Beetroot Supplementation on Non - Alcoholic Fatty Liver Disease Patients

Abstract

Nonalcoholic fatty liver disease (NAFLD) has emerged as the one of the most common chronic liver disease worldwide. The pathogenesis of this disease is closely related to obesity and insulin resistance. Beetroot is proposed to have hepatoprotective and hypolipidemic effects due to presence of active compound betaine. The aim of this study was to evaluate the therapeutic effect of beetroot supplementation in patients with NAFLD. The present study was case control prospective study in which 40 cases and 40 controls with NAFLD were advised to follow a life style modification along with prescribed treatment but in cases beetroot powder supplementation was also given orally for 12 weeks. The clinical, symptoms, biochemical parameters, and ultrasonography measured were recorded at baseline and after 12 weeks post beetroot supplementation. Beetroot powder supplementation improved clinical symptoms, significant reduction in liver enzymes and lipid profiles, as well as significant reduction in liver size as compared to controls. We did not find any significant effect of beetroot supplementation on fatty liver grade. The supplementation of beetroot powder for 12 weeks showed hepatoprotectective effect in NAFLD subjects. Further long- term studies are recommended to assess beetroot powder supplementation effect on grade of fatty liver.

Full text

Beetroot Supplementation on Non - Alcoholic
Fatty Liver Disease Patients
SHIKHA SRIVASTAVA,1 ZEBA SIDDIQI,2 TARUNA SINGH3 and LAKSHMI BALA*4
1Departments of Food and Nutrition, Era’s Lucknow Medical College, Lucknow, Uttar Pradesh, India.
2Departments of Medicine, Era’s Lucknow Medical College, Lucknow, Uttar Pradesh, India.
3Departments of Radiology, Era’s Lucknow Medical College, Lucknow, Uttar Pradesh, India.
4Department of Biochemistry, Babu Banarasi Das University, Lucknow, Uttar Pradesh, India.
Abstract
Nonalcoholic fatty liver disease (NAFLD) has emerged as the one of
the most common chronic liver disease worldwide. The pathogenesis of
this disease is closely related to obesity and insulin resistance. Beetroot
is proposed to have hepatoprotective and hypolipidemic effects due
to presence of active compound betaine. The aim of this study was to
evaluate the therapeutic effect of beetroot supplementation in patients
with NAFLD. The present study was case control prospective study in
which 40 cases and 40 controls with NAFLD were advised to follow a life
style modification along with prescribed treatment but in cases beetroot
powder supplementation was also given orally for 12 weeks. The clinical,
symptoms, biochemical parameters, and ultrasonography measured were
recorded at baseline and after 12 weeks post beetroot supplementation.
Beetroot powder supplementation improved clinical symptoms, significant
reduction in liver enzymes and lipid profiles, as well as significant reduction
in liver size as compared to controls. We did not find any significant effect
of beetroot supplementation on fatty liver grade. The supplementation of
beetroot powder for 12 weeks showed hepatoprotectective effect in NAFLD
subjects. Further long- term studies are recommended to assess beetroot
powder supplementation effect on grade of fatty liver.
Current Research in Nutrition and Food Science
www.foodandnutritionjournal.org
ISSN: 2347-467X, Vol. 07, No. (1) 2019, Pg. 96-101
CONTACT Lakshmi Bala balalakshmi@rediffmail.com Department of Biochemistry, Babu Banarasi Das University, Lucknow,
Uttar Pradesh, India.
© 2019 The Author(s). Published by Enviro Research Publishers.
This is an Open Access article licensed under a Creative Commons license: Attribution 4.0 International (CC-BY).
Doi: doi.org/10.12944/CRNFSJ.7.1.10
Article History
Received: 02 December 2018
Accepted: 09 April 2019
Keywords
Beetroot Powder;
Hepatoprotectective;
Liver Size;
NAFLD.
Introduction
In recent years Non-Alcoholic fatty liver disease
(NAFLD) has emerged as the most prevalent chronic
liver disease in the developed and developing nations
because of the global obesity epidemic.1 It has been
estimated that NAFLD with epidemic obesity will
become the major cause of liver associated morbidity
and mortality by 2030.2 The prevalence of NAFLD

