The Bioactive Effect  of Red Beetroot  on  Women with the Polycystic Ovarian Syndrome(PCOS)

Shaimaa SH. Matar

Nutri. & Food Sci. Dept., Faculty of Home Economics, Helwan University, Egypt

Ahmed A. Farrag

Nutri. & Food Sci. Dept., Faculty of Home Economics, Helwan University, Egypt

Samar  M. Hafez

Pharmacology Dept.Faculty of Veterinary Medicine,Cairo 

University, Egypt

Radwa M. Fahmy

Obstetrics and Gynecology. Dept.,Faculty of Medicine (Kasr Alainy),Cairo  University, Egypt

Abstract

  The present study aimed to  to investigate the effect of the active 

substances found in dried ground red beets on improving ovarian cysts, overcoming the symptoms and complications caused by this disease, and rebalancing the state of hormones in the body, the most important of which is the treatment of insulin resistance, lowering body weight all with the aim of desire and ambition to bring about pregnancy and childbirth   in women with  poly cystic ovarian syndrome (PCOS) .

Thirty women with PCOS, between 18 to 40 years  were  selected , women with PCOS were divided into 3 groups (10 woman/group) All groups were subjected to a diet low in carbohydrates and protein to reduce weight, in addition to taking the basal medications, with the exception of metformin tablets,the experiment lasted for 3 months .  The results of the present study  showed that ground  red beets with the application and following of a diet low in carbohydrates and protein, all together have a significant positive effect in improving cases of polycystic ovaries, treating hormonal imbalance, regulating the occurrence of the menstrual cycle and the occurrence of pregnancy and childbearing in some women.

Introduction

Red beetroot (Beta vulgarisssp. vulgaris L.) is a herbaceous biennial (flowering in the second year of growth) or, rarely, perennial plant up to 120 cm (up to 200 cm in second year) in height, but cultivated forms are mostly biennial. The roots of the cultivated forms are dark red,white, or yellow, and moderately to strongly swollen and fleshy or brown, fibrous, sometimes swollen and woody in the wild subspecies (Ceclu and Nistor,2020).

Beetroot  is rich in several other bioactive compounds that may provide health benefits, particularly for disorders characterised by chronic inflammation. Also, recent research has provided compelling evidence that beetroot ingestion offers beneficial physiological effects that may translate to improved clinical outcomes for several pathologies, such as hypertension, atherosclerosis, type 2 diabetes and dementia (Gilchrist et al., 2013). Red beetroot  has anti-glycaemic effect could be attributed to one of the many antioxidant compounds contained in beetroot particularly alpha-lipoic acid, which improves insulin sensitivity (Megan, 2016). Also, betanin the bioactive compound of redbeetroot   caused low ovarian cysts with a high incidence of ovarian primary, antral, graafian follicles and corpus luteum. The plasma glucose, cholesterol, LDL and LH levels were found to be diminished  the cases of PCOS whereas plasma HDL and FSH levels were increased ( Montazeri  et al., 2018).

Betanin exhibits an antioxidant activity that is ten times higher than tocopherol. Betalains, especially betacyanins, play an important role in human health because of their pharmacological activities as an antioxidant, anti-cancer, antiinflammatory,hepatoprotective (Georgiev et al.,2010), anti-lipidemic and antimicrobial agent. They inhibit cervical ovarian and bladder cancer cells in vitro, and can also inhibit the proliferation of cells in human tumors(Neha et al.,2018).

               Therefore,the present study Possible  therapeutic  ability of red beetroot powder on decrease biochemical parameters especially Hyperinsulinemia, Insulin resistance, Hyperandrogenism in addition to Loss  of weight and regulation of menstrual cycle and regulating ovulation hormones and estrogen, and regulating the the menstrual cycle, all with the aim of desire and ambition to bring about pregnancy and childbirth   in cases of  poly cystic ovarian syndrome (PCOS) .

Chemical Composition Of Raw And Dried Redbeetroot Per   

100/gm :

( Mirmiran et al.,2020)

Bioactive Substances Of Red Beetroot :

Bioactive substances of red beetroot  .

