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Published: 31 July 2017

Demystifying traditional herbal medicine with modern approach

Fu-Shuang Li 1 &
Jing-Ke Weng ORCID: orcid.org/0000-0003-3059-0075 1 , 2

Nature Plants volume 3 , Article number: 17109 ( 2017 ) Cite this article

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Plants have long been recognized for their therapeutic properties. For centuries, indigenous cultures around the world have used traditional herbal medicine to treat a myriad of maladies. By contrast, the rise of the modern pharmaceutical industry in the past century has been based on exploiting individual active compounds with precise modes of action. This surge has yielded highly effective drugs that are widely used in the clinic, including many plant natural products and analogues derived from these products, but has fallen short of delivering effective cures for complex human diseases with complicated causes, such as cancer, diabetes, autoimmune disorders and degenerative diseases. While the plant kingdom continues to serve as an important source for chemical entities supporