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					                        Desertbloom Home Page

 Desert Bloom Discovers Potential New Drug
  Treatment for Diabetics to Prevent Lower
           Extremity Amputations

                     For the Treatment of
  Diabetic Vasoneural Extremity Disease (DVED)

                        William L. Davis
                      J Desert Bloom, LLC

Nopalamine has not been approved by the United States Food
and Drug Administration (FDA) as a drug product to diagnose,
treat, cure or prevent any disease. Clinical trials to test the
safety and effectiveness of Nopalamine for the treatment of
Diabetic Vasoneural Disease (DVED), as such term is defined
herein, in accordance with FDA standards, requirements and
guidelines, are scheduled to commence in the near future. At
the present time, no claim may be made by any party
regarding the use of Nopalamine for the treatment of any
disease including DVED.

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Most diabetics are familiar with the threat of lower extremity amputations (LEAs) as
a potential complication of their diabetes.

LEAs, while viewed as necessary in certain cases to save lives, result in varying
degrees of physical disability which can adversely affect the individual’s ability to
earn income as well as the individual’s ability to perform normal day-to-day physical
activities and needed physical exercise regimens. There are also psychological
implications (stress and depression) that accompany amputations as well. There is
fear of even minor amputation because it is well known among diabetics that
subsequent to a first (and perhaps minor) LEA, a second or third LEA may be
required (i.e. a toe(s) followed by a foot, the foot followed by the lower leg, etc.). This
progression is logically the result of failure of (or more specifically, lack of) existing
drugs or medication and/or other therapeutic measures to effectively intervene the
underlying pathological condition(s) that gave rise to the initial amputation and
which remain or reoccur after the initial amputation at another lower extremity site.

Furthermore, various studies have shown that amputees have significantly lower life
expectancies than the general population. For example, one paper, focused on
assessing the difference in mortality rates between diabetics and non-diabetics that
had nontraumatic LEAs, found that 61% of diabetic amputees died during the five-
year follow-up period tracked by the study, compared to 54.3% for non-diabetics [1].
Another study found that after an amputation, “diabetic subjects had 55% greater
risk of death than those without diabetes” [2].

Finally, significant cost (to Medicare and to affected individuals) is associated with
diabetic lower extremity amputations. A Centers for Disease Control (CDC) paper on
this subject states that for the year 1997, “66.7% of LEA hospitalizations were paid by
Medicare and an additional 8.1% were paid by Medicaid”[3], total of 74.8%; the
remaining 25.2% presumably being paid by private sources. A 1996 study of
Medicare beneficiaries by Drs. TR Dillingham and LE Perrin found that the acute
and post acute medical care costs among persons with dysvascular amputations
exceeded $4.3 billion annually [4]. A study of diabetes-related amputations for the
year 1991 using retrospective hospital discharge records for the state of California
revealed that the mean direct hospital charges per patient amputation amounted to
$27,930 [5]. The cost is likely more today. However, assuming that number to be
representative and assuming 82,000 such amputations annually in the United States
[6, 7], would place the direct cost alone of diabetes-related non-traumatic LEAs in
the range of $2.3 billion per year.

Consequently, the development or discovery of a drug or other form of treatment as
an effective alternative to lower extremity amputations, would be extremely
beneficial to the health and well-being of individuals faced with the prospect or
necessity of a lower extremity amputation as a complication of diabetes, while
achieving potentially significant cost savings to the government and to affected

Desert Bloom will soon commence clinical trial studies of the drug product
Nopalamine discussed in this paper. In reading the information that follows, the
reader is cautioned to remember that Nopalamine has not been approved by FDA as

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a drug product and that the botanical source of Nopalamine is currently marketed by
Desert Bloom only as a nutritional health supplement in juice form known as Desert
Bloom Nopal Extract (hereafter referred to as Nopal Extract). Nopal Extract is not
intended, nor can any claim be made that Nopal Extract is intended, to diagnose,
treat, cure or prevent any disease. The purpose of the clinical trial work referred to
above is to determine and establish, under strict FDA requirements and guidelines
for clinical trial studies, that the drug form of Desert Bloom Nopal Extract (i.e.
Nopalamine) will be safe and effective for use in treating Diabetic Vasoneural
Extremity Disease.

As discussed more fully below, the potential use of Nopal Extract (in drug form,
Nopalamine) to treat Diabetic Vasoneural Extremity Disease (DVED) was discovered
quite by accident!

What is Diabetic Vasoneural Extremity Disease (DVED)?

DVED may be described as the medical condition where an individual has been
diagnosed as having diabetes and complications associated with diabetes (including
peripheral arterial disease (“PAD”) and/or peripheral neuropathy (“PN”) and/or
infection), singularly or in combination, have advanced to the point where, under
current medical practice, amputation of a lower extremity (toe, foot, leg) affected by
such complication(s) would normally be the next step to be considered or
undertaken in order to prevent the onset or spread of infection-generated toxins
that, if not effectively intervened, would cause systemic damage to vital organs and
ultimately result in death of the patient.

Marvin E. Levin, MD, in a 2002 paper published in the journal of the Southern
Medical Association noted in describing the progression of pathological events
preceding amputation that:

   “Risk factors for lower extremity amputation vary from series to series.
   Most diabetic amputations, however, are due to peripheral arterial disease
   (PAD), peripheral neuropathy (PN), and infection.” “This triad is the
   harbinger of the final pathologic events, gangrene and amputation” [8].

The Centers for Disease Control paper referred to above also states that:

   “Among persons with diabetes, LEAs result from the single or combined
   effects of vascular disease, peripheral neuropathy, and infection. “Foot
   deformity and ulcers occurring as a consequence of neuropathy and/or
   peripheral vascular disease, minor trauma, and poor foot care also might
   contribute to LEAs” [3].

“Component causes” of a lower extremity amputation are said to include trauma,
ulceration and/or failure to heal, and “sufficient causes” are said to include gangrene
and infection [9].

Gangrene and DVED

Regarding gangrene, it should be noted that amputations are not necessarily or
entirely predicated or conditioned upon the presence of gangrene although the

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presence of gangrene is considered to be a “sufficient cause” for amputation. Simply
defined, gangrene is “death of tissue” [10]. It is noted that the CDC paper referred to
above does not include mention of gangrene as a condition precedent to amputation.
There are two types of gangrene: dry gangrene which is not directly associated with
infection and wet or moist gangrene called gas gangrene which is directly associated
with infection [11]. However, the toxins that are associated with gas gangrene (being
the product of Clostridium Perfringens, an anaerobic bacteria that thrives in a low or
no oxygen environment and that is the hallmark characteristic of gas gangrene) and
which ultimately cause the systemic damage to vital organs that results in death, are
not exclusively associated with Clostridium Perfringens bacterial infection. For
example, infections caused by aerobic staphylococcus aurous bacteria also produce
A-toxin capable of causing life-threatening systemic damage [12, 13, 14].
Furthermore, according to the Medline Plus online medical encyclopedia, the
incidence of cases of gas gangrene from all causes in the United States is only 1,000
to 3,000 cases per year [15]; while the incidence of lower extremity nontraumatic
amputations among diabetics is reported by the American Diabetes Association and
the National Diabetes Clearinghouse (National Institutes of Health), to be about
82,000 per year [6, 7] or over 27 times the reported incidence of gas gangrene.
Additionally, gas gangrene among diabetics is reported to be uncommon [16].
Consequently, although gangrene is frequently mentioned as a last stage pathological
event immediately preceding amputations of any type, it is the broader set of
underlying pathological conditions and risk factors that immediately precede lower
extremity amputations among diabetics and the need to intervene the progression of
such conditions so as to avert such amputations that is relevant to defining DVED.
More specifically, DVED is not the presence of gangrene in a lower extremity per se,
but the presence and treatment of a broader combination of underlying pathological
conditions that with progression over time, have reached a stage where the next
following pathological event will be the production of toxins (triggered by infection)
that cause life-threatening systemic damage, which final pathological event is
currently intervened by amputation. In this context, gangrene may or may not be
present but where present, is considered to be a symptom that alone is sufficient
cause for amputation.

How does DVED develop as a complication of diabetes?

Based upon review of a large body of research study abstracts and encyclopedic
articles available online from PubMed (a service of the National Library of Medicine,
the National Institutes of Health) and other sources pertaining to diabetes and lower
extremity amputation (“LEA”), the progression from the onset of diabetes to
amputation (which occurs in only a very small percentage of diabetics) may be
generally summarized as follows.

The progression from onset of diabetes to LEA begins with high blood sugar (blood
glucose) levels. A diagnosis of diabetes is made where 8-hour fasting blood glucose
level is found to be higher than 126 mg/dl on 2 or more testing occasions [17].

Over time, blood glucose levels above normal causes or contributes to the onset of
several pathological conditions or complications, three in particular, that ultimately
become associated with the need for lower extremity amputations.

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   1. The first of these is damage to the lower extremity vascular system in the form
      of arteriosclerosis (arteriosclerosis obliterans), resulting in peripheral arterial
      disease (PAD) in a lower extremity.

   2. A second is damage to the lower extremity nervous system in the form of
      peripheral neuropathy (PN).

   3. The third of these conditions is impaired immune system function in fighting
      infection that develops in part due to sustained failure to effectively manage
      blood glucose levels (i.e. diabetes).

Over time, these three pathological conditions promote or permit a “second round”
of consequent effects. These second round effects, as such relate to predisposing
diabetics to the risk of LEAs, are:

   1. The peripheral arterial disease results in diminished blood supply to lower
      extremity cell tissues and consequent diminished delivery of needed oxygen
      and nutrients. Sustained failure of cell tissue to receive needed oxygen and
      nutrients results in death of affected cell tissue (necrosis), which provides a
      breeding ground for the growth of infection causing bacteria and ultimately
      system damaging toxins. Additionally, late stage PAD also impairs, and may
      by virtue of vascular occlusion render impossible, the delivery of antibiotics to
      the local site of a lower extremity infection.

   2. The peripheral neuropathy (1) reduces lower extremity sensitivity to
      nontraumatic injury (typically at the toes and feet) such that minor injury
      (such as a minor bone fracture) goes undetected for lack of pain sensation and
      (2) due to impaired neurotransmitter function, the immune system may fail to
      detect and respond effectively to the presence of even simple infection. PN is
      said to be the major cause of ulceration in a lower extremity.

   3. Impaired immune system function may permit an otherwise simple infection
      to become life-threatening, one mechanism for such being impaired leukocyte
      function (insufficient white blood cell production) caused by higher than
      normal blood glucose levels.

Acting independently or together, Peripheral arterial disease and peripheral
neuropathy promote the onset of diabetic foot ulcers (that become infected and may
become non-healing), bone deformities that may initially go undetected due to loss
of pain sensation (resulting in weakened adjoining musculature and consequent
abnormalities including “claw toe” and “Charcot foot”) and cell tissue death
(necrosis) caused by lack of blood supply to affected tissue and consequent
insufficiency in the delivery of oxygen, nutrients and antibiotics when and where
needed to treat infection. The presence of dead cell tissue (particularly soft cell
tissue between the outer skin and muscle or bone that may go undetected) promotes
the growth of toxin-producing bacteria capable of ultimately causing local as well as
systemic vital organ damage. With the onset of toxin production stemming from
infection that cannot be controlled by antibiotics due to vascular system deficiency of
delivery and inability to remove waste, the stage is now set for the onset of systemic
damage and consequent need for drastic last resort intervention in the form of

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The foregoing summarization is based upon papers referenced in the attached
Bibliography as items: 8, 18, 19, 20, 21, 22, 23, and 24.

In summary, DVED develops as the result of certain pathological events that have
evolved over time because of ineffective measures of intervention and that, in a
relatively small number of diabetics, reach a stage where the risk of lower extremity
amputation (LEA) is either extremely high or has become virtually eminent. In this
context, the mere presence of peripheral arterial disease, peripheral neuropathy or
impaired immune system function in responding to infection present in a lower
extremity, singularly or in combination, at an early stage, is not sufficient to classify
a diabetic patient as having DVED. Indeed, while many diabetics are affected by one
or more of these conditions, only a very few are affected to the extent that an
amputation of a lower extremity is performed. [8, 9, 19] In fact, even where
gangrene is present, it is reported that, provided there is early diagnosis and proper
care, most people make a full recovery. [25] In most cases, amputations are avoided
by standard treatment and care procedures short of amputation including effective
blood glucose control, use of orthopedic foot wear, proper daily care of feet and
particularly foot ulcerations where present, use of pressure-relieving casts to prevent
nontraumatic foot injury and promote circulation, surgical intervention where bone,
joint or muscle deformity is present, debridgement of necrotic tissue where present,
revascularization where feasible to reestablish blood circulation to affected tissue,
use of antibiotics where infection is present, etc.

