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Beneficial Effects of Chromium
in People with Type 2 Diabetes,
and Urinary Chromium Response
to Glucose Load as a Possible
Indicator of Status
SUHAD M. A. BAHIJRI*,1AND ASAAD M. B. MUFTI2
1Department of Clinical Biochemistry, Faculty of Medicine
and Allied Sciences and 2Department of Mineral Resources
Faculty of Earth Sciences, King Abdulaziz University,
Jeddah, Saudi Arabia
Received May 1, 2001; Revised June 23, 2001; Accepted July 1, 2001
ABSTRACT
No reliable method for the estimation of chromium (Cr) status is
available yet. The aim of this study is to investigate the possibility of using
urinary Cr response to glucose load as an indicator of Cr status. Seventy-
eight non-insulin-dependent diabetes mellitus patients were divided ran-
domly into two groups and given Cr supplements as brewer’s yeast and
CrCl3sequentially with placebo in between, in a double-blind, crossover
design of four stages, each lasting 8 wk. At the beginning and end of each
stage, subjects were weighed, their dietary data and drug dosage recorded,
and blood and urine samples collected for analysis of glucose and urinary
chromium (fasting and 2 h post-75-g glucose load) and fructosamine.
The mean urinary Cr after the glucose load was significantly higher
than the fasting mean at zero time (p<0.01). However, only 52 of the
patients showed an obvious increase; the others showed a slight decrease
or no change. Both supplements caused a significant increase in the means
of urinary Cr and a significant decrease in the means of glucose and fruc-
tosamine. Only those subjects responding to Cr supplement by improved
glucose control showed an increase in post-glucose-load urinary Cr over
Biological Trace Element Research 97 Vol. 85, 2002
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All rights of any nature, whatsoever, reserved.
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*Author to whom all correspondence and reprint requests should be addressed.
Accelerated Article
fasting level, after the supplement but not at zero time. Therefore, it was
concluded that urinary Cr response to glucose load could be used as an
indicator of Cr status.
Index Entries: NIDDM patients; Cr status; urinary Cr response; glu-
cose load; Cr supplement.
INTRODUCTION
The role of chromium (Cr) in maintaining normal glucose tolerance is
well documented (1–4). However, supplementation studies gave conflict-
ing results, with some showing beneficial effects on glucose control (5–8)
and lipid profile (7–10), and others showing a lack of response (11–13) or
even deterioration of measured parameters (14). This could be, among
other reasons, the result of the Cr status of the studied subjects. So far, no
reliable method reflecting status is available. The use of serum and 24-h
urinary Cr levels were suggested, as mean serum levels were reported to
be lower in non-insulin-dependent diabetes mellitus (NIDDM) patients
(15,16) and mean urinary Cr levels were reported to be higher (17,18).
However, there was a great degree of overlap between values for normal
and diabetic subjects, and the use of these measurements as indicators of
Cr status is questionable. Gürson and Saner (19) reported an increase in
urinary excretion of Cr following glucose load in normal but not in dia-
betic subjects and suggested that this increase can be used as an indicator
of Cr status. However, Anderson et al. (20), working on normal healthy
subjects, concluded that urinary Cr excretion after a glucose challenge was
not predictable and did not depend on Cr status. The type of subjects and
their diet as well as glucose load and method of urine collection differed
between the two studies. Furthermore, no other study could be found in
the literature to verify either of them. Therefore, this study was planned to
investigate the possibility of using urinary Cr response following glucose
load as an indicator of Cr status, by supplementing NIDDM patients with
two types of chromium, noting the ones showing improvement in glucose
control, and comparing their urinary Cr response before and after Cr sup-
plement to the response of those showing no effect of supplement.
MATERIALS AND PROCEDURES
Subjects
Seventy-eight NIDDM patients (48 females and 30 males) ranging in
age from 36 to 68 yr were recruited into the study from the outpatient clin-
ics at King Abdulaziz University Hospital. All subjects gave informed con-
sent and the general research committee at King Abdulaziz University
granted ethical approval. Subjects were either of Saudi origin or Arabs
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Biological Trace Element Research Vol. 85, 2002
with at least 10 yr residence in the country. Potential subjects were
excluded if they had a history of pituitary, thyroid, kidney, or liver disease,
digestive problems, chronic infection, pancreatitis, or hemochromatosis or
were taking mineral or vitamin supplements or chronically ingested yeast.
