Effects of glutamine and epigallocatechin-3-gallate on glucose tolerance, markers of inflammation, oxidative stress and procoagulant status in Type 2 diabetes mellitus

In this pilot study the individual and combined effect of glutamine and
epigallocatechin-3-gallate will be studied on glucose tolerance, inflammatory
and oxidative stress parameters and procoagulant state in newly diagnosed type
2 diabetics.
It is a prospective randomized single center 4 arms intervention study
including 30 patients in each arm. Patients are 18 years and older with newly
diagnosed type 2 diabetes with two times a post absorptive glucose of >
7mmol/l. Although, patients with a post absorptive glucose * 15 mmol/l or * 10
mmol/l and hyperglycemic complaints (polydipsia, polyuria, weight loss more
that 10% in the last month) will be excluded.
For a duration of 4 weeks the effects of daily supplementation of L-glutamine
(GLN, 0.3-0.5 g/kg/day) with epigallocatechin-3-gallate (EGCG, 3 x 150 mg)
versus control (no intervention) will be studied on glucose tolerance,
parameters for the inflammatory and oxidative stress response and parameters
for a procoagulant state. During the 4 weeks of supplementation no diet or
lifestyle interventions will be started. After the supplementation period
patients will immediately start with diet and lifestyle interventions.
Background of the study.
In the year 2025, the number of patients with type 2 diabetes is expected to
reach 1.3 million (RIVM 2007) taking into consideration the increase in aging
and obesity. This calls for new affordable treatment modalities focusing on
prevention of diabetes and its complications.
This study investigates the effects of two well known nutritional supplements,
L-glutamine and EGCG, on inflammatory and oxidative markers and procoagulant
state in newly diagnosed type 2 diabetes. The oxidative stress in type 2
diabetes is thought to underlie the atherosclerotic vascular changes typical
for organ dysfunction. The significant lower level of glutamine in diabetics is
related to reduced anti-oxidant capacity and impaired immune function,
increasing the risk for infections. L glutamine supports endogenous antioxidant
capacity via the production of glutathion and EGCG supports exogenous
anti-oxidant capacity. In addition to these effects, glutamine and EGCG also
have been reported to cause weight loss in the overweight which may reduce
adiposity related type 2 diabetes. The potential efficacy of glutamine and EGCG
is based on extensive in vitro, ex vivo, animal experimental, clinical and
epidemiological research data of each individual molecule. The focus of these
studies has been on insulin production and resistance, glutathion production,
the anti-oxidative and anti-inflammatory effect. The hypothesis is that the
reduction in oxidative and inflammatory stress that can be achieved with both
L-glutamine and EGCG will result in better glusose homeostasis and less
endothelial damage preventing micro and macrovascular complications in type 2
diabetes.
Glutamine and EGCG are relatively low cost supplements with no reported side
effects in the dosages used. The expected short term results of this study are
lower lower circulating markers of inflammatory and oxidative stress, and lower
markers for procoagulant state. These improvements will eventually result in
less endothelial damage with reduced micro and macrovascular complications in
type 2 diabetes patients providing a better and more cost effective improvement
in quality of life.
If results are promising a longer intervention study is needed to study the
effects on micro- and macrovscular complications in patients with diabetes type
2.

In this pilot study, the objective is to show an improvement in glucose
tolerance,a decrease in parameters for inflammation, oxidative stress and a
procoagulant state after 4 weeks of daily supplementation of L -glutamine and
Epigallocatechin-3-gallate.
Apart from chosen parameters a BIA will be performed at start, after 2 weeks
and after 4 weeks of supplementation.
The conditionally essential amino acid glutamine was chosen because:
- it induces insulin production by stimulating the release of glucagon like
peptide -1 by jejunal cells
- in beta cells it is recognized as an important signaling molecule in the
production of insulin.
- it reduces insulin resistance and improves postprandial glucose tolerance in
type 2 DM.
- it is a preferred oxidative fuel for gut epithelial and immune cells.
- it is a precursor for glutathion, arginine, HSP's and PPAR gamma.
-- it reduces the proinflammatiry cytokine response by inhibiting the
activation of NFkB.
EGCG is chosen because it is an exogenous, ant-ioxidative phyto-polyphenol that
- inhibits amyloid deposition pancreatic isle cells.
- regulates glucose homeostasis by supporting GLUT 4 translocation in skeletal
muscle
- suppresses gluconeogenesis in the liver
- at the level of the gut acts as an antioxidant and antibacterial agent
inhibiting carbohydrate splitting enzymes
- after bacterial fermentation in the gut modulates protein kinase and lipid
kinase signalling pathways (PI 3-kinase, Akt/PKB, PKC en MAP
kinase) beinvloedt
- modulates NFkB activation by downregulation of gene expression.

The effect of both supplements will be assessed by the following parameters
1 Insulin sensitivity, by using an OGTT
2 Inflammatory parameters (CRP, IL-6, IL-18, TNF-*, leucocyte NFkappaB, IL-4,
IL-10). IL-6 en TNF-* na vol bloed LPS stimulatie.
3 Oxidatieve stress parameters(Malondialdehyde, TBARS, 8-iso-prostaglandin F2*).
4 Endothelial dysfunction parameters (VCAM-1, E-selectin, ICAM-1, vWF, cGMP,
nitrate/nitrite).
5 Pro-coagulant state (PAI-1, fibrinogen, P-selectin)
6 Body composition (BIA).
7 weight changes

The association of general practitioners (HONK) has a large population of newly
diagnosed type 2 diabetic patients who will meet the inclusion criteria and who
will want to participate in the study (based on expert opinion). The study will
be performed independently from the producer of the product 2-Prepare® GLNP
Life Sciences. The study will be coordinated by a research fellow in a PhD
program.
Design
The study is a prospective, open label, randomised, single-center, pilot,
intervention study on the effects of glutamine and EGCG in newly diagnosed DMT2
patients.
The duration of the study is 4 weeks of supplementation. At start, after 2
weeks and after 4 weeks a blood sample (20 ml) will be drawn, an oral glucose
tolerance test (OGTT) will be taken together with a BIA.

During the study no change in lifestyle will be advised. Each arm contains 30
patients who will receive for 4 weeks; Control (group1), L-glutamine 0.3-0.5
g/kg/day (group 2), EGCG 3 x 150mg/day or no intervention (group 3) and
L-glutamine/EGCG (group 4). Both L-glutamine and EGCG are produced according
GMP quidelines. analysed in a ISO certified pharmacy and packed according to
HACCP.
L -glutamine is a 9 g sachet protected by light and moisture by a aluminum
cover.
EGCG is packed in a capsule of 150 mg (Vcap) contained in a aluminum cover.

During this 4 weeks study patients have to visit the research department 3
times. At these points the blood samples (20ml) will be taken an OGTT will be
performed with a BIA. A BIA takes about 10 minutes. An OGTT takes about 300
minutes