This randomized clinical trial assesses the efficacy and safety of berberine therapy to reduce visceral adipose tissue and liver fat content in diabetes-free individuals with obesity and metabolic dysfunction–associated steatotic liver disease.
Key Points
Question
Can treatment with berberine reduce visceral adipose tissue (VAT) and liver fat content in diabetes-free individuals with obesity and metabolic dysfunction–associated steatotic liver disease (MASLD)?
Findings
In this randomized clinical trial including 337 participants, those treated with berberine for 6 months had similar changes in VAT area and liver fat content and showed no excess risk compared with placebo.
Meaning
The findings suggest that berberine therapy in diabetes-free individuals with obesity and MASLD is safe but has no significant effect on VAT area or liver fat content.
Abstract
Importance
Berberine is a potential therapy for metabolic disorders, yet its effects on visceral adipose tissue (VAT) and liver fat remain uncertain.
Objectives
To evaluate the efficacy and safety of berberine in reducing VAT area and liver fat content in diabetes-free individuals with obesity and metabolic dysfunction–associated steatotic liver disease (MASLD).
Design, Setting, and Participants
In this multicenter, double-blind randomized clinical trial, diabetes-free individuals with obesity and MASLD were enrolled at 11 hospitals in China between July 6 and December 29, 2023, with a follow-up duration of 6 months.
Interventions
Participants were randomly assigned to receive either oral berberine, 1 g/d, or a matching placebo.
Main Outcomes and Measures
The primary outcomes were relative percentage change in VAT area and absolute change in liver fat content assessed by computed tomography. Other outcomes included changes in parameters of glucose, lipids, and inflammation. Analyses were conducted according to the intention-to-treat principle.
Results
Among 337 randomized participants (mean [SD] age, 41.8 [10.6] years; 221 [65.6%] male), 169 received berberine and 168 placebo. The mean (SD) medication adherence rates were 90.3% (14.7%) for berberine and 90.7% (17.4%) for placebo. No significant differences were observed between study arms for VAT area (1.4% [97.5% CI, −2.4% to 5.2%]) or liver fat content (0.9% [97.5% CI, −0.4% to 2.1%). Berberine was associated with larger reductions in low-density lipoprotein cholesterol (−7.72 [95% CI, −13.13 to −1.93] mg/dL), apolipoprotein B (−3.42 [95% CI, −6.33 to −0.51] mg/dL) and high-sensitivity C-reactive protein (hs-CRP) (−0.072 [95% CI, −0.140 to −0.004] mg/dL) vs placebo, but not other secondary outcomes. The incidence of adverse events was similar between study arms. Post hoc analyses suggested consistent patterns of larger reductions in low-density lipoprotein cholesterol, apolipoprotein B, and hs-CRP levels in participants with higher baseline hs-CRP levels.
Conclusions and Relevance
In this randomized clinical trial of diabetes-free individuals with obesity and MASLD, a 6-month berberine treatment at a daily dose of 1 g had an excellent safety profile but did not reduce VAT area or liver fat content.
Trial Registration
ClinicalTrials.gov Identifier: NCT05647915
Introduction
Excess adiposity, defined by either general obesity or abdominal obesity, affects more than 40% of the global population.1 The accumulation of visceral adipose tissue (VAT) and ectopic fat deposition in the liver, known as metabolic dysfunction–associated steatotic liver disease (MASLD), are the key drivers of systemic insulin resistance, inflammation, and cardiometabolic risk, making them critical targets for intervention.2,3,4,5 While glucagon-like peptide 1 receptor agonists demonstrate efficacy in reducing visceral fat and liver fat,6,7 their long-term use is limited by weight regain after withdrawal,8,9,10 gastrointestinal adverse effects,11,12 and high costs.
