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Risk of Type 2 Diabetes Is Lower in US Adults Taking Chromium-Containing Supplements1–3

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Risk of Type 2 Diabetes Is Lower in US Adults Taking Chromium-Containing Supplements1–3 The Journal of Nutrition Nutrition and Disease Risk of Type 2 Diabetes Is Lower in US Adults Taking Chromium-Containing Supplements1–3 David J McIver,4,5* Ana Maria Grizales,5,6 John S Brownstein,4,5 and Allison B Goldfine5,6 4Boston ChildrenÕs Hospital, Boston, MA; 5Harvard Medical School, Boston, MA; and 6Joslin Diabetes Center, Boston, MA Abstract Background: Dietary supplement use is widespread in the United States. Although it has been suggested in both in vitro and small in vivo human studies that chromium has potentially beneficial effects in type 2 diabetes (T2D), chromium supplementation in diabetes has not been investigated at the population level. Objective: The objective of this study was to examine the use and potential benefits of chromium supplementation in T2D by examining NHANES data. Downloaded from Methods: An individual was defined as having diabetes if he or she had a glycated hemoglobin (HbA1c) value of $6.5%, or reported having been diagnosed with diabetes. Data on all consumed dietary supplements from the NHANES database were analyzed, with the OR of having diabetes as the main outcome of interest based on chromium supplement use. Results: The NHANES for the years 1999–2010 included information on 62,160 individuals. After filtering the database for the required covariates (gender, ethnicity, socioeconomic status, body mass index, diabetes diagnosis, supplement jn.nutrition.org usage, and laboratory HbA1c values), and when restricted to adults, the study cohort included 28,539 people. A total of 58.3% of people reported consuming a dietary supplement in the previous 30 d, 28.8% reported consuming a dietary supplement that contained chromium, and 0.7% consumed supplements that had ‘‘chromium’’ in the title. Compared with nonusers, the odds of having T2D (HbA1c $6.5%) were lower in persons who consumed chromium-containing by guest on December 29, 2016 supplements within the previous 30 d than in those who did not (OR: 0.73; 95% CI: 0.62, 0.86; P = 0.001). Supplement use alone (without chromium) did not influence the odds of having T2D (OR: 0.89; 95% CI: 0.77, 1.03; P = 0.11). Conclusions: Over one-half the adult US population consumes nutritional supplements, and over one-quarter consumes supplemental chromium. The odds of having T2D were lower in those who, in the previous 30 d, had consumed supplements containing chromium. Given the magnitude of exposure, studies on safety and efficacy are warranted. JNutr2015;145:2675–82. Keywords: chromium, diabetes, glucose intolerance, insulin resistance, dietary supplements, safety, NHANES Introduction been a field of interest to address this public health burden (2). In 2012, the CDC estimated that 29.1 million Americans had Although there are multiple classes of pharmacologic agents diabetes, accounting for 12.3% of the adult population (1). approved for diabetes treatment, many persons use nutritional Modifiable social and behavioral factors, such as adopting dif- supplements to help manage their diabetes, as well as a myriad of ferent dietary patterns and consuming nutritional supplements 7 other conditions. In 2007, Americans spent nearly $34 billion of aimed at preventing or controlling type 2 diabetes (T2D) ,have their personal money on complementary and alternative medi- cines, including dietary supplements (3). a-Lipoic acid, banaba, 1 This work was supported in part by the National Institute of Diabetes and bitter lemon, blonde psyllium, cinnamon, dandelion, fenugreek, Digestive and Kidney Diseases grant P30-DK03836. Research reported in this ginseng, gymnema sylvestre, milk thistle, nopal from the prickly publication was supported by the National Human Genome Research Institute of pear, vanadium, and others are among the many dietary sup- the NIH under award number U54HG007963. plements with purported benefit in T2D, despite the low level 2 Author disclosures: DJ McIver, AM Grizales, JS Brownstein, and AB Goldfine, no conflicts of interest. of evidence to support effectiveness or safety (4). Nutritional 3 The content is solely the responsibility of the authors and does not necessarily substances, when taken to excess or for extended periods of time, represent the official views of the NIH. may have adverse effects. 7 Abbreviations used: HbA1c, glycated hemoglobin; SES, socioeconomic status; Many people appear to use chromium supplements for T2D, type 2 diabetes; T2D-M1, type 2 diabetes defined on the basis of HbA1c values glycemia despite the fact that randomized clinical trials have only; T2D-M2, type 2 diabetes defined by both HbA1c values and doctor diagnosis. * To whom correspondence should be addressed. E-mail: david.mciver@ generally not demonstrated differences in fasting glucose or childrens.harvard.edu. oral glucose tolerance between chromium picolinate– and ã 2015 American Society for Nutrition. Manuscript received March 30, 2015. Initial review completed May 5, 2015. Revision accepted September 10, 2015. 