Free Radical Biology & Medicine 52 (2012) 35–45

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Free Radical Biology & Medicine

journal homepage: www.elsevier.com/locate/freeradbiomed

Review Article

Flavonoids, cognition, and dementia: Actions, mechanisms, and potential therapeutic

utility for Alzheimer disease
Robert J. Williams a, Jeremy P.E. Spencer b,⁎
a
Department of Biology and Biochemistry, University of Bath, Bath BA2 7AY, UK
b
Centre for Integrative Neuroscience and Neurodynamics, School of Chemistry, Food and Pharmacy, University of Reading, Reading RG6 6AP, UK

a r t i c l e i n f o a b s t r a c t

Article history: There is increasing evidence that the consumption of flavonoid-rich foods can beneficially influence normal
Received 22 March 2011 cognitive function. In addition, a growing number of flavonoids have been shown to inhibit the development
Revised 13 September 2011 of Alzheimer disease (AD)-like pathology and to reverse deficits in cognition in rodent models, suggestive of
Accepted 13 September 2011
potential therapeutic utility in dementia. The actions of flavonoid-rich foods (e.g., green tea, blueberry, and
Available online 17 September 2011
cocoa) seem to be mediated by the direct interactions of absorbed flavonoids and their metabolites with a
Keywords:
number of cellular and molecular targets. For example, their specific interactions within the ERK and PI3-ki-
Flavonoid nase/Akt signaling pathways, at the level of receptors or kinases, have been shown to increase the expression
Brain of neuroprotective and neuromodulatory proteins and increase the number of, and strength of, connections
Cognition between neurons. Concurrently, their effects on the vascular system may also lead to enhancements in cog-
Memory nitive performance through increased brain blood flow and an ability to initiate neurogenesis in the hippo-
Dementia campus. Additional mechanisms have been suggested for the ability of flavonoids to delay the initiation of
Cell signaling and/or slow the progression of AD-like pathology and related neurodegenerative disorders, including a po-
Free radicals
tential to inhibit neuronal apoptosis triggered by neurotoxic species (e.g., oxidative stress and neuroinflam-
mation) or disrupt amyloid β aggregation and effects on amyloid precursor protein processing through the
inhibition of β-secretase (BACE-1) and/or activation of α-secretase (ADAM10). Together, these processes
act to maintain the number and quality of synaptic connections in key brain regions and thus flavonoids
have the potential to prevent the progression of neurodegenerative pathologies and to promote cognitive
performance.
© 2011 Elsevier Inc. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Flavonoids and dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Flavonoids and neurocognitive performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Brain localization of flavonoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Mechanisms underpinning the actions of flavonoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Interactions within intracellular signaling pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Flavonoid-induced changes in vascular function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Protection against neurotoxins and neuroinflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Introduction

Representing one of the most important lifestyle factors, diet can

⁎ Corresponding author. Fax: + 44 118 931 0080. strongly influence the incidence and onset of cardiovascular disease
E-mail address: j.p.e.spencer@rdg.ac.uk (J.P.E. Spencer). and neurodegenerative disorders. A combination of preclinical studies

0891-5849/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.freeradbiomed.2011.09.010
36 R.J. Williams, J.P.E. Spencer / Free Radical Biology & Medicine 52 (2012) 35–45
and epidemiology suggests that flavonoids might be effective at revers-
ing neurodegenerative pathology and age-related declines in neurocog-
nitive performance, although at present a direct association between
flavonoid consumption and improvement in neurological health has
not been made. The potential of flavonoids to improve neurological
health seems to be related to their ability to interact with intracellular
neuronal and glial signaling pathways, to influence the peripheral and
cerebral vascular system, and to reduce neuronal damage and losses in-
duced by various neurotoxic species and neuroinflammation. Flavo-
noids comprise the most common group of polyphenolic compounds
in the human diet and are found ubiquitously in plants. Major dietary
sources of flavonoids include fruits, vegetables, cereals, tea, wine, and
fruit juices [1]. Structurally, flavonoids consist of two aromatic carbon
rings, benzopyran (A and C rings) and benzene (B ring), and may be di-
vided into various subgroups based on the degree of the oxidation of the
C ring, the hydroxylation pattern of the ring structure, and the substitu-
tion of the 3-position. The main dietary groups of flavonoids are (1) fla-
vonols (e.g., kaempferol, quercetin), which are found in onions, leeks,
and broccoli; (2) flavones (e.g., apigenin, luteolin), which are found in
parsley and celery; (3) isoflavones (e.g., daidzein, genistein), which
are mainly found in soy and soy products; (4) flavanones (e.g., hesper-
etin, naringenin), which are mainly found in citrus fruit and tomatoes;
(5) flavanols (e.g., (+)-catechin, (−)-epicatechin, epigallocatechin,
epigallocatechin gallate (EGCG)), which are abundant in green tea, red
wine, and chocolate; and (6) anthocyanidins (e.g., pelargonidin, cyani-
din, malvidin), whose sources include red wine and berry fruits. Once
ingested, flavonoids undergo extensive metabolism in the small and
large intestine, in the liver, and in cells, resulting in forms in the body
very different from those found in foods [2,3].