Berberine, a bioactive alkaloid derived from plants such as Berberis vulgaris, has emerged as a potential therapy for MASLD and for reducing VAT by mechanisms that differ from glucagon-like peptide 1 receptor agonists. Berberine primarily acts via the activation of adenosine monophosphate kinase and extracellular regulated protein kinases,13 promoting glucose and fatty acid use and inhibiting de novo lipogenesis. It has been reported to improve insulin sensitivity,14,15,16 suppress hepatic lipid synthesis,17,18 and modulate inflammatory responses.19,20 A meta-analysis showed that berberine improved lipid profiles and insulin sensitivity in patients with MASLD.21 Additionally, both an open-label trial and a double-blind trial reported that berberine reduced liver fat in patients with MASLD.22,23 However, these studies predominantly involved individuals with diabetes or impaired glucose regulation, leaving it uncertain whether the fat-reducing effects extend to individuals with normal glucose levels. Moreover, the effect of berberine on VAT, an important marker associated with cardiometabolic morbidity and mortality, has not yet been investigated. Clarifying these issues could help determine whether berberine may serve as an early, well-tolerated, and affordable intervention to mitigate metabolic risk before the onset of overt diabetes.
In this multicenter, double-blind, placebo-controlled randomized clinical trial, we evaluated the efficacy and safety of berberine in reducing VAT area and liver fat content in diabetes-free individuals with MASLD and obesity. We also assessed the effects of berberine on glucose and lipid profiles, high-sensitivity C-reactive protein (hs-CRP), parameters of liver fibrosis, liver enzymes, and body composition.
Methods
Study Design
We conducted a double-blind, randomized clinical trial at 11 hospitals in China to evaluate the efficacy and safety of berberine in reducing VAT area and liver fat content in diabetes-free individuals with obesity and MASLD over a treatment period of 6 months. All investigators are listed in eMethods 1 in Supplement 1. The trial protocol and the statistical analysis plan are available in Supplement 2. The central ethics committee at Fuwai Hospital and the ethics committee of each participating site approved the trial. The trial was registered December 4, 2022, on ClinicalTrials.gov. The trial was conducted and reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline. All participants provided written informed consent.
Participants
Individuals who were at least 18 years of age with obesity and nonalcoholic fatty liver disease (NAFLD) were eligible for this study. The term NAFLD had not been replaced by MASLD at the time of enrollment. Obesity was defined as meeting the criteria of both body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) more than 28 and waist circumference of more than 85 cm in females or 90 cm in males.24 NAFLD was determined by evidence from ultrasonography, computed tomography (CT), or magnetic resonance imaging. Major exclusion criteria were history of cardiovascular disease, diabetes, excess alcohol consumption (≥30 g/wk for males or ≥20 g/wk for females), or other causes of fatty liver disease. The full inclusion and exclusion criteria are listed in eMethods 2 in Supplement 1.
Randomization and Masking
Eligible participants entered a 30-day prerandomization run-in phase in which berberine hydrochloride (0.5 g) was administered twice daily. Individuals who no longer met the eligibility criteria, were intolerant of berberine hydrochloride, or had medication adherence lower than 80% were excluded. Those who remained eligible were randomly allocated in a 1:1 ratio using a minimized randomization program via a central online system to receive either berberine hydrochloride (0.5 g) twice daily or a matching placebo for 6 months. All eligible participants also received tailored lifestyle interventions (eMethods 3 in Supplement 1).25,26,27 A daily dose of 1.0 g total was selected to optimize tolerability and adherence. This dose was supported by a systematic review suggesting that a dose of 1.0 g/d was equally effective in improving cardiovascular risk factors compared with higher doses (≥1.5 g/d).28 However, higher doses of berberine therapy were reported to have increased risk of gastrointestinal intolerance.29,30 Six months for treatment duration was chosen to allow sufficient time for measurable changes in visceral and liver fat.31 Randomization factors include age (<65, ≥65 years), sex (female, male), prediabetes (yes, no), abnormal liver function (yes, no), and lipid-lowering medication use (yes, no).
Berberine hydrochloride and the matching placebo were manufactured by Yunnan Biovalley Pharmaceutical Co Ltd in compliance with Good Manufacturing Practice standards. The active medication was formulated into tablets, each containing 0.1 g of berberine hydrochloride. Both berberine and placebo tablets were indistinguishable in appearance, weight, color, taste, and packaging to maintain blinding. Participants were required to take 5 tablets twice daily (after breakfast and dinner) orally for 6 months. The study medications were prepared and packaged in tamper-proof bottles labeled with a unique blinded medication code and dispensed to the study sites by Yunnan Biovalley Pharmaceutical Co Ltd. The central online system instructed the local physician to dispense the medication based on the medication code, ensuring allocation concealment. Study investigators, participants, data managers, local CT technicians, and radiologists in the core laboratory were blinded to the treatment allocation. The final statistical analysis was performed by independent statisticians (Xiaoyan Yan and Y.Z.) after database lock and unblinding.