All subjects agreed to maintain their usual eating habits and health-related
behaviors throughout the study.
Experimental Design
Selected subjects were medically examined, given code numbers, and
asked to present themselves on a specific date for sample collection. They
were all requested to fast from the previous night for 10–12 h, void their
morning urine, and drink an 8-oz glass of water before coming for testing.
On arrival, total urine void samples were collected in Falcon polypropy-
lene specimen containers from all subjects. No special precautions were
taken for urine collection from female subjects. Ten milliliters of each urine
sample collected were transferred to polypropylene tubes containing 0.1
mL of sodium ethyl mercurithiosalicylate solution (1.25 g/L) (Sigma Co.,
England) as a preservative. The tubes were centrifuged for 5 min at 200g
to remove any detritus that may have been introduced from the urinary
tract (21). One hundred microliters of magnesium nitrate solution [0.186
g/L Mg(NO3)2· 6H2O] was then added to each tube as a matrix modi-
fier/ashing aid to minimize chemical interference in the graphite furnace
(22) and the samples were frozen at –20°C until needed for chromium
analysis. The weights and heights of all subjects were measured to calcu-
late body mass index (BMI). Blood samples were obtained while fasting
and 2 h after a 75-g glucose load and transferred into appropriate tubes for
analysis of glucose and fructosamine.
While waiting, a 24-h dietary recall and dietary history was obtained
from each subject and reviewed by a personal interview.
The subjects were divided randomly into two groups (A and B) in
preparation for the supplementation study. The study design was double
blind and crossover, with each stage lasing 8 wk. The three types of sup-
plement (brewer’s yeast, Torula yeast, or placebo, and CrCl3) were given
consecutively in the form of capsules similar in shape, size, and numbers.
Neither the subjects nor the treating physicians knew which type were
taken at any time, and there were four stages in all (Fig. 1). The chromium
chloride dose was 200 µg of Cr3+/d, whereas the brewer’s yeast supple-
ment provided a total of 23.2 µg chromium/d and torula yeast provided a
total of 0.54 µg/d, both verified by analysis in our lab. Patients were
instructed to attend the outpatient clinics as usual and to contact a given
number in case of any adverse effects. At the end of each stage, compliance
was monitored by counting capsules, and subjects were reweighed, their
dietary intakes and history recorded, and urine and blood samples col-
lected. Medications taken by the patients at various stages were obtained
from their medical records at the end of the study.
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Biological Trace Element Research Vol. 85, 2002
Fig. 1. Experimental design of supplementation study and numbers of subjects remaining after various stages.
Methods
Plasma glucose was estimated on the same day of sample collection
by a fully automated method on a Hitachi system 705, employing the
“gluco-quant” reagent pack (Boehringer Mannheim). Quality control
checks were carried out at the beginning and end of each run. Serum fruc-
tosamine was determined by the nitro blue tetrazolium (NBT) method
(23). Chemicals were purchased from Sigma Chemical Co. and measure-
ment was carried out on a Beckman spectrophotometer model 42.
Chromium was measured using a Perkin-Elmer 5000 atomic absorption
spectrometer, which was equipped with a tungsten–halogen lamp for
enhanced background correction capabilities at the 357.9-nm chromium
line, a graphite furnace (Model HGA 500, Perkin-Elmer), and a strip-chart
recorder (Model 56, Perkin-Elmer). The method was based on work done
by Kayne et al. (24) and Veillon et al. (22) with slight modification. The
furnace program is shown in Table 1. Argon flow was interrupted at
atomization. After thawing urine samples, 3.0 mL of concentrated Aristar
nitric acid (BDH, England) was added to each sample, to dissolve any
precipitate, and the volume was made up to 25 mL using distilled, deion-
ized water, which contained no detectable chromium. A calibration graph
was prepared using urine pool treated exactly as samples and adding dif-
ferent concentrations of diluted certified atomic absorption K2Cr2O7stan-
dard (Fisher Scientific) to give final concentrations of 0–20 µg Cr3+/L.
Ten-microliter aliquots of the prepared standards were then pipetted into
the furnace to measure chromium and to construct the calibration graph
of the peak height against the concentration of the standards. Treated
replicate urine samples were pipetted in the furnace and the average peak
height obtained was compared to the calibration graph to obtain
chromium concentration.
