A review of the human clinical studies involving Citrus aurantium (bitter orange) extract and its primary protoalkaloid p-synephrine

Citrus aurantium L. and synephrine improve brown adipose tissue function in adolescent mice programmed by early postnatal overfeeding

Introduction and aims

Obesity is a multifactorial condition with high health risk, associated with important chronic disorders such as diabetes, dyslipidemia, and cardiovascular dysfunction. Citrus aurantium L. (C. aurantium) is a medicinal plant, and its active component, synephrine, a β-3 adrenergic agonist, can be used for weight loss. We investigated the effects of C. aurantium and synephrine in obese adolescent mice programmed by early postnatal overfeeding.

Methods

Three days after birth, male Swiss mice were divided into a small litter (SL) group (3 pups) and a normal litter (NL) group (9 pups). At 30 days old, SL and NL mice were treated with C. aurantium standardized to 6% synephrine, C. aurantium with 30% synephrine, isolated synephrine, or vehicle for 19 days.

Results

The SL group had a higher body weight than the NL group. Heart rate and blood pressure were not elevated. The SL group had hyperleptinemia and central obesity that were normalized by C. aurantium and synephrine. In brown adipose tissue, the SL group showed a higher lipid droplet sectional area, less nuclei, a reduction in thermogenesis markers related to thermogenesis (UCP-1, PRDM16, PGC-1α and PPARg), and mitochondrial disfunction. C. aurantium and synephrine treatment normalized these parameters.

Conclusion

Our data indicates that the treatment with C. aurantium and synephrine could be a promising alternative for the control of some obesity dysfunction, such as improvement of brown adipose tissue dysfunction and leptinemia.

Synephrine and Its Derivative Compound A: Common and Specific Biological Effects

This review is focused on synephrine, the principal phytochemical found in bitter orange and other medicinal plants and widely used as a dietary supplement for weight loss/body fat reduction. We examine different aspects of synephrine biology, delving into its established and potential molecular targets, as well as its mechanisms of action. We present an overview of the origin, chemical composition, receptors, and pharmacological properties of synephrine, including its anti-inflammatory and anti-cancer activity in various in vitro and animal models. Additionally, we conduct a comparative analysis of the molecular targets and effects of synephrine with those of its metabolite, selective glucocorticoid receptor agonist (SEGRA) Compound A (CpdA), which shares a similar chemical structure with synephrine. SEGRAs, including CpdA, have been extensively studied as glucocorticoid receptor activators that have a better benefit/risk profile than glucocorticoids due to their reduced adverse effects. We discuss the potential of synephrine usage as a template for the synthesis of new generation of non-steroidal SEGRAs. The review also provides insights into the safe pharmacological profile of synephrine.

Notifications and Health Consequences of Unauthorized Pharmaceuticals in Food Supplements

Health concerns associated with the consumption of food supplements rise in parallel with the rise in the popularity and market availability of these products. In pursuit of data related to the unauthorized presence of pharmaceuticals in food supplements, the Rapid Alert System for Food and Feed (RASFF) database was searched for the 2011-2022 period. The most "popular" pharmaceuticals for the adulteration of food supplements were phosphodiesterase-5 inhibitors (235 records); anorexics and laxatives (76), including sibutramine and its active metabolite N-didesmethyl sibutramine, phenolphthalein and 2,4-dinitrophenol; stimulants, among which 1,3-dimethylamine (97), and synephrine (53) were the most numerous; nootropic drugs (24); anabolics and prohormones (16); and cannabinoid cannabidiol (14) (pending authorization as a novel food ingredient). Over 65% of notifications of interest were classified as serious risks, and over 80% of these were alert or border rejection notifications, mainly generated as a result of official control on the market. The alarming number of RASFF notifications should be considered a public health issue, demanding clear and targeted recommendation for action for the legislature and authorities. A harmonized nutrivigilance system should be considered as a tool to detect and scrutinize the adverse health effects of food supplements, along with measures to improve their safety, quality, and testing.

Roles of citrus fruits on energy expenditure, body weight management, and metabolic biomarkers: a comprehensive review

Citrus fruits are widely consumed for their nutritional and health benefits. They belong to the Rutaceae and have many varieties, such as sweet orange (Citrus sinensis), which is the most popular. Citrus fruits are rich in water (>80%), dietary fiber, and vitamins. They also contain bioactive components, which may modulate energy metabolism and lipid oxidation through various mechanisms. These mechanisms include stimulating β3-adrenergic receptors, increasing mitochondrial biogenesis and thermogenesis, activating AMP kinase and peroxisome proliferator-activated receptor-gamma coactivator-1α pathways, inhibiting lipogenesis and lipid accumulation, and inducing browning of white adipose tissue. This review summarizes the mechanisms and outcomes of citrus fruits and their metabolites on energy metabolism and body weight in different experimental models. The literature was searched for in vitro and in vivo animal and human studies that investigated the effects of citrus consumption on energy expenditure, thermogenesis, adipogenesis, and lipid accumulation. Citrus fruits and their metabolites have shown promising effects on energy metabolism and lipid oxidation in in vitro and in vivo animal studies. However, the evidence from human studies is limited and inconsistent. Possible reasons for the discrepancy are briefly discussed, and knowledge gaps and research needs are identified for future studies. Citrus fruits may have beneficial effects on energy metabolism and body weight, but more rigorous and well-designed human trials are needed to confirm their efficacy and safety.

A review of citrus plants as functional foods and dietary supplements for human health, with an emphasis on meta-analyses, clinical trials, and their chemical composition

Fruits, flowers, leaves, essential oils, hydrosols, and juices of citrus spp. Are utilized to prepare various forms of food products. Along with their nutritional values, in the health industry, different parts of the plants of the citrus genus have been used as supplements or remedies to prevent or control diseases. This review focused on reported meta-analyses and clinical trials on the health benefits of citrus plants as functional foods. Also, chemical compounds of various citrus species were reviewed. The following information sources were used for data collection: Google Scholar, the Web of Science, Scopus, and PubMed. Various keywords, including "citrus AND chemical compounds," "citrus AND phytochemicals," "citrus species," "citrus AND meta-analysis," "nutritional and therapeutical values of citrus spp.," "clinical trials AND citrus," "clinical trials AND Rutaceae," "health benefits of citrus spp.," "citrus edible or non-edible applications," and scientific names of the citrus plants were utilized to collect data for the review. The scientific name and common name of all twenty-eight citrus species, along with any of the above keywords, were also searched in the mentioned databases. Scientific papers and data sources were sought to review and discuss the citrus plant's nutritional and therapeutic importance. Several meta-analyses and clinical trials have reported beneficial effects of citrus spices on a variety of cancer risks, cardiovascular risk factors, neurologic disorders, urinary tract conditions, and gastrointestinal tract conditions. They have shown anxiolytic, antimicrobial, and pain-alleviating effects. Some of them can be helpful in managing obesity and cardiovascular risk factors.

Health Risk and Metal Contamination Assessment in Orange (Citrus aurantium) of Pakistan: a Multivariate Study

Toxic metals (TMs) are serious health hazard and are known to accumulate in fruits, which are consumed by people, owning to their distinct sweet flavor and potential health benefits. In the present study, arsenic (As), lead (Pb), chromium (Cr), copper (Cu), cadmium (Cd), nickel (Ni), and mercury (Hg) were measured by atomic absorption spectrometry (AAS) techniques in orange samples from 11 farmhouses of Sargodha, Pakistan. Principal component analysis (PCA) is a very useful analysis and data-reducing tool. This technique was used to explore the relationship between different metal levels in the oranges. The conventional wet acid digestion method was validated and assured with two (02) certified reference materials NIST-SRM 1515-Apple and (CRM) NIST-1570a Spinach Leaves by recovery test coupled with standard addition procedure. The results showed that Cd and Cr average daily intakes are 0.084 and 0.15 mg slightly higher than World Health Organization/Food and Agriculture Organization of the United Nations (WHO/FAO) recommended tolerable daily intake respectively. The assessment of health risk was also carried out in form of total hazard quotient (THQ) and hazard index (HI), indicating three heavy metals (Pb, Cd, and Cr) have significant human health risk potential to consumers while Cu, As, Hg, and Ni have non-significant (THQ < 1) health risks.

