Finding Heart Health in Fruit Extracts
Share this post
Apples, pomegranates, and Bergamot citrus for cardiovascular health
“An apple a day keeps the doctor away,” my nephew sings before biting into the honey crisp he’s holding. “But…” he thinks as he chews and then clarifies to me, his doctor-auntie, “I don’t want you to go away.”
Where did he learn the saying about an apple a day? Where did I, for that matter? Probably from the same place where we learned the golden rule about doing unto others, and that a stitch in time saves nine. And, as it turns out, apples are indeed of value to our health, especially when it comes to cholesterol and heart health.
While most if not all plant-based foods are part of a healthy lifestyle, two other fruits in particular are worth mentioning when it comes to cardiovascular health: pomegranate and Bergamot citrus.
Let’s take a closer look at these tasty – and heart healthy – wonder fruits:
Although they aren’t particularly rich in vitamins and minerals (other than vitamin C), apples nevertheless contain potent therapeutic value in the form of polyphenols, a type of phytonutrient. Much like those found in green tea and grape seed extract, the polyphenols in apples are well known for their antioxidant, detoxifying, and cancer-preventative benefits.,,,
Much like those found in green tea and grape seed extract, the polyphenols in apples are well known for their antioxidant, detoxifying, and cancer-preventative benefits.
Apple polyphenols have been shown to trigger a domino of antioxidant effects by activating Nrf2, a protein responsible for detoxification, glutathione synthesis, and other antioxidant functionality., In fact, in vitro studies suggest that apple extracts (high in polyphenols) have a significant antioxidant potential – with only 0.4% of the effect coming from vitamin C. This is likely why apple polyphenols have been shown to support cardiovascular health and fight the oxidation of low-density lipoprotein (LDL) cholesterol (which contributes to fatty plaques formation in the arteries),,,
Apple polyphenols not only reduce the oxidation of cholesterol, but also help reduce the overall levels of harmful types of cholesterol – in other words, they optimize both the quality and the quantity of cholesterol in the bloodstream. Specifically, animal studies have shown that apple polyphenols reduce cholesterol production, limit cholesterol transport, and facilitate the fecal excretion of cholesterol and its oxidation products.,, Improvements in cholesterol balance with supplementation of apple polyphenols also have been observed in humans. In a randomized, double-blind, placebo controlled (RDBPC) study, healthy adults with slightly elevated cholesterol levels were given apple polyphenols at a dosage of 300, 600, or 1,500 mg per day for four weeks. Apple polyphenols were shown to reduce total cholesterol levels in a dose-dependent manner and to significantly decrease LDL (aka “bad cholesterol”) at higher dosages. In another RDBPC study, overweight individuals in otherwise good health were given apple polyphenols at a dosage of 600 mg/day for 12 weeks. These individuals were found to have significantly lower total cholesterol and LDL levels compared to their baseline, with a significant reduction seen as quickly as four weeks after the start of supplementation. Decreases in visceral fat (the deep fat that surrounds the organs) and body weight were also seen.
As a new apple grows on a tree, the polyphenols it contains offer protection against ultraviolet radiation and harmful bacteria. It’s likely for this reason that the total polyphenol content of an unripe apple is 10 to 100 that of a ripe one. Given the thin skin of apples, it’s also important to go with products derived from sources free of pesticides, herbicides, and fungicides. Apples are often high on the Environmental Working Group’s list of the “Dirty Dozen,” a ranking of fruits and vegetables highest in pesticide contaminations. For this reason, it’s likely worth the extra effort to choose organic when shopping for apples.
Epidemiological evidence correlates apple consumption with a decreased risk of lung cancer, chronic obstructive pulmonary disease (COPD), asthma, type 2 diabetes, cardiovascular disease, coronary mortality, thrombotic stroke in women, and possibly coronary heart disease in men. Although eating apples is indeed an effective way to give the body a healthy dose of polyphenols, taking polyphenols in supplemental form is another easy way to boost polyphenol intake.
Named for the city of Punica, the “punic apple” – or pomegranate, as we call it today – has been consumed as far back as the early Green and Roman civilizations. To this day the fruit carries the Latin name of Punica granatum.
Like the apple, the pomegranate is rich in polyphenols, delivering potent antioxidant functionality to the body. Pomegranate consumption has been shown to protect against cellular changes that can lead to cancer, slow the proliferation of cancer cells,, retard the progression of chronic inflammatory diseases (including autoimmune and neurodegenerative diseases), and improve metabolic dysfunction in adults and children alike.,,,
Consumption of pomegranate extract has also been shown to improve several markers of cardiovascular health.
