Volume

No

2 2004

Modern Phytotherapist
FOR PROFESSIONAL USE ONLY. NOT FOR PUBLIC DISTRIBUTION MEDIHERB 2004

The Value of Complex Antioxidants

BY MICHELLE MORGAN

Although there were sound reasons for advocating their therapeutic use, results of large intervention trials published in mid 2003 cast doubt on the efficacy of beta-carotene and vitamin E supplementation. This article briefly discusses these clinical results, and suggests the benefit of complexity in antioxidant therapy, by use of fruit and vegetables and herbs in particular. In addition to providing antioxidant activity through complexity (and potentially avoiding adverse effects), herbs can confer many other therapeutic benefits.

Free Radicals and Oxidative Stress

Free radicals are highly reactive chemical species. (They have an unpaired electron in an atomic or molecular orbital, instead of stable paired electrons.) Examples include the hydroxyl radical, superoxide anion radical and nitric oxide radical. The human body also produces reactive oxygen species (ROS), which are oxidising agents and include the free radicals superoxide and hydroxyl as well as hydrogen peroxide, hypochlorite and singlet oxygen. Free radicals and ROS are produced in both normal and pathological processes. Free radical scavengers are substances that combine with free radicals in a chemical reaction and can quench the damaging chain reactions that they cause.
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Contents
The Value of Complex Antioxidants 1

Editorial: Managing the Issue of Endangered Herbs 2 Phytotherapy for Polycystic Ovarian Syndrome 13 Case Study: Bacopa and a Child with Epilepsy Clinical Monitor

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The Value of Complex Antioxidants continued from page 1

Free radicals and ROS are involved in the generation of oxidative damage. Antioxidants are substances that protect biological systems against the potentially harmful effects of excessive oxidation. Oxidative stress represents a disturbance in the oxidant-antioxidant balance in favour of oxidation. There are three components to oxidative stress: oxidant generation, antioxidant protection and repair of oxidative damage. Oxidative stress can affect lipids (e.g. of cell membranes) via lipid peroxidation, nucleic acids (e.g. initiate carcinogenesis) and proteins. It can lead to tissue damage and contribute to chronic disease development.1,2 Oxidative stress plays a role in:1,3,4 alcohol-induced damage arthritis and inflammatory diseases atherosclerosis, stroke autoimmune diseases (including rheumatoid arthritis) cancer cataracts contact dermatitis coronary artery bypass, myocardial infarction drug toxicity emphysema, obstructive lung disease hypertensive cerebrovascular injury reduced immune function associated with ageing iron overload disease liver cirrhosis, nephrotoxicity multiple sclerosis nutrient deficiencies Parkinsons disease premature ageing senile dementia and neurologic degeneration thermal injury vascular disorders (e.g. chronic venous insufficiency, retinal microangiopathy) viral infections, including AIDS although the role of oxidative stress in atherosclerosis has been questioned.5 Cigarette smoking results in an increased cumulative exposure to ROS.6 Infections may also cause oxidative stress that leads to antioxidant depletion by activating phagocytic cells.7 Supplementation of antioxidants may be desirable for physically active individuals by providing a greater protective margin in the oxidantantioxidant homoeostasis.8
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Many defence mechanisms have evolved to limit the levels of oxidants and the damage they inflict. These include: enzymatic scavengers such as superoxide dismutase (SOD), catalase, glutathione peroxidase; hydrophilic (water-associated) radical scavengers such as ascorbate, urate, and glutathione (GSH); hydrophobic (fat-associated) radical scavengers such as tocopherols, flavonoids, carotenoids; enzymes such as GSH reductase, dehydroascorbate reductase, thioredoxin reductase; the cellular machinery that maintains a reducing environment (e.g. glucose-6-phosphate dehydrogenase, which regenerates NADPH); the storage and transport of iron and copper ions in forms that will not catalyse formation of reactive radicals.

