Effect of Emblica officinalis (Amla) Extract Versus Exercise on Lipid Levels in Participants With Abnormal Lipid Levels: An Open-Label Clinical Study

Abstract

Background

Dyslipidemia, marked by abnormal lipid levels, significantly increases the risk of cardiovascular diseases. Effective management of these lipid abnormalities is essential for reducing cardiovascular risk. Emblica officinalis, known as amla in Ayurveda, is traditionally considered the best fruit due to its numerous health benefits.

Objective

To evaluate the efficacy and tolerability of amla extract on participants with abnormal lipid levels and compare with the effect of physical activity in reducing atherogenic factors.

Methods

Forty-five inactive participants having abnormal lipid levels were selected and instructed to initiate lifestyle changes, including a healthy diet and aerobic exercise for 14 days. Thirty-nine participants who met the study criteria even after exercise were allocated a 500 mg capsule of amla extract (Tri-Low®) twice daily for 90 days. The effect of amla extract on lipid parameters, atherogenic index of plasma (AIP), apolipoprotein (Apo) B/Apo A ratio, high-sensitivity C-reactive protein, coenzyme Q10, and hydroxy methylglutaryl coenzyme A reductase levels was studied and compared with the effect of physical activity or exercise on these parameters. Laboratory parameters, global tolerability, and treatment-emergent adverse events were evaluated for the assessment of safety profile of amla extract.

Results

Amla extract over a period of 90 days significantly reduced triglyceride (P = 0.007), total cholesterol (P < 0.001), LDL (P = 0.006), VLDL (P = 0.014), and AIP (P < 0.001) but reported no significant effect on HDL (P = 0.967) and fasting blood sugar (P = 1.00). Varying the intensity of exercise from low to moderate and high had no significant effect on triglyceride (P = 0.516), total cholesterol (P = 0.676), LDL (P = 0.511), VLDL (P = 0.454), or AIP (P = 0.472). However, LDL exhibited a significant reduction with amla extract, combined with exercise (P < 0.001). Apolipoprotein B/Apo A1 ratio exhibited a trend toward significance (P = 0.061). Weight and reductions were statistically significant with amla extract and exercise, after 45 days (P < 0.001) and 90 days (P = 0.002). Hydroxy methylglutaryl coenzyme A, Apo B, and coenzyme Q10 exhibited no significant changes. Overall, it was evident that the significant changes in lipid parameters are attributable to amla extract rather than physical activity alone. All other factors are not affected by exercise intensity, and the significant changes observed are purely due to the effect of amla extract.

Conclusions

Exercise alone is often insufficient for optimal cardiovascular health. The supplementation of amla extract (Tri-Low®) from this study reported significant potential in improving lipid profiles and other atherogenic factors, thereby providing a comprehensive strategy for cardiovascular health management.

Clinical Trial Registration

Clinical Trial Registry - India (CTRI/2017/02/007829).

Introduction

Cardiovascular disease (CVD) remains the leading cause of death worldwide, including developed countries. Atherosclerotic CVD (ASCVD) is the primary contributor to CVD prevalence, majorly from the accumulation of plaque in the arterial walls.¹ In contrast to cancer, which is the second most common cause of death, one notable feature of CVD is that it is preventable through early identification of risk factors and timely intervention using lifestyle modifications and medication interventions.² The association between LDL-C and CVD has been well established in observational epidemiologic studies and interventional clinical trials, and LDL-C remains the primary target of therapy in the US National Cholesterol Education Program Adult Treatment Panel III.^3,4

Factors, including obesity, sedentary lifestyles, coupled with high carbohydrate diet, alcohol consumption, medical conditions such as diabetes and renal failure, genetic conditions (familial combined hyperlipidemia, familial dysbetalipoproteinemia, and familial hypertriglyceridemia), certain medications such as estrogen and corticosteroids, can contribute to dyslipidemia, characterized by elevated triglycerides (TGs) and reduced HDL-C.^{5, 6, 7}

Interventional studies reported the necessity of targeted strategies, including structured aerobic exercise and dietary interventions, to improve lipid parameters. Activities, such as jogging, swimming, cycling, or aerobic dance moves, help in weight management and lipid profile management, contributing to mental well-being, stress reduction, and overall well-being.⁸ Beyond the lifestyle interventions, combining dietary supplements along with exercises reportedly supports lipid management significantly. Among these natural supplements, studies reported promising results with Emblica officinalis (amla) in modulating lipid profiles through its potent antioxidant properties. Several studies reported that E officinalis (amla) has significant lipid-lowering effects through its antioxidant activity, anti-inflammatory properties, and modification of hydroxy methylglutaryl coenzyme A (HMG-CoA) reductase.^9,10 Amla extract reportedly has potential antioxidant and anti-inflammatory properties that can mitigate atherosclerosis progression.¹¹ For atherogenesis, oxidized LDL is a key contributor that promotes endothelial dysfunction, foam cell formation, and the development of plaques.¹² LDL oxidation can be reportedly reduced by tannins and gallic acid,¹³ which is available in amla, resulting in the prevention of formation of proatherogenic oxidized LDL particles. Individuals linked to increased cardiovascular risk are often observed with elevated high-sensitivity C-reactive protein (hs-CRP), which is a marker of systemic inflammation.¹⁴ Such an anti-inflammatory action potentially can help stabilize atherosclerotic plaques and hence reduce cardiovascular risk. Apart from the antioxidant and anti-inflammatory effects of amla, studies reported that amla extracts downregulate HMG-CoA reductase expression, which in turn reduce cholesterol biosynthesis, resulting in lower LDL-C, total cholesterol (TC), and TGs without significantly affecting HDL levels.^15,16 This mechanism is similar to the HMG-CoA reductase inhibition characteristics of statins. Moreover, amla also reportedly enhances lipoprotein lipase activity, facilitating TGs breakdown, which in turn supports its lipid-lowering effects.

