CHANGES ON SERUM LIPID PROFILE IN STREPTOZOTOCIN INDUCED

DIABETIC RATS TREATED WITH LEAF EXTRACT OF TERMINALIA CATAPPA

A RESEARCH PROJECT

BY

UDOH ITORO-OBONG ALFRED

18/BM/PHS/594

SUBMITTED TO

DEPARTMENT OF PHYSIOLOGY

FACULTY OF BASIC MEDICAL SCIENCES

UNIVERSITY OF UYO, UYO

AKWA-IBOM STATE

IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF

BACHELOR OF SCIENCE (B. Sc) DEGREE IN PHYSIOLOGY.

APRIL, 2023
 CERTIFICATION

We certify that this research work on changes on serum lipid profile in Streptozotocin

induced diabetic rats treated with leaf extract of Terminalia catappa is an authentic research

carried out by UDOH, ITORO-OBONG ALFRED with registration number 18/BM/PHS/594 of

the Department of Physiology, Faculty of Basic Medical Sciences University of Uyo, Uyo.

We have examined and found it acceptable for the award of a bachelor of science (B.Sc)

Degree in Physiology.
 DECLARATION

This is to declare that this research work is an authentic one carried out by me, UDOH,

ITORO-OBONG ALFRED (18/BM/PHS/594) of the Department of Physiology, Faculty of

Basic Medical Sciences, University of Uyo, Uyo, under the supervision and guidance of Dr.

Ezekiel. E. Ben.
 DEDICATION

This study is dedicated to God almighty for his love grace protection and support in my

academic pursuits. To my mother for her unconditional love, emotional and spiritual support, and

her financial contributions towards the creation of this work and finally to my brother Nsikan for

living accommodations and crucial advice in the final polishing of this study. To you all I am

eternally grateful.
 ACKNOWLEDGEMENTS

I would like to firstly appreciate the almighty god for being my olive branch in the storm,

for being there for me and making all this possible. Without you lord I would not be here to

present this study.

I would also extend my most profound and deepest gratitude to my parents, for being my

motivation and for both their financial, spiritual and emotional support during the course of this

study. My brother for continuous support and for the experience and advice he has given to me

that contributed to the compilation of this project, Mr. Asuquo and my colleagues for their

assistance in corrections and fact finding that, made this project possible.

I am also thankful to all my lecturers that have impacted in me then knowledge that was

necessary to make this study comprehensive

Finally I am thankful to my supervisor Dr. Ezekiel E. Ben for his wisdom, experience,

cooperation, correction sand constructive criticism which together greatly improved the quality

of this project.
 ABSTRACT

The study was conducted to investigate the effect of aqueous extract of Terminalia catappa on

the serum lipid profile of Streptozotocin induced diabetic male Wistar rats. Forty eight (48) rats

were grouped into eight groups of 6 rats each. Group 1 was Normal control group, Group 2 was

Non-Diabetic rats treated with Terminalia Catappa leaf extract at a dose of 130mg/kg, Group 3

was Diabetic control group, Group 4 were Diabetic rats treated with Terminalia Catappa leaf

extract at a dose of 130mg/kg, Group 5 were Diabetic rats treated with Insulin at a dose of

0.75IU/kg, Group 6 were diabetic rats treated with Methanolic extract of Terminalia Catappa at

a dose of 130mg/kg, Group 7 were diabetic rats treated with Ethanolic extract of Terminalia

Catappa at a dose of 130mg/kg, Group 8 were rats treated with Aspirin at dose of 130mg/kg.

After 3 weeks of treatment, rats were euthanized under ketamine at a dose of 0.6ml.blood was

obtained from the animals via cardiac puncture. The blood obtained was stored in a plain sample

bottle and after coagulation, was centrifuged at 3000 revolutions per minute for 15 minutes. The

serum was collected and stored in plain sample bottles pending analysis. Data was analyzed

using statistical software, graphical prism version 5.0. One way analysis of varience followed by

post hoc Turkey’s test at p˂0.05. Results show that Male rats treated with Terminalia catappa

leaf extract experienced significant decrease in Low Density Lipoproteins, Very Low Density

Lipoproteins and Total Cholesterol levels in all treated groups when compared to the control and

diabetic groups however there was a significant increase in Triglyceride levels in the extract

treated diabetic group. This study shows that Terminalia catappa leaf extract reduced levels of

harmful lipoproteins in diabetic conditions and can be used as alternative treatment of diabetes

associated dyslipidemia.
 CHAPTER 1

INTRODUCTION

1.1 Background of study

Type 1 Diabetes or insulin dependent diabetes is a chronic condition characterized by the

reduced or total inability of the islet cells in the pancreas to produce the blood glucose level

regulating peptide hormone called insulin due to the destruction of these cells by the immune

system. The function of this hormone insulin is to facilitate the absorption of glucose into

liver, fat and skeletal muscle cells for storage and utilization in the production of energy. In

the absence of this insulin, the blood glucose level is left to rise to problematic levels.

As time passes, The elevated glucose levels leads to adverse effects on different organs and

systems in the body such as kidney, nerve, eye and cardiovascular damage. Diabetic

dyslipidemia is one of these threats commonly associated with damage to the cardiovascular

system due to accumulation of lipids in the blood vessels. Dyslipidemia usually manifests

through elevated serum concentrations of small dense lipoproteins i.e low and very low

density lipoproteins (LDL & VLDL) in particular. This condition along with the associated

diabetic conditions can be managed through the usual means i.e pharmaceutical means as

well as dietary/lifestyle adjustments and insulin therapy.

1.2 Aim of the study

This aim of this study is to evaluate the changes on serum lipid profile in Streptozotocin

induced Diabetic rats treated with leaf extract of Terminalia catappa.

1.3 Objective of the study
The objective of this study is to determine the:

1. Total cholesterol levels following administration of extract of Terminalia catappa.

2. Triglyceride levels following administration of extract of Terminalia catappa.

3. High density lipoprotein levels following administration of extract of Terminalia catappa.

4. Low density lipoprotein levels following administration of extract of Terminalia catappa.

5. Very low density lipoproteins levels following administration of extract of Terminalia

catappa.

1.4 Significance of study

The significance of the study on changes in serum levels of lipoproteins in streptozotocin-

induced diabetic rats administered with aqueous extract of Terminalia catappa lies in its potential
implications for the management of diabetes and its complications. Diabetes is a chronic
metabolic disorder that affects millions of people worldwide, and it is associated with a range of
complications, including cardiovascular disease, neuropathy, nephropathy, and retinopathy.

The study aims to investigate the effects of Terminalia catappa extract on serum lipoprotein
levels in diabetic rats. The findings of this study may have important implications for the
development of new treatments for diabetes and its complications. If the extract is found to be
effective in regulating lipoprotein levels in diabetic rats, it could potentially be developed into a
novel therapeutic agent for the management of diabetes and its complications. Additionally, the
study could provide insights into the mechanisms underlying the effects of Terminalia catappa
extract on lipoprotein metabolism, which could lead to the discovery of new therapeutic targets
for the treatment of diabetes and its complications.

Furthermore, the study could contribute to the understanding of the potential benefits of natural
remedies in the management of diabetes. Terminalia catappa, also known as Indian almond, has
been traditionally used in the treatment of various ailments, including diabetes. However,
scientific evidence supporting its efficacy and safety in the management of diabetes is limited.
The study could provide important information on the potential therapeutic benefits of
Terminalia catappa extract in the management of diabetes and its complications.

Overall, the study on changes in serum levels of lipoproteins in streptozotocin-induced diabetic

rats administered with aqueous extract of Terminalia catappa has significant implications for the
development of new treatments for diabetes and its complications, as well as for the
understanding of the potential benefits of natural remedies in the management of diabetes.