Nutrient Antioxidants
Antioxidants are produced within the body or received from external sources such as the diet or by supplementation. In addition to the enzymes mentioned above, antioxidants include minerals (such as selenium), vitamins (vitamins A (and its precursor beta-carotene), C and E) and phytochemicals (such as flavonoids, proanthocyanidins, polyphenols, lignans and other carotenoids (e.g. lycopene) to name a few). In this section the focus will be on the common antioxidant nutrients. Information verifying the antioxidant activity of these nutrients has been obtained from in vitro studies and animal models. In addition, results of epidemiological studies show: an association of increased lung cancer risk with low amounts of dietary beta-carotene or low plasma beta-carotene.9 an inverse relationship between coronary heart disease mortality rate and measured serum vitamin E and vitamin C across 12 European countries;10 in review, a relationship between low alphatocopherol levels and the development of atherosclerosis;11 in review, equivocal results for carotenoids, vitamin C, vitamin E and cancer prevention;12 in review, an association (for good-quality studies) between vitamin C, vitamin E supplements and lower risk for cardiovascular disease;13 a protective effect for consumption of fruit and vegetables on heart disease14 and stroke;15 a lack of adequate intake of fruit and vegetables
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linked to increased cancer incidence (particularly cancers not associated with hormone levels).7 In some of these studies benefits were attributed to supplementation rather than diet alone,16 and in some studies serum levels of nutrients were investigated (which would largely reflect on dietary intake).11 Despite serum levels of nutrients correlating with intake of fruit or vegetables in some studies,2 it would be reductionist to assume that the protective effect of fruit and vegetables can be ascribed solely to these constituents alone17-20 (see below) and other dietary and lifestyle factors may also have contributed.21,22 Results from clinical trials investigating primary and secondary disease prevention have however been equivocal. A meta-analysis published in June 2003 did not support the routine use of vitamin E for the prevention of cardiovascular disease. In order to limit the effects of publication bias, the analysis included only randomised trials of 1000 or more patients, and was limited to studies in populations from developed countries without overt evidence of vitamin deficiencies. In the all-cause mortality analysis, the vitamin E trials involved a total of 81 788 patients and the beta-carotene trials, 138 113 patients. Vitamin E did not provide reduced mortality compared with control treatment and did not significantly decrease the risk of cardiovascular accident. beta-Carotene led to a small but significant increase in all-cause mortality and with a slight increase in cardiovascular death. Of the 12 trials identified, 8 trials involved beta-carotene alone or in combination with other antioxidants (vitamin C and/or vitamin E); 7 trials investigated vitamin E alone or in combination with other antioxidants and were assessed in a separate analysis. The daily dosage range for vitamin E was 50600 mg and for beta-carotene was 60200 mg.23 The cause of the conflicting results between epidemiological and clinical is not clear, although many factors have been suggested to play a role, including for example, the use of synthetic vitamin E, the absence of tocopherols other than alpha-tocopherol and a prooxidant effect.16,20,24-26 (Vitamin E is the name given to a group of eight fat-soluble compounds (four tocopherols and four tocotrienols). The most abundant form of vitamin E is alpha-tocopherol.) Two of the trials included in the meta-analysis demonstrated an increased risk of lung cancer among smokers. High doses (of beta-carotene, and betacarotene + vitamin A) may have produced prooxidant effects in combination with the oxidants produced by cigarette smoke and asbestos exposure. beta-Carotene may have competitively inhibited the antioxidant
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activity of other dietary carotenoids. Cigarette smoke also causes decreased tissue levels of other antioxidants, such as ascorbate and alpha-tocopherol, which have a stabilising effect on the unoxidised form of betacarotene. A combination of antioxidants may be a more appropriate way to reduce cancer risk.20,27 (Prooxidant activity is not restricted to the nutrient antioxidants, flavonoids have demonstrated copper-initiated prooxidant activity in vitro, (as has ascorbic acid and alpha-tocopherol) although the relevance of this for in vivo is not known.28) Excess vitamin supplementation may cause a disturbance in equilibrium,29 a high concentration of one nutrient may affect the balance of antioxidant interactions.1 Antioxidant administration after oxidative damage has begun could also promote damage.26

