Pomegranates and Prostate Health: A Research Report
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Pomegranates and Prostate Health: A Research Report

Mark Dreher, Ph.D.
Chief Scientific Officer, POM Wonderful, LLC
Edited from PCRI Insights August, 2008 v 11.3

Fruits and Vegetables: Recognized Role in Reducing Cancer Risk

How well we age is influenced partly by our genetics but even more so by our lifestyle (e.g., eating right, exercising often, and managing stress). Since these lifestyle factors are under our control, we have the ability to influence the outcomes of some chronic diseases, including certain cancers.1 Increasing evidence supports the important role of nutrition in cancer prevention, including prostate cancer.2,3 Cancer is ranked as a leading cause of death in the United States, in part because U.S. diets tend to be high in fat and calories and low in fruits and vegetables. Studies of population groups in various parts of the world indicate that diets rich in plant foods are associated with a lower risk of some cancers.

Accordingly, one of the strongest U.S. authoritative dietary guidance and promotional efforts ever initiated, the “5-A-Day for Better Health” Program (now called the National Fruit & Vegetable Program), was created in 1991 in order to promote increased fruit and vegetable consumption across the nation. Additionally, the newest revision of the Dietary Guidelines for Americans, released in January 2005, changed fruit and vegetable recommendations for all Americans, increasing the number of recommended servings per day. The association of plant food intake and reduction in cancer risk has been recognized by the FDA4, through its approved health claims and qualified health claims. The National Cancer Institute (NCI) offers an important dietary guidance message for consumers saying that diets rich in fruits and vegetables may reduce the risk of some types of cancer and other chronic diseases.5 In spite of these efforts, only a fifth of Americans consume five servings or more of fruits and vegetables daily. Reversing this trend could help many Americans reduce their cancer risk.

Fruits and vegetables are a major source of nutrients and phytochemicals such as polyphenols, important natural antioxidants, which work as phyto-chemoprevention agents.6 The normal process of cellular metabolism, which requires oxygen from the air we breathe, leads to the production of free radicals – unstable, highly-reactive molecules that lack an electron. Free radicals seek stability by stealing electrons from other stable molecules, creating a chain reaction of free radical formation that can cause damage to body cells, proteins, and DNA if gone unchecked. Aging and/or environmental stress may enhance this oxidative stress and may also lead to chronic inflammation, which can further exacerbate damage and increase cancer risk. The polyphenol antioxidants found in certain colorful fruits and vegetables can boost the body’s natural antioxidant systems to defend against free radical damage.6 This antioxidant defense appears to be well suited to prostate cancer prevention because this cancer develops slowly over the course of decades (typically diagnosed in men over age 50). Research is beginning to connect fruits and vegetables to reduced risk or delay in the onset of prostate cancer7,8 This may help promote many years of prostate health, for even a modest delay in disease progression could significantly impact the quality of life for patients.2

Of the fruits, pomegranates (Figure 1) have been shown to promote prostate health, including possible support for prostate cancer risk reduction. This report provides an update on the latest pomegranate prostate medical research.

pomegranite

Figure 1 Pomegranate fruit and arils (berries)

Pomegranate Fruit: A Traditional Medicinal Remedy

The pomegranate was chosen as the logo for the British Medical Journal’s Millennium Festival of Medicine because of its historically recognized medicinal properties.9 It is also featured in the heraldic crests of several medical institutions. Pomegranates were domesticated around 4,000 B.C. and the pomegranate fruit has a fascinating history of traditional use as food, medicine, and cultural icon. The fruit of the pomegranate tree has been used extensively in the folk medicine of many cultures. The healing property of pomegranates was discussed in one of the oldest medical texts, the Ebers Papyrus from ancient Egypt (circa 1500 BC). The fruit is mentioned in both Greek and Persian mythology representing life, regeneration, and marriage. In Judaism, pomegranate seeds are said to number 613 – one for each of the Torah’s 613 commandments. The fruit is also one of the three blessed fruits in Buddhism. In various forms of traditional Asian medicine, pomegranate fruits were recommended as a health tonic and as a treatment for numerous ailments including diarrhea, dysentery, and diabetes. For centuries, pomegranates have been used in traditional Chinese medicine as antimicrobial and anti-inflammatory agents, and the arils (pomegranate berries) symbolized longevity and immortality.

