The trouble with herbals

October 6th, 2007 by Ben Goldacre in bad science, herbal remedies | 103 Comments »

Ben Goldacre
The Guardian
Saturday October 6 2007

The news this week that herbal remedies can be ineffective or dangerous is boring: but come with me on a journey through time (time… time…) to the origins of medicine.

Herbs contain bioactive compounds. That’s why they can be effective, but it’s also why they can have side effects (some will inactivate your contraceptive pill, others will cause renal failure). Huge numbers of bioactive compounds extracted or derived from plants are used today in medical practice, including even common stuff like aspirin. There is little difference between herbal medicine and medicine in terms of what is used, only in how.

Digoxin in foxglove is very good at treating atrial fibrillation, a common kind of irregular heart movement. Unfortunately the dose range is very narrow, so it’s really quite easy to kill your patient. From the moment of its discovery, pharmacologists worked hard to standardise the dose.

They started with standardised preparations of the plant, but this proved dangerously inconsistent, because the quantity of the active component in foxglove was so variable, so new strategies were developed: standardised preparations of each batch of plant were tested in animals first, to work out how potent they were, and so on. Eventually we worked out how to extract the digitalis, and it could be weighed out.

Now people do careful studies of large numbers of patients on digoxin to see which dose is most beneficial, to understand how it works, and careful monitoring of side effects takes place, from individual clinicians writing about their concerns in medical journals all the way up to the yellow card system, where doctors and even patients can send in their concerns to the MHRA, however trivial or unproven they may be.

This process of enquiry, and standardisation, and testing, and verification, and negative findings, and dismissal of ineffective methods, and more, is one of the great developments in medical and intellectual history. Many people were disappointed along the way, as their ideas and theories were proved to be unfounded. Digoxin pills and foxglove both contain the same ingredient, but it is how they are managed and handed over that differs.

Until a herbal practitioner can show that giving a whole plant instead of an extract really is better, they’re making stuff up when they make those claims. Similarly, until they can show that using herbs at such low doses that they have no measurable effect is somehow beneficial, beyond the placebo (and placebo is great by the way) then they’re shooting with the stars.

But there are structural problems in the way that herbalists work: they have failed – over millennia – to collectivise, so they do not work together on research, but rather as independent commercial traders. They do not move to university settings, where the culture of critical self-appraisal might infect them, and possibly extinguish them too, if their ideas don’t stand up.

And where alternative therapists do move into universities, they wall themselves off from the most valuable influences. CAM therapists don’t rub shoulders with colleagues from other disciplines, who could share ideas and insights with them, and move ideas forward, or help brush the bad ones aside. The alternative medicine university courses I have approached have simply, flatly, refused to tell me the most basic things, like what they teach and how.

It’s because of this culture, not funding, that the “research” on herbal remedies is inadequate. Huge numbers of “trials” are produced, at great expense, but the trials are inept, they are not “fair tests”, they have inadequate “blinding” and “randomisation”, positive results alone are “cherry-picked”, and worse.

An inept trial, bound by design to give a false positive result, costs just as much as a fair test of a treatment. And these problems are endemic: one study looked at the entire cannon of research on traditional Chinese medicine, and found 1100 papers: not one single trial published in China, in the entire history of research into traditional treatments, had ever found a test treatment to be ineffective. Not a single one.

Herbal pills contain bioactive compounds which can have real effects, but it is these differences of style, not content, that divide alternative therapies from medicine: and it will ever be the same.

References:

Do certain countries produce only positive results? A systematic review of controlled trials.
Vickers A, Goyal N, Harland R, Rees R.
Control Clin Trials. 1998 Apr;19(2):159-66.

A systematic review of randomised clinical trials of individualised herbal medicine in any indication
R Guo, P H Canter, and E Ernst
Postgrad. Med. J., Oct 2007; 83: 633 – 637.