Complexity versus Isolates

As early as 1936, Szent-Gyorgi showed that flavonoid preparations from citrus peel and paprika could heal scorbutic pigs where ascorbate alone was ineffective.30 The sparing effect of flavonoids on ascorbate oxidation may explain many of the physiological interactions of flavonoids with ascorbic acid.31 The German Society for Nutrition in 1999 recommended the daily consumption of 375 g of vegetables and approximately 250300 g of fruit. The anticarcinogenic effect of vegetable consumption is believed to be not due to vitamins, minerals and fibre alone, but includes the secondary plant substances, which act in a variety of different ways.32 Examples of food sources of antioxidants: carotenoids: brightly coloured fruit and vegetables e.g. carrots, pumpkin, tomato, corn, spinach, peach; paprika ascorbic acid: citrus fruit, berries, Brussels sprouts, broccoli, capsicum, buckwheat tocopherols: vegetable and wheat germ oils, wheat germ, seed-like cereal grains, nuts, avocado, olives, eggs flavonoids: berries, apples, citrus fruits, broccoli, capsicum, onion, tea, wine catechins (polyphenols): berries, green tea anthocyanins: berries lignans: linseed, legumes e.g. soya bean; sesame seed indoles: broccoli, Brussels sprouts isothiocyanates: horseradish, mustard, radish
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More than 80% of the in vitro antioxidant capacity measured in fruit and vegetables is associated with ingredients other than vitamin C. Increasing consumption of fruit and vegetables from the usual 5 to the experimental 10 servings/day in healthy volunteers resulted in a significant increase in plasma oxygen radical absorbance capacity. This increase in plasma antioxidant capacity could not be explained solely by the increase in plasma alpha-tocopherol or carotenoid concentration. Plasma vitamin C was not determined but was not expected to be a major contributor.33 A study involving healthy elderly women concluded that strawberries and spinach are as effective in enhancing the overall antioxidant status in serum as a large dose of vitamin C. Antioxidants other than vitamin C and urate contributed to half of the increased serum antioxidant capacity following consumption of strawberries or spinach. Red wine also significantly increased the overall antioxidant capacity. (The strawberry (240 g), spinach (294 g), red wine (300 mL, with alcohol removed) and vitamin C (1250 mg) were provided as breakfast beverages and all had the same in vitro antioxidant capacity. The strawberry drink contained approximately 120 mg vitamin C.)34 Results of a case-control study conducted in the USA and published in 2003 indicated that consumption of a wide variety of vegetables has a greater bearing on lung cancer risk in a population of smoking and nonsmoking women than intake of any specific (dietary) carotenoid or total carotenoids. These results support earlier findings.35 With regard to baseline serum concentrations of beta-carotene reflecting total intake of fruit and vegetables, beta-carotene may have been only a marker for the actual protective agents.20 A controlled trial demonstrated that vitamins A, C, E as well as fruit significantly decreased lipid peroxide levels and oxidant load in Indian patients with coronary heart disease. However, unlike the vitamins, administration of fruit favourably modified plasma cholesterol.36 A clinical trial demonstrated that supplementation with carotenoids (beta-carotene and lutein) caused a decrease in plasma lycopene (also a carotenoid). The lycopene contents of the control and carotenoidsupplemented diets were similar. The results of this and other clinical studies suggest that carotenoid supplements compete with lycopene for absorption or transport in plasma.37 It is not exactly known why complexity offers more effective activity. In addition to humans being inherently complex, the individual and differing

chemical properties of antioxidants may work together in an integrated and complementary manner. The human body consists of compartments with a range of physical variables, anatomical subdivisions and waterand lipid-soluble phases. Within these phases and at interfaces between phases there are numerous chemical variables which can influence the uptake of antioxidants. The characteristics of the antioxidants themselves also affect their entry or restriction from cell membranes. Many antioxidants are known to operate synergistically and those with different characteristics may recharge neighbouring antioxidants. A variety of antioxidants are necessary to maintain the proper reduction-oxidation status in a heterogeneous biological system (similar to the coordinated reductionoxidation reactions that occur during the respiratory chain in mitochondria) and to provide different lines of defence against ROS.38-40

Herbal Antioxidants Profiled: A Focus on Clinical Results

Green Tea
Green tea is the unprocessed, dried, young leaves of Camellia sinensis. The main active constituents are polyphenols including epigallocatechin gallate (EGCG).

