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Blood Sugar lowering effect of zinc and multi vitamin/ mineralsupplementation is dependent on initial fasting blood glucose

P. Gunasekara1, M. Hettiarachchi2, C. Liyanage3, S. Lekamwasam 4

Corresponding author:Manjula Hettiarachchi, manjula.hettiarachchi@gmail.comAuthor Affiliations: 1- Coronary Care Unit, Teaching Hospital, Karapitiya, Galle. Sri Lanka.

2- Nuclear Medicine Unit, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka.3- Department of Community Medicine, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka.

4- Department of Medicine, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka.Abstract| PDF File

ABSTRACT

To evaluate the effect of zinc and other multi vitamin mineral supplementation onglycemic control and l ipid prof i le in patients with type 2 diabetes mell itus. Diabetespatients (n=96) were randomly allocated to 3 groups; 29 subjects were supplementedwith oral zinc sulfate (22 mg/day) and multivitamin mineral (zi nc+MVM) preparation; 31subjects were supplemented with the same preparation, without zi nc (MVM) and 36 weregiven a matching placebo, for a period of 4 months in a single blinded study. Bloodsamples were taken at the baseline and after 4 months of supplementation, to assessblood glucose (fasting and post prandial) and glycosylated haemoglobin % (HbA1C%)levels. The Zinc+MVM group had a mean change of fasting blood sugar (FBS) -0.33

(SEM, 0.21) mmol/l and was significant (p =0.05) when compared with the other twogroups (mean change in the MVM group +0.19 (0.31) and +0.43 (0.23) mmol/l in thecontrol group respectively). When the baseline FBS was >5.56 (>100mg/dL) mmol/l,supplementation either with Zinc+MVM (p

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efficacy of drugs which act through this pathway. Previous studies indicated thatmarginal zinc deficiency is more prevalent among diabetic adults, compared to thenormal adult population (11, 12). Abnormal zinc and l ipid plasma levels occur morefrequently in metabolical ly uncontrol led diabetic patients (13). Yet, z inc sulfatesupplementation may be a therapeutical resource to recover some functions andimprove life span (14). Therefore, we intended to determine whether zinc (and othervitamins/minerals with similar antioxidant properties) supplementation for a short-term

could improve the levels of fasting glucose and HbA1C% as well as the i nsulin levels inSri Lankan type 2 diabetic patients. Moreover, this study aimed to find out whether thechanges in glycemic control by zinc and other multi vitamin mineral supplementation areassociated with changes in lipid profile of type 2 diabetes mell itus patients.

METHODOLOGY

The study received approval from the Ethical Review Committee of the Faculty of

Medicine, University of Ruhuna. Previously diagnosed (for at least 2 years) patients ofadult onset (type II) diabetes mellitus attending medical clinics of the teaching hospital,Karapitiya, Galle, were considered as the study population.

Following were the exclusion criteria:

1 . Those, who were d iagnosed to have renal or l iver fai lu re or any other chron icdisease except essential hypertension and dyslipidemia.2. Those, who were taking vitamin-mineral supplements or any hormonereplacement therapy.3 . Those, wi th a history o f a recent surgery or acute infection .4. Pregnant or lactating women.5. Those, who were receiving insulin preparations as a part of diabetes

management.

All subjects (n=96) were stratified by sex, age and duration of treatment and randomlyassigned to three treatment groups, using the block randomization procedure. Group A(Zinc+MVM) was supplemented with oral zinc sulfate (22mg of elemental zinc/day) andmultivitamin/mineral preparation (vitamin A, Vitamin D3, Vitamin E, magnesium,manganese, copper and selenium) Group B (MVM) was supplemented with the samepreparation but without zinc. Group C was supplemented with an identical placebotab le t. The study was regi ste red in t he S ri Lanka Cl ini cal Tria l Regi stry(SLCTR/2008/017), managed by Sri Lanka Medical Association, linked to the RegistryNetwork of the International Clinical Trial s Registry Platform of WHO.Table 1: Nutrient composition of the preparation 1

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1 Group A subjects got the tablets prepared with full formulae where as group B subjects got

the same without zinc sulphate monohydrate and the group C subjects gOt the placebo tabletconsisting of filling base magnesium stearate.

