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The Herbal Minefield

July 18, 2010

Herbal Medicine.

This is such a difficult topic.  The Herbologists are always trying to convince the public they are a viable alternative to “real” medicine and the doctors are always trying to convince the public that all Herbologists are quacks.  Since I am a medical doctor, anything I might say which denigrates supplements or herbal “remedies” is often looked upon with some incredulity, as if MDs weren’t willing to face the “facts” about remedies other than the ones we provide.  I promise you that if true evidence shows that an herbal “remedy” is found to to cure any medical problem in a superior fashion, compared with the current drug pharmaceuticals, we as doctors would be on it like white on rice!  We are all about curing disease with the fewest side effects as possible.  The paragraphs below are based entirely on the scientific research.  The facts.  Not the folklore, myth or traditions which permeate herbal medicine.  I will show you what they can do, and more importantly, what they can’t do.

This blog entry is long and I am going to separate this blog into two parts.  The first part is going to be a warning and description of the true minefield that is Herbal Medicine.  The second part will be a resource guide of the herbal products which are probably worth considering along with a list of “popular” herbal products that are being used, probably without any scientific basis.

A small bit on “The Placebo Effect”.  There are people who are “Placebo Responders”.  What this means is that they can take a substance which has no drug effects whatsoever, and get a real physiological response, because they truly believe the “drug” works.  This is not a sham effect.  The mind is a very powerful thing, and the “mind over matter” idiom is a real one in some cases.  There are many people, largely placebo responders, who swear by certain remedies because they work for them.  The fact is, they really do work for them! This is why it is really important that any scientific study have a placebo control group; to make sure the “drug” works better than the placebo.  The literature on “Herbal Remedies” is full of bad science; largely done by “pseudo-scientists” who do not know how to design a Double-Blind Placebo Controlled Study, or know how to control the study for extraneous variables.  As an example, there have been 108 published studies on the effects of 5-HTP for depression, obesity and headaches.  Of the 108 studies, only 2 fulfill the criteria for a properly designed scientific study, from which you can take away valid medical information.  Unfortunately, the herbologists will refer to these 108 studies as real science, indiscriminately.

The Minefield

Portions of this section have been heavily influenced by the writings of Dr.Stephen Barrett and the position paper of the NCAHF (National Council Against Health Fraud).

Americans spend billions of dollars every year for capsules, tablets, bulk herbs and herbal teas.  The majority of these are purchased/consumed for their supposed medicinal qualities.  Pharmacies and health-food stores offer many products that are obviously intended for self-medication with or without the aid of a professional practitioner of any kind.  Herbs are also marketed, for profit, by naturopaths, acupuncturists, iridologists, chiropractors and herbalists; many of whom prescribe them for the entire gamut of health problems (with or without any scientific proof that they work).  The vast majority of these practitioners are not qualified to make appropriate medical diagnoses or to determine how the products they “prescribe” compare to the proven drugs.  Most are unlicensed (and many of these occupations have no licensing program).

Herbal advocates will point out that about half of the drugs on the market today came from plants.  This statement is true, but it is also misleading.  Drug products contain specified and measured portions of active ingredients.  Herbs in their natural state can and do vary greatly from batch to batch and contain dozens or hundreds of other chemicals, in unknown concentrations, that may cause side effects but provide no benefit.  The idea that “natural” means fewer side effects or more “safe” is not only incorrect, it is less correct than if the statement were made about pharmaceutical products.  The “real drugs” have been tested rigorously and we know what the side effects and possible toxicities are, which helps us to screen for them and identify them when they occur.  This is not the case for herbal products.

When potent natural substances are discovered in plants, the drug companies try to isolate them and synthesize only the active chemical from the plant; the portion that is actually providing a benefit, eliminating the other possibly toxic chemicals.  This allows them to place a reliable dose of the chemical into each pill.  They will also then try to identify derivatives of these plant products which might produce enhanced effects and fewer side effects or toxicity, making them both safer and more potent than their natural counterparts.  Many herbs contain thousands of uncatalogued/untested chemicals.  Some of these chemicals may prove to be helpful and useful therapeutic agents.  The vast majority will be found to be inert or toxic.

