cancer anorexia and cachexia correlate with a high mortality rate , poor response to chemotherapy , poor performance status , and poor quality of life ( qol ) , particularly in physical , psychological , and social functions in cancer patients [ 1 , 2 ] . anorexia , which is characterized by the loss of desire to eat or loss of appetite , causes weight loss and malnutrition in cancer patients [ 3 , 4 ] . cachexia is a multifactorial condition described by muscle loss , which is in part associated with loss of body weight , anorexia , asthenia , and anemia [ 5 , 6 ] . cachexia occurs in about half of all cancer patients , and lung and upper gastrointestinal tract cancer patients have the highest frequency of cachexia , whereas patients with breast and lower gastrointestinal tract cancer have the lowest frequency of cachexia . in addition , cachexia affects an ability of cancer patients to sustain chemotherapy or radiotherapy . however , current therapies for cancer patients with anorexia and cachexia are limited due to both poor efficacies and side effects of chemotherapeutics . sipjeondaebo - tang ( juzen - taiho - to in japanese and shi - quan - da - bu - tang in chinese ; sjdbt ) , commonly used traditional herbal medicines in korea , china , and japan , is composed of 10 species of herbs . sjdbt is prescribed for patients suffering from anemia , fatigue , anorexia , scaly skin , and dryness of the mouth [ 1113 ] . in addition , sjdbt has been known to have anticancer effects [ 1419 ] . nevertheless , its effect on cancer cachexia is poorly understood . here , we examined the effect of sjdbt on key parameters of cancer anorexia and cachexia and found that sjdbt ameliorated cancer anorexia and cachexia in vivo by altering body and muscle weights , food intakes , and levels of cytokines , hormones , rbc , hb , and hct in ct-26 tumor - bearing mice suffering from anorexia and cachexia , thereby suggesting that sjdbt may be useful for treating cancer anorexia and cachexia . sjdbt were prepared by and obtained from hanpoong pharmaceutical company ( jeonju , korea ) following the good manufacturing practices ( gmp ) procedures . sjdbt is manufactured as dried powder of hot water extract obtained from 10 herbs ( 320  g of angelica gigas , 320  g of astragalus membranaceus , 320  g of atractylodes japonica , 320  g of cinnamomum cassia , 320  g of cnidium officinale , 160  g of glycyrrhiza uralensis , 320  g of paeonia lactiflora , 320  g of panax ginseng , 320  g of poria cocos , and 320  g of rehmannia glutinosa ; average yield = 28.85% ) . the dried powders were lyophilized and then dissolved the three different doses ( low dose : 6.784  mg / kg , middle dose : 67.84  mg / kg , and high dose : 678.4  mg / kg ) in distilled water . ( seoul , korea ) at 6 weeks of age , and all mice were kept in pathogen - free environment . each group was divided into subgroups ( 5 prevention groups : normal , control , low dose sjdbt ( l - sjdbt of 6.784  mg / kg ) , middle dose sjdbt ( m - sjdbt of 67.84  mg / kg ) , and high dose sjdbt ( h - sjdbt of 678.4  mg / kg ) ; 6 treatment groups : normal , control , l - sjdbt , m - sjdbt , h - sjdbt , and megestrol acetate- ( ma- ) treated ) . animal studies were approved by the animal care center of kyung - hee university ( khuasp ( se)-12 - 048 ) . the murine ct-26 tumor - bearing mouse was widely used for cancer cachexia model . ct-26 colon carcinoma cell was obtained from the american type culture collection ( atcc ) ( manassas , va , usa ) and from dr . suk - chan lee ( department of genetic engineering , sungkyunkwan university , suwon , korea ) . for the prevention model of cancer - induced anorexia and cachexia , mice were injected s.c . with ct-26 cells ( 5  10 ) . a day after tumor cell injection , three different doses of sjdbt ( l - sjdbt , m - sjdbt , or h - sjdbt ) were p.o . added daily for 21 days . for the treatment model of cancer - induced anorexia and cachexia , mice were injected s.c . with ct-26 