2 The elemental zinc content in the preparation was 22 mg

The composition of the supplement is shown in Table 1. All subjects were instructed totake one tablet per day for a period of 4 months along with their usual treatmentregimen. The supplement and placebo tablets looked identical in colour and shape.Since the reported mean dai ly intake of z inc in our population is low (15), thesupplemented zinc dose was set at the recommended dietary intake (20-25 mg/day) forSri Lankan population. All other minerals and vitamins that were included in the tabletwere more or less equal to the dietary reference intake (DRI) levels set by the Nutritioncoordination division of the Ministry of Health, Sri Lanka (16).

Once enrolled, all subjects were advised to attend a phlebotomy session at 0800 hours,after overnight fasting. A sample of 5mL of venous blood was drawn before the patient

has taken any oral hypoglycemic agent(s) or other drugs and aliquots were made forFBS and HbA1C% in sugar and EDTA bottles, respectively. Remaining portion of theblood sample was centrifuged at 5000 rpm for 10 minutes and serum was separated andstored in acid washed polystyrene tubes at -80oC until analysis for serum insulin, zincand creatinine was done. In addition, urine creatinine was measured from an aliquot offresh urine sample obtained from each subject. Another portion of urine was stored at-80oC for analys is of urinary z inc. Fol lowing this, the patients were served withbreakfast and two hours later another blood sample (2ml) was drawn for the assessmentof post prandial blood sugar (PPBS). Another blood sample was collected on the nextday, after 14 hours fasting for the assessment of lipid profile. Further, their dietary

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intakes were assessed using a 24-hr dietary recall questionnaire at their entry into thestudy.

They were advised to take the trial medication once daily, along with other medicationand a monthly follow-up was arranged. Clinicians were blinded to the trial medicationand they were allowed to continue the usual care given for diabetic subjects during thetrial period. Changes in pharmacological or non-pharmacological management occurredduring the trial period were recorded. Compliance on the supplementation was assessedby counting the remaining tablets at weeks 4, 8 and 12 and all side effects of the trialmedication were noted. After 4 months of supplementation, blood and urine sampleswere collected under the same conditions as described before, for the same biochemicalanalyses.Laboratory analysis

The zinc content in serum and urine was measured using enzyme linked immunosorbantassay (ELISA) kit of BioAssay Systems, USA, by the quantitative colorimetric zincdetermination at 425nm. Serum Insulin level was measured by ELISA kit provided byBIOSOURCE, Europe S.A., Belgium. Fasting and post prandial b lood glucose wasenzymatically measured. HbA1C% was measured by chromatography method, usingcommercial k it (Sigma), and the normal range of HbA1C% was 5.58.5%. Serumtriglycerides and total cholesterol were enzymatically measured. HDL cholesterol wasdetermined after precipitation with phosphotangestate/ magnesium and LDL cholesterolafter precipitation with heparin/sodium citrate. Intra- and inter- assay coefficient ofvariation was < 5% for all laboratory tests.Statistical analysisNumber of subjects per group was calculated, based on the mean improvement in FBS(0.701.10mmol/L), shown by Farvid et al., (17), when supplemented with multiv itamin-mineral supplementation. Twenty f ive subjects per group would provideadequate power (80%) at the alpha error of 5% to detect the treatment effect of zincsupplementation. The number of patients per group was increased by 3 in each group,with an assumption of 10% dropout rate.

A one-sample KolmogorovSmirnov test was used to determine whether the baselinebiochemical markers were normally distributed. Because the distributions of HbA1C%,triglycerides and zinc, urine zinc and creatinine values were skewed, they were log-

transformed in all calculations. For presentation, these variables were transformed backto the orig inal scale. The dif ference between the three groups at basel ine wasdetermined by one-way ANOVA, for continuous data and the Chi test, for categoricaldata. Paired-t-tests were used to study within-group treatment effects. The effect ofintervention was determined by the univariate analysis - repeated measures design ofthe general linear model using SPSS version 10.0 (SPSS Inc., Chicago, USA). Baselinevalues of respective parameters were also included in the analysis as a covariant forbetween-subject factors to correct for their possible confounding inf luence on thechange in each parameter. Of the 96 subjects randomized, only 86 completed the studyand their data were included in the final analysis (Per-protocol analysis). Spearmansrho correlation was used to analyze the mean change of treatment effect with therespective baseline parameter. Two-tailed p

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1Results presented as mean (SD) except the duration of treatment which is given as mean(range). Treatment categories are given as number of subjects (%)

2There were no significant differences in age and anthropometric parameters between groupsat the study entry.

