Journal of High Institute of Public Health 2016; 46(1): 8-14

Original Article

Effect of Moringa Oleifera on Lipid Profile in Rats

Samar Aborhyem1 ¥, Hanaa Ismail1, Neveen Agamy1, Dalia Tayel2
1
Food Analysis Specialty, Department of Nutrition, High Institute of Public Health, Alexandria University, Egypt
2
Nutrition Specialty, Department of Nutrition, High Institute of Public Health, Alexandria University, Egypt

Abstract
Background: Coronary heart disease, stroke, atherosclerosis and hyperlipidemia are primary causes of Available on line at:
death worldwide. Moringa Oleifera tree was used as a health supplement introduced to Africa from www.jhiph.alexu.edu.eg
India. Its leaves have various biological activities, including hypolipidemic effect.
Objective(s): The aim of present study was to assess the effect of Moringa Oleifera consumption on
lipid profile and histopathology of the liver in hyperlipidemic rats. ¥Correspondence:
Methods: A total of 50 male albino rats were divided into five equal groups. Group I was left as control Email: [email protected]
and fed on standard diet only. Group II was fed on standard diet and orally injected with 400 mg/kg of
rat body weight extract of Moringa Oleifera. Hyperlipidemia was induced in the remaining 30 rats by
feeding an atherogenic diet for four weeks. Group III was fed on atherogenic diet only. Group IV was
fed on atherogenic diet and orally injected with 400 mg/kg of rat body weight extract of Moringa Suggested Citations: Aborhyem
Oleifera. Group V was fed on atherogenic diet with 2mg/kg of rat body weight Atorvastatin drug. Lipid S, Ismail H, Agamy N, Tayel D.
profile of rat blood was measured including total cholesterol (TC), triglyceride (TG), low density Effect of Moringa Oleifera on Lipid
lipoprotein (LDL), high density lipoprotein (HDL), and very low density lipoprotein (VLDL). Liver Profile in Rats. JHIPH. 2016;
tissue was evaluated by carrying out histopathological examination. 46(1): 8-14.
Results: The rats fed on Moringa Oleifera showed a significant decrease in total cholesterol and LDL by
26.8% and 40.6% respectively compared to baseline values after 4 weeks. Although VLDL and TG
showed slight increase by 5.6% and 5.1% respectively, they were still within the normal range.
Otherwise, there was a significant increase in LDL, VLDL, TC, and total TG levels in rats fed on
atherogenic diet only by 17.13%, 195.4%, 29.2%, and 193% respectively compared to baseline values
after 4 weeks. Atorvastatin drug affected the HDL level, as it increased by 16.4% % 28% from baseline
after two and four weeks respectively. Atorvastatin and Moringa Oleifera decreased VLDL level by
53.9% & 36.5% respectively when compared to rats fed on atherogenic diet.
Conclusion: Moringa Oleifera was comparable to hypolipidemic medication (Atorvastatin) in
improving the lipid profile of rats fed on atherogenic diet. Moringa Oleifera intake is more effective in
prevention than in treatment of hyperlipidemia.

Keywords: lipid profile, atherosclerosis, Moringa Oleifera, atherogenic diet, atorvastatin.

INTRODUCTION known to act as antioxidants, hypocholesterolemic,

enzyme modulating agents and phytohormones.(2,3)

H yperlipidemia has been ranked as one of the

greatest risk factors contributing to the
prevalence and severity of coronary heart
diseases. Coronary heart disease, stroke,
atherosclerosis and hyperlipidemia are primary causes
Moringa Oleifera is one of the 14 species of family
Moringaceae, native to India, Africa, Arabia,
Southeast Asia, South America, and the Pacific and
Caribbean Islands.(4,5) Its known as Drumstick tree.
Various parts of this plant such as the leaves, roots,
of death worldwide.(1) Currently many research studies seed, bark, fruit, flowers and immature pods are used
focus on the beneficial effects of bioactive medicinally.(5) Moringa leaves contain more vitamin A
phytochemicals present in micro level in our daily than carrots, more vitamin C than oranges, more
diet. These phytochemicals are abundant in grains, calcium than milk, more potassium than bananas and
vegetables, fruits, seeds and nuts. They are believed to more iron than spinach. The Moringa Oleifera tree was
contribute positively in the prevention of degenerative introduced to Africa from India at the turn of the
diseases. The mechanics behind the different twentieth century where it was to be used as a health
beneficial effects of dietary photochemical are not supplement. It has been consumed by humans
fully understood. However, these compounds are throughout the century in diverse culinary ways.

