Components of the cell signaling network, especially those which converge on the ubiquitous

eukaryotic redox-sensitive transcription factor nuclear factor-kappa B (NF-κB), have been

implicated in pathogenesis of many inflammation-associated disorders. Under normal
physiologic conditions, NF-κB is sequestered in the cytoplasm by binding to the inhibitory
protein called IκBa. Phosphorylation and subsequent ubiquitination results in degradation of
IκBa by proteasomes. Phosphorylation of IκBa is mainly mediated by the IκB kinase (IKK)
complex. Phosphorylation of specific serine residues of p65 subunit of NF-κB has been
considered to facilitate the translocation of NF-κB to nucleus and interaction with the coactivator
CBP/p300. Induction of κphase-2 detoxifying or antioxidant genes represents an important
cellular defense in response to oxidative and electrophilic insults. Nuclear transcription factor
erythroid 2p45 (NF-E2)-related factor 2 (Nrf2) plays a crucial role in regulating phase-2
detoxifying/antioxidant gene induction. Like NF-κB, Nrf2 is present in the cytoplasm as an
inactive complex with the inhibitory protein subunit, in this case Keap1. Dissociation of Nrf2
from Keap1 is prerequisite for nuclear translocation and subsequent transactivational activity.
Once translocated into nucleus, Nrf2 interacts with a small Maf protein, forming a heterodimer
that binds to antioxidant responsive elements (ARE) or electrophile responsive elements (EpRE)
present in the promoter/enhancer regions of genes encoding many antioxidant and detoxifying
enzymes. Keap1 contains several cysteine residues that function as sensors of redox changes.
Oxidation or covalent modification of these critical cysteine thiols diminishes the affinity of Nrf2
for Keap1, releasing Nrf2 for nuclear translocation. Dissociation of the Nrf2-Keap1 complex is
also assumed to be stimulated through the phosphorylation of Nrf2 by distinct upstream kinases
such as MAPKs, PKC, PI3K, etc. As in the case of NF-κB, phosphorylation of Nrf2 is also
considered to facilitate the interaction of this redox-sensitive transcription factor with
CBP/p300.NRF2 is a known regulator of the antioxidant response. NRF2- regulated phase II
enzymes protect against the development of cancer by catalyzing reactions that convert highly
reactive, carcinogenic chemicals to less reactive products . Singh et al. (2012) recently
demonstrated that vitamin C and BHA provide protection against E2-mediated oxidative DNA
damage but the mechanism is not well understood. Many antioxidants derived from dietary and
medicinal plants have been found to modulate Nrf2-Keap1 signaling, thereby potentiating
cellular antioxidant capacity or facilitating detoxification of carcinogens and other toxicants.
Table 4 describes 7 observational studies reporting changes in serum, plasma, or whole blood
levels of vitamins Cand E, selenium,β-carotene, and total radical antioxidant parameter (TRAP),
which represents total body antioxidant status, in patients undergoing anticancer therapy.
Information is grouped by malignancy and includes subject demographics, cancer data, cancer
treatment, end points evaluated, results, and comments. No specific treatment was consistently
associated with changes in the individual antioxidants (Table 4)