Outcomes
Participants attended follow-up visits at 2, 4, and 6 months (eMethods 4 in Supplement 1). Outcomes were measured at baseline and 6 months. The 2 primary outcomes were the relative percentage change in VAT area and the absolute change in liver fat content. Both were assessed by CT and analyzed by independent radiologists who were blinded to the treatment allocation (eMethods 5 in Supplement 1). Liver fat content derived from CT demonstrates good correlation and accuracy with proton density fat fraction obtained from chemical shift encoded magnetic resonance imaging in the Chinese population.32
Secondary outcomes were changes in a comprehensive panel of cardiometabolic parameters, including levels of glycated hemoglobin A1c, fasting plasma glucose, 2-hour postprandial plasma glucose, homeostatic model assessment of insulin resistance,33 homeostatic model assessment of β cell function,33 homeostatic model assessment of insulin sensitivity,33 triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol (LDL-C), total cholesterol, lipoprotein(a), apolipoprotein A1, apolipoprotein B (apoB), serum uric acid, systolic and diastolic blood pressure, BMI, body weight, waist circumference, and waist to height ratio. We also compared the remission of prediabetic status to normal glucose status between arms among participants with prediabetes at baseline. Prediabetic status was defined as fasting plasma glucose between 109.8 and 126.0 mg/dL, inclusive, or as 2-hour postprandial plasma glucose between 140.4 and 199.8 mg/dL, inclusive (to convert to mmol/L, multiply by 0.0555). Normal glucose status was defined as meeting 3 criteria: fasting plasma glucose less than 109.8 mg/dL, 2-hour postprandial plasma glucose of 140.4 mg/dL or lower, and glycated hemoglobin A1c of 5.7% or lower (to convert to proportion of total hemoglobin, multiply by 0.01). Exploratory outcomes included changes in hs-CRP, the fibrosis-4 index,34 NAFLD fibrosis score,35 and levels of alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transferase. Safety outcomes included frequency of serious adverse events, nonserious adverse events of interest, and treatment discontinuation (eMethods 6 in Supplement 1).
Prespecified subgroups analyses for the primary outcomes included age (<40, ≥40 years), sex (female, male), LDL-C (≤131.3, >131.3 mg/dL; to convert to mmol/L, multiply by 0.0259), prediabetic status (yes, no), and abnormal liver function (yes, no). Abnormal liver function was defined as alanine aminotransferase or aspartate aminotransferase exceeding 2 times the upper limit of normal. We also conducted a post hoc subgroup analysis of baseline hs-CRP (<0.2, 0.2-0.3, >0.3 mg/dL; to convert to mg/L, multiply by 10) for primary and secondary outcomes.
Statistical Analysis
The sample size was calculated based on the 2 primary outcomes. Assuming a rate of individuals unavailable for follow-up of 2% and medication adherence over 90%, a sample of 326 participants was estimated to provide 80% power to detect a placebo-adjusted relative reduction of 5% (SD, 13%) in VAT area at a 2-sided significance level of .025. A sample of 149 participants was estimated to provide 80% power to detect a placebo-adjusted absolute reduction of 4% (SD, 7%) in liver fat content at a 2-sided significance level of .025. The larger of these 2 estimates was targeted for enrollment.
All randomized participants were included in the full analysis set for the main analysis of the primary outcomes according to the intention-to-treat principle. Missing data for VAT area and liver fat content were handled using multiple imputation with the Markov chain Monte Carlo method (statistical analysis plan in Supplement 2). The primary analysis used a linear regression model to compare the change in VAT area and liver fat content between study arms, including a treatment arm indicator (berberine, placebo) and the baseline VAT area or liver fat content. We performed several sensitivity analyses: a per-protocol analysis restricted to participants with complete outcome measurements and good treatment adherence (statistical analysis plan in Supplement 2); a multivariable analysis adjusting for age (<65, ≥65 years), sex (male, female), prediabetic status (yes, no), abnormal liver function (yes, no), and use of lipid-lowering medications (yes, no); a mixed-effect model with sites as random effects; and a post hoc analysis in the full analysis set without imputation.