8
Aborhyem et al., 9
Almost all parts of the plant are used culturally for its clinical group. The doses of Moringa Oleifera extract were
nutritional value, purported medicinal properties and given orally with the help of syringe directly into the
for taste and flavor as a vegetable and seed. The leaves eosopharyngeal regions according to the animal's body
of Moringa Oleifera can be eaten fresh, cooked, or weight every day for 28 days.(13)
stored as a dried powder for many months without any Biochemical tests: The following parameters: total
major loss of its nutritional value.(4,6) cholesterol (TC), TG, LDL, high density lipoprotein
Leaves of this plant are reported to possess (HDL), and very low density lipoprotein (VLDL) were
various biological activities, including measured using spectrophotometer Microlab 300 (ELI tech
hypocholesterolemic, antidiabetic, hypotensive and semi-automated) at baseline, after two weeks, and at the
antihyperlipidemic effect. Drugs used in treatment of end of four weeks.(14-18)
hyperlipidemia currently include statins (simvastatin, Histopathological study: Tissue processing was carried
pravastatin), resins (cholecystyramine) and fibrates out using the method of Baker and Silverton (1998).(15,19)
(gemfibrozil). Less commonly used drugs include Statistical analysis
nicotinic acid, probucol, clofibrate and colestipol. Fish Data analysis was carried out using the statistical package
oils have been advocated for the treatment of for social sciences software version 17.0 (SPSS Inc.,
increased triglyceride (TG) but were found to raise Chicago, Illinois, USA). Data were presented in tabular
low density lipoprotein (LDL). Statins have been used form and graphically using means and SD. For all
for almost a decade and have not produced untoward analyses, a P value of 0.05 or less was set as level of
effects.(7-10) significance. One-way analysis of variance (ANOVA) test
Therefore, the present study aimed to assess the was used to compare means of at least three independent
effect of Moringa Oleifera consumption on lipid groups.
profile in rats.
Ethical Considerations
METHODS This study was approved by the institutional review board
and the Ethics Committee of the High Institute of Public
Study Setting & Design: An experimental animal study Health, Alexandria University. The study conformed to the
was conducted at the Nutrition Department Laboratory, international ethical guidelines. All laboratory biological
High Institute of Public Health, Alexandria University, and specimens and hazardous waste were disposed of safely.
the Medical Research Institute Laboratory, Alexandria
University. RESULTS
Preparation of Moringa Oleifera: Three kg of fresh
leaves of Moringa Oleifera were collected from a private Table (1) shows the TC level (mg/dl) in rats fed on
farm in El-Gharbya governorate, Ashmoun center and Moringa Oleifera after two and four weeks. There was no
were taken to the Nutrition Department laboratory. These significant change with time in TC level in rats fed on
leaves were air-dried and reduced to powdered form. The normal diet. Those fed on normal diet with Moringa
powdered leaves were percolated in distilled water and Oleifera (control +ve) showed a significant decrease in TC
ethanol 1:1 for 12 h and filtered with subsequent level by 21.6% and 26.8% after two and four weeks
evaporation of the filtrate. A weighted amount of dried respectively. There was a significant increase in TC level
