Journal of Functional Foods 98 (2022) 105284

Contents lists available at ScienceDirect

Journal of Functional Foods

journal homepage: www.elsevier.com/locate/jff

Efficacy and safety of Pueraria lobata radix and Pueraria thomsonii radix for
patients with mild dyslipidemia: A randomized, double-blind,
placebo-controlled trial
Xu Zhou a, Jianwei Yu b, Qing Wan c, Wei Wang c, Xinyu Yu c, Jianyu You d, Hui Ouyang e,
Xiaofan Chen a, Yuan Cong d, Shuailiang Huang d, Jianchun Song f, Kaimin Zhu f,
Yongmei Guan g, *, Weifeng Zhu a, *
a
Evidence-based Medicine Research Center, Jiangxi University of Chinese Medicine, Nanchang 330004, China
b
Department of Scientific Research, the Affiliated Hospital of Jiangxi University of Chinese Medicine, Jiangxi 330006, China
c
Department of Preventive Treatment of Disease, Nanchang Hongdu Hospital of Chinese Medicine, Jiangxi 330006, China
d
Graduate School, Jiangxi University of Chinese Medicine, Nanchang, 330004, China
e
National Pharmaceutical Engineering Center for Solid Preparation in Chinese Herbal Medicine, Jiangxi University of Chinese Medicine, Nanchang 330004, China
f
Song’s Ge Ye Co., Ltd., Shangrao 334200, China
g
Key Laboratory of Modern Preparation of Traditional Chinese Medicine under Ministry of Education, Jiangxi University of Chinese Medicine, Nanchang 330004, China

A R T I C L E I N F O A B S T R A C T

Keywords: This randomized, double-blind trial assessed the efficacy and safety of Pueraria lobata radix (PLR) and Pueraria
Pueraria lobata radix thomsonii radix (PTR) for dyslipidemia. We randomly assigned 174 patients with mildly elevated low-density
Pueraria thomsonii radix lipoprotein cholesterol (LDL-C) levels to receive 15 g/day PLR, PTR, or a placebo for 12 weeks. Changes in
Dyslipidemia: Randomized controlled trial
baseline LDL-C levels after PLR or PTR treatments compared with placebo treatment were not significant. High-
Edible and medicinal plant
density lipoprotein cholesterol (HDL-C) levels increased more significantly after PLR treatment than placebo
treatment (+3.05 mg/dl, 95 % confidence interval = 0.75–5.35), whereas this effect was not observed for PTR
treatment. Regarding PLR treatment, increases in HDL-C levels were mainly observed in the female, >50 years
old, and nondrinker subgroups. The treatments did not show significant effects on other outcomes. No PLR- or
PTR-related adverse events were reported. Given its effect on HDL-C, daily consumption of PLR, but not PTR,
may represent an edible, medicinal remedy to manage dyslipidemia.

1. Introduction the global burden of disease related to suboptimal LDL-C levels was
94.92 million disability-adjusted life years (3.8 % of all DALYs) in 2017,
Dyslipidemia is a common metabolic disorder that manifests as an accounting for 4.32 million deaths (7.7 % of global mortality) (Mattiuzzi
elevation of low-density lipoprotein cholesterol (LDL-C), total choles­ et al., 2020). In the United States, 73.5 million or 31.7 % of adults suffer
terol (TC), or triglycerides (TGs) or a reduction in high-density lipo­ from high LDL-C, and only 48.1 % of them receive LDL-C-lowering
protein cholesterol (HDL-C). According to the estimates of the World therapy (Ibrahim et al., 2022). Therefore, the appropriate manage­
Health Organization, the global prevalence of elevated TC levels is 39 % ment of dyslipidemia, especially high LDL-C levels, is becoming
among people over 25 years of age (Pirillo et al., 2021). In developing increasingly necessary.
countries, such as China, the prevalence is also high; a survey including Currently, statins are the first-line drugs for dyslipidemia and have
a million samples showed that 33.8 % of Chinese adults suffered from been demonstrated to be effective for preventing CVDs and all-cause
dyslipidemia (Lu et al., 2021). Dyslipidemia, especially elevated plasma mortality (Taylor et al., 2013). However, the sole use of statins to
LDL-C levels, is considered a major risk factor for cardiovascular dis­ manage dyslipidemia is associated with several limitations. According to
eases (CVDs), the leading cause of death worldwide (Ference et al., a network meta-analysis of 181 trials, even at a dose of>40 mg/day, the
2017). A survey based on the Global Health Data Exchange revealed that average reductions in LDL-C and TC with statin therapy are limited to

* Corresponding authors.
E-mail addresses: 20081015@jxutcm.edu.cn (Y. Guan), zwf0733@163.com (W. Zhu).

https://doi.org/10.1016/j.jff.2022.105284
Received 8 August 2022; Received in revised form 7 October 2022; Accepted 9 October 2022
Available online 11 October 2022
1756-4646/© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
X. Zhou et al. Journal of Functional Foods 98 (2022) 105284

