Rooibos (Aspalathus linearis) and Honeybush (Cyclopia spp.): From Bush Teas to Potential Therapy for Cardiovascular Disease

*Shantal Windvogel*

## **Abstract**

Cardiovascular disease (CVD) is a leading cause of worldwide deaths. A number of risk factors for cardiovascular disease as well as type 2 diabetes and stroke present as the metabolic syndrome. Metabolic risk factors include hypertension, abdominal obesity, dyslipidaemia and increased blood glucose levels and may also include risk factors such as vascular dysfunction, insulin resistance, low high density lipoprotein (HDL) cholesterol levels and inflammation. Rooibos (*Aspalathus linearis*) and honeybush (*Cyclopia* spp.) are indigenous South African plants whose reported health benefits include anti-tumour, anti-inflammatory, anti-obesity, antioxidant, cardioprotective and anti-diabetic properties. The last two decades have seen worldwide interest and success for these plants, not only as health beverages but also as preservatives, flavourants and skincare products. This review will focus on the current literature supporting the function of these plants as nutraceuticals capable of potentially reducing the risk of cardiovascular disease.

**Keywords:** honeybush, rooibos, cardiovascular disease, diabetes, polyphenols

## **1. Introduction**

Cardiovascular disease is the leading cause of deaths worldwide, killing 17.9 million people in 2016 [1]. While the number of cardiovascular disease related morbidity and mortality in the developed world has decreased or remained steady, the developing world has seen an increase. Limited resources, poverty, poor access to affordable healthcare, poor implementation of health policies, as well as poor education may be some of the reasons for the increase in cardiovascular diseases in low to middle income countries [2]. A number of risk factors for cardiovascular disease as well as type 2 diabetes and stroke present as metabolic syndrome. Metabolic risk factors include hypertension, abdominal obesity, dyslipidaemia, increased blood glucose levels, and may also include risk factors such as vascular dysfunction, insulin resistance, low levels of high density lipoprotein cholesterol (HDL-C) and inflammation. Natural products could play a significant role in drug discovery and development with examples including morphine, isolated from the opium poppy (*Papaver somniferum*) and artemisinin, from *Artemisia afra* [3–5]. Nutraceuticals are foods or supplements with health benefits [6]. To this end, a

number of nutraceuticals including fruits, vegetables, tea and herbal infusions have shown health benefits. Approximately 80% of the emerging world relies on herbal supplements [7]. This may often be a more accessible form of health or self-care, due to a lack of access to modern medicine, an alternative to modern medicine or due to the high cost of treatment of modern medicine. This practice may involve the use of herbs or plants, including polyphenol rich rooibos (*Aspalathus linearis*) and honeybush (*Cyclopia* spp.), indigenous South African plant species with reported health benefits [8]. Many nutraceuticals contain polyphenols, the most abundant antioxidants in the diet which could help in the prevention of neurodegenerative diseases, diabetes, cancer, and cardiovascular disease [9]. Oxidative stress is a key process occurring in these diseases and is marked by imbalances between oxidants and the availability of antioxidants as well as perturbations in redox signalling mechanisms [10, 11]. Drugs used in the treatment of cardiovascular disease and obesity often have side effects, hence there is a need for better tolerated, safer and more natural treatment options [12]. A number of epidemiological studies and meta-analyses show some cardiovascular benefits with the intake of tea [13]. Furthermore, a review of some clinical studies show benefits of tea consumption in reducing cardiovascular risk factors, especially in overweight or obese subjects [14]. Rooibos and honeybush have a number of reported health properties, many of them targeting risk factors for the development of cardiovascular disease. The purpose of this paper was to review the role of rooibos and honeybush as potential nutraceuticals in the treatment of cardiovascular disease.

## **2. Risk factors for cardiovascular disease**

A multitude of risk factors predispose to the onset of cardiovascular disease. This includes unmodifiable risk factors, such as increasing age, male gender, ethnicity, family history and genetics [15]. Modifiable risk factors include tobacco smoking, an unhealthy diet, a sedentary lifestyle, high alcohol intake, high blood pressure, being overweight or having central obesity, dyslipidaemia, impaired glucose tolerance or diabetes [15]. Diabetes not only quadrupled from 1980 to 2014 but approximately 57% of diabetic women and 67% of diabetic men are likely to present with cardiovascular disease by the age of 50 [1, 16]. Metabolic syndrome is largely preventable and includes a number of clinical findings which when occurring together, increase the risk of diabetes and cardiovascular disease. These include central obesity with any of the following risk factors including increased triglycerides, fasting plasma glucose, blood pressure and reduced HDL cholesterol levels [17]. Metabolic syndrome is also accompanied by changes in neuroendocrine and autonomic function [18]. It is known that early life stressors can predispose to disease outcome in later life, including cardiovascular disease [19]. Chronic stress influences cardiovascular outcome and anxiety and depression are also risk factors for cardiovascular disease [20–22]. This leads to changes in glucocorticoids and mineralocorticoids via modulation of the hypothalamic pituitary axis (HPA) [18]. Xenobiotics, including drugs and herbal infusions are metabolised by drug metabolising enzymes such as the phase I, cytochrome P450 system, which also influences the formation of steroid hormones [23]. CYP21A2 are precursors to both mineralocorticoids such as aldosterone and glucocorticoids such as cortisol and cortisone. Interestingly, rooibos flavonoids aspalathin and nothofagin inhibits CYP21A2 but not CYP11B1, which is responsible for converting 11-deoxycortisol to cortisol [24]. Substrate conversion of CYP117A1 and CYP21A2 was also inhibited by rooibos but other flavonoids such as rutin, orientin and vitexin were unable to inhibit CYP21A2. Rutin, under forskolininduced stress, was the best inhibitor of steroid production followed by nothofagin

**29**

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential…*

and vitexin and lastly by aspalathin and nothofagin [24]. The observed effects for steroid inhibition were attributed to structural differences in these rooibos flavonoids. Rooibos also decreased rat glucocorticoids by decreasing the corticosterone, deoxycorticosterone as well as the corticosterone: testosterone ratio [25]. In the accompanying human study the cortisol: corticosterone ratio was reduced by rooibos, which also inhibited 11 β-hydroxysteroid dehydrogenase type 1 (11βHSD1). This enzyme catalyses the conversion of cortisone to cortisol and is associated with risk factors for cardiovascular disease [26]. In a stress model using steroid producing H295R cells, rooibos and rutin were able to reduce cortisol levels. The inhibition of mineralocorticoid and glucocorticoid steroids by rooibos and the dihydrochalcones aspalathin and nothofagin were also demonstrated in H295R cells [27]. This suggests that rooibos may offer a possible therapeutic role in the management of cardiovascular complications relating from stress, by altering the biosynthesis of steroid hormones via the HPA axis. Inhibition of 11βHSD1 has been suggested as a potential target mechanism for drugs to modulate the metabolic syndrome; therefore, this could be further explored in the context of rooibos or even honeybush. The cardiovascular complications of metabolic syndrome include coronary artery disease, peripheral vascular disease, hypertension as well as heart failure [28]. Primary management of metabolic syndrome is structured around lifestyle and dietary changes, including regular physical activity and a modest 5–10% initial reduction in caloric intake, failing which the use of pharmaceutical drugs may also be prescribed [17]. Approximately 1.9 billion people were overweight in 2016, of which 650 million people were obese [29]. A sedentary lifestyle, excess calories, a high fat diet and genetics contribute to the development of obesity, which is characterised by a body

activity, along with an energy-rich Western diet, have contributed to the increase in cardiovascular disease in developing countries [31]. As a largely preventable disorder, obesity increases the risk of type 2 diabetes mellitus, cancer, cardiovascular disease, infertility, respiratory illnesses and a number of other health issues. In fact, obesity is not only a major independent risk factor but also an independent predictor for cardiovascular disease [32]. Strategies to avoid unnecessary deaths could include therapeutics that are safe, easily accessible and cost-effective. Rooibos and honeybush are relatively safe but long term clinical studies considering their safety are lacking [33, 34]. Two clinical case reports recommended caution in rooibos consumption but patients had consumed infusions containing rooibos and other herbs, thus the effects of these preparations and potential interactions between them need to be considered [35, 36]. Rooibos and honeybush are caffeine free and have low tannin levels making them ideal beverages for health conscious people, pregnant women and young children [37–39]. These plants may therefore be viable options in the future, provided sufficient evidence is generated to support their use

[30]. Urbanisation and a reduction in physical

*DOI: http://dx.doi.org/10.5772/intechopen.86410*

mass index greater (BMI) >30 kg/m2

as nutraceuticals capable of reducing cardiovascular risk.

**3. Origin, distribution and markets for rooibos and honeybush**

Rooibos [*Aspalathus linearis* L. (Burm.f.) R. Dahlgren (Leguminosae)] is a member of the fynbos biome, which contains needle-like leguminous plants. It occurs in the Cederberg area of the Western Cape, and in South Africa it is one of the most widely consumed herbal teas or tisanes. Its marketing potential was realized by Benjamin Gunzberg in 1904 and since then its popularity has steadily risen worldwide [40]. The top five export markets for rooibos are Germany, Japan, the Netherlands, the United Kingdom and the United States of America [41]. Rooibos is used as herbal infusion, health beverage, an ingredient in skin care products and cosmetics as well

#### *Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential… DOI: http://dx.doi.org/10.5772/intechopen.86410*

and vitexin and lastly by aspalathin and nothofagin [24]. The observed effects for steroid inhibition were attributed to structural differences in these rooibos flavonoids. Rooibos also decreased rat glucocorticoids by decreasing the corticosterone, deoxycorticosterone as well as the corticosterone: testosterone ratio [25]. In the accompanying human study the cortisol: corticosterone ratio was reduced by rooibos, which also inhibited 11 β-hydroxysteroid dehydrogenase type 1 (11βHSD1). This enzyme catalyses the conversion of cortisone to cortisol and is associated with risk factors for cardiovascular disease [26]. In a stress model using steroid producing H295R cells, rooibos and rutin were able to reduce cortisol levels. The inhibition of mineralocorticoid and glucocorticoid steroids by rooibos and the dihydrochalcones aspalathin and nothofagin were also demonstrated in H295R cells [27]. This suggests that rooibos may offer a possible therapeutic role in the management of cardiovascular complications relating from stress, by altering the biosynthesis of steroid hormones via the HPA axis. Inhibition of 11βHSD1 has been suggested as a potential target mechanism for drugs to modulate the metabolic syndrome; therefore, this could be further explored in the context of rooibos or even honeybush. The cardiovascular complications of metabolic syndrome include coronary artery disease, peripheral vascular disease, hypertension as well as heart failure [28]. Primary management of metabolic syndrome is structured around lifestyle and dietary changes, including regular physical activity and a modest 5–10% initial reduction in caloric intake, failing which the use of pharmaceutical drugs may also be prescribed [17]. Approximately 1.9 billion people were overweight in 2016, of which 650 million people were obese [29]. A sedentary lifestyle, excess calories, a high fat diet and genetics contribute to the development of obesity, which is characterised by a body mass index greater (BMI) >30 kg/m2 [30]. Urbanisation and a reduction in physical activity, along with an energy-rich Western diet, have contributed to the increase in cardiovascular disease in developing countries [31]. As a largely preventable disorder, obesity increases the risk of type 2 diabetes mellitus, cancer, cardiovascular disease, infertility, respiratory illnesses and a number of other health issues. In fact, obesity is not only a major independent risk factor but also an independent predictor for cardiovascular disease [32]. Strategies to avoid unnecessary deaths could include therapeutics that are safe, easily accessible and cost-effective. Rooibos and honeybush are relatively safe but long term clinical studies considering their safety are lacking [33, 34]. Two clinical case reports recommended caution in rooibos consumption but patients had consumed infusions containing rooibos and other herbs, thus the effects of these preparations and potential interactions between them need to be considered [35, 36]. Rooibos and honeybush are caffeine free and have low tannin levels making them ideal beverages for health conscious people, pregnant women and young children [37–39]. These plants may therefore be viable options in the future, provided sufficient evidence is generated to support their use as nutraceuticals capable of reducing cardiovascular risk.

## **3. Origin, distribution and markets for rooibos and honeybush**

Rooibos [*Aspalathus linearis* L. (Burm.f.) R. Dahlgren (Leguminosae)] is a member of the fynbos biome, which contains needle-like leguminous plants. It occurs in the Cederberg area of the Western Cape, and in South Africa it is one of the most widely consumed herbal teas or tisanes. Its marketing potential was realized by Benjamin Gunzberg in 1904 and since then its popularity has steadily risen worldwide [40]. The top five export markets for rooibos are Germany, Japan, the Netherlands, the United Kingdom and the United States of America [41]. Rooibos is used as herbal infusion, health beverage, an ingredient in skin care products and cosmetics as well

*Nutraceuticals - Past, Present and Future*

cals in the treatment of cardiovascular disease.

**2. Risk factors for cardiovascular disease**

number of nutraceuticals including fruits, vegetables, tea and herbal infusions have shown health benefits. Approximately 80% of the emerging world relies on herbal supplements [7]. This may often be a more accessible form of health or self-care, due to a lack of access to modern medicine, an alternative to modern medicine or due to the high cost of treatment of modern medicine. This practice may involve the use of herbs or plants, including polyphenol rich rooibos (*Aspalathus linearis*) and honeybush (*Cyclopia* spp.), indigenous South African plant species with reported health benefits [8]. Many nutraceuticals contain polyphenols, the most abundant antioxidants in the diet which could help in the prevention of neurodegenerative diseases, diabetes, cancer, and cardiovascular disease [9]. Oxidative stress is a key process occurring in these diseases and is marked by imbalances between oxidants and the availability of antioxidants as well as perturbations in redox signalling mechanisms [10, 11]. Drugs used in the treatment of cardiovascular disease and obesity often have side effects, hence there is a need for better tolerated, safer and more natural treatment options [12]. A number of epidemiological studies and meta-analyses show some cardiovascular benefits with the intake of tea [13]. Furthermore, a review of some clinical studies show benefits of tea consumption in reducing cardiovascular risk factors, especially in overweight or obese subjects [14]. Rooibos and honeybush have a number of reported health properties, many of them targeting risk factors for the development of cardiovascular disease. The purpose of this paper was to review the role of rooibos and honeybush as potential nutraceuti-

A multitude of risk factors predispose to the onset of cardiovascular disease. This includes unmodifiable risk factors, such as increasing age, male gender, ethnicity, family history and genetics [15]. Modifiable risk factors include tobacco smoking, an unhealthy diet, a sedentary lifestyle, high alcohol intake, high blood pressure, being overweight or having central obesity, dyslipidaemia, impaired glucose tolerance or diabetes [15]. Diabetes not only quadrupled from 1980 to 2014 but approximately 57% of diabetic women and 67% of diabetic men are likely to present with cardiovascular disease by the age of 50 [1, 16]. Metabolic syndrome is largely preventable and includes a number of clinical findings which when occurring together, increase the risk of diabetes and cardiovascular disease. These include central obesity with any of the following risk factors including increased triglycerides, fasting plasma glucose, blood pressure and reduced HDL cholesterol levels [17]. Metabolic syndrome is also accompanied by changes in neuroendocrine and autonomic function [18]. It is known that early life stressors can predispose to disease outcome in later life, including cardiovascular disease [19]. Chronic stress influences cardiovascular outcome and anxiety and depression are also risk factors for cardiovascular disease [20–22]. This leads to changes in glucocorticoids and mineralocorticoids via modulation of the hypothalamic pituitary axis (HPA) [18]. Xenobiotics, including drugs and herbal infusions are metabolised by drug metabolising enzymes such as the phase I, cytochrome P450 system, which also influences the formation of steroid hormones [23]. CYP21A2 are precursors to both mineralocorticoids such as aldosterone and glucocorticoids such as cortisol and cortisone. Interestingly, rooibos flavonoids aspalathin and nothofagin inhibits CYP21A2 but not CYP11B1, which is responsible for converting 11-deoxycortisol to cortisol [24]. Substrate conversion of CYP117A1 and CYP21A2 was also inhibited by rooibos but other flavonoids such as rutin, orientin and vitexin were unable to inhibit CYP21A2. Rutin, under forskolininduced stress, was the best inhibitor of steroid production followed by nothofagin

**28**

**Figure 1.** *Honeybush plant in flower. Image courtesy of the SAHTA.*

as a flavourant and colouring agent in a number of food applications. Honeybush (*Cyclopia* spp.), another member of the fynbos biome, is a bushy shrub found between the Piketberg area in the West, and Port Elizabeth in the East of South Africa (**Figure 1**). The year 1996 welcomed the first commercial harvests for honeybush, followed by the establishment of the South African Honeybush Tea Association (SAHTA) to manage the farming and sustainability practices as well as commercial interests of honeybush. After harvesting of rooibos or honeybush crops, leaves and stems are cut into small pieces, moistened and are fermented, either on open heaps or alternatively for honeybush also using an oven or fermentation tank. This is followed by drying of the fermented rooibos or honeybush. Fermentation of these plants is however associated with a change in phenolic composition as well as colour compared, to the green or unfermented plants which undergoes considerably less oxidation [42, 43]. The main contributors to the commercial market out of the 24 species of *Cyclopia* are *C. intermedia*, *C. genistoides* and *C. subternata*. *C. intermedia* has the largest market share; however, it is harvested from the wild, making the future sustainability and profitability of the crop problematic [44]. Honeybush is a budding commercial interest, used mainly as a tisane with great potential for development and is exported to countries such as the Netherlands, Germany and Japan [45].

## **4. Polyphenols that may be responsible for beneficial effects**

Polyphenols are secondary plant metabolites commonly occurring in the diet in tea, coffee, wine, fruit, vegetables and cereals. The four main types of polyphenols, namely stilbenes, phenolic acids, flavonoids and lignins, can be classified according to the number of polyphenol rings and various chemical groups associated with the rings [46]. Flavonoids share a C3-C6-C3 backbone and the classification system includes groups such as the flavonols, flavones, isoflavones, flavanones, antho-cyanidins, and flavanols [46]. A number of studies have reported a reduction in the risk of cardiovascular disease with the intake of polyphenols [47]. The most prevalent polyphenols in rooibos include aspalathin, nothofagin, orientin, iso-orientin, vitexin and isovitexin, isoquercitrin and rutin [48, 49]. Aspalathin and aspalalinin are two unique dihydrochalcones in rooibos, with the former having been widely researched to date for its antioxidant and other health promoting properties [50, 51]. The flavonoid precursor in rooibos, Z-2-(β-ᴅ-glucopyranosyloxy)-3-phenylpropenoic acid (PPAG), has also received considerable attention for its anti-diabetic properties [52]. In *Cyclopia* species, the xanthones mangiferin, isomangiferin and the flavanone hesperidin are predominant [43, 53]. Mangiferin is not unique to honeybush, and also occurs in mangoes (*Mangifera indica*) and plants such as *Pyrrosia sheareri* and *Anemarrhena asphodeloides* [54–56]. Bioavailability refers to the amount of the substance that is ingested that is available for metabolism [46]. It involves a number of processes, including intestinal absorption, plasma kinetics, metabolism, binding to plasma albumin and excretion

**31**

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential…*

by the liver and kidneys [46]. Factors affecting bioavailability include isomeric form, processing methods, the type of compound and matrices surrounding the compound. The bioavailability of rooibos and honeybush is poor [57, 58]. The potential benefits attributed to their intake may therefore be hampered by poor bioavailability and also affect their maximal efficacy. Recently, the use of nanoencapsulation methods have been explored in order to increase the bioavailability and stability of aspalathin which could possibly promote the use of more effective nutraceuticals [59]. Since fermentation reduces polyphenol content, a number of studies have explored the benefits of unfermented, green rooibos or so called aspalathin rich extracts of rooibos in an attempt to elucidate the health promoting properties of the tisane [60, 61]. Others have looked at the effects of single isolate polyphenols from rooibos and honeybush such as aspalathin and mangiferin, to explore their functional benefits and identify a more

*Chemical structures of aspalathin (a) and mangiferin (b) showing phenol rings [62].*

Oxidative stress occurs due to an imbalance in the production of reactive oxygen species (ROS) and the availability of ROS scavengers. This may occur due to an excess of unstable reactive species including free radicals, such as reactive oxygen, reactive chlorine, reactive nitrogen and non-radical species, all of which may interact with cells, causing cellular damage [65]. Oxidative stress contributes to the pathobiology of cancer, cardiovascular disease, ageing, diabetes and atherosclerosis; therefore, it is plausible that dietary sources of antioxidants may be useful in reducing oxidative stress. Aerobic organisms are therefore reliant on innate antioxidant defences, e.g., superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPX), reduced glutathione (GSH), uric acid, albumin and peroxiredoxins, to deal with large quantities of ROS in an attempt to reduce oxidative stress. Mitochondria are key generators of ROS in aerobic organisms, producing them as they generate energy; however, ROS are also important in cell signalling and released by macrophages to promote immunological attacks [66]. Xenobiotics, including rooibos and honeybush, are metabolised by the cytochrome P450 family and in the process, radicals are also produced and further detoxification processes facilitate their removal [67]. In cardiovascular disease, oxidative stress may manifest as dysfunction in the vascular endothelium or cardiac myocytes, and may arise due to increased intracellular Ca2+ as a result of ROS [68]. Oxidative stress associated with hyperglycaemia may occur from the glycation of proteins and the formation of advanced glycation end products, the auto-oxidation of glucose and the polyol pathway.

*DOI: http://dx.doi.org/10.5772/intechopen.86410*

targeted therapeutic option (**Figure 2**) [63, 64].

**5. Antioxidant effects**

**Figure 2.**

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential… DOI: http://dx.doi.org/10.5772/intechopen.86410*

**Figure 2.** *Chemical structures of aspalathin (a) and mangiferin (b) showing phenol rings [62].*

by the liver and kidneys [46]. Factors affecting bioavailability include isomeric form, processing methods, the type of compound and matrices surrounding the compound. The bioavailability of rooibos and honeybush is poor [57, 58]. The potential benefits attributed to their intake may therefore be hampered by poor bioavailability and also affect their maximal efficacy. Recently, the use of nanoencapsulation methods have been explored in order to increase the bioavailability and stability of aspalathin which could possibly promote the use of more effective nutraceuticals [59]. Since fermentation reduces polyphenol content, a number of studies have explored the benefits of unfermented, green rooibos or so called aspalathin rich extracts of rooibos in an attempt to elucidate the health promoting properties of the tisane [60, 61]. Others have looked at the effects of single isolate polyphenols from rooibos and honeybush such as aspalathin and mangiferin, to explore their functional benefits and identify a more targeted therapeutic option (**Figure 2**) [63, 64].

## **5. Antioxidant effects**

*Nutraceuticals - Past, Present and Future*

*Honeybush plant in flower. Image courtesy of the SAHTA.*

**Figure 1.**

as a flavourant and colouring agent in a number of food applications. Honeybush (*Cyclopia* spp.), another member of the fynbos biome, is a bushy shrub found

is exported to countries such as the Netherlands, Germany and Japan [45].

**4. Polyphenols that may be responsible for beneficial effects**

Polyphenols are secondary plant metabolites commonly occurring in the diet in tea, coffee, wine, fruit, vegetables and cereals. The four main types of polyphenols, namely stilbenes, phenolic acids, flavonoids and lignins, can be classified according to the number of polyphenol rings and various chemical groups associated with the rings [46]. Flavonoids share a C3-C6-C3 backbone and the classification system includes groups such as the flavonols, flavones, isoflavones, flavanones, antho-cyanidins, and flavanols [46]. A number of studies have reported a reduction in the risk of cardiovascular disease with the intake of polyphenols [47]. The most prevalent polyphenols in rooibos include aspalathin, nothofagin, orientin, iso-orientin, vitexin and isovitexin, isoquercitrin and rutin [48, 49]. Aspalathin and aspalalinin are two unique dihydrochalcones in rooibos, with the former having been widely researched to date for its antioxidant and other health promoting properties [50, 51]. The flavonoid precursor in rooibos, Z-2-(β-ᴅ-glucopyranosyloxy)-3-phenylpropenoic acid (PPAG), has also received considerable attention for its anti-diabetic properties [52]. In *Cyclopia* species, the xanthones mangiferin, isomangiferin and the flavanone hesperidin are predominant [43, 53]. Mangiferin is not unique to honeybush, and also occurs in mangoes (*Mangifera indica*) and plants such as *Pyrrosia sheareri* and *Anemarrhena asphodeloides* [54–56]. Bioavailability refers to the amount of the substance that is ingested that is available for metabolism [46]. It involves a number of processes, including intestinal absorption, plasma kinetics, metabolism, binding to plasma albumin and excretion

between the Piketberg area in the West, and Port Elizabeth in the East of South Africa (**Figure 1**). The year 1996 welcomed the first commercial harvests for honeybush, followed by the establishment of the South African Honeybush Tea Association (SAHTA) to manage the farming and sustainability practices as well as commercial interests of honeybush. After harvesting of rooibos or honeybush crops, leaves and stems are cut into small pieces, moistened and are fermented, either on open heaps or alternatively for honeybush also using an oven or fermentation tank. This is followed by drying of the fermented rooibos or honeybush. Fermentation of these plants is however associated with a change in phenolic composition as well as colour compared, to the green or unfermented plants which undergoes considerably less oxidation [42, 43]. The main contributors to the commercial market out of the 24 species of *Cyclopia* are *C. intermedia*, *C. genistoides* and *C. subternata*. *C. intermedia* has the largest market share; however, it is harvested from the wild, making the future sustainability and profitability of the crop problematic [44]. Honeybush is a budding commercial interest, used mainly as a tisane with great potential for development and

**30**

Oxidative stress occurs due to an imbalance in the production of reactive oxygen species (ROS) and the availability of ROS scavengers. This may occur due to an excess of unstable reactive species including free radicals, such as reactive oxygen, reactive chlorine, reactive nitrogen and non-radical species, all of which may interact with cells, causing cellular damage [65]. Oxidative stress contributes to the pathobiology of cancer, cardiovascular disease, ageing, diabetes and atherosclerosis; therefore, it is plausible that dietary sources of antioxidants may be useful in reducing oxidative stress. Aerobic organisms are therefore reliant on innate antioxidant defences, e.g., superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPX), reduced glutathione (GSH), uric acid, albumin and peroxiredoxins, to deal with large quantities of ROS in an attempt to reduce oxidative stress. Mitochondria are key generators of ROS in aerobic organisms, producing them as they generate energy; however, ROS are also important in cell signalling and released by macrophages to promote immunological attacks [66]. Xenobiotics, including rooibos and honeybush, are metabolised by the cytochrome P450 family and in the process, radicals are also produced and further detoxification processes facilitate their removal [67]. In cardiovascular disease, oxidative stress may manifest as dysfunction in the vascular endothelium or cardiac myocytes, and may arise due to increased intracellular Ca2+ as a result of ROS [68]. Oxidative stress associated with hyperglycaemia may occur from the glycation of proteins and the formation of advanced glycation end products, the auto-oxidation of glucose and the polyol pathway.

In rodent models of streptozotocin (STZ)-induced diabetes, rooibos exerted antioxidant effects through increases in the activity of superoxide dismutase, catalase, glutathione peroxidase and decreasing lipid peroxidation [64, 69, 70]. Rooibos also decreased advanced glycation end products but clinical markers of diabetes such as fructosamine, glycated haemoglobin and glucose were unaffected [70]. Nuclear factor erythroid 2-related factor 2 (Nrf2), a critical regulator of the antioxidant response of the cell, facilitates the removal of oxidants through increased antioxidant enzyme activity [67]. The regulator of Nrf2, Kelch-like ECH-associated protein 1 (Keap 1), has oxidative and electrophilic sensitive cysteine residues which upon activation allows for dissociation and activation of Nrf2 [71]. In H9c2 cardiomyocytes, aspalathin (1 μM) increased the expression of Nrf2, and antioxidant genes and enzymes, including SOD, CAT, GPX and peroxiredoxins [64]. The expression of cytoprotective genes including heme oxygenase 1 (H0-1), NAD(P)H dehydrogenase (quinone 1), uncoupling protein 2 and apoptotic genes such as B-cell lymphoma 2 (Bcl-2) were also increased after aspalathin treatment. Uncoupling protein (UCP)3 and caspase 8, were however decreased. This suggests cellular survival due to reduced caspase 8, an important trigger for cell death [72]. UCP3 and UCP2 act in concert in the mitochondrial antioxidant response with UCP2 appearing to play a greater cytoprotective role in cardiomyocytes [73]. In the diabetic (db/db) mouse model, aspalathin increased Nrf2 expression as well as its downstream gene targets [74]. High dose aspalathin (130 mg/kg) also ameliorated the effects of hyperglycaemia in the heart by reducing the expected left ventricular enlargement. It could not however reduce fasting plasma glucose levels compared to metformin in these mice. The study confirmed the role of Nrf2 in the antioxidant response of the cell, strengthened the case for the potential use of nutraceuticals such as aspalathin in the treatment of diabetes, and also provides evidence for the differential effects observed with isolates compared to whole extracts of plants. Oxidative stress and inflammation co-exists in a number of diseases. The relationship between the two appears complex and is suggested to be a possible reason why antioxidant supplements in clinical trials have been unsuccessful [75]. In humans, no clear evidence of the antioxidant effects of flavonoids or pro-oxidant effects exist [76]. Supplementation of six cups of rooibos per day over a 6 week period in adults with increased cardiovascular risk increased plasma total polyphenols, reduced glutathione (GSH), and increased the GSH: oxidized glutathione (GSSG) ratio compared to the control period [77]. Furthermore, TBARS and conjugated dienes were reduced, indicating a reduction in oxidative stress after rooibos consumption. Ferric reducing antioxidant power (FRAP), oxygen radical absorbance capacity (ORAC) and 2,2′-azinobis-(3-ethylbenzothiazoline-6-sulfonate (ABTS) were unaffected. It is however known that assays for the measurement of antioxidant status can be difficult to compare and may also be non-specific and complicated by the instability of the species they are measuring [78]. Flavanoids and other polyphenols in honeybush are responsible for its antioxidant effects [79]. Fermentation of honeybush and rooibos however reduces antioxidant activity [80]. Mangiferin was the most effective scavenger of ABTS˙<sup>+</sup> and in terms of its ability to reduce ferric ion, than the flavanone eriocitrin or the flavone luteolin [43]. This could be due to the hydrophilic nature of mangiferin, which is a glucoside. In an *in vitro* study using skin cells, aqueous extracts of *Cyclopia subternata* sp. exhibited the highest ABTS˙<sup>+</sup> scavenging ability compared to other unfermented species of rooibos and *Camellia sinensis* [53]. In addition, rooibos, honeybush and Chinese green tea demonstrated ferric reducing antioxidant power (FRAP) and oxygen radical absorbance capacity (ORAC) abilities. Rooibos and honeybush also had better ORAC values than green tea, while rooibos aqueous extracts had the highest FRAP. In another model using hairless SKH-1 mice, unfermented honeybush and mangiferin had the highest FRAP compared to the fermented honeybush and hesperidin, and also the highest total antioxidant capacity [63]. Fermented and unfermented

**33**

**6. Anti-inflammatory effects**

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential…*

honeybush as well as mangiferin and hesperidin also protected against ultraviolet (UV) B-induced lipid peroxidation. Fermented and unfermented extracts of honeybush as well as hesperidin increased SOD and CAT activity, while mangiferin increased SOD but

not catalase activity [63]. When Chinese green tea, rooibos and honeybush were evaluated for their ability to reduce lipid peroxidation, unfermented extracts generally offered better protection against lipid peroxidation but green tea offered the highest level of protection compared to the other infusions [53]. Mangiferin activated phosphatidylinositol 3-kinase (PI3K) induced protein kinase b (PKB/Akt) and Nrf2 signalling pathways, thus decreasing oxidative stress in an *in vivo* model using human kidney cells exposed to *tert*-butyl hydroperoxide [81]. The activities of SOD, CAT, GPX and the non-enzymatic intracellular antioxidant GSH were also enhanced and lipid peroxidation was decreased. When compared to vitamin C, ROS scavenging ability as measured by the 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical scavenging method and FRAP was decreased at lower concentrations compared to vitamin C, which was used as the positive control. The expression of Nrf2, HO-1, SOD, Akt and GSK-β and the mechanistic target of rapamycin (mTOR) and cyclin D were also increased by exposure to mangiferin. In an STZ-induced diabetic Wistar rat model, mangiferin improved antioxidant status and reduced apoptosis and inflammation [82]. This could be due to modulation of the AGE-RAGE/MAPK signalling pathways. Advanced glycation end products (AGEs), which are increased in diabetes, lead to upregulation and activation of the receptor for advanced glycation end products (RAGE). This interaction causes inflammation and oxidative stress, through increases in the production of ROS, leading to lipid peroxidation. AGEs can also inhibit peroxisome proliferator activated receptor (PPAR)γ, a regulator in inflammation as well as the metabolism of lipids and glucose [83]. In the study mangiferin also displayed potential as a therapeutic in preventing AGE mediated lipogenesis. Antioxidants such as β-carotene, α-tocopherol and ascorbate were unsuccessful in reducing incidences of cardiovascular [84] and other diseases such as cancer [85], in fact appearing to increase risk in some cases, e.g., with vitamin C, x-tocopherol and beta-carotene [86–88]. Antioxidant supplementation to alleviate oxidative stress could however be affected by other factors such as the dose of the antioxidant, timing of the intervention, interactions with other antioxidants, whether it as administered as an isolate or a whole extract, the type of extract, the model as well as the methods that are used to detect oxidative stress. Rooibos and honeybush exert antioxidant effects by scavenging free radicals, chelating metal ions, or upregulating indigenous antioxidant enzymes. The aromatic ring structures of polyphenols also contain free hydroxyl groups which contribute to their antioxidant ability. The structural differences between rooibos polyphenols may thus also explain differences in antioxidant activity of these compounds [89]. The antioxidant activity of rooibos and honeybush polyphenols may also be explained by their ability to increase the activity of antioxidant enzymes, through upregulation of Nrf2, PI3K and other signalling pathways involved in cell survival. It may also be explained by their ability to act as antioxidants themselves, exerting differential physiological effects. The antioxidant effects of rooibos and honeybush and their polyphenols have been extensively studied in detail elsewhere and some of these effects are discussed here under the anti-inflammatory, anti-obesity,

anti-diabetic and cardiovascular effects of these nutraceuticals (**Tables 1**–**4**).