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103 Responses



  1. Mongoose said,

    October 14, 2007 at 11:15 am

    Ben Goldacre writes that herbalists need to provide evidence that giving a whole plant instead of an extract or active ingredient is a better idea. Bear with me…

    We know that single bioactive compounds can be used medicinally because of the experimental methods developed by medical science. These methods have been specifically developed to test the effects of single bioactive compounds on our bodies. However, it is one thing to say ‘we have an experimental method that enables us to develop medicines from single bioactive compounds’, but it is another matter entirely to say, as medical scientists do, ‘therefore, all medicines must be single bioactive compounds’. This is simply false logic. Unfortunately, this is the mind-set of the medical orthodoxy. They have reached a point half way up the mountain, planted a flag and called it the summit. Instead of viewing their method as useful but limited, they have set up camp and attempted to impose its limitations on the world. This is the approach of the fundamentalist and the anti-scientist…

    If we followed Ben Goldacre’s ‘digitalis=digoxin’ argument to its logical conclusion we would be asking greengrocers why we should consume whole fruits and vegetables as opposed to pills containing the active ingredients. Fruit and vegetables also contain a number of toxic compounds that can be isolated, concentrated and used to kill rodents (for example, isothiocyanates in the brassica family; tropane
    alkaloids in potatoes, tomatoes, and peppers; opiates in lettuce; prussic
    acid in stone fruits etc.). Perhaps we should close down the greengrocers… Just as the human race has consumed certain fruits and vegetables for thousands of years, so it has used whole herbs medicinally. The knowledge of what works and what doesn’t has been passed down the generations – this is the knowledge of experience – and to many people this is sufficient evidence to use herbs medicinally.

    The ‘digitalis=digoxin’ example implies that herbs contain a single active ingredient that can be isolated, concentrated and administered in a pill. This is simply not true. In many cases the so-called ‘active ingredient’ of a herb is unknown (for example, Vitex agnus-castus) or there are a number of contenders (for example, hypericin and hyperforin in St John’s Wort). Herbalists use the concept of ‘synergy’ to explain the action of whole herbs medicinally. The idea is that the various compounds that make up a herb work together to produce various medicinal effects. Therefore, isolating ‘active ingredients’ not only reduces a herb’s efficacy, it is also potentially harmful. An experimental method of testing the idea of ‘synergy’ is yet to be developed, but that doesn’t mean it won’t happen. Remember we’re only half way up the mountain…

    Orthodox medicine’s criticism of herbalism is old hat. Requiring herbal medicine to prove efficacy using methods designed to develop medicines from single bioactive compounds is never going to work. Herbalists shouldn’t even attempt to play a game where the rules are skewed in favour of the other team. In any case, it’s not a competition.

  2. Ben Goldacre said,

    October 14, 2007 at 11:18 am

    sure.

    have you got any evidence to show that giving a wholeplant as a herbal medicine is better than giving an extract?

    i’m not saying it doesn’t exist, i’d just be more interested to read it than this slightly dreary bombast.

  3. Robert Carnegie said,

    October 14, 2007 at 4:14 pm

    Isn’t the natural behaviour of a plant to poison anyone who eats it, until we learn not to eat it? Except for those that we have tamed and learned to defuse. Which bits to eat, which not. Potato fruit for instance.

  4. Gramlin said,

    October 14, 2007 at 4:31 pm

    There appears to be no reason not to conduct a study using, lets say Hypericum (St. John’s Wort) in which half the subjects receive a standardised extract and the other half receive an equivalent amount of whole herb – from the same crop as the extract was obtained. Who shows most improvement? Let’s see.

    Repeat this for other herbs, blinded and controlled for, obviously.

    My herbalist friend, whom I already mentioned, blamed the peer-review process for research not getting “through” to mainstream, but when I suggested the above, he went on about the lack funding instead. So which is it? Either the studies are flawed due to lack of funding (so don’t blame peer review) or they are not (in which case they will pass peer-review).

  5. gonzo said,

    October 15, 2007 at 9:48 am

    Ayurvedic Medicine is the primary health care system in India and a few other countries and serves nearly 1 billion people. It uses methods developed over 5,000 years which bear little relationship to western medicine. A large part of this system is the use of herbs for healing. The herbs and how they should be prepared and used are published in “The Ayurvedic Pharmacopoeia of India” in 5 volumes. These are “legal” documents. Modern Ayurveda has identified more than 1200 useful plants. Different parts of the plants are used in complex hetrogeneous mixtures. www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1.section.95686

    None of these concoctions has ever been tested in the West by random double blind controlled trials. Are we to conclude then this whole healthcare system is unsound? Are these so called remedies ineffective, or worse make people ill? How can a system that treats so many people be so flawed?