Does the Time of Day Play a Role in the Acute Effect of p-Synephrine on Fat Oxidation Rate during Exercise in Women? A Randomized, Crossover and Double-Blind Study

p-Synephrine is deemed a safe and effective substance to increase fat utilization during exercise of low-to-moderate intensity in men but not in women. Additionally, the existence of a diurnal variation in substrate utilization has been documented during exercise with enhanced fat oxidation in the evening compared with early morning. However, it remains unknown whether there is an interaction between the effect of p-synephrine and the time of the day on fat oxidation during exercise. This study aimed to evaluate the effect of the acute ingestion of 3 milligram of p-synephrine per kilogram of body mass (mg/kg) on fat oxidation during exercise of increasing intensity when the exercise is performed in the morning vs. the evening. Using a randomized, double-blind, placebo-controlled experimental design, 16 healthy and active women performed four identical exercise trials after the ingestion of 3 mg/kg of p-synephrine and 3 mg/kg of a placebo (cellulose) both in the morning (8-10 am) and in the evening (5-7 pm). In the exercise trials, the substances were ingested 60 min before an incremental test on a cycle ergometer with 3 min stages at workloads from 30 to 80% of maximal oxygen uptake (VO₂max). Substrate oxidation rates were measured by indirect calorimetry. In each trial, the maximum rate of fat oxidation (MFO) and the intensity that elicited MFO (Fatmax) were measured. A two-way analysis of variance (time-of-the day × substance) was used to detect differences among the trials. With the placebo, MFO was 0.25 ± 0.11 g/min in the morning and 0.24 ± 0.07 g/min in the evening. With p-synephrine, MFO was 0.26 ± 0.09 g/min in the morning and 0.21 ± 0.07 g/min in the evening. There was no main effect of substance (p = 0.349), time of day (p = 0.186) and the substance × time of day (p = 0.365) on MFO. Additionally, Fatmax was reached at a similar exercise intensity with the placebo (41.33 ± 8.34% VO₂max in the morning and 44.38 ± 7.37% VO₂max in the evening) and with p-synephrine (43.33 ± 7.24% VO₂max in the morning and 45.00 ± 7.43% VO₂max in the evening), irrespective of the time of day with no main effect of substance (p = 0.633), time of day (p = 0.191), or interaction (p = 0.580). In summary, the acute intake of 3 mg/kg of p-synephrine before exercise did not increase MFO and Fatmax, independently of the time of day, in female athletes. This indicates that the time of day is not a factor explaining the lack of effectiveness of this substance to enhance fat oxidation during aerobic exercise in women.

Mechanistic Insights into the Neuroprotective Potential of Sacred Ficus Trees

Ficus religiosa (Bo tree or sacred fig) and Ficus benghalensis (Indian banyan) are of immense spiritual and therapeutic importance. Various parts of these trees have been investigated for their antioxidant, antimicrobial, anticonvulsant, antidiabetic, anti-inflammatory, analgesic, hepatoprotective, dermoprotective, and nephroprotective properties. Previous reviews of Ficus mostly discussed traditional usages, photochemistry, and pharmacological activities, though comprehensive reviews of the neuroprotective potential of these Ficus species extracts and/or their important phytocompounds are lacking. The interesting phytocompounds from these trees include many bengalenosides, carotenoids, flavonoids (leucopelargonidin-3-O-β-d-glucopyranoside, leucopelargonidin-3-O-α-l-rhamnopyranoside, lupeol, cetyl behenate, and α-amyrin acetate), flavonols (kaempferol, quercetin, myricetin), leucocyanidin, phytosterols (bergapten, bergaptol, lanosterol, β-sitosterol, stigmasterol), terpenes (α-thujene, α-pinene, β-pinene, α-terpinene, limonene, β-ocimene, β-bourbonene, β-caryophyllene, α-trans-bergamotene, α-copaene, aromadendrene, α-humulene, alloaromadendrene, germacrene, γ-cadinene, and δ-cadinene), and diverse polyphenols (tannin, wax, saponin, leucoanthocyanin), contributing significantly to their pharmacological effects, ranging from antimicrobial action to neuroprotection. This review presents extensive mechanistic insights into the neuroprotective potential, especially important phytochemicals from F. religiosa and F. benghalensis. Owing to the complex pathophysiology of neurodegenerative disorders (NDDs), the currently existing drugs merely alleviate the symptoms. Hence, bioactive compounds with potent neuroprotective effects through a multitarget approach would be of great interest in developing pharmacophores for the treatment of NDDs.

The Safety and Efficacy of Citrus aurantium (Bitter Orange) Extracts and p-Synephrine: A Systematic Review and Meta-Analysis

Synephrine has been used to promote weight loss; however, its safety and efficacy have not been fully established. The goals of our study were to give an overview of the safety and efficacy of p-synephrine, to systematically evaluate its efficacy regarding weight loss and to assess its safety, focusing on its cardiovascular side effects in a meta-analysis. PubMed, the Cochrane Library, Web of Science and Embase were searched for relevant studies. Only placebo-controlled, human clinical trials with synephrine intervention were included in the meta-analysis. The meta-analysis was reported according to the PRISMA guidelines using the PICOS format and taking into account the CONSORT recommendations. Altogether, 18 articles were included in the meta-analysis. Both systolic and diastolic blood pressure (DBP) increased significantly after prolonged use (6.37 mmHg, 95% CI: 1.02–11.72, p = 0.02 and 4.33 mmHg, 95% CI: 0.48–8.18, p = 0.03, respectively). The weight loss in the synephrine group was non-significant after prolonged treatment, and it did not influence body composition parameters. Based on the analyzed clinical studies, synephrine tends to raise blood pressure and heart rate, and there is no evidence that synephrine can facilitate weight loss. Further studies are needed to confirm evidence of its safety and efficacy.

A Comprehensive Review on Anti-obesity Potential of Medicinal Plants and their Bioactive Compounds

Background:

Obesity is a complex health and global epidemic issue. It is an increasing global health challenge covering significant social and economic costs. Abnormal accumulation of fat in the body may increase the health risks including diabetes, hypertension, osteoarthritis, sleep apnea, cardiovascular diseases, stroke and cancer. Synthetic drugs available on the market reported to have several side effects. Therefore, the management of obesity got to involve the traditional use of medicinal plants which helps to search the new therapeutic targets and supports the research and development of anti-obesity drugs.

Objective:

This review aim to update the data and provide a comprehensive report of currently available knowledge of medicinal plants and phyto-chemical constituents reported for their anti-obesity activity.

Methodology:

An electronic search of the periodical databases like Web of Science, Scopus, PubMed, Scielo, Niscair, ScienceDirect, Springerlink, Wiley, SciFinder and Google Scholar with information reported the period 1991-2019, was used to retrieve published data.

Results:

A comprehensive report of the present review manuscript is an attempt to list the medicinal plants with anti-obesity activity. The review focused on plant extracts, isolated chemical compounds with their mechanism of action and their preclinical experimental model, clinical studies for further scientific research.

Conclusion:

This review is the compilation of the medicinal plants and their constituents reported for the managements of obesity. The data will fascinate the researcher to initiate further research that may lead to the drug for the management of obesity and their associated secondary complications. Several herbal plants and their respective lead constituents were also screened by preclinical In-vitro and In-vivo, clinical trials and are effective in the treatment of obesity. Therefore, there is a need to develop and screen large number of plant extracts and this approach can surely be a driving force for the discovery of anti-obesity drugs from medicinal plants.

p-Synephrine and its various pharmacological effects

There is a number of diseases for which, scientists are constantly looking for a promising new treatments. Isolation of novel substances with biological activity from plants gives hope for its use in treatment. In this review, we focused on the biological activity of p-synephrine (4-(2-aminoethyl)phenol) which was previously confirmed during both in vitro and in vivo tests. The main part of the review is dedicated to the anti-obesity activity of p-synephrine, as obesity is a disease of contemporary civilization. However, synephrine also possesses anti-diabetic, anti-inflammatory and antidepressant activity and it is confirmed to be a hypotensive agent in portal hypertension. The review also emphasize that, based on current knowledge, the use of p-synephrine appears to be exceedingly safe with only limited range of side effects. Therefore, it seems that this substance may be of great importance in the pharmacotherapy of many disease states and further research is necessary.