Oxidative Stress/Antioxidant Activity

A Japanese epidemiological study noted that green tea consumption (10 cups/day) was associated with decreased serum lipid peroxides (among smokers) and decreased serum ferritin, asparate aminotransferase and alanine aminotransferase (smokers and nonsmokers). Green tea intake may prevent cell damage of the liver, atherosclerosis as well as having a chemopreventative effect.41 (Ferritin is one of two iron binding proteins in the body which soak up free iron to prevent it from generating toxic quantities of free radicals.) Green tea consumption decreased oxidative DNA damage, lipid peroxidation and free radical generation in smokers. Nonsmokers also exhibited a decrease in overall oxidative stress.42 An increase in plasma antioxidant activity has been demonstrated ex vivo after ingestion of green tea or green tea extract by volunteers,43-48 although in one study the effect only occurred for smokers and there was no effect on markers of oxidative stress.45 A number of clinical studies have demonstrated that ingestion of green tea, or green tea polyphenols in healthy volunteers (including smokers) has not enhanced the resistance of LDL to oxidation ex vivo,49-51

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despite the presence of green tea catechins in plasma LDL particles.49 In addition, green tea (6 cups/day, 3 g/day of tea solids) did not affect serum lipid concentrations, markers of oxidative damage to lipids (malondialdehyde, lipid hydroperoxides), or the activity of antioxidant enzymes (glutathione peroxidase, SOD, catalase) although it did slightly increase total antioxidant activity of plasma. Fat intake of the participants during the trial was not assessed.50 It was proposed that the absence of effects of green tea on the capacity of LDL to resist oxidation ex vivo may be related to the standard method used to assess this (which involves isolation of the LDL particles from the aqueous phase of the serum). This may explain the increases in the total antioxidant capacity of serum after ingestion of green tea (above). A trial using a different assay (not involving the isolation of lipoproteins) found a nonsignificant trend to inhibition of LDL oxidation in serum after ingestion of green tea.43 In a later trial the same research team measured a marker of lipid peroxidation (urinary excretion of F2-isoprostanes) and found that lipid peroxidation was not inhibited by ingestion of green tea (10 g/day dried leaf).52

Anticancer Activity
A review of 26 epidemiological and 2 substantial human studies (19741997) found conflicting results, but an overall positive association between

consumption of green tea and protection against cancer.53 The studies were mainly case-control studies, relying largely on interview and subject responses. The studies were conducted mostly in Japan and China, with a few in Hong Kong (2), USA (2: one study of Hawaiians of Japanese ancestry), Taiwan (1), Singapore (1), Iran (1) and Korea (1). The effect of tea consumption on cancer may depend on the causative factors of the specific cancer. Two studies each investigated two cancer types (hence 30 studies are listed). Positive association means consumption of green tea was associated with increased risk of cancer. Inverse association means consumption was associated with decreased risk. The results and association for consumption of green tea were: colon cancer: 3 studies found inverse association, 1 positive association rectal cancer: only 1 of 4 studies reported an inverse association; increased risk was seen in 2 studies bladder cancer: 2 studies found inverse association stomach cancer: 6 of 10 studies suggest an inverse association and 3 a positive association pancreatic cancer: possible inverse association in 2 of 3 studies oesophageal cancer: strong inverse effect shown (6 studies), although increased risk with increasing temperature of tea (not specifically green tea) lung cancer: 1 study (Okinawan (partiallyfermented) tea) found inverse association, slight increased risk in another study pharmacological studies (2): chemopreventive effect demonstrated in smokers and volunteers at highrisk of gastric cancer The results of epidemiologic studies published after or not included in this review are listed: cancer (all forms): inverse association (> 10 cups/day green tea);54 prostate cancer: decrease in risk observed with (black and green) tea intake of 2 cups/day or 500 g/day;55 breast cancer (Asian American women): inverse association;56 breast cancer: long-term consumption of green tea ( 5 cups/day) associated with lower recurrence in stage I and II breast cancer; no improvement in prognosis was observed in stage III breast cancer; increased consumption was closely associated with decreased numbers of axillary lymph node metastases among premenopausal patients (with stage I and II), and with increased expression of progesterone receptor and oestrogen receptor among postmenopausal patients;57
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breast cancer: decrease risk for recurrence in women with invasive breast cancer for green tea intake of > 3 cups/day (for stages I and II, but not stage III);58 ovarian cancer: inverse association with further decreased risk with increasing duration of ingestion;59 digestive tract and urinary tract (American postmenopausal women): inverse association ( 2 cups/day green tea; 1 cup = 237 mL); no association found for melanoma, non-Hodgkins lymphoma, cancers of the pancreas, lung, breast, uterine corpus or ovary;60 gastric cancer: no association.61

