Effect of Lifestyle Modification Combined with Metformin on Serum

Chemerin Concentration in Metabolic Syndrome Subjects

Brama Ihsan Sazli

, Dharma Lindarto

, Dian Anindita Lubis

, Melati Silvani Nasution

Department of Internal Medicine, Faculty of Medicine, Universitas Sumatera Utara

H. Adam Malik Hospital, Jalan Bunga Lau No 17, Medan 20136, Indonesia

Keywords: Lifestyle modification, Chemerin, Metabolic Syndrome.

Abstract: Chemerin is an adipokine that plays an important role in inflammation development and insulin resistance

by accommodating macrophage infiltration into adipose tissue. This study aimed to determine the effect of

lifestyle modification with and without metformin on chemerin in metabolic syndrome. Forty-five metabolic

syndrome subjects (IDF-2005) were randomly assigned to one of the two groups: placebo group (n=22) and

metformin group (n=23). Both groups underwent a 12-week lifestyle modification (diet and moderate

aerobic-exercise). Only 40 participants (placebo group n=20 and metformin group n=20) completed the

survey whereas 5 participants dropped out of the study. After their lifestyle was modified, body weight,

body mass index, waist circumference, and chemerin decreased significantly (P<0.001) in both groups.

Moreover, there was a significant difference between both groups in body weight, BMI, and WC (P<0.05)

but not for chemerin. Thus, lifestyle modification with metformin improved BW, BMI, and WC on

metabolic syndrome, and there were no significant differences in reduced chemerin between placebo and

metformin groups. Further investigations should be done to establish the effect of lifestyle modification

combined with metformin on chemerin after an extended follow-up period.

1 INTRODUCTION

Metabolic syndrome represents a combination

of cardiometabolic risk factors including glucose

intolerance, insulin resistance, central adiposity,

hypertension, non-alcoholic fatty liver disease, and

dyslipidemia. The prevalence of metabolic

syndrome increases rapidly worldwide as a result of

the continuous obesity epidemic.

This will also

increase global risk in the incidence of cardiovascular

disease and type 2 diabetes mellitus (T2DM)

(Bruce and

Byrne, 2009). Adiposity has been known as an

important endocrine organ that does not only store

energy but also regulates metabolism and energy

homeostasis (Rosen,2006)

Chemerin, an adipokine that was recently

found, increased its expression in obesity state

(Goralski et al., 2007; Bozauglu et al., 2007).

Several specific functions of chemerin are regulation

of specific immune cell migration

(Zabel, Silverio

and Butcher, 2007), anti-inflammatory effects on

macrophages (Cash et al., 2008), and regulation of

adipogenesis (Zabel, Silverio, and Butcher, 2007),

Previously, a significant association has been

identified between characteristics of the metabolic

syndrome and circulating chemerin levels in a

relatively small sample of human subjects from

Mauritius (Bozauglu et al., 2007). Bozaoglu et al

(2009) evaluated plasma chemerin concentration in

human subjects and found that plasma chemerin

concentrations were highly associated with body

mass index (BMI), blood pressure, and plasma

triglycerides. And in women with polycystic ovary

syndrome, treatment with metformin decreases

serum chemerin levels. (Tan et al., 2009).

Physical inactivity is well known as the risk

factor for T2DM (Venables and Jeukendrup, 2009)

and aerobic training in obese adults has been shown

to reduce adiposity and insulin resistance (O'Leary et

al., 2006). There has been no previous report about

lifestyle modification induces alteration in chemerin

concentrations in metabolic syndrome, which may

serve a connection between obesity and insulin

resistance. Modification of lifestyle against

overweight, physical inactivity, and atherogenic diet

has been recommended as a primary in the

management of metabolic syndrome (Eckel, Grundy

and Zimmet, 2005). However, lifestyle

modifications alone often cannot achieve clinically

Sazli, B., Lindarto, D., Lubis, D. and Nasution, M.

Effect of Lifestyle Modiﬁcation Combined with Metformin on Serum Chemerin Concentration in Metabolic Syndrome Subjects.

DOI: 10.5220/0009855700380043

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 38-43

ISBN: 978-989-758-469-5

meaningful weight loss (Miler, Kojeca and

Hamilton, 1997).