It is now understood that the biological actions of flavonoids within
the nervous system are not due to their direct (i.e., classical) antioxidant
effects [4], but rather through their potential to protect vulnerable neu-
rons, enhance existing neuronal function, stimulate neuronal regenera-
tion, and induce neurogenesis [4–7]. Indeed, it has become evident that
flavonoids are able to exert neuroprotective actions (at low, physiolog-
ical concentrations) via their interactions with critical neuronal/glial in-
tracellular signaling pathways pivotal in controlling neuronal resistance
to neurotoxins, including oxidants (“indirect” antioxidant nature) and
inflammatory mediators, neuronal differentiation, long-term potentia-
tion, and memory [5,8,9]. This review examines the beneficial effects
of flavonoids on neurocognitive performance and their protective qual-
ities against Alzheimer disease (AD)-related pathology and attempts to
classify the mechanisms that underpin such diverse actions.
Flavonoids and dementia
There is increasing evidence that plant-derived flavonoid-rich foods
or supplements might delay the initiation of and/or slow the progres-
sion of AD and related neurodegenerative disorders. With regard to
AD the consumption of polyphenolic-rich vegetables, fruit juices, and
red wine has been shown to delay the onset of the disease [10,11].
This is in accordance with previous studies linking high consumption
of flavonoids to improvements in dementia [12,13] and collectively
these reports lend some support to the hypothesis that dietary inter-
vention with plant-derived flavonoid-rich foods or supplements has
an impact on the development of AD. A number of studies using trans-
genic mouse models of AD pathology have begun to investigate the pos-
sible mechanisms involved in these effects of polyphenol-rich diets.
For example, oral administration of the green tea flavonoid EGCG for
6 months to mice overexpressing the Swedish mutation of APP
(Tg2576) reduced amyloid β (Aβ) pathology as well as improving cog-
nition [14], and similarly long-term green tea catechin administration
improved spatial learning and memory in senescence-prone mice
[15]. Furthermore, feeding APP+ PS1 double-transgenic mice blueberry
from 4 months of age prevented deficits in Y-maze performance at
12 months, without altering the Aβ burden [16].
The mechanism(s) underlying these changes is not clear but
might be linked to increased α-secretase activity [17] reported in
vitro and in vivo after ip injection of EGCG [18,19] or due to disrup-
tion of cAbl/Fe65 interactions [20]. Alternatively, it is conceivable
that EGCG reduces Aβ plaque pathology by inhibiting protein aggre-
gation and fibrillization either as a result of metal chelation activity
[21–23] or by favoring the formation of off-target oligomers [24]. In-
terestingly, in addition to possessing the ability to inhibit the forma-
tion of β-sheet-rich amyloid fibrils, EGCG also converts large mature
Aβ fibrils into smaller nontoxic aggregates [25] (Fig. 1). These are sig-
nificant and potentially exciting observations although serious con-
sideration must be given to whether dietary EGCG could drive Aβ
disaggregation in AD brain, as the micromolar concentrations re-
quired to exert these effects in vitro are not easily achievable in
vivo. Antiamyloidogenic activity is not unique to EGCG and a number
of other flavonoids, most notably myricetin, bind to Aβ fibrils and
prevent further fibrillization [26–28]. Gallic acid and catechin-rich
grape seed polyphenolic extract (GSPE) administered for 5 months
to Tg2576 mice inhibited cognitive deterioration coincident with re-
duced levels of soluble high-molecular-weight oligomers of Aβ [29].
Repeated ip injection of the polymethoxylated citrus flavone nobile-
tin has similar effects [30].
