM) was monitored at baseline and every 3 months forthe 3-year study.
Results:
By the end of intervention period, cumulative incidence rate of diabetes reduced significantly in Fenugreek group when compared to controls. The Fenugreek group also saw a significant reduction in fasting plasma glucose (FPG), postprandial plasma glucose (PPPG) and low density lipoprotein cholesterol (LDLc) whereas serum insulin increased significantly. It was observed that controls had 4.2 times higher chance of developing diabetes compared to subjects in the Fenugreek group. The outcome of diabetes in Fenugreek group was positively associated with serum insulin and negatively associated with insulin resistance (HOMA IR). CONCLUSIONS: Dietary supplementation of 10 g Fenugreek/day in prediabetes subjects was associated with lower conversion to diabetes with no adverse effects and beneficial possibly due to its decreased insulin resistance.