  6. Mongoose said,

    October 15, 2007 at 1:55 pm

    Good to see that my patellar reflex is in good working order…

    Let me join the dots for you on the whole plant vs extracts issue:

    Herbalists use whole plants medicinally. Medics use single bioactive compounds medicinally. Why should herbalists who use whole plant medicine provide evidence of efficacy for extracts, even if these are from plants? Single bioactive compound research is orthodox medicine’s area of speciality. If you want evidence for the efficacy of active ingredients from plants, then speak to medical scientists, don’t ask herbalists. Extracted, concentrated active ingredients are no longer ‘herbs’.

    Orthodox drugs were originally synthesised from plant extracts (like digoxin), but we don’t call them ‘herbs’ and herbalists can’t prescribe them.

    Kindly stop pestering herbalists for evidence that is not theirs to provide. I

  7. Gramlin said,

    October 15, 2007 at 6:31 pm

    Ben’s point was that someone needs to prove that a whole plant is *better* than an extract, before they go around saying that it is.

  8. gonzo said,

    October 15, 2007 at 6:40 pm

    The original article makes an interesting subtle turn of logic. There are herbs, and other things in nature, which when concentrated are dangerous. Some of these are used in medicine and are dose critical. The false logic in the orinal article is that because some substances need tight control, then all substances do. Many substances are not that dose critical and the herbal substances that can cause harm in excess are well documented.

  9. gonzo said,

    October 15, 2007 at 7:15 pm

    Gramlin,
    Depends how you define “better”. The main issue in my mind is side-effects. I’ve seen people crippled with the side-effects of statins for example. I believe herbals do not to have side effects (at least not to the same extent). In my book that makes them “better”, but they will not be as powerful or may take longer to become effective. I can call to mind an example. I sometimes used to get colds that went onto my chest and I could not get rid of the damn thing for ages, and eventually had to go to the docs for anti-biotics. Last year the same thing happened again, but instead of going to the docs I thought I’d try echinacea (6 caps in one day). On rising the next day, I ejected a most revolting load of green phlegm and that was an end to it. Not a single cough after that. In my mind it was “better” than the anti-biotics because it was much faster and anti-biotics can cause gut dysbiosis. Also, sometimes the antibiotics in the past had been completely ineffective and I’d had to go back for more. My doc says he has to keep changing them because I could become sensitive to the same one and eventually they would not work. Now I take Echinacea at the first sign of colds/sore throat and it always helps. The Mayo clinic says “A National Center for Complementary and Alternative Medicine study released in 2005 found that echinacea did little to prevent or shorten colds.” The clinic also says “Most studies indicate that zinc reduces the duration of cold symptoms but doesn’t prevent colds. However many of the zinc studies — both those that find the mineral beneficial and those that do not — have been flawed”. Why do we have so many flawed studies? They cost so much, you think we’d have learned to get them right by now! My point is that just because there is no study backing it up does not mean it does not work.

  10. Gramlin said,

    October 15, 2007 at 9:23 pm

    I never said these things don’t work, and neither did I ask about additional bonuses, such as fewer side effects.

    Don’t misunderstand me. All I asked was for evidence to show that treatment using a whole plant is more effective than treatment using an extract from the *same* plant.

    It’s a claim herbalists make, and is pretty crucial, so why not prove it true?
    It was Ben’s point, not mine, I believe.

  11. Ben Goldacre said,

    October 15, 2007 at 10:01 pm

    i’d actually really be interested to see some evidence for whole herb vs extract, i assume there must be some somewhere? all this stuff about using stuff at low doses so there is no effects or side effects and anecdotal little stories is like the homeopathy nonsense.

    seriously, herbalists, whole herb vs extract, please, we want to read about it, give us some evidence.

    if there is some you dont have to deliver it in a triumphalist tone, just post the journal reference.

  12. gonzo said,

    October 16, 2007 at 12:42 am

    “anecdotal little stories is like the homeopathy nonsense”

    What do you mean by that? Please explain

  13. gonzo said,

    October 16, 2007 at 12:50 am

    Gramlin,

    >>Don’t misunderstand me. All I asked was for evidence to show that treatment using a whole plant is more effective than treatment using an extract from the *same* plant.

