J. Trop, Mea. Plants. Vol. 10. No.

1 (June 2009)

Hypoglycmie Activity of Certain Plant Extracts Used on Rats

Chee Beng Jin
Medicinal Plant Division. Forest Research Institute Malaysia (FRJM),
52109 Kepong. Selangor. Malaysia.
Email: cheebengjin@yahoo.com
Abstract: Traditional herbal remedies for treattnent of diabetes are cotnmon in tnany cultures and societies. A Malay
traditional herbal preparation is claimed to lower the blood glucose content in diabetes patients. The preparation consists
ofthe extracts of Tinospora crispa. Momordica charantia. Alpinia galanga and Portulaca olercea. The same preparation
was used to verify the claimed hypoglycmie property using rats. Five doses (2.5, 25, 250, 500 and 2500 mg/kg body
weight) of the aqueous extracts were administered. The dose of 500mg/kg body weight lowered the blood sugar level
significantly . The hypoglycmie mechanism ofthe mixed herbal preparation is yet to be identified.
Keywords: Hypoglycmie activity, Alpinia galanga. Momordica charantia, Portulaca olercea, Tinospora crispa

INTRODUCTION

Jayne, 2006).

Plants remaiti the main source of medication for

patients with diabetes from the ancient to modern
human civilizations. In many parts ofthe world,
they are sometimes taken in preference to other
treatments. Globally, there are more than 1000
plants reputed to be hypoglycmie (Day and
Bailey, 2006) and abotjt 292 plant species are
used for the treatment of diabetes in Malaysia
(Liza and Hamdan, 2004) and most of which
are poorly studied. Among the plants reputedly
used are Alpinia galanga, Momordica charantia,
Portulaca olercea, Tinospora crispa (Maries and
Farnsworth, 1995)

Momordica charantia (Family: Curcubitaceae)

(Figure 4) or Peria Katak in Malay, originated from
eastern India and southern China, found widely
throughout the tropics and cultivated in Southeast
Asia, The fruits of M. charantia are a popular
local vegetable either eaten raw or cooked. In local
traditional medicine, consuming the fruit in raw
form or blended as juices is used to treat diabetes
(Shamsul, et. al., 2003, Samy, et al., 2005 and Wiart,
2006). Elsewhere in Africa, India, Central America,
Australia and the Middle East, the fruit and leaves
were reported to be used for diabetes (Monique and
Melanie-Jayne, 2006). (Nguyen and Sri Hayati,
1999).

2) or locally called Patawali is widespread in the

Malesian region. It occurs from India Sri Lanka,
south China, Peninsula Malaysia to the Philippines.
In Malaysia and Indonesia, the stem and leaves of
T. crispa are traditionally used for treating diabetes
(Fasihuddin and Hasmah, 1993, Umi Kalsom, et al.,
1999, Shamsul, et. al., 2003 and Samy, et al., 2005),
also commonly used in other Asian countries to
treat diabetes (Monique and Melanie-Jayne, 2006).

Alpinia galanga (Family: Zingiberaceae) (Figure 5)

locally called Lengkuas in Malay, originated from
India and is now widely cultivated in tropical Asia.
It is mainly used as spice, in traditional medicine as
well as an ornametital (Halijah, 2001), It is easily
propagated using the rhizome. The fresh rhizomes
and flowers are consumed raw. In Malaysia and
India, the infusion ofthe Lengkuas rhizomes is used
for treating diabetes (Samy, et al., 2005, Monique
and Melanie-Jayne, 2006).

Portulaca olercea (Family: Portulacaceae) (Figure

3) is locally known as Beremi or Gelang Pasir, It is
a widespread weed that probably originated from
tropical America, The young shoots and stem are
eaten raw or cooked as vegetable, especially in
Indian cooking. The World Health Organisation
has named P. olercea in its most used medicinal
plants (Ong, 2004), also reported to decrease blood
glucose levels (Samy, et al., 2005), The plant was
reported to be used for treatment of diabetes in
India, Africa and Europe (Monique and Melanie-

A local Malay traditional medicinal practitioner

in the state of Johor in Malaysia claimed that the
combination of all the four plants was effective
in lowering the blood glucose level in diabetic
patients. (Broadhurst, 1997 and Li, 2000), Studies
were carried out to explore and validate the above
claimed hypoglycmie effects and results obtained
are reported.