− 47.1 to − 66.9 mg/dl and − 27.3 to − 60.82 mg/dl, respectively; all 2. Materials and methods
kinds of statins do not effectively increase HDL-C levels (Naci et al.,
2013). There are also safety concerns regarding statins, particularly the 2.1. Study design
potential damage to the muscles and liver (Adhyaru et al., 2018). In
addition, long-term use of statins is associated with an increased risk of This study was designed as a multicenter, randomized, double-blind,
new-onset diabetes, hemorrhagic stroke, and cognitive impairment placebo-controlled trial. At a 1:1:1 ratio, 174 patients with mild dysli­
(Adhyaru & Jacobson, 2018). These limitations impact patient adher­ pidemia recruited from two tertiary hospitals (the Affiliated Hospital of
ence and efficacy (Bates et al., 2009). In fact, a large number of patients Jiangxi University of Chinese Medicine and Nanchang Hongdu Hospital
with dyslipidemia do not have well-controlled lipid levels. For example, of Traditional Chinese Medicine) were randomly assigned to receive
only 42.9 % of Chinese people at high risk for atherosclerotic CVD daily treatment with PLR, PTR, or a placebo for 12 weeks. This study is
exhibit ideal LDL-C control, and this proportion is even lower (26.6 %) described based on the Consolidated Standards of Reporting Trials
for people with established atherosclerotic CVD (Lu et al., 2021). (CONSORT) statement (Schulz et al., 2010) (Supplementary file 1).
Therefore, it is imperative to explore complementary and alternative
therapies for the management of dyslipidemia. 2.2. Ethics approval and registration
In China, the application of edible and medicinal plants to manage
metabolic diseases has a long history and is widely accepted among the The RCT was approved by ethics committees at both research hos­
public (Song and Jiang, 2017). The roots of Pueraria lobata (Wild.) Ohwi pitals (see ethics approval documents in Supplementary file 2). All pa­
(Pueraria lobata radix; PLR; Chinese name “Gegen”) and Pueraria tients provided written informed consent prior to participation with a
thomsonii Benth (Pueraria thomsonii radix; PTR; Chinese name “Fenge”) full understanding of the study details and potential merits and harms.
are ancient and representative species. PLR and PTR are both legumi­ Patients can actively withdraw from the trial at any point for any reason.
nous vines native to Southeast Asia (Wong et al., 2011) and were once The study protocol is registered at Clinicaltrials.gov (registration no.
considered the same species “Pueraria radix” in China due to the limi­ NCT04861376).
tations of early chemical differentiation methods. In fact, PTR and PLR
contain many similar compound components, but in significantly 2.3. Subjects
different proportions (e.g., PLR contains 11 times more puerarin than
PTR (Wong et al., 2015)); therefore, the 2005 edition of the Chinese Patients who intended to participate in the trial were evaluated for
Pharmacopoeia began to separate them into two different monographs eligibility by clinicians. Adult dyslipidemic patients who suffered mildly
to ensure their quality, safety, and efficacy (Wong et al., 2011). elevated LDL-C levels were eligible for participation in the RCT. Eligible
In Chinese traditional medicine, PLR and PTR are usually used to patients exhibited LDL-C levels between 131.5 and 189.5 mg/dl (3.4 and
treat diseases that manifest as weight loss and thirst (i.e., diabetes in 4.9 mmol/L) as demonstrated by serological screening. This range is
modern medicine) (Wang et al., 2022; Yang et al., 2019). Several studies above the upper limit of normal but below the threshold for being
have also shown that puerarin can lower blood glucose levels, demon­ considered a high risk to develop atherosclerotic CVD and requiring
strating its ability to regulate metabolism (Chen et al., 2018; Zeng et al., pharmacologic intervention as defined by Chinese guidelines (Chinese
2006). In recent years, PLR and PTR have increasingly been used for Medical Association, 2019). To improve patient-level heterogeneity and
lipid regulation. The effect was first discovered in patients with dysli­ overall patient compliance, patients’ ages were restricted to<80 years.
pidemia treated with herbal formulas containing PLR, such as Gegen Patients were excluded if they met any of the following conditions: 1)
Qinlian Decoction composed of PLR, Scutellariae radix, Coptidis rhizoma, dyslipidemia secondary to other diseases (e.g., hypothyroidism) or
and Glycyrrhizae radix et Rhizoma Praeparata cum Melle and Danshen medications (e.g., long-term use of glucocorticoids); 2) pregnant or
Gegen Decoction composed of PLR and Salvia miltiorrhiza Bunge (Cheung breastfeeding; 3) history of allergy to PLR or PTR; 4) severe liver or
et al., 2017; Kwok et al., 2014; Xu et al., 2021). By analyzing these kidney dysfunction, obviously abnormal electrocardiogram, severe
formulas, researchers found that PLR may play an important role in lipid mental disorders, or malignancies; 5) taking drugs or diet supplements
regulation. Animal experiments further showed that the components of with lipid-regulating effects (e.g., statins) within one week; or 6) un­
puerarin, flavonoids, and polysaccharides in PLR may have a lipid- willingness to provide personal information or expected to have poor
regulating effect (Kan, 2019; Luo et al., 2021). compliance.
In addition to medicinal uses, PLR and PLR are also legal edible
plants in China, so they can be used in diets or as a food additive (Chi­ 2.4. Randomization and blinding
nese Ministry of Health, 2002). Thus, the daily consumption of PLR or
PLR may represent a safe option for long-term complementary man­ We generated blocked random sequence numbers with permuted
agement or as an alternative to statins in patients with dyslipidemia if blocks of sizes 3 or 6 using the “blockrand” package in the R program
their lipid-regulating effects are established. However, given obvious (Ross Ihaka, Robert Gentlemen, New Zealand). An independent
differences in dosage, form, and preparation methods between the randomization center was in charge of labeling packages of PLR, PTR, or
edible and medicinal uses, the above evidence of medicinal use cannot placebo sequentially according to the random sequence and consecu­
prove the lipid-regulating effects of daily consumption of PLR. In addi­ tively assigning the trial samples to the patients according to the label
tion, evidence from the PLR studies cannot be generalized to PTR given number. As a result, patients, clinicians, and outcome assessors do not
the wide variation in the proportion of components. have access to information indicating the group assignment of the next
To date, there is a lack of high-quality evidence on PLR and PTR for patient. During the trial, the patients, clinicians, and outcome assessors
dyslipidemic populations, which limits their clinical and dietary uses. are blinded. A procedure was developed to unblind the random number
Therefore, we conducted a randomized placebo-controlled trial (RCT) to if a serious adverse event (SAE) occurred, but no patients were un­
separately evaluate the efficacy and safety of a 12-week daily PLR and blinded during the trial.
PTR treatment for the management of patients with mild dyslipidemia.
To ensure ethical compliance and to reduce patient-level heterogeneity, 2.5. Intervention
we only focused on patients with mildly elevated LDL-C levels.
Patients in the PLR group, the PTR group, and the placebo group
received PLR, PTR, or a placebo for 12 weeks at a dose of 15 g/day,
respectively. PLR and PTR were purchased from Jiangxi Jiangzhong
Traditional Chinese Medicine Decoction Pieces Co., ltd. and were

2
X. Zhou et al. Journal of Functional Foods 98 (2022) 105284

identified as authentic by Professor Ge Fei of Jiangxi University of 2.7. Primary outcome

Chinese Medicine. The origin of PLR was Qinling City, Shaanxi Province,
and the origin of PTR was Teng County, Guangxi Province. All trial The primary outcome was the change in LDL-C levels from baseline
samples were prepared granules that could be taken orally or after at week 12 assessed by a Hitachi 7180 biochemistry automatic analyzer.
brewing in 100 ml of water and were packaged in the same bag with the
same labeling and color. The PLR and PTR granules were prepared by 2.8. Secondary outcomes
decoction and extraction of dried PLR and PTR followed by concentra­
tion and drying. The placebo granules were produced by mixing lactose, 1. Changes in LDL-C levels from baseline at week 4 and changes in HDL-
caramel pigment, sunset yellow and essence. There were minor differ­ C, TC, and TG levels at weeks 4 and 12, assessed by a Hitachi 7180
ences in taste among PLR, PTR, and placebo granules that were difficult biochemistry automatic analyzer;
to distinguish. All granules were manufactured by Jiangxi Baishen 2. Severity of symptoms related to dyslipidemia assessed by a validated
Pharmaceutical Co., ltd, a Good Manufacturing Practice-certified Constitution in Chinese Medicine Questionnaire for phlegm damp­
manufacturer. The results of the chemical composition tests of the ness (Bai et al., 2022): the scale assesses eight aspects of symptoms,
samples are presented in Supplementary file 3. During follow-up, pa­ including eyelid edema, sticky mouth, abundance of phlegm in the
tients were required not to use any other medications or dietary sup­ throat, chest or abdominal stuffiness, heavy or lethargic body, oily
plements that may affect lipid metabolism. If such medications or forehead and/or T-zone, flabby abdomen, and thick tongue coating.
supplements were used, patients were asked to report it truthfully, and The severity of each item is divided into five ranked categories with
use of these substances did not affect their continued participation in the scores of 1–5 points. The total score was the sum of the points for all
study. Patients were allowed to take treatments not stipulated in the items (range: 8–40). A higher score indicated more severe symptoms.
exclusion criteria for comorbidities (e.g., hypotensive drugs for The details of the scale are presented in Supplementary file 4.
hypertension). 3. Changes in systolic blood pressure (SBP) and diastolic blood pressure
(DBP) measured by an Omron fully automatic blood pressure
2.6. Outcomes monitor HBP-9030, fasting blood glucose (FBG) by a Hitachi 7180
biochemistry automatic analyzer, and body mass index (BMI) were
Based on the funding budget, we scheduled three patient visits, assessed at weeks 4 and 12; and
including one visit at baseline and one visit each at weeks 4 and 12 4. Safety, including any adverse events (AEs), SAEs, treatment-related
(Fig. 1), with a visit time window of ± 3 days. The visits at week 4 and AEs, and withdrawal due to AEs: AEs are defined as obvious
week 12 were designed to observe the short-term and long-term efficacy abnormal values in laboratory examinations and doctor-observed
and safety, respectively, of PLR and PTR for dyslipidemia. At baseline, and patient-reported AEs. We performed routine blood, urine, and
we collected patient demographics, comorbidities, and medication his­ stool examinations (tested by a Mindray BC-6800 plus auto 5-diff
tory. The following outcomes were assessed at all visits. hematology analyzer, a URIT-1600 fully automatic urinanalysis
workstation, and a Keyu KU-F10 Full Automatic feces analyzer,
respectively), coagulation tests (prothrombin time, activated partial
thromboplastin time, thrombin time, and fibrinogen tested using a

Fig. 1. Schedule of study visits. Abbreviation: ALT, alanine transaminase; APTT, activated partial thromboplastin time; AST, aspartate aminotransferase; BUN,
blood urea nitrogen; FIB, fibrinogen; PLR, Pueraria Lobata Radix; PT, prothrombin time; PTR, Pueraria Thomsonii Radix; Scr, serum creatinine; TBIL, total bilirubin;
TT, thrombin time.