  14. gonzo said,

    October 16, 2007 at 12:57 am

    Sorry , I did not realise this blog truncated so abruptly.
    I’ll try again.. >>Don’t misunderstand me. All I asked was for evidence to show that treatment using a whole plant is more effective than treatment using an extract from the *same* plant.>someone needs to prove that a whole plant is *better* than an extract,

  15. gonzo said,

    October 16, 2007 at 12:59 am

    Sorry , Arrows seem to upset this bolg, I’ll try try again.. !!Don’t misunderstand me. All I asked was for evidence to show that treatment using a whole plant is more effective than treatment using an extract from the *same* plant.!! No you did not. you said !!someone needs to prove that a whole plant is *better* than an extract, !! But you did not define *better than*. More effective is not the same thing. What do you mean by more effective? Works quicker? Cures more people? Please be precise.

  16. Gramlin said,

    October 16, 2007 at 9:20 am

    OK, I’ll try again too.

    (I actually said someone needs to prove it *before* they go round *saying* it – that’s what I asked for).

    Lets set aside value judgements like “better” for a minute. What research has been done on the difference between administering a whole plant compared to an extract from the *same* plant? Not compared to pills or drugs, exactly, simply between whole herb vs. standardised extract?

    For example, my herbalist friend asserts that using whole Kava Kava is safer than using an extract of kavalactones, because, I’m told, the natural glutathione present in Kava supports the liver against the otherwise toxic kavalactones. Whether this is an evidence based belief or a conjecture I do not know.

  17. gonzo said,

    October 16, 2007 at 12:12 pm

    I’m not sure that anyone would ever undertake that research per se on account of ethics. Kava has been used as an infusion in the South Pacific for a long time without reports of negative effects. The kava extract on the other hand has given rise to reports of liver disease. Users are warned about excessive dose. This paper asserts the same www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T8D-4GK1GJN-2&_user=10&_coverDate=08%2F22%2F2005&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=7413d0b60a377516b680f0bf6ca638d6
    This report looks into kava induced liver disease www.cdc.gov/MMWR/preview/mmwrhtml/mm5147a1.htm
    It asserts that the issue is the concentration of kava pyrones. The issue as Ben points out in the original article is not the safety of the original plant, but its efficacy. Extracts can be much more powerful and so their dose must be controlled. Doses from the original plant can be variable.
    “someone needs to prove it *before* they go round *saying* it ” Individuals obviously do not have the resources to prove things for themselves. So they will deduce things for existing research. Obviusly, I agree that all statements should be supportable with evidence. In this case, IMHO there is evidence to support your herbalist friends statement (but you may disagree – as you are entitled to do).

  18. Gramlin said,

    October 17, 2007 at 10:13 am

    Thanks, hope I didn’t muddy the water by bringing kava into it specifically. I mentioned it only because its something I have personally enjoyed using.

    I’m fairly familiar with the cases you cite.

    Thing is, traditionally kava is used for pleasure, for celebrations, for ceremonies, not healthcare, so a long historical use tells us nothing about the efficacy of kava for treating anxiety or insomnia.

    Also, it is traditionally prepared by everyone standing around, chewing it up, and spitting into a bowl. I don’t think it has ever been used in the west this way.

    Indeed, simply ingesting the plant without chewing is not supposed to release the kavalactones. So at best an an alcohoic tincture is prescribed, if not a standardised extract.

    All I’m saying is, there’s a gulf between what we know for certain about Kava and what is claimed. Perhaps chewing with human saliva is the process which renders kava safe. Does this make it more or less effective for healthcare? We do not know. Most of the cases of harm did involve other drugs or alcohol, apart from the two cited in those studies, so even the evidence that kava harms the liver is inconclusive, in my veiw.

    Not enough research.

    Which is a pity, because I for one would like to use it again.

  19. Mongoose said,

    October 17, 2007 at 2:25 pm

    So the debate continues: is a whole herb more or less than the sum of its active ingredients?

