Use of Evidence Based Phytopharmaceuticals in the Physician’s Clinic

Use of

Evidence Based

Phytopharmaceuticals

in the Physician’s Clinic

Romulo S. de Villa, MD, PhD, Cert. Biochemistry Molecular & Nutritional Oncologist

Prof. of Biochemistry & Nutrition

Molecular Biology & Biotechnology Consultant

800

700

600

500

400

300

200

100

0 1946 ‘50 ‘60 ‘70 ‘80 ‘90

Philippine Health Statistics, 1996 (Department of Health)

Communicable Disease

Rate per 100,000 Population, Philippines, 1946-1996

MORTALITY TREND

Communicable Disease

100

90

80

70

60

50

40

30

20

10

0

1946 ‘50 ‘60 ‘70 ‘80 ‘90

Diseases of the Heart

Diseases of the Heart

Malignant Neoplasms

Philippine Health Statistics, 1996 (Department of Health)

Malignant Neoplasms

Rate per 100,000 Population, Philippines, 1946-1996

MORTALITY TREND

800

700

600

500

400

300

200

100

0

100

90

80

70

60

50

40

30

20

10

0

1946 ‘50 ‘60 ‘70 ‘80 ‘90

Philippine Health Statistics, 1996 (Department of Health)

Communicable Disease

Diseases of the Heart and

Malignant Neoplasms

Rate per 100,000 Population, Philippines, 1946-1996

MORTALITY TREND

Communicable Disease

Diseases of the Heart

Malignant Neoplasms

LEADING CAUSES OF DEATH Number and Rate/100,000 Population

PHILIPPINES, 1997

CAUSES NUMBER RATE*

1. Diseases of the Heart 49,962 69.8

2. Diseases of the Vascular System 38,693 54.1

3. Pneumonia 30,811 43.1

4. Accidents 28,563 39.9

5. Malignant Neoplasm (cancer) 26,842 37.5

6. Tuberculosis, All Forms 23,056 32.2

7. Chronic Obstructive Pulmonary

Diseases and Allied Condition 11,807 16.5

8. Other Dses of Respiratory System 6,961 9.7

9. Diabetes Mellitus 6,749 9.4

10. Nephritis, Nephrotic Syn &

Nephrosis 6,704 9.4

Source: Philippine Health Statistics 1997

Scientific Evidence is Mounting • The common culprit in non-communicable

diseases is oxidative stress (excess free radicals over antioxidant capacity) – Free radicals and antioxidants in normal physiological functions

and human disease

Cardiovascular Disease

– Oxidative stress has been suggested to be involved in the pathogenesis of hypertension

– Reactive oxygen species remodels vascular system in hypertension

Diabetes and its Vascular Complications

– Oxidative stress is the leading cause of acute myocardial infarction in diabetics

– Controlling oxidative stress is a novel molecular approach to protecting the vascular wall in diabetes

– Hypertension Induces Oxidative Stress but Not Macrophage Infiltration in the Kidney in the Early Stage of Experimental Diabetes Mellitus

Phytochemicals

Substances

found exclusively in plants

Phytochemicals

have biomolecular targets! • Non-communicable, degenerative, lifestyle

diseases can be prevented and addressed by substances found exclusively in plants called phytochemicals – Polyphenols from grape seeds protect against high glucose-

induced oxidative stress

– Ganoderma lucidum inhibits oxidative stress-induced invasiveness of cancer cells through the suppression of interleukin-8 secretion

– Lycopene consumption decreases oxidative stress and bone resorption markers in postmenopausal women

– Corosolic acid prevents oxidative stress, inflammation and hypertension in SHR/NDmcr-cp rats, a model of metabolic syndrome

– Lutein and EPA interact to modulate iNOS mRNA expression

Phytochemicals in plant foods,

shown to have

biologic functions in the body,

are now called

Phytonutrients

Foods that contain Phytonutrients

are called

Functional Foods

The nutritional or dietary

supplement industry

is growing by leaps and bounds.

However,

it is essentially unregulated.

As Responsible Physicians

• Practice based on current up-to-date scientific evidence

• Recommend and prescribe based on credible criteria

– Safety from contamination

– Contains what is in the label

– Standardized to maintain consistency of effects

– Substantiated claims

“If we don’t guide our patients, they will be at the mercy of layman testimonial claims or just anecdotal evidence when there are already stronger scientific evidence.”