Little Public Protection

In the United States, herbs intended for preventative or therapeutic use would/should be regulated as drugs under federal law.  To evade this law, these products are marketed as “foods” or “dietary supplements” without health claims on their labels.  Since these are not regulated as drugs, no legal standards exist for their processing, harvesting, packaging or purity.  In many cases, particularly for products with expensive raw ingredients, contents and potency are not accurately disclosed on the label.  Many products marked as “herbs” contain no useful ingredients, and some even lack the principle ingredient for which the people buy them!  Investigations by Consumer Reports, The Los Angeles Times, Good Housekeeping Institute, The University of Arkansas, D-Magazine and even The AMA Archives of Internal Medicine all identified that the majority of herbal supplements did not contain the stated amount of the active ingredient, and often were under or over the stated amount, from 0% of the stated ingredient to as much as 135% of the stated amount, leading to dramatic overdosing.  The American Medical Association study discovered that only 57% of 880 tested products were using ingredients and dosages that had been studied in published research.  While some manufacturers are trying to develop industry-wide quality-assurance standards, it would appear that such standards are a long way off.

The Dietary Supplement Health and Education Act of 1994 included herbal products in its definition of “dietary supplements”, even though the herbs have little or no nutritional value (the Bill was spearheaded by the health-food industry in order to weaken FDA regulation of its products).  This included herbal or other botanical ingredients; including processed or unprocessed plant parts (bark, leaves, flowers, fruits and stems) as well as extracts and essential oils.  They may be marketed alone or combined with other ingredients such as other herbs, vitamins, minerals, amino acids or non-nutrient ingredients.  Products containing multiple herbal ingredients may produce adverse effects which are impossible to predict since the resulting concoction might contain thousands of ingredients with an almost infinite source of chemical interactions.  A 1999 survey by Prevention magazine found that 12% of herbal remedy users reported adverse reactions (and the actual number who experienced them is probably much higher).  This number is approximately the same as those found with pharmaceutical preparations.

It gets worse. The manufacture and prescription of over-the-counter drugs is closely regulated by the FDA, but herbal products are not (see above).  Thus, even when an herbal product is found to be toxic, it may not be removed from the marketplace since the FDA does not have the power or authority to do so!  When the FDA concludes that an herb is dangerous, it usually issues a warning rather than a ban.

It gets even worse. For many years, the FDA Center for Food Safety and Applied Nutrition maintained a database of reports the FDA had received about adverse events associated with the use of supplements and herbal products.  However the database is no longer posted because the FDA could not be certain that the reported problems were caused by the products! Oy vey!!

Unreliable Information

To make a rational choice about an herbal product, it would be necessary to know what it contains, whether it is safe and whether it has been demonstrated to be as good or better than the pharmaceutical products available for the same purpose. This is not complicated.  It is rational and lucid, yet this information is not available for the vast majority of herbal products.  Even worse…the information which is available is unreliable.  The late Varro E. Tyler, former Dean of the Purdue University School of Pharmacy and leading authority on pharmacognosy (the science of medicines from natural sources), observed:

More misinformation about the safety and efficacy of herbs is reaching the public currently than at any previous time, including the turn-of-the-century heyday of patent medicines.  The literature promoting herbs includes pamphlets, magazine articles and books ranging in quality from cheaply printed flyers to elaborately produced studies in fine bindings with attractive illustrations.  Practically all of the writings recommend large numbers of herbs for treatment based on hearsay, folklore and tradition.  The only criterion that seems to be avoided in these publications is scientific evidence.  Some writings are so comprehensive and indiscriminate that they seem to recommend everything for anything.  Even deadly poisonous herbs are sometimes touted as remedies, based on some outdated report or misunderstanding of the facts.  Particularly insidious is the myth that there is something almost magical about herbal drugs that prevents them, in their natural state, from harming people.

A study published in 2002 found that many web sites located by searching for “herbs and “cancer cure” contained illegal claims.  It is probably good policy to avoid getting advice about herbal products from sources who have a financial interest in the sale of those herbs.  You would be leery of a doctor who promoted a specific drug if they made money from its sale, right?

