1 s2.0 S2773050622000349 Main
1 s2.0 S2773050622000349 Main
1 s2.0 S2773050622000349 Main
a r t i c l e i n f o a b s t r a c t
Keywords: Background: Zinc deficiency is common in patients with non-alcoholic fatty liver disease (NAFLD) and evidence
Zinc supplement indicates the role of zinc as an antioxidant and improvement in insulin resistance in obesity and type 2 dia-
Mental health betes. The aim of this study was to investigate the effects of zinc supplementation on mental health among
Non-alcoholic fatty liver
overweight/obese patients with NAFLD.
Depression
Methods: Fifty- seven overweight/obese subjects with confirmed non-alcoholic fatty liver disease (NAFLD) were
Anxiety
Stress randomly allocated to treatment (30 mg/day supplement) or placebo groups under a calorie restricted diet for
12 weeks. Mental health was assessed using a valid 21-item questionnaire, the Depression, Anxiety, and Stress
Scale (DASS-21). Anthropometric measurements, food assessment, and mental health were assessed at the first,
6th, and 12th weeks. Serum zinc was assessed at the beginning and end of the intervention.
Results: A total of 50 participants completed the study. Serum zinc deficiency was significantly compensated in the
treatment group (P<0.05). Although the DASS-21 depression, anxiety, and stress scores decreased significantly
during the intervention, after adjusting for confounder factors, no significant differences were seen between the
two groups. After 12 weeks, only waist circumference decreased significantly in the treatment group compared
to the placebo group (P<0.05).
Conclusions: The study showed daily intake of 30 mg of zinc elemental improves zinc deficiency and waist circum-
ference in patients with NAFLD. However, further clinical trial studies with a longer duration, dose-dependent
and considering gender and severity of mood disorders are needed to clarify the effect of zinc supplementation on
depression, anxiety, and stress in overweight/obese patients with NAFLD [IR.MUI.RESEARCH.REC.1399.071].
∗
Corresponding author at: Department of Clinical Nutrition, School of Nutrition and Food Security Research Center, Isfahan University of Medical Sciences, Isfahan,
Iran.
E-mail address: [email protected] (R. Amani).
https://doi.org/10.1016/j.jtemin.2022.100035
Received 18 June 2022; Received in revised form 16 November 2022; Accepted 16 November 2022
Available online 25 November 2022
2773-0506/© 2022 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
M. Fathi, P. Alavinejad, Z. Haidari et al. Journal of Trace Elements and Minerals 2 (2022) 100035
tional studies [11,12], results of observational studies are controversial of the DASS questionnaire among patients with NAFLD, we conducted
[9,13,14]. a pilot study as part of the Ph.D. thesis of MF which was registered in
Evidence indicated zinc deficiency through the hypothalamic– the Iranian Registry of Clinical Trials (IRCT NO: 20181005041238N1).
pituitary–adrenal axis causes susceptibility to stress and vice versa, Participants were selected from overweight/ obese patients with NAFLD
stress conditions lead to zinc deficiency [15,16]. Animal model studies referred to the gastroenterology clinic of the Ahvaz Imam Educational
have also shown that resistance to antidepressant treatments is lower in Hospital. All participants signed the informed consent.
patients with lower serum zinc levels [17,18]. Results of a meta-analysis Inclusion criteria: adult (18–65 year), body mass index (BMI) be-
showed serum levels of zinc approximately 0.12 μg/mL is lower in de- tween 25 and 35 kg/m2, waist circumference (WC > 94 cm for men and
pressed subjects than in normal subjects [19]. Zinc has also been shown > 80 cm for women) [21], grade 1 or 2 NAFLD. Exclusion criteria: a
in some experimental studies to regulate antioxidant, neurotransmit- clinical history of chronic diseases (diabetes, hepatic or kidney dysfunc-
ter systems, neurotrophic factors, and neuronal precursor cells [20,21]. tion, major cardiovascular diseases, cancer, malabsorption, hormonal
Therefore, the objective of this clinical trial study is to evaluate the effect disturbances), pregnant or lactating women, smoking and drinking alco-
of zinc supplementation on mood status in overweight or obese patients hol habits, used any supplements (zinc or other supplements), adhered
with NAFLD. to any special diet or highly physically active (> 3 h/week) over the
past 3 months as well as not taking more than 10% of the zinc supple-
ment. Patients with major neural disorder (such as Alzheimer, multiple
Material and methods
sclerosis, Parkinson et cetera) were excluded.