3
X. Zhou et al. Journal of Functional Foods 98 (2022) 105284

Sysmex CS-5100 superb hemostasis analyzer), and liver and kidney interactions were considered the main effects. Sex, age, and drinking
function tests (alanine transaminase, aspartate aminotransferase, were considered fixed-effect covariates, and the subjects’ IDs and study
total bilirubin, serum creatinine, and blood urea nitrogen tested sites were considered random-effect covariates. We used the least
using a Hitachi 7180 biochemistry automatic analyzer) to identify squares mean differences and 95 % confidence intervals (CIs) as the
any abnormal values. SAEs are those AEs that lead to hospital effect measures. To explore differences in effects on serum lipid out­
admission, prolong the length of hospital stay, require transfer to the comes between patients with different characteristics, we performed the
intensive care unit, or cause disability, life-threatening illness, or following subgroup analyses: 1) male versus female, considering the
death. Treatment-related AEs were judged by clinicians according to potential differences in lipid metabolism profiles by gender (Magkos and
the principles proposed by Edwards et al (Edwards and Aronson, Mittendorfer, 2009); 2) < 50 versus ≥ 50 years old, considering that
2000). lipid metabolism may be altered around the age of 50 years (Liu and Li,
2015) and that Chinese women generally experience menopause around
2.9. Quality control age 50 (L. Li et al., 2012); and 3) drinkers vs nondrinkers, considering
the potential impacts of alcohol consumption on lipid metabolism levels
A steering committee consisting of cardiovascular specialists, endo­ (Jeon and Carr, 2020). The boundary of statistical significance was not
crinologists, dietitians, herbologists, statisticians, and directors in the adjusted (i.e., a p value<0.05 indicated a statistically significant
study hospitals was established for developing standard operating pro­ difference).
cedures (SOPs), organizing implementation, and monitoring the study
quality. Each study site was staffed with a physician and two clinical 3. Results
coordinators. They were responsible for prescribing examinations and
conducting one-on-one patient reception (e.g., asking questions, col­ 3.1. Patient recruitment and follow-up
lecting biological samples, and distributing study samples) after being
trained with SOPs. To enhance compliance, all enrolled patients un­ We recruited the first patient on June 5, 2021, and recruitment
derwent a regular medical examination at the two research hospitals and ended on November 4, 2021. On January 22, 2022, all patients had
volunteered to participate in the study after learning all about the study completed the 12 weeks of treatment and follow-up. During follow-up,
rationale and schedule. Their long-term partnership and trust with five patients in the PLR group, six in the PTR group, and six in the
physicians and their interest in the study represent core factors in placebo group dropped out, resulting in an attrition rate of 9.8 %. There
maintaining their compliance with the study protocol. We also provided were no significant differences in attrition rate or reasons for loss to
a 100 China Yuan traffic subsidy to the patients for each visit, and the follow-up between the two groups (all p > 0.05). All patients had at least
study samples and examinations were provided free of charge. The one visit after randomization, so the full analysis set based on the
collected data were stored in paper copies. Two coordinators entered the intention-to-treat principle included all 58 patients in each group. The
data into a Microsoft Access database independently and in duplicate, recruitment and follow-up process are presented in Fig. 2.
and data were cross-checked to ensure correct entry.
3.2. Baseline characteristics
2.10. Sample size estimation
The baseline characteristics are presented in Table 1. Overall, the
The trial used a superiority design. The following formula for sample female:male ratio was approximately 1:1.5. Most patients are married
size estimation was employed: with a junior college or higher education level. No statistically signifi­
cant differences in age, sex, BMI, marital status, education level,
⎛ ⎞2
smoking and drinking habits, blood pressure, FBG, comorbidities, or
⎜Z1− α + Z1− β ⎟ serum lipid levels were noted between the PLR group and the placebo
N =2×⎝ 2 ⎠ × s2
δ group or between the PTR group and the placebo group (all p > 0.05).
During the study, no patients reported the use of medications or dietary
Based on expert opinion and our expected minimum clinically supplements that could affect lipid metabolism.
important difference between PLR/PTR and placebo as adjuvant treat­
ment for dyslipidemia, we assumed a mean difference (MD) (δ) in LDL-C 3.3. Serum lipids
between the two groups of 5.0 mg/dl and a pooled standard deviation (s)
of 9.0 mg/dl with a type I error (α) of 0.05 and a type II error (β) of 0.2. 3.3.1. LDL-C
The calculated minimum sample size was 51 patients per group. As shown in Table 2, compared with baseline, the LDL-C level
Considering a potential 10 % attrition rate and funding constraints, our showed a significant downward trend in the PLR group during the first 4
total sample size was set at 174 (58 in each group). weeks of follow-up (-5.32 mg/dl, CIs − 8.86 to − 1.78, p = 0.003) and in
the PTR group (-4.52 mg/dl, CIs − 7.83 to − 1.21, p = 0.008) during the
2.11. Statistical analysis 12-week follow-up. However, the trend was not significantly different
compared with the placebo group at all visits (PLR vs placebo: − 2.89
The between-group comparison of efficacy outcomes was based on mg/dl [CIs − 7.78, 2.01], p = 0.247 at week 4; 3.54 mg/dl [CIs − 1.33,
the intention-to-treat principle, in which missing follow-up data were 8.40], p = 0.154 at week 12; PTR vs placebo: − 0.99 mg/dl, [CIs − 5.96,
imputed using the last observation carried forward method. A sensitivity 3.99], p = 0.697 at week 4; 0.93 mg/dl [CIs − 3.89, 5.75], p = 0.704 at
analysis using the per protocol population was also conducted. Safety week 12). Sensitivity analyses using the per protocol data set did not
analysis was based on the safety population that included all patients reveal any important changes (Table S1 in Supplementary file 5).
who actually received PLR, PTR, or placebo treatment, in which missing Subgroup analysis showed that some subgroups had significant
data were not imputed. within-group improvements in LDL-C compared with baseline, including
Statistical analyses were performed in SAS 9.4 (SAS Institute Inc., male patients receiving PLR at week 4 (-8.23 mg/dl, CIs − 12.76 to
Cary, NC, USA). We compared PLR with placebo and PTR with placebo − 3.69, p = 0.001) and receiving PTR at week 4 (-5.44 mg/dl, CIs − 9.66
separately. The baseline differences between the groups were compared to − 1.22, p = 0.012) and week 12 (-5.47 mg/dl, CIs − 9.00 to − 1.95, p =
using chi-square tests or analysis of variance. The efficacy outcomes 0.003), patients aged ≥ 50 years receiving PLR at week 4 (-5.65 mg/dl,
were analyzed with mixed effects models for repeated measures (the CIs − 10.73 to − 0.56, p = 0.030), both nondrinkers (-6.43 mg/dl, CIs
MIXED procedure in SAS). Here, visits, treatments, and their − 12.10 to − 0.76, p = 0.002) and drinkers (-6.66 mg/dl, CIs − 10.93 to

4
X. Zhou et al. Journal of Functional Foods 98 (2022) 105284

Fig. 2. Flowchart of recruitment and follow-up.

− 2.38, p = 0.027) receiving PLR at week 4, and nondrinkers receiving improvement was still not better than that in the placebo group
PTR at week 12 (-5.47 mg/dl, CIs − 9.47 to − 1.47, p = 0.008). However, (Table S1 in Supplementary file 5).
for all these subgroups, the reduction in LDL-C levels was not signifi­ Subgroup analyses found a significantly greater increase in HDL-C
cantly greater in either the PLR or PTR group compared with the placebo levels in the PLR group than in the placebo group among females
group (Tables S2-S4 in Supplementary file 6). (+4.01 mg/dl, CIs 0.48 to 7.54, p = 0.026), patients aged ≥ 50 years
(+3.17 mg/dl, CIs 0.39 to 5.95, p = 0.026), and nondrinkers (+3.10 mg/
3.3.2. HDL-C dl, CIs 0.35 to 5.85, p = 0.027) at week 12. However, no such difference
At week 4, no significant between-group differences were found was observed in other subgroups at any time (Tables S2-S4 in Supple­
between the PLR or PTR groups and the placebo group. At week 12, the mentary file 6).
test based on a mixed effects model for repeated measures showed a
significantly greater increase in the HDL-C level in the PLR group than in 3.3.3. TC and TGs
the placebo group (+3.05 mg/dl, CIs 0.75 to 5.35, p = 0.010) but no At all visits, no between-group differences in changes in TC levels or
significant difference in the HDL-C level between the PTR group and the changes in TG levels were noted (Table 2). Sensitivity analyses using per
placebo group (-0.005 mg/dl, CIs − 2.36 to 2.35, p = 0.997) (Table 2). protocol population also did not show any significant improvement in
Sensitivity analyses using the per protocol population found no impor­ TC and TG levels (Table S1 in Supplementary file 5).
tant changes, except that the within-group HDL improvement at week In the male subgroup, the PTR intervention resulted in a significantly
12 in the PTR group became statistically significant (+1.91 mg/dl, CIs greater reduction in TC levels than placebo treatment at week 4 (-6.68
0.14 to 3.69, p = 0.035) compared to marginally significant in the main mg/dl, CIs − 13.14 to − 0.23, p = 0.042), and PTR treatment also facil­
analysis (1.58 mg/dl, CIs − 0.07 to 3.22, p = 0.060), but the itated a significant improvement in the TG levels compared with placebo