Harvard University did an in-depth study to evaluate claims made by 443 web sites located by searching for information about 8 widely used herbal supplements (Ginko Biloba, St Johns Wart, Echinacea, ginseng, garlic, Saw Palmetto, kava kava and valerian root).  This research concluded:

  • 338 of the 443 sites (76%) were retail sites that were selling the products or directly linked to a vendor.
  • 273 of the 338 retail sites (81%) made 1 or more health claims, with 149 (55%) claiming to treat, diagnose or cure specific diseases.
  • 153 of the 292 (52%) of the sites that made health claims omitted the legally required standard federal disclaimer regarding making such claims.
  • Only 52 of the 443 sites (12%) provided referenced scientific information without a link to a distributor or vendor.

Harvard determined that consumers were likely to be misled by vendors’ claims that the herbal products can treat, prevent, diagnose or cure specific diseases despite regulations prohibiting such statements, since no such proof exists for their products.  They warned physicians to be aware of this widespread misinformation which was so easily accessible to the public.  Harvard also stated they felt more effective regulation was required to put this class of therapeutics on the same evidence-based footing as other medicinal products.  They were equally aware that the industry would collapse under such scrutiny since the vast majority of such products could not stand up to the same scrutiny required for pharmaceutical drugs.

The involvement of drug companies into the herbal marketplace may improve standardization of dosage for a few products.  Additionally, the professional and public interest in such products is likely to stimulate more research in the near term.  However, with safe, proven, highly scrutinized and effective medicines available to treat these same conditions for which herbs are recommended, it doesn’t usually make sense to use the herbs except in rare circumstances such as allergies or intolerances to the drug formulations.  As well, many of the conditions for which the herbs are recommended are not suitable for self treatment.

Reliable Sources of Information

For those of you who wish to delve into natural medicine with reliable scientific information, the following sources of information are good starting places:

The Natural Medicines Comprehensive Database is available online and in print.  it costs $92/year (or $151 for both versions).  The online version is updated daily, while the print version is updated several times yearly as new information comes into existence.  A review of the book in 1999 covered almost 1000 herbs and supplements, of which only 15% had been proven safe and only 11% had been proven effective.

AboutHerbs – This database from the prestigious Memorial Sloan-Kettering Cancer Center has more than 300 entries about herbs, supplements and “alternative” cancer treatments.  Each item provides details about constituents, adverse effects, interactions and potential benefits or problems.  “Professional” and consumer versions are provided, but most of the professional information is readily understandable by laypersons.  The articles have less information than their counterparts in the database mentioned above, but they are researched and written well.

ConsumerLab.com does product evaluations, including laboratory tests of ingredient levels.

RESOURCE GUIDE FOR HERBAL PRODUCTS

Ok, 1800 words which probably scared the crap out of you.  Sorry about that.  It was a necessary evil before I go on to talk about the herbal products which might actually help you.  It is imperative for the reader to understand that the herbal remedies I will discuss below are not a replacement for real medicine. They are neither as safe or as good as the drugs which we use to treat these problems.  I will repeat that.  They are neither as safe or as good as the drugs we use for these problems.  They are useful adjuncts to real medicine, or replacements for people who cannot tolerate the medicines, or for people who have extraordinarily mild versions of these illnesses that the “real” medicine is not necessary.  Anyone who tells you that the herbal products are either safer or better than real medications is just not learned in the field, and is doing a disservice to both you and themselves.

So what supplements might be useful?  I’m glad I asked!

The Players

The supplements which are listed in this section comprise a group that has real usefulness.  They have been proven to be safe and efficacious although most of them have efficacy which is quite limited (i.e.  they work, but not very well).  Not to be a broken record, but please remember that these supplements do not replace real medications and their use should never supplant real diagnoses and treatment by a licensed physician.  Since there are very few studies showing which doses are best, and most supplements cannot be trusted to have a consistent amount of the actual active ingredient, patients will have to follow the directions on the supplement and pray.  Let The Buyer Beware.

Fish Oil – Perhaps the king of supplements.  Fish Oil is probably the most useful of the dietary supplements.  It has been shown to be both safe and efficacious in the treatment of high Triglycerides.  It is so good in this regard, that the pharmaceutical industry has created their own version in a drug called Lovaza, available by prescription only.  The supplement version works, but the prescription version works better with fewer side effects (and fewer calories, actually).  This supplement does give some people a fishy breath and has a heavy Pill Burden (i.e. you have to down a lot of the tablets in order to get enough to bring down the Triglycerides, one portion of the cholesterol panel.  The prescription version purifies the good portion of the Omega-3 Fatty Acids, allowing a smaller pill burden, less fish breath and more cholesterol-lowering for fewer calories.