    Nobody cares! Herbalists certainly don’t and neither does the pharmaceutical industry because (newsflash!) they wouldn’t be able to recoup research costs by patenting a naturally occurring chemical compound…

    Furthermore, you cannot directly compare a whole herb to its active ingredient extract because a herb is a herb and a chemical is a chemical and never the twain will meet. To say, for example, digitalis=digoxin is to commit a category mistake and is meaningless. But hey! We’re in Ben Goldacre’s bad science universe – enter through the crack in the fabric of logic and don’t forget to take your broccoli pills.

    Have you heard the latest? Herbalists and Homeopaths are colluding to drive down the dosages of their remedies in order to make them ineffective – someone call the Competition Commission!

    Ben Goldacre and his ilk evince a nasty combination of arrogance and ignorance. Don’t respond to the drivel he writes and don’t participate in his inane debates, it just encourages him. Think of your own mental health…

    Over and out.

  20. Ben Goldacre said,

    October 17, 2007 at 2:31 pm

    Wow.

    Am I correct in thinking that little temper tantrum was precipitated simply by someone asking for a reference?

    It really is another universe…

  21. Mongoose said,

    October 17, 2007 at 3:42 pm

    Ingenious response from Ben Goldacre – deflection – it works every time…

    References? Google not working for you? If you can’t find any, then they don’t exist – for reasons outlined above.

    I’ve had more satifying interactions with my dog.

    Back to the universe of sane people…

    This time it really is over and out.

  22. gonzo said,

    October 17, 2007 at 4:18 pm

    Mongoose,

    As a reader, I just thought I’d mention that your contribution was much appreciated by me. I came in late to this debate, but I’ve learned a lot.

    Chill. Take some herbals

    Ben is a past master at handling himself – you really did not expect to make an impression did you? He’s bullet proof.

    I’ve spent years trying to discover why people who deride CAM therapies do so. I believe that they believe they are a waste of time or money making scams or else they are put up to it by the pharamas. There is no easy answer – they have their world view and I have mine, which is decidely different.

  23. Gramlin said,

    October 17, 2007 at 5:37 pm

    Gonzo,

    I’m not sure whether the outright ban on kava was justified by the data either.

    But have you ever tried preparing it with just water? Drinking an infusion made with water does not produce a sensation, while chewing it, on the other hand, produces an immediately noticeable numbness in the mouth. I’ve no idea whether this is the active ingredient being extracted, but there is definitely something extra from chewing.

    Whatever the truth of it, even if the ban on Kava was implemented hastily, I don’t think we have the data to conclude anything regarding its efficacy as a herb beneficial to health, nor can we answer the question with regard to whole plant vs. extract, as the traditional usage, millennia-long though it may be, is markedly different
    to modern western consumption. Too many unknowns. More data needed. Although it is the case that I would still feel fairly confident about chewing it up and consuming it myself, there is no way I’d recommend anyone to do so, especially not as a treatment for a medical condition.

    Ben’s insistence on research is far from unreasonable, its the only responsible way to approach this kind of thing.

  24. gonzo said,

    October 17, 2007 at 6:55 pm

    Of course. Research is the way we move foward our understanding. However, sometimes evidence comes from observation and deduction, and that’s all there is.

    I thought a bit about this question and concluded that for some hebal remedies, dose is not too big an issue, but for others it is. We know that humans are sensitive to nightshade, hemlock, foxglove etc., and for these dose is crucial when being administed as a medicine. The extract method does this. So I do not think there is an answer, all substances have to be taken on their merrits.

    I do think it strange though that a herbal interfering with a medicine is thought of a “side-effect” of the herbal. I know grapefruit interferes with some medicines (makes them too powerful) – does that mean grapefriut has “side-effects”?

  25. Gramlin said,

    October 17, 2007 at 8:51 pm

    And it might well transpire that in some cases extracts have greater efficacy, while in other cases whole herbs do.

    Regarding grapefruit, yes, I would say that any unwanted effect is a side effect (sustenance or pleasure being the desired effects from grapefruit, presumably).

  26. gonzo said,

    October 17, 2007 at 9:05 pm

    Exactly

  27. Ben Goldacre said,

    October 17, 2007 at 9:46 pm

    you’re talking about interactions, not side effects.

  28. gonzo said,

    October 17, 2007 at 9:53 pm

    “Herbs contain bioactive compounds. That’s why they can be effective, but it’s also why they can have side effects (some will inactivate your contraceptive pill, others will cause renal failure).”