extract was freshly dissolved in water in order to prepare a of rats fed on atherogenic diet (control –ve) comparing to
solution to be used for treatment.(11,12) baseline level (114.4 mg/dl). It increased to 146.2 mg/dl
Experimental Animals: A total 50 healthy adult male after two weeks then to 148.1 mg/dl after four weeks. The
albino rats of Wistar strain weighing around 120 to 150g TC level of rats fed on Moringa Oleifera with atherogenic
were procured from the central animal house of the diet was 107.3 mg/dl at baseline. This was slightly
Medical Research Institute, "Smouha", Alexandria increased to reach 112.9 mg/dl at two weeks then
University. The animals were housed under laboratory decreased to reach 111.1 mg/dl at four weeks of treatment.
conditions and kept for one week for rehabilitation. They In rats fed on atherogenic diet with atorvastatin, TC level
were divided randomly into five equal groups of 10 rats slightly increased in a time dependent manner.
each as follows: Group I (control) included 10 rats that Table (2) illustrates the TG level (mg/dl) of rats fed on
were left as control and fed on standard feed only. Group II Moringa Oleifera after two and four weeks. There was no
(control +ve) included 10 rats that were fed on standard significant change in TG level among all groups except for
diet and injected orally with 400 mg/kg extract of Moringa rats fed on atherogenic diet (control –ve) where TG level
Oleifera. The remaining 30 rats were subjected to increased by 73.4% to reach 76.3 mg/dl after two weeks,
hyperlipidemic diet for four weeks as follow: Group III and by 193% to reach 129.9 mg/dl after four weeks.
(control –ve) included 10 rats that were fed on atherogenic Baseline TG level in rats fed on Moringa Oleifera (control
diet only; Group IV included 10 rats that were fed on +ve) was 39.3 mg/dl. It decreased to reach 38.7mg/dl after
atherogenic diet and orally injected with 400 mg/kg extract two weeks then increased by 5.3% to reach 41.4 mg/dl
of Moringa Oleifera; Group V included 10 rats that were after four weeks. The level of TG in rats fed on atherogenic
fed on atherogenic diet with 2mg/kg Atorvastatin drug as a diet + Moringa Oleifera increased from baseline (37.3
 10 Journal of High Institute of Public Health 2016; 46(1): 8-14
mg/dl) by 9.9% and 7.5% to reach 41 mg/dl and 40.1 level decreased by 9.6% after two weeks to reach 18.8
mg/dl after two and four weeks respectively. mg/dl, and increased by 10.5% to reach 23 mg/dl after four
Table (3) reports the HDL level (mg/dl) in rats fed on weeks. It was evident that the level of HDL increased in a
Moringa Oleifera after two and four weeks. The level of time dependent manner in rats fed on atherogenic diet +
HDL in rats fed on Moringa Oleifera (control +ve) group Moringa Oleifera. It was 23.3 mg/dl at baseline, and
increased from baseline value (22.3 mg/dl) by 48.8% to increased by 18% and 20.6% to reach 27.5 mg/dl and 28.1
reach 33.5 mg/dl after two weeks, and by 10.7% to reach mg/dl after two and four weeks respectively. The baseline
24.7 mg/dl after four weeks. There was a significant HDL level of rats fed on normal diet was 20.5 mg/dl. It
increase in HDL level in rats fed on atherogenic diet + decreased by 0.9% to reach 20.3 mg/dl after two weeks,
atorvastatin. It increased by 16.4% from baseline after two and then increased by 5.3% to reach 21.6 mg/dl after four
weeks to reach 24.8 mg/dl, and by 28% after four weeks to weeks.
reach 27.3 mg/dl. High density lipoprotein level changed
significantly in rats fed on atherogenic diet only where its

