Nutrients 14 00427 v3
Nutrients 14 00427 v3
Nutrients 14 00427 v3
Article
Effectiveness of “Moro” Blood Orange Citrus sinensis Osbeck
(Rutaceae) Standardized Extract on Weight Loss in Overweight
but Otherwise Healthy Men and Women—A Randomized
Double-Blind Placebo-Controlled Study
David Briskey 1,2 , Giuseppe Antonio Malfa 3, * and Amanda Rao 2
1 School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, QLD 4072,
Australia; [email protected]
2 RDC Clinical, Newstead, Brisbane, QLD 4005, Australia; [email protected]
3 Department of Drug and Health Science, University of Catania, Viale A. Doria 6, 95125 Catania, Italy
* Correspondence: [email protected]
Abstract: This study aimed to assess the efficacy of a blood orange Citrus sinensis standardized extract
from “Moro” cultivar, on weight loss in overweight but otherwise healthy individuals. Anthocyanins
and particularly cyanidin 3-glucoside, found in a large variety of fruits including Sicilian blood
oranges, can help to counteract weight gain and to reduce body fat accumulation through the
modulation of antioxidant, anti-inflammatory and metabolic pathways. In this randomized, double
blind, placebo-controlled study, all participants (overweight adults aged 20–65 years old) were
randomized to receive either Moro blood orange standardized extract or a placebo daily for 6-months.
Citation: Briskey, D.; Malfa, G.A.; The primary outcome measure was change in body mass and body composition at the end of the
Rao, A. Effectiveness of “Moro” study. After 6-months, body mass (4.2% vs. 2.2%, p = 0.015), body mass index (p = 0.019), hip (3.4 cm
Blood Orange Citrus sinensis Osbeck vs. 2.0 cm, p = 0.049) and waist (3.9 cm vs. 1.7 cm, p = 0.017) circumferences, fat mass (p = 0.012) and
(Rutaceae) Standardized Extract on fat distribution (visceral and subcutaneous fat p = 0.018 and 0.006, respectively) were all significantly
Weight Loss in Overweight but better in the extract supplemented group compared to the placebo (p < 0.05). In addition, all safety
Otherwise Healthy Men and
markers of liver toxicity were within the normal range throughout the study for both analyzed
Women—A Randomized
groups. Concluding, the present study demonstrates that Moro blood orange standardized extract
Double-Blind Placebo-Controlled
may be a safe and effective option for helping with weight loss when used in conjunction with diet
Study. Nutrients 2022, 14, 427.
https://doi.org/10.3390/
and exercise.
nu14030427
Keywords: cyanidin 3-glucoside; flavonoids; BMI; fat distribution; body mass; physical activity
Academic Editor: Zoltan Pataky
fruit [10–14]. The “Moro” orange cultivar Citrus sinensis Osbeck (Rutaceae) is native to
Sicily and cultivated only in a restricted area at the feet of the south side of Etna volcano
(Protected Geographical Indication, PGI), it is the most highly pigmented and with the
higher amount of anthocyanins among red oranges varieties [15–17], with deep red violet
flesh ripening from December to February. In blood o range cultivars, the production of
anthocyanins in the flesh and epicarp during fruit ripening is not due to particular agro-
nomic techniques other than those common to all citrus fruits but is strictly dependent on
the climate conditions and particularly by strong day-night thermal clines. The particular
district of Sicily (PGI), where blood oranges are cultivated is characterized by limited rain-
fall and not extremely cold winter but with a temperature variation between day and night
of more than 10 ◦ C, conditions not found in any other orange-producing countries [18,19].
Moro orange is a rich source of active compounds such as hydroxycinnamic acid, flavone
glycosides and ascorbic acids, including anthocyanins with an average content of about
140 mg/L [18–21]. Evidence to date has shown that blood oranges demonstrate potent
antioxidant activity and cytoprotective effects that reflect their substantial role in preventing
chronic pathological conditions such as cardiovascular diseases and in many forms of can-
cers [21–25]. Moreover, a recent study showed that a red orange standardized extract is able
to inhibit 3T3-L1 differentiation, by downregulating adipogenic gene and enzymes together
with the modulation of adiponectin secretion and leptin release [26]. Red orange intake
(especially Moro juice) has also been found to limit body weight gain, enhance insulin
sensitivity, and decrease serum triglycerides and total cholesterol in mice [27,28]. Similarly,
a study by Titta and colleagues (2009) showed anthocyanin rich Moro juice inhibited fat
accumulation in obesity induced mice despite an increase in overall energy intake [28].
