Development process of a clinical guideline to manage type 2 diabetes in adults by Ayurvedic practitioners.

Background: Type 2 diabetes mellitus (T2DM), a common chronic health condition, has major health and socioeconomic consequences. In the Indian subcontinent, it is a health condition for which individuals commonly consult Ayurvedic (traditional medical system) practitioners and use their medicines. However, to date, a good quality T2DM clinical guideline for Ayurvedic practitioners, grounded on the best available scientific evidence, is not available. Therefore, the study aimed to systematically develop a clinical guideline for Ayurvedic practitioners to manage T2DM in adults. Methods: The development work was guided by the UK's National Institute for Health and Care Excellence (NICE) manual for developing guidelines, the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, and the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. First, a comprehensive systematic review was conducted which evaluated Ayurvedic medicines' effectiveness and safety in managing T2DM. In addition, the GRADE approach was used for assessing the certainty of the findings. Next, using the GRADE approach, the Evidence-to-Decision framework was developed, and we focused on glycemic control and adverse events. Subsequently, based on the Evidence-to-Decision framework, a Guideline Development Group of 17 international members made recommendations on Ayurvedic medicines' effectiveness and safety in T2DM. These recommendations formed the basis of the clinical guideline, and additional generic content and recommendations were adapted from the T2DM Clinical Knowledge Summaries of the Clarity Informatics (UK). The feedback given by the Guideline Development Group on the draft version was used to amend and finalize the clinical guideline. Results: A clinical guideline for managing T2DM in adults by Ayurvedic practitioners was developed, which focuses on how practitioners can provide appropriate care, education, and support for people with T2DM (and their carers and family). The clinical guideline provides information on T2DM, such as its definition, risk factors, prevalence, prognosis, and complications; how it should be diagnosed and managed through lifestyle changes like diet and physical activity and Ayurvedic medicines; how the acute and chronic complications of T2DM should be detected and managed (including referral to specialists); and advice on topics like driving, work, and fasting including during religious/socio-cultural festivals. Conclusion: We systematically developed a clinical guideline for Ayurvedic practitioners to manage T2DM in adults.

Intestinal anti-inflammatory and visceral analgesic effects of a Serpylli herba extract in an experimental model of irritable bowel syndrome in rats.

Ethnopharmacological relevance: Serpylli herba extract (SHE), composed of the aerial parts of wild thyme (Thymus serpyllum L.) (Lamiaceae family), is traditionally used in Europe and North Africa to treat diarrhea, gastric ulcers, intestinal parasites and upper respiratory tract infections. Recently, SHE has generated a great interest for irritable bowel syndrome (IBS) management, probably due to its intestinal anti-inflammatory properties shown in experimental colitis and the fact that its active components could preserve the intestinal barrier integrity, which is altered in patients with IBS. Aim of study: We aimed to test the effects of a SHE in a rat experimental model resembling human IBS. Materials and methods: IBS was provoked by deoxycholic acid (DCA). Rats were then treated with SHE (100 mg/kg) or gabapentin (70 mg/kg) and different inflammatory and gut barrier integrity markers were evaluated. Moreover, several gut hypersensitivity and hyperalgesia determinations were performed. Results: SHE improved referred pain and visceral hypersensitivity. Additionally, SHE enhanced immune status by downregulating of the expression of the pro-inflammatory mediators Il-1ß, Il-6, Ifn-γ, Tlr-4, and the inducible enzyme Cox-2, thus inducing visceral analgesia, and promoting the restore of the gut barrier function by upregulating the mucins Muc-2 and Muc-3. These anti-inflammatory effects could be related to its action on mast cells since it significantly inhibited the ß-Hexosaminidase production in RBL-2H3 cells. Lastly, SHE also seems to modulate the serotonin pathway by restoring the altered expression of the 5-HT receptors Htr-3 and Htr-4. Conclusion: SHE could be considered a potential new treatment for IBS, since it ameliorates hypersensitivity, visceral hyperalgesia, and inflammation. These beneficial effects may be due to the inhibition of mast cells degranulation and serotonin pathway.