5
X. Zhou et al. Journal of Functional Foods 98 (2022) 105284

Table 1 Table 2
Baseline characteristics of included patients. Results of serum lipid outcomes (mg/dl) based on the full analysis set.
Characteristics PLR group PTR group Placebo Group (n = Outcome Visit PLR PTR Placebo PLR vs PTR vs
(n = 58) (n = 58) 58) group group group Placebo Placebo
(n = 58) (n = 58) (n = 58)
Age, year 52.1 ± 51.5 ± 52.4 ± 13.6
12.6 12.9 LDL Week 150.5 142.9 145.6 4.91 − 2.74
Female, n (%) 38 (65.5 32 (55.2 31 (53.4 %) 0 (145.5, (137.8, (140.6, (-1.97, (-9.60,
%) %) 155.6) 147.9) 150.6) 11.80) 4.12)
Body mass index, kg/m2 23.5 ± 2.7 23.8 ± 2.3 23.2 ± 2.0 Week 145.2 139.5 143.2 2.03 − 3.72
Married, n (%) 56 (96.6 52 (91.2 51 (87.9 %) 4 (140.2, (134.4, (138.2, (-4.81, (-10.56,
%) %) 150.3) 144.5) 148.2) 8.86) 3.11)
College or higher education, n 45 (84.9 44 (80.0 46 (80.7 %) Week 148.6 138.4 140.2 8.45 − 1.81
(%) %) %) 12 (143.6, (133.4, (135.2, (1.63, (-8.57,
Smoker, n (%) 7 (12.3 %) 17 (29.8 10 (17.2 %) 153.6) 143.3) 145.2) 15.26) 4.96)
%) Week − 5.32 − 3.41 − 2.43 − 2.89 − 0.99
Drinker, n (%) 15 (26.3 16 (28.1 17 (29.3 %) 4– (-8.86, (-7.07, (-5.81, (-7.78, (-5.96,
%) %) week − 1.78)** 0.24) 0.95) 2.01) 3.99)
SBP, mmHg 121.8 ± 123.1 ± 121.8 ± 13.9 0
13.9 12.4 Week − 1.91 − 4.52 − 5.45 3.54 0.93
DBP, mmHg 76.2 ± 78.8 ± 8.6 78.6 ± 9.8 12 – (-5.29, (-7.83, (-8.95, (-1.33, (-3.89,
14.0 week 1.47) − 1.21)** − 1.95)** 8.40) 5.75)
FBG, mg/dl 99.0 ± 99.0 ± 97.2 ± 21.6 0
32.4 39.6 HDL Week 53.9 57.3 56.8 − 2.89 0.53
Comorbidities, n (%) 0 (51.0, (54.3, (54.0, (-6.79, (-3.46,
Hypertension 11 (19.0 12 (20.7 12 (20.7 %) 56.8) 60.4) 59.7) 1.02) 4.51)
%) %) Week 53.8 55.8 55.7 − 1.82 0.12
Type 2 diabetes 5 (8.6 %) 6 (10.3 %) 12 (20.7 %) 4 (51.0, (53.0, (52.9, (-5.64, (-3.66,
Hyperuricemia 5 (8.6 %) 3 (5.2 %) 0 (0 %) 56.7) 58.5) 58.5) 2.01) 3.90)
Serum lipid levels, mg/dl Week 55.5 55.9 55.3 0.17 0.52
LDL-C 154.1 ± 146.6 ± 149.0 ± 11.9 12 (52.6, (53.0, (52.5, (-3.80, (-3.39,
18.7 14.0 58.4) 58.7) 58.2) 4.13) 4.43)
HDL-C 57.5 ± 61.9 ± 59.5 ± 16.4 Week − 0.09 − 1.57 − 1.16 1.07 − 0.41
13.3 17.4 4– (-1.61, (-3.19, (-2.63, (-1.04, (-2.59,
TC 230.3 ± 226.9 ± 225.8 ± 25.7 week 1.42) 0.05) 0.31) 3.18) 1.78)
30.7 27.5 0
TG 153.6 ± 162.5 ± 139.5 ± 67.3 Week 1.58 − 1.48 − 1.47 3.05 − 0.005
63.8 86.6 12 – (-0.07, (-3.21, (-3.08, (0.75, (-2.36,
week 3.22) 0.25) 0.13) 5.35)## 2.35)
Continuous data are presented as mean ± standard deviation; DBP = diastolic 0
blood pressure, FBG = Fasting blood glucose, HDL-C = high-density lipoprotein TC Week 228.1 226.3 224.6 3.51 1.75
cholesterol, LDL-C = low-density lipoprotein cholesterol, SBP = systolic blood 0 (221.7, (219.9, (218.2, (-5.28, (-7.05,
pressure, TC = total cholesterol, TG = triglyceride. 234.6) 232.8) 231.0) 12.31) 10.54)
Week 229.2 222.6 224.0 5.18 − 1.47
4 (222.8, (216.2, (217.7, (-3.47, (-10.07,
treatment in the nondrinkers at week 12 (-16.51 mg/dl, CIs − 30.54 to 235.6) 228.9) 230.4) 13.84) 7.13)
− 2.49, p = 0.021) (Tables S2-S4 in Supplementary file 6). Week 230.4 225.6 224.8 5.53 0.80
12 (223.8, (219.2, (218.3, (-3.34, (-8.02,
236.9) 232.1) 231.3) 14.40) 9.61)
3.4. Symptoms related to dyslipidemia Week 1.11 − 3.77 − 0.56 1.67 − 3.22
4– (-2.66, (-7.67, (-4.32, (-3.66, (-8.63,
During follow-up, symptom scores associated with dyslipidemia week 4.89) 0.12) 3.21) 7.00) 2.20)
0
showed significant reductions relative to baseline in both the PLR (-0.50
Week 2.24 − 0.72 0.23 2.02 − 0.95
[CIs − 0.95, − 0.05] at week 4) and PTR groups (-0.62 [CIs − 1.04, 12 – (-1.73, (-4.79, (-4.03, (-3.81, (-6.84,
− 0.21] at week 4 and − 0.76 [CIs − 1.23, − 0.30] at week 12); however, week 6.22) 3.35) 4.48) 7.84) 4.94)
the changes were not significantly different from those in the placebo 0
group at the same time point (Table 3). TG Week 135.7 136.5 124.7 10.96 11.85
0 (120.7, (121.6, (110.0, (-9.20, (-8.27,
150.6) 151.5) 139.4) 31.12) 31.96)
3.5. Blood pressure Week 135.4 138.1 131.8 3.61 6.34
4 (120.0, (123.0, (116.5, (-17.37, (-14.43,
150.8) 153.3) 147.1) 24.59) 27.10)
At week 4, the PLR group showed significantly greater reductions in Week 136.1 134.7 130.8 5.30 3.95
both SBP (-5.63 mmHg, CIs − 10.56 to − 0.69) and DBP (-4.68 mmHg, CIs 12 (120.4, (119.1, (114.9, (-16.20, (-17.56,
− 8.58 to − 0.78) compared to the placebo group, whereas the PTR group 151.7) 150.4) 146.6) 26.81) 25.46)
Week − 0.27 1.57 7.09 − 7.35 − 5.51
showed significantly more improvement exclusively in DBP (-5.25
4– (-10.36, (-8.37, (-2.50, (-21.27, (-19.32,
mmHg, CIs − 9.33 to − 1.16). However, none of the downward trends in week 9.82) 11.51) 16.67) 6.56) 8.30)
blood pressure compared with the placebo group persisted through 0
week 12 (Table 3). Week 0.43 − 1.81 6.09 − 5.66 − 7.90
12 – (-9.88, (-12.36, (-4.67, (-20.56, (–22.97,
week 10.74) 8.73) 16.85) 9.24) 7.16)
3.6. FBG and BMI 0

vs baseline (week 0): * p < 0.05, ** p < 0.01; vs placebo: # p < 0.05, ## p < 0.01.
Minimal changes from baseline in FBG and BMI were noted in both Effects are estimated by mixed-effects models for repeated measures adjusted for
the PLR and PTR groups during the follow-up, and the changes were not fixed-effect covariates including sex, age, and drinking and random-effect
statistically significant compared to those in the placebo group covariates including subjects’ IDs and study sites and are measured with least-
(Table 3). squares mean differences and 95% confidence intervals.