Inflammation and oxidative stress form a common thread in the metabolic syndrome, type 2 diabetes and cardiovascular disease [132, 133]. The rooibos flavonoid orientin from rooibos reduced the number of mast cells in colon sections as well as

*DOI: http://dx.doi.org/10.5772/intechopen.86410*

#### *Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential… DOI: http://dx.doi.org/10.5772/intechopen.86410*

honeybush as well as mangiferin and hesperidin also protected against ultraviolet (UV) B-induced lipid peroxidation. Fermented and unfermented extracts of honeybush as well as hesperidin increased SOD and CAT activity, while mangiferin increased SOD but not catalase activity [63]. When Chinese green tea, rooibos and honeybush were evaluated for their ability to reduce lipid peroxidation, unfermented extracts generally offered better protection against lipid peroxidation but green tea offered the highest level of protection compared to the other infusions [53]. Mangiferin activated phosphatidylinositol 3-kinase (PI3K) induced protein kinase b (PKB/Akt) and Nrf2 signalling pathways, thus decreasing oxidative stress in an *in vivo* model using human kidney cells exposed to *tert*-butyl hydroperoxide [81]. The activities of SOD, CAT, GPX and the non-enzymatic intracellular antioxidant GSH were also enhanced and lipid peroxidation was decreased. When compared to vitamin C, ROS scavenging ability as measured by the 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical scavenging method and FRAP was decreased at lower concentrations compared to vitamin C, which was used as the positive control. The expression of Nrf2, HO-1, SOD, Akt and GSK-β and the mechanistic target of rapamycin (mTOR) and cyclin D were also increased by exposure to mangiferin. In an STZ-induced diabetic Wistar rat model, mangiferin improved antioxidant status and reduced apoptosis and inflammation [82]. This could be due to modulation of the AGE-RAGE/MAPK signalling pathways. Advanced glycation end products (AGEs), which are increased in diabetes, lead to upregulation and activation of the receptor for advanced glycation end products (RAGE). This interaction causes inflammation and oxidative stress, through increases in the production of ROS, leading to lipid peroxidation. AGEs can also inhibit peroxisome proliferator activated receptor (PPAR)γ, a regulator in inflammation as well as the metabolism of lipids and glucose [83]. In the study mangiferin also displayed potential as a therapeutic in preventing AGE mediated lipogenesis. Antioxidants such as β-carotene, α-tocopherol and ascorbate were unsuccessful in reducing incidences of cardiovascular [84] and other diseases such as cancer [85], in fact appearing to increase risk in some cases, e.g., with vitamin C, x-tocopherol and beta-carotene [86–88]. Antioxidant supplementation to alleviate oxidative stress could however be affected by other factors such as the dose of the antioxidant, timing of the intervention, interactions with other antioxidants, whether it as administered as an isolate or a whole extract, the type of extract, the model as well as the methods that are used to detect oxidative stress. Rooibos and honeybush exert antioxidant effects by scavenging free radicals, chelating metal ions, or upregulating indigenous antioxidant enzymes. The aromatic ring structures of polyphenols also contain free hydroxyl groups which contribute to their antioxidant ability. The structural differences between rooibos polyphenols may thus also explain differences in antioxidant activity of these compounds [89]. The antioxidant activity of rooibos and honeybush polyphenols may also be explained by their ability to increase the activity of antioxidant enzymes, through upregulation of Nrf2, PI3K and other signalling pathways involved in cell survival. It may also be explained by their ability to act as antioxidants themselves, exerting differential physiological effects. The antioxidant effects of rooibos and honeybush and their polyphenols have been extensively studied in detail elsewhere and some of these effects are discussed here under the anti-inflammatory, anti-obesity, anti-diabetic and cardiovascular effects of these nutraceuticals (**Tables 1**–**4**).

## **6. Anti-inflammatory effects**

Inflammation and oxidative stress form a common thread in the metabolic syndrome, type 2 diabetes and cardiovascular disease [132, 133]. The rooibos flavonoid orientin from rooibos reduced the number of mast cells in colon sections as well as

*Nutraceuticals - Past, Present and Future*

In rodent models of streptozotocin (STZ)-induced diabetes, rooibos exerted antioxidant effects through increases in the activity of superoxide dismutase, catalase, glutathione peroxidase and decreasing lipid peroxidation [64, 69, 70]. Rooibos also decreased advanced glycation end products but clinical markers of diabetes such as fructosamine, glycated haemoglobin and glucose were unaffected [70]. Nuclear factor erythroid 2-related factor 2 (Nrf2), a critical regulator of the antioxidant response of the cell, facilitates the removal of oxidants through increased antioxidant enzyme activity [67]. The regulator of Nrf2, Kelch-like ECH-associated protein 1 (Keap 1), has oxidative and electrophilic sensitive cysteine residues which upon activation allows for dissociation and activation of Nrf2 [71]. In H9c2 cardiomyocytes, aspalathin (1 μM) increased the expression of Nrf2, and antioxidant genes and enzymes, including SOD, CAT, GPX and peroxiredoxins [64]. The expression of cytoprotective genes including heme oxygenase 1 (H0-1), NAD(P)H dehydrogenase (quinone 1), uncoupling protein 2 and apoptotic genes such as B-cell lymphoma 2 (Bcl-2) were also increased after aspalathin treatment. Uncoupling protein (UCP)3 and caspase 8, were however decreased. This suggests cellular survival due to reduced caspase 8, an important trigger for cell death [72]. UCP3 and UCP2 act in concert in the mitochondrial antioxidant response with UCP2 appearing to play a greater cytoprotective role in cardiomyocytes [73]. In the diabetic (db/db) mouse model, aspalathin increased Nrf2 expression as well as its downstream gene targets [74]. High dose aspalathin (130 mg/kg) also ameliorated the effects of hyperglycaemia in the heart by reducing the expected left ventricular enlargement. It could not however reduce fasting plasma glucose levels compared to metformin in these mice. The study confirmed the role of Nrf2 in the antioxidant response of the cell, strengthened the case for the potential use of nutraceuticals such as aspalathin in the treatment of diabetes, and also provides evidence for the differential effects observed with isolates compared to whole extracts of plants. Oxidative stress and inflammation co-exists in a number of diseases. The relationship between the two appears complex and is suggested to be a possible reason why antioxidant supplements in clinical trials have been unsuccessful [75]. In humans, no clear evidence of the antioxidant effects of flavonoids or pro-oxidant effects exist [76]. Supplementation of six cups of rooibos per day over a 6 week period in adults with increased cardiovascular risk increased plasma total polyphenols, reduced glutathione (GSH), and increased the GSH: oxidized glutathione (GSSG) ratio compared to the control period [77]. Furthermore, TBARS and conjugated dienes were reduced, indicating a reduction in oxidative stress after rooibos consumption. Ferric reducing antioxidant power (FRAP), oxygen radical absorbance capacity (ORAC) and 2,2′-azinobis-(3-ethylbenzothiazoline-6-sulfonate (ABTS) were unaffected. It is however known that assays for the measurement of antioxidant status can be difficult to compare and may also be non-specific and complicated by the instability of the species they are measuring [78]. Flavanoids and other polyphenols in honeybush are responsible for its antioxidant effects [79]. Fermentation of honeybush and rooibos however reduces antioxidant activity [80]. Mangiferin was the most effective scavenger

and in terms of its ability to reduce ferric ion, than the flavanone eriocitrin or

scavenging ability compared to other

the flavone luteolin [43]. This could be due to the hydrophilic nature of mangiferin, which is a glucoside. In an *in vitro* study using skin cells, aqueous extracts of *Cyclopia* 

unfermented species of rooibos and *Camellia sinensis* [53]. In addition, rooibos, honeybush and Chinese green tea demonstrated ferric reducing antioxidant power (FRAP) and oxygen radical absorbance capacity (ORAC) abilities. Rooibos and honeybush also had better ORAC values than green tea, while rooibos aqueous extracts had the highest FRAP. In another model using hairless SKH-1 mice, unfermented honeybush and mangiferin had the highest FRAP compared to the fermented honeybush and hesperidin, and also the highest total antioxidant capacity [63]. Fermented and unfermented

**32**

of ABTS˙<sup>+</sup>

*subternata* sp. exhibited the highest ABTS˙<sup>+</sup>


**35**

**Plant species/compound**

*C. subternata flavonoids*: scolymoside (SCL); vicenin-2 (VCN)

Human umbilical vein endothelial cells (HUVECs); C57BL/6 mice

VCN 11.9 μg/mouse; SCL 23.8 μg/mouse (±20 μmol/L)

Unfermented rooibos (uf) + methanol extracts; ASP, Noth Honeybush (fermented, green ethanol soluble extracts); mangiferin (Mangif); hesperidin (Hesp)

Rooibos

Whole blood cultures unstimulated or stimulated with

250–7.8 μg/ml

endotoxins or

phytohemagglutinin PHA

LPS stimulated

0.5 μg/ml

Decreased IL-6, IL-10; increased COX2 > 25%

Increased SOD vs. DSS rats; decreased 8-hydroxy-2′-deoxyguanosine (8-OHdG)

Increased ovalbumin; increased sheep RBC antibody production; no effect

on specific LPS stimulated antibody response; increased IL-2 in ova anti-CD3

primed splenocytes (10–100 μg/ml); decreased IL-4 in ova primed splenocytes;

increased ova-induced antibody production in cyclosporine A rats; increased

IL-2 in splenocytes

*Extracts are considered fermented unless otherwise indicated.*

**Table 1.**

*Anti-inflammatory and immune modulatory effects of rooibos and honeybush.*

Mueller et al.,

2010 [99]

Baba et al., 2009

[100]

Kunishiro et al.,

2001 [101]

macrophages

Wistar rats (Dextran

1.6 g/100 ml BW *ad* 

*libitum*

vs. controls

sodium sulphate (DSS)

induced rat colitis model)

Murine splenocytes

1–100 μg/ml

Rooibos Rooibos Rooibos

Non-steroidogenic transfected COS-1 cells, H295R cells

SKH-1 mice

30 mg/ml extract; 3 mg/

ml (Hesp); 4 mg/ml (Mang): 100 μl applied to dorsal skin

4.3 mg/ml; ASP (10 μm); Noth (10 μm)

Decreased steroid production; decreased glucocorticoids during forskolin

treatment; decreased aldosterone and cortisol precursors (variable effects between individual polyphenols and extract)

Anti-inflammatory: Fermented and unfermented extract decreased oedema, epidermal hyperplasia cyclooxygenase-2 (COX-2), ornithine decarboxylase (ODC), GADD45 and OGG1/2 expression; fermented extract decreased lipid peroxidation by increasing superoxide dismutase, catalase; isolated compounds hesperidin and mangiferin less effective than whole extracts

Increased IL-6, 10, IFNγ (unstimulated cells); increased IL-6, decreased IL-10

(stimulated cells)

Schloms et al., 2012 [27]

**Model**

**Dosage**

**Mechanistic effects**

Decreased vascular permeability, monocyte adhesion, CAM expression, NFκ-B expression and ROS induced by high glucose; increased expression of SOD, CAT

Ku and Bae, 2015 [97]

**Author and year**

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential…*

Hendricks and

Pool, 2010 [98]

*DOI: http://dx.doi.org/10.5772/intechopen.86410*

Petrova et al., 2011 [63]


*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential… DOI: http://dx.doi.org/10.5772/intechopen.86410*

> **Table 1.**

*Nutraceuticals - Past, Present and Future*

Yang et al., 2018

[91]

**34**

**Plant species/compound**

*C. genistoides*; *C. subternata*;

Mesenteric lymph

node cells; murine

splenocytes

C57BL/6 mouse sepsis

1 mg/kg BW

model

*C. maculata*

ASP; Noth

Orientin

1,2-dimethyl hydrazine

10 mg/kg BW

stimulated colorectal

cancer in Wistar rats

*C. intermedia*; *C. subternata*

Honeybush (fermented

HaCaT human

10–100 μg/ml; 200 μg/ml

(cell viability)

keratinocyte cells

exposed to UVB

irradiation

LPS-induced HUVECs;

Various up to 30 µM *in* 

Inhibition of LPS-induced barrier disruption; decreased expression of cell

Lee and Bae, 2015

[95]

adhesion molecules (CAMs); decreased adhesion/transendothelial migration of

leukocytes (HUVECs); decreased *in vivo* LPS-induced migration of leukocytes;

decreased hyperpermeability; differentially decreased TNF-α, interleukin

(IL)-6, NF-κB or ERK 1/2 by LPS; decreased LPS-induced lethal endotoxemia;

increased antioxidant activity, decreased ROS; ASP inhibits effects on anti-

Decreased adhesion and migration to HUVECS by human neutrophils *in vitro*,

Lee et al., 2015

[96]

*in vivo*; decreased LPS release of transforming growth factor β-induced protein

(TGFBIp); decreased TGFBIp mediated hyperpermeability; decreased TNF-α,

IL-6, NF-κB, extracellular regulated kinases ½

inflammatory responses > Noth

*C. subternata* (scolymoside;

HUVECs; C57BL/6 mice

Various up to 20 µM

*in vitro*; 23.8 µg/mouse

vicenin-2)

*vitro*; ASP 27.1 µg/mouse,

Noth 26.2 µg/mouse

*in vivo*

C57BL/6 mice

and scale up fermented

honeybush extracts

ASP; Noth

UVB/keratinocytes

Various (0.09–0.1 mg/

Increased inhibition of cell viability, proliferation induced by UVB (aqueous *C.* 

*intermedia*); increased apoptosis, decreased intracellular interleukin (IL) 1-α

(0.09–0.1 mg/ml); *C. subternata* (0.09–0.1 mg/ml) increased intracellular IL1-α

and decreased extracellular IL-1α; methanol extracts alleviated reduction of cell

growth parameters induced by UVB

Anti-inflammatory: Decreased IL-1β, IL-6, IL-8; decreased ERK, P38,

Im et al., 2016

[94]

metallomatrix proteases (MMPs) and C-Jun N-terminal kinase (JNK); increased

SOD, CAT activities

ml), aqueous extracts;

0.18-0.71/3 µg/ml,

methanol extracts

(HaCaT)

**Model**

**Dosage** Various up to 250 μg/ml

cells: Total CD4

IL-17a in splenocytes

**Mechanistic effects**

Modulated immune response; increased IFN-γ, IL-4, CD4

+ cell ratio in mesenteric lymph node cells; increased IL-10 and

Decreased plasma blood urea nitrogen (BUN), creatinine, urine protein, LDH;

inhibition of NF-κβ activation; decreased plasma nitric oxide (NO), TNF-α,

IL-6, myeloperoxidase (MPO) and sepsis associated lethality; decreased

oxidative stress by increasing kidney superoxide dismutase (SOD), catalase

(CAT), glutathione peroxidase (GPx), and decreasing lipid peroxidation

Decreased inflammatory mast cells, NFκ-B, TNFX, IL-6, iNOS and

Thangaraj and

Vaiyapuri, 2017

[92]

Magcwebeba

et al., 2016 [93]

cyclooxygenase-2 (COX)-2

+CD25+FOXP3 TREG

**Author and year**

Murakami et al.,

2018 [90]


**37**

**Table 2.**

*Anti-obesity effects of rooibos and honeybush.*

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential…*

3T3-L1 adipocytes 60–100 μg/ml Anti-obesogenic

Various up to 1600 μg/ml

10 g/L (mice); 600 μg/ml (adipocytes)

**Model Dosage Mechanistic effects Author and** 

60–100 μg/ml fermented extracts increased glycerol release; 80 μg/ml increased lipolysis maximally; increased expression of perilipin, hormone sensitive lipase (HSL); not cytotoxic (up to 100 μg/ml)

Anti-obesogenic: decreased adipocyte differentiation; decreased intracellular triglycerides (> 100 μg/ml); decreased cellular ATP (*C. Maculata*) decreased PPARγ isoform 2; increased adiponectin (fermented *C. maculata*); increased leptin cytotoxic: 800 µg/ml (*C. maculata unfermented*), 1600 µg/ml (*C. maculata+ C. subternata, unfermented*)

Increased lipolysis; decreased serum cholesterol; triglycerides, free fatty acids; increased food consumption in mice fed normal chow; decreased body weight; altered adipocyte size, number; inhibition of dietaryinduced steatosis; increased liver AMPK; decreased triglyceride accumulation; anti-adipogenic in 3T3-L1 adipocytes

**year**

Pheiffer et al., 2013 [106]

Dhudhia et al., 2013 [107]

Beltrán-Debón et al., 2011 [108]

*DOI: http://dx.doi.org/10.5772/intechopen.86410*

3T3-L1 pre-adipocytes

LDLr−/− mice; 3T3-L1 adipocytes

**Plant species/ compound**

*Cyclopia maculata* (aqueous)

*Cyclopia maculata* (fermented, fermented), *Cyclopia subternata* (unfermented)

Rooibos (not explicitly stated in paper but considered to be the fermented extract)


*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential… DOI: http://dx.doi.org/10.5772/intechopen.86410*

#### **Table 2.**

*Anti-obesity effects of rooibos and honeybush.*

*Nutraceuticals - Past, Present and Future*

ASP Ventricular

ASP; GRE Palmitate-

Human C3A liver cells; obese insulin-resistant

cardiomyocytes isolated from healthy, aged control and obese insulin resistant

induced insulin resistant adipocytes

Fermented rooibos 3T3-L1 adipocytes 10 μg/ml,

rats

rats

**Model Dosage Mechanistic effects Author and** 

10 μM Increased

GRE (10 μg/ ml); ASP (10 μM)

100 μg/ml

insulin mediated glucose uptake in cardiomyocytes from young and aged rats, but not in high-caloric diet animals. Insulin actions enhanced via a PI3K-dependent mechanism

Increased GLUT4 expression (GRE); Both treatments: decreased lipidmediated insulin resistance; decreased NFκβ, IRS1 (ser307), phosphorylated AMPK (GRE); increased Akt phosphorylation; Only ASP increased peroxisome proliferator-activated receptor (PPAR) α, γ and CPT1

Decreased lipid accumulation; decreased adipogenesis; decreased PPARγ, α, sterol regulatory binding factor 1 (SREBF1), fatty acid synthase (FASN) expression impaired; leptin secretion decreased

Increased glucose and lipid metabolism: Increased glucose metabolism in C3A cells; increased insulin sensitivity in OBIR rats: increased GLUT2 expression; increased PI3K/Akt, phosphorylated AMPK and stimulation of insulin receptor substrate (IRS) 1, 2 forkhead box protein 01 (FOXO1) and carnitine palmitoyl transferase 1 (CPT1)

10 μg/ml (cells); up to 195 mg/kg BW (6 cups), rats

**year**

Mazibuko-Mbeje et al., 2019 [102]

Smit et al., 2018

Mazibuko et al., 2015 [104]

Sanderson et al., 2014 [105]

[103]

**Plant species/ compound**

Unfermented green rooibos extract (GRE)

**36**


**39**

**Plant species/compound**

Fermented rooibos

H9c2 cardiomyocytes isolated from male Wistar STZ-induced diabetic rats (40 mg/kg BW); *in vivo*, *ex-vivo* rat heart perfusions

10 mg/kg

Phenylpyruvic acid-2-

d-glucoside (PPAG)

Mangiferin *Cyclopia maculata*

RIN-5F cells

0.001–1000 μg/ml (*C.* 

*maculata*); 0.01–1000 μg/ml

viability (mangiferin)

(mangiferin)

30/300 mg/kg BW

Increased glucose tolerance; decreased fasting blood glucose;

improved serum triglycerides; increased β-cell area; increased

β-cell proliferation (300 mg/kg BW); decreased plasma nitrite;

unaltered catalase, glutathione, liver lipid peroxidation and

Increased glucose uptake; decreased fasting blood glucose;

Muller et al.,

2013 [52]

increased glucose tolerance; increased mRNA expression of liver

GLUT1, 2, glucokinase, PPARγ

and SOCS3

nitrotyrosine

(*unfermented*); Mangiferin

*Cyclopia maculata*

Z-2-(β-ᴅ-

Chang cells; Obese insulin-resistant

1–31.6 μM; 0.3–3 mg/kg BW

(obese rats)

glucopyranosyloxy)-3-

rats

phenylpropenoic acid

(PPAG)

STZ-diabetic Wistar rats

Diabetic insulin resistant Wistar

20 mg/kg BW

rats

*O*-β-

Obese mice

**Model**

**Dosage** 1, 10 μg/ml

**Mechanistic effects**

Anti-diabetic/cardioprotective; decreased ROS, apoptosis; increased glutathione, metabolic activity *in vitro*

**Author and year** Dludla et al., 2014 [113]

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential…*

Chellan et al.,

2014 [116]

*DOI: http://dx.doi.org/10.5772/intechopen.86410*

2014 [114]

Mathijs et al.,

Protection from diet-induced hyperglycaemia; increased beta cell mass; decreased apoptosis; *In vitro*, protection of β-cells

from palmitate-induced apoptosis; increased Bcl-2 expression;

increased β-cell mass; protective effect of PPAG via increased

No change in body weight; decreased serum glucose; increased

Saleh et al.,

2014 [115]

serum insulin; decreased HOMA IR; increased β-cell function;

decreased serum TNFα; improved serum lipids; increased

adiponectin; no effect on antioxidant activity

Increased viability (0.001–1000 μg/ml) *Cyclopia*; no effect on

expression of Bcl-2 in β-cells


*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential… DOI: http://dx.doi.org/10.5772/intechopen.86410*

*Nutraceuticals - Past, Present and Future*

Johnson et al.,

2016 [109]

**38**

**Plant species/compound**

ASP ASP Fermented *Cyclopia* 

HaCaT human keratinocyte cells

50–100 μg/ml

*intermedia* (methanol

fermented and scaled up

extracts

*Cyclopia subternata* (aqueous

STZ Wistar rat model; C2C12

 cells

30–600 mg/kg (*in vivo*);

Increased glucose tolerance 30, 60, 120 min (600 mg/kg BW;

mangiferin, isomangiferin increased glucose uptake in C2C12

Both isolates decreased palmitate-induced insulin resistance;

decreased NFκ-β, IRS1 (Ser307), phosphorylated AMPK; increased

Akt activation; GRE increased GLUT4 expression; ASP increased

Increased glucose uptake; increased phosphorylated AMPK, Akt;

increased GLUT4 translocation; decreased AGE-induced ROS

increase; decreased fasting blood glucose

Cardioprotective/anti-diabetic: Decreased vascular permeability

caused by high blood glucose, decreased monocyte adhesion;

Antioxidant: Decreased reactive oxygen species; Anti-

inflammatory: Decreased NFκ-β

PPARα, γ, CPT1 expression

 cells

Schulze et al.,

2016 [110]

Mazibuko

et al., 2015

[104]

Kamakura

et al., 2015

[111]

Ku et al., 2014

[112]

1 nM–100 μM (isolated

compounds

100 μM; 10 μg/ml

10 μg/ml

extracts); mangiferin,

isomangiferin

ASP; Green rooibos extract

3T3-L1 adipocytes

(GRE)

Unfermented rooibos

Rooibos; Aspalathin (ASP);

HUVECs; C57BL/6 mice

5–50 μM

Nothofagin (Noth)

L6 myotubules; RIN-5F Cells; obese

350 μg/ml (L6 myotubules);

50 μg/ml (RIN-5F cells);

0.3–0.6% (mice)

diabetic KK-Ay mice

Glucose-exposed H9c2

cardiomyocytes

H9c2 Cardiomyocytes; db/db mice

1 μM (cardiomyocytes);

(13 mg/kg BW)/130 mg/kg

BW(mice)

1 μM

antioxidant genes

**Model**

**Dosage**

**Mechanistic effects**

Diabetic/cardioprotective/antioxidant; reduced high glucose

induced oxidative stress; Nrf2-mediated activation of downstream

Cardioprotective, anti-diabetic, antioxidant effects: Enhanced

metabolism of glucose, decreased phosphorylation of AMPK,

decreased CPT1; increased GLUT4, acetyl–CoA carboxylase

expression; increased glutathione, SOD; decreased ROS, increased

ucp2, bcl-2: bax; Anti-apoptotic; decreased DNA nicks

Antioxidant: Increased SOD, CAT in UVB-exposed HaCaT

Im et al., 2016

[94]

keratinocytes

**Author and** 

**year**

Dludla et al.,

2017 [64]


**Table 3.**

**41**

**Plant species/compound**

Aspalathin Aspalathin Fermented rooibos

H9c2 cardiomyocytes isolated from male Wistar STZ diabetic rats (40 mg/

1/10 μg/ml

kg BW) STZ diabetic induced Wistar

10 µ/kg BW

Decreased LDH, incidences of arrhythmias; decreased infarct size;

increased left ventricular ejection fraction; decreased myocardial

apoptosis; increased FGFR2, LIF expression; increased PI3K/Akt, Bcl-2

associated death promoter (BAD), Bcl-2:Bax ratio; inhibited MPO

expression, IL-6, IL-1a and TNFα production (anti-inflammatory effects)

Luteolin pre-treatment before I/R injury increased contractions in isolated

Wu et al., 2013

[123]

rat heart and cardiomyocytes; decreased LDH, apoptosis; increased Bcl-2:

Bax ratio; decreased infarct size; protection involves ERK 1/2-PP1a-PLB-

Single dose inhibited ACE after 30, 60 min; ACE II genotype inhibited

Persson et al.,

2010 [124]

Persson et al.,

2006 [125]

Persson et al.,

2012 [126]

after 60 min; no effect on nitric oxide

Increased nitric oxide after 1 day (1:400, 1:200); no effect on ACE

SERCA2a mechanism

rats

Luteolin Luteolin Rooibos Rooibos Rooibos

Human serum with

Enalaprilat as positive

control

HUVEC

Ischemia/reperfusion (I/R)

Various up to 40 µM,

model dependant

Wistar rats and isolated

cardiomyocytes

Human volunteers

400 ml (0.025 g/ml)

0.05 g/ml in phosphate

buffered saline (PBS)

0.05 g/ml in PBS

inhibition after 10 min

Inhibition of ACE via a mixed inhibition method

H9c2 cardiomyocytes exposed to glucose

1 μM

H9c2 cardiomyocytes; db/

db mice

1 μm (cardiomyocytes) (13 mg/kg)/130 mg/kg

Diabetic/cardioprotective/antioxidant: reduced high glucose induced oxidative stress. Nrf2 activated downstream antioxidant genes; high dose aspalathin treatment was more successful than metformin or lower dose aspalathin at activating Nrf2 and antioxidant genes

Cardioprotective/anti-diabetic: Enhanced metabolism of glucose, decreased 172 phosphorylated AMPK, decreased carnitine palmitoyltransferase (CPT)1, increased GLUT4, acetyl-CoA carboxylase expression; antioxidant effects: increased glutathione and SOD, decreased ROS, increased UCP2, Bcl-2:Bax; anti-apoptotic; decreased DNA nicks

Dludla et al., 2014 [113]

Decreased ROS, apoptosis, increased glutathione, and metabolic activity *in vitro*

**Model**

**Dosage**

**Mechanistic effects**

**Author and year** Dludla et al., 2017 [64]

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential…*

Sun et al., 2012

[122]

*DOI: http://dx.doi.org/10.5772/intechopen.86410*

Johnson et al., 2016 [109]

*Anti-diabetic effects of rooibos and honeybush.*

#### *Nutraceuticals - Past, Present and Future*

**40**


*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential… DOI: http://dx.doi.org/10.5772/intechopen.86410*

*Nutraceuticals - Past, Present and Future*

Mazibuko

et al., 2013

[118]

Muller et al.,

2012 [119]

**40**

**Plant species/compound**

ASP

L6 myocytes; RIN-5F cells; type 2

25–100 μM

0.1% ASP (100 mg/kg

BW); 10 mg/kg BW ASP

(intraperitoneal glucose

tolerance test)

Unfermented green rooibos;

C2C12 skeletal muscle cells

10 μg/ml

fermented rooibos

ASP; rutin Aspalathin: rutin

Aspalathin rich green

rooibos

*Cyclopia intermedia*

ASP from GRE

L6 myotubules

RIN-5F cells

db/db mice

Fermented rooibos (aqueous +

STZ-induced diabetic Wistar rats

2.5% *ad libitum*

alkaline extracts)

**Table 3.**

*Anti-diabetic effects of rooibos and honeybush.*

STZ diabetic rats

STZ diabetic rats

STZ diabetic induced Wistar rats

Obese insulin resistant (OBIR) rats

Chronic: 538–2688 mg/ml

(OBIR rats)

1–100 μM

100 μm 0.1–0.2%

Acute: 5 mg/kg bw-50 mg/kg

BW (STZ rats)

C2C12 myotubules

1,10,100 μM; 100 μm

1:1 (1.4 mg/kg BW)

25 mg/kg BW, 30 mg/kg BW

Increased glucose uptake

Decreased blood glucose (not obtained by individual compounds)

Decreased blood glucose; increased glucose tolerance

Decreased fasting blood glucose (50 mg/kg)

Decreased plasma cholesterol, fasting blood glucose; α:β cell mass

(538–2150 mg/ml); decreased glucose tolerance (1075–2688 mg/ml)

Increased glucose uptake

Increased insulin secretion

Decreased fasting blood glucose for 5 weeks; increased glucose

tolerance 30, 60, 90, 120 min

Decrease AGE's + MDA (plasma, lens, liver and kidney);

Uličná et al.,

2006 [70]

decreased total cholesterol and creatinine

Kawano et al.,

2009 [121]

Muller et al.,

2011 [120]

diabetic ob/ob mice

**Model**

**Dosage**

**Mechanistic effects**

Increased glucose uptake; increased AMPK phosphorylation;

increased GLUT4 translocation in L6 myoblasts and myotubules;

decreased age-induced ROS; decreased blood glucose; increased

glucose tolerance; decreased expression of liver gluconeogenic and

lipogenic gene expression in mice

Increased glucose uptake; increased mitochondrial activity;

increased ATP (unfermented >fermented); decreased PKCq

activation; decreased palmitate-induced insulin resistance;

increased insulin-dependent Akt activation, increased AMP

Insulin-independent signalling pathways; increased GLUT4

**Author and** 

**year**

Son et al.,

2013 [117]


**Table 4.**

**43**

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential…*

reduction in neutrophil adhesion, and other mechanisms [96], **Table 1**.