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is estimated to be about 9 - 32 % in general Indian
population but the real prevalence of NAFLD is
unknown due to under diagnosis.3 Prevalence of
NAFLD in different populations are estimated to be
as follows; United States 30 % , Middle East 32 % ,
South America 30 % , Asia 27 % , Europe 24 % and
Africa 13%.1 It is not surprising that the prevalence
of NAFLD in increasing every year worldwide due
to dietary irresponsibility and predominance of
sedentary lifestyle. According one of the studies
from United States it was found that the incidence
of NAFLD was 10% higher in overweight individuals
than in lean persons. As it currently stands, NAFLD
has become the second most common cause for
liver transplantation.4 Generally there is no effective
treatment available for NAFLD.5 Beetroot is said to
have a hepatoprotective effect and it effectively keeps
away fat from depositing in the liver. This is probably
due to presence of betaine in beetroot which is a
methyl group donor in the liver transmethylation
process.6 To date there is no single approved therapy
for NAFLD patients. Several drug therapies have
been tried in both research and clinical settings, yet
the results have so far not been encouraging.
Keeping above background in view, present study
was planned on beetroot powder with following
objective. To assess the effect of short term
supplementation of beetroot on NAFLD subjects
with regards to Clinical, biochemical and radiological
parameters.
Material and Methods
Procurement of Beetroot
The beetroot used in this study were organically
grown in Ghaila Farm, Hardoi Bypass Road,
Lucknow , (U.P.)
Beetroot Powder
The beetroot powder was prepared in Regional Food
Research and Analysis Centre (r-frac), Lucknow, U.P.
The procedure is given Fig.1.
Study Design and Site
This was a case control prospective study. In this
study the beetroot powder supplementation was
done in NAFLD subjects for three months of period
at Era's Lucknow Medical College and Hospital,
Lucknow. The present study was done after approval
from Institutional ethical committee and written
informed consent for this study was taken from
subjects enrolled who were then divided into cases
and controls as follows:
1. Cases were NAFLD subjects who received
beetroot supplement along with prescribed
medication and lifestyle modification for the
duration of 3 months.
2. Controls were NAFLD subjects who received
only medication and lifestyle modification for
the same duration.
Study Population
All known NAFLD subjects were included in this
study according to following criteria.
Inclusion Criteria
Subjects older than 18 years with a diagnosis of fatty
liver on ultrasonography were included.
Exclusion Criteria
Diabetic patients, those who consumed alcohol,
patients of known liver disease apart from NAFLD,
End stage disease or terminally ill patients, pregnant
females and patients who could not take were
excluded.
Sample Size
40 cases and 40 controls were included in this study.
Procedure
The organic beetroot powder was given to cases
for three months of period along with prescribed
medication and life style modification. However, for
controls only prescribed medication and life style
modification were given. In cases, 5 gm of beetroot
powder twice a day were given after meal for 14
days. After that the dose was 5 gm per day for 3
months. The following parameters were evaluated
in all subjects included in this study at baseline and
after 12 weeks.
Anthropometric Measurement
Weight and Height were evaluated for calculating
BMI.
Clinical Symptoms
Pain epigastrium, right hypochondrium pain and
flatulence.