6
X. Zhou et al. Journal of Functional Foods 98 (2022) 105284

Table 3 Table 3 (continued )

Results of other efficacy outcomes based on per protocol set. Outcome Visit PLR PTR Placebo PLR vs PTR vs
Outcome Visit PLR PTR Placebo PLR vs PTR vs group group group Placebo Placebo
group group group Placebo Placebo (n = 58) (n = 58) (n = 58)
(n = 58) (n = 58) (n = 58)
Week 24.0 23.9 23.6 0.48 0.32
Symptom Week 11.56 11.38 11.13 0.44 0.26 4 (7.2, (7.1, (6.8, (-2.04, (-2.05,
(score) 0 (10.84, (10.67, (10.41, (-0.54, (-0.71, 40.8) 40.7) 40.4) 3.01) 2.68)
12.28) 12.09) 11.84) 1.41) 1.23) Week 22.8 23.5 23.1 − 0.31 0.41
Week 11.33 10.76 10.58 0.75 0.17 12 (6.0, (6.7, (6.3, (-2.49, (-1.98,
4 (10.62, (10.05, (9.88, (-0.21, (-0.79, 39.6) 40.3) 39.9) 1.88) 2.79)
12.05) 11.47) 11.29) 1.71) 1.13) Week − 0.82 − 0.40 0.39 − 1.21 − 0.79
Week 11.06 10.62 10.50 0.57 0.13 4– (-3.07, (-2.46, (-1.97, (-4.46, (-3.91,
12 (10.33, (9.90, (9.78, (-0.42, (-0.85, week 1.43) 1.65) 2.75) 2.05) 2.32)
11.80) 11.35) 11.21) 1.55) 1.10) 0
Week − 0.23 − 0.62 − 0.54 0.31 − 0.08 Week − 2.06 − 0.76 − 0.06 − 2.00 − 0.70
4– (-0.63, (-1.04, (-0.96, (-0.27, (-0.68, 12 – (-4.18, (-3.01, (-2.23, (-5.04, (-3.84,
week 0.17) − 0.21)** − 0.12)* 0.89) 0.51) week 0.06) 1.49) 2.12) 1.05) 2.44)
0 0
Week − 0.50 − 0.76 − 0.63 0.13 − 0.13
vs baseline (week 0): * p < 0.05, ** p < 0.01; vs placebo: # p < 0.05, ## p < 0.01.
12 – (-0.95, (-1.23, (-1.07, (-0.50, (-0.77,
week − 0.05)* − 0.30)** − 0.19)** 0.76) 0.51) Effects are estimated by mixed-effects models for repeated measures adjusted for
0 fixed-effect covariates including sex, age, and drinking and random-effect
SBP (kg/ Week 124.6 125.7 125.2 − 0.54 0.53 covariates including subjects’ IDs and study sites and are measured with least-
m2 ) 0 (121.3, (122.5, (121.9, (-5.02, (-3.89, squares mean differences and 95% confidence intervals.
127.9) 128.9) 128.5) 3.95) 4.95)
Week 123.9 126.4 130.0 − 6.16 − 3.67
4 (119.8, (121.9, (125.8, (-11.83, (-9.64,
3.7. Safety
127.9) 130.8) 134.3) − 0.50) 2.29)
Week 125.4 126.1 125.2 0.23 0.98 During the 12 weeks of follow-up, one patient in the PLR group
12 (121.1, (122.0, (121.0, (-5.59, (-4.68, presented with + 1 protein in urine (normal at baseline), and one patient
129.7) 130.2) 129.3) 6.05) 6.64)
complained of gastric boredom; two patients in the PTR group com­
Week − 0.74 0.68 4.88 − 5.63 − 4.20
4– (-4.10, (-3.12, (1.17, (-10.56, (-9.46, plained of dizziness; and one patient in the placebo group experienced
week 2.62) 4.47) 8.59) − 0.69)# 1.05) positive urinary occult blood (normal at baseline). All AEs were mild and
0 not related to the interventions as judged by the clinicians. No SAEs
Week 0.77 0.45 0.00 0.77 0.45
occurred. No patients withdrew due to AEs.
12 – (-2.84, (-2.79, (-3.45, (-4.18, (-4.24,
week 4.37) 3.68) 3.45) 5.71) 5.14)
0 4. Discussion
DBP (kg/ Week 80.2 80.7 79.0 1.18 1.69
m2 ) 0 (78.0, (78.6, (76.8, (-1.79, (-1.24, Given that CVDs are the main cause of morbidity and mortality
82.4) 82.9) 81.2) 4.15) 4.63)
Week 77.8 77.8 81.3 − 3.50 − 3.56
worldwide, the management of dyslipidemia has become a core
4 (75.0, (74.7, (78.1, (-7.66, (-7.87, component of primary and secondary prevention strategies for CVDs
80.7) 80.8) 84.5) 0.66) 0.75) (Yandrapalli et al., 2019). There is a longstanding consensus that
Week 78.3 78.9 79.0 − 0.66 − 0.02 elevated LDL-C concentrations are a major risk factor for CVDs, whereas
12 (75.2, (76.0, (76.1, (-4.75, (-4.05,
HDL-C concentrations are negatively associated with the severity of
81.4) 81.9) 81.8) 3.44) 4.00)
Week − 2.39 − 2.95 2.30 − 4.68 − 5.25 atherosclerosis (Ference et al., 2017; Mahdy Ali et al., 2012). A large-
4– (-4.90, (-5.74, (-0.77, (-8.58, (-9.33, scale meta-analysis showed that all-cause mortality was reduced by
week 0.13) − 0.16)* 5.37) − 0.78)# − 1.16)# 12 % for every 40 mg/dl (1 mmol/L) reduction in LDL-C levels (Baigent
0 et al., 2005); therefore, LDL-C reduction is considered to be the most
Week − 1.89 − 1.77 − 0.06 − 1.84 − 1.72
12 – (-4.72, (-4.46, (-2.61, (-5.59, (-5.37,
attractive target for lipid-lowering therapy. Of course, the residual risk is
week 0.94) 0.91) 2.49) 1.92) 1.93) also of concern, emphasizing the need to identify new targets to achieve
0 further benefits. Of all possibilities, increasing HDL-C levels seems to be
FBG Week 100.9 98.1 93.2 7.74 4.88 a promising strategy. Epidemiological surveys have shown that a 1 mg/
(mmol/ 0 (92.9, (90.3, (85.4, (-2.49, (-5.21,
dl (0.03 mmol/L) decrease in HDL-C concentration is associated with a
L) 109.0) 105.8) 100.9) 17.98) 14.97)
Week 100.3 98.7 93.6 6.71 5.09 2–3 % increase in cardiovascular risk (Gordon et al., 1989) and that
4 (91.9, (90.2, (85.4, (-4.11, (-5.85, patients with an HDL-C level higher than 35 mg/dl have a 70 % lower
108.6) 107.1) 101.8) 17.54) 16.03) risk for coronary heart disease over 6 years compared with those with
Week 101.4 99.1 96.2 5.21 2.87 levels<35 mg/dl (Assmann et al., 1996).
12 (93.1, (90.6, (87.9, (-5.65, (-8.12,
109.8) 107.6) 104.6) 16.07) 13.86)
The present RCT showed that after taking 15 g/day PLR or PTR for
Week − 0.65 0.59 0.38 − 1.03 0.21 12 weeks, patients with mildly elevated LDL-C (between 131.5 and
4– (-3.75, (-2.78, (-2.86, (-5.52, (-4.47, 189.5 mg/dl) had a small reduction in the LDL-C level compared to
week 2.46) 3.97) 3.63) 3.45) 4.89) baseline; the reductions were statistically significant at week 4 in the
0
PLR group and at week 12 in the PTR group. The difference in effect
Week 0.52 1.04 3.05 − 2.53 − 2.01
12 – (-2.84, (-2.52, (-0.52, (-7.43, (-7.06, between the two plants may be related to the different contents of a
week 3.88) 4.61) 6.63) 2.37) 3.04) component called daidzein (2:1 in PTR to PLR (Wong et al., 2015)),
0 which has been shown to have a hypolipidemic effect (Kgomotso et al.,
BMI (kg/ Week 24.9 24.3 23.2 1.69 1.11 2008). In addition, several studies have shown that blood lipid levels,
m2) 0 (8.1, (7.5, (6.4, (-0.38, (-0.87,
41.6) 41.0) 39.9) 3.76) 3.09)
including LDL-C, HDL-C, TC, and TG, are often low in summer and high
in winter (Joshi et al., 2014; Moura et al., 2013). In the present RCT,
most patients completed the week 4 visit in hot weather (July to
September) and the week 12 visit in cold weather (November to