Salamone and colleagues also studied the effect of Moro juice on liver steatosis in mice
with diet-induced obesity over a 12-week period. Results revealed Moro juice exerted a
metabolic hepatoprotective effect due to changes in the expression of several enzymes
involved in lipid homeostasis [27]. Preliminary research in humans has shown 400 mg of a
Moro blood orange standardized extract (Morosil® ) supplementation in overweight yet
otherwise healthy participants for 12 weeks induced a significant reduction in body weight,
body mass index (BMI), waist and hip circumference in comparison to placebo group [20].
As there has only been one human trial specifically on this extract of “Moro” orange cultivar,
the aim of this study is to further assess the effect of the above-mentioned standardized
extract at the same dose on weight loss and on all safety markers of liver toxicity in healthy
adult males and females aged between 20 and 65 years to better understand its action
in conjunction with a calorie-controlled diet and exercise over a 6-month period. It was
hypothesized that the supplementation with the standardized extract, in conjunction with
diet and exercise, would improve weight loss in overweight but otherwise healthy male
and female compared to placebo control group.
This study was conducted between November 2018 and June 2020 in Brisbane, Australia.
At the completion of the study (month 6), an assessment identical to that undertaken at
baseline was completed. Throughout the 6-month trial, all participants were monitored for
compliance with the protocol by a combination of telephone and email communications in
addition to each scheduled site visit. Compliance was measured regularly during the study
with participants returning the product containers at the end of the study.
3. Results
Of the 180 randomized participants, 44 participants (25 active and 19 placebo) with-
drew from the trial prior to completing all the baseline requirements. The most common
reason being participants found the daily calorie counting too time consuming and there-
Nutrients 2022, 14, 427 6 of 14
fore did not enter enough food diaries to meet the entry criteria. Of the 136 participants
who completed the baseline requirements, 98 completed (45 active and 53 placebo) the full
6-months. Of the 38 withdrawals, there were 20 in the active treatment group, and 18 in the
placebo treatment group (Figure 1). There were no significant differences between groups
for exercise or dietary intake throughout the study. Both groups were well matched, with
no significant differences between groups for any baseline measures (Tables 1–3).
Active Placebo
Baseline Month 3 Month 6 Baseline Month 3 Month 6
WC (cm) 101.1 ± 9.9 98.5 ± 10.5 # 97.2 ± 10.7 *# 103.4 ± 11.0 101.3 ± 11.4 # 101.7 ± 11.7 #
HC (cm) 113.4 ± 6.9 111.0 ± 7.5 # 110.1 ± 7.5 *# 115.6 ± 7.2 113.6 ± 6.7 # 113.5 ± 7.2 #
Weight (kg) 88.4 ± 11.2 85.5 ± 11.5 # 84.7 ± 11.7 *# 90.8 ± 13.8 89.0 ± 14.1 # 88.8 ± 14.5 #
Weight loss (%) −3.2 ± 3.7 # −4.2 ± 5.0 *# −2.1 ± 3.3 −2.2 ± 4.2 #
BMI (kg/m2 ) 29.5 ± 1.6 28.6 ± 2.0 # 28.3 ± 2.2 *# 29.4 ± 1.4 28.9 ± 1.7 # 28.8 ± 1.9 #
Lean Mass (kg) 54.0 ± 11.3 52.5 ± 10.1 52.4 ± 10.2 # 56.1 ± 13.0 55.4 ± 12.8 55.6 ± 13.2 #
FM (kg) 32.1 ± 7.2 30.6 ± 6.4 *# 29.7 ± 6.7 *# 33.1 ± 7.5 31.8 ± 8.0 # 31.2 ± 8.2 #
FM Arm (kg) 3.9 ± 1.1 3.7 ± 0.9 3.6 ± 0.9 # 3.7 ± 1.0 3.6 ± 1.0 3.5 ± 1.0 #
FM Leg (kg) 11.9 ± 3.3 11.4 ± 3.2 11.4 ± 3.8 # 12.2 ± 3.8 11.5 ± 4.0 11.3 ± 3.6 #
FM abdominal
15.9 ± 3.3 14.6 ± 3.5 *# 14.1 ± 3.5 *# 16.3 ± 4.1 15.6 ± 4.4 # 15.3 ± 4.4 #
(trunk) (kg)
Android Fat (kg) 3.6 ± 1.8 2.7 ± 1.0 # 2.6 ± 1.0 # 4.0 ± 2.1 3.1 ± 1.4 3.0 ± 1.4 #
Gynoid Fat (kg) 7.0 ± 3.8 5.2 ± 1.5 # 5.1 ± 1.5 # 7.7 ± 4.0 5.9 ± 2.8 # 5.9 ± 2.8 #
Visceral Fat (g) 632.9 ± 223.5 588.6 ± 245.3 # 554.2 ± 232.4 *# 632.8 ± 249.6 581.5 ± 256.6 # 575.8 ± 254.9 #
Visceral Fat Area
131.4 ± 46.4 122.0 ± 51.0 115.6 ± 47.4 # 131.5 ± 52.0 120.1 ± 53.1 118.6 ± 52.6 #
(cm2 )
Subcutaneous Fat
15.2 ± 3.1 14.0 ± 3.4 # 13.5 ± 3.4 *# 15.7 ± 3.9 15.0 ± 4.2 # 14.7 ± 4.3 #
(kg)
# Indicated significant decrease from baseline within group (p < 0.05); * indicates significant difference between
groups (p < 0.05) in ITT analysis; (DEXA measures baseline placebo n = 69, active n = 62; 3- and 6-month placebo
n = 56, active n = 46). WC = waist circumference; HC = hip circumference; BMI = body mass index; FM = fat mass.