J. Trop. Mea. Plants. Vol. ONo. 1 (June 2009)

MATERIALS AND METHOD

Experimental Animals: Normal adult white rats ofthe Spraque-Dawley strain were obtained from the Animal
House of Biology Department, Universiti Putra Malaysia. Male rats with body weights ranging between 200-350g
were selected and kept in a cage measuring 50cm x 32cm x 19cm. Tbey were fed witb ample kernel rat pellet and
water. Male rats were used in order to avoid tbe interaction of tbe oral hypoglycmie agent with hormonal changes
and possible pregnancy in female rats (Carter, 2005).
Experimental design: Seven experimental groups, each with 5 rats were formed. The first group was given saline
solution (0.98%) and the second group given glibenclamide (lOmg/kg body weight). The other 5 groups were given
aqueous extract of doses 2.5,25, 250, 500 and 2500 mg/kg rat body weight respectively. The aqueous extracts were
given once at the beginning ofthe experiment at time -30 minutes.
Aqueous extract preparation: Fresh plants of Alpiniagalanga (0.70kg), Momordica charantia (L40kg), Portulaca
olercea (0.70kg) and Tinospora crispa (0.16kg) were washed, cut and boiled in 9 liters of distilled water under slow
flame for 4 hours. Tbe liquid obtained was sieved, cooled and finally centrifuged to separate tbe plant debris from
the supernatant. The supernatant was dehydrated in a rotary evaporator and finally freeze-dried to obtain dark brown
crystals.
Oral Glucose Tolerance Test (OGTT): The normal rats were fasted for 18 hours prior to tbe test. Initial blood
sampling was recorded at time -30 minutes and followed by the oral administration of treatments or control. After
30 minutes, blood samples were taken and eacb group was given a glucose load (1.5g/kg body weight). Subsequent
blood samplings were taken at 5,15,30, 60, 90, 120,150,180 and 210 minutes.
Blood glucose assay: Blood glucose concentrations at time -30, 0, 5, 15, 30, 60, 90, 120, 150, 180 and 210 minutes
for each group were determined by using Glucose Oxidase Kit. Absorbanee readings were obtained at 510nm. The
plasma glucose concentration was calculated by using the formula: blood glucose concentration (mg%) = (Absorbanee
of Sample)/(Absorbanee of Standard) X 100.
Area under curve: Area under the curves (AUCs) were calculated by the trapezoidal integration method (Campbell
and Madden, 1990)
Statistical analysis: Statistical analysis was performed using ANOVA and Student's t-test. Differences were
considered to be significant when P<0.05. The results are expressed as mean values S.E. (Standard Error).

RESULTS AND DISCUSSIONS

The average blood glucose levels for the normal rats in the complete Oral Glucose Tolerance Test are represented
in Figure 1. The blood glueose values at tbe beginning ofthe experiment (-30 minutes) showed no difference in all
rats. They were a!l in the narrow normal blood glucose range (70-110mg%) after an 18-hour fast (Beers, 2003). After
tbe treatment at -30 minutes, the blood glucose readings for 500 and 2500 mg/kg body weight was higher than the
two controls; saline and glibenclamide at minute 0. The plant extracts had 14% glucose. Therefore, the high natural
glucose content had contributed the higher glucose values. The presence of natural glucose was possibly due to tbe
carbohydrate content found in A. galanga. M. charantia and P. olercea (Ismail, 2000 and Ong, 2004).
After glueose load, the blood glucose levels in the rats rose comparatively higher and increased until they reached
a peak value (Table 1). Normal rats fed with 2500mg/kg body weight (0.69 0.21 mg%/min) and 500mg/kg body
weight (1.03 0.25mg%/min) of extract showed lower average rate of increase compared to glibenclamide (1.11
0.30mg%/min). The higher doses prevented the sudden increase of glucose level in tbe rat blood plasma. The
findings suggested tbat the likely existence of unknown substances or secondary metabolites in the two higher doses
enabled to hold back tbe glucose surge.