Nutrients and bioactives in citrus fruits: Different citrus varieties, fruit parts, and growth stages

Citrus fruits are consumed in large quantities worldwide due to their attractive aromas and taste, as well as their high nutritional values and various health-promoting effects, which are due to their abundance of nutrients and bioactives. In addition to water, carbohydrates, vitamins, minerals, and dietary fibers are important nutrients in citrus, providing them with high nutritional values. Citrus fruits are also rich in various bioactives such as flavonoids, essential oils, carotenoids, limonoids, and synephrines, which protect from various ailments, including cancer and inflammatory, digestive, and cardiovascular diseases. The composition and content of nutrients and bioactives differ significantly among citrus varieties, fruit parts, and growth stages. To better understand the nutrient and bioactive profiles of citrus fruits and provide guidance for the utilization of high-value citrus resources, this review systematically summarizes the nutrients and bioactives in citrus fruit, including their contents, structural characteristics, and potential health benefits. We also explore the composition variation in different citrus varieties, fruits parts, and growth stages, as well as their health-promoting effects and applications.

Online Marketing of Ephedra Weight Loss Supplements: Labeling and Marketing Compliance with the U.S. Food and Drug Administration Ban on Ephedra

Objective: To characterize dietary supplements marketed online as "ephedra-containing or ephedra-like products" for weight management and to assess labeling/marketing compliance with the ban on the sale of ephedrine alkaloids. Materials and Methods: This cross-sectional study assessed websites selling ephedra-like supplements using the search term "buy ephedra." For each website, the first three featured products were characterized by evaluating the label for (1) Ephedra sp. or its alkaloid content, (2) serving size, (3) other ingredients, (4) directions, (5) side effects, (6) reported interactions, (7) recommendation to consult a health care provider, (8) recommendation to use with diet and exercise, and (9) Food and Drug Administration (FDA) disclaimer. Results: Thirty-six (71%) of the first 51 websites evaluated sold at least one weight loss product. A total of 105 products were assessed, 93 had labeling with 10 (11%) in possible violation of the ephedra ban. Five were labeled as containing ephedrine or ephedrine hydrochloride, two reported containing ephedrine alkaloids, and two reported containing unidentified Ephedra sp. not formulated as an extract; one reported containing Ma Huang. Sixty-seven (72%) products listed caffeine with a daily serving size averaging 400 mg. Other ingredients with stimulant properties include green tea, yohimbe, and phenylethylamine. Conclusions: Nearly 20% of websites sold weight loss products that potentially violated the 2004 ban of ephedra alkaloids. Ephedrine, unidentified Ephedra sp. not formulated as an extract, and Ma Huang were labeled as present in 11% of products evaluated. Incomplete reporting of adverse effects and drug interactions was common.

Effects of p-Synephrine during Exercise: A Brief Narrative Review

The p-synephrine is the principal phytochemical found in bitter orange (Citrus aurantium). This substance is widely included in dietary supplements for weight loss/body fat reduction due to its potential benefits of increasing fat oxidation. For years, p-synephrine-containing dietary supplements have been marketed without proper knowledge of their true effectiveness to enhance fat utilization, especially when combined with exercise. However, the effects of p-synephrine on fat oxidation during exercise have been investigated in the last few years. The aim of the current discussion is to summarize the evidence on the effects of p-synephrine intake on fat oxidation and performance during exercise. Previous investigations have demonstrated that the acute intake of p-synephrine does not modify running sprint performance, jumping capacity, or aerobic capacity. However, the acute intake of p-synephrine, in a dose of 2-3 mg/kg of body mass, has been effective to enhance the rate of fat oxidation during incremental and continuous exercise. This effect has been observed in a range of exercise workloads between 30% and 80% of peak oxygen uptake (VO_2peak). The p-synephrine has the ability to increase the maximal rate of fat oxidation during exercise of increasing intensity without affecting the workload at which maximal fat oxidation is obtained (Fatmax). The effect of p-synephrine on fat oxidation is normally accompanied by a concomitant reduction of carbohydrate utilization during exercise, without modifying the energy expended during exercise. The shifting in substrate oxidation is obtained without any effect on heart rate during exercise and the prevalence of adverse effects is negligible. Thus, the acute use of p-synephrine, or p-synephrine-containing products, might offer some benefits for those individuals seeking higher fat utilization during exercise at low to moderate intensities. However, more research is still necessary to determine if the effect of p-synephrine on fat oxidation during exercise is maintained with chronic ingestion, in order to ascertain the utility of this substance in conjunction with exercise programs to produce an effective body fat/weight loss reduction.

HPLC-UV-QDa analysis of Citrus aurantium-labelled pre-workout supplements suggest only a minority contain the plant extract

Bitter orange (Citrus aurantium) is a common ingredient in pre-workout supplements with purported weight-loss and performance-enhancing effects. Supplements listing Citrus aurantium or p-synephrine have been associated with reports of adverse cardiovascular events attributed to the active biogenic amines, p-synephrine, p-octopamine or p-tyramine. Additionally, questions have been raised as to the authenticity of the plant-derived active components listed on the supplement labels. The aim of this study was to determine the quantities of these amines in a sample of pre-workout supplements which specifically listed Citrus aurantium, and assess the authenticity of plant material by comparing the ratios of amines found to that found in Citrus aurantium standardized reference materials (SRM). The quantities of amines in the supplements and SRMs were determined using a validated high-performance liquid chromatography-single quadrupole mass spectrometry (HPLC-UV-QDa) method. In the Citrus aurantium SRMs the quantities of trace amines found ranged from 5.30 to 38.00 mg/g (synephrine) 0.14-0.35 mg/g (octopamine) and 0.15-1.90 mg/g (tyramine) with an average ratio of 100:1:5 (synephrine: octopamine: tyramine). Only 42 % (5/12) of the supplements tested had ratios consistent with that found in the SRMs. The average trace amine ratio in those supplements was 100:1:3 while the quantities of trace amines found ranged from 0.35 to 31.31 mg/g (synephrine); 0.005 - 0.10 mg/g (octopamine) and 0.01-1.51 mg/g (tyramine). For the remaining supplements, some did not contain any detectable levels of trace amines or only synephrine was detected with concentrations ranging from 0.003 - 0.95 mg/g. These results suggest a role for authenticity/quality assurance testing of pre-workout supplements and more stringent regulation of pre-workout supplements.

Current Evidence to Propose Different Food Supplements for Weight Loss: A Comprehensive Review

The use of food supplements for weight loss purposes has rapidly gained popularity as the prevalence of obesity increases. Navigating through the vast, often low quality, literature available is challenging, as is providing informed advice to those asking for it. Herein, we provide a comprehensive literature revision focusing on most currently marketed dietary supplements claimed to favor weight loss, classifying them by their purported mechanism of action. We conclude by proposing a combination of supplements most supported by current evidence, that leverages all mechanisms of action possibly leading to a synergistic effect and greater weight loss in the foreseen absence of adverse events. Further studies will be needed to confirm the weight loss and metabolic improvement that may be obtained through the use of the proposed combination.

p-Synephrine, the main protoalkaloid of Citrus aurantium, raises fat oxidation during exercise in elite cyclists

The aim of this study was to investigate the acute effects of p-synephrine ingestion on substrate oxidation during exercise in elite cyclists. Fifteen elite cyclists volunteered to participate in a double blind, crossover, randomized and placebo-controlled experimental trial. During two different trials, participants either ingested a placebo (cellulose) or 3 mg/kg of p-synephrine. After 60 min for substances absorption, participants performed an incremental maximal cycle ergometer test until volitional fatigue (25 W/min). Breath-by-breath gas exchange data was continuously recorded during the entire test to estimate energy expenditure, carbohydrate oxidation, and fat oxidation rates by stoichiometric equations. Heart rate was continuously measured by using a heart rate monitor. The ingestion of p-synephrine had no significant effects on energy expenditure (F = 0.71, P = 0.40) or heart rate (F = 0.66, P = 0.43) during exercise. However, there was a main effect of p-synephrine to increase the rate of fat oxidation over the placebo (F = 5.1, P = 0.04) and the rate of fat oxidation was higher with p-synephrine in the following loads: 45 ± 2%, 51 ± 3%, 62 ± 3%, 67 ± 4%, 79 ± 5% and 85 ± 5% of the maximum wattage obtained in the test (all P < 0.05). The ingestion of p-synephrine did not modify the maximal rate of fat oxidation during the ramp test (mean value; 95%CI =  0.91; 0.79-1.03 vs 1.01; 0.91-1.11 g/min, respectively, P = 0.06) nor the exercise intensity at which maximal fat oxidation was achieved (i.e. Fatmax =  49; 48-53 vs 50; 47-51% Wmax, P = 0.52). Acute p-synephrine ingestion moved the fat oxidation-exercise intensity curve upwards during an incremental cycling test without affecting Fatmax.