Table 3. Pathology results for the active and placebo group for all participants.
Active Placebo
Baseline Month 3 Month 6 Baseline Month 3 Month 6
ALT (U/L) 25.9 ± 15.6 20.9 ± 7.9 23.3 ± 9.1 25.9 ± 11.5 23.6 ± 10.6 24.7 ± 10.0
AST (U/L) 23.7 ± 7.2 23.4 ± 8.2 25.8 ± 9.1 22.2 ± 9.8 22.3 ± 8.9 23.1 ± 10.4
GGT (U/L) 29.7 ± 15.3 26.3 ± 14.7 24.3 ± 13.9 36.4 ± 25.7 33.1 ± 28.2 32.7 ± 28.3
TBIL (umol/L) 11.9 ± 4.5 11.9 ± 4.7 12.3 ± 5.6 11.7 ± 5.0 11.1 ± 4.8 11.0 ± 3.9
Cholesterol (umol/L) 5.8 ± 1.1 5.7 ± 1.1 5.7 ± 1.2 5.8 ± 1.2 5.6 ± 1.1 5.7 ± 1.1
HDL (mmol/L) 1.8 ± 0.4 1.8 ± 0.5 1.9 ± 0.6 1.7 ± 0.5 1.6 ± 0.5 1.7 ± 0.4
LDL (pg/mL) 3.6 ± 0.9 3.5 ± 0.9 3.5 ± 0.9 3.7 ± 1.0 3.5 ± 1.0 3.5 ± 0.8
TRI (mmol/L) 1.0 ± 0.4 1.0 ± 0.5 1.1 ± 0.7 1.4 ± 0.7 1.3 ± 0.7 1.3 ± 0.7
Glucose (mmol/L) 5.6 ± 1.0 5.6 ± 0.8 5.5 ± 0.9 5.6 ± 1.0 5.6 ± 0.8 5.7 ± 0.8
Insulin (mU/L) 12.2 ± 8.1 13.0 ± 9.9 11.4 ± 7.9 11.2 ± 6.6 12.0 ± 7.8 12.7 ± 8.4
Creatine (umol/L) 92.4 ± 11.8 96.4 ± 21.8 94.0 ± 13.3 90.9 ± 18.1 94.2 ± 15.4 93.2 ± 14.6
Ghrelin (ng/mL) 0.41 ± 0.32 0.47 ± 0.51 0.49 ± 0.47 0.40 ± 0.36 0.39 ± 0.34 0.40 ± 0.38
Leptin (ng/mL) 5.71 ± 5.13 5.10 ± 5.72 5.51 ±7.11 4.77 ±4.10 4.06 ± 3.50 3.9 ±3.64
Adiponectin (ug/mL) 6.26 ± 3.77 6.43 ± 4.11 6.35 ± 3.62 5.22 ± 3.59 5.21 ± 3.50 5.54 ± 3.83
ALT = Alanine transaminase, AST = Aspartate aminotransferase, GGT = Gamma-glutamyl transferase, TBIL
= total bilirubin, GLU = glucose, TRI = triglycerides, HDL = high density lipoproteins, LDL = low density
lipoproteins. Values represented as mean ± SD.
Figure 2. Change in body weight over 6 months for all participants; * Indicates significant difference
between groups (p < 0.05) in ITT analysis (active n = 65, placebo n = 71). † Indicates significant differ-
ence between groups for sub-group participants (BMI > 25–30) in ITT analysis (active n = 48, placebo
n = 54); # indicates significant difference between groups for sub-group participants (BMI > 25–30) in
pp analysis (active n = 30, placebo n = 38).
Figure 3. Change in waist (A) and hip (B) circumference (cm) at month 3 and 6 for all participants;
* indicates significant difference between groups (p < 0.05) in ITT analysis (active n = 65, placebo
n = 71); † indicates significant difference between groups for sub-group participants (BMI > 25–30)
in ITT analysis (active n = 48, placebo n = 54); # indicates significant difference between groups for
sub-group participants (BMI > 25–30) in pp analysis (active n = 30, placebo n = 38).
