Evaluation of The Effectiveness of Ellagic Acid on Liver Steatosis in Overweight/Obese Non-Alcoholic Fatty Liver Disease Patients: Study Protocol for A Randomized Controlled Trial

Document Type : Protocol Study

Authors

1 Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

2 Department of Nutrition, Varastegan Institute for Medical Sciences, Mashhad, Iran.

3 Department of Radiology, Mashhad Medical Sciences Branch, Islamic Azad University, Mashhad, Iran.

4 Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.

5 Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

6 Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.

7 Pharmacological Research Center of Medicinal Plants, Mashhad University of Medical Sciences, Mashhad, Iran.

8 Neurogenic Inflammation Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran.

Abstract

Introduction: Non-alcoholic fatty liver (NAFLD) is a condition that can lead to liver fibrosis, cirrhosis, and hepatocellular carcinoma. There is no definite treatment for NAFLD. Ellagic acid (EA) is natural polyphenol with proven pharmacological properties, but its effectiveness on NAFLD in patients is not clear. The aim of this study is to evaluate the effect of ellagic acid on liver fibrosis in NAFLD patients. Method: This randomized, double-blind, controlled, and parallel clinical trial will be conducted on 60 patients with NAFLD (grade 2 or above) who will be allocated in intervention or placebo groups with 1:1 ratio. The intervention group will receive capsules containing 200 mg EA while the placebo group will receive avicel as placebo for 8 weeks. Body composition and anthropometric indices will be measured at baseline, end of 4th and 8th week. Transient elastography, 3-day food record, International Physical Activity Questionnaire (IPAQ), and laboratory tests (CBC/diff, uric acid, creatinine, lipid profile (total cholesterol, triglyceride [TG], low-density lipoprotein cholesterol [LDL-c], and high-density lipoprotein cholesterol [HDL-c]), aspartate aminotransferase [AST], alanine aminotransferase [ALT], alkaline phosphatase [ALP], and gamma-glutamyl transpeptidase [GGT], albumin, high sensitive C-reactive protein [hs-CRP] and insulin) will be performed for both groups at baseline and end of the study. Conclusion: We expect that 200 mg EA ellagic acid administration for 8 weeks will improve liver steatosis, clinical and paraclinical outcomes in NAFLD patients.  

