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reviewed a cross-sectional study of the daily dietaryintake of flavonoids on risk faao rs for co ronaryartery disease.^ The endpoints measured wereblood pressure and arterial stiffness. The flavonoidswere obtained primarily from wine, grapes, andberries, which are goo d sources of vitamins andantioxidants. The study found that higher intakeof only the anthocyanin subclass of flavonoids wasassociated with significantly lower blood pressureand arterial stiffness.These reports, coupled w ith the m eta-analysisrepo rted here, exemplify the conflicting results ofstudies examining the efficacy of muldvitamins.They also point to some of the reasons forthese different results and toward some ways tointerpret these contradictory results for patients.Cross-sectional studies like the one reviewed inJanu ary use food frequency questionnaires torecord people's dietary consum ption, while RCTslike the PHSn and those reviewed in the m eta-analysis focus on a multivitamin intervention. Theyare, so to speak, examining apples and orang es.Multivitamin preparation s are syntheticallyproduce d w ith controlled am ounts of specificvitamins and other components. Questions aboundover the com bination of vitamins, the dose ofeach, their bioavailability, and how they have beenman ufactured and stored. In contrast, fruits a ndvegetables contain a wide variety of different naturalproducts in varying proportions. Although many

case-control and cohort studies of fruit and vegetableconsumption find beneficial results, the RCTs ofmultivitamin p roducts have tended to have lessbeneficial effects. Th e meta-an alysis repo rted here isthus in keeping with this general trend.Wh ile at first glance the results of these studiesmay appear to conflict, they are in keeping withcurrent guidelines. Thus, consum ption of fruit a ndvegetables is recommended as part of an overallhealthy lifestyle to reduce the risk of cardiovasculardisease. Con sump tion of daily multivitaminand a ntioxidant supplements is not pa rt of suchguidelines and is not w arranted by the most recentmeta-analysis of RCTs. It is not looking like a dailymultivitamin is going to take the place of an apple aday. References1 . Shea BJ, et al. Development of AMSTAR- A nneasurement tool to

assess the methodological quality of systematic reviews. MC MedRes/Vlet/iodo/2007;7:IO.

2. Myung SK, et al. Effects of antioxidant supplements on cancerprevention: Meta-analysis o f random ized c ontrolled trials. An nOnco/20IO;21:166-179.

3. Quick M , Kiefer DK . D o multivitamins prevent cancer in men?/megratA/Med A/ert 2012 ; 15:141 -1 44 .

4. SessoHD,etal. Multivitamins in the prevention of candiovasculardisease in men: The Physicians' Health Study II randomizedcontrolled trial. M4 A 2012;308:1751 -1760.

5. Marcolina ST Dietary anthocyanins for coronary artery disease:Beny good results, /ntegrotive Med Alert 2013; 16:3-6.

ANTIOXIDANTABSTRACT & COMMENTARYAnother Intriguing Antioxidant Tropical Plant:MoringaBy David Kiefer, IA DSYNOPSIS: In vit ro and an in vivo animal mode l show that anextract of Moringa olefera leaves has antioxidant effects,decreasing liver damage from a high-fat diet.SOURCE: Das N, et al. Moringa oleifera Lam. leaf extract prevents early liver injury and restores antioxidant status in mice fed with high-fatdiet. Indian] Exp Biol 2012;50:404-412.

The researchers in this study used a mousemodel to mimic nonalcoholic fatty liverdisease (NAFLD) from a high-fat diet and tostudy the effect of an extra of Moringa oleifera(moringa) on that liver pathology. Some of the Uverinjury in NA FLD occurs because of b eta-oxidationof fatty acids and an overproduction of reactiveoxygen species. The au thors' hypothesis is thatmoringa has a hepatoprotectant mechanism of

action by mod erating oxidad ve stress, a complexand somew hat controversial topic for many diseaseprocesses. For example, the researchers list severalphytochemicals in moringa that have antioxidanteffects (see TflWe 2).The researchers collected leaves from one treein a specific region of In dia, wa shed the leaveswith distilled water, and then dried, crushed, and

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Summary Points Moringa olefera leaf extract has in vitro

antioxida nt effects as pe r sev eral assays. Moringa olefera leaf extract prevents and

treats the liver damage in mice that resultsfro m a sho rt- term , h igh-fat d iet.

Th e results have relevance to nonalco-holic fatty liver disease, but need to bereplicated in humans.