3.3. BMI
The average baseline BMI was 29.5 and 29.4 in the active and placebo groups, respec-
tively (Range 25–33). Both groups had a significant reduction from baseline in BMI after 3
and 6-months of supplementation (p < 0.05). However, at 6-months, the active group had
a significant reduction in BMI compared with the placebo group (p = 0.019) (Table 2 and
Figure 4).
Figure 4. Change in Body weight (A) and BMI (B) at month 3 and 6 for all participants; * indicates
significant difference between groups (p < 0.05) in ITT analysis (active n = 65, placebo n = 71);
† indicates significant difference between groups for sub-group participants (BMI > 25–30) in ITT
analysis (active n = 48, placebo n = 54); # indicates significant difference between groups for sub-group
participants (BMI > 25–30) in pp analysis (active n = 30, placebo n = 38).
A DXA scan was conducted every 3 months during the study, if a value was missing
at month 6, an intention to treat last observation carried forward imputation method was
used. Of the 136 participants, 102 participants completed the DXA measurement with
no significant differences between groups (p = 0.338). Both the active and placebo group
had a significant reduction in Fat mass after 3 and 6-months of supplementation (p < 0.05).
However, at both 3 and 6-months, the active treated group had a significant reduction in Fat
mass compared with the placebo group (p = 0.01 and 0.012) (Table 2). This was supported
by the Lean mass data that remained constant in both groups over the 6 months of the
study. The active group also showed a significant reduction in the amount of abdominal
fat at month 3 and 6 compared to placebo (p = 0.01 and 0.018). Additionally, visceral, and
subcutaneous fat were reduced significantly at month 6 compared to placebo (p = 0.018 and
0.006, respectively, Table 2).
Nutrients 2022, 14, 427 9 of 14
3.4.4. Fatigue
There was no difference between participant groups for fatigue at any monthly time-
point as measured by Visual Analogue Scale.
Table 4. Baseline participant details for participants with a 25 < BMI < 30 kg/m2 .
After 6-months, the active group had a significant reduction in body weight from base-
line (4.2%, p < 0.05). After 6-months, the placebo group had a non-significant reduction in
body weight from baseline (2.3%, p = 0.37) (Figure 4A). The active group had a significantly
greater body weight loss compared to the placebo group at months 1,2,3,4 and 6 (p < 0.026;
Table 5, Figure 2). Additionally, 35% of the participants in the active group had a weight
loss of more than 5% vs. 24% of the participants in the placebo group.
Table 5. Anthropometry Data for Participants with a BMI > 25– < 30 kg/m2 .
Active Placebo
Baseline Month 3 Month 6 Baseline Month 3 Month 6
WC (cm) 98.6 ± 9.0 96.1± 9.7 # 95.0 ± 10.2 *#† 101.8 ± 11.1 99.4 ± 11.1 # 99.8 ± 11.2#
HC (cm) 112.8 ± 7.2 110.5 ± 8.0 # 109.7 ± 8.1 *#† 114.7 ± 7.3 112.6 ± 6.8# 112.5 ± 7.05 #
Weight (kg) 85.5 ± 10.3 82.7 ± 10.5 *#† 81.9 ± 10.9 *#† 87.8 ± 13.4 86.1 ± 14.0 # 85.83 ± 14.02 #
Weight loss (%) −3.3 ± 3.7 #† −4.2 ± 5.2 # *† −2.1 ± 3.4 −2.3 ± 4.0 #
BMI (kg/m2 ) 28.8 ± 1.4 28.0 ± 1.8 #† 27.7 ± 2.1 *#† 28.9 ± 1.2 28.4 ± 1.6 # 28.3 ± 1.7 #
Lean Mass (kg) 51.0 ± 9.1 50.0 ± 8.0 50.1 ± 8.3 52.9 ± 11.6 52.7 ± 11.6 52.8 ± 11.7
FM (kg) 32.5 ± 6.3 30.6 + 6.7 # 29.9 ± 7.0 # 33.2 ± 8.0 31.5 ± 8.3 # 31.0 ± 8.5 #
FM Arm (kg) 3.9 ± 1.2 3.7 ± 0.9 3.7 ± 1.0 3.8 ± 1.0 3.6 ± 1.0 3.6 ± 1.0
FM Leg (kg) 12.2 ± 3.2 11.7 ± 3.1 11.8 ± 3.9 # 12.4 ± 3.9 11.4 ± 4.0 11.4 ± 3.7 #
FM abdominal
15.6 ± 3.5 14.4 ± 3.8 # 14.0 ± 3.8 *#† 16.2 ± 4.5 15.3 ± 4.6 # 15.1 ± 4.6 #
(trunk) (kg)
Android Fat (kg) 3.6 ± 2.0 2.6 ± 1.1 # 2.5 ± 1.0 # 3.8 ± 2.0 3.1 ± 1.5 3.0 ± 1.5 #
Gynoid Fat (kg) 7.3 ± 3.8 5.4 ± 1.5 # 5.3 ± 1.6 # 7.5 ± 3.7 6.1 ± 3.0 # 6.1 ± 3.0 #
Visceral Fat (g) 662.2 ± 207.6 641.6 ± 234.8 # 596.0 ± 229.8 *#† 686.3 ± 251.2 637.1 ± 261.4 628.9 ± 260.1 #
Visceral Fat Area
125.1 ± 41.6 116.3 ± 49.4 107.6 ± 43.6 124.7 ± 51.0 112.4 ± 47.9 111.4 ± 47.1
(cm2 )
Subcutaneous
14.9 ± 3.4 13.8 ± 3.6 #† 13.5 ± 3.6 *#† 15.6 ± 4.3 14.8 ± 4.5 14.6 ± 4.5 #
Fat (kg)
# Indicates significant decrease from baseline (p < 0.05); * indicates significant difference in between groups in
ITT analysis (p < 0.05); † indicates significant difference between groups in PP analysis (p < 0.05); WC = waist
circumference; HC = hip circumference; BMI = body mass index; FM = fat mass.