    So is inactivating a contraceptive pill an interaction or a side-effect?

  29. Ben Goldacre said,

    October 17, 2007 at 10:01 pm

    jesus.

    it’s an interaction.

    can i just say: it sends an actual chill down my spine that the herbalists posting here didn’t know that.

    you prescribe things to patients all the time which have potentially very serious interactions, many of your patients will already be on other medications, and you don’t even know the word.

    brrr.

  30. gonzo said,

    October 17, 2007 at 10:29 pm

    For me, the real issue about herbals is the side effects. St. John’s wart is known to interact with anti-depreseants and other medications, which is why you should not mix the two. It can also have the self-same side effects as prescription medicine. However, the reaction differs in different people (some are better off with St. John’s wart, some with prescrption medicine).
    I thought the options were set out quite well in this article. www.mamashealth.com/mental/johndep.asp

    Like everything it’s horses for courses.

    Ps. I have a Hypericum bush in my garden. I’m not about to dig it up – caps are much easier (not that I’m depressed).

  31. gonzo said,

    October 17, 2007 at 10:31 pm

    Ben,

    Don’t be daft, of course I new it was an interaction, but research would revel that I am not indeed a herbalist.

  32. Gramlin said,

    October 18, 2007 at 10:03 pm

    Indeed:
    muppet.wikia.com/wiki/Gonzo

  33. Robert Carnegie said,

    October 20, 2007 at 11:24 am

    “wart”?

  34. Gramlin said,

    October 23, 2007 at 10:40 am

    Ben,

    I’ve been pressing my herbalist friend on evidence for the concept of “synergy” but sadly he seems too busy to provide me with actual links to studies, which he is adamant do exist.

    The example he keeps raising it that of St. John’s Wort. This, he says, is demonstrably effective as an SSRI (and has a similar influence on dopamine as it does on sertonin) but he maintains that medical science, despite having proved this, does not now how or why it works. According to him, no extract of the plant functions as an SSRI, only the mysterious combination of chemicals in the whole herb.

    I am wondering why capsules are sold with a standardised level of hepericin in this case.

    What are you thoughts on this? My research skills are not awesome, but I do intend to try and find whatever studies might be available.

    Meanwhile, I did listen to a Podcast from Sciantific American last month, on which an ethnobotanist gave a fascinating description of his job, liaising between drug companies and indigenous peoples, using their tribal lore to pinpoint potential combinations of herbs that might have synergistic effects amenable to research. This seemed like rather a turn around to me, so it caught my attention.

    You can hear that here:
    www.sciam.com/podcast/podcast.mp3?e_id=1E5B6D81-E7F2-99DF-3A1431B73A41F3B9&ref=p_sciam

  35. Gramlin said,

    October 24, 2007 at 10:57 am

    Right, OK then, I have done my best, scouring Pubmed and other sources for any sign of a study that compares the efficacy of whole herb Hypericum P. (St John’s Wort) treatment of depression with that of isolated compounds, but I can find no such thing.

    For sure, Hypericum contains a vast array of compounds capable of exerting a serotonergic or dopaminergic effect upon the nervous systems of humans or animals, and some studies do suggest that the compound hyperforin is especially active in these roles. While it must be the case that a whole-herb treatment will include action by many or all of these compounds, I have been completely unable to uncover any research that compares the efficacy of compounds to each other or combinations of the same.

    Certainly these things are amenable to research, and the individual effects of certain compounds has been studied, as has the efficacy of the whole herb when compared to standard pharmaceutical treatments. And yet, there seems to be nothing to support or refute the claim that a whole herb treatment has greater efficacy, or is preferable on some other grounds, when compared to isolated compounds. Neither does there seem to be anything to suggest that a designed combination of compounds would necessarily be inferior to a naturally occurring one.

    I tried, but I just don’t think the research has been done.

  36. gonzo said,

    October 25, 2007 at 1:45 am

    www.hbcprotocols.com/study2.html

    www.hypericum.com/

    Have fun,

  37. Gramlin said,

    October 25, 2007 at 10:14 am

    Gonzo, you misunderstand. I am aware there a numerous studies comparing whole St. J’s Wort to other pharmaceuticals.