Table 3 Effect of supplementation on blood glucose and other serum/urine parameters 1

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1Results expressed as mean (SD) except for mean change; mean (SEM). Only those who hadcompleted the trial (n=86) were included in the analysis

a, b , c Superscripts within a row indicate significant difference (p

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difference in age distribution of the patients in the three groups (males had mean ageof 54.6 7.0 years, whereas females had mean age of 54.9 9.0 years). Group Aconsisted of 29 subjects (12 males, 17 females), Group B; 31 subjects (11 males, 20females) and Group C; 36 subjects (10 males, 26 females). However, only 86 patientscompleted the study (28 out of 29 subjects from the group A, 31 subjects from thegroup B and 32 out of 36 from the group C). Of the 10 patients who did not completethe tria l, 6 were lost to fol low up, 3 did not take tablets for more than 2 weeks

continuously, and diabetes treatment regimen was interrupted in the other individual.Those who completed the trial had drug compliance of >98%. Majority of the patientswere receiving a combination of medication for their diabetes complications. There wereno dif ferences in the cholesterol lower ing treatment (stat ins) and other cardioprotective medications between the groups. Further, dietary intake of trace mineral andvitamins were not different and the dietary zinc intake was 3.96 (SD 1.68) mg per day(Table 2).

Compared to the baseline, the Zinc+MVM group had a mean reduction in FBS by -0.33(SEM, 0.21) mmol/L (p =0.05). The FBS changes observed in the MVM (+.19 (0.31)mmol/L) and the control groups (+0.43 (0.23) mmol/L) were not statistically significant(p=0.89). The PPBS level also reduced significantly (p=0.04) in the Zinc+MVM groupwith a mean change of -1.55 (0.56) mmol/L, after the intervention. The MVM group hada significant increase (p=0.002) in HbA1C% level (+1.28 (0.21) %) from the baseline,whereas in the Zinc+MVM group a significant reduction of HbA1C% was seen (-0.01(0.25)%, p

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mmol/L, p

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1Results expressed as mean (SD) except for mean change mean (SEM); ratio =Cholesterol/HDL

a, b , cSuperscripts within a row indicate significant difference (p5.56 mmol/L) while on treatment. These resultsindicated that most of diabetic participants in this study were not under a tight glycemiccontrol. It seems that they were not aware of the importance of dietary compliance tocontrol the blood glucose level. Thus, inappropriate food choices might have resulted in

the deterioration of zinc status. Both HbA1C % and fasting glucose were significantlyimproved, after the supplementation in this subset of individuals. Sri Lanka Diabetes,Cardiovascular Study (SLDCS) indicated that the prevalence of diabetes mellitus hascontinuously increased in the Island (18) and the age-sex standardized prevalence(95% confidence interval) of diabetes for Sri Lankans aged >or= 20 years was 10.3%(9.4-11.2%) [males 9.8% (8.4-11.2%), females 10.9% (9.7-12.1%), P = 0.129). It hasbeen concluded that one in five adults in Sri Lanka has either diabetes or pre-diabetesand one-third of those with diabetes are undiagnosed. Further, the projected diabetesprevalence for the year 2030 is 13.9%.

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There is exper imental and c l in ical evidence, especial ly in developed countries,supporting an alteration of zinc metabolism in patients with diabetes (1, 19). However,only few studies have examined the relationship between zinc and diabetes indeveloping countries (20). The mean serum zinc level in healthy individuals has variedfrom 11.4 to 17.8 mol/L (21). A study in Iran by Al-Maroof and Al-Sharbatti (22)reported a lower mean serum zinc value (9.40 mol/L) among diabetic patients. We arereporting a mean zinc level of 10.29 mol/L (SD 7.50 mol/L) in 96 diabetic patients