Although these are clearly important studies in that they show in
principle that chronic exposure to polyphenolics can influence AD pa-
thology and behavior in vivo, it is quite possible that the optimal flavo-
noid structures possessing the necessary bioactivity and bioavailability
have not yet been identified and mechanisms of action are unclear. In-
terestingly in this regard, certain flavonols and flavones have been
reported to act as BACE-1 inhibitors and to suppress BACE-1 expression
[31,32] (Fig. 1), which would also be consistent with some of the ob-
served Aβ-lowering effects reported for flavonoid-rich extracts in vivo
and in vitro. The identification of those flavonoid structures possessing
the greatest potential inhibitory activity at BACE-1 and definition of
their precise mechanisms of action are needed. Despite the compelling
link between Aβ and AD, Aβ pathology and cognitive deficits are not
well correlated. Consequently, beneficial effects of flavonoids on cogni-
tion may be unrelated to changes in Aβ per se but to key downstream
changes, for example, in tau phosphorylation and fibrillization. Indeed,
a number of flavonoids, including myrecetin and epicatechin 5-gallate,
have been shown to potently inhibit heparin-induced tau aggregation
[33]. Moreover, GSPE also inhibits tau fibrillization, promotes the loss
of preformed tau aggregates, and disrupts paired helical filaments
[34–37]. EGCG seems to have broadly similar effects. (−)-Epicatechin
and hesperetin hold the potential to inhibit the development of tau pa-
thology through an alternative mechanism relating to their ability to
enhance Akt phosphorylation, thereby inhibiting GSK3β-induced tau
hyperphosphorylation [38,39]. Whatever the mechanisms involved,
collectively this suggests that orally active flavonoids could have utility
in AD beyond anti-Aβ actions. The challenge ahead is to determine if fla-
vonoids have efficacy in individuals affected by dementia.
Flavonoids and neurocognitive performance
There are a number of studies that have indicated that the con-
sumption of flavonoid-rich plant foods and extracts may also be capa-
ble of inducing improvements in cognitive performance [4,12,13,40].
Human observational and interventional studies have hinted at the
potential benefits of such foods and their regular intake (reviewed
in [41]). Many of these studies have detailed the efficacy of isofla-
vones, a subgroup of flavonoids found predominately in soy and
soy-derived foods, in influencing cognition and aspects of memory
[42–49]. The effects of isoflavones on these outcomes may lie in
their potential to mimic the actions of estrogens in the brain [50,51]
or to influence the synthesis of acetylcholine and neurotrophic factors
such as brain-derived neurotrophic factor (BDNF) and nerve growth
factor in hippocampus and frontal cortex [52,53].
 R.J. Williams, J.P.E. Spencer / Free Radical Biology & Medicine 52 (2012) 35–45
Fig. 1. Flavonoid modulation of amyloid β (Aβ) pathology. Flavonoids can reduce Aβ production either by enhancing α-secretase (ADAM10) activity or by inhibiting β-secretase.
They can lead to the production of off-target Aβ oligomers, thereby disrupting fibrillization, and inhibit Aβ aggregation through metal-chelating activity. By acting to improve ce-
rebral vascular blood flow flavanols may have the potential to reduce brain Aβ levels through a peripheral sink mechanism.
With regard to other flavonoids, notably the flavanols, flavonols,
flavanones, and flavones, human data are somewhat scarcer. Obser-
vational data have suggested that the regular and moderate intake
of flavonoid-rich foods, such as wine, berries, and cocoa, may result
in cognitive benefits [12,13,54]. In addition, two intervention studies
have examined the effects of flavonoid-rich extracts of Ginkgo biloba
in older adults with [55] and without [56] AD, two detailed the effects
of procyanidin-rich pine bark extracts on healthy older adults [57,58],
and one examined the effects of flavanol-rich cocoa on cognitive func-
tion in young healthy female adults [59]. In terms of more commonly
consumed flavonoid-rich foods, intervention trials have shown that
grape juice, blueberry, and cocoa intake results in positive effects on
cognitive outcome measures [60–62], although there are studies
that suggest no changes in neurophysiological effects [63]. These dis-
crepancies may be due, on the one hand, to an inadequate control of
intervention studies and, on the other hand, to inadequate character-
ization of test materials in relation to their flavonoid content. In the
future, it is essential to fulfill both of these requirements to fully as-
sess the efficacy of flavonoid-rich foods in humans [64].
In addition to the human evidence, there is a large body of animal
behavioral evidence that supports the efficacy of flavonoids on mem-
ory and learning. Grape, pomegranate, strawberry, and blueberry (1–
2% (w/w) freeze-dried fruit/fruit juice), as well as pure flavonoids
(epicatechin and quercetin), have been shown capable of affecting
several aspects of memory and learning, notably rapid [65] and slow
[66–70] memory acquisition, short-term working memory [71–74],
long-term reference memory [75,76], reversal learning [65,71], and
memory retention/retrieval [77]. For example, strawberry, blueberry,
and blackberry, all rich sources of anthocyanins and flavanols, retard
functional age-related CNS and cognitive behavioral deficits in rodent
models [67,68,78], whereas blueberries are effective at reversing age-
related deficits in spatial working memory [73–75,78–81]. The effects
of blueberry and blackberry seem to be most pronounced in terms of
short-term memory, suggesting that these improvements are, in part,
dependent on CA3–CA3 excitatory connections in the hippocampus
[78,82]. In addition, pure (−)-epicatechin (500 μg/g), a flavanol found
in cocoa, apple, pear, grape, and berries, enhances the retention of rat
spatial memory, especially when combined with exercise [77], suggest-
ing that flavonoids may be causal agents in inducing the behavioral
effects.