1.5 Justification of study

The study on changes in serum levels of lipoproteins in streptozotocin-induced diabetic rats

administered with aqueous extract of Terminalia catappa is justified by the need to investigate

new and effective treatments for diabetes and its complications. The study aims to provide

insights into the potential therapeutic benefits of Terminalia catappa extract in regulating

lipoprotein metabolism and its potential use as a novel therapeutic agent. Additionally, the study

could contribute to the understanding of the potential benefits of natural remedies in the

management of diabetes. Ultimately the study is justified by the significant health burden posed

by diabetes and the need for new and effective treatments to manage the disease and its

complications.
 CHAPTER 2

LITERATURE REVIEW

2.1 Diabetes

Diabetes mellitus is a disorder of carbohydrate metabolism characterized by impaired ability

of the body to produce or respond to insulin and thereby maintain proper levels of sugar
(glucose) in the blood (Grant et al, 2011). diabetes can also be described a s a disease condition
characterized by the inability of the body cells to take in glucose for energy utilization thereby
leading to the buildup of extra sugar in the blood stream. A condition known as Hyperglycemia.
According to WHO, about 422 million people worldwide have diabetes mellitus with the
majority of the number living in low and middle class income countries. About 1.5million deaths
are directly attributed to diabetes each year, a staggering number. Unfortunately, both the
number of cases and the prevalence of diabetes have been steadily increasing over the past few
decades (Thompson et al, 2021). Diabetes mellitus has no known definitive cure due to the
nature of the condition but there are several steps that can be taken to manage the complications
that inevitably follow to ensure improved quality of life for those affected (Karl, 2012).

There are several types of diabetes mellitus s depending on the specific characteristics of the
disease. The two main and most commonly known types are Types 1&2 (Cooper et al, 2010).

2.1.1 Type 1 diabetes/ insulin dependent diabetes mellitus (IDDM)

Type 1 diabetes or IDDM is an auto immune disorder condition in which the immune
system destroys Insulin producing pancreatic beta cells thereby leading to a generalized and
severe reduction in production of insulin the body (Pecoit-filho et al, 2015). It can also be
defined as a a chronic illness characterized by the body’s inability to produce insulin due to the
auto immune destruction of beta cells in the pancreas (Joshua, 2014). Viral infections and auto
immune disorders may also be involved in the destruction of these beta cells, although heredity
also plays a major role in determining the susceptibility of the beta cells to destruction, for
instance, there may be a hereditary tendency for beta cells to degenerate even without viral
infections or auto immune disorders. The usual onset of Type 1 diabetes occurs at about 14 years
of age or generally below 30 (Tom et al, 2012) hence it’s often called “juvenile diabetes
mellitus”. Due to the absence or low level of insulin in this type of diabetes, patients usually
have to inject daily levels of insulin to help manage their blood glucose level.

2.1.1.2 Risk factors

 Family history: Generally there is an increased chance of an individual to develop type 1

diabetes if their parents or grandparents had the condition. (Duke, 2009).
 Environmental factors: Circumstances such as exposure to a viral illness likely plays a
role in type 1 diabetes (Rewers et al, 2011).
 Diabetes antibodies: The presence of diabetes antibodies detected in the testing of
closely related family members may indicate an increased risk of developing type1
diabetes (Stene, 2013).
 Age: Type 1 diabetes can develop in an individual of any age but it has been found to be
mostly commonly developing in young people or people below the age of 30, hence its
previous name of juvenile diabetes (Norris et al, 2012).

2.1.1.3 Symptoms

 High blood glucose concentration: Due to the lack of insulin, there is decreased
efficiency of peripheral glucose utilization and augmented glucose production, raising
plasma glucose to 300 - 1200mg/100ml. This increased plasma glucose level then has
multiple effects throughout the body (Sawrar, 2011).
 Dehydration: Since glucose does not diffuse easily through the pores of the cell
membrane, the increased osmotic pressure in the extracellular fluids causes osmotic
transfer of water out of the cells. The loss of fluid in the urine also causes osmotic
diuresis which leads to massive loss of fluid in the urine and thus dehydration (Forbes,
2011).
 Diabetic ketoacidosis: This occurs when blood glucose is dangerously high and the body
cannot get nutrients into the cells due to the absence of diabetes, As a result, the body
resorts to breaking down of muscle and fat for energy, thereby causing an accumulation
of ketones in the blood and urine (Gudnason, 2011).
2.1.1.4 Management

The most common and effective method of management of type 1 diabetes is insulin
therapy. This involves the administration of prescribed amounts of the hormone insulin via
injection (Biadal et al, 2021). It can also be managed by closely watching the blood glucose level
by the use of instruments and equipment like insulin pump.

2.1.2 Type 2 diabetes/insulin dependent diabetes mellitus

Type 2 diabetes, a far more common type of diabetes than type 1, accounts for about
90% of all cases of diabetes mellitus.in most cases, the onset of type 2 diabetes occurs only after
age 30, often between the ages of 50 and 60 years and the disease develops gradually (McCabe,
2019). Therefore this symptom is often referred to as adult onset diabetes. In recent years
however, there has been a steady increase in the number of younger individuals, some less than
20 years old, with the type 2 diabetes. This trend appears to be related mainly to the increasing
prevalence of obesity which ids the most important risk factor for type 2 diabetes in children as a
well as in adults. Type 2 diabetes is characterized by increased plasma insulin concentration also
known as hyperinsulinemia This is as a result of an attempt of the pancreatic beta cells to make
up for the diminished sensitivity of target tissues to the metabolic effects of insulin, a condition
known as insulin resistance. This is why it is also known as insulin independent diabetes. It
occurs gradually and is a lifelong condition since it has no cure. Rates of type 2 diabetes have
increased markedly since 1960 in parallel with obesity. As of 2015, they were approximately 592
million people diagnosed with the disease compared to around 30 million in 1985. Type 2
diabetes is associated with a 10 year shorter life expectancy.

1.1.2.1 CAUSE
The specific mechanisms through which type 1 diabetes is caused cannot currently be
fully explained. However, there are several factors that are closely related with the diabetes
condition and can be said to play an important role in leading to the development of the disease.
These are:
 INSULIN RESISTANCE.
Insulin resistance is a complex condition in which your body does not respond as it
should to insulin, Insulin is a hormone produced from the islet of langerhans in the
pancreas that is essential in the regulation of blood glucose level through its ability to
facilitate the uptake and utilization of glucose from the blood in target tissues like the
liver, muscles and adipose tissue. Development of insulin resistance and impaired
glucose metabolism usually begins with excess weight gain and obesity. Most of the
insulin resistance appears to be caused by abnormalities in the signaling pathways that
link receptor activation with multiple cellular effects. Insulin is a part of a cascade of
disorders that includes fasting hyperglycemia, lipid abnormalities and hypertension.

 OBESITY.
Obesity is the abnormal or excessive accumulation of fat that may impair normal health.
Adults with a body mass index over 25 are considered to be obese. Obesity has been
observed to have a relationship to diabetes due to the presence of obesity in 70-80% of
patients with type 2 diabetes, however the exact mechanism by which this relationship
manifests itself remains to be elucidated. Scientists have hypothesized that the increased
plasma levels of non-esterified fatty acids (NEFA’s) leads to significantly malfunction in
the glucose stimulated insulin secretion pathway resulting in reduced insulin
biosynthesis.

 EXCESS FORMATION OF CORTISOL (CUSHING’S SYNDROME)

Cushing’s syndrome is a condition that occurs from exposure to high levels of the stress
hormone cortisol for a long period of time. Individuals with this condition have chronic
Hyper-cortisolism which is elevated levels of cortisol in the blood. Hyper-cortisolism
blocks or impedes the action of insulin on peripheral tissues such as the liver, muscle and
adipose tissue leading to increase insulin resistance. It has also been seen to partially
inhibit insulin release from the pancreatic beta cells. Thus, many individuals with
Cushing’s syndrome develop diabetes mellitus.
 2.1.2.2 RISK FACTORS

Risk factors of type 2 diabetes include

 Weight: being overweight or obese is a main risk

 Fat distribution: storing fat mainly in the abdomen, rather than the hips or thighs indicates a
greater risk. The risk of type 2 diabetes rises if you’re a man with a waist circumference above
40inches (101.6cm) or a woman with a measurement above 35 inches (88.9cm).
 Inactivity: the less active you are, the greater your risk. Physical activity helps control your
weight, uses up glucose as energy and makes your cells more sensitive to insulin.
 Race and ethnicity: although it’s unclear why, people of certain races and ethnicities, including
Black, Hispanic, Native American and Asian people are more likely to develop type 2 diabetes
than white people.
 Blood lipid levels: an increased risk is associated with low levels of high density lipoproteins
(HDL) cholesterol and high levels of triglycerides.
 Age: the risk of type 2 diabetes increases as you get older , especially after age 45.
 Prediabetes: Prediabetes is a condition in which the blood sugar level is higher than normal, but
not high enough to be classified as diabetes. Left untreated, prediabetes progresses to type 2
diabetes.
 Pregnancy related risks: the risk of developing type 2 diabetes increases if an individual
developed gestational diabetes when they were pregnant or if they gave birth to baby weighing
more than 4 kilograms.
 Areas of darkened skin, usually in the armpits or neck. This condition often indicates insulin
resistance.

