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Review Article
 

Iranian Medicinal Plants for Diabetes Mellitus: A Systematic Review



Ali Akbar Rashidi, Seyyed Mehdi Mirhashemi, Mohsen Taghizadeh and Parisa Sarkhail
 
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ABSTRACT

In the Iranian traditional medicine a significant usage of herbs is promoted for their anti-diabetic activity. The aim of this review to assess the efficacy of glucose lowering effects of medicinal plants cultivated in Iran. An electronic literature search of MEDLINE, Science Direct, EMBASE, Scopus, Web of Science, Cochrane Library Database, Ebsco and Google Scholar from database inception conducted up to May 2012. A total of 85 studies (18 humans and 67 animals) examining 62 plants were reviewed. The quality of Randomized Controlled Trials (RCTs) assessed by using the Jadad scale. Among the RCTs studies, the best results in glycemic control was found in Aloe vera, Citrullus colocynthus, Plantago ovata, Silybum marianum, Rheum ribes and Urtica dioica. The majority of plants that have been studied for antidiabetic activity showed promising results. However, efficacy and safety of the most plants used in the treatment of diabetes are not sufficient.

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  How to cite this article:

Ali Akbar Rashidi, Seyyed Mehdi Mirhashemi, Mohsen Taghizadeh and Parisa Sarkhail, 2013. Iranian Medicinal Plants for Diabetes Mellitus: A Systematic Review. Pakistan Journal of Biological Sciences, 16: 401-411.

DOI: 10.3923/pjbs.2013.401.411

URL: https://scialert.net/abstract/?doi=pjbs.2013.401.411
 
Received: December 11, 2012; Accepted: February 15, 2013; Published: March 26, 2013

INTRODUCTION

Diabetes mellitus is a group of metabolic disorders which are characterized by chronic hyperglycemia, resulting from defects in insulin secretion or insulin action (Patel et al., 2012). The disease causes substantial morbidity, mortality, long term complications and is defined as an important risk factor for cardiovascular disease (Yeh et al., 2003). It is predicated that the number of diabetic patients in the world could reach up to 366 million by the year 2030 (Patel et al., 2012). Approximately two million people (7.7%) of Iranian adults, aged 25-64 years, have been diagnosed as diabetic and about 4.4 million(16.8%) of them have impaired fasting glucose (Mirbadalalzadeh and Shirdel, 2010). Since, ancient times, plants have played an important role in the treatment of many diseases. Different parts of medicinal plants such as leaf, root, flower and seed are used as extracts and chemical compounds to produce drugs (Nikbakht et al., 2008). Properties of medicinal plants are due to the presence of various complex chemical substances categorized as alkaloids, glycosides, flavonoids, saponins, tannins, carbohydrate and essential oils (Najafi et al., 2010). Today, more than 400 plants in traditional medicine are reported for the treatments of diabetes, although only some of them have been evaluated (Modak et al., 2007). The use of plants for the treatment of diabetes has been common among the Iranian population (Hasani-Ranjbar et al., 2008). Plants which have been shown to have hypoglycemic activity affect on blood glucose through different mechanisms (Estakhr and Javdan, 2011). Many medications currently used in conventional medicine are obtained from natural plants. For instance, Metformin which is the common drug for management of type 2 diabetes with hypoglycemic activity is derived from the plant, Galega officinalis. However, there isn't so many evidence about efficacy and safety of medicinal plants glycemic control (Yeh et al., 2003). Our objective was to review and summarize the literature on Iranian native medicinal plants which are used to control of glycemia in diabetes, to guide patients and practitioners in advising their patients and to provide recommendations for future research.

MATERIALS AND METHODS

We searched MEDLINE, Science Direct, EMBASE, Scopus, Web of Science, Cochrane Library Database, Ebsco and Google Scholar databases for studies investigating Iranian medicinal plants in prevention and treatment of diabetes from 1998 up to May 2012. The search terms were the reference lists of articles were also reviewed for additional relevant studies. The search terms were diabetes, hyperglycemia, plants, herb, traditional and herbal medicine. To assess quality of RCTs we employed the Jadad scale, a previously validated instrument that assesses trials based on appropriate randomization, blinding and description of study withdrawals or drop outs (Jadad et al., 1996) (Table 1).