Obesity and overweight are major risk factors for cardiovascular disease and type 2 diabetes. Insulin resistance, a key finding in the metabolic syndrome, is characterised by alterations in glucose uptake in insulin sensitive tissues such as the liver, skeletal muscle and adipose tissue [134]. Non-alcoholic fatty liver disease (NAFLD), characterised by fat accumulation in the liver, is an independent predictor of the metabolic syndrome which influences the progression of cardiovascular disease [135]. Since NAFLD is complex, utilising therapeutic strategies with multiple targets may be beneficial. The PI3K/Akt pathway is a complex insulin regulated pathway involved in glucose and lipid metabolism, as well as other cellular processes, including protein synthesis, cell signalling cell growth and apoptosis [136]. In type 2 diabetes and obesity, inhibition of the pathway interferes with beta cell function and insulin secretion, exacerbating insulin resistance. A green rooibos extract reduced lipid accumulation as well as lipolysis in C3A liver cells [102]. Rooibos also ameliorated palmitate-induced insulin resistance, by activating phosphorylated PKB/Akt and 5′ adenosine monophosphate-activated protein kinase (AMPK), as well as increasing glucose transporter (GLUT)2 expression. Furthermore, fatty acid oxidation was enhanced by increasing FOXO1, decreasing malonyl-CoA decarboxylase, increasing carnitine palmitoyl transferase 1 (CPT1) and increasing acetyl CoA carboxylase in insulin deficient cells. In the accompanying obese insulin resistant rat model, only a high dose (195 mg/kg) of green rooibos extract (GRE) could reduce insulin levels and the HOMA-IR index. No significant differences were detected in blood glucose, body weights or food intake. Insulin receptor and insulin receptor substrates 1, and 2 were however upregulated by GRE, suggesting that GRE may be beneficial in ameliorating obesity-induced insulin resistance. In 3T-L1 adipocytes, palmitate-induced insulin resistance was ameliorated by both aspalathin, as well as GRE [104]. This was accompanied by increases in Akt activation and decreases in nuclear factor (NF)-κB, IRS1 and AMP phosphorylation. GLUT4 expression was enhanced by the GRE but not aspalathin, suggesting that the whole extract rather than the isolated compound may be beneficial in providing a more multi-targeted therapeutic approach in improving palmitate-induced effects on glucose and lipids. A number of other rooibos polyphenols, such as the C-glycosidic flavones orientin, iso-orientin and luteolin, have anti-obesity effects, as reflected by their inhibition of pancreatic lipase, which is responsible for digesting and absorbing triglycerides [137]. Fermented rooibos also inhibited lipid accumulation

NFK-β, TNF-α, IL-6, iNOS and COX2, reflecting its anti-inflammatory potential [92]. Aspalathin and nothofagin inhibited LPS-mediated expression of the lipopolysaccharide (LPS) receptor (TLR4) and LPS-mediated barrier disruption. This occurred by increasing barrier integrity and inhibiting the expression of cell adhesion molecules (CAMs) and reducing neutrophil adhesion and migration in human umbilical vein endothelial cells [95]. The barrier protective effects of aspalathin and nothofagin were confirmed in a mouse model, in which the dihydrochalcones reduced LPS-induced mortality. This suggests that aspalathin and nothofagin can be regarded as potential therapeutics against vascular inflammation. The protective effects of aspalathin and nothofagin in a systemic inflammatory response induced by caecal ligation included decreases in inflammatory markers, including TNFα-expression NF-κB, NO and IL-6 production, enhanced antioxidant activity and decreased lipid peroxidation. [91]. The anti-inflammatory effects of rooibos and honeybush may involve a reduction in inflammatory cytokines such as IL-6, TNF-α, COX2 [91, 92, 94]. It may also involve a

*DOI: http://dx.doi.org/10.5772/intechopen.86410*

**7. Anti-obesity effects**

*Cardiovascular effects of rooibos and its flavonoids.*

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential… DOI: http://dx.doi.org/10.5772/intechopen.86410*

NFK-β, TNF-α, IL-6, iNOS and COX2, reflecting its anti-inflammatory potential [92]. Aspalathin and nothofagin inhibited LPS-mediated expression of the lipopolysaccharide (LPS) receptor (TLR4) and LPS-mediated barrier disruption. This occurred by increasing barrier integrity and inhibiting the expression of cell adhesion molecules (CAMs) and reducing neutrophil adhesion and migration in human umbilical vein endothelial cells [95]. The barrier protective effects of aspalathin and nothofagin were confirmed in a mouse model, in which the dihydrochalcones reduced LPS-induced mortality. This suggests that aspalathin and nothofagin can be regarded as potential therapeutics against vascular inflammation. The protective effects of aspalathin and nothofagin in a systemic inflammatory response induced by caecal ligation included decreases in inflammatory markers, including TNFα-expression NF-κB, NO and IL-6 production, enhanced antioxidant activity and decreased lipid peroxidation. [91]. The anti-inflammatory effects of rooibos and honeybush may involve a reduction in inflammatory cytokines such as IL-6, TNF-α, COX2 [91, 92, 94]. It may also involve a reduction in neutrophil adhesion, and other mechanisms [96], **Table 1**.

## **7. Anti-obesity effects**

*Nutraceuticals - Past, Present and Future*

Marnewick

et al., 2011

[77]

Fu et al., 2006

[127]

**Author and** 

**year**

**42**

**Plant species/compound**

Rooibos Orientin

Human volunteers at risk for

0.005 g/ml (6 cups/day)

Increased antioxidant status and decreased oxidative stress by increased

GSH: GSSG ratio, decreased lipid peroxidation (TBARS, conjugated

Decreased apoptosis in cardiomyocytes; increased Bcl-2, decreased

bcl-2-like protein 4 (Bax), increased Bcl-2: Bax; decreased cytochrome-c,

caspase expression in cardiomyocytes and myocardium

Decreased apoptosis (decreased MPTP opening)

Increased aortic output; decreased cleaved caspase 3, poly (ADP-ribose)

polymerase (PARP), reduced apoptosis; increased GSH: GSSG ratio

Glibenclamide sensitive relaxation of low K+-induced contractions;

weak inhibitory effect on atrial force and contraction rate; blood

pressure lowering effects; chrysoeriol caused concentration-dependent,

glibenclamide-sensitive relaxation of low K+ induced contractions, EC50

(61 μg/ml), n = 2 in aorta

ACE inhibitory activity of some flavonoids found in rooibos and

Guerrero et al.,

2012 [131]

honeybush. Luteolin had the greatest ACE inhibitory effects compared to

the other flavonoids with hesperitin and genestein exhibiting moderate but

lower, yet marked effects

Lu et al., 2011

[128]

Pantsi et al.,

2011 [129]

Khan and

Gilani, 2006

[130]

dienes); increased HDL cholesterol

cardiovascular disease

Ischemia/reperfused Wistar

0.5–2 mg/kg BW (rat

hearts); 3–30 μmol/l

(cardiomyocytes)

rat hearts; cardiomyocytes

injured by hypoxia/

reoxygenation

Ischemia/reperfusion

30 μM

injured H9c2 cardiomyocytes

*Ex vivo* working heart from

2% w/v

Wistar rats

Sprague Dawley rats (blood

20% w/w, 10–100 mg/

kg BW

pressure effects); rabbit

aorta, guinea pig atria

Orientin Rooibos (fermented and

unfermented)

Rooibos; chrysoeriol

Rooibos and honeybush

*In vitro* ACE-inhibition assay

500 μM, 100 μM

flavonoids (various including

luteolin, quercetin, rutin,

genestein, hesperitin, etc.)

**Table 4.**

*Cardiovascular effects of rooibos and its flavonoids.*

**Model**

**Dosage**

**Mechanistic effects**

Obesity and overweight are major risk factors for cardiovascular disease and type 2 diabetes. Insulin resistance, a key finding in the metabolic syndrome, is characterised by alterations in glucose uptake in insulin sensitive tissues such as the liver, skeletal muscle and adipose tissue [134]. Non-alcoholic fatty liver disease (NAFLD), characterised by fat accumulation in the liver, is an independent predictor of the metabolic syndrome which influences the progression of cardiovascular disease [135]. Since NAFLD is complex, utilising therapeutic strategies with multiple targets may be beneficial. The PI3K/Akt pathway is a complex insulin regulated pathway involved in glucose and lipid metabolism, as well as other cellular processes, including protein synthesis, cell signalling cell growth and apoptosis [136]. In type 2 diabetes and obesity, inhibition of the pathway interferes with beta cell function and insulin secretion, exacerbating insulin resistance. A green rooibos extract reduced lipid accumulation as well as lipolysis in C3A liver cells [102]. Rooibos also ameliorated palmitate-induced insulin resistance, by activating phosphorylated PKB/Akt and 5′ adenosine monophosphate-activated protein kinase (AMPK), as well as increasing glucose transporter (GLUT)2 expression. Furthermore, fatty acid oxidation was enhanced by increasing FOXO1, decreasing malonyl-CoA decarboxylase, increasing carnitine palmitoyl transferase 1 (CPT1) and increasing acetyl CoA carboxylase in insulin deficient cells. In the accompanying obese insulin resistant rat model, only a high dose (195 mg/kg) of green rooibos extract (GRE) could reduce insulin levels and the HOMA-IR index. No significant differences were detected in blood glucose, body weights or food intake. Insulin receptor and insulin receptor substrates 1, and 2 were however upregulated by GRE, suggesting that GRE may be beneficial in ameliorating obesity-induced insulin resistance. In 3T-L1 adipocytes, palmitate-induced insulin resistance was ameliorated by both aspalathin, as well as GRE [104]. This was accompanied by increases in Akt activation and decreases in nuclear factor (NF)-κB, IRS1 and AMP phosphorylation. GLUT4 expression was enhanced by the GRE but not aspalathin, suggesting that the whole extract rather than the isolated compound may be beneficial in providing a more multi-targeted therapeutic approach in improving palmitate-induced effects on glucose and lipids. A number of other rooibos polyphenols, such as the C-glycosidic flavones orientin, iso-orientin and luteolin, have anti-obesity effects, as reflected by their inhibition of pancreatic lipase, which is responsible for digesting and absorbing triglycerides [137]. Fermented rooibos also inhibited lipid accumulation

in 3T3-L1 adipocytes [105]. Z-2-(β-ᴅ-glucopyranosyloxy)-3-phenylpropenoic acid (PPAG), increases glucose uptake, as demonstrated in Chang cells [52]. In their *in vivo* model of obese insulin resistant rats, basal fasting glucose decreased and glucose tolerance was improved by PPAG. Increases in mRNA expression of genes involved in glucose (GLUT1 and GLUT4) and insulin metabolism (IR) and others such as PPARα and SOCS3 in the liver were also seen. PPARα regulates the action of fatty acids in the liver, suggesting that insulin signalling, glucose and lipid metabolism may be altered by PPAG. SOCS3 associates with various proteins to inhibit cytokine signals, e.g., leptin, growth hormone, IL-6, leukaemia inhibitory factor (LIF) as well as insulin [138]. It may therefore mediate leptin resistance, which occurs in obesity but is also regulated by leptin, which may partially explain these findings. Administration of rooibos to LDL receptor deficient (Ldlr<sup>−</sup>/ <sup>−</sup>) mice reduced liver steatosis and white adipose tissue and increased brown adipose tissue in high fat diet rats. Macrophage recruitment was decreased but no difference was seen in adipocyte size or number in the rooibos supplemented group. Furthermore, there appeared to be no liver toxicity, and free fatty acids, triglycerides and cholesterol were reduced by rooibos in the high fat diet group [108]. In humans, rooibos reduced oxidative stress, improved HDL-C, and triacylglycerol and low density lipoprotein cholesterol (LDL-C) in adults at risk of developing cardiovascular disease. [77]. These results suggest that rooibos and flavonoids in rooibos, such as aspalathin, may be potential adjuvants in the management of the metabolic syndrome. The anti-obesity effects of *Cyclopia intermedia*, *C. subternata* and *C. maculata* are limited but have been studied in 3T3-L1 adipocytes [106, 107, 139]. *C. maculata* and *C. subternata* decreased intracellular lipid and triglycerides and increased PPARγ, a regulator of glucose and lipid metabolism [107]. Their antiobesity effects also include increased release of glycerol [106]. Hormone sensitive lipase (HSL) expression, which is regulated by SIRT1a, a rate limiter of lipolysis, was also increased by fermented *C. maculata*. Furthermore, perilipin expression, which appears to play a key role in the metabolism of lipids and lipolysis of adipose tissue was upregulated [140]. *C. intermedia* increased HSL, SIRT1, UCP3 as well as PPARγ expression in 3T3-L1 adipocytes [139]. The authors attributed increases in SIRT1 and PPARγ to be indicative of changes from white to brown adipose tissue, however the expression of UCP1, which characterises brown adipose tissue was not measured in the study [141]. While the exact function is unclear, UCP3 may protect against lipotoxicity of the mitochondria [142]. In the parallel obese db/db mouse model, no increases in body weight gain were seen with *C. intermedia* treatment, and neither food nor water consumption was affected [139]. Extracts of mangiferin and other polyphenols isolated from plants containing components similar to that found in honeybush have proven useful in understanding their mechanisms of action and how they could be used as nutraceuticals in the treatment of cardiovascular disease. In a double-blind randomised placebo controlled clinical trial, mangiferin (150 mg/day) from mangoes, was given to 97 overweight, hyperlipidaemic patients over a period of 12 weeks. Increased high density lipoprotein cholesterol (HDL-C), L-carnitine, as well as decreases in total cholesterol, low density lipoprotein cholesterol (LDL-C) and triglycerides were obtained in the patients [143]. No alterations in liver and kidney function markers were seen, suggesting that chronic treatment over 12 weeks was safe in human participants. Since the metabolic syndrome is so complex, providing a multi-targeted approach, such as through affecting the PI3K/Akt pathway may be somewhat beneficial. The anti-obesity effects are further described in **Table 2**. The limited available information on the anti-obesity effects of rooibos and honeybush however, suggests that more research is needed to fully understand and enable the translation of these effects from animals to man.

**45**

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential…*

Diabetic hyperglycaemia involves macro-and microvascular complications [144]. Free radicals are also produced, promoting oxidative stress [145]. Evidence suggests that rooibos and its polyphenols may reduce oxidative stress associated with the pathogenesis of diabetes [34, 69]. A meta-analysis and systematic review narrowed down to 12 peer-reviewed studies reported a reduction in blood glucose levels in diabetic rodent models that had received either rooibos or its polyphenols, while no clinical trials have investigated the effects of rooibos in the context of type 2 diabetes [146]. Rooibos decreases fasting blood glucose and improves glucose tolerance [117]. The anti-diabetic actions may be related to the expression of genes responsible for glucose uptake (GLUT1, GLUT2), insulin signalling (IR), as well as other genes such as PPRα in the liver in a model of obese insulin resistant rats treated with PPAG [52]. The involvement of insulin dependent GLUT4, in skeletal muscle has also been reported [111]. Rooibos may be exerting anti-diabetic effects by affecting the metabolism and uptake of glucose. Aspalathin influences key genes involved in the metabolism of lipids, insulin resistance, inflammation and apoptosis, possibly reversing metabolic abnormalities by involving PPARγ, Adipoq, IL-6/Jak2 pathway and Bcl-2 [74]. PPAG increased beta cell mass and delayed hyperglycaemia in STZ-diabetic mice [147]. This was accompanied by increases in anti-apoptotic B-cell lymphoma 2 (Bcl-2), but no antioxidant effect, and in human islet cells PPAG also decreased cell death. This suggests that PPAG increases beta cell mass by decreasing apoptosis and increasing Bcl-2 as reflected in both STZ diabetic and obese mouse models [114, 148]. In the absence of insulin, GRE also increased phosphorylation of both AMPK and Akt, in L6 skeletal myotubules. Activation of AMPK could be a therapeutic strategy in the treatment of obese and type 2 diabetics, as animal studies suggest a dysregulation of AMPK in these states. The mechanism for the amelioration of diabetic complications in rodents by rooibos and honeybush may also be due α-glucosidase inhibition; or SGLT2 inhibiting potential of rooibos and honeybush or their respective flavonoids [119, 149–151]. α-Glucosidase is an enzyme present on the intestinal brush border where it digests starch, increasing blood glucose [152]. Anti-diabetic drugs, therefore commonly utilize strategies such as α-glucosidase inhibition or SGLT2 inhibition to facilitate their actions [152, 153]. The dihydrochalcone phlorizin, an SGLT2 inhibitor, provides a basis to explore natural plant based agents for use in the management of diabetes [154]. Strategies to target SGLT2 rather than SGLT1 is also associated with reduced drug toxicity as found in studies of phlorizin and anti-diabetic drugs [153]. In an STZ-diabetic model, unfermented extracts of *Cyclopia maculata* improved glucose tolerance, fasting glucose, β-cell area, triglyceride levels as well as the insulin: glucagon ratio. Plasma nitrite was reduced but no alterations were seen in other markers of nitrotyrosine and lipid peroxidation or the serum antioxidant enzymes [155]. Mangiferin and naringenin from *Salacia oblonga* also reduced blood glucose, normalised AST and ALT levels, improved antioxidant status and decreased protein carbonyl levels, glycogen and TBARS in the liver. Beta cell damage in the pancreas was also ameliorated by the compounds. It was proposed that activation of PPARγ and GLUT4, which was also accompanied by insulin sensitisation, may be partially responsible for the anti-diabetic effects [156]. Since naringenin is also found in honeybush, it suggests that extracts from honeybush could possibly also produce similar effects. Mangiferin from *Anemarrhena asphodeloides Bunge* reduced blood glucose levels and ameliorated hyperinsulinemia, the anti-diabetic properties possibly due to a reduction in insulin resistance in these rats [157]. Furthermore, mangiferin and naringenin isolated from *Salacia oblonga* reduced blood glucose levels, and increased GLUT4 and PPARγ expression, suggesting increased insulin sensitisation and demonstrating the anti-diabetic properties of the polyphenols. In conclusion, the anti-diabetic effects of

*DOI: http://dx.doi.org/10.5772/intechopen.86410*

**8. Anti-diabetic effects**

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential… DOI: http://dx.doi.org/10.5772/intechopen.86410*

## **8. Anti-diabetic effects**

*Nutraceuticals - Past, Present and Future*

in 3T3-L1 adipocytes [105]. Z-2-(β-ᴅ-glucopyranosyloxy)-3-phenylpropenoic acid (PPAG), increases glucose uptake, as demonstrated in Chang cells [52]. In their *in vivo* model of obese insulin resistant rats, basal fasting glucose decreased and glucose tolerance was improved by PPAG. Increases in mRNA expression of genes involved in glucose (GLUT1 and GLUT4) and insulin metabolism (IR) and others such as PPARα and SOCS3 in the liver were also seen. PPARα regulates the action of fatty acids in the liver, suggesting that insulin signalling, glucose and lipid metabolism may be altered by PPAG. SOCS3 associates with various proteins to inhibit cytokine signals, e.g., leptin, growth hormone, IL-6, leukaemia inhibitory factor (LIF) as well as insulin [138]. It may therefore mediate leptin resistance, which occurs in obesity but is also regulated by leptin, which may partially explain

these findings. Administration of rooibos to LDL receptor deficient (Ldlr<sup>−</sup>/

reduced liver steatosis and white adipose tissue and increased brown adipose tissue in high fat diet rats. Macrophage recruitment was decreased but no difference was seen in adipocyte size or number in the rooibos supplemented group. Furthermore, there appeared to be no liver toxicity, and free fatty acids, triglycerides and cholesterol were reduced by rooibos in the high fat diet group [108]. In humans, rooibos reduced oxidative stress, improved HDL-C, and triacylglycerol and low density lipoprotein cholesterol (LDL-C) in adults at risk of developing cardiovascular disease. [77]. These results suggest that rooibos and flavonoids in rooibos, such as aspalathin, may be potential adjuvants in the management of the metabolic syndrome. The anti-obesity effects of *Cyclopia intermedia*, *C. subternata* and *C. maculata* are limited but have been studied in 3T3-L1 adipocytes [106, 107, 139]. *C. maculata* and *C. subternata* decreased intracellular lipid and triglycerides and increased PPARγ, a regulator of glucose and lipid metabolism [107]. Their antiobesity effects also include increased release of glycerol [106]. Hormone sensitive lipase (HSL) expression, which is regulated by SIRT1a, a rate limiter of lipolysis, was also increased by fermented *C. maculata*. Furthermore, perilipin expression, which appears to play a key role in the metabolism of lipids and lipolysis of adipose tissue was upregulated [140]. *C. intermedia* increased HSL, SIRT1, UCP3 as well as PPARγ expression in 3T3-L1 adipocytes [139]. The authors attributed increases in SIRT1 and PPARγ to be indicative of changes from white to brown adipose tissue, however the expression of UCP1, which characterises brown adipose tissue was not measured in the study [141]. While the exact function is unclear, UCP3 may protect against lipotoxicity of the mitochondria [142]. In the parallel obese db/db mouse model, no increases in body weight gain were seen with *C. intermedia* treatment, and neither food nor water consumption was affected [139]. Extracts of mangiferin and other polyphenols isolated from plants containing components similar to that found in honeybush have proven useful in understanding their mechanisms of action and how they could be used as nutraceuticals in the treatment of cardiovascular disease. In a double-blind randomised placebo controlled clinical trial, mangiferin (150 mg/day) from mangoes, was given to 97 overweight, hyperlipidaemic patients over a period of 12 weeks. Increased high density lipoprotein cholesterol (HDL-C), L-carnitine, as well as decreases in total cholesterol, low density lipoprotein cholesterol (LDL-C) and triglycerides were obtained in the patients [143]. No alterations in liver and kidney function markers were seen, suggesting that chronic treatment over 12 weeks was safe in human participants. Since the metabolic syndrome is so complex, providing a multi-targeted approach, such as through affecting the PI3K/Akt pathway may be somewhat beneficial. The anti-obesity effects are further described in **Table 2**. The limited available information on the anti-obesity effects of rooibos and honeybush however, suggests that more research is needed to fully understand and enable the translation of these effects from animals to man.

<sup>−</sup>) mice

**44**

Diabetic hyperglycaemia involves macro-and microvascular complications [144]. Free radicals are also produced, promoting oxidative stress [145]. Evidence suggests that rooibos and its polyphenols may reduce oxidative stress associated with the pathogenesis of diabetes [34, 69]. A meta-analysis and systematic review narrowed down to 12 peer-reviewed studies reported a reduction in blood glucose levels in diabetic rodent models that had received either rooibos or its polyphenols, while no clinical trials have investigated the effects of rooibos in the context of type 2 diabetes [146]. Rooibos decreases fasting blood glucose and improves glucose tolerance [117]. The anti-diabetic actions may be related to the expression of genes responsible for glucose uptake (GLUT1, GLUT2), insulin signalling (IR), as well as other genes such as PPRα in the liver in a model of obese insulin resistant rats treated with PPAG [52]. The involvement of insulin dependent GLUT4, in skeletal muscle has also been reported [111]. Rooibos may be exerting anti-diabetic effects by affecting the metabolism and uptake of glucose. Aspalathin influences key genes involved in the metabolism of lipids, insulin resistance, inflammation and apoptosis, possibly reversing metabolic abnormalities by involving PPARγ, Adipoq, IL-6/Jak2 pathway and Bcl-2 [74]. PPAG increased beta cell mass and delayed hyperglycaemia in STZ-diabetic mice [147]. This was accompanied by increases in anti-apoptotic B-cell lymphoma 2 (Bcl-2), but no antioxidant effect, and in human islet cells PPAG also decreased cell death. This suggests that PPAG increases beta cell mass by decreasing apoptosis and increasing Bcl-2 as reflected in both STZ diabetic and obese mouse models [114, 148]. In the absence of insulin, GRE also increased phosphorylation of both AMPK and Akt, in L6 skeletal myotubules. Activation of AMPK could be a therapeutic strategy in the treatment of obese and type 2 diabetics, as animal studies suggest a dysregulation of AMPK in these states. The mechanism for the amelioration of diabetic complications in rodents by rooibos and honeybush may also be due α-glucosidase inhibition; or SGLT2 inhibiting potential of rooibos and honeybush or their respective flavonoids [119, 149–151]. α-Glucosidase is an enzyme present on the intestinal brush border where it digests starch, increasing blood glucose [152]. Anti-diabetic drugs, therefore commonly utilize strategies such as α-glucosidase inhibition or SGLT2 inhibition to facilitate their actions [152, 153]. The dihydrochalcone phlorizin, an SGLT2 inhibitor, provides a basis to explore natural plant based agents for use in the management of diabetes [154]. Strategies to target SGLT2 rather than SGLT1 is also associated with reduced drug toxicity as found in studies of phlorizin and anti-diabetic drugs [153]. In an STZ-diabetic model, unfermented extracts of *Cyclopia maculata* improved glucose tolerance, fasting glucose, β-cell area, triglyceride levels as well as the insulin: glucagon ratio. Plasma nitrite was reduced but no alterations were seen in other markers of nitrotyrosine and lipid peroxidation or the serum antioxidant enzymes [155]. Mangiferin and naringenin from *Salacia oblonga* also reduced blood glucose, normalised AST and ALT levels, improved antioxidant status and decreased protein carbonyl levels, glycogen and TBARS in the liver. Beta cell damage in the pancreas was also ameliorated by the compounds. It was proposed that activation of PPARγ and GLUT4, which was also accompanied by insulin sensitisation, may be partially responsible for the anti-diabetic effects [156]. Since naringenin is also found in honeybush, it suggests that extracts from honeybush could possibly also produce similar effects. Mangiferin from *Anemarrhena asphodeloides Bunge* reduced blood glucose levels and ameliorated hyperinsulinemia, the anti-diabetic properties possibly due to a reduction in insulin resistance in these rats [157]. Furthermore, mangiferin and naringenin isolated from *Salacia oblonga* reduced blood glucose levels, and increased GLUT4 and PPARγ expression, suggesting increased insulin sensitisation and demonstrating the anti-diabetic properties of the polyphenols. In conclusion, the anti-diabetic effects of

rooibos and honeybush (**Table 3**) are mediated by complex signalling pathways that affect glucose and lipid metabolism as well as oxidative stress.

## **9. Cardiovascular effects**

Angiotensin converting enzyme (ACE) inhibitors reduce blood pressure by inhibiting the conversion of angiotensin to angiotensin II, the latter being a potent vasoconstrictor which increases blood pressure through a variety of mechanisms [158]. Angiotensin II can also interact with the angiotensin I receptor, enhancing ROS production, which contributes to endothelial dysfunction by inactivating vasodilatory nitric oxide [158]. Endothelial dysfunction is commonly associated with risk factors of cardiovascular disease, including obesity and type 2 diabetes [159]. It also precedes atherosclerosis, which involves a number of complex processes such as the release of pro-inflammatory cytokines and inflammation, oxidation of LDL as well as macrophage recruitment and platelet adhesion [158]. Cardiovascular protective effects of rooibos have also been established in a number of studies (**Table 4**). In an *in vitro* human umbilical vein endothelial cell (HUVEC) study, rooibos could not inhibit ACE but increases in nitric oxide were detected [125]. ACE-inhibition was also determined in 17 healthy volunteers receiving a single oral dose of rooibos [124]. Inhibition of ACE occurred up to 60 min after ingestion but no change in blood pressure or nitric oxide was detected. ACE-inhibitory effects have also been reported for rooibos and honeybush and some of their flavonoids [131]. This effect on ACE could be due to the presence of the C2〓C3 double bond, the catechol group at the B-ring and the cetone group on C4 on the C-ring of flavonoids [131]. The best ACE-inhibitor in HUVEC's was luteolin, followed by quercetin, rutin, kaempferol, rhoifolin and apigenin K. The honeybush flavonoids genistein and hesperetin also displayed ACE-inhibitory effects but these were less potent than luteolin. Rooibos probably inhibits ACE using a mixed type of inhibition, which binds to the enzyme's active and allosteric sites [126]. Organic fractions of, as well as flavonoids in rooibos such as chrysoeriol and rutin inhibited spontaneous and low and/or high K+ -induced contractions in models utilising jejunum and bronchial smooth muscle [130, 160]. Anti-contractile effects were reportedly due to the opening of K+ channels as well as a Ca2+ antagonistic action. These studies were not done in vascular smooth muscle, but it is possible that rooibos could exert antihypertensive effects via similar mechanisms in vascular smooth muscle. It also caused mild reduction of atrial force and rate of spontaneous contractions in the Guinea pig and decreased blood pressure in anaesthetised rats [130]. In comparison, isolated compounds of rooibos tested in jejunal, tracheal and aortic preparations showed variable effects. In adults with cardiovascular risk factors, six cups of rooibos was able to increase antioxidant status by increasing the GSH: GSSG ratio and decrease lipid peroxidation by decreasing TBARS and conjugated dienes [77]. Furthermore, increases in the healthy HDL cholesterol were also seen. In a recent study using a high fat diet to induce obesity in Wistar rats, treatment with an enriched GRE, containing large quantities of aspalathin, improved glucose tolerance, vascular function, as determined by aortic vascular contraction-relaxation studies and enhanced the antioxidant status. Modest improvements in blood pressure were also seen in a recent study in obese rats, suggesting cardiovascular benefits with the intake of the rooibos [161]. Fermented rooibos also improved vascular function in nicotine exposed rats [162]. Since tobacco smoking is a major risk factor for cardiovascular disease, this suggests a possible therapeutic role for rooibos in the reduction of cardiovascular complications associated with tobacco smoking, such as vascular dysfunction or oxidative stress. Cardioprotective effects of rooibos and its flavonoids typically appear to involve a reduction in lipid peroxidation and upregulation of the antioxidant enzymes through Nrf2 activation, and a reduction in apoptosis which may also be associated with

**47**

**Author details**

**Thanks**

Shantal Windvogel

**Conflict of interest**

provided the original work is properly cited.