Consumption of pomegranate extract has also been shown to improve several markers of cardiovascular health. In patients with a history of heart attack taking the indicated pharmaceutical medications, 300 mg of pomegranate extract (containing 30% punicalagins, a type of polyphenol) taken twice daily for four weeks yielded significantly greater improvements in triglycerides, total cholesterol, LDL, high-density lipoprotein (HDL) (aka “good cholesterol”), and non-HDL cholesterol levels than seen in those who only took pharmaceuticals. The pomegranate group also experienced significantly greater reductions in oxidized LDL cholesterol, homocysteine, and high sensitivity C-reactive protein (hs-CRP) levels. Of the patients in the study who also had type 2 diabetes, significant improvements in blood sugar and hemoglobin A1c levels were also observed. Other clinical studies have reported similar outcomes,,, and yet other studies have shown pomegranate juice and/or its extracts to lower blood pressure,,, and decrease carotid intima media thickness (CIMT) – a marker of coronary heart disease risk – by up to 30%.48
Although most of us wouldn’t be able to identify a Bergamot orange in the market, we might nevertheless recognize its bright, floral fragrance rising from a cup of Earl Grey tea. In fact, the fragrance of Bergamot citrus has been shown to lift mood, lower cortisol, and reduce fatigue,, which has lead researchers to wonder if it could be a non-pharmacological therapy for anxiety.
The fruit of Bergamot citrus has also been studied for its heart health benefits, especially with respect to cholesterol levels. As with the other fruits explored above, Bergamot citrus peel and juice are rich in polyphenols.,, Conjugates of these polyphenols are structurally similar to statins (the pharmaceutical drugs used to lower cholesterol levels), and have been shown to work in a similar fashion. Because statin medications come with a slew of unpleasant side effects, however, researchers are eager to find natural therapies that can be used in conjunction with or in lieu of these drugs.
In an open-label, parallel group, placebo-controlled study, patients were randomized to receive one of the following treatments for 30 days: (a) placebo, (b) rosuvastatin (a statin drug) at a dosage of 10 or (c) 20 mg/day, (d) 1,000 mg of Bergamot polyphenols (BPs) a day, or (e) 1,000 mg of BPs plus 10 mg of rosuvastatin. The findings of this study were quite compelling: both rosuvastatin and BPs were observed to significantly reduce both total and LDL cholesterol and increase HDL cholesterol. A combination of 10 mg of rosuvastatin and 1,000 mg of BPs had an effect similar to 20 mg of rosuvastatin alone. Interestingly, treatment with BPs (both alone and in combination with rosuvastatin) significantly reduced triglyceride levels – almost twice as effectively as either dosage of rosuvastatin alone. In other words, when it came to triglyceride levels, BPs outperformed the statin drug.
Treatment with Bergamot polyphenols (both alone and in combination with rosuvastatin) significantly reduced triglyceride levels – almost twice as effectively as… rosuvastatin alone.
Triglycerides are often elevated in those with diabetes and pre-diabetes. Understanding that high cholesterol and high blood sugar often go hand-in-hand, this effect on triglycerides might make BPs a wise choice for those battling high blood sugar who also have high cholesterol levels. This is further supported by the findings of the animal studies in which BPs were shown to fight insulin resistance and fatty liver.,
In those unable to tolerate the side effects of statins, 1,500 mg of BPs daily taken for 30 days resulted in a 25% reduction in total cholesterol and a 27.6% reduction in LDL cholesterol, without the recurrence of any statin-related side effects. These findings suggest that BPs may help lower cholesterol levels sufficiently enough to allow individuals to either lower their statin dose or avoid statins altogether.
BPs may help lower cholesterol levels sufficiently enough to allow individuals to either lower their statin dose or avoid statins altogether.
Even lower doses of bergamot extract may significantly support healthy cholesterol levels. In a study of adults with moderately high cholesterol, supplementation with 400 mg of Bergamot extract (providing 150 mg BPs per dose) taken daily for six months lead to significant reductions in both total and LDL cholesterol – 12% and 20%, respectively. BPs also dropped triglyceride levels by up to 17% and increased HDL cholesterol by up to 8%.