2.1.2.3 SYMPTOMS

 Increased thirst
 Frequent urination
 Unintended weight loss
 Fatigue
 Blurred vision
 Slow healing sores
 Slow healing sores
 Frequent infections
 Numbness or tingling in hands or feet

2.1.2.4 PREVENTION
 Eating healthy foods: foods lower in fat and calories and higher in fiber. Also fruits, vegetables
and whole grains
 Losing weight: losing a modest amount of weight and keeping it off can delay the progression
from prediabetes to type 2 diabetes.
 Avoiding inactivity for long periods: sitting still for long periods can increase your risk of type 2
diabetes therefore frequent activity and movement is advised
 Monitoring blood sugar levels: elevated blood sugar levels is assign of prediabetes, therefore
monitoring blood sugar levels will help in early spotting and treatment of diabetes (WHO.Int,
2022)

2.1.2.5 TREATMENT
 Metaformin: This is usually the first medication used to treat type 2 diabetes. It lowers the
amount of glucose your liver produces and helps the body respond better to the insulin
(Monterossa, 2013).
 Sulfonylureas: A group of drugs that increase insulin production (Yogish, 2013)
 Meglitinides: Also increases insulin production. Works faster than Sulfonylureas (Yogish, 2013)
 Thiazolidinediones: they increase insulin sensitivity but may also raise the risk of heart
problems (Yogish, 2013)
 Dpp4 inhibitors: these medications help lower the blood sugar levels, but they can also cause
joint pain and pancreas inflammation (Yogish, 2013)
 Insulin: taking long lasting shots at night or short lasting ones helps to treat the elevated glusoce
levels (Yogish, 2013)
2.1.3 Gestational diabetes
Gestational diabetes is a condition in which a woman without diabetes develops high blood
sugar levels during pregnancy usually due to insulin resistance or reduced production of insulin
(Kühl, 2014). It affects 3-9% of pregnancies depending on the population studied; it is especially
during the last 3 months of pregnancy. It affects 1% of those under the age of20 and15% of those
over the age of 44.a number of ethnic groups including Asians American Indians, indigenous
Australians and pacific islanders are of higher risk (Paletas, 2010). In 90% of cases, gestational
diabetes will resolve after the baby is born. Women however rare at an increased risk of
developing type 2 diabetes.

2.1.3.1 Test & diagnosis.

Testing for gestational diabetes usually occurs between 24 and 28 weeks of pregnancy.
Tests include the glucose challenge test and the oral glucose tolerance test (OGTT). If the result
of the glucose challenge test shows high blood glucose, you will return for an OGTT test to
confirm the diagnosis of gestational diabetes (Pezeshki, 2010).

2.1.3.2 Classification.

Type A1: Characterized by abnormal oral glucose tolerance test (OGTT), but there are normal
blood glucose levels during fasting and 2 hours after meals. Diet modifications are sufficient to
control glucose levels.
Type A2: Characterized by abnormal OGTT compounded by abnormal glucose levels during
fasting and or after meals, additional therapy with insulin or other medications is required
(Bekiari, 2010) .

2.1.3.3 Cause

During pregnancy, the placenta produces hormones that cause buildup of glucose in the
blood as a result, failure of the pancreas to produce adequate amounts of insulin to handle the
increased blood glucose level leads to increased blood glucose level and gestational diabetes.
Regarding symptoms for most women, gestational diabetes doesn’t cause noticeable symptoms
or signs. But increased thirst and more frequent urination may be present as possible symptoms.

2.1.5 Diagnosis of diabetes mellitus

The normal blood glucose level for healthy adults is between 90 to 110 mg/dl while a fasting
blood glucose level in adults of less than 100mg/dl (between 80and 100 mg/dl) is considered
normal. Elevations above these levels indicate diabetes mellitus. The following tests are used to
determine blood glucose level and therefore diagnose diabetes (Monterossa, 2013).

2.1.6 Complications associated with diabetes mellitus

2.1.6.1 Diabetic retinopathy

Diabetic retinopathy is a common cause of adult blindness in the world ( Rask-Madsen and King,
2018). It is characterized initially by retinal capillary micro aneurysms (background retinopathy)
and later by neovascularization (proliferative retinopathy) and macular edema. There are no early
symptoms or signs, but focal blurring, vitreous or retinal detachment, and partial or total vision
loss eventually develop; rate of progression is highly variable.
Screening and diagnosis are by retinal examination performed by an ophthalmologist, which
should be done regularly (usually annually) in both type 1 and type 2 diabetes. Early detection
and treatment are critical to preventing vision loss. Treatment for all patients includes intensive
glycemic and blood pressure control. Pan-retinal laser photocoagulation is used for proliferative
diabetic retinopathy and sometimes severe non-proliferative diabetic retinopathy. Vascular
endothelial growth factor (VEGF) inhibitors such as Aflibercept, Bevacizumab,
and Ranibizumab are used for macular edema and can also be used for proliferative retinopathy,
but this treatment requires frequent regular visits.

2.1.6.2 Diabetic nephropathy

Diabetic nephropathy is a leading cause of chronic kidney disease in the world (Feldman, 2002).
It is characterized by thickening of the glomerular basement membrane, mesangial expansion,
and glomerular sclerosis. These changes cause glomerular hypertension and progressive decline
 in glomerular filtration rate. Systemic hypertension may accelerate progression. The disease is
usually asymptomatic until nephrotic syndrome or renal failure develops (Cleary et al, 2002).
Diagnosis is by detection of urinary albumin. Once diabetes is diagnosed (and annually
thereafter), urinary albumin level should be monitored so that nephropathy can be detected early.
Monitoring can be done by measuring the albumin:creatinine ratio on a spot urine specimen or
total urinary albumin in a 24-hour collection. A ratio > 30 mg/g (> 3.4 mg/mmol) or an albumin
excretion of 30 to 300 mg/day signifies moderately increased albuminuria (previously called
microalbuminuria) and early diabetic nephropathy. An albumin excretion > 300 mg/day is
considered severely increased albuminuria (previously called macroalbuminuria), or overt
proteinuria, and signifies more advanced diabetic nephropathy. Typically a urine dipstick is
positive only if the protein excretion exceeds 300 to 500 mg/day (Danish, J et al, 2018).
Treatment is rigorous glycemic control combined with blood pressure control. An angiotensin-
converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) should be used
at the earliest sign of albuminuria (albumin-to-creatinine ratio ≥ 30 mg/g), to prevent progression
of renal disease because these drugs lower intraglomerular blood pressure and thus have
renoprotective effects. However, these drugs have not been shown to be beneficial for primary
prevention (ie, in patients who do not have albuminuria). Sodium-glucose cotransporter- 2
(SGLT-2) inhibitors also delay progression of renal disease in selected patients with diabetic
nephropathy (estimated glomerular filtration rate [eGRF] < 25 to 30 mL/minute and urine
albumin/creatinine ratio > 300 mg/g). Fineronone, a nonsteroidal mineralocorticoid receptor
antagonist, was shown to decrease the risk of progression of diabetic kidney disease and
cardiovascular events (Captoge, 2002).