5.3. Antioxidant vs diabetes

Glucose overload may damage the cells through oxidative stress. This is currently the
basis of the “unifying hypothesis” that hyperglycemia-induced oxidative stress may account for
the pathogenesis of all diabetic complications. Increasing evidence in both experimental and
clinical studies suggests that oxidative stress plays a major role in the pathogenesis of both types
of diabetes mellitus. Free radicals are formed disproportionately in diabetes by glucose
oxidation, non-enzymaticglycation of proteins, and the subsequent oxidative degradation of
glycatedproteins. This increased superoxide production causes the activation of 5 major
pathways involved in the pathogenesis of complications: polyol pathway flux, increased
formation of AGEs (advanced glycation end products), increased expression of the receptor for
AGEs and its activating ligands, activation of protein kinase C isoforms, and overactivity of the
hexosamine pathway. It also directly inactivates 2 critical anti-atherosclerotic enzymes,
endothelial nitric oxide synthase and prostacyclin synthase. Through these pathways, increased
intracellular reactive oxygen species cause defective angiogenesis in response to ischemia,
activate a number of pro-inflammatory pathways, and cause long-lasting epigenetic changes that
drive persistent expression of proinflammatory genes after glycemia is normalized
(“hyperglycemic memory”). Atherosclerosis and cardiomyopathy in diabetes are caused in part
by pathway-selective insulin resistance, which increases mitochondrial ROS production from
free fatty acids and by inactivation of anti-atherosclerosis enzymes by ROS. Over expression of
antioxidant enzymes in diabetic patients prevents diabetic retinopathy, nephropathy, and
cardiomyopathy. Antioxidants have proven to play a minimal if any role in the treatment of
diabetic complications in humans. Decreases in expression, and in some instances the activity of
antioxidant enzymes, has been previously reported in diabetic microvascular disease. Indeed, the
over expression of Cu+Zn2+ superoxide dismutase (SOD) protects against end organ damage in
models of type II diabetic nephropathy [169]. Other studies in mice with genetic deletions of
various antioxidant enzymes have also provided insight into the specific relative contributions of
Mn2+SOD [170] to the development of diabetes complications. Mn2+SOD mimetics such as
MnTBAP have also shown efficacy in preventing ROS-induced injury in vitro, although the
utility in vivo of such drugs may be limited. Further strengthening a potential role for the
antioxidant Mn2+SOD, specific polymorphisms of the Mn2+SOD gene are associated with the
development of diabetic complications. Interestingly, GPx-1-deficient mice have no increased
risk for microvascular disease, in particular diabetic complications, most likely because of
redundancy with respect to GPx isoforms. Over-expression of catalase in experimental models of
type 2 diabetic appears to be protective the diabetic complications. In contrast to Mn2+SOD,
however, studies in humans have indicated no relationship between catalase gene polymorphisms
that interfere with its cellular expression and the incidence of type 2 diabetic patients.