Stellenbosch University, Cape Town, South Africa

the SAHTA for allowing the use of the honeybush image.

disease but until then we may as well enjoy a cuppa.

There is no conflict of interest to disclose.

\*Address all correspondence to: shantalw@sun.ac.za

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Thanks go to Professor H. Kuivaniemi for proofreading this manuscript and to

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential…*

increases in the Bcl-2: Bax ratio [77, 122, 129]. The anti-inflammatory effects of rooibos, also support its role as a cardioprotective agent (**Table 1**). No literature investigating the vascular modulating effects of honeybush are currently available and anti-inflammatory effects on HUVECs are discussed above. Decreases in VLDL, LDL-C and increases in HDL-C by naringenin and mangiferin from *Salacia* sp. however suggests the potential of similar isolates from honeybush to ameliorate endothelial dysfunction [156].

Rooibos and honeybush have a number of health benefits. The evidence for their use as functional nutraceuticals is reflected in anti-diabetic, anti-inflammatory, antioxidant, anti-obesity, and vascular effects in animal and *in vitro* studies. The translation of these results into human medical care has however been limited. The inability to translate animal studies to that of humans may be due to the result of the controlled genetic background and environmental conditions of animals used as models to study disease [163]. Given the unstable nature of ROS and the limitations in assays used to detect oxidative stress, it is noteworthy to remember that intervention studies may only as good as the biomarkers used to measure the intervention. As we investigate the therapeutic role of rooibos or honeybush in the treatment of cardiovascular disease, it is evident that we are only but scratching the surface. These plants have complex chemical compositions and while isolating single components could be beneficial, the interplay and additive effects of other components in whole extracts could be more beneficial [111]. The mechanisms behind these benefits involve numerous signalling pathways that regulate their effects. Understanding these complexities may be what is needed to promote their transition from bush teas to nutraceutical therapy against cardiovascular

*DOI: http://dx.doi.org/10.5772/intechopen.86410*

**10. Conclusions and perspectives**

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential… DOI: http://dx.doi.org/10.5772/intechopen.86410*

increases in the Bcl-2: Bax ratio [77, 122, 129]. The anti-inflammatory effects of rooibos, also support its role as a cardioprotective agent (**Table 1**). No literature investigating the vascular modulating effects of honeybush are currently available and anti-inflammatory effects on HUVECs are discussed above. Decreases in VLDL, LDL-C and increases in HDL-C by naringenin and mangiferin from *Salacia* sp. however suggests the potential of similar isolates from honeybush to ameliorate endothelial dysfunction [156].

## **10. Conclusions and perspectives**

Rooibos and honeybush have a number of health benefits. The evidence for their use as functional nutraceuticals is reflected in anti-diabetic, anti-inflammatory, antioxidant, anti-obesity, and vascular effects in animal and *in vitro* studies. The translation of these results into human medical care has however been limited. The inability to translate animal studies to that of humans may be due to the result of the controlled genetic background and environmental conditions of animals used as models to study disease [163]. Given the unstable nature of ROS and the limitations in assays used to detect oxidative stress, it is noteworthy to remember that intervention studies may only as good as the biomarkers used to measure the intervention. As we investigate the therapeutic role of rooibos or honeybush in the treatment of cardiovascular disease, it is evident that we are only but scratching the surface. These plants have complex chemical compositions and while isolating single components could be beneficial, the interplay and additive effects of other components in whole extracts could be more beneficial [111]. The mechanisms behind these benefits involve numerous signalling pathways that regulate their effects. Understanding these complexities may be what is needed to promote their transition from bush teas to nutraceutical therapy against cardiovascular disease but until then we may as well enjoy a cuppa.

### **Conflict of interest**

There is no conflict of interest to disclose.

### **Thanks**

*Nutraceuticals - Past, Present and Future*

**9. Cardiovascular effects**

low and/or high K+

of K+

rooibos and honeybush (**Table 3**) are mediated by complex signalling pathways that

Angiotensin converting enzyme (ACE) inhibitors reduce blood pressure by inhibiting the conversion of angiotensin to angiotensin II, the latter being a potent vasoconstrictor which increases blood pressure through a variety of mechanisms [158].

Angiotensin II can also interact with the angiotensin I receptor, enhancing ROS production, which contributes to endothelial dysfunction by inactivating vasodilatory nitric oxide [158]. Endothelial dysfunction is commonly associated with risk factors of cardiovascular disease, including obesity and type 2 diabetes [159]. It also precedes atherosclerosis, which involves a number of complex processes such as the release of pro-inflammatory cytokines and inflammation, oxidation of LDL as well as macrophage recruitment and platelet adhesion [158]. Cardiovascular protective effects of rooibos have also been established in a number of studies (**Table 4**). In an *in vitro* human umbilical vein endothelial cell (HUVEC) study, rooibos could not inhibit ACE but increases in nitric oxide were detected [125]. ACE-inhibition was also determined in 17 healthy volunteers receiving a single oral dose of rooibos [124]. Inhibition of ACE occurred up to 60 min after ingestion but no change in blood pressure or nitric oxide was detected. ACE-inhibitory effects have also been reported for rooibos and honeybush and some of their flavonoids [131]. This effect on ACE could be due to the presence of the C2〓C3 double bond, the catechol group at the B-ring and the cetone group on C4 on the C-ring of flavonoids [131]. The best ACE-inhibitor in HUVEC's was luteolin, followed by quercetin, rutin, kaempferol, rhoifolin and apigenin K. The honeybush flavonoids genistein and hesperetin also displayed ACE-inhibitory effects but these were less potent than luteolin. Rooibos probably inhibits ACE using a mixed type of inhibition, which binds to the enzyme's active and allosteric sites [126]. Organic fractions of, as well as flavonoids in rooibos such as chrysoeriol and rutin inhibited spontaneous and


smooth muscle [130, 160]. Anti-contractile effects were reportedly due to the opening

 channels as well as a Ca2+ antagonistic action. These studies were not done in vascular smooth muscle, but it is possible that rooibos could exert antihypertensive effects via similar mechanisms in vascular smooth muscle. It also caused mild reduction of atrial force and rate of spontaneous contractions in the Guinea pig and decreased blood pressure in anaesthetised rats [130]. In comparison, isolated compounds of rooibos tested in jejunal, tracheal and aortic preparations showed variable effects. In adults with cardiovascular risk factors, six cups of rooibos was able to increase antioxidant status by increasing the GSH: GSSG ratio and decrease lipid peroxidation by decreasing TBARS and conjugated dienes [77]. Furthermore, increases in the healthy HDL cholesterol were also seen. In a recent study using a high fat diet to induce obesity in Wistar rats, treatment with an enriched GRE, containing large quantities of aspalathin, improved glucose tolerance, vascular function, as determined by aortic vascular contraction-relaxation studies and enhanced the antioxidant status. Modest improvements in blood pressure were also seen in a recent study in obese rats, suggesting cardiovascular benefits with the intake of the rooibos [161]. Fermented rooibos also improved vascular function in nicotine exposed rats [162]. Since tobacco smoking is a major risk factor for cardiovascular disease, this suggests a possible therapeutic role for rooibos in the reduction of cardiovascular complications associated with tobacco smoking, such as vascular dysfunction or oxidative stress. Cardioprotective effects of rooibos and its flavonoids typically appear to involve a reduction in lipid peroxidation and upregulation of the antioxidant enzymes through Nrf2 activation, and a reduction in apoptosis which may also be associated with

affect glucose and lipid metabolism as well as oxidative stress.

**46**

Thanks go to Professor H. Kuivaniemi for proofreading this manuscript and to the SAHTA for allowing the use of the honeybush image.

### **Author details**

Shantal Windvogel Stellenbosch University, Cape Town, South Africa

\*Address all correspondence to: shantalw@sun.ac.za

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **References**

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[2] Agyemang C, van den Born B-J. Limited access to CVD medicines in low-income and middle-income countries: Poverty is at the heart of the matter. The Lancet Global Health. 2018;**6**(3):e234-e235

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[6] DeFelice SL. Foundation for innovation in medicine rationale and proposed guidelines for the nutraceutical research & education act. Journal of Nutraceuticals Functional & Medical Foods. 2002;**2**(1):43-52

[7] Ekor M. The growing use of herbal medicines: Issues relating to adverse reactions and challenges in monitoring safety. Frontiers in Pharmacology. 2014;**4**:1-10

[8] Mahomoodally MF. Traditional medicines in Africa: An appraisal of ten potent African medicinal plants. Evidence-based Complementary and Alternative Medicine. 2013;**2013**:1-14

[9] Scalbert A, Johnson IT, Saltmarsh M. Polyphenols: Antioxidants and

beyond. The American Journal of Clinical Nutrition. 2005;**81**:215-217

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[11] Jones DP. Redefining Oxidative Stress. Antioxid Redox Signal. 2006;**8**(9-10):1865-1879

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[14] Lorenzo ADi, Curti V, Tenore GC, Nabavi SM, Daglia M. Effects of tea and coffee consumption on cardiovascular diseases and relative risk factors: An update. Current Pharmaceutical Design. 2017;**23**:2474-2487

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[17] Alberti KG, Zimmet P, Shaw J. Metabolic syndrome—A new world wide definition. Lancet. 2005;**366**(9491):1059-1062

[18] Hjemdahl P. Stress and the metabolic syndrome: An interesting but enigmatic association. Circulation. 2002;**106**(21):2634-2636

[19] Barker DJ, Godfrey K, Gluckman P, Harding J, Owens J, Robinson J.

**49**

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential…*

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[34] Uličná O, Greksák M, Vančová O, Zlatoš L, Galbavý Š, Božek P, et al. Hepatoprotective effect of rooibos tea (*Aspalathus linearis*) on CCl4-induced liver damage in rats. Physiological Research. 2003;**52**(4):461-466

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*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential… DOI: http://dx.doi.org/10.5772/intechopen.86410*

Fetal nutrition and cardiovascular disease in adult life. Lancet. 1993;**341**(8850):938-941

[20] Brunner EJ. Social factors and cardiovascular morbidity. Neuroscience and Biobehavioral Reviews. 2017;**74** (Pt B):260-268

[21] Allgulander C. Anxiety as a risk factor in cardiovascular disease. Current Opinion in Psychiatry. 2016;**29**(1):13-17

[22] Seligman F, Nemeroff CB. The interface of depression and cardiovascular disease: Therapeutic implications. Annals of the New York Academy of Sciences. 2015;**1345**(1):25-35

[23] Smith C, Swart A. *Aspalathus linearis* (rooibos)—A functional food targeting cardiovascular disease. Food & Function. 2018;**9**(10):5041-5058

[24] Schloms L, Swart AC. Rooibos flavonoids inhibit the activity of key adrenal steroidogenic enzymes, modulating steroid hormone levels in H295R cells. Molecules. 2014;**19**(3):3681-3695

[25] Schloms L, Smith C, Storbeck KH, Marnewick JL, Swart P, Swart AC. Rooibos influences glucocorticoid levels and steroid ratios *in vivo* and *in vitro*: A natural approach in the management of stress and metabolic disorders? Molecular Nutrition & Food Research. 2014;**58**(3):537-549

[26] Gathercole LL, Lavery GG, Morgan SA, Cooper MS, Sinclair AJ, Tomlinson JW, et al. 11β-hydroxysteroid dehydrogenase 1: Translational and therapeutic aspects. Endocrine Reviews. 2013;**34**(4):525-555

[27] Schloms L, Storbeck KH, Swart P, Gelderblom WCA, Swart AC. The influence of *Aspalathus linearis* (rooibos) and dihydrochalcones on adrenal steroidogenesis: Quantification of steroid intermediates and end products in H295R cells. The Journal of Steroid Biochemistry and Molecular Biology. 2012;**128**(3-5):128-138

[28] Sobel BE, Schneider DJ. Cardiovascular complications in diabetes mellitus. Current Opinion in Pharmacology. 2005;**5**(2 Spec. Iss):143-148

[29] World Health Organisation. Obesity and Overweight Factsheet No. 311. Geneva: 2018 [cited 2019 Apr 2015]. Available from https://www.who.int/ en/news-room/fact-sheets/detail/ obesity-and-overweight

[30] Nammi S, Koka S, Chinnala KM, Boini KM. Obesity: An overview on its current perspectives and treatment options. Nutrition Journal. 2004;**3**:1-8

[31] Kruger HS, Venter CS, Vorster HH, THUSA Study. Physical inactivity as a risk factor for cardiovascular disease in communities undergoing rural to urban transition: The THUSA study. Cardiovascular Journal of Southern Africa. 2003;**14**(1):16-23

[32] Eckel RH, Krauss RM. American Heart Association call to action: Obesity as a major risk factor for coronary heart disease. Circulation. 1998;**97**(21):2099-2100

[33] Marnewick JL, Joubert E, Swart P, Van Der Westhuizen F, Gelderblom WC. Modulation of hepatic drug metabolizing enzymes and oxidative status by rooibos (*Aspalathus linearis*) and honeybush (*Cyclopia intermedia*), green and black (*Camellia sinensis*) teas in rats. Journal of Agricultural and Food Chemistry. 2003;**51**(27):8113-8119

[34] Uličná O, Greksák M, Vančová O, Zlatoš L, Galbavý Š, Božek P, et al. Hepatoprotective effect of rooibos tea (*Aspalathus linearis*) on CCl4-induced liver damage in rats. Physiological Research. 2003;**52**(4):461-466

**48**

2014;**4**:1-10

*Nutraceuticals - Past, Present and Future*

[1] World Health Organization. Noncommunicable diseases

fs355/en/

**References**

2018;**6**(3):e234-e235

2016;**60**(11):861-862

Factsheet No. 355. Geneva, 2018 [cited 2019 Apr 15]. Available from: http:// www.who.int/mediacentre/factsheets/

beyond. The American Journal of Clinical Nutrition. 2005;**81**:215-217

[10] Sies H. Oxidative stress: From basic research to clinical application. The American Journal of Medicine.

[11] Jones DP. Redefining Oxidative Stress. Antioxid Redox Signal. 2006;**8**(9-10):1865-1879

[12] Naganathan V. Cardiovascular drugs in older people. Australian Prescriber.

cardiovascular disease. Pharmacological

[14] Lorenzo ADi, Curti V, Tenore GC, Nabavi SM, Daglia M. Effects of tea and coffee consumption on cardiovascular diseases and relative risk factors: An update. Current Pharmaceutical Design.

[15] Shah S. Primary prevention of cardiovascular disease. InnovAiT Education and Inspiration for General

[16] Lloyd-Jones DM, Leip EP, Larson MG, D'Agostino RB, Beiser A, Wilson PWF, et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation.

[17] Alberti KG, Zimmet P, Shaw J. Metabolic syndrome—A new world wide definition. Lancet. 2005;**366**(9491):1059-1062

[18] Hjemdahl P. Stress and the metabolic syndrome: An interesting but enigmatic association. Circulation.

[19] Barker DJ, Godfrey K, Gluckman P, Harding J, Owens J, Robinson J.

2002;**106**(21):2634-2636

Practice. 2012;**5**(4):195-203

2006;**113**(6):791-798

1991;**91**(3 SUPPL. 3):31-38

2013;**36**(6):190-194

2017;**23**:2474-2487

[13] Deka A, Vita JA. Tea and

Research. 2011;**64**:136-145

[2] Agyemang C, van den Born B-J. Limited access to CVD medicines in low-income and middle-income countries: Poverty is at the heart of the matter. The Lancet Global Health.

[3] Newman DJ, Cragg G. Natural products as sources of new drugs over the 30 years. Journal of Natural

[4] Krishnamurti C, Rao SSCC. The isolation of morphine by Serturner. Indian Journal of Anaesthesia.

[5] Tu Y. Artemisinin—A gift from traditional Chinese medicine to the world (Nobel lecture). Angewandte Chemie, International Edition. 2016;**55**(35):10210-10226

[6] DeFelice SL. Foundation for innovation in medicine rationale and proposed guidelines for the

Medical Foods. 2002;**2**(1):43-52

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of Tropical Medicine. 2014;**7**(7):

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fundamental theme of aerobic life. Plant

The transcription profile unveils the cardioprotective effect of Aspalathin against lipid toxicity in an *in vitro* H9c2 model. Molecules. 2017;**22**(2):219

interdependence between oxidative stress and inflammation explain the antioxidant paradox? Oxidative Medicine and Cellular Longevity.

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2013;**85**(5):957-998

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2008;**119**(3):376-412

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[92] Thangaraj K, Vaiyapuri M. Orientin, a C-glycosyl dietary flavone, suppresses colonic cell proliferation and mitigates NF-κB mediated inflammatory response in 1,2-dimethylhydrazine induced colorectal carcinogenesis. Biomedicine & Pharmacotherapy. 2017;**96**:1253-1266

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[118] Mazibuko SE, Muller CJF, Joubert E, De Beer D, Johnson R, Opoku AR, et al. Amelioration of palmitate-induced insulin resistance in C2C12 muscle cells by rooibos (*Aspalathus linearis*). Phytomedicine. 2013;**20**(10):813-819

[119] Muller CJF, Joubert E, de Beer D, Sanderson M, Malherbe CJ, Fey SJ, et al. Acute assessment of an aspalathin-enriched green rooibos (*Aspalathus linearis*) extract with hypoglycemic potential. Phytomedicine.

[120] Muller CJF, Joubert E, Gabuza K, De Beer D, Fey SJ, Louw J. Assessment of the antidiabetic potential of an aqueous extract of Honeybush (*Cyclopia intermedia*) in streptozotocin and obese insulin resistant Wistar rats. In: Rasooli I, editor. Phytochemistry-Bioactivities and Impact on Health. London: IntechOpen; 2011:313-332. DOI: 10.5772/28574

[121] Kawano A, Nakamura H, Hata S, Minakawa M, Miura Y, Yagasaki K. Hypoglycemic effect of aspalathin,

[122] Sun D, Huang J, Zhang Z, Gao H, Li J, Shen M, et al. Luteolin limits infarct size and improves cardiac function after myocardium ischemia/reperfusion injury in diabetic rats. PLoS One.

[123] Wu X, Xu T, Li D, Zhu S, Chen Q, Hu W, et al. ERK/PP1a/PLB/SERCA2a

a rooibos tea component from *Aspalathus linearis*, in type 2 diabetic model db/db mice. Phytomedicine.

2009;**16**(5):437-443

2012;**7**(3)

in obese diabetic ob/ob mice. European Journal of Nutrition.

2014;**80**(8-9):622-629

2013;**52**(6):1607-1619

2012;**20**(1):32-39

*DOI: http://dx.doi.org/10.5772/intechopen.86410*

[110] Schulze AE, De Beer D, Mazibuko SE, Muller CJF, Roux C, Willenburg EL, et al. Assessing similarity analysis of chromatographic fingerprints of Cyclopia subternata extracts as potential screening tool for *in vitro* glucose utilisation. Analytical and Bioanalytical Chemistry. 2016;**408**(2):639-649

[111] Kamakura R, Son MJ, de Beer D, Joubert E, Miura Y, Yagasaki K. Antidiabetic effect of green rooibos (*Aspalathus linearis*) extract in cultured cells and type 2 diabetic model KK-ay mice. Cytotechnology.

[112] Ku SK, Kwak S, Kim Y, Bae JS. Aspalathin and nothofagin from rooibos (*Aspalathus linearis*) inhibits high glucose-induced inflammation *in vitro* and *in vivo*. Inflammation.

[113] Dludla PV, Muller CJF, Louw J, Joubert E, Salie R, Opoku AR, et al. The cardioprotective effect of an aqueous extract of fermented rooibos (*Aspalathus linearis*) on cultured cardiomyocytes derived from diabetic rats. Phytomedicine. 2014;**21**(5):595-601

[114] Mathijs I, da Cunha DA, Himpe E, Ladriere L, Chellan N, Roux CR, et al. Phenylpropenoic acid glucoside augments pancreatic beta cell mass in high-fat diet-fed mice and protects beta cells from ER stress-induced apoptosis. Molecular Nutrition & Food Research.

[115] Saleh S, El-Maraghy N, Reda E, Barakat W. Modulation of diabetes and dyslipidemia in diabetic insulinresistant rats by mangiferin: Role of adiponectin and TNF-α. Anais da Academia Brasileira de Ciências.

[116] Chellan N, Joubert E, Strijdom H, Roux C, Louw J, Muller CJF. Aqueous extract of unfermented honeybush (*Cyclopia maculata*)

2014;**58**(10):1980-1990

2014;**86**(4):1935-1948

2015;**67**(4):699-710

2014;**38**(1):445-455

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential… DOI: http://dx.doi.org/10.5772/intechopen.86410*

[110] Schulze AE, De Beer D, Mazibuko SE, Muller CJF, Roux C, Willenburg EL, et al. Assessing similarity analysis of chromatographic fingerprints of Cyclopia subternata extracts as potential screening tool for *in vitro* glucose utilisation. Analytical and Bioanalytical Chemistry. 2016;**408**(2):639-649

*Nutraceuticals - Past, Present and Future*

keratinocytes. BMC Complementary and Alternative Medicine. 2016;**16**(1):261

[103] Smit SE, Johnson R, Van Vuuren MA, Huisamen B. Myocardial glucose clearance by Aspalathin treatment in Young, mature, and obese insulin-resistant rats. Planta Medica.

[104] Mazibuko SE, Joubert E,

[105] Sanderson M, Mazibuko SE, Joubert E, De Beer D, Johnson R, Pheiffer C, et al. Effects of fermented rooibos (*Aspalathus linearis*) on adipocyte differentiation. Phytomedicine. 2014;**21**:109-117

[106] Pheiffer C, Dudhia Z, Louw J, Muller C, Joubert E. *Cyclopia maculata* (honeybush tea) stimulates lipolysis in 3T3-L1 adipocytes. Phytomedicine.

[107] Dudhia Z, Louw J, Muller C, Joubert E, De Beer D, Kinnear C, et al. *Cyclopia maculata and Cyclopia subternata* (honeybush tea) inhibits adipogenesis in 3T3-L1 pre-adipocytes. Phytomedicine. 2013;**20**(5):401-408

[108] Beltrán-Debón R, Rull A, Rodríguez-Sanabria F, Iswaldi I, Herranz-López M, Aragonès G, et al. Continuous administration of polyphenols from aqueous rooibos (*Aspalathus linearis*) extract ameliorates dietary-induced metabolic disturbances in hyperlipidemic mice. Phytomedicine.

[109] Johnson R, Dludla P, Joubert E, February F, Mazibuko S, Ghoor S, et al. Aspalathin, a dihydrochalcone

cardiomyocytes against high glucose induced shifts in substrate preference and apoptosis. Molecular Nutrition & Food Research. 2016;**60**(4):922-934

C-glucoside, protects H9c2

2011;**18**(5):414-424

2015;**59**(11):2199-2208

2013;**20**(13):1168-1171

Johnson R, Louw J, Opoku AR, Muller CJF. Aspalathin improves glucose and lipid metabolism in 3T3-L1 adipocytes exposed to palmitate. Molecular Nutrition & Food Research.

2018;**84**(2):75-82

[95] Lee W, Bae JS. Anti-inflammatory effects of aspalathin and nothofagin from rooibos (*Aspalathus linearis*) *in vitro* and *in vivo*. Inflammation.

Ameliorative Effect of Vicenin-2 and Scolymoside on TGFBIp-Induced Septic Responses. Inflammation.

[97] Ku S-K, Bae J-S. Vicenin-2 and scolymoside inhibit high-glucoseinduced vascular inflammation *in vitro* and *in vivo*. Canadian Journal of Physiology and Pharmacology.

[98] Hendricks R, Pool EJ. The *in vitro* effects of rooibos and black tea on immune pathways. Journal of Immunoassay and Immunochemistry.

[99] Mueller M, Hobiger S, Jungbauer A. Anti-inflammatory activity of extracts from fruits, herbs and spices. Food Chemistry. 2010;**122**(4):987-996

[100] Baba H, Ohtsuka Y, Haruna H, Lee T, Nagata S, Maeda M, et al. Studies of anti-inflammatory effects of rooibos tea in rats. Pediatrics International.

[101] Kunishiro K, Tai A, Yamammoto I. Effects of rooibos tea extract on antigen-specific antibody production and cytokine generation *in vitro* and *in vivo*. Bioscience, Biotechnology, and Biochemistry. 2001;**65**(10):2137-2145

[102] Mazibuko-Mbeje SE, Dludla PV, Roux C, Johnson R, Ghoor S, Joubert E, et al. Aspalathin-enriched green rooibos extract reduces hepatic insulin resistance by modulating PI3K/Akt and AMPK pathways. International Journal of Molecular Sciences. 2019;**20**(3):633

2015;**38**(4):1502-1516

2015;**38**(6):2166-2177

2016;**94**(3):287-295

2010;**31**(2):169-180

2009;**51**(5):700-704

[96] Lee W, Ku S-K, Bae J-S.

**54**

[111] Kamakura R, Son MJ, de Beer D, Joubert E, Miura Y, Yagasaki K. Antidiabetic effect of green rooibos (*Aspalathus linearis*) extract in cultured cells and type 2 diabetic model KK-ay mice. Cytotechnology. 2015;**67**(4):699-710

[112] Ku SK, Kwak S, Kim Y, Bae JS. Aspalathin and nothofagin from rooibos (*Aspalathus linearis*) inhibits high glucose-induced inflammation *in vitro* and *in vivo*. Inflammation. 2014;**38**(1):445-455

[113] Dludla PV, Muller CJF, Louw J, Joubert E, Salie R, Opoku AR, et al. The cardioprotective effect of an aqueous extract of fermented rooibos (*Aspalathus linearis*) on cultured cardiomyocytes derived from diabetic rats. Phytomedicine. 2014;**21**(5):595-601

[114] Mathijs I, da Cunha DA, Himpe E, Ladriere L, Chellan N, Roux CR, et al. Phenylpropenoic acid glucoside augments pancreatic beta cell mass in high-fat diet-fed mice and protects beta cells from ER stress-induced apoptosis. Molecular Nutrition & Food Research. 2014;**58**(10):1980-1990

[115] Saleh S, El-Maraghy N, Reda E, Barakat W. Modulation of diabetes and dyslipidemia in diabetic insulinresistant rats by mangiferin: Role of adiponectin and TNF-α. Anais da Academia Brasileira de Ciências. 2014;**86**(4):1935-1948

[116] Chellan N, Joubert E, Strijdom H, Roux C, Louw J, Muller CJF. Aqueous extract of unfermented honeybush (*Cyclopia maculata*)

attenuates stz-induced diabetes and β-cell cytotoxicity. Planta Medica. 2014;**80**(8-9):622-629

[117] Son MJ, Minakawa M, Miura Y, Yagasaki K. Aspalathin improves hyperglycemia and glucose intolerance in obese diabetic ob/ob mice. European Journal of Nutrition. 2013;**52**(6):1607-1619

[118] Mazibuko SE, Muller CJF, Joubert E, De Beer D, Johnson R, Opoku AR, et al. Amelioration of palmitate-induced insulin resistance in C2C12 muscle cells by rooibos (*Aspalathus linearis*). Phytomedicine. 2013;**20**(10):813-819

[119] Muller CJF, Joubert E, de Beer D, Sanderson M, Malherbe CJ, Fey SJ, et al. Acute assessment of an aspalathin-enriched green rooibos (*Aspalathus linearis*) extract with hypoglycemic potential. Phytomedicine. 2012;**20**(1):32-39

[120] Muller CJF, Joubert E, Gabuza K, De Beer D, Fey SJ, Louw J. Assessment of the antidiabetic potential of an aqueous extract of Honeybush (*Cyclopia intermedia*) in streptozotocin and obese insulin resistant Wistar rats. In: Rasooli I, editor. Phytochemistry-Bioactivities and Impact on Health. London: IntechOpen; 2011:313-332. DOI: 10.5772/28574

[121] Kawano A, Nakamura H, Hata S, Minakawa M, Miura Y, Yagasaki K. Hypoglycemic effect of aspalathin, a rooibos tea component from *Aspalathus linearis*, in type 2 diabetic model db/db mice. Phytomedicine. 2009;**16**(5):437-443

[122] Sun D, Huang J, Zhang Z, Gao H, Li J, Shen M, et al. Luteolin limits infarct size and improves cardiac function after myocardium ischemia/reperfusion injury in diabetic rats. PLoS One. 2012;**7**(3)

[123] Wu X, Xu T, Li D, Zhu S, Chen Q, Hu W, et al. ERK/PP1a/PLB/SERCA2a

and JNK pathways are involved in luteolin-mediated protection of rat hearts and cardiomyocytes following ischemia/reperfusion. PLoS One. 2013;**8**(12)

[124] Persson IA-L, Persson K, Hägg S, Andersson RGG. Effects of green tea, black tea and rooibos tea on angiotensin-converting enzyme and nitric oxide in healthy volunteers. Public Health Nutrition. 2010;**13**(05):730

[125] Persson IA-L, Josefsson M, Persson K, Andersson RGG. Tea flavanols inhibit angiotensin-converting enzyme activity and increase nitric oxide production in human endothelial cells. The Journal of Pharmacy and Pharmacology. 2006;**58**(8):1139-1144

[126] Persson IA-L. The pharmacological mechanism of angiotensin-converting enzyme inhibition by green tea, rooibos and enalaprilat—A study on enzyme kinetics. Phytother Research. 2012;**26**(4):517-521

[127] Fu XC, Wang MW, Li SP, Wang HL. Anti-apoptotic effect and the mechanism of orientin on ischaemic/ reperfused myocardium. Journal of Asian Natural Products Research. 2006;**8**(3):265-272

[128] Lu N, Sun Y, Zheng X. Orientininduced cardioprotection against reperfusion is associated with attenuation of mitochondrial permeability transition. Planta Medica. 2011;**77**(10):984-991

[129] Pantsi WG, Marnewick JL, Esterhuyse AJ, Rautenbach F, Van Rooyen J. Rooibos (*Aspalathus linearis*) offers cardiac protection against ischaemia/reperfusion in the isolated perfused rat heart. Phytomedicine. 2011;**18**(14):1220-1228

[130] Khan AU, Gilani AH. Selective bronchodilatory effect of rooibos tea (*Aspalathus linearis*) and its flavonoid, chrysoeriol. European Journal of Nutrition. 2006;**45**(8):463-469

[131] Guerrero L, Castillo J, Quiñones M, Garcia-Vallvé S, Arola L, Pujadas G, et al. Inhibition of angiotensinconverting enzyme activity by flavonoids: Structure-activity relationship studies. PLoS One. 2012;**7**(11):1-11

[132] Inoguchi T, Li P, Umeda F, Yu HY, Kakimoto M, Imamura M, et al. High glucose level and free fatty acid stimulate reactive oxygen species production through protein kinase-C dependent activation of NAD(P)H oxidase in cultured vascular cells. Diabetes. 2000;**49**:1939-1945

[133] Esser N, Legrand-Poels S, Piette J, Scheen AJ, Paquot N. Inflammation as a link between obesity, metabolic syndrome and type 2 diabetes. Diabetes Research and Clinical Practice. 2014;**105**(2):141-150

[134] Reaven GM. Pathophysiology of insulin resistance in human disease. Physiological Reviews. 1995;**75**(3):473-486

[135] Sookoian S, Pirola CJ. Review article: Shared disease mechanisms between non-alcoholic fatty liver disease and metabolic syndrome—Translating knowledge from systems biology to the bedside. Alimentary Pharmacology & Therapeutics. 2019;**49**(November 2018):516-527

[136] Huang X, Liu G, Guo J, Su Z. The PI3K/Akt pathway in obesity and type 2 diabetes. International Journal of Biological Sciences. 2018;**14**(11):1483-1496

[137] Lee EM, Lee SS, Chung BY, Cho JY, Lee IC, Ahn SR, et al. Pancreatic lipase inhibition by C-glycosidic flavones isolated from *Eremochloa* ophiuroides. Molecules. 2010;**15**(11):8251-8259

**57**

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential…*

[147] Himpe E, Cunha DA, Song I, Bugliani M, Marchetti P, Cnop M, et al. Phenylpropenoic acid glucoside from rooibos protects pancreatic Beta cells against cell death induced by acute injury. PLoS One.