Thus, pomegranates were highly regarded for their medicinal health benefits. Over the last decade, the pomegranate has been studied by modern medicinal research methods, which are confirming an emerging multi-faceted health role. These studies have been reviewed in several books10,11 and by Dr. James Duke, formerly a U.S. Department of Agriculture phytochemicals expert and now Executive Director of the Green Farmacy Garden. Dr. Duke says that pomegranate juice is his health-food beverage of choice.12

Pomegranates: An Emerging Role in Promoting Prostate Health

A number of review articles and chapters have summarized the emerging role of pomegranates in prostate cancer protection.10,13,14,15 These articles conclude that pomegranates contain promising phytochemicals for the chemoprevention and chemotherapy of prostate cancer. The most active of these compounds are ellagitannins, which are converted to phenolic metabolites such as urolithins in the large intestine.15,16 These compounds have been shown to be potent antioxidant and anti-inflammatory agents.10,15

Chronic inflammation has been linked to prostate cancer.10,11,13 Inflammation, which can result in persistent oxidative stress in cancer cells, may stimulate cancer cell proliferation and increase mutation rates through DNA damage. Oxidative stress may also increase cancer cell proliferation by increasing the sensitivity of growth factor receptors. Oxidative stress is inherent in prostate cancer cells and is responsible for many observed characteristics such as uncontrolled cell cycling and metastasis.18 Increased free radical generation may have a fundamental role in the initiation, maintenance, and promotion of prostate cancer phenotype. Products rich in antioxidant activity might help reduce oxidative stress and chronic inflammation. 100% pomegranate juice from the Wonderful variety, which contains about 2½ pomegranate fruits per serving, has been shown to contain the highest levels of polyphenol antioxidant among fruit beverages.15,16,19 Further, pomegranates can directly suppress NF-kB activation.10 NF-kB is thought to be a key factor in the control of cell proliferation, inhibition of apoptosis and oncogenesis in prostate cancer. A study published in the Proceedings of the National Academy of Sciences20 provides a promising overall perspective on the role of pomegranates and prostate cancer.

Pomegranate fruit juice extract, known to be rich in pomegranate ellagitannins, was studied in mice implanted with androgen-sensitive prostate cancer cells. The research showed significant inhibition in tumor growth, and a significant decrease in serum prostate-specific antigen (PSA) levels. Pomegranate extract consumption resulted in a significant drop in PSA levels or PSA doubling time in direct relationship to prostate cancer tumor volume.  Pomegranate ellagitannins inhibited PSA, a marker for prostate cancer progression. Also, in vitro results demonstrated that treating highly aggressive human prostate cancer PC3 cells with pomegranate extract (10-100 ug/ml) resulted in a dose-dependent inhibition of cell growth/cell viability and induction of apoptosis – programmed cell death. Also, the ellagitannins decreased PSA expression in human prostate cancer cells. The researchers concluded that “the fruit pomegranate and its associated antioxidants may possess a strong potential for development as a chemopreventive and possible therapeutic agent against prostate cancer.”

POM Research Program

Coupled with their acquisition of pomegranate trees as part of their tree nut farming operation in the late 1980s, the Resnicks (owners of POM and Paramount Farms) began exploring the incorporation of this ancient medicinal and nutritious fruit into the American diet. In 1998, the Resnicks became the first to sponsor the scientific validation of the traditional medicinal healthful properties of pomegranates by asking Dr. Michael Aviram, head of the Technion Lipid Research Laboratory at the Rambam Medical Center in Haifa, Israel, to start research on heart health. In 2000, Dr. Aviram published the first clinical and mechanistic research on the impact of Wonderful variety pomegranate juice on atherosclerosis.21

In 2001, POM initiated preclinical research on pomegranate effects on prostate cancer for the first time with Agensys.22 This research showed that pomegranate juice and extracts inhibit the proliferation of androgen-independent prostate cancer cells and angiogenesis (formation of new blood vessels important to cancer cell growth). With this basic research, a POM PJ human pilot clinical study was initiated the following year. This well-designed proof-of-principle clinical trial, published in Clinical Cancer Research in 200623, suggests that POM PJ may be effective in slowing the progression of prostate cancer by extending the prostate specific antigen doubling time (PSADT) and reducing key indicators of prostate cancer development.

To date, the Resnicks have sponsored more than $25 million in medical research ranging from heart and prostate health to common cold protection with over 20 human clinical studies completed or in progress. POM PJ research was recently reviewed by the American Botanical Council in their Scientific and Clinical Monograph series with a primary focus on heart and prostate health.15

POM PJ was first launched in 2002, and this initiated the current worldwide focus on fresh fruit, pomegranate juice, and other products for their health benefits. POM currently farms 18,000 acres of pomegranate trees, which only include the Wonderful variety grown in California. POM has the only clinically tested products for prostate health.