For secondary and exploratory continuous outcomes, a similar linear model was used with log transformation applied to outcomes with skewed distributions. Categorical outcomes were analyzed using a logistic regression model. All analyses of these outcomes were performed on a complete-case basis without imputation. Safety analyses included all participants who received at least 1 dose of berberine or placebo. Safety outcomes were compared between study arms using χ2 tests or Fisher exact tests, as appropriate.
All statistical analyses were performed in SAS, version 9.4 (SAS Institute Inc), and R, version 4.1.1 (R Project for Statistical Computing). For the 2 primary outcomes, we reported estimates and 97.5% CIs at a 2-sided significance level of .025 to account for multiplicity. All the other results were reported as point estimates with 95% CIs at a 2-sided significance level of .05, with no adjustment for multiplicity given the exploratory nature of these assessments.
Results
The enrollment was conducted from July 6 to December 29, 2023. A total of 337 participants were randomly assigned to 1 of the 2 study arms, of whom 169 received berberine and 168 received placebo. All participants completed the follow-up until August 9, 2024, and were included in the full analysis set (Figure 1). There were 54 participants and 68 participants who were excluded in the per-protocol set for assessment of VAT area and liver fat content, respectively (eTable 1 in Supplement 1). Of the randomized participants, the mean (SD) age was 41.8 (10.6) years, 116 (34.4%) were female, and 221 (65.6%) were male. The mean (SD) BMI was 31.8 (3.5), the mean (SD) waist circumference was 104.1 (10.2) cm, and the mean (SD) liver fat content was 17.5% (7.8%). Baseline characteristics of the participants included in the full analysis set and per-protocol set are shown in Table 1 and eTables 2 and 3 in Supplement 1, respectively.
Figure 1. Trial Flowchart.
ALT indicates alanine aminotransferase; AST, aspartate aminotransferase; eGFR, estimated glomerular filtration rate; and ULN, upper limit of normal.
Table 1. Baseline Characteristics in the Full Analysis Set.
| Variable | Overall (N = 337) | Placebo (n = 168) | Berberine hydrochloride (n = 169) |
|---|---|---|---|
| Age, mean (SD), y | 41.8 (10.6) | 41.0 (10.4) | 42.5 (10.7) |
| Sex, No. (%) | |||
| Female | 116 (34.4) | 57 (33.9) | 59 (34.9) |
| Male | 221 (65.6) | 111 (66.1) | 110 (65.1) |
| Employment, No. (%) | |||
| Unemployed | 19 (5.6) | 10 (6.0) | 9 (5.3) |
| Employed | 318 (94.4) | 158 (94.1) | 160 (94.7) |
| Education level, No. (%) | |||
| ≤High school | 74 (22.0) | 41 (24.4) | 33 (19.5) |
| ≥College | 263 (78.0) | 127 (75.6) | 136 (80.5) |
| Smoking, No. (%) | |||
| Never | 220 (65.3) | 110 (65.5) | 110 (65.1) |
| Former | 10 (3.0) | 4 (2.4) | 6 (3.6) |
| Current | 107 (31.8) | 54 (32.1) | 53 (31.4) |
| Alcohol consumption, No. (%) | |||
| Never | 156 (46.3) | 74 (44.1) | 82 (48.5) |