cells ( 5  10 ) and then three different doses of sjdbt ( l - sjdbt , m - sjdbt , or h - sjdbt ) were p.o . added daily for 21 days at 3 weeks after tumor cell injection ( figure 6 ) . ma ( santa cruz biotechnology , ca , usa ) was used as a positive control for anorexic effect and dissolved in corn oil ( 100  mg / kg ) . the measured quantity of food intake was divided by the number of mice to determine each intake per animal per day . at the time of sacrifice , whole blood samples were collected by cardiac puncture , and serum was obtained after being centrifuged from the whole blood . cytokines and hormones level were measured using a milliplex mouse metabolic magnetic bead panel mmhmag-44k-14 ( millipore , mo , usa ) in a luminex 200 . the blood samples were placed in vacutainer tm tubes containing edta ( bd science , nj , usa ) . blood analysis was performed using the hemavet 950 hematology analyzer ( drew scientific , inc . , p values less than 0.05 in two - tailed student 's t - test or one - way anova were considered statistically significant . to examine whether sjdbt prevents cancer - induced cachexia or treats cancer - induced cachexia , we divided into two groups ( figure 1 ) . a day when ct-26 tumor cells were injected into mice we found that control groups in each experimental set compared to the normal group showed reductions of body weights by approximately 14.8% and 36.8% , respectively , at 21 days after tumor cell inoculations ( figures 2(a ) and 2(b ) ) , confirming that the injection of ct-26 tumor cells resulted in the loss of body weight . sjdbt was treated for 21 days prior to cancer - induced anorexia and cachexia in the prevention model and treated for 21 days after cancer - induced anorexia and cachexia in a therapy model . as shown in figure 2(a ) , we found that l - sjdbt and h - sjdbt compared to the control increased body weights slightly by approximately 11.1% and 8.9% , respectively , while being not statistically significant . otherwise , when sjdbt were administered into mice after cancer - induced weight loss , m - sjdbt - treated mice compared to the control significantly increased the weight by approximately 36.6% ( figure 2(b ) ) . next , we performed experiments to determine whether sjdbt improves the appetite in a model of either prevention or treatment . l - sjdbt and h - sjdbt , compared to the control , ameliorated cancer - induced anorexia by approximately 25.3% and 25.1% , respectively , in the prevention model ( figure 2(c ) ) . in addition , m - sjdbt compared to the control significantly increased food intake in the therapy model ( figure 2(d ) ) . the control group compared to the normal decreased muscle weight by approximately 70% at 22 days after tumor cell injection and by approximately 87.5% at 43 days after tumor cell inoculation ( figures 2(e ) and 2(f ) ) . both l - sjdbt and m - sjdbt prevented tumor - induced loss of muscle weight in the therapy model , since muscle weights of tumor - bearing mice treated with each of them were higher than those of tumor - bearing mice untreated by approximately 4-fold ( figure 2(f ) ) . however , those were not effective in the prevention model ( figure 2(e ) ) . those results indicate that sjdbt may be effective for treating anorexia and for attenuating cachectic phenomenon , loss of muscle weight . furthermore , our data showed that m - sjdbt was much more effective than ma in the treatment of cancer - induced reduction of food intake , while ma has been used to treat anorexia . as proinflammatory cytokines such as interleukin-6 ( il-6 ) , monocyte chemoattractant protein-1 ( mcp-1 ) , and tumor necrosis factor- ( tnf- ) derived from tumor cells were associated with cancer - related anorexia and cachexia [ 21 , 22 ] , we next examined whether sjdbt affects serum levels of il-6 , mcp-1 , and tnf-. levels of il-6 and mcp-1 significantly increased in the control compared to the normal by approximately 480-fold and 91-fold , respectively ( figures 3(a ) and 