37
Blueberry-derived flavonoids may also act to enhance the efficiency
of spatial memory indirectly by acting on the dentate gyrus (DG), the
hippocampal subregion most sensitive to the effects of aging [83–85].
Blueberry supplementation has been shown to significantly increase
the proliferation of precursor cells in the DG of aged rats [75]. This
link between DG neurogenesis, cognitive performance, and aging is
well documented [86–90] and may represent another mechanism by
which fruits rich in flavonoids may improve memory by acting on the
hippocampus. Again, it is unclear at present whether flavonoids them-
selves are wholly responsible for the effects of flavonoid-rich fruits in
vivo and also whether they induce global changes in hippocampal
(and other brain region) morphology/function or are capable of more
specific changes in hippocampal subregions. In addition to those with
berries, animal studies with tea [91] and pomegranate juice [66], or
pure flavonols such as quercetin, rutin [72], or fisetin [92], have provid-
ed further evidence that dietary flavonoids are beneficial in reversing
the course of neuronal and behavioral aging. There is also evidence sug-
gesting that these effects may not be isolated only to memory and learn-
ing but may also exert positive changes in psychomotor activity in older
animals [67,93].
Brain localization of flavonoids
The ability of flavonoids to influence the nervous system will de-
pend to some extent on their accessibility to the brain via the blood–
brain barrier (BBB). Although the evidence as to whether flavonoids
and/or their metabolites enter the brain is not conclusive, there are
abundant data from animal studies demonstrating that certain flavo-
noids are able to penetrate the blood–brain barrier. For example (−)-
epicatechin and some of its principle metabolites have been detected
in rodent brain after oral administration [77,94] and the brain levels of
catechin and (−)-epicatechin have been found to increase upon repet-
itive dosing with a grape seed polyphenolic extract [95]. Similar obser-
vations have been made with EGCG [96,97], flavanones [98], flavonols
from a G. biloba extract [99], and anthocyanins [100,101]. The precise
brain distribution of flavonoids after oral administration is less well
studied, although it has been reported that anthocyanins were detected
in the cerebellum, cortex, hippocampus, and striatum of blueberry-
supplemented rats [79], and several anthocyanins have been identified
in various regions of the rat [102] and pig [103,104] brain after berry
38 R.J. Williams, J.P.E. Spencer / Free Radical Biology & Medicine 52 (2012) 35–45

intervention. Similarly, chronic administration of the O-methylated fla-
vanone tangeretin resulted in detectable levels in the hypothalamus,
striatum, and hippocampus [105].
It seems that the ability of flavonoids/metabolites to penetrate the
BBB is dependent on the degree of lipophilicity of each compound
[106], with less polar flavonoids or metabolites (i.e., O-methylated de-
rivatives) capable of greater brain uptake than the more polar flavonoids
and/or metabolites (i.e., sulfated and glucuronidated derivatives). Their
brain entry will also depend on their interactions with specific efflux
transporters expressed in the BBB, such as the P-glycoprotein, which
seems to be responsible for the differences between naringenin and
quercetin flux into the brain in situ [107]. However, the time-dependent
transport of catechin, quercetin, and cyanidin-3-glucoside across cere-
bral capillary endothelial cells further suggests that a range of flavonoids
and their metabolites may be capable of BBB transfer [108]. These are
important studies as they demonstrate that flavonoids seem to be able
to reach areas of the mammalian brain that are important for memory
formation and those regions that are adversely affected in neurodegen-
erative disease. Despite this, further work is necessary before a firm
conclusions may be formulated with regard to the extent of brain bio-
availability of flavonoids in humans [109].