Even with these encouraging findings, there are limited comprehensive studies evaluating the combined effect of varying intensities of physical activity and E officinalis supplementation on lipid profiles.

Previous research has evaluated the safety profile of E officinalis (amla) extract¹ used in this clinical study in various preclinical and clinical settings. The acute and subchronic toxicity of the standardized amla extract (Tri-Low®) was assessed in a study conducted by Benny et al¹⁷ according to Organisation for Economic Co-operation and Development (OECD) guidelines. In this study, the extract exhibited a high safety profile with an Lethal dose 50% (LD50) of >2000 mg/kg (Globally Harmonized System category 5) and no observed adverse effects at doses up to 1000 mg/kg/d in a 90-day repeated-dose study. In preclinical studies, the efficacy of amla extract was evaluated in Triton WR-1339 (tyloxapol)-induced dyslipidemia in male Sprague–Dawley rats (unpublished data). In the study, 45 and 90 mg/kg body weight in rats were effective in reducing the high level of TGs and TC in rats. These dosages in rats are equivalent to 500 and 1000 mg in human adults.¹⁸ Upadya et al¹⁶ investigated the initial effects of supplementation of amla extract (Tri-Low®) and found it to be tolerable for human participants. These findings provided a strong basis for selecting doses and further research. Based on this robust safety profile, this study aims to evaluate the impact of supplementation of amla extract (Tri-Low®) on lipid parameters and atherogenic factors.

Hence, this study aims at comparing the impact of high-intensity, moderate-intensity, low-intensity physical activity and the effect of E officinalis supplementation on lipid parameters and atherogenic factors. This study will specifically assess the mean change in TC levels as the primary end point and explore secondary end points, including changes in TGs, LDL, HDL, and biomarkers such as coenzyme Q10 (CoQ10) and HMG-CoA reductase. This study is based on the hypothesis that amla extract has significant lipid-lowering effects, especially in the reduction of TC, LDL-C, TGs, and atherogenic index of plasma (AIP) compared with physical exercise alone over a period of 90 days and is also well tolerated without any significant side effects. It is also hypothesized that a combination of amla extract with structured exercise can have a synergistic impact on improving lipid parameters and thereby reducing atherogenic factors. The outcomes from this study are expected to provide valuable insights into effective strategies for managing dyslipidemia and thereby reducing cardiovascular risk.

Methods

Ethical conduct of the study

The study protocol was reviewed and approved by the Institutional Ethics Committee of Pristine Hospital and Research Centre Pvt Ltd, Bangalore, Karnataka (protocol number AN-05ASE 1216H6-SYN05; approval date January 23, 2017). The study was conducted in accordance with the principles enunciated in the Declaration of Helsinki (Edinburgh, 2000) and the International Council for Harmonisation of Technical Requirements of Pharmaceuticals for Human Use (ICH)-harmonized tripartite guideline regarding Good Clinical Practice and Ethical Guidelines for Biomedical Research on Human Participants, 2006 of Indian Council of Medical Research in India (Clinical Trial Registry - India (CTRI) number: CTRI/2017/02/007829, registered on February 10, 2017. The clinical trial was prospectively registered with the Clinical Trials Registry–India. The study protocol and related documents were reviewed and approved by the Institutional Ethics/Committee for study initiation. Written and oral information about the study in a language understandable by the participants were provided to all the participants. Before entry into the study or initiation of any study-related procedures, written informed consent was obtained from all the participants by the study doctor. The participant identification information was handled only by a delegated staff, and all the study documents of each participant were identified by using their initials and participant study number.

Study population

Inactive population between 18 and 65 years of age having TGs >200 mg/dL, LDL-C >130 mg/dL, and TC >200 mg/dL and not taking any medication (including herbal products) for the management of abnormal lipid levels since last 4 weeks were included in the study. Inactive population is defined as less than 150 minutes of moderate-intensity physical activity throughout the week, or less than 75 minutes of vigorous-intensity physical activity throughout the week, or less than an equivalent combination of moderate- and vigorous-intensity activity, assessed using the International Physical Activity Questionnaire.

The following participants were excluded from the study: cigarette smokers and those with uncontrolled CVD or advanced atherosclerosis, hypertension, very high TG levels (>500 mg/dL), or uncontrolled diabetes. Pregnancy, lactation, and female patients not using acceptable contraceptive measures were not included in the study. Participants with hepatic impairment or renal impairment, or any other severe systemic illness, and those who, in the opinion of the investigator, would be noncompliant with the visit schedule or study procedures were excluded from the study. Participants with a known history of hypersensitivity to amla or any product containing amla extract were also excluded. Participants with a continuing history of alcohol and/or drug abuse, with any other serious concurrent illness or malignancy, or participated in another clinical trial in the past 3 months were also excluded.

