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DOI: https://doi.org/10.53350/pjmhs211551449
ORIGINAL ARTICLE
P J M H S Vol. 15, NO. 5, MAY 2021 1449
The Effects of Alkaline Ionized Water Administration to the Total
Cholesterol Levels in Patients with Type 2 Diabetes Mellitus
Accompanied by Dyslipidemia
ANDRI RAMADHAN1, SATRIO ADI WICAKSONO1, TAUFIK EKO NUGROHO1, SULISTIYATI BAYU UTAMI2
1Department of Anesthesiology and Intensive Therapy. Faculty of Medicine, Diponegoro University. Semarang
2Department of Cardiology and Vascular Medicine. Faculty of Medicine, Diponegoro University. Semarang
Jl. Prof. H. Soedarto, SH., Tembalang, Semarang, Central Jawa, Indonesia 50275. Telephone/Fax . +62 (0) 24-76928010.
Andri Ramadhan and Satrio Adi Wicaksono were equally contributed in this study.
Correspondence to = Satrio Adi Wicaksono, MD. Department of Anesthesiology and Intensive Therapy. Faculty of Medicine. Diponegoro
University. Jl. Prof. H. Soedarto, SH., Tembalang, Semarang, Indonesia 50275. Telephone/Fax . +62 (0) 24-76928010. Email =
drsaw11@yahoo.com.
ABSTRACT
Background: Total cholesterol is a measure of the total amount of cholesterol components including LDL (low-
density lipoprotein), HDL (high-density lipoprotein), and VLDL (very low-density lipoprotein). Alkaline ionized
water (AIW) is an electrolyzed water with a hydrogen-rich molecule and an alkaline pH. It has a negative
oxidation-reduction potential (ORP) and reactive oxygen species (ROS)-scavenging activity, which shows an
antioxidant and has beneficial effects on reducing total cholesterol level, but the results still vary. This study was
to investigate the effect of AIW to total cholesterol and other lipid profiles level in patients with type-2 diabetes
mellitus (T2DM) accompanied by dyslipidemia.
Methods: This was a randomized double blind controlled trial performed in December 2017–December 2018.
Thirty patients that had been diagnosed with T2DM accompanied by dyslipidemia in Diponegoro National Hospital
Semarang and met the inclussion criteria were determined by consecutive sampling. Subjects were randomly
divided into two groups: AIW group (n=15) and control group (mineral water, MW) (pH 7) (n=15). Both were
administered orally 1 liter per day for 12 days; total cholesterol level and other lipid profiles were measured before
and after 12 days treatment. The statistical analysis was using independent t-test, paired t-test, and non-
parametric Mann-Whitney test.
Result: There were no differences between AIW group and mineral water group in all lipid profiles at before and
after treatment, including total cholesterol (pre-treatment: 290.2 ± 41.45 mg/dL vs 282.2 ± 15.81 mg/dL, p=0.575,
and post-treatment: 249.8 ± 41.17 vs 268.5 ± 16.73 mg/dL, p=0.097), LDLc (pre-treatment: 167.0 ± 9.17 mg/dL vs
162.2 ± 4.75 mg/dL, p=0.227, and post-treatment: 157.2 ± 8.88 mg/dL vs 157.6 ± 5.39 mg/dL, p=0.518), HDLc
(pre-treatment: 43.8 ± 4.16 mg/dL vs 42.8 ± 4.45 mg/dL, p=0.136 and post-treatment: 47.1 ± 3.24 mg/dL vs 45.2 ±
1.98 mg/dL, p=0.142), and triglyceride (pre-treatment: 351.0 ± 119.36 mg/dL vs 381.3 ± 59.38 mg/dL, p=0.934
and post-treatment: 266.4 ± 115.63 mg/dL vs 317.6 ± 70.50 mg/dL, p=0.154), respectively. There was a wider
differences between post- and pre-treatment of total cholesterol (Δtotal cholesterol) (40.4 ± 31.57 vs 13.7 ± 10.65,
p=0.002), LDLc (ΔLDLc) (9.8 ± 4.29 vs 4.6 ± 1.54, p=0.000), and HDLc (ΔHDLc) (4.3 ± 1.87 vs 3.4 ± 3.11,
p=0.031) in AIW group compared to mineral water group.
Conclusion: Alkaline ionized water (AIW) decreased total cholesterol and improved other lipid profiles level in
patients with T2DM accompanied by dyslipidemia. These findings might have important implications for the
management of T2DM accompanied by dyslipidemia.