7
X. Zhou et al. Journal of Functional Foods 98 (2022) 105284

January). Therefore, another possibility to explain the disappearance of and animal studies also revealed that PLR had a hypotensive effect in
the effect of PLR on LDL-C levels at week 12 is that the lipid-lowering patients with hypertension (Y. Liu et al., 2020; Zhou et al., 2020) and
effect of PLR may be more susceptible to the impact of cold weather. suggested that the effect may be attributed to puerarin, which can lower
Of course, the difference is more likely due to the placebo effect because blood pressure by regulating the renin-angiotensin-aldosterone system
the changes from baseline in LDL-C levels were not statistically signifi­ (X. Li et al., 2017). Nevertheless, the trend of blood pressure reduction in
cant between either the PTR group or the PLR group compared to the the PLR and PTR groups in the present RCT was not maintained until the
placebo group at each visit, and there were also no significantly stronger end of the study. This finding may be related to the fact that patients’
effects of PTR or PTR treatment on LDL-C levels than placebo treatment blood pressure in our study was mostly in the normal range, whereas the
in any subgroups. However, our findings are not consistent with those of previous studies included patients diagnosed with hypertension (Y. Liu
previous studies in which PLR treatment significantly reduced LDL-C et al., 2020; Noone et al., 2020), namely, due to the difference in the
levels (Kwok et al., 2014; Okamura et al., 2008). This finding may be study population. Therefore, further validation of the antihypertensive
associated with differences in chemical compositions due to the climate effects of PLR and PTR is necessary. In terms of symptoms related to
and soil of different strains of PLR (Huang et al., 2019; Wong et al., dyslipidemia, the results showed that both PLR and PTR significantly
2015), or may be the consequence of differences in methodological reduced the scores on the symptom scale compared to baseline at week 4
quality control between the studies. In addition, there are no previous and/or week 12, but a placebo effect cannot be excluded because there
clinical studies investigating the lipid-lowering effect of PTR. Therefore, was no significant difference compared to the placebo group.
the effects of PLR and PTR on LDL-C should be further validated. Reviewing the findings, we consider that PLR may be used as a
An important positive finding of this study is that PLR showed an compensatory edible and medicinal remedy in patients with mild dys­
HDL-C-elevating effect, which is not even possible with statins. At week lipidemia given its HDL-C-regulating ability. The benefit is more
12, the average HDL-C level in the PLR group was significantly increased apparent in female patients over 50 years based on the subgroup find­
by 3.05 mg/dl compared to the placebo group. In the subgroup analyses, ings. PTR is currently not recommended for the management of dysli­
we found that the significant elevation in HDL-C levels by PLR was pidemia because it failed to show a better effect on lipid outcomes than
clustered in females, patients aged > 50 years, and nondrinkers. Based the placebo in the full population. Of course, as an herbal intervention
on the subgroup findings and the chemical composition of PLR, we requiring daily consumption, the safety of PLR is critical. Although
suggest that the effect might be associated with the phytoestrogens Chinese regulations have approved PLR as an edible and medicinal
contained in PLR. The decreased estradiol levels in women after plant, this is mainly based on food-use traditions and animal studies.
menopause tend to induce impaired lipid metabolism, of which However, evidence of long-term safety at daily doses in the human body
decreased HDL-C levels are one of the main issues (Anagnostis et al., is lacking. In the present RCT, the administration of 15 g of PLR or PTR
2015). PLR is rich in flavonoids, including puerarin, daidzin, genistin, per day for 12 weeks was tolerated well, as evidenced by the absence of
daidzein, and genistein, which can selectively bind to estrogen receptors AEs associated with these interventions and no obvious abnormalities in
and exert estrogenic modulatory effects; hence, they are also known as liver function, renal function, electrocardiogram, or urinary and fecal
phytoestrogens (Cherdshewasart et al., 2007; Lee et al., 2021). It has examinations. Therefore, such a dose of PLR or PTR can be safely used
been demonstrated that phytoestrogens in PLR can increase HDL-C for the daily management of dyslipidemia, as long as their efficacy can
levels through estrogen receptor α- and/or β-mediated transactivation be demonstrated.
(Okamura et al., 2008). By analyzing the proportion of different flavo­ Although we rigorously conducted the protocol design, recruitment,
noids in PLR and PTR, we hypothesize that puerarin, daidzin, and randomization, follow-up, and data analysis, there are also limitations in
genistein may represent the main components with HDL-C-elevating the RCT due to funding and study setting. One potential limitation is that
effects, as the mean levels of these flavonoids in PLR were consider­ due to the lack of collecting data on dietary intake, we were unable to
ably higher compared with those in PTR (60.69 vs 5.08 mg/g, 11.83 vs assess the effect of diet on the results. However, under randomization,
1.37 mg/g, 3.00 vs 0 mg/g, respectively); in contrast, the mean levels of the diet structure was potentially balanced across all groups, so we
other flavonoids were similar or lower in PLR than in PTR (genistein believe that the differences in diet structure among the groups should
0.99 vs 0.72 mg/g; daidzein 2.31 vs 4.73 mg/g) (Wong et al., 2015). have no substantial effect on the results. In addition, the small sample
Additionally, there is no evidence of an LDL-C lowering effect of flavo­ size, the specific eligibility criteria, and the lack of a dose–response
noids, which may explain the insignificant effect of PLR on LDL-C. In design also limit the applicability of the findings of this study. Therefore,
addition, the possible explanation for the different effects on HDL-C more studies are needed in the future to validate the previously
between people with different drinking habits is that alcohol con­ mentioned inconclusive results and explore the optimal timing of
sumption interferes with phytoestrogen metabolism and the effect of dosing, optimal dose ranges, and interactions with other lipid-lowering
phytoestrogens on estrogen receptors by affecting aromatase activity, agents for the treatment of dyslipidemia.
thereby depriving PLR of its HDL-C-elevating effect (Frydenberg et al.,
2015). 5. Conclusion
In terms of TGs and TC, the subgroup analysis showed that PTR
significantly reduced the TC level in males at week 4 and the TG level in The results of the RCT suggest that daily consumption of PLR
nondrinkers at week 12 compared to placebo. However, because these compared to a placebo over a 12-week period can increase HDL-C levels
effects were not found in the full population, we do not consider that the in patients with mild dyslipidemia with good safety. The findings sup­
beneficial effects of PTR on TC or TG are clinically significant. In port the use of PLR as a daily regimen for mild dyslipidemia, especially
contrast, we observed that the TC levels in patients aged < 50 years in for women aged > 50 years. The lipid-regulating effects of PTR remain
the PLR group were unexpectedly more elevated than those in the pla­ uncertain, but its safety for long-term daily consumption can be
cebo group. We hypothesize that this phenomenon may be associated demonstrated.
with the increased HDL-C level, as the mean increase in HDL-C levels in
this subgroup reached 3.59 mg/dl (CIs − 0.05 to 7.23; marginally sig­ Funding
nificant between-group difference: p = 0.0535).
Interestingly, compared to the placebo group, both the PLR and PTR This work was supported by the National Key Research and Devel­
groups showed a significant reduction in average SBP (PLR: − 5.63 opment Program of China “Modernization of Traditional Chinese med­
mmHg) and/or DBP (PLR: − 4.68 mmHg; PTR: − 5.25 mmHg) at week 4. icine” [grant number 2017YFC1702905], the National Natural Science
The magnitude of the reductions was no less than that of some poorly Foundation of China [grant number 82274681], the National Key
effective antihypertensive drugs (Noone et al., 2020). Previous human Research and Development Program of China “Key Technology of Food