2.1.6.3 Diabetic neuropathy

Diabetic neuropathy is the result of nerve ischemia due to microvascular disease, direct effects of
hyperglycemia on neurons, and intracellular metabolic changes that impair nerve function. There
are multiple types, including
 Symmetric polyneuropathy (with small- and large-fiber variants)
 Autonomic neuropathy
 Radiculopathy
 Cranial neuropathy
 Mononeuropathy
Symmetric polyneuropathy is most common and affects the distal feet and hands (stocking-glove
distribution); it manifests as paresthesias, dysesthesias, or a painless loss of sense of touch,
vibration, proprioception, or temperature. In the lower extremities, these symptoms can lead to
blunted perception of foot trauma due to ill-fitting shoes and abnormal weight bearing, which
can in turn lead to foot ulceration and infection or to fractures, subluxation, and dislocation or
destruction of normal foot architecture (Charcot arthropathy). Small-fiber neuropathy is
characterized by pain, numbness, and loss of temperature sensation with preserved vibration and
position sense (Navarro-Gonzalez J. F. et al, 2014) . Patients are prone to foot ulceration and
neuropathic joint degeneration and have a high incidence of autonomic neuropathy. Predominant
large-fiber neuropathy is characterized by muscle weakness, loss of vibration and position sense,
and lack of deep tendon reflexes. Atrophy of intrinsic muscles of the feet and foot drop can
occur.
Autonomic neuropathy can cause orthostatic hypotension, exercise intolerance, resting
tachycardia, dysphagia, nausea and vomiting (due to gastroparesis), constipation and/or diarrhea
(including dumping syndrome), fecal incontinence, urinary retention and/or incontinence,
erectile dysfunction and retrograde ejaculation, and decreased vaginal lubrication.
Radiculopathies most often affect the proximal lumbar (L2 through L4) nerve roots, causing
pain, weakness, and atrophy of the lower extremities (diabetic amyotrophy), or the proximal
thoracic (T4 through T12) nerve roots, causing abdominal pain (thoracic polyradiculopathy).
Cranial neuropathies cause diplopia, ptosis, and anisocoria when they affect the 3rd cranial nerve
or motor palsies when they affect the 4th or 6th cranial nerve.
Mononeuropathies cause finger weakness and numbness (median nerve) or foot drop (peroneal
nerve). Patients with diabetes are also prone to nerve compression disorders, such as carpal
tunnel syndrome. Mononeuropathies can occur in several places simultaneously (mononeuritis
multiplex). All tend to affect older patients predominantly and usually abate spontaneously over
months; however, nerve compression disorders do not.
Diagnosis of symmetric polyneuropathy is by detection of sensory deficits and diminished ankle
reflexes. Loss of ability to detect the light touch of a nylon monofilament identifies patients at
highest risk of foot ulceration (see figure Diabetic foot screening). Alternatively, a 128-Hz
tuning fork can be used to assess vibratory sense on the dorsum of the first toe.

Electromyography and nerve conduction studies may be needed to evaluate all forms of
neuropathy and are sometimes used to exclude other causes of neuropathic symptoms, such as
radiculopathy not caused by diabetes and carpal tunnel syndrome.

Management of neuropathy involves a multidimensional approach including glycemic control,

regular foot care, and management of pain. Strict glycemic control may lessen neuropathy.
Treatments to relieve symptoms include topical capsaicin cream, tricyclic antidepressants (eg,
amitriptyline), serotonin-norepinephrine reuptake inhibitors (eg, duloxetine), and antiseizure
drugs (eg, pregabalin, gabapentin). Patients with sensory loss should examine their feet daily to
detect minor foot trauma and prevent it from progressing.

2.1.6.4 Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is an acute and dangerous complication that is always a medical
emergency and requires prompt medical attention. Low insulin levels cause the liver to turn fatty
acid to ketone for fuel (i.e., ketosis); ketone bodies are intermediate substrates in that metabolic
sequence. This is normal when periodic, but can become a serious problem if sustained. Elevated
levels of ketone bodies in the blood decrease the blood's pH, leading to DKA. On presentation at
hospital, the patient in DKA is typically dehydrated and breathing rapidly and deeply.
Abdominal pain is common and may be severe. The level of consciousness is typically normal
until late in the process, when lethargy may progress to coma. Ketoacidosis can easily become
severe enough to cause hypotension, shock, and death. Urine analysis will reveal significant
levels of ketone bodies (which have exceeded their renal threshold blood levels to appear in the
urine, often before other overt symptoms). Prompt, proper treatment usually results in full
recovery, though death can result from inadequate or delayed treatment, or from complications
(e.g., brain edema). Ketoacidosis is much more common in type 1 diabetes than type 2.ressing to
limb-threatening infection.
 2.1.6.5 Cardiovascular complications
Large-vessel atherosclerosis is a result of the hyperinsulinemia, dyslipidemias, and
hyperglycemia characteristic of diabetes mellitus (Whincup, 2011). Manifestations are
 Angina pectoris and myocardial infarction
 Transient ischemic attacks and strokes
 Peripheral arterial disease
Diagnosis is made by history and physical examination. Treatment is rigorous control of
atherosclerotic risk factors, including normalization of plasma glucose, lipids, and blood
pressure, combined with smoking cessation, daily intake of aspirin, and statins (Lennon et al,
2011). A multifactorial approach that includes management of glycemic control, hypertension,
and dyslipidemia may be effective in reducing the rate of cardiovascular events. In contrast with
microvascular disease, intensive control of plasma glucose alone has been shown to reduce risk
in type 1 diabetes but not in type 2. Certain diabetes drugs decrease the risk of major adverse
cardiovascular events, including metformin and some SGLT2-inhibitors and glucagon-like
peptide-1 (GLP-1) receptor agonists.

2.1.6.6 Diabetic dyslipidemia

Diabetic dyslipidemia is characterized by elevated fasting and postprandial (after dinner or

lunch) triglycerides, low HDL-cholesterol, elevated LDL-cholesterol and the predominance of
small dense LDL particles (Gopkumar, 2005). These lipid changes represent the major link
between diabetes and the increased cardiovascular risk of diabetic patients. The underlying
pathophysiology is only partially understood. Alterations of insulin sensitive pathways, increased
concentrations of free fatty acids and low grade inflammation all play a role and result in an
overproduction and decreased catabolism of triglyceride rich lipoproteins of intestinal and
hepatic origin (Divya, 2018). The observed changes in HDL and LDL are mostly sequence to
this. Lifestyle modification and glucose control may improve the lipid profile but statin therapy
mediates the biggest benefit with respect to cardiovascular risk reduction (Behl T, 2001).
Therefore most diabetic patients should receive statin therapy. The role of other lipid lowering
drugs, such as ezetimibe, fibrates, omega-3 fatty acids, niacin and bile acid sequestrates is less
well defined as they are characterized by largely negative outcome trials. More cardiovascular
disease occurs in patients with either type 1 or 2 diabetes. The link between diabetes and
atherosclerosis is, however, not completely understood. Among the metabolic abnormalities that
commonly accompany diabetes are disturbances in the production and clearance of plasma
lipoproteins. Moreover, development of dyslipidemia may be a harbinger of future diabetes. A
characteristic pattern, termed diabetic dyslipidemia, consists of low high density lipoprotein
(HDL), increased triglycerides, and postprandial lipemia (turbidity of a sample caused by
accumulation of lipoprotein particles). This pattern is most frequently seen in type 2 diabetes and
may be a treatable risk factor for subsequent cardiovascular disease.

2.1.6.6.1 Causes of lipoprotein abnormalities in diabetes

Defects in insulin action and hyperglycemia could lead to changes in plasma lipoproteins in
patients with diabetes. Alternatively, especially in the case of type 2 diabetes, the obesity/insulin-
resistant metabolic disarray that is at the root of this form of diabetes could, itself, lead to lipid
abnormalities exclusive of hyperglycemia.
Type 1 diabetes, previously termed insulin-dependent diabetes mellitus, provides a much clearer
understanding of the relationship among diabetes, insulin deficiency, and lipid/lipoprotein
metabolism. In poorly controlled type 1 diabetes and even ketoacidosis, hypertriglyceridemia
and reduced HDL commonly occur (1). Replacement of insulin in these patients may correct
these abnormalities, and well controlled diabetics may have increased HDL and lower than
average triglyceride levels.
The lipoprotein abnormalities commonly present in type 2 diabetes, previously termed non
insulin-dependent diabetes mellitus, include hypertriglyceridemia and reduced plasma HDL
cholesterol. In addition, low density lipoprotein (LDL) are converted to smaller, perhaps more
atherogenic (tending to cause or promote artheroscerosis) lipoproteins termed small dense LDL
(2). In contrast to type 1 diabetes, this phenotype is not usually fully corrected with glycemic
control. Moreover, this dyslipidemia often is found in prediabetics, patients with insulin
resistance but normal indexes of plasma glucose (3). Therefore, abnormalities in insulin action
and not hyperglycemia per se are associated with this lipid abnormality. In support of this
hypothesis, some thiazoladinediones improve insulin actions on peripheral tissues and lead to a
greater improvement in lipid profiles than seen with other glucose-reducing agents (4).