Therefore, DVED occurs at the point where one or more of the pathological
conditions described above are present in late stage form placing the individual at
extremely high risk for amputation, but where the production of infection-generated
toxin capable of causing serious systemic damage to vital organs has not yet become
fully manifest (i.e. become “life-threatening”). A life-threatening condition is said to
be signaled by a combination of symptoms of systemic damage such as sweating,
fever, anxiety, decreased blood pressure (hypotension), kidney failure, liver damage
and shock due to the spread of toxin [11].

What is Nopalamine?

Nopalamine is intended for oral use to treat Diabetic Vasoneural Extremity Disease
(DVED) as an alternative to lower extremity amputations among diabetics.
Nopalamine is a botanical drug product. The drug substance in Nopalamine is a
concentrated extract of phytochemicals naturally present in the Nopal plant (genus
Nopalea, also called Opuntia), in liquid form.

What Led to the Development of Nopalamine?

In 1996, Mr. John I. Shin, President of Desert Bloom, learned about Nopal, the plant
source of Nopalamine, from a business associate. This individual was at the time
conducting experiments with Nopal as the result of his interest in diabetes in general
and because his young daughter had recently been diagnosed as having Type I
insulin dependent diabetes mellitus (“IDDM”). Mr. Shin’s family in his native
country of Korea had for many generations been medical practitioners. Upon his
arrival in the United States in 1971, Mr. Shin majored in microbiology at the
University of Missouri. Owing to his long standing interest in promoting health care,

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Mr. Shin began a long term effort to study Nopal. Some pertinent highlights of Mr.
Shin’s initial studies and findings regarding Nopal are as follows.

Like the Aloe Vera plant, Nopal has a long history of use among the indigenous
populations of the southwestern United States and Mexico dating back to the time of
the Aztecs. The word Nopal derives from the Aztec word Nopalli. Among the
medicinal uses made of Nopal by the Aztecs are said to have been its use to rid the
body of intestinal parasites, to promote the secretion and excretion of urine, to
strengthen the lungs, to increase milk production for mothers, to cure abscesses and
to heal wounds.

In the 1990s, physicians associated with government-operated hospitals in Mexico
City, Mexico, became interested in pursuing the clinical testing of several species of
Nopal for its possible use for blood sugar and cholesterol management among
diabetics. Abstracts of several of the Mexican hospital-based clinical studies of
Nopal are included, together with their respective PubMed PMID reference
numbers, as Appendix A to this paper. Several U.S. university-based studies of
Nopal are also included in Appendix A. These studies found positive therapeutic
benefits for Type 2 diabetics from the use of Nopal [26] and have been cited by
scientists in the United States. For example, the following is excerpted from
Treating Type II Diabetes Nutritionally by C. Leigh Broadhurst, PH.D., Nutrition
Science News, July 1998. [27] Dr. Broadhurst is a research geochemist at the U. S.
Department of Agriculture Nutrient Requirements and Functions Laboratory,
Beltsville Maryland.

   “Beyond Fiber”

    “High-fiber diets are uniformly recommended for diabetics. Particularly
   important is soluble fiber, including gums, mucilages, pectins and
   polysaccharides, all of which can slow the absorption of glucose in the
   intestines. However, some plant foods provide synergistic benefits beyond
   just inhibiting glucose absorption.”

   “Nopal (Opuntia spp.): In a 1990 La Raza, Mexico, hospital study, eight
   diabetics were given 500 g of nopal, also known as prickly pear cactus, on an
   empty stomach. Five tests were performed on each subject, four with different
   cooked or raw cactus preparations and one with water. After 180 minutes,
   fasting glucose was lowered 22 to 25 percent by all nopal preparations
   compared to 6 percent for water.23 Nopal is rich in pectin, but again, fasting
   glucose was affected, so the effect is more than inhibition of glucose
   absorption. Animal studies corroborate this, showing small amounts of an
   active fraction isolated from nopal can partially reverse diabetes.24 “

     23 Frati AC, et al. Hypoglycemic effect of Opuntia ficus indica in non
     insulin-dependent diabetes mellitus patients. Phytother Res 1990;4:195-7.

     24 Trejo-Gonzales A, et al. A purified extract from prickly pear cactus
     (Opuntia fulignosa) controls experimentally induced diabetes in rats. J
     Ethnopharm 1996;55:27-33.

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The Nopal plant, which is classified by the U. S. Department of Agriculture (“USDA”)
as a vegetable, is native to Mexico and the southwestern United States. The USDA’s
analysis of the raw pads of the Nopal Plant reveals that Nopal contains dietary fiber
(soluble and insoluble), carotene (Alpha and Beta), 18 Amino acids (including all 8 of
the “essential” amino acids), 10 vitamins and 10 minerals [28].

Encouraged by these initial findings, Mr. Shin chartered J Desert Bloom, LLC in July
of 2002 for the purpose of producing Nopal as a nutritional health supplement in the
form of a concentrated extract in juice form (hereafter referred to as “Nopal
Extract”). Also at this time, in order to market the Nopal Extract as a nutritional
health supplement, Mr. Shin chartered a sister company, Desert Bloom Marketing
USA, Inc.

In 2005, Mr. Shin commenced the construction of a 35,000 square foot processing
facility. Today Desert Bloom Nopal Extract is produced as a nutritional health
supplement for distribution in the US and Asia. Desert Bloom Nopal Extract has
been approved by the governments of Japan and Korea for import into those
countries as a nutritional health supplement product. As currently formulated and
laboratory tested, Nopal Extract contains the following dietary ingredients per liquid
ounce (28 grams by weight):

   Description                  Content


   Vitamin A                      2.80 IU
   Vitamin C                      0.81 mg
   Thiamin (B1)                   0.22 mg
   Riboflavin (B2)                0.25 mg
   Niacin (B3)                    0.45 mg
   Pyridoxine (B6)                0.45 mg
   Folate                       168.00 mg
   Pantothenic Acid (B5)          7.48 mg


   Calcium                      106.68 mg
   Iron                           0.50 mg
   Sodium                        30.80 mg
   Potassium                    114.24 mg
   Phosphorus                     0.28 mg
   Magnesium                     35.56 mg
   Zinc                           0.50 mg
   Manganese                     27.30 mg
   Chromium                       14.00 ug

   Amino Acids:

   Cystine /2                    2.408 mg
   Aspartic Acid / Asparagine   14.112 mg
   Threonone                     4.760 mg
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   Description                 Content

   Amino Acids (Continued):

   Serine                       7.756 mg
   Glutamic Acid / Glutamine   18.312 mg
   Proline                      5.506 mg
   Glycine                      5.264 mg
   Alanine                      8.512 mg
   Valine                       4.732 mg
   Methionine                   1.512 mg
   Isoleucine                   2.716 mg
   Leucine                      4.592 mg
   Tyrosine                     3.444 mg
   Phenylalanine                2.296 mg
   Histidine                    2.352 mg
   Tryptophan                   1.372 mg
   Lysine                       6.776 mg
   Arginine                     3.332 mg


   Fiber, TD                         0.67 g
    Soluble Fiber                    0.42 g
    Insoluble Fiber                  0.25 g

   Other Dietary & Proximate Ingredients:

   Total Fat                         0.03 g
    Saturated                        0.00 g
    Cholesterol                      0.00 mg
   Total Carbohydrates               2.04 g
   Protein                           0.08 g
    Sugars                           0.00 g
   Total Calories                      10
   Calories from Fat                    0

   Source: Food Products Laboratory, Inc. (FPL) report to Mr. John Shin dated June
   15, 2004. [29]

Based on the FPL report above, a one ounce “serving” of Nopal Extract qualifies
(under FDA guidelines) to have the following “content claims” made about it as a
dietary supplement:

   1. It is a Good Source of: Calcium, Thiamin (Vitamin B1), Riboflavin (Vitamin
      B2) and Chromium. (a one ounce serving contains at least 10% of the FDA
      established Daily Recommended Value (DRV) for each of these nutrients.

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   2. It is High in: Pryridoxine (Vitamin B6), Folate and Pantothenic Acid
      (Vitamin B5). (a one ounce serving contains at least 20% of the established
      DRV for each of these nutrients.

   3. It is a High Potency source of: Manganese (a one ounce serving contains at
      least 100% of the established DRV for each of this nutrients.

The pure unsupplemented extract of Nopal constitutes 98.85% of the finished Nopal
Extract nutritional health supplement product (drug name Nopalamine) by weight,
with the remaining weight being comprised of sodium benzoate and grapefruit seed
extract and/or potassium sorbate added as preservatives, citric acid added as a
stabilizer and preservative and stevia added as a health supplement.

How Was Nopalamine Discovered as a Possible Treatment for DVED?

The use of Nopal Extract (in drug form, Nopalamine) as a potential alternative to
lower extremity amputations (LEAs) among individuals affected by DVED was, as
has been the case with a number of other useful medicinal products, discovered quite
by accident. A brief history of this discovery follows.

In the course of recruiting and employing personnel for Desert Bloom Marketing
USA, Mr. Shin observed a remarkable effect of using Nopal Extract among diabetics.
One member of Mr. Shin’s marketing team, 62 year old Howard Limb, developed
inflammation, discoloration and an ulcer on the calf of his right leg, as a
complication of diabetes. The inflammation developed very rapidly and he became
unable to wear his shoes. He could not walk without substantial pain. At this point,
Mr. Limb entered a local hospital in Los Angeles, California for treatment. At the
hospital, he was told that his leg was infected and that he might be facing amputation
of the leg. Upon his release from the hospital for initial treatment of his condition,
he searched for an alternative to possible future amputation of his leg. He had heard
of Nopal and found Desert Bloom’s Nopal Extract in a local health supplement store.
He began taking 1 ounce 2 times daily. In a few days, his blood glucose level dropped
from 270 to normal. After using the Nopal Extract for 22 days, the inflammation
and skin discoloration had disappeared, he was again able to wear his shoes and he
could walk without pain. The ulcer on his leg also began to show signs of healing and
by the 45th day was virtually completely healed.

Another example occurred during the construction of Desert Bloom’s manufacturing
facility when the steel erector subcontractor brought his father’s condition to the
attention of Mr. Shin. This individual, aged 63, was confined to a wheelchair and
unable to walk due to inflammation of his right leg and severe pain as a complication
of diabetes. After taking Nopal Extract given to him by Mr. Shin (1½ ounces, 2 times
daily) for about 3 weeks, his pain subsided, his skin color returned to almost normal
and the inflammation subsided to the point that he was again able to walk without

Nopalamine and DVED - - Some Case Examples

Based upon these early observations, Mr. Shin began an effort to locate and provide
free samples of Nopal Extract to individuals who, as a complication of diabetes, were
faced with the possible prospect of a lower extremity amputation. These efforts were

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intended to see what possible observable effects the use of the Nopal Extract might
have on other diabetics whose lower extremity condition had advanced to the point
that their physician had discussed the possible or probable need for a LEA.

Desert Bloom’s Nopal Extract distributor in Korea (COTEXS) took a particularly
active interest in this exploratory work. Through the cooperation of a network of
pharmacists in Korea, COTEXS identified and provided samples of Nopal Extract to
3 individuals who had been informed by their physicians that they had exhausted all
medical means short of amputation for treating their diabetes-related lower
extremity problems and that their condition was not improving. Subsequently, each
of these individuals had refused amputations and had ceased taking antibiotics and
other medications prescribed specifically for their lower extremity conditions, at the
time they began using Nopal Extract provided to them by their pharmacist through
COTEXS. The results were as follows for the time periods indicated.

Case #1:

A Korean male, age 60, with history of diabetes, presenting with open foot ulceration
and evidence of dry gangrene. The photos below show before and after results after a
dosage of 2 ounces of Nopal Extract per day from January 10, 2007 thru March 14,
2007 (63 days).

Case #2:

A Korean female, age 56, with history of diabetes, presenting with open toe
ulceration with evidence of dry gangrene. The photos below show before and after
results after a dosage of 2 ounces of Nopal Extract per day from May 28, 2007 thru
June 14, 2007 (18 days).

