Biochemical and Molecular Actions of Nutrients

Oral Chromium Picolinate Improves Carbohydrate and Lipid Metabolism

and Enhances Skeletal Muscle Glut-4 Translocation in Obese,
Hyperinsulinemic (JCR-LA Corpulent) Rats
William T. Cefalu,1 Zhong Q. Wang, Xian H. Zhang, Linda C. Baldor
and James C. Russell*
Department of Medicine, University of Vermont College of Medicine, Burlington, VT and *Department of
Surgery, University of Alberta, Edmonton, AB, Canada

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ABSTRACT Human studies suggest that chromium picolinate (CrPic) decreases insulin levels and improves
glucose disposal in obese and type 2 diabetic populations. To evaluate whether CrPic may aid in treatment of the
insulin resistance syndrome, we assessed its effects in JCR:LA-corpulent rats, a model of this syndrome. Male lean
and obese hyperinsulinemic rats were randomly assigned to receive oral CrPic [80 ␮g/(kg 䡠 d); n ⫽ 5 or 6,
respectively) in water or to control conditions (water, n ⫽ 5). After 3 mo, a 120-min intraperitoneal glucose tolerance
test (IPGTT) and a 30-min insulin tolerance test were performed. Obese rats administered CrPic had significantly
lower fasting insulin levels (1848 ⫾ 102 vs. 2688 ⫾ 234 pmol/L; P ⬍ 0.001; mean ⫾ SEM) and significantly improved
glucose disappearance (P ⬍ 0.001) compared with obese controls. Glucose and insulin areas under the curve for
IPGTT were significantly less for obese CrPic-treated rats than in obese controls (P ⬍ 0.001). Obese CrPic-treated
rats had lower plasma total cholesterol (3.57 ⫾ 0.28 vs. 4.11 ⫾ 0.47 mmol/L, P ⬍ 0.05) and higher HDL cholesterol
levels (1.92 ⫾ 0.09 vs. 1.37 ⫾ 0.36 mmol/L, P ⬍ 0.01) than obese controls. CrPic did not alter plasma glucose or
cholesterol levels in lean rats. Total skeletal muscle glucose transporter (Glut)-4 did not differ among groups;
however, CrPic significantly enhanced membrane-associated Glut-4 in obese rats after insulin stimulation. Thus,
CrPic supplementation enhances insulin sensitivity and glucose disappearance, and improves lipids in male obese
hyperinsulinemic JCR:LA-corpulent rats. J. Nutr. 132: 1107–1114, 2002.

KEY WORDS: ● insulin ● glucose ● chromium ● lipids ● rats

Insulin resistance is a key pathophysiologic feature of type
2 diabetes and is strongly associated with coexisting cardio-
vascular risk factors and accelerated atherosclerosis (1). As a
consequence, one of the most desirable goals of treatment for
patients with type 2 diabetes is increasing insulin sensitivity in
vivo. Although energy restriction and exercise greatly improve
insulin resistance, the long-term success of dietary interven-
tion in humans is poor (2). Therefore, strategies to improve
insulin resistance by pharmacologic means or nutritional sup-
plementation represent a very attractive approach. Dietary
supplementation with chromium picolinate (CrPic)2 has been
proposed as one such nutritional intervention (3– 6). How-
ever, routine use of CrPic in subjects with diabetes is not
currently recommended, and, indeed, the most recent clinical
practice recommendations from the American Diabetes Asso-
ciation state that “chromium supplementation has no known
benefit” (2). Further, the cellular and molecular mechanisms
1
To whom correspondence should be addressed. E-mail: William.
Cefalu@uvm.edu.
2
Abbreviations used: AUC, area(s) under the curve; CrPic, chromium picoli-
nate; ECL, enhanced chemiluminescence; Glut, glucose transporter; HbA1c,
hemoglobin A1c; ITT, insulin tolerance test; IPGTT, intraperitoneal glucose toler-
ance test; JCR, LA-cp; JCR, LA-corpulent; PMSF, phenylmethylsulfonyl fluoride;
TPN, total parenteral nutrition.
by which chromium (Cr) supplementation affects insulin ac-
tion in vivo are currently unknown and an understanding of
these mechanisms would be required before firm recommen-
dations could be made regarding its routine use in the man-
agement of type 2 diabetes.
Cr use by the general public, and in diabetic patients in
particular, has surpassed our ability as a scientific community
to provide evidence regarding its safety and efficacy. Part of
the problem stems from the lack of definitive, randomized
trials because many of the earlier studies evaluating Cr use
were open-label studies and, therefore, generated substantial
bias. Additional concerns are the lack of “gold standard”
techniques to assess glucose metabolism, the use of differing
doses and formulations, and heterogeneous study populations.
As a result, a large body of conflicting data has been reported
that contributes greatly to the confusion among health care
providers regarding use of Cr.
Several lines of evidence in both rodent and human studies,
however, suggest that Cr may modulate intracellular pathways
of glucose metabolism and improve comorbidities associated
with insulin resistance (3–9). Thus, the overall objective of
this study was to evaluate the role of CrPic in improving the
clinical sequelae of the insulin resistance syndrome (e.g., dys-
lipidemia, glucose intolerance, hyperinsulinemia) by use of a
rat model of insulin resistance.