*Several factors are likely to be responsible for diabetic dyslipidemia: insulin effects on liver
apoprotein production, regulation of lipoprotein lipase (LpL), actions of cholesteryl ester transfer
protein (CETP), and peripheral actions of insulin on adipose and muscle.

Insulin regulation of liver apoproteins and lipid-metabolizing proteins

A number of studies using tracer kinetics in humans have demonstrated that liver production of
apolipoprotein B (ApoB), the major protein component of very low density lipoprotein (VLDL)
and LDL, is increased in type 2 diabetes. ApoB is a large (>500-kDa) protein whose production
is not modulated at the level of protein synthesis. In animals and cultured liver cells,
transcription of the apoB gene is not remarkably altered by dietary changes and diabetes. Rather,
a large amount of newly synthesized protein is degraded either during or immediately after
translation. This degradation is prevented when lipid is added to the protein; this occurs via the
actions of microsomal triglyceride transfer protein (the protein that is defective in patients with
apobetalipoproteinemia). *Thus, lipid regulates apoB production. Increased lipolysis in
adipocytes due to poor insulinization results in increased fatty acid release from fat cells. The
ensuing increase in fatty acid transport to the liver, which is a common abnormality seen in
insulin-resistant diabetes, may cause an increase in VLDL secretion. Tissue culture (5), animal
experiments (6), and human studies (7) suggest that fatty acids modulate liver apoB secretion.

*A second regulatory process may be a direct effect of insulin on liver production of apoB and
other proteins involved in degradation of circulating lipoproteins. In some studies insulin directly
increased degradation of newly synthesized apoB (8). Therefore, insulin deficiency or hepatic
insulin resistance may increase the secretion of apoB. Insulin may modulate the production of a
number of other proteins that affect circulating levels of lipoproteins. These include apoCIII (9),
a small apoprotein that may increase VLDL by preventing the actions of LpL and inhibiting
lipoprotein uptake via the LDL receptor-related protein (LRP). Hepatic lipase is an enzyme
synthesized by hepatocytes that hydrolyzes phospholipids and triglycerides on HDL and remnant
lipoproteins. Some (10, 11), but not all (12), studies suggest that this enzyme is reduced by
insulin deficiency. One effect of hepatic lipase deficiency is to decrease the clearance of
postprandial remnant lipoproteins (see below).

LpL is the major enzyme responsible for conversion of lipoprotein triglyceride into free fatty
acids. This protein has an unusual intercellular transport; LpL is synthesized primarily by
adipocytes and myocytes, but must be transferred to the luminal side of capillary endothelial
cells, where it can interact with circulating triglyceride-rich lipoproteins such as VLDL and
chylomicrons (13). Humans with both type 1 and type 2 diabetes have been reported to have
reduced LpL activity measured in postheparin blood (14); the enzyme is released from the
capillary walls and into the circulation by heparin. Several steps in the production of biologically
active LpL may be altered in diabetes, including its cellular production (15, 16) and possibly its
transport to and association with endothelial cells (17). LpL is stimulated by acute (18) and
chronic insulin therapy (19). LpL activity is low in patients with diabetes and is increased with
insulin therapy (20).

The release of stored fatty acids from adipocytes requires conversion of stored triglyceride into
fatty acids and monoglycerides that can be transferred across the plasma membrane of the cell.
The primary enzyme that is responsible for this is hormone-sensitive lipase (HSSL). HSSL is
inhibited by insulin, which decreases phosphorylation of HSSL and its association with the
stored lipid droplet (21).

Specific lipoprotein abnormalities

Postprandial lipemia. Compared with normal subjects, patients with type 2 diabetes have a
slower clearance of chylomicrons from the blood after dietary fat (14, 22, 23); in treated type 1
patients, abnormalities in the postprandial period may not be found (24). This increased
postprandial lipemia is especially marked in women, who generally have less postprandial
lipemia than men. Chylomicron clearance requires several steps (Fig. 1). After chylomicrons
enter the bloodstream via the thoracic duct, apoCII, the activator of LpL, is transferred to these
particles primarily from HDL. The particle then interacts with LpL on capillary lumenal
endothelial cells of cardiac and skeletal muscle and adipose tissue. Released fatty acids are taken
up by those tissues, perhaps via the fatty acid transporter, CD36 (25), and a smaller triglyceride-
depleted particle, a chylomicron remnant, is created. Chylomicrons contain a truncated form of
apoB termed apoB48. This protein is 48% of full-length apoB and lacks the portion of apoB that
interacts with the LDL receptor. A correlation between postprandial lipemia and atherosclerosis
has been found in a number of clinical studies (26). In addition, apoB48 remnants are found in a
number of atherogenic animal models made with diets and genetic modifications (27, 28). It is
generally accepted that remnant lipoproteins, in addition to LDL, are atherogenic.

Figure 1.
Effects of diabetes on postprandial lipemia. A defect in removal of lipids from the
bloodstream after a meal is common in patients with diabetes. Chylomicron
metabolism requires that these lipoproteins obtain apoCII after they enter the
bloodstream from the thoracic duct. Triglyceride within the particles can then be
hydrolyzed by LpL, which is found on the wall of capillaries. LpL activity is
regulated by insulin, and its actions are decreased in diabetes. Triglyceride-depleted
remnant lipoproteins are primarily degraded in the liver. This requires them to be
trapped by liver heparan sulfate proteoglycans (HSPG) and then internalized by
lipoprotein receptors, LDL receptor and LRP. Because remnants contain a truncated
form of apoB, apoB48, that does not interact with these receptors, this uptake is
mediated by apoE.
Effects of diabetes on postprandial lipemia. A defect in removal of lipids from the
bloodstream after a meal is common in patients with diabetes. Chylomicron
metabolism requires that these lipoproteins obtain apoCII after they enter the
bloodstream from the thoracic duct. Triglyceride within the particles can then be
hydrolyzed by LpL, which is found on the wall of capillaries. LpL activity is
regulated by insulin, and its actions are decreased in diabetes. Triglyceride-depleted
remnant lipoproteins are primarily degraded in the liver. This requires them to be
trapped by liver heparan sulfate proteoglycans (HSPG) and then internalized by
lipoprotein receptors, LDL receptor and LRP. Because remnants contain a truncated
form of apoB, apoB48, that does not interact with these receptors, this uptake is
mediated by apoE.
Remnant lipoproteins can be removed from the bloodstream via several pathways,
some of which appear to be modulated by diabetes. Liver is the major, although not
exclusive, site of remnant clearance. As these particles percolate through the liver,
they are trapped by association with the negatively charged proteoglycans within the
space of Disse. This process may be aided by the presence of apoE and hepatic lipase,
proteins that bind to both lipid particles and proteoglycans. Both hepatic lipase and
heparan sulfate proteoglycan production (29) may be reduced in diabetes. The second
step in remnant clearance is via cellular internalization and degradation of the
particles. Some of the remnants may be directly internalized along with cell surface
proteoglycans. Most remnant uptake is via receptors. ApoE is a ligand for both the
LDL receptor and LRP. Lipase enzymes (LpL and hepatic lipase) also interact with
the LRP. In very poorly controlled diabetes LDL receptors may be decreased.
Although LRP may be regulated by insulin in cultured macrophages (30), liver LRP
is not decreased in diabetic mice (29).

Although most patients with poorly controlled diabetes develop hypertriglyceridemia,

occasional patients develop severe hyperchylomicronemia. Triglyceride levels
exceeding 1000 mg/dL lead to visibly lipemic serum. At higher levels the patients can
develop eruptive xanthomas, lipemia retinalis, and pancreatitis. Most of these patients
have an underlying lipid disorder, such as heterozygous LpL deficiency, that is then
exacerbated by diabetes (31).

The relationship between severe hypertriglyceridemia and diabetes is sometimes

obscured because primary LpL deficiency can lead to recurrent pancreatitis and
insulin deficiency. In contrast to this, recent experimental data have shown that the
LpL is expressed in the islet cells, and it has been postulated that this enzyme may
promote fat-induced toxicity leading to defective insulin secretion (32).

Increased plasma VLDL. Patients with diabetes, especially type 2 diabetes, have
increased VLDL production (1). Insulin infusion will correct this abnormality (7)
either because of the concomitant reduction in plasma fatty acids or because of direct
effects of insulin on the liver (Fig. 2).