Table I : Antioxidant Phytochemicalsin tAoringo olefero

QuercetinIsoquercetinKaempferolZeatnRutin-caroteneAscorbic acid

powd ered the leaves. Afterward, the powde r w asextracted with 50% alcohol, the alcohol wasevaporated, an d the extract was then reconstituted inwater. The researchers did not attempt to standardizeor further charaaerize this preparation.The extract was analyzed for various charaaerisdcs,including total polyphenol content, free radicalscavenging activity (as estimated by th e DP PH test,a standard in vitro analytic technique), hydroxylradical scavenging activity, and metal ch eladngactivity. Th e extract was then given to Swiss strainmale albino mice. First, a pre-experimental phase{data not shown) was undertaken to determine that

the optimal dose for the actual experiment was 150mg/kg of b ody weight. Then , five groups of mice(n = 6 each) were treated according to a specificprotocol for 1 5 days {see Table 2). Of note, group 4was created to analyze the "curative" effects of themoringa extract, after the liver injury from a high-fatdiet had presumably already occurred. Subsequenttesting included blood analysis for liver function,liver histology, and liver homogenate antioxidantand lipid peroxidation status.The researchers docum ented th at the moringaextracts contained "rich" concentrations ofpolyphenols, and higher DPPH radical scavengingactivity and metal chlelating activity than thecontrol preservative compound BHA. The moringaextracts h ad a variety of effects in the animal mo del.Mo ringa appeared to attenuate weight gain in micefed a high-fat diet (both groups 4 and 5). In thehigh-fat diet group w ithou t mo ringa, a loweringof liver antioxidant status and glutathione levelswas docu mented; alternatively, when m oringa w asadded, liver antioxidant status and glutathioneconcentration was maintained (? < 0.05). The trendcontinued for the remainder of the parametersmeasured in this study, including liver function testsand histology; adverse effects of a high-fat diet werereversed or prevented in groups 4 and 5, the groupsreceiving the moringa extraa.COMMENTARYMoringa olefera is a tree native to Asia, withcenturies of traditional medicinal use for almostevery body system.' The tree is now knov^rnthroug hou t the tropics and subtropics, includingLadn America. A testament to the popu larity of thisplant as a medicine is a recent report by the Latinotelevision network, Univision, partly spurred byinterviews about its medicinal effectiveness by FidelCastro, the ex-President of Cuba.^The extent of research, both human clinicaltrials and in vitro research, coming ou t ab out

Table 2:Group

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Experimental Protocol of Diets and Moringa ExtractD i e t

Standard laboratory dietStandard laboratory dietHigh-fat dietHigh-fat dietHigh-fat diet

Ex trac tN o n eMoringa 150 m^kgN o n eMoringa 150 m^ kg , only for last 5 daysMoringa 150 m^kg

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the antioxidant and anti-inflammatory effects ofdifferent plants (especially tropical fruits) is trulystaggering. No w w e can add to th at list Moringaolefera, albeit this study is abou t a leaf e xt raa ,no t a fruit juice. Will the leaves of this plan t t rum ppomegranante juice, blueberries, or cranberries inthe search for the best antioxidant? It is hard to say,but the study reviewed here is an example of theintriguing results that may lead to increased interestin Moringa olefera.The researchers convincingly documented theantioxidant effects of moringa leaf extract, whichagrees with other results in the medical literatureabou t its antioxidan t phytochemicals and in vitroeffeas.-* Less immediately or intuitively obvious is therelevance of this short-term dietary insult in albinomice to human nonalcoholic fatty liver disease,though the researchers provide numerous citatiorisfor an oxidative pathophysiological mechanismof action relevant to NAF LD, nonalcoholicsteatohepatitis, and cirrhosis; this 15-day mousemodel may at least approxim ate part of the NAFLDdisease process. The comm on theme seems to beoxidation and resulting inflammation. It seemscompelling, then, that an an tioxidant and anti-

inflammatory intervention with a plant like Moringaolefera might just be wh at the doctor ordered, soto speak. It remains to be seen whether the 15-dayeffect of a high-fat diet is similar to our NAFLDpatients' pathophysiological changes, or if 15 days ofsimultaneous moringa extract ingestion constitutes"prevention" (group 5), whereas 5 days of ingestionis "treatm ent" (group 4). It goes withou t saying tha tfollow-up studies, especially in hum ans , are neededto clarify the use, efficacy, and safety of moringaleaf extract for this indication . At this point, it is toopremature to recommend moringa supplements forpeople with NAF LD, bu t it is something to keep onthe clinical rada r as research results accum ulate. References1. Fbsmorrtier B. The medicinal qualities t Moringa oleifero. Holist

Nu;3 fVoc t20 l l ;25 :80 -87 .2. La Moringa, mito o realidad? Univisin. Available at: http://

univisionnuevayork.univision.comAHdeos/Video/2012-10-26/moringa-planta-fidel

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