Participants
Dietary weight loss protocol
The Medical Ethics Committee at the Isfahan University of Medical
Sciences approved the present study under the registration cod number 56 overweight/obese patients with NAFLD participated in a 12-week
IR.MUI.RESEARCH.REC.1399.071. The study was conducted in accor- randomized, double-blind, placebo-controlled trial. At the first of inter-
dance with the Declaration of Helsinki between Jun 2020 and Decem- vention, after randomization, each participant received a personalized
ber 2020. Before the current study, in order to investigate the feasibility diet plan containing 55% carbohydrate, 30% fat, and 15% protein with
2
M. Fathi, P. Alavinejad, Z. Haidari et al. Journal of Trace Elements and Minerals 2 (2022) 100035
Table 1
Baseline demographics, clinical, laboratory data.
500–1000 kcal/day energy restriction targeting 0/5–1 kg weight loss subscale (depression, anxiety and, stress). The questionnaire was con-
per week. A trained dietitian followed the adherence to the diet (assess- ducted for all participants in each visit. For each item was considered
ment food recalls and weight loss at least 3% of body weight during the score ranging from 0 “Did not apply to me at all - NEVER” to 3 “Applied
study) and supplementation (taking > 90% of the supplements) in each to me very much, or most of the time - ALMOST ALWAYS”. The degree
visit and by phone call. of severity of emotional states was determined using multiplication by
two the DASS-21 sub-scale and categorization to yield equivalent scores
ranging from normal to extremely severe. Previous studies reported high
Supplementation
reliability of the questionnaire with a Cronbach’s alpha coefficient 0.84
and high convergent validity and internal consistency [17].
By considering blinding conditions, simultaneously with the weight
loss diet, one group received daily 220 mg zinc gluconate (as 30- mg
Statistical analysis
elemental zinc), and the other received a placebo for 12-weeks. Either
zinc supplement or placebo was exactly the same and made and packed
All statistical analyses were performed using SPSS version 21 (SPSS
by Dineh Pharmacy Company, Tehran, Iran.
Inc., Chicago, IL, USA). Q–Q plot and skewness of the data were explored
to evaluate data distribution. Data was presented as mean ± standard
Measurement and assessment deviation (SD) and frequency (percentage) as appropriate. Independent
sample t-tests or chi-squared tests were used to compare variables be-
The body weight, waist circumference, hip circumference, lean body tween two groups. Assessments of differences over time within groups
mass, fat mass, 24-h food recall and physical activity were assessed at were made by repeated measure ANOVA. Changes from baseline ad-
first, 6th week, and 12th week. justed for baseline measurement were explored using repeated measure
At the beginning and end of the intervention, after 12- h of fast- ANCOVA. A P < 0.05 was considered statistically significant.
ing, participants were asked for blood collecting and ultrasonography.
Serum zinc was measured using the assay kit (Bionik, Iran) based direct Results
colorimetric technique [15]. (the detail of measurements are presented
in the previous study) [16]. Among 141 participants who were screened, 56 subjects were eli-
Depression, anxiety and, stress was assessed using a self-reported 21- gible. Four participants in the treatment group and two participants in
itemes questionnaire (DASS-21) that there are seven questions in each the placebo did not continue the study for personal reasons and entirely
3
M. Fathi, P. Alavinejad, Z. Haidari et al. Journal of Trace Elements and Minerals 2 (2022) 100035
Table 2 Table 3
Anthropometric measurements in the both groups. Dietary zinc intakes status and serum zinc in the both groups.
Variable Zinc supplementation Placebo p-value b p-value c Variable Zinc supplementation placebo group p-value
4
M. Fathi, P. Alavinejad, Z. Haidari et al. Journal of Trace Elements and Minerals 2 (2022) 100035
Fig. 2. A: Comparison Depression, Anxiety and Stress score in zinc supplementation versus placebo group at baseline, week 6 and 12 after intervention., Fig. 2B:
Comparison Anxiety score in zinc supplementation versus placebo group at baseline, week 6 and 12 after intervention, Fig 2C: Comparison Stress score in zinc
supplementation versus placebo group at baseline, week 6 and 12 after intervention.
tation. It is suggested that the appropriate proportion of copper and zinc longer durations, and does dependent are warranted to determine the
should be evaluated in future studies [41]. effect of zinc supplementation in NAFLD patients with different intensi-
All stress, anxiety, and depression scores decreased during the inter- ties of mood disorders, from mild to extremely severe.