Included criteria: We included randomized control trials studies which evaluate hypoglycemic effect of medicinal plants in diabetic subjects (humans and animals) with the outcome of change in Fasting Blood Glucose (FBG), Postprandial Blood Glucose (PBG) and HbA1c.We limited studies to those published in the English language and restricted search to Iran affiliation. In addition, we did hand search references of key articles.

Excluded criteria: We excluded trials that examined other diabetic complications such as neuropathy, nephropathy, or retinopathy. Studies on type 1 diabetic patients, herbal component, in vitro studies, review articles and letters to the editor, unpublished data such as thesis, studies in subjects with impaired glucose tolerance and studies that published by non-Iranian authors. Two reviewers examined the title and abstract and references of each article. The reviewers independently extracted data on the medicinal plant, dose, intervention, trial duration, sample size, outcome and results.

RESULTS

A total of 85 (18 humans and 67 animals) studies were found examining 62 plants. The most common outcomes measures encountered in these trials included Fasting Blood Glucose (FBG), Postprandial Blood Glucose (PBG) and HbA1c. Of publications identified in the initial database search, 18 trials on the efficacy of medicinal plants in type 2 diabetic patients were reviewed. Table 2 presents the controlled clinical trials of medicinal plans for glycemic control in patients with type 2 diabetes. The higher quality RCTs (with Jadad scores of 3 or greater) are available for Aloe vera, Citrullus colocynthus, Plantago ovata, Silybum marianum, Rheum ribes and Urtica dioica.

Aloe vera: Beneficial effect of Aloe vera gel on blood glucose and lipid parameters in diabetic patients has been demonstrated in several randomized clinical trials and no adverse effects were reported in these trials (Huseini et al., 2012; Williamson et al., 2011; Yeh et al., 2003). Aloe gel, obtained from the inner portion of the leaves, contains glucomannan, a hydrosoluble fiber which may in part account for its hypoglycemic effects (Yeh et al., 2003). The Natural Standard Research Collaboration reported that the oral use of Aloe vera gel for its hypoglycemic effects is possibly safe (Williamson et al., 2011).

Urtica dioica: The most animal studies have been shown the beneficial effect of Urtica dioica in diabetes but only two human studies have been shown this (Mehri et al., 2011; Tarighat et al., 2012b). Urtica dioica can decrease blood glucose both pancreatic and extra pancreatic pathways. Regarding to pancreatic effects, have been suggested that it is a potent stimulator of insulin release from β-cells and has shown protective effect on β-cells in diabetic rats (Fazeli et al., 2008; Mehri et al., 2011). Inhibited intestinal absorption of glucose and inhibitory effects on the alpha amylase activity are extra-pancreatic mechanisms (Bnouham et al., 2003; Nickavar and Yousefian, 2011).

Silybum marianum: Silybum marianum is a member of the Asteraceae family and its seed extract contains large numbers of chemical constituents including several flavonolignans collectively known as silymarin. Glycemic control effect of Silybum marianum has been demonstrated in four RCTs that decreased FBS and HbA1C significantly (Fallah Hoseini et al., 2004, 2005; Huseini et al., 2006). Silybum marianum improve insulin resistance and ameliorate β-cell restoration (Huseini et al., 2006; Soto et al., 2010). Adverse effects related to silymarin have been published in several studies involving a total of over 7000 patients and those confirmed that it is safe. Only three reports of significant adverse reactions (Kalantari et al., 2011).

Citrullus colocynthis: C. colocynthis (L.) Schrad is a member of the Cucurbitaceae family and is used traditionally as an antidiabetic medication (Huseini et al., 2009). Two RCTs, in this review demonstrated that C. colocynthis significantly decreased FBG and HbA1c in the dose of 300 mg kg-1. The glycemic control effect of C. colocynthis mechanisms is not well known, but it may be have an insulin tropic effect on isolated pancreatic islets (Nmila et al., 2000) or inhibited the toxic effect of streptozotocin on pancreatic cells in rats (Al-Ghaithi et al., 2004; Huseini et al., 2009). The toxicity of large doses of C. colocynthis has been reported in some animals and humans studies (Huseini et al., 2009).