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Case #3:

A Korean male, age 61, with history of diabetes, presenting with inflammation of the
right leg and foot with evidence of subcutaneous soft tissue infection. The photos
below show before and after results after a dosage of 2 ounces of Nopal Extract per
day from September 1, 2006 thru September 19, 2006 (19 days).

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How Does Nopalamine Work?

Based upon these observations, Mr. Shin became firmly convinced that the Nopal
Extract has an observable effect on mitigating underlying pathological conditions
that would ordinarily result in a lower extremity amputation. Accordingly, an effort
was commenced to investigate the scientific basis of possible underlying mechanisms
whereby the observed effects, resulting in avoidance of a lower extremity
amputation, were potentially caused or supported by the Nopal Extract.

As indicated above in the discussion of the pathological conditions that immediately
precede a decision or diagnosis to amputate, it was noted that the core issues that in
theory must be addressed in preventing the necessity for and current medical
practice of performing LEAs among diabetics are the presence, generally in advanced
stages, of (1) peripheral arterial disease (PAD) and/or (2) peripheral neuropathy
(PN) and/or (3) infection. These conditions, singularly or in combination, are said
to be the precedent “harbingers” of approximately 82,000 lower extremity
amputations performed among diabetics in the United States each year. [6, 7 and 8]
Consequently, it is theorized that any alternative to amputation must potentially be
able to effectively deal with late-stage effects of the three pathological conditions
noted and, as corollary; the need to effectively control blood glucose level because of
its role in promoting continuing and progressive deterioration and dysfunction of the
circulatory, neural and immune systems in general as well as in the lower
extremities. [22]

A starting point for explaining the observed improvement in the pathological
conditions underlying DVED following the use of Nopal Extract noted in the case
examples discussed above, would be that the Nopal Extract used by these individuals
must contain phytochemicals that have biological activities that would serve to
positively impact certain of the underlying pathological conditions that would
ordinarily result in a lower extremity amputation.

The Agricultural Research Service (ARS) division of USDA maintains a database of
phytochemicals found in a wide range of botanicals together with their indicated
“biological activity” characteristics. The ARS database is titled “Dr. Duke’s
Phytochemical and Ethnobotanical Database” [30]. Some examples of biological
activities included in the ARS phytochemical database that appear to be relevant to
DVED in terms of mitigating the effects of its underlying pathological conditions
(PAD, PN and infection) are: “angiogenic” (promotes growth of new blood vessel and
lymphatic tissue), “vasodilator” (promotes blood circulation), and “immuno-
stimulant” (promotes immune system response to infection).

The USDA/ARS provides online access to Dr. Duke’s Phytochemical and
Ethnobotanical Databases. The following chart is a listing of Biological Activities
considered most relevant to DVED and the phytochemicals found in raw Nopal that
promote each activity listed.

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   BIOLOGICAL                                PHYTOCHEMICALS
ACE Inhibitor           Quercitrin, Zinc
Analgesic               Ascorbic Acid, Shikimic Acid, Thiamin, Tocopherol,
Angiogenic              Beta-Sitosterol
Angiotensin Receptor Ascorbic Acid, Fiber, Potassium
Blocker (ARB)
Antiaggregant           Ascorbic Acid, Kaempferol, Magnesium, Rutin, Tocopherol,
Antiarteriosclerotic    Linoleic Acid, Tocopherol
Antiatherosclerotic     Ascorbic Acid, Calcium, Magnesium, Malic Acid, Rutin,
Antibacterial           Ascorbic Acid, Beta-Sitosterol, Kaempferol, Citric Acid,
                        Isorhamnetin, Lauric Acid, Pectin, Quercitrin, Rutin
Antibiotic              Cysteine
Anticapillary-Fragility Rutin
Anticoagulant           Citric Acid
Anticoronary            Beta Carotene, Linoleic Acid, Magnesium, Tocopherol, Zinc
Antidiabetic            Ascorbic Acid, Copper, Fiber, Fructose, Magnesium, Pectin,
                        Rutin, Tocopherol, Xylose, Zinc
Antidiabetic ?          Arginine
Antihepatotoxic         Ascorbic Acid, Glucose, Quercitrin, Rutin, Stigmasterol
Antihyperkeratotic      Beta Carotene
Antihypertensive        Arginine, Ascorbic Acid, Calcium, Fiber, Magnesium,
                        Potassium, Rutin, Tryptophan
Antiinflammatory        Ascorbic Acid, Beta-Sitosterol, Copper, Isorhamnetin,
                        Kaempferol, Linoleic Acid, Luteolin, Magnesium, Oleic Acid,
                        Quercitrin, Rutin, Stigmasterol, Tocopherol
Antiobesity             Ascorbic Acid, Fiber, Pectin, Zinc
Antioxidant             Alanine, Ascorbic Acid, Beta Carotene, Beta-Sitosterol,
                        Betanin, Campesterol, Cysteine, Isorhamnetin, Kaempferol,
                        Lauric Acid, Luteolin, Methionine, Myristic Acid, Palmitic
                        Acid, Quercitrin, Rutin, Shikimic Acid, Stigmasterol, Sucrose,
                        Tocopherol, Tryptophan
Antioxidant Synergist   Citric Acid, Malic Acid, Tartaric Acid
Antioxidant ?           Arginine, Threonine
Antiphenylketonuric     Tryptophan, Tyrosine
Antiplaque              Kaempferol, Zinc
Antistaphylococcic      Kaempferol, Quercitrin
Antistress              Beta Carotene
Antithrombogenic        Quercitrin, Rutin
Antothrombotic          Tocopherol
Antithromboxane-B2      Tocopherol
Antitriglyceride        Zinc
Capillaryprotective     Rutin
Cardioprotective        Fiber
Cardiotonic             Quercitrin
Cardiovascular          Histamine, Mescaline, Tyramine
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Collagenic           Ascorbic Acid
Cytoprotective       Rutin
Detoxicant           Ascorbic Acid, Cysteine
Diuretic             Arginine, Ascorbic Acid, Calcium, Fiber, Kaempferol, Luteolin,
                     Magnesium, Potassium, Quercitrin
Glutathionergic      Cysteine
Gluthionigenic       Methionine
Hepatomagenic        Rutin
Hepatoprotective     Beta-Sitosterol, Isorhamnetin, Kaempferol, Linoleic Acid,
                     Luteolin, Methionine, Niacin, Rutin, Tocopherol
Hepatotonic          Quercitrin
Immunomodulator      Linoleic Acid, Rutin
Immunostimulant      Ascorbic Acid, Beta Carotene, Phosphorous, Tocopherol, Zinc
Insulin-Sparing      Tocopherol
Insulinase-Inhibitor Tryptophan
Insulinogenic        Magnesium, Zinc
Insulinotinic        Tryptophan
NO (Nitric Oxide)- Arginine
NO (Nitric Oxide)- Kaempherol, Luteolin
Neuroexcitant        Aspartic Acid
Neuroprotective      Kaempherol
Phagocytotic         Beta Carotene
Phospholipase-A2-    Tocopherol
Protein-Kinase-C-    Luteolin, tocopherol
VEGF-Inhibitor       Luteolin
Vasoconstrictor      Tyramine
Vasodilator          Arginine, Ascorbic Acid, Calcium, Fiber, histamine,
                     Isorhamnetin, Kaempferol, Luteolin, Magnesium, Niacin,
                     Potassium, Rutin, Tocopherol

   Source: U. S. Department of Agriculture, Agricultural Research Service, “Dr. Duke’s
   Phytochemical and Ethnobotanical Database” [30].

   In all, the ARS Database lists 246 separate biological activities for the
   phytochemicals found naturally in raw Nopal.

   It is important to emphasize that a major factor in DVED is the broader issue of
   diabetes itself, as manifested by failure to effectively control high blood glucose
   levels (hyperglycemia). In their paper “Diabetic Foot Disease”, Drs. Younes and
   Amad observed that:

      Uncontrolled hyperglycemia has been linked to various degrees of
      microvascular complications in both type 1 and type 2 diabetes. Persistent
      uncontrolled hyperglycemia interferes with wound healing, results in
      endothelial dysfunction and increases the risk of sepsis. Several theories have

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   been proposed to explain the effect of uncontrolled hyperglycemia, including
   glycation of proteins, increased polyol pathway flux, negative nitrogen
   balance, increased activation of protein kinase C, and increased hexosamine
   pathway flux.

   An interesting observation has been noted in primary dermal fibroblasts and
   endothelial cells, particularly in diabetes-related foot ulcers, that
   hyperglycemia interferes with the function of hypoxia-inducible factor-1, a
   transcription factor that is essential for adaptive responses of the cell to
   hypoxia. This situation will produce a status of pseudohypoxia even under
   normal oxygen tension and will interfere with the healing process of diabetes-
   related foot lesions.     In addition, hyperglycemia can result in an
   immunopathologic condition that predisposes patients with diabetes to
   infection, which is usually progressive and responds poorly to standard
   treatment. Diabetic immune disease seems to occur at the cellular level,
   where impaired leukocyte chemotaxis and impaired intracellular killing have
   been observed. Correcting glycemia has been shown to improve chemotaxis.
   Cell-mediated immune responses are also substantially impaired by elevated
   glucose concentrations. Although controversial, short term hyperglycemia
   has been suggested to affect wound healing through mechanisms related to
   negative nitrogen balance, reduced hydroxyproline content of the newly
   formed collagen, and interference with the cellular transport of vitamin C.

   It is important to remember that patients with diabetes may have an altered
   systemic response to infection, and some patients with diabetes and severe
   sepsis do not respond to the infection with elevation of body temperature or
   leukocyte count. In one study, approximately two-thirds of the patients with
   limb-threatening infection did not have temperature elevation, chills, or
   leukocytosis, and in another study, about 50% of patients lacked clinical signs
   of infection. Although the physician should not wait for these signs to develop
   in order to judge the severity of infection, their presence explicitly indicates
   the seriousness of the condition. [22]

All published studies of Nopal known to us have shown positive benefits for blood
glucose (and cholesterol) control among type 2 diabetics as noted above [26] and
such findings are consistent with our 0wn observations regarding the use of Nopal
Extract (in drug form, Nopalamine).

While the biological activities of certain of the phytochemicals found naturally in
Nopal and in Desert Bloom’s Nopal Extract as discussed above are undoubtedly
important as precursor and/or supporting systemic and local biological activities in
treating DVED, we believe there are other specific local mechanisms that are
involved which more fully account for the results observed in the case studies
described above.

In an online series titled “Nitric Oxide and its Role in Health and Diabetes”, Dr.
Thomas Burke asserts several major points that relate to DVED and the prevention
of lower extremity amputations among diabetics. Dr. Burke received his PhD in
Physiology from University of Houston, with Post Doctoral Training at Duke Medical
School, He was an Associate Professor of Medicine and Physiology at the University
of Colorado Medical School. He has authored more than 70 published scientific

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clinical articles and has been a visiting scientist at the Mayo Clinic, Yale University,
University of Alabama, and University of Florida. He is a recognized international
lecturer on cell injury and nephrology [31].

Dr. Burke’s work in this area draws substantially on pioneering work that in 1998
earned the Nobel Peace Prize in medicine for R. F. Furchgott, Louis Ignarro and
Ferid Murad. Furchgott is a pharmacologist at the New York State University Health
Science Center-Brooklyn, Ignarro is a pharmacologist at the University of California-
Los Angeles and Murad is a pharmacologist at the University of Texas Medical
School-Houston. Furchgott and Ignarro were collaborators and Murad worked
independently. Together, these three scientists are credited with discovery of the
role of Nitric Oxide in health [32]. We believe that the work of these Nobel Prize
recipients, together with Dr. Burke’s application of their discovery to diabetes and
peripheral arterial disease, diabetic neuropathy and infection, unlocks
understanding of certain mechanisms whereby the natural phytochemical
constituents found in Nopal Extract (in drug form, Nopalamine) may be effective in
avoiding the necessity of lower extremity amputations among diabetics observed in
the case examples discussed above. More specifically, how it is that Nopal Extract
(in drug form, Nopalamine) operates to ameliorate late stage effects of peripheral
arterial disease, peripheral neuropathy and infection that immediately precede

Detailed excerpts from Dr. Burke’s online series follow. Other than minor editing for
continuity and clarity, no changes were made that would alter the context or
meaning of Dr. Burke’s original material. [31]

(1) Nitric Oxide in General.