Keywords : alkaline ionized water, total cholesterol level, type 2 diabetes mellitus, T2DM
INTRODUCTION
The global prevalence of DM has doubled since 1980,
rising from 4.7% to 8.5% in the adult population. World
Health Organization (WHO) Global Report on diabetes
mellitus (DM) in 2016 estimated that there was 422 million
adults in the world population were living with DM in 2014,
compared to 108 million in 1980.(1) International Diabetes
Federation (IDF) estimated that the world numbers of
patients with DM in 2015 were 415 million and were
expected to increase until 642 million in 2040.(2) This
increase was in line with an increase in risk factors
including overweight, obese, or dyslipidemia. Diabetes
prevalence has increased faster in low-to-middle-income
countries than in high-income countries in the past decade,
including in Indonesia.(1) Indonesian Basic Health Research
(Riset Kesehatan Dasar, RISKESDAS) in 2013 revealed
that the prevalence of DM in Indonesia was 1.5–2.1%.(3)
Type 2 diabetes mellitus (T2DM) is a metabolic
disorder represented with chronic hyperglycemia and
disorders of carbohydrate, lipid, and protein metabolism
that is correlated to insulin resistence, insulin secretion
defect, or their combination. Hyperglycemia has been one
of fundamental diagnosis criteria of T2DM represented by
increased fasting blood glucose and/or post prandial
glucose.(4)
Type 2 DM (T2DM) may initiate chronic and acute
complications. It has brought 1.5 million mortalities in 2012,
and an additional 2.2 million mortalities occured in a higher-
than-optimal blood glucose, by increasing the risks of
cardiovascular and other diseases.(1) Its chronic
complications contained microangiopathy such as diabetic
retinopathy, diabetic nephropathy, diabetic neuropathy; and
macroangiopathy such as atherosclerotic cardiovascular
disease (ASCVD), stroke or cerebrovascular disease
(CVD), and peripheral arterial disease (PAD).(5) Coronary
The Effects of Alkaline Ionized Water Administration to the Total Cholesterol Levels in Patients with Type 2 Diabetes Mellitus
1450 P J M H S Vol. 15, NO. 5, MAY 2021
heart disease (CHD) has caused death in more than 80%
patients with T2DM.(5)
Studies indicated that the elevated extracellular and
intracellular glucose levels might triger oxidative stress
which played role in the pathogenesis of onset,
progressivity, and complication of T2DM.(6-8) Oxidative
stress was correlated to the onset of T2DM through insulin
resistance.(9) The origin of oxidative stress derived from
leakage of reactive oxygen species (ROS) from
mitochondria.(10, 11) Some antioxidants have been examined
for their properties in handling or preventing oxidative
stress in T2DM.(12, 13) However several studies with
antioxidant supplements were failed in preventing oxidative
stress-related diseases.(14)
Dyslipidemia is one of several risk factors for CHD in
T2DM. It is a lipid metabolism disorder that represents as
increase in total cholesterol, triglyceride (TG), low density
lipoprotein cholesterol (LDLc) levels, and decrease in high
density lipoprotein cholesterol (HDLc) levels.(15) The
pathogenesis of diabetic dyslipidemia is multifactorial.
Insulin resistance with attendant increase in free fatty acid
flux into the liver plays a central role in promoting the
typical triad of diabetic dyslipidemia, namely high plasma
triglyceride concentrations, low plasma HDLc, and
increased concentration of small dense LDLc particles.(16)
Studies showed that the normalization of cholesterol
or TG, was essential to decrease the risk of CHD in
patients with metabolic syndrome or T2DM. Therefore,
therapy of T2DM should be followed with control of
metabolic disorders such as normalization of TG and
cholesterol levels, as other important therapies other than
normalisation of blood glucose levels alone.(15)
Insulin resistance in T2DM influences metabolism,
production, and excretion of plasma lipoprotein. Insulin
resistance causes decrease of insulin effects in adipose
tissue that may influence lipogenesis and lipolysis in
adipose tissue, causing blood lipid increment including
cholesterol and TG. These may increase LDLc level due to
glucotoxicity and lipotoxicity. LDLc structure in patients with
T2DM is modified, oxidized, and glycated into smaller,
denser, and more atherogenic particle and a faster oxidized
LDLc due to prolonged hyperglycemia.(15) Several
components have been studied to influence the level of
total cholesterol, LDLc, HDLc, and TG, including AIW.(17, 18)
Alkaline ionized water (AIW), an alkaline electrolysis-
treated water, that can increase its reduction potential, is a
promising solution in providing a safe source of free
electrons to block the oxidation of normal tissue by free
oxygen radicals. Several studies showed that it was rich in
hydogen (H2) molecule which brought some therapeutic
effects by acting as antioxidant.(19, 20) Reactive hydrogen
was also considered to be the ideal scavenger of ROS in
T2DM.(21) However previous studies showed diverge
interpretations in the effects of AIW to the blood glucose
and lipid levels.(17, 18, 22-25)
Electrochemically alkaline ionized water (AIW) has
been freely marketed and consumed in Indonesia, however
there was still insufficient study to prove its clinical effects
in patients with T2DM accompanied with dyslipidemia in
Indonesia. The effects of AIW in Indonesian patients with
T2DM accompanied by dyslipidemia might differ from other
region since they could be influenced by genetic, race, or
sosioeconomic factors.
METHODS
Study Design and Population: This study was a
randomized double blind controlled trial conducted to
investigate the effects of alkaline ionized water (AIW)
administration on total cholesterol and other lipid profiles
levels in patients with T2DM accompanied by dyslipidemia.
This study involved 30 patients diagnosed with T2DM
accompanied by dyslipidemia. Subjects were determined
by consecutive sampling that met the inclusion criteria,
namely Indonesian men and women, aged from 20 to 80
years old, undergoing routine outpatient care at
Diponegoro National Hospital, Semarang, Indonesia,
between December 2017–December 2018 and had been
diagnosed with T2DM accompanied by dyslipidemia. The
exclusion criteria were previously known cardiovascular
diseases, insulin therapy, diabetic ulcer, chronic kidney
disease, anemia, cancer or hematologic malignancies,
infection or sepsis, lung tuberculosis, previously known
autoimmune diseases, increased AST/ALT and/or
creatinine of three times above normal value and major
physical or mental disabilities.
Participants were randomly divided into two groups:
treatment group who received alkaline ionized water (AIW)
(n=15) and control group who received placebo (mineral
water) with neutral pH of 7 (n=15). Both AIW or placebo
was administered orally ad libitum with maximum of 1 liter
per day for 12 days. Placebo was made to have the same
appearance with AIW. Electrochemically AIW was
produced with electrolysis machine.
Ethics approval for the study protocol and analysis of
the data was obtained from the Ethics Committee in Health
and Medical Research (KEPK) Faculty of Medicine,
Diponegoro University Semarang, Indonesia. All
participants had been given explanation of the purpose,
benefits, research protocols, possible side effects,
questionnaire, and a written informed consent.
Clinical and Laboratory Measurements: Study data
included demography and medical history, physical
examination, information provided by questionnaire,
anthropometric measurements and laboratory
measurements. The medical and drug prescription history
was assessed by the examining physicians.