    However, I was attempting to answer Ben’s point, which was, “Until a herbal practitioner can show that giving a whole plant instead of an extract really is better, they’re making stuff up when they make those claims.”

    My friend suggested that Hypericum was just such an example. So I trawled through every study I could find. What I discovered were studies that a) show the whole plant works, and b) studies that show parts of the plant work; but no studies looking to see whether the whole plant works better than parts of the plant alone, or in what circumstances this would be true.

    Had I found such a study, I would also have wanted to ask, can we also test a *designed* combination of constituents against a naturally occurring combination of constituents, to see if we cannot improve upon the combo found in nature.

  38. gonzo said,

    October 26, 2007 at 1:06 am

    Ben’s point is a trueism. I do not think it can be answered or disputed. If one cannot justify a point, it must be made up (or copied from a source that made it up). (and note as stated it does not preclude any way of justifying any claim).
    I really don’t understand how you hope to answer the point.

  39. Gramlin said,

    October 26, 2007 at 2:22 pm

    Ultimately we can always refine our knowledge, yes, I was simply interested in whether anyone had bothered to do studies comparing these things. It appears not.

    I’m not a fan of any approach to knowledge that says, “we can’t know everything, therefore don’t bother trying to know anything,” nor am I particularly keen on an approach that says, “You don’t know which is best, therefore my way is best.”

  40. gonzo said,

    October 26, 2007 at 4:15 pm

    I think you are right about no studies having been done. I had a look at white willow compared to aspirin. I could not find any of these either, but in studies of white willow vs pain killers, white willow had significantly fewer side effects, but may not have been as effective.

  41. Gramlin said,

    October 27, 2007 at 6:03 pm

    Interesting. But as aspirin is exactly the same chemical as is found in white willow bark, I now want to answer this: are there fewer side-effects because it is a weaker dose, or is some additional ingredient responsible? Should it be the latter, would extracting this additional ingredient and administering along side aspirin allow for strong effect AND fewer side effects, or not?

  42. gonzo said,

    October 27, 2007 at 10:00 pm

    I’m not sure how you would tell that.
    This link says “A typical daily dose of salicin is 60 mg to 120 mg. In some studies, doses up to 240 mg per day have been used without apparent side effects”. www.drugdigest.org/DD/PrintablePages/herbMonograph/0,11475,4111,00.html

    This paper (page 330s) says that there was a small but significant increase in gastric bleeding at doses as low as 75mg/d of aspirin.
    www.chestjournal.org/cgi/reprint/102/4/327S.pdf

    I don’t know what the relationship between salicin and aspirin is, but at face value, it would appear to be the other components of white willow that protect. (but white willow can have side-effects too).

  43. Gramlin said,

    October 27, 2007 at 10:16 pm

    Salicin is a single molecule extracted from willow, not the whole plant. It is chemically very close to aspirin, though not identical.

    The difference in dosage and efficacy may not be completely comparable.

    The aspirin I have in my cupboard is in 300mg capsules, and up to three may be taken at once, up to four times a day. Perhaps the intestinal bleeding you mention is from prolonged use?

    If white willow bark is used whole, say as a tea, then several thousand milligrams of whole herb are used. The advice is to have no more than three cups a day, as it is not possible to say how much salicin is in the actual herb.

    It’s all too vague to really compare, but the safe dose of salicin you quoted has nothing to do with what’s in white willow as a whole, as it is only one chemical extracted from the plant being discussed there.

  44. Robert Carnegie said,

    October 28, 2007 at 1:01 am

    It’s also assuming that the unspecified no-side-effects studies on willow would have detected gastric and/or intestinal bleeding – btw which is it, as far as I recall it’d be the stomach but I’m not a doctor or a scientist.

  45. gonzo said,

    October 28, 2007 at 1:54 am

    “the safe dose of salicin you quoted has nothing to do with what’s in white willow as a whole, as it is only one chemical extracted from the plant being discussed there.”

    I thought that was the point: comparison of the active herb ingedient vs the active ingedient in aspirin.

    To get some sort of answer to your question, you need the active ingredient in the herb to exceeed the quantity of active ingredient in the drug and the herb to be safe and the drug to have side-effects. Or the converse (herb is only safe at low dose of active ingredient).