J. Trop. Med. Plants. Vol. lONo. 1 (June 2009)

50
1

-30

15

60

90

120

150

180 210

Time (Minuteil
Saline
250mg/l(6

- Glibenclamide
- - - 500nig/lt

9 2.5mg/kg

25mg/kg

2500mgAg

Figure 1: Average Blood Glucose Levels in Normai Rats in the Oral Glucose Tolerance Test
Table I: Rate of Blood Glucose Level Increase From 0 Minute To Peak and the rate of Blood Glucose Level
Decrease From Peak To 210 Minutes
Treatment
Saline

Rate of Increase
(mg%/minSE)
1.72 + 0.49

Glibenclamide

1.11 +0.30

2.5 mg of Extract

1.59 + 0.42

25 nig of Fxtract

2.74 + 0.41

250 mg of Extract
500 mg of Extract
2500 mg of Extract

1.88 + 0.43
1.03 + 0.25*
0.69 + 0.21*

Rate of Decrease
(mg%/min SE)
0.54 + 0.12
0.41 + 0.22

Time of Glucose peak

values (minutes)

0.90 + 0.38*
0.87 + 0.45

90

0.64 + 0.11

60

0.95 + 0.33*
0.36 + 0.12

90

60
60
60

90

Note: Results are presented as Mean S.E.M.

* Shows mean values significantly different compared to saline control (P<0.05)
Glibenclamide-treated rats had the lowest peak ofthe glucose load (150.88 9.99 mg%) (Figure 1). These results
warranted that the established Oral Hypoglycaemic Agent (glibeticlamide) was able to stimulate insuliti discharge
frotn the -cells in normal animals (Henry, 2007). The dose highest dose of 2500 mg/kg body weight had a lower
peak (185.7616.33mg%) than saline (l92.005.56mg%). The other peak values of doses of 500mg/kg body
weight (201.4411.37tng%) and 250mg/kg body weight (214.6917.46mg%) also did not differ statistically from
saline. Moreover, the effect of all the extracts was less pronounced compared to glibenclamide.
There was a decrease in all the glucose readings after the peak values for all treated rats until the end ofthe test.
Interestingly, from minute 120 to 210, the average blood glucose level for 500mg/kg body weight dose was lower
than saline (Figure 1). The dose of 500mg/kg body weight was the only extract that reduced the blood glucose
level to a basal value at minute 210 which was similar to glibenclamide (Figure 1). The blood glucose levels for the
other extracts did not reach basal values. Moreover, the rate of blood glucose level decrease was also the highest in
the 500mg/kg body weight (0.95 + 0.33 mg%/min) compared to saline (0.54 + 0.12 mg%/min) and giibenclamide
(0.41 + 0.22 mg%/min) (Table 1).
Areas under the blood glucose concentration curves (AUC) were calculated from minute 0 to 210 are the same

J. Trop. Med. Plants, Vol. 0 No. ! (June 2009)

data used to determine the amount of blood glucose level (Hallfrisch and Behall, 2000). The total area under the
tolerance curve represents the total concentration ofblood plasma glucose for a certain time interval (Rydberg, et al..
1994). As anticipated, the glibenclamide-treated rats had the most minimal AUC value (25008.87 661.57mg%min)
compared to saline. Interestingly, when the AUC values of saline and dose 500mg/kg body weight were compared,
both values were not significantly different and results were comparable.
Prabhakar and Doble (2008) reported that there were around 410 experimentally proven medicinal plants having
antidiabetic properties but the complete mechanism of action is available only for about 109 plants. The reported
hypoglycmie property of Alpinia galanga, Momordica charantia, Portulaca olercea, Tinospora crispa were
summarized in Table 2
Table 2: The reported hypoglycmie property of Alpinia galanga, Momordica charantia,
olercea, Tinospora crispa
Plant species
Alpinia galanga

Reported hypoglycmie property

The aqueous and methanol extracts showed
hypoglycmie effect as good as to gliclazide, an
established hypoglycmie agent. The organic and
inorganic contents in the rhizome particularly the
polysaccharides might be responsible for the effect.
Polysaccharides are known to increase the serum
insulin levels, reduce the blood glucose levels and
improve glucose tolerance

Momordica charantia

The hypoglycmie property was due to the presence Ng, etai-, 1986
of vicine, polypepide-p and charantin that boosted McWhorter, 2001.
glucose uptake and glycogen synthesis in the muscles
and liver and suppressed the synthesis of glucose.
Charantin, a steroidal saponin is known to have an
insulin-like activity.