Although citrus is typically a health-friendly food, it’s worth noting that citrus extracts naturally contain furocoumarins, compounds that can affect the body’s metabolism of certain medications. This is why pharmacists often recommend that patients avoid drinking grapefruit juice while taking pharmaceutical drugs. Furocoumarins can also make the skin more sensitive to sunlight, thereby increasing the chance of rash or burn with sun exposure. For this reason, it’s a good idea to purchase Bergamot (and other citrus) products from companies that remove furocoumarins in the manufacturing process.58
Natural foods yet again save the day. As drug companies race to develop new drugs, the healing power we seek might just come from a source as simple, nourishing, and tasty as, well, fruit salad. Given the limited availability of certain fruits year round and the chemicals often used in the food industry, however, supplemental extracts might be the next best thing. And they certainly carry fewer side effects than what we might find at the pharmacy.
Click here to see References
 Du GJ, et al. Epigallocatechin Gallate (EGCG) is the most effective cancer chemopreventive polyphenol in green tea. Nutrients. 2012 Nov 8;4(11):1679-91.
 Na HK, Surh YJ. Modulation of Nrf2-mediated antioxidant and detoxifying enzyme induction by the green tea polyphenol EGCG. Food Chem Toxicol. 2008 Apr;46(4):1271-8.
 Kidd PM. Bioavailability and activity of phytosome complexes from botanical polyphenols: the silymarin, curcumin, green tea, and grape seed extracts. Altern Med Rev. 2009 Sep;14(3):226-46.
 Liu RH, et al. Antioxidant and antiproliferative activities of selected New York apple cultivars. New York Fruit Quarterly 2001;9:15-7.
 Hu ML. Dietary polyphenols as antioxidants and anticancer agents: more questions than answers. Chang Gung Med J. 2011 Sep-Oct;34(5):449-60.
 Nguyen T, et al. The Nrf2-antioxidant response element signaling pathway and its activation by oxidative stress. J Biol Chem. 2009 May 15;284(20):13291-5.
 Eberhardt MV, et al. Antioxidant activity of fresh apples. Nature. 2000 Jun 22;405(6789):903-4.
 Pearson DA, et al. Apple juice inhibits human low density lipoprotein oxidation. Life Sci. 1999;64(21):1913-20.
 Gerhauser C. Cancer chemopreventive potential of apples, apple juice, and apple components. Planta Med. 2008 Oct;74(13):1608-24.
 Lu Y, Foo LY. Antioxidant and radical scavenging activities of polyphenols from apple pomace. Food Chem. 2000 Jan 1;68(1):81-5.
 Osada K, et al. Dose-dependent hypocholesterolemic actions of dietary apple polyphenol in rats fed cholesterol. Lipids. 2006 Feb;41(2):133-9.
 Lam CK, et al. Apple polyphenols inhibit plasma CETP activity and reduce the ratio of non-HDL to HDL cholesterol. Mol Nutr Food Res. 2008 Aug;52(8):950-8.
 Ogino Y, et al. Absorption of dietary cholesterol oxidation products and their downstream metabolic effects are reduced by dietary apple polyphenols. Lipids. 2007 Mar;42(2):151-61.
 Nagasako-Akazome Y, et al. Serum cholesterol-lowering effect of apple polyphenols in healthy subjects. J Oleo Sci. 2005;54(3):143-51.
 Nagasako-Akazome Y, et al. Apple polyphenols influence cholesterol metabolism in healthy subjects with relatively high body mass index. J Oleo Sci. 2007;56(8):417-28.
 Picinelli A, et al. Polyphenolic pattern in apple tree leaves in relation to scab resistance. A preliminary study. J Ag Food Chem. 1995 Aug;43(8):2273-8.
 Yue T, et al. Ultrasound-assisted extraction, HPLC analysis, and antioxidant activity of polyphenols from unripe apple. J Sep Sci. 2012 Aug;35(16):2138-45.
 Boyer J, Liu RH. Apple phytochemicals and their health benefits. Nutr J. 2004 May 12;3:5.
 Stover ED, Mercure EW. The pomegranate: a new look at the fruit of paradise. HortScience. 2007 Aug 1;42(5):1088-92.
 Seeram NP, et al. In vitro antiproliferative, apoptotic and antioxidant activities of punicalagin, ellagic acid and a total pomegranate tannin extract are enhanced in combination with other polyphenols as found in pomegranate juice. J Nutr Biochem. 2005 Jun;16(6):360-7.