Figure 2.
Effects of diabetes on VLDL production. Poorly controlled type 1 diabetes and type 2
diabetes are associated with increased plasma levels of VLDL. Two factors may
increase VLDL production in the liver: the return of more fatty acids due to increased
actions of hormone-sensitive lipase (HSL) in adipose tissue and insulin actions
directly on apoB synthesis. Both of these processes will prevent the degradation of
newly synthesized apoB and lead to increased lipoprotein production. VLDL, like
chylomicrons, requires LpL to begin its plasma catabolism, leading to the production
of LDL or the return of partially degraded lipoprotein to the liver.
Open in new tabDownload slide
Effects of diabetes on VLDL production. Poorly controlled type 1 diabetes and type 2
diabetes are associated with increased plasma levels of VLDL. Two factors may
increase VLDL production in the liver: the return of more fatty acids due to increased
actions of hormone-sensitive lipase (HSL) in adipose tissue and insulin actions
directly on apoB synthesis. Both of these processes will prevent the degradation of
newly synthesized apoB and lead to increased lipoprotein production. VLDL, like
chylomicrons, requires LpL to begin its plasma catabolism, leading to the production
of LDL or the return of partially degraded lipoprotein to the liver.

Both the composition and the size of VLDL determine its metabolic fate. In diabetes
greater amounts of fatty acids returning to the liver are reassembled into triglycerides
and secreted in VLDL. A greater content of triglyceride leads to the production of
larger particles. Not all VLDL are equally likely to be converted to LDL. A greater
proportion of large lighter VLDL returns to the liver without complete conversion to
LDL (33); this pathway is akin to that of chylomicrons. Like chylomicrons, apoE may
be the ligand that mediates liver uptake of these particles. Thus, VLDL metabolism is
a competition between liver uptake of partially catabolized lipoproteins and
intracapillary lipolysis, a process that may require several steps to complete VLDL
conversion to LDL.

LDL are not usually increased in diabetes. In part this may represent a balance of
factors that affect LDL production and catabolism. A necessary step in LDL
production is hydrolysis of its precursor VLDL by LpL. A reduction in this step due
to LpL deficiency or excess surface apoproteins (C1, C3, or possibly E) decreases
LDL synthesis. Conversely, increases in this lipolytic step that accompany weight
loss, fibric acid drug therapy, and treatment of diabetes may increase LDL levels. In
diabetes a reduction in LDL production may be counterbalanced by decreases in LDL
receptors and/or the affinity of LDL for those receptors. Both glycosylated LDL and
small, dense LDL bind to LDL receptors less avidly than does normal LDL.
Occasionally diabetic patients, especially those with very poor glycemic control, may
have increased LDL that is reduced by treatment of their diabetes. This is due to
effects on either the LDL or the receptor.

Increased small dense LDL. Heterogeneity exists in the size and composition of all
classes of lipoproteins. The ratio of lipid to denser protein varies, and this determines
both the buoyancy and the size of the particle, as the lipids are primarily contained in
the core. In the case of VLDL and HDL, the particles also differ in their content of
apoproteins, especially in the amounts of apoCs and apoE on the particle. The core of
all lipoproteins contains hydrophobic cholesteryl ester and triglyceride. The
proportions of these lipids are determined by CETP-mediated exchange of lipids (Fig.
3) and the actions of lipases that remove triglyceride by converting it into
monoglycerides, glycerol, and free fatty acids. In the absence of a defect in these
enzymes, lipoproteins enriched in triglyceride will be converted to small, denser
forms. This is true for both HDL and LDL.

Figure 3.
Plasma lipid exchange. In the presence of increased concentrations of VLDL in the
circulation, CETP will exchange VLDL triglyceride for cholesteryl ester in the core
of LDL and HDL. This triglyceride can then be converted to free fatty acids by the
actions of plasma lipases, primarily hepatic lipase. The net effect is a decrease in size
and an increase in density of both LDL and HDL.
Plasma lipid exchange. In the presence of increased concentrations of VLDL in the
circulation, CETP will exchange VLDL triglyceride for cholesteryl ester in the core
of LDL and HDL. This triglyceride can then be converted to free fatty acids by the
actions of plasma lipases, primarily hepatic lipase. The net effect is a decrease in size
and an increase in density of both LDL and HDL.

A decrease in the size and an increase in density of LDL are characteristic of most
hypertriglyceridemic states, including diabetes. Because of this, small dense LDL is
considered by many to be one of the hallmarks of diabetic dyslipidemia rather than
the expected companion of reduced HDL and increased triglyceride levels (2). The
special designation given to LDL size, rather than HDL and VLDL size, is based on a
large amount of clinical and experimental data implying that these particles confer
additional atherosclerotic risk. In vitro, small dense LDL can be oxidized more easily,
the particles do not interact with LDL receptors as well, and they may associate with
proteoglycans on the surface of cells or in matrix more readily. Although several
human studies imply that small dense LDL are an additional marker for
atherosclerosis development (34), this observation may be restricted to patients with
increased levels of apoB and decreased HDL (35). In other studies the concomitant
association of hypertriglyceridemia and low HDL appears to obscure any additional
risk profiling attributable to LDL size (36). In dietary studies using primates, larger,
not smaller, LDL size correlates with atherosclerosis, presumably because each of
these LDL carries more cholesterol (37).

Although one could question the need to search for additional risk factors in diabetic
patients who are clearly at increased risk of disease, many clinicians and research
centers do measure LDL density and/or size. This can be done by measuring LDL
density using an ultracentrifuge or by measuring size using gradient gels or light
scattering. Another method of determining the likelihood of a patient having small
dense LDL is by waist measurement, a cheaper and easier test (38, 39). Obesity and
insulin resistance are highly correlated with small dense LDL.

Reduced HDL. There are several reasons for the decrease in HDL found in patients
with diabetes (Fig. 4). Increased concentrations of plasma VLDL drive the exchange
of triglyceride from VLDL for the cholesteryl esters found in HDL. Thus, the
etiology of the hypertriglyceridemia and reduced HDL can be accounted for; CETP-
mediated exchange of VLDL triglyceride for HDL cholesteryl esters is accelerated in
the presence of hypertriglyceridemia (40). Clinical measurements of HDL are of HDL
cholesterol; therefore, substitution of triglyceride for cholesteryl ester in the core of
the particle leads to a decrease in this measurement. Moreover, the triglyceride, but
not cholesteryl ester, in HDL is a substrate for plasma lipases, especially hepatic
lipase that converts HDL to a smaller particle that is more rapidly cleared from the
plasma (41). Another contributor to HDL is the surface lipid from triglyceride-rich
particles that are transferred to HDL during VLDL and chylomicron lipolysis. This
increases HDL lipid content. Defective lipolysis leads to reduced HDL production.

Figure 4.
Effects of diabetes on HDL metabolism. HDL production requires the addition of
lipid to small nascent particles. This lipid arrives via hydrolysis of VLDL and
chylomicrons with transfer of surface lipids [phospholipid (PL) and free cholesterol
(FC)] via the actions of phospholipid transfer protein (PLTP). A second pathway is
via efflux of cellular free cholesterol (FC), a process that involves the newly
described ABC1 transporter and esterification of this cholesterol by the enzyme
lecithin cholesterol acyl transferase (LCAT). HDL catabolism may occur through
several steps. Hepatic lipase and scavenger receptor-BI are found in the liver and in
steroid-producing cells. HDL lipid can be obtained by these tissues without
degradation of entire HDL molecules. In contrast, the kidney degrades HDL protein
(apoAI) without lipid, perhaps by filtering nonlipid-containing protein.
Open in new tabDownload slide
Effects of diabetes on HDL metabolism. HDL production requires the addition of
lipid to small nascent particles. This lipid arrives via hydrolysis of VLDL and
chylomicrons with transfer of surface lipids [phospholipid (PL) and free cholesterol
(FC)] via the actions of phospholipid transfer protein (PLTP). A second pathway is
via efflux of cellular free cholesterol (FC), a process that involves the newly
described ABC1 transporter and esterification of this cholesterol by the enzyme
lecithin cholesterol acyl transferase (LCAT). HDL catabolism may occur through
several steps. Hepatic lipase and scavenger receptor-BI are found in the liver and in
steroid-producing cells. HDL lipid can be obtained by these tissues without
degradation of entire HDL molecules. In contrast, the kidney degrades HDL protein
(apoAI) without lipid, perhaps by filtering nonlipid-containing protein.