vention in all participants except one participant in the placebo group
who had a minimum score for stress, depression, and anxiety at the
Ethics approval and consent to participate
beginning of the intervention. At the end of the intervention, 30- mg el-
emental zinc supplementation did not have significant effects on mood
The Medical Ethics Committee at the Isfahan University of Medical
outcomes in the adjusting models that were controlled for education
Sciences approved the present study under the registration cod number
and the history duration of NAFLD, and also baseline factors in over-
IR.MUI.RESEARCH.REC.1399.071.
weight/obese patients with NAFLD. Consist of previous studies, it seems
that the improvement in mood status can be attributed to the dietary
weight loss [42,43]. Consent for publication
The present study is the first clinical trial to evaluate the effect of Data availability statement
zinc supplementation on mood disorders in patients with NAFLD. How-
ever, allowing for the severity of stress, depression, and anxiety, further The datasets analyzed in this study are accessible by the correspond-
long-term and dose-dependent clinical trials are needed to clarify the ing author on any reasonable request.
influence of zinc supplementation on the mood status of patients with
NAFLD. It is suggested that serum levels of hormonal and metabolomic
factors related to mood disorders will be investigated. Funding/support
This work was supported by the Vice Chancellor for Research of Is-
Conclusion
fahan University of Medical Sciences, Iran under Grant number 16902.
There is an ethical statement.
The present study showed although 30 mg elemental zinc supple-
ment compensated serum levels of zinc deficiency in overweight/obese
patients with NAFLD, did not significant effect on the mood outcomes Declarations of Competing Interest
in these patients. It seems weight loss diet prompts an improvement
in depression, anxiety, and stress status. Studies of larger sample sizes, None.
5
M. Fathi, P. Alavinejad, Z. Haidari et al. Journal of Trace Elements and Minerals 2 (2022) 100035
CRediT authorship contribution statement [20] C. Marchetti, Interaction of metal ions with neurotransmitter receptors and potential
role in neurodiseases, Biometals 27 (6) (2014) 1097–1113.
[21] G. Satała, B. Duszyńska, K. Stachowicz, A. Rafalo, B. Pochwat, C. Luckhart, et al.,
Mojdeh Fathi: Conceptualization, Methodology, Software, Writing Concentration-dependent dual mode of Zn action at serotonin 5-HT1A receptors: in
– review & editing, Investigation. Pezhman Alavinejad: Visualization. vitro and in vivo studies, Mol. Neurobiol. 53 (10) (2016) 6869–6881.
Zahra Haidari: Software, Data curation. Reza Amani: Supervision, In- [22] J. Veran, J. Kumar, P.S. Pinheiro, A. Athané, M.L. Mayer, D. Perrais, et al., Zinc
potentiates GluK3 glutamate receptor function by stabilizing the ligand binding do-
vestigation, Conceptualization, Methodology, Writing – original draft. main dimer interface, Neuron 76 (3) (2012) 565–578.
[23] K. Mlyniec, Zinc in the glutamatergic theory of depression, Curr. Neuropharmacol.
Acknowledgments 13 (4) (2015) 505–513.
[24] A. Takeda, H. Tamano, T. Ogawa, S. Takada, M. Ando, N. Oku, et al., Significance
of serum glucocorticoid and chelatable zinc in depression and cognition in zinc de-
We would like to appreciate all patients who kindly contributed in ficiency, Behav. Brain Res. 226 (1) (2012) 259–264.
the study. [25] W. Swardfager, N. Herrmann, G. Mazereeuw, K. Goldberger, T. Harimoto, K.L. Lanc-
tôt, Zinc in depression: a meta-analysis, Biol. Psychiatry 74 (12) (2013) 872–878.
[26] H.-.L. Gao, W. Zheng, N. Xin, Z.-.H. Chi, Z.-.Y. Wang, J. Chen, et al., Zinc deficiency
References
reduces neurogenesis accompanied by neuronal apoptosis through caspase-depen-
dent and-independent signaling pathways, Neurotox. Res. 16 (4) (2009) 416–425.
[1] S.M. de la Monte, L. Longato, M. Tong, J.R. Wands, Insulin resistance and neurode- [27] S. Pfaender, K. Föhr, A.-.K. Lutz, S. Putz, K. Achberger, L. Linta, et al., Cellular zinc
generation: roles of obesity, type 2 diabetes mellitus and non-alcoholic steatohep- homeostasis contributes to neuronal differentiation in human induced pluripotent
atitis, Curr. Opin. Invest. Drugs 10 (10) (2009) 1049. stem cells, Neural Plast. (2016) 2016.