 Turrini E, et al. Potential effects of pomegranate polyphenols in cancer prevention and therapy. Oxid Med Cell Longev. 2015;2015:938475.
 Lansky EP, Newman RA. Punica granatum (pomegranate) and its potential for prevention and treatment of inflammation and cancer. J Ethnopharmacol. 2007 Jan 19;109(2):177-206.
 Danesi F, Ferguson LR. Could pomegranate juice help in the control of inflammatory diseases? Nutrients. 2017 Aug 30;9(9).
 Banihani S, et al. Pomegranate and type 2 diabetes. Nutr Res. 2013 May;33(5):341-8.
 Katz SR, et al. Punica granatum: heuristic treatment for diabetes mellitus. J Med Food. 2007 Jun;10(2):213-7.
 Shishehbor F, et al. Effects of concentrated pomegranate juice on subclinical inflammation and cardiometabolic risk factors for type 2 diabetes: a quasi-experimental study. Int J Endocrinol Metab. 2016 Jan 30;14(1):e33835.
 Kelishadi R, et al. Acute and long term effects of grape and pomegranate juice consumption on endothelial dysfunction in pediatric metabolic syndrome. J Res Med Sci. 2011 Mar;16(3):245-53.
 Goyal R, et al. An antioxidative effect of punica granatum (pomegranate) on biochemical parameters in patients with myocardial infarction: a double blind placebo controlled trial. Eur J Boimed Pharm Sci. 2016.3(5):662-7.
 Goyal R, et al. Antioxidative effect of punica granatum (pomegranate) on biochemical parameters in patients with diabetes mellitus (type 2) and myocardial infarction: a double blind placebo controlled trial. Int J Adv Res. 2016 May;4(5):857-864.
 Esmaillzadeh A, et al. Concentrated pomegranate juice improves lipid profiles in diabetic patients with hyperlipidemia. J Med Food. 2004 Fall;7(3):305-8.
 Aviram M, et al. Pomegranate juice consumption for 3 years by patients with carotid artery stenosis reduces common carotid intima-media thickness, blood pressure and LDL oxidation. Clin Nutr. 2004 Jun;23(3):423-33.
 Sohrab G, et al. Effects of pomegranate juice consumption on oxidative stress in patients with type 2 diabetes: a single-blind, randomized clinical trial. Int J Food Sci Nutr. 2017 Mar;68(2):249-255.
 Stowe CB, et al. The effects of pomegranate juice consumption on blood pressure and cardiovascular health. Complement Ther Clin Pract. 2011 May;17(2):113-5.
 Moazzen H, Alizadeh M. Effects of pomegranate juice on cardiovascular risk factors in patients with metabolic syndrome: a double-blinded, randomized crossover controlled trial. Plant Foods Hum Nutr. 2017 Jun;72(2):126-33.
 Lynn A, et al. Effects of pomegranate juice supplementation on pulse wave velocity and blood pressure in healthy young and middle-aged men and women. Plant Foods Hum Nutr. 2012 Sep;67(3):309-14.
 Sahebkar A, et al. Effects of pomegranate juice on blood pressure: A systematic review and meta-analysis of randomized controlled trials. Pharmacol Res. 2017 Jan;115:149-161.
 Saiyudthong S, Marsden CA. Acute effects of bergamot oil on anxiety-related behaviour and corticosterone level in rats. Phytother Res. 2011 Jun;25(6):858-62.
 Watanabe E, et al. Effects of bergamot (Citrus bergamia (Risso) Wright & Arn.) essential oil aromatherapy on mood states, parasympathetic nervous system activity, and salivary cortisol levels in 41 healthy females. Forsch Komplementmed. 2015;22(1):43-9.
 Ni CH, et al. The anxiolytic effect of aromatherapy on patients awaiting ambulatory surgery: a randomized controlled trial. Evid Based Complement Alternat Med. 2013;2013:927419.
 Cappello AR, et al. Bergamot (Citrus bergamia Risso) flavonoids and their potential benefits in human hyperlipidemia and atherosclerosis: an overview. Mini Rev Med Chem. 2016;16(8):619-29.
 Mandalari G, et al. Characterization of flavonoids and pectins from bergamot (Citrus bergamia Risso) peel, a major byproduct of essential oil extraction. J Agric Food Chem. 2006 Jan 11;54(1):197-203.