who have been on treatment over a period ranging from 2- 22 years. This level is lowerthan that (11.30 mol/L) reported in a study of 110 Tunisian adult diabetic subjects(both type 1 and type 2) (23). When the cutoff le vel of 100mg/dL), who are on long-term follow up. Furthermore,supplementation significantly improved PPBS and HbA1C% level when compared withplacebo. This was similar to the results reported by Hussain et al., (26) where theyshowed a 25% reduction in FBS and 17% reduction in HbA1C%, with supplementationwith zinc and melatonin for 3 month. The mean HbA1C% of the supplemented groups(Zinc+MVM and MVM groups) reduced signif icantly by 0.3 0.8% at the end of 4months of follow up, while no significant change was found in the control group. Higherlevels of HbA1C% and fasting glucose with longer diabetic duration have been noted byother investigators (27). The significant changes observed in the supplemented groupsrefer to the effective improvement in their glycemic control in response to zinc andother multivitamin and mineral supplementation. Our observations are consistent withthe results of other trials that examined the effect of zinc supplementation on patientswith type 2 d iabetes (22, 23) . Therefore, we suggest that a short-term z incsupplementation may be effective on glycaemic control for diabetic patients with poorlymanageable fasting blood glucose.

The significant negative correlation we, observed between serum zinc level change aftersupplementation and the basel ine serum zinc level suggests that z inc def icientindividuals had greater absorption of zinc than individuals with higher zinc level at thebaseline. This finding is consistent with the results of other studies suggesting that zinctreatment wil l have a h igh chance of success in changing the zinc status in z inc-

deficient subjects (28). In addition we observed that baseline serum Insulin levels werepositively correlated with final serum Insulin levels and negatively with mean changeafter the intervention (data not shown). Previous studies examining the effect of zincsupplementation on insulin level are sparse. Hussain et al, (26) found no change inserum C-peptide level with zinc supplementation. Our findings may indicate a directeffect of zinc on insulin secretion by pancreatic cells. However, studies with longerfollow up are required to see whether increase in insulin secretion is sustained over alonger time period. Zinc treatment has also been shown to raise body defenses inimmune suppressed patients (29). It is important to note that a large proportion ofsubjects in our study had a low serum zinc level at the baseline and the 4 months daily

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administration resulted in almost doubling of the baseline value (mean improvement+12.44 mol/L). We have not addressed issues related to immune status, in the currentstudy and the clinical importance of high prevalence of zinc deficiency among adultdiabetics is not known to us.

Due to zinc+MVM supplementation, a significant decrease occurred in tr iglycerides(p=0.02), total cholesterol (p=0.005), LDL (p=0.05) and significant improvement inHDL (p=0.002), when compared with MVM and placebo supplementation. Someinvestigations indicated that a zinc-enriched diet has beneficial effects on basal andpostprandial glycaemia, the content of cholesterol and triglycerides (30). Cunnane (31)bel ieved that z inc int imately affects many aspects of l ipid metabolism, throughestablished enzymes, but also has a modulator effects, the mechanism of which is notobvious or established. Our observations are consistent with those reported by Kadhimet al., (32), where a group of poorly controlled diabetic patients were supplementedwith zinc and melatonin for a period of 3 months. El-Hendy et al., (33) have shownincreased cholesterol, TG and LDL in the serum of zinc-deficient rats. In the currentstudy, we observed a significant decrease in triglyceride concentration (mean change of-0.07mmol/L; P50 mg/d (34).Hooper et al. (35) examined the effect of zinc administration on serum lipoproteinvalues when 12 healthy adult men ingested 440 mg of zinc sulfate per day for f iveweeks. He observed that HDL concentration decreased 25% below baseline values (40.5to 30.1 mg/dL), without changing the total cholesterol, triglyceride and LDL cholesterollevels. In Freeland-Graves et al. (36) study, four levels of zinc supplements (0, 15, 50,or 100 mg/day) were given to 32 women for 8 weeks. No significant differences wereseen in HDL-cholesterol over, 8 week except in the 100 mg group at week 4 (36).