Keywords

Main Subjects


[1] E.E. Powell, V.W.-S. Wong, M. Rinella, Non-alcoholic fatty liver disease, The Lancet 397(10290) (2021) 2212-2224.doi: https://doi.org/10.1016/S0140-6736(20)32511-3
[2] C. Zhang, M. Yang, Current options and future directions for NAFLD and NASH treatment, International Journal of Molecular Sciences 22(14) (2021) 7571.doi: 10.3390/ijms22147571
[3] S. Mitra, A. De, A. Chowdhury, Epidemiology of non-alcoholic and alcoholic fatty liver diseases, Translational gastroenterology and hepatology 5 (2020) 16.doi: 10.21037/tgh.2019.09.08
[4] H. Karimi-Sari, S. Mousavi-Naeini, A. Khonche, Comments on prevalence of non-alcoholic fatty liver disease and its related factors in Iran, International Journal of Organ Transplantation Medicine 8(1) (2017) 52.doi:
[5] L.A. Adams, Q.M. Anstee, H. Tilg, G. Targher, Non-alcoholic fatty liver disease and its relationship with cardiovascular disease and other extrahepatic diseases, Gut 66(6) (2017) 1138-1153.doi: 10.1136/gutjnl-2017-313884
[6] A.C. Sheka, O. Adeyi, J. Thompson, B. Hameed, P.A. Crawford, S. Ikramuddin, Nonalcoholic Steatohepatitis: A Review, JAMA 323(12) (2020) 1175-1183.doi: 10.1001/jama.2020.2298
[7] R.P. Myers, A. Fong, A.A.M. Shaheen, Utilization rates, complications and costs of percutaneous liver biopsy: a population‐based study including 4275 biopsies, Liver International 28(5) (2008) 705-712.doi: 10.1111/j.1478-3231.2008.01691.x
[8] S. Kose, G. Ersan, B. Tatar, P. Adar, B.E. Sengel, Evaluation of percutaneous liver biopsy complications in patients with chronic viral hepatitis, The Eurasian journal of medicine 47(3) (2015) 161.doi: 10.5152/eurasianjmed.2015.107
[9] H.I. Fallatah, Noninvasive biomarkers of liver fibrosis: an overview, Advances in Hepatology 2014 (2014) 1-15.doi:
[10] M.V. Machado, H. Cortez-Pinto, Non-invasive diagnosis of non-alcoholic fatty liver disease. A critical appraisal, Journal of hepatology 58(5) (2013) 1007-1019.doi: 10.1016/j.jhep.2012.11.021
[11] V. Ratziu, S. Bellentani, H. Cortez-Pinto, C. Day, G. Marchesini, A position statement on NAFLD/NASH based on the EASL 2009 special conference, Journal of hepatology 53(2) (2010) 372-384.doi: 10.1016/j.jhep.2010.04.008
[12] K. Podrug, I. Sporea, R. Lupusoru, F. Pastrovic, S. Mustapic, V. Bâldea, T. Bozin, T. Bokun, N. Salkic, R. Șirli, Diagnostic performance of 2-d shear-wave elastography with propagation maps and attenuation imaging in patients with non-alcoholic fatty liver disease, Ultrasound in Medicine & Biology 47(8) (2021) 2128-2137.doi: 10.1016/j.ultrasmedbio.2021.03.025
[13] A. Berzigotti, S. Seijo, U. Arena, J.G. Abraldes, F. Vizzutti, J.C. García–Pagán, M. Pinzani, J. Bosch, Elastography, spleen size, and platelet count identify portal hypertension in patients with compensated cirrhosis, Gastroenterology 144(1) (2013) 102-111. e1.doi: 10.1053/j.gastro.2012.10.001
[14] G.C. Farrell, C.Z. Larter, Nonalcoholic fatty liver disease: from steatosis to cirrhosis, Hepatology 43(S1) (2006) S99-S112.doi: 10.1002/hep.20973
[15] P.H. Black, The inflammatory consequences of psychologic stress: relationship to insulin resistance, obesity, atherosclerosis and diabetes mellitus, type II, Medical hypotheses 67(4) (2006) 879-891.doi: 10.1016/j.mehy.2006.04.008
[16] Y. Li, C. Xu, C. Yu, L. Xu, M. Miao, Association of serum uric acid level with non-alcoholic fatty liver disease: a cross-sectional study, Journal of hepatology 50(5) (2009) 1029-1034.doi: 10.1016/j.jhep.2008.11.021
[17] S.L. Friedman, B.A. Neuschwander-Tetri, M. Rinella, A.J. Sanyal, Mechanisms of NAFLD development and therapeutic strategies, Nature medicine 24(7) (2018) 908-922.doi: 10.1038/s41591-018-0104-9
[18] A. Marina, A.D. Von Frankenberg, S. Suvag, H.S. Callahan, M. Kratz, T.L. Richards, K.M. Utzschneider, Effects of dietary fat and saturated fat content on liver fat and markers of oxidative stress in overweight/obese men and women under weight-stable conditions, Nutrients 6(11) (2014) 4678-4690.doi: 10.3390/nu6114678
[19] S. Periasamy, S.-P. Chien, P.-C. Chang, D.-Z. Hsu, M.-Y. Liu, Sesame oil mitigates nutritional steatohepatitis via attenuation of oxidative stress and inflammation: a tale of two-hit hypothesis, The Journal of nutritional biochemistry 25(2) (2014) 232-240.doi: 10.1016/j.jnutbio.2013.10.013