   Nitric oxide is a free radical gas that is a powerful regulator of circulation (it is an
   endogenous vasodilator) and a neurotransmitter (it helps in the processing of
   nerve signals as they cross synapses). L-Arginine, one of 20 amino acids that
   make up proteins, is the only amino acid that generates significant amounts of
   Nitric Oxide.

   The blood flow and nerve responses to Nitric Oxide are rapid. Small increases in
   Nitric Oxide lead to both vasodilation and to better sensory perception. Nitric
   Oxide metabolism is necessary for normal circulation (venous, arterial, and
   lymph flows) and for the ability to sense pain, temperature, and pressure.

   Nitric Oxide Synthase (NOS), the enzyme that generates Nitric Oxide from L-
   Arginine, exists in three different forms called isoforms. Oxygen is a cofactor for
   the activity of NOS and therefore adequate oxygen is necessary for Nitric Oxide
   production. In the absence of sufficient oxygen there is less Nitric Oxide
   produced because the enzyme NOS will not function as well as normal. All three
   isoforms of NOS require molecular oxygen in order to function appropriately.

       NOS1 is the neural (or brain) isoform, sometimes referred to as bNOS. It
       helps in synaptic transmission, the processing of nervous information from
       nerve to nerve, across gaps between the nerves called synapses, and from
       peripheral nerves to the brain.

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   NOS2 is called inducible or iNOS. This enzyme generates extraordinarily high
   concentrations of Nitric Oxide, in part to kill bacteria. When the body mounts
   an inflammatory response to injury, macrophages are attracted to the site of
   injury where they produce large amounts of Nitric Oxide (100 to 1000 times
   normal). In fact, reports suggest that wound (ulcer) fluid contains levels of
   Nitric Oxide that can only be attributed to iNOS.

   NOS3 is called ecNOS which stands for “endothelial cell” NOS. This isoform
   is active at all times (it doesn’t need to be induced as does iNOS) and is found
   in endothelial cells which are the small cells that make up capillaries and line
   every blood vessel and lymph duct in the body. EcNOS is activated by the
   pulsatile flow of blood through vessels; meaning the stretching and relaxation
   of the blood vessel wall in response to each beat of the heart. Each time the
   heart beats it leads to an acute increase in the diameter of the blood vessel,
   followed by an equally acute return to a normal diameter. This leads to a
   “shear stress” on the membrane of the endothelial cells as the column of
   blood, in the vessel moves forward and then stops. In endothelial cells, L-
   Arginine can be converted to Nitric Oxide. The Nitric Oxide diffuses into the
   smooth muscle cells that surround the endothelial lining of blood vessel cells
   causing a biologic chain of events that lead to smooth muscle cell relaxation.
   This results in more blood flow to the tissues. Nitric Oxide produced by
   ecNOS maintains the diameter of blood vessels so that perfusion of tissues
   (skin, muscle, nerves, and bone) is maintained at optimal levels. In addition,
   ecNOS mediated Nitric Oxide causes angiogenesis, which is the growth of new
   blood vessels. This is especially important in healing an ulcer or wound on the

One interesting interplay of iNOS and ecNOS is in tissue repair. Initially, Nitric
Oxide is generated from iNOS in order to ward off infection and to destroy and
remove irreversibly damaged necrotic tissue. This is often referred to as the
inflammatory stage of wound repair. This phase lasts only a short time and then
ecNOS is (or should be) mobilized to cause vasodilation and angiogenesis to
induce the healing response. Nitric Oxide will relax smooth muscle cells and thus
dilate veins, arteries, and lymphatics. This increases blood supply both to the
repairing tissues and from the damaged region. The latter removes metabolic
waste products, reduces edema, and prevents swelling that would otherwise
compress capillaries. In the absence of adequate blood supply tissue will remain
hypoxic and heal only slowly, if at all. Moreover, since iNOS is produced in large
part by white blood cells (WBC), ecNOS activated vasodilation permits delivery of
additional WBC to the area that needs to be defended from infection. There are
wounds that do become infected and often only marginal reduction of the
infection is seen even with high dose and high potency antibiotics. If the vascular
bed (arteries, veins, and lymphatics) were dilated, more of the antibiotic would
get to site of infection. Thus it is essential that ecNOS be activated to produce
Nitric Oxide. Finally, Nitric Oxide generated at physiologic levels, via ecNOS, will
suppress the activity of the enzyme iNOS. This is why there is usually only a
transient increase in iNOS activity in the normal response to wounds or tissue
damage. Clearly both ecNOS and iNOS play a role in wound healing; neither
alone is sufficient to achieve full recovery.

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   Once generated, Nitric Oxide is a gas that is a short-lived, unstable free radical
   and, within seconds of production, must become stabilized. To do so, it reacts
   with one or more elements or biologic compounds, as described below.

      First, Nitric Oxide may diffuse into smooth muscle cells and bind to an
      enzyme called guanylate cyclase (GC). This binding to GC initiates the process
      of vasodilation.

      Secondly, Nitric Oxide can interact with oxygen to form the stable nitrates and
      nitrites that are measurable in serum, urine, or saliva. Clinically, nitrates and
      nitrites reflect the status of a particular patient in producing Nitric Oxide at
      the time the measurement is made. Higher concentrations of nitrate and
      nitrite are suggestive that high amounts of Nitric Oxide have recently been

      Lastly, Nitric Oxide may bind to sulfur (S) elements that are found as a part of
      certain amino acids, such as Cysteine, and in other biologic compounds, such
      as glutathione, a well recognized anti-oxidant. This binding to S molecules
      results in the formation of nitrosothiols. (A nitrosothiol is another name for a
      compound in which Nitric Oxide is attached to sulfur). Later, the Nitric Oxide
      can be released from the nitrosothiols in hemoglobin to cause biologic
      responses such as smooth muscle cell relaxation and vasodilation.

      Hemoglobin is a protein within Red Blood Cells (RBC) and is made up of two
      alpha chains and two beta chains. Although hemoglobin is well known for its
      ability to carry oxygen to tissues, a less well-appreciated fact is that on the
      beta chain are Cysteine amino acids (which contain S) that bind Nitric Oxide
      as nitrosothiols. Thus hemoglobin carries both Nitric Oxide, which may be
      subsequently released, and oxygen.

(2) Nitric Oxide and Circulation.

   Nitric Oxide initiates and maintains vasodilation through a cascade of biological
   events that culminate in the relaxation of smooth muscle cells that line arteries,
   veins and lymphatics. While somewhat complex, the sequence of biological
   events that are triggered by Nitric Oxide is described below:

      Step 1. Nitric Oxide gas released from nitrosothiols in hemoglobin or from
      endothelial cells, diffuses into smooth muscle cells that line small blood

      Step 2.Once inside the smooth muscle cell, Nitric Oxide binds to an enzyme,
      called guanylate cyclase (GC) and this binding results in GC activation.

      Step 3. Activated GC is able to cleave two phosphate groups from another
      compound called guanosine triphosphate (GTP). This results in the formation
      of cyclic guanosine monophosphate (cGMP) that is used to phosphorylate
      proteins, including the smooth muscle contractile protein called myosin.
      Phosphorylation is the addition of a phosphate group.

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     Step 4. Once phosphorylated, smooth muscle cell myosin relaxes, resulting in
     dilation of the vessel that was originally exposed to Nitric Oxide.

     Only a limited number of GC enzymes are present in any one smooth muscle
     cell and once all the GC enzymes have been activated, additional Nitric Oxide
     will not initiate any further vasodilation. Any “extra” Nitric Oxide is simply
     sequestered as a nitrosothiol bound to hemoglobin in Red Blood Cells (RBC)
     for future use.

  Eventually the phosphate groups bound to myosin in smooth muscle cells must
  be removed to return the blood vessels to their normal diameter. This removal, or
  dephosphorylation, is accomplished by another enzyme, a phosphatase. If the
  phosphatase enzyme is inhibited, then Nitric Oxide/GC/cGMP mediated
  vasodilation will be sustained for a longer period of time. This, in fact, is the basis
  of the erectile dysfunction drug Viagra™ which inactivates the phosphatase.

  Normal vasodilation cannot occur in patients whose Nitric Oxide production or
  release and absorption into the smooth muscle tissue lining blood vessels is
  depressed. Without vasodilation, healing of ulcers will be slow, development of
  nerve damage will accelerate, and circulation to organs such as eyes, kidney,
  heart, and intestine will remain below normal. People with diabetes produce
  lower than normal levels of nitric oxide that may account for decreases in blood
  flow and a decreased capacity of blood vessels to dilate. [Sponsor’s Note: Nitric
  Oxide deficiency in diabetics is discussed in more detail below.]

(3) Nitric Oxide and Neuropathy

  Nerves communicate with one another across synapses and several biochemical
  compounds diffuse from one nerve to the second nerve. Nitric Oxide is one of
  these biochemical “neurotransmitter” molecules and is produced by both brain
  tissue and peripheral nerves.

  Nitric Oxide has both a direct and indirect effect on neurotransmission. The
  direct effect relates to permeability of nerve membranes regulating ion transport
  that is important for nerve signal transmission. Indirectly, Nitric Oxide enables
  nerves to properly function by causing increases in blood flow (vasodilation)
  allowing essential oxygen and nutrients to be transported to nerve cells.

     Direct: Dispersal of ions across the nerve cell membrane is dependent, in
     part, on transporter proteins that act as channels for ion transport. These
     channels regulate the permeability of the cell membrane. As was the case for
     the smooth muscle cell protein myosin, the contractile protein,
     phosphorylation of these channels is essential in controlling ion permeability
     of the membrane of the nerve. Physiologic changes in ion permeability
     determine the transmission of impulse along the nerve. In nerve cells, Nitric
     Oxide generates cGMP, which results in phosphorylation of a nerve cell ion
     channel that is permeable to potassium ions. Thus, Nitric Oxide must be
     present in order to regulate membrane permeability to potassium ions, which
     is necessary for nerve signal transmission. Normalization of the inadequate
     Nitric Oxide levels in diabetic patients can directly impact nerve function by
     improving nerve membrane permeability to potassium ions.

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     Indirect: Poor circulation to feet and the lower leg, results in swelling
     (edema), tissue damage, and ulcers. The lack of oxygen and nutrients also
     adversely affects nerves that also rely on oxygen and glucose to generate the
     energy source, adenosine triphosphate (ATP). ATP maintains ions such as
     potassium and sodium at normal physiologic concentrations inside and
     outside nerve cells. If oxygen and glucose delivery to nerves is impaired, then
     normal levels of ATP will not be generated. This event adversely affects
     potassium/sodium homeostasis across the membrane. The nerves will not
     receive and process information (touch, temperature) when the potassium
     and sodium ions become chronically disturbed due to the lack of sufficient
     oxygen and nutrients. In addition, bNOS found in some peripheral nerves is,
     like ecNOS, an oxygen dependent enzyme. The lack of oxygen available to the
     nerve itself would impair formation of Nitric Oxide and compromise
     neurotransmission. Nerves, like other tissues are supplied with oxygen
     through blood vessels. By inducing vasodilation and improving circulation,
     Nitric Oxide can improve nerve function by increasing available oxygen and
     glucose, thereby allowing ATP production to establish normal ion
     concentrations across the nerve cell membrane. Specifically, increased oxygen
     availability to the bNOS enzyme will improve impaired formation of neural
     Nitric Oxide and thus neurotransmission.

  In summary, Nitric Oxide has both a direct and indirect influence on
  neurotransmission. Nitric Oxide, by affecting cGMP, allows phosphorylation of
  ion channels, especially potassium channels necessary for normal transmission of
  nerve signals. Nitric Oxide also increases blood flow. This allows sufficient
  oxygen and glucose to be transported to nerve cells, positively affecting ATP
  production and, in turn, potassium/sodium homeostasis essential for
  neurotransmission. Increases in blood flow may also allow the oxygen dependent
  isoform, bNOS, to produce more Nitric Oxide.