Photo (1):

Bioactive substances of red beetroot according to ( Ninfali and  Angelino,2013., Georgiev et al.,2010 and Kujala et al.,2002)

Materials and Methods

Red beetroot (Beta vulgaris)  was obtained from  the Agriculture Research Center  and it was dried then it was ground .

Preparation of Red Betroot  :

One hundred and  twenty kg of red beets were purchased from the Agriculture Research Center  and they were soaked, washed well and cleaned, then they were cut into thin slices such as crunchy potato chips, then they were dried in the Solar Energy Center at the National 

Research Center in Dokki, Cairo, and they were packed in jars, one package weighing 300 gm, and it was distributed to patients at a rate One package for each patient every month for 3 consecutive months.

Experimental design:

               Thirty five  woman with PCOS, between 18 to 40 years  were  selected  from the department of  obstetrics /gynaecology and Radiology department, Al Qasr Al Ainy Hospital Hospital , Cairo .

Exclusion Criteria : pregnant , lactating and women with hypertension will be excluded from the  samples .

Women with PCOS were divided into 3 groups (10 woman/group) All groups  were subjected to a diet low in carbohydrates and protein to reduce weight, in addition to taking the basal medications, with the exception of metformin tablets,the experiment lasted for 3 months  as follows: 

Group (1) : control, The women had taken the basal medication  in addition to metformin tablets.

Group (2) : The women had taken the basal  medication exception  metformin tablets . 

Group (3):  women were   provided with red beetroot  powder and instructed to take orally 10 gram of red beetroot  powder (5 gm in the morning and 5 gm in the evening )  with a spoon provided, in Lemon juice before meals( Gilchrist et al.,2013) .

Cases were followed up and communicated with their daily via  mobile .

Five of the thirty-five women withdrew from the experiment due to their travel and distance from Al Qasr Al Ainy Hospital Hospital , Cairo .

Blood samples were taken from cases of polycystic ovaries before the beginning of the experiment and at the end of the experiment. The blood samples were separated and transferred to a serum for the necessary analysis .

Analysis For PCOS :

Ovulation evaluation may be broken down into types:

Hormones Tests: These Hormonal  Tests Include The Following :

Luteinizing Hormone (LH):Luteinizing Hormone (LH) was determined according to Sherman et al., (1976).

Follicle Stimulating Hormone(FSH):Follicle Stimulating Hormone(FSH)was analyzed  according to Rose et al., (2000).

Anti-Mulirian Hormone (AMH):Anti-Mulirian Hormone (AMH)  was estimated according to Tobler et al.,(2015).

Fasting Insulin( F.Insulin):Fasting Insulin( F.Insulin)  was analyzed according to Young  ,(1972)

Cortisol AM :Cortisol AM  was determined according to  Casals and  Hanzu (2020)

Estradiol(E₂) :Estradiol  was estimated  according to  Scott  et al.,(1993)

Free Testosterone :Free Testosterone was analyzed according to Salameh et al.,(2010)

Random blood sugar  :Random blood sugar  was determined according to Young  et al.,(1972)

These  biochemical  analysis were performed in biochemical Analysis Laboratory of   El-kasr Elini Hospital .

Dietary Studies :

Diet history including food habits was taken during an interview with patients including food likes and dislikes .

1-Nutrients intake :

Two types of menus were designed according to patients BMI . Daily energy and nutrients intake ( e.g., protein , fat , vitamins , minerals were calculated for all patients using food intake analysis system (FIAS) .

2-Anthropometric Measurements :

Measurements of height, weight , and body mass index .

Height was measured to the nearest 0.5 centimeter with subject standing with head , shoulder , but tocks and heals vertically aligned and bare footed.

Weight was measured to the nearest 0.1 kg with light clothing and without shoes . Body weights of all participants were recorded at the base line after 6 and 12 weeks of the following regimen .Body mass index (BMI) was calculated according to Mitch and Klahr,(1993), as the weight (kg)/height  ( _m²₎. The prevalence of overweight or obesity was determined.