Both the active and placebo group had a significant reduction in waist (−3.6 cm vs.
−2.1 cm, respectively) and hip (−3.2 cm vs. −2.2 cm, respectively) circumference from
baseline following 6-month of supplementation (Figure 3A, B, Table 5). However, the
active group had a significant reduction in both hip and waist circumference at 6-months
compared to the placebo group (Table 5; p = 0.033, 0.015, respectively). Compared to
baseline values, BMI was significantly reduced in both the active and placebo group
after 3 and 6-months of supplementation (p < 0.05). At 6-months, the active group had
a significantly greater reduction in BMI compared with the placebo group (p = 0.041,
Figure 4B, Table 5).
Both the active and placebo group had a significant reduction in Fat mass from baseline
after 3 and 6-months of supplementation (p < 0.05). At 6-months, the active group had a
Nutrients 2022, 14, 427 11 of 14
significant reduction in abdominal, visceral and subcutaneous fat mass compared with
the placebo group (p < 0.05) (Table 5). For the total fat mass there was a between group
difference trending toward significance (p = 0.06). There were no differences either within
or between groups for any pathology or fatigue measures at any time-point and exercise
and diet compliance was also the same between groups.
4. Discussion
To date, this is the second known study investigating the effects of a standardized
extract from “Moro” blood orange (Morosil® ) on weight reduction in human participants.
A previous study supplemented 60 overweight but otherwise healthy adults with either
400 mg of standardized extract or a placebo for 12-weeks [20]. Following 12-week of
supplementation, Cardile and colleagues reported significant reductions (p < 0.05) in body
weight, BMI, waist and hip measurements. The study presented here, aimed to replicate
previous results and see if a continuation of the effects could be seen with a longer duration.
Subsequently it showed that supplementation over a 6-month period not only produced
similar results at the 3-month point, but it continued to provide beneficial effects for the
full 6-month trial. Following 6-months of supplementation, both the active and placebo
supplemented groups showed significant (p < 0.05) improvements in body weight, BMI
and waist and hip circumferences. However, after 6-months of supplementation, the active
group had a greater weight loss than the placebo. This was supported by the DXA results
which showed a significant decrease in fat mass, visceral and abdominal fat at 6-months
compared to placebo. These results translated to a significant reduction in BMI for both
groups at both month 3 and month 6, with the active group having a significantly lower
BMI than the placebo group at month 6. A significant reduction in BMI in the active group
was also shown by Cardile after 4 weeks, however in that study no significant reduction
was seen at any time points in the placebo group [20]. Weight loss findings were further
reflected in the waist and hip circumferences, these were also consistent with the findings by
Cardile and colleagues [20]. In the earlier study, participants in both the active and placebo
group had significant reductions in hip and waist measurements at 12 weeks (p < 0.05).
Following 6-months of supplementation in this trial, both groups had a significant reduction
in waist and hip circumference. However, the active group had a greater reduction in both
waist (p < 0.05) and hip (p < 0.05) circumference at 6-months compared to the placebo.