Diabetes mellitus was defined as either participant
had history of fasting serum glucose level ≥126 mg/dl, or
serum hemoglobin A1c (HbA1c) level ≥6.5%, or the
participant ever having been diagnosed with diabetes, or
the current use of blood glucose-lowering agents.
Hypertension was defined as either the participant ever
having been diagnosed with hypertension or as having a
measured blood pressure (BP) ≥140/90 mmHg at initial
examination. Trained nurses measured participants’ seated
BP 3 times using automated equipment (53000-E2, Welch
Allyn, NY, USA) after a 5 minutes rest. Final BP was
calculated as the average of BP measurements. The body
mass index (BMI) was calculated by dividing weight
(kilograms) by the square of height (m2).
Participants who have met the inclusion criteria
underwent a blood sampling from an antecubital vein at
baseline (before treatment) and after 12 days treatment.
Andri Ramadhan, Satrio Adi Wicaksono, Taufik Eko Nugroho et al
P J M H S Vol. 15, NO. 5, MAY 2021 1451
Serum creatinine were determined using the Jaffe reaction
method (Advia 1650 kit, Bayer Corp, PA, USA). Levels of
AST and ALT were examined with International Federation
of Clinical Chemistry and Laboratory Medicine (IFCC)
method without Pyridoxal Phosphate in 37oC. The serum
fasting glucose and 2 hours post prandial glucose were
measured by biochemical analyzer with hexokinase assay
(Roche Cobas C311, Roche, Germany). All lipid profiles
were collected in the fasting state and included total
cholesterol, LDL cholesterol (LDLc), HDL cholesterol
(HDLc), and triglyceride levels.
Statistical Analysis: Data of patients with T2DM
accompanied by dyslipidemia were collected, sorted,
tabulated, coded and processed using descriptive statistical
methods. Data were presented as mean±standard
deviation for continuous variables and as proportions (n, %)
for categorical variables. Categorical variables were
presented as frequency distribution tables. The chi-square
test was used to determine the differences in proportions
for categorical variables. The continuous independent
variables were compared using independent t-test, if
normally distributed, or non-parametric Mann-Whitney test,
if not normally distributed. Statistically significance was
considered as p<0.05. All statistical analyses were
performed using statistical computing program.
RESULTS
Baseline Clinical Characteristics of the Study
Population: Clinical and demographic characteristics of
the study population are presented in Table 1. The 30
study subjects consisted of 15 (50.0%) male and 15
(50.0%) female, and there was no difference in gender
distributions between AIW group and mineral water group
with pH 7 (p=0.715). In overal, the mean age and the mean
BMI of study population were 51.5 ± 6.53 years old and
26.2 ± 2.97 kg/m2, respectively. There was no difference in
mean age (p=0.134) and mean BMI (p=0.533) between
AIW group and mineral water group (Table 1).
There was no difference in medication history
between both groups, including sulfonylureas (p=0.195),
biguanides (p=0.283), angiotensin converting enzyme
inhibitors (ACEi) or angiotensin receptor blockers (ARBs)
(p=0.409), ß-blockers (p=0.269), calcium channel blockers
(CCBs) (p=0.705), and statins (p=0.283) (Table 2).
Blood Glucose Profiles between Alkaline Ionized Water
and Mineral Water: Glucose profile in pre- and post-
treatment between both groups are presented in Table 3.
At baseline (pre-treatment), there were no differences
between AIW group and mineral water group in fasting
blood glucose (FBG) (197.6 ± 51.18 mg/dL vs 183.6 ±
42.66 mg/dL, respectively, p=0.221) and in two hours post
prandial glucose (2hPPG) (272.6 ± 37.36 mg/dL vs 274.2 ±
26.55 mg/dL, respectively, p=0.917). At post-treatment,
there were no differences in FBG (171.6 ± 51.29 vs 162.8 ±
17.17, p=0.934) and in 2hPPG (234.6 ± 23.11 mg/dL vs
248.2 ± 25.32 mg/dL, p=0.138) between the AIW group and
the mineral water group (Table 3).
There were lower FBG and 2hPPG both in the AIW
group and mineral water group at post-treatment in
comparison with at pre-treatment. There was a wider
decrease between post- and pre-treatment fasting blood
glucose (∆FBG) in AIW group compared to mineral water
group, although it was not significant (26.0 ± 22.16 mg/dL
vs 20.7 ± 28.70 mg/dL, respectively, p=0.346). There was
also a wider decrease between post- and pre-treatment
2hPPG (∆2hPPG) in AIW group compared to mineral water
group, although it was not significant (41.0 ± 31.70 mg/dL
vs 26.0 ± 25.12 mg/dL, p=0.212) (Table 3).
Lipid Profiles between Alkaline Ionized Water and
Mineral Water: There were no differences between AIW
group and mineral water group in all lipid profiles at before
and after treatment, including total cholesterol (pre-
treatment: 290.2 ± 41.45 mg/dL vs 282.2 ± 15.81 mg/dL,
p=0.575, and post-treatment: 249.8 ± 41.17 vs 268.5 ±
16.73 mg/dL, p=0.097), LDLc (pre-treatment: 167.0 ± 9.17
mg/dL vs 162.2 ± 4.75 mg/dL, p=0.227, and post-treatment:
157.2 ± 8.88 mg/dL vs 157.6 ± 5.39 mg/dL, p=0.518), HDLc
(pre-treatment: 43.8 ± 4.16 mg/dL vs 42.8 ± 4.45 mg/dL,
p=0.136 and post-treatment: 47.1 ± 3.24 mg/dL vs 45.2 ±
1.98 mg/dL, p=0.142), and triglyceride (pre-treatment:
351.0 ± 119.36 mg/dL vs 381.3 ± 59.38 mg/dL, p=0.934
and post-treatment: 266.4 ± 115.63 mg/dL vs 317.6 ± 70.50
mg/dL, p=0.154), respectively (table 4).