Red Rice Yeast – This one works and lowers LDL cholesterol (the “bad” cholesterol).  The active ingredient in Red Rice Yeast is identical to the active ingredient in the cholesterol medication Lovastatin (trade name Mevacor in the class of medications called “statins”).  Only short-term studies have been completed, so none can tell us if the supplement is safe in the long term.  The short term studies show cholesterol lowering of unpredictable amounts.  This is not unexpected since supplements have varying amounts of active ingredient from sample to sample as mentioned earlier.  The problem with Red Rice Yeast is that there is a reason why Mevacor is a prescription medication; it has a variety of potential toxicities and multiple drug-to-drug interactions.  Some of these interactions can be life threatening.  While we have a firm grasp on the long term safety of Mevacor, there are hundreds of other substances in Red Rice Yeast and we do not know if they are safe.  People who take statins (or Red Rice Yeast) absolutely need regular blood testing to ensure that liver toxicity is not occurring and to monitor for other side effects.  You can use this one, but do so under the supervision of a physician.  Honestly, you can probably save yourself money, and treat your cholesterol more effectively and safely by using one one of the generic prescription statins.

Green Tea – Another player, Green Tea has been studied for its anti-oxidant properties.  While it has been purported to fight cancer, cause weight loss, lower cholesterol and cure heart disease, the truth of its health benefit is still unclear due to less than ideal methods used in the studies, which have mostly been done in Eastern countries.  What is clear is that there is some potential for this supplement to modestly lower LDL cholesterol, reduce your risk for cancer and possibly reduce your risk for heart disease.  Do not confuse these statement with “Green Tea Cures Cancer” or “Green Tea Prevents Heart Disease” or “Green Tea Lowers Cholesterol”.  The benefits seen in the studies were very modest and probably require enormous quantities of the Green Tea to be ingested to see any effect at all.  You probably could not drink enough Green Tea in liquid form to see measurable benefits.  They have Green Tea capsules which are a concentrated form of the Catechins (the active ingredients in Green Tea).  This allows someone to ingest the equivalent of a dozen cups of Green Tea, in a couple capsules.  Green Tea can be toxic to the liver, so should not be taken by someone who has any history of liver problems, and probably should be used with caution in someone taking multiple medications which are metabolized by the liver.

St. Johns Wort – This herbal substance is used to treat depression.  Whoa!  Even if this supplement works, depression is a disease that absolutely requires the diagnostic and therapeutic skills of a trained physician.  You should never try to treat depression without the advice of a physician, especially with herbal substances which may have little or no benefit.  So does St Johns Wort work?   There is some scientific evidence that St. John’s wort is helpful in treating mild to moderate depression. However, two large studies, one sponsored by the National Center for Complementary and Alternative Medicine (NCCAM), showed that the herb was no more effective than placebo in treating Major Depression.  NCCAM is currently studying the use of St. John’s wort in a wider spectrum of mood disorders, including minor depression.  It appears that St. Johns Wort has mild activity as a Seratonin Uptake Inhibitor, so it is functioning like a very weak form of the modern antidepressants like Prozac, Zoloft or Lexapro.  St Johns Wort can cause irritability, insomnia, high blood pressure, stomach upset and increased sensitivity to the sun.  It can also interact with some prescription medications, so be sure to tell your doctor you are taking it!

Saw Palmetto – This extract of a type of Palm Tree is used to treat the symptoms of enlarged prostate glands in elderly men.  One study showed it was no better than a placebo, but 2 other studies showed mild relief to men who used it, but inferior to the prescription drug Finasteride, which shrinks the prostate gland over time.  In my experience, it does help men who have mild symptoms of an enlarged prostate (e.g.  difficulty initiating a urinary stream, urinating frequently or inadequate urine flow), but when their prostate glands enlarge beyond this initial state, it appears to have little or no effect.  Rarely, Finasteride can cause erectile dysfunction, and the Saw Palmetto appears to do this less.  While the studies on Saw Palmetto are scant, this supplement appears to be pretty safe, with only some occasional indigestion.