| Former | 10 (3.0) | 7 (4.2) | 3 (1.8) |
| Current | 171 (50.7) | 87 (51.8) | 84 (49.7) |
| Physical activity, median (IQR), MET min/wk | 1386 (693-2772) | 1386 (685-2772) | 1386 (693-2772) |
| Waist circumference, mean (SD), cm | 104.1 (10.2) | 104.9 (9.9) | 103.3 (10.4) |
| Body mass index, mean (SD)a | 31.8 (3.5) | 32.1 (3.6) | 31.5 (3.3) |
| Systolic blood pressure, mean (SD), mm Hg | 132.4 (13.2) | 132.0 (13.1) | 132.8 (13.3) |
| Diastolic blood pressure, mean (SD), mm Hg | 86.9 (9.4) | 86.6 (9.2) | 87.3 (9.7) |
| eGFR, mean (SD), mL/min/1.73 m2 | 117.32 (10.98) | 117.58 (9.90) | 117.05 (11.98) |
| ALT, mean (SD), U/L | 33.7 (22.9) | 35.4 (25.4) | 32.1 (20.1) |
| AST, mean (SD), U/L | 24.8 (11.6) | 25.6 (13.1) | 24.0 (9.9) |
| Liver function, No. (%)b | |||
| Normal | 229 (68.0) | 117 (69.6) | 112 (66.3) |
| Abnormal | 108 (32.1) | 51 (30.4) | 57 (33.7) |
| FPG, mean (SD), mg/dL | 94.68 (10.80) | 95.04 (11.16) | 94.32 (10.44) |
| 2hPG, mean (SD), mg/dL | 129.60 (33.30) | 129.24 (33.84) | 129.78 (32.94) |
| HbA1c, mean (SD), % | 5.69 (0.45) | 5.71 (0.44) | 5.68 (0.45) |
| Prediabetic status, No. (%)c | |||
| No | 208 (61.7) | 104 (61.9) | 104 (61.5) |
| Yes | 129 (38.3) | 64 (38.1) | 65 (38.5) |
| LDL-C, mean (SD), mg/dL | 115.44 (31.66) | 117.76 (31.27) | 113.13 (31.66) |
| TG, mean (SD), mg/dL | 196.63 (133.74) | 189.54 (131.97) | 203.71 (135.51) |
| Serum uric acid, mean (SD), mg/dL | 6.94 (1.75) | 6.94 (1.69) | 6.94 (1.80) |
| hs-CRP, mean (SD), mg/dL | 0.23 (0.35) | 0.24 (0.34) | 0.22 (0.35) |
| VAT area, mean (SD), cm2 | 249.67 (75.94) | 249.21 (73.27) | 250.13 (78.71) |
| Liver fat content, mean (SD), % | 17.5 (7.8) | 18.1 (7.8) | 17.0 (7.7) |
| Missing, No. (%) | 15 (4.5) | 6 (3.6) | 9 (5.3) |
| Antihypertensive medication, No. (%) | |||
| No | 295 (87.5) | 146 (86.9) | 149 (88.2) |
| Yes | 42 (12.5) | 22 (13.1) | 20 (11.8) |
| Lipid-lowering medication, No. (%) | |||
| No | 329 (97.6) | 165 (98.2) | 164 (97.0) |
| Yes | 8 (2.4) | 3 (1.8) | 5 (3.0) |
Abbreviations: 2hPG, 2-hour postprandial plasma glucose; ALT, alanine aminotransferase; AST, aspartate aminotransferase; eGFR, estimated glomerular filtration rate; FPG, fasting plasma glucose; HbA1c, hemoglobin A1c; hs-CRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; MET, metabolic equivalent; TG, triglyceride; VAT, visceral adipose tissue.
SI conversion factors: To convert ALT and AST to µkat/L, multiply by 0.0167; hs-CRP to mg/L, multiply by 10; LDL-C and TG to mmol/L, multiply by 0.0259 and 0.0113, respectively; FPG and 2hPG to mmol/L, multiply by 0.0555; HbA1c to proportion of total hemoglobin, multiply by 0.01; and uric acid to mmol/L, multiply by 0.0595.
Body mass index was calculated as weight in kilograms divided by height in meters squared.
Abnormal liver function was defined as ALT or AST exceeding 2 times the upper limit of normal.
Prediabetic status was defined as FPG between 109.8 and 126.0 mg/dL, inclusive, or 2hPG between 140.4 and 199.8 mg/dL, inclusive.