chylomicrons and in plasma were lower for GSE. Plasma antioxidant capacity increased in the postprandial phase only following the meal supplemented with grape seed extract. LDL isolated 3 hours after the GSE meal tended to be less susceptible to oxidative modification.67 Grape seed OPCs (100 mg/day) reduced the elevated expression of adhesion molecules and reduced the increased concentration of malonaldehyde (a marker of oxidative stress) present in the plasma of patients with systemic sclerosis.68 (The induction of adhesion molecules is a result of inflammatory response.) A combination of grape seed extract and niacin-bound chromium significantly decreased total cholesterol and LDL-cholesterol in hypercholesterolaemic patients compared to placebo. There was a trend to decrease the circulating autoantibodies to oxidised LDL in the group of patients receiving grape seed extract and those receiving the combination.69 Grape seed OPC ingestion by healthy volunteers (110 mg/day, for 30 days) did not lead to modification of plasma total antioxidant activity or of plasma alphatocopherol concentration. However, the level of alphatocopherol in red blood cell membranes increased, the lymphocyte oxidised DNA was reduced and the red blood cell membrane fatty acid composition shifted to a higher level of polyunsaturated fatty acids. This suggests that DNA oxidative damage was reduced and liposoluble vitamin E was spared.70

The preventative and treatment potential of green tea has also been assessed in clinical trials. Decreased levels of prostaglandin E2 (PGE2) in rectal mucosa were demonstrated at 4 and 8 hours after consumption of green tea by healthy volunteers. (Inhibition of PGE2 in other settings is related to a lower risk of certain cancers.)62 Decaffeinated green tea did not confer a preventive effect in alleviating oesophageal precancerous lesions and abnormal cell proliferation in a high-risk population given treatment for 11 months.63 Limited antineoplastic activity was demonstrated for green tea (6 g/day) in a phase II (unblinded) trial of asymptomatic patients with androgen independent metastatic prostate carcinoma. Only one of the 42 patients experienced a decline in serum prostate specific antigen, no patients showed tumour response and 7 patients experienced substantial side effects.64 Ingestion of and topical application of a green and black tea mixture decreased lesion size in patients with oral mucosa leucoplakia (a precancerous condition) compared to that experienced by the control group.65

Conditions Related to Oxidative Stress

Grape seed extract (200300 mg/day) relieved the symptoms of three patients with chronic pancreatitis after other medications had failed.71 Benefit has also been demonstrated in: ocular stress (double-blind, placebo-controlled trial; 300 mg/day grape seed OPCs);72 retinopathy (uncontrolled trials; 100150 mg/day grape seed OPCs).73-75

Grape Seed
Grape seed extract is obtained from the seeds of red or white grapes (Vitis vinifera). Grape seed contains oligomeric procyanidins (OPCs) which are made up of 2 or 3 units of (+)-catechin, (-)-epicatechin and (-)epicatechin 3-O-gallate.66

Capillary Disorders and Oedema

It has been suggested that the capillary protective activity of OPCs may be based on the antioxidant activity and inhibition of key enzymes of the microvascular endothelium and extravascular matrix.76 Uncontrolled77,78 and double-blind controlled trials79-84 conducted in Europe during the 1980s demonstrated that oral administration of grape seed OPCs (100300 mg/day) improved capillary resistance in a variety of conditions. The benefit of OPCs for peripheral venous insufficiency was reflected in the
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Oxidative Stress
In a trial involving 8 healthy volunteers, supplementation of a meal with OPCs from grape seed extract (300 mg) minimised postprandial oxidative stress. Compared to results obtained after ingesting a high fat control meal, lipid hydroperoxides in
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Clinical