(4) Nitric Oxide and Pain

  In addition to improving neurotransmission, Nitric Oxide functions to reduce
  pain. Nitric Oxide reduces pain directly by increasing cGMP (the mechanism by
  which opioids work), and indirectly by increasing circulation to restore normal
  membrane potential and reduce pressure on nerves due to localized edema.
  Impaired circulation often leads to swelling in the extremities, exerting pressure
  on the nerves, which also causes pain. Diffuse extremity pain is often associated
  with peripheral neuropathy. Swelling also compresses capillaries that provide
  oxygen to the nerves (and other tissues as well). Lack of adequate oxygen and
  nutrients, and the lower synthesis of ATP, adversely affects normal membrane
  potential. Under normal conditions, nerves operate at -70 mV (millivolts) and
  fire (signaling pain) at -20 mV. Due to lack oxygen and nutrients, the membrane
  potential more closely approximates -20 mV and in those circumstances it takes
  little stimuli to reach the firing threshold. Poor circulation to the nerves prevents
  them from sending the appropriate signals (for pressure and temperature) to the
  brain and often the poor circulation is first perceived as pain. Nitric Oxide, which
  increases arterial flow to nerves and venous drainage away from nerves, counters
  the effect of impaired diabetic circulation and in doing so removes the edema and

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(5) Nitric Oxide and New Tissue Growth (Wound Healing)

  Nitric Oxide is a powerful regulator of cell division and proliferation necessary for
  tissue repair, wound healing, including the regeneration of nerves. Nitric Oxide
  and its interrelationship with essential growth factors is critically involved in the
  entire continuum of events associated with wound repair, including cell division,
  maturation, neovascularization, and collagen synthesis including proper cross
  linking of collagen fibers.

  Nitric Oxide is a powerful stimulator of cell division. This is called proliferation,
  one cell into two, two into four, four into eight, and so on. For wounds to heal,
  new tissue is formed through induced division of existing cells. Several of the 10
  to 20 known growth factors are necessary to induce cell division required in
  tissue repair. Of these, epidermal growth factor and/or keratinocyte growth
  factor, which are important for re-epithelialization and wound closure, cannot
  perform their biological function without their common chemical mediator,
  Nitric Oxide. Additionally, Nitric Oxide is important in duplicating some of the
  components of the cell so that each new cell is identical to its parent.

  Proliferating cells must then differentiate into mature cells capable of responding
  to external signals. Nitric Oxide also stimulates the process of differentiation, in
  part, by regulating the formation of other proteins within the cell. One critical
  protein is the cytoskeleton, a complex network of proteins that form the internal
  structure of the cell. These cytoskeletal proteins exert many functions, one of
  which is the insertion of receptors into the cell membrane. One end of some of
  these proteins is exposed to the external environment (the interstitial fluid) and
  the other end of the protein communicates with the cell interior (the cytoplasm).
  In the absence of Nitric Oxide, cytoskeletal protein development does not occur.
  Thus, without Nitric Oxide, a cell cannot form proteins that recognize process
  and transmit information from outside of the cell to the cell interior.

  Stated another way, without cell division and receptor formation, mediated in
  part by Nitric Oxide, wound healing will not occur.

  J. V. Boykin, Jr., M.D., first suggested that Nitric Oxide-mediated wound
  vascularization was an important mechanism for impressive wound healing.
  Formation of new blood vessels, called angiogenesis, is essential for wound
  healing otherwise newly formed tissue will eventually deteriorate again due to
  lack of oxygen and nutrients. Growth factors, including vascular endothelial
  growth factor (VEGF) determine the extent of revascularization of damaged
  tissues. All growth factors bind to receptors on the cell surface and generate
  Nitric Oxide-mediated cGMP. Therefore, Nitric Oxide is a powerful and necessary
  mediator of angiogenesis.

  Fibroblasts are cells that also respond to growth factors. Nitric Oxide increases
  the number of fibroblasts (fibroblastic proliferation) and thereby enhances
  collagen formation for the healing wound. Fibroblast growth factor exists in
  several isoforms but each causes local increases in Nitric Oxide production by
  fibroblasts. Furthermore, L-Arginine availability ensures that the collagen that is
  formed is structurally similar to native collagen, i.e., that which was present prior

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to the injury to the skin. L-Arginine is absolutely necessary for the proper cross-
linking of collagen fibers to one to another, via Proline, one of metabolites of L-
Arginine metabolism. Without L-Arginine and thus Nitric Oxide and proline,
collagen cross linking is disrupted and the collagen that is formed is structurally
abnormal. Scars or poor tendon/ligament integrity are principally manifestations
of inadequate amounts of both L-Arginine and Nitric Oxide early in the healing
process brought about by fibroblasts.

In summary, Nitric Oxide is critical in many of the cellular processes involved
with wound healing. Nitric Oxide is a powerful stimulator of cell division
(proliferation) and maturation, particularly formation of appropriate cell
receptors (differentiation). Nitric Oxide is a powerful and necessary mediator of
neovascularization, i.e., the formation of new and eventually mature blood
vessels (angiogenesis) and lymph ducts to nourish the healing tissues. Nitric
Oxide increases the number of fibroblasts (fibroblastic proliferation) and thereby
enhances collagen formation for the healing wound. Lastly, L-Arginine and Nitric
Oxide are necessary for the proper cross-linking of collagen fibers to one another,
via proline, to minimize scarring and maximize the tensile strength of healed
tissue. Nerves must also "regrow" in healing tissues.

The overall implication of Nitric Oxide in wound prevention and wound healing
is summarized as follows:

   Vasodilation: The risk of developing a lower extremity ulcer in people with
   diabetes may be greatly reduced if loss of sensation due to peripheral
   neuropathy is either prevented or can be reversed. To do so, requires an
   improved blood flow. Nitric Oxide is a powerful regulator of acute
   vasodilation, both for arteries, veins, and lymphatics. The increase in blood
   flow fills capillaries that were underperfused bringing oxygen and nutrients to
   the peripheral nerves and tissue. In addition, the enhanced venous drainage
   as well as the increase in lymphatic motility helps to remove edematous fluid
   that accumulates in the wound area. The latter effects of Nitric Oxide allow
   more oxygen and nutrient delivery to the wound site and speeds the removal
   of metabolic waste products from the area. Simply put, hypoxia and ischemia
   are reversed.

   Growth factors: Increased circulation through Nitric Oxide also provides
   an increased delivery of platelets, the source of platelet-derived growth factor.
   Additionally, other growth factors and the cells that produce them will also
   have greater access to the wound area. Each of these growth factors is
   necessary for complete tissue remodeling in a healing wound.

   However, Dr. Boykin recently made an interesting observation. He noted that
   diabetic patients who didn’t heal with growth factor therapy had very low
   levels of nitrates and nitrites in their urine, whereas those that did heal had
   higher, near normal concentrations of urinary nitrates and nitrites. The
   interpretation was that failure to heal a diabetic ulcer might be related to low
   rates of Nitric Oxide production and not to the absence of sufficient growth
   factors. As Dr. Boykin pointed out, growth factors such as becaplermin, fail to
   achieve an acceleration of the wound healing process if the patient is deficient
   in Nitric Oxide. Elevation of the concentration of Nitric Oxide locally, in

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addition to simple vasodilation, facilitates the action of all growth factors in
speeding cell division to rapidly replace damaged tissue. Thus, local increase
in Nitric Oxide near the wound site will cause initial cell proliferation and
then differentiation. These cellular activities relate to all tissues involved
including blood vessels (angiogenesis), lymph ducts (lymphogenesis),
muscles, epithelial cells, and nerves.

Inflammation: Nitric Oxide will down regulate the activity of iNOS, which
produces large amounts of peroxynitrite (ONOO). INOS activity is important
to destroy injured cells, in order to prepare the site of injury for new cell
growth. However, uncontrolled activity of iNOS continues the inflammatory
process and tissue destruction. Reducing iNOS activity with small, local
amounts of Nitric Oxide will reduce shorten the inflammatory stage of wound
healing and speed the repair process.

Immune Response: It has been reported that dietary L-Arginine will
increase the concentration and activity of T-lymphocytes. This effect is likely
mediated by Nitric Oxide itself rather than by L-Arginine and thus Nitric
Oxide is considered to be a powerful mediator of immune defenses. Therefore,
in addition to Nitric Oxide mediated vasodilation that aids in the recruitment
of white blood cells which defend against bacterial infections in non-healing
ulcers, Nitric Oxide apparently strengthens the immune system, especially T-

Skin flaps: Wounds are often covered by grafts from other areas of the body.
To survive, this viable tissue must be nourished with a good blood supply. We
suspect that local elevations of Nitric Oxide in diabetic or other patients with
reduced concentrations of Nitric Oxide in their circulation would enhance the
viability of these grafts. In fact, enhanced viability of skin grafts due to Nitric
Oxide has been reported by Suzuki in Plastic Reconstructive Surgery (1998).

Cardiovascular integrity:          Diabetes is accompanied by serious
cardiovascular disease. Nitric Oxide reduces platelet adhesion so in theory,
there should be fewer atherosclerotic events. The ability of Nitric Oxide to
grow new blood vessels reduces ischemia locally and removes edematous fluid
in areas of low perfusion. Thus, the threat of clot formation, hypoxic or
ischemic injury, and swelling of tissues are all minimized by elevations of
Nitric Oxide toward normal.

Cumulative effect: Continued elevation of local Nitric Oxide availability
builds on the physiologic and biochemical effects, which were begun, with the
first dose of Nitric Oxide. It is similar to starting up a staircase, where the first
elevation of Nitric Oxide (first step) exerts positive effects on wound healing.
Subsequent Nitric Oxide is important since the wound is never again as poor
biochemically and physiologically as it was prior to the first increase in local
Nitric Oxide. The first Nitric Oxide exposure stimulates acute angiogenesis,
perhaps only one or two new capillaries. However, using the staircase
analogy, subsequent Nitric Oxide delivery to the wound site will result in the
progressive development of many new blood vessels. What starts as a modest
acute vasodilation eventually results in a well perfused, well healed tissue bed,
one in which a subsequent ulcer is very unlike to occur. This is not to say that

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     an ulcer won’t occur in another area of the body based on the underlying
     disease state.

  In summary, increased local Nitric Oxide, besides just increasing blood flow,
  oxygen, and nutrient delivery, has other secondary effects. Increased circulation
  restores the ability of cells such as fibroblasts to secrete growth factors, and Nitric
  Oxide enhances cell division so that new cells are formed faster than in the
  absence of Nitric Oxide. In addition, the increase in circulation delivers more
  white blood cells to the area so that healing and infection control can be achieved
  naturally. If needed, antibiotics are also delivered more effectively to the site of
  an infection when localized blood flow is increased. This is a remarkable series of
  outcomes, all attributed to increasing local Nitric Oxide at the treatment site.

(6) Nitric Oxide and Infection

  [Sponsor’s Note: The excerpts above describe the role of Nitric Oxide in fighting
  infection but in the context of other major topics. The following is a restatement
  of those points made by Dr. Burke above, regarding Nitric Oxide and infection.]

  NOS2, one of the three isoforms of Nitric Oxide Synthase, has a specific role in
  infection. This enzyme generates extraordinarily high concentrations of Nitric
  Oxide, in part to kill bacteria. When the body mounts an inflammatory response
  to injury, macrophages are attracted to the site of injury where they produce large
  amounts of Nitric Oxide (100 to 1000 times normal). In fact, reports suggest that
  wound (ulcer) fluid contains levels of Nitric Oxide that can only be attributed to

  NOS2 produced by macrophages is responsible, in part, for their effects to repair
  injury and to ward off infections. NOS2 is produced in large part by white blood
  cells (WBC). There are wounds that do become infected and often only marginal
  reduction of the infection is seen even with high dose and high potency
  antibiotics. If the vascular bed (arteries, veins, and lymphatics) were dilated,
  more of the antibiotic would get to the site of infection. Thus it is essential that
  ecNOS be activated to produce Nitric Oxide.

  NOS2 activity is also important to destroy injured cells and to prepare the site of
  injury for new cell growth by removing the irreversibly damaged necrotic tissue.

  NOS2 (iNOS) takes several hours to be mobilized and the response is due to an
  injury or infectious process. Unlike NOS1, which is part of normal
  neurotransmission, there must be something very abnormal (a wound, tissue
  damage, hypoxia, bacterial infection, etc.) to induce this enzyme.

  Regarding immune system response, it has been reported that dietary L-Arginine
  will increase the concentration and activity of T-lymphocytes. This effect is likely
  mediated by Nitric Oxide itself rather than by L-Arginine and thus Nitric Oxide is
  considered to be a powerful mediator of immune defenses. Therefore, in addition
  to Nitric Oxide mediated vasodilation that aids in the recruitment of white blood
  cells which defend against bacterial infections in non-healing ulcers, Nitric Oxide
  apparently strengthens the immune system, especially T-cells.