3- Presence of hirsutism:

4- Menstrual cycle History: included age at menarche, frequency, duration and severity of menstrual flow and history of dysmenorrheal. In addition, information on history of difficulty in conception were collected ( Debra et al.,2007).

A healthy diet to reduce weight provided for cases of polycystic ovary syndrome  Regimen  diets low in carbohydrates and protein  presented to women with polycystic ovarian syndrome PCOS :

Provided 1500 k.calories :

( 40%  Carbohydrate , 20% protein  and  40% fats )

The diet is divided into three meals per day ( Breakfast ,  Lunch  and Dinner )

Breakfast :

100 g Grilled cauliflower cooked  in the oven,5 spoons of baba ghanouj salad  and  100 g Cucumber slices.

or

100g Grilled falafel in the oven, 5spoons (100g) cooked fava beans

And  agreen salad plate(20g onions+50g coriander +50g lettuce+50g Cucumber+20g tomatoes +1 tps olive oil ) 

or

100g of lentils soup ,60g boiled egg and  agreen salad plate(30g onions+50g coriander +50g lettuce+50g Cucumber+20g tomatoes +1 tps olive oil )  . 

or

100 g Koshari dish without rice, vermicelli and pasta ,60g boiled egg

And agreen salad plate(20g onions+50g coriander +50g lettuce+50g Cucumber+20g tomatoes +1 tps olive oil )   .

Between Each Meal :

Intermittent fasting  which you drink  warm unsweetened drinks.

Warm drinks:

Big cup of 200ml (Cinnamon with cloves or ginger with lemon or sage with marjoram  aor fennel anise) .

Twenty minutes before lunch :

100g apple  or  100g orange  or  100g five strawberries .

Lunch :

150g  fish grilled or cooked in the oven, preferably (mackerel - tuna - catfish - tilapia) , A plate of green salad and  60g three spoons of rice or grits .

Or

Vegetable soup plate ( 50g cabbage leaf – 50gcelery – 50g green coriander - - 100g  zucchini – 100g  green beans   ) 150 g  1/4 chicken, and  green salad plate .

Or

280g  stuffed dish of  vine leaves or cabbage or Stuffed assorted vegetables(zucchini, eggplant, bell pepper and green pepper) stuffed with(100g  leafy vegetables ,50g onions ,100g  minced chicken meat,30g  sunflower oil )  and  100g  Yogurt salad with cucumber, green coriander, garlic and pickled olives .

Or

250 g dish of  lentil soup with carrots and zucchini (mashed), 60g  a boiled local , baladi egg and a green salad dish .

Dinner:

60g  (3tps) of raw sesame or Pumpkin seeds and pulp or Sunflower seeds and pulp or almonds or walnuts  with adish of green salad with 1 tps olive oil   .

A day of detox:

               It is done at a rate of three times every week, after every two days of eating the previous meals.

At  Detox  Day  the following is addressed:

               Vegetable soup two twice aday  and green juice (watercress, lettuce, green coriander, cucumber, mint and anise)  and  previous warm drinks without sugar  .

Statistical analysis:

The obtained data were statistically analyzed using SPSS-PC statistical package software  and the type of test is ANOVA followed by Duncale  at  0.05 significant (SAS., 2004). 

Results and Discussion

Nutritional Studies

Body Mass Index(BMI):

Results in table (1) indicated that a total of  30 women with polycystic  ovarian syndrome( PCOS)  were included in the final analysis,there were married ,women with PCOS who treated with oral dietary supplement of (10 g  redbeets   )powder / day  had the lowest mean body mass index  then followed by women treated  with only low carbohydrate,protein diet  and women with diet  regime  compared  to women  who were subjected to only drug administration (the control group) had the highest mean body mass  index and lowest weight loss,the differences between the groups were significant at post treatment and this  was in agreement with (Yari et al.,2021) . 