Kunisaki et al. investigated the effects of treatments with classical antioxidants such as
vitamin E,vitamin C and lipoic acid. Specifically, vitamin E normalizes retinal blood flow and
protein kinase C (PKC) activity in the vascular tissue of diabetic rats. One short-term
experimental study showed that high doses of vitamin C can improve some aspects of endothelial
dysfunction in diabetes. Another experimental study has demonstrated that intra-peritoneal
administration of α- lipoic acid to streptozotocin (STZ) diabetic Wistar rats normalizes TBARS
levels in plasma, and the retina, liver, and pancreas. Furthermore, it has been reported that α-
lipoic acid leads to a decrease in the severity of diabetic neuropathy by maintaining GSH levels
and/or by its direct antioxidant properties. However, lipoic acid administration improved
endothelial function in subjects with metabolic syndrome. In another study to determine the
effects of vitamin E on oxidative stress and cell membrane fluidity in the brains of
diabetesinduced experimental rats, Hong et al. reported that vitamin E was found to be effective
for strengthening the antioxidant defense system. They noted a reduction of the accumulation of
ROS such as superoxide radicals, a decrease in the generation of oxidative damaging substances
such as the carbonyl value, a significantly improved lipid composition, and maintenance of
membrane fluidity in the brains of the rats. Coleman suggested that triple antioxidant therapy
(vitamin E, lipoic acid and vitamin C) in diabetic volunteers attenuates the experimental
oxidative stress of met-hemoglobin formation in vitro and reduces haemoglobin glycation in
vivo. Panjwani et al. suggested that vitamin C administered alone or in combination with
vitamin E reduced the fall in ulnar nerve conduction velocity. Sivan and Reece investigated
whether dietary supplementation with vitamin E would reduce the incidence of diabetic
embryopathy in an in vivo rat model. Fifty pregnant rats were designated as the control group
and received a normal diet while the diabetic group received vitamin E supplements (400
mg/day). This experimental study found that supplementation with vitamin E reduces the
incidence of neural tube defects by more than 75%. These findings suggest that vitamin E
reduces this oxidative load, confers a protective effect against diabetic embryopathy, and thus
may potentially serve as a dietary prophylaxis in the future. These results are in line with the
reports of Chang et al. which showed that diabetic embryopathy of rat or mouse embryos is
prevented by vitamin C, vitamin E, SOD, N-acetyl-cysteine, or glutathione ethyl ester. Another
study by Otero et al. showed the effects of supplementation with vitamin E to diabetic mice. The
beneficial effect of vitamin E observed in this model was shown to retard coronary
atherosclerosis accelerated by DM, and was demonstrated to be due to a reduction in oxidative
stress, and not secondary to a decrease in plasma glucose or cholesterol since their respective
plasma concentrations remained unchanged in the diabetic mice supplemented with vitamin E.
Furthermore, it has been recently reported that macrophages from diabetic mice are under excess
oxidative stress, and that the antioxidant vitamin E can attenuate macrophage oxidative stress
which exists in DM and leads to accelerated atherosclerosis development. In a placebocontrolled,
randomized trial of diabetic patients, Reaven investigated the effect of 1600 IU of RRR-α-
tocopherol supplementation daily for 10 weeks on hyperglycemia-induced LDL modifications.
The result of the study pointed to a reduction of approximately 60% of plasma LDL oxidation in
diabetic patients, which was statistically significant when compared to healthy controls. These
results are supported and confirmed by other similar clinical data. Salonen et al. found that doses
equal to or higher than 450 IU are sufficient to significantly ameliorate the susceptibility of LDL
to oxidation, indicating that relatively high doses of RRR-α-tocopherol for supplementation are
needed. Furthermore, Bellomo and others have shown that the effects of RRR- α-
tocopherolsupplementation on LDL oxidation are accompanied by a concomitant reduction in
autoantibody levels againsthyperglycemiainduced LDL modifications. Moreover, clinical studies
have shown an inhibitory effect of RRR-α-tocopherol supplementation on thehyperglycemia-
induced LDL modifications inT1DM and T2DM diabetic patients. Based on nutrition
recommendations and interventions for diabetes, there is no clear evidence of benefits that can be
derived from vitamin or mineral supplementation in people with diabetes. Routine
supplementation with antioxidants, such as vitamins E and C and carotene, is not advised
because of lack of evidence of efficacy, and concern related to long term safety, and therefore
cannot be recommended. The majority of studies included in this review support a possible role
of antioxidant supplementation in reducing the risk of diabetic complications.