Mechanisms underpinning the actions of flavonoids
It is now believed that the activity of these low-molecular-weight,
nonnutrient components and their metabolites on neurological pro-
cesses can be defined through a number of distinct biological processes:
(1) through their interactions with neuronal/glial signaling pathways
crucial in inducing neuronal function and survival [4,9] through the
up-regulation of antioxidant enzymes [110–112] and the expression
of proteins involved in synaptic plasticity and neuronal repair [5]; (2)
through their potential to induce changes in blood flow to the brain
[59,113,114]; and (3) through an ability to inhibit known neuropatho-
logical processes in specific brain regions [19,29]. The next sections out-
line the effects flavonoids and their metabolites on neuronal/glial
signaling, vascular function, and neurotoxicity and how these may un-
derpin improvements in cognition and neuronal function.
Interactions within intracellular signaling pathways
There is extensive evidence indicating that some native flavonoids
[8,9] and some of their small intestinal metabolites [115,116] are capa-
ble of exerting beneficial effects on neurological processes and that
this is linked to their interactions with neuronal signaling pathways.
Data are also beginning to emerge that indicate that large intestinal de-
rivatives derived from the bacterial metabolism of flavonoids may also
be capable of such activity [117–119]. Various flavonoid-binding sites
on neurons have now been described and include adenosine [120],
GABAA[121–125], δ-opioid [126,127], nicotinic [128,129], TrkB [130], es-
trogen [18], and testosterone receptors [131], and a specific brain plas-
ma membrane binding site for polyphenols has been proposed [132].
Receptor binding by flavonoids and their metabolites may underlie the
reported changes in the activation status of various downstream ki-
nases, including various members of both the MAP kinase and the PI3-
kinase pathways [4,5,7,9] and the nuclear factor-κB pathway [133]
(Fig. 2). Indeed, the phosphorylation (activation/inhibition) profiles of
such downstream kinases in response to flavonoids in vitro is highly
suggestive of high-affinity receptor agonist-like actions at low concen-
trations (low to midnanomolar) and desensitization or direct enzyme
inhibition at higher concentrations (high nanomolar to micromolar).
Their influence on such pathways suggests that they may modulate ac-
tivity-dependent plasticity and new synaptic protein synthesis leading
to morphological changes involved in neurodegenerative processes
and memory acquisition, consolidation, and storage.
Nanomolar concentrations of flavonoids, in particular flavanols
and flavanones, have been shown to activate the ERK pathway
[38,39,92,115,134] in a way that seems to be mediated by their interac-
tions with MEK1 and MEK2 and, potentially, membrane receptors
[135,136] (Fig. 3). Indeed, the flavone backbone (2-phenyl-1,4-
benzopyrone) has close structural homology to specific pharmacological

Fig. 2. Potential cell surface binding sites for initiating flavonoid signaling to PI3-kinase-dependent neuroprotection. Various flavonoids have been reported to interact selectively
with ligand-gated ion channels, G-protein-coupled receptors (GPCR), receptor tyrosine kinases (RTK), and cell-surface steroid receptors. Signaling from these receptors to the ac-
tivation of PI3-kinase may exert neuroprotection by enhancing the expression of genes downstream of Nrf2, such as γ-glutamylcysteine synthetase (GGCS); suppressing Forkhead
(Foxo) transcriptional activation of apoptotic genes such as Fas ligand (FasL); and inhibiting GSK3β-mediated hyperphosphorylation of the microtubule-stabilizing protein tau,
thereby maintaining axonal function.
 R.J. Williams, J.P.E. Spencer / Free Radical Biology & Medicine 52 (2012) 35–45
Fig. 3. Signaling pathways underlying neuronal survival and cognitive performance. Flavonoids activate the ERK–CREB pathway and the PI3-kinase–mTOR cascade leading to
changes in synaptic plasticity and potentially angiogenesis/neurogenesis through the activation of eNOS. On the other hand they are known to inhibiting proapoptotic signaling
through the inhibition of JNK and ASK1. The inhibition of these kinases along with the activation of ERK1/2 leads to a suppression of apoptosis and neuroinflammation and thus
the neurodegeneration associated with them.
modulators of ERK signaling, such as PD98059 (2′-amino-3′-methoxy-
flavone). Such an activation of ERK results in downstream cAMP re-
sponse element binding protein (CREB) activation, which may result in
a number of beneficial changes, such as long-lasting changes in synaptic
plasticity and memory [137–139] and the up-regulation of neuroprotec-
tive pathways. For example, blueberry-induced enhancement of spatial
memory in old rats correlated well with increased CREB activity and
one of its target proteins, BDNF [74], both of which are linked to the con-
trol of synaptic plasticity and long-term memory.