The decrease of body mass index (weight  loss )was attributed to the active constituent  of  redbeet powder   such as adietary fiber  ,phenolic  compounds many antioxidant compounds contained in beetroot particularly alpha-lipoic acid, which improves insulin sensitivity (Megan, 2016). Also, betanin the bioactive compound of red beetroot   caused low ovarian cysts and low  plasma glucose, cholesterol, LDL ( Montazeri  et al., 2018).and vitaminsespecialy B-Vitamins which play an important role in so many chemical reactions in the body  including hormone regulation, fat and sugar metabolism, and other functions that help the body maintain homeostasis (Thatcher, 2000), also they play an important role  in decrease of insulin resistance ,consequently ,an increase  in fat metabolism  and its burn in the body  leads to weight loss and decrease of body mass index  ,these results are agreement with  (Yari et al.,2021).

Biochemical Analysis

1. Follicular  Stimulating Hormone (FSH) , Leutinizing  Hormone (LH) and Anti-Mulirian Hormone (AMH):

Analysis presented in table(2) illustrated that almost of treated groups induced increase of follicular stimulating hormone (FSH) compared to the control group , the differences  were significant between groups especially  at post treatment  ,and the group inducedthe greatest increase in (FSH) was obtained  by supplementation  with  red beetroot powder    then followed by the group only  treated with low carbohydrate low protein diet compared to the control group ,the differences were significant  and this was in agreement with (Megan, 2016) . 

               Concerning  leutinizing  hormone (LH)  and antimullerian hormone (AMH), data analysis revealed that  almost of treated groups  induced decrease in (LH and AMH)compared to the control group .The greatest  decrease in (LH and AMH ) was obtained by supplementation  with red beetroot powder    compared to the other tested  groups  and this decrease were significant   . The women who consumed red beetroot powder    , two of them became pregnant, just as the menstrual cycle was regular for the majority of the women of this group, then followed by the women who only  treated with low carbohydrate low protein diet , two of  them became pregnant and the menstrual cycle was regular for the majority of them . Whereas, women in the group that took metformin did not get pregnant, with irregular menstruation.

An increase of (FSH) and the decrease of (LH and AMH) by almost of treated groups may be attributed to   the good effects of red beetroot powder and low carbohydrate low protein diet    which they contain  antioxidant properities compounds contained in beetroot particularly alpha-lipoic acid, which improves insulin sensitivity and these results were in agreement with  (Megan, 2016). Also, betanin the bioactive compound of redbeetroot   caused low ovarian cysts with a high incidence of ovarian primary, antral, graafian follicles and corpus luteum. The plasma glucose, was found to be diminished  the cases of PCOS whereas FSH levels were increased .

Betanin exhibits an antioxidant activity that is ten times higher than tocopherol. Betalains, especially betacyanins, play an important role in human health and , all  of these factors  each to other resulted in  hypoinsulinemia  and  an increase of the receptors sensitivity  of the body cells to insulin hormone  ,consequently ,hypoandrogenism ,increase of (FSH) hormone and decrease of (LH and AMH ) hormones and  these results  were  agreed with( Montazeri  et al., 2018)   .

3. Fasting  Insulin Hormone (F.Insulin), Cortisol , Estradiol (E2), Free Testosterone (F.Testosterone) and  Glucose :

Data presented in  two table (3a and 3b) illustrated that almost of treated groups induced decrease of glucose level ,insulin hormone  and decrease of  cortisol AM  at post treatment compared to  pre- treatment . 