Acute and Chronic Effects of Green Oat (Avena sativa) Extract on Cognitive Function and Mood during a Laboratory Stressor in Healthy Adults: A Randomised, Double-Blind, Placebo-Controlled Study in Healthy Humans.

Green oat (Avena sativa) extracts contain several groups of potentially psychoactive phytochemicals. Previous research has demonstrated improvements in cognitive function following a single dose of these extracts, but not following chronic supplementation. Additionally, whilst green oat extracts contain phytochemicals that may improve mood or protect against stress, for instance species-specific triterpene saponins, to date this possibility has not been examined. The current study investigated the effects of a single dose and four weeks of administration of a novel, Avena sativa herbal extract (cognitaven®) on cognitive function and mood, and changes in psychological state during a laboratory stressor. The study adopted a dose-ranging, double-blind, randomised, parallel groups design in which 132 healthy males and females (35 to 65 years) received either 430 mg, 860 mg, 1290 mg green oat extract or placebo for 29 days. Assessments of cognitive function, mood and changes in psychological state during a laboratory stressor (Observed Multitasking Stressor) were undertaken pre-dose and at 2 h and 4 h post-dose on the first (Day 1) and last days (Day 29) of supplementation. The results showed that both a single dose of 1290 mg and, to a greater extent, supplementation for four weeks with both 430 mg and 1290 mg green oat extract resulted in significantly improved performance on a computerised version of the Corsi Blocks working memory task and a multitasking task (verbal serial subtractions and computerised tracking) in comparison to placebo. After four weeks, the highest dose also decreased the physiological response to the stressor in terms of electrodermal activity. There were no treatment-related effects on mood. These results confirm the acute cognitive effects of Avena sativa extracts and are the first to demonstrate that chronic supplementation can benefit cognitive function and modulate the physiological response to a stressor.

The Acute and Chronic Cognitive and Cerebral Blood Flow Effects of a Sideritis scardica (Greek Mountain Tea) Extract: A Double Blind, Randomized, Placebo Controlled, Parallel Groups Study in Healthy Humans.

BACKGROUND: The presence of polyphenols such as hydroxy-cinnamic acids and flavonoids in Sideritis scardica (Greek mountain tea) are likely responsible for the cognitive and mood effects of its consumption and this could be underpinned by the ability of such polyphenols to prevent monoamine neurotransmitter reuptake and to increase cerebral blood flow (CBF). OBJECTIVE: The current study extends the small amount of Sideritis scardica literature in humans by assessing both cognitive and mood outcomes in a sample of older adults, as well as blood pressure (BP) and CBF, in a subsample, utilizing near-infrared spectroscopy (NIRS). DESIGN: This randomized, double-blind, placebo-controlled, parallel groups trial randomized N = 155, 50⁻70-year-old male and female participants who were assessed for the cognitive (N = 140), mood (N = 142), BP (N = 133) and CBF (N = 57) effects of two doses of Greek mountain tea (475 and 950 mg) as well as an active control of 240 mg Ginkgo biloba, and a placebo control, following acute consumption (Day 1) and following a month-long consumption period (Day 28). RESULTS: Relative to the placebo control, 950 mg Greek mountain tea evinced significantly fewer false alarms on the Rapid Visual Information Processing (RVIP) task on Day 28 and significantly reduced state anxiety following 28 days consumption (relative also to the active, Ginkgo control). This higher dose of Greek mountain tea also attenuated a reduction in accuracy on the picture recognition task, on Day 1 and Day 28, relative to Ginkgo and both doses of Greek mountain tea trended towards significantly faster speed of attention on both days, relative to Ginkgo. Both doses of Greek mountain tea, relative to placebo, increased oxygenated haemoglobin (HbO) and oxygen saturation (Ox%) in the prefrontal cortex during completion of cognitively demanding tasks on Day 1. The higher dose also evinced greater levels of total (THb) and deoxygenated (Hb) haemoglobin on Day 1 but no additional effects were seen on CBF on Day 28 following either dose of Greek mountain tea. Ginkgo biloba led to lower levels of Ox% and higher levels of Hb on Day 1 and lower levels of both HbO and THb on Day 28. CONCLUSIONS: The significantly improved cognitive performance following Greek mountain tea on Day 1 could be due to significant modulation of the CBF response. However, these improvements on Day 28 are more likely to be due to the reductions in state anxiety and, taken together, suggests that the former mechanism is more likely to facilitate acute cognitive effects and the latter more likely to underpin more prolonged cognitive improvements.

