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Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

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Open Access   Full Text Article                                                                                                                                                                   Research Article 

Comparative Effects of Cashew Nut, Leaf and Stem Bark (Anacardium Occidentale L.) on Hyperglycemia and Associated Abnormalities in Streptozotocin-Induced Diabetic Rats

Ajao Folasade Omobolanle*, Akanmu Oluwatosin, Iyedupe Marcus Olaoye

Physiology Department, Faculty of Basic Medical Science, Ladoke Akintola University of Technology, P.M.B. 4000,  Ogbomoso, Oyo State, Nigeria.

INTRODUCTION

Diabetes mellitus has been implicated in the causes of morbidity and mortality worldwide. Its prevalence is increasing at an alarming rate with a global estimation of 463 million individual are diabetes in2019, predicted to rise to 578million by 2030 and 700million by 2045 ^{1, 2}.

Diabetes mellitus refers to a group of metabolic disease characterized by chronic hyperglycemia with abnormalities in carbohydrate, fat and protein metabolism, primarily as a result of deficiency in insulin secretion from beta-cell of pancreas or ineffectiveness of insulin in target tissues (insulin action) or both leading to micro-vascular and macro-vascular complications such as retinopathy, neuropathy, nephropathy, myocardial infarction, heart failure and stroke ^3-5. These metabolic derangements cause dyslipidemia which contribute to high cardiovascular disease risk ⁶.

Chronic hyperglycemia in diabetes mellitus induced oxidative stress which releases excessive free radicals from reactive oxygen species (ROS) and a diminution in antioxidant defense status ⁷. Alterations in endogenous antioxidant defense system by extreme free radicals cause oxidative damage and progression of diabetes mellitus-related complications ^8-10. Intervention for prevention and treatment of diabetes is urgently needed.

Present conventional treatment for diabetes mellitus involves insulin therapy and oral synthetic antidiabetic drugs. However, most synthetic anti-diabetic drugs have their own limitations and deleterious side effects. Due to these toxicities, scientists’ attention has been focus on phyto-herbal medicine sources as alternative therapy for diabetes ^11-12. Most of these plants contain classes of chemical compounds with hypoglycemic effect ¹³.

Anacardium occidentale Linn (family Anacardiaceae) alternatively known as cashew tree originated from Brazil. Different parts of this plant such as stem bark, fruits, and leaf extract are ethno-medicinally used for management of diseases such as diabetes, infection, diarrhea, hemorrhage, and as well as antimicrobial activity ¹⁴. Also, Anacardium occidentale nut has been reported to attenuate dyslipidemia in rats ¹⁵. Phytochemical analysis of this plant revealed the presences of high levels of secondary metabolites such as tannins, flavonoids, phenols, saponins, and alkaloids, as well as derivatives such as anacardic acid, which are used as raw material for herbal medicines formulation ¹⁶. There has been experimental report on the hypoglycemic activity of Anacardium occidentale leaf, stem bark, and nut extracts separately. Nevertheless, none of these data validate the specific efficient part of Anacardium occidentale plant for diabetes therapy. This study therefore investigated the antidiabetic comparative effects of Anacardium occidentale methanolic leaf, stem bark and nut extracts. 

MATERIALS AND METHODS

Drugs and Chemicals: Glimepiride (GMP), Streptozotocin (STZ), Ketamin and Xylazine.

Plant Materials Collection

Fresh nut, leaves and stem bark of Anacardium occidentale were harvested from Agricultural Science Plant Research Farm, Ladoke Akintola University of Technology, Ogbomoso, Oyo State, Nigeria. The plant was identified, authenticated and assigned a voucher specimen number LH0533 by Dr. A. T. J. Ogunkunle at Biology Department Laboratory of the institution.

Extraction of the Plant Materials

Anacardium occidentale leaves, stem bark and nuts were thoroughly washed. The leaves was air-dried at room temperature, while the nut and stem bark were sun-dried. The outer coated layer of the nut was removed to obtain the pure plant nut. The leaves, stem bark and nut were separately grinded into fine powder forms using electric blender and stored in air-tight container. 500g of each fine powder forms were also extracted separately in a Soxhlet apparatus with a methanol solvent (95%). The extracts were concentrated using rotary evaporator under reduced pressure and the dried methanolic extracts obtained were kept in air-tight container at 4^oC until used.