Study intervention

The amla extract (Tri-Low) used in this clinical study was manufactured and supplied by M/s Arjuna Natural Ltd, Kerala, India. The extract was prepared following a standardized process to ensure quality and consistency, as detailed in Upadya et al.¹⁶ The raw material consisted of fresh, wild fruits of E officinalis (amla), collected from Tamil Nadu, India. The fruits were botanically and taxonomically authenticated, thoroughly cleaned using running water, and crushed into small pieces to increase the surface area for efficient extraction. The extraction was carried out at ambient conditions (25°C) using a proprietary solvent mixture composed of water, ethyl alcohol, and ethyl acetate in a 70:15:15 ratio. Four volumes of this mixture, relative to the raw material, were used, and the material was soaked for 3 hours. This procedure was repeated 3 times. The solvent-extract mixture was filtered using a polypropylene cloth (15 µm), and the filtered extract was evaporated to dryness under controlled temperature conditions (hot water temperature: 95 ± 5°C; vacuum, 550–650 mm Hg). To ensure purity, potency, and safety, the extract underwent rigorous quality control measures. Gas chromatography was used to analyze α-linolenic acid–diacylglycerol (ALA-DAG), UV-visible spectrophotometry was employed to measure polyphenols and triterpenoids, and high-performance thin-layer chromatography was used to assess DAG. Safety assessments included analysis for heavy metals using inductively coupled plasma mass spectrometry, pesticide residues using gas chromatography–mass spectrometry, and residual solvents by headspace gas chromatography. The extract was standardized to contain not less than 35% total polyphenols, Not less than (NLT) 7% triterpenoids, omega-3 fatty acids, total ALA NLT 5%, and ALA-DAG NLT 4%. The amla extract was encapsulated into 500 mg, zero-size vegetarian capsules (Tri-Low, Arjuna Natural Private Ltd, Kerala, India). Participants in the study were instructed to take one 500 mg capsule of amla extract twice daily for 90 days.

Study procedure

This was an open-label study consisting of 4 visits: screening (visit 1, 14 days), rescreening and enrollment (visit 2, day 0 ± 2 days), follow-up (visit 3, day 45 ± 5 days), and end of study (visit 4, day 90 ± 5 days).

Participants were screened at visit 1, were instructed to do moderate exercise, and were recommended to follow a healthy diet for a period of 14 days from the day of screening. After 14 days, at visit 2, lipid levels of the participants were rescreened to confirm eligibility. Participants fulfilling the eligibility criteria at visit 2 were enrolled into the study. Enrolled participants were instructed to take 500 mg of amla extract twice daily for 90 days. The enrolled participants were not permitted to take any medication (allopathic or herbal preparation) that could potentially affect their lipid levels. All the participants enrolled in the study were asked to initiate lifestyle changes (a healthy diet with aerobic exercise at least 4 days a week) along with the study medication.

Efficacy assessments were conducted at all visits during the study period. Demographic data and other characteristics (age, sex, height, weight, and body mass index [BMI]) were collected. Physical activity and sedentary behavior were evaluated using the long-form International Physical Activity Questionnaire (IPAQ). Based on the physical activity measured by IPAQ data, the participants were categorized into low (inactive), moderate, and vigorous physical activity groups.

Lipid parameters, including TC, TGs, LDL-C, HDL-C, and VLDL-C, were measured at screening (visit 1), day 0 (visit 2), day 45 (visit 3), and day 90 (visit 4). Other parameters in correlation with progression of coronary artery disease such as AIP, apolipoprotein (Apo) A1 and B, Apo A1/B ratio, CoQ10, HMG-CoA reductase levels, and chronic inflammatory markers such as hs-CRP were analyzed at day 0 and day 90.

The AIP was calculated as the logarithm to the base 10 (common logarithm) of the ratio of the molar concentration of TGs to the molar concentration of HDL-C with concentrations expressed in millimoles per liter. Fasting blood sugar (FBS), complete safety laboratory assessments (hematological and biochemical), and ECG evaluations were performed at screening and at the end of the study, to ensure safety profile of the study medication. A urine pregnancy test was done during screening and end of the study in females of child-bearing potential. Compliance with study medications was monitored, and clinical adverse events were monitored and recorded at every visit.

Determination of sample size

Sample size calculations were performed to establish the necessary minimum participant count for detecting significant results in our study,¹⁹ based on a previous clinical research that reported amla extract lowered TC from 231 mg/dL to under 200 mg/dL in 65% of participants (33 of 49). The determined sample size came to 32 subjects when using an effect size of 0.6 with 5% significance (α = 0.05) and a 90% power level (β = 0.10). With an estimated dropout of 20%, a total number of 39 participants was required for the study.

Statistical analysis

General Linear Model Analysis of Variance (GLM ANOVA) with Tukey–Kramer multiple-comparison test was used in the statistical analysis for efficacy parameters. Wilcoxon signed-rank test and paired t test were used in the statistical analysis for safety parameters. Normality tests used were Shapiro–Wilk normality, skewness normality, kurtosis normality, and omnibus normality. If any of the aforementioned tests confirmed normality, the distribution was treated as normal and paired t test was performed in normal distribution data, and Wilcoxon signed-rank test was applied when the data distribution was not normal. To enhance the clinical relevance of the statistical outcomes, in addition to P values, effect sizes (Cohen’s d) and 95% CIs were calculated for key outcomes (between visit and between exercise intensity).