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Biological Trace Element Research Vol. 85, 2002
Table 1
Perkin-Elmer HGA 5000 Furnace Program for Chromium Determination
The use of the same urine pool to prepare calibration graphs with each
run allowed internal monitoring of accuracy and interassay reproducibil-
ity. The intra-assay coefficient of variation (CV) was 6.4% and the interas-
say CV was 9.8%.
Using the collected 24-h food intake data, total calories consumed per
day, carbohydrates, fats, proteins, calcium, iron, and vitamins A and C
intakes were calculated for each subject using the nutrient values given in
various food composition tables (25–27), as well as dietary information
available with some of the packed foods consumed.
Statistical Analysis
Results are expressed as mean ±SD, and statistical analysis was by the
paired Student’s t-test. Significance was assigned at p<0.05.
RESULTS
Sixty-seven subjects completed the study, with excellent compliance
to therapy and no reports of adverse effects. Others either dropped out or
were excluded at various stages because of a lack of compliance. The mean
±SD for BMI at the start of the study was 31.04 ±8.41, indicating a high
percentage of obesity among the selected sample. Dietary intakes of total
calories and all calculated nutrients varied greatly in our subjects; how-
ever, all, except iron, were within or above the Recommended Daily
Allowance (RDA) at the start of the study. Iron was <77% RDA in some
female subjects. No significant change in BMI or calculated dietary intakes
was found at any stage of the study.
No subject needed increased dosage of medication at any stage,
except for two subjects taking a combination of insulin and metformin.
These subjects stopped taking insulin shortly after starting the brewer’s
yeast supplement and depended on an increased dosage of metformin
only. Both of them went back to taking insulin after brewer’s yeast was
stopped. When CrCl3was given, only one of them stopped taking insulin
again.
The glucose, fructosamine, and urinary chromium levels at all stages
of the study are presented in Table 2. Both types of Cr supplements, but
not torula yeast, caused a significant decrease in the mean glucose levels
in the fasting state and 2 h after the glucose load (p-value shown in Table
2). When both supplements were stopped and followed by torula yeast,
the fasting and 2-h postglucose means increased significantly (p<0.01 in all
cases) and became not significantly different to the zero time mean. Look-
ing at individual cases, it was noted that not all subjects were affected by
chromium supplements. After brewer’s yeast, 13 subjects (17.57% of total)
showed an improvement in glucose level (a decrease of ≥0.8 mmol/L)
while fasting or/and after glucose load, with no increase in drug dosage
102 Bahijri and Mufti
Biological Trace Element Research Vol. 85, 2002
or even a decrease. A similar improvement was noted in eight subjects fol-
lowing CrCl3supplement (11.9% of total at that stage). Other subjects
showed no or less significant decrease in glucose level, and two subjects
showed a slight increase (0.3–0.36 mmol/L), which was accompanied by
some reduction in their drug dosage. Similarly, brewer’s yeast and CrCl3
supplements caused a significant decrease in the mean fructosamine lev-
els. After stopping the two Cr supplements, the mean increased in both
cases and became not significantly different to the zero time mean. How-
ever, some subjects continued to have lowered fructosamine values by
≥15% of the zero time value when the placebo followed brewer’s yeast, but
not when it followed CrCl3supplement. Looking at individual cases, it
was noted that following brewer’s yeast, 14 subjects (18.92% of total in
group) showed a significant decrease in their fructosamine levels of ≥0.6
mmol/L (i.e., ≥15% of the zero time value), with no change or a decrease
in drug dosage. Nine of these subjects (13.43% of the group) showed a sim-
ilar decrease following CrCl3. Other subjects showed no or less significant
decrease in fructosamine level after either or both supplements. All sub-
jects (except one) showing a decrease following Cr supplements showed a
decrease in glucose level also at the same time.
Both types of supplement increased the mean urinary chromium
(fasting and post glucose load) significantly (p-values shown in Table 2).
However, the means following CrCl3supplement were significantly
higher than the means following brewer’s yeast (p=1.8×10–3 for fasting
and 7.8 ×10–4 for post-glucose-load). The means after stopping brewer’s
yeast and giving torula yeast decreased but remained significantly
higher than the zero time mean. However, when torula yeast followed
Urinary Cr as Indicator of Cr Status 103
Biological Trace Element Research Vol. 85, 2002
Table 2
Effect of Different Types of Supplements on Glucose, Fructosamine,
and Urinary Chromium Levels (Mean ±SD)
n= number of subjects. A= group of subjects starting with brewers yeast. B= group of sub-
ject starting with placebo. P*= when comparing mean to zero time mean.