Table (1): Cholesterol level of rats at baseline and after two and four weeks
Cholesterol level (mg/dl)
Group Baseline Two weeks Four weeks P
MeanSD MeanSD % change MeanSD % change
Rats fed on normal diet (Control) (G I) 114.29.0 110.86.1 -3.6 116.34.8 1.8 0.741
Rats fed on Moringa Oleifera (Control +ve) (G II) 109.45.0 85.69.2 -21.6 80.17.4 -26.8 0.002*
Rats fed on atherogenic diet (Control –ve) (G III) 114.19.5 146.29.5 27.9 148.15.9 29.7 0.002*
Rats fed on atherogenic diet + Moringa Oleifera (G IV) 107.34.1 112.93.7 5.2 111.13.7 3.4 0.027*
Rats fed on atherogenic diet +atorvastatin drug (G V) 101.83.6 106.25.3 4.3 108.86.0 6.8 0.045*
P# 0.003* 0.001* 0.001*
Interaction of groups and time is significant (P=0.006)* P: Adjusted P value for repeated measures ANOVA
P#: Adjusted P value for One Way ANOVA * P < 0.05

Table (2): Total triglyceride level of rats at baseline and after two and four weeks
Total triglyceride(mg/dl)
Group Baseline Two weeks Four weeks P
MeanSD MeanSD % change MeanSD % change
Rats fed on normal diet (Control) (G I) 41.24.3 44.86.0 8 41.93.5 1.6 0.624
Rats fed on Moringa Oleifera (Control +ve) (G II) 39.310.6 38.710.6 -1.5 41.410.3 5.3 0.831
Rats fed on atherogenic diet (Control –ve) (G III) 44.07.7 76.322.0 73.4 129.927.2 193 0.001*
Rats fed on atherogenic diet + MoringaOleifera(G IV) 37.33.3 41.03.7 9.9 40.14.3 7.5 0.317
Rats fed on atherogenic diet +atorvastatin drug (G V) 36.03.8 36.93.6 2.5 39.45.0 9.4 0.351
P# 0.210 0.001* 0.001*
Interaction of groups and time is significant (P=0.006)* P: Adjusted P value for repeated measures ANOVA
P#: Adjusted P value for One Way ANOVA * P < 0.05

Table 3: High Density Lipoprotein level of rats at baseline and after two and four weeks
High Density Lipoprotein(mg/dl)
Group Baseline Two weeks Four weeks P
MeanSD MeanSD % change MeanSD % change
Rats fed on normal diet (Control) (G I) 20.52.8 20.32.0 -0.9 21.61.3 5.3 0.824
Rats fed on Moringa Oleifera (Control +ve) (G II) 22.33.0 33.54.1 48.8 24.72.3 10.7 0.001*
Rats fed on atherogenic diet (Control –ve) (G III) 20.82.6 18.81.8 -9.6 23.02.0 10.5 0.003*
Rats fed on atherogenic diet + Moringa Oleifera (G IV) 23.32.4 27.53.5 18 28.14.3 20.6 0.057
Rats fed on atherogenic diet +atorvastatin drug (G V) 21.31.3 24.83.0 16.4 27.32.2 28 0.001*
P# 0.300 0.001* 0.009*
Interaction of groups and time is significant (P=0.006)* P: Adjusted P value for repeated measures ANOVA
P#: Adjusted P value for One Way ANOVA * P < 0.05
Aborhyem et al., 11

Table (4) shows LDL level (mg/dl) in rats fed on Moringa Table (5) shows the VLDL (mg/dl) in rats fed on Moringa
Oleifera after two and four weeks. The level significantly Oleifera after two and four weeks. The level significantly
increased by 32.6% and 17.13% of baseline to reach 112.2 increased in rats fed on atherogenic diet (control –ve) by
mg/dl and 99.1 mg/dl after two and four weeks 73.8% from baseline (8.2 mg/dl) after two weeks to reach
respectively. There was a significant decrease in LDL level 15.3 mg/dl, and by 195.4% after four weeks to reach 26
in rat fed on Moringa Oleifera (control +ve). It decreased mg/dl. There was no significant increase in VLDL level in
by 44.5% and 40.6% from baseline to reach 44.4 mg/dl rats fed on atherogenic diet + Moringa Oleifera where it
and 47.1 mg/dl after two and weeks respectively. A increased by 9.3% and 6.6 % of baseline level (7.5 mg/dl)
statistically significant irregular pattern of change in LDL to reach 8.8 mg/dl and 8 mg/dl after two and four weeks
level was noticed in rats fed on Moringa Oleifera + respectively. Regarding VLDL level in rats fed on
atherogenic diet. It increased by 0.78% from baseline (76.6 Moringa Oleifera (control +ve), it decreased by 2.5% from
mg/dl) to reach 77.2 mg/dl after two weeks, and then baseline (7.9 mg/dl) after two weeks to reach 7.7 mg/dl,
decreased by 2% to reach 75 mg/dl after four weeks. On and increased by 5.06% from baseline after four weeks to
the other hand, there was no significant change in LDL in reach 8.3 mg/dl.
rats fed on normal diet where its level slightly decreased by Throughout the study, there was a statistical
4.6% from baseline after two weeks to reach 81.5 mg/dl, significant difference between groups as regards the
and increased by 0.9% after four weeks to reach 86.3 change in the assessed biochemical parameters by the
mg/dl. However, its level remained within the normal duration of the study (two and four weeks) (P<0.05).
range.