 Gattuso G, et al. Flavonoid glycosides in bergamot juice (Citrus bergamia Risso). J Agric Food Chem. 2006 May 31;54(11):3929-35.
 Di Donna L, et al. Statin-like principles of bergamot fruit (Citrus bergamia): isolation of 3-hydroxymethylglutaryl flavonoid glycosides. J Nat Prod. 2009 Jul;72(7):1352-4.
 Leopoldini M, et al. On the inhibitor effects of bergamot juice flavonoids binding to the 3-hydroxy-3-methylglutaryl-CoA reductase (HMGR) enzyme. J Agric Food Chem. 2010 Oct 13;58(19):10768-73.
 Gliozzi M, et al. Bergamot polyphenolic fraction enhances rosuvastatin-induced effect on LDL-cholesterol, LOX-1 expression and protein kinase B phosphorylation in patients with hyperlipidemia. Int J Cardiol. 2013 Dec 10;170(2):140-5.
 Alam MA, et al. Effect of citrus flavonoids, naringin and naringenin, on metabolic syndrome and their mechanisms of action. Adv Nutr. 2014 Jul 14;5(4):404-17.
 Parafati M, et al. Bergamot polyphenols boost therapeutic effects of the diet on non-alcoholic steatohepatitis (NASH) induced by “junk food”: evidence for anti-inflammatory activity. Nutrients. 2018 Nov 1;10(11).
 Mollace V, et al. Hypolipemic and hypoglycaemic activity of bergamot polyphenols: from animal models to human studies. Fitoterapia. 2011 Apr;82(3):309-16.
 Toth PP, et al. Bergamot reduces plasma lipids, atherogenic small dense LDL, and subclinical atherosclerosis in subjects with moderate hypercholesterolemia: a 6 months prospective study. Front Pharmacol. 2016 Jan 6;6:299.
 Girennavar B, et al. Furocoumarins from grapefruit juice and their effect on human CYP 3A4 and CYP 1B1 isoenzymes. Bioorg Med Chem. 2006 Apr 15;14(8):2606-12.
 Schlatter J, et al. Dietary intake and risk assessment of phototoxic furocoumarins in humans. Food Chem Toxicol. 1991 Aug;29(8):523-30.
Share this post
Dr. Erica Zelfand
Probiotics and the Human Microbiome: Beyond the Gut
Dr. Don Brown, ND, discusses cutting edge research on the use of probiotics Biography: Naturopathic physician Dr. Donald Brown is one of the leading authorities in the U.S. on evidence-based herbal medicine and the safety and efficacy of nutritional supplements and probiotics. He currently serves as the Director of Natural Product Research Consultants in…
Tocotrienols: Protectors of Cardiovascular and Bone Health
How the lesser-known tocotrienol form of vitamin E may be the one we should be studying Vitamin E has long been heralded for its many health benefits, however, the majority of this research has been focused on the tocopherol forms which are more commonly found in nature. In this interview we chat with Barrie…
Reducing the Risk of Alzheimer’s
A proactive approach to reducing the risk of dementia Anyone who has watched the health of a love one decline after a diagnosis of Alzheimer’s disease knows all too well the challenges that come with this condition. Not just memory loss, but personality changes, impaired reasoning skills, and even motor issues – dementia slowly…
Vitamin D: The Sunshine Vitamin
The role of vitamin D in autoimmunity and mood Vitamin D is known as the “sunshine vitamin” because it is generated within the skin upon exposure to ultraviolet B (UVB) rays, the rays responsible for suntans. Vitamin D is essential for strong bones, immunity, and many other bodily functions.,, In the absence of sun…
Pine Bark for Blood Vessels Big and Small, Part 1 of 2
A natural solution for high blood pressure, hemorrhoids, and varicose veins At first glance, the ailments of high blood pressure, hemorrhoids, and varicose veins seem to have little in common. As any holistically trained healthcare provider knows, however, these conditions all share one common cause: poor vascular health. Also known as the circulatory system,…
Taking a Month Off Alcohol: What Will a Month Booze-Free Do for You?
A trend growing in popularity takes center stage, with clinical studies backing its benefits Perhaps you’ve seen it proudly announced on social media, “I’m going a month booze-free,” by a friend or acquaintance. Or maybe it has infiltrated your sphere because of news stories on outlets such as NPR, the BBC, Fortune, or the…