CrCl3, the means decreased significantly (p=9.1 ×10–4 for fasting and 7.7
×10–4 for post-glucose-load) and became not significantly different to the
zero time mean.
The individual urinary chromium concentration while fasting and
post-glucose-load were examined at all stages. At zero time, glucose load
caused an increase in urinary excretion of chromium (positive response)
above basal (fasting) level in 52 patients out of the total of 78. The increase
ranged from 115% to 145% (post-glucose-conc./fasting conc. ×100). Out
of the remaining patients, 14 showed no significant change (up to ±7%)
and 12 showed a slight decrease (between 8% and 10%) or negative
response. Urinary chromium values of those subgroups of patients are
show in Table 3. A significant increase in the mean 2 h after glucose load
was found only in the first subgroup. As can be seen from actuals ranges,
it was difficult to predict urinary response from the fasting value only
because ranges overlapped. However, no fasting values <0.270 µg/L
could be found among patients showing no change or a decrease in
chromium excretion post-glucose-load, whereas values as low as 0.185
µg/L were found among patients showing increased chromium excretion
following glucose load.
After the brewer’s yeast supplement, 10 of the patients showing a
negative urinary chromium response after glucose load at zero time
showed an increase ranging from 116% to 125%, and 4 of the patients
showing no change at zero time showed an increase ranging from 118% to
127%. In addition, all of the patients showing a positive response at zero
time; and remaining at this stage, continued to show an increase in
chromium excretion in response to glucose load. Thus, the total number of
patients showing a positive response to glucose load was 64 subjects, with
a mean increase of 121%. None of the remaining 10 subjects showed a sig-
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Biological Trace Element Research Vol. 85, 2002
Table 3
Urinary Chromium Values at Zero Time Divided According to Subjects’
Response to Glucose Load (µg/L)
aMean ±SD.
bActual range.
cpwhen comparing post-glucose mean to fasting mean.
nificant change in urinary chromium concentration in response to glucose
load (range: 98–103%).
When placebo (torula yeast) followed in the next stages, the effect of
brewer’s yeast on urinary response was lost in about half of the subjects
and some patients showed a small negative response to glucose load.
Chromium chloride supplement had a similar effect to brewer’s yeast
on urinary chromium response to glucose load; however, fewer subjects
responded to this type of supplement. Out of the total of 67 subjects, 51
subjects showed a positive response to glucose load, 10 of which showed
a negative response or no response at zero time. The remaining 16 subjects
showed no significant change in urinary chromium concentration follow-
ing glucose load (post-glucose-load conc./fasting conc. = 97–104%). This
effect was totally lost when torula yeast followed.
The patients showing positive response after chromium supplements
only were the same ones showing a decrease in their fructosamine value
by ≥15% of the zero time level. Subjects showing no change in chromium
concentration after glucose load following Cr supplements also showed no
improvement in glucose control reflected on blood glucose and fruc-
tosamine levels following these supplements. Those subjects had fasting
urinary chromium levels > 0.455 µg/L.
DISCUSSION AND CONCLUSION
The aim of the study was to investigate the possibility of using uri-
nary chromium response to glucose load as an indicator of chromium sta-
tus in the body. Two different types of supplement provided different
forms (organic and inorganic) and different amounts of chromium most
commonly cited in literature. The use of a double-blind, crossover design
has helped in minimizing most nonspecific variations (assay variations,
physiological differences, variation with time).
The lack of change in BMI and dietary intakes throughout the study
indicates that noted changes in biochemical parameters are the result of
the given Cr supplements, especially that placebo had no effect, and there
was no increase in dosage given to any of the subjects.
Both types of chromium supplement caused a significant improve-
ment in the control of blood glucose reflected on lower means of glucose
and fructosamine indicating the presence of Cr deficiency in the studied
population. However, not all subjects responded to the supplements.