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Biochemical and Radiological Parameters
Liver enzymes (Serum Bilirubin, ALT, AST, SALP),
serum lipid profile (Fasting). The liver biopsy is
currently the gold standard test for diagnosing
NAFLD. But it has many drawbacks such as
sampling error, high cost and risk of complications.
However, ultrasonography is a non-invasive
method for diagnosing NAFLD. So we have used
ultrasonography method for diagnosing NAFLD (liver
size and fatty liver grade) in all subjects.
Statistical Analysis
The results were analyzed using descriptive statistics
and to make comparisons between the cases
and controls with respect to various parameters.
Catagorical data were summarized as in proportions
and percentages (%) and continuous variables as
Mean ± SD (standard deviation). A sample size of
40 in each group would give 90% power of study.
Table 2: Changes in biochemical parameters before and after beetroot supplementation
Parameters Cases(n = 40) Controls(n = 40) P - Value
Before After Before After
LIVER ENZYMES
Serum Bilirubin 1.4 ± 0.6 0.9 ± 0.3 1.4 ± 0.6 1.5 ± 0.6 < 0.001
Serum AST 61.4 ± 14.2 57.7 ± 14.4 62.0 ± 14.2 61.6 ± 14.3 0.230 NS
Serum ALT 46.3 ± 11.0 43.1 ± 11.5 46.9 ± 11.3 45.9 ± 11.0 0.259 NS
Serum ALP 116.9 ± 10.8 118.6 ± 16.7 116.9 ± 10.8 122.7 ± 27.3 0.421NS
LIPID PROFILE
Total Cholesterol 229.5 ± 33.5 188.6 ± 7.5 229.5 ± 33.5 221.3 ± 29.3 < 0.001
Serum LDL 140.9 ± 15.9 128.0 ± 11.7 144.6 ± 23.7 137.3 ± 17.8 0.007
Serum HDL 54.5 ± 7.9 58.0 ± 6.7 54.1 ± 7.5 54.8 ± 7.6 0.055NS
Serum TG 178.5 ± 24.1 152.9 ± 17.4 174.2 ± 23.8 174.2 ± 23.8 < 0.001
Data presented as mean ± standard error (SE). Abbreviations: Serum AST, Serum aspartate aminotransferase;
Serum ALT, serum alanine aminotransferase; Serum ALP, Serum Alkaline phosphatase; Serum LDL, Serum low-
density lipoproteins; Serum HDL, high-density lipoprotein; Serum TG , Serum triglyceride.
p -value shows the difference between baseline and 12 - weeks.
Table 1: Baseline Characteristics of cases and controls
Variables Cases (n = 40) P - Value Cases (n = 40) P - Value
Age (Years) 45 ± 2.3 42.2 ± 1.5
Gender
Male 18 19
Female 22 21
BMI (kg / m2)
Before 29.5 ± 14 31.6 ± 1.9
0.966 0.377
After 29.5 ± 14 31.5 ± 1.9
Data presented as mean ± standard error (SE). Abbreviations: BMI, Body Mass Index.
p -value shows the difference between baseline and 12 - weeks

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Results
Total eighty subjects were included in this study
out of which 40 were cases and 40 controls. Table
1 shows the baseline characteristics of cases and
controls enrolled in this study.
According to the data present in this table there is
no significant difference was observed in BMI after
12 weeks of follow-up in both cases and control. The
change in clinical symptoms at baseline and after
12 weeks of follow-up was observed in both cases
and controls. The symptoms of heaviness or pain in
epigastrium and indigestion were observed in both
cases and controls at 55 % and 100 % respectively
on baseline. Although on baseline the flatulence
was present in both cases and controls. It was 70
% observed in cases and 30% was in controls. Post
supplementation of beetroot powder for 12 weeks,
changes in clinical symptoms were observed in both
cases and controls. The symptoms like heaviness or
pain in epigastrium, indigestion and flatulence were
reduced to nil in cases and 2.5% in controls after 12
weeks of beetroot powder supplementation.
The changes in biochemical parameters (liver
enzymes and lipid profile) characteristics of the
study subjects are shown in Table 2. On comparing
level of serum bilirubin from baseline to 12 weeks
it was significantly (p < 0.05) decreased in cases
than in controls. However, in serum AST there was
insignificant difference between cases and controls
from baseline to 12 weeks.
But in cases the level of AST were significantly
decreased from baseline to 12 weeks. Similar
results were observed in serum AST. But the
differences in serum alkaline phosphatase between
cases and controls after 12 weeks of beetroot
powder supplementation was insignificant (p <
0.05). The changes in lipid profiles before and
after supplementation of beetroot powder are also
given in Table 2. After 12 weeks of beetroot powder
supplementation the serum cholesterol levels was
significantly decreased from baseline to 12 weeks in
cases than controls. However in controls there was
insignificant difference from baseline to 12 weeks.
It was observed that serum LDL was significantly
Fig. 1: Flow chart of the procedure for preparation of beetroot powder