Sub-group analysis of participants in the overweight range only (25 < BMI < 30 kg/m2 )
were similar to the total group analysis indicating the treatment works consistently in a
BMI range of 25–33 kg/m2 . The above-reported results confirmed the experimental data
present in the literature on the role of the bioactive compounds present in Moro blood
orange extract in promoting weight management and preventing obesity through the
regulation of both lipolytic and lipogenic genes [29]. The Phytocomplex present in Moro
orange mainly composed of flavonoids such as anthocyanins, naringenin and hesperetin, is
able in adipocytes to reduce lipids accumulation and to modulate adipocytokines release
with a concomitant reduction of inflammation and oxidative stress [30]. Particularly,
Cyanidin-3-glucoside along with the aforementioned molecular effects was demonstrated
to improve also mitochondrial biogenesis, which is strictly involved in the modulation
of lipid metabolism [31]. The synergistic action exerted by the phytocomplex results in
a significant reduction in adipocytes size and a restoration of cellular homeostasis [30].
All safety markers of liver toxicity were within the normal range at baseline and month 3
and 6 for both treatment groups indicating that the Moro orange standardized extract is
well tolerated and has no safety concerns. Gastrointestinal symptoms were reported in a
small number of trial participants (placebo n = 5, active n = 1). These symptoms were not
reported in the 2015 trial [20] and the incidence is significantly below the current prevalence
of gastrointestinal symptoms in the healthy population [32]. The participant selection and
grouping criteria used in this trial suggest that the benefits of 400 mg orally daily of
the standardized extract will be experienced by the general ‘healthy’ adult population.
Participants were given a daily calorie target based on their Basal metabolic rate and
Nutrients 2022, 14, 427 12 of 14
starting weight. Participants also completed a food tracker, and this was checked regularly
to ensure compliance. The daily calorie target was adjusted based on weight lost every
2 months. However, both groups did not firmly adhere to the recommended diet and
exercise regime during the 6-month trial. This result however may not be too surprising.
While the participants recruited were interested in losing weight, they may not have
been psychologically ready to undertake such lifestyle changes. As such, the observed
compliance to the prescribed diet and exercise is likely the start of a lifestyle change that
may need to be made at a slower rate than introduced in this trial. Despite this, while
the reduced compliance may have affected the amount of weight the participants could
potentially have lost, as each group had an equivalence adherence to the prescribed protocol,
it can still be assumed that the additional benefits seen in the active group is due to the
supplementation and not an external factor confirming the effectiveness of Moro blood
orange extract when is associated with regular physical activity and a healthy balanced
diet. As with all studies, there were limitations with this study. First, there was a 30%
withdrawal rate of participants in the first 3 months of the study. This could be attributed to
the amount of baseline assessment data that was required to be collected and participants
not wanting to adhere to dietary and lifestyle advice. Second, participant exercise and diet
data were self-reported. Third, comparative to other weight loss trials, 6-months was a
relatively short period. Some studies range from 12 to 18 months. Last, there were limited
Moro blood orange studies on weight reduction in human participants for comparison of
our findings.
5. Conclusions
In the present study, “Moro” blood orange standardized extract, in conjunction with
diet and exercise, was shown to be safe and well tolerated. The secondary metabolites
present in the active ingredient by regulating lipid metabolism through fatty acid biosynthe-
sis and oxidation promoted increased weight loss and reduced waist and hip circumference
in overweight but otherwise healthy male and female participants compared to placebo.
As reported by the scientific literature, this effect is probably linked with the activity and
modulation at the gene level exerted by the phytocomplex in a combined way. Lastly,
further pre-clinical and clinical studies could be useful to prove the efficacy of “Moro”
blood orange standardized extract (Morosil® ) supplementation in weight management.
In conclusion, results confirmed that the supplementation with the standardized extract
may significantly contribute as a complementary strategy in weight management programs.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or
in the decision to publish the results.
References
1. World Health Organisation. Obesity and Overweight. Available online: www.who.int/news-room/fact-sheets/detail/obesity-
and-overweight (accessed on 1 April 2020).
2. Shang, A.; Gan, R.Y.; Xu, X.Y.; Mao, Q.Q.; Zhang, P.Z.; Li, H.B. Effects and mechanisms of edible and medicinal plants on obesiy:
An updated review. Crit. Rev. Food Sci. Nutr. 2021, 61, 2061–2077. [CrossRef] [PubMed]
3. De Freitas Junior, L.M.; de Almeida, E.B., Jr. Medicinal plants for the treatment of obesity: Ethnopharmacological approach and
chemical and biological studies. Am. J. Transl. Res. 2017, 9, 2050–2064.
4. Mopuri, R.; Islam, M.S. Medicinal plants and phytochemicals with anti-obesogenic potentials: A review. Biomed. Pharmacother.