Mean (SD) medication adherence (defined as the percentage of medication consumed across all visits) was 90.5% (16.1%) (90.3% [14.7%] for berberine and 90.7% [17.4%] for placebo). Participant-level VAT area relative changes and liver fat content absolute changes are presented in the intention-to-treat set (Figure 2) and in the per-protocol set (eFigure 1 in Supplement 1). There were no significant differences in the relative percentage change in VAT area between arms (mean [SD] change in placebo arm, −2.0% [14.4%]; mean change in berberine arm, −0.6% [16.7%]; placebo-adjusted estimated treatment difference 1.38% [97.5% CI, −2.43% to 5.18%]; P = .42) (Table 2). There were no significant differences in the absolute change in liver fat content between arms (mean [SD] change in placebo arm, −1.1% [5.1%]; mean [SD] change in berberine arm, 0.1% [6.2%]; placebo-adjusted estimated treatment difference 0.87% [97.5% CI, −0.39% to 2.13%]; P = .12) (Table 2). The between-arm differences in the 2 primary outcomes were consistent across all prespecified subgroups (eFigure 2 in Supplement 1), and in sensitivity analyses, post hoc analyses, and per-protocol analysis (eTables 4-5 in Supplement 1). For secondary and exploratory outcomes, berberine was associated with larger reductions in LDL-C (−7.72 [95% CI, −13.13 to −1.93] mg/dL; P = .008) , apoB (−3.42 [95% CI, −6.33 to −0.51] mg/dL; P = .02; to convert to g/L, multiply by 0.01) and hs-CRP (−0.072 [95% CI, −0.140 to −0.004] mg/dL; P = .04) compared with placebo (eTable 6 in Supplement 1). Berberine did not have a significant effect on glycated hemoglobin A1c, fasting plasma glucose, 2-hour postprandial plasma glucose, homeostatic model assessment of insulin resistance,33 homeostatic model assessment of β cell function,33 homeostatic model assessment of insulin sensitivity, total cholesterol, high-density lipoprotein cholesterol, serum uric acid, blood pressure, body composition, fibrosis-4 index, NAFLD fibrosis score, and liver function (eTable 6 in Supplement 1). The occurrence of remission from prediabetic status to normal glucose status did not differ significantly between study arms among participants with prediabetes at baseline (prevalence in placebo arm 10 of 62 [16.1%], prevalence in berberine arm 14 of 64 [21.9%]; odds ratio, 1.46 [95% CI, 0.59-3.58]; P = .41).
Figure 2. Participant-Level Changes in Primary Outcomes in the Full Analysis Set.
VAT indicates visceral adipose tissue.
Table 2. Comparison of Fat Distribution and Body Composition in the Full Analysis Set.
| Outcomes | Mean (SD) | Difference of changes between groups (95% CI) | P value | |||||
|---|---|---|---|---|---|---|---|---|
| Placebo (n = 168) | Berberine hydrochloride (n = 169) | |||||||
| Baseline | 6 mo | Change | Baseline | 6 mo | Change | |||
| Primary outcomes | ||||||||
| Liver fat content, % | 17.9 (7.8)a | 16.8 (7.0)a | −1.1 (5.1) | 16.9 (7.7)a | 17.1 (7.2)a | 0.1 (6.2) | 0.87 (−0.39 to 2.13)b | .12 |
| VAT area, mean (SD), cm2 | 249.2 (73.3) | 241.9 (73.8)a | −2.0 (14.4) | 250.1 (78.7) | 246.8 (82.0)a | −0.6 (16.7) | 1.38 (−2.43 to 5.18)b | .42 |
| Body composition | ||||||||
| Weight, kg | 92.3 (15.8) | 90.4 (16.3) | −1.9 (3.6) | 90.8 (15.7) | 88.9 (16.0) | −1.8 (3.7) | 0.05 (−0.74 to 0.84) | .90 |
| Body mass indexc | 32.1 (3.6) | 31.4 (3.9) | −0.7 (1.2) | 31.5 (3.3) | 30.9 (3.5) | −0.6 (1.3) | 0.02 (−0.26 to 0.29) | .90 |
| Waist circumference, cm | 104.9 (9.9) | 102.1 (10.6) | −2.8 (5.9) | 103.3 (10.4) | 100.6 (10.9) | −2.7 (5.2) | −0.07 (−1.26 to 1.12) | .91 |
| Waist to height ratio | 0.62 (0.05) | 0.60 (0.06) | −0.02 (0.04) | 0.61 (0.05) | 0.59 (0.06) | −0.02 (0.03) | 0.00 (−0.01 to 0.01) | .78 |
Abbreviation: VAT, visceral adipose tissue.
Here shown as the imputed value.
Since a 2-sided P value < .025 was considered statistically significant for the primary outcome, we calculated the 97.5% CI of difference of changes between groups.
Body mass index was calculated as weight in kilograms divided by height in meters squared.
There were no significant between-arm differences in the frequency of serious adverse events overall, nonserious adverse events of interest, and treatment discontinuation (Table 3). Serious adverse events were reported in 6 participants (3.6%) in the berberine arm and 2 participants (1.2%) in the placebo arm. Nonserious adverse events of interest were reported in 17 participants (10.1%) in the berberine arm and 13 participants (7.7%) in the placebo arm. There were 5 participants (3.0%) who discontinued berberine and 6 participants (3.6%) who discontinued placebo.