[20] E.S. George, A. Forsyth, C. Itsiopoulos, A.J. Nicoll, M. Ryan, S. Sood, S.K. Roberts, A.C. Tierney, Practical dietary recommendations for the prevention and management of nonalcoholic fatty liver disease in adults, Advances in nutrition 9(1) (2018) 30-40.doi: 10.1093/advances/nmx007
[21] W. Nseir, E. Hellou, N. Assy, Role of diet and lifestyle changes in nonalcoholic fatty liver disease, World journal of gastroenterology: WJG 20(28) (2014) 9338.doi: 10.3748/wjg.v20.i28.9338
[22] K.L. Donnelly, C.I. Smith, S.J. Schwarzenberg, J. Jessurun, M.D. Boldt, E.J. Parks, Sources of fatty acids stored in liver and secreted via lipoproteins in patients with nonalcoholic fatty liver disease, The Journal of clinical investigation 115(5) (2005) 1343-1351.doi: 10.1172/JCI23621
[23] M. Tasaki, T. Umemura, M. Maeda, Y. Ishii, T. Okamura, T. Inoue, Y. Kuroiwa, M. Hirose, A. Nishikawa, Safety assessment of ellagic acid, a food additive, in a subchronic toxicity study using F344 rats, Food and Chemical Toxicology 46(3) (2008) 1119-1124.doi: 10.1016/j.fct.2007.10.043
[24] R. Bobinaitė, P. Viškelis, P.R. Venskutonis, Variation of total phenolics, anthocyanins, ellagic acid and radical scavenging capacity in various raspberry (Rubus spp.) cultivars, Food Chem 132(3) (2012) 1495-1501.doi: 10.1016/j.foodchem.2011.11.137
[25] N.A. Neves, P.C. Stringheta, S. Gómez-Alonso, I. Hermosín-Gutiérrez, Flavonols and ellagic acid derivatives in peels of different species of jabuticaba (Plinia spp.) identified by HPLC-DAD-ESI/MS(n), Food Chem 252 (2018) 61-71.doi: 10.1016/j.foodchem.2018.01.078
[26] L. Raudone, R. Bobinaite, V. Janulis, P. Viskelis, S. Trumbeckaite, Effects of raspberry fruit extracts and ellagic acid on respiratory burst in murine macrophages, Food Funct 5(6) (2014) 1167-74.doi: 10.1039/c3fo60593k
[27] E. Bate-Smith, Detection and determination of ellagitannins, Phytochemistry 11(3) (1972) 1153-1156.doi: 10.1016/S0031-9422(00)88470-8
[28] J.L. Maas, G.J. Galletta, G.D. Stoner, Ellagic acid, an anticarcinogen in fruits, especially in strawberries: a review, HortScience 26(1) (1991) 10-14.doi:
[29] M.K. Tiwari, P.C. Mishra, Scavenging of hydroxyl, methoxy, and nitrogen dioxide free radicals by some methylated isoflavones, Journal of Molecular Modeling 24 (2018) 1-17.doi: 10.1007/s00894-018-3805-6
[30] I. Kang, T. Buckner, N.F. Shay, L. Gu, S. Chung, Improvements in metabolic health with consumption of ellagic acid and subsequent conversion into urolithins: evidence and mechanisms, Advances in nutrition 7(5) (2016) 961-972.doi: 10.3945/an.116.012575
[31] I. Kang, Y. Kim, F.A. Tomás‐Barberán, J.C. Espín, S. Chung, Urolithin A, C, and D, but not iso‐urolithin A and urolithin B, attenuate triglyceride accumulation in human cultures of adipocytes and hepatocytes, Molecular nutrition & food research 60(5) (2016) 1129-1138.doi: 10.1002/mnfr.201500796
[32] V. Aishwarya, S. Solaipriya, V. Sivaramakrishnan, Role of ellagic acid for the prevention and treatment of liver diseases, Phytotherapy Research 35(6) (2021) 2925-2944.doi: 10.1002/ptr.7001
[33] D. Soleimani, M. Rezaie, F. Rajabzadeh, J. Gholizadeh Navashenaq, M. Abbaspour, M. Miryan, F. Razmpour, G. Ranjbar, R. Rezvani, L. Jarahi, Protective effects of propolis on hepatic steatosis and fibrosis among patients with nonalcoholic fatty liver disease (NAFLD) evaluated by real‐time two‐dimensional shear wave elastography: A randomized clinical trial, Phytotherapy Research 35(3) (2021) 1669-1679.doi: 10.1002/ptr.6937
[34] F.C. Bull, S.S. Al-Ansari, S. Biddle, K. Borodulin, M.P. Buman, G. Cardon, C. Carty, J.-P. Chaput, S. Chastin, R. Chou, World Health Organization 2020 guidelines on physical activity and sedentary behaviour, British journal of sports medicine 54(24) (2020) 1451-1462.doi: 10.1136/bjsports-2020-102955
[35] M. Kazemi, F. Lalooha, M.R. Nooshabadi, F. Dashti, M. Kavianpour, H.K. Haghighian, Randomized double blind clinical trial evaluating the Ellagic acid effects on insulin resistance, oxidative stress and sex hormones levels in women with polycystic ovarian syndrome, Journal of Ovarian Research 14(1) (2021) 1-12.doi: 10.1186/s13048-021-00849-2
[36] P. Vancells Lujan, E. Vinas Esmel, E. Sacanella Meseguer, Overview of non-alcoholic fatty liver disease (NAFLD) and the role of sugary food consumption and other dietary components in its development, Nutrients 13(5) (2021) 1442.doi: 10.3390/nu13051442
[37] S.K. Panchal, L. Ward, L. Brown, Ellagic acid attenuates high-carbohydrate, high-fat diet-induced metabolic syndrome in rats, European journal of nutrition 52 (2013) 559-568.doi: 10.1007/s00394-012-0358-9