Portulaca olercea

The aqueous extract elevates insulin sensitivity in Shen and Lu, 2003
diabetic rats. The mechanism might be related to its Sharma, et al., 2009
actions in improving lipid metabolism and decreasing Prabhakar, 2008.
free fatty acids. The oral administration of P. olercea
extract for three weeks significantly reversed
antioxidant enzymes to near normal values in diabetic
rats. It might be due to the presence of flavanoids in
the plant

Tinospora crispa

The plasma glucose levels of moderately diabetic rats

were significantly improved after 2 weeks treatment of
aqueous extracts The in-vitro insulinotropic activity
was detected in the human and H1T-T15 beta-cells.
The antihypergiycaemic effect of Z crispa is probably
due to stimulation of insulin release via modulation
of intracellular Ca-' concentration in pancreatic betacells. In another study, the presence of three compounds
in T. crispa with free radical and free scavenging
property had effective antioxidant property in diabetic
condition

Portulaca

References
Akhtar,etal.,2002,
Quanhong, et al., 2005,
Mukherjee, et al., 2006.
Henry, 2007.

Noor and Ashcroft, 1989,

Noor, etal., 1989,
Noor and Ashcroft, 1998a,
Noor and Ashcroft, 1998b,
Cavin, etal, 1998,
Muhajir et al., 2008.

It is important to consider potential harm from the use of traditional herbal medicine due to the synergistic effect

J. Trop. Med. Plants. Vol O No. I (June 2009)

of the chemical components (Ogbonnia, 2008). The use of T. crispa was associated with markedly elevated liver
enzymes in 2 diabetes patients (Sangsuwan, et al., 2004). Another study showed that M diarantia were abortiftcants
and not to be used for the period of pregnancy and there were also cases of reported severe hypoglycemia with the
use of M charantia in children {Krawinkel and Keding, 2006). Therefore, extra safety measures should be taken on
the aspects of toxicity, allergic reactions, contaminations and interaction in the usage of non-conventional therapies
(McGuffin et al., 1997 and Day, 2005). Plant remedies are unavoidably the foundation of treatments in undeveloped
and developing regions in the world. (Martin, 1997). Indisputably, oral hypoglycmie agents will continue to be
indispensible especially in diabetes management (Weiss, 1998) but traditional treatments may offer priceless clues
for the development of new oral hypoglycmie agents or simple nutritional addition (Bailey and Day, 1989).
In conclusion, the traditional herbal mixture of extracts derived from the combination of T. crispa, M. charantia, A.
galanga and P. olercea showed hypoglycmie activity. The synergistic interaction ofthe chemical components in
the mixed extracts impart hypoglycmie property.
ACKNOWLEDGEMENTS
The author thanks the staff of Animal Physiology Lab and Animal House ofthe Biology Department, Faculty of
Science, Universiti Putra Malaysia for their kind assistance.

REFERENCES
Akhtar, M.S., Khan. M.A. and Malik, M.T. 2002. Hypoglycmie activity of Alpiniagalanga rhizome and its extracts in rabbits.
Fitoterapia. 73:623-628.
Bailey, C.J. and Day, C. 1989. Traditional plant medicines as treatments for diabetes. Diabetes Care. 12(8):553-64.
Beers, M.H. 2003. The Merck Manual of Medical Information. Second Home Edition. Pocket Books, Simon and Schuster, Inc.,
New York.
Broadhurst, C.L. 1997. Nutrition and Non-Insulin Dependent Diabetes Mellitus from an Anthropological Perspective. Altemative
Medicine Review. 2(5):378-399.
Campbell, C.L. & Madden, L.V. 1990. Introduction to plant disease epidemiology. John Wiley and Sons, New York. pp. 192193.
Carter, W. 2005. The Complete Home Guide to Medication. Hinkler Books Pte. Ltd. Victoria, Australia.
Cavin, A., Hostettmann, K., Dyatmyko, W. and Potterat, O. 1998. Antioxidant and Lipophilic Constituents of Tinospora crispa.
Planta Medica. 64(5):393-396.
Day, C. 2005. Are herbal remedies of use in diabetes? Diabetes Medicine. 22:10-12. Day, C and Bailey, C.J. 2006. Preclinical
and Clinical methods for evaluating antidiabetic activity of plants. (In: Traditional Medicines for Modem Times: Antidiabetic
Plants Edited by Soumyanath. A.) CRC Press, Taylor & Francis Group. Boca Raton. USA.
Fasihuddin. A. and Hasmah, R. 1993. Kimia Hasilan Semula Jadi dan Tumbuhan Ubatan (Natural Product Chemistry and
Medicinal Plants). Dewan Bahasa dan Pustaka, Kuala Lumpur.
Halijah, 1. 200\.Alpinia Roxb. In: van Valkenburg, J.L.C.H and Bunyapraphatsara, N. (Editors): Plant Resources of South-East
Asia No 12(2). Medicinal and Poisonous Plants. Backhuys Publishers, Leiden, the Netherlands, pp. 52-61.
Hallfrisch, J. and Behall, K.M. 2000. Improvement in insulin and glucose responses related to grains. Cereal Foods World.
45(2):66-69.