Experimental Animals

Ninety (90) adult male Wistar rats weighing (200±20g) were used and obtained from Physiology Department Research Animal Breed House, Ladoke Akintola University of Technology, Ogbomoso, Oyo State, Nigeria. The animals were house in a plastic cage (10rats/cage) and acclimatized for 14days under free-pathogen environment at constant room temperature of (25 ±2^oC), relative humidity (45±5%) and natural 12:12hours light/dark cycle with free access to commercial rat pellet feed and water ad libitum. All experimental procedures and handling of animals were performed according to the National Institutes of Health Guide for the Care and Use of Laboratory Animals for Biomedical Research and were approved by the Institutional Animals Care and Use Committee of Ladoke Akintola University of Technology.

Experimental Diabetes Induction

The rats were fasted overnight (12hrs fasting) on the last day of acclimatization prior to diabetes induction. A single dose of freshly prepared streptozotocin (50mg/kgb.wt) dissolved in 0.1M citrate buffer (pH4.5) was injected intraperitoneally to induced diabetes ¹⁷. The animals were allowed to drink a 20% glucose solution overnight to forestall initial drug induced hypoglycemic death.   Fasting blood samples were withdrawn from the rats’ tail after 72hours of streptozotocin injection to determine the blood glucose levels using one-touch Accu-Chek glucometer and animals with fasting plasma blood glucose level above 200 mg/dl were selected as diabetic and used for this study. 

Experimental Design and Treatment 

The ninety (90) rats were randomly selected and grouped into 9 groups (10rats/group). The diabetic induced rats were allotted into 8 groups in addition to the normal group. The groupings were as follow:

Group I: Control (non-diabetic rats)

Group II: Diabetic (untreated rats)

Group III: Diabetic rats treated with 100mg/kgb.wt AOMNE

Group IV: Diabetic rats treated with 200mg/kgb.wt AOMNE

Group V: Diabetic rats treated with 100mg/kgb.wt AOMLE

Group VI: Diabetic rats treated with 200mg/kgb.wt AOMLE

Group VII: Diabetic rats treated with 100mg/kgb.wt AOMSBE

Group VIII: Diabetic rats treated with 200mg/kgb.wt AOMSBE 

Group IX: Diabetic rats treated with 2.0mg/kgb.wt p.o Glimepiride (GMP)

The extracts and Glimepiride were administered orally using oral canular for 28days with feed and water ad libitum. During treatment phase, food and water intake were measured each day. 

Body weights Measurement and Fasting Plasma Glucose level Determination

The body weights and fasting plasma glucose levels were taken on day 1 of acclimatization and each week throughout the entire treatment period. The body weights were measured with a digital weighing scale and glucose oxidase-peroxidase (GOD-POD) method was used to determine the fasting plasma glucose levels from the blood samples obtained from the tail puncture of the rats using Accu-Chek glucometer.

Sample Collection and Biochemical Assays

After the last dose of treatment, the rats were fasted overnight (12hours fasting), anesthetized with ketamin (45mg/kgb.w) and xylazine (20mg/kgb.w) injected intraperitoneally and sacrificed by cervical dislocation. The fasting plasma blood samples were withdrawn from the rats’ heart via cardiac puncture into heparinized tubes, centrifuge at 3500rpm for 5minutes and clear supernatant plasma were retrieved for estimation of biochemical parameters. Levels of triglycerides (TG), total cholesterol (TC) and high density lipoprotein-cholesterol (HDL-C) were determined using enzymatic colorimetric method with a commercial kit Diagnostic Kit (Genzyme Diagnostics, MA, USA) followed the manufacturers’ protocol. The level of low density lipoprotein-cholesterol (LDL-C) was calculated according to Friedewald et al. formula; LDL-C = TC – (HDL-C - TG/5) ¹⁸.

Marker of oxidative stress malondialdehyde (MDA) level and antioxidant superoxide dismutase (SOD), glutathione peroxidase (GPx), and catalase (CAT) levels were measured by enzyme linked immunosorbent assay (ELISA) methods using Rat MDA, SOD, GPx and CAT commercial Elisa Kit (Elabscience, China) according to manufacturer’s instruction. Glutathione reductase (GSH) was measured based on the Gupta and Gupta method ¹⁹.

Plasma hepatic enzymes aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) levels were measured spectrophotometrically using standard automated techniques based on the instruction of the manufacturer. Kidney function markers urea, uric acid and creatinine levels were determined using a commercial assay kit obtained from Siemens Health Care Diagnostics.

Statistical Analysis

Data were analyzed using statistical package for social sciences (SPSS version, 21.0). The data were expressed as standard error of mean (mean ± SEM) and statistical difference comparison between groups was evaluated using one-way analysis of variance (ANOVA) followed by Tukey’s post-hoc test. Data were considered statistically significant at p<0.01, p<0.05.