Table 4: Low density lipoprotein level of rats at baseline and after two and four weeks
Low density lipoprotein(mg/dl)
Group Baseline Two weeks Four weeks P
MeanSD MeanSD % change MeanSD % change
Rats fed on normal diet (Control) (G I) 85.57.1 81.57.0 -4.6 86.35.7 0.9 0.624
Rats fed on Moringa Oleifera (Control +ve) (G II) 79.33.7 44.411.1 -44.5 47.17.4 -40.6 0.001*
Rats fed on atherogenic diet (Control –ve) (G III) 84.612.4 112.212.6 32.6 99.111.9 17.13 0.001*
Rats fed on atherogenic diet + Moringa Oleifera(G IV) 76.65.7 77.26.2 0.78 75.07.1 -2 0.854
Rats fed on atherogenic diet +atorvastatin drug (G V) 73.44.3 74.15.7 0.95 73.76.2 0.4 0.957
P# 0.085 0.001* 0.001*
Interaction of groups and time is significant (P=0.006)* P: Adjusted P value for repeated measures ANOVA
P#: Adjusted P value for One Way ANOVA * P < 0.05

Table 5: Very low density lipoprotein level of rats at baseline and after two and four weeks

Very low density lipoprotein(mg/dl)

Group Baseline Two weeks Four weeks P
MeanSD MeanSD % change MeanSD % change
Rats fed on normal diet (Control) (G I) 8.20.9 9.01.2 9.7 8.40.7 2.4 0.448
Rats fed on Moringa Oleifera (Control +ve) (G II) 7.92.1 7.72.1 -2.5 8.32.1 5.06 0.899
Rats fed on atherogenic diet (Control –ve)(G III) 8.81.5 15.34.4 73.8 26.05.4 195.4 0.001*
Rats fed on atherogenic diet + Moringa Oleifera(G
7.50.7 8.20.7 9.3 8.00.9 6.6 0.299
IV)
Rats fed on atherogenic diet +atorvastatin drug (G
7.20.8 7.40.7 2.7 7.91.0 9.7 0.308
V)
P# 0.274 0.010* 0.001*
Interaction of groups and time is significant (P=0.006)* P: Adjusted P value for repeated measures ANOVA
P#: Adjusted P value for One Way ANOVA * P < 0.05

The histopathological analysis of liver of rats in different degeneration within the liver cells as hepatocytes are
experimental groups revealed the presence of early widening due to deposition of fats in rats fed on
steatosis within the hepatocytes and also foamy atherogenic diet (control –ve group III) (Figures 1-3).
12 Journal of High Institute of Public Health 2016; 46(1): 8-14

Figure 1: Transverse section in liver of rats in group I, II, IV & V (H&E X100)