[148] Song I, Roels S, Martens GA, Bouwens L. Circulating microRNA-375 as biomarker of pancreatic beta cell death and protection of beta cell mass by cytoprotective compounds. PLoS

[149] Beelders T, Brand DJ, de Beer D, Malherbe CJ, Mazibuko SE, Muller CJF, et al. Benzophenone C- and O-glucosides from *Cyclopia genistoides* (Honeybush) inhibit mammalian α-glucosidase. Journal of Natural Products. 2014;**77**(12):2694-2699

[150] Liu W, Wang H, Meng F. In silico modeling of aspalathin and nothofagin against SGLT2. Journal of Theoretical and Computational Chemistry.

[151] Chen D, Chen R, Wang R, Li J, Xie K, Bian C, et al. Probing the catalytic promiscuity of a regio- and stereospecific C-glycosyltransferase from *Mangifera indica*. Angewandte Chemie, International Edition. 2015;**54**(43):12678-12682

[152] Santos CMM, Freitas M, Fernandes E. A comprehensive review on xanthone derivatives as α-glucosidase inhibitors. European Journal of Medicinal Chemistry.

[153] Jesus AR, Vila-Viçosa D,

Machuqueiro M, Marques AP, Dore TM, Rauter AP. Targeting type 2 diabetes with *C*-glucosyl dihydrochalcones as selective sodium glucose

Co-transporter 2 (SGLT2) inhibitors: Synthesis and biological evaluation. Journal of Medicinal Chemistry.

2018;**157**:1460-1479

2017;**60**(2):568-579

2015;**14**(08):1550056

One. 2017;**12**(10):e0186480

2016;**11**(6):e0157604

*DOI: http://dx.doi.org/10.5772/intechopen.86410*

[138] Krebs DL. SOCS Proteins: Negative Regulators of Cytokine Signaling. Stem

[139] Jack BU, Malherbe CJ, Huisamen B, Gabuza K, Mazibuko-Mbeje S, Schulze AE, et al. A polyphenol-enriched

fraction of *Cyclopia intermedia* decreases lipid content in 3T3-L1 adipocytes and reduces body weight gain of obese db/db mice. South African Journal of Botany.

[140] Tansey JT, Sztalryd C, Hlavin EM, Kimmel AR, Londos C. The central role of perilipin a in lipid metabolism and adipocyte lipolysis. IUBMB Life.

[141] Poher AL, Altirriba J, Veyrat-

[142] Schrauwen P, Hesselink MKC. The role of uncoupling protein 3 in fatty acid metabolism: Protection against lipotoxicity? The Proceedings of the Nutrition Society.

improves serum lipid profiles in

2004;**63**(2):287-292

2003;**17**(1):24-38

Durebex C, Rohner-Jeanrenaud F. Brown adipose tissue activity as a target for the treatment of obesity/insulin resistance. Frontiers in Physiology. 2015;**6**(4):1-9

[143] Na L, Zhang Q, Jiang S, Du S, Zhang W, Li Y, et al. Mangiferin supplementation

overweight patients with hyperlipidemia: A double-blind randomized controlled trial. Scientific Reports. 2015;**5**:1-9

[144] Laakso M. Hyperglycemia and cardiovascular disease in type 2 diabetes. Diabetes. 1999;**48**(5):937

[145] Maritim AC, Sanders RA, Watkins JB. Diabetes, oxidative stress, and antioxidants: A review. Journal of Biochemical and Molecular Toxicology.

[146] Sasaki M, Nishida N, Shimada MA. Beneficial role of rooibos in diabetes mellitus: A systematic review and metaanalysis. Molecules. 2018;**23**(4):839

Cells. 2001;**19**:378-387

2017;**110**:216-229

2004;**56**(7):379-385

*Rooibos (*Aspalathus linearis*) and Honeybush (*Cyclopia *spp.): From Bush Teas to Potential… DOI: http://dx.doi.org/10.5772/intechopen.86410*

[138] Krebs DL. SOCS Proteins: Negative Regulators of Cytokine Signaling. Stem Cells. 2001;**19**:378-387

*Nutraceuticals - Past, Present and Future*

and JNK pathways are involved in luteolin-mediated protection of rat hearts and cardiomyocytes following ischemia/reperfusion. PLoS One.

(*Aspalathus linearis*) and its flavonoid, chrysoeriol. European Journal of Nutrition. 2006;**45**(8):463-469

[131] Guerrero L, Castillo J, Quiñones M, Garcia-Vallvé S, Arola L, Pujadas G, et al. Inhibition of angiotensinconverting enzyme activity by flavonoids: Structure-activity relationship studies. PLoS One.

[132] Inoguchi T, Li P, Umeda F, Yu HY, Kakimoto M, Imamura M, et al. High glucose level and free fatty acid stimulate reactive oxygen species production through protein kinase-C dependent activation of NAD(P)H oxidase in cultured vascular cells. Diabetes.

[133] Esser N, Legrand-Poels S, Piette J, Scheen AJ, Paquot N. Inflammation as a link between obesity, metabolic syndrome and type 2 diabetes. Diabetes

Research and Clinical Practice.

[134] Reaven GM. Pathophysiology of insulin resistance in human disease. Physiological Reviews.

[135] Sookoian S, Pirola CJ. Review article: Shared disease mechanisms between non-alcoholic fatty liver disease and metabolic syndrome—Translating knowledge from systems biology to the bedside. Alimentary Pharmacology & Therapeutics. 2019;**49**(November

[136] Huang X, Liu G, Guo J, Su Z. The PI3K/Akt pathway in obesity and type 2 diabetes. International Journal of Biological Sciences.

[137] Lee EM, Lee SS, Chung BY, Cho JY, Lee IC, Ahn SR, et al. Pancreatic lipase inhibition by C-glycosidic flavones isolated from *Eremochloa* ophiuroides. Molecules. 2010;**15**(11):8251-8259

2018;**14**(11):1483-1496

2012;**7**(11):1-11

2000;**49**:1939-1945

2014;**105**(2):141-150

1995;**75**(3):473-486

2018):516-527

[124] Persson IA-L, Persson K, Hägg S, Andersson RGG. Effects of green tea, black tea and rooibos tea on angiotensin-converting enzyme and nitric oxide in healthy volunteers.

[125] Persson IA-L, Josefsson M, Persson K, Andersson RGG. Tea flavanols inhibit angiotensin-converting enzyme activity and increase nitric oxide production in human endothelial cells. The Journal of Pharmacy and Pharmacology.

[126] Persson IA-L. The pharmacological mechanism of angiotensin-converting enzyme inhibition by green tea, rooibos and enalaprilat—A study on enzyme kinetics. Phytother Research.

[127] Fu XC, Wang MW, Li SP, Wang HL.

mechanism of orientin on ischaemic/ reperfused myocardium. Journal of Asian Natural Products Research.

[128] Lu N, Sun Y, Zheng X. Orientininduced cardioprotection against reperfusion is associated with attenuation of mitochondrial

permeability transition. Planta Medica.

[129] Pantsi WG, Marnewick JL, Esterhuyse AJ, Rautenbach F, Van Rooyen J. Rooibos (*Aspalathus linearis*) offers cardiac protection against ischaemia/reperfusion in the isolated perfused rat heart. Phytomedicine. 2011;**18**(14):1220-1228

[130] Khan AU, Gilani AH. Selective bronchodilatory effect of rooibos tea

Anti-apoptotic effect and the

Public Health Nutrition.

2006;**58**(8):1139-1144

2012;**26**(4):517-521

2006;**8**(3):265-272

2011;**77**(10):984-991

2010;**13**(05):730

2013;**8**(12)

**56**

[139] Jack BU, Malherbe CJ, Huisamen B, Gabuza K, Mazibuko-Mbeje S, Schulze AE, et al. A polyphenol-enriched fraction of *Cyclopia intermedia* decreases lipid content in 3T3-L1 adipocytes and reduces body weight gain of obese db/db mice. South African Journal of Botany. 2017;**110**:216-229

[140] Tansey JT, Sztalryd C, Hlavin EM, Kimmel AR, Londos C. The central role of perilipin a in lipid metabolism and adipocyte lipolysis. IUBMB Life. 2004;**56**(7):379-385

[141] Poher AL, Altirriba J, Veyrat-Durebex C, Rohner-Jeanrenaud F. Brown adipose tissue activity as a target for the treatment of obesity/insulin resistance. Frontiers in Physiology. 2015;**6**(4):1-9

[142] Schrauwen P, Hesselink MKC. The role of uncoupling protein 3 in fatty acid metabolism: Protection against lipotoxicity? The Proceedings of the Nutrition Society. 2004;**63**(2):287-292

[143] Na L, Zhang Q, Jiang S, Du S, Zhang W, Li Y, et al. Mangiferin supplementation improves serum lipid profiles in overweight patients with hyperlipidemia: A double-blind randomized controlled trial. Scientific Reports. 2015;**5**:1-9

[144] Laakso M. Hyperglycemia and cardiovascular disease in type 2 diabetes. Diabetes. 1999;**48**(5):937

[145] Maritim AC, Sanders RA, Watkins JB. Diabetes, oxidative stress, and antioxidants: A review. Journal of Biochemical and Molecular Toxicology. 2003;**17**(1):24-38

[146] Sasaki M, Nishida N, Shimada MA. Beneficial role of rooibos in diabetes mellitus: A systematic review and metaanalysis. Molecules. 2018;**23**(4):839

[147] Himpe E, Cunha DA, Song I, Bugliani M, Marchetti P, Cnop M, et al. Phenylpropenoic acid glucoside from rooibos protects pancreatic Beta cells against cell death induced by acute injury. PLoS One. 2016;**11**(6):e0157604

[148] Song I, Roels S, Martens GA, Bouwens L. Circulating microRNA-375 as biomarker of pancreatic beta cell death and protection of beta cell mass by cytoprotective compounds. PLoS One. 2017;**12**(10):e0186480

[149] Beelders T, Brand DJ, de Beer D, Malherbe CJ, Mazibuko SE, Muller CJF, et al. Benzophenone C- and O-glucosides from *Cyclopia genistoides* (Honeybush) inhibit mammalian α-glucosidase. Journal of Natural Products. 2014;**77**(12):2694-2699

[150] Liu W, Wang H, Meng F. In silico modeling of aspalathin and nothofagin against SGLT2. Journal of Theoretical and Computational Chemistry. 2015;**14**(08):1550056

[151] Chen D, Chen R, Wang R, Li J, Xie K, Bian C, et al. Probing the catalytic promiscuity of a regio- and stereospecific C-glycosyltransferase from *Mangifera indica*. Angewandte Chemie, International Edition. 2015;**54**(43):12678-12682

[152] Santos CMM, Freitas M, Fernandes E. A comprehensive review on xanthone derivatives as α-glucosidase inhibitors. European Journal of Medicinal Chemistry. 2018;**157**:1460-1479

[153] Jesus AR, Vila-Viçosa D, Machuqueiro M, Marques AP, Dore TM, Rauter AP. Targeting type 2 diabetes with *C*-glucosyl dihydrochalcones as selective sodium glucose Co-transporter 2 (SGLT2) inhibitors: Synthesis and biological evaluation. Journal of Medicinal Chemistry. 2017;**60**(2):568-579

[154] Ehrenkranz JRL, Lewis NG, Ronald Kahn C, Roth J. Phlorizin: A review. Diabetes/Metabolism Research and Reviews. 2005;**21**(1):31-38

[155] Chellan N. Aqueous extract of unfermented honeybush (*Cyclopia maculata*) attenuates STZ-Induced diabetes and β-cell cytotoxicity. Planta Medica. 2014;80:622-629

[156] Singh AK, Raj V, Keshari AK, Rai A, Kumar P, Rawat A, et al. Isolated mangiferin and naringenin exert antidiabetic effect via PPARγ/ GLUT4 dual agonistic action with strong metabolic regulation. Chemico-Biological Interactions. 2018;**280**:33-44

[157] Miura T, Ichiki H, Hashimoto I, Iwamoto N, Kao M, Kubo M, et al. Antidiabetic activity of a xanthone compound, mangiferin. Phytomedicine. 2001;**8**(2):85-87

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**59**

**Chapter 4**

Probiotics and Other Bioactive

Compounds with Proven

(*Solanum quitoense*)

*and Cristina Barrera*

chapter will also discuss some of them.

**1. Foods, technology, and metabolic syndrome**

**Abstract**

Effect against Obesity and

Hypertension: Food Design

Opportunities from Lulo Fruit

*Noelia Betoret, Leidy Indira Hinestroza, Lucía Seguí* 

This book chapter aims to identify those bioactive compounds that are the most effective in obesity and hypertension prevention and/or treatment, these being the two main disorders associated with metabolic syndrome. Focusing on probiotics and phytochemicals, the document will provide evidences from both in vitro and in vivo studies as well as information about the action mechanisms and how they are affected by the interaction with other food ingredients, the food matrix in which they are placed, etc. Given its high antioxidant capacity, in part due to its spermidine content, lulo fruit has generated considerable interest among health researchers. This, together with its exotic organoleptic properties, offers interesting growth opportunities for the design of new food products from lulo fruit. This book

**Keywords:** probiotics, phytochemicals, metabolic syndrome, spermidine, lulo

Overweight and obesity are defined as "abnormal or excessive fat accumulation that may impair health" [1]. Since 1975, obesity has almost tripled worldwide so that in 2016, 39% of the adult population and 18% of children and adolescents were overweight. Very often, a high body mass index (BMI ≥ 25–30) is associated with other metabolic abnormalities, such as high blood pressure (hypertension), high blood sugar (hyperglycemia), high serum triglycerides, and low serum high-density lipoprotein (HDL) [2]. The occurrence of at least three of these interconnected physiological, biochemical, clinical, and metabolic factors that directly increase the risk of atherosclerotic cardiovascular disease, cancer, and type 2 diabetes is known as metabolic syndrome [3]. The International Diabetes Federation estimates that one-quarter of the world's adult population suffers from this syndrome, with little

## **Chapter 4**

*Nutraceuticals - Past, Present and Future*

[155] Chellan N. Aqueous extract of unfermented honeybush (*Cyclopia maculata*) attenuates STZ-Induced diabetes and β-cell cytotoxicity. Planta

[156] Singh AK, Raj V, Keshari AK, Rai A, Kumar P, Rawat A, et al. Isolated mangiferin and naringenin exert antidiabetic effect via PPARγ/ GLUT4 dual agonistic action with strong metabolic regulation. Chemico-Biological Interactions. 2018;**280**:33-44

[157] Miura T, Ichiki H, Hashimoto I, Iwamoto N, Kao M, Kubo M, et al. Antidiabetic activity of a xanthone compound, mangiferin. Phytomedicine.

[158] Schulman IH, Zhou MS, Raij L. Nitric oxide, angiotensin II, and reactive oxygen species in hypertension and atherogenesis. Current Hypertension

[160] Gilani AH, Khan A, Ghayur MN, Ali SF, Herzig JW. Antispasmodic effects of rooibos tea (*Aspalathus linearis*) is mediated predominantly

Clinical Pharmacology Toxicology.

[161] Maqeda Z. Investigating the Modulating Effects of Afriplex GRTTM Extract on Vascular Function and Antioxidant Status in Obese Wistar Rats [Master's thesis]. Stellenbosch: Stellenbosch University; 2018

channel activation. Basic

2001;**8**(2):85-87

Reports. 2005;**7**(1):61-67

[159] Hadi HAR, Carr CS, Al Suwaidi J. Endothelial dysfunction: Cardiovascular risk factors, therapy, and outcome. Vascular Health and Risk Management. 2005;**1**(3):183-198

Reviews. 2005;**21**(1):31-38

Medica. 2014;80:622-629

[154] Ehrenkranz JRL, Lewis NG, Ronald Kahn C, Roth J. Phlorizin: A review. Diabetes/Metabolism Research and

[162] Smit-van Schalkwyk M. Rooibos and Melatonin: Putative Modulation of Nicotine-induced Effects on Vascular Function [Doctoral thesis]. Stellenbosch: Stellenbosch University;

[163] Williams SM, Haines JL, Moore JH. The use of animal models in the study of complex disease: All else is never equal or why do so many human studies fail to replicate animal findings?

BioEssays. 2004;**26**(2):170-179

2016

**58**

through K<sup>+</sup>

2006;**99**(5):365-373

Probiotics and Other Bioactive Compounds with Proven Effect against Obesity and Hypertension: Food Design Opportunities from Lulo Fruit (*Solanum quitoense*)

*Noelia Betoret, Leidy Indira Hinestroza, Lucía Seguí and Cristina Barrera*

## **Abstract**

This book chapter aims to identify those bioactive compounds that are the most effective in obesity and hypertension prevention and/or treatment, these being the two main disorders associated with metabolic syndrome. Focusing on probiotics and phytochemicals, the document will provide evidences from both in vitro and in vivo studies as well as information about the action mechanisms and how they are affected by the interaction with other food ingredients, the food matrix in which they are placed, etc. Given its high antioxidant capacity, in part due to its spermidine content, lulo fruit has generated considerable interest among health researchers. This, together with its exotic organoleptic properties, offers interesting growth opportunities for the design of new food products from lulo fruit. This book chapter will also discuss some of them.

**Keywords:** probiotics, phytochemicals, metabolic syndrome, spermidine, lulo

## **1. Foods, technology, and metabolic syndrome**

Overweight and obesity are defined as "abnormal or excessive fat accumulation that may impair health" [1]. Since 1975, obesity has almost tripled worldwide so that in 2016, 39% of the adult population and 18% of children and adolescents were overweight. Very often, a high body mass index (BMI ≥ 25–30) is associated with other metabolic abnormalities, such as high blood pressure (hypertension), high blood sugar (hyperglycemia), high serum triglycerides, and low serum high-density lipoprotein (HDL) [2]. The occurrence of at least three of these interconnected physiological, biochemical, clinical, and metabolic factors that directly increase the risk of atherosclerotic cardiovascular disease, cancer, and type 2 diabetes is known as metabolic syndrome [3]. The International Diabetes Federation estimates that one-quarter of the world's adult population suffers from this syndrome, with little

difference between developed and developing countries. Main factors contributing to it include, beyond the genetic susceptibility, the increased consumption of calorie-dense food and the scarce physical activity. Given that metabolic syndrome can occur in several forms, according to the combination of the different components, it is apparently difficult to treat it pharmacologically, being lifestyle change the most effective preventive approach. However, the fact that a low-grade chronic inflammatory state accompanies the metabolic syndrome in any of its forms suggests that anti-inflammatory therapies could have a place in its prevention and treatment [4].

Inflammation is a response of the body's immune system to harmful stimuli. In the case of metabolic syndrome, inflammation takes place in response to imbalance of blood glucose and insulin levels or insulin resistance, which leads to unhealthy high concentration of unused sugar in the bloodstream that is sent to the liver, muscle, or pancreas [5, 6]. Once there, the sugar is converted into fat, thus leading to progressive adipocyte enlargement. Hypertrophy reduces blood supply to adipocytes and causes hypoxia. Subsequent necrosis and macrophage infiltration into adipose tissue lead to overproduction of reactive oxygen species (ROS), low-density lipoproteins (LDLs), inflammatory cytokines (tumor necrosis factoralpha, interleukin-6, adiponectin, etc.), and C-reactive protein (CRP). High-fat diets, frequently consumed by obese individuals, aggravate this problem both directly, when the fat is rich in saturated fatty acids, and indirectly, through effects on the microbiota and intestinal permeability [5]. The normal blood plasma concentration of CRP varies between 0.08 and 0.3 mg/dL in healthy adults and reaches values between 2 and 10 mg/dL in individuals suffering from metabolic syndrome. High levels of the inflammatory marker CRP in blood are associated with increased odds of having plaque in the carotid arteries and, therefore, with increased risk of myocardial infarction and stroke [7].

In addition to CRP, some dietary food components involved as intermediates in various metabolic pathways appear altered in population with metabolic syndrome, making possible its use as biomarkers. Polyunsaturated fatty acids (PUFA), specifically eicosapentaenoic acid (20:5 n-3; EPA) and docosahexaenoic acid (22:6 n-3; DHA), are inversely related to metabolic syndrome in adults [8]; several studies have stablished an association between this syndrome and selenium blood concentration [9] or serum levels of vitamin B12 [10]; Urrunaga-Pastor et al. [11] also found an association between vitamin D deficiency and hyperinsulinemia; adults with metabolic syndrome also have suboptimal concentrations of several antioxidants (retinyl esters, vitamin C, and all carotenoid concentrations, except lycopene), partly due to the lower intake of fruit and vegetables by these individuals [12]. These results reinforce the relationship between diet and the incidence of metabolic syndrome.

Evidence from prospective observational in vitro and in vivo studies (preclinical and clinical trials) has converged to support the importance of individual nutrient or food intake and dietary patterns in the prevention and management of obesity and metabolic syndrome. In vitro studies seek to determine the biochemical mechanisms at the cellular level as physiological ones, which are involved in the proper functioning both at the transcriptional and protein expression in the pancreas, skeletal muscle, liver, and adipose tissue. In vivo studies allow establishing a cause-effect relationship in experimental animals (preclinical trials) or in humans (clinical trials). While in vitro or animal in vivo studies are standardized and there are countless works done, even today a standard profile for clinical trials in humans with metabolic syndrome has not yet been established. Clinical trials about therapeutic efficacy for metabolic syndrome are scarce and concentrated in the last 8 years in high-income countries (USA, Italy, and Spain). Interventions that affect three or more factors and evaluate various outcome variables are reduced, highlighting the lifestyle factors (diet and physical activity) as the most important

**61**

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity…*

pasteurization or freeze-drying instead of hot air drying.

**2. Food components against metabolic syndrome**

level of high-density lipoproteins (HDLs) [17].

in one of the following groups:

suitable for metabolic syndrome prevention and/or amelioration.

in this multifactorial syndrome [13]. Specifically, a low intake of saturated and total fat; reduced consumption of sodium, simple sugars, and high glycemic index foods; and increased intake of fruits, vegetables, legumes, and whole grains are suggested to be the most effective actions in reducing the incidence of obesity and cardiovascular disease. However, the urban lifestyle leads us to mainly consume foods in processed form, which reinforces the decisive role that the food industry plays in the promotion of healthy diets. In fact, in recent years the supply of functional foods with a reduced content of fat, sugar or salt, as well as that of functional foods formulated with phytosterols or polyunsaturated fatty acids has increased considerably. In order to achieve this, not only traditional techniques of food formulation and blending or cultivation and breeding are involved but also more recent ones, such as microencapsulation, vacuum impregnation, or coating with edible films [14]. Moreover, the increasing knowledge about the negative impact that processing and cooking techniques have on the concentration and functionality of the active compounds naturally present in foods has encouraged the use of alternative techniques, such as the application of high-pressure homogenization replacing the

Later in this book chapter, the most relevant bioactive compounds with proven

Main food components considered in the literature as having potential ameliorating effect on any disorder associated with metabolic syndrome may be included

• *Fiber*, both soluble (e.g., pectins, beta-glucans, naturally occurring gums, inulin, psyllium) and insoluble (e.g., cellulose, hemicellulose, lignin), is reported to have laxative properties and to mitigate both hypercholesterolemia and hyperglycemia [15]. When fermented by probiotic bacteria, *prebiotic fiber* (fiber that resists digestion in the stomach and the small intestine and reaches the colon intact) breaks down into short-chain fatty acids (butyrate, acetate, and propionate), which are reported to enhance glucose and fat metabolism [16].

• *Monounsaturated fats, polyunsaturated fats (both omega-3 and omega-6), plant sterols, and essential fatty acids* instead of saturated fats and trans-fatty acids are proved to be effective in decreasing total cholesterol and increasing the blood

• *Vitamin E and C* consumption is associated to a reduction of vascular risk by decreasing oxidative stress (lipid peroxidation) and proinflammatory cytokines [17]. Improved vitamin C status is hypothesized to alleviate endotoxemia and its consequent proinflammatory responses that are suggested to initiate insulin resistance and related metabolic disorders; on the contrary, inadequate vitamin C status contributes to small intestinal bacterial overgrowth, transcytosis of enteric bacteria, and an elevation of circulating lipopolysaccharide, which elicits a low-grade inflammatory response [18]. As for *vitamin D*, it reduces the intestinal absorption of fat by increasing that of calcium [17].

effect against any disorder associated with the metabolic syndrome are listed. Focusing on probiotic microorganisms and phytochemical compounds, evidences obtained from in vitro, in vivo, or clinical studies in the last 10 years have been compiled. Finally, new functional foods made from lulo fruit are suggested as being

*DOI: http://dx.doi.org/10.5772/intechopen.85482*

#### *Probiotics and Other Bioactive Compounds with Proven Effect against Obesity… DOI: http://dx.doi.org/10.5772/intechopen.85482*

in this multifactorial syndrome [13]. Specifically, a low intake of saturated and total fat; reduced consumption of sodium, simple sugars, and high glycemic index foods; and increased intake of fruits, vegetables, legumes, and whole grains are suggested to be the most effective actions in reducing the incidence of obesity and cardiovascular disease. However, the urban lifestyle leads us to mainly consume foods in processed form, which reinforces the decisive role that the food industry plays in the promotion of healthy diets. In fact, in recent years the supply of functional foods with a reduced content of fat, sugar or salt, as well as that of functional foods formulated with phytosterols or polyunsaturated fatty acids has increased considerably. In order to achieve this, not only traditional techniques of food formulation and blending or cultivation and breeding are involved but also more recent ones, such as microencapsulation, vacuum impregnation, or coating with edible films [14]. Moreover, the increasing knowledge about the negative impact that processing and cooking techniques have on the concentration and functionality of the active compounds naturally present in foods has encouraged the use of alternative techniques, such as the application of high-pressure homogenization replacing the pasteurization or freeze-drying instead of hot air drying.

Later in this book chapter, the most relevant bioactive compounds with proven effect against any disorder associated with the metabolic syndrome are listed. Focusing on probiotic microorganisms and phytochemical compounds, evidences obtained from in vitro, in vivo, or clinical studies in the last 10 years have been compiled. Finally, new functional foods made from lulo fruit are suggested as being suitable for metabolic syndrome prevention and/or amelioration.

## **2. Food components against metabolic syndrome**

Main food components considered in the literature as having potential ameliorating effect on any disorder associated with metabolic syndrome may be included in one of the following groups:


*Nutraceuticals - Past, Present and Future*

myocardial infarction and stroke [7].

difference between developed and developing countries. Main factors contributing to it include, beyond the genetic susceptibility, the increased consumption of calorie-dense food and the scarce physical activity. Given that metabolic syndrome can occur in several forms, according to the combination of the different components, it is apparently difficult to treat it pharmacologically, being lifestyle change the most effective preventive approach. However, the fact that a low-grade chronic inflammatory state accompanies the metabolic syndrome in any of its forms suggests that anti-inflammatory therapies could have a place in its prevention and treatment [4]. Inflammation is a response of the body's immune system to harmful stimuli. In the case of metabolic syndrome, inflammation takes place in response to imbalance of blood glucose and insulin levels or insulin resistance, which leads to unhealthy high concentration of unused sugar in the bloodstream that is sent to the liver, muscle, or pancreas [5, 6]. Once there, the sugar is converted into fat, thus leading to progressive adipocyte enlargement. Hypertrophy reduces blood supply to adipocytes and causes hypoxia. Subsequent necrosis and macrophage infiltration into adipose tissue lead to overproduction of reactive oxygen species (ROS), low-density lipoproteins (LDLs), inflammatory cytokines (tumor necrosis factoralpha, interleukin-6, adiponectin, etc.), and C-reactive protein (CRP). High-fat diets, frequently consumed by obese individuals, aggravate this problem both directly, when the fat is rich in saturated fatty acids, and indirectly, through effects on the microbiota and intestinal permeability [5]. The normal blood plasma concentration of CRP varies between 0.08 and 0.3 mg/dL in healthy adults and reaches values between 2 and 10 mg/dL in individuals suffering from metabolic syndrome. High levels of the inflammatory marker CRP in blood are associated with increased odds of having plaque in the carotid arteries and, therefore, with increased risk of

In addition to CRP, some dietary food components involved as intermediates in various metabolic pathways appear altered in population with metabolic syndrome, making possible its use as biomarkers. Polyunsaturated fatty acids (PUFA), specifically eicosapentaenoic acid (20:5 n-3; EPA) and docosahexaenoic acid (22:6 n-3; DHA), are inversely related to metabolic syndrome in adults [8]; several studies have stablished an association between this syndrome and selenium blood concentration [9] or serum levels of vitamin B12 [10]; Urrunaga-Pastor et al. [11] also found an association between vitamin D deficiency and hyperinsulinemia; adults with metabolic syndrome also have suboptimal concentrations of several antioxidants (retinyl esters, vitamin C, and all carotenoid concentrations, except lycopene), partly due to the lower intake of fruit and vegetables by these individuals [12]. These results reinforce the relationship between diet and the incidence of metabolic syndrome. Evidence from prospective observational in vitro and in vivo studies (preclini-

cal and clinical trials) has converged to support the importance of individual nutrient or food intake and dietary patterns in the prevention and management of obesity and metabolic syndrome. In vitro studies seek to determine the biochemical mechanisms at the cellular level as physiological ones, which are involved in the proper functioning both at the transcriptional and protein expression in the pancreas, skeletal muscle, liver, and adipose tissue. In vivo studies allow establishing a cause-effect relationship in experimental animals (preclinical trials) or in humans (clinical trials). While in vitro or animal in vivo studies are standardized and there are countless works done, even today a standard profile for clinical trials in humans with metabolic syndrome has not yet been established. Clinical trials about therapeutic efficacy for metabolic syndrome are scarce and concentrated in the last 8 years in high-income countries (USA, Italy, and Spain). Interventions that affect three or more factors and evaluate various outcome variables are reduced, highlighting the lifestyle factors (diet and physical activity) as the most important

**60**


### **2.1 Phytochemicals**

Phytochemicals are naturally occurring plant chemicals that, beyond providing plants with color, odor, and flavor, can influence chemical processes within human bodies in a beneficial way. Main phytochemicals under research include carotenoids (β-carotene, lycopene, lutein, zeaxanthin) and polyphenols, which include phenolic acids, flavonoids, and stilbenes/lignans [30]. Flavonoids can be further divided into groups based on their similar chemical structure, such as anthocyanins, flavones, flavanones, isoflavones, flavonols, and flavanols. Flavanols further are classified as catechins, epicatechins, and proanthocyanidins.