RESULTS

Effects of Anacardium occidentale methanolic nut, leaf, and stem bark extracts on body weight, food and water intake in streptozotocin-induced diabetic rats.

In untreated diabetic group rats, body weight and food intake were significantly (p<0.05) reduced whereas, water intake significantly increased. The body weight and food intake were increased after administration of Anacardium occidentale methanolic nut, leaf and stem bark extracts along with significantly reduction in water intake. The low and high doses of nut extract greatly improved the body weight. Also, high dose of the stem bark slightly improves the body weight but effectively reduced the water intake.

Effects of Anacardium occidentale methanolic nut, leaf, and stem bark extracts on fasting plasma blood glucose levels and lipids profiles in streptozotocin-induced diabetic rats.

Diabetic untreated rats demonstrated significant (p<0.01) increase in plasma fasting blood glucose levels in comparison with non-diabetic rats. Anacardium occidentale methanolic nut, leaf and stem bark extracts administrations significantly decreased the elevated fasting blood glucose levels compared with untreated diabetic rats. High dose of Anacardium occidentale stem bark extract distinctly lowered the fasting plasma blood glucose levels of diabetic rats than other extracts (fig. 2a).

The triglycerides (TG), total cholesterol (TC) and low density lipoprotein- cholesterol (LDL-C) levels of untreated diabetic induced rats were significantly (p<0.05) higher and high density lipoprotein-cholesterol (HDL-C) level was significantly lowered compared with the non-diabetic rats. Administrations of methanolic nut, leaves and stem bark extracts of Anacardium occidentale to the diabetic rats significantly reduced the TG, TC, and LDL-C levels and increased the HDL-C level in comparison with untreated diabetic induced rats. Low and high doses of Anacardium occidentale nut extract were the most effective in diminishing the TG, TC, and LDL-C levels. Furthermore, the nut extract high dose remarkably enhanced the HDL-C level with fair effect by the leaves extract high dose (fig. 2b).

Effects of Anacardium occidentale methanolic nut, leaf, and stem bark extracts on marker of oxidative stress and antioxidant enzymes activity in streptozotocin-induced diabetic rats.

Malondialdehyde (MDA) level, a biomarker of oxidative stress in untreated diabetic rats significantly (p<0.05) increased compared with non-diabetic rats. The Anacardium occidentale methanolic leaves, stem bark and nut extracts supplement to the diabetic rats attenuate the MDA level when compared with the untreated diabetic rats. Among these extracts, Anacardium occidentale nut extract high and low doses exhibited reasonable diminution in MDA level. Further, the levels of superoxide dismutase (SOD), glutathione peroxidase (GPx), catalase (CAT) and reduced glutathione (GSH) were significantly (p<0.05) decreased in untreated diabetic rats in comparison to the non-diabetic rats. SOD, GPx, CAT, and GSH levels were increased after administration of Anacardium occidentale methanolic leaves, nut and stem bark extracts to the diabetic rats compared with untreated diabetic rats. Specifically, Anacardium occidentale nut extract high and low doses extremely elevated SOD, GPx, CAT and GSH levels followed by stem bark and leaves extract high doses (table 2). 

Effects of Anacardium occidentale methanolic nut, leaf, and stem bark extracts on hepatic enzymes and kidney function parameters in streptozotocin-induced diabetic rats.

There were significant (p<0.01) elevation in hepatic plasma aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) levels in untreated diabetic induced rats compared with the non-diabetic rats. Administration of Anacardium occidentale methanolic nut, leaf and stem bark extracts lessen the elevated AST, ALT and ALP levels in comparison to the untreated diabetic rats. The nut extract high dose radically reduced the AST, ALT, and ALP levels (table 3). 

Furthermore, kidney function parameters urea, uric acid and creatinine levels were significantly (p<0.01) higher in untreated diabetic rats compared with the non-diabetic rats. Treatment of the diabetic rats with high and low doses of Anacardium occidentale methanolic nut, leaf and stem bark extracts lowered the urea, uric acid and creatinine levels compared with untreated diabetic. All the extracts drastically lowered these parameters (table 3).

Table 1: Preliminary Phytochemicals Analysis of Anacardium occidentale Nut, Leaf and Stem bark extracts.

(+) means detected, (-) means not detected.

a                

b.

c.

Figure 1: Effects of Anacardiun occidentale methanolic nut, leaf, and stem bark extracts on (a) body weight (b) food intake (c) water intake in streptozotocin (STZ)-induced diabetic rats. Values are expressed as mean ± SEM (n=10). *significant at p<0.05 compared with control; ^#significant at p<0.05 compared with untreated diabetic group

a.

b.