The greatest decrease of glucose level , insulin hormone  and cortisol hormone   at post treatment were obtained by supplementation with redbeetroot powder  then followed by diet group(women who only underwent a low-protein, low-carbohydrate meal) compared to the control group and  this decrease was significant , these results are agreement with (Haidari et al., 2020) and these  may be attributed to  bioactive compounds of plant species have shown that increasing levels of anthocyanins, flavonoids( Farid et al.,2015).These polyphenols are very popular because of their antihyperglycaemic  effects, safety and non side-effects. Potential efficacy of polyphenols on carbohydrate metabolism and glucose homeostasis  may offer unique treatment modalities for various aspects of type 2 diabetes( Andrica et al., 2015). These includes inhibition of α-amlylase and α-glucosidase, increase in paraoxonase 1 (PON1) activity, modification of intracellular signal transduction which is a major mechanism of reducing blood glucose by foods (Uchida-Maruki et al.,2015).The reduction in blood glucose stimulated the release of cortisol as a counter regulatory mechanism  ( Olumese and Oboh, 2016). The correlation studies revealed a weak relationship between glucose and cortisol.Cortisol, a stress hormone has been reported to increase gluconeogenesis, decrease peripheral glucose utilization and increase the availability of fuel substances by the mobilization of glucose, free fatty acids, and amino acids from endogenous stores. The results from this study showed that cortisol correlated posititively with insulin.

The hypoglycaemic activity of beetroot juice as clearly established by this study may not be dependent on insulin secretion. The possible mechanisms could include inhibition of carbohydrate digestion and glucose absorption in the intestine, and the modulation of glucose release from the liver. ( Olumese and Oboh, 2016) .   Concerning estrogen hormone and free testosterone  hormone ,the analysis revealed that almost of supplemented groups induced increase of estrogene hormone level and decrease of  free testosterone level at post treatment compared to the control group    .

            The greatest decrease at post treatment  of  free testosterone 

and increase of estrogen level  were obtained by supplementation with redbeets then followed by  women who only underwent a low-protein, low-carbohydrate meal compared to the control group and these differences were significant ,these results were  in agreement with(Haidari et al., 2020)  . 

4.Thyroid Stimulating Hormone(TSH), Triiodothyronine (T3) and Thyroxine(T4) :

Data presented in table (4) illustrated that the greatest increase of TSH,T3 and T4 hormones were obtained by supplementation with redbeets then followed by low carbohydrate ,low protein meal  compared to the control group ,the differences at post treatment  between experimental groups were significant . The greatest decrease of TSH,T3 and T4 was obtained by control group .The increase induced in TSH,T3 and T4 hormones in all treated groups may be attributed to their antioxidant  properties of their bioactive constituents since,adding redbeets and low carbohydrate low protein meal  caused a significant decrease of testosterone, increased estradiol concentration, also each of growth hormone and TSH hormones increased significantly , As decrease in genomic DNA concentration with redbeets supplementation may due to one of the mechanisms by which phytoestrogens may influence reproductive physiology that involve in inhibition of enzymes essential for DNA replication.These results are agreement with  (Yousif ,2019) .

Also these results were agreement with (Zhang et al., 2019).They found that  low carbohydrate low protein meal treatment in women with PCOS has significantly improved BMI, lipid levels (TC,and LDL-C), HOMA-IR, FSH, SHBG  and  thyroid gland  functions ,and this result was agreement with(Diana, 2017)  ,the results support the hypothesis that an increased intake of foods high in nitrate over 250 g carrots or beetroot 250 g/day  is a risk factor for the de novo development of hypothyroidism .The decrease in TSH,T3 and T4  in the control groub may be interpreted as  adverse metformin  medication  impact on thyroid gland (Yousif , 2019).

In  conclusion,  the results of the present study  showed that ground red beets improved body mass index (BMI), follicular stimulating hormone (FSH), Leutinizing Hormone (LH) ,  anti-mulirian hormone (AMH), insulin hormone, cortisol, estradiol(E₂) , free testosterone, glucose, and thyroid gland hormones in women who have been on alow carbohydrate low protein diet . The ground red beets have given  better results in improving the cases of polycystic ovaries, achieving a balance in hormones and producing pregnancy and childbearing compared to the rest of the experiment groups.

Table (1) :Effect  of  Red Beetroot and Diet Regimen Between All      

                  Groups (pre and post ) on Body Mass Index (Weight Loss).

Data expressed as mean ± SD, significant differences at  P < 0.05
No significant differences between  the values had the same letter in each column .