There were lower total cholesterol, LDLc, triglyceride,
and higher HDLc both in the AIW group and mineral water
group at post-treatment in comparison with at pre-
treatment. There was a wider differences between post-
and pre-treatment of total cholesterol (Δtotal cholesterol)
(40.4 ± 31.57 vs 13.7 ± 10.65, p=0.002), LDLc (ΔLDLc) (9.8
± 4.29 vs 4.6 ± 1.54, p=0.000), and HDLc (ΔHDLc) (4.3 ±
1.87 vs 3.4 ± 3.11, p=0.031) in AIW group compared to
mineral water group (Table 4).
DISCUSSION
Hyperglycemia in T2DM is thought to be correlated to
oxidative stress and diabetic complications that may
decrease quality of life and increase the financial burden.(5,
26) The formation of a group of modified proteins and/or
lipids with damaging potential known as advanced
glycation end products (AGEs), is playing role in the
development and progression of T2DM and their role in
diabetic complications.(9) Endogenous and exogenous
AGEs increase ROS or free radicals formation and weaken
antioxidant systems. Reactive oxygen species may cause
severe oxidative damage to biological macromolecules.(9)
Studies on electrochemically AIW that have been
performed in Japan showed that AIW was assumed to play
role in alleviating oxidative stress-related diseases such as
diabetes and dyslipidemia. Ionized water was described to
be able to scavenge ROS in cultured cells. It has been
presumed that the active agents in ionized water were
hydrogen (atoms and molecules), mineral nanoparticles,
and mineral nanoparticle hydrides.(19)
Our study showed that there was comparable fasting
blood glucose (FBG) and 2hPPG in the post-treatment
between AIW group and mineral water group. However, we
found wider decrease of fasting blood glucose (∆FBG) and
∆2hPPG in AIW group in comparison with control group,
although they were not significant. Meanwhile, this study
showed that there were significant ∆total cholesterol,
∆LDLc, and ∆HDLc. These findings were difference to our
previous study that showed a significant wider ∆FBG in
AIW group compared to control group.(27) This might be due
to different population profile between both studies, in
The Effects of Alkaline Ionized Water Administration to the Total Cholesterol Levels in Patients with Type 2 Diabetes Mellitus
1452 P J M H S Vol. 15, NO. 5, MAY 2021
which at present study, the study population were patients
with T2DM accompanied with dyslipidemia, meanwhile in
previous study, the study population were patients with
T2DM.(27) Unfortunately, our previous study did not
calculate ∆ in all lipid profiles.(27) The existence of
dyslipidemia in this present study might contribute to higher
oxidative stress.
It was considered that AIW could improve total
cholesterol levels within blood in which it might affect lipid
metabolism process, its absorption process, and its
excretion process.(25) In the digestive process, bile salt is
important for lipid solubilization and absorption, in which,
the contraction of gall bladder is stimulated by
cholecystokinin (CCK) hormone.(28, 29) Lipid absorption can
be affected by alteration of bile salt synthesis, secretion of
CCK, or bile release into the duodenum. Another important
function of CCK is the inhibition of gastric emptying, that
can decrease the gastric digestion result into the
duodenum, so that stimulation of CCK secretion may
decrease. That mechanism is a feeback system in which
CCK regulate its own secretion.(28)
Kindel et al observed that lipid absorption in intestine
lumen could be mediated through micelles and liposome,
however the absorption of cholesterol was only mediated
with micelles.(29) Absorption through micelle is going well in
low pH.(18) Inhibition of micelle solubilisation has been used
as theurapetical approach to reduce hypercholesterolemia
in human.(30) This hypothesis was supported with a study in
a post-menopause woman which showed that there was a
lower cholesterol chylomicron with a supplementation of
bicarbonated mineral water.(18) This might have similar
mechanism with a supplementation of alkaline ionized
water (AIW).
Laura et al showed the mechanism of how sodium
bicarbonated mineral water could have its main alkaline
nature by reducing lipid absorption. This was in line to our
present study in which total cholesterols were significantly
improved after the administration of AIW. Gastric lipase
was activated in acid condition in gastric and would remain
active such in pH2 until pankreatic bicarbonic was
secreted.(31) The consumption of bicarbonated mineral
water might neutralized gastric acid in stomach, and might
affect hidrolysis caused by inhibition in lipase activity.
Optimal function of gastric lipase is an important factor in
lipolysis. Products resulting from gastric lipase (such as
monoglyceride, diglyceride, and lipid acid) could stimulate
the secretion of CCK and the activation of pankreatic lipase
colipase in supporting the activity of pankreatic lipase.(28, 32)
The action of pankreas lipase in intestinal lumen would be
disturbed if there was inhibition in activation of pankreatic
lipase colipase.(33) Triglyceride that was not hydrolysed by
pankreatic lipase could not induce the secretion of CCK.
The reduction of CCK levels due to the inhibition of lipase
activity might cause the reduction in gall bladder
contraction, so that reduced the secretion of bile salts to
the duodenum, in which further might reduce lipid
absorption.(34) It was hypothezised that the alteration of
gastrointestinal tract acidity might alter lipid absorption.