2675 First published online October 7, 2015; doi:10.3945/jn.115.214569. placebo-treated groups (5–9), and meta-analysis of published supplement information from the NHANES database, and extracted investigations likewise does not support clinical use (10–13). information from all dietary supplements that contained chromium Chromium was previously classified as an essential trace (NHANES supplement use data are provided as the number of supple- element, important in carbohydrate, lipid, and protein metab- ments taken in the past 30 d at the time of NHANES interview). In the olism, because when it is deficient, it might lead to glucose NHANES database, information is provided for the name of each dietary intolerance and insulin resistance (6, 14, 15). Historically, the supplement consumed by an individual in the previous 30 d, along with nutritional importance of chromium was initially described frequency of use, the ingredients for each supplement, and the quantity in 1957 when rodents provided a diet lacking chromium be- of each ingredient in the supplement. Individual ingredients in any came unable to adequately metabolize glucose, but when chro- supplement could span in quantity from a primary ingredient (e.g., iron mium was supplemented in the form of brewerÕs yeast, glucose in an iron supplement) to minute amounts. With this data, we calculated metabolism was restored. The chromium-dependent molecule the quantity of chromium consumed in any of its varieties from all responsible for the restoration of glucose metabolism was consumed dietary supplements over the 30 d period. We did not estimate initially named glucose tolerance factor (16), although, if nonsupplement dietary chromium consumption. A wide variety of chro- existent, identification of glucose tolerance factor and mode mium supplement consumption values was created with the use of this of action remains elusive (17). The essentiality of chromium for method, ranging from individuals who consumed a single dietary humans was subsequently described in a patient who received supplement with a small amount of chromium only once in the 30 d total parenteral nutrition and developed glucose intolerance, period, to individuals who consumed multiple dietary supplements with high chromium quantities multiple times in the 30 d period. Two subsets weight loss, and peripheral neuropathy, a condition that was of dietary supplements were then created: those whose ingredients list unresponsive to insulin, but that was resolved with the admin- included chromium and those supplements that contained the word istration of chromium (18). Additional reports of patients receiv- ‘‘chromium’’ in its title (by definition, a subset of the former group). This ing total parenteral nutrition who developed T2D, which was was in order to separate out individuals actively seeking chromium resolved with chromium replacement, supported the essential Downloaded from supplementation (those taking supplements with ‘‘chromium’’ in the status (19, 20). However, the essential function of chromium title) and those simply consuming the chromium from a multivitamin or remains incompletely substantiated and the European Food a supplement whose main purpose may not be chromium supplemen- Safety Authority expert scientific panel and others currently do tation (with chromium appearing only in the ingredients list). Informa- not support continued essential classification (17, 21). tion on participant age, gender, BMI, ethnicity, and socioeconomic status There are no large or long-term studies, to our knowledge, (SES) was also collected. SES was coded as the ratio of family income to evaluating the efficacy or safety of chromium in treating or poverty, with values below 1.00 representing household income below jn.nutrition.org preventing T2D in humans. To this end, we examined the NHANES poverty. All analyses were restricted to individuals $18 y of age. database, created and administered by the CDC (22, 23), to describe Logistic regression analyses were performed with independent vari- the proportion of Americans who are consuming dietary supple- ables in the model categorized in the following manner, with an asterisk ments containing chromium, and how this affects T2D prevalence. denoting the baseline referent category for analyses: Gender (male = 0*, and female = 1); age (18–29, 30–49*, 50–69, and $70); ethnicity (non- by guest on December 29, 2016 Hispanic white*, Mexican American, other Hispanic, non-Hispanic Methods black, and other); BMI (in kg/m2; <18.5, 18.5–24.9*, 25–29.9, and $30); and SES (categorized by quartiles, with lowest 25% as
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