Table 3. Summary of Safety Outcomes.
| Safety outcome | Events, No. (%) | P value | |
|---|---|---|---|
| Placebo (n = 168) | Berberine hydrochloride (n = 169) | ||
| Serious adverse events | 2 (1.2) | 6 (3.6) | .28 |
| Nonserious adverse events of interest | 13 (7.7) | 17 (10.1) | .57 |
| Liver function impairment | 0 | 1 (0.6) | >.99 |
| Renal function impairment | 1 (0.6) | 2 (1.2) | >.99 |
| Constipation | 0 | 1 (0.6) | >.99 |
| Other gastrointestinal tract reactions | 3 (1.8) | 5 (3.0) | .72 |
| Hypoglycemia | 9 (5.4) | 8 (4.7) | .81 |
| Treatment discontinuation | 6 (3.6) | 5 (3.0) | .75 |
In the post hoc analysis, we found significant interactions of berberine and baseline levels of hs-CRP with levels of total cholesterol , LDL-C, apoB, and hs-CRP as well as BMI, waist to height ratio, waist circumference, and body weight (eTable 7 in Supplement 1). Berberine treatment was associated with greater reduction in these parameters among participants with higher baseline hs-CRP level.
Discussion
In this multicenter, double-blind, placebo-controlled, randomized clinical trial, we first evaluated the efficacy and safety of berberine in reducing VAT and liver fat among diabetes-free individuals with obesity and MASLD. We found that berberine at a daily dose of 1 g over a 6-month intervention period did not lead to significant changes in VAT area and liver fat content compared with the placebo. The results were consistent across subgroups of age, sex, LDL-C level, prediabetic status, and liver function. Exploratory analyses showed that administration of berberine was associated with reduced LDL-C, apoB, and hs-CRP levels, with a consistent pattern of greater reductions in these levels in participants with higher baseline hs-CRP levels. Berberine was well tolerated with no excess risk of adverse events.
The study was distinguished by a randomized, placebo-controlled design and high compliance with study treatment and follow-up, which ensured a reliable testing of the primary hypothesis. The results of our study differed from 2 previous trials22,23 that enrolled patients with MASLD who had a higher baseline metabolic risk profile. A 3-arm trial22 including 184 patients with MASLD who had impaired glucose regulation or type 2 diabetes (62 in the berberine plus lifestyle intervention vs 62 in the lifestyle intervention alone) found that berberine at a daily dose of 1.5 g for 16 weeks reduced liver fat content. Another trial23 including 89 participants with metabolic dysfunction–associated steatohepatitis found treatment of berberine ursodeoxycholate (comparable dose of berberine component in our trial) for 18 weeks reduced liver fat content. Compared with our study population, the higher baseline glucose level and liver fat content in the 2 trials may have contributed to the different results. The discrepancy suggests that the efficacy of berberine for hepatic steatosis may be modulated by the underlying magnitude of metabolic dysfunction, such as the degree of insulin resistance or the severity of MASLD. Furthermore, it has been suggested that individuals with insulin resistance or type 2 diabetes may experience greater glucose lowering from berberine.36 While 1 previous study used a higher dose of berberine (1.5 g/d), evidence suggested that the dose of 1 g/d used in our study is effective in improving glycemic control in diabetes and lipid profile in dyslipidemia,13,36,37 which was also chosen to optimize safety and treatment compliance. Although our 6-month intervention was longer than most prior trials, studies of even longer duration are needed to rule out any potential delayed effects on fat redistribution.