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(7) Diabetic Conditions.

   Both Type I and Type II diabetic patients have a reduced ability to generate Nitric
   Oxide from L-Arginine, reflected in part by direct measurements of plasma
   nitrate and nitrite levels lower than in normal subjects. Nitric oxide production
   by diabetic patients is often 50% or more below normal levels.

   Several factors influence nitric oxide production and metabolism. Circulation is
   notoriously impaired in diabetic patients and, with poor circulation to sites such
   as nerves and skin, not enough oxygen is available to fully activate the enzyme
   (NOS) that generates Nitric Oxide from the amino acid L-Arginine.

   Because Nitric Oxide is derived from the amino acid L-Arginine, one of the amino
   acids that make up proteins, it is clear that adequate protein intake is essential
   for Nitric Oxide production. However, simply adding more L-Arginine to the diet
   of diabetic patients may not solve the problem of low Nitric Oxide production.

      First, as part of normal metabolism of L-Arginine small amounts of a natural
      inhibitor of NOS are formed. These inhibitors do not accumulate in the blood
      because they are rapidly eliminated in the urine provided kidney function is
      normal. The major inhibitor is named asymmetrical dimethyl Arginine
      (ADMA). ADMA does, however, accumulate as kidney function declines and
      many diabetic patients lose kidney function as part of the disease process.
      Therefore, increasing dietary L-Arginine, in an attempt to increase Nitric
      Oxide production, may be counterproductive in diabetic patients with
      decreased kidney function. Reduced kidney function is a part of aging (more
      than 24% of all Americans over 65 have Type 2 diabetes) and kidney
      dysfunction, which is accelerated by diabetes, may prevent the elimination of
      the major NOS inhibitor, ADMA. In this case, the production of Nitric Oxide
      would be low because NOS activity was inhibited by ADMA. However,
      irrespective of whether or not kidney function is below normal, plasma nitrate
      and nitrite concentrations are often lower in both Type I and Type II diabetic
      patients than in normal subjects thus indicating lower levels of Nitric Oxide

      Second, Nitric Oxide is produced from L-Arginine due to the enzymatic
      activity of nitric oxide synthase (NOS). NOS is a pH (acid/base measurement)
      dependent enzyme; it is active at slightly alkaline (basic) conditions but is
      suppressed by acidotic conditions. In diabetes, glycolysis and ketoacidosis
      force pH toward acid conditions and this may account, in part, for the reduced
      production of Nitric Oxide since a slightly basic pH is ideal for NOS enzymatic

   In diabetic patients, ecNOS activity is often well below normal (due to diminished
   vascular pulsative action) so these patients cannot produce Nitric Oxide at
   normal levels. In diabetic patients, with low production of Nitric Oxide from
   ecNOS, iNOS may not be inhibited and iNOS mediated Nitric Oxide production
   may remain high well beyond its intended time. This could contribute to
   continuous and uncontrolled tissue destruction, thereby slowing the healing

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Impaired circulation often leads to swelling in the extremities, exerting pressure
on the nerves, which also causes pain. Nitric Oxide mediated increases in cGMP
may be impaired limiting its ability to directly reduce neuropathic pain.

Some may ask whether it isn’t “too much” vasoconstriction rather than “too little”
vasodilation that characterizes poor perfusion in people with diabetes? In normal
subjects, the control of perfusion involves several vasoconstrictor hormones and
activation of sympathetic nerves, which together cause vasoconstriction. To
induce vasodilation, the body must reduce these biologic responses or counter
them with vasodilators such as Nitric Oxide (or a prostaglandin called
prostacyclin). Therefore, in the absence of normal concentrations of Nitric Oxide,
even normal levels of vasoconstrictive hormones or nervous activity results in
abnormally low blood flow (vasoconstriction and its effect to reduce tissue
perfusion). One does not need to implicate “too much” vasoconstrictive activity
(via hormones or nerves) as a cause of perfusion problems in people with
diabetes, although this certainly can be a contributing factor in some instances.
Nitric Oxide is the most important of the body’s countermeasures against normal
vasoconstriction and, if production or release of Nitric Oxide is impaired, as in
the case of people with diabetes, poor circulation, and all the consequences
thereof, ensues.

In diabetic patients, atherosclerotic disease often occludes a portion of a vessel so
that the endothelial cells are not able to properly absorb Nitric Oxide. If the
endothelial cell can’t take up L-Arginine, then Nitric Oxide synthesis will be
impaired. Moreover, if atherosclerotic disease is present, oxygen delivery to all
cells is impaired and molecular oxygen is one of the cofactors needed by the
enzyme to generate Nitric Oxide from L-Arginine. Tissues that are hypoxic
(deprived of good, normal circulation) can not produce as much Nitric Oxide as
do normal, well oxygenated tissues. Thus an initial period of hypoxia leads to
declines in Nitric Oxide production and less and less blood flow over time, a
viscous cycle to say the least. It is no wonder that diabetes is a progressive disease
with wounds, kidney, heart, and eye disease becoming worse and worse over
time. The key to slowing this progressive deterioration is to delay the decrease in
blood flow, or if possible, to restore it back toward normal levels.

Peripheral nerve damage, Diabetic Peripheral Neuropathy (DPN), is a common
complication of diabetes. Almost 70% of people with diabetes develop DPN
within 5 years and after 5 years the incidence rate increases to almost 100%. DPN
most often begins as a tingling feeling and insidiously progresses to loss of
sensation to hot and cold and to pressure. Additionally, DPN sometimes
manifests itself as diffuse pain in the extremities. DPN is uncomfortable, may
lead to poor balance and higher risks of falls, and is dangerous to those who have
it. We have all come in contact with people with insensate feet who have
developed ulcers because they did not sense poorly fitting shoes or unexpected
foreign objects.

On October 17, 2001, the Centers for Medicare and Medicaid Services (formerly
HCFA) in Decision Memorandum CAG 00059 characterized DPN with loss of
protective sensation (LOPS) as a localized illness of the foot and the most
important factor leading to amputation in people with diabetes. Diagnostically,
this Decision Memorandum states that DPN with LOPS is determined by

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insensitivity to a Semmes Weinstein 5.07 Monofilament at 2 sites on the bottom
of the foot.

The causation of DPN is debated among researchers and clinicians in the field.
One theory is that progressive loss of circulation to the peripheral nerves is the
cause of DPN. Another theory is that DPN is due to nerve dysfunction possibly
due to accumulation of sorbitol (sugar molecules) in peripheral nerves. According
to the NIDDK (Peripheral Neuropathy: The Nerve Damage of Diabetes), other
researchers believe that lack of nitric oxide or poor nitric oxide metabolism may
be the culprit.

People with diabetes experience elevated glucose levels. Some of this glucose
becomes incorporated into hemoglobin and is measured as glycosylated
hemoglobin (Hgb) or HgbA1C. Glycosylated hemoglobin binds Nitric Oxide in the
form of nitrosothiols very tightly so that any Nitric Oxide that is formed cannot
be easily released from RBC to help maintain blood flow through smooth muscle
cell relaxation.

The American Diabetes Association, based on the 10-year study of 1,441 patients
with IDDM, recommends that tight glucose control is one of the best ways to
delay the onset or progression of DPN. Tight glucose control may delay the onset
of LOPS in DPN, by decreasing the accumulation of sorbitol within the nerves
themselves. Reducing serum glucose levels also lowers the concentration of
glycosylated hemoglobin (HbA1c). When HbA1c is elevated, the Nitric Oxide that
is present in red blood cells is not easily released to promote vasodilation and
increased blood flow. This may account, in part, for very low blood flow to the
nerves of the feet and, thus to the symptoms of DPN.

Reduced production and higher than normal binding, may be partly responsible
for the poor circulation in diabetic patients and would be one of the reasons for
their high propensity to develop an ulcer.

In view of the risks associated with DPN, either slowing its progression or,
hopefully, reversing its course, is a worthwhile clinical goal.

Many diabetic patients receive diuretics for kidney or cardiovascular disease.
Diuretics may cause problems with potassium and magnesium metabolism.
Magnesium is a regulator of intracellular calcium which itself is a co-factor for
NOS activity. Magnesium also helps regulate intracellular potassium content and
the excretion of potassium by the kidney. Importantly, potassium imbalance also
affects transmembrane potential in nerves. Addressing these possible co-morbid
factors in a diabetic ulcer, may speed the healing of an otherwise slow healing
wound. Clearly, the sensation of pressure, temperature, balance, and pain can be
adversely affected unless the possible effects of diuretic usage are considered by
the healthcare professional in the overall approach to diabetic ulcer management.

It is not clear yet whether, in diabetic patients, low L-Arginine intake, acidosis,
low oxygen, or accumulation of ADMA, or all of these are responsible for the
decreased production of Nitric Oxide, reflected by low urinary nitrate and
nitrites. Most likely, all these events are occurring simultaneously.

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In conclusion, we recognize that research continues in the field of nitric oxide every
day and that, in the future, targeted pharmaceutical drugs might be developed to
locally increase nitric oxide.

Source: “Nitric Oxide and its Role in Health and Diabetes”, Thomas Burke, PhD,
http://diabetesincomtrol.com/anodyne/burkeseries.php. [31]

To Dr. Burke’s analysis, we would add the following:

   First, Dr. Burke notes that in order for Nitric Oxide and its co-factors to
   commence their work, they must be deliverable, together with oxygen, to the site
   that has become affected by DVED. This would likely involve or require at least a
   marginal improvement in vascular circulation sufficient to initiate the local
   generation or release of Nitric Oxide, in the progressive “stair-step” fashion noted
   by Dr. Burke. As noted by Dr. Burke: “Small increases in Nitric Oxide lead to
   both vasodilation and to better sensory perception.” “What starts as a modest
   acute vasodilation eventually results in a well perfused, well healed tissue bed.”
   “Once Nitric Oxide is made available and local blood flow (both arterial perfusion
   and venous return) is increased, ulcers heal faster and sensory and other nerve
   functions improve toward normal (All these events occur through the effect of
   nitric oxide to elevate cGMP and the phosphorylation events that follow).” Based
   upon observed results, we believe that Nopal Extract (in drug form, Nopalamine)
   contains a combination of phytochemical compounds that act synergistically to
   effect the starting point improvement needed in vascular circulation to generate
   and distribute higher levels of Nitric Oxide. These phytochemicals include
   Arginine, Ascorbic Acid, Calcium, Fiber, Histidine, Isorhamnetin, Kaempferol,
   Luteolin, Magnesium, Niacin, Potassium, Rutin and Tocopherol; all of which
   have vasodilation as an indicated biological activity [30]. Dr. Richard E.
   Klabunde, PhD, in his paper titled “Cardiovascular Physiology Concepts”, states
   that “shearing forces acting on the vascular endothelium generated by blood flow
   causes release of calcium and subsequent cNOS activity. Therefore, increases in
   blood flow stimulate NO [Nitric Oxide] formation (flow-dependant NO
   formation).” [33] Furthermore, Nopalamine provides a natural source of the
   amino acid Arginine from which Nitric Oxide is generated [28, 29 and 30].

   Second, Dr. Burke notes that impaired kidney function is present in many
   diabetics and can compromise elimination by the kidney of the NOS inhibitor
   ADMA. The National Diabetes Clearinghouse (NDIC) and the American Diabetes
   Association note that “lowering blood pressure can reduce the decline in kidney
   function by 30 to 70 percent” and that “Treatment with ACE inhibitors and
   Angiotensin Receptor Blockers (ARBs) are more effective in reducing the decline
   in kidney function than other blood pressure-lowering drugs.” [10,11] Nopal (and
   Nopalamine) contains ACE inhibitors Quercitrin and Zinc and ARBs Ascorbic
   Acid, Fiber and Potassium; as well as other phytochemicals (shown above in the
   chart on Phytochemicals and Biological Activities) that have cardio-vascular
   biological activities. [30] Dr. Burke also notes that many diabetics receive
   pharmaceutical diuretics for their kidney or cardiovascular disease and that these
   diuretics may interfere with the metabolism of Potassium and Magnesium,
   thereby adversely affecting NOS activity. Nopal (and Nopalamine) contains 9
   phytochemicals (also shown on the chart above) that have natural non-
   pharmaceutically compounded diuretic biological activity.