Traditional Herbal Medicine in Mesoamerica: Toward Its Evidence Base for Improving Universal Health Coverage

The quality of health care in Mesoamerica is influenced by its rich cultural diversity and characterized by social inequalities. Especially indigenous and rural communities confront diverse barriers to accessing formal health services, leading to often conflicting plurimedical systems. Fostering integrative medicine is a fundamental pillar for achieving universal health coverage (UHC) for marginalized populations. Recent developments toward health sovereignty in the region are concerned with assessing the role of traditional medicines, and particularly herbal medicines, to foster accessible and culturally pertinent healthcare provision models. In Mesoamerica, as in most regions of the world, a wealth of information on traditional and complementary medicine has been recorded. Yet these data are often scattered, making it difficult for policy makers to regulate and integrate traditionally used botanical products into primary health care. This critical review is based on a quantitative analysis of 28 survey papers focusing on the traditional use of botanical drugs in Mesoamerica used for the compilation of the "Mesoamerican Medicinal Plant Database" (MAMPDB), which includes a total of 12,537 use-records for 2188 plant taxa. Our approach presents a fundamental step toward UHC by presenting a pharmacological and toxicological review of the cross-culturally salient plant taxa and associated botanical drugs used in traditional medicine in Mesoamerica. Especially for native herbal drugs, data about safety and effectiveness are limited. Commonly used cross-culturally salient botanical drugs, which are considered safe but for which data on effectiveness is lacking constitute ideal candidates for treatment outcome studies.

Influence of a Novel Food-Grade Formulation of Red Chili Extract (Capsicum annum) on Overweight Subjects: Randomized, Double-Blinded, Placebo-Controlled Study

Capsaicinoids from pungent red chilies (Capsicum annum and Capsicum frutescens) have received significant attention as a natural supplement for the management of obesity. However, the consumption of chili extract at physiologically relevant dosage of capsaicinoids is a challenge owing to its pungency and gastrointestinal discomforts. The present study reports the systemic absorption, safety and influence of a novel, food-grade, and sustained-release formulation of capsaicinoids-rich red chili extract using fenugreek dietary fiber (Capsifen^®). Twenty-four healthy overweight subjects were randomized into placebo (n = 12) and Capsifen (n = 12) groups and supplemented with 200 mg × 1/day of Capsifen (4 mg capsaicinoids/day) for 28 days. Influence of Capsifen on eating behavior and appetite was followed by Three-Factor Eating Questionnaire (TFEQ) and Council of Nutrition Appetite Questionnaire (CNAQ), respectively. Consumption of Capsifen did not reveal any adverse events or deviations in hematology and biochemical parameters related to safety. However, a significant decrease in body weight (2.1%), w/h ratio (4%) and body mass index (BMI) (2.2%) were observed among Capsifen group when compared to placebo. The TFEQ and appetite analysis revealed a significant improvement in uncontrolled eating and reduction in appetite among Capsifen subjects. The UPLC-ESI-MS/MS analysis confirmed the absorption of capsaicinoids from CAP supplementation. The study further demonstrated the safety and tolerability of Capsifen at the investigational dosage. Thus, the significant reduction in anthropometric parameters such as body weight, w/h ratio, and BMI along with the improvement in eating behaviour as well as appetite, indicated the potential body weight management effect of Capsifen.

A Critical Review on the Role of Food and Nutrition in the Energy Balance

The mass media has increasingly frequently suggested to the general population that specific foods or nutritional schemes are able to affect both human metabolism and energy expenditure, thus facilitating weight loss. This critical review is aimed at assessing available evidence on the roles of nutrients, food and dietary regimens in energy intake and energy expenditure. We queried the National Library of Medicine, the Cochrane Library, Excerpta Medica dataBASEand the Cumulative Index to Nursing and Allied Health Literature database, and a search strategy was performed by using database-specific subject headings and keywords. We found that available scientific evidence on these topics is scarce, and that the limited number of available studies often have poor methodological quality. Only a few foods show beneficial effects on metabolism and energy expenditure, as the human energy balance is complex and multifactorial. Finally, microbiota may interfere with the intake, use and expenditure of energy in the human body. Conclusive evidence is still lacking, and, at present, it is not possible to identify a food or a diet with a significant impact on human energy expenditure.

In-vivo biotransformation of citrus functional components and their effects on health

Citrus, one of the most popular fruits worldwide, contains various functional components, including flavonoids, dietary fibers (DFs), essential oils (EOs), synephrines, limonoids, and carotenoids. The functional components of citrus attract special attention due to their health-promoting effects. Food components undergo complex biotransformation by host itself and the gut microbiota after oral intake, which alters their bioaccessibility, bioavailability, and bioactivity in the host body. To better understand the health effects of citrus fruits, it is important to understand the in-vivo biotransformation of citrus functional components. We reviewed the biotransformation of citrus functional components (flavonoids, DFs, EOs, synephrines, limonoids, and carotenoids) in the body from their intake to excretion. In addition, we described the importance of biotransformation in terms of health effects. This review would facilitate mechanistic understanding of the health-promoting effect of citrus and its functional components, and also provide guidance for the development of health-promoting foods based on citrus and its functional components.

Mediterranean products as promising source of multi-target agents in the treatment of metabolic syndrome

Alteration of nutritional habits play an essential role on the risk of developing Metabolic Syndrome (MetS). Several epidemiological studies have shown that assuming diets rich of foods included in the Mediterranean diet (MetDiet) pattern like, such as olive oil, nuts, fruit, fiber, vegetables, wine and grain cereals has protective effects on the different risk factors characterizing the MetS. The beneficial effects of the MetDiet in the MetS are mainly due to the antioxidant and anti-inflammatory properties of the most abundant phytochemical components of such foods as polyphenols like resveratrol and oleuropein, allyl sulfides, ellagic acid, mono- and poly-unsaturated fatty acids (MUFA and PUFA), tocopherols and flavonoids like quercetin, which have shown positive results in the prevention of cardiovascular diseases (CVDs), with related risk factors, like hypertension, hypercholesterolemia and obesity. In this review, we highlighted the multi-target activities of the bioactive components contained in some foods typical of the Mediterranean area like olive oil, onion, liquorice, rosemary, oregano, hazelnut, pistachio, "Melannurca" apple, red wine, hot pepper, Citrus sp. fruits, saffron and garlic, with particular focus on their impact on health outcomes in relation to MetS main key factors, such as insulin resistance (IR) and type 2 diabetes mellitus (T2DM), endothelial dysfunctions, inflammatory response, oxidative stress and dyslipidaemic and hypercholesterolemic effects.

Acute p-synephrine ingestion increases whole-body fat oxidation during 1-h of cycling at Fatmax

PURPOSE

p-Synephrine, the principal alkaloid of bitter orange (Citrus aurantium), is widely used in dietary supplements for weight loss due to its purported effect of increasing fat oxidation. However, there is a paucity of scientific information about its effectiveness in enhancing fat oxidation during exercise. The aim of this investigation was to determine the effect of an acute dose of p-synephrine on substrate oxidation during prolonged and constant intensity exercise.

METHODS

In a double-blind and randomized experiment, 14 healthy subjects performed two acute experimental trials after ingesting either p-synephrine (3 mg kg^-1) or a placebo (cellulose). Energy expenditure and fat oxidation rates were continuously measured by indirect calorimetry during 1 h of continuous cycling at Fatmax, the intensity that induces maximal fat oxidation rate.

RESULTS

In comparison to the placebo, energy expenditure during 1 h of cycling remained unchanged with p-synephrine (698 ± 129 vs. 686 ± 123 kcal, P = 0.08). However, p-synephrine increased whole-body fat oxidation (33.6 ± 10.4 vs. 37.3 ± 9.8 g, P < 0.01) while also reducing carbohydrate oxidation (99.5 ± 30.4 vs. 85.0 ± 28.4 g, P < 0.01). However, the magnitude of the shift on substrate oxidation induced by p-synephrine was small.