Figure 2: Effects of Anacardiun occidentale methanolic nut, leaf, and stem bark extracts on (a) fasting blood glucose levels (b) lipids profiles in streptozotocin (STZ)-induced diabetic rats. Values are expressed as mean ± SEM (n=10). *significant at p<0.05 compared with control; ^#significant at p<0.05 compared with untreated diabetic group. 

Table 2: Effects of Anacardium occidentale methanolic nut, leaf and stem bark extracts on oxidative stress marker and antioxidant enzymes activities in streptozotocin-induced diabetic rats

Values are expressed as mean ± SEM (n=10). *significant at p<0.05 compared with control; ^#significant at p<0.05 compared with untreated diabetic group

Table 3: Effects of Anacardium occidentale methanolic nut, leaf and stem bark extracts on hepatic enzymes biomarkers and kidney function parameters in streptozotocin-induced diabetic rats.

Values are expressed as mean ± SEM (n=10). **significant at p<0.01 compared with control; ^##significant at p<0.01 compared with untreated diabetic group

DISCUSSION

Humans have been using various plants species as alternative therapy for different ailments including diabetes due to their own efficacy ²⁰. Here in this present study, antidiabetic comparison effects of Anacardium occidentale methanolic nut, leaf, and stem bark extracts was investigated in streptozotocin induced-diabetic rats. Streptozotocin is commonly used as diabetogenic agent in animal model of diabetes due to its ability to induce pancreatic cells necrosis that consequences in loss of insulin secretion, leading to hyperglycemia and diabetic complications ^{21, 22}.

Diabetes is associated with excessive body weight loss due to imbalance of metabolic pathways ²³. In this study, diabetes induced rats demonstrated obviously reduction in body weight and this is in line with the report of Abbasi et al. ²⁴. The body weight reduction observed in this study could be due to muscle wasting and tissue protein loss. In addition, severe reduction in food intake in this study could also contribute to body weight loss. The bodyweight was improved after treated the diabetic rats with Anacadium occidentale methanolic nut, leaf, and stem extracts, indicating that these extracts restored the normal metabolic pathways and prevent the tissue proteolysis thereby inhibit the muscle wasting induced by hyperglycemia condition, which is parallel with the findings of Rines et al. ²⁵.

Additionally, chronic exposure to hyperglycemia in diabetes is the main etiology of diabetic complications and vasculopathy which promote atherosclerosis ²⁶. Elevated blood glucose levels were also observed in untreated diabetic rats in this study. This finding corroborates the result of Dakam et al. ²⁷ who also reported substantial increase in blood glucose level of streptozotocin-induced diabetic rats. This rise in the blood glucose levels maybe as a result of reduced glucose uptake by peripheral cells due to insensitivity to insulin action or diminutive insulin secretion from damage pancreatic beta cells ²⁸. Many phytochemicals such as saponins, tannins, alkaloids, flavonoids and terpenoids have been reported to possess anti-hyperglycemic effect ²⁹.  Administration of methanolic leaves, stem bark and nut extracts of Anacardium occidentale plant diminished the elevated blood glucose levels. The observed anti-hyperglycemia activity of these extracts may be attributed to the presences of one or more phytochemicals capable of stimulating glucose uptake in peripheral tissues, inhibition of ⍺-amylase and ⍺-glucosidase enzyme activities to slow down intestinal glucose absorption, restoration of damage pancreatic beta cell to secrete sufficient insulin and prevention of hepatic gluconeogenesis. These extracts were compared with glimepiride, the stem bark extract high dose lowering the elevated blood glucose level proficiently.

The major metabolic disorder associated with diabetes is dyslipidemia ³⁰. The diabetic untreated rats in this study showed the main features of diabetic dyslipidemia: elevated triglycerides (TG), total cholesterol (TC), low density lipoprotein-cholesterol (LDL-C) and a decrease in the high density lipoprotein-cholesterol (HDL-C). This observation is in consonance with the finding of Abdel-Azim Assi et al. ³¹. The observed elevated TG, TC and LDL could be partly due to increased intestinal biosynthesis of cholesterol because diabetes shifted the major site of cholesterogenesis from the liver to the small intestine leading to hypercholesterolemia ³². However, on treatment of diabetic rats with Anacardium occidentale methanolic nut, leaf and stem bark extracts, this altered lipid profile was reversed noticeably with reduction in TG, TC, and LDL-C levels while HDL-C level increased and this result support the data of  Sharma et al. ³³, on the lipid lowering effect of stevia extract on humans. This improvement in HDL level will be helpful in preventing several cardiovascular disease complications induced by diabetic dyslipidemia. Saponins, one of the active phyto-chemical have been reported to possess ability to reduce hyperlipidemia by effectively reducing absorption of fats after digestion by pancreatic lipases thereby inhibiting adipogenesis ³⁴. This anti-hyperlipidemic action of Anacadium occidentale methanolic nut, leaf and stem bark extracts might be due to the presence of phyto-constituent saponins. A light effect was observed in diabetic rats treated with leaf extract high dose (200mg/kgb.wt) while a more noticeable effect was observed in rats treated with high dose (200mg/kg/b.wt) of Anacardium occidentale nut extract than other extracts.