Table (2) :Effect of Red Beetroot and Diet Regimen between all Groups (pre and post ) on Ovulation Hormones , Follicular  Stimulating Hormone (FSH) , Leutinizing Hormone (LH) and Anti-Mulirian Hormone (AMH).

Data expressed as mean ± SD, significant differences at  P < 0.05
No significant differences between  the values had the same letter in each column .

Table (3a) :Effect of Red Beetroot and Diet Regimen between all Groups (pre and post ) on Fasting  Insulin  Hormone (F.Insulin), Cortisol and Estradiol (E2).

 Data expressed as mean ± SD, significant differences at  P < 0.05
No significant differences between  the values had the same letter in each column .

Table (3b) :Effect of Red Beetroot and Diet Regimen between all Groups (pre and post ) on Free  Testosterone (F.Testosterone) and  Glucose .

Data expressed as mean ± SD, significant differences at  P < 0.05
No significant differences between  the values had the same letter in each column .

Table (4) :Effect of Red Beetroot  and Diet Regimen between all Groups  (pre and post ) on Thyroid Gland Analysis (Thyroid Stimulating Hormone (TSH), Triiodothyronine (T3) and Thyroxine(T4) .

Data expressed as mean ± SD, significant differences at  P < 0.05
No significant differences between  the values had the same letter in each column .

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التأثير الحيوى للبنجر الأحمر على النساء المصابات بمتلازمة

 تکيس المبايض

شيماء شعبان مطر

قسم التغذية وعلوم الأطعمة – کلية الاقتصاد المنزلى – جامعة حلوان

أحمد عوض فراج

قسم التغذية وعلوم الأطعمة – کلية الاقتصاد المنزلى – جامعة حلوان

سمر منير حافظ

 قسم الصيدلة – کلية الطب البيطرى – جامعة القاهرة

رضوى محمد فهمى

قسم النسا والتوليد – کلية طب القصر العينى –جامعة القاهرة

الملخص

               استهدفت الدراسة الحالية معرفة تأثير المواد الفعالة الموجودة في البنجر الأحمر المجفف  المطحون على تحسين حالات  النساء المصابات بمتلازمة  تکيس المبايض (PCOS) ، أى متلازمة خلل الهرمونات الذى يترتب عليه خلل فى عملية التمثيل الغذائى وخلل فى حرق الدهون وحدوث الالتهابات بالجسم وتأخر الحمل وعدم انتظام الدورة الشهرية  ، والتغلب على الأعراض والمضاعفات التي يسببها هذا المرض ، وإعادة التوازن إلى حالة الهرمونات في الجسم ، وأهمها علاج مقاومة الإنسولين وخفض وزن الجسم بهدف تحقيق الحمل والإنجاب  عند هؤلاء النساء.

               تم اختيار خمسة وثلاثون امرأة مصابة بمتلازمة تکيس المبايض ، تتراوح أعمارهن بين 18 إلى 40 عامًا ، وتم تقسيم النساء المصابات بمتلازمة تکيس المبايض إلى 3 مجموعات (10 نساء / مجموعة). استمرت التجربة لمدة 3 أشهر  خضعت المجموعات الثلاث إلى اتباع نظام غذائى منخفض النشويات والبروتين مع تطبيق صيام متقطع  بجانب تناول الأدوية الطبية جميعها  ما عدا عقار الميتفورمين  باستثناء المجموعة الأولى فقط ( المجموعة الضابطة ) هى المجموعة الوحيدة فقط التى تناولت  أقراص الميتفورمين ضمن العلاج الدوائى . وقد أظهرت نتائج الدراسة الحالية أن البنجر الأحمر المطحون مع تطبيق واتباع نظام غذائي منخفض النشويات  والبروتينات لهما تأثير إيجابي کبير في تحسين حالات تکيس المبايض ، وعلاج خلل الهرمونات ، وتنظيم حدوث الدورة الشهرية. وقد حدثت بعض حالات  الحمل والإنجاب  للمرة الأولى عند بعض النساء بعد العديد من المحاولات الطبية السابقة التى کانت قد استمرت ستة أعوام دون جدوى .