5.4. Antioxidant vs arthrosclerosis

The mechanisms of oxidative stress and antioxidants are in patients with atherosclerosis
have been evaluated in extensive animal experiments and clinical research. There is a
relationship between atherosclerotic risk factors (ARF) and increased vascular production of
ROS; the most important ARFs are heredity, age, hypertension, dyslipidemia, diabetes and
smoking . It has been reported that in in-vitro studies an increased vascular production of ROS,
particularly superoxide causes deleterious effects in cell death. ROS and reactive nitrogen
species (RNS) are closely linked to the disease process. Incomplete scavenging of ROS and RNS
influences the mitochondrial lipid cardiolipin, stimulates the release of mitochondrial
cytochrome c and finally activates the intrinsic death pathway [193]. Local generation of RNS
may contribute to vascular tissue injury. Therefore, ROS and RNS participate as signalling
molecules that regulate diverse pathophysiological signalling pathways. High levels of ROS are
potent inducers of the intrinsic apoptotic pathway and tissue injury in pathophysiological
conditions as an integral part of atherosclerotic plaque stabilization. The most important sources
of ROS production associated with CVD pathology are the mitochondrial respiratory chain,
nicotinamide adenine dinucleotide phosphate oxidases (NADP oxidase). The pathogenesis of
atherosclerosis is further related to inflammation, immune response and the proliferative process.
Endothelial denuding injury leads to platelet aggregation and releases platelet-derived growth
factor, which triggers the proliferation of smooth muscle cells forming the nidus of the
atherosclerotic plaque in the arterial intima, implicating inflammatory changes in the
development of the disease. Supplementing treatment with antioxidants might be helpful to
patients. Vitamin E reduces the consequences of lipid peroxide content in mouse peritoneal
macrophages (MPMs). E-selectin has been proposed as an important factor in the development
of the inflammatory process underlying atherothrombosis. The expression of E-selectin is
decreased by vitamin E in the diabetic rats. Vitamin C has also been investigated in studies on
the prevention of atherosclerosis. The following proposals have been put forward regarding the
mechanisms of vitamin C in preventing atherosclerosis: First, vitamin C has been shown to
prevent apoptosis caused by cytokines in cultured endothelial cells. It also decreases the release
of micro-particles derived from endothelial cells and suppresses pro-apoptotic activity in
congestive heart failure patients in vivo. Second, vitamin C stimulates all types of collagen
synthesis by specific hydroxylase enzymes. Endothelial cell proliferation is, in part, associated
with the synthesis of type IV collagen. Thus, the lack of vitamin C prevents the generation of
type IV collagen in cultured endothelial cells. Third, vitamin C protects the vascular endothelium
by enhancing endothelial NO synthase. Endothelial NO synthase activity is inhibited by ROS
that oxidize and deplete the co-factor tetrahydrobiopterin . Therefore, vitamin C prevents the loss
of NO synthase activity by maintaining tetrahydrobiopterin. Glutathione monoethyl ester, but not
ascorbic acid, exerted protective effects against ischemia–reperfusion injury. Interestingly, the
protective effects of glutathione monoethyl ester are enhanced by co-administration with vitamin
C in rat hearts subjected to ischemia and reperfusion. The oxidized LDL leads to increased
platelet-endothelial cell adhesion, which can be prevented by superoxide dismutase (SOD) and
catalase. In fact, the vascular extracellular expression of SOD is stimulated by NO. Narang et al.
reported that dietary palmolein oil, which is rich in monounsaturated fatty acid and antioxidant
vitamins, “protected rat heart from oxidative stress associated with ischemiareperfusion injury”.
Das et al. [209] found “a role for c-Src [a family of proto-oncogenic tyrosine kinases] in post
ischemic cardiac injury and dysfunction and demonstrate direct cardio protective effects of [the
tocotrienol-rich fraction of palm oil (TRF)]. The cardio protectiveproperties of TRF appear to be
due to inhibition of c-Src activation and proteasome stabilization”. Carlson et al. using a rat
model, reported: “Antioxidant vitamin therapy [vitamin C, vitamin E, vitamin A and zinc]
abrogated myocardial inflammatory cytokine signaling and attenuated sepsis-related contractile
dysfunction, suggesting that antioxidant vitamin therapy may be a potential approach to treat
injury and disease states characterized by myocardial dysfunction”. Hypertension is directly
regulated by the kidneys and cardiovascular system and adversely affects these organs. Tian et
al. found that in salt sensitive rat model of hypertension, vitamin C and vitamin E treatments
“decreased renal inflammatory cytokines and chemokines, renal immune cells, NF-κB, and
arterial pressure and improved renal function and damage”. As noted above, chronic zidovudine
administration promotes cardiovascular damage, and vitamin C has been found to combat this
effect in rats. Diabetes mellitus may initiate increased myocardial vulnerability to ischemia
reperfusion injury and pro/antioxidant imbalance. Resistance to ischemia-induced ventricular
arrhythmias and levels of endogenous antioxidants (α-tocopherol) has been found to be increased
in diabetic rat myocardium. The currently available evidence needs to be confirmed in clinical
trials. Consumption of fruit and vegetable diets rich in antioxidant nutrients can be recommended
for all individuals, and there is some indication that such a diet can be beneficial in the effects of
cardiovascular events. Fig. 2 shows the involvement of cellular antioxidant enzymes in
cardiovasculardisease.