CONCLUSION

Acute ingestion of p-synephrine augments fat oxidation during prolonged and constant-intensity exercise.

p-Synephrine exhibits anti-adipogenic activity by activating the Akt/GSK3β signaling pathway in 3T3-L1 adipocytes

This work aimed to investigate the effects of p-synephrine on the differentiation of adipocyte and explore the underlying mechanism. We found that p-synephrine suppressed the 3T3-L1 cell adipogenesis by reducing the expression level of CCAAT/enhancer-binding protein α (C/EBPα) and peroxisome proliferator-activated receptor γ (PPARγ), which subsequently led to a reduction in the fatty acid-binding protein 4 (aP2) expression. p-Synephrine treatment markedly activated the protein kinase B (PKB/Akt) pathway and sequentially inhibited glycogen synthase kinase 3β (GSK3β) activity. Inhibition of GSK3β activity by LiCl was found to partially ameliorate the above-mentioned effects. All these data suggested that p-synephrine exhibited the anti-adipogenic effects via the regulation of Akt signaling pathway and the suppression of adipogenesis-related proteins. PRACTICAL APPLICATIONS: Citrus aurantium often uses as herbal or dietary supplement in various countries around the world, including in Seville, Spain and South Africa. In traditional Chinese herbs, it is referred to as "Fructus aurantii immaturus," "Zhi shi," or "Zhi ke," and has been used for hundreds of years for various digestive problems. Its primary protoalkaloid, p-synephrine, exhibited lipolytic effects and energy expenditure, which has rapidly replaced ephedrine as an "ephedra-free" alternative dietary supplement. The current study firstly demonstrated the anti-adipogenic effects of p-synephrine in 3T3-L1 preadipocytes, which was due to the regulation of Akt signaling pathway and the subsequent suppression of adipogenesis-related proteins. The present study may offer invaluable opinions into the mechanisms of body weight/fat-losing activities of p-synephrine in theory, and scientific experimental evidence on dietary supplement in practice. p-Synephrine could be utilized for the preventive and therapeutic uses against metabolic syndrome.

Physicochemical and cytotoxicity analysis of green synthesis carbon dots for cell imaging

Carbon dots (CDs) have outstanding optical properties, biocompatibility, and photostability, making them attractive for imaging applications. A facile and green one-step hydrothermal synthesis method is proposed, which can be safely used in a wide range of applications such as chemical sensing, bioimaging, and optoelectronics. In this study, we report green synthesis of carbon dots from bitter orange juice (Citrus Aurantium) by hydrothermal treatment for the first time. We studied effects of time, temperature, and pH on fluorescence of CDs, characterized them using various spectroscopic and microscopic methods, and evaluated their toxicity to different cell lines. Identifying an optimum reaction condition of 180 ºC for 7 h heating gave CDs that showed pH-dependent fluorescence, with the largest fluorescence at a pH of 7.0. The CDs were 1-2 nm in size with a spherical morphology and negative surface charge. The CDs showed a high quantum yield of 19.9 %, reasonable photostability, excellent water solubility, and long fluorescence lifetime. A one step hydrothermal rout led to various hydrophilic functional groups on the surface of the CDs. Our results showed that the CDs were non-toxic over a large concentration range and effective for imaging of cells, indicating their potential as imaging probes in medical diagnostics and biosensor applications.

Effects of p-Synephrine and Caffeine Ingestion on Substrate Oxidation during Exercise

PURPOSE

Caffeine and p-synephrine are substances usually included in commercially available products for weight loss because of their purported thermogenic effects. However, scientific information is lacking about the effects of combining these substances on substrate oxidation during exercise. The purpose of this investigation was to determine the isolated and combined effects of p-synephrine and caffeine on fat oxidation rate during exercise.

METHODS

In a double-blind randomized experiment, 13 healthy subjects participated in four experimental trials after the ingestion of a capsule containing a placebo, 3 mg·kg of caffeine, 3 mg·kg of p-synephrine, or the combination of these doses of caffeine and p-synephrine. Energy expenditure and substrate oxidation rates were measured by indirect calorimetry during a cycle ergometer ramp test from 30% to 90% of V˙O2max.

RESULTS

In comparison with the placebo, the ingestion of caffeine, p-synephrine, or p-synephrine + caffeine did not alter total energy expenditure or heart rate during the whole exercise test. However, the ingestion of caffeine (0.44 ± 0.15 g·min, P = 0.03), p-synephrine (0.43 ± 0.19 g·min, P < 0.01), and p-synephrine + caffeine (0.45 ± 0.15 g·min, P = 0.02) increased the maximal rate of fat oxidation during exercise when compared with the placebo (0.30 ± 0.12 g·min). The exercise intensity that elicited maximal fat oxidation was similar in all trials (~46.2% ± 10.2% of V˙O2max).

CONCLUSION

Caffeine, p-synephrine, and p-synephrine + caffeine increased the maximal rate of fat oxidation during exercise compared with a placebo, without modifying energy expenditure or heart rate. However, the coingestion of p-synephrine and caffeine did not present an additive effect to further increase fat oxidation during exercise.

Analysis of the cytotoxic, genotoxic, mutagenic, and pro-oxidant effect of synephrine, a component of thermogenic supplements, in human hepatic cells in vitro

Thermogenic supplements containing synephrine (SN) are widely used to weight loss. SN is a proto-alkaloid naturally found in the bark of immature fruits of Citrus aurantium (bitter orange) that has been added to thermogenic supplements due to its chemical and pharmacological similarity with adrenergic amines, such as ephedrine and amphetamines. Although orally ingested SN is mainly metabolized in the liver, it remains unclear whether it affects the redox status and genetic material of human hepatic cells. The present study aims to examine whether SN affects cell viability, cell cycle, redox balance, genomic stability, and expression of the DNA damage response (DDR)-related genes ATM, ATR, CHEK1, CHECK2, TP53, and SIRT1 in HepG2 cells - used as in vitro hepatocyte model. SN induced overproduction of intracellular reactive oxygen species (ROS) after 6 h of treatment with the three concentrations tested (2, 20 and 200 μM). After 24 h of treatment, SN at 200 μM induced intracellular ROS overproduction and exerted cytostatic effects, while SN at 20 and 200 μM increased the levels of GPx and GSH. SN was not cytotoxic (2-5000 μM), genotoxic, and mutagenic and did not alter the expression of DDR-related genes (2-200 μM), indicating that the fast/specific SN metabolization and upregulation of antioxidant defense components to detoxify intracellular ROS were sufficient to prevent intracellular damage in HepG2 cells. In conclusion, SN showed no cytotoxic, genotoxic, and mutagenic potential at relevant concentrations for thermogenic users in human hepatic cells in vitro, although, it plays pro-oxidative action, and cytostatic effects. Taken together, our results suggest that other investigations about the hazard absence of this thermogenic compound should be performed.

Citrus Aurantium and caffeine complex versus placebo on biomarkers of metabolism: a double blind crossover design

BACKGROUOND

The purpose of this study was to examine resting the metabolic response to the ingestion of a complex containing Citrus Aurantium + Caffeine (CA + C) and if its consumption influences metabolic recovery following a high-intensity anaerobic exercise bout in habitual caffeine users.

METHODS

Ten physically active males (25.1 ± 3.9 years; weight 78.71 ± 9.53 kg; height 177.2 ± 4.6 cm; body fat 15.5 ± 3.13%) participated in this study. This study was performed in a double-blind, randomized crossover fashion consisting of two exhaustive exercise protocols. On each visit the participants consumed either a CA + C (100 mg of CA and 100 mg of C) or placebo (dextrose) capsule. After consumption, participants were monitored throughout a 45-min ingestion period, then completed a repeated Wingate protocol, and were then monitored throughout a 45-min recovery period. Metabolic function was measured through blood glucose, plasma insulin, plasma triglycerides, and plasma catecholamines: epinephrine (E) and norepinephrine (NE). Biomarkers were taken at four different time points; Ingestion period: baseline (I1), post-ingestion period (I2); Recovery period: immediately post-exercise (R1), post-recovery period (R2).

RESULTS

A repeated measures ANOVA revealed significant time-dependent increases in plasma E and NE at I2 only in the CA + C trial (p < 0.05), and a significant decrease in blood glucose at I2 in the PLA trial (p < 0.05); however, no meaningful changes in glucose was observed following CA + C ingestion. No changes in insulin or triglycerides were observed during the ingestion period. No trial-dependent differences were observed in the Recovery period. All biomarkers of metabolic recovery were equivalent when evaluating R1 v R2. Participants recovered in a similar time-dependent manner in all markers of metabolism following the PLA and CA + C trials.

CONCLUSION

The findings of this study suggested that normal recommended dosages of 100 mg CA + 100 mg C is sufficient to promote glucose sparing at rest, with modest increases in SNS activity; however, the individual role of CA or C in this response cannot be determined.