Results

Ninety-two participants were screened. Based on physical activity measured by IPAQ, 45 participants met the inclusion/exclusion criteria and were eligible for rescreening. They were instructed to do lifestyle modification with moderate exercise and rescreened for lipid profile after 14 days. Thirty-nine participants met the eligibility criteria of lipid profile on rescreening and were allocated to the study intervention (Figure 1). Using IPAQ, all the participants were included under the low physical activity category as per the inclusion criteria. Demographic characteristics are shown in Table 1. During visit 1, all participants were under the low physical activity category. During visit 2, 15 participants were in the high physical activity category, 21 participants were in the moderate physical activity category, and 3 participants were in the low physical activity category. During visit 3, 13, 24, and 2 participants were in the high, moderate, and low physical activity category, respectively. During visit 4, 15 participants were in the high physical activity category, 23 participants were in the moderate physical activity category, and 1 participant was in the low physical activity category. Mean data of the studied variables across the participant visits and percentage change are detailed in Figures 2 and 3.

Figure 1.

Consolidated Standards of Reporting Trials flow diagram of disposition of subjects.

Table 1.

Demographic and other baseline characteristics.

Characteristics	Values
Age (y), mean (SD)	38.85 (9.50)
Gender, n (%)
Male	12 (30.7)
Female	27 (69.23)
Height (cm), mean (SD)	164.05 (6.28)
Weight (kg), mean (SD)	72.08(10.07)
BMI (kg/m2), mean (SD)	26.82(3.86)

Figure 2.

Effect of Amla extract on weight, body mass index (BMI), atherogenic index of plasma (AIP), and lipid profile. Inset values represent percentage change at visit 4 from visit 1. TC = total cholesterol; TG = triglyceride; V1 = visit 1; V2 = visit 2; V3 = visit 3; V4 = visit 4. The asterisks represent statistical significance; *p < 0.05; **p < 0.01; **p < 0.001.

Figure 3.

Effect of amla extract on mean concentration of lipoprotein markers. Inset values represent percentage change at visit 4 from visit 2. Apo = apolipoprotein; Co-Q10 = coenzyme Q10; HMGCoA = hydroxy methylglutaryl coenzyme A; hsCRP = high-sensitivity C-reactive protein; V2 = visit 2; V4 = visit 4. The asterisks represent statistical significance. *p < 0.05; **p < 0.01.

With amla extract, significant change in weight (Cohen’s d = 1.15; CI, 11.4–20.55) and BMI (Cohen’s d = 0.96; CI, 3.28–6.73) is observed after 45 days (visit 3) (P < 0.001) and 90 days (visit 4) (weight: P < 0.001; Cohen’s d = 1.03; CI, 9.76–18.91; BMI: P = 0.002; Cohen’s d = 0.53; CI, 1.03–4.48) when compared with visit 1. Significant change in weight is observed in high exercise category compared with moderate exercise (P < 0.001; Cohen’s d = 0.73; CI, −12.69 to −4.82) and moderate exercise category compared with low exercise (weight: P = 0.002; Cohen’s d = 0.51; CI, −9.93 to −2.17; BMI: P = 0.008; Cohen’s d = 0.45; CI, −3.45 to −0.52). Weight and BMI do not show any significant reduction based on the overall F test. However, multiple-comparison test shows that exercise intensity as well as amla extract significantly reduced weight and BMI. With amla extract, significant change was observed in TC, TG, LDL level after 45 days (visit 3) (TC: P = 0.017; Cohen’s d = 0.403; CI, −23.44 to −2.36; TG: P < 0.001; Cohen’s d = 0.68; CI, 11.79–33.97; LDL: P < 0.001; Cohen’s d = 1.24; CI, 13.44–23.16; VLDL: P = 0.014; Cohen’s d = 0.415; CI, 0.58–4.98) and 90 days (visit 4) (TC: P < 0.001; Cohen’s d = 0.59; CI, −29.32 to −8.24; TG: P = 0.007; Cohen’s d = 0.46; CI, 4.37–26.55; LDL: P = 0.006; Cohen’s d = 0.463; CI, 1.99–11.71) when compared with visit 1.

Significant change was observed in VLDL level after 45 days (visit 3) (P = 0.014) but not observed after 90 days (visit 4) (P = 0.366; Cohen’s d = 0.152; CI, −1.19 to 3.21) when compared with visit 1. No significant change in TC, TG, and VLDL level was observed when high exercise category was compared with moderate exercise (TC: P = 0.46; Cohen’s d = 0.125; CI, −5.63 to 12.51; TG: P = 0.226; Cohen’s d = 0.203; CI, −15.41 to 3.67; VLDL: P = 0.523; Cohen’s d = 0.107; CI, −2.51 to 1.28) and moderate exercise category was compared with low exercise (TC: P = 0.79; Cohen’s d = 0.045; CI, −7.72 to 10.17; TG: P = 0.078; Cohen’s d = 0.295; CI, −17.85 to 0.96; VLDL: P = 0.418; Cohen’s d = 0.135; CI, −2.61 to 1.1). Significant change in LDL was observed in the high exercise group compared with moderate exercise (P < 0.001; Cohen’s d = 0.866; CI, −15.16 to −6.8) and the moderate exercise group compared with low exercise (P < 0.001; Cohen’s d = 1.05; CI −17.27 to −9.03). The effect of amla extract on weight, BMI, and lipid profile is illustrated in Table 2.

Table 2.

Effect of amla extract on weight, BMI, and lipid profile.