Phytonutrient containing

nutritional supplements with claims that are

scientifically substantiated

are now called

Nutraceuticals

6S Process

of a Nutraceutical

• Selection

• Sourcing

• Structure

• Safety

• Standardization

• Substantiation

Substantiation

with studies

• Supplementation as adjuvant to disease

management and prevention

– Suboptimal intake of some vitamins, above levels

causing classic vitamin deficiency, is a risk factor for

chronic diseases

– Multivitamin and multimineral supplementation

reduces incidence of infection among type 2 diabetics

• Antioxidants as adjuvant to disease prevention

– Antioxidant (vitamins C & E) use associated with

reduced risk of Alzheimer’s disease

– Increase in beta-carotene, vitamin C and selenium is

associated with a 10-20% reduction in asthma

prevalence

• Low carotenoid levels correlate with disease

– Higher lycopene (a carotenoid) associated with lower

risk of CVD in women

– Lower levels of beta-carotene and higher levels of uric

acid and MDA among those with hypertension

compared to normotensive participants.

– Lower alpha- and beta-carotene in patients with acute

ischemic stroke than in healthy controls and associated

with higher hs-CRP levels and neurologic deficits.

– Early-stage breast cancer survivors with the highest

plasma total carotenoid concentrations had reduced risk

for a new breast cancer event

• Carotenoids as marker of antioxidant status

– Plasma carotenoids correlate with intakes of

antioxidants in coffee, wine, and vegetables

• Raman Spectroscopic Measurement of Macular Pigments

– Macular pigment Raman detector for clinical applications

– Noninvasive detection of macular pigments in the human eye

– Resonance Raman measurement of macular carotenoids in normal

subjects and in ARMD

– Resonance Raman measurement of macular carotenoids in retinal,

choroidal, and macular dystrophies

– Resonance Raman measurement of macular carotenoids in the

living human eye

– Simple Raman instrument for in vivo detection of macular

pigments

• Non-invasive measurement of carotenoids in:

– Resonance Raman spectroscopic measurement of carotenoids in

the skin and retina

– NIR-FT-Raman spectroscopy of carotenoids in intact tissue

• Raman Spectroscopic Measurement of Skin

– Noninvasive selective detection of lycopene and beta-

carotene in human skin using Raman spectroscopy

• Diagnostic Application of

Raman Spectroscopy

– Results indicate that Raman spectroscopic technique

will play an important role in clinical diagnosing

– Non-invasive raman spectroscopic detection of

carotenoids in human skin

Substantiation of

Skin Carotenoid Measurement

• Skin carotenoid levels correlate with

– blood level standard

• Resonance Raman quantification correlates with HPLC-determined blood carotenoid levels

– Fruit and vegetable intake

• Plasma carotenoids are biomarkers of fruit and vegetable intake

– Body mass index

– Air pollution exposure • People with high oxidative stress, like smokers, and subjects with

high sunlight exposure have reduced skin carotenoid levels, independent of their dietary carotenoid consumption

– Free radical level

– Antioxidant supplementation

Scanner Readings Correlate with

Fruits & Vegetable Intake

10,000

15,000

20,000

25,000

30,000

35,000

Reported Daily Fruit & Vegetable Servings

Ra

ma

n In

ten

sit

y, C

ou

nts

.

21,981

1 or Less

n = 9,336

24,773

2 to 3

n = 13,600

28,560

4 to 5

n = 6,916

p < 0.01 p < 0.01 p < 0.01

2004 Data of 32,648 Non-Supplement Users

6 or More

n = 2,796

31,100

BACK

Scanner Readings Correlate with

Body Mass Index

29,236

25,612

20,835

16,603

10,000

15,000

20,000

25,000

30,000

35,000

< 25 25-29 30-39 > 40

Body Mass Index (BMI, kg/m 2 )

Ram

an

In

tes

ity,

Co

un

ts .

n = 11,588 n = 8,475 n = 422

p < 0.01 p < 0.01 p < 0.01

n = 4,550

2004 Data of 25,035 Subjects Overweight people need extra

antioxidant protection through

diet and supplementation.