reduction of symptoms such as pain, oedema, nocturnal cramp and paraesthesia.83,84 In controlled trials, OPCs from grape seed also demonstrated benefit for preventing and speeding up the disappearance of oedema.85-87 Twenty-four patients with non-complicated chronic venous insufficiency showed a positive clinical response to grape seed OPCs (100 mg/day).88

to 4 months, the daily dose peaked at and corresponded to 180 mg of curcumin (2.2 g of turmeric extract). Ingestion of 440 mg/day of turmeric extract for 29 days was accompanied by a 59% decrease in lymphocytic GST activity. Five patients experienced stable disease for 3 months or longer, and in one additional patient abatement of tumour progression may have resulted from turmeric treatment.95 In patients with oral submucous fibrosis (a precancerous condition), treatment with alcohol extract of turmeric, turmeric oil or turmeric oleoresin normalised the number of micronucleated cells both in exfoliated oral mucosal cells and in circulating lymphocytes.96 Very high doses of curcumin (starting at 500 mg/day) showed demonstrable chemoprevention in 28% of 25 patients with high-risk or premalignant lesions. This phase I trial found that curcumin is not toxic in humans up to 8 g/day when taken by mouth for 3 months.97 However, curcumin has low oral bioavailability in humans.95 Nonetheless its metabolites could be the true active form. Turmeric (1.5 g/day) administered for 30 days to 16 chronic smokers significantly reduced the urinary excretion of mutagens.98 Studies on humans at high risk of palatal cancer due to reverse smoking demonstrated that turmeric (1 g/day) for 9 months had a significant impact on the regression of precancerous lesions. The treatment also decreased micronuclei and DNA adducts in oral epithelial cells.99 (Reverse smoking is a practice where the burning end of the cigarette is kept in the mouth and causes a high incidence of oropharyngeal carcinoma.)

Turmeric
In India, turmeric has been used for centuries as a spice and a food preservative, as well as for its medicinal properties.89 Active constituents of Curcuma longa include yellow pigments (35%) known as curcuminoids consisting of curcumin and methoxylated curcumins.90

Anticancer Activity
Epidemiological data suggest that curcumin may be responsible for the lower rate of colorectal cancer in Asian countries.91 The low incidence of large bowel cancers in Indians observed to 1999 has been partially attributed to the presence of curcumin in Indian cooking.92 An early 1980s estimate indicates communities in the Indian subcontinent consume up to 1.5 g/day/person of dietary turmeric.93 In 1993 the turmeric consumption in India was measured at 0.160.44 kg/year per capita. An intake of 0.6 g/day per capita is reported in rural areas.94 An extract of turmeric containing turmeric essential oil and curcuminoids did not have an effect on leucocytic M1G levels (antioxidant biomarker) in 15 patients with advanced colorectal cancer refractory to standard chemotherapies. Turmeric extract was prescribed for up

Other Herbs with Demonstrated Antioxidant Activity

Clinical Trials Ginkgo (Ginkgo biloba) Direct Antioxidant Activity Red blood cells from volunteers given standardised Ginkgo extract (200 mg/day, for 1 week) were more resistant to oxidative damage.100 Standardised Ginkgo extract (120 mg/day, for 2 months) decreased the clastogenic activity (a marker of oxidative stress) of blood from personnel exposed to radiation.101 Standardised Ginkgo extract significantly decreased superoxide dismutase (SOD) compared to placebo in patients with refractory schizophrenia also taking haloperidol. The reduction of SOD correlated with improvements in clinical rating scores.102,103 Pretreatment with standardised Ginkgo extract (320 mg/day) limited oxidative stress in patients undergoing coronary bypass surgery compared to those who received placebo.104