Most peripheral cells are unable to metabolize
cholesterol. Thus the transport of excess cholesterol from
peripheral tissue to return to the liver, which is known as
reverse cholesterol transport, is the only mechanism to
keep the homeostasis of cholesterol in vivo. The pathway
of reverse cholesterol transport can be divided into three
main steps: 1) uptake cellular cholesterol by HDL; 2)
esterification of HDL by lecitin: acyltransferase cholesterol;
and 3) captation of HDL cholesteryl esters by liver in which
cholesterol can be metabolized and excreted through
bile.(18)
The consumption of bicarbonated mineral water or
AIW was thought to cause the increase of reverse
cholesterol transport due to the increment of HDLc level. It
was thought that only HDLc that had the ability to eliminate
unesterified cholesterol in bile through reverse cholesterol
transport mechanism. Schoppen et al showed that
bicarbonated mineral water that had an alkaline nature
could improve serum triacylglycerol consentration
compared than water with low mineral content. Serum
triglyceride consentration showed lower value with
administration of bicarbonated water that might correlate
with faster hydrolysis from triacylglycerol into the
circulation.(18)
Several studies showed that hydrogen (H2) molecule
in alkaline reduced water could bring therapetic benefits as
an antioxidant. One of the merits was to reduce glucose
levels or as anti-diabetes.(19, 20, 22, 23, 35, 36) Hita Tenryosui
water, an electrolysed reduced water, and Nordenau water,
a natural reduced water, have been shown to scavange
intracellular ROS in a hamster pancreatic β cell line HIT-
T15 cells, and improve the secretion of insulin.(22, 24)
Reduced water, Hita Tenryosui water and Nordenau water,
also scavanged ROS in rat L6 myotube cells and improved
sugar uptake.(22, 24, 37) These waters also could alleviate
sugar tolerance damage in T2DM model mice,(22, 24, 38)
meanwhile electrolysed reduced water derived from tap
water has been reported to improve the symptoms of
diabetes model mice.(21) Other report also showed that
alloxan-induced oxidative damage was suppressed by
electrolysed reduced water and natural reduced water in
cells and in alloxan-induced type 1 diabetes model mice.(23)
Pancreatic beta cells are secreting insulin that is
consist of amino acids series and has role in glucose
uptake into the cells. Glucose transporters (GLUTs) are
amino acids that are responsible in transporting glucose in
insulin in which the majority of them that is responsible in it
is GLUT-4. Hita Tenryosui water and Nordenau water might
induce the phosphorylation of the insulin receptors by
suppressing of the activity of tyrosine protein phosphatase,
a redox-sensitive protein, and might activate
phophatidylinositol-3-kinase (PI-3-kinase) and Akt, as well
as might induce the translocation of the sugar transport
carrier GLUT4 to the cell membrane to promote intracellular
glucose uptake.(19, 24, 36)
The formation of ROS was thought to cause extensive
oxidative damage to biomolecules such as DNA, RNA, and
protein. Lee M et al studied the preventive, suppressive,
and protective effects of in vitro supplementation with
electrolyzed-ionized water on H2O2-induced DNA damage
in human lymphocytes. Lee M et al revealed that pre-
treatment, co-treatment, and post-treatment with
electrolyzed-ionized water improved human lymphocyte
resistance to the DNA strand breaks induced by H2O2 in
vitro. Ionized water inhibited single-strand breakage of DNA
caused by ROS produced by the Cu(II)-catalyzed oxidation
Andri Ramadhan, Satrio Adi Wicaksono, Taufik Eko Nugroho et al
P J M H S Vol. 15, NO. 5, MAY 2021 1453
of ascorbic acid in a dose-dependent manner.(39) It seemed
that ionized water could scavenge not only O2.- and H2O2,
but also O2 and OH-. Ionized water reduced the amount of
H2O2 produced by XOD in an SOD accumulated H2O2 in
the HX-XOD system.(36)
Several limitations should be considered. First, we
only studied patients with T2DM accompanied by
dyslipidemia who were stable non-complicated condition,
we were not able to generalize this results to patients in
more severe clinical condition. Second, the real mechanism
of how ionized water could improve lipid profile could not
be fully explained yet from our study. Third, we could not
explain why Δtriglyceride was not improved in this study.