Metformin, a biguanide insulin sensitizer agent

has been shown to decrease body weight,

hyperinsulinemia, and hyperglycemia in adult

patients with T2DM (UKPDS 34, 1998). Metformin

has recently also been suggested to increase the

effect of insulin sensitivity from exercise (Sharoff et

al., 2010), inhibit platelet aggregation, as an

antioxidant activity, reduce weight, and gives effect

on lipid parameters like total cholesterol, low-

density lipoprotein cholesterol (LDL-C),

triglycerides (TG), high-density lipoprotein

cholesterol (HDL-C), and arterial hypertension

[Glueck et al., 2001; Wulffele et al., 2004).

Metformin does not induce hypoglycemia so it can

be given safely to euglycemic patients (Pasquali et

al.,200)

Therefore, the aim of this study was to

evaluate the effect of lifestyle modification

combined with metformin on chemerin in metabolic

syndrome.

2 MATERIALS AND METHODS

The research subjects were recruited in Haji Adam

Malik Hospital, Medan, Indonesia. From 184 obese

nurses (BMI ≥25), only 45 subjects were diagnosed

with metabolic syndrome (IDF-2005) and agreed to

involve in lifestyle modification for 12 weeks.

Diagnosis of metabolic syndrome by IDF-2005

guidelines were used, namely central obesity with a

Waist Circumference (WC) of ≥90 cm for men and

≥80 cm for women (Asian population), and any two

of the following four factors: (1) triglyceride ≥150

mg/dl or specific treatment for lipid abnormality; (2)

HDL-C (men <40 mg/dl and women <50 mg/dl) or

specific treatment for lipid abnormality; (3)

hypertension ≥130/85 mmHg or history of treatment

previously diagnosed hypertension; and (4) FBS

≥100 mg/dl or previously diagnosed T2DM (WHO,

2004: Grundy et al., 2005). They were divided

randomly to either the placebo group (n=22) or

metformin group (n=23).

All subjects gave their fully informed consent

before participated in the study. The Ethics

Committee of Medical Faculty of Universitas

Sumatera Utara has approved the study. We

excluded subjects who had cardiovascular diseases

or any other major illnesses, smokers, or were taking

medications that could affect the laboratory test

results. Before and during the study, trained health

nurses and participants discussed the lifestyle

modification programs including diet and exercise.

To facilitate changes in behavior, each participant

receives leaflets and diaries to record their

behavioral performance, diet, physical activity, WC,

and body weight (BW) monitored by phone

. Participants attended a follow-up meeting every

week to confirm how the participants had complied

with the targeted behaviors and checked whether the

participants had experienced any health and safety

problems related to behavioral changes including the

side effect of drugs.

2.1 Anthropometric Measurements

Weight in kilograms (kg) and heights in meters (m)

were measured, and the weight in kilograms divided

by the square of the height in meters to calculated

BMI as For the Asian population, BMI <18.5 is

classified as underweight, BMI 18.5-22.9 is

classified as normal, BMI 23-24.9 is classified as

overweight, BMI 25-29.9 is classified as obese I and

BMI ≥30.0 is classified as obese II. The WC was

measured midway between the uppermost border of

the iliac crest and the lower border of the coastal

margin (rib cage), and using Asian values (male ≥90

cm; female ≥80 cm) (WHO, 2004). The exercise

program consists of moderate aerobic exercise at

least 3 times per week (30 minutes each) (Misra,

Misra and Wijesuriya, 2006). The aerobic exercise

was supervised by a physiotherapist at each training

session. The exercise group performed a warm-up

exercise for 5 min, followed by the main exercise for

20 min, and relaxation exercise for 5 min at the end

of the exercise period (PERKENI, 2015).

2.2 Diet

Between 0 and 12-week period throughout the study,

all subjects followed a standard weight maintenance

diet (55–60% carbohydrate, 15–20% protein, and

20–25% fat) (PERKENI, 2015). All subjects were

free to consume and choose the food according to

their dietary habits and from the list of food

replacement.

2.3 Blood Pressure and Blood Sample

Analysis

Blood pressure was measured by an average of twice

measurement after a 10-minute break with a mercury

sphygmomanometer. After overnight fasting and

collection, blood samples were centrifuged for 15

min while plasma and serum containing tubes were

stored at - 20

C until analysis. Blood glucose levels

Effect of Lifestyle Modiﬁcation Combined with Metformin on Serum Chemerin Concentration in Metabolic Syndrome Subjects

were measured by photometer autoanalyzer Modular

P 800, plasma HDL-C and LDL-C were measured

by the Architect Ci 8200 (Abbott, USA), triglyceride

was measured by GPO-PAP methods of Architect,

hs-CRP was measured by sensitive immunoassay

(Siemens Medical Solution Inc, IL, USA) of

Immulite 1000, HbA1c was measured by high-

performance liquid chromatographic (HPLC) of the

Bio-Rad D 10, and chemerin was measured by

Mediagnost ELISA E-102 (Sandwich-Assay).