POM PJ

Standardized effective dose. Dr. Aviram studied the dose response effects of POM PJ (Figure 2). He found that the consumption of eight ounces of POM PJ daily for two weeks can lead to a significant decline in the oxidation of lipids in the bloodstream – a key indicator of biological activity in humans.24 POM PJ contains at least 650 mg of polyphenol antioxidants measured as GAE (gallic acid equivalents) per eight-ounce serving (currently POM PJ generally delivers in the range of 25-60% more than this level). With this research, POM established 650 mg GAE polyphenols as the minimum target efficacious level.

chart1

Figure 2. POM PJ Human Dose Response Study on Plasma Lipid Peroxidation

Superior Antioxidant Capacity.
A recent study compared the antioxidant potency of POM PJ to other leading brands of polyphenol-rich beverages.19 Often, a beverage will make a claim about its superior antioxidant content based on the results of one antioxidant, which can distort the true antioxidant capacity, since natural products may contain multiple compounds with varying antioxidant activity. Significant in this study is that all the beverages were tested using several methods, resulting in a more complete assessment of antioxidant activity [antioxidant potency composite index (Antioxidant Index)]. As shown in Figure 3, the Antioxidant Index of POM PJ was at least 20% greater than any of the other polyphenol-rich beverages tested.

chart2

Figure 3. Antioxidant potency composite index of ready-to-drink polyphenol-rich antioxidant beverages (Antioxidant index score) [(sample score/best score) × 100]*

* Wonderful variety pomegranate juice; averaged for all tests for each beverage for the antioxidant potency composite index; TEAC, Trolox equivalent antioxidant capacity; ORAC, oxygen radical absorbing capacity; FRAP, ferric reducing antioxidant capacity; DPPH, free radical scavenging properties by diphenyl-1-picrylhydrazyl radical.

POMx

POMx is the product of the pressed whole fruit after most of the juice is extracted, filtered and concentrated using juice processing techniques to produce a polyphenol-rich pomegranate juice concentrate. POMx and POM PJ have similar polyphenol components since they are produced from the same fruit. There are two forms of POMx: a serving of POMx Liquid (5 ml) or POMx Pill (1,000 mg), which are formulated to deliver at least the same target amount of active polyphenol antioxidants as an eight-ounce serving of POM PJ.

With its careful standardization, POMx has very high antioxidant potency. Internal POM data, measured by an independent laboratory, showed that POMx Pills were more potent than any other natural dietary supplement antioxidant, including red wine, grape seed, green tea, turmeric, açaí, lutein, lycopene, and other pomegranate extracts.25

Human Bioavailability Research

Studies have been conducted to follow the fate of POM PJ polyphenols and their metabolites in the human body, and they have been shown to be bioavailable.26 In a study conducted at UCLA, 18 healthy volunteers consumed POM PJ concentrate, and blood and urine samples were obtained to measure the levels of pomegranate polyphenols and their metabolites appearing in the blood and urine after juice consumption. One compound, ellagic acid (EA) was detected in plasma of all subjects with a maximum concentration of 0.06 mmol/L occurring one hour after consumption. EA metabolites, including dimethylellagic acid glucurnide (DMEAG) and hydroxy-6H-benzopyran-6-one derivatives (urolithins), were also detected in both blood and urine. DMEAG was found in the urine obtained from subjects 24-hours after juice consumption, while urolithin A-glucuronide took more than 48 hours to appear in the urine of subjects. These biologically active urolithins, formed from the polyphenols by intestinal bacteria, persist in plasma and tissues and may account for some of the health benefits noted after daily pomegranate juice consumption.

A recent human clinical study confirmed similar polyphenol bioavailability profiles of the primary POM products – POM PJ (eight ounces), POMx Liquid (5 ml in eight ounces of water), and POMx Pills (1000 mg).27 Tests of plasma and urine bioavailability did not show any statistical difference between the POM products. The results demonstrate that the consumption of pomegranate polyphenol antioxidants delivered by POM PJ, POMx Liquid, and POMx Pills resulted in similar absorption of ellagic acid and excretion of urolithin-A glucuronide. The same level of Urolithin-A glucuronide was detected in all urine samples regardless of the product used, reaching maximum concentrations of 1000 ng/mL, and the levels remained elevated for over 48 hours after consumption of POM products.