The solvation properties and effect of d-fructose on the taste behavior of Citrus aurantium active components in aqueous solutions

The densities and viscosities of synephrine hydrochloride and octopamine hydrochloride aqueous solutions were determined. Apparent molar volumes, apparent molar volume at infinite dilution, viscosity B-coefficients and hydration number were calculated, and it was found that synephrine hydrochloride acts as a better structure maker than octopamine hydrochloride in aqueous solutions. The densities of the investigated salts were measured in aqueous d-fructose solutions, and the corresponding apparent molar volumes of transfer at infinite dilution were determined. Its taste behavior was discussed based on the calculated values for apparent specific volume and intrinsic viscosity. Molecular dynamics simulations and radial distribution functions were applied in order to understand the nature of the interactions and water structuring in the studied systems. The change in taste behavior was observed with increasing concentration of the cosolute, and it was found that the addition of sugar increases the bitterness of the solution. From a molecular docking study on the bitter receptor TAS2R38, the strongest interactions for synephrine-HCl were noted causing the most bitter taste.

Clinical Investigations of the Effect of Citrus unshiu Peel Pellet on Obesity and Lipid Profile

Objectives

Several experimental studies have reported antiobesity and lipid-improving effects of Citrus unshiu. However, clinical studies on its effects are lacking. This study was designed to evaluate the impact of Citrus unshiu peel pellet (CUPP) on obesity and lipid profile.

Methods

For 118 patients with body mass index (BMI) > 23 who took Citrus unshiu peel pellet (CUPP) for 4 weeks in a Public Health Center, laboratory and biometric readings before and after CUPP administration were analyzed.

Results

Mean age of these subjects was 53.8±10.6 years (range: 18-75 years). There were 88 (74.6%) females in the study sample (n = 118). A significant (p < 0.01) decrease in BMI from 27.47±2.24 to 27.27±2.22 was observed in all subjects after CUPP treatment and 65.3% (N = 77) of them lost 1.03±0.83 kg of weight after 4 weeks of treatment. Total cholesterol level was significantly (p < 0.01) decreased from 204.0±37.4 mg/dL to 193.5±36.5 mg/dL. Significant (p < 0.05) decreases in levels of low-density lipoprotein, cholesterol, and triglyceride were also observed.

Conclusions

These results suggest that CUPP in practice could help weight control and improve total cholesterol level. Findings of this study provide clinical foundation for future large-scale trials to establish clinical benefits of CUPP.

The influence of citrus aurantium and caffeine complex versus placebo on the cardiac autonomic response: a double blind crossover design

Background

The purpose of this study was to examine the resting cardiac autonomic nervous system’s response to the ingestion of a complex containing Citrus aurantium + Caffeine (CA + C) and its influence on recovery following a high-intensity anaerobic exercise bout in habitual caffeine users.

Methods

Ten physically active males (25.1 ± 3.9 years; weight 78.71 ± 9.53 kg; height 177.2 ± 4.6 cm; body fat 15.5 ± 3.13%) participated in this study, which consisted of two exhaustive exercise protocols in a randomized crossover design. On each visit the participants consumed either a CA + C (100 mg of CA and 100 mg of C) or placebo (dextrose) capsule. After consumption, participants were monitored throughout a 45-min ingestion period, then completed a repeated Wingate protocol, and were then monitored throughout a 45-min recovery period. Cardiac autonomic function (Heart Rate (HR) and Heart Rate Variability (HRV)) and plasma epinephrine (E) and norepinephrine (NE) were taken at four different time points; Ingestion period: baseline (I1), post-ingestion period (I2); Recovery period: immediately post-exercise (R1), post-recovery period (R2). Heart rate variability was assessed in 5-min increments.

Results

A repeated measures ANOVA revealed significant time-dependent increases in HR, sympathetic related markers of HRV, and plasma E and NE at I2 only in the CA + C trial (p < 0.05); however, no meaningful changes in parasympathetic markers of HRV were observed. Participants recovered in a similar time-dependent manner in all markers of HRV and catecholamines following the PLA and CA + C trials.

Conclusion

The consumption of CA + C results in an increase of sympathetic activity during resting conditions without influencing parasympathetic activity. CA + C provides no influence over cardiac autonomic recovery.

An Overview on Citrus aurantium L.: Its Functions as Food Ingredient and Therapeutic Agent

Citrus aurantium L. (Rutaceae), commonly known as bitter orange, possesses multiple therapeutic potentials. These biological credentials include anticancer, antianxiety, antiobesity, antibacterial, antioxidant, pesticidal, and antidiabetic activities. The essential oil of C. aurantium was reported to display marked pharmacological effects and great variation in chemical composition depending on growing locations but mostly contained limonene, linalool, and β-myrcene. Phytochemically, C. aurantium is rich in p-synephrine, an alkaloid, and many health-giving secondary metabolites such as flavonoids. Animal studies have demonstrated a low affinity of p-synephrine for adrenergic receptors and an even lower affinity in human models. The present review focuses on the different biological activities of the C. aurantium in animal and human models in the form of extract and its pure secondary metabolites. Finally, it is concluded that both the extract and isolated compounds have no unwanted effects in human at therapeutic doses and, therefore, can confidently be used in various dietary formulations.

Acute hematological and mood perception effects of bitter orange extract (p-synephrine) consumed alone and in combination with caffeine: A placebo-controlled, double-blind study

The purpose of this study was to examine acute hematological and mood perception responses to supplementation with p-synephrine alone and in combination with caffeine during quiet sitting. Sixteen subjects visited the laboratory on 6 occasions and were given (in randomized double-blind manner) 103-mg p-synephrine (S), 233-mg caffeine + 104-mg p-synephrine, 240-mg caffeine, 337-mg caffeine + 46-mg p-synephrine, 325-mg caffeine, or a placebo (PL). The subjects sat quietly for 3 hr while completing mood state questionnaires every 30 min. Venous blood samples were collected at baseline (pre) and 3 hr (post) to determine immune, lipid, and chemistry panels. Compared with PL, no significant supplement differences were observed during the S trial with the exception of differential time effects seen in hematocrit (decrease in PL, no change in S), triglycerides and very low-density lipoproteins (no changes in PL, significant decreases in S), and iron (no change in PL, significant elevation in S). Supplements containing caffeine showed increased feelings of attention, excitement, energy, and vigor. These data indicate that consumption of 103-mg p-synephrine does not negatively impact acute blood parameters, does not augment the effects of caffeine, or produce stimulant-like perceptual mood effects.

Citrus aurantium L. dry extracts promote C/ebpβ expression and improve adipocyte differentiation in 3T3-L1 cells

Metabolic and/or endocrine dysfunction of the white adipose tissue (WAT) contribute to the development of metabolic disorders, such as Type 2 Diabetes (T2D). Therefore, the identification of products able to improve adipose tissue function represents a valuable strategy for the prevention and/or treatment of T2D. In the current study, we investigated the potential effects of dry extracts obtained from Citrus aurantium L. fruit juice (CAde) on the regulation of 3T3-L1 cells adipocyte differentiation and function in vitro. We found that CAde enhances terminal adipocyte differentiation of 3T3-L1 cells raising the expression of CCAAT/enhancer binding protein beta (C/Ebpβ), peroxisome proliferator activated receptor gamma (Pparγ), glucose transporter type 4 (Glut4) and fatty acid binding protein 4 (Fabp4). CAde improves insulin-induced glucose uptake of 3T3-L1 adipocytes, as well. A focused analysis of the phases occurring in the pre-adipocytes differentiation to mature adipocytes furthermore revealed that CAde promotes the early differentiation stage by up-regulating C/ebpβ expression at 2, 4 and 8 h post the adipogenic induction and anticipating the 3T3-L1 cell cycle entry and progression during mitotic clonal expansion (MCE). These findings provide evidence that the exposure to CAde enhances in vitro fat cell differentiation of pre-adipocytes and functional capacity of mature adipocytes, and pave the way to the development of products derived from Citrus aurantium L. fruit juice, which may improve WAT functional capacity and may be effective for the prevention and/or treatment of T2D.

Actions of p-synephrine on hepatic enzyme activities linked to carbohydrate metabolism and ATP levels in vivo and in the perfused rat liver

p-Synephrine is one of the main active components of the fruit of Citrus aurantium (bitter orange). Extracts of the bitter orange and other preparations containing p-synephrine have been used worldwide to promote weight loss and for sports performance. The purpose of the study was to measure the action of p-synephrine on hepatic enzyme activities linked to carbohydrate and energy metabolism and the levels of adenine mononucleotides. Enzymes and adenine mononucleotides were measured in the isolated perfused rat liver and in vivo after oral administration of the drug (50 and 300 mg/kg) by using standard techniques. p-Synephrine increased the activity of glycogen phosphorylase in vivo and in the perfused liver. It decreased, however, the activities of pyruvate kinase and pyruvate dehydrogenase also in vivo and in the perfused liver. p-Synephrine increased the hepatic pools of adenosine diphosphate and adenosine triphosphate. Stimulation of glycogen phosphorylase is consistent with the reported increased glycogenolysis in the perfused liver and increased glycemia in rats. The decrease in the pyruvate dehydrogenase activity indicates that p-synephrine is potentially capable of inhibiting the transformation of carbohydrates into lipids. The capability of increasing the adenosine triphosphate-adenosine diphosphate pool indicates a beneficial effect of p-synephrine on the cellular energetics.