Melatonin – This hormone is derived from the natural substance in the human body which usually stimulates the  production  of Melanin, the pigment that darkens our skin when we tan.  It has been used for decades for sleep problems.  Specifically, it appears to be most helpful for those individuals who have to reset their natural clocks due to jet lag or working odd shifts at work.  When someone goes to sleep at the same time every day, this substance appears to have less benefit as a sleep aid.  This supplement works.  There is even a pharmaceutical version called Rozerem which uses a derivative of Melatonin.  Is it safe?  Probably.  There has been some concern that stimulating melanocytes would lead to higher risk for Melanoma, a deadly skin cancer.  This concern is probably overblown.  If Melatonin works for you, it is probably a safe way to treat insomnia and it certainly appears to be most useful for people trying to get their internal clocks back in order!

Ginko – This is a really tough paragraph to write.  Ginko definitely has some beneficial effects in the scientific literature, but it also has a long list of side effects and drug interactions.  Ginko has possible beneficial effects on memory and memory-related diseases like Alzeimer’s Dementia.  It probably has beneficial effects on Raynaud’s Syndrome, dizziness or balance disorders, PMS and Glaucoma.  In addition, it thins the blood and thus can aid in the pain associated with poor blood flow to the legs (Claudication).  Sounds like a wonder drug, eh?  Unfortunately, the possible beneficial effects in these conditions are small though measurable.  It has also been used to counteract the sexual side effects of anti-depressant medications, but studies seem to show Ginko doesn’t work for this.   It has also been clearly shown not to help any form of depression, altitude sickness or tinnitus (ringing in the ears),  anxiety, Attention-Deficit Disorder, hearing loss, high cholesterol, atherosclerosis, cancer or Chronic Fatigue Syndrome; all diseases for which Ginko has been touted as a cure. Now, onto the long list of problems with Ginko.  Since it thins the blood, it can cause all manner of bleeding problems including worsening the effects of a stroke, or bleeding problems from trauma.  It  also causes easy bruising, indigestion, constipation, allergic skin rashes and headache.  Possible other serious side effects include seizures, worsening diabetes, bleeding during pregnancy or childbirth, infertility and bleeding during surgery.  The use of the raw ginko seeds has been associated with shock and death.  Given some of the possible beneficial side effects, I am including this supplement in the “beneficial” category, but I strongly warn against its over-use and suggest vigilant observation for side effects or toxicity.

The Pretenders

This group of supplements are probably not helpful, but probably also not harmful.  You are probably throwing away good money, but you are probably not going to hurt yourself in the process!  This list also contains supplements which don’t appear to be helpful, but the studies are inconclusive.

Echinacea – Here’s one we all hoped would pan out!  There was a study in the Journal of Family Practice back around 1996 that showed Echinacea shortened the course of viral upper respiratory illnesses by several days (i.e. the common cold).  Rejoice!  A way to treat a cold!  The vast machinery of the drug companies went into full gear, trying to capitalize on this possible “real” drug to help cure the common cold caused by the myriads of viruses for which there are currently no treatment.  Unfortunately, these larger and better-designed studies showed fairly conclusively that Echinacea has no effect whatsoever on the duration of the common cold.  Folklore also claims that Echinacea has effects on Attention-Deficit Disorder, indigestion, migraines, arthritis and rattlesnake bites!  The good news is that Echinacea appears to not have significant side effects.  The bad news is that there is really no scientific evidence that it has any medicinal qualities whatsoever.

Co-Enzyme Q-10 – This supplement is purported help in providing cardiovascular health, and possibly enhance the immune system to fight cancer.  While these benefits have not been proven directly in any study, there is some indirect evidence that it may be helpful.  Scientists have found low levels of Q10 in people who have cancer.  While this does not mean that taking Q10 will decrease your chance of getting cancer, or enhance your ability to fight it, it is noteworthy of further study.  Its benefit for heart disease, and specifically on heart failure have been largely dismissed by scientific studies.  Tradition has also spoken of its ability to help with periodontal disease and muscular dystrophy, but these claims have also not been born out in scientific studies.  Thus, how Q10 might help you is hazy at best, but deserves more scientific study.  Unfortunately, Q10 can have some significant side effects including liver toxicity, insomnia, nausea, abdominal pain, headache, heartburn, fatigue, irritability, sensitivity to light and dizziness.  It can also interact with a variety of prescription medications in a variety of ways.  All in all, I think the jury is still out on this one, but I would avoid it until more studies are done.