[2] H.M. Francis, R.J. Stevenson, J.R. Chambers, D. Gupta, B. Newey, C.K. Lim, A brief [28] F. Kosari, R. Jamali, T. Ramim, E.M.J. Abad, The correlation between serum zinc
diet intervention can reduce symptoms of depression in young adults–a randomised level and liver histology in non-alcoholic steatohepatitis, Iran. J. Pathol. 14 (1)
controlled trial, PLoS ONE 14 (10) (2019) e0222768. (2019) 17.
[3] N. Geiker, A. Astrup, M. Hjorth, A. Sjödin, L. Pijls, C.R. Markus, Does stress influ- [29] T. Himoto, T. Masaki, Associations between zinc deficiency and metabolic abnor-
ence sleep patterns, food intake, weight gain, abdominal obesity and weight loss malities in patients with chronic liver disease, Nutrients 10 (1) (2018) 88.
interventions and vice versa? Obes. Rev. 19 (1) (2018) 81–97. [30] T. Ito, M. Ishigami, Y. Ishizu, T. Kuzuya, T. Honda, T. Ishikawa, et al., Correlation
[4] C. Rodriguez-Lozada, M. Cuervo, A. Cuevas-Sierra, L. Goni, J.I. Riezu-Boj, S. Navas– of serum zinc levels with pathological and laboratory findings in patients with non-
Carretero, et al., Changes in anxiety and depression traits induced by energy restric- alcoholic fatty liver disease, Eur. J. Gastroenterol. Hepatol. 32 (6) (2020) 748–753.
tion: predictive value of the baseline status, Nutrients 11 (6) (2019) 1206. [31] A.S PRASAD, The role of zinc in gastrointestinal and liver disease, Clin. Gastroen-
[5] E. Brietzke, R.B. Mansur, M. Subramaniapillai, V. Balanzá-Martínez, M. Vinberg, terol. 12 (3) (1983) 713–741.
A. González-Pinto, et al., Ketogenic diet as a metabolic therapy for mood disorders: [32] A. Sawa, K. Okita, The role of copper and zinc as pathogenic factors in liver disease,
evidence and developments, Neurosci. Biobehav. Rev. 94 (2018) 11–16. in: Trace Elements in Clinical Medicine, Springer, 1990, pp. 89–92.
[6] C.P. Day, O.F. James, Steatohepatitis: a Tale of Two “Hits”?, Elsevier, 1998. [33] M. Colognesi, D. Gabbia, S. De Martin, Depression and cognitive impair-
[7] L.D. Estrada, P. Ahumada, D. Cabrera, J.P. Arab, Liver dysfunction as a novel player ment—extrahepatic manifestations of NAFLD and NASH, Biomedicines 8 (7) (2020)
in Alzheimer’s progression: looking outside the brain, Front. Aging Neurosci. 11 229.
(2019) 174. [34] Ó. Soto-Angona, G. Anmella, M.J. Valdés-Florido, N. De Uribe-Viloria, A.F. Car-
[8] H. Fukui, Role of gut dysbiosis in liver diseases: what have we learned so far? Dis- valho, B.W. Penninx, et al., Non-alcoholic fatty liver disease (NAFLD) as a neglected
eases 7 (4) (2019) 58. metabolic companion of psychiatric disorders: common pathways and future ap-
[9] W. Tomeno, K. Kawashima, M. Yoneda, S. Saito, Y. Ogawa, Y. Honda, et al., Non-al- proaches, BMC Med. 18 (1) (2020) 1–14.
coholic fatty liver disease comorbid with major depressive disorder: the pathologi- [35] J.M. Choi, G.E. Chung, S.J. Kang, M.-.S. Kwak, J.I. Yang, B. Park, et al., Association
cal features and poor therapeutic efficacy, J. Gastroenterol. Hepatol. 30 (6) (2015) between anxiety and depression and nonalcoholic fatty liver disease, Front. Med. 7
1009–1014. (2020).
[10] J.M. Gorman, Comorbid depression and anxiety spectrum disorders, Depress Anxiety [36] K.A. Lomagno, F. Hu, L.J. Riddell, A.O. Booth, E.A. Szymlek-Gay, C.A. Nowson,
4 (4) (1996) 160–168. et al., Increasing iron and zinc in pre-menopausal women and its effects on mood
[11] S.G. Higarza, S. Arboleya, M. Gueimonde, E. Gómez-Lázaro, J.L. Arias, N. Arias, and cognition: a systematic review, Nutrients 6 (11) (2014) 5117–5141.