2017, 89, 1442–1452. [CrossRef]
5. Luo, S.; Lenon, G.B.; Gill, H.; Yuen, H.; Yang, A.; Hung, A.; Nguyen, L.T. Do the Natural Chemical Compounds Interact with the
Same Targets of Current Pharmacotherapy for Weight Management?—A Review. Curr. Drug Targets 2019, 20, 399–411. [CrossRef]
[PubMed]
6. Mondello, L.; Cotroneo, A.; Errante, G.; Dugo, G.; Dugo, P. Determination of anthocyanins in blood orange juices by HPLC
analysis. J. Pharm. Biomed. Anal. 2000, 23, 191–195. [CrossRef]
7. Lee, B.; Lee, M.; Lefevre, M.; Kim, H.R. Anthocyanins inhibit lipogenesis during adipocyte differentiation of 3T3-L1 preadipocytes.
Plant Foods Hum. Nutr. 2014, 69, 137–141. [CrossRef]
8. Tsuda, T.; Ueno, Y.; Yoshikawa, T.; Kojo, H.; Osawa, T. Microarray profiling of gene expression in human adipocytes in response
to anthocyanins. Biochem. Pharmacol. 2006, 71, 1184–1197. [CrossRef] [PubMed]
9. Tsuda, T. Regulation of Adipocyte Function by Anthocyanins; Possibility of Preventing the Metabolic Syndrome. J. Agric. Food
Chem. 2008, 56, 642–646. [CrossRef]
10. Park, J.; Kim, H.L.; Jung, Y.; Ahn, K.S.; Kwak, H.J.; Um, J.Y. Bitter Orange (Citrus aurantium Linné) Improves Obesity by
Regulating Adipogenesis and Thermogenesis through AMPK Activation. Nutrients 2019, 11, 1988. [CrossRef]
11. Ballistreri, G.; Amenta, M.; Fabroni, S.; Consoli, V.; Grosso, S.; Vanella, L.; Sorrenti, V.; Rapisarda, P. Evaluation of lipid and
cholesterol-lowering effect of bioflavonoids from bergamot extract. Nat. Prod. Res. advance online publication. 2020. [CrossRef]
12. Lo Furno, D.; Graziano, A.C.; Avola, R.; Giuffrida, R.; Perciavalle, V.; Bonina, F.; Mannino, G.; Cardile, V. A Citrus bergamia
Extract Decreases Adipogenesis and Increases Lipolysis by Modulating PPAR Levels in Mesenchymal Stem Cells from Human
Adipose Tissue. PPAR Res. 2016, 2016, 4563815. [CrossRef] [PubMed]
13. Karn, A.; Zhao, C.; Yang, F.; Cui, J.; Gao, Z.; Wang, M.; Wang, F.; Xiao, H.; Zheng, J. In-vivo biotransformation of citrus functional
components and their effects on health. Crit. Rev. Food Sci. Nutr. 2021, 61, 756–776. [CrossRef]
14. Ahmed, O.M.; AbouZid, S.F.; Ahmed, N.A.; Zaky, M.Y.; Liu, H. An Up-to-Date Review on Citrus Flavonoids: Chemistry and
Benefits in Health and Diseases. Curr. Pharm. Des. 2021, 27, 513–530. [CrossRef] [PubMed]
15. Fallico, B.; Ballistreri, G.; Arena, E.; Brighina, S.; Rapisarda, P. Bioactive compounds in blood oranges (Citrus sinensis (L.) Osbeck):
Level and intake. Food Chem. 2017, 215, 67–75. [CrossRef]
16. Kelebek, H.; Canbas, A.; Selli, S. Determination of phenolic composition and antioxidant capacity of blood orange juices obtained
from cvs. Moro and Sanguinello (Citrus sinensis (L.) Osbeck) grown in Turkey. Food Chem. 2008, 107, 1710–1716. [CrossRef]
17. Fabroni, A.S.; Ballistreri, G.; Amenta, M.; Rapisarda, P. Anthocyanins in different citrus species: An UHPLC-PDA-ESI/MSn-
assisted qualitative and quantitative investigation. J. Sci. Food Agric. 2016, 96, 4797–4808. [CrossRef]
18. Legua, P.; Modica, G.; Porras, I.; Conesa, A.; Continella, A. Bioactive compounds, antioxidant activity and fruit quality evaluation
of eleven blood orange cultivars. J. Sci. Food Agric. 2021. [CrossRef]
19. Giuffrè, A.M.; Zappia, C.; Capocasale, M. Physicochemical stability of blood orange juice during frozen storage. Int. J. Food Prop.
2017, 20, 1930–1943.