Assessment of the Acute and Subchronic Toxicity and Mutagenicity of Sideritis scardica Griseb. Extracts.

Sideritis scardica Griseb. has a long history of collection from the wild as a traditional remedy for respiratory and gastrointestinal complaints. It has also been investigated for its promising pharmacological activities in the central nervous system. However, its toxicological data is entirely missing. This study investigated the acute and repeated-dose oral toxicity of a S. scardica 20% (v/v) ethanol extract in Sprague Dawley rats, and mutagenicity using the Ames test. No gross pathological abnormalities and no toxicity signs or mortality were detected in animals treated with the dose of 2000 mg/kg bw during 14 days of observation. The tested extract was assigned to category 5 of the GHS. To evaluate a repeated-dose toxicity, an extract has been tested over a 28-day period followed by a 14-day recovery period. No mortality and no changes in body/organ weight or food consumption have been observed. The no-observed-adverse-effect-level of the extract was determined at 1000 mg/kg bw. The results of Ames tests conducted on extracts of different polarity (water; 20% (v/v) ethanol; 50% (v/v) ethanol; n-heptane), were unequivocally negative. The study reveals no toxicity of S. scardica and no concerns for its mutagenic effects, supports its positive safety profile, and confirms the acknowledged traditional medicinal use in human.

Hibiscus sabdariffa L. - a phytochemical and pharmacological review.

Hibiscus sabdariffa L. (Hs, roselle; Malvaceae) has been used traditionally as a food, in herbal drinks, in hot and cold beverages, as a flavouring agent in the food industry and as a herbal medicine. In vitro and in vivo studies as well as some clinical trials provide some evidence mostly for phytochemically poorly characterised Hs extracts. Extracts showed antibacterial, anti-oxidant, nephro- and hepato-protective, renal/diuretic effect, effects on lipid metabolism (anti-cholesterol), anti-diabetic and anti-hypertensive effects among others. This might be linked to strong antioxidant activities, inhibition of α-glucosidase and α-amylase, inhibition of angiotensin-converting enzymes (ACE), and direct vaso-relaxant effect or calcium channel modulation. Phenolic acids (esp. protocatechuic acid), organic acid (hydroxycitric acid and hibiscus acid) and anthocyanins (delphinidin-3-sambubioside and cyanidin-3-sambubioside) are likely to contribute to the reported effects. More well designed controlled clinical trials are needed which use phytochemically characterised preparations. Hs has an excellent safety and tolerability record.

Intestinal anti-inflammatory activity of the Serpylli herba extract in experimental models of rodent colitis.

INTRODUCTION: Nowadays, there is an increasing interest for alternative options in the treatment of inflammatory bowel diseases (IBDs) that combine efficacy and an adequate safety profile. METHODS: The intestinal anti-inflammatory effects of Serpylli herba, the officinal drug in the European Pharmacopeia composed by the aerial parts of wild thyme (Thymus serpyllum), were evaluated in the trinitrobenzenesulfonic acid (TNBS)-induced rat colitis and dextran sodium sulfate (DSS)-induced mouse colitis, which are well characterized experimental models with some resemblance to human IBD. RESULTS: S. herba extract exerted an intestinal anti-inflammatory effect in both experimental models of colitis, as evidenced both histologically, since it facilitated the tissue recovery of the damaged colon, and biochemically as showed by the improvement of the different inflammatory markers evaluated, including myeloperoxidase activity, glutathione content, and leukotriene B4 levels as well as the expression of the inducible proteins iNOS and COX-2. This beneficial effect was associated with the reduction in the expression of different cytokines, like TNFα, IL-1ß, IFNγ, IL-6 and IL-17, the chemokine MCP-1, and the adhesion molecule ICAM-1, thus ameliorating the altered immune response associated with the colonic inflammation. CONCLUSION: S. herba extract displays an anti-inflammatory effect on different models of rodent colitis that could be attributed to its immunomodulatory properties.