8
X. Zhou et al. Journal of Functional Foods 98 (2022) 105284

Safety” [grant number 2019YFC1604905], Jiangxi University of Chi­ Bai, M. H., Wong, W., Hou, S. J., Zheng, Y. F., Li, Q. R., Li, Z. Q., et al. (2022).
Development and evaluation of short form of constitution in Chinese medicine
nese Medicine Science and Technology Innovation Team Development
questionnaire: A national epidemiological survey data of 21 948 case. Journal of
Program [Grant No CXTD-22004, CXTD-22012], and Jiangxi University Traditional Chinese Medicine, 42(1), 122–131. https://doi.org/10.19852/j.cnki.
of Chinese Medicine 1050 Youth Talent Project [grant numbers jtcm.20211228.001
1142001007, 5142001011]. All funders had no role during the entire Baigent, C., Keech, A., Kearney, P. M., Blackwell, L., Buck, G., Pollicino, C., et al. (2005).
Efficacy and safety of cholesterol-lowering treatment: Prospective meta-analysis of
process of this study. data from 90,056 participants in 14 randomised trials of statins. Lancet, 366(9493),
1267–1278. https://doi.org/10.1016/S0140-6736(05)67394-1
Bates, T. R., Connaughton, V. M., & Watts, G. F. (2009). Non-adherence to statin therapy:
Ethical statement
A major challenge for preventive cardiology. Expert Opinion on Pharmacotherapy, 10
(18), 2973–2985. https://doi.org/10.1517/14656560903376186
Ethical approval for the involvement of human subjects in this study Chen, X., Yu, J., & Shi, J. (2018). Management of Diabetes Mellitus with Puerarin, a
was granted by the Ethics Committees in the Affiliated hospital of Natural Isoflavone From Pueraria lobata. American Journal of Chinese Medicine, 46
(8), 1771–1789. https://doi.org/10.1142/S0192415X18500891
Jiangxi University of Chinese Medicine (approval number JZFY­ Cherdshewasart, W., Subtang, S., & Dahlan, W. (2007). Major isoflavonoid contents of
KYLL20210125003, January 25, 2021) and Nanchang Hongdu Hospital the phytoestrogen rich-herb Pueraria mirifica in comparison with Pueraria lobata.
of Traditional Chinese Medicine (approval number KY-2020–010, Journal of Pharmaceutical and Biomedical Analysis, 43(2), 428–434. https://doi.org/
10.1016/j.jpba.2006.07.013
December 30, 2020). Cheung, D. W., Koon, C. M., Wong, P. H., Yau, K. C., Wat, E., Hung, A. S., et al. (2017).
Evaluating Efficacy and Safety of Combination Medication of Atorvastatin and a
CRediT authorship contribution statement Herbal Formula Containing Salvia miltiorrhiza and Pueraria lobata on
Hyperlipidemia. Phytotherapy Research, 31(10), 1579–1589. https://doi.org/
10.1002/ptr.5888
Xu Zhou: Methodology, Data curation, Formal analysis, Funding Chinese Medical Association. (2019). Guideline for primary care of dyslipidemias (2019).
acquisition, Writing – original draft. Jianwei Yu: Supervision, Valida­ Chinese Journal of General Practitioners, 18(5), 406–416. https://doi.org/10.3760/
cma.j.issn.1671-7368.2019.05.003
tion, Writing – review & editing. Qing Wan: Supervision, Validation, Chinese Ministry of Health. (2002). Ministry of health announced Medicinal and Edible
Writing – review & editing. Wei Wang: Supervision, Validation, Writing items can be used in health food items list. Chinese Archives of Traditional Chinese
– review & editing. Xinyu Yu: Investigation, Writing – review & editing. Medicine, 20(2), 176.
Edwards, I. R., & Aronson, J. K. (2000). Adverse drug reactions: Definitions, diagnosis,
Jianyu You: Writing – original draft. Hui Ouyang: Methodology, and management. Lancet, 356(9237), 1255–1259. https://doi.org/10.1016/s0140-
Writing – review & editing. Xiaofan Chen: Methodology, Writing – 6736(00)02799-9
review & editing. Yuan Cong: Investigation, Writing – review & editing. Ference, B. A., Ginsberg, H. N., Graham, I., Ray, K. K., Packard, C. J., Bruckert, E., et al.
(2017). Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1.
Shuailiang Huang: Investigation, Writing – review & editing. Jian­
Evidence from genetic, epidemiologic, and clinical studies. A consensus statement
chun Song: Methodology, Writing – review & editing. Kaimin Zhu: from the European Atherosclerosis Society Consensus Panel. European Heart Journal,
Methodology, Writing – review & editing. Yongmei Guan: Conceptu­ 38(32), 2459–2472. https://doi.org/10.1093/eurheartj/ehx144
alization, Funding acquisition, Writing – review & editing. Weifeng Frydenberg, H., Flote, V. G., Larsson, I. M., Barrett, E. S., Furberg, A. S., Ursin, G., et al.
(2015). Alcohol consumption, endogenous estrogen and mammographic density
Zhu: Conceptualization, Funding acquisition, Writing – review & among premenopausal women. Breast Cancer Research, 17, 103. https://doi.org/
editing. 10.1186/s13058-015-0620-1
Gordon, D. J., Probstfield, J. L., Garrison, R. J., Neaton, J. D., Castelli, W. P., Knoke, J. D.,
et al. (1989). High-density lipoprotein cholesterol and cardiovascular disease. Four
Declaration of Competing Interest prospective American studies. Circulation, 79(1), 8–15. https://doi.org/10.1161/01.
cir.79.1.8
Huang, Z. Y., Shen, Q. N., Li, P., Su, L. L., Chen, L. H., Lu, T. L., et al. (2019). Quality
The authors declare that they have no known competing financial research of Puerariae Lobatae Radix from different habitats with UPLC fingerprint
interests or personal relationships that could have appeared to influence and determination of multi-component content. Zhongguo Zhong Yao Za Zhi, 44(10),
the work reported in this paper. 2051–2058. https://doi.org/10.19540/j.cnki.cjcmm.20190116.002
Ibrahim, M. A., Asuka, E., & Jialal, I. (2022). Hypercholesterolemia. [Updated 2022 Jun
19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.
Data availability Available from: https://www.ncbi.nlm.nih.gov/books/NBK459188/.
Jeon, S., & Carr, R. (2020). Alcohol effects on hepatic lipid metabolism. Journal of Lipid
Research, 61(4), 470–479. https://doi.org/10.1194/jlr.R119000547
Data will be made available on request. Joshi, P., Martin, S., Blaha, M., McEvoy, J., Santos, R., Cannon, C., et al. (2014). Seasonal
Variations in Lipid Profiles from 2.8 Million US Adults: the Very Large Database of
Acknowledgements Lipids (VLDL 14). Journal of the American College of Cardiology, 63(12_Supplement),
A1458-A1458. doi: doi:10.1016/S0735-1097(14)61458-3.
Kan, X. Y. (2019). Study on hypolipidemic activity and liposomal formulation of Pueraria
Thanks to the participants in the study and the staff of laboratory at lobata polysaccharides. Zhenjiang: Jiangsu University. Master Dissertation.
the Affiliated Hospital of Jiangxi University of Chinese Medicine and Kgomotso, T., Chiu, F., & Ng, K. (2008). Genistein- and daidzein 7-O-beta-D-glucuronic
acid retain the ability to inhibit copper-mediated lipid oxidation of low density
Nanchang Hongdu Hospital of Traditional Chinese Medicine for their lipoprotein. Molecular Nutrition & Food Research, 52(12), 1457–1466. https://doi.
contributions. org/10.1002/mnfr.200800010
Kwok, T., Leung, P. C., Lam, C., Ho, S., Wong, C. K., Cheng, K. F., et al. (2014).
A randomized placebo controlled trial of an innovative herbal formula in the
Appendix A. Supplementary material prevention of atherosclerosis in postmenopausal women with borderline
hypercholesterolemia. Complementary Therapies in Medicine, 22(3), 473–480. https://
Supplementary data to this article can be found online at https://doi. doi.org/10.1016/j.ctim.2014.03.010
Lee, M. R., Kim, B., Lee, Y., Park, S. Y., Shim, J. H., Chung, B. H., et al. (2021).
org/10.1016/j.jff.2022.105284.
Ameliorative Effects of Pueraria lobata Extract on Postmenopausal Symptoms
through Promoting Estrogenic Activity and Bone Markers in Ovariectomized Rats.
References Evidence-based Complementary and Alternative Medicine, 2021, 7924400. https://doi.
org/10.1155/2021/7924400
Li, L., Wu, J., Pu, D., Zhao, Y., Wan, C., Sun, L., et al. (2012). Factors associated with the
Adhyaru, B. B., & Jacobson, T. A. (2018). Safety and efficacy of statin therapy. Nature
age of natural menopause and menopausal symptoms in Chinese women. Maturitas,
Reviews Cardiology, 15(12), 757–769. https://doi.org/10.1038/s41569-018-0098-5
73(4), 354–360. https://doi.org/10.1016/j.maturitas.2012.09.008
Anagnostis, P., Stevenson, J. C., Crook, D., Johnston, D. G., & Godsland, I. F. (2015).
Li, X., Lin, Y., Zhou, H., Li, Y., Wang, A., Wang, H., et al. (2017). Puerarin protects
Effects of menopause, gender and age on lipids and high-density lipoprotein
against endothelial dysfunction and end-organ damage in Ang II-induced
cholesterol subfractions. Maturitas, 81(1), 62–68. https://doi.org/10.1016/j.
hypertension. Clinical and Experimental Hypertension, 39(1), 58–64. https://doi.org/
maturitas.2015.02.262
10.1080/10641963.2016.1200603
Assmann, G., Schulte, H., von Eckardstein, A., & Huang, Y. (1996). High-density
Liu, H. H., & Li, J. J. (2015). Aging and dyslipidemia: A review of potential mechanisms.
lipoprotein cholesterol as a predictor of coronary heart disease risk. The PROCAM
Ageing Research Reviews, 19, 43–52. https://doi.org/10.1016/j.arr.2014.12.001
experience and pathophysiological implications for reverse cholesterol transport.
Liu, Y., Liang, S., Bu, P., Liang, E., Yan, F., Xing, Y., et al. (2020). Radix Puerariae
Atherosclerosis, 124 Suppl, S11–S20. https://doi.org/10.1016/0021-9150(96)05852-
rebalances vasomotor factors and improves left ventricular diastolic dysfunction in
2