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   Therefore, with respect to the three cases described above, if impaired kidney
   function was present as a complication of diabetes, Nopalamine may have had
   the effect of offsetting some unknown level of impaired kidney function, thereby
   facilitating improved generation and effective distribution of Nitric Oxide.

   Third, Dr. Burke notes that NOS, the enzyme needed to release Nitric Oxide
   from Arginine, is active at slightly alkaline (basic) conditions but is suppressed by
   acidotic conditions and that in diabetics, ketoacidosis may force PH toward acid
   conditions and that this may in part account for reduced NO production. A Mayo
   clinic paper titled “Diabetic Ketoacidosis” states that ketoacidosis is a serious
   complication of diabetes in which insufficient insulin production or inadequate
   insulin therapy results in high blood glucose and buildup of ketones in the blood
   and that the main risk factor for this condition is type 1 (insulin dependant)
   diabetes, usually among persons younger than 19 years of age. Further, that
   Ketoacidosis is treatable by fluid replacement (for dehydration), electrolyte
   replacement and intravenous insulin therapy [34]. Accordingly, given that the
   pathological conditions underlying DVED have progressed over a period of years
   primarily among type 2 diabetics and the resulting LEAs occur primarily among
   persons over 40, it is doubtful that ketoacidosis is a factor in suppressing Nitric
   Oxide production among the vast majority of persons having DVED.

   Fourth, as noted above, blood glucose control, which is not directly addressed by
   Nitric Oxide, is also an important factor in DVED [22] that is addressed by
   Nopalamine, as reflected in the hospital clinical studies cited above [26], as
   reported to us by individuals using the Nopal Extract and as further indicated by
   the biological activities of certain of the phytochemicals present in Nopal (and
   Nopalamine) as reported by ARS [30].

Our conclusion is that the phytochemical components of Nopalamine (including but
not limited to Arginine the primary source of Nitric Oxide) work synergistically to
control blood glucose, initiate vasodilation and blood flow and provide or stimulate
Nitric Oxide mediated mechanisms within the human body as described above; the
effects of which have been observed to be a potentially effective alternative to lower
extremity amputations among diabetics.

Accordingly, our scientific rationale for use of Nopal Extract (in drug form,
Nopalamine) to treat DVED is based (1) on observations of its effective use by
individuals actually affected by DVED and (2) on theory supported by available
scientific information regarding the underlying conditions that cause DVED and are
the basis for diabetic-related LEAs, (3) on the known phytochemical contents of
Nopal Extract (in drug form, Nopalamine) and their cited systemic and local
biological activities that relate to the pathological conditions that underlie DVED, in
particular, biological activities that include blood glucose regulation, circulation
(vasodilation), neurotransmission, angiogenesis and response to infection and (4) on
the particular role of Arginine (present in Nopalamine) as a generator of Nitric Oxide
and its metabolism, which impacts all three of the underlying pathological
conditions that constitute DVED and that ordinarily result in LEAs.

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Symptoms for use of Nopalamine to treat DVED are:

   •   Diagnosis of diabetes and indications of and/or a patient history of ineffective
       blood sugar management, and

   •   Evidence of the presence of advanced peripheral arterial disease (PAD) as
       determined by physician examination and or pulse measurements taken in a
       lower extremity indicating lack of circulation, and/or

   •   Evidence of the presence of advanced peripheral neuropathy (PN) as
       determined by physician examination and/or pressure sensitivity testing of a
       lower extremity indicating loss of pain sensation, and/or

   •   Presence of ulceration or nontraumatic wound of a lower extremity and
       failure to heal properly with medication,

   •   Presence of infection in a lower extremity that may have become unresponsive
       to treatment with antibiotics.


While it is true that much research remains to be done to clearly establish the nexus
between the observed effects of the use of Nopal Extract (in drug form, Nopalamine)
and the underlying mechanisms responsible for such effects, and to determine more
specifically the range of patient conditions under which Nopalamine can be
predictably effective and to what extent, we at Desert Bloom are firmly convinced
that sufficient scientific rationale exists to support further investigation and
development of Nopalamine as a drug treatment alternative to lower extremity
amputations among diabetics affected by DVED and we are committed to that

Pending the initiation of true clinical trials approved by FDA, observation of the use
of Nopal Extract by diabetics faced with a possible lower extremity amputation, is
continuing. Additionally, the Korean equivalent of the U.S. Veteran’s Administration
recently announced that it is commencing government sponsored testing of the
Nopal Extract among Korean Veterans for diabetes and for lower extremity
amputational conditions (i.e. DVED).


As stated at the beginning of this paper, Nopalamine has not been approved by the
United States Food and Drug Administration (FDA) as a drug product to diagnose,
treat or cure any disease. Clinical trials to test the safety and effectiveness of
Nopalamine for the treatment of Diabetic Vasoneural Disease (DVED), as such term
is defined herein, in accordance with FDA standards, requirements and guidelines,
are scheduled to commence in the near future. At the present time, no claim may be
made by any party regarding the use of Nopal Extract or Nopalamine for the
treatment of DVED or for the diagnosis, treatment, cure or prevention of any other

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1   “Mortality in Diabetic and Nondiabetic Patients After Amputations Performed From
    1990 to 1995, a 5-year follow-up study, Nicholas Teutolouris, MD, Sameer Al-
    Sabbagh, MRCP, Michael G. Walker, MD, FRCS, Andrew Boulton, MD, MRCP and
    Edward B. Jude, MD, FRCP, University of Manchester, Department of Medicine,
    Manchester Royal Infirmary, U.K., Diabetes Care 27: 1598-1604, 2004.

2 “Mortality and Hospitalization in Patients After Amputation”, a comparison between
  patients with and without diabetes, Christopher J. Schofield, MB, CHB, Gillian
  Libby, MSC, Geraldine M. Brennan, MB, BCH, Ritchie R. MacAlpine, BSC, Andrew
  D. Morris, MD, Graham P. Leese, MD, Diabetes Care 29: 2252-2256, 2006.

3 “Hospital Discharge Rates for Nontraumatic Lower Extremity Amputations by
   Diabetic Status – United States, 1997”, The Centers For Disease Control, MMWR
   Weekly, March 2, 2001/50/(43); 954-8.

4 “Reamputation, Mortality, and Health Care Costs Among Persons with Dysvascular
   Lower-limb Amputations”, TR Dillingham, LE Pezzin, AD Shore, Department of
   Physical Medicine, Medical College of Milwaukee, Wisconsin.
  http://www.ncbi.nlm.nih.gov/sites/entrez. (search on Title or Author)

5 “Cost of Diabetes-related Amputations in Minorities”, HR Ashry, LA Avery, DG
   Armstrong, WH Van Houtum, Department of Orthopaedics, University of Texas
   Health Science Center, San Antonio, Texas.
  http://www.ncbi.nlm.nih.gov/sites/entrez. (search on Title or Author)

6 “Complications of Diabetes in the Unites States”, American Diabetes Association.

7 “National Diabetes Statistics”, National Diabetes Information Clearinghouse

8 “Management of the Diabetic Foot: Preventing Amputation”, Marvin E. Levin, MD,
   Southern Medical Journal 95 (1): pp 10-20, 2001.

9 “Identifying Cause for Advancement to Amputations in Patients with Diabetes: The
  Role of Medical Care and Patient Compliance”, Taffney Nash, James W. Beliew, Ed,
  PT, Marshall Cunningham, MD, Joseph McCulloch, PhD, PT, Wounds. 2005; 17 (2):

10 “Gangrene”, Medline Plus – Medical Encyclopedia.
    http://www.nlm.nih.gov/medlineplus (Click on “Medical Encyclopedia, Click on
    alphabet letter “G” then select “Gangrene”)

11 “Gangrene”, Health Square.

12 “Gas Gangrene”, Jason K. Wong, January 2006, E Medicine.

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13 “Gas Gangrene and Related Clostridial Wound Infections”, Medical Microbiology,
    University of Texas Medical Branch at Galveston.

14 “Alpha Toxin”, Wikipedia Encyclopedia.

15 “Gas Gangrene”, Medline Plus – Medical Encyclopedia.
   http://www.nlm.nih.gov/medlineplus (Click on “Medical Encyclopedia, Click on
    alphabet letter “G” then select “Gas Gangrene”)

16 “Diabetic Foot Infections”, Burke A. Cunha, MD, MACP, Professor of Medicine, State
   University of New York, Chief, Infectious Disease Division, Winthrop University
   Hospital, E Medicine.

17 “Diabetes Overview”, National Diabetes Information Clearinghouse (NDIC).

18 “Diabetes Foot Care”, Medline Plus – Medical Encyclopedia.
   http://www.nlm.nih.gov/medlineplus (Click on “Medical Encyclopedia, Click on
   alphabet letter “D-Di” then select “Diabetes Foot Care”)

19 “Stratification of Foot Ulcer Risk in Patients With Diabetes: A Population-Based
   Study”, G.P. Leese, F. Reid, R. McAlpine, S. Cunningham, A. M. Emslie-Smith, A. D.
   Morris, B. McMurray, A. C. Connacher, International Journal of Clinical Practice,
   2006; 60(5):541-545.

20 “Amputations of the Lower Extremity”, Janos P. Ertl, MD, Department of
   Orthopedic Surgery, University of California at Davis, James K. DeOrio, MD,
   Department of Orthopedics, University of Oklahoma, James W. Pritchett, MD,
   FACS, Orthopedic Surgery and Sports Medicine, University of Washington, School of
   Medicine, E Medicine.

21 “Surgical Treatment of Diabetes Foot Complications: Clinical Review”, Timothy
   Daniels, MD, FRCSC, Eran Tamir, MD, Genetics Aging. 2006;9(7):499-504.

22 “Diabetic Foot Disease”, Nidal A. Younes, MD, MS, Azmi Ahmad, MD,
   Endocrinology Practice, 2006;12(5): 583-592.

23 “Necrotizing Fascistic and Related Soft Tissue Infections”, Rashid Net University.

24 “Diabetic Foot Infection Classification System Validated”, Laura Barclay, MD,
   Charles Vega, MD, FAAFP, Medscape, February 2007.

                                  Desertbloom Home Page

25 “Gangrene”, BBC Health.
   http://www.bbc.co.uk/health/conditions/ (Click on alphabet letter “G” then select

26 “Hospital and University Studies of Nopal”, PubMed.
   http://www.ncbi.nlm.nih.gov/sites/entrez. (search on PMID#)

27 “Treating Type II Diabetes Nutritionally”, C. Leigh Broadhurst, PH.D., Nutrition
   Science News, July 1998.

28 U. S. Department of Agriculture, Agricultural Research Service, 2007, USDA
   National Nutrient Database for Standard Reference.
  http://www.nal.usda.gov/fnic/foodcomp/search/ (Search on Nopal)

29 “Desert Bloom Pure Nopal Extract Platinum Exp. 01/05/07”, FPL Sample #0527015,
   Food Products Laboratory, Inc., Portland, Oregon.

30 U. S. Department of Agriculture, Agricultural Research Service, “Dr. Duke’s
   Phytochemical and Ethnobotanical Database”.

   http://sun.ars-grin.gov:8080/npgspub/xsql/duke/pl_act.xsql?taxon=676 (Nopal)
   http://www.ars-grin.gov/duke/chem-activities.html (Search o Chemical Name)

31 “Nitric Oxide: It’s Role in Diabetes, Peripheral Neuropathy and Wound Healing”,
   Thomas Burke, PhD, Diabetes in Control.Com.

32 “U. S. Discoverers of Viagra Principle Get Nobel Prize”, CNN Interactive News,
   October 12, 1998.

33 “Cardiology Physiology Concepts - Nitric Oxide”, Richard E. Klabunde, PhD.

34 “Diabetic Ketoacidosis”, Mayo Clinic.
   http://www.mayoclinic.com/ (Search on Diabetic Ketoacidosis in Mayo search bar)

                                   Desertbloom Home Page


The study abstracts below regarding the use of Nopal are based on the utilization of raw
and cooked Nopal pads. Several sub-species of Nopal were tested; including Ficus-
Indica, Streptacantha-Lemaire, Fulignosa, etc. All are members of the Opuntia family
and have essentially the same phytochemical composition. See citation #26 in the
References above for the source of the abstracts shown below.


Hypoglycemic Effect of Opuntia Streptacantha Lemaire in NIDDM

Frati-Munari AC, Gordillo BE, Altqmirano P, Ariza CR. Department of Internal
Medicine, Hospital de Especialidades del Centro Medico La Raza, Instituto Mexicano
del Seguro Social, Mexico D.F.