Partida-Hernndez et al, (14) however, showed a significant decrease in triglycerideconcentration following 12 week supplementation with 100 mg zinc sulfate amongdiabetics who were not on cholesterol lowering treatment. Furthermore, they showed asignificant reduction in total cholesterol and an increase in HDL cholesterol indicatingthat supplementation, in addition to improving glycaemic indices, have favorable effects

on other cardiovascular risk factors. Even though, we have shown a similar trend, thereduction in total cholesterol and reduction in HDL levels were not as great as reported.Most of our patients were already on cholesterol lowering drugs and as such they mayhave achieved the desired lipid targets at the study entry. Additionally, hyperglycemiaincreases glycation of lipoprotein, including LDL and HDL, associated with the elevationof trig lyceride levels in the blood through increased synthesis f rom glucose andimpaired l ipid metabolism. Garber and Karlsson (37) showed that the treatment ofdyslipidemia in diabetes must be focused on several targets involving glycemic controland bulk reductions of LDL levels. Results of the present study are agreeable to thesesuggestions. There is a strong evidence suggesting that zinc can act as an endogenousprotective factor against atherosclerosis by inhibiting the oxidation of LDL in thepresence of transition metals (38), and that adequate zinc nutrition may protect againstinflammatory diseases such as atherosclerosis by inhibiting the activation of oxidativestress responsive transcription factors as well as the expression of inflammatory

cytokines.

The present intervention did not show any significant effect on renal functions measuredby serum as well as urine creatinine. Similar observations were made by Khadim et al,(32) and El-Hendy et al, (33). In contrast, a significant improvement in renal functionhas been observed in a previous study (39) after 60 days of supplementation. Further,Parham et al. , (40) showed that z inc supplementation has benefic ia l effects onmicroalbuminuria and serum lipid prof i le in type 2 DM with microalbuminuria andreduced serum homocysteine and increased vitamin B12 and folate concentrations which

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may exert vascular-protective effects in type 2 diabetes patient (25). A limitation of ourstudy is that we did not measure urinary micro-albumin level of these patients.

We performed this study in single-blinded manner for logistic reasons and this mayreduce the validity of data. This may one of the limitations in the study, as alternativedesigns are possible which are likely to have expectation bias or change in the behaviorof the study subjects. However, only the FBS results were available at the follow-upsessions at their respective cli nics. Secondly, we did not measure the change in physicalactivity and anthropometry because of short duration (4 months) of follow up. We areunable to generalize the generated results to the diabetes patient community in SriLanka as a who le because o f small sample s ize that may have contr ibuted toinconclusive results seen in some analyses. To minimize the effects of disparity inbaseline values between the groups (i.e. high HbA1C% levels in Zinc+MVM group overthe other two groups), we included baseline measurements in each analysis as a cofactor (see statistical analysis). Although, physicians were free to make changes in themanagement of these patients, no changes in the major drugs such as anti-diabetics,anti-hypertensives or lipid lowering therapy, were made during the trial period. Apartfrom the trial drug we inquired about the compliance of their regular medication as well.However, there is a possibility that patients might have changed their behavior (i.e.,diet and physical activity) during the trial period. However we expected this change tobe uniform in all three groups. This altered behavior can considerably limit the studyoutcome.

In summary, this study indicated significant improvement of fasting glucose as well asHbA1C% in zinc supplemented diabetic patients with shorter diabetic duration, poorerglycemic control, and marginal zinc status. However, further investigation is neededbe fore a fi rm conclus ion could be d rawn for the re la tionship between z in csupplementation and glycemic control. At present, more attention must be paid toimprove the zinc status and glycemic control of Sri Lankan diabetes patients, in order toprevent or minimize complications.

CONCLUSION

The supplementation of zinc with other multi vitamins minerals daily, to adult diabetes

patients with glycemic and l ipid control, for a per iod of 4 months, demonstratedfavorable changes in metabolic profile, including a better glycemic control and desirablechanges in lipid profile. Based on the results presented in this report, it seems that zincis a beneficial mineral for diabetic patients. Consumption of zinc sulfate, in addition toother nutritional and pharmacological treatments in type 2 diabetes patients could beeffective in improving the lipid profile.

ACKNOWLEDGEMENTS

The study was funded by the International Atomic Energy Agency (IAEA-SRL-11958).Multi vitamin-mineral Supplements were provided by the Apex Laboratories, Indiathrough their local partner, A Baur & Co Ltd, Sri Lanka. We would li ke to thank Drs. M DManjula and N M Kaluthantri and other technical staff of the Nuclear Medicine Unit forhelping in data collection and sample analysis respectively. The cooperation extended

by the Cardiology Unit and the physicians of the Teaching Hospital , Karapitiya in subjectrecruitment and follow up is also appreciated.