Oxidative stress induced by persistent hyperglycemia also contributes to the pathogenesis and progression of cellular injury in diabetes mellitus through production of reactive oxygen species that further upsurge releasing of lipid peroxidation end product malondialadehyde (MDA) level, a marker of free radicals production and dwindling in biological antioxidant defense system ³⁵. This study also observed increase in MDA level and reduced antioxidant superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) and reduced glutathione (GSH) levels in untreated diabetic rats, which are in consistent with finding of Almatroodi et al. ³⁶. Oral supplementation of Anacardium occidentale methanolic nut, leaf and stem bark extracts to the diabetic rats attenuated the MDA level and ameliorates the activity of antioxidant SOD, CAT, GPx and GSH. This finding indicated that Anacardium occidentale nut, leaf leaves, nut and stem bark posses a strong antioxidant properties capable of neutralizing free radicals and preventing cellular damage by oxidative stress in diabetes mellitus which is in accordance with report of Domekouo et al. ³⁷, who reported antioxidant properties of Morinda lucida aqueous stem bark extract in streptozotocin-induced diabetic rats. High dose (200mg/kgb.wt) and low dose (100mg/kgb.wt) of Anacardium occidentale nut extract were the most effective in attenuating the oxidative stress marker and elevate the antioxidant enzymes activity. The stems back extract high dose (200mg/kgb.wt) as well as the leaves extract high dose (200mg/kgb.wt) also lessen the oxidative stress and ameliorate the antioxidant enzymes but not as efficient as the nut.  

The elevation in hepatic enzymes aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) is typically associated with the hyperglycemia status in diabetes mellitus condition. These hepatic enzymes (AST, ALT and ALP) are useful biomarkers of hepatocytes damage and the levels are usually increased in acute hepatoxicity ^{38, 39}. These elevated hepatic enzymes might contribute to the development of diabetic ketogenesis and gluconeogenesis ⁴⁰. Elevated levels of hepatic enzymes AST, ALT, and ALP were also observed in this current study, which revealed some levels of hepatic damage and this support the result of Shahla Rezaei ⁴¹. Furthermore, hyperglycemia in diabetes induced renal dysfunction markedly by elevation in kidney function markers urea, uric acid and creatinine levels ⁴². In this study, renal biomarkers urea, uric acid and creatinine levels were elevated in untreated diabetic rats, suggesting the impairment of the renal function in filtering and eliminating toxic waste product and this finding is in agreement with previous results of Rashid and Khan ⁴³. However, in diabetic rats treated with methanolic extracts of nut, leaf and stem bark of Anacardium occidentale plant, a decline in the elevated markers of hepatic enzymes and renal function parameters were observed, which proven the protection of vital organs from chronic hyperglycemia damages by these extracts and this harmonize the finding of Hasan et al. ⁴⁴. Also, phyto-chemical constituents such as alkaloids, tannins, and saponins in plants extract have previously reported to exhibit vital organs protective effects ⁴⁵.The restoration of hepatic enzymes and renal functions of these extracts could be attributed to possession of these bioactive compounds. Comparably, Anacardium occidentale nut extract high dose (200mg/kgb.wt) attenuated the elevated hepatic enzymes closely to glimepiride and (100 mg/kgb.wt) and (200mg/kgb.wt) of nut, leaf and stem bark methanolic extracts efficiently showed renal protective effects with  negligible differences.

CONCLUSION 

From our findings, Anacardium occidentale nut, leaf and stem bark have hypoglycemic, hypolipidemic and antioxidant therapeutic properties. The Anacardium occidentale nut posses the most potent anti-diabetic therapeutic effects followed by the stem bark with the leaves being the least. The nut of Anacardium occidentale plant could be useful as alternative therapy for diabetes. Further, synergistic anti-diabetic effect of the nut, leaf and stem bark should be investigated.