Safety evaluation of p-synephrine following 15 days of oral administration to healthy subjects: A clinical study

Extracts of bitter orange (BOE, Citrus aurantium L.) and its primary protoalkaloid p-synephrine are extensively consumed as dietary supplements. p-Synephrine is also present in foods and juices prepared from various Citrus species. The safety of p-synephrine has been questioned as a result of structural similarities with ephedrine. This study assessed the cardiovascular (stimulant) and hemodynamic effects of BOE (49 mg p-synephrine) daily given to 16 healthy subjects for 15 days in a placebo-controlled, cross-over, double-blinded study. A physical evaluation by a cardiologist, as well as heart rates, blood pressures, and electrocardiograms were determined, and blood samples were drawn at baseline, and Days 5, 10, and 15. Serum levels for caffeine and p-synephrine were measured at 1 and 2 weeks. Subjects completed a 10-item health and metabolic questionnaire at baseline and on Day 15. No significant changes occurred in heart rate, electrocardiograms, systolic blood or diastolic pressures, blood cell counts, or blood chemistries in either the control or p-synephrine treated groups at any time point. No adverse effects were reported in response to the bitter orange (p-synephrine). Caffeine consumed by the participants varied markedly. Under these experimental conditions, BOE and p-synephrine were without stimulant (cardiovascular) and adverse effects.

Bitter orange (Citrus aurantium L.) extract subchronic 90-day safety study in rats

Bitter orange (Citrus aurantium L.) extracts are widely used in dietary supplements and bitter oranges are used in various juices and food products. p-Synephrine, the primary active constituent, comprises approximately 90% of total protoalkaloids. This study, performed per OECD 408 guidance, examined the 90-day subchronic safety/toxicity of an extract standardized to 50% p-synephrine at doses of 100, 300 and 1000 mg/kg/day to male and female rats. No adverse effects were observed with respect to any of the observed parameters of clinical signs, functional observations of sensory reactivity, grip strength and motor activity, ophthalmology, body weights, hematology, food consumption, urinalysis, organ weights, as well as gross and microscopic pathology at termination at any of the doses in either sex. Treatment at 1000 mg/kg body weight/day of the extract resulted in non-adverse effects including fully reversible signs of repetitive head burrowing in the bedding material and piloerection for short periods of time in both sexes immediately after administration, which gradually disappeared by treatment day-81. A slight and reversible elevation of BUN and urea levels in male rats, and slight to mild increase in the relative but not absolute heart weights of male and female rats was observed. Based on these results, the no-observed-effect-level (NOEL) for this bitter orange extract standardized to 50% p-synephrine was 300 mg/kg, while the no-observed-adverse-effect-level (NOAEL) was 1000 mg/kg. The results indicate a high degree of safety for this bitter orange extract.

The Combined Effects of Exercise, Diet, and a Multi-Ingredient Dietary Supplement on Body Composition and Adipokine Changes in Overweight Adults

BACKGROUND

Very few weight and fat loss supplements undergo finished-product research to examine efficacy. The purpose of this study was to determine the effects of an 8-week diet and exercise program on body composition, hip and waist girth, and adipokines and evaluate whether a dietary supplement containing raspberry ketone, capsaicin, caffeine, garlic, and Citrus aurantium enhanced outcomes.

METHODS

Overweight men and women completed this randomized, placebo-controlled, double-blind study. Participants consumed 4 capsules/d of supplement (EXP; n = 18) or placebo (PLA; n = 18). Participants underwent 8 weeks of daily supplementation, calorie restriction (500 kcal < RMR [resting metabolic rate] × 1.2), and supervised progressive exercise training 3 times a week. Body composition, girth, and adipokines were assessed at baseline and postintervention (T1 and T2).

RESULTS

Significant decreases in weight (-2.6 ± 0.57 kg, p < 0.001), fat mass (-1.8 ± 0.20 kg; p < 0.001), and percentage body fat (-3.7% ± 0.29%, p < 0.001) and a significant increase in lean body mass (LBM; 1.5 ± 0.26 kg; p < 0.001) were seen from T1 to T2 in both groups. For men, only those in the EXP group increased LBM from T1 to T2 (1.3 ± 0.38 kg; p < 0.05). Hip girth was also reduced, with the women in the EXP group (-10.7 ± 2.15 cm, p < 0.001) having a greater reduction. There was a time by group interaction, with significant decreases in leptin (p < 0.001) and significant increases in adiponectin (p < 0.05) in the EXP group.

CONCLUSIONS

Significant improvements in adipokines and leptin support the utility of exercise, diet, and fat loss for impacting inflammatory biomarkers. The improvement in adiponectin with EXP may suggest a unique health mechanism.

Acute cardiovascular effects of bitter orange extract (p-synephrine) consumed alone and in combination with caffeine in human subjects: A placebo-controlled, double-blind study

The purpose was to examine cardiovascular responses to supplementation with p-synephrine alone and in combination with caffeine during quiet sitting. Sixteen subjects were given (in double-blind manner) either 103 mg of p-synephrine (S), 233 mg of caffeine +104 mg of p-synephrine (LC + S), 240 mg of caffeine (LC), 337 mg of caffeine +46 mg of p-synephrine (HC + S), 325 mg of caffeine (HC), or a placebo. The subjects sat quietly for 3 hr while heart rate (HR) and blood pressure were measured. Only HC + S and HC significantly increased mean systolic blood pressure (SBP) during the second hour and tended to increase mean SBP during the third hour. Mean diastolic blood pressure in S was significantly lower than the other trials during the first and second hours, and mean arterial pressure was significantly lower in S compared to the LC, LC + S, HC, and HC + S trials. No differences were observed in HR. Consumption of p-synephrine may acutely reduce diastolic blood pressure and mean arterial pressure and not affect SBP or HR during quiet sitting. The addition of p-synephrine to caffeine did not augment SBP or HR indicating that consumption of up to 104 mg of p-synephrine does not induce cardiovascular stress during quiet sitting.

Heart Toxicity Related to Herbs and Dietary Supplements: Online Table of Case Reports. Part 4 of 5

BACKGROUND

The purpose of this review was to create an online research summary table of heart toxicity case reports related to dietary supplements (DS; includes herbs).

METHODS

Documented PubMed case reports of DS appearing to contribute to heart-related problems were used to create a "Toxic Table" that summarized the research (1966 to April, 2016, and cross-referencing). Keywords included "herb," "dietary supplement," and cardiac terms. Case reports were excluded if they were herb combinations (some exceptions), Chinese herb mixtures, teas of mixed herb contents, mushrooms, poisonous plants, self-harm (e.g. suicide), excess dose (except vitamins/minerals), drugs or illegal drugs, drug-herbal interactions, and confounders of drugs or diseases. The spectrum of heart toxicities included hypertension, hypotension, hypokalemia, bradycardia, tachycardia, arrhythmia, ventricular fibrillation, heart attack, cardiac arrest, heart failure, and death.

RESULTS

Heart related problems were associated with approximately seven herbs: Four traditional Chinese medicine herbs - Don quai (Angelica sinensis), Jin bu huan (Lycopodium serratum), Thundergod vine or lei gong teng (Tripterygium wilfordii Hook F), and Ting kung teng (Erycibe henryi prain); one an Ayruvedic herb - Aswagandha, (Withania somnifera); and two North American herbs - blue cohosh (Caulophyllum thalictroides), and Yohimbe (Pausinystalia johimbe). Aconitum and Ephedra species are no longer sold in the United States. The DS included, but are not limited to five DS - bitter orange, caffeine, certain energy drinks, nitric oxide products, and a calming product. Six additional DS are no longer sold. Licorice was the food related to heart problems.

CONCLUSION

The online "Toxic Table" forewarns clinicians, consumers and the DS industry by listing DS with case reports related to heart toxicity. It may also contribute to Phase IV post marketing surveillance to diminish adverse events that Government officials use to regulate DS.