Rheum ribes: Rheum ribes known as an α-amylase and α-glucosidase inhibitor (Kasabri et al., 2011). One of the RCT studies was conducted on 36 type 2 diabetic patients.

Table 1: Effects of Iranian medicinal plants in animal diabetic models

Table 2: Effects of Iranian medicinal plants in type 2 diabetic patients
RCT: Randomized control trial, T2DM: Type 2 diabetes mellitus, FBG: Fasting blood glucose and HbA1c: Glycosylated hemoglobin

One group received 1200 mg Rheum ribes daily in three 400 mg capsule and other received placebo similarly. The results showed a significant decreased in FBS in Rheum ribes treated patients compared with control (Fallah Huseini et al., 2008). Rheum ribes has anti-hyperlipidemic properties and decreased serum lipids significantly (Fallah Hoseini et al., 2004; Fallah Huseini et al., 2008; Huseini et al., 2012; Huseini et al., 2006; Vosough-Ghanbari et al., 2010).

Plantago ovata: The seeds and the husks of Plantago ovata contain high levels of fiber (Hannan et al., 2006). Plantago psyllium significantly reduce glycemic index of carbohydrate foods. In one clinical trial showed that 8 weeks treatment with 5.1 g psyllium (Plantago ovata) two times daily could reduce FBS and HbA1c significantly (Ziai et al., 2005). It seems that glucose-lowering effect of P. ovata is due to inhibition of glucose absorption in the gut (Hannan et al., 2006).

DISCUSSION

Asian continents have 56% share of the worldwide distribution of therapeutic herbal plants (Chan et al., 2012). Iran with 1.64 million km2 areas has 7500-8000 plant species and is an ancient country in usage of medicinal plants. Several medicinal species are cultivated in Iran (Zahedi-Asl et al., 2006). This review focuses on some medicinal plants that used to management of diabetes. In this review, a total of 85 human and animal trials of Iranian medicinal plants used for glycemic control were obtained. Aloe vera, Citrullus colocynthus, Plantago ovata, Silybum marianum, Rheum ribe and Urtica dioica have enough efficacy to decrease blood glucose and really effective in reducing blood glucose in diabetic patients (Fallah Hoseini et al., 2004, 2005, 2006b, 2008; Huseini et al., 2006, 2009, 2012; Sarkhail, 2011; Tarighat et al., 2012a; Ziaei et al., 2004: Ziai et al., 2005).

The obtained information from the various parts of the plants indicated that leaves are the most favorable storage sites for active components. The extraction methods commonly employed in anti diabetic plant extraction are conventional methods involving solvents (Chan et al., 2012). Several animal studies also have shown that some medicinal plants are even more effective than chemical drugs such as glibenclamide (Asgary et al., 2008; Eidi et al., 2006a, 2004; Hedayati et al., 2010; Najafzadeh et al., 2011). Salvia officinalis, Nasturtium officinale and Phlomis anisodonta have similar effects of glibenclamide in reducing blood glucose (Sarkhail et al., 2010). Chemical medicines, because of their harmful and irreversible effects on people, are slowly being replaced by active substances of plants. Despite of beneficial effects, hypoglycaemic effect of these medicinal plants can interfere with hypoglycaemic drugs and insulin. Therefore, physicians should have adequate knowledge about medicinal plants effects on blood glucose to manage patients who are at risk. Any consumption of medicinal plants must be under the supervision of physicians (Hasani-Ranjbar et al., 2008).

CONCLUSION

A considerable number of plant species are traditionally used for the treatment of diabetes mellitus in Iran. The majority of those plants that have been studied for anti-diabetic activity showed promising results. However, efficacy and safety of the most plants used in the treatment of diabetes are not sufficient.

ACKNOWLEDGMENT

This study was funded and supported by Deputy of Research, Kashan University of Medical Sciences (KAUMS).

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