Phytochemical compounds have gained popularity in recent years due to their broadly documented effect in cancer prevention among other biological effects,

**63**

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity…*

such as the prevention and treatment of obesity, cholesterol, and diabetes [31]. Mechanisms employed by phytochemicals in ameliorating metabolic syndrome risk factors are diverse and dependent on their particular chemical structure. Whereas catechins mainly induce fat oxidation and improve endothelial function, cyanidins and theaflavins inhibit enzymes involved in the synthesis of fatty acids and triglycerides. Other phytochemicals, such as gallic acid, quercetin, and capsaicin, reduce preadipocyte proliferation by induction of cell apoptosis, while low-molecular proanthocyanidins have the ability to inhibit the activity of specific angiotensinconverting enzyme. Having a similar chemical structure, isoflavones can also

For some bioactive components, several in vitro and in vivo (either animals or humans) studies have been performed; however, as evidenced in **Tables 1**–**3**, results differ among them. While in vitro or animal studies usually yield positive results, clinical human studies are still inconclusive. The lack of standardization or aspects related to the dose or duration of supplementation may be the cause of these results. Moreover, studies both in vitro and with animals (**Tables 1** and **2**) have been carried out with synthetic components (only spermidine was obtained directly from lulo fruit), while in vivo studies with humans have been carried out mainly with extracts

**Phytochemical(s) Methodology Beneficial effect(s) Reference**

Anti-adipogenic, antioxidant, antiinflammatory, and antiapoptosis effects

Decreased obesity-induced inflammation, stimulated lipolysis, and decreased adipocyte differentiation

Anti-inflammatory potential

Quercetin efficiently inhibited cell population growth and increased induction of apoptosis

Decreased adipogenesis, increased lipolysis, induced apoptosis, and reduced lipogenesis and proliferation, thereby contributing to reduce lipid accumulation. Reduced inflammatory response and improved insulin sensitivity

Hypertension control [35]

[32, 33]

[26]

[34]

[36]

[37]

*vulgaris*-treated HaCaT cell line. Naringenin was added to the cell growing media in a dose of 25 μg/mL, and effect was measured after 24, 48, 72, 96,

3 T3-L1 cell line or 10 T1/2 cells and primary fat SVF cells or

Doses and times were not

In vitro measurement of angiotensin-converting enzyme

IC50 = 40.4 μM for quercetin IC50 ≥ 500 μM for naringenin, rutin, hesperidin, resveratrol,

*DOI: http://dx.doi.org/10.5772/intechopen.85482*

influence the activity of human estrogens.

including the bioactive compounds (**Table 3**).

Synthesis naringenin 3T3-L1 cell line and *Pemphigus* 

Pentacyclic triterpenes (oleanolic acid, 18β-glycyrrhetinic acid, ursolic acid, celastrol, maslinic acid, ilexgenin A)

Spermidine (from ethanolic lulo pulp extract)

Flavonoids (naringenin, rutin, hesperidin, resveratrol, naringin, and quercetin)

or 120 hours

HepG2 cells

IC50 = 0.8 μM

inhibition IC50 = 1.8 ppm

3 T3-L1 cell line

and naringin

Resveratrol Maturing preadipocytes and adipocytes. Dose not specified

specified

Synthesis carvacrol Cyclooxygenase-2 assay

#### *Probiotics and Other Bioactive Compounds with Proven Effect against Obesity… DOI: http://dx.doi.org/10.5772/intechopen.85482*

such as the prevention and treatment of obesity, cholesterol, and diabetes [31]. Mechanisms employed by phytochemicals in ameliorating metabolic syndrome risk factors are diverse and dependent on their particular chemical structure. Whereas catechins mainly induce fat oxidation and improve endothelial function, cyanidins and theaflavins inhibit enzymes involved in the synthesis of fatty acids and triglycerides. Other phytochemicals, such as gallic acid, quercetin, and capsaicin, reduce preadipocyte proliferation by induction of cell apoptosis, while low-molecular proanthocyanidins have the ability to inhibit the activity of specific angiotensinconverting enzyme. Having a similar chemical structure, isoflavones can also influence the activity of human estrogens.

For some bioactive components, several in vitro and in vivo (either animals or humans) studies have been performed; however, as evidenced in **Tables 1**–**3**, results differ among them. While in vitro or animal studies usually yield positive results, clinical human studies are still inconclusive. The lack of standardization or aspects related to the dose or duration of supplementation may be the cause of these results. Moreover, studies both in vitro and with animals (**Tables 1** and **2**) have been carried out with synthetic components (only spermidine was obtained directly from lulo fruit), while in vivo studies with humans have been carried out mainly with extracts including the bioactive compounds (**Table 3**).


*Nutraceuticals - Past, Present and Future*

• *Bioactive peptides*, having a size range of 2–50 amino acids, have potential to regulate blood pressure and glycemia, reduce cholesterol level and body mass, and scavenge free radicals [19]. Lactotripeptides isoleucine-proline-proline and valine-proline-proline, whose concentrations increase during the ripening process of cheese, are particularly considered as strong antihypertensive agents [20]. In the case of obesity, foods that contain bioactive peptides provide a

• *Minerals'* (selenium, magnesium, and zinc) ability to decline metabolic syndrome is related with their antioxidant properties and their participation in insulin synthesis and regulation [20]. Moreover, calcium intake (1200 mg/ day) has been demonstrated to increase fat mass loss in overweight and obese adults [21]. Mechanisms to explain this effect include that during low calcium intake, more calcium enters adipose tissues cells and subsequently stimulates the expression of lipogenic genes in parallel with suppressing lipolysis [22]. Also, calcium increases fecal fat loss by binding to fat in the lumen and forming non-absorbed complexes [23]. This ability of calcium to decrease lipogenesis may be enhanced due to a synergistic effect with other components in dairy products (vitamin D and angiotensin-converting enzyme inhibitors) [21].

• *Essential amino acids*, mainly histidine and glycine, are associated with a decrease in insulin resistance and blood pressure, respectively, although conclusive evidence is lacking and additional studies are needed [17].

• *Phytochemicals*, mainly polyphenols (phenolic acids, curcuminoids, stilbenes, lignans, flavonoids, flavonols, flavones, anthocyanins, etc.) but also other bioactive components present in small quantities in fruits and vegetables (triterpenes, carotenoids, etc.), have demonstrated anti-inflammatory, antioxidative, antiadiposity, and cardioprotective functions in a huge amount of studies [24–28]. Some phytochemicals, among which are caffeine, ephedrine, capsaicin, and salicylic acid, also act as thermogenic compounds that produce heat from lipids and fats, thus burning extra calories and preventing the

• *Probiotics* are microorganisms that improve the availability and digestibility of nutrients while maintaining the balance of intestinal microflora in the gut [20]. Mainly belonging to the *Lactobacillus* and *Bifidobacterium* genera, probiotics emerge as prospective biotherapies in the management of metabolic disorders including obesity and diabetes by counteracting the adverse effects of a high-

Phytochemicals are naturally occurring plant chemicals that, beyond providing plants with color, odor, and flavor, can influence chemical processes within human bodies in a beneficial way. Main phytochemicals under research include carotenoids (β-carotene, lycopene, lutein, zeaxanthin) and polyphenols, which include phenolic acids, flavonoids, and stilbenes/lignans [30]. Flavonoids can be further divided into groups based on their similar chemical structure, such as anthocyanins, flavones, flavanones, isoflavones, flavonols, and flavanols. Flavanols further are classified as

Phytochemical compounds have gained popularity in recent years due to their broadly documented effect in cancer prevention among other biological effects,

satiating effect and lead to appetite suppression.

accumulation of fat in body tissues [20].

catechins, epicatechins, and proanthocyanidins.

fat diet [29].

**2.1 Phytochemicals**

**62**


#### **Table 1.**

*Fruits, vegetables (or extracts), and phytochemicals endorsed by recent in vitro studies.*


**65**

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity…*

Rats were fed with high-fat diets with curcuminoid supplement at concentrations of 30, 60, and 90 mg per kilogram of body weight every day

for 12 weeks

20 weeks

6–22 weeks

Rats and mice fed with a Western diet containing 0.05% quercetin for

Different dose-time treatment: from 0.5–4% of different catechins for

**Phytochemical(s) Methodology Beneficial effect(s) Reference**

in obesity

pressure

body weight gain

hyperlipidemia, and hypercholesterolemia

of insulin resistance

Decreased plasma free fatty acid levels and improves cardiac autonomic nervous system activity

Contributed to lower body fat and

Improved obesity-associated inflammation and associated metabolic disorders such as insulin resistance, hyperglycemia,

Decreased body weight, visceral fat, blood glucose, free cholesterol, total antioxidant status, lipid accumulation, and systolic blood

Decreased body weight, total lipids, cholesterol, and triglycerides in liver and plasma. Also improved glucose homeostasis: increased glucose tolerance and decreased serum glucose, insulin resistance, and homeostasis model assessment

**Phytochemical(s) Methodology Beneficial effect(s) Reference**

*Fruits, vegetables (or extracts), and phytochemicals endorsed by recent in vivo (preclinical trials) studies.*

Decreased weight, body mass index, fat mass, waist circumference, and total insulin secretion

Decreased ox-LDL and triglyceride levels

Decreased body weight, abdominal circumference, and visceral fat volume

Did not modify insulin secretion and sensitivity in patients with obesity; however, the natural evolution to increased weight and adiposity was halted

[44]

[43]

[24]

[27]

[45]

[46]

[47]

controlled clinical trial was carried out in 24 patients with diagnosis of metabolic

12 patients received trans-resveratrol (500 mg) three times per day before

Double-blind placebo-controlled randomized clinical trial was carried out in 80 patients with a diagnosis of

80 patients with metabolic syndrome received 1800 mg of artichoke leaf extract as four tablets per day for

controlled study with 18 subjects. All subjects took two capsules of Oligonol (50 mg/capsule) twice a day for 10 weeks.

controlled clinical trial was carried out in 20 obese [body mass index (BMI)

10 patients received 120 mL of pomegranate juice or placebo while in a fasted state before breakfast every day for

Resveratrol A randomized, double-blind, placebo-

syndrome

12 weeks

Oligonol extract Randomized double-blind, placebo-

Pomegranate juice A randomized, double-blind, placebo-

30.0–39.9] adults

1 month

Artichoke leaf extracts rich in flavonoids and caffeoylquinic acid derivatives

**Table 2.**

meals for 90 days

metabolic syndrome

*DOI: http://dx.doi.org/10.5772/intechopen.85482*

Curcuminoids Rats

Quercetin Rats and mice

Green tea catechins Rats and mice

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity… DOI: http://dx.doi.org/10.5772/intechopen.85482*


#### **Table 2.**

*Nutraceuticals - Past, Present and Future*

Green tea catechins 3 T3-L1 cells

Naringenin Rats and mice

Synthesis apigenin Mice

Synthesis carvacrol Mice

Oryzanol and ferulic

acid

Pentacyclic triterpenes: oleanolic acid, 18β-glycyrrhetinic acid, ursolic acid, α, β-amyrin, carbenoxolone, asiatic acid, corosolic acid, bardoxolone methyl, lupeol, ilexgenin A

**Table 1.**

Ajoene Mature 3T3-L1 adipocytes

of treatment

(8–16 days)

Epigallocatechin or epigallocatechin gallate was added to the cell growing media in a dose from 1, 10, 50, 100, 200, and 200 μM for some hours until some days

*Fruits, vegetables (or extracts), and phytochemicals endorsed by recent in vitro studies.*

10 mg/kg∙day by oral gavage for 4 weeks; 0.1% in an experimental diet for 6 months; 1% and 3% in a high-fat diet for 4 and 30 weeks,

50 mg/kg∙day by oral gavage for 4 weeks

respectively

Rats and mice Oleanolic acid (25 mg/ kg∙day, once daily, 10 weeks) to fructosefed rats; ursolic acidtreated fat-fed mice at a dose of 50 or 200 mg/kg of body weight (orally for 8 weeks); lupeol at 0.67 g/kg, given orally

for 7 weeks

10 weeks

Mice High-fat diet

7 weeks

Carvacrol was added to the diet in a 0.1% (w/w) (equivalent to 100 mg/ kg body weight) for

supplemented with 0.5% (w/w) oryzanol or 0.5% (w/w) ferulic acid for

**Phytochemical(s) Methodology Beneficial effect(s) Reference**

**Phytochemical(s) Methodology Beneficial effect(s) Reference**

Influenced the regulation of

Increased apoptosis and decreased preadipocyte

[38]

[27]

[39]

[40]

[26]

[41]

[42]

fat cell number

proliferation

Antioxidant, antihyperlipidemic, anti-obesity, antihyperglycemic, anti-diabetic, anti-inflammatory,

Attenuated insulin resistance, dyslipidemia and liver injury, and mitigated oxidative stress

Decreased fatty acid synthesis, triglyceride synthesis and plasma triglycerides, leptin and free fatty acids, and also triglyceride content

Reduced fatty liver, adipocyte size, hepatic steatosis, insulin resistance, inflammation, oxidative stress, body weight, atherosclerosis, and

Decreased cholesterol synthesis, total cholesterol, VLDL and LDLcholesterol, cholesterol in liver and

Prevented obesity by decreasing body weight gain, visceral fat-pad weights, and plasma lipid levels; also inhibited visceral adipogenesis and attenuated the production of pro-inflammatory cytokines in visceral adipose tissues

Decreased in body weight, improved blood glucose metabolism, may be beneficial for the treatment of diabetic

hyperglycemia

in skeletal muscle

hypertension

in adipose tissue

antihypertensive, and cardioprotective activities

Ajoene at 200 μM decreased cell viability in 50% after 24 hours

**64**

*Fruits, vegetables (or extracts), and phytochemicals endorsed by recent in vivo (preclinical trials) studies.*



#### **Table 3.**

*Fruits, vegetables (or extracts), and phytochemicals endorsed by recent in vivo (clinical trials) studies.*

In vitro studies achieve 50% of cell population growth inhibition with active compound amount of ppm, and, in some cases (some flavonoids, ajoene, catechins), a dose-time-dependent effect is detected. These dose-time-dependent effects, together with the multivariate effects observed in most cases, are largely due to the antioxidant properties of the phytochemicals considered. Flavonoids tested on cell population growth were well correlated with their antioxidant activity [36].

The doses used in the preclinical studies were much higher than those used in the clinical trials, and the limitations in the ingested doses may be the cause of the ineffective results. Kobori et al. [24] concluded that in vitro anti-aggregatory effects of flavonoids are caused by concentrations that cannot be attained in vivo by dietary consumption.

In most preclinical studies, imbalances are induced in mice with a high fructose diet, and the effect that the active component has on these induced disorders is determined. Also in the clinical studies performed with positive results, the component of interest was provided as part of a low-fat diet to patients with physiological alterations associated with metabolic syndrome. In these conditions the results show a palliative effect but in no case a preventive effect. Thus, quercetin supplementation did not affect the antioxidant status under healthy, normal conditions [24].

Sometimes solubility and bioavailability are a major limitation factor. As an example, pentacyclic triterpenes such as ursolic acid are poorly bioavailable because of poor aqueous solubility and permeability through biological membranes [26]. These limit their biological effects. Some strategies have increased bioavailability. For example, on comparing the oral bioavailability of ursolic acid microcrystals and nanocrystals to its coarse suspension in rats, ursolic acid microcrystals and nanocrystals exhibited 1.40- and 2.56-fold enhancement, respectively. Also, a new

**67**

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity…*

allow to provide the adequate doses avoiding toxicity problems.

product from polyphenols of lychee has been developed. Oligonol, a unique lowmolecular-weight polyphenol, was developed to enhance absorption of polyphenols from the intestines. It contains 15.7% polyphenol monomer ((+)-catechin, (−)-epicatechin, etc.) and 13.3% polyphenol dimer (procyanidin B2, etc.), while lychee fruit-derived polyphenol contains 6.4% polyphenol monomer and 9.9% polyphenol

Concluding from above, translational studies from animal observations to human clinical trials and ultimately community interventions are needed to further confirm the effects of phytochemicals and foods rich in these bioactive compounds. The technological development should be aimed at the implementation of strategies that increase the bioavailability of active components with proven activity and that

Probiotics are defined as live microorganisms which, when administered in adequate amounts, confer a health benefit on the host [50]. Evidence from the latest studies in which probiotic efficiency in metabolic disorder management is assessed by both in vitro and in animal or human subjects is compiled in **Tables 4** and **5**.

Regarding the strains employed in the management of several inflammatory diseases, they usually belong to the *Lactobacillus* and *Bifidobacterium* genera, although *Pediococcus pentosaceus* LP28, *Bacteroides uniformis* CECT 7771, and *Akkermansia muciniphila* have also been proved to have anti-obesity effects [65]. In general, doses

**Probiotic organism Methodology Beneficial effect(s) Reference**

Mice fed on a standard diet or a high-fat diet (5–7 mice per group) supplemented or not with

CFU/day for 5 weeks

 CFU/rat/day or 1.05 × 1010 CFU/rat/day for 8 weeks

10 rats fed on a normal diet and 30 rats fed on a high-energy diet supplemented or not

Rats fed for 8 weeks on a normal diet or a high-fat diet supplemented or not with: • Unfermented tea powder • (12.5 mg EGCG/day) Fermented

• (12.5–25 mg EGCG/day plus 3.75–7 × 1010 CFU/day) NTU 101

5 × 108

with 2.1 × 109

tea powder

powder

• (7.5 × 1010 CFU/day) • EGCG powder (25 mg/day)

3T3-L1 adipocytes Inhibited adipogenesis

3T3-L1 pre-adipocyte model Fermented tea powder

and stimulated glucose

Reduced diet-induced weight gain, lipid accumulation, and insulin resistance

Reduced obesity by decreasing proinflammation factors and increasing antioxidant enzymes in the serum

promoted lipase activity in adipocytes, which thereby improves the lipolytic effect

NTU 101-fermented tea had a more significant effect on the reduction of body weight gain and body fat content than the unfermented tea

[51]

[52]

[53]

uptake

*DOI: http://dx.doi.org/10.5772/intechopen.85482*

dimer [46].

**2.2 Probiotics**

*Lactobacillus plantarum* Ln4 isolated from napa cabbage kimchi

*Lactobacillus reuteri* 263 patented strain

Green tea (rich in epigallocatechin gallate) and *Houttuynia cordata* leaf (rich in chlorogenic acid) extract fermented with *Lactobacillus paracasei* subsp. *paracasei* NTU 101 originally isolated from infant

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity… DOI: http://dx.doi.org/10.5772/intechopen.85482*

product from polyphenols of lychee has been developed. Oligonol, a unique lowmolecular-weight polyphenol, was developed to enhance absorption of polyphenols from the intestines. It contains 15.7% polyphenol monomer ((+)-catechin, (−)-epicatechin, etc.) and 13.3% polyphenol dimer (procyanidin B2, etc.), while lychee fruit-derived polyphenol contains 6.4% polyphenol monomer and 9.9% polyphenol dimer [46].

Concluding from above, translational studies from animal observations to human clinical trials and ultimately community interventions are needed to further confirm the effects of phytochemicals and foods rich in these bioactive compounds. The technological development should be aimed at the implementation of strategies that increase the bioavailability of active components with proven activity and that allow to provide the adequate doses avoiding toxicity problems.

### **2.2 Probiotics**

*Nutraceuticals - Past, Present and Future*

Green tea catechins

Black seeds and turmeric

**Table 3.**

Cocoa extract Double-blind, randomized, placebo-

[30.59(2.33) kg/m2

extract for 4 weeks

controlled parallel nutritional intervention with 50 obese volunteers

]. Meals supplemented with 1.4 g/day cocoa

Various randomized, double-blind, placebo-controlled clinical trials. Some studies with different dose-time treatment: from 38 to 600 mg/day of different catechins for 6–24 weeks

Double-blind randomized controlled trial Black seeds (1.5 g/day), turmeric (2.4 g/ day), its combination (900 mg black seeds and 1.5 g turmeric/day) for 8 weeks

In vitro studies achieve 50% of cell population growth inhibition with active compound amount of ppm, and, in some cases (some flavonoids, ajoene, catechins), a dose-time-dependent effect is detected. These dose-time-dependent effects, together with the multivariate effects observed in most cases, are largely due to the antioxidant properties of the phytochemicals considered. Flavonoids tested on cell population growth were well correlated with their antioxidant activity [36]. The doses used in the preclinical studies were much higher than those used in the clinical trials, and the limitations in the ingested doses may be the cause of the ineffective results. Kobori et al. [24] concluded that in vitro anti-aggregatory effects of flavonoids are caused by concentrations that cannot be attained in vivo by

*Fruits, vegetables (or extracts), and phytochemicals endorsed by recent in vivo (clinical trials) studies.*

**Phytochemical(s) Methodology Beneficial effect(s) Reference**

A marginal decrease (P = 0.072) in oxidized bases was observed, which attributed to weight

Not all studies have found positive results for obesity-related measures. Green tea administration has also shown no influence on body weight, body mass index, fat mass, and waist and hip circumference

Improved blood pressure, waist circumference, hip circumference, body mass index, LDL-cholesterol, HDL-cholesterol, and triglyceride content

[48]

[27]

[49]

loss

In most preclinical studies, imbalances are induced in mice with a high fructose diet, and the effect that the active component has on these induced disorders is determined. Also in the clinical studies performed with positive results, the component of interest was provided as part of a low-fat diet to patients with physiological alterations associated with metabolic syndrome. In these conditions the results show a palliative effect but in no case a preventive effect. Thus, quercetin supplementation did not affect the antioxidant status under healthy, normal conditions [24]. Sometimes solubility and bioavailability are a major limitation factor. As an example, pentacyclic triterpenes such as ursolic acid are poorly bioavailable because of poor aqueous solubility and permeability through biological membranes [26]. These limit their biological effects. Some strategies have increased bioavailability. For example, on comparing the oral bioavailability of ursolic acid microcrystals and nanocrystals to its coarse suspension in rats, ursolic acid microcrystals and nanocrystals exhibited 1.40- and 2.56-fold enhancement, respectively. Also, a new

**66**

dietary consumption.

Probiotics are defined as live microorganisms which, when administered in adequate amounts, confer a health benefit on the host [50]. Evidence from the latest studies in which probiotic efficiency in metabolic disorder management is assessed by both in vitro and in animal or human subjects is compiled in **Tables 4** and **5**.

Regarding the strains employed in the management of several inflammatory diseases, they usually belong to the *Lactobacillus* and *Bifidobacterium* genera, although *Pediococcus pentosaceus* LP28, *Bacteroides uniformis* CECT 7771, and *Akkermansia muciniphila* have also been proved to have anti-obesity effects [65]. In general, doses



#### **Table 4.**

*Probiotic strains endorsed by in vitro and animal studies.*

greater than 108 CFU/day were orally administered to the drinking water or by oral gavage of the lyophilized bacterial powder in water (in animal studies) as well as in the form of capsules or fermented milk products (in human studies). Probiotic supplementation in rat and mouse studies usually applies to both diet-induced obese individuals and lean individuals fed on a high-fat diet, thus showing the effect of probiotics in both the treatment and the prevention of several metabolic abnormalities. However, human studies are basically applied to overweight or obese healthy individuals, submitted or not to energy restriction and/or regular exercise. As regards in vitro studies, treatment of 3T3-L1 pre-adipocytes with test substances during their differentiation stage is the most common technique.

**69**

**Table 5.**

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity…*

A randomized, double-blinded, placebo-controlled study in 50 female aged 19–65 with BMI > 25 kg/m2

A double-blind, placebocontrolled, randomized trial in 125 healthy overweight men and women (age between 18 and 55, BMI between 29 and 41 kg/m2

following a supervised diet and consuming two capsules per day or placebo for 24 weeks

A randomized, double-blind, placebo-controlled, paralleldesigned study in 40 subjects with metabolic syndrome following a hypocaloric diet supplemented with 50 g/day of probiotic or control cheese for 3 weeks

Multicenter, double-blind, placebo-controlled intervention trial in which 87 subjects (BMI of

were randomly assigned to consume 200 g/day of fermented milk with or without LG2055 for 12 weeks while maintaining their habitual mode of living

A placebo-controlled, doubleblind crossover clinical investigation with 28 healthy but overweight individuals (BMI between 25 and 32 kg/m2

visceral fat area of 81.2–178.5 cm2

and abdominal

)

)

24.2–30.7 kg/m2

**Probiotic organism Methodology Beneficial effect(s) Reference**

)

Probiotics increased HDL cholesterol level and effectively modified the composition of gut microbiota *Bifidobacterium breve* was the only strain showing a significant tendency of declination of endotoxin level, so it was suggested as a promising probiotic strain specified for obesity treatment

LPR supplementation accentuated body-weight loss in women submitted to energy restriction; this effect persisted in the subsequent maintenance phase, when energy restriction was not further imposed

The hypocaloric diet supplemented with the probiotic cheese reduced BMI, arterial blood pressure, and the risk of metabolic syndrome in obese patients with hypertension

Intake of the probiotic LG2055 reduced abdominal visceral and subcutaneous fat areas as well as body weight, BMI, waist and hip circumferences, and body fat mass

Probiotic consumption altered intestinal microflora in a manner that was associated with reduced total body adiposity, an important anthropometric indicator of obesity

[60]

[61]

[62]

[63]

[64]

 and waist circumference > 85 cm following usual dietary intake and lifestyle receiving Bofutsushosan (3 g per administration) and probiotics (1 capsule) or Bofutsushosan and placebo twice per day for 8 weeks

*DOI: http://dx.doi.org/10.5772/intechopen.85482*

DUOLAC 7 including *S. thermophilus* KCTC 11870BP, *L. plantarum* KCTC 10782BP, L. *acidophilus* KCTC 11906BP, *L. rhamnosus* KCTC 12202BP, *B. lactis* KCTC 11904BP *B. longum* KCTC 12200BP, and *B. breve* KCTC 12201BP

(5 × 1012 CFU/capsule)

*L. plantarum* TENSIA (DSM 21380) isolated from the gastrointestinal tract of healthy Estonian children added to cheese milk in amounts of 1.5 × 1011 CFU/g before

Milk fermented with or without *Lactobacillus gasseri* SBT2055 (LG2055)

renneting

*Lactobacillus amylovorus* and *Lactobacillus fermentum* microencapsulated in yogurt (1.39 × 109

yogurt)

CFU/

*Probiotic strains endorsed by in vivo studies.*

*L. rhamnosus* CGMCC1.3724 (LPR) in capsules (1.62 × 108 CFU/capsule) with a mix 70:30, v/v of oligofructose and inulin (300 mg/capsule)


#### **Table 5.**

*Nutraceuticals - Past, Present and Future*

*Lactobacillus fermentum* strain 4B1 isolated from fermented rice and shrimp compared to a commonly prescribed weight loss drug

Heat-killed and live *Lactobacillus reuteri* GMNL-263

Live or pasteurized *Akkermansia muciniphila*

*Bifidobacterium pseudocatenulatum* SPM 1204, *Bifidobacterium longum* SPM 1205, and *Bifidobacterium longum* SPM 1207

*Lactobacillus reuteri* ATCC PTA 4659, *Lactobacillus reuteri* DSM 17938, and *Lactobacillus reuteri*

L6798

**Table 4.**

*Pediococcus pentosaceus* LP28 isolated from longan fruit and *Lactobacillus plantarum* SN13T

**68**

greater than 108

CFU/day were orally administered to the drinking water or by oral

gavage of the lyophilized bacterial powder in water (in animal studies) as well as in the form of capsules or fermented milk products (in human studies). Probiotic supplementation in rat and mouse studies usually applies to both diet-induced obese individuals and lean individuals fed on a high-fat diet, thus showing the effect of probiotics in both the treatment and the prevention of several metabolic abnormalities. However, human studies are basically applied to overweight or obese healthy individuals, submitted or not to energy restriction and/or regular exercise. As regards in vitro studies, treatment of 3T3-L1 pre-adipocytes with test substances

CFU/g of a specific strain

**Probiotic organism Methodology Beneficial effect(s) Reference**

Prevented obesity in lean hosts and reduced body weight gain and adipose tissue weight in mice receiving the high-fat

Both heat-killed and live cells prevented obesity, insulin resistance, and hepatosteatosis in high-fat diet rats by suppressing the inflammatory response and the expressions of specific cytokines

Pasteurizationenhanced bacterium capacity to reduce fat mass development, insulin resistance, and dyslipidemia induced by a high-fat diet

Reduced body weight and fat gain, as well as total cholesterol, HDL-cholesterol, and LDL-cholesterol levels in serum blood and harmful enzyme activity

Strain ATCC prevented obesity, lowered blood insulin level, and affected liver steatosis in hypercholesterolemic mice on a high-fat diet

Live LP28 reduced body weight gain and liver lipid contents, whereas heat-killed and SN13T were ineffective

[54]

[55]

[56]

[57]

[58]

[59]

diet

35 obese induced mice. Daily dose: none, 12 mg/kg orlistat (Xenical®) or 2.5 × 1010 CFU/kg for 21 days

Rats fed for 12 weeks on a normal diet or a high-fat diet supplemented or not with 2 × 109

Obese and diabetic diet-induced

36 rats fed for 5 weeks on a normal diet or a high-fat diet supplemented or not with

CFU(1:1:1)/day

40 mice fed on a high-fat diet for 12 weeks supplemented or not with

CFU/day of a specific strain

5 lean control and 30 diet-induced obese mice fed for 6 weeks with a regular diet or a high-fat diet supplemented or not with

cells/day for 12 weeks

mice

108 –109

109

1.25 × 109

*Probiotic strains endorsed by in vitro and animal studies.*

during their differentiation stage is the most common technique.