0022-3166/02 $3.00 © 2002 American Society for Nutritional Sciences.

Manuscript received 18 September 2001. Initial review completed 1 October 2001. Revision accepted 20 February 2002.

1107
1108 CEFALU ET AL.
MATERIALS AND METHODS
Study design
The effect of CrPic was assessed in the JCR:LA-corpulent (JCR:
LA-cp) rat, a strain incorporating the autosomal recessive cp gene
that induces obesity (10,11). The JCR:LA-cp rat, when homozygous
for the autosomal recessive cp gene (cp/cp), lacks membrane-bound
leptin receptors, leading to marked obesity (12). The cp/cp rats are
hyperphagic, become insulin resistant, hyperinsulinemic and hyper-
triglyceridemic, and develop advanced atherosclerotic disease as well
as myocardial lesions consistent with an ischemic origin (13,14). The
hyperinsulinemia develops rapidly after 4 wk of age, with an age at
half-maximum of 5.5 wk. Breeding is done using heterozygous rats
(cp/⫹) and yields 25% obese rats (cp/cp) and 75% lean rats [a 2:1 mix
of cp/⫹ and ⫹/⫹ referred to as ⫹/?; for review see (15)]. Hyperten-
sion does not develop in this strain, thus providing a rat model of
spontaneous cardiovascular disease that exhibits all of the aspects
seen in obese, insulin-resistant humans, including vasculopathy, but
without the confounding effects of hypertension. In addition to the
alterations in carbohydrate metabolism, a characteristic dyslipidemia
associated with elevated triglycerides and increased LDL-cholesterol
is observed (13,16).
Male cp/cp and ⫹/? rats were bred in the established JCR:LA-cp
colony at the University of Alberta as previously described (17). The
rats were maintained in a controlled environment at 20°C and
40 –50% humidity, with 12 h of light per 24-h period. Nonpurified
diet (Rodent Diet 5001, PMI Nutrition, St. Louis, MO) and tap water
were consumed by rats ad libitum. At 6 wk of age, obese (cp/cp)
insulin-resistant rats and lean normal (⫹/?) male rats were shipped to
the University of Vermont by air freight, within a 24-h period.
All procedures involving rats were conducted in strict compliance
with relevant state and federal laws, the Animal Welfare Act, Public
Health Services Policy, and guidelines established by the Institutional
Animal Care and Use Committee.
The study consisted of a 4-wk baseline phase and a 12-wk treat-
ment phase. During both the baseline and treatment phases, each
rat’s food and water intake and body weight were monitored weekly.
The rats were fed a fixed formula diet (Harlan Teklad LM-485,
Harlan Teklad, Madison, WI). The diet contained 19% crude pro-
tein, 5% crude fat, 5% crude fiber and 0.4 mg elemental Cr/kg. After
completion of the baseline assessment, rats were randomly assigned to
receive CrPic (n ⫽ 6 obese, n ⫽ 5 lean) or to the control group (n
⫽ 5 obese, n ⫽ 5 lean). The CrPic was provided in the water and, on
the basis of calculated water intake, was administered to provide an
intake of 80 ␮g/(kg body 䡠 d), corresponding to ⬃18 ␮g elemental
Cr/(kg body 䡠 d) during the treatment phase. The Cr concentration of
the water provided the control group was negligible (⬍1 ␮g/L). The
water provided the Cr-supplemented group was initially prepared as a
solution containing 3000 ␮g CrPic/L of water. The concentration of
the initial solution was 7.1 ␮mol/L, well below the reported solubility
of CrPic in water3 (0.6 mmol/L). The CrPic-supplemented water was
diluted to achieve the target Cr intake per group on the basis of
measured water intake. At the end of the treatment phase, a 120-min
intraperitoneal glucose tolerance test and a 30-min insulin tolerance
test were performed 7 d apart to evaluate carbohydrate metabolism
and lipid levels. Skeletal muscle biopsies (vastus lateralis) were ob-
tained at the end of insulin stimulation to assess glucose transporter
(Glut)-4 levels.
Analytical methods
Intraperitoneal glucose tolerance test (IPGTT). One week
before necropsy, rats underwent an IPGTT, after overnight food
deprivation (⬃10 h). An intraperitoneal glucose injection was used
to provide a rapid glucose challenge with minimal stress and without
the possible confounding effects of gavage-related esophageal trauma.
A D-glucose (500 g/L) solution was injected intraperitoneally using a
27-gauge needle at a dose of 1 g/kg body. Blood samples (0.5– 0.6 mL)
were taken at time 0 (before glucose injection) and at 30, 60, 90 and
3
The Merck Index, 12th edition.
120 min postglucose by tail cut (18). Insulin and glucose levels were
measured at each time point and the areas under the curve (AUC)