3(b ) ) . in addition , m - sjdbt significantly inhibited cancer - induced induction of il-6 and mcp-1 by approximately 50.5% and 90.8% , respectively ( figures 3(a ) and 3(b ) ) . furthermore , mcp-1 level was uniquely altered in all tested doses of sjdbt . whereas the serum level of tnf- increased slightly in the control compared to the normal by approximately 1.7-fold , m - sjdbt compared to the control reduced tnf- level by approximately 41.4% while it was not statistically significant ( figure 3(c ) ) . these results suggest that m - sjdbt may ameliorate cancer - induced anorexia and cachexia by altering levels of cytokines such as il-6 and mcp-1 . as anorexia involves appetite - regulating hormones such as gut hormones ( glp-1 , pyy , and ghrelin ) and leptin [ 23 , 24 ] , we further examined whether sjdbt affects their levels in serum . levels of glp-1 and pyy significantly increased in the control compared to normal by approximately 1.3-fold and 20-fold , respectively ( figures 4(a ) and 4(b ) ) . m - sjdbt significantly inhibited cancer - induced induction of both glp-1 and pyy by approximately 63.2% and 44.9% , respectively ( figures 4(a ) and 4(b ) ) . those results suggest that m - sjdbt regulation of glp-1 and pyy may affect cancer - associated anorexia and cachexia . because cancer - induced anorexia and cachexia are a multifactorial syndrome including anemia , we measured levels of red blood cells in blood samples using hemavet 950 hematology analyzer . the control compared to the normal accrued anemia , which was measured by numbers of red blood cells ( rbc ; normal mice versus control mice ; 9.04  0.68  m/l versus 6.53  0.44  m/l ; p = 0.02 ) , hemoglobins ( hb ; normal mice versus control mice ; 16.91  1.15  g / dl versus 10.6  0.38  m/l ; p = 0.0001 ) , and hematocrits ( hct ; percentage of red blood cells in whole blood ; normal mice versus control mice ; 52.9  4.32% versus 32.53  2.68% ; p = 0.03 ) . l - sjdbt compared to the control significantly increased values of rbc , hb , and hct by approximately 18% , 34.7% , and 22% , respectively ( figures 5(a ) , 5(b ) , and 5(c ) ) . in addition , ma similarly affected those values , indicating that the treatment of anorexia might be linked to alterations of those values . while m - sjdbt compared to the control increased values of rbc , hb , and hct by approximately 7.6% , 24.5% , and 9.4% , respectively , those were not statistically significant . therefore , those results indicate that l - sjdbt may be a good remedy for cancer - mediated anemia . as herbal medicine therapy has been known to be beneficial with high efficacy and safety , market of herbal medicine therapy is growing in korea , china , and japan as well as in the united states . especially , herbal medicines are used for clinical trial and therapy in cancer patients [ 27 , 28 ] . however , biomedical scientists have limitations to use the herbal medicines due to the lack of evidence even in lab - based experimental studies . for example , sjdbt is widely used for cancer patients suffering from symptoms such as loss of appetite , fatigue , and anemia in korea , china , and japan [ 10 , 12 , 13 , 29 ] . however , its effect on the loss of either weight or food intake is still unknown . in this present study cancer - induced anorexia and cachexia involve proinflammatory cytokines such as il-6 , mcp-1 , and tnf- [ 21 , 22 ] . furthermore , it has been suggested that mcp-1 rather than tnf- is more important for cancer cachexia [ 22 , 30 , 31 ] . circulating level of il-6 is known to be important for keeping body weight and for survival in cancer patients [ 3234 ] . in our study , sjdbt reduced il-6 but increased mcp-1 , while it did not affect tnf-. thus , it is plausible that sjdbt may modulate effects of cytokines on cancer - induced anorexia and cachexia . meanwhile , glp-1 , pyy , ghrelin , and leptin are known as readouts for anorexia / cachexia . sjdbt significantly suppressed glp-1 and pyy levels , whereas it