Human Drug Interactions

There are no known specific human drug interactions for pomegranate juice.28 One member of the family of drug metabolizing enzymes, CYP3A, is thought to be the most important enzyme involved in the majority of cytochrome P450-catalyzed drug metabolism. Although several in vitro and in vivo studies show a possible effect of oral pomegranate juice on CYP3A-mediated drug metabolism, these pre-clinical findings have not been confirmed in clinical research.

In one study with healthy human volunteers, it was found that pretreatment with eight ounces of POM PJ did not alter the elimination half-life volume of distribution, or clearance of intravenous or oral midazolam (drug metabolized by CYP3A).28 Alternatively, the same amount of oral grapefruit juice was found to impair clearance and lead to elevated plasma levels of oral midazolam. The results of this study suggest that oral consumption of eight ounces of pomegranate juice does not alter the P450 drug metabolizing system. Further, POM PJ has been given to people with Type 2 diabetes taking oral hypoglycemic drugs for three months with no apparent negative effects on glycemic control with a significant reduction in oxidative stress.29

POM Prostate Cancer Research *

Preclinical Studies

Antioxidant Activity. The potent antioxidant capacity of pomegranate polyphenols has been reported by numerous scientists using multiple in vitro assay systems.22 Pomegranate juice was found to be a much more potent antioxidant in protecting nitric oxide (an important messenger molecule involved in many physiological processes within our body) than Concord grape juice, blueberry juice, red wine, vitamin C, and vitamin E.30 As an antioxidant, Wonderful variety pomegranate juice was found to be 100 times more powerful than blueberry juice and 300 times more powerful than grape juice. Pomegranate juice made from the Wonderful cultivar exhibited antioxidant activity up to three times greater than that of phenolic-rich green tea and red wine. Also, animals whose diets were supplemented with POM PJ for four weeks exhibited significantly higher antioxidant capacity and decreased DNA damage compared to control animals receiving their regular diet. 22 Similar results have been observed for POMx products.
* POM completed all animal testing on juice as of October, 2006 and POMx as of December, 2007, and has no plans for future animal testing.

Prostate Cancer. In addition to initial POM PJ Agensys research in 200122, POM has sponsored three additional studies on POM PJ, pomegranate extracts, and individual pomegranate polyphenols. Seeram and co-workers confirmed the Agensys findings on antiproliferative, apoptotic and antioxidant activities of POM PJ on a number of cancers including prostate cancer.31 This research was further studied for effects on inhibiting the growth of human prostate cancer cells as described in the following studies.

POMx Liquid supplementation was shown to inhibit prostate tumor growth by 50% when compared to control in immunodeficient mice injected with human prostate cancer cells (xenograft model).17 Urolithin-A (a bioactive metabolite of pomegranate polyphenols) is absorbed and taken up in highest concentrations in the prostate gland, and the researchers concluded that “we have shown that pomegranate ET (ellagitannins) metabolites (Urolithin A) are concentrated to a high degree in mouse prostate tissues. Given our recent observation of the effects of pomegranate juice in prostate cancer patients, the current study contributes to the increasing body of evidence demonstrating the prostate cancer chemopreventative potential of pomegranate ETs.”

POMx Pills were shown to inhibit prostate tumor growth compared to control in immunodeficient mice injected with human prostate cancer cells.32 The mice were given a POMx dose comparable to that taken by humans. POMx was shown to significantly decrease the overall blood vessel density (angiogenesis) in mouse tumors, which is important in slowing prostate cancer cell growth that is dependent upon on a blood supply. The researchers concluded that “These findings strongly suggest the potential of pomegranate ellagitannins for prevention of the multi-focal development of prostate cancer as well as to prolong survival in the growing population of prostate cancer survivors of primary therapy.”

Human Clinical Evidence

Wonderful variety pomegranate juice has been shown to increase PSA doubling time (PSADT), a measurement used to monitor disease progression and predict risk of disease recurrence. An initial proof-of-principle clinical study showed promising findings linking pomegranate juice consumption to the promotion of prostate health, specifically the prolonging of PSADT. In this study, the researchers sought to determine the effects of pomegranate polyphenol antioxidants consumption on PSA progression in men with a rising PSA following primary therapy.23

This Phase II, open-label, single-arm clinical trial was conducted by Dr. Allan Pantuck at the Clark Urologic Center David Geffen School of Medicine, University of California at Los Angeles. It involved forty-six men (ages are not given) with recurrent prostate cancer who had rising PSAs after treatment with surgery or radiotherapy. Eligible patients had a detectable PSA > 0.2 and < 5 ng/ml that was documented as rising before treatment. Serial PSA measurements taken before they entered the study were used to determine a baseline PSADT.