*Probiotic strains endorsed by in vivo studies.*

Among the analytical determinations, the most representative are changes in the body weight and the body fat content as well as main serum biochemical parameters (glucose, insulin, leptin, lipids, lipoproteins, and inflammatory indicators). Postmortem determinations, such as the liver weight or the adipose tissue histology, are also common in animal studies. Finally, since probiotics are known to increase the bacterial diversity of intestinal microflora, in vivo studies usually include viable counts in fecal samples and evaluation of intestinal survival. In fact, a lot of recent research relates gut microbiota composition with almost every chronic disease: from gastrointestinal diseases to obesity, diabetes, cancer, and even neurological and neurodegenerative disorders such as depression, autism, anxiety, and Parkinson's disease [66]. Not only does a certain microbiota predispose to suffer certain diseases, but also the incidence of a certain disorder modifies the gut microbiota of an individual. In overweight/obese subjects, *Bacteroides*, *Parabacteroides*, *Ruminococcus*, *Campylobacter*, *Dialister*, *Porphyromonas*, *Staphylococcus*, and *Anaerostipes* are the dominant genera linked to a low diversity of species, while *Faecalibacterium*, *Bifidobacterium*, *Lactobacillus*, *Butyrivibrio*, *Alistipes*, *Akkermansia*, *Coprococcus*, and *Methanobrevibacter* are predominant in lean individuals with a high bacterial diversity [67]. Apparently, the intestinal microflora of obese subjects is more efficient at extracting energy from a given diet than that of lean individuals, thus leading to increased energy storage and adiposity [65]. Moreover, beneficial intestinal microflora is known to produce short-chain fatty acids (e.g., acetate, butyrate, and propionate) from indigestible polysaccharides, which may act as energy substrates as well as regulators of satiety and food intake. Last but not least, *Lactobacilli* and *Bifidobacteria* are known to synthesize bioactive isomers of conjugated linoleic acid with antidiabetic, anti-atherosclerotic, immunomodulatory, and anti-obesity properties [68]. In other words, low bacterial diversity in obese individuals is associated with a reduction in butyrate-producing bacteria, a reduction in hydrogen and methane production, an increase in mucus degradation, and an increase in the potential to manage oxidative stress. Since intestinal microflora composition is strongly affected by dietary patterns, studies evaluating the effect of certain food components on the growth of bacteria with beneficial effect on metabolic syndrome and obesity, particularly *Akkermansia muciniphila* and *Faecalibacterium prausnitzii*, are of great interest. Increasing the intestinal population of these two species has become a real opportunity to decrease alterations associated with obesity and metabolic disorders [69]. In addition to this, high-fat diet treatment has been proven to induce metabolic changes that impair gut barrier function in rats [55].

Together with increasing gut microbiota diversity, the production by fermentative action of those bioactive molecules involved in the metabolic pathways that trigger the metabolic syndrome has also taken a lot of interest in the last years. In particular, many studies focus on the phenolic compound bioconversion by food fermentation into other components with greater beneficial effect on the abnormalities associated with metabolic syndrome. As an example, Wang et al. [53] proved that the use of *Lactobacillus paracasei* subsp. *paracasei* strain NTU 101 in the fermentation of green tea and *Houttuynia cordata* leaves increased the levels of epigallocatechin gallate (EGCG), epigallocatechin (EGC), and chlorogenic acid, which enhanced the probiotic effect on body fat reduction. These results show the synergistic or complementary effect between the two bioactive compounds: the probiotic strain increases gut microbiota diversity and enhances intestinal absorption, while the EGCG acid promotes the lipolysis process. Zarrati et al. [70] also reported a synergistic effect between a weight loss diet and probiotic yogurt in overweight and obese individuals.

It should be noted that in order to exert their health benefits, probiotics do not necessarily have to be alive. In fact, heat-killed *Lactobacillus reuteri* GMNL 263 was as effective as live *Lactobacillus reuteri* GMNL 263 in attenuating obesity-induced

**71**

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity…*

metabolic abnormalities in high-fat diet-induced rats by reducing insulin resistance and hepatic steatosis formation [55]. Also both heat-killed *Lactobacillus plantarum* strain Ln4 and freeze-dried cultured MRS broth significantly reduced lipid accumulation and stimulated glucose uptake in 3T3-L1 adipocytes [51]. Finally, Plovier et al. [56] found that pasteurization enhanced the capacity of *Akkermansia muciniphila* to reduce fat mass development, insulin resistance, and dyslipidemia in mice. It seems that a specific protein isolated from the outer membrane of *Akkermansia muciniphila* is stable at temperatures used for pasteurization and improves the gut barrier, thus being the main responsible factor of the beneficial

Of all the studies analyzed, it is concluded that many microorganisms have the potential for development as therapeutic probiotics for obesity and associated disorders. However, due to the strain specificity of probiotic microbes in exerting their beneficial effects, bacterial strains of the same species have different effects on

The lulo fruit (*Solanum quitoense* Lam.), also known as "naranjilla," is an impor-

**3. Case study: functional food development from lulo fruit with** 

tant native Andean crop. Grown and consumed mainly in Colombia, Ecuador, and Central America, the plant produces a spherical, 3–8-cm-diameter fruit with orange skin (epicarp) covered by short, stiff, and thorny hairs or spines. The internal structure of the fruit is similar to that of the tomato fruit: a very juicy, acidic, and translucent yellow-green pulp (mesocarp and endocarp) that is located in four compartments separated by membranous partitions [71]. In Colombia, lulo is an economically important crop which, in 2015, was grown in a total area of 10,623 ha, with a total yield of 82,354 tons and an average yield of 9.6 tons/ha [72]. Although the principal market of this crop is in the producing countries themselves, it has gained interest in recent years in national and international markets due to its organoleptic properties and its nutritional value. In fact, lulo has an intense and refreshing taste and is rich in proteins, vitamin C, fiber, and antioxidant compounds, such as alltrans-β-carotene, lutein and zeaxanthin, chlorogenic acids, and flavonol glycosides [73–76], in addition to iron, calcium, phosphorus, and some precursors of vitamin A [77] (**Table 6** [78]). In particular, fruit carotenoids present in lulo fruit have been associated to the prevention of several illnesses, including hypertension, obesity, and cardiovascular diseases [79–81]. Also the potential of lulo as an antihypertensive agent is related to its content in N1,N4,N8-tris (dihydrocaffeoyl) spermidine and N1,N8-bis (dihydrocaffeoyl) spermidine (actually bioactive amines), which are bitter active compounds with inhibitory activity against the angiotensin-converting enzyme (ACE-1) that indirectly increases the blood pressure by causing blood vessels to constrict [35]. In turn, when evaluating the antihypertensive activity of some compounds of the lulo fruit by means of chemical computation techniques, the researchers of the Natural Additives of Aroma and Color group from the Chemistry Department of the Universidad Nacional de Colombia found that this was between 10 and 20 times higher than that of the drugs traditionally used to treat hypertension. Based on the considerations made above, the lulo fruit comes to be a promising alternative with regard to the prevention and relief of hypertension-related diseases. However, being a highly perishable fruit, technological transformation processes are indispensable to take advantage of its beneficial properties by as many consumers as possible. According to this, the group of Functional Foods of the University Institute of Food Engineering for Development of the Polytechnic

**potential effect against metabolic syndrome**

*DOI: http://dx.doi.org/10.5772/intechopen.85482*

effect of the bacteria on health.

adiposity and insulin sensitivity.

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity… DOI: http://dx.doi.org/10.5772/intechopen.85482*

metabolic abnormalities in high-fat diet-induced rats by reducing insulin resistance and hepatic steatosis formation [55]. Also both heat-killed *Lactobacillus plantarum* strain Ln4 and freeze-dried cultured MRS broth significantly reduced lipid accumulation and stimulated glucose uptake in 3T3-L1 adipocytes [51]. Finally, Plovier et al. [56] found that pasteurization enhanced the capacity of *Akkermansia muciniphila* to reduce fat mass development, insulin resistance, and dyslipidemia in mice. It seems that a specific protein isolated from the outer membrane of *Akkermansia muciniphila* is stable at temperatures used for pasteurization and improves the gut barrier, thus being the main responsible factor of the beneficial effect of the bacteria on health.

Of all the studies analyzed, it is concluded that many microorganisms have the potential for development as therapeutic probiotics for obesity and associated disorders. However, due to the strain specificity of probiotic microbes in exerting their beneficial effects, bacterial strains of the same species have different effects on adiposity and insulin sensitivity.

## **3. Case study: functional food development from lulo fruit with potential effect against metabolic syndrome**

The lulo fruit (*Solanum quitoense* Lam.), also known as "naranjilla," is an important native Andean crop. Grown and consumed mainly in Colombia, Ecuador, and Central America, the plant produces a spherical, 3–8-cm-diameter fruit with orange skin (epicarp) covered by short, stiff, and thorny hairs or spines. The internal structure of the fruit is similar to that of the tomato fruit: a very juicy, acidic, and translucent yellow-green pulp (mesocarp and endocarp) that is located in four compartments separated by membranous partitions [71]. In Colombia, lulo is an economically important crop which, in 2015, was grown in a total area of 10,623 ha, with a total yield of 82,354 tons and an average yield of 9.6 tons/ha [72]. Although the principal market of this crop is in the producing countries themselves, it has gained interest in recent years in national and international markets due to its organoleptic properties and its nutritional value. In fact, lulo has an intense and refreshing taste and is rich in proteins, vitamin C, fiber, and antioxidant compounds, such as alltrans-β-carotene, lutein and zeaxanthin, chlorogenic acids, and flavonol glycosides [73–76], in addition to iron, calcium, phosphorus, and some precursors of vitamin A [77] (**Table 6** [78]). In particular, fruit carotenoids present in lulo fruit have been associated to the prevention of several illnesses, including hypertension, obesity, and cardiovascular diseases [79–81]. Also the potential of lulo as an antihypertensive agent is related to its content in N1,N4,N8-tris (dihydrocaffeoyl) spermidine and N1,N8-bis (dihydrocaffeoyl) spermidine (actually bioactive amines), which are bitter active compounds with inhibitory activity against the angiotensin-converting enzyme (ACE-1) that indirectly increases the blood pressure by causing blood vessels to constrict [35]. In turn, when evaluating the antihypertensive activity of some compounds of the lulo fruit by means of chemical computation techniques, the researchers of the Natural Additives of Aroma and Color group from the Chemistry Department of the Universidad Nacional de Colombia found that this was between 10 and 20 times higher than that of the drugs traditionally used to treat hypertension.

Based on the considerations made above, the lulo fruit comes to be a promising alternative with regard to the prevention and relief of hypertension-related diseases. However, being a highly perishable fruit, technological transformation processes are indispensable to take advantage of its beneficial properties by as many consumers as possible. According to this, the group of Functional Foods of the University Institute of Food Engineering for Development of the Polytechnic

*Nutraceuticals - Past, Present and Future*

Among the analytical determinations, the most representative are changes in the

body weight and the body fat content as well as main serum biochemical parameters (glucose, insulin, leptin, lipids, lipoproteins, and inflammatory indicators). Postmortem determinations, such as the liver weight or the adipose tissue histology, are also common in animal studies. Finally, since probiotics are known to increase the bacterial diversity of intestinal microflora, in vivo studies usually include viable counts in fecal samples and evaluation of intestinal survival. In fact, a lot of recent research relates gut microbiota composition with almost every chronic disease: from gastrointestinal diseases to obesity, diabetes, cancer, and even neurological and neurodegenerative disorders such as depression, autism, anxiety, and Parkinson's disease [66]. Not only does a certain microbiota predispose to suffer certain diseases, but also the incidence of a certain disorder modifies the gut microbiota of an individual. In overweight/obese subjects, *Bacteroides*, *Parabacteroides*, *Ruminococcus*, *Campylobacter*, *Dialister*, *Porphyromonas*, *Staphylococcus*, and *Anaerostipes* are the dominant genera linked to a low diversity of species, while *Faecalibacterium*, *Bifidobacterium*, *Lactobacillus*, *Butyrivibrio*, *Alistipes*, *Akkermansia*, *Coprococcus*, and *Methanobrevibacter* are predominant in lean individuals with a high bacterial diversity [67]. Apparently, the intestinal microflora of obese subjects is more efficient at extracting energy from a given diet than that of lean individuals, thus leading to increased energy storage and adiposity [65]. Moreover, beneficial intestinal microflora is known to produce short-chain fatty acids (e.g., acetate, butyrate, and propionate) from indigestible polysaccharides, which may act as energy substrates as well as regulators of satiety and food intake. Last but not least, *Lactobacilli* and *Bifidobacteria* are known to synthesize bioactive isomers of conjugated linoleic acid with antidiabetic, anti-atherosclerotic, immunomodulatory, and anti-obesity properties [68]. In other words, low bacterial diversity in obese individuals is associated with a reduction in butyrate-producing bacteria, a reduction in hydrogen and methane production, an increase in mucus degradation, and an increase in the potential to manage oxidative stress. Since intestinal microflora composition is strongly affected by dietary patterns, studies evaluating the effect of certain food components on the growth of bacteria with beneficial effect on metabolic syndrome and obesity, particularly *Akkermansia muciniphila* and *Faecalibacterium prausnitzii*, are of great interest. Increasing the intestinal population of these two species has become a real opportunity to decrease alterations associated with obesity and metabolic disorders [69]. In addition to this, high-fat diet treatment has been proven to

induce metabolic changes that impair gut barrier function in rats [55].

Together with increasing gut microbiota diversity, the production by fermentative action of those bioactive molecules involved in the metabolic pathways that trigger the metabolic syndrome has also taken a lot of interest in the last years. In particular, many studies focus on the phenolic compound bioconversion by food fermentation into other components with greater beneficial effect on the abnormalities associated with metabolic syndrome. As an example, Wang et al. [53] proved that the use of *Lactobacillus paracasei* subsp. *paracasei* strain NTU 101 in the fermentation of green tea and *Houttuynia cordata* leaves increased the levels of epigallocatechin gallate (EGCG), epigallocatechin (EGC), and chlorogenic acid, which enhanced the probiotic effect on body fat reduction. These results show the synergistic or complementary effect between the two bioactive compounds: the probiotic strain increases gut microbiota diversity and enhances intestinal absorption, while the EGCG acid promotes the lipolysis process. Zarrati et al. [70] also reported a synergistic effect between a weight loss diet and probiotic yogurt in overweight and obese individuals. It should be noted that in order to exert their health benefits, probiotics do not necessarily have to be alive. In fact, heat-killed *Lactobacillus reuteri* GMNL 263 was as effective as live *Lactobacillus reuteri* GMNL 263 in attenuating obesity-induced

**70**


#### **Table 6.**

*Nutrition facts of lulo fruit.*

University of Valencia (Spain), in conjunction with the group of Biodiversity Evaluation and Use of the Technological University of Chocó (Colombia), is working on the development of new functional foods from lulo fruit (*Solanum quitoense* Lam). On the one hand, a stable lulo juice with improved antioxidant properties has been obtained by means of the application of moderate high homogenization pressures (from 50 to 150 MPa) instead of traditional thermal pasteurization. The same juice has proved to be a suitable impregnation liquid for the enrichment of other fruits with a porous structure, such as Granny Smith apples. The lulo fruit itself was found to have a high impregnation capacity, which implies susceptibility to be enriched with different bioactive compounds. Finally, after fermentation with *Lactobacillus reuteri*, selected for being one of the strains with proven effect against the metabolic syndrome, the number of viable counts in lulo juice resulted to be high enough to claim that it also may exert a probiotic effect. Most relevant results in relation to these advances are shown next.

### **3.1 Enhancing antioxidant properties of lulo juice by means of moderate high-pressure homogenization**

This section shows the effect that homogenization pressures in the range of 50–150 MPa have on main physicochemical properties, including the total content of phenols and flavonoids and the antioxidant activity measured by both DPPH and ABTS methods. To obtain the juice, washed and without peduncle lulo fruits were crushed for 10 min in a blender (Phillips Avance Collection Standmixer, 800W 2L). The liquefied product was then filtered with a stainless steel sieve of 500 μm nominal aperture. When necessary, the juice was homogenized at 50, 100 or 150 MPa in a laboratory scale high-pressure homogenizer (Panda Plus 2000, GEA-Niro Soavi, Parma, Italy).

**73**

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity…*

**Brix pH ρ (g/cm3**

*abc… different superscripts in the same column indicate statistically significant differences (p < 0.05).*

0 MPa 6.57 ± 0.12a 3.13 ± 0.02a 1.04 ± 0.02a 0.39 ± 0.12a 0.44 ± 0.06b 50 MPa 6.4 ± 0.4a 3.12 ± 0.02a 1.06 ± 0.04a 0.9 ± 0.4b 0.37 ± 0.04a 100 MPa 6.33 ± 0.15a 3.18 ± 0.03a 1.07 ± 0.02a 0.79 ± 0.02ab 0.37 ± 0.03a 150 MPa 6.4 ± 0.4a 3.15 ± 0.02a 1.09 ± 0.02a 1.3 ± 0.5b 0.34 ± 0.04a

**) K (Pa sn) n**

As it can be observed in **Table 7**, neither the soluble solid content nor the pH or the density of the lulo juices was significantly affected by homogenization pressure. On the contrary, the consistency index (K) increased significantly after the homogenization step, which is directly related to particle size reduction. As regards the average size of particles, it was maximum in the non-homogenized juice (251 ± 5 μm) and minimum in the juice homogenized at 150 MPa (57.94 ± 0.14 μm). Therefore, homogenization increased the amount of solids in suspension and,

*Effect of homogenization pressure on pH, soluble solid content (brix), apparent density (ρ), and rheological* 

As regards the antioxidant properties of lulo juice, the fruit's own transformation into juice significantly reduced both total phenol and total flavonoid contents, which were probably separated from the juice together with the bagasse during the filtration step. However, the concentration of such compounds increased slightly (from 1.03 ± 0.16 to 1.28 ± 0.07 mg GAE/g for phenols and from 0.35 ± 0.24 to 0.570 ± 0.011 mg QE/g for flavonoids) after juice homogenization at 150 MPa and the subsequent reduction in the average particle size. Similar trends were observed when analyzing the total antioxidant activity by both the ABTS and the DPPH methods and when quantifying spermidine by HPLC analysis. For the latter compound, concentration increased from 1.86 ppm in non-homogenized lulo juice

Regarding the ability of the homogenized lulo juice treated at 150 MPa to impregnate Granny Smith apples sliced, it was found to be similar to that of an isotonic sucrose solution. In this way, the bioactive compounds present in lulo juice may become part of the vacuum impregnated fruit composition. To be more pre-

**3.2 Lulo fruit as a food matrix for vacuum impregnation and food property** 

In this section, impregnation properties of lulo fruit are discussed. Vacuum impregnation being a matrix engineering technique allows to introduce desirable compounds into the porous structure of foods by applying a pressure gradient [14]. Among the impregnation parameters, the volume of the external liquid that can be

out, which informs about the feasibility of incorporating physiologically active compounds into its porous structure for the formulation of new products with enhanced functional properties. Hence, unpeeled lulo fruit was cut into 5 mm thick slices and immersed in an isotonic sucrose solution (aw = 0.994 ± 0.003). Vacuum impregnation was carried out in a pilot plant scale equipment located at the University Institute of Food Engineering for Development of the Universitat Politècnica de

incorporated into the cellular tissue in a controlled way (i.e., X, in m3

of lulo juice homogenized at 150 MPa could be incorporated to

/m3

) stands

*DOI: http://dx.doi.org/10.5772/intechopen.85482*

**Homogenization pressure**

**Table 7.**

*properties of lulo juice.*

consequently, the stability of the cloud.

to 2.04 ppm in lulo juice homogenized at 150 MPa.

cise, around 0.22 m3

**improvement**

of fresh apple.

every m3

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity… DOI: http://dx.doi.org/10.5772/intechopen.85482*


#### **Table 7.**

*Nutraceuticals - Past, Present and Future*

*Values expressed for 100 g of fresh fruit.*

*Nutrition facts of lulo fruit.*

**Table 6.**

University of Valencia (Spain), in conjunction with the group of Biodiversity Evaluation and Use of the Technological University of Chocó (Colombia), is working on the development of new functional foods from lulo fruit (*Solanum quitoense* Lam). On the one hand, a stable lulo juice with improved antioxidant properties has been obtained by means of the application of moderate high homogenization pressures (from 50 to 150 MPa) instead of traditional thermal pasteurization. The same juice has proved to be a suitable impregnation liquid for the enrichment of other fruits with a porous structure, such as Granny Smith apples. The lulo fruit itself was found to have a high impregnation capacity, which implies susceptibility to be enriched with different bioactive compounds. Finally, after fermentation with *Lactobacillus reuteri*, selected for being one of the strains with proven effect against the metabolic syndrome, the number of viable counts in lulo juice resulted to be high enough to claim that it also may exert a probiotic effect. Most relevant results

**Proximates Minerals Vitamins**

Carb 5.9 g Ca 8 mg Folate 3 μg Fiber 1.1 g Mg 11 mg Vit B3 1.45 mg Protein 0.44 g P 12 mg Vit B5 0.22 mg Sugars 3.74 g K 200 mg Vit B1 0.05 mg Fat 0.22 g Na 4 mg Vit B6 0.11 mg Water 93.05 g Cu 0.03 mg Vit C 3.2 mg Energy 25 cal Fe 0.35 mg α-Carotene 4 μm

> Mn 0.07 mg β-Carotene 333 μm Se 0.4 μg β-Cryptoxanthin 10 μm Zn 0.1 mg Lutein and zeaxanthin 299 μm

> > γ-Tocopherol 0.2 mg α-Tocotrienol 0.01 mg γ-Tocotrienol 0.01 mg Vit A 28 μm Vit E 0.75 mg Vit K 14.6 μ

**3.1 Enhancing antioxidant properties of lulo juice by means of moderate** 

This section shows the effect that homogenization pressures in the range of 50–150 MPa have on main physicochemical properties, including the total content of phenols and flavonoids and the antioxidant activity measured by both DPPH and ABTS methods. To obtain the juice, washed and without peduncle lulo fruits were crushed for 10 min in a blender (Phillips Avance Collection Standmixer, 800W 2L). The liquefied product was then filtered with a stainless steel sieve of 500 μm nominal aperture. When necessary, the juice was homogenized at 50, 100 or 150 MPa in a laboratory scale high-pressure homogenizer (Panda Plus 2000, GEA-Niro Soavi,

in relation to these advances are shown next.

**high-pressure homogenization**

**72**

Parma, Italy).

*Effect of homogenization pressure on pH, soluble solid content (brix), apparent density (ρ), and rheological properties of lulo juice.*

As it can be observed in **Table 7**, neither the soluble solid content nor the pH or the density of the lulo juices was significantly affected by homogenization pressure. On the contrary, the consistency index (K) increased significantly after the homogenization step, which is directly related to particle size reduction. As regards the average size of particles, it was maximum in the non-homogenized juice (251 ± 5 μm) and minimum in the juice homogenized at 150 MPa (57.94 ± 0.14 μm). Therefore, homogenization increased the amount of solids in suspension and, consequently, the stability of the cloud.

As regards the antioxidant properties of lulo juice, the fruit's own transformation into juice significantly reduced both total phenol and total flavonoid contents, which were probably separated from the juice together with the bagasse during the filtration step. However, the concentration of such compounds increased slightly (from 1.03 ± 0.16 to 1.28 ± 0.07 mg GAE/g for phenols and from 0.35 ± 0.24 to 0.570 ± 0.011 mg QE/g for flavonoids) after juice homogenization at 150 MPa and the subsequent reduction in the average particle size. Similar trends were observed when analyzing the total antioxidant activity by both the ABTS and the DPPH methods and when quantifying spermidine by HPLC analysis. For the latter compound, concentration increased from 1.86 ppm in non-homogenized lulo juice to 2.04 ppm in lulo juice homogenized at 150 MPa.

Regarding the ability of the homogenized lulo juice treated at 150 MPa to impregnate Granny Smith apples sliced, it was found to be similar to that of an isotonic sucrose solution. In this way, the bioactive compounds present in lulo juice may become part of the vacuum impregnated fruit composition. To be more precise, around 0.22 m3 of lulo juice homogenized at 150 MPa could be incorporated to every m3 of fresh apple.

### **3.2 Lulo fruit as a food matrix for vacuum impregnation and food property improvement**

In this section, impregnation properties of lulo fruit are discussed. Vacuum impregnation being a matrix engineering technique allows to introduce desirable compounds into the porous structure of foods by applying a pressure gradient [14]. Among the impregnation parameters, the volume of the external liquid that can be incorporated into the cellular tissue in a controlled way (i.e., X, in m3 /m3 ) stands out, which informs about the feasibility of incorporating physiologically active compounds into its porous structure for the formulation of new products with enhanced functional properties. Hence, unpeeled lulo fruit was cut into 5 mm thick slices and immersed in an isotonic sucrose solution (aw = 0.994 ± 0.003). Vacuum impregnation was carried out in a pilot plant scale equipment located at the University Institute of Food Engineering for Development of the Universitat Politècnica de

València (Spain). This equipment consists of a stainless steel vacuum chamber connected to a liquid ring pump (SIHI model LOHE-25007). The vessel containing the impregnating solution was placed into the vacuum chamber, and the lulo samples were immersed in the liquid by means of a pneumatic arm operated by a compressor (COMBA, 1,5 HP de 25 L). The working conditions were set at 50 mbar for 10 min and atmospheric pressure for 10 min more. In each trial, the weight change of the samples was recorded according to the procedure described by [82], thus allowing to calculate the characteristic impregnation parameters of the lulo fruit.

As it is shown in **Table 8**, the different batches analyzed behaved in a similar way during the vacuum impregnation step. Positive values of parameters X1 (between 1 and 5%) and X (between 8.6 and 16%) indicate that the impregnating liquid entered the porous structure after both the vacuum and the atmospheric steps. Likewise, positive values of parameters γ1 (between 3.9 and 7.1%) and γ (between 2.9 and 6.6%) indicate a volumetric expansion of the lulo matrix after both the vacuum and the atmospheric steps. Compared to other fruits and vegetables [83], the volume fraction of fresh lulo that was filled with the impregnating solution at the end of the process (X, in m3 /100 m3 ) was significantly lower than that of Granny Smith apple (21.0 ± 0.9) or Soraya aubergine (64 ± 2) but considerably higher than that of Chandler strawberry (6.4 ± 0.3), Hayward kiwifruit (0.7 ± 0.5), or Bulida apricot (2.2 ± 0.2). Despite such differences, the lulo matrix can be considered as suitable to be enriched with other active compounds by means of the vacuum impregnation technique.

## **3.3 Probiotic food development from lulo fruit**

The growing number of consumers with lactose intolerance, high cholesterol levels, and/or following vegetarian or vegan diets has encouraged the recent use of fruits and vegetables as probiotic carriers in the development of new functional foods. Fruit and vegetable juices are especially suitable for the growing of probiotic microorganisms since they inherently contain beneficial nutrients and have taste profiles that are pleasing to all the age groups [84]. In addition, due to their fast passage through the digestive tract, the viability of probiotic cells in the juices is hardly affected by the harsh acidic environment of stomach [85]. However, these food matrices do not always fulfill the pH or the essential amino acids and vitamins required for the optimum growth of most LAB with proven probiotic effect. This section evaluates the possibility of using the non-homogenized lulo juice as a medium for the growth of *Lactobacillus reuteri* CECT 925T. For this purpose, the lulo juice obtained by the procedure described above was pasteurized at 75°C for


*abc… different superscripts in the same column indicate statistically significant differences (p* ≤ *0.05).*

*X1 and X stand for the volume fraction of fresh sample impregnated at the end of the vacuum step and at the end of the atmospheric step, respectively; γ1 and γ stand for the relative volume deformation of fresh sample at the end of the vacuum step and at the end of the atmospheric step, respectively; εe stands for the effective porosity.*

**75**

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity…*

at 37°C, viable counts in the juice were of the order of 106

2.5 min before being inoculated with 4 mL/L of MRS broth containing the active

value was high enough to make an EU-based health claim [86], it was significantly lower to that obtained in mandarin juice inoculated with either *Lactobacillus salivarius* spp. *salivarius* CECT 4063 or *Lactobacillus acidophilus* CECT 903 [87].

nating liquid for the vacuum impregnation of Granny Smith apple slices (5 mm thick). In this way, the probiotic was introduced into a solid matrix without disturbing its organized cellular structure. However, since only 20% of the initial volume of the apple is filled with the impregnation liquid during the vacuum impregnation step, the probiotic content in the impregnated apple was not greater than 105

Subsequent lyophilisation of the vacuum impregnated apples did not increase the *Lactobacillus reuteri* content as expected by water removal and subsequent weight

both the lulo juice and the impregnated apple snack could be improved by adding certain ingredients (e.g., prebiotics, cryprotectants, soygerm powder, yeast extract, etc.) and/or applying specific processing technologies that can improve microorganism survival such as microencapsulation or sublethal homogenization. In any case, it should be interesting to evaluate through both in vivo and in vitro studies the antihypertensive activity of *Lactobacillus reuteri* in the products designed*,* since it could be enhanced due to a synergistic effect with the spermidine from the lulo juice.

Revolution in living standard, eating habits, and increased health awareness has shifted consumer's acceptance toward nutritious, healthy, and disease-preventive food with wider health benefits. Consumer is becoming more and more conscious about the role of food in life extension, well-being, and prevention of chronic diseases [87]. Specific consumer characteristics, such as demographic background or personal motivation to participate in pro-health activities, play a remarkable role in functional food acceptance and consumption. Some sociodemographic characteristics such as gender, education, and age are the most important factors related to the acceptance of functional food. In addition, apart from health benefits, the carrier and the origin of functional components play an important role in making the decision to purchase functional products, consumers being more likely to purchase those functional components found naturally in foods. Other factors, such as organoleptic attributes, convenience, or label information, are found to be essential for consumer's acceptance. In his study, Kraus [88] concludes that consumers are not willing to sacrifice taste and general pleasure of eating and also states that

Particularly for probiotics, a major challenge for these products is product acceptability by consumers with regard to sensory criteria. Traditionally, health benefits of probiotics were based in the consumption of fermented dairy products; however, lactose intolerance, cholesterol content, and allergic milk proteins have limited the growth of dairy probiotics. Besides, the increase in vegetarian consumers in both developed and developing countries has also contributed to a growing demand for plant-based probiotic products [87]. According to Panghal et al. [89], fruits are healthy and refreshing and have good taste and flavor profile and can be suitable for probiotics. They are an ideal medium to develop functional foods and have more nutritional values due to the presence of various phytochemicals, antioxidants, no cholesterol, vitamins, mineral content, and dietary fibers. Besides,

**4. Market and consumer trends toward functional foods**

naturalness of a product is very important.