Henry, J.A. 2007. New Guide to Medicines and Drugs. 7th Edition. Dorling Kindersley Ltd. London.
Ismail, S. 2000. Sayuran Tradisional, Ulam dan Penyedap Rasa (Traditional vegetables, salads and appetizers). Pusat Pengurusan
Penyelidikan, Universiti Kebangsaan Malaysia.
Krawinkel, M.B. and Keding, G.B. 2006. Bitter gourd {Momordica charantia): a dietary approach to hyperglycemia. Nutrition
Review. 64:331-337.
Li, S.C. 2000. Medicinal plants: Culture, Utilization and Phytopharmacology. Technomic Publishing Company Ltd. Lancaster,
U.S.A.

J. Trop. Med. Plants. Vol. 10 No. (June 2009)

Liza, O and Hamdan, N. 2004. Malaysian anti-diabetic plants. Proceedings ofthe Seminar on Medicinal Plants. (Eds: Chang,
Y.S., Mastura, M. and Nurhanan, M.Y.). 20-21 August 2002, Forest Research Institute Malaysia.
Maries, R.J. and Famswotih, N.R., 1995. Antidiabetic plants and their active constituents. Phytomedicine. 2(2):I37-I89.
Marlin, G.J. 1997. Ethnobotany: a methods manual. Chapman and Hall. London.
McGuffin, M., Hobbs, C , Upton, R. and Golberg, A. 1997. American Herbal Products Association's Botanical Safety Handbook.
CRC Press, Boca Raton. U.S.A.
McWhorter, L.S. 2001. Biological complementary therapies: a focus on botanical products in diabetes. Diabetes Spectrum.
14:199-208.
Monique, S.J.S. and Melanie-Jayne, R.H. 2006. Plants used in the treatment of Diabetes. (In: Traditional Medicines for Modem
Times: Antidiabetic Plants Edited by Soumyanath, A.) CRC Press, Taylor & Francis Group. Boca Raton. U.S.A.
Muhajir, H., Siti Pauliena, M.B., Mohd. Saufi, B., Abdul Manaf, A., Nik Musa'adah. M and Khozirah, S. 2008. Evaluation of
insulinotropic activity of Malaysian traditional plant extracts. Joumal of Biological Sciences. 8(l):20I-204.
Mukherjee. P.K., Maiti, K.. Mukherjee, K. and Houghton, P.J. 2006. Leads from Indian medicinal plants with hypoglycmie
potentials. Journal of Ethnopharmacology 106:1-28.
Ng, T.B., Wong. CM., Li, W.W. and Yeung, H.W. 1986. Insulin-Iike molecules in Momordica charantia seeds. Joumal of
Ethnopharmacology. 15:107-117.
Nguyen, H.H. and Sri Hayati, W. 1999. Momordica L. In: de Padua, L.S., Bunyapraphatsara, N. and Lemmens, R.H.M.J.
(Editors): Plant Resources of South-East Asia No 12(1). Medicinal and Poisonous Plants. Backhuys Publishers, Leiden, the
Netherlands, pp. 353-359.
Noor, H., Hatiimonds. P., Sutton, R. and Ashcroft, S.J.H. 1989. The hypoglycaemic and insulinotropic activity of Tinospora
crispa: studies with human and rat islets and H1T-T15 B-cells. Diabetologia. 32:354-359.
Noor, H. and S.J.H. Ashcroft. 1989. Antidiabetic effects o Tinospora crispa in rats. Joumal of Ethnopharmacology. 27:149161.
Noor, H. and S.J.H. Ashcroft. 1998a. Insulinotropic activity o Tinospora crispa: Effect on -cell Ca^*^ handling. Phytotherapy
Research. 12:98-102.
Noor, H. and S.J.H. Ashcroft. 1998b. Phamiacological characterization ofthe antihypergiycaemic properties on Tinospora crispa
extract. Joumal of Ethnopharmacology. 62:7-13.
Ogbonnia, S.O., Odimegwu, J.I. and Enwuru, V.N. 2008. Evaluation of hypoglycaemic and hypolipidaemic effects of aqueous
ethanolic extracts of Treculia qfricana Decne and Bryophyllum pinnatum Lam. and their mixture on streptozotocin (STZ)induced diabetic rats. African Joumal of Biotechnology. 7(15):2535-2539.
Ong, H.C. 2004. Sayuran: Khasiat Makanan dan Ubatan. (Vegetables: Nutritional and Medicinal Values). Utusan Publications
and Distributors Sdn. Bhd., Kuala Lumpur.
Prabhakar. P.K. and Doble, M. 2008. A Target Based Therapeutic Approach Towards Diabetes Mellitus Using Medicinal Plants.
Current Diabetes Reviews, 4(4):29l-308.
Quanhong, L., Caili, F., Yukui, R., Guanghui, H. and Tongyi, C. 2005. Effects of protein-bound polysaccharides isolated from
pumpkin on insulin in diabetic rats. Plant Foods for Human Nutrition. 60:13-16.
Rydberg, T., A. Jonsson, M. Roder and A. Melander. 1994. Hypoglycmie activity of glyburide (glibenclamide) metabolites in
humans. Diabetes Care. 17(9): 1026-1030.
Samy, J., Sugumaran, M. and Lee, K.L.W. 2005. Herbs of Malaysia. Federal Publications Sdn. Bhd. Kuala Lumpur.
Sangsuwan, C , Udompanthurak. S, Vannasaeng, S. and Thamlikitkul, V. 2004. Randomized controlled trial of Tinospora crispa
for additional therapy in patients with type 2 diabetes mellitus. Joumal of Medical Association Thailand. 87:543-546.
Shamsul, K., Tajuddin, A.M. and Mazina, M.Y. 2003. Tumbuhan Ubatan Tradisionai Malaysia (Malaysian Traditional Medicinal
Plants). 1st Edition. Institut Biosains, Universiti Putra Malaysia.
Sharma, A., Vijayakumar, M.; Rao, C. V.; Unnikrishnan, M.K.; and Reddy, G.D. 2009. Action of Portulaca olercea against
Streptozotocin-Induced Oxidative Stress in Experimental Diabetic Rats. Joumal of Complementary and Integrative Medicine.