[38] S. Mişe Yonar, M. Yonar, Y. Yöntürk, A. Pala, Effect of ellagic acid on some haematological, immunological and antioxidant parameters of rainbow trout (O ncorhynchus mykiss), Journal of animal physiology and animal nutrition 98(5) (2014) 936-941.doi: 10.1111/jpn.12162
[39] S.A. Polce, C. Burke, L.M. França, B. Kramer, A.M.d.A. Paes, M.A. Carrillo-Sepulveda, Ellagic acid alleviates hepatic oxidative stress and insulin resistance in diabetic female rats, Nutrients 10(5) (2018) 531.doi: 10.3390/nu10050531
[40] C. Zhang, J. Hu, L. Sheng, M. Yuan, Y. Wu, L. Chen, G. Wang, Z. Qiu, Ellagic acid ameliorates AKT-driven hepatic steatosis in mice by suppressing de novo lipogenesis via the AKT/SREBP-1/FASN pathway, Food & Function 10(6) (2019) 3410-3420.doi:
[41] A. Venkatasubramanian, A. Thiyagaraj, V. Subbiah, S. Solairaja, S. Arumugam, S. Ramalingam, S. Venkatabalasubramanian, Ameliorative role of ellagic acid against acute liver steatosis in adult zebrafish experimental model, Comparative Biochemistry and Physiology Part C: Toxicology & Pharmacology 247 (2021) 109061.doi: 10.1016/j.cbpc.2021.109061
[42] R.M. Bidanchi, L. Lalrindika, M. Khushboo, B. Bhanushree, R. Dinata, M. Das, N. Nisa, S. Lalrinzuali, B. Manikandan, L. Saeed-Ahmed, Antioxidative, anti-inflammatory and anti-apoptotic action of ellagic acid against lead acetate induced testicular and hepato-renal oxidative damages and pathophysiological changes in male Long Evans rats, Environmental Pollution 302 (2022) 119048.doi: 10.1016/j.envpol.2022.119048
[43] M.M. Elseweidy, A.E. Elesawy, M.S. Sobh, G.M. Elnagar, Ellagic acid ameliorates high fructose-induced hyperuricemia and non-alcoholic fatty liver in Wistar rats: focusing on the role of C1q/tumor necrosis factor-related protein-3 and ATP citrate lyase, Life Sciences 305 (2022) 120751.doi: 10.1016/j.lfs.2022.120751
[44] J.Z. ALTamimi, G.M. Alshammari, N.A. AlFaris, R.I. Alagal, D.H. Aljabryn, N.A. Albekairi, M.A. Alkhateeb, M.A. Yahya, Ellagic acid protects against non-alcoholic fatty liver disease in streptozotocin-diabetic rats by activating AMPK, Pharmaceutical biology 60(1) (2022) 25-37.doi: 10.1080/13880209.2021.1990969
[45] A. Kábelová, H. Malínská, I. Marková, O. Oliyarnyk, B. Chylíková, O. Šeda, Ellagic Acid Affects Metabolic and Transcriptomic Profiles and Attenuates Features of Metabolic Syndrome in Adult Male Rats, Nutrients 13(3) (2021).doi: 10.3390/nu13030804
[46] K. Kasai, M. Yoshimura, T. Koga, M. Arii, S. Kawasaki, Effects of oral administration of ellagic acid-rich pomegranate extract on ultraviolet-induced pigmentation in the human skin, Journal of nutritional science and vitaminology 52(5) (2006) 383-388.doi: 10.3177/jnsv.52.383
[47] I. Ertam, B. Mutlu, I. Unal, S. Alper, B. Kivcak, O. Ozer, Efficiency of ellagic acid and arbutin in melasma: A randomized, prospective, open‐label study, The Journal of dermatology 35(9) (2008) 570-574.doi: 10.1111/j.1346-8138.2008.00522.x
[48] M. Ghadimi, F. Foroughi, S. Hashemipour, M. Rashidi Nooshabadi, M.H. Ahmadi, B. Ahadi Nezhad, H. Khadem Haghighian, Randomized double‐blind clinical trial examining the Ellagic acid effects on glycemic status, insulin resistance, antioxidant, and inflammatory factors in patients with type 2 diabetes, Phytotherapy Research 35(2) (2021) 1023-1032.doi: 10.1002/ptr.6867
[49] Z. Mirzaie, A. Bastani, S. Hesami, E. Pouryousefi, M. Kavianpour, H.K. Haghighian, Improving Effect of Ellagic Acid on Sleep Quality and Gastrointestinal Symptoms in Patient With Irritable Bowel Syndrome: Randomized Double-Blind Clinical Trial, Turk J Gastroenterol 32(11) (2021) 937-944.doi: 10.5152/tjg.2021.20344
[50] Y. Liu, S. Yu, F. Wang, H. Yu, X. Li, W. Dong, R. Lin, Q. Liu, Chronic administration of ellagic acid improved the cognition in middle-aged overweight men, Applied Physiology, Nutrition, and Metabolism 43(3) (2018) 266-273.doi: 10.1139/apnm-2017-0583
[51] R.G. Barr, G. Ferraioli, M.L. Palmeri, Z.D. Goodman, G. Garcia-Tsao, J. Rubin, B. Garra, R.P. Myers, S.R. Wilson, D. Rubens, Elastography assessment of liver fibrosis: society of radiologists in ultrasound consensus conference statement, Radiology 276(3) (2015) 845-861.

Articles in Press, Accepted Manuscript
Available Online from 03 January 2024
  • Receive Date: 30 December 2023
  • Revise Date: 02 January 2024
  • Accept Date: 03 January 2024