In a further step, the lulo juice containing the probiotic was employed as impreg-

CFU/mL. After 24 hours of incubation

CFU/g in the liophylized sample. Probiotic counts in

CFU/mL. Although this

CFU/g.

*DOI: http://dx.doi.org/10.5772/intechopen.85482*

microorganism in a concentration of 108

loss, it being lower than 106

#### **Table 8.**

*Vacuum impregnation response of lulo fruit slices (5 mm thick).*

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity… DOI: http://dx.doi.org/10.5772/intechopen.85482*

2.5 min before being inoculated with 4 mL/L of MRS broth containing the active microorganism in a concentration of 108 CFU/mL. After 24 hours of incubation at 37°C, viable counts in the juice were of the order of 106 CFU/mL. Although this value was high enough to make an EU-based health claim [86], it was significantly lower to that obtained in mandarin juice inoculated with either *Lactobacillus salivarius* spp. *salivarius* CECT 4063 or *Lactobacillus acidophilus* CECT 903 [87].

In a further step, the lulo juice containing the probiotic was employed as impregnating liquid for the vacuum impregnation of Granny Smith apple slices (5 mm thick). In this way, the probiotic was introduced into a solid matrix without disturbing its organized cellular structure. However, since only 20% of the initial volume of the apple is filled with the impregnation liquid during the vacuum impregnation step, the probiotic content in the impregnated apple was not greater than 105 CFU/g. Subsequent lyophilisation of the vacuum impregnated apples did not increase the *Lactobacillus reuteri* content as expected by water removal and subsequent weight loss, it being lower than 106 CFU/g in the liophylized sample. Probiotic counts in both the lulo juice and the impregnated apple snack could be improved by adding certain ingredients (e.g., prebiotics, cryprotectants, soygerm powder, yeast extract, etc.) and/or applying specific processing technologies that can improve microorganism survival such as microencapsulation or sublethal homogenization. In any case, it should be interesting to evaluate through both in vivo and in vitro studies the antihypertensive activity of *Lactobacillus reuteri* in the products designed*,* since it could be enhanced due to a synergistic effect with the spermidine from the lulo juice.

## **4. Market and consumer trends toward functional foods**

Revolution in living standard, eating habits, and increased health awareness has shifted consumer's acceptance toward nutritious, healthy, and disease-preventive food with wider health benefits. Consumer is becoming more and more conscious about the role of food in life extension, well-being, and prevention of chronic diseases [87].

Specific consumer characteristics, such as demographic background or personal motivation to participate in pro-health activities, play a remarkable role in functional food acceptance and consumption. Some sociodemographic characteristics such as gender, education, and age are the most important factors related to the acceptance of functional food. In addition, apart from health benefits, the carrier and the origin of functional components play an important role in making the decision to purchase functional products, consumers being more likely to purchase those functional components found naturally in foods. Other factors, such as organoleptic attributes, convenience, or label information, are found to be essential for consumer's acceptance. In his study, Kraus [88] concludes that consumers are not willing to sacrifice taste and general pleasure of eating and also states that naturalness of a product is very important.

Particularly for probiotics, a major challenge for these products is product acceptability by consumers with regard to sensory criteria. Traditionally, health benefits of probiotics were based in the consumption of fermented dairy products; however, lactose intolerance, cholesterol content, and allergic milk proteins have limited the growth of dairy probiotics. Besides, the increase in vegetarian consumers in both developed and developing countries has also contributed to a growing demand for plant-based probiotic products [87]. According to Panghal et al. [89], fruits are healthy and refreshing and have good taste and flavor profile and can be suitable for probiotics. They are an ideal medium to develop functional foods and have more nutritional values due to the presence of various phytochemicals, antioxidants, no cholesterol, vitamins, mineral content, and dietary fibers. Besides,

*Nutraceuticals - Past, Present and Future*

at the end of the process (X, in m3

vacuum impregnation technique.

**3.3 Probiotic food development from lulo fruit**

València (Spain). This equipment consists of a stainless steel vacuum chamber connected to a liquid ring pump (SIHI model LOHE-25007). The vessel containing the impregnating solution was placed into the vacuum chamber, and the lulo samples were immersed in the liquid by means of a pneumatic arm operated by a compressor (COMBA, 1,5 HP de 25 L). The working conditions were set at 50 mbar for 10 min and atmospheric pressure for 10 min more. In each trial, the weight change of the samples was recorded according to the procedure described by [82], thus allowing

As it is shown in **Table 8**, the different batches analyzed behaved in a similar way during the vacuum impregnation step. Positive values of parameters X1 (between 1 and 5%) and X (between 8.6 and 16%) indicate that the impregnating liquid entered the porous structure after both the vacuum and the atmospheric steps. Likewise, positive values of parameters γ1 (between 3.9 and 7.1%) and γ (between 2.9 and 6.6%) indicate a volumetric expansion of the lulo matrix after both the vacuum and the atmospheric steps. Compared to other fruits and vegetables [83], the volume fraction of fresh lulo that was filled with the impregnating solution

) was significantly lower than that of

to calculate the characteristic impregnation parameters of the lulo fruit.

/100 m3

Granny Smith apple (21.0 ± 0.9) or Soraya aubergine (64 ± 2) but considerably higher than that of Chandler strawberry (6.4 ± 0.3), Hayward kiwifruit (0.7 ± 0.5), or Bulida apricot (2.2 ± 0.2). Despite such differences, the lulo matrix can be considered as suitable to be enriched with other active compounds by means of the

The growing number of consumers with lactose intolerance, high cholesterol levels, and/or following vegetarian or vegan diets has encouraged the recent use of fruits and vegetables as probiotic carriers in the development of new functional foods. Fruit and vegetable juices are especially suitable for the growing of probiotic microorganisms since they inherently contain beneficial nutrients and have taste profiles that are pleasing to all the age groups [84]. In addition, due to their fast passage through the digestive tract, the viability of probiotic cells in the juices is hardly affected by the harsh acidic environment of stomach [85]. However, these food matrices do not always fulfill the pH or the essential amino acids and vitamins required for the optimum growth of most LAB with proven probiotic effect. This section evaluates the possibility of using the non-homogenized lulo juice as a medium for the growth of *Lactobacillus reuteri* CECT 925T. For this purpose, the lulo juice obtained by the procedure described above was pasteurized at 75°C for

**Batch X1 γ<sup>1</sup> X γ ε<sup>e</sup>** 5 ± 7a 5 ± 4a 8.8 ± 1.6a 3 ± 3a 6 ± 4a 2.1 ± 1.8a 6 ± 5a 10 ± 3a 5 ± 4a 6 ± 5a 2 ± 4a 5 ± 2a 11 ± 2ab 3.7 ± 0.9a 8 ± 2a 1 ± 1.4a 3.9 ± 0.9a 16 ± 6b 6.6 ± 1.0a 9 ± 6a 2.5 ± 1.3a 7.1 ± 1.0a 8.6 ± 0.9a 2.9 ± 0.8a 6.3 ± 1.2a

*X1 and X stand for the volume fraction of fresh sample impregnated at the end of the vacuum step and at the end of the atmospheric step, respectively; γ1 and γ stand for the relative volume deformation of fresh sample at the end of the* 

*abc… different superscripts in the same column indicate statistically significant differences (p* ≤ *0.05).*

*vacuum step and at the end of the atmospheric step, respectively; εe stands for the effective porosity.*

*Vacuum impregnation response of lulo fruit slices (5 mm thick).*

**74**

**Table 8.**

economic reasons for the developing countries also require the search for an alternative to dairy products with good nutrients along with health-promoting factors, e.g., fruits, vegetables, cereal, legume, etc., and products which lack cholesterol content but are rich in protein, starches, minerals, fiber, vitamins, and antioxidants.

Nowadays an increasing trend in the Western society is consumer interest and focus toward natural and organic products, where the use of synthetic additives is limited. It has been suggested that natural ingredients with strong antioxidant activity could be used to design novel functional beverages. An increased interest relies upon the fortification with polyphenols due to their beneficial role against cardiovascular diseases, type 2 diabetes, and obesity, among other conditions. The combination of prebiotics, and also phenols with probiotic microorganisms, represents an innovative biotechnology to enlarge the functional food market and especially beverages [90].

According to Grand View Research [91], the global functional food market was higher than 129 billion dollars (US) in 2015, and it is expected to increase up to 250 billion in 2024. Growing consciousness among consumers on their health and proper diet, together with the prospect of reducing or even eliminating nutrition-related diseases, is responsible of this market trend. Society is becoming more and more conscious on the impact that changing dietary patterns may have in the incidence of type 2 diabetes, coronary heart disease, cancer, periodontal disease, and obesity. In this regard, functional foods are believed to play an outstanding role. In addition, increasing healthcare cost, along with the desire of improving later years among the geriatric population, has driven the growth of the functional food industry worldwide.

The global functional food market includes that of carotenoids, dietary fibers, fatty acids, minerals, prebiotics and probiotics, vitamins, minerals, phytochemicals, enzymes, and antioxidants in general. Market revenue of all these products separately is also expected to increase in the coming years. For example, dietary fibers, which are considered to prevent obesity and diabetes, are expected to grow by 8.4% in the next 8 years. Other phytochemicals, such as flavonoids, held a share of over 30% in terms of market value. Although these have been commonly consumed in their natural form, consumer's habits have led to their use in the form of functional food products which are aimed at preventing diet-related chronic diseases including those related to the metabolic syndrome. North America accounts for the largest market in flavonoids, the Asia Pacific demand was over 110 million US Dollars in 2015, and Europe is expected to grow, although at a slower pace. In any case, prevalence of diabetes, obesity, and chronic diseases is likely to propel demand for these nutritional foods and beverages in Europe.

With regard to probiotics, there is also a growing concern on awareness in their functional health benefits against different conditions, including those related to the metabolic syndrome such as obesity or type 2 diabetes [92]. The global probiotic market was thought to be worth 35.5 billion dollars in 2016, with predictions of this increasing up to 65 billion dollars by 2024 [93]. As reported by Lumina intelligence [92], a survey of Ganeden on consumers concluded that almost 80% of consumers preferred to consume probiotics in food and beverage products than in supplements. This is of special value taking into account that consumer preference is a key currency for measuring product success and predicting upcoming tendencies. North America demand for probiotics is expected to increase by 7.9% from 2016 to 2025, whereas the European market will grow at a pace of 7.3%. As for Asia Pacific countries, the probiotics industry is also expected to increase significantly.

Probiotics have achieved a prominent position in the global food market. Among the countries that have shown growth in the probiotic market, Europe represents the largest and fastest growing market, followed by Japan. Currently, there is a wide range of probiotic products offered by companies such as BioGaia Biologics AB, Christian Hansen A/S, ConAgra Functional Foods, Danisco, Groupe Danone, or Lifeway [87].

**77**

**Author details**

declare.

**Acknowledgements**

**Conflict of interest**

Noelia Betoret1

de València, Valencia, Spain

of Chocó, Colombia

provided the original work is properly cited.

, Leidy Indira Hinestroza2

\*Address all correspondence to: mcbarpu@tal.upv.es

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

1 University Institute of Food Engineering for Development, Universitat Politècnica

Authors of this book chapter state that they do not have conflict of interest to

2 Research Group on Assessment and Use of Biodiversity, Technological University

, Lucía Seguí1

and Cristina Barrera1

\*

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity…*

The huge increase in obesity and consequently of physiological disorders associated with this has led to a massive increase in research work conducted in this area over the past 10 years. The relationship between diet and the incidence of metabolic syndrome is clearly contrasted. Although this relationship is tremendously complex and it is hardly affected by other variables related to lifestyle, specific works establish phytochemicals and probiotics as two of the active components present in food, which have the greatest effect on prevention and in the reduction of symptoms

Currently, the technological development achieved by the food industry allows both the design and development of specific foods that include active components in their composition as well as the application of specific techniques that increase the functional value of natural foods. The use of these advances in the right direction can be decisive in the solution of health problems related to obesity. Specifically, the applications of moderate homogenization pressures or food formulation techniques, such as vacuum impregnation, are presented as possibilities to develop liquid and/ or solid foods that combine the presence of phytochemicals and probiotics with demonstrated effectiveness against obesity in natural foods such as lulo fruit.

This research was funded in part by a PhD Research Fellowship from the Technological University of Chocó (Colombia). Authors specially thank Alicia Ríos Hurtado for her support, to the Government of the Department of Chocó and to the

Research Group on Assessment and Use of Biodiversity (Chocó, Colombia).

*DOI: http://dx.doi.org/10.5772/intechopen.85482*

associated with metabolic syndrome.

**5. Conclusions**

*Probiotics and Other Bioactive Compounds with Proven Effect against Obesity… DOI: http://dx.doi.org/10.5772/intechopen.85482*

## **5. Conclusions**

*Nutraceuticals - Past, Present and Future*

economic reasons for the developing countries also require the search for an alternative to dairy products with good nutrients along with health-promoting factors, e.g., fruits, vegetables, cereal, legume, etc., and products which lack cholesterol content but are rich in protein, starches, minerals, fiber, vitamins, and antioxidants. Nowadays an increasing trend in the Western society is consumer interest and focus toward natural and organic products, where the use of synthetic additives is limited. It has been suggested that natural ingredients with strong antioxidant activity could be used to design novel functional beverages. An increased interest relies upon the fortification with polyphenols due to their beneficial role against cardiovascular diseases, type 2 diabetes, and obesity, among other conditions. The combination of prebiotics, and also phenols with probiotic microorganisms, represents an innovative biotechnology to enlarge the functional food market and especially beverages [90]. According to Grand View Research [91], the global functional food market was higher than 129 billion dollars (US) in 2015, and it is expected to increase up to 250 billion in 2024. Growing consciousness among consumers on their health and proper diet, together with the prospect of reducing or even eliminating nutrition-related diseases, is responsible of this market trend. Society is becoming more and more conscious on the impact that changing dietary patterns may have in the incidence of type 2 diabetes, coronary heart disease, cancer, periodontal disease, and obesity. In this regard, functional foods are believed to play an outstanding role. In addition, increasing healthcare cost, along with the desire of improving later years among the geriatric

population, has driven the growth of the functional food industry worldwide.

these nutritional foods and beverages in Europe.

The global functional food market includes that of carotenoids, dietary fibers, fatty acids, minerals, prebiotics and probiotics, vitamins, minerals, phytochemicals, enzymes, and antioxidants in general. Market revenue of all these products separately is also expected to increase in the coming years. For example, dietary fibers, which are considered to prevent obesity and diabetes, are expected to grow by 8.4% in the next 8 years. Other phytochemicals, such as flavonoids, held a share of over 30% in terms of market value. Although these have been commonly consumed in their natural form, consumer's habits have led to their use in the form of functional food products which are aimed at preventing diet-related chronic diseases including those related to the metabolic syndrome. North America accounts for the largest market in flavonoids, the Asia Pacific demand was over 110 million US Dollars in 2015, and Europe is expected to grow, although at a slower pace. In any case, prevalence of diabetes, obesity, and chronic diseases is likely to propel demand for

With regard to probiotics, there is also a growing concern on awareness in their functional health benefits against different conditions, including those related to the metabolic syndrome such as obesity or type 2 diabetes [92]. The global probiotic market was thought to be worth 35.5 billion dollars in 2016, with predictions of this increasing up to 65 billion dollars by 2024 [93]. As reported by Lumina intelligence [92], a survey of Ganeden on consumers concluded that almost 80% of consumers preferred to consume probiotics in food and beverage products than in supplements. This is of special value taking into account that consumer preference is a key currency for measuring product success and predicting upcoming tendencies. North America demand for probiotics is expected to increase by 7.9% from 2016 to 2025, whereas the European market will grow at a pace of 7.3%. As for Asia Pacific

countries, the probiotics industry is also expected to increase significantly.

Probiotics have achieved a prominent position in the global food market. Among the countries that have shown growth in the probiotic market, Europe represents the largest and fastest growing market, followed by Japan. Currently, there is a wide range of probiotic products offered by companies such as BioGaia Biologics AB, Christian Hansen A/S, ConAgra Functional Foods, Danisco, Groupe Danone, or Lifeway [87].

**76**

The huge increase in obesity and consequently of physiological disorders associated with this has led to a massive increase in research work conducted in this area over the past 10 years. The relationship between diet and the incidence of metabolic syndrome is clearly contrasted. Although this relationship is tremendously complex and it is hardly affected by other variables related to lifestyle, specific works establish phytochemicals and probiotics as two of the active components present in food, which have the greatest effect on prevention and in the reduction of symptoms associated with metabolic syndrome.

Currently, the technological development achieved by the food industry allows both the design and development of specific foods that include active components in their composition as well as the application of specific techniques that increase the functional value of natural foods. The use of these advances in the right direction can be decisive in the solution of health problems related to obesity. Specifically, the applications of moderate homogenization pressures or food formulation techniques, such as vacuum impregnation, are presented as possibilities to develop liquid and/ or solid foods that combine the presence of phytochemicals and probiotics with demonstrated effectiveness against obesity in natural foods such as lulo fruit.

## **Acknowledgements**

This research was funded in part by a PhD Research Fellowship from the Technological University of Chocó (Colombia). Authors specially thank Alicia Ríos Hurtado for her support, to the Government of the Department of Chocó and to the Research Group on Assessment and Use of Biodiversity (Chocó, Colombia).

## **Conflict of interest**

Authors of this book chapter state that they do not have conflict of interest to declare.

## **Author details**

Noelia Betoret1 , Leidy Indira Hinestroza2 , Lucía Seguí1 and Cristina Barrera1 \*

1 University Institute of Food Engineering for Development, Universitat Politècnica de València, Valencia, Spain

2 Research Group on Assessment and Use of Biodiversity, Technological University of Chocó, Colombia

\*Address all correspondence to: mcbarpu@tal.upv.es

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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co-administration of probiotics with herbal medicine on obesity, metabolic endotoxemia and dysbiosis: A randomized double-blind controlled clinical trial. Clinical Nutrition. 2014;**33**(6):973-981. DOI: 10.1016/J. CLNU.2013.12.006

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jf801515p

2009;**59**(1):88-94

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[74] Gancel AL, Alter P, Dhuique-Mayer C, Ruales J, Vaillant F. Identifying carotenoids and phenolic compounds in naranjilla (*Solanum quitoense* Lam. Var. puyo hybrid), an Andean fruit. Journal of Agricultural and Food Chemistry. 2008;**56**(24):11890-11899. DOI: 10.1021/

[75] Acosta Ó, Pérez AM, Vaillant F. Chemical characterization, antioxidant properties, and volatile constituents of Naranjilla (*Solanum quitoense* Lam.) cultivated in Costa Rica. Archivos Latinoamericanos de Nutrición.

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postgradmedj-2015-133285

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[70] Zarrati M, Salehi E, Nourijelyani K, Mofid V, Zadeh MJH, Najafi F, et al. Effects of probiotic yogurt on fat distribution and gene expression of proinflammatory factors in peripheral blood mononuclear cells in overweight and obese people with or without weight-loss diet. Journal of the American College of Nutrition. 2014;**33**(6):1-9. DOI: 10.1080/07315724.2013.874937

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[72] Ministerio de Agricultura y Desarrollo Rural de Colombia.

10.1038/nature12506

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[66] Ghaisas S, Maher J, Kanthasamy A. Gut microbiome in health and disease: Linking the microbiome-gut-brain axis and environmental factors in the pathogenesis of systemic and neurodegenerative diseases. Pharmacology & Therapeutics. 2016;**158**:52-62. DOI: 10.1016/j. pharmthera.2015.11.012

*Nutraceuticals - Past, Present and Future*

NCA, Balolong EC Jr, Hallare AV, Elegado F. Evaluating the anti-obesity potential of *Lactobacillus fermentum* 4B1, a probiotic strain isolated from balao-balao, a traditional Philippine fermented food. International Food Research Journal. 2017;**24**(2):819-824

[55] Hsieh FC, Lan CCE, Huang TY, Chen KW, Chai CY, Chen WT, et al. Heat-killed and live *Lactobacillus reuteri* GMNL-263 exhibit similar effects on improving metabolic functions in high-fat diet-induced obese rats. Food & Function. 2016;**7**(5):2374-2388. DOI:

[56] Plovier H, Everard A, Druart C, Depommier C, Van Hul M, Geurts L, et al. A purified membrane protein from *Akkermansia muciniphila* or the pasteurized bacterium improves metabolism in obese and diabetic mice. Nature Medicine. 2017;**23**(1):107-113.

10.1039/c5fo01396h

DOI: 10.1038/nm.4236

[57] An HM, Park SY, Lee DK, Kim JR, Cha MK, Lee SW, et al. Antiobesity and lipid-lowering effects of *Bifidobacterium* spp. in high fat diet-induced obese rats. Lipids in Health and Disease. 2011;**10**:116. DOI:

10.1186/1476-511X-10-116

[58] Fåk F, Bäckhed F. *Lactobacillus reuteri* prevents diet-induced obesity, but not atherosclerosis, in a strain dependent fashion in *Apoe*−/− mice. PLoS One. 2012;**7**(10):e46837. DOI: 10.1371/journal.pone.0046837

[59] Zhao X, Higashikawa F, Noda M, Kawamura Y, Matoba Y, Kumagai T, et al. The obesity and fatty liver are reduced by plant-derived *Pediococcus pentosaceus* LP28 in high fat dietinduced obese mice. PLoS One.

2012;**7**(2):e30696. DOI: 10.1371/journal.

[60] Lee SJ, Bose S, Seo JG, Chung WS,

Lim CY, Kim H. The effects of

[54] Balolong MP, Bautista RLS, Encarma

co-administration of probiotics with herbal medicine on obesity, metabolic endotoxemia and dysbiosis: A randomized double-blind controlled clinical trial. Clinical Nutrition. 2014;**33**(6):973-981. DOI: 10.1016/J.

[61] Sanchez M, Darimont C, Drapeau V, Emady-Azar S, Lepage M, Rezzonico E, et al. Effect of *Lactobacillus rhamnosus* CGMCC1.3724 supplementation on weight loss and maintenance in obese men and women. British Journal of Nutrition. 2014;**111**(8):1507-1519. DOI:

[62] Sharafedtinov KK, Plotnikova OA, Alexeeva R, Sentsova TB, Songisepp E, Stsepetova J, et al. Hypocaloric diet supplemented with probiotic cheese improves body mass index and blood pressure indices of obese hypertensive patients—A randomized doubleblind placebo-controlled pilot study. Nutrition Journal. 2013;**12**:138. DOI:

CLNU.2013.12.006

10.1017/S0007114513003875

10.1186/1475-2891-12-138

10.1038/ejcn.2010.19

[63] Kadooka Y, Sato M, Imaizumi K, Ogawa A, Ikuyama K, Akai Y, et al. Regulation of abdominal adiposity by probiotics (*Lactobacillus gasseri* SBT2055) in adults with obese

tendencies in a randomized controlled trial. European Journal of Clinical Nutrition. 2010;**64**(6):636-643. DOI:

[64] Omar JM, Chan YM, Jones ML, Prakash S, Jones PJH. *Lactobacillus fermentum* and *Lactobacillus amylovorus* as probiotics alter body adiposity and gut microflora in healthy persons. Journal of Functional Foods. 2013;**5**(1):116-123.

DOI: 10.1016/j.jff.2012.09.001

s12986-016-0067-0

[65] Kobyliak N, Conte C, Cammarota G, Haley AP, Styriak I, Gaspar G, et al. Probiotics in prevention and treatment of obesity: A critical view. Nutrition and Metabolism. 2016;**13**:14. DOI: 10.1186/

**82**

pone.0030696

[67] Le Chatelier E, Nielsen T, Qin J, et al. Richness of human gut microbiome correlates with metabolic markers. Nature. 2013;**500**(7464):541-546. DOI: 10.1038/nature12506

[68] Lehnen TE, Ramos da Silva M, Camacho A, Marcadenti A, Lehnen AM. A review on effects of conjugated linoleic fatty acid (CLA) upon body composition and energetic metabolism. Journal of the International Society of Sports Nutrition. 2015;**12**:36. DOI: 10.1186/s12970-015-0097-4

[69] Patterson E, Ryan PM, Cryan JF, Dinan TG, Ross P, Fitzgerald GF, et al. Gut microbiota, obesity and diabetes. Postgraduate Medical Journal. 2016;**92**(1087):286-300. DOI: 10.1136/ postgradmedj-2015-133285

[70] Zarrati M, Salehi E, Nourijelyani K, Mofid V, Zadeh MJH, Najafi F, et al. Effects of probiotic yogurt on fat distribution and gene expression of proinflammatory factors in peripheral blood mononuclear cells in overweight and obese people with or without weight-loss diet. Journal of the American College of Nutrition. 2014;**33**(6):1-9. DOI: 10.1080/07315724.2013.874937

[71] Igual M, Ramires S, Mosquera LH, Martínez-Navarrete N. Optimization of spray drying conditions for lulo (*Solanum quitoense* L.) pulp. Powder Technology. 2014;**256**:233-238. DOI: 10.1016/j.powtec.2014.02.003

[72] Ministerio de Agricultura y Desarrollo Rural de Colombia.

Producción Nacional por Producto. Available from: http:// www.agronet.gov.co/Paginas/ ProduccionNacionalProducto.aspx

[73] Contreras-Calderón J, Calderón-Jaimes L, Guerra-Hernández E, García-Villanova B. Antioxidant capacity, phenolic content and vitamin C in pulp, peel and seed from 24 exotic fruits from Colombia. Food Research International. 2011;**44**(7):2047-2053. DOI: 10.1016/j. foodres.2010.11.003

[74] Gancel AL, Alter P, Dhuique-Mayer C, Ruales J, Vaillant F. Identifying carotenoids and phenolic compounds in naranjilla (*Solanum quitoense* Lam. Var. puyo hybrid), an Andean fruit. Journal of Agricultural and Food Chemistry. 2008;**56**(24):11890-11899. DOI: 10.1021/ jf801515p

[75] Acosta Ó, Pérez AM, Vaillant F. Chemical characterization, antioxidant properties, and volatile constituents of Naranjilla (*Solanum quitoense* Lam.) cultivated in Costa Rica. Archivos Latinoamericanos de Nutrición. 2009;**59**(1):88-94

[76] González-Loaiza DI, Ordóñez-Santos LE, Venegas-Mahecha P, Vásquez-Amariles HD. Cambios en las propiedades fisicoquímicas de frutos de lulo (*Solanum quitoense* Lam.) cosechados en tres grados de madurez. Acta Agronómica. 2014;**63**(1):11-17. DOI: 10.15446/acag.v63n1.31717

[77] Vasco C, Ruales J, Kamal-Eldin A. Total phenolic compounds and antioxidant capacities of major fruits from Ecuador. Food Chemistry. 2008;**111**(4):816-823. DOI: 10.1016/j. foodchem.2008.04.054

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[87] Panghal A, Janghu S, Virkar K, Gat Y, Kumar V, Chhikara N. Potential non-dairy probiotic products—A healthy approach. Food Bioscience. 2018;**21**:80-89. DOI: 10.1016/j. fbio.2017.12.003

[88] Kraus A. Factors influencing the decisions to buy and consume functional food. British Food Journal. 2015;**117**(6):1622-1636. DOI: 10.1108/ BFJ-08-2014-0301

[89] Panghal A, Virkar K, Kumar V, Dhull SB, Gat Y, Chhikara N. Development of probiotic beetroot drink. Current Research in Nutrition and Food Science Journal. 2017;**5**(3):257-262. DOI: 10.12944/ CRNFSJ.5.3.10

[90] Corbo MR, Bevilacvqua A, Petruzzi L, Casanova FP, Sinigaglia M. Functional beverages: The emerging side of functional foods commercial trends, research, and health implications. Comprehensive Reviews in Food Science and Food Safety. 2014;**13**:1192-1206. DOI: 10.1111/1541-4337.12109

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**85**

**Chapter 5**

Athletes

**Abstract**

be studied more.

**1. Introduction**

*Bifidobactrium bifidum* (BIB2)

The *Bifidobacterim bifidum* (BIB2)

Foods supplemented with probiotics enhance athletes' immune system functions, improve body health and consequently decreases athlete's health maintenance costs. Probiotics improve immune system function against pathogens via affecting on innate immune system, humeral immunity and cytokines. The effects of consumption of Iranian probiotic *Bifidobactrium bifidum* (BIB2) on athletes' immune system functions were evaluated. The results showed studied immune system factors were significantly different between test and control groups, so that IgA, IgM, lymphocyte and monocytes percentage and CD4 measurements of test group were higher than control. The *Bifidobacterim bifidum* (BIB2) probiotic consumption can affect some immune system factors; therefore its ability to improved general health should

**Keywords:** probiotics, CD4, IgA, IgM, monocyte, lymphocyte, sprint athletes,

There is a general belief among elite athletes and their coaches that overtraining causes resistance to infection. Epidemiological studies report that symptoms of respiratory tract infection increases in 1–2 weeks after strenuous endurance competitions. The highest percentages of patients were athletes who exceeded their training threshold level that is associated with the training load [1, 2]. The biological balance of body organs improves the health of the host, improving performance and increasing power of the immune system [3]. Probiotics are a group of living microorganisms that improve health by improving biological balance when added to foods or consumed as supplements. These organisms increase immune system function and enhance host defense against harmful microorganisms. The benefits of probiotics such as reducing toxins, increase immunity and resistance to infection, produce vitamins and nutrients, organic acids, reduce allergic reactions, respiratory infections, reduce the symptoms of irritable bowel syndrome, arthritis, rheumatoid and modulating immune responses have been shown in many studies [4, 5]. Overwhelming exercise undertaken by athletes or military personnel diminishes

Probiotic Increased Immune

System Factors in Men Sprint

*Ali Hossein Khani, Seyed Milad Mousavi Jazayeri,* 

*Elahe Ebrahimi and Ayoub Farhadi*

## **Chapter 5**

*Nutraceuticals - Past, Present and Future*

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and non-dairy probiotic products—A review. Journal of Food Science and Technology. 2015;**52**(10):6112-6124. DOI: 10.1007/s13197-015-1795-2

[86] Rad AH, Torab R, Mortazavian AM, Mehrabany EV, Mehrabany LV. Can probiotics prevent or improve common cold and influenza? Nutrition. 2013;**29**(5):805-806. DOI: 10.1016/j.

[87] Panghal A, Janghu S, Virkar K, Gat Y, Kumar V, Chhikara N. Potential non-dairy probiotic products—A healthy approach. Food Bioscience. 2018;**21**:80-89. DOI: 10.1016/j.

[88] Kraus A. Factors influencing the decisions to buy and consume functional food. British Food Journal. 2015;**117**(6):1622-1636. DOI: 10.1108/

[89] Panghal A, Virkar K, Kumar V, Dhull SB, Gat Y, Chhikara N. Development of probiotic beetroot

Nutrition and Food Science Journal. 2017;**5**(3):257-262. DOI: 10.12944/

Petruzzi L, Casanova FP, Sinigaglia M. Functional beverages: The emerging side of functional foods commercial trends, research, and health implications. Comprehensive Reviews in Food Science and Food Safety. 2014;**13**:1192-1206. DOI: 10.1111/1541-4337.12109

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