ABBREVIATIONS

AOMNE: Anacardium occidentale methanolic nut extract; AOMLE: Anacardium occidentale methanolic leaves extract; AOMSBE: Anacardium occidentale methanolic stem bark extract.

DECLARATIONS:

Authors’ Contributions

FO conceived the original idea, designed and supervised the research. AO and MO performed the experiments with the support of FO. FO, MO and AO collected the data. MO and AO analyzed the data and prepared the manuscript. FO reviewed the manuscript. All authors’ have read and approved the final manuscript. 

Competing Interests

No competing interests.

Funding

This research work did not receive any specific funding/financial support.

REFERENCES

1. Diaz-de-Cerio E, Rodriguez-Nogales A, Algieri F, Romero M, Verardo V, Segura-Carretero A, et al. The hypoglycemic effects of guava leaf (psidium guajava L) extract are associated with improving endothelial dysfunction in mice with diet-induced obesity. Food Res Int. 2017; 96: 64-71 https://doi.org/10.1016/j.foodres.2017.03.019

2. Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas. Diabetes Res. Clin. Pract. 2019; 157:107843. https://doi.org/10.1016/j.diabres.2019.107843

3. Key facts of Diabetes [https://www.who.int/news-room/fact-sheets/detail/diabetes]. Accessed 30 Oct 2018.

4. Alaboud AF, Tourkmani AM, Alharbi TJ, Alobikan AH, Abdelhay O, Al Batal SM, et al. Microvascular and macrovascular complications of type 2 diabetes mellitus in central, Kingdom of Saudi Arabia. Saudi Med J. 2016; 37(12):1408. https://doi.org/10.15537/smj.2016.12.17062

5. Kosiborod M, Gomes MB, Nicolucci A, Pocock S, Rathmann W, Shestakova MV, et al. Vascular complications in patients with type 2 diabetes: prevalence and associated factors in 38 countries (the DISCOVER study program). Cardiovasc Diabetol. 2018; 17(1):150. https://doi.org/10.1186/s12933-018-0787-8

6. Newman J, Schwartzbard AZ, Weintraub H, Goldberg IJ, Berger JS. Primary Prevention of Cardiovascular Disease in Diabetes Mellitus. J. Am. Coll. Cardiol. 2017; 70:883-893 https://doi.org/10.1016/j.jacc.2017.07.001

7. Shidfar F, Rajab A, Rahideh T, Khandouzi N. The effect of ginger (Zingiber officinale) on glycemic markers in patients with type 2diabetes. J Complement Integr Med. 2015; 12:165-170 https://doi.org/10.1515/jcim-2014-0021

8. Volpe CMO, Villar-Delfino PH, Dos Anjos PMF, Nogueira-Machado JA. Cellular death, reactive oxygen species (ROS) and diabetic complications. Cell Death Dis. 2018; 9:119. https://doi.org/10.1038/s41419-017-0135-z

9. Asmat U, Abad K and Ismail K. (2016). Diabetes mellitus and oxidative stress-A concise review. Saudi. Pharm. J, 24, 547-553. https://doi.org/10.1016/j.jsps.2015.03.013

10. Gupta S, Nair A, Jhawat V, Mustaq N, Sharma A, Dhanawat M, et al. Unwinding Complexities of Diabetic Alzheimer by Potent Novel Molecules. Am. J. Alzheimers Dis. 2020; 35. https://doi.org/10.1177/1533317520937542

11.Choudhury H, Pandey M, Hua CK, Mun CS, Jing JK, Kong L, et al. An update on natural compounds in the remedy of diabetes mellitus: A systematic review. J. Tradit. Complementary Med. 2018; 8:361-376 https://doi.org/10.1016/j.jtcme.2017.08.012

12. Sharma A, Gupta S, Chauhan S, Nair A, Sharma P. Astilbin: A promising unexplored compound with multi-dimensional medicinal and health benefits. Pharmacol. Res. 2020; 158. https://doi.org/10.1016/j.phrs.2020.104894

13. He JH, Chen LX, Li H. Progress in the discovery of naturally occurring antidiabetic drugs and in the identification of their molecular targets. Fitoterapia. 2019; 134:270-289 https://doi.org/10.1016/j.fitote.2019.02.033

14. Silva RA, Liberio S, Amaral FM, Nascimento FRF, Torres LM, Monteiro-Neto V, et al. Antimicrobial and antioxidant activity of Anacardium occidentale L. flowers in comparison to back and leaves extracts. J. Biosci. Med. 2016; 4:87-99. https://doi.org/10.4236/jbm.2016.44012