Within the last 2 years, a number of additional enzymes and receptors have been
discovered that are integral regulators of HDL metabolism and presumably the effects
of HDL on atherosclerosis. It is not yet clear whether hyperglycemia or insulin is an
important regulator of these molecules. One of the first steps in HDL production is
the addition of lipid to the small, newly formed HDL particles manufactured in the
liver and intestine. Phospholipid transfer protein may be required for lipid transfer
from triglyceride-rich lipoproteins (42). In addition, newly formed HDL receive
cholesterol from non-hepatic tissues. Theoretically, the most important of these
tissues for atherosclerosis development should be the arterial wall and lipid-rich
vessel macrophages. Several groups have recently identified the gene responsible for
Tangier disease, a rare defect associated with very low levels of HDL and deposits of
cholesterol in the tonsils and other lymphoid tissues. ABC1, a member of a family of
ATP-binding cassette transporters, is defective in this disease (43). This protein
appears to be necessary for transfer of excess cholesterol out of cells and into HDL.
Cholesterol is an amphipathic molecule that would be expected to remain on the
surface of a lipoprotein. Lecithin acyl transferase converts cholesterol into its
hydrophobic ester form, allowing it to enter the core of the lipoprotein particle.
Unlike LDL, but more akin to triglyceride-rich lipoproteins, HDL protein and lipid
metabolism are sometimes disparate. Cholesterol is the substrate for steroid hormones
and bile. Liver, adrenal, and gonads can obtain HDL lipid without uptake and
degradation of the entire lipoprotein. This process involves scavenger receptor-BI. By
controlling the return of cholesterol to the liver, this receptor appears to play an
antiatherogenic role in models of mouse atherosclerosis (44, 45). Kidneys are a major
site of degradation of apoAI, the major protein component of HDL. This appears to
occur due to filtration of this 22-kDa protein when it is freed from HDL lipid. Fatty
acids may be important for this effect; these fatty acids may be derived from hepatic
lipase hydrolysis of HDL triglyceride (46).

2.1.6.6.2 RELATIONSHIP OF DIABETIC DYSLIPIDEMIA TO

ATHEROSCLEROTIC RISK.
Trials of glucose reduction have confirmed that glucose control is the key to
preventing microvascular diabetic complications. These trials have, however, failed to
show a marked benefit of glucose control on macrovascular disease. There are several
reasons why this could have occurred. The time course of the effects of diabetes on
diseases of large arteries and small vessels differs (47), and longer trials may be
needed. Reversal of underlying vascular disease may require a different degree of
control or may follow a different time course than that for small vessels. Finally, the
pathological processes are probably different. Small vessel disease of diabetic
patients occurs in both type 1 and type 2 diabetes and does not occur in nondiabetics.
It is clearly related to the defective glucose control. Large vessel atherosclerosis is not
a diabetes-specific disorder, yet it is worse in patients with diabetes; however,
processes unrelated to diabetes must be the most important. For this reason it may not
be surprising that treatment of these other processes, such as hypertension (48, 49)
and hyperlipidemia (50), appears to impact macrovascular disease more than does
glucose control. Similarly, the incidence of coronary heart disease in a diabetic
population with low plasma cholesterol levels is much less than that found in western,
atherosclerosis-prone populations (51). In contrast, the metabolic abnormalities
associated with the insulin-resistant syndrome and increased coronary artery disease
are found in the U.S. population even before the development of overt hyperglycemia
(3). Is it these abnormalities and not the glucose per se that are atherogenic?

A variety of animal models have been used to try to reproduce the relationship
between diabetes and macrovascular disease. In a classic experiment, Duff et al. (52)
used alloxan to produce diabetes in cholesterol-fed rabbits. In a seemingly
paradoxical result the diabetic rabbits had less, not more, atherosclerosis. This
atherosclerosis was increased with insulin treatment. The reasons for this result are
now apparent. These rabbits developed hyperlipidemia that was due in part to a
marked defect in LpL. Large chylomicrons were not converted to more atherogenic
remnant lipoproteins and were unable to penetrate the vessel and lead to lipid
deposition (53). This pathophysiological situation is not reproduced in human
diabetes, except for the rare situation in which patients are also LpL deficient.

Other animal studies have more closely imitated the situation in man. Limited studies
have been performed in monkeys made diabetic using streptozotocin; in some studies
the monkeys have increased LDL retention and reduced HDL (54, 55). Alloxan-
treated pigs develop diabetes and increased atherosclerosis (56); however, plasma
LDL was more than doubled by the diabetes. Thus, the effects of diabetes cannot be
discerned, because increased lipoprotein levels alone should increase atherosclerosis.

Within the past decade, genetic manipulation has made mice the most widely used
animal for the study of human disease. For this reason, several investigative groups
have studied the effects of hyperglycemia on atherosclerosis progression. Except for a
small increase in lesions in BALB/c mice, most nontransgenic strains of mice do not
have diabetes-induced atherogenesis (57); most importantly, atherosclerosis was not
increased in C57BL6 mice fed an atherogenic diet. There are three well defined
mouse models of atherosclerosis, and all have been studied under diabetic conditions.
Park et al. (58) found that diabetes increased lesion size in diabetic mice deficient in
apoE0, an effect that was inhibited by the infusion of soluble fragments of the
receptor for advanced glycosylation end products. In these mice the diabetes
markedly increased circulating cholesterol levels, perhaps due to a decrease in liver
uptake of remnant lipoproteins via the proteoglycan-mediated pathway (29).
Therefore, the secondary hyperlipidemia, rather than effects of the diabetes itself,
might have been the primary reason for the increased atherosclerosis. Diabetic LDL
receptor knockout mice do not have more atherosclerosis than control mice (59).
Mice that contain a transgene for expression of human apoB are more hyperlipidemic
than wild-type animals and develop atherosclerotic lesions when fed a diet similar to
that eaten by inhabitants of northern Europe and North America. Addition of diabetes
using streptozotocin (60) and by crossing with brown adipose tissue-deficient mice
did not increase atherosclerosis in these mice (61). If one were convinced that
hyperglycemia alone is responsible for accelerated atherosclerosis, it would appear
that the mouse, despite its production of AGEs, is resistant to diabetic macrovascular
disease. An alternative hypothesis that is compatible with the known human data and
is consistent with the mouse and other animal models is that diabetes-mediated
acceleration of vascular disease requires some additional factors missing in the mouse
model. One such factor is diabetic dyslipidemia.

2.1.6.6.3 Treatment of dyslipidemia in patients with diabetes.

There are two reasons to specifically correct lipoprotein abnormalities in patients with
diabetes. These are to prevent pancreatitis due to severe hypertriglyceridemia and to
reduce the risk of macrovascular complications. A number of recent reviews have
focused on the use of lipid-lowering medications in diabetic patients (62). The
objectives of that therapy will be discussed here.

The American Diabetes Association has published clinical goals for lipoprotein levels
in adults with diabetes (63). They are as follows: optimal LDL cholesterol levels less
than 100 mg/dL (2.60 mmol/L), optimal HDL cholesterol levels more than 45 mg/dL
(1.15 mmol/L), and desirable triglyceride levels less than 200 mg/dL (2.3 mmol/L).
The rationale for the LDL recommendation is based on the observations that adult
patients with diabetes and no overt macrovascular disease appear to have the same
risk of development of cardiac events as non-diabetics who already have had a
cardiac event (64). The current National Cholesterol Education Program goal for
patients with coronary heart disease is LDL levels below 100 mg/dL. Most
importantly, there are available medications that should allow practitioners to reach
this goal in most patients. Moreover, data exist showing that statin drugs are
efficacious for LDL-lowering and disease prevention in diabetic patients.