Flavonoids also modulate PI3-kinase, via direct interactions with
its ATP binding site [140,141], and one of the most selective PI3-
kinase inhibitors available, LY294002, was modeled on the structure
of quercetin [142,143]. These studies also indicated that the number
of, and substitution of, hydroxyl groups on the flavonoid B ring and
the degree of unsaturation of the C2–C3 bond in the C ring are impor-
tant determinants of this particular bioactivity. In light of this, it
seems that interactions with this and other signaling pathways may
be structure-dependent, meaning that different flavonoids are likely
to express different cellular outcomes depending on their degree of
interaction with either receptors or downstream kinases. As an exam-
ple of this, the flavonol quercetin and some of its in vivo metabolites
were shown to inhibit prosurvival Akt/PKB signaling pathways by a
mechanism of action consistent with quercetin and its metabolites
acting at and inhibiting PI3-kinase activity [115], whereas flavanones
have been shown to activate Akt/PKB to confer prosurvival properties
[39]. In agreement with the latter study, supplementation of rodents with
blueberry has been shown to induce the phosphorylation of hippocampal
Akt, the activation downstream of mTOR, and the increased expression
of activity-regulated cytoskeletal-associated protein (Arc/Arg3.1) [74]
(Fig. 3). Such changes are highly likely to underpin enhancements in spa-
tial memory through the facilitation of changes in synaptic strength and
the induction of morphological changes [144], in particular changes in
neuronal spine density and morphology that are considered vital for
learning and memory [145]. In support of this, studies have indicated
that changes in neuronal morphology occur in response to flavonoid sup-
plementation [76] and that certain flavonoids can influence neuronal
dendrite outgrowth in vitro [146].
39
Flavonoid-induced changes in vascular function
There are a number of risk factors associated with both AD and
vascular dementia, including age, hypertension, arteriosclerosis, dia-
betes mellitus, smoking, arterial fibrillation, and the ApoE4 genotype
[147]. As such, modulation of these classical cardiovascular risk fac-
tors by flavonoids may result in lessening of both typical and atypical
reductions in cognitive function. Epidemiological data suggest that
this may be the case with flavonoids reported capable of preventing
many forms of cerebrovascular disease, including those associated
with stroke and dementia [11,12]. There is strong evidence to suggest
that flavonoids, in particular flavanols, are capable of promoting clin-
ically significant improvements in cardiovascular health through
their potential to lower blood pressure [148–152], improve endothe-
lial function [153–155], inhibit platelet aggregation [156–158], and
curtail the inflammatory response [159,160] after oral intake. Such
peripheral vascular changes will facilitate more efficient cerebral
blood flow (CBF), something that is known to deteriorate with age,
to be vital for optimal brain function, and to be decreased in patients
with dementia [161,162]. In this respect, flavanol-rich cocoa has also
been shown to exert a positive effect on CBF through the middle cere-
bral artery in humans [59,113,114]. In support of these findings, “ar-
terial spin-labeling sequence magnetic resonance imaging” also
indicates that flavanols increase CBF up to a maximum of 2 h after in-
gestion [163].
These vascular effects are additionally significant, as increased ce-
rebrovascular function is known to facilitate adult neurogenesis in the
hippocampus [164]. Indeed, new hippocampal cells are clustered near
blood vessels and areas of angiogenesis and proliferate in response to
vascular growth factors [165]. Angiogenesis itself is known to be ac-
companied by the production of endothelium-derived nitric oxide
and vasodilatation [166,167] and nitric oxide is a key regulator of vas-
cular remodeling and angiogenesis [168]. The vascular effects of flava-
nols and other flavonoids are partly mediated by their ability to induce
nitric oxide production in the endothelium [154,169], via a mechanism
involving the activation of endothelial nitric oxide synthase (eNOS)
[170–172] (Fig. 3). Flavonoids may activate eNOS by their ability to
40 R.J. Williams, J.P.E. Spencer / Free Radical Biology & Medicine 52 (2012) 35–45
induce the phosphorylation of Ser-473 of Akt, a kinase known to acti-
vate eNOS by its phosphorylation at Ser-1177. Therefore, it may be pos-
tulated that flavonoid-induced activation of Akt and eNOS in endothelial
cells may increase nitric oxide bioavailability in the vasculature of the
hippocampus leading to subsequent angiogenesis and neurogenesis
(Fig. 3). In addition, the presence of increased vascularization in the hip-
pocampus is likely to stabilize the presence of the new neurons [173]. In
this way flavonoids have much in common with exercise, which is
known to promote adaptive mechanisms in both the peripheral and
the cerebral vasculature, such as improved organ blood flow, induction
of antioxidant enzymes, and enhanced angiogenesis and vascular regen-
eration [174,175].