Chromium is not a drug and will improve glucose control only in patients
with low status of the mineral originally. The dietary intake of our subjects
and their urinary excretion of the mineral varied greatly as noted from the
Results section. Therefore, the variations in response to chromium supple-
ments were expected. Subjects ingesting adequate amounts of chromium
are not likely to respond in any way to additional supplement of the ele-
ments, especially if their urinary excretion is low. On the other hand, sub-
Urinary Cr as Indicator of Cr Status 105
Biological Trace Element Research Vol. 85, 2002
jects with inadequate kidney function, leading to excretion of large
amount of Cr in urine, are likely to have low chromium status and, hence,
will respond favorably to the given supplement, especially if the intake
was initially inadequate. It seemed that approx 18% of the subjects
responded to brewer’s yeast supplement by showing a significant
decrease in their blood glucose and fructosamine levels and, hence, were
likely to be Cr deficient initially. However, only approx 13% responded to
CrCl3supplement even though it provided a higher amount of Cr. This
could be the result of the different bioavailability and utilization of the two
forms in the body. The significant increase in urinary Cr following both
types of Cr supplement indicate proper absorption from both types and
that the lack of response of some subjects to CrCl3supplement is not the
result of defective absorption of Cr from this form. However, the higher
mean urinary Cr after CrCl3, followed by the decrease to zero time value
when the placebo was given in the following stage, compared with a per-
sistently higher mean when the placebo followed the brewer’s yeast sup-
plement suggests that the higher intake of Cr from CrCl3(200 µg/d) is not
equally well utilized or stored as the much lower amount provided by
brewer’s yeast (23.2 µg/d). Brewer’s yeast is said to contain biologically
active chromium or “glucose tolerance factor” (GTF) (28). Thus, it can be
suggested that Cr resulting form absorption of GTF or the products of its
digestion is more readily assimilated by the body, whereas the body pools
of inorganic Cr are quickly saturated and the excess after oral administra-
tion is excreted in urine. This will explain the maintained improvement in
some subjects when the placebo followed the brewer’s yeast supplement,
but not when it followed CrCl3. Another possibility is that some individu-
als cannot convert ingested inorganic Cr into a biologically active storable
form and, hence, will not respond to CrCl3supplement or will need a
higher amount of supplemental CrCl3to do so and, hence, will not
respond to CrCl3at the amount given. In fact, it could be possible that a
higher amount of both types of supplement might have given rise to
improvement in a higher percentage of subjects, as suggested by some
recent work (29,30).
The finding that only those patients showing improved glucose con-
trol following supplements also showed a change in their urinary response
to glucose load from negative or no response to a positive response indi-
cates that urinary chromium response is connected strongly to Cr body
status. Cr potentiates insulin action, and, hence, is expected to be released
from the body stores in response to glucose load in a similar way to
insulin, but only if stores have adequate amounts of Cr. This excess
amount in the blood is likely to be cleared by the kidney, once insulin
action is completed, and appears in urine as an increase over basal (fast-
ing) level. Therefore, a low status, as at zero time for some subjects, results
in negative or no urinary response, whereas after supplements, the Cr sta-
tus is improved and the urinary Cr response becomes positive. This
change in urinary chromium response following the supplement could not
106 Bahijri and Mufti
Biological Trace Element Research Vol. 85, 2002
be predicted just by examining the fasting or the post-glucose urinary
chromium, as can be deduced from Table 3. However, it was interesting to
note that all of the subjects showing no significant response to the given
supplement had fasting urinary chromium > 0.455 µg/L (i.e., on the higher
side of the range for all subjects). Hence, it could be postulated that those
subjects needed a higher amount of supplement than given to saturate or
replenish their Cr stores and, hence, still had marginal Cr status after the
supplements. A further study using higher amounts of supplemental
chromium will clarify this point.
Thus, and according to the above, it is suggested that urinary Cr
response to glucose load could be used as an index of Cr status, which vali-
dates the earlier suggestion by Gürson and Saner (19). The inconsistent
response to glucose load reported by Anderson et al. (20) might be the result
of their use of a urine sample collected 90 min after a glucose load (i.e., when
the glucose level is still not back to normal and Cr is still involved in poten-
tiating insulin action) or to the difference in the type of subjects used.
To conclude, our results indicate that chromium deficiency, corrected
by Cr supplementation, is present in our population and that different
forms of Cr are utilized to a different extent by the body, with Cr from
brewer’s yeast eliciting better glucose control (at a lower dose) in more
subjects. Results also indicate that Cr urinary response 2 h after glucose
load could be used as an index of Cr status.
ACKNOWLEDGMENTS
We wish to thank the research committee at King AbdulAziz Univer-
sity for their financial support and Dr. Siraj Mira from the Department of
Internal Medicine for providing the samples and drug dosage of each
patient.
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