    “Perhaps the intestinal bleeding you mention is from prolonged use? ” I’m sure that is so. But the article did state that this is the most significant side-effect.

    Yes Robert, that may be so also.

    I only posted for interest, conclusive results are going to be hard to find.

  46. Mongoose said,

    November 2, 2007 at 7:34 pm

    Salicins are found in a number of plants including white willow and meadowsweet. Salicins are converted into salicylic acid by the body when ingested.

    Aspirin is acetylsalicylic acid and is a synthetic derivative of salicylic acid.

    Salicylic acid and acetylsalicylic acid are different compounds and have different effects on the body – comparing them is like comparing apples and oranges (like I tried to say earlier…)

  47. Gramlin said,

    November 5, 2007 at 9:26 am

    It is fairly easy to ascertain the differences between apples and oranges though – that is definitely amenable to research.

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  49. AmbientGravity said,

    January 11, 2010 at 8:18 am

    (Thank you Ben, I have had many laughs reading Bad Science over the last week, even though I’m officially in the enemy camp) Re: Give me some evidence that giving a whole plant is frequently a better idea.

    I guess one plant only needs to be better (more efficacy, without more side-effects)in one scenario to prove that such a possiblity exists.

    Natural complex substances are often attributed “superior” effects to constituent chemicals because of synergy, a concept not unique to plant medicine. I find it curious that almost all conventional medicines are single chemicals when synergy is such an appealing notion – more bang for your buck! Of course there are a few mixed drugs, and not all mixtures are synergistic.

    Synergy in the action of plants has been demonstrated in three distinct ways:

    1 Synergy between herbal constituents in one plant
    2 Synergy between herbs
    3 Synergy between a herbs and a conventional medicine

    Here is the abstract from a 2001 review

    Here is the abstract from a review of synergy in plant medicines:

    Synergistic interactions are of vital importance in phytomedicines, to explain difficulties in always isolating a single active ingredient, and explain the efficacy of apparently low doses of active constituents in a herbal product. This concept, that a whole or partially purified extract of a plant offers advantages over a single isolated ingredient, also underpins the philosophy of herbal medicine. Evidence to support the occurrence of synergy in within phytomedicines is now accumulating and is reviewed here. Synergistic interactions are documented for constituents within a total extract of a single herb, as well as between different herbs in a formulation. Positive and negative aspects of interactions are discussed together with the methods used to identify and measure synergy. The evidence is divided into experimental, in vitro instances, as well as clinical examples where available. Herbs discussed include Ginkgo biloba, Piper methysticum (Kava-Kava), Glycyrrhiza glabra, Hypericum perforatum, Valeriana officinalis, Cannabis sativa, Salix alba and others.

    Williamson EM 2001 Synergy and other interactions in phytomedicines. Phytomedicine 8(5):401-409

    Looking at more recent work, here is one that finds synergy between a plant’s constituents:

    Kan WL, Cho CH, Rudd JA, Lin G 2008 Study of the anti-proliferative effects and synergy of phthalides from Angelica sinensis on colon cancer cells. Journal of Ethnopharmacology 120(1):36-43

    Here are two that find synergy between plants:

    Adams LS, Seeram NP, Hardy ML, Carpenter C, Heber D 2006 Analysis of the interactions of botanical extract combinations against the viability of prostate cancer cell lines. Evidence Based Complementary & Alternative Medicine 3(1):117-124

    Gao JL, He TC, Li YB, Wang YT 2009 A traditional Chinese medicine formulation consisting of Rhizoma Corydalis and Rhizoma Curcumae exerts synergistic anti-tumor activity. Oncology Reports 22(5):1077-1083

    I have examples of the third type of synergy, but I guess they would not address your argument.

    Not much clinical evidence here. And, on that note, I presume you regard in vitro or animal evidence of toxicity with the same degree of circumspection that you reserve for in vitro or animal evidence of a plant’s efficacy?

  50. gonzo said,

    March 29, 2012 at 1:02 am

    At last science shows us a herbal that might help acne better than patent medicine! (due to diminished side effects).
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    uk.health.lifestyle.yahoo.net/thyme-could-be-an-effective-treatment-for-acne.htm