Protection against neurotoxins and neuroinflammation
The neurodegeneration observed in Parkinson disease (PD), AD, and
other neurodegenerative diseases seems to be triggered by multifacto-
rial events including neuroinflammation, glutamatergic excitotoxicity,
increases in iron, and/or depletion of endogenous antioxidants [176–
178]. There is a growing body of evidence to suggest that flavonoids
may be able to counteract the neuronal injury underlying these disor-
ders and thus slow the progression of the disease [40,179]. There is
good evidence to suggest that the consumption of green tea may have
a beneficial effect in reducing the risk of PD [180], as has been exten-
sively reviewed elsewhere [179,181,182]. The efficacy of green tea is
likely to be mediated by the effects of EGCG, which has been shown to
attenuate neurodegeneration induced by the parkinsonian toxins 6-
hydroxydopamine [183] and MPTP [184] and hippocampal injury in-
duced by transient global ischemia [185]. EGCG has been noted to inter-
act with and modulate signaling pathways involved in neuroprotection,
notably protein kinase C and PI3-kinase [21,186–188], and has been im-
plicated in reducing nigral damage via the chelation of free iron
[21,186,189–191], something also relevant to AD pathology [23]. In
vitro studies have also indicated that flavonoids might act to prevent
PD pathology via their ability to prevent the formation of the endoge-
nous neurotoxin 5-S-cysteinyldopamine [119,192–194]. Neuroprotec-
tive effects of flavonoids have also been observed in animal models of
Huntington disease, in which the flavonol fisetin has been reported to
be effective at reducing pathophysiology through its actions on the
ERK pathway [92,195,196].
Recent evidence suggests that nonsteroidal anti-inflammatory drugs
are effective at delaying the onset of neurodegenerative disorders, partic-
ularly PD [197]. As such, there has been an interest in the development of
new compounds with an ability to counteract neuroinflammatory injury
to the brain. The citrus flavanone naringenin has been shown to be high-
ly effective at reducing lipopolysaccharide/interferon-γ-induced glial
cell activation and the resulting neuronal injury, via an inhibition of the
p38/STAT-1 pathway and a reduction in inducible NOS (iNOS) expres-
sion capable of reducing the formation of neurotoxic levels of nitric
oxide [198]. The potential to inhibit nitric oxide production in activated
microglia is perhaps counterintuitive when we consider that flavonoids
have also been shown to induce nitric oxide production in endothelial
cells. However, it seems that similar, nanomolar, concentrations of flavo-
noids are, on the one hand, capable of inhibiting iNOS expression
(through an inhibition of p38 activity), while at the same time being ca-
pable of transiently activating eNOS (through the PI3-kinase/Akt path-
way). In support of this, blueberry flavonoids have also been shown to
inhibit nitric oxide, IL-1β, and TNF-α production in activated microglia
cells [199,200], whereas the flavonol quercetin [201], the flavones wogo-
nin and bacalein [202], and the flavanols catechin and EGCG [203] have
all been shown to attenuate microglial- and/or astrocyte-mediated nitric
oxide production and neuroinflammation. Their ability to exert such ac-
tions, again, seems to rely on their ability to directly modulate protein
and lipid kinase signaling pathways [133,204–206], proinflammatory
transcription factors [198,201], and the downstream regulation of
iNOS and cyclooxygenase (COX-2) expression, nitric oxide production,
cytokine release, NADPH oxidase activation, and oxidative stress. With
regard to the last, flavonoids have been shown to be effective at blocking
oxidant-induced neuronal injury [177], although not via direct radical-
or oxidant-scavenging activity [4,38,115,116,134,207]. For example, fla-
vanones, such as hesperetin and its metabolite 5-nitro-hesperetin, inhib-
it oxidant-induced neuronal apoptosis via a mechanism involving the
activation/phosphorylation of signaling proteins important in the pro-
survival pathways [39]. In addition a number of flavonoids, including
(−)-epicatechin and genistein/daidzein, have been shown to increase
glutathione production through PI3-kinase-dependent regulation of
Nrf2-mediated antioxidant response element activity [208,209].