REFERENCE

1. Chausmer AB. Zinc, Insul in and Diabetes. J . Am. Coll . Nutr 1998; 17: 109-115.2. Salgueiro MJ, Krebs N, Zubillaga MB, Weill R, Postaire E, Lysionek AE, et al., Zinc

and Diabetes Mel l itus. Is there a need of z inc supplementation in d iabetesmellitus patients. Bi ol Trace Elem Res 2001; 81: 215228

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3 . K inlaw WB, Levine AS, Morley JE , S il vi s SE, McClain CJ. Abnormal z in cmetabolism in type II diabetes mel litus. Am J Med 1983; 75: 273277.

4. Gol ik A, Cohen N, Ramot Y, Maor J , Moses R, Weissgarten J , e t a l. Type IIdiabetes mellitus, congestive heart failure, and zinc metabolism. Biol Trace ElemRes 1993; 39: 171175.

5. Haase H, Overbeck S, R ink L. Z inc supplementation for the treatment orprevention of disease: Current status and future perspectives. Experimental

Gerontology. 2008; 43: 394408.6. Yoon JS. Zinc status and dietary quality of type 2 diabetic patients: implication of

physical activity levels. Nutrition Research and Practice. 2008; 2: 4145.7. Simon SF, Taylor CG. Dietary zinc supplementation attenuates hyperglycemia in

db/db mice. Exp Biol Med 2001; 226: 4351.8. Marchesini G, Bugianesi E, Ronchi M, F lamia R, Thomaseth K, Pacini G. Zinc

supplementation improves glucose disposal in patients with cirrhosis. Metabolism1998; 47: 792798.

9. Cunningham JJ, Fu A, Mearkle PL, Brown RG. Hyperzincuria in individuals withinsulin-dependent diabetes mellitus: concurrent zinc status and the effect ofhigh-dose zinc supplementation. Metaboli sm 1994; 43: 15581562.

10.Karine CMS, Almeida DMA, Mirza MS, Vanessa TL, Lucia FCP. Effects of zincsupplementation in patients with type 1 diabetes. Biol Trace Elem Res 2005; 105:19.

11.Lee JH, Lee HJ, Lee IK, Yoon JS. Zinc and copper status of middle- and old-agedwoman in type 2 diabetes. The Korean Journal of Nutrition 2005; 38: 5666.

12.Yoon JS, Lee JH. A suggestion to improve zinc status of type 2 diabetic women:relation among zinc, protein and phytate intake. Journal of Korean DieteticAssociation 2007;1 3: 301310.

13.Soinio M, Marniemi J, Laakso M, et al., Serum zinc level and coronary heartdisease events in patients with type 2 diabetes. Diabetes Care. 2007; 30:523528.

14.Partida-Hernndez G, Arreola F, Fenton B, Cabeza M, Romn-Ramos R, Revilla-Monsalve MC. Effect of zinc replacement on l ipids and l ipoproteins in type 2-diabetic patients. Bi omedicine & Pharmacotherapy. 2006; 60: 161168.

15.Hettiarachchi M, Liyanage C, Wickremasinghe R, Hilmers D, Abrams S. NutrientIntake and Growth of Adolescents in Southern Sri Lanka. Cey Med J. 2006;51(3): 89-92.

16. Nutrition Guide, Ministry of Health and Indegenous Medicine, Sri Lanka, 2000.17.Farvid MS, Jalali M, Siassi F, Mostafa H. Comparison of the Effects of Vitamins

and/or Mineral Supplementation on Glomerular and Tubular Dysfunction in Type 2Diabetes. Diabetes Care 2005; 28:2458-2464.

18.Katulanda P, Constantine GR, Mahesh JG, Sheriff R, Seneviratne RDA, WijeratneS, et al. Prevalence and projections of diabetes and pre-diabetes in adults in SriLanka--Sri Lanka Diabetes, Cardiovascular Study (SLDCS). Diabet Med. 2008;25(9): 1062-9.

19.Prasad AS. Zinc deficiency has been known of for 40 years but ignored by globalhealth organizations. BMJ 2003; 326: 409-410.