did not affect ghrelin and leptin . in sum , our data suggest that sjdbt ameliorates cancer - associated anorexia / cachexia by regulating cytokines ( il-6 and mcp-1 ) and hormones ( glp-1 and pyy ) . anemia is tone of common features of cancer cachexia [ 6 , 8 , 36 ] . especially , anemia is linked to the fatigue and qol in cancer patients . in addition , hb level is supposed to be related to qol . sjdbt increased values of rbc , hb , and hct , which further indicates that sjdbt is beneficial for treating cancer anorexia / cachexia . short - term reaction for food intake is mediated by peptides produced by enteroendocrine cells in the gastrointestinal tract . incretin hormones such as glp-1 mediate a response of the pancreas to nutrients , resulting in the reduction of food intake . furthermore , cancer - associated anorexia is caused by chronic stimulations via cytokines released from cancer cells or from host cells responding to cancer cells . furthermore , cytokines impair muscle and fat metabolisms , which is tightly linked to cancer - associated anorexia [ 42 , 43 ] . while cytokines such as tnf- and il-6 have been known to mediate cancer cachexia , sjdbt reduced il-6 level without altering tnf-. il-6 is known to cause the loss of lean body weight in ct-26 tumor - bearing cachectic mice by inducing proteolytic pathways . in addition , mcp-1 , the circulating level of which was altered by sjdbt , has been known to regulate leptin level in the adipose and to mediate cachexia [ 22 , 45 ] . therefore , it is plausible that sjdbt may target cytokine production in cancer cells , which may result in modulations of hormone levels . however , we could not exclude possibilities that sjdbt may target multiple sources including cancer cells , cancer - associated immune cells , adipocytes , and hypothalamic neurons . recent studies have revealed functional relationships between cytokines ( il-6 and mcp-1 ) and hormones ( glp-1 and pyy ) [ 4651 ] . thus , it remains to be deciphered molecular and cellular mechanisms of sjdbt to ameliorate cancer - associated anorexia and cachexia . our study demonstrates that the sjdbt ameliorates cancer - induced anorexia and cachexia in ct-26 tumor - bearing mouse model by altering the production of il-6 , mcp-1 , pyy , and glp-1 . our in vivo studies first provide evidence on the role of sjdbt in cancer - associated anorexia / cachexia , which suggests that sjdbt may be useful for patients with cancer - associated anorexia / cachexia .
cancer - associated anorexia and cachexia are a multifactorial condition described by a loss of body weight and muscle with anorexia , asthenia , and anemia . moreover 
 , they correlate with a high mortality rate , poor response to chemotherapy , poor performance status , and poor quality of life . 
 cancer cachexia is regulated by proinflammatory cytokines such as interleukin-6 ( il-6 ) , monocyte chemoattractant protein-1 ( mcp-1 ) , and tumor necrosis factor- ( tnf- ) . 
 in addition , glucagon like peptide-1 ( gip-1 ) , peptide yy ( pyy ) , ghrelin , and leptin plays a crucial role in food intake . in this study , we investigated the therapeutic effects of one of the traditional herbal medicines , sipjeondaebo - tang ( juzen - taiho - to in japanese ; sjdbt ) , on cancer anorexia and cachexia in a fundamental mouse cancer anorexia / cachexia model , ct-26 tumor - bearing mice . 
 sjdbt was more significantly effective in a treatment model where it was treated after anorexia and cachexia than in a prevention model where it was treated before anorexia and cachexia on the basis of parameters such as weights of muscles and whole body and food intakes . 
 moreover , sjdbt inhibited a production of il-6 , mcp-1 , pyy , and glp-1 and ameliorated cancer - induced anemia . 
 therefore , our in vivo studies provide evidence on the role of sjdbt in cancer - associated anorexia and cachexia , thereby suggesting that sjdbt may be useful for treating cancer - associated anorexia and cachexia .