Parameter	Exercise category	Visit 1		Visit 2		Visit 3		Visit 4		Exercise category wise comparison	P value*	Visit wise comparison (time wise)			P value†
		Mean	SEM	Mean	SEM	Mean	SEM	Mean	SEM			1,2	1,3	1,4	Exercise intensity–time interaction	Exercise intensity	Time
Weight	High	60.76	0	70.73	2.64	72.58	2.84	70.27	2.64	H/M	<0.001‡	<0.001‡	<0.001‡	<0.001‡	0.949	0.479	0.884
	Low	72.1	1.64	66.1	5.90	63.2	7.23	62.1	10.22	L/M	0.002§
	Moderate	25.47	0	74.38	2.23	70.49	2.09	68.96	2.13
BMI	High	25.43	0	26.64	0.99	28.62	1.07	26.67	0.99	H/M	<0.001‡	<0.001‡	<0.001‡	0.002§	0.725	0.241	0.483
	Low	26.85	0.62	26.4	2.22	25.05	2.72	21	3.85	L/M	0.008§
	Moderate	12.55	0	27.22	0.84	26.18	0.79	25.41	0.80
TC	High	219.52	0	252.87	6.08	212.92	6.53	207.33	6.08	H/M	0.460	<0.001‡	0.017װ	0.001§	0.676	0.967	<0.001‡
	Low	253	3.77	238	13.59	199.5	16.65	211	23.55	L/M	0.790
	Moderate	210.59	0	255.38	5.14	232	4.81	208.44	4.91
TG	High	166.39	0	237.8	6.39	198.46	6.87	192.87	6.39	H/M	0.226	<0.001‡	<0.001‡	0.007§	0.516	0.989	<0.001‡
	Low	226.15	3.97	220.67	14.30	178	17.52	181	24.77	L/M	0.078
	Moderate	130.89	0	229.57	5.41	215.63	5.06	195.96	5.16
LDL	High	97.49	0	143.27	2.80	121.62	3.01	116.47	2.80	H/M	<0.001‡	<0.001‡	<0.001‡	0.006§	0.511	0.679	<0.001‡
	Low	140.18	1.74	140.33	6.27	111	7.68	96	10.86	L/M	<0.001‡
	Moderate	63.47	0	138.81	2.37	123.42	2.22	109.22	2.26
HDL	High	52.19	0	49	1.15	48.15	1.24	46.47	1.15	H/M	0.653	0.654	0.141	0.086	0.916	0.986	0.522
	Low	49.97	0.71	48.67	2.57	47	3.15	49	4.45	L/M	0.907
	Moderate	46.09	0	51.95	0.97	48.63	0.91	47.57	0.93
VLDL	High	35.38	0	47.56	1.27	39.69	1.37	37.91	1.27	H/M	0.523	<0.001‡	0.014װ	0.366	0.454	0.995	<0.001‡
	Low	45.23	0.79	44.13	2.84	35.6	3.48	36.2	4.92	L/M	0.418
	Moderate	29.66	0	45.91	1.07	43.33	1.01	39.19	1.03
AIP	High	0.15	0	0.33	0.02	0.25	0.02	0.26	0.02	H/M	0.299	<0.001‡	<0.001‡	<0.001‡	0.472	0.997	0.055
	Low	0.29	0.01	0.29	0.04	0.22	0.05	0.21	0.07	L/M	0.088
	Moderate	0.11	0	0.29	0.01	0.28	0.01	0.25	0.01

AIP = atherogenic index of plasma; BMI = body mass index; H = high; L = low; M = moderate; TC = total cholesterol; TG = triglyceride.

^⁎Tukey−Kramer multiple-comparison test.

^†ANOVA F test.

^‡Statistical significance at p < 0.001.

^§Statistical significance at p < 0.01.

^װStatistical significance at p < 0.05.

Exercise along with amla extract (TC, P = 0.676; TG, P = 0.516; LDL, P = 0.511; VLDL, P = 0.454) and exercise alone (TC, P = 0.967; TG, P = 0.989; LDL, P = 0.679; VLDL, P = 0.995) did not influence the reduction in TC, TGs, LDL, and VLDL. The significant reduction observed in TC, TG, LDL, and VLDL levels was purely due to the effect of amla extract (P < 0.001). The significant reduction observed in TC, TGs, and VLDL was purely by the effect of amla extract (P < 0.001), and exercise intensity did not influence the reduction. Overall, F test for LDL data reported that the significant reduction observed for LDL is by the effect of amla extract only (P < 0.001), and Tukey–Kramer multiple-comparison test reported that exercise as well as amla extract use resulted in a significant reduction (P < 0.001).

No significant change is seen in HDL value across the visits neither with exercise nor with amla extract. Exercise along with amla extract also did not influence HDL. Statistically significant change was observed in AIP after 45 days (visit 3) (P < 0.001; Cohen’s d = 0.745; CI, 0.04–0.095) and 90 days (visit 4) (P < 0.001; Cohen’s d = 0.59; CI, 0.02–0.08) when compared with baseline (visit 1). No significant difference in AIP level was observed between high and moderate exercise groups (P = 0.299; Cohen’s d = 0.174; CI, −0.04 to 0.01) and low and moderate exercise groups (P = 0.088; Cohen’s d = 0.287; CI, −0.05 to 0.003). Exercise along with amla extract (P = 0.472) and exercise alone (P = 0.997) did not influence the reduction in AIP. Based on overall F test, AIP found a trend toward significant reduction (P = 0.055), and a multiple-comparison test shows that they are significantly reduced due to amla extract and not by exercise intensity.