Despite its neutral effect on adiposity in our study, berberine produced modest but significant reductions in key atherogenic lipids (LDL-C, apoB) and systemic inflammation (hs-CRP). These findings are promising for the prevention of cardiovascular diseases and extend prior evidence of the cardiometabolic benefits of berberine to diabetes-free individuals with obesity and MASLD, an understudied population with a metabolic high risk.28,38 The lipid-lowering effect aligns with the established mechanism of berberine to upregulate LDL receptor expression via the adenosine monophosphate kinase and extracellular regulated protein kinase pathways, an action distinct from statins.13 Additional mechanisms may involve PCSK9 inhibition and gut microbiota modulation.39,40 The reduction in apoB level is of clinical importance, as apoB is a superior marker of atherogenic particle burden and cardiovascular risk, especially in insulin-resistant states41,42; however, evidence for the effect of berberine on apoB is scarce. Furthermore, by employing a double-blind, randomized design, our study provides new evidence for the anti-inflammatory property of berberine, a relevant contribution given the increasingly recognized role of inflammation in the pathogenesis of cardiovascular disease.43 A notable finding from our post hoc analysis was that the hs-CRP level appeared to modify the treatment effects of berberine, with greater improvement in lipids, inflammation, and even anthropometric measures observed in individuals with elevated hs-CRP levels. This finding suggests a heterogeneous treatment response of berberine and positions hs-CRP as a potential biomarker for predicting which patients with obesity and MASLD are most likely to benefit from berberine therapy. Future studies should validate this interaction and explore the role of other inflammatory biomarkers in personalizing berberine therapy.
Limitations
Several limitations should be acknowledged. First, a small proportion (4.4%) of measurements for liver fat content were missing due to uninterpretable images. The consistent results from multiple imputations and per-protocol analysis suggested that the missing data were unlikely to influence the results. Second, the results of the secondary and exploratory analyses on LDL-C, apoB, and hs-CRP, as well as subgroup analysis of hs-CRP, are presented without formal adjustment for multiplicity and should not be used to infer definitive treatment effects due to potential false-positive risks.
Conclusions
In this randomized clinical trial of diabetes-free individuals with obesity and MASLD, a 6-month treatment of berberine, 1 g/d, showed an excellent safety profile but did not reduce VAT area or liver fat content. Exploratory findings suggested a potential role of berberine in lowering atherogenic lipid levels (LDL-C, apoB) and systemic inflammation (hs-CRP), with effects appearing more pronounced in individuals with higher baseline hs-CRP levels. These potential benefits warrant further investigation to define the role of berberine in cardiovascular risk reduction in this population.
eMethods 1. Details of the BRAVO Collaborative Group
eMethods 2. The details of inclusion and exclusion criteria
eMethods 3. The lifestyle intervention
eMethods 4. The study procedure
eMethods 5. The measurement of adipose tissue
eMethods 6. The definition of safety outcomes
eTable 1. Participants excluded in the per-protocol set stratified by outcomes
eTable 2. Baseline characteristics in the per-protocol set of liver fat content
eTable 3. Baseline characteristics in the per-protocol set of VAT area
eTable 4. Sensitivity analyses and post-hoc analyses of primary outcomes
eTable 5. Comparison of primary outcomes in the per-protocol set
eTable 6. Comparison of biomarkers of metabolism, inflammation and liver function in the full analysis set
eTable 7. Subgroup analysis for primary and other outcomes stratified by baseline high sensitivity C-reactive protein in the full analysis set
eFigure 1. Participant-level changes in primary outcomes in the per-protocol set
eFigure 2. Effect of berberine hydrochloride on primary outcomes by subgroups
Trial Protocol
The BRAVO Collaborative Group
Data Sharing Statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eMethods 1. Details of the BRAVO Collaborative Group
eMethods 2. The details of inclusion and exclusion criteria
eMethods 3. The lifestyle intervention
eMethods 4. The study procedure
eMethods 5. The measurement of adipose tissue
eMethods 6. The definition of safety outcomes
eTable 1. Participants excluded in the per-protocol set stratified by outcomes
eTable 2. Baseline characteristics in the per-protocol set of liver fat content
eTable 3. Baseline characteristics in the per-protocol set of VAT area
eTable 4. Sensitivity analyses and post-hoc analyses of primary outcomes
eTable 5. Comparison of primary outcomes in the per-protocol set
eTable 6. Comparison of biomarkers of metabolism, inflammation and liver function in the full analysis set
eTable 7. Subgroup analysis for primary and other outcomes stratified by baseline high sensitivity C-reactive protein in the full analysis set
eFigure 1. Participant-level changes in primary outcomes in the per-protocol set
eFigure 2. Effect of berberine hydrochloride on primary outcomes by subgroups
Trial Protocol
The BRAVO Collaborative Group
Data Sharing Statement