Future directions
The consumption of flavonoid-rich foods, such as berries or cocoa,
throughout life may have the potential to limit or even reverse age-
dependent deteriorations in memory and cognition and to delay the
onset and progression of dementia. However, at present there are
not enough data to clearly associate flavonoid consumption with im-
provements in neurological health. Indeed, there are a number of im-
portant questions still to be resolved. Most notably, at present there
are limited data in support of a causal relationship between the con-
sumption of flavonoids and behavioral outcomes. To make such rela-
tionships, future intervention studies will be required to utilize
better-characterized intervention materials, more appropriate con-
trols, and more rigorous clinical outcomes. Although cognitive behav-
ioral testing in humans and animals provides an appropriate way of
assessing function, in vivo structural and dynamic quantitative as-
sessments will ultimately be required to provide hard evidence of ef-
fects in the brain. For example, it would be highly advantageous to
directly link behavioral responses to changes in hippocampal volume
and density, changes in neural stem cell and progenitor cell popula-
tions, molecular changes related to synaptic plasticity, and alterations
in brain blood flow using MRI and fMRI techniques. Functional MRI
measures may be used to assess changes in blood flow that underlie
improved cognitive functioning as a result of flavonoid supplementa-
tion. In addition, such hemodynamic changes may be further com-
pared to changes in gray matter density and to biomarkers of neural
stem and progenitor cells using proton nuclear magnetic resonance
spectroscopy. Such an approach will be essential to provide links be-
tween flavonoid intake and brain function in a mechanistic, dynamic,
and quantitative way.
Taking such an approach one may also be able to assess other fac-
tors relating to intake, such as what time frame is required to gain
maximum beneficial effects and which flavonoids, or flavonoid-
containing foods, are most effective at inducing these changes and
in which doses. It is highly unlikely that all of the many flavonoids
found within foods are equivalent with regard to their interactions
with molecular targets and in their abilities to induce brain/vascular
benefits. At present, the largest body of in vivo evidence exists for
the actions of flavanols (from cocoa, wine, grape, etc.) and anthocya-
nins (from blueberry, grape, raspberry, etc.), making it difficult to
draw solid conclusions as to which flavonoids are most potent. How-
ever, despite this a lack of efficacy data, investigations into the ab-
sorption and metabolism of various flavonoids/foods in humans
indicate that there are common pathways for the metabolism of the
majority of flavonoids, notably via their bacterial metabolism in the
large intestine [210–212]. This may mean that a wide variety of cur-
rently untested flavonoids and flavonoid-rich foods may also be capa-
ble of inducing vascular and cognitive benefits through the actions of
a common set of metabolic derivatives.
In relation to dementia it will be particularly important to investi-
gate the potential utility of flavonoids beyond their modulation of amy-
loid β pathology, particularly given the number of recent high-profile
phase 3 clinical trial failures with anti-amyloid β strategies. Although
some data exist to suggest an ability to modify tau pathology, this
 R.J. Williams, J.P.E. Spencer / Free Radical Biology & Medicine 52 (2012) 35–45
needs to be investigated in much more detail, as does the influence of
flavonoids on microglial activation in AD. In addition, it will be impor-
tant to give careful consideration as to whether supplementation with
individual flavonoids or flavonoid combinations or simply clearer die-
tary recommendations on flavonoid intake (including potentially a
“recommended daily intake” level) represents the best initial approach
for the rapid translation of these findings into effective interventions for
individuals affected by dementia. Despite significant advances in our
understanding of the biology of flavonoids over the past 10 years or so
they are still mistakenly regarded by many as acting simply as antioxi-
dants, and this is creating a significant barrier to the full development of
bioactive flavonoids at the preclinical level.
With respect to this, flavonoids are much more likely to thwart
both normal and disease-related losses in cognitive performance
through their actions on the brain's cellular and molecular architec-
ture of memory [5]. Compounds or drugs that are capable of enhanc-
ing the activity of CREB (Fig. 3) may be capable of facilitating memory
consolidation by promoting gene expression and changes in synaptic
morphology critical for long-term memory [213–217]. Such effects
could be achieved by targeting the CREB pathway at a number of
levels, including via the inactivation of enzymes that reduce CREB ac-
tivation, such as phosphodiesterase 4 [218]. In addition, molecules
that are capable of entering the brain and activating upstream regula-
tors of CREB, e.g., ERK and Akt, may also be considered excellent can-
didates for memory-enhancing drugs. Flavonoids, by way of their
ability to localize in the brain [74] and their capacity to activate ERK–
CREB and Akt–CREB circuitry [4,5], may be regarded as promising candi-
dates for the enhancement of memory. Clearly such drugs have the po-
tential to aid patients suffering from Alzheimer disease. However, drugs
that act on the CREB pathway should also be beneficial in treating many
types of memory dysfunction, including that associated with Parkinson
disease, stroke, or even normal age-associated memory deficits. As such,
flavonoids represent important precursor molecules in the quest
to develop a new generation of memory-enhancing drugs capable
of counteracting and perhaps even reversing age-related losses in
cognitive performance.
Acknowledgments
The authors are sponsored by the Biotechnology and Biological Sci-
ences Research Council (BB/F008953/1, BB/E023185/1, BB/G005702/1),
the European Union (FP7 FLAVIOLA), and the Alzheimer's Society.
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