9
X. Zhou et al. Journal of Functional Foods 98 (2022) 105284

patients with essential hypertension. Experimental and Therapeutic Medicine, 20(2), Schulz, K. F., Altman, D. G., & Moher, D. (2010). CONSORT 2010 statement: Updated
705–713. https://doi.org/10.3892/etm.2020.8746 guidelines for reporting parallel group randomised trials. BMJ, 340, Article c332.
Lu, Y., Zhang, H., Lu, J., Ding, Q., Li, X., Wang, X., et al. (2021). Prevalence of https://doi.org/10.1136/bmj.c332
Dyslipidemia and Availability of Lipid-Lowering Medications Among Primary Health Song, D. X., & Jiang, J. G. (2017). Hypolipidemic Components from Medicine Food
Care Settings in China. JAMA Network Open, 4(9), e2127573. Homology Species Used in China: Pharmacological and Health Effects. Archives of
Luo, D., Dong, X., Huang, J., Huang, C., Fang, G., & Huang, Y. (2021). Pueraria lobata Medical Research, 48(7), 569–581. https://doi.org/10.1016/j.arcmed.2018.01.004
root polysaccharide alleviates glucose and lipid metabolic dysfunction in diabetic Taylor, F., Huffman, M. D., Macedo, A. F., Moore, T. H., Burke, M., Davey Smith, G., et al.
db/db mice. Pharmaceutical Biology, 59(1), 382–390. https://doi.org/10.1080/ (2013). Statins for the primary prevention of cardiovascular disease. Cochrane
13880209.2021.1898648 Database of Systematic Reviews, 2013(1), CD004816. https://doi.org/10.1002/
Magkos, F., & Mittendorfer, B. (2009). Gender differences in lipid metabolism and the 14651858.CD004816.pub5
effect of obesity. Obstetrics and Gynecology Clinics of North America, 36(2), 245–265, Wang, Z., Du, H., Peng, W., Yang, S., Feng, Y., Ouyang, H., et al. (2022). Efficacy and
vii. https://doi.org/10.1016/j.ogc.2009.03.001 Mechanism of Pueraria lobata and Pueraria thomsonii Polysaccharides in the
Mahdy Ali, K., Wonnerth, A., Huber, K., & Wojta, J. (2012). Cardiovascular disease risk Treatment of Type 2 Diabetes. Nutrients, 14(19), 3926. https://doi.org/10.3390/
reduction by raising HDL cholesterol–current therapies and future opportunities. nu14193926
British Journal of Pharmacology, 167(6), 1177–1194. https://doi.org/10.1111/ Wong, K. H., Li, G. Q., Li, K. M., Razmovski-Naumovski, V., & Chan, K. (2011). Kudzu
j.1476-5381.2012.02081.x root: Traditional uses and potential medicinal benefits in diabetes and
Mattiuzzi, C., Sanchis-Gomar, F., & Lippi, G. (2020). Worldwide burden of LDL cardiovascular diseases. Journal of Ethnopharmacology, 134(3), 584–607. https://doi.
cholesterol: Implications in cardiovascular disease. Nutrition Metabolism and org/10.1016/j.jep.2011.02.001
Cardiovascular Diseases, 30(2), 241–244. https://doi.org/10.1016/j. Wong, K. H., Razmovski-Naumovski, V., Li, K. M., Li, G. Q., & Chan, K. (2015).
numecd.2019.09.008 Comparing morphological, chemical and anti-diabetic characteristics of Puerariae
Moura, F. A., Dutra-Rodrigues, M. S., Cassol, A. S., Parra, E. S., Zago, V. H., Lobatae Radix and Puerariae Thomsonii Radix. Journal of Ethnopharmacology, 164,
Panzoldo, N. B., et al. (2013). Impact of seasonality on the prevalence of 53–63. https://doi.org/10.1016/j.jep.2014.12.050
dyslipidemia: A large population study. Chronobiology International, 30(8), Xu, Z., Sheng, Y., Zeng, G., Zeng, Z., Li, B., Jiang, L., et al. (2021). Metabonomic Study on
1011–1015. https://doi.org/10.3109/07420528.2013.793698 the Plasma of High-Fat Diet-Induced Dyslipidemia Rats Treated with Ge Gen Qin
Naci, H., Brugts, J. J., Fleurence, R., & Ades, A. E. (2013). Dose-comparative effects of Lian Decoction by Ultrahigh-Performance Liquid Chromatography-Mass
different statins on serum lipid levels: A network meta-analysis of 256,827 Spectrometry. Evidence-based Complementary and Alternative Medicine, 2021,
individuals in 181 randomized controlled trials. European Journal of Preventive 6692456. https://doi.org/10.1155/2021/6692456
Cardiology, 20(4), 658–670. https://doi.org/10.1177/2047487313483600 Yandrapalli, S., Gupta, S., Andries, G., Cooper, H. A., & Aronow, W. S. (2019). Drug
Noone, C., Leahy, J., Morrissey, E. C., Newell, J., Newell, M., Dwyer, C. P., et al. (2020). Therapy of Dyslipidemia in the Elderly. Drugs & Aging, 36(4), 321–340. https://doi.
Comparative efficacy of exercise and anti-hypertensive pharmacological org/10.1007/s40266-018-00632-x
interventions in reducing blood pressure in people with hypertension: A network Yang, L., Chen, J., Lu, H., Lai, J., He, Y., Liu, S., et al. (2019). Pueraria lobata for Diabetes
meta-analysis. European Journal of Preventive Cardiology, 27(3), 247–255. https:// Mellitus: Past, Present and Future. American Journal of Chinese Medicine, 47(7),
doi.org/10.1177/2047487319879786 1419–1444. https://doi.org/10.1142/S0192415X19500733
Okamura, S., Sawada, Y., Satoh, T., Sakamoto, H., Saito, Y., Sumino, H., et al. (2008). Zeng, Y. P., Huang, Y. S., & Hu, Y. G. (2006). Effect of gegen qinlian decoction combined
Pueraria mirifica phytoestrogens improve dyslipidemia in postmenopausal women with short-term intensive insulin treatment on patients with type 2 diabetes mellitus
probably by activating estrogen receptor subtypes. Tohoku Journal of Experimental of dampness-heat syndrome. Zhongguo Zhong Xi Yi Jie He Za Zhi, 26(6), 514–516,
Medicine, 216(4), 341–351. https://doi.org/10.1620/tjem.216.341 520.
Pirillo, A., Casula, M., Olmastroni, E., Norata, G. D., & Catapano, A. L. (2021). Global Zhou, T., Wang, Z., Guo, M., Zhang, K., Geng, L., Mao, A., et al. (2020). Puerarin induces
epidemiology of dyslipidaemias. Nature Reviews Cardiology, 18(10), 689–700. mouse mesenteric vasodilation and ameliorates hypertension involving endothelial
https://doi.org/10.1038/s41569-021-00541-4 TRPV4 channels. Food & Function, 11(11), 10137–10148. https://doi.org/10.1039/
d0fo02356f

10