Patients were treated with eight ounces per day of pomegranate juice. Clinical end points were effect on serum PSA, as well as serum-induced proliferation and apoptosis of prostate cancer cells, serum lipid peroxidation, and serum nitric oxide levels.

Mean PSA doubling time significantly increased with treatment from a mean of 15 months at baseline to 54 months post-treatment. Serum taken from patients before and after treatment was added to prostate cancer cells that were cultured and grown in the laboratory. There was a 12% decrease in cell proliferation, a 17% increase in apoptosis, and a 23% increase in serum nitric oxide. Moreover, there were significant reductions in oxidative state and sensitivity to oxidation of serum lipids in cells treated with serum taken after treatment, compared with cells cultured with serum obtained before treatment began.

This robust, open label study was the first clinical trial of pomegranate polyphenol antioxidants in patients with prostate cancer. The statistically significant prolongation of PSA doubling time, coupled with corresponding laboratory effects on prostate cancer in vitro cell proliferation and apoptosis as well as oxidative stress provide a good indication of a relationship between pomegranate polyphenol antioxidants and prostate health. Although the science has not yet reached the point of identifying pomegranate polyphenols as a treatment for prostate cancer, these studies and other evidence demonstrate the protective effects of these polyphenols in promoting prostate health.

Because of the statistically significant results experienced by many of the participants in the clinical study described above, the study was amended to allow patients to continue treatment to undergo evaluation in three-month intervals to monitor disease progression.33 As of August 2007, seventeen (35%) active patients remained on the study with a median follow up of 30 months post-treatment (range 3-55 months). The mean PSADT for the entire cohort continues to show a significant increase following treatment, from a mean of 15 months at baseline to 58 months post-treatment. Patients remaining in the study (active) were compared to those no longer in the study (non-active). At baseline, the mean PSADTs were similar between active and non-active patients. The mean post-treatment PSADT increased in non-active patients to 51 months, but the PSADT increased to 69 months post-treatment in active patients.

The researchers concluded that “Long-term follow-up of pomegranate juice consumption in men with prostate cancer and a rising PSA demonstrates a durable increase in PSA doubling time.” The data suggest that a sub-set of patients may be more sensitive to the effects of pomegranate juice. Overall, this research reaffirms the value of the earlier Pantuck research by showing that the effects can be long-term. The findings of this promising human clinical study are consistent with an underlying body of scientific evidence and have encouraged further study of pomegranate products and prostate health.

Currently, three POM-sponsored multi-center human studies including a total of about 400-subjects are in progress:

  1. a 200-subject randomized, placebo-controlled clinical trial using the POMx Liquid beverage with PSADT as the primary outcome.
  2. a 100-subject POMx Pill dose response study with PSADT as the primary outcome.
  3. an 80-subject pre-prostatectomy human study is currently in progress to confirm the distribution of pomegranate polyphenols and metabolites in the prostate tissues.

These ongoing studies on POM product s are expected to further demonstrate the relationship between the POM products and prostate health including reduced prostate cancer risk.

Pomegranate Prostate Cancer Research: Current Status
Editor’s Note: POM Wonderful, LLC (POM) has a comprehensive pomegranate medical research program with a focus on prostate cancer. All the medical research discussed was tested on POM Wonderful 100% pomegranate juice (POM PJ) or POMx extracts from the Wonderful variety grown in California by POM. POM PJ and POMx are the only pomegranate products with prostate clinical studies completed or in progress. See pomegranatetruth.com and pomwonderful.com for updated information on POM pomegranate products.