Fourth, we could not avoid the influence of patients’
complience to anti-diabetic, anti-cholesterol, or other drugs,
diet, and physical activities.
Table 1. Baseline Characteristics of Study Population
Parameter
Group
Total (n=30)
P
Alkaline Ionized Water (n=15)
Mineral Water (n=15)
Gender (n, %)
Male
Female
7 (23.3%)
8 (26.7%)
8 (26.7%)
7 (23.3%)
15 (50.0%)
15 (50.0%)
0.715 ɸ
Age (years)
52.7 ± 6.1; 53.0 (36.0 – 60.0)
50.3 ± 6.92; 48.0 (43.0 – 65.0)
51.5 ± 6.53 52.0 (36.0–65.0)
0.134 ¶
Body Weight (kg)
72.2 ± 10.50; 70.0 (60.0 – 100.0)
73.6 ± 3.60; 75.0 (68.0 – 78.0)
72.9 ± 7.74; 72.0 (60.0 –
100.0)
0.087 ¶
Height (cm)
169.4 ± 2.82; 169.0 (165.0 –
176.0)
172.2 ± 4.21; 175.0 (164.0 –
176.0)
170.8 ± 3.80; 170.0 (164.0 –
176.0)
0.057 ¶
Body Mass Index (BMI) (kg/m2)
26.6 ± 4.04; 25.9 (19.3 – 35.4)
25.7 ± 1.21; 25.7 (24.2 – 29.4)
26.2 ± 2.97; 25.7 (19.3 –
35.4)
0.533 ¶
Hypertension (n, %)
15 (50.0%)
15 (50.0%)
30 (100.0%)
Smoking (n, %)
0.701 ɸ
Current smoker
4 (13.3%)
3 (10.0%)
7 (23.3%)
Ex-smoker
3 (10.0%)
5 (16.7%)
8 (26.7%)
Non smoker
8 (26.7%)
7 (23.3%)
15 (50.0%)
Exercise (n, %)
≤2 times/week
13 (43.3%)
8 (26.7%)
21 (70.0%)
0.046* ɸ
>2 times/week
2 (6.7%)
7 (23.3%)
9 (30.0%)
Systolic Blood Pressure (mmHg)
143.8 ± 5.36; 145.0 (132.0 –
152.0)
146.0 ± 5.86; 147.0 (136.0 –
154.0)
144.9 ± 5.63; 145.5 (132.0 –
154.0)
0.278 §
Diastolic Blood Pressure (mmHg)
88.8 ± 4.81; 89.0 (81.0 – 95.0)
86.8 ± 3.44; 86.0 (82.0 – 94.0)
87.8 ± 4.22; 88.0 (81.0 –
95.0)
0.216 §
Mean Arterial Pressure (mmHg)
106.8 ± 3.54; 106.0 (101.0 –
113.0)
106.4 ± 2.82; 106.0 (101.0 –
112.0)
106.6 ± 3.15; 106.0 (101.0 –
113.0)
0.735 §
Hemoglobin (g/dL)
12.8 ± 0.66; 13.0 (11.5 – 14.1)
12.8 ± 0.51; 12.7 (12.1 – 13.8)
12.8 ± 0.58; 12.8 (11.5 –
14.1)
0.867 ¶
Leukocyte (103/μL)
7.4 ± 1.06; 7.5 (6.2 – 9.4)
7.4 ± 1.06; 7.3 (6.2 – 9.4)
7.4 ± 1.04; 7.4 (6.2 – 9.4)
0.973 §
Platelet (103/μL)
493.9 ± 59.33; 480.0 (410.0 –
650.0)
450.3 ± 65.66; 465.0 (300.0 –
550.0)
472.1 ± 65.36; 475.0 (300.0
– 650.0)
0.124 ¶
Ureum (mg/dL)
42.2 ± 6.75; 44.0 (30.0 – 55.0)
44.8 ± 5.38; 46.0 (35.0 – 55.0)
43.5 ± 6.14; 45.0 (30.0 –
55.0)
0.166 ¶
Creatinine (mg/dL)
0.6 ± 0.15; 0.6 (0.4 – 0.9)
0.6 ± 0.14; 0.6 (0.4 – 0.9)
0.6 ± 0.15; 0.6 (0.4 – 0.9)
0.934 §
*significant if p< 0.05. Presented as mean ± SD; median (min – max).
ɸ Chi-square test; § Independent t-test; ¶ Non-parametric Mann-Whitney test.
Table 2. Medication History of Study Population
Characteristics
Alkaline Ionized Water (n=15)
Mineral Water (n=15)
Total
n (%)
P
Sulfonylureas
Yes
10 (33.3%)
13 (43.3%)
23 (76.7%)
0.195
No
5 (16.7%)
2 (6.7%)
7 (23.3%)
Biguanides
Yes
12 (40.0%)
14 (46.7%)
26 (86.7%)
0.283
The Effects of Alkaline Ionized Water Administration to the Total Cholesterol Levels in Patients with Type 2 Diabetes Mellitus
1454 P J M H S Vol. 15, NO. 5, MAY 2021
No
3 (10.0%)
1 (3.3%)
4 (13.3%)
ACEi/ARBs
Yes
10 (33.3%)
12 (40.0%)
22 (73.3%)
0.409
No
5 (16.7%)
3 (10.0%)
8 (26.7%)
ß-Blockers
Yes
5 (16.7%)
8 (26.7%)
13 (43.3%)
0.269
No
10 (33.3%)
7 (23.3%)
17 (56.7%)
CCBs
Yes
10 (33.3%)
9 (30.0%)
19 (63.3%)
0.705
No
5 (16.7%)
6 (20.0%)
11 (36.7%)
Statins
Yes
14 (46.7%)
12 (40.0%)
26 (86.7%)
0.283
No
1 (3.3%)
3 (10.0%)
4 (13.3%)
*significant if p< 0.05 between alkaline ionized water and mineral water with Chi-square test.
ACEi, angiotensin converting enzyme inhibitors; ARBs, angiotensin receptor blockers; CCBs, calcium channel blockers.
Table 3. Blood Glucose Profile between Alkaline Ionized Water Group and Control Group
Parameter
Group
P
Alkaline Ionized Water (n=15)
Mineral Water (n=15)
FBG Pre-treatment (mg/dL)
197.6 ± 51.18; 180.0 (116.0 – 289.0)
183.6 ± 42.66; 162.0 (142.0 – 264.0)
0.221 ¶
FBG Post-treatment (mg/dL)
171.6 ± 51.29; 176.0 (103.0 – 264.0)
162.8 ± 17.17; 159.0 (140.0 – 202.0)
0.934 ¶
∆ FBG
26.0 ± 22.16; 19.0 (1.0 – 71.0)
20.7 ± 28.70; 4.0 (2.0 – 81.0)
0.346 ¶
2h PPG, Pre-treatment (mg/dL)
272.6 ± 37.36; 278.0 (215.0 – 320.0)
274.2 ± 26.55; 262.0 (242.0 – 324.0)
0.917 ¶
2h PPG, Post-treatment (mg/dL)
234.6 ± 23.11; 228.0 (203.0 – 277.0)
248.2 ± 25.32; 255.0 (210.0 – 295.0)
0.138 §
∆ 2h PPG
41.0 ± 31.70; 42.0 (1.0 – 94.0)
26.0 ± 25.12; 12.0 (2.0 – 71.0)
0.212 ¶
*significant if p< 0.05. Presented as mean ± SD; median (min – max).
§ Independent t-test; ¶ Non-parametric Mann-Whitney test.
FBG, fasting blood glucose; 2h PPG, two hours post-prandial glucose.