20.Singh RB, Mohammad AN, Rastogi SS, Bajaj S, Gaoli Z, Shoumin Z. Current zincintake and risk of diabetes and coronary artery disease and factors associatedwith insulin resistance in rural and urban populations in North India. J Am CollNutr 1998; 17: 564-570.

21.King JC, Shames DM, Woodhouse LR. Zinc homeostasis in human. J Nutr 2000;130: 1360-1366.

22.Al-Maroof RA, Al-Sharbatti SS. Serum zinc levels in diabetic patients and effectof zinc supplementation on glycemic control of type 2 diabetics. Saudi Med J2006; 27 (3): 344-350.

23.Anderson R, Roussel AM, Zouar i N, Sylv ia M, Jean-Marc M, Abdelhamid K.Potential antioxidant effects of zinc and chromium supplementation in peoplewith type 2 diabetes mellitus. J Am Coll Nutr 2001; 20:212218.

24.Maret W, Sandstead HH. Zinc requirements and the r isks and benefits of zincsupplementation. J Trace Elem Med Biol. 2006. 20:3-18.

8/3/2019 EBP1

14/14

25.Heidarian E, Amini M, Parham M, Aminorroaya A. Effect of zinc supplementationon serum homocysteine in type 2 diabetic patients with microalbuminuria. TheReview of Diabetic Studies . 2009; 6: 64-70.

26.Hussain SA, Khadim HM, Khalaf BH, Ismail SH, Hussein KI, Sahib AS. Effect ofmelatonin and zinc on glycaemic control in type 2 diabetic patients poorlycontrolled with metformin. Saudi Med J 2006; 27: 1483-1488.

27.Oh HM, Yoon JS. Glycemic control of type 2 diabetic patients after short-term

zinc supplementation. Nutr Res Pract. 2008; 2: 283-288.28.Wood RJ. Assessing marginal zinc deficiency: where are we now and where are

we going in the future? J Nutr 2000; 130: 1350S-1354.29. Klaus-Helge I, Lothar R. Zinc-altered immune function. J Nutr 2003; 133: 1452S

1456S.30.Ghayour-Mobarhan MA, Taylor SA, New DJ, Lamb DJ, Ferns GA. Determinants of

serum copper, zinc and selenium in healthy subjects. Ann. Clin. Biochem., 2005;42: 364-75.

31.Cunnane SC. Role of zinc in lipid and fatty acid metabolism and in membranes.Prog. Food Nutr. Sci., 1988; 12: 151-88.

32.Kadhim HM, Ismail SH, Hussein KI. Effects of melatonin and zinc on lipid profileand renal function in type 2 diabetic patients poorly controlled with metformin. JPineal Res 2006; 41:189193.

33.El-Hendy HA, Yousef MI, Abo-El-Haga NI. Effect of dietary zinc deficiency on

hematological and biochemical parameters and concentrations of zinc, copper andiron in growing rats. Toxicology. 2001; 167:161170.

34.Hughes S, Samman S. The Effect of Zinc Supplementation in Humans on PlasmaLipids, Antioxidant Status and Thrombogenesis. J. Am. Coll. Nutr. 2006; 25: 285-291.

35.Hooper PL, V iscont i L , Garry PJ, Johnson GE. Z inc lowers h igh-dens itylipoproteincholesterol levels. JAMA 1980; 244, 19601961.

36.Freeland-Graves JH, Friedman BJ, Han WH, Shorey RL, Young R. Effect of zincsupplementation on plasma high-density lipoprotein cholesterol and zinc. Am. J.Clin. Nutr. 1982; 35: 988-992.

37.Garber AJ, Karlsson FO. Treatment of dyslipidemia in diabetes. Endocrinol MetabClin North Am 2001; 30:9911010.

38.Hennig B, Toborek M, McClain CJ. High-energy diets, fatty acids and endothelialcell function: implication for atherosclerosis. J Am Coll Nutr. 2001; 20:91105.

39.Garg JP. Microalbuminuria: marker of vascular dysfunction, r isk factor forcardiovascular disease. Vascular Medicine 2002; 7(1): 35-43.

40.Parham M, Amini M, Aminorroaya A, Heidarian E. Effect of zinc supplementationon microalbuminuria in pat ients with type 2 d iabetes: a double b lind,randomized, placebo controlled, cross-over trial. Rev Diabet Stud. 2008. 5:102-109.