were then determined.
Insulin tolerance test (ITT). An ITT was conducted before rats
were killed. After induction of anesthesia, a baseline tail cut was
obtained, followed by intraperitoneal injection of regular insulin (5
U/kg) at time 0. Repeat tail cuts occurred at 5, 10, 15 and 30 min and
then the rat was killed. The rate of glucose disappearance [mmol/
(L 䡠 min)] was determined.
For both the IPGTT and the ITT, rats inhaled 5% halothane in
100% oxygen via a facemask for 3– 4 min at a flow rate of 1.25 L/min,
then reduced to 2% in 100% oxygen. This method of anesthesia
allows the rats to recover completely between tail cuts and has been
shown to have minimal effects on insulin and glucose levels (19,20).
Plasma was obtained at baseline, at wk 6 of treatment and at the
end of the study (12 wk) for determination of glucose and insulin
levels. A lipid profile was obtained at baseline and at wk 12 (end of
study). Glucose was determined by an enzymatic method using the
Cobs Mira autoanalyzer (Roche Biomedical, Nutley, NJ). The CV for
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the glucose assay as determined within-run and day-to-day of glucose
were 1.2 and 1.5%, respectively. Plasma cholesterol, triglyceride, and
HDL cholesterol were measured by kits (Sigma Chemical, St. Louis,
MO). The inter- and intra-assay CV were 3.5 and 4.1% for choles-
terol, 2.9 and 2.7% for triglyceride and 2.5 and 3.1% for HDL
cholesterol, respectively. Plasma insulin concentrations were ana-
lyzed by RIA kit (Incstar, Stillwater, MN); the inter- and intra-assay
CV were 3.8 and 4.5%.
Muscle biopsy. Rats were anesthetized with ventilated halo-
thane and the skin covering the lateral portion of the vastus lateralis
muscle was cleaned with alcohol. After incision, the subcutaneous
tissues were dissected down to the muscle. A bundle of vastus lateralis
muscle fibers (⬃1 g) was dissected and clamped with a forked hemo-
stat, cut, immediately put into a vial and frozen in liquid nitrogen.
The incision was covered with a sterile dressing. The ITT was then
conducted and a repeat muscle biopsy was taken at 30 min postinsulin
stimulation. Rats were killed by rapid decapitation.
Skeletal muscle fractionation and marker enzyme analyses. The
isolation of plasma and intracellular membranes from rat muscle was
performed as described by Douen (21) with minor modification.
Briefly, 1 g rat muscle was minced in 250 mmol/L sucrose, 10 mmol/L
NaHCO3, pH 7.0, containing 5 mmol/L NaN3 and 100 ␮mol/L
phenylmethylsulfonyl fluoride (PMSF). The tissue was then homog-
enized by Polytron for 5 s. The homogenate was subjected to a series
of differential centrifugation steps (1200 ⫻ g for 10 min, followed by
9000 ⫻ g for 10 min and 190,000 ⫻ for 60 min) to yield a crude
membrane pellet. The last step of purification was performed in
discontinuous sucrose gradients (25, 30 and 35% sucrose) at 100,000
⫻ g for 180 min. Membranes were collected atop each sucrose layer,
washed by 10-fold dilution in 10 mmol/L NaHCO3 (pH 7.0) and
recovered by high speed centrifugation. A marker enzyme analysis of
these membrane fractions showed that membranes obtained from the
25% sucrose fraction and from the 35% sucrose fraction had ⬎10-
and 6-fold enrichments, respectively, in the plasma membrane
marker enzyme 5⬘-nucleotidase compared with muscle homogenates.
5⬘-Nucleotidase activity was assayed as described by Brake (22).
Glut-4 content. For analysis, an aliquot of the muscle biopsy was
homogenized in 3 mL extraction buffer (1% Triton X-100, 100
mmol/L Tris (pH 7.4), 100 mmol/L sodium pyrophosphate, 100
mmol/L sodium fluoride, 10 mmol/L EDTA, 10 mmol/L sodium
vanadate, 2 mmol/L PMSF and 0.1 g/L aprotinin) at 4°C. The
extracts were centrifuged at 100,000 ⫻ g at 4°C for 45 min to remove
insoluble material and the supernatant used for the assay. Extracts,
corresponding to 50 ␮g of protein, were separated on 10% SDS-
PAGE minigels. Proteins were transferred to a nitrocellulose sheet
with 500 mA for 2 h and then blocked with 5% nonfat dry milk in
PBS for 1 h. The nitrocellulose sheets were incubated with anti-
Glut-4 antibody (Santa Cruz Biotechnology, Santa Cruz, CA) 1:200
at 4°C overnight. After washing, the sheets were incubated with
horseradish peroxidase– conjugated rabbit anti-goat immunoglobulin
G diluted 1:5000 at room temperature for 60 min. Antibody-antigen
complexes were detected by enhanced chemiluminescence and an
exposure obtained on hyperfilm-enhanced chemiluminescence (ECL)
 CHROMIUM AND INSULIN ACTION 1109