20. Cardile, A.; Graziano, A.C.E.; Venditti, A. Clinical evaluation of Moro (Citrus sinensis (L.) Osbeck) orange juice supplementation
for the weight management. Nat. Prod. Res. 2015, 29, 2256–2260. [CrossRef]
21. Grosso, G.; Galvano, F.; Mistretta, A.; Marventano, S.; Nolfo, F.; Calabrese, G.; Buscemi, S.; Drago, F.; Veronesi, U.; Scuderi, A. Red
Orange: Experimental Models and Epidemiological Evidence of Its Benefits on Human Health. Oxidative Med. Cell. Longev. 2013,
2013, 157240. [CrossRef]
22. Buscemi, S.; Rosafio, G.; Arcoleo, G.; Mattina, A.; Canino, B.; Montana, M.; Verga, S.; Rini, G. Effects of red orange juice intake on
endothelial function and inflammatory markers in adult subjects with increased cardiovascular risk. Am. J. Clin. Nutr. 2012, 95,
1089–1095. [CrossRef] [PubMed]
23. Magalhães, M.; Lima, L.C.; Lunguinho, A.D.; Rezende, D.A.; Ferreira, V.R.; Brandão, R.M.; Souza, J.A.; Souza, É.D.; Almeida,
K.J.; Nelson, D.; et al. Influence of Cold Storage on the Bioactivity Properties and the Quality of the Juice of Moro Blood Orange
(Citrus sinensis (L.) Osbeck). Am. J. Plant Sci. 2019, 10, 24–37. [CrossRef]
24. Magalhães, M.L.; de Sousa, R.V.; Miranda, J.R.; Konig, I.; Wouters, F.; Souza, F.R.; Simão, S.D.; da Silva Lunguinho, A.; Nelson,
D.L.; das Graças Cardoso, M. Effects of Moro orange juice (Citrus sinensis (L.) Osbeck) on some metabolic and morphological
parameters in obese and diabetic rats. J. Sci. Food Agric. 2021, 101, 1053–1064. [CrossRef] [PubMed]
Nutrients 2022, 14, 427 14 of 14
25. Ribeiro, A.; Pereira, A.G.; Todo, M.C.; Fujimori, A.; Dos Santos, P.P.; Dantas, D.; Fernandes, A.A.; Zanati, S.G.; Hassimotto, N.;
Zornoff, L.; et al. Pera orange (Citrus sinensis) and Moro orange (Citrus sinensis (L.) Osbeck) juices attenuate left ventricular
dysfunction and oxidative stress and improve myocardial energy metabolism in acute doxorubicin-induced cardiotoxicity in rats.
Nutrition 2021, 91–92, 111350. [CrossRef]
26. Tomasello, B.; Malfa, G.A.; La Mantia, A.; Miceli, N.; Sferrazzo, G.; Taviano, M.F.; Di Giacomo, C.; Renis, M.; Acquaviva, R.
Anti-adipogenic and anti-oxidant effects of a standardised extract of Moro blood oranges (Citrus sinensis (L.) Osbeck) during
adipocyte differentiation of 3T3-L1 preadipocytes. ), Nat. Prod. Res. 2021, 35, 2660–2667.
27. Salamone, F.; Li Volti, G.; Titta, L.; Puzzo, L.; Barbagallo, I.; La Delia, F.; Zelber-Sagi, S.; Malaguarnera, M.; Pelicci, P.G.; Giorgio,
M.; et al. Moro orange juice prevents fatty liver in mice. World J. Gastroenterol. 2012, 18, 3862–3868. [CrossRef] [PubMed]
28. Titta, L.; Trinei, M.; Stendardo, M.; Berniakovich, I.; Petroni, K.; Tonelli, C.; Riso, P.; Porrini, M.; Minucci, S.; Pelicci, P.G.; et al.
Blood orange juice inhibits fat accumulation in mice. Int. J. Obes. 2010, 34, 578–588. [CrossRef] [PubMed]
29. Rupasinghe, H.P.V.; Sekhon-Loodu, S.; Mantso, T.; Panayiotidis, M.I. Phytochemicals in regulating fatty acid β-oxidation: Potential
underlying mechanisms and their involvement in obesity and weight loss. Pharmacol. Ther. 2016, 165, 153–163. [CrossRef]
[PubMed]
30. De Lima, L.P.; de Paula Barbosa, A. A review of the lipolytic effects and the reduction of abdominal fat from bioactive compounds
and moro orange extracts. Heliyon 2021, 7, e07695. [CrossRef] [PubMed]
31. Zhang, Q.; de Mejia, E.G. Protocatechuic acid attenuates adipogenesis-induced inflammation and mitochondrial dysfunction in
3T3-L1 adipocytes by regulation of AMPK pathway. J. Funct. Foods 2020, 69, 103972. [CrossRef]
32. Tielemans, M.M.; Jaspers Focks, J.; van Rossum, L.G.; Eikendal, T.; Jansen, J.B.; Laheij, R.J.; van Oijen, M.G. Gastrointestinal
symptoms are still prevalent and negatively impact health-related quality of life: A large cross-sectional population based study
in The Netherlands. PLoS ONE 2013, 8, e69876.