With amla extract for 90 days, a significant increase in Apo A1 value in visit 4 is seen when compared with visit 2 (P = 0.012; Cohen’s d = 0.432; CI, 0.03–0.22). No significant change is seen in Apo B in visit 4 when compared with visit 2 (P = 0.098; Cohen’s d = 0.28; CI, −0.23 to 0.02). Significant decrease in Apo B/Apo A1 ratio in visit 4 was seen when compared with visit 2 (P < 0.001; Cohen’s d = 0.583; CI, −0.32 to −0.09). No significant change in Apo A1, Apo B, and Apo B/Apo A1 ratio was observed between high and moderate exercise (Apo A1: P = 0.202; Cohen’s d = 0.215; CI, −0.16 to 0.04; Apo B: P = 0.938; Cohen’s d = 0.013; CI, −0.14 to 0.13; Apo B/Apo A: P = 0.641; Cohen’s d = 0.078; CI, −0.09 to 0.15) and low and moderate exercise categories (Apo A1: P = 0.431; Cohen’s d = 0.132; CI, −0.13 to 0.31; Apo B: P = 0.566; Cohen’s d = 0.097; CI, −0.21 to 0.37; Apo B/Apo A: P = 0.928; Cohen’s d = 0.015; CI, −0.25 to 0.26). Apo A1 does not show any significant change based on the overall F test (P = 0.133). However, a multiple-comparison test showed that Apo A1 significantly increased by the effect of amla extract and not by exercise intensity. Exercise and amla extract did not influence in reducing Apo B (P = 0.579). Based on the overall F test, Apo B/Apo A1 ratio reported a trend toward significant reduction (P = 0.061), and multiple-comparison test showed that they are significantly reduced due to amla extract and not by exercise intensity. With amla extract for 90 days, a significant decrease in hs-CRP in visit 4 was seen when compared with visit 2 (P = 0.035; Cohen’s d = 0.378; CI, −0.18 to −0.012). No significant change in hs-CRP was observed between high and moderate exercise (P = 0.990; Cohen’s d = 0.002; CI, −0.09 to 0.09) and low and moderate exercise categories (P = 0.203; Cohen’s d = 0.215; CI, −0.07 to 0.32). Based on the overall F test, exercise and amla extract do not show any significant change in reducing hs-CRP (P = 0.947). However, a multiple-comparison test shows that hs-CRP got significant decrease by the effect of amla extract and not by exercise intensity.

No significant change is seen in HMG-CoA (P = 0.127; Cohen’s d = 0.257; CI, −4.58 to 0.59) and CoQ10 (P = 0.464; Cohen’s d = 0.123; CI, −53.45 to 24.63) in visit 4 when compared with visit 2. No significant difference in HMG-CoA and CoQ10 was observed between high and moderate exercise (HMG-CoA: P = 0.595; Cohen’s d = 0.088; CI, −1.98 to 3.43; CoQ10:P = 0.677; Cohen’s d = 0.07; CI, −32.25 to 49.39) and low and moderate exercise groups (HMG-CoA: P = 0.091; Cohen’s d = 0.285; CI, −0.845 to 11.08; CoQ10: P = 0.568; Cohen’s d = 0.096; CI, −115.95 to 64.11). Exercise and amla extract did not influence HMG-CoA expression (P = 0.398) and CoQ10 (P = 0.626). No significant change is seen in FBS value between visit 1 and visit 4. No significant difference in FBS level was observed between high and moderate exercise (P = 0.649) and low and moderate exercise categories (P = 0.107). Exercise and amla extract did not influence FBS level (P = 1.00). Variability in coronary artery disease during the study from the amla extract administration is detailed in Table 3.

Table 3.

Effect of amla extract on parameters related to coronary artery disease.

Parameter	Exercise category	Visit 2		Visit 4		Exercise category wise comparison	P value*	Visit wise comparison (time wise)	P value†
		Mean	SEM	Mean	SEM				Exercise intensity–time interaction	Exercise intensity	Time
Apo A	High	1.04	0.05	1.30	0.05	H/M	0.202	0.012‡	0.133	0.295	0.163
	Low	0.99	0.12	1.05	0.21	L/M	0.431
	Moderate	1.08	0.05	1.13	0.04
Apo B	High	1.01	0.07	0.99	0.07	H/M	0.938	0.098	0.579	0.869	0.364
	Low	1.07	0.16	0.75	0.28	L/M	0.566
	Moderate	0.98	0.06	1.01	0.06
Apo B/Apo A1	High	0.97	0.07	0.79	0.07	H/M	0.641	0.001‡	0.301	0.885	0.061
	Low	1.13	0.15	0.71	0.26	L/M	0.928
	Moderate	0.93	0.06	0.89	0.05
hs-CRP	High	0.39	0.05	0.32	0.05	H/M	0.990	0.035§	0.947	0.524	0.220
	Low	0.29	0.11	0.17	0.19	L/M	0.203
	Moderate	0.40	0.04	0.31	0.04
HMG-CoA	High	26.55	1.48	24.64	1.48	H/M	0.595	0.127	0.398	0.318	0.404
	Low	20.71	3.31	21.70	5.73	L/M	0.091
	Moderate	28.86	1.25	23.78	1.19
CoQ10	High	493.22	22.33	439.96	22.33	H/M	0.677	0.464	0.626	0.776	0.690
	Low	482.16	49.93	520.00	86.48	L/M	0.568
	Moderate	489.06	18.87	461.25	18.03
		Visit 1		Visit 4
FBS	High	93.01	0.00	91.20	3.36	H/M	0.649	0.542	1	0.994	1.000
	Low	88.03	2.09	89.00	13.03	L/M	0.107
	Moderate	96.37	0.00	91.78	2.72

Apo = apolipoprotein; CoQ10 = coenzyme Q10; FBS = fasting blood sugar; H = high; HMG-CoA = hydroxy methylglutaryl coenzyme A; hs-CRP = high-sensitivity C-reactive protein; L = low; M = moderate.