The second goal is to increase HDL to 45 or greater. Although this may be an ideal
goal, for many patients and their physicians it is not a practical one. This is
acknowledged in the American Diabetes Association report (63). Unlike for LDL,
there are limited options to achieve this goal, especially in patients with diabetic
dyslipidemia who begin with HDL cholesterol levels below 35 mg/dL. Exercise,
weight loss, and smoking cessation all increase HDL. Diets low in cholesterol and
saturated fat tend to decrease HDL. The most effective single medication to raise
HDL is niacin (65). A good response to this medication is an increase in HDL of
25%, which is still not enough to raise many low HDL levels to the goal. Although
niacin can be given to diabetic patients, it is generally avoided because it causes
worsening hyperglycemia. Fibric acids and statins also increase HDL; however, their
effects are more modest that those found with niacin. Two recent intervention trials
showed effective methods to reduce cardiac disease in subjects with low HDL.
Neither method raised HDL to the ADA goal, nor did the studies use medications that
are likely to achieve this goal in most patients. In one study subjects with HDL below
50 were treated with statins; lower LDL was associated with fewer cardiac events
(66). In the second, termed VA-HIT (67), patients with cardiac disease and average
HDL of 31 mg/dL were treated with gemfibrozil, leading to a 7% HDL increase,
approximately 25% triglyceride reduction, and fewer recurrent events. Therefore, it is
this author’s opinion that to set a goal for HDL at 45 mg/dL is impractical, and the
benefits of such a goal are unproven.

Triglyceride levels below 200 mg/dL are termed desirable; this appears to
differentiate this from a goal. The primary and in many cases essential approach to
 triglyceride reduction is glycemic control. In type 2 patients this also means weight
reduction. Although severe hypertriglyceridemia leads to increased risk for
pancreatitis, proof that reduction of triglycerides is of benefit is lacking. Several
investigators quote the VA-HIT trial and several subgroup analyses of fibric acid
studies as evidence that treatment of elevated triglycerides is beneficial. Triglycerides
can be reduced with niacin, fibric acids, high dose statins, and fish oil. It should be
noted that the use of fibric acids to reduce triglyceride along with statins increases the
risk of myositis and should be used with caution.

2.6 Terminalia Catappa

Scientific classification

Kingdom plantae

Class 1: Angiosperm

Class 2: Eudicots

Class 3: Rosids

Order: Myrtales

Family: Combretaceae

Genus: Terminalia

Species: T.catappa

2.6.1 Description of terminalia catappa

 Terminalia catappa is a large tropical tree in the lead wood tree family, combretaceae that grows

mainly in the tropical regions of Asia Africa and Australia (Pankaj et al, 2008). It is known by

the English common names country-almond, indian almond, malabar-almond, tropical- almond

(GRIN, 2016) and false kamani (Kepler, 2010).

The tree grows to 35 m (115 ft) tall, with an upright, symmetrical crown and horizontal branches.

Terminalia catappa has corky, light fruit that are dispersed by water. The seed within the fruit is

edible when fully ripe, tasting almost like almond. As the tree gets older, its crown becomes

more flattened to form a spreading, vase shape. Its branches are distinctively arranged in tiers.

The leaves are large, 15-25 cm (5.9-9.8 in) long and 10- 14 cm (3.9-5.5 in) broad, ovoid, glossy

dark green, and leathery. They are dry-season deciduous; before falling, they turn pinkish-

reddish or yellow brown, due to pigments such as violaxanthin, lutein, and zeaxanthin (Pank et

al, 2008).

The trees are monoecious with distinct male and female flowers on the same tree. Both are 1 cm

(0.39 in) in diameter, white to green The trees are monoecious, with distinct male and female

flowers on conspicuous with no petals; they are produced on axillary or m Spikes. The fruit is a

drupe 5-7 cm (2.0-2.8 in) long and 3-55 cm (12-22 my broad, green at first, then yellow and

finally red when ripe (GRIN, 2016)

2.6.2 Phytochemistry of Terminalia catappa

Various phytochemicals have been identified from the fruits, seeds, leaves and barks of the

Terminalia catappa.

 Fruits
 The mesocaro of the fruit contain: glucose, moisture, tannin, pentosans ellagic acid, brevifolin,

carboxylic acid, B carotene, cyanidin-3-glucoside (Mininel et al. 2014) and oil with 3,

439.5kcal/kg caloric value (Gao ,et al. 2004). These chemicals are essentials for its nutritive

value. The fruit provides protein (1.95g), carbohydrates (12.03g) and oil (Gao et al, 2004).

 Seed

The seed yield 4.13% moisture. 4.94% crude fibre, 23.7% crude protein. 4.27% ash, 51.80% fats

and 16.02% carbohydrates. The seed also contain ascorbic acid, arachidic acid. B-carotene,

linoleic acid, myristic acid, palmitoleic acid, stearic acid, phosphones, potassium, niacin,

riboflavin, thiamin and water.

 Leaves

Recently, compounds such as punicalagin (polyphenol), its derivatives and other several

compounds in the leaves of Terminalia catappa have been isolated Mininel et al, 2014). It was

shown that the leaves contain glucose, chebulagic acid, genistic acid, corilgan, gercetin,

tercetain, tergallogin, erlain A and teclay in 1 (Minimel oral, 2014). Quercetin was identified in

the leaf of T catappa (Mandlist et al, 2011).

2.6.3 Therapeutic uses of Terminalia catappa (T.catappa)

1) Anti-inflammatory activity

Medicine plants are used worldwide as remedy for various inflammatory disorders.

Terminalia catappa as a medicinal plant has been found to contain various polyphenolic

compounds and triterpenoids which is responsible for anti-inflammatory activities (Anand et al,
2015). The extract from tender leaves of T. Catappa have anti-inflammatory activity also it has

been discovered that dosage does not induce sedation (Ratnasooriya er dl. 2002) as compared to

other medicinal plants.

2) Anti-Diabetic activity

Anti-diabetic potential of T.catappa fruits have been evaluated with levels of fasting blood

sugar and various serum biochemical parameters in diabetic, alloxan induced rats (Nagappa et al,

2003). There is a significant anti-diabetic activity shown in Tcatappa extract dosage 1/5th of

their lethal doses.

3) Antioxidants and radical scavenging activity

The antioxidant defense in the body can merely defend itself when the free radicals are

within the normal level (Anand et al. 2015). Great effort has been made to focus on using the

available experimental techniques to identify the natural antioxidants from plants. Treatment

with aqueous extracts of Terminalia catappa exhibited anti hepatotoxic activity against carbon

tetrachloride (cel) (Arumugam et al, 2015), Multiple antioxidants effects of tannin component

from Terminalia catappa have the capability to prevent lipids peroxidation (IPO) (Lin et al.

2001), Punicatin and punicalagin are the most copious phytoconstituents and have the effective

antioxidant activity of Teatappa (Li et al, 2005)..

4) Anti-aging activity
Hydrophilic Extract of Terminalia catappa shows diphenylpicry hydrazyl (DPPH) free radical

scavenging activity and protects erythrocytes from hemolysis induced by 2, 2-Azobis (2- amino

propane) dihydrochloride (AAPH).

Terminalia catappa inhibits matrix metallo proteinase-9 (MMP-9) and MMP-1 protein

expression at 25 µg/ml and inhibits MMP-3 protein at 50 µg/ml. Terminalia catappa also

promotes the protein expression of type I collagen (Wen et al. 2011). Terminalia catappa (10-

500ug/ml) inhibits collagenase activity in a dose- dependent manner (82.3-101.0%) but not in

elastase activity (wen et al. 2011).

5) Hepatoprotective Activity

Liver is the metabolic super achiever in the body and in the body and it is the main target organ

for the toxicants that enter the body (Anand er a 2015) Terminalia catappa inhibits the over

expression of interleukin-6 (IL-6) the liver of chemokine-ligand 4 (Norazmir and Ayub, 2010).

An experiment showed that carbon tetra choride cel, induce mice and the Alanine

Aminotransferme (ALT) activity were reversed, using T.catappas extract. Also histological

alterations such as the infiltration of several inflammatory cells and heptocyte swelling in injured

mice are efficiently lessened by pretreatment o Tcatappa (Tang et al. 2003)

6) Wound healing activity

A wound is the loss of breaking of cellular and functional ability of the living tissue (Anand et al,

2015). The application of E.catappa leaves extract induces epitheization (Khan et al, 2014). Also

the bark extract promotes considerable wound-healing activity (Khan et al, 2014). 7) Ant
microbial activity of Terminalia catappa Micro-organisms are responsible for many diseases and

deaths. Natural sourves have been made to overcome the problem of harmful side effects of

medicine. The chloroform as well as the methanolic extracts show antimicrobial activity against

gram-positive and gram-negative micro- organisms (Anand et al, 2015). The chloroform root

extract of Terminalia catappa shows antimicrobial activity against Escherichia coli and

staphylococcus aureus while petroleum root either extracts of Terminalia catappa shows

antifungal activity and antimicrobial activity (Pawar et al, 2008).