To assess the hypoglycemic effect of the Nopal Opuntia Streptacantha Lemaire (a
spineless species of Nopal), three groups of patients with non-insulin-dependent
diabetes mellitus (NIDDM) were studied. Group one (16 patients) ingested 500 g of
broiled Nopal stems. Group 2 (10 patients) received only 400 ml of water as a control
test. Three tests were performed on group 3 (6 patients): one with Nopal, a second with
water, and a third with ingestion of 500 g broiled squash. Serum glucose and insulin
levels were measured at 0, 60, 120, and 180 min. After the intake of O. Streptacantha
Lem., serum glucose and serum insulin levels decreased significantly in groups 1 and 3,
whereas no similar changes were noticed in group 2. The mean reduction of glucose
reached 17.6% (+/- 2.2% of basal values) at 180 min in group 1 and 16.2% (+/- 1.8%) in
group 3; the reduction of serum insulin at 180 min reached 50.2% (+/- 8.0%) in group 1
and 40.3% (+/- 12.4%) in group 3. This study shows that the stems of O. Streptacantha
Lemaire cause a hypoglycemic effect in patients with NIDDM. The mechanism of this
effect is unknown, but increased insulin sensitivity is suggested.
Source: PMID: 3276479

Influence of Nopal intake upon fasting glycemia in type II diabetics and
healthy subjects.

Frati AC, Gordillo BE, Altamirano P, Ariza CR, Cortes-Franco R, Chavez-Negrete A,
Islas-Andrade S. Departamento de Medicina Interna y Medicina Nuclear, Hospital de
Especialidades del Centro Medico La Raza, Instituto Mexicano del Seguro Social, D.F.

To assess if the acute hypoglycemic effect of Nopal, which occurs in diabetic patients,
also appears in healthy individuals, 500 g of Nopal stems (O. Streptacantha Lem.) were
given orally to 14 healthy volunteers and to 14 patients with NIDDM. Serum glucose and
insulin levels were measured at 0, 60, 120 and 180 minutes after Nopal ingestion. A
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control test was performed with the intake of 400 ml of water. The intake of Nopal by
the NIDDM group was followed by a significant reduction of serum glucose and insulin
concentration reaching 40.8 + 4.6 mg/dl (n = 14) (mean+SEM) and 7.8 + 1.5 uU/ml (n
= 7) less than basal value, respectively, at 180 minutes. (P less than 0.001 vs control
test). No significant changes were noticed in the healthy group as compared with the
control test (P greater than 0.05). Acute hypoglycemic effect of Nopal was observed in
patients with NIDDM but not in healthy subjects, thus the mechanisms of this effect
differs from current hypoglycemic agents.
Source: PMID: 1668138

A purified extract from prickly pear cactus (Opuntia fulignosa) controls
experimentally induced diabetes in rats.

Trejo-Gonzalez A, Gabriel-Ortiz G, Puebla-Perez AM, Huizar-Contreras MD, Munguia-
Mazariegos MR, Mejia-Arreguin S, Calva E. Department of Biotechnology, CIIDIR-IPN,
Jiquilpan, Michoacan, Mexico.

The hypoglycemic activity of a purified extract from prickly pear cactus (Opuntia
fulignosa) was evaluated on STZ-induced diabetic rats. Blood glucose and glycated
hemoglobin levels were reduced to normal values by a combined treatment of insulin
and Opuntia extract. When insulin was withdrawn from the combined treatment, the
prickly pear extract alone maintained normoglycemic state in the diabetic rats. The
blood glucose response to administered glucose also showed that the rats receiving the
combination treatment of insulin and Opuntia extract for 7 weeks followed by Opuntia
extract alone were capable of rapidly returning blood glucose to the levels of the
nondiabetic rats. Although the mechanism of action is unknown, the magnitude of the
glucose control by the small amount of Opuntia extract required (1 mg/kg body weight
per day) preclude a predominant role for dietary fiber. These very encouraging results
for diabetes control by the purified extract of this Opuntia cactus make the need for
clinical studies in humans evident.
Source: PMID: 9121164

Hypoglycemic action of different doses of Nopal (Opuntia Streptacantha
Lemaire) in patients with type II diabetes mellitus]

Frati-Munari AC, Del Valle-Martinez LM, Ariza-Andraca CR, Islas-Andrade S, Chavez-
Negrete A.

To assess the relationship between the doses of Opuntia Streptacantha-Lem. and its
acute hypoglycemic action in diabetics, eight patients with type II diabetes mellitus were
studied. Four test were performed to each patient with the intake of: (a) 400 ml of
water, (b) 100 g (c) 300 g and (d) 500 g of broiled stems of Opuntia Streptacantha-Lem.
Serum glucose was measured at 0, 60, 120 and 180 minutes. Maximal decrease of serum
glucose was noticed at 180 minutes, with a mean of 2.3, 10, 30.1 and 46.7 mg/dl less
than basal value with 0, 100, 300 and 500 g respectively (P = NS, less than 0.05, less
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than 0.001 and less than 0.001 respectively). A significant direct correlation (r = 0.690,
P less than 0.001) was noticed between the doses and the hypoglycemic effect.
Source: PMID: 2557805

Prickly pear (Opuntia sp.) pectin alters hepatic cholesterol metabolism
without affecting cholesterol absorption in guinea pigs fed a
hypercholesterolemic diet.

Fernandez ML, Lin EC, Trejo A, McNamara DJ. Department of Nutritional Sciences
University of Arizona, Tucson.

Prickly pear pectin intake decreases plasma LDL concentrations by increasing hepatic
apolipoprotein B/E receptor expression in guinea pigs fed a hypercholesterolemic diet.
To investigate whether prickly pear pectin has an effect on cholesterol absorption and
on enzymes responsible for hepatic cholesterol homeostasis, guinea pigs were fed one of
three semi purified diets, each containing 15 g lard/100 g diet: 1) the lard-basal diet with
no added cholesterol or prickly pear pectin (LB diet); 2) the LB diet with 0.25 g added
cholesterol/100 g diet (LC diet); or 3) the LC diet containing 2.5 g prickly pear
pectin/100 g diet, added at the expense of cellulose (LC-P diet). Animals fed the LB diet
had the lowest plasma LDL and hepatic cholesterol concentrations, followed by animals
fed the LC-P diet (P < 0.001). Hepatic 3-hydroxy-3-methylglutaryl CoA (HMG-CoA)
reductase activity was highest in the group fed the LB diet, with similar values for
animals in the other two groups. A positive correlation existed between plasma LDL
cholesterol concentration and hepatic acyl CoA: cholesterol acyltransferase activity (r =
0.87, P < 0.001). Cholesterol absorption was not different among the three dietary
groups. These results indicate that the decreased plasma and hepatic cholesterol
concentrations of animals fed prickly pear pectin are not explained by differences in
cholesterol absorption but rather are due to mechanisms that alter hepatic cholesterol
homeostasis, resulting in lower plasma LDL concentrations.
Source: PMID: 8207539

Prickly pear (Opuntia sp.) pectin reverses low-density lipoprotein receptor
suppression induced by a hypercholesterolemic diet in guinea pigs.

Fernandez ML, Lin EC, Trejo A, McNamara DJ. Department of Nutrition and Food
Science, University of Arizona, Tucson.

The effects of prickly pear pectin on plasma LDL metabolism were investigated by
feeding guinea pigs either a diet containing 15 g/100 g lard and 0.25 g/100 g cholesterol
(LC diet) or the LC diet in which cellulose was partially replaced (2.5 g/100 g) by prickly
pear pectin (LC-P diet). The LC-P diet lowered plasma LDL cholesterol concentrations
by 33% (P < 0.001). Low-density lipoprotein composition was modified by intake of
prickly pear pectin; the relative percentages of free and esterified cholesterol were lower
and triglycerides were higher in LDL from animals fed the LC-P diet (P < 0.05). Intake
of prickly pear pectin did not affect hepatic 3-hydroxy-3-methylglutaryl coenzyme A
reductase activity; however, hepatic free and esterified cholesterol concentrations were
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lowered by 46 and 64%, respectively. Hepatic apolipoprotein B/E receptor expression
(Bmax) was 60% higher in animals fed the LC-P diet (P < 0.01). Similar to the in vitro
data, receptor-mediated LDL fractional catabolic rates were 190% higher in animals fed
the LC-P diet (P < 0.05), whereas apolipoprotein LDL flux rates were not affected.
Apolipoprotein LDL pool size and fractional catabolic rates exhibited a significant
correlation (r = -0.52, P < 0.01). These data indicate that an increase in apolipoprotein
B/E receptor expression is a major metabolic response by which intake of prickly pear
pectin decreases plasma LDL concentrations.
Source: PMID: 1333520

Pectin isolated from prickly pear (Opuntia sp.) modifies low-density
lipoprotein metabolism in cholesterol-fed guinea pigs.

Fernandez ML, Trejo A, McNamara DJ. Department of Nutrition and Food Science,
University of Arizona, Tucson.

The effect of prickly pear soluble fiber on low density lipoprotein (LDL) metabolism was
investigated by feeding male guinea pigs either a no purified diet containing 0.25%
cholesterol (HC diet) or the HC diet + 1% prickly pear pectin (HC-P diet). Plasma
cholesterol levels were significantly decreased by the HC-P diet, with a 33% decrease in
LDL levels (p less than 0.02) and an increase in LDL density. Hepatic free and esterified
cholesterol levels were reduced 40 and 85%, respectively (p less than 0.002), by the HC-
P diet. Hepatic microsomal 3-hydroxy-3-methylglutaryl coenzyme A reductase levels
were not different. 125I-LDL binding to hepatic membranes was increased 1.7-fold by
the HC-P diet (p less than 0.001), with receptor affinity (Kd) being unaltered and
receptor number (Bmax) being significantly increased (p less than 0.001). These data
suggest that prickly pear pectin may act by a mechanism similar to that of bile acid-
binding resins in lowering plasma cholesterol levels. The observed reduction in LDL and
hepatic cholesterol levels and increase in LDL density and hepatic apolipoprotein B/E
receptors are responses suggesting an increased demand on hepatic cholesterol from
increased excretion of bile acids and interruption of the enterohepatic circulation.
Source: PMID: 2231018

Effect of raw and cooked Nopal (Opuntia ficus indica) ingestion on growth
and profile of total cholesterol, lipoproteins, and blood glucose in rats

Cardenas Medellin ML, Serna Saldivar SO, Velazco de la Garza J. Instituto Tecnologico
y de Estudios Superiores de Monterrey, Mexico.

Two different concentrations (approx. 6 and 12%) and two presentations (raw and
cooked) of dehydrated Nopal were fed to laboratory rats and growth and serum total
cholesterol, lipoprotein profile and glucose determined. Samples of raw and cooked
Nopal were chemically characterized for moisture, protein, ash, crude fiber, ether
extract, total dietary fiber, reducing sugars, amino acids, minerals and gross energy.
Cooking slightly affected some of the nutrients analyzed. After one month feeding, blood
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                                                                         Appendix A

was withdrawn via intracardiac puncture and serum glucose, total cholesterol, HDL,
LDL, and VLDL were determined. Rats fed 12% Nopal had lower weight gains (P < 0.05)
when compared with counterparts fed 6% Nopal or the control diet. Consumption of
Nopal did not affect (P > 0.05) glucose, total cholesterol and HDL cholesterol levels.
However, rats fed raw Nopal at the 12% concentration level had a 34% reduction in LDL
cholesterol levels; thus, it was concluded that raw Nopal had a potentially beneficial
effect for hypercholesterolemic individuals.
Source: PMID: 10347696

                     Other Studies (Spanish language Only)

Studies on the mechanism of "hypoglycemic" effect of Nopal (Opuntia sp.)

Frati-Munari AC, Yever-Garces A, Islas-Andrade S, Ariza-Andraca CR, Chavez-Negrete
Source: PMID: 3307675

Effects of Nopal (Opuntia sp.) on serum lipids, glycemia and body weight

Frati-Munari AC, Fernandez-Harp JA, de la Riva H, Ariza-Andraca R, del Carmen
Torres M.
Source: PMID: 6314922

Decreased blood glucose and insulin by Nopal (Opuntia sp.)

Frati-Munari AC, Fernandez-Harp JA, Banales-Ham M, Ariza-Andraca CR.
Source: PMID: 6367685