film. Glut-4 content in skeletal muscle was quantified by densitomet-

ric scanning as described previously (23).

Statistical analysis
Data were analyzed by repeated measures 2-way ANOVA using
the Scheffé F-test for post-hoc analysis. AUC for glucose tolerance
and insulin response were determined using the trapezoidal rule (24).

RESULTS
There was no effect of CrPic on daily food and water
intakes or body weights over the 90-d treatment period (Table
1). On the basis of the measured food and water intakes, the
control groups (both lean and obese) had daily elemental Cr
intakes ranging from 16 to 20 ␮g/kg. The Cr-supplemented
groups had daily elemental Cr intakes ranging from 33 to 38
␮g/kg.

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There was also no difference between treatment groups in
fasting insulin levels obtained at study initiation. However, by
wk 12, fasting insulin was lower in the CrPic-treated obese rats
than in controls; there was no effect for CrPic in lean rats (Fig.
1A). Further, there appeared to be no significant effect for
CrPic on glucose levels at wk 6 or 12 for either the lean or
obese groups (Fig. 1B). Glucose disappearance during the ITT
was significantly improved in obese rats treated with CrPic
compared with obese controls [0.0933 ⫾ 0.0006 vs. 0.0717
⫾ 0.0062 mmol/(L 䡠 min)]. In addition, glucose and insulin
AUC for the IPGTT were significantly less for obese rats
treated with CrPic compared with obese control rats (P
⬍ 0.001) (Figs. 2, 3). Lean rats treated with CrPic did not
differ from lean controls in glucose disappearance or glucose
FIGURE 1 Fasting plasma insulin (A) and glucose (B) levels in lean
AUC (data not shown). and obese JCR:LA corpulent rats that consumed water (control) or
Total Glut-4 content, assessed in the vastus lateralis muscle chromium picolinate (CrPic) for 12 wk. Values are means ⫾ SEM, n
at wk 12, did not differ between obese control or CrPic-treated ⫽ 5– 6. *Different from obese control, P ⬍ 0.001.
rats; however, membrane-associated Glut-4 was greater in
CrPic-treated rats than controls after in vivo insulin stimula-
tion (Table 2). Obese-CrPic treated rats had lower plasma
total cholesterol levels at the end of the study compared with decrease in total cholesterol and a reduced total cholesterol/
obese controls (Fig. 4). In addition, obese CrPic-treated rats HDL cholesterol ratio at the end of the study in obese rats.
had higher HDL cholesterol levels (1.92 ⫾ 0.09 vs. 1.37 CrPic did not alter total Glut-4 levels in muscle, but enhanced
⫾ 0.36 mmol/L, P ⬍ 0.001) and improved cholesterol/HDL Glut-4 translocation in skeletal muscle after insulin stimula-
ratio at wk 12 (Table 2) compared with obese controls. tion. The cellular mechanism(s) responsible for these effects
are unknown but are being evaluated.
DISCUSSION Although routine use of supplemental Cr remains contro-
versial in clinical diabetes management, it has been estab-
This study demonstrated that CrPic enhances insulin sen- lished that Cr is an essential nutrient required for normal
sitivity and glucose disappearance in a hyperinsulinemic, obese carbohydrate metabolism, as demonstrated in early studies of
rat model, yet no difference was observed in lean controls. total parenteral nutrition (TPN) in which Cr deficiency was
Further, CrPic improved lipid levels, as demonstrated by a well documented (25–27). A Cr intake of 5 ␮g/1000 kcal was

TABLE 1
Oral chromium picolinate (Cr-Pic) in JCR:LA corpulent rats that consumed water (control)
or Cr-Pic for 12 wk: weight, food, and water intake during study1

Body weight, g Food intake, g/(rat 䡠 d) Water intake, mL/(rat 䡠 d)

n Baseline 6 wk End of study Baseline 6 wk End of study Baseline 6 wk End of study