15. Dias CCQ, Madruga MS, Pintado MME, Almeida GHO, Alves APV, Dantas FA, et al. Cashew nuts (Anacardium occidentale L.) decrease visceral fat, yet augment glucose in dyslipidemic rats. PLoS ONE. 2019; 14 https://doi.org/10.1371/journal.pone.0225736

16. Salehi B, Gultekin-ozguven M, Kirkin C. Anacardium Plants: Chemical, Nutritional Composition and Biotechnological Applications. Biomolecules. 2019; 9(9): 465. https://doi.org/10.3390/biom9090465

17. Furman BL. Streptozotocin-induced diabetic models in mice and rats, Curr. Protoc. Pharmacol. 2015; 70:5.47.1-5.20. https://doi.org/10.1002/0471141755.ph0547s70

18. Friedewald WT, Levy RI, Fredrickson DS. "Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge," Clin Chem . 1972; 18(6):499-502 https://doi.org/10.1093/clinchem/18.6.499

19. Gupta R, Gupta RS. Protective Role of Pterocarpus marsupium in Diabetes-Induced Hyperlipidemic Condition. J. Complement. Integr. Med. 2009; 6(1): 21 https://doi.org/10.2202/1553-3840.1288

20. Kooti W, Farokhipour M, Asadzadeh Z, Ashtary-Larky D, Asadi-Samani M. The role of medicinal plants in the treatment of diabetes: A systematic review. Electron. Physician. 2016; 8:1832-1842. https://doi.org/10.19082/1832

21. Bidani AK, Picken M, Hacioglu R, Williamson G, Griffin KA. Spontaneously reduced BP load in the rat streptozotocin-induced diabetes model: Potential pathogenetic relevance. Am. J. Physiol. Renal Physiol. 2007; 292:F647-F654. https://doi.org/10.1152/ajprenal.00017.2006

22. Miric G, Dallemagne C, Endre Z, Margolin S, Taylor SM, Brown L. Reversal of cardiac and renal fibrosis by pirfenidine and spironolactone in streptozotocin-diabetic rats. Br. J. Pharmacol. 2001; 133: 687-694. https://doi.org/10.1038/sj.bjp.0704131

23. Yang S, Wang S, Yang B, Zheng J, Cai Y, Yang Z. Weight loss before a diagnosis of type 2 diabetes mellitus is a risk factor for diabetes complications. Medicine. 2016; 95. https://doi.org/10.1097/MD.0000000000005618

24. Abbasi Z, Jelodar G, Nazifi S. Extracts of the walnut leaf (Juglans regia L.) improved activity of sorbitol dehydrogenase in diabetic male rats. Physiol. Pharmacol. 2017; 21:80-86.

25. Rines AK, Sharabi K, Tavares CD, Puigserver P. Targeting hepatic glucose metabolism in the treatment of type 2 diabetes. Nat. Rev. Drug Discov. 2016; 15:786-804 https://doi.org/10.1038/nrd.2016.151

26. Badin JK, Kole A, Stivers B, Progar V, Pareddy A, Alloosh M et al. Diabetes exacerbates coronary atherosclerosis in Ossabaw Miniature Swine with Metabolic Syndrome. J. Transl. Med. 2018; 16(1):58. https://doi.org/10.1186/s12967-018-1431-9

27. Dakam W, Biyegue CF, Fannang SV, Oben JE. Leaf extracts of Glyphaea brevis attenuate high blood glucose and lipids in diabetic rats induced with streptozotocin. Phcog Res. 2021; 13:82-88. https://doi.org/10.5455/jcmr.2022.13.02.21

28. Ankur R, Ali S. Alloxan induced diabetes: mechanism and effects. Int. j. pharm. biomed. res. 2012; 3(2):819-823.

29 .Mashi JA, Atiku MK, Shehu D, Idris RI, Sa'id AM, Dangambo MA, et al. Comparative Study of Different Solvents Extract of Persea americana Leaf on Alloxan Induced Hyperglycemic Rats. Asian J. Biol. Sci. 2019; 12: 67-72. https://doi.org/10.3923/ajbs.2019.67.72

30. Preuss HG, Bagchi D, Bagchi M, Rao CV, Dey DK, Satyanarayana S. Effects of a natural extract of (-)-hydroxycitric acid (HCA-SX) and a combination of HCA-SX plus niacin-bound chromium and Gymnema sylvestre extract on weight loss. Diabetes Obes. Metab. 2004; 6:171-180. https://doi.org/10.1111/j.1462-8902.2004.00328.x