5.5. Anti oxidant vs neurodegerative diseases

Neurodegenerative disorders are a heterogeneous group of diseases of the nervous

system, including the brain, spinal cord, and peripheral nerves that have much different
aetiology. ROS are particularly active in the brain and neuronal tissue as the excitatory amino
acids and neurotransmitters, whose metabolism is factory of ROS, which are unique to the brain
and serve as sources of oxidative stress. ROS attack glial cells and neurons, which are post-
mitotic cells and therefore, they are particularly sensitive to free radicals, leading to neuronal
damage. It has been reported that deleterious effects of ROS on human cells may end in
oxidative injury leading to programmed cell death i.e. apoptosis. A multitude of genes involved
in redox status, antiinflammation and detoxification are transcribed by Nrf2–ARE pathway
activation. These genes are known to be involved in cytoprotection from various oxidative insult
and cellular injuries in numerous different tissues and organs including brain. Intracellular
peroxidases are cleared by a group of enzymes that are transcribed by Nrf2–ARE pathway. The
peroxisomal CAT catalyses the conversion of H2O2 to water and molecular oxygen. However,
the specific activity of CAT is much lower in brain than peripheral tissue. Glutathione-s-
peroxidase (Gpx) is another enzyme that metabolizes H2O2 and depends on reduced glutathione
(GSH). The oxidized GSH (GS-SG) is recycled to GSH by glutathione reductase (GR).
Glutathione (GSH), a tripeptide γ-glutamyl-cysteinylglycine, is the most abundant low molecular
weight thiol expressed ubiquitously. It is widely recognized as an endogenous non-enzymatic
antioxidant and an oxyradical scavenger, and is thereby critical to maintaining a reducing
environment in the cell and protect against oxidative damage by ROS. GSH has been implicated
in a wide range of metabolic processes, including cell division, DNA repair, regulation of
enzyme activity, and activation of transcription factors, modulation of anion and cation
homeostasis, and protection against oxidative damage.

GSTs are key detoxification enzymes that catalyze the conjugation of various
electrophiles, reactive alkenals, and numerous other xenobiotic to GSH. These GSH-S-
conjugates are removed from cells by the multidrug resistant protein-1 (MRP-1), an ATP binding
cassette (ABC) family protein. MRP-1 is an integral plasma membrane protein that exports
glutathione-S conjugates out of the cell in an ATP-dependent manner. Studies have shown
reduced GST activity in brain and ventricular fluids in AD. Increased expression of GST leads to
increased resistance towards oxidative stress in neuroblastoma cells and provides protection
against HNE-mediated toxicity in neuronal cell culture . Growing evidence demonstrates that the
AD brain is under tremendous oxidative stress. A significantly increased HO-1 expression was
reported in post-mortem AD temporal cortex and hippocampus compared to aged-matched
control. Additionally, an increased Nqo1 activity and expression was found in astrocytes and
neurons of AD brain and Nrf2 was predominantly localized in cytoplasm in AD hippocampal
neurons. Furthermore, there is increased protein oxidation and lipid peroxidation in AD brain
when compared to aged matched controls. Recent studies in aged APP/PS1 AD mouse models
showed reduced Nrf2, Nqo1, GCL catalytic subunit (GCLC) and GCL modifier subunit (GCLM)
mRNA and Nrf2 protein levels. Additionally, in a triple transgenic AD mouse, the GSH/GSSG
ratio was reported to be reduced.