Weight Control

• Balance of calorie intake and calorie

consumption through metabolism and

physical activity

BACK

Scanner Readings Correlate with the

Pollutant, Cigarette Smoking

19890

13030

17600 17591

13056 11593

0

5000

10000

15000

20000

25000

30000

Non-

Smokers

Smokers

(all)

Past

Smokers

< 1/day 1-5/day > 5/day

n = 1047

n = 58

p < 0.01

n = 39 n = 10

n = 16

n = 32

Air Pollution

• Cigarette Smoke

• Factory Emissions

• Vehicle Exhaust

• Burning of Leaves, Plastics, Rubber

• Cooking Oil Fumes

BACK

Correlation of Scanner Readings with Free Radical Levels

Measured by Urinary MDA

U r i n a r y M D A

BACK

Substantiation of

an Antioxidant Supplement* (evidence for a responsible recommendation)

• Improvement of antioxidant status

• Bioavailability

• Protection of LDL against oxidation

– Clinical applications of circulating oxidized LDL

biomarkers in cardiovascular disease

– Flavonoids Vit C Vit E Enhance LDL resistance to

oxidation

– Vitamin E supplementation increases LDL resistance to

oxidation

* LifePak® NEXT

32175

25991

28924

18828

10000

15000

20000

25000

30000

35000

40000

0 4 8 12

Time (Weeks)

Ram

an

In

ten

sit

y, C

ou

nts

.

p < 0.001

p < 0.01

p = 0.23

Effects of Supplementation with an Antioxidant*

* LifePak® BACK

Clinical Study Showing Effects of

a Nutritionally Complete Dietary Supplement*

Smidt CR, Seidehamel RJ, Devaraj S, Jialal I. The Effects of a Nutritionally Complete Dietary Supplement on Antioxidant Status and LDL-Oxidation in Healthy Non-Smokers. Federation of American Societies for Experimental Biology (FASEB) 1999;13(4):A546.

(means +/- SD)

0

1

2

3

4

5

6

7

8

3.429 3.305

Baseline

PL

NCDS

3.477

6.248

Endpoint

p < 0.001

(means +/- SD)

0

200

400

600

800

1000

1200

331 335

Baseline

PL

NCDS

299

716

Endpoint

p < 0.001

b-Carotene

* LifePak®

Vitamin E

BACK

Clinical Study Showing Effects of

a Nutritionally Complete Dietary Supplement*

Smidt CR, Seidehamel RJ, Devaraj S, Jialal I. The Effects of a Nutritionally Complete Dietary Supplement on Antioxidant Status and LDL-Oxidation in Healthy Non-Smokers. Federation of American Societies for Experimental Biology (FASEB) 1999;13(4):A546.

(means +/- SD)

30

35

40

45

50

55

60

65

42.1 43.4

Start

Placebo

NCDS

42

50.9

After 6 Weeks

p < 0.001

Protection of LDL against free radicals

* LifePak® BACK

Lipoic Acid

• Phytonutrient found in spinach

• Differential Effect – Transformed vs Non-transformed

• Reversible cell cycle arrest of non-transformed cells

• Apoptosis of – human tumor cell lines (FaDu, Jurkat)

– Transformed cells (Ki-v-Ras-transformed Balb/c-3T3 murine mesenchymal cell line)

– Leukemic vs Normal T Lymphocytes • Toxic via apoptosis of Jurkat cells

• Non-toxic to normal T Lymphocytes

– Low dose vs High dose • Low dose (1 umol/L) acts as growth factor

• High dose (100 umol/L) antiproliferative

• Enhances high dose ascorbate cytotoxicity to cancer cells

• Prolongs survival of leukemic mice when added to Doxorubicin therapy

• Reduces ROS and raises GPx which correlates with good ECOG performance status

• Increase glutathione synthesis

• Neuroprotective

• Restores mitochondrial function in old rats

• Restores T-cell function of cancer patients

• Improves clinical outcome of cancer patients

• Treats oxaliplatin induces polyneuropathy

• Enhance cytotoxicity of high dose ascorbate and doxorubicin

Omega-3 Fatty Acids (evidence for a responsible recommendation)

• Polyunsaturated fatty acids (PUFA) have anti-inflammatory effects

• Gamma Linolenic Acid (GLA) and EPA suppress growth of cancer cells

• Omega-3 Fatty Acids – hypotriglyceridemic effect

– inhibit vascular calcification

– in Retinal Health and Disease

– reduce risk factors associated with cardiovascular diseases, diabetes, and cancer

