1. 1 Human Intervention Study From Report of the EU reviewers (Midterm review 14-02-2002, Brussels) “The human studies need careful thought otherwise there is a danger of the project appearing to have failed simply because it did not provide the hoped for cure for heart disease and cancer”

2. 2 Human Intervention Study History - Garlic would influence lipid metabolism / atherosclerosis - Proposed study: - 2 * 24 apparently healthy subjects with increased risk (mildly hypercholesterolemic, smoking) - parallel trial (24 garlic / 24 placebo) - biochemical measures lipid metabolism / inflammation

3. 3 Human Intervention Study Current situation: - No indications that ‘garlic’ influences lipid metabolism  (human) intervention study without rationale is unethical; previous proposal not feasible - New situation requires evaluation; other type of intervention study

4. 4 Human Intervention Study Considerations: - Indications that ‘garlic’ may influence inflammation - Cardiovascular disease (atherosclerosis; AS) shares common features with inflammation; CRP is primary endpoint - Current treatment strategies for AS also focus on inflammation (for example: lipid lowering drugs; statins)

5. 5 Human Intervention Study Garlic and Inflammation/Atherosclerosis -parallel design; 3 groups (n=30); risks groups; high doses!! 1.garlic powder (Kwai / EU??) 2.aged garlic extract (Kyolic??) 3.control power = 0.87- 0.72 for 30 - 25% CRP-reduction

6. 6 Human Intervention Study - Garlic powder (Kwai / EU??) - all compounds present in fresh garlic / sulphur-rich compounds (Alliin) preserved - Aged garlic extract (Kyolic??) - fermented garlic (S-allyl cystein)

7. 7 Human Intervention Study - Recruitment: advertisements - Medical screening - 2-week run-in period - Duplicate sampling (10-14 days apart) / measurements - Randomisation - Duplicate sampling / measurements HALF-WAY (6 wks) & END treatment period (12 wks)

8. 8 Garlic and Inflammation - Biomarkers for inflammation - C-Reactive Protein (!!) - Fibrinogen - Cytokines after whole blood stimulation with LPS (TNF-  ; IL-10) - Biomarkers for endothelial function - von Willebrand Factor

9. 9 Additional biomarkers; atherosclerosis - Clinical measures (ECG / HRV / BP) - Routine lab (chol / HDL-C / triglyc / LDH etc.) - PAI / s-VCAM / s-ICAM / s-Selectine - SAA - ox-LDL (plasma) / isoprostanes (urine) - soluble CD40L (platelets)

10. 10 Additional biomarkers; atherosclerosis - IL-18 (IL-6) - mRNA - leukocytes - gene array - (Metabolites) of garlic compounds in urine (and blood?)

11. 11 Additional biomarkers; other Cancer biomarkers - phase II enzymes as glutathione S-transferase and quinone reductase (plasma and lymphocytes) - DNA damage (lymphocytes) - comet assay - Anti-mutagenic properties (urine) - Ames test

12. 12 Points to discuss - Design -Positive control? (statin) - Study group Characteristics - mildly obese, smokers, postmenopausal women - Intervention material and supplier - Lichtwer and Wakanuga?; EU-preparation?) - Dosages - 6 g/day aged garlic extract / 2-4 g garlic powder

13. 13 Points to discuss - Questions - is there a garlic effect? - is it dependent on the preparation? - Are these the questions we want to answer?