Lean Rats
Control 5 368.8 ⫾ 9.8 379.0 ⫾ 8.1 393.2 ⫾ 7.1 21.0 ⫾ 1.6 20.8 ⫾ 0.9 20.0 ⫾ 0.6 25.3 ⫾ 1.4 26.6 ⫾ 1.0 23.5 ⫾ 0.9
CrPic 5 374.2 ⫾ 9.5 392.0 ⫾ 10.1 413.6 ⫾ 6.8 21.5 ⫾ 1.3 21.1 ⫾ 0.6 20.0 ⫾ 0.3 26.1 ⫾ 0.5 27.7 ⫾ 1.0 26.0 ⫾ 0.6
Obese Rats
Control 5 644.4 ⫾ 21.9 695.0 ⫾ 23.1 737.5 ⫾ 24.2 28.6 ⫾ 1.6 29.6 ⫾ 1.0 29.8 ⫾ 1.1 35.6 ⫾ 1.6 37.6 ⫾ 1.8 35.7 ⫾ 0.7
CrPic 6 629.6 ⫾ 13.0 679.0 ⫾ 17.3 733.8 ⫾ 14.5 25.2 ⫾ 1.5 27.8 ⫾ 1.1 28.3 ⫾ 0.6 24.4 ⫾ 1.5 32.6 ⫾ 1.9 31.2 ⫾ 1.8

1 Values are mean ⫾ SEM.

1110 CEFALU ET AL.

TABLE 2
Oral chromium picolinate (Cr-Pic) in JCR:LA corpulent rats
that consumed water (control) or Cr-Pic for 12 wk: lipids and
membrane-associated glucose transporter (Glut)-41

Membrane-
Cholesterol/HDL cholesterol associated
ratio Glut-42

n Baseline End of study End of study

Lean rats
Control 5 1.76 ⫾ 0.04 1.88 ⫾ 0.02 137.2 ⫾ 7.6
FIGURE 2 Insulin response of JCR:LA corpulent rats that con- CrPic 5 1.70 ⫾ 0.05 1.76 ⫾ 0.10 132.8 ⫾ 3.9
sumed water (control) or chromium picolinate (CrPic) for 12 wk to Obese rats
intraperitoneal glucose tolerance test (IPGTT) as assessed with area Control 5 2.51 ⫾ 0.18 3.19 ⫾ 0.35 93.8 ⫾ 6.9
under the curve (AUC). Values are means ⫾ SEM, n ⫽ 5– 6. *Different CrPic 6 2.56 ⫾ 0.22 1.86 ⫾ 0.10* 142.4 ⫾ 6.0**
from obese control, P ⬍ 0.001.

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shown to deplete subjects and was associated with hypergly-
cemia, hyperinsulinemia, insulin resistance and increased ex-
ogenous insulin need. The addition of Cr to the TPN solutions
markedly improved glycemic status and greatly reduced insulin
requirements; therefore, Cr is now routinely added to TPN
solutions (26). Although Cr replacement in individuals sub-
jected to TPN in early studies ameliorated specific symptoms
thought to be representative of a Cr-deficient state, the role of
Cr supplementation in enhancing glucose metabolism in sub-
jects not likely to be Cr deficient is an area of great controversy
in the clinical management of diabetic patients.
Several valence states exist for Cr; the most prevalent
oxidation states are trivalent Cr, a stable and biologically
active form, and hexavalent Cr, the state associated with
industrial exposure and toxicity. Trivalent Cr is available in
the chloride or picolinate salt form or in an organic complex
with nicotinic acid and amino acids. Absorption of trivalent
Cr is low, and there appears to be little storage in tissues
(although it concentrates in liver, spleen, kidney and bone)
because most is rapidly excreted in the urine, with excretion
increasing as a result of a glucose load (28,29). As a result, a
major limitation of assessing Cr status in biological tissues is
analytical, due to the extremely low levels of Cr in these
1 Values are means ⫾ SEM; * P ⬍ 0.05 vs. control; ** P ⬍ 0.01 vs.
control.
2 ASU (arbitrary scanning units), postinsulin stimulation.
tissues. Other limitations include availability of techniques,
cost, interference from sample matrix and specimen contam-
ination (30 –36).
However, despite inherent problems with Cr assessment,
recent studies have demonstrated successful determination of
plasma Cr. Davies et al. (37) reported that Cr levels diminish
with age; in ⬎40,800 patients aged 1 to ⬎75 y, Cr levels in
hair, sweat and blood diminished significantly with age, with
values decreasing 25– 40% depending on the tissue of interest.
In addition, it has been reported that diabetic subjects may
have altered Cr metabolism because both absorption and ex-
cretion were higher than in nondiabetic subjects (4,29). Hair
and blood Cr levels are reported to be lower in diabetic
subjects; Morris et al. (5) reported that mean levels of plasma
Cr were ⬃33% lower in 93 type 2 diabetic subjects compared
with controls. Ding et al. (38) reported that Cr levels were
reduced ⬎50% in 57 diabetic subjects compared with 55
control subjects. Ekmekcioglu et al. (39) confirmed the obser-
vations of Ding et al. by evaluating Cr concentrations in