– suppress HER-2/neu signaling pathways involved in the pathogenesis of breast cancer

• Nutrigenomics – Omega-3 influence gene expression

– FISH increase transcription of the antioxidant enzyme, peroxidase

– PUFA induced changes in gene expression of white adipose tissue

Lactobacillus fermentum VRI Strain

(evidence for a responsible recommendation)

• Resiliency to stomach acids

• Colonization of the large intestine

• Reduction of abdominal disturbances

Lactobacillus fermentum

(evidence for a responsible recommendation)

Lactobacillus fermentum

(evidence for a responsible recommendation)

Lactobacillus fermentum

(evidence for a responsible recommendation)

Lactobacillus fermentum

(evidence for a responsible recommendation)

Gac Fruit

(evidence for a responsible recommendation)

Gac Fruit (evidence for a responsible recommendation)

Gac Fruit (evidence for a responsible recommendation)

Carotene

• Associated with lower mortality from cancer

• Differential Effect:

– Smokers vs Non-smokers

• Directly associated with risk among smokers

• Inversely associated with risk among non-smokers

– Low vs High Levels

• Low levels associated with disease progression

• Lycopene at high conc reduces LNCaP cancer cell survival

• Plasma carotenoids – markers of fruits and vegetable

intake

– CELLULAR CAROTENOID MEAUREMENT

Cili Fruit

Chinese Lycium Fruit

Cordyceps sinensis

(evidence for a responsible recommendation)

Cordyceps sinensis

Cordyceps sinensis

Cordyceps sinensis

Krill Phospholipids

(evidence for a responsible recommendation)

Flavonoids

• Antitumor

• Antimetastatic

– to melanoma

– down regulate MMP from DU145 prostate cancer cells

• Induce apoptosis

– human leukemia cells

• Reverse Multidrug Resistance

– Modulate Organic Anion Transporting Polypeptide OATP1B1

– Reverse multidrug resistance

• Suppress angiogenesis

Resveratrol • Actions

– Improved • function of T, B lymphocytes

• killing activity of NK cells

• release of antibodies

• total complement activity in serum

– increased • IL-2

• TGF-beta1

– reduced • IL-8

• VEGF

Isoflavones • Found in soya

• Action – inhibit steroidogenesis

– block several protein tyrosine kinases, including epidermal growth factor receptor and src tyrosine kinases

– arrests the cell cycle

– induces apoptosis

– antiangiogenic

– antimetastatic

– antioxidant

Biological Effects of

Genistein • Growth inhibition of Melanoma cells in

vivo & in-vitro » Rocoral et al, Int J. Cancer 72(5)860,1997

• Inhibits lung tumor nodule formation in rats

& increases life span » Menon et al, Nutri Cancer 30(1)74, 1998

• Cytotoxic to breast cancer cells » Uckun et al, Clin Cancer Res 4(4)901, 1998

• Chemoprevention of NMU induced rat

mammary tumors » Gotoh et al, Jpn J Cancer Res 9(2)137, 1998

DR. DE VILLA

Biological Effects of Genistein

• Induce cell cycle arrest at S/G2-M and

apoptosis in HN4

• upregulates CDKI, p21waf-1

• induces BAX accompanied apoptosis

» Alhasan, 1999 (AACR abstract # 1710)

DR. DE VILLA

Curcumin

• Curcuminoids inhibit human multi-drug

resistance protein

Green Tea Polyphenols

(evidence for a responsible recommendation)

Large group of plant substances that

include catechins, flavonol,

isoflavones, and more

Polyphenols from Green Tea

Green Tea Polyphenols

(evidence for a responsible recommendation)

• Medicinal Uses of Green Tea Polyphenolic

Catechins

• Diabetes

– Prevention

• EGCG suppresses cytokine-induced pancreatic beta-cell

damage

– Blood Effects

• Effects of green tea catechin on phospholipase A2 activity and

antithrombus in streptozotocin diabetic rats

• Anti-diabetic Effect – Anti-diabetic activity of green tea polyphenols

– Anti-diabetic activity of green tea polyphenols n role in reducing ox stress in exp diabetes

– Epigallocatechin gallate supplementation alleviates diabetes in rodents

– Green tea supplementation ameliorates insulin resistance and increases glucose transporter IV

– Nutrigenomics - Administration of green tea that contains EGCG caused a reduction in the level of mRNAs for gluconeogenic enzymes.