Table 4. Lipid Profile between Alkaline Ionized Water Group and Control Group
Parameter
Group
P
Alkaline Ionized Water (n=15)
Mineral Water (n=15)
Total cholesterol Pre-treatment (mg/dL)
290.2 ± 41.45; 292.0 (204.0 – 360.0)
282.2 ± 15.81; 276.0 (263.0 – 321.0)
0.575 ¶
Total cholesterol Post-treatment (mg/dL)
249.8 ± 41.17; 252.0 (129.0 – 312.0)
268.5 ± 16.73; 267.0 (241.0 – 310.0)
0.097 ¶
Δtotal cholesterol (mg/dL)
40.4 ± 31.57; 24.0 (8.0 – 116.0)
13.7 ± 10.65; 11.0 (2.0 – 40.0)
0.002* ¶
LDLc Pre-treatment (mg/dL)
167.0 ± 9.17; 164.0 (157.0 – 187.0)
162.2 ± 4.75; 163.0 (154.0 – 169.0)
0.227 ¶
LDLc Post-treatment (mg/dL)
157.2 ± 8.88; 156.0 (145.0 – 177.0)
157.6 ± 5.39; 158.0 (149.0 – 166.0)
0.518 ¶
ΔLDLc (mg/dL)
9.8 ± 4.29; 10.0 (4.0 – 17.0)
4.6 ± 1.54; 5.0 (2.0 – 8.0)
0.000* §
HDLc Pre-treatment (mg/dL)
43.8 ± 4.16; 44.0 (38.0 – 51.0)
42.8 ± 4.45; 42.0 (34.0 – 48.0)
0.136 §
HDLc Post-treatment (mg/dL)
47.1 ± 3.24; 48.0 (43.0 – 52.0)
45.2 ± 1.98; 45.0 (42.0 – 49.0)
0.142 ¶
ΔHDLc
4.3 ± 1.87; 4.0 (1.0 – 6.0)
3.4 ± 3.11; 3.0 (1.0 – 10.0)
0.031* §
Triglyceride Pre-treatment (mg/dL)
351.0 ± 119.36; 415.0 (130.0 – 485.0)
381.3 ± 59.38; 395.0 (280.0 – 465.0)
0.934 ¶
Triglyceride Post-treatment (mg/dL)
266.4 ± 115.63; 270.0 (110.0 – 412.0)
317.6 ± 70.50; 315.0 (180.0 – 419.0)
0.154 §
Δtriglyceride (mg/dL)
84.6 ± 80.30; 50.0 (16.0 – 112.0)
63.7 ± 61.14; 45.0 (5.0 – 100.0)
0.430 ¶
*significant if p< 0.05. Presented as mean ± SD; median (min – max).
§ Independent t-test; ¶ Non-parametric Mann-Whitney test.
LDLc, low density lipoprotein cholesterol; HDLc, high density lipoprotein cholesterol.
REFERENCES
1. Global Report on Diabetes. Geneva: World Health
Organization; 2016.
2. International Diabetes Federation Diabetes Atlas. 7 ed.
Karakas: International Diabetes Federation; 2015.
3. Riset Kesehatan Dasar (RISKESDAS) 2013. Jakarta: Badan
Penelitian dan Pengembangan Kesehatan Kementerian
Kesehatan RI; 2013.
Andri Ramadhan, Satrio Adi Wicaksono, Taufik Eko Nugroho et al
P J M H S Vol. 15, NO. 5, MAY 2021 1455
4. Grant RW, Donner TW, Fradkin JE, Hayes C, Herman WH,
Hsu WC, et al. Classification and diagnosis of diabetes:
standards of medical care in diabetes 2015. Diabetes Care.
2015;38(Suppl. 1):S8–S16.
5. Chiang JL, Berg EG, McElvaine AT. American Diabetes
Association: Standards of Medical Care in Diabetes 2016.
Diabetes Care. 2016;39(Supplement 1):S1-S112.
6. Paneni F, Beckman JA, Creager MA, Cosentino F. Diabetes
and vascular disease: pathophysiology, clinical
consequences, and medical therapy: part I. Eur Heart J.
2013;34(31):2436–43.
7. Singhania N, Puri D, Madhu SV, Sharma SB. Assessment of
oxidative stress and endothelial dysfunction in Asian Indians
with type 2 diabetes mellitus with and without
macroangiopathy. Q J Med. 2008;101(6):449-55.
8. Rosen P, Nawroth PP, King G, Moller W, Tritschler HJ,
Packer L. The Role of Oxidative Stress in the onset and
progression of diabetes and Its complications: a summary of
a Congress Series sponsored by UNESCO-MCBN, the
American Diabetes Association and the German Diabetes
Society. Diabetes Metab Res Rev. 2001;17(3):189-212.
9. Nowotny K, Jung T, Hohn A, Weber D, Grune T. Advanced
glycation end products and oxidative stress in type 2
diabetes mellitus. Biomolecules. 2015;5(1):194-222.
10. Niedowicz DM, Daleke DL. The Role of Oxidative Stress in
Diabetic Complications. Cell Biochem Biophys.
2005;43(2):289-330.
11. West IC. Radicals and oxidative stress in diabetes. Diabet
Med. 2000;17(3):171-80.
12. Bajaj S, Khan A. Antioxidants and diabetes. Indian journal of
endocrinology and metabolism. 2012;16(Suppl 2):S267-71.
13. Bloomgarden ZT. Antioxidants and Diabetes. Diabetes Care.
1997;20(4):670-3.
14. Steinhubl SR. Why Have Antioxidants Failed in Clinical
Trials? Am J Cardiol. 2008;101(Supplement 10):14D–9D.
15. Chehade JM, Gladysz M, Mooradian AD. Dyslipidemia in
type 2 diabetes: prevalence, pathophysiology, and
management. Drugs. 2013;73(4):327-39.
16. Mooradian AD. Dyslipidemia in type 2 diabetes mellitus. Nat
Clin Pract Endocrinol Metab. 2009;5:150-9.