FIGURE 3 Plasma glucose response of obese JCR:LA corpulent
rats that consumed water (control) or chromium picolinate (CrPic) for 12
wk to intraperitoneal glucose tolerance testing. Values are means
⫾ SEM, n ⫽ 5– 6. Plasma glucose was lower in treated rats at each time
point , P ⬍ 0.0001.
FIGURE 4 Total plasma cholesterol levels in lean and obese
JCR:LA corpulent rats that consumed water (control) or chromium
picolinate (CrPic) for 12 wk for each treatment group over the course of
study. Values are means ⫾ SEM, n ⫽ 5– 6. *Different from obese control,
P ⬍ 0.01.
 CHROMIUM AND INSULIN ACTION 1111

different hematological matrices in 53 subjects with type 2
diabetes compared with 50 controls; they reported significantly
lower Cr levels in the plasma of the diabetic subjects compared
with the nondiabetic healthy controls. In contrast, Zima et al.
(40) suggested no alteration of Cr levels in type 2 diabetes;
however, only 11 subjects with type 2 diabetes were compared
with 19 healthy controls. If clinical states such as diabetes are
truly shown to be associated with diminished Cr levels, and if
supplementation generally leads to an increase in Cr concen-
tration, it is possible that diabetic patients may have inade-
quate dietary Cr intake. However, this area remains contro-
versial because studies demonstrating an inadequate Cr intake
in subjects with diabetes are not available.
The controversy surrounding Cr as an adjunctive treatment
in diabetes stems in large part from conflicting data reported in
previous studies of subjects with impaired glucose tolerance or
diabetes in which the diets were supplemented with Cr in an
metabolism; they used differing doses and formulations, eval-
uated heterogeneous study populations and had widely varying
periods of observation. Indeed, one study by Ravina et al. (42)
suggested an effect that was observed after only 7 d of admin-
istration. Thus, the many confounders make these studies
difficult to interpret when trying to suggest a consistent effect
of supplemental Cr on human carbohydrate metabolism. It
appears, however, that studies that specifically evaluated ⱕ200
␮g of Cr as Cr chloride (CrCl) did not elicit a clinical response
in subjects with type 2 diabetes (Table 3), whereas a more
consistent clinical response was observed with daily supple-
mentation of Cr ⬎200 ␮g/d for a duration of at least 2 mo. In
addition, other forms of Cr, especially CrPic, appeared to be
more bioavailable and clinically more effective than CrCl in
both human and rat studies (43).
Anderson et al. (4) provided evidence for a dose effect of
CrPic in a study of Chinese type 2 diabetic subjects. Short- (2

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effort to demonstrate an effect on carbohydrate metabolism.
Table 3 provides an overview of many of the human studies
reported and demonstrates that considerable differences in
efficacy were noted, contributing greatly to the present day
confusion among health care providers regarding routine use of
Cr in patients with diabetes. Specifically, many of the reported
studies were open label without adequate control groups (des-
ignated as “OL” in Table 3) and thus generated substantial
bias. Additional concerns were that overall nutritional status
was not reported, nor was Cr intake from diet evaluated. For
the latter concern, it may be difficult to assess dietary Cr
intake because currently available software (e.g., Food Proces-
sor 7.5, ESHA Research, Salem, OR) may have Cr content
values for ⬍5% of foods. Therefore, Cr intake for these studies
was assessed primarily with supplementation. Most of the
studies did not use “gold standard” techniques to assess glucose
mo) and long-term (4 mo) efficacy were observed, as evi-
denced by reductions in fasting and 2-h glucose and insulin
concentrations, and long-term reductions in hemoglobin A1c
(HbA1c) concentrations utilizing varying doses of CrPic (200
or 1000 ␮g). The effectiveness of the 1000-␮g dose in the
Chinese study agrees with the effective dose observed in our
human trial (3). In a more recent study, Anderson et al. (44)
evaluated antioxidant and glycemic effects in Tunisian adults
with type 2 diabetes. The amount of Cr given (400 ␮g/d), was
similar to previous studies, but the formulation was different
(Cr pidolate as opposed to CrPic). Although they reported a
significant antioxidant effect, no statistically significant effect
was seen on glycemia in either the zinc/Cr-supplemented
group or the Cr-supplemented group, despite a drop in mean
HbA1c of 0.9 and 1.0%, respectively. Anderson reported that
the discrepancy in response to Cr may be dependent upon the