Ficus carica leaf extract modulates the lipid profile of rats fed with a high-fat diet through an increase of HDL-C.

Ficus carica has been traditionally used for the treatment of several metabolic syndrome-related health problems. It was the objective of this study to investigate the preventive effects of a Ficus carica (FC) leaf extract on hyperlipidemia in high fat diet (HFD)-induced obese male rats. Male Sprague-Dawley rats (180-200 g) were fed with a regular diet, HFD or a HFD + oral treatment of either 50 mg/kg or 100 mg/kg of FC or 30 mg/kg pioglitazone for six weeks. A range of parameters was evaluated including body weight development, plasma levels of total cholesterol, triglycerides (TG), low-density-lipoprotein cholesterol, high-density lipoprotein cholesterol (HDL-C), adiponectin, leptin, glucose, insulin, interleukin-6 (IL-6), atherogenic index (AI) and the coronary risk index (CRI). FC significantly lowered TG and IL-6 levels and elevated HDL cholesterol (p < 0.05). The effects of FC on lipid parameters were more pronounced than those of the positive control pioglitazone. FC significantly lowered AI and CRI (p < 0.01) while it had no effect on adiponectin and leptin levels. Our results demonstrate that preventive treatment with FC significantly improved the lipid profile and decreased adipogenic risk factors in HFD rats most likely mediated through an increase in HDL-C levels.

Opuntia ficus-indica ingestion stimulates peripheral disposal of oral glucose before and after exercise in healthy men.

The purpose of this study was to investigate the effect of Opuntia ficus-indica (OFI) cladode and fruit-skin extract on blood glucose and plasma insulin increments due to high-dose carbohydrate ingestion, before and after exercise. Healthy, physically active men (n = 6; 21.0 ± 1.6 years, 78.1 ± 6.0 kg) participated in a double-blind placebo-controlled crossover study involving 2 experimental sessions. In each session, the subjects successively underwent an oral glucose tolerance test at rest (OGTT(R)), a 30-min cycling bout at ~75% VO(2max), and another OGTT after exercise (OGTT(EX)). They received capsules containing either 1,000 mg OFI or placebo (PL) 30 min before and immediately after the OGTT(R). Blood samples were collected before (t0) and at 30-min intervals after ingestion of 75 g glucose for determination of blood glucose and serum insulin. In OGTT(EX) an additional 75-g oral glucose bolus was administered at t60. In OGTT(R), OFI administration reduced the area under the glucose curve (AUC(GLUC)) by 26%, mainly due to lower blood glucose levels at t30 and t60 (p < .05). Furthermore, a higher serum insulin concentration was noted after OFI intake at baseline and at t30 (p < .05). In OGTT(EX), blood glucose at t60 was ~10% lower in OFI than in PL, which resulted in a decreased AUC(GLUC) (-37%, p < .05). However, insulin values and AUC(INS) were not different between OFI and PL. In conclusion, the current study shows that OFI extract can increase plasma insulin and thereby facilitate the clearance of an oral glucose load from the circulation at rest and after endurance exercise in healthy men.

Comparative evaluation of two different Artemisia dracunculus L. cultivars for blood sugar lowering effects in rats.

Recent concerns about the potential carcinogenicity of estragole and methyleugenol led a number of regulatory bodies to call for restrictions on the use of herbs that contain these constituents. A number of medicinal plants produce essential oils that contain estragole and methyleugenol, including Artemisia dracunculus L. (tarragon). Previous studies have proven the antidiabetic properties of tarragon. In order to address the safety concerns of estragole containing tarragon extracts, an extraction procedure was developed to minimize the estragole and methyleugenol content in tarragon extracts and the ethanol versus aqueous extracts from two Artemisia dracunculus cultivars (French and Russian tarragon) were tested for blood glucose lowering effects in rats. It could be demonstrated that aqueous extracts of both Artemisia cultivars did not contain detectable amounts of estragole and methyleugenol, whereas ethanol extracts (60% v/v) of the French cultivar contained higher levels of the aforementioned compounds than those of the Russian cultivar. Further testing revealed that Russian tarragon lowered blood glucose levels in rats after glucose challenge, with the ethanol extract being as active as the aqueous extract. The results suggest that by using adequate production procedures the amount of potentially harmful compounds in extracts can be limited without affecting the overall pharmacological activities of these preparations.