17. Kajiyama S, Hasegawa G, Asano M, Hosoda H, Fukui M,
Nakamura N, et al. Supplementation of hydrogen-rich water
improves lipid and glucose metabolism in patients with type
2 diabetes or impaired glucose tolerance. Nutrition research.
2008;28(3):137-43.
18. Schoppen S, Perez-Granados AM, Carbajal A, Sarria B,
Sanchez-Muniz FJ, Gomez-Gerique JA, et al. Sodium
bicarbonated mineral water decreases postprandial lipaemia
in postmenopausal women compared to a low mineral water.
The British journal of nutrition. 2005;94(4):582-7.
19. Shirahata S, Hamasaki T, Teruya K. Advanced research on
the health benefit of reduced water. Trends Food Sci
Technol. 2012;23(2):124-31.
20. Ohta S, Nakao A, Ohno K. The 2011 Medical Molecular
Hydrogen Symposium: An inaugural symposium of the
journal Medical Gas Research. Med Gas Res. 2011;1(1):10.
21. Kim M-J, Kim HK. Anti-diabetic effects of electrolyzed
reduced water in streptozotocin-induced and genetic diabetic
mice. Life sciences. 2006;79(24):2288-92.
22. Osada K, Li Y, Hamasaki T, Abe M, Nakamichi N, Teruya K,
et al. Anti-Diabetes Effects of Hita Tenryou-Sui Water®, a
Natural Reduced Water. In: Kamihira M, Katakura Y, Ito A,
editors. Animal Cell Technology: Basic & Applied Aspects.
16. Dordrecht: Springer, Dordrecht; 2010. p. 307-13.
23. Li Y, Hamasaki T, Teruya K, Nakamichi N, Gadek Z,
Kashiwagi T, et al. Suppressive effects of natural reduced
waters on alloxan-induced apoptosis and type 1 diabetes
mellitus. Cytotechnology. 2012;64(3):281-97.
24. Gadek Z, Hamasaki T, Shirahata S. “Nordenau
Phenomenon” - Application of Natural Reduced Water to
Therapy: Follow-Up Study upon 411 Diabetes Patients. In:
Shirahata S, Ikura K, Nagao M, Ichikawa A, Teruya K,
editors. Animal Cell Technology: Basic & Applied Aspects.
15. Dordrecht: Springer, Dordrecht; 2008. p. 265-71.
25. Sato Y, Kajiyama S, Amano A, Kondo Y, Sasaki T, Handa S,
et al. Hydrogen-rich pure water prevents superoxide
formation in brain slices of vitamin C-depleted SMP30/GNL
knockout mice. Biochem Biophys Res Commun.
2008;375(3):346-50.
26. American Diabetes A. Economic costs of diabetes in the
U.S. In 2007. Diabetes Care. 2008;31(3):596-615.
27. Wicaksono SA, Nabyla DH, Utami SB. The Effects of
Alkaline Reduced Water Administration to the Fasting Blood
Glucose Levels in Patients with Type 2 Diabetes Mellitus.
Pak J Med Health Sci. 2020 14(3):1260-5.
28. Otsuki M. Interaction among fat, lipase, CCK, and gastric
emptying. J Gastroenterol. 1999;34(4):542-4.
29. Kindel T, Lee DM, Tso P. The mechanism of the formation
and secretion of chylomicrons. Atheroscler Suppl.
2010;11(1):11-6.
30. Lima J, Fonollosa V, Chacón P. Selective cholesterol
absorption inhibition as a new prospect in treatment of
hypercholesterolemia. Med Clin (Barc). 2005;125(1):16-23.
31. Aloulou A, Carrière F. Gastric lipase: an extremophilic
interfacial enzyme with medical applications. Cell Mol Life
Sci. 2008;65(6):851-4.
32. Embleton JK, Pouton CW. Structure and function of gastro-
intestinal lipases. Advanced Drug Delivery Reviews.
1997;25(1):15-32.
33. Watanabe S, Lee KY, Chang TM, Berger-Ornstein L, Chey
WY. Role of pancreatic enzymes on release of
cholecystokinin-pancreozymin in response to fat. Am J
Physiol. 1988;254(6 Pt 1):G837-G42.
34. Hildebrand P, Petrig C, Burckhardt B, Ketterer S, Lengsfeld
H, Fleury A, et al. Hydrolysis of dietary fat by pancreatic
lipase stimulates cholecystokinin release. Gastroenterology.
1998;114(1):123-9.
35. Hayashi H, Kawamura M. Clinical Applications of
Electrolyzed-Reduced Water. In: Shirahata S, Teruya K,
Katakura Y, editors. Animal Cell Technology: Basic &
Applied Aspects. 12. Dordrecht: Springer, Dordrecht; 2002.
p. 31-6.
36. Shirahata S, Kabayama S, Nakanoa M, Miura T, Kusumoto
K, Gotoh M, et al. Electrolyzed-reduced water scavenges
active oxygen species and protects DNA from oxidative
damage. Biochem Biophys Res Commun. 1997;234(1):269-
74.
37. Park S-K, Park S-K. Electrolyzed-reduced water increases
resistance to oxidative stress, fertility, and lifespan via
insulin/IGF-1-like signal in C. elegans. Biol Res.
2013;46(2):147-52.
38. Gadek Z, Shirahata S. Changes in the Relevant Test
Parameters of 101 Diabetes Patients under the Influence of
the So-Called “Nordenau-Phenomenon”. In: Shirahata S,
Teruya K, Katakura Y, editors. Animal Cell Technology:
Basic & Applied Aspects. 12. Dordrecht: Springer,
Dordrecht; 2002.
39. Lee MY, Kim YK, Ryoo KK, Lee YB, Park EJ. Electrolyzed-
reduced water protects against oxidative damage to DNA,
RNA, and protein. Appl Biochem Biotechnol.
2006;135(2):133-44