• Management of Diabetes Complications – Green tea polyphenols and diet fibre protect against kidney

damage in rats with diab nephropathy

– Black n Green Teas inhibit diabetic cataracts in rat model of diabetes

– green tea extract may be an adjuvant to management of diabetic neuropathic pain

Polyphenols from

Green Tea

Tegreen97

Polyphenols from

Green Tea

Green Tea and the Cardiovascular System

(evidence for a responsible recommendation)

– Therapeutic effect of green tea extract on

advanced glycation and cross-linking of

collagen in the aorta

– Therapeutic effect of green tea extract on

oxidative stress in aorta and heart of

streptozotocin diabetic rats

Tegreen97

Green Tea and Cancer

(evidence for a responsible recommendation)

• Prostate Cancer Prevention

– Clinical trials in cancer prevention

– Chemoprevention of human prostate cancer

– Lycopene, a potent antioxidant found in tomatoes, may exert a protective effect in the prostate

• Breast Cancer Management

– Green tea polyphenols and its constituent epigallocatechin gallate inhibits proliferation of human breast cancer cells

• Prostate Cancer Management

– Growth inhibition of prostate cancer cells by epigallocatechin gallate in the presence of Cu2

– phase II trial of green tea in the treatment of patients with androgen independent metastatic prostate carcinoma.

– Prostate carcinoma and green tea

– Protective effects of green tea against prostate cancer

– Role of p53 and NF-kappaB in epigallocatechin-3-gallate-induced apoptosis of LNCaP cells

– Role of vitamins, minerals and supplements in the prevention and management of prostate cancer

Tegreen97

Catechins • Found in green tea, grapes, apples, pears

• Forms found in green tea – epicatechin (EC)

– epigallocatechin (EGC)

– epicatechin gallate (ECG)

– epigallocatechin gallate (EGCG)

• Actions – antioxidant activity

– anticarcinogenic

– anti-inflammatory

– anti-atherogenic

– thermogenic

– antimicrobial activities

EGCG • Induce apoptosis in some tumor cell lines

• Inhibit angiogenesis

• Inhibit tyrosine phosphorylation of the receptor tyrosine kinase PDGF-Rbeta (platelet-derived growth factor receptor-beta) and its downstream signaling pathway and, consequently, to inhibit transformation of human glioblastoma cells

• Upregulate the synthesis of some hepatic phase II enzymes that are involved in the detoxification of some xenobiotics, including chemical carcinogens

• Inhibit the proteolytic enzyme urokinase used by cancer cells to invade normal tissue and metastasize

• Downregulate the expression of the androgen receptor in human prostate cancer cells in culture, consequently inhibiting androgen action

• Inhibit 5-alpha reductase of human prostate cancer cells

Studies on EGCG

• Catechin reverses Tamoxifen induced liver injury

• Protects cells from free radical damage (w/ Ames test)

• 80x more than Vit C

• 10x more than Vit E

• 2x more than anti-ox in red wine

• Blocks phase I enzymes and prevents formation of nitrosoamines

• Increase • Glutathione Peroxidase

• Catalase

• Inhibit spontaneous & photoenhanced lipid peroxidation

DR. DE VILLA

Biological Effects of

Epigallocatechin-3-Gallate

• Go/G1 phase arrest » 1999 (AACR abstract # 3507)

• induce expression of p21 & p27 (cdki) » Lin et al, 1999

• induce apoptosis by down regulating ras-

p21 & enhance p53 expression in MCF7 » Jin et al, 1999 (AACR abstract # 3506)

• inhibit EGFR, MAPK activation, AKT

activation & p21 induction » Chen, 1999 (AACR abstract # 3518)

DR. DE VILLA

Biological Effects of

Epigallocatechin-3-Gallate

• Induce WAF1/p21 in LNCAP & DU145 » Gupta, 1999 (AACR abstract # 3509)

• macrophage activation in mice which is tumoricidal

» Naraparaju, 1999(AACR abstract # 3515)

• inhibit erb-B1 activation and impair AKT (PI3 kinase) activation

» Bhatia, 1999 (AACR abstract # 3517)

DR. DE VILLA

Reishi (Ganoderma lucidum)

(evidence for a responsible recommendation)

Reishi (Ganoderma lucidum)

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