^⁎Tukey–Kramer multiple-comparison test.

^†ANOVA F test; P < 0.05 was considered statistically significant.

^‡Statistical significance at p < 0.01.

^§Statistical significance at p < 0.05.

Assessment of safety variables from the study reported that urine parameters, hematological indices, and biochemistry parameters, including liver function tests, renal function tests, and blood profiles, were within normal limits at baseline and end of the study. Vital signs, including systolic and diastolic blood pressure, pulse rate, respiratory rate, and axillary temperature, were within normal ranges during all study visits. No clinically significant change was observed with amla extract throughout the study period (Table 4). There were no reports of gastrointestinal discomfort, allergic reactions, musculoskeletal complaints, or any other clinically significant adverse symptoms among participants. There were no withdrawals or dropouts reported, and all 39 participants completed the study with good compliance to study supplements.

Table 4.

Safety laboratory evaluation.

Safety parameter	Visit 1		Visit 4		P value
	Mean	SEM	Mean	SEM
SGOT (IU/L)	28.90	1.61	24.23	1.53	0.007*,†
SGPT (IU/L)	31.30	1.96	27.03	1.89	0.094‡
Total bilirubin (mg/dL)	0.84	0.03	0.72	0.04	0.005*,‡
Blood urea (mg/dL)	23.15	0.83	24.13	0.66	0.05‡
Serum creatinine (mg/dL)	0.88	0.02	0.87	0.03	0.404†
Hemoglobin (%)	13.53	0.29	13.92	0.36	0.275‡
RBC (millions/mm3)	5.16	0.11	5.30	0.07	0.219‡
Hematocrit (%)	41.41	0.78	43.26	1.04	0.067‡
Total leukocyte count (cells/mm3)	8208.72	320.77	7148.46	262.91	0.027*,‡
Absolute neutrophil count (%)	53.80	1.42	57.73	1.98	0.015*,†
Lymphocyte count (%)	38.26	1.35	33.72	1.25	0.011*,‡
Eosinophil count (%)	3.21	0.36	2.27	0.24	0.032*,‡
Basophil count (%)	0.29	0.07	0.55	0.07	0.001*,‡
Monocyte count (%)	4.42	0.31	4.26	0.33	0.714‡
Platelet count (cells/mm3)	299615.40	11103.53	329897.40	12466.90	0.073‡
ESR (mm/h)	13.72	2.04	15.95	1.26	0.075†

SGOT = Serum Glutamic Oxaloacetic Transaminase, SGPT = Serum Glutamate Pyruvic Transaminase, RBC = Red Blood Cells, ESR = Erythrocyte Sedimentation Rate. SEM = Standard Error Mean.

^⁎P < 0.05 was considered a statistically significant difference.

^†Wilcoxon signed-rank test.

^‡Paired t test.

Discussion

This study evaluated the impact of physical activities and amla supplementation on lipid profiles such as HDL, TC, LDL, and TG levels. The observations from this study illustrate that although exercise alone had minimal impact on lipid parameters, supplementation of amla has significantly improved lipid profile, particularly in reducing TC, LDL, TGs, and VLDL. Such observations suggest that amla supplementation could play significant role in lipid modulation than exercise alone for a shorter period.

Although previous studies reported inconsistent reduction in lipid profiles from physical activities, our study reported no significant improvement in lipid profiles even with adherence to aerobic exercise regimens.

A similar observation of limited reduction in TC was reported among participants with exercise from previous studies, when weight loss was not a factor.^20,21 Similarly, other studies reported that exercise alone did not significantly reduce plasma LDL concentrations without notable weight loss.²² In this study, it was evident that there is no significant improvement in lipid parameters with exercise alone. This could be potentially from the inconsistency in the exercise activities, duration, and intensity of physical activity by the participants. Although the participants were advised to engage in aerobic physical activities, at least 4 d/wk, the exercise activities were not objectively tracked. The exercise tracking during this study was using IPAQ, which potentially has caused variability in self-reported physical activity across visits that might have introduced inconsistent observations. Moreover, it is also reported that significant improvement in lipid profiles, especially LDL and TGs, needs sustained high-intensity or longer-duration exercise interventions.²³ The lack of significant change in lipid profiles with exercise in our study points to the fact that the duration and exercise intensity used in the study might not be sufficient to bring our measurable variability in lipid profiles. Studies reported that longer and intense exercise training can significantly increase HDL-C levels^{24, 25, 26} and improve HDL particle size and concentration.