Artemisia dracunculus L. (tarragon): a critical review of its traditional use, chemical composition, pharmacology, and safety.

Artemisia dracunculus L. (tarragon) has a long history of use as a spice and remedy. Two well-described "cultivars" (Russian and French) are used widely and differ in ploidy level, morphology, and chemistry. Key biologically active secondary metabolites are essential oils (0.15-3.1%), coumarins (>1%), flavonoids, and phenolcarbonic acids. In vivo studies mainly in rodents, particularly from Russian sources, highlight potential anti-inflammatory, hepatoprotective, and antihyperglycemic effects. Despite concerns about the toxic effects of two of its main constituents, estragole (up to 82%) and methyleugenol (up to 39%), no acute toxicity or mutagenic activity has been reported at doses relevant for human consumption. Water extracts of A. dracunculus contain very low amounts of estragole and methyleugenol and, therefore, are considered to pose a very limited risk. Overall, a stronger focus on clinical studies and precise taxonomic and phytochemical definition of the source material will be essential for future research efforts.

Comparative evaluation of two different Opuntia ficus-indica extracts for blood sugar lowering effects in rats.

Stems of Opuntia ficus-indica (L.) Mill. (OFI) are traditionally used in Mexico to treat diabetes mellitus. Less research data are available for combinations of stem and fruit preparations. The present study was designed to investigate the effects of an aqueous extract prepared from the cladodes and a proprietary stem/fruit skin-blend (stem/fruit skin ratio 75/25) of OFI on blood glucose and plasma insulin in normal rats. A dose finding study with the traditional cladode OFI extract revealed that maximum effects on blood glucose and insulin were observed after oral administration in a dose range of 6-176 mg/kg. The proprietary OFI blend significantly lowered blood glucose levels in the glucose tolerance test to a similar extent (p < 0.05 vs control) as the traditional aqueous cladode extract when administered in a dose of 6 mg/kg. In contrast to the aqueous extract, the proprietary blend significantly increased basal plasma insulin levels (p < 0.01 vs control) indicating a direct action on pancreatic beta cells. The results suggest that both OFI extracts exert hypoglycemic activities in rats in doses as low as 6 mg/kg but that the effects of the proprietary stem/fruit blend were more pronounced in our model.

Acute blood glucose lowering effects and long-term safety of OpunDia supplementation in pre-diabetic males and females.

AIM OF THE STUDY: The aim of this study was to evaluate the acute and chronic effects of OpunDia (Opuntia ficus-indica) in obese pre-diabetic men and women. MATERIALS AND METHODS: This double-blind placebo controlled study included participants (age range of 20-50 years) randomly assigned to one of the two groups and given a 16-week supply of either the 200 mg OpunDia (n=15), or placebo (n=14). The acute phase of the study consisted of an oral glucose tolerance test (OGTT) with a 400 mg bolus of OpunDia given 30 min before orally ingesting a 75 g glucose drink. Baseline and post 16-week concentrations of glucose, insulin, hsCRP, adiponectin, proinsulin, Hb1Ac, cholesterol, and a comprehensive metabolic panel were collected along with body composition measured via densitometry (BOD POD). A repeated measures ANOVA was conducted to determine any significant interactions between group and time. Follow-up analysis was performed to determine differences among groups at each time point. Paired t-tests were performed on all variables to determine if any within group differences existed across time. RESULTS: There was a statistically significant decrease (P<0.05) in the blood glucose concentrations at the 60 (205.92+/-36.90 and 188.84+/-38.43 mg/dL, respectively), 90 (184.55+/-33.67 and 169.74+/-35.16 mg/dL, respectively) and 120 min (159.24+/-17.85 and 148.89+/-24.86 mg/dL, respectively) time points with the pre-OGTT compared to the OpunDia bolus trial. There were no between-group differences found with the OGTT time points, area under the curve, blood chemistry variables (insulin, hsCRP, adiponectin, proinsulin, Hb1Ac), diet analysis variables (carbohydrates, fat, protein and total kcals), body composition variables (fat mass, fat free mass, percent body fat and total body weight), or blood chemistry safety parameters (comprehensive metabolic panel) pre-to-post 16-week intervention. CONCLUSIONS: This study shows the acute blood glucose lowering effects and the long-term safety of the proprietary product OpunDia, thus supporting the traditional use of Opuntia ficus-indica for blood glucose management.