Figure 2: Transverse section in liver of rats fed on Figure 3: Transverse section in liver of rats fed on
atherogenic diet (control –ve) (H&E X100) atherogenic diet (control –ve) (H&E X400)
Aborhyem et al., 13
fed on atherogenic diet. On the other hand, VLDL
DISCUSSION increased by 14.6% in rats fed on atherogenic diet
comparing to control group.
Hypolipidaemic activity of several medicinal plants has To the best of our knowledge, this is the first study to
been associated to bioactive agents like alkaloids, tannins, clearly demonstrate for the first time that water, and
and cardiac glycosides, and β sitosterol. Alkaloids may ethanolic extract of Moringa Oleifera leaves significantly
mediate hypolipidaemic action either by up regulation of reduced the formation of atherosclerotic plaque, along with
activities of lipolytic enzymes or by stimulating faecal bile levels of cholesterol and triglycerides. These results agree
acid excretion.(20) Also, β-sitosterol could be the major well with earlier findings where the water extract of the
cholesterol reducing components of the ethanol leaf extract Leaves of this plant significantly lowers the levels of serum
of Moringa Oleifera as it may work singly or in synergy TC or that of TC, VLDL and LDL in
with other bioactive agents.(21) hypercholesterolaemic wistar rats.(22, 25)
Plant sterols inhibit the absorption of dietary Atorvastatin has been known to exert its lipid
cholesterol. Βeta sitosterol present in the extract of lowering effect by competitive inhibition of the hepatic
Moringa Oleifera is one of the plant sterol which lowers HMG-CoA reductase. Importantly, it was demonstrated in
the cholesterol level by lowering plasma concentration of this study that the Moringa Oleifera leaf extract could
LDL and by inhibiting the reabsorption of cholesterol from reduce cholesterol and triglyceride levels in rats at degrees
endogenous sources in association with a simultaneous comparable to those of atorvastatin.
increase in its excretion into feces in the form of neutral Moringa Oleifera leaf extract possessed strong radical
steroids. Therefore, it can be concluded that β -sitosterol scavenging activity and antioxidant activity. Polyphenols
may be a bioactive phytoconstituents in the leaves of has been known to exert powerful antioxidant effect in
Moringa Oleifera.(20) vitro. They inhibit lipid peroxidation by acting as chain
The present study revealed that Moringa Oleifera breaking peroxyl radical scavengers, and can protect low
extract had improved the serum lipid profile in density lipoprotein from oxidation.(26) Polyphenolic
hyperlipidemic rats by decreasing serum TC, TG, LDL-C compounds also possess a variety of other biological
and increasing serum HDL-C, thus improving the activities, such as reduction of plasma lipids, which might
atherogenic index. This finding provides some be due to the up regulation of low density lipoprotein
biochemical basis for the use of Moringa Oleifera leaf receptor expression, inhibition of hepatic lipid synthesis,
extract as an antihyperlipidemic agent. The present lipoprotein secretion(27), and increase in cholesterol
findings agreed with Mehta et al.,(22) who found that elimination via bile acids.(28) Previous studies concluded
cholesterol, and triglyceride levels increased by 152.9%, that the activity in lowering lipid levels of the Moringa
and 127.3% respectively compared to control group, Oleifera leaf extract may result from the phenolic
Mehta et al.,(22) stated that cholesterol and TG lightly compounds, poly phenolic, and flavonoids present in the
increased by 22% and 42% respectively in rats fed on extract which may greed with our study.
Moringa Oleifera comparing to control group. Dongmeza et al.,(29) and Fakurazi et al.,(30) agreed with
Nevertheless, the results of the present study revealed a the present study as regards liver histopathological
decrease in TG and TC levels among rats fed Moringa findings. They found that the consumption of high fat diet
Oleifera by 22.7%, and 31.29% respectively comparing to may play a crucial role in the pathogenesis of fatty liver or
control rats after two and four weeks. Moreover, the hepatic steatosis. The results obtained in the present study
clinical group showed a decrease in TC and TG levels confirmed that high fat diet causes histopathological
comparing to rats fed on atherogenic diet by 37.6%, and changes in the form of hepato-cellular damage and
36.12%, and by106%, and 229.6% after two and four exaggerated hepatic steatosis. However, treatment with
weeks respectively. The later findings agreed with Mehta Moringa Oleifera causes a momentary reduction in the
et al.,(22) who found that atorvastatin decreased the levels of enzyme levels and prevents liver damage.
TC and TG comparing to rats fed on atherogenic diet by
52.2%, and 54.5% respectively. CONCLUSION & RECOMMENDATIONS
As regards the effect on LDL, similar findings were
reported by Natio et al.,(18) who found that LDL increased Moringa Oleifera was comparable to hypolipidemic
in rats fed atherogenic diet comparing to control group by medication (Atorvastatin) in improving the lipid
14.8%, while it decreased by 32.5, and 19.2% in clinical profile of rats fed on atherogenic diet. Moringa
group, and in rats fed on atherogenic diet + Moringa Oleifera intake is more effective in prevention than in
Oleifera respectively comparing to rats fed on atherogenic treatment of hyperlipidemia. Therefore, awareness of
diet only. people about the beneficial effect of this miracle tree
The results concerning HDL and LDL agreed with (Moringa Oleifera) should be increased. Consumption
several studies.(22-24) Mehta et al.,(22) found that HDL level of Moringa Oleifera daily as a herb or even as spices
increased by 23.8%, and 18.4% in clinical group and rats should be encouraged. Cultivation area of Moringa
fed on Moringa Oleifera, respectively comparing to rats Oleifera in Egypt should be increased. Fortification of
14 Journal of High Institute of Public Health 2016; 46(1): 8-14
several types of food including biscuits, breads, even 15. Burtis CA, Bruns DE. Tietz fundamentals of clinical chemistry. 6th
ed. Philadelphia: Saunders; 2008. p. 506.
cakes with Moringa Oleifera extract can be applied.
16. Burtis CA, Ashwood ER, Bruns DE. Tietz textbook of clinical
chemistry and molecular diagnostics. 4thed. Philadelphia: WD
Conflict of Interest: None to declare. Saunders Co; 2005. p. 1508.
17. Friedman RB, Young DS. Effects of disease on clinical laboratory
tests. 4thed. Washington: AACC Press; 2001. p. 250.
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