The reported improvement in lipid profiles from amla supplementation study from this study corroborates the established role of dietary supplements in combination with physical activities in improving these benefits and is gaining attention. One such supplement, E officinalis (amla) extracts, used in this study, has reportedly shown promising outcomes toward lipid profiles and managing cardiovascular risks.^16,27 Amla reportedly contains potent antioxidants, including tannins, flavonoids, and vitamin C that can reduce the risk of CVD development potentially by combating oxidative stress.^{28, 29, 30} Studies report that amla can significantly lower TC, LDL-C, and TG levels while increasing HDL-C, offering a potential alternative to conventional therapies.^{31, 32, 33} The lipid management capability of amla is potentially from its ability to inhibit hepatic cholesterol synthesis and enhance the functioning of lipoprotein lipase, improving TG metabolism.³⁴ Additionally, its antioxidant properties can reduce anthropogenic potential by working against the oxidation of LDL-C, which aligns with the improved cardiovascular parameters, including reduced arterial stiffness and better endothelial function.^35,36

Both TGs and cholesterol are independent predictors of Ischemic Heart Disease (IHD), but their combined assessment better determines IHD risk.³⁷ The AIP, used as a risk predictor in this study, remained unchanged with exercise alone, showing an insignificant impact of exercise on the lipid indices. In addition, though the highly sensitive CRP is a marker of inflammation which has an inverse relationship to physical activity levels,^38,39 our study reported so significant changes in CRP with exercise. This points to the fact that the intensity and duration of the exercise regimen used in this study were insufficient to reduce inflammation, as reported in other studies.⁴⁰

This study demonstrates that HDL-C and other atherogenic factors, except LDL, were not significantly altered after 90 days of regular physical activity at varying intensities when health supplements were not used. Although there is a potential possibility that the changes in HDL-C might have been observed in participants with initially low HDL-C levels, our participants represented a cross-section of individuals with reasonably adequate HDL-C levels. Previous reports suggest that HDL levels are inversely related to body weight, as reported in previous studies.^{41, 42, 43, 44} Changes in HDL, TG, VLDL, and TC are likely influenced significantly by weight loss, diet, or other lifestyle changes rather than by exercise alone. Our study concludes that exercise alone may not significantly affect atherogenic factors, whereas amla supplementation significantly improved the lipid profile, especially lowering TC, LDL, TGs, and VLD, even after 45 days of consumption, and potentially reducing CVD risk.

In general, prospective studies employing less intensive exercise regimens have induced little or no change in HDL.^45,46 Notably, earlier studies reported no significant variability in plasma TG, VLDL, and LDL with exercise, except for a significant decrease in the TC. It is also possible that the intensity or duration of exercise performed by the participants in these studies was insufficient to induce a training effect, despite an increase in VO₂ max (maximal oxygen consumption). From our study, it is evident that major lipid variables were not affected by exercise intensity, and we achieved a nonsignificant weight reduction, whereas the supplementation of amla extract reported significant improvement in the lipid profile. Moreover, the study reported no clinically significant adverse effects among the participants during the study period. The safety assessment, along with the improved efficacy of the amla intervention, as observed from this study, corroborates previous findings and clearly demonstrates the tolerability and compatibility of using amla supplementation to manage healthy lipid profiles.^16,17

Limitations and Future Directions

A major limitation of this study is associated with the observed fluctuation, specifically in the intervisit variability in physical activity characteristics of those participants, evident from the shifting of participants between low, moderate, and vigorous activity groups. These variations might be due to differences in adherence of different participants to the recommendations of the study. This assessment is based on the IPAQ, which was used to measure and categorize activity independently; however, issues of inter-participant variability arising out of nonstratified random sampling or determining prespecified activity boundary may have influenced the analysis of data. It is suggested that future works should employ stratified randomization and enhanced adherence to following the guidelines in order to reduce this degree of variation and produce a tighter convergence of results with regard to the influence of physical activity on the effectiveness of the interventions. Additionally, the reliance on self-reported physical activity data solely through the IPAQ method is another limitation, and future studies should incorporate objective activity tracking methods such as wearable monitors to ensure proper exercise quantification. Additionally, this study was conducted with a relatively small cohort of 39 participants, which might have affected the statistical power. Future studies should involve larger, diverse population to improve generalizability. This study also relied on self-reported exercise adherence information that might have led to variability in exercise intensity assessed among participants. This limitation can be reduced in future studies by incorporating objective biometric tracking methods such as wearable activity monitors to ensure consistency of data collected. Although this study did not identify any safety profile issues in the administration of amla extract in the 90-day period, it is important to conduct long-term clinical trials to determine long-term efficacy and potential delayed adverse effects. This study also did not include independent “exercise only,” “amla only,” and “combined exercise and amla” intervention arms, which potentially limits the ability to separate and discuss the comparison of individual and synergistic effects of each intervention. Further studies could establish a randomized, controlled factorial design to evaluate the independent and interactive contributions of exercise and amla supplementation more precisely. Another limitation in this study is that potential confounding factors were not considered, and this study emphasizes the need for monitoring and controlling these factors in future studies. Addressing these limitations in future studies will enhance the evidence base for amla extract as a potential supplement therapy for improving overall health and especially cardiovascular health.

Conclusions

Our findings clearly show that although regular physical activity alone may not significantly improve lipid profiles, supplementation with amla extracts demonstrated significant improvement in TC, LDL, TGs, and AIP. In conclusion, amla extract, as an adjunct therapy, shows potential in improving lipid profiles and could serve as a valuable supplement to exercise interventions in the prevention and management of cardiovascular risk.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.