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decreased in cases from baseline to 12 weeks but
this was not seen in controls. Serum HDL was not
changed significantly between controls and cases
from baseline to 12 weeks.
But the level of HDL was significantly increased
in cases from baseline to 12 weeks. The serum
triglyceride was significantly decreased in cases
as compared to controls after 12 weeks of beetroot
powder supplementation.
The results of ultrasonographic parameters are
given in Table 3. The liver size was significantly
decreased in cases on comparing with controls after
12 weeks of beetroot powder supplementation and
the significant differences were also observed in
cases from baseline to 12 weeks.
Although the grade of fatty liver was not changed in
both cases and controls from baseline to 12 weeks
after supplementation of beetroot powder; in two
cases it was found that the fatty liver grade improved
i.e. in one subject; grade two was changed into grade
one and in the other subject grade one was changed
into no fatty liver.
Discussion
To our knowledge, this is the first case control
prospective study that examined the effect of beetroot
supplementation on NAFLD subjects. In this study,
there is no significant change was observed in BMI
of both case and control. It shows that consumption
of only 10 to 5 gm beetroot powder for the period
of 12 weeks is not sufficient for reduction of weight.
However, the consumption of beetroot powder for 12
weeks decreased clinical symptoms i.e. heaviness
pain in epigastrium, flatulence and indigestion more
than controls. So our study has shown that beetroot
is beneficial for relief of symptom of indigestion in
subjects of NAFLD. Clifford et al. also reported in their
review of potential benefits of beetroot that beetroot
juice stimulates digestion.7 Amnah and Alushaibani
(2013) reported in their study done on rats that
consumption of biscuits prepared with beetroot
powder significantly decreased liver enzymes,
cholesterol and total lipids in cases than in controls.8
Nouri et al. (2017) found that with consumption of
beetroot juice by male wistar rats the liver enzymes
in were decreased in liver diseases rats.9
Rabeh also reported that dried, fresh and of red
beetroot significantly restored the liver enzymes to
normal levels in against carbon tetrachloride induced
rats.10 The study done in humans by Sigh et al.
(2015) shown that the consumption of beetroot juice
lowered the lipid profile i.e. LDL, total cholesterol,
triglycerides levels and also significantly increased
the levels of HDL in physically active individuals.11
Thus, our study confirmed these previous studies
and showed that beetroot has a hepatoprotective
apart from its lipid lowering effect. It may be due to
the presence of active compound betaine in beetroot
having antioxidant properties.
In this study, liver size was significantly decreased
in cases than controls and the fatty liver grade did
not changed significantly with the supplementation
of beetroot powder for 3 months. The reason for less
shows subjects an improvement in grade of fatty liver
could be that in our study the supplementation of
Table 3: Changes in Ultrasonographic Parameters before
and after beetroot supplementation
Parameters Cases Controls P - Value
Before After Before After
Liver size 14.4 ± 0.9 12.6 ± 1.0 14.4 ± 0.9 14.4 ± 1.0 < 0.001
Fatty Liver 1.9 ± 0.6 1.9 ± 0.6 1.9 ± 0.6 1.9 ± 0.6 0.871NS
Grade
Data presented as mean ± standard error (SE). p -value shows the difference between baseline and 12 - weeks.

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beetroot powder was done for short intervention of
time. Another limitation of this study was the lack of
liver biopsy as to confirm histological improvement.
However, we evaluated liver enzymes, lipid profile
and ultrasonographic parameters which provided
quantitative, noninvasive positive results. The novelty
of our study is that to the best of our knowledge, it is
the first study evaluating the hepatoprotective effect
of beetroot supplementation on human subjects of
NAFLD.
To conclude, this case control prospective study
found some evidences that beetroot supplementation
could improve clinical symptoms, decrease liver
enzymes and improve lipid profiles when prescribed
along with life style modification and pharmacological
treatment in NAFLD subjects. However fatty liver
grade showed improvement only in two subjects.
This can be attributed to the short duration of
supplementation. Thus further studies of longer
duration and larger samples are required to validate
and support our findings of beneficial effects of
beetroot supplementation in NAFLD subjects.
Acknowledgment
We thank our institution Era’s Lucknow Medical
College and Hospital for providing Ethical approval
for this study and also providing infrastructure
required for this study. The authors declare that there
is no conflict of interests regarding the publication
of this paper. The authors also declare that the
funding required for this study was provided by Era's
Lucknow Medical College and Hospital.
Conflict of Interest
The author(s) declare no conflict of interest.
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