Key References
1. Weil, A. Opening remarks at the Nutrition and Health State of the Science and Clinical Applications Conference in Phoenix, AZ, April 13-16. 2008.
2. Carroll, et al. Report to the Nation on Prostate cancer: A Guide for Men and Their Families. Prostate Cancer Foundation. 2005
3. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. 2007
4. 21 CFR 101.76-78
5. NCI. Cancer Trends Progress Report. Fruit and Vegetable Consumption. 2007
6. Heber, D. What color is your diet? The 7 colors of health. Collins. 2001
7. Chan JM et. al., Role of diet in prostate cancer development and progression. J. of Clinical Oncology. 2005: 23(32):8152-8159.
8. Kirsh, VA et al., Prospective Study of Fruit and vegetable Intake and Risk of Prostate Cancer. JNCI. 2007; 99(15):1200-09
9. Langley P. Why a pomegranate? BMJ. 2000; 321:1153–1154.
10. Leppert JT and Pantuck, AJ. Pomegranate and Prostate Cancer Chemoprevention. Pomegranates: Ancient Roots to Modern Medicine. Boca Raton: CRC Press, Seeram N, Schulman R, Heber D, eds; 2006:31-43.
11. Newman, RA and Lansky, EP Pomegranate the most medicinal Fruit. Basic Health Publications, Inc. 2007.
12. Duke, JA. Pomegranate, Old and New. Alternative & Complementary Therapies. April. 2008:57-63
13. Malik, A and Mukhtar, H. Prostate Cancer Prevention Through Pomegranate Fruit. Cell Cycle. 2006; 5(4):371-373
14. Lansky, EP and Newman, RA. Punica granatum (pomegranate) and its potential for prevention and treatment of inflammation and cancer. J. Ethnopharmacology. 2007; 109:177-206
15. American Botanical Council. Scientific and Clinical Monograph for POM Wonderful(R) pomegranate juice, McCutcheon, A., Udani, J, and Brown, DJ. (2008)
16. Gil, MI et al., Antioxidant activity of pomegranate juice and its relationship with phenolic composition and processing. J. Agric. Food Chem. 2000; 48:4581-89
17. Seeram N, et al. Pomegranate ellagitannin derived metabolites inhibit prostate cancer growth and localize to the mouse prostate gland. J Agric Food Chem 2007; 55:7732–7737.
18. Kumar B, et. al., Oxidative Stress Is Inherent in Prostate Cancer Cells and Is Required for Aggressive Phenotype. Cancer Research, 2008: 68(6):1777-1785.
19. Seeram NP et. al., Comparison of Antioxidant Potency of Commonly Consumed Polyphenol-Rich Beverages in the United States, J. Agric. Food Chem. 2008; 1415-1422
20. Malik, et al., Pomegranate Fruit Juice For Chemoprevention And Chemotherapy Of Prostate Cancer, Proceedings of the National Academy of Science.2005; 102(41).14813-18.
21. Aviram, M et. al., Pomegranate juice consumption reduces oxidative stress, atherogenic modification to LDL, and platelet aggregation: studies in humans and in atherosclerotic apolipoprotein E-deficient mice. Am. J. Clin. Nutr. 2000; 71:1062-1076
22. Agensys. Investigation of the effect of pomegranate juice on human prostate cancer. POM Wonderful Research files. 2001.
23. Pantuck AJ, et al. Phase II study of pomegranate juice for men with rising prostate-specific antigen following surgery or radiation for prostate cancer. Clin Cancer Res. 2006; 12:4018–4026.
24. Aviram, M Antioxidant effect of pomegranate juice consumption by healthy males: a dose response study. POM Wonderful Internal Research files. 2003.
25. Reed, J., POM Wonderful Internal Report. 2008.
26. Seeram N, et al. Pomegranate juice ellagitannin metabolites are present in human plasma and some persist in urine for up to 48 hours. J Nutr. 2006; 136:2481–2485.
27. Seeram, et al., Pomegranate Juice And Extracts Provide Similar Levels Of Plasma And Urinary Ellagitannin Metabolites In Human Subjects, Journal of Medicinal Foods. 2008; 11(2)
28. Farkas D, et al. Pomegranate juice does not impair clearance of oral or intravenous midazolam, a probe for cytochrome P450-3A activity: Comparison with grapefruit juice. J Clin Pharmacol. 2007; 47:286–294.
29. Rosenblat M, Hayek T, Aviram M. Anti-oxidative effects of pomegranate juice (PJ) consumption by diabetic patients on serum and macrophages. Atherosclerosis. 2006; 187:363–371.
30. Ignarro, LJ et. al., Pomegranate juice protects nitric oxide against oxidative destruction and enhances biological actions of nitric oxide. Nitric Oxide.2006; 15:93-102.
31. 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. Nutritional Biochemistry
32. Sartippour, et al., Ellagitannin-Rich Pomegranate Extract Inhibits Angiogenesis In Prostate Cancer In Vitro And In Vivo, 32 International J. of Oncology. 2008;475-480.
33. Pantuck AJ, et al., Abstract presented at the American Society of Clinical Oncology 2008 Genitourinary Cancers Symposium (Abstract 40): Long Term Follow Up Of Pomegranate Juice For Men With Prostate Cancer And Rising PSA Shows Durable Improvement in PSA Doubling Time.