J. Trop. Med. Plants. Vol. ONo. ! (June 2009)

6(0:1-12,
Shen. L. and Lu, F. 2003. Effects of Portulaca olercea on insulin resistance in rats with type 2 diabetes mellitus. Chinese
Joumal of Integrative Medicine. 9:289-292.
Umi Kalsom, Y., Horsten, S.F.A.J. and Lemmens, R.H.M.J. 1999. Tinospora Miers. In: de Padua, L.S., Bunyapraphatsara, N.
and Lemmens, R.H.M.J. (Editors): Plant Resources of South-East Asia No 12(1). Medicinal and Poisonous Plants. Backhuys
Publishers, Leiden, the Netherlands, pp. 479-484.
Weiss. R. F. 1998. Herbal Medicine. 6th Edition, Beaconsfield Publishers Ltd, London.
Wiart, C. 2006. Medicinal Plants ofthe Asia-Pacific: Drugs for the future? World Scientific Publishing Co. Pte. Ltd. Singapore.

Figure 2: Tinospora crispa plant with heart-shaped leaves (left) and dried stems (right).

Figure 3: Portulaca olercea plant and flowers (left) and succukiii sieiii and leaves (riglil).

J. Trop. Med. Plants. Vol. 10 No. I (June 2009)

Figure 4: Momordica charantia plant (left) and flowers and fruits (right).

Figure 5: Alpinia gaianga leaves, flowers and rhizome.

Copyright of Journal of Tropical Medicinal Plants is the property of Tropical Botanics Sdn Bhd and its content
may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express
written permission. However, users may print, download, or email articles for individual use.