Garlic – Garlic has been claimed to have beneficial effects on heart disease (by lowering “bad” cholesterol) and reducing the risk of cancer.  Herbal traditions going back hundreds of years show “Medicine Men” using Garlic as an anti-infective.  There have been a number of poorly designed scientific studies which showed some mild cholesterol reductions.  In 2007, the NIH (National Institute of Health) did a large-scale properly designed scientific study which found that the consumption of garlic in any form did not reduce blood cholesterol levels in patients with moderately high baseline cholesterol levels.

According to the Heart.org, “despite decades of research suggesting that garlic can improve cholesterol profiles, a new NIH-funded trial found absolutely no effects of raw garlic or garlic supplements on LDL, HDL or Triglycerides… The findings underscore the hazards of meta-analyses made up of small, flawed studies and the value of rigorously studying popular herbal remedies.”

5-HTP – Also called 5-Hydroxytryptophan.  This amino acid is a precursor to the production of both Melatonin and Seratonin.  It is thought that 5-HTP would increase the amount of both of these substances in the body.  The effects of Melatonin have been described above.  Seratonin (or rather, the lack of it) has been associated with depression, and 5-HTP has been used to help people with this diagnosis.  Trying to decide if 5-HTP is helpful or not  has been a real difficulty.  As mentioned earlier in this blog, there have been 108 studies about 5-HTP but only 2 of the 108 have been considered “good science” and useful in determining if the substance is either helpful or safe.  While many of the 108 show benefits for depression, Friedrich’s Ataxia, Fibromyalgia, anxiety, binge eating and insomnia,  the two studies that were deemed of sufficient quality did not deal with 5-HTP exclusively, instead combining results for 5-HTP and tryptophan, so the results may not be completely applicable for 5-HTP alone. While the combined analysis of these two studies showed significant effectiveness over placebo in treating depression, the authors state that overall “the evidence was of insufficient quality to be conclusive”.  They also state that “because alternative antidepressants exist which have been proven to be effective and safe, the clinical usefulness of 5-HTP and tryptophan is limited at present”.  Like many other herbal supplements, it has not been studied enough to know if significant drug-to-drug interactions might exist; but given its possible mechanism of action, it is very likely that there are significant effects on other drugs.  Excessive seratonin has been shown to cause hypertension, heart valve damage, nausea, Seratonin Syndrome (a potentially serious problem) and lowered libido (and associated inability to achieve orgasm in women and erectile dysfunction in men).  Since you can never know how much 5-HTP is present in any over-the-counter supplement, I would avoid this supplement since there are pharmaceutical alternatives available that do the same thing in a known and safe fashion.

The Liars

The following supplements appear to have side effects and toxicity which are in excess to any possible benefit (for which none have been proven, scientifically).  Avoid these supplements.

Valerian Root – This herbal remedy has been touted as a treatment for insomnia, irritable bowel syndrome and anxiety.  Some studies show that it interacts with the receptors in the brain, in an unknown fashion.  These receptors are the same ones that many sedatives stimulate (such as the Benzodiazepines which include Valium and Xanax and the Barbital drugs like Phenobarbital).  There are very few good studies on this herbal remedy.  A recent article in the Journal of Sleep Medicine states, “Most studies found no significant differences between valerian and placebo either in healthy individuals or in persons with general sleep disturbance or insomnia”.  Since there are associated side effects, such as night terrors, agitation and headaches, this is an herbal “remedy” which is best avoided.

Kava Kava – The studies on Kava Kava are scant, but the herb seems to have an effect not unlike the sedatives in the Benzodiazepine class as noted above for Valerian.  It seems to promote restful sleep and have some effects on anxiety.  Its use is diminished by known liver toxicity, even in healthy people, including some deaths.  It can also cause a scaly rash, shortness of breath and facial swelling.  All in all, I cannot find any reason why this herb should be ingested for any of its purported uses (which have not been proven in any reasonable scientific study).