31. Assi A, Abd Elhamid DH, Abdel Rahman MS, Ashry EE, Bayoumi S, Ahmed AM. The Potential Efficacy of Stevia Extract, Glimepiride and Their Combination in Treating Diabetic Rats: A Novel Strategy in Therapy of Type 2 Diabetes Mellitus. Egyptian Journal of Basic and Clinical Pharmacology. 2020; 10:15. https://doi.org/10.32527/2020/101455

32. Balamurugan R, Ignacimuthu S Antidiabetic and hypolipidemic effect of methanol extract of Lippia nodiflora L. in streptozotocin induced diabetic rats. Asian Pac. J. Trop. Biomed. 2011; 1:30-36. https://doi.org/10.1016/S2221-1691(11)60117-2

33. Sharma N, Mogra R, Upadhyay B. "Effect of Stevia Extract Intervention on Lipid Profile," Studies on Ethno-Medicine. 2017; 3(2): 137-140. https://doi.org/10.1080/09735070.2009.11886351

34. Marrelli M, Conforti F, Araniti F, Statti G. Effect of saponins on lipid metabolism: A review of potential health benefits in the treatment of obesity. Molecules. 2016; 21:1404 https://doi.org/10.3390/molecules21101404

35. Tiwari BK, Pandey KB, Abidi AB, Rizvi SI. Markers of oxidative stress during diabetes mellitus. J Biomark. 2013: 378790 https://doi.org/10.1155/2013/378790

36. Almatroodi SA, Alnuqaydan AM, Babiker AY, Almogbel MA, Khan AA, Husain Rahmani A. 6-Gingerol, a Bioactive Compound of Ginger Attenuates Renal Damage in Streptozotocin-Induced Diabetic Rats by Regulating the Oxidative Stress and Inflammation. Pharmaceutics. 2021; 13:317 https://doi.org/10.3390/pharmaceutics13030317

37. Domekouo UL, Longo F, Tarkang PA, Tchinda AT, Tsabang N, Donfagsiteli NT et al. Evaluation of the antidiabetic and antioxidant properties of Morinda lucida stem back extract in streptozotocin-intoxicated rats. Pak. J. Pharm. Sci. 2016; 29(3):903-11

38. Teshome G, Ambachew S, Fasil A, Abebe M. Prevalence of Liver Function Test Abnormality and Associated Factors in Type 2 Diabetes Mellitus: A Comparative Cross-Sectional Study. Electron. J. Int. Fed. Clin. Chem. 2019; 30:303-316

39. Mohamed J, Nazratun NA, Zariyantey AH, Budin SB. Mechanisms of Diabetes- Induced Liver Damage; The role of oxidative stress and inflammation. Sultan Qaboos Univ Med J. 2016; 16(2):132-141. https://doi.org/10.18295/squmj.2016.16.02.002

40. Qian K, Zhong S, Xie K, Yu D, Yang R, Gong DW. Hepatic ALT isoenzymes are elevated in gluconeogenic conditions including diabetes and suppressed by insulin at the protein level. Diabetes Metab. Res. Rev. 2015; 31:562-571 https://doi.org/10.1002/dmrr.2655

41.Rezaei S, Ashkar F, Koohpeyma F, Mahmoodi M, Gholamalizadeh M, Mazloom Z, et al. Hydroalcoholic extract of Achillea millefolium improved blood glucose, liver enzymes and lipid profile compared to metformin in streptozotocin-induced diabetic rats. Lipids Health Dis. 2020; 19:81 https://doi.org/10.1186/s12944-020-01228-4

42. Yu SM, Bonventre JV. Acute Kidney Injury and Progression of Diabetic Kidney Disease. Adv. Chronic Kidney Dis. 2018; 25:166-180 https://doi.org/10.1053/j.ackd.2017.12.005

43. Rashid U, Khan MR. Phytochemicals of Periploca aphylla Dcne. ameliorated streptozotocin-induced diabetes in rats. Environ. Health Prev. Med. 2021; 26:38 https://doi.org/10.1186/s12199-021-00962-0

44. Hasan MN, Sabrin F, Rokeya B, Khan MSH, Ahmed MU, Matondo A, et al. Glucose and lipid lowering effects of Enhydra fluctuans extract in cadmium treated normal and type-2 diabetic model rats BMC Complement Altern Med. 2019; 19:278 https://doi.org/10.1186/s12906-019-2667-5

45. Rashid U, Khan MR, Sajid M. Antioxidant, anti-inflammatory and hypoglycemic effects of Fagonia olivieri DC on STZ-nicotinamide induced diabetic rats - in vivo and in vitro study. J Ethnopharmacol. 2019; 242:112038. https://doi.org/10.1016/j.jep.2019.112038