TABLE 3
Effect of chromium supplementation on carbohydrate metabolism in humans1

Results
Study Study
Reference type duration Dose (␮g) Subjects n Technique assessed Glucose Insulin HbA1c IS

Studies using CrCl formulation

Trow (56) OL 2 mo 100 Type 2 12 OGTT — — NA NA
Sherman (57) DB 4 mo 150 Type 2; 1; NonDM 14 OGTT — NA NA NA
Rabinowitz (41) DB 4 mo 150 Type 1; Type 2 43 Meal challenge — — NA NA
Uusitupa (58) DB 6 mo 160 IGT, Elderly 26 OGTT — — — NA
Uusitupa (59) DB 6 wk 200 Type 2 DM 10 OGTT, HbA1c — 2 — NA
Potter (60) OL 3 mo 200 IGT 5 Hyperglycemic clamp — — — 12
Mossop (61) DB 3 mo 600 Type 1; Type 2 26 FBG 2 NA NA NA
Nath (62) OL 2 mo 500 Type 2 12 OGTT 2 2 NA NA
Glinsmann (63) OL 18–133 d 180–3000 Type 1; Type 2 6 IVGTT, OGTT 2 NA NA NA
Amato (54) DB 2 mo 1000 NonDM, Elderly 19 Minimal model — — NA —
Wilson (45) DB 3 mo 220 NonDM, Young 26 FBG/insulin — 23 NA NA
Studies using CrPic formulation
Evans (64) DB 42 d 200 Type 2 11 FBG, HbA1c 2 NA 2 NA
Lee (51) DB 2 mo 200 Type 2 30 FBG, HbA1c — NA — NA
Ravina (65) OL 10 d 200 Type 1; Type 2 48/114 Insulin tolerance, HbA1c NA NA 2 1
Anderson (4) DB 4 mo 200, 1000 Type 2 180 OGTT, HbA1c 2 2 2 NA
Cefalu (3) DB 4, 8 mo 1000 Obese, NonDM 29 Minimal model — 2 NA 1
Jovanovic (66) DB 2 mo 320, 640 Gest DM 20 OGTT, HbA1c 2 2 — NA
Ravina (42) OL 1–7 d 600 DM 3 FBG 2 NA NA NA
Morris (67) OL 3 mo 400 Type 2 5 Insulin tolerance, HOMA — 2 NA 1
Cheng (68) OL 1–10 mo 500 Type 2 833 Fasting, postmeal 2 NA NA NA