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Clinical Trials Ginkgo (Ginkgo biloba) Direct Antioxidant Activity Ginkgo leaf extract suppressed the free radical production, scavenged free radicals and reduced lipid peroxidation injury in asphyxia neonates.105 Fourteen-day supplementation with Ginkgo extract inhibited the extent of oxidative stress (in serum) caused by exposure to ultraviolet light. Efficacy of antioxidants: selenium > Ginkgo > beta-carotene > vitamin E.106 Conditions where Oxidative Injury is or may be involved Six-week treatment of standardised Ginkgo extract decreased the elevated levels of malonaldehyde in serum and red cell membranes of insulin-dependent diabetics.107 A meta-analysis indicates that standardised Ginkgo extract (80600 mg/day, usually less than 200 mg/day) shows promising evidence of improvement in cognition and function for the treatment of patients with dementia or cognitive decline.108 Standardised Ginkgo extract (160 mg/day) for six months improved visual acuity compared to placebo in a double-blind placebo-controlled trial of patients with senile macular degeneration.109 St Marys thistle (Silybum marianum) Direct Antioxidant Activity Plasma total antioxidant capacity was significantly increased in volunteers taking 858 mg/day of silymarin compared to placebo treatment. In a second study group, a decrease was observed after dialysis for patients with chronic renal disease, which correlated with a decrease in creatinine, urea and uric acid.110 Plasma antioxidant capacity was higher in healthy volunteers who received silymarin (858 mg/day) compared to that of the placebo group.111 Silymarin or silybin has demonstrated antioxidant activity in clinical trials for patients with alcoholic liver disease/cirrhosis. Demonstrated activity includes: reduction in lipid peroxidation, increase in glutathione (erythrocyte and plasma), increase in retinoids (plasma), increase in activity of glutathione peroxidase (serum), reduction (from elevated level) of MDA (erythrocytes), increase in SOD expression (erythrocytes and/or lymphocytes).112-118 Three patients with chronic hepatitis C and cirrhosis recovered quickly and avoided liver transplantation after administration of triple antioxidant therapy (alpha-lipoic acid, silymarin, selenium).119 Conditions where Oxidative Injury is or may be involved Oral treatment with a silybin and beta-cyclodextrin combination caused the significant reduction in malondialdehyde levels in patients with chronic alcoholic liver disease and concomitant non-insulin-dependent diabetes. Plasma glucose and triglycerides were also decreased at the end of the 6-month treatment.120 Schisandra (Schisandra chinensis) Schisandra fruit given as an oral liquid (10 g/day) for 60 days significantly increased the SOD activity in serum compared with that of the control group.121 Dan shen (Salvia miltiorrhiza) Dan shen demonstrated antioxidant activity in a controlled study involving children with acute viral myocarditis.122 Administration of dan shen reduced lipid peroxidation and adjusted the imbalance of three antioxidant enzymes in a controlled trial of patients with chronic pulmonary heart disease.123

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Other Promising Herbal Antioxidants

The following herbs have yet to be evaluated in clinical trials for antioxidant effects. The current information suggests they have the potential to be effective antioxidants.

free radical scavenging of DPPH (aqueous ethanol extract;133,134 carnosol, carnosic acid, rosmarinic acid130); protection against oxidative damage to DNA as a consequence of scavenging of both hydroxyl radicals and singlet oxygen (rosemary ethanol extract of rosemary);135 inhibition of DNA strand breaking (carnosol, carnosic acid, rosmarinic acid).131

Rosemary
The leaf of rosemary (Rosmarinus officinalis) contains an essential oil (12%), consisting of 1,8-cineole, borneol, bornyl acetate, alpha-pinene and camphene; phenolic diterpenes (including carnosol and carnosic acid), rosmarinic acid, flavonoids and triterpenoids.90,124 The relative amount of carnosol in dry ground rosemary leaves is 3.84.6%.125 Rosemary is a strong lipid antioxidant and is used in the food industry as a preservative, particularly for meat products. It has a strong antioxidant activity in saturated fats, which is unusual as most antioxidant plant extracts and phytochemicals demonstrate activity in aqueous systems. An in vitro assessment of 15 herbs found that rosemary exhibited the highest antioxidant activity across all the tested fats.126 The addition of rosemary to meat dishes in addition to providing flavour may serve a medicinal purpose such as assisting in the prevention of atherosclerosis. Rosemary leaf, in the words of Culpeper helps all cold diseases, both of the head, stomach, liver and belly and taken as a decoction in wine, helps treat retention of meat and assists digestion.127 In vitro evaluation has indicated that the volatile oil as well as the ethanol extract has antioxidant activity.128 The strong antioxidative activity of rosemary is attributable to the phenolic diterpenes,129 about 90% of the activity is attributed to carnosol and carnosic acid.130 Rosemary and/or its constituents have demonstrated the following antioxidant activity in vitro: inhibition of superoxide anion production (carnosol, carnosic acid, rosmanol and epirosmanol (330 M));131 inhibition of mitochondrial and microsomal lipid peroxidation (carnosol, carnosic acid, rosmanol and epirosmanol (330 M));131 inhibition of lipid peroxidation in human blood (carnosol, rosmanol, epirosmanol);132 protection of red cells against oxidative haemolysis (carnosol, carnosic acid, rosmanol and epirosmanol (330 M));131