Zinc – Zinc tablets and nasal spray (i.e. Zycam) are on the market, also claiming to treat your cold.  Again, like Echinacea, there was a small study about 15 years ago that showed a mild shortening of the duration of viral upper respiratory infections.  Follow up studies showed no such benefits. Further, they showed that the medication could cause neuropathy and even a complete or partial loss of the ability to smell.  This is another one to avoid.  In general, high doses of any trace metals (like Zinc, Selenium, etc..) should be avoided.

There are far more supplements available than I have written about here, of course, but these are the most common ones.

Costs

With the cost of medical care skyrocketing, many people might think that prescription remedies are too expensive, and they turn to herbal remedies because they feel it will be a cheaper means of treating their symptoms or disease.  In fact, herbal remedies are very expensive.  Amongst the drugs used to treat the diseases for which there is a legitimate herbal alternative, there are very inexpensive generic alternatives (i.e.  think $4 at Wal-Mart generics).  These include medications for enlargement of the prostate, depression, cholesterol, etc.  In most cases, believe it or not, the generic drugs will be a fraction of the cost of the herbal alternatives.  There is a reason the business of supplements is a billion dollar industry.

When using dietary supplements, keep in mind the following (quoted from WEB MD):

  • Like conventional medicines, dietary supplements may cause side effects, trigger allergic reactions, or interact with prescription and nonprescription medicines or other supplements you might be taking. A side effect or interaction with another medicine or supplement may make other health conditions worse. Always tell your doctor or pharmacist about all dietary supplements you are taking.
  • The way dietary supplements are manufactured may not be standardized. Because of this, how well they work or any side effects they cause may differ among brands or even within different lots of the same brand. The form of supplement that you buy in health food or grocery stores may not be the same as the form used in research.
  • Other than for vitamins and minerals, the long-term effects of most dietary supplements are not known.

I expect there will be naysayers who will read this blog; stalwart supporters of Alternative Herbal Care.  I have done my best to lay out the objective facts based on the studies available.  I am sure we will discover other herbal remedies which show benefit, or ones being used currently for which we will finally get enough data on to support their use.  The harsh reality is that the vast majority of herbal supplements are, at best, unhelpful…and at worst, potentially toxic.

Never use herbal supplements to treat real medical problems without discussing your condition with a licensed physician.

Good Health!

Dr Mike

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12 Comments
  1. Bobby permalink

    Interesting and useful article.

  2. BigLeeH permalink

    While I quite agree with everything you say it is worth remembering that by insisting that a proposed treatment be better than placebo to be considered effective one is setting the bar rather high. Study after study shows that the placebo proves to be an effective treatment in a significant percentage of the cases, often giving good relief of symptoms in one-third of the population. When a drug does better than placebo that is quite an accomplishment because the placebo is often pretty darn good.

    That said, I think there is a helpful role to be played by herbalists in the treatment of conditions for which the more-rigorously scientific medical field has gotten little or no traction. People should by all means go to their doctor first but in those cases where he admits that he’s got nothing, then the herbalists can step in with their vague, anecdotal assurances that their snake oil helps in many cases. As long as it is harmless and not ruinously expensive, and it doesn’t pull people away from better alternatives, there is nothing particularly wrong with a treatment that is *exactly* as good as placebo.

    The downside of evidence-based medicine is that in those cases where placebo is the best treatment the doctors don’t offer it.

  3. Those people ought to be given a sugar pill then, since we know that’s non-toxic, and let the placebo effect do its thing. You are right, up to 1/3 of people are placebo responders (though 5-10% is more common for anything other than pain). As the mantra goes, first do no harm 🙂

    The exceptions, in my mind, are for incurable diseases where there is very little downside and nothing but upside (and possible discovery for others)!

    • BigLeeH permalink

      I remember once, when I was poking around in a shop that sells such things, coming across a bottle of capsules that claimed to contain “oxygen molecules” (no doubt packed in nitrogen to preserve freshness.) I didn’t buy any since they had a non-zero cost and oxygen molecule capsules are contraindicated for people with an above room-temperature IQ — but if you think about it, they are otherwise the perfect placebo, much better than your sugar pills which might be bad for diabetics.