1 Abbreviations used: DB, double blind; DM, Diabetes Mellitus; FBG, fasting plasma glucose; HbA1c, hemoglobin A1c; HOMA, homeostasis model
assessment; IGT, impaired glucose tolerant; IS, insulin sensitivity; IVGTT, intravenous glucose tolerance test; NA, not assessed; OGTT, oral glucose
tolerance test; OL, open label; 2, decreased; 1, increased; —, no change.
2 ␤-cell sensitivity to glucose.
3 In hyperinsulinemic patients only.
1112 CEFALU ET AL.
form (pidolate vs. picolinate), duration of diabetes and status
of subjects (44).
Our data suggest a role for supplemental CrPic in obese,
insulin-resistant states because CrPic improved glucose toler-
ance and insulin levels in obese rats but not in lean controls.
It is not known whether the obese JCR:LA-cp rat is Cr
deficient; thus, a limitation of this study is the lack of blood or
urine Cr levels in the rats. A very important question would be
whether blood Cr status could have explained the differences
in the responses to Cr supplementation between lean and
obese rats; if so, it would suggest an abnormality in the insulin
signaling cascade in obesity that appears to be overcome with
Cr supplementation. Whether hyperinsulinism, insulin resis-
tance and/or obesity, therefore, play a role in Cr metabolism
and/or excretion is an interesting question suggested by the
present studies. Such an observation may also explain in part
the reported discrepancies in response to CrPic in humans (see
Table 3).
Our observations in this rat model are in agreement with
the limited human data, which suggest that Cr has a more
predictable response in hyperinsulinemic or obese states
(45,46) Wilson et al. (45) reported that Cr had no effect in
reducing insulin levels in healthy young subjects, but had a
positive effect in those subjects with elevated fasting insulin
levels. In addition, Morris et al. (46) used insulin and glucose
infusions to demonstrate an inverse relationship in humans
between plasma insulin levels and plasma Cr levels under
conditions in which plasma glucose was unchanged. These
studies strengthen the association between Cr and insulin
action and support our approach of characterizing both the
phenotype and metabolic conditions when assessing the role of
adjunctive use of Cr.
Thus, subject phenotype, i.e., body fat distribution, may be
an important parameter in predicting a consistent effect of Cr
and is a very relevant area of human investigation. In human
studies, it has been clearly demonstrated that central obesity
and, in particular, an increase in visceral or intra-abdominal
fat is related to insulin resistance (3,47,48) and interventions
that reduce visceral fat, i.e., energy restriction, markedly im-
prove resistance (49). However, we have evidence in humans
that demonstrates an effectiveness of Cr at 1000 ␮g/d provided
as CrPic in improving insulin sensitivity without a change in
body fat distribution (3). Although no effect on total body
weight was observed in the present study of the JCR rat, the
effect on body fat distribution was not addressed.
The dose of supplemental Cr used in this rat study should
be put in perspective. For example, recently established
adequate intake of Cr for men was suggested to be 35 ␮g/d
(50). Assuming an average 75 kg body mass, this would relate
to an intake of ⬃0.47 ␮g/kg. In our recent human trial, we
demonstrated improved insulin sensitivity with 1000 ␮g/d of
Cr as CrPic (3) and, given the range of body weights of
subjects, intake of Cr ranged from 10 to 13 ␮g/kg. Other
human trials have demonstrated a response at much lower Cr
intakes (4). On the basis of the measured food and water
intakes, rats treated with Cr in this study were receiving twice
as much elemental Cr from the water as from the diet and had
a total approximate daily intake of ⬎30 ␮g/kg. Thus, the rats
in this study received supplemental Cr at levels greater than
those observed to be effective in our human trials and that
could be considered a pharmacologic dose.
Our data also demonstrate that supplemental CrPic may
improve lipid levels because we observed decreased plasma
total cholesterol, increased HDL cholesterol and an improved
cholesterol/HDL cholesterol ratio in obese rats treated with
CrPic. This observation has been noted in some, but not all
human trials with supplemental Cr (4,51–53), i.e., in studies of
type 2 diabetic subjects, Anderson et al. (4) noted a significant
drop in cholesterol levels, and Lee et al. (51) observed a 17%
drop in triglyceride levels. Other reported human studies
showed no significant effects on lipids with Cr nicotinic acid
(200 ␮g) or CrPic (1000 ␮g) supplementation (53,54). Ben-
eficial effects on lipids were also demonstrated in rats given a
synthetic, functional biomimetic Cr compound parenterally
(52). Whether the improvement in lipid levels is secondary to
improvements in insulin levels per se or a direct effect of Cr on
lipid metabolism, is currently unknown. However, there re-
main interspecies differences in response to dietary changes
between rodent and human studies, and this effect on lipids,
before being extrapolated to human studies, will have to be
evaluated specifically in human trials.
Despite recognition of a specific Cr-deficient state, Cr re-
mains the only essential transition metal whose mechanism of
Downloaded from jn.nutrition.org at GlaxoSmithKline Enterprise Licence on May 4, 2011
action is not known. Recent studies, however, have shed light
on the potential mechanism by which Cr may help to main-
tain proper carbohydrate metabolism at a molecular level. It
has been demonstrated that a naturally occurring oligopeptide,
low-molecular-weight Cr-binding substance (termed “chro-
modulin”), binds chromic ions in response to an insulin-
mediated chromic ion flux, and the metal-saturated oligopep-
tide then binds to an insulin-stimulated insulin receptor,
activating the receptor’s tyrosine kinase activity as much as
eightfold in the presence of insulin (8,9,55). Thus, chromodu-
lin appears to play a role in an autoamplification mechanism in
insulin signaling and provides new insights into how insulin
action can be enhanced with Cr supplementation (55). In-
creased insulin signaling would be expected to enhance the
regulated movement of Glut-4 and, subsequently, enhance
glucose disposal. Thus, we evaluated for changes in Glut-4
content and translocation in this rat study. Although skeletal
muscle Glut-4 content was not affected, an enhanced Glut-4
translocation was observed in the obese rats, as demonstrated
by an increase in membrane-associated Glut-4 content after
insulin stimulation. The upstream cellular signals responsible
for the enhanced translocation (i.e., enhanced insulin receptor
substrate phosphorylation, increased phosphatidyl inositol-3,
Akt activity) are currently being evaluated.
In summary, this study has confirmed previous reports dem-
onstrating a favorable effect of supplemental Cr in humans and
suggests that Cr supplementation in obese insulin-resistant
states may improve insulin action. Further, the improvement
in insulin sensitivity resulted in significant improvement in
lipid levels. These physiologic improvements occurred without
differences in body weight between treatment groups, suggest-
ing a direct effect of CrPic on insulin action. Although insulin
signaling was not assessed in this study, improvement in cel-
lular insulin signaling was suggested by enhanced Glut-4 trans-
location after insulin stimulation. These findings will have to
be confirmed in human trials with mechanistic aims before
definitive recommendations can be made.
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