2.4 Statistical Analysis

Data were presented as mean ± SD. The normality

assumption of the placebo group and metformin

group data were evaluated and confirmed using

Shapiro-Wilk in each group. Differences between

and within each data of the placebo group and

metformin group were tested using an independent

sample t-test and dependent t-test. However, the

abnormal data were tested using the Mann-Whitney

U test and Wilcoxon test. Two-sided P-values of

<0.05 were considered as statistically significant.

The data were analyzed using SPSS 22 software.

3 RESULTS

Of the 45 participants at the baseline, 40 participants

(placebo group, n=20; metformin group, n=20)

completed in the 12-week survey, whereas 5

participants (2 participants from the placebo group

and 3 participants from the metformin group)

dropped out of the study. In Table 1, there was no

significant difference in the baseline characteristics

of the two groups.

In Table 2, after 12 weeks of lifestyle

modification, there was a significant decrease in

BW, BMI, WC, SBP, and chemerin in placebo and

metformin group. But there were no statistically

significant differences in reduced chemerin between

the two groups.

Table 1: Clinical Characteristics of Placebo and Metformin Groups on Metabolic Syndrome Subjects

Variable Placebo group Metformin group P

=22 =23

n (F/M) 17/5 20/3

Age (yr) 40.41±5.61 42.91±5.62 0.142

BW (kg) 76.98±11.64 80.53±14.72 0.374

BMI (kg/m

) 32.11±4.09 34.03±5.76 0.206

WC (cm) 95.40±7.41 97.23±10.95 0.927

SBP (mmHg) 123.18±11.29 125.21±19.74 0.567

DBP (mmHg) 82.00±9.99 80.65±10.69 0.247

HDL-C (mg/dl) 45.72±8.48 48.34±15.47 0.918

TG (mg/dl) 150.40±51.05 152.00±63.87 0.974

FBG (mg/dl) 85.27±11.98 86.69±10,06 0.351

PPG (mg/dl) 115.72±11.98 104.21±21.40 0.401

hs-CRP (mg/dl) 3.45±2.47 3.83±2.34 0.467

Chemerin (ng/mL) 344.09±104.58 345.15±83.90 0.970

BW: body weight; BMI: Body Mass Index; CRP: C-reactive protein; DBP: Diastolic Blood

Pressure: FBS: fasting Blood Sugar; PPG: Postprandial Glucose; SBP: Systolic Blood Pressure;

TG: Triglyceride; WC: Waist Circumference; PPG: Postprandial glucose.

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

Table 2: Clinical Characteristics of Placebo and Metformin Groups after 12-Week Follow-Up for both Groups of Metabolic

Syndrome Subjects

Placebo group Metformin group

Variable (n=20) (n=20) P

Baseline At 12-

week

Differe

nce

Baseline At 12-

week

Diffe

rence

Weight

(kg)

77.6 ± 11.0 75.2±10.8 -2.3 0.001** 81.4±14.6 77.4±14.5 -3.9 0.001** 0.001*

BMI

(kg/m

)

32.1 ± 4.1 30.9±4.1 -1.1 0.001** 34.2±5.6 32.4±5.6 -1.8 0.001** 0.002*

(cm)

95.7 ± 7.3 89.9±7.5 -5.8 0.001** 97.9±11.5 91.8±10.7 -6.2 0.001** 0.047*

SBP

(mmHg)

123.5±11.4 114.0±8.2 -9.5 0.007** 127.0±20.3 112.8±8.5 -14.3 0.001** 0.231

DBP

(mmHg)

82.2±10.5 69.0±5.5 -31.8 0.001* 80.6±11.0 67.5±7.2 -13.3 0.001** 0.300

HDL-C

(mg/dl)

46.4±8.5 45.3±10.0 -1.1 0.628 48.9±16.4 46.5±9.8 -2.4 0.653 0.103

(mg/dl)

147.5±50.5 153.3±67.

5.8 0.634 152.3±66.9 149.0±10

2.4

-3.3 0.147 0.285

FBS

(mg/dl)

83.4±10.6 91.7±20.6

8.3 0.001* 84.9±8.9 87.7±10.7 2.8 0.305 0.039*

PPG

(mg/dl)

114.9±35.4 112.3±37.

-2.5 0.717 105.1±22.4 102.3±19.