Safety, Efficacy, and Mechanistic Studies Regarding Citrus aurantium (Bitter Orange) Extract and p-Synephrine

Citrus aurantium L. (bitter orange) extracts that contain p-synephrine as the primary protoalkaloid are widely used for weight loss/weight management, sports performance, appetite control, energy, and mental focus and cognition. Questions have been raised about the safety of p-synephrine because it has some structural similarity to ephedrine. This review focuses on current human, animal, in vitro, and mechanistic studies that address the safety, efficacy, and mechanisms of action of bitter orange extracts and p-synephrine. Numerous studies have been conducted with respect to p-synephrine and bitter orange extract because ephedra and ephedrine were banned from use in dietary supplements in 2004. Approximately 30 human studies indicate that p-synephrine and bitter orange extracts do not result in cardiovascular effects and do not act as stimulants at commonly used doses. Mechanistic studies suggest that p-synephrine exerts its effects through multiple actions, which are discussed. Because p-synephrine exhibits greater adrenergic receptor binding in rodents than humans, data from animals cannot be directly extrapolated to humans. This review, as well as several other assessments published in recent years, has concluded that bitter orange extract and p-synephrine are safe for use in dietary supplements and foods at the commonly used doses. Copyright © 2017 The Authors Phytotherapy Research Published by John Wiley & Sons Ltd.

Citrus aurantium (bitter orange) extract: Safety assessment by acute and 14-day oral toxicity studies in rats and the Ames Test for mutagenicity

The primary active constituent in bitter orange extract (BOE) is p-synephrine. This study assessed the safety of a BOE standardized to 50% p-synephrine following short-term exposure to rats and by the Ames Test. Following 5000 mg/kg of the extract orally to female rats all animals survived. Administration at 2000 mg/kg to female rats for four days yielded no signs of toxicity. Five male and five female rats were administered the BOE at 0, 250, 500, 1000 and 2000 mg/kg/day for 14 days. No significant effects were observed at any dose with respect to body weights, food intake, absolute and relative organ weights, hematology, clinical chemistry, and pathology. Two male rats died after 2000 mg/kg with gastrointestinal impaction at necropsy. During week two of 1000 mg/kg and 2000 mg/kg/day, rats exhibited transient signs of repetitive burrowing of heads in the bedding material (hypoactivity) for about 15 and 45 min, respectively. The no-observed-effect-level (NOEL) was 500 mg/kg/day. The mutagenic potential was assessed at and up to the limit dose of 5000 μg/plate in a Salmonella typhimurium reverse mutation (Ames) test, performed in duplicate as a pre-incubation assay in the presence and absence of metabolic activation (S9). The BOE did not induce an increase in the frequency of revertant colonies at any dose in the five tester strains, and was therefore non-mutagenic.

Liver toxicity mechanisms of herbs commonly used in Latin America

Mexico owns approximately 4500 medicinal plants species, a great diversity that position it at the second place after China. According to the Mexican health department, 90% of common population consumes them to treat various diseases. Additionally, herbal remedies in Latin America (LA) are considered a common practice, but the frequency of use and the liver damage related to its consumption is still unknown. Despite the high prevalence and indiscriminate herbal consumption, the exact mechanism of hepatotoxicity and adverse effects is not fully clarified and is still questioned. Some herb products associated with herb induced liver injury (HILI) are characterized by presenting a different chemical composition that may vary from batch to batch, also the biological activity of many medicinal plants and other natural products are directly related to their most active component and its concentration. There are two main biological components that are associated with liver damage, alkaloids, and flavonoids, which are frequent constituents of commonly used herbs. The interaction with the different cytochrome P-450 isoforms, inflammatory, and oxidative activities seem to be the main damage pathway involved in the liver. It is important to know the herbal adverse effects and mechanisms involved; therefore, this article is focused on the beneficial and deleterious effects as well as the possible toxicity mechanisms and interactions of the herbs that are frequently used in LA, since the herb-host interaction may not always be the expected or desired depending on the clinical context in which it is administered.

Effects of acute ingestion of a pre-workout dietary supplement with and without p-synephrine on resting energy expenditure, cognitive function and exercise performance

BACKGROUND

The purpose of this study was to examine the effects of acute ingestion of a pre-workout dietary supplement (PWS) with and without p-synephrine (S) on perceptions of readiness to perform, cognitive function, exercise performance, and markers of safety.

METHODS

In a randomized, double-blind, and counterbalanced manner; 25 healthy and recreationally active male and female participants ingested a flavored maltodextrin placebo (PLA), a PWS containing beta-alanine (3 g), creatine nitrate as a salt (2 g), arginine alpha-ketoglutarate (2 g), N-Acetyl-L-Tyrosine (300 mg), caffeine (284 mg), Mucuna pruiriens extract standardized for 15% L-Dopa (15 mg), Vitamin C as Ascorbic Acid (500 mg), niacin (60 mg), folate as folic acid (50 mg), and Vitamin B12 as Methylcobalamin (70 mg) with 2 g of maltodextrin and flavoring; or, the PWS with Citrus aurantium (PWS + S) extract standardized for 30% p-synephrine (20 mg). Participants had heart rate (HR), blood pressure, resting energy expenditure (REE), 12-lead electrocardiograms (ECG), perceptions about readiness to perform, cognitive function (Stroop Color-Word test), bench and leg press performance (2 sets of 10 repetitions at 70% of 1RM and 1 set to failure), and Wingate anaerobic capacity (WAC) sprint performance determined as well as donated blood samples prior to and/or following exercise/supplementation. Data were analyzed by MANOVA with repeated measures as well as mean changes from baseline with 95% confidence intervals (CI).

RESULTS

No clinically significant differences were observed among treatments in HR, blood pressure, ECG, or general clinical blood panels. There was evidence that PWS and PWS + S ingestion promoted greater changes in REE responses. Participants reported higher perception of optimism about performance and vigor and energy with PWS and PWS + S ingestion and there was evidence that PWS and PWS + S improved changes in cognitive function scores from baseline to a greater degree than PLA after 1 or 2 h. However, the scores in the PWS + S treatment did not exceed PLA or PWS responses at any data point. No statistically significant differences were observed among treatments in total bench press lifting volume, leg press lifting volume or WAC sprint performance.

CONCLUSIONS

Within the confines of this study, ingestion of PWS and/or PWS + S prior to exercise appears to be well-tolerated when consumed by young, healthy individuals. The primary effects appear to be to increase REE responses and improve perceptions about readiness to perform and cognitive function with limited to no effects on muscular endurance and WAC. The addition of 20 mg of p-synephrine to the PWS provided limited to no additive benefits.

TRIAL REGISTRATION

This trial (NCT02952014) was retrospectively registered on September 13th 2016.

Acute p-synephrine ingestion increases fat oxidation rate during exercise

AIMS

p-Synephrine is a protoalkaloid widely used in dietary supplements for weight management because of its purported thermogenic effects. However, there is a lack of scientific information about its effectiveness to increase fat metabolism during exercise. The purpose of this investigation was to determine the effects of an acute ingestion of p-synephrine on fat oxidation at rest and during exercise.

METHODS

In a double-blind, randomized and counterbalanced experimental design, 18 healthy subjects performed two acute experimental trials after the ingestion of p-synephrine (3 mg kg(-1) ) or after the ingestion of a placebo (cellulose). Energy expenditure and fat oxidation rates were measured by indirect calorimetry at rest and during a cycle ergometer ramp exercise test (increases of 25 W every 3 min) until volitional fatigue.

RESULTS

In comparison with the placebo, the ingestion of p-synephrine did not change energy consumption (1.6 ± 0.3 vs. 1.6 ± 0.3 kcal min(-1) ; P = 0.69) or fat oxidation rate at rest (0.08 ± 0.02 vs. 0.10 ± 0.04 g min(-1) ; P = 0.15). However, the intake of p-synephrine moved the fat oxidation-exercise intensity curve upwards during the incremental exercise (P < 0.05) without affecting energy expenditure. Moreover, p-synephrine increased maximal fat oxidation rate (0.29 ± 0.15 vs. 0.40 ± 0.18 g min(-1) ; P = 0.01) during exercise although it did not affect the intensity at which maximal fat oxidation was achieved (55.8 ± 7.7 vs. 56.7 ± 8.2% VO2peak ; P = 0.51).

CONCLUSIONS

The acute ingestion of p-synephrine increased the fat oxidation rate while it reduced the carbohydrate oxidation rate when exercising at low-to-moderate exercise intensities.