The hallmark of PD is a severe reduction of dopamine in all components of the basal

ganglia. Dopamine and its metabolites are depleted in the caudate nucleus, putamen,
globuspallidus, nucleus accumbens, the ventral tegmental area, and the substantianigra pars
compacta and reticulata. Moderate losses of dopamine are found in the lateral hypothalamus,
medial olfactory region and amygdaloid nucleus. In early parkinsonism, there appears to be a
compensatory increase in dopamine receptors to accommodate the initial loss of dopamine
neurons. As the disease progresses, the number of dopamine receptors are decreases, apparently
due to the concomitant degeneration of dopamine target sites on striatal neurons. In the
remaining neurons in patients with PD, dopamine turnover seems greatly increased, judging from
the concentrations of homovannilic acid [HVA] in the nerve terminals in the striatum and the cell
bodies and dendrites in the substantia nigra and the ROS production may very well increase in
consequence. This hypothesis is strengthened by a study showing that the concentrations of GSH
decrease when dopamine turnover increase after reserpine treatment in rats, indicating increased
activity of the peroxide scavenging enzyme GSH-Px. If the increase in ROS production due to
increased dopamine turnover is not buffered by the scavenging enzymes (SOD, catalase, and
GSH-Px), the compensatory hyperactivity of the dopaminergic neurons may become
selfdestructive. Chronic administration of L-DOPA would then only exacerbate the production of
destructive ROS. The administration of L-DOPA itself has been postulated to enhance the
accumulation of ROS. Another index of oxidative stress in PD might be the evidence of a robust
increase of NF-κB in the nuclei of dopaminergic neurons in the substantia nigra of PD patients.
This clinical finding is consistent with in vitro data showing that oxidative stress induced by C2-
ceramide treatment causes nuclear translocation of NF-κB in cultured mesencephalic neurons.
More recently, it has been shown that the neurotoxin 6-OHDA activates NF-κB in PC12 cells by
enhancing intracellular ROS levels . Interestingly, in this experimental model, NF-κB seems to
sustain cell survival by stimulating the expression of the anti-apoptotic proteins Bcl-2 and Bfl-
1144. Moreover, as already mentioned, the potent green tea polyphenol antioxidant EGCG exerts
a neuroprotective effect in a MPTP mouse model of PD [258]. However, there are still few and
controversial epidemiological data on this important point, which might be partly due to the
intrinsic difficulties in performing epidemiological surveys regarding the dietary habits of large
populations. Nevertheless, it is desirable that future studies aimed at investigating the
relationship between dietary antioxidant intake and the relative risk for neurodegenerative
disorders such as AD, PD, and ALS will throw more light on this very important aspect of public
health.

6. Conclusion

In summary the reactive oxygen species and oxidative stress play an important role in the
aetiology and progression of major human degenerative diseases has triggered enormous and
worldwide interest in endogenous and exogenous antioxidants. There is now abundant evidence
that substances in fruit and vegetables are potent preventives of various diseases, especially
arthritis, cancer, heart disease, diabetes and neurodegenerative diseases. With these recent
developments in scientific knowledge which firmly establish the links between food factors and
the prevention of disease. The present review reveals a vast number of relevant studies related to
oxidative stress and selected human diseases. The research field actually presents a variety of
approaches that have been produced suggestive evidence that antioxidants might have an impact
against many diseases. However, more systematic research in this line is imperative in order to
reveal the relationship and involvement of antioxidants with other diseases. The large diversity in
the molecular mechanisms and the methodology of antioxidants discussed here are factors
probably responsible for the consistent findings of their prevention of diseases. This shows that it
will be very useful in controlling many oxidative stress mediated diseases as discussed above. In
comparison with the effects of the antioxidants analysed in the previous study we can expect that
many plant derived compounds which have excellent antioxidant property and were successfully
investigated here and validates or corroborates the antioxidant hypothesis of many diseases.
Current review highlights the perspectives and possibilities of unrevealing the uncapped
potentials of antioxidants in herbal plants for disease cure and warrants the need for systematic
research in the field to clear the insights in this very complex matter. However, recent research
work with antioxidant therapy suggests another promising area i.e., combining potential
antioxidants and using them during the early onset of the disease as a prophylactic measure to
prevent the disease that may eventually prove to be more effective in treating several devastating
diseases.