Neurobehavioral dysfunction in non-alcoholic steatohepatitis is associated with hy- [37] L.E.M. da Silva, M.L.P. de Santana, P.R.F. Costa, E.M. Pereira, C.M.M. Nepomuceno,
perammonemia, gut dysbiosis, and metabolic and functional brain regional deficits, V.A.O. Queiroz, et al., Zinc supplementation combined with antidepressant drugs
PLoS ONE 14 (9) (2019) e0223019. for treatment of patients with depression: a systematic review and meta-analysis,
[12] J.E. Elwing, P.J. Lustman, H.L. Wang, R.E. Clouse, Depression, anxiety, and nonal- Nutr. Rev. 79 (1) (2021) 1–12.
coholic steatohepatitis, Psychosom. Med. 68 (4) (2006) 563–569. [38] M. Siwek, D. Dudek, I.A. Paul, M. Sowa-Kućma, A. Zięba, P. Popik, et al., Zinc supple-
[13] K. Lee, M. Otgonsuren, Z. Younoszai, H.M. Mir, Z.M. Younossi, Association of chronic mentation augments efficacy of imipramine in treatment resistant patients: a double
liver disease with depression: a population-based study, Psychosomatics 54 (1) blind, placebo-controlled study, J. Affect. Disord. 118 (1–3) (2009) 187–195.
(2013) 52–59. [39] A.M. DiGirolamo, M. Ramirez-Zea, M. Wang, R. Flores-Ayala, R. Martorell,
[14] N.A. Youssef, M.F. Abdelmalek, M. Binks, C.D. Guy, A. Omenetti, A.D. Smith, et al., L.M. Neufeld, et al., Randomized trial of the effect of zinc supplementation on the
Associations of depression, anxiety and antidepressants with histological severity of mental health of school-age children in Guatemala, Am. J. Clin. Nutr. 92 (5) (2010)
nonalcoholic fatty liver disease, Liver Int. 33 (7) (2013) 1062–1070. 1241–1250.
[15] N.M. Negruţ, E.M. Domuța, M.V. Nanulescu, Plasma concentration of zinc in children [40] M. De Hert, J. Detraux, D. Vancampfort, The intriguing relationship between coro-
aged 0-3 years, Jurnalul Pediatrului (2013) 16. nary heart disease and mental disorders, Dialogues Clin. Neurosci. (2022).
[16] M. Fathi, P. Alavinejad, Z. Haidari, R. Amani, The effect of zinc supplementa- [41] G. Tarantino, C. Porcu, M. Arciello, P. Andreozzi, C. Balsano, Prediction of carotid
tion on steatosis severity and liver function enzymes in overweight/obese patients intima–media thickness in obese patients with low prevalence of comorbidities by
with mild to moderate non-alcoholic fatty liver following calorie-restricted diet: a serum copper bioavailability, J. Gastroenterol. Hepatol. 33 (8) (2018) 1511–1517.
double-blind, randomized placebo-controlled trial, Biol. Trace. Elem. Res. 197 (2) [42] M. Sanchez, C. Darimont, S. Panahi, V. Drapeau, A. Marette, V.H. Taylor, et al., Ef-
(2020) 394–404. fects of a diet-based weight-reducing program with probiotic supplementation on
[17] Sahebi A., Asghari M.J., Salari R.S. Validation of depression anxiety and stress scale satiety efficiency, eating behaviour traits, and psychosocial behaviours in obese in-
(DASS-21) for an Iranian population. 2005. dividuals, Nutrients 9 (3) (2017) 284.
[18] E.P. Huang, Metal ions and synaptic transmission: think zinc, Proc. Natl. Acad. Sci. [43] G. Brinkworth, N. Luscombe-Marsh, C. Thompson, M. Noakes, J. Buckley, G. Wittert,
94 (25) (1997) 13386–13387. et al., Long-term effects of very low-carbohydrate and high-carbohydrate weight-loss
[19] B.I. Kalappa, C.T. Anderson, J.M. Goldberg, S.J. Lippard, T. Tzounopoulos, AMPA diets on psychological health in obese adults with type 2 diabetes: randomized con-
receptor inhibition by synaptically released zinc, Proc. Natl. Acad. Sci. 112 (51) trolled trial, J. Intern. Med. 280 (4) (2016) 388–397.
(2015) 15749–15754.