      As for “incurable diseases” I expect you have in mind those that are also likely to be fatal. By the time you get to be my age — which, judging by your profile photo may be a while — you will undoubtedly have accumulated several incurable diseases of a lesser sort. These are the annoying conditions for which you would seek treatment if a safe and effective treatment had been identified but your doctors assure you there are none. Since these “incurable” diseases won’t kill you — at least not right away — there is a downside and considerations of safety do apply, but if the available research and common sense suggest a tolerable probability of safety then it is rational to review the flawed and inconclusive research that does exist for herbs, supplements and off-label use of over-the-counter medicines and allow oneself to hope. Without a coating of hope the sugar pills don’t work.

  4. I have occasionally opted to refrain from expressing an opinion of certain alternative medicine choices made by people I’ve encountered for precisely the reason that I don’t wish to unnecessarily kill their placebo effect. I make my decision based on my relationship with the individual (are they likely to listen to me anyway?), the cost of their alternative medicine and whether they seem like they can afford it, and whether the condition they are treating with it seems to need more legitimate medical attention. It’s a tough call, and I will all way give my honest, and skeptical, opinion if asked for it. But if I feel that no great harm is being done, and my opinion is not being asked, I may keep my mouth shut.

    Dr. Mike, your blog is, as always, thorough, smart and invaluable.

  5. Tracy permalink

    I am not going to really dispute your thoughts against herbal treatments, as it seems that much of what you say is there is misinformation, incomplete information or not evidence of effectiveness with these alternative medicines. All of which is true – which does not actually make herbal supplements more or less effective (or toxic). It means we haven’t done the research, we don’t have the proof and we don’t know everything this substances will do. What I did want to address is this statement:

    “the drug companies try to isolate them and synthesize only the active chemical from the plant; the portion that is actually providing a benefit, eliminating the other possibly toxic chemicals. This allows them to place a reliable dose of the chemical into each pill. They will also then try to identify derivatives of these plant products which might produce enhanced effects and fewer side effects or toxicity, making them both safer and more potent than their natural counterparts.”

    I think that when you are talking about the active ingredient, this may be true. However, I think far too many over the counter drugs have additional ingredients in them that the doctor does not consider when prescribing. Preservatives, fillers, chemicals, dyes – and they are all discounted because the drug is “tested” and it is “safe”. Sure – the main ingredient is – but what about all the other stuff in there. Also, far to many physicians (not you Dr. Mike) do not consider the patient holistically. I have had blood pressure medication that was clearly shown to increase allergic reactions – and I have high blood pressure as a symptom of – a food allergy! So – although I think you make an excellent point here that herbs have many chemicals that are not being considered when taking them for there “main” benefit – so do drugs. And I further think that this is a more insidious problem with prescription drugs because these are considered “safe” and the other ingredients in them are not carefully scrutinized in many cases.

  6. There are absolutely fillers in all prescription and over-the-counter meds. For the vast majority of people (not you, unfortunately), these are largely chemically inert (calcium carbonate or preservatives to maintain potency) and are a drop in the ocean compared to the hundreds (or thousands) of untested/unknown compounds that are in all herbal supplements. The difference is magnificent and of vital importance to understand because it is one of the primary reasons herbal remedies are less safe than the pharmaceutical counterparts. So while this does occur to some extent with pharmaceutical drugs, it is orders of magnitude less of a problem than with herbal supplements.

    Your specific situation is unusual, and unfortunate, and requires a very special touch by your physician(s).

  7. Michelle R. Gould permalink

    I’ve had bad reflux from high doses of Echinacea, so it’s not without side effects. Glad to know about the Zinc – I wondered about the ineffectiveness. Did not know about the Rozerem/Melatonin connection. I was told Melatonin isn’t as effective when it’s used regularly, and that seems to bear out, at least from my personal experience. I’m curious that you didn’t mention Hops, which features regularly in most herbal sleeping potions I come across. Also curious about Glucosamine Chondroitin (sp?), which my mother is forever trying to get me to take, and which is prohibitively expensive.

    • Glucosamine and Chondroitin were found in 2 small studies in the 90s to help mild arthritis and to have no effect on moderate and severe arthritis. A much larger study done in the last 5 years showed no effect on arthritis of any severity. I’ve had patients who swear by it. The data is clearly not complete on this supplement. You can stop taking the echinacea, it clearly does nothing for anyone.

  8. Good to know, great work

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