Garcinia mangostana L.: a phytochemical and pharmacological review.

Garcinia mangostana L. (mangosteen, Clusiaceae) has a long history of use as a medical plant, mostly in Southeast Asia. This is a review of the phytochemistry and pharmacology of mangosteen. Traditionally mangosteen is famous for its antiinflammatory properties and is used in the treatment of skin infections and wounds. Other applications include the therapy of various conditions such as dysentery, different urinary disorders, cystitis and gonorrhoea. This review highlights the development of this botanical drug into a widely used nutraceutical. Products derived from G. mangostana are now distributed increasingly all over the world. This has given rise to a concomitant increase in research on the phytochemical constituents and biological activity of mangosteen. Central to the biological activity of the species are xanthones which are reviewed in detail. A comprehensive assessment of the biological activities of individual xanthones as well as extracts of G. mangostana is included. In addition, its potential in terms of developing novel drug leads is assessed. Products containing its fruits are now sold widely as 'liquid botanical supplements', but evidence for the health benefits of these products is still lacking. As shown here, a serious weakness in our knowledge is the lack of clinical data and it is not yet clear to what extent the findings about pharmacological activities are of potential clinical relevance.

Flavonoids of Cynara scolymus possess potent xanthinoxidase inhibitory activity in vitro but are devoid of hypouricemic effects in rats after oral application.

Artichoke (Cynara scolymus L.) leaves have been historically used for the treatment of hyperuricemia and gout, however whether artichoke is truly efficacious for this indication, is still a matter of debate. Thus, the goal of the present study was first to examine the xanthine oxidase (XO) inhibitory activity of an artichoke leaf extract (ALE) and some of its main compounds in vitro and then further test potentially active substances for possible hypouricemic effects using an in vivo rat model. The in vitro study showed that ALE inhibited XO with only minimal inhibitory action (< 5 %) at 100 microg/mL. However, when selected compounds were tested, the caffeic acid derivatives revealed a weak XO inhibitory effect with IC (50) > 100 microM. From the tested flavones the aglycone luteolin potently inhibited XO with an IC (50) value of 1.49 microM. Luteolin 7-O-glucoside and luteolin 7-O-glucuronide showed lower XO inhibition activities with IC (50) values of 19.90 microM and 20.24 microM, respectively. However, oral administration of an aqueous ALE, luteolin, and luteolin 7-O-glucoside did not produce any observable hypouricemic effects after acute oral treatment in potassium oxonate-treated rats. After intraperitoneal injection of luteolin a decrease in uric acid levels was detected suggesting that the hypouricemic effects of luteolin are due to its original form rather than its metabolites produced by the gut flora. In conclusion, an aqueous ALE, caffeic acid derivatives and flavones exerted XO inhibitory effects in vitro but a hypouricemic activity could not be confirmed after oral administration.

Creatine--its chemical synthesis, chemistry, and legal status.

Creatine, a small molecule present in muscular tissue of many vertebrates, evolves to one of the most widely used and successful dietary supplements of recent decades (Graham and Hatton, 1999). Importantly, in the industrial manufacturing process, a high quality standard must be maintained. Validated analytical methods capable of providing reliable and consistent analysis of the main substance, side products and potentially harmful impurities must be employed. The principles of those determinations and the nature of possible byproducts will be elucidated in this chapter. In addition, the pure creatine produced may be unstable under certain conditions, e.g. within special formulations or galenical forms. Some hints how to deal with this fact and how to avoid instability will also be discussed. Thus, this chapter will serve as a survey of the paths of chemical synthesis of creatine, its chemistry, properties, stability, analytical determination methods and legal status.