Results from in vivo studies in rats (for administration by oral route) include: induction of phase I and phase II (e.g. glutathione S-transferase) enzymes (water-soluble extract of rosemary);136 increase in liver GST and quinone reductase activities (rosemary extract);137 hepatoprotective activity in carbon tetrachlorideinduced acute hepatotoxicity by antioxidant activity and improving GST-dependent detoxification (concentrated methanol extract of rosemary (corresponding to 6 mg/kg/day of carnosol;138 ethanol extract without volatile oil, (volatile oil less active)139); reduction of DMBA-induced mammary gland tumour incidence.140

Hawthorn
Hawthorn (Crataegus monogyna, C. oxyacantha) extracts of leaf, flower and berry have demonstrated antioxidant activity in several in vitro models: inhibition of lipid peroxidation and scavenging of ROS. The antioxidant capacity was linked to the content of OPCs and flavonoids.141-144 The activity of the OPCs were higher than that of the flavonoids.144 Hawthorn tincture inhibited the oxidation of LDL and VLDL particles isolated from the plasma of diabetic patients.145 Alcoholic extract of Crataegus demonstrated a protective effect on oxidative stress in atherosclerotic rats. The extract prevented the increase of lipid peroxidation and the decrease of glutathione and alphatocopherol concentration in tissue. Antioxidant enzyme levels were normalised in liver, aorta and heart tissue.146 Administration with hawthorn increased the activity of SOD in hyperlipidaemic mice.147

Conclusion
Studies investigating the effect of supplementation with individual nutrient antioxidants (vitamin E and betaFor professional use only. Not for Public Distribution.

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carotene) produced unexpected results: a lack of efficacy and potential adverse (prooxidant) effects. Although further verification is required (through more rigorous epidemiological studies and disease intervention clinical trials), complex sources of antioxidants such as fruit, vegetables and herbs (green tea, grape seed, turmeric, Ginkgo, St Marys thistle, Schisandra, dan shen) have been associated with decreased cardiovascular disease and cancer incidence and have also shown plasma antioxidant activity and benefit in other conditions related to oxidative stress. Clinical trials investigating promising herbal antioxidants such as hawthorn and rosemary are also required to fully understand their therapeutic potential. Best therapeutic effects will be achieved by intake of a complex array of antioxidants, preferably from natural sources such as a diet high in fruit and vegetables, and supplementation with herbal antioxidants. When prescribing any isolated or synthetic antioxidant such as vitamin E, vitamin C or beta-carotene the addition of the more complex herbal antioxidant may enhance activity and protect against potential adverse effects.
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Ms Michelle Morgan
BSc, Dip App Sci (Herb), MATMS

Michelle Morgan has a Bachelor of Science degree majoring in Chemistry from the University of Queensland (1987) and worked in the scientific field as a laboratory technician for many years. She has expertise in Quality Assurance, working for more than 3 years as a Quality Assurance Chemist in building products manufacture. Michelle has worked for nearly 9 years at MediHerb as Technical Writer where she is responsible for information gathering, technical writing, editing, some regulatory functions, and the organising and indexing of technical publications including those on MediHerbs websites. She has assisted in the research and writing of several herbal medicine text books including A Clinical Guide to Blending Liquid Herbs: Herbal Formulations for the Individual Patient, recently published by Churchill Livingstone. Michelle is a qualified herbalist, available for staff consultations at MediHerb and she practises parttime in Warwick.

12 Modern Phytotherapist

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