-2.8 0.491 0.142

CRP

(mg/dl)

3.6±2.5 3.0±2.2 -0.6 0.048* 3.9±2.4 3.5±1.9 -0.6 0.327 0.482

Chemeri

(ng/mL)

339.5±106.

225.5±43.

-113.9 0.001** 339.9±82.9 226.5±46.

113.9

0.001** 0.430

BMI: Body Mass Index; CRP: C-reactive protein; DBP: Diastolic Blood Pressure: FBS: Fasting Blood Sugar; PPG; SBP:

Systolic Blood Pressure; TG: Triglyceride; WC: Waist Circumference; 2h-PPG: 2 hour-Postprandial glucose.

Difference between the baseline and 12-week follow-up surveys

Difference between the baseline and 12-week follow-up surveys in the Placebo group, based on a dependent t-test.

Difference between the baseline and 12-week follow-up surveys in the Metformin group, based on a dependent t-test.

Δ Difference between the Placebo group and Metformin group after the 12-week follow-up surveys, based on an

independent t-test.

*P < 0.05, **P < 0.01

4 DISCUSSIONS

Adipose tissue is an active organ secreting many

metabolically important proteins known as

adipokines (Lau et al., 2006). Some of these

adipokines have important functions in insulin

resistance and cardiovascular complications with

central or visceral obesity (Murakami et al., 2006).

The latest systematic review of the literature

promotes the dose-response effect of aerobic

exercise on visceral adiposity, but the ability of

exercise to reduce visceral adipose tissue is less

significant in those who have metabolic disorders

)Kelley and Kelley, 2007). Thus, it remains unclear

whether a dose-response of exercise on central

Effect of Lifestyle Modiﬁcation Combined with Metformin on Serum Chemerin Concentration in Metabolic Syndrome Subjects

adiposity is also consistent in metabolic syndrome.

Nevertheless, regular exercise plays an important

role in abdominal fat loss during weight

maintenance and can avoid weight gain in those who

have successfully reduce body weight. (Wing and

Hill, 2001). Chemerin may play an important role in

the metabolic syndrome and may be an independent

promising adipokine marker.

In these studies, lifestyle modification

decreased BW, BMI, WC, diastolic BP, and

chemerin significantly in the placebo group and

metformin group, whereas FBS and CRP only

decreased significantly in the placebo group.

Saremi et al in 2010 showed that chemerin

levels decreased significantly after body weight

reduction (particularly visceral fat) in overweight

and obese males after 12-week of aerobic training.

The recent results of a large-scale epidemiological

study from Mauritius also indicate the same results

(Bozaouglu et al., 2007).

Plasma CRP levels are well known to be an

important part of systemic inflammation. Some

previous studies have reported the effect of exercise

training on plasma CRP concentrations. Mattusch et

al. found a significant reduction in CRP levels after

nine months of marathon training in 12 athletes.

Furthermore, Smith et al. also reported lower CRP

levels in 43 volunteers after six months of exercise

training. Based on these studies, chemerin decreased

more significantly than CRP, and the future

chemerin might replace the position of CRP as the

key index of systemic inflammation.

Thus, lifestyle modification with metformin

improved BW, BMI, WC, and chemerin on

metabolic syndrome. But there were no significant

differences in reduced chemerin between placebo

and metformin groups. Esteghamati et al in 2014

found 3 months monotherapy with metformin was

associated with a significant reduction in chemerin

in type 2 diabetes patient, so we need further

evaluation of using metformin to reduce chemerin in

a nondiabetic patient like in this study.

There are some limitations to our study.

Some detailed exercise records by the participant

were not obtained, which can attenuate the outcome

of some adipokines. In addition, we did not evaluate

whether the beneficial effects on b-cell function,

insulin sensitivity, glycemic control, other

inflammatory parameters support this result. We

evaluated only a limited number of inflammation

biomarkers. Longer and larger sample size studies

are needed to evaluate the positive effects lifestyle

and metformin on chemerin level, as to prevent

cardiovascular event related to metabolic syndrome.

5 CONCLUSIONS

Lifestyle modification with metformin improved

BW, BMI, WC on metabolic syndrome, and there

was no significant decrease of chemerin between

placebo and metformin groups. Further

investigations should be done to confirm the effects

of lifestyle modification combined with metformin

on chemerin after an extended follow-up period.

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Effect of Lifestyle Modiﬁcation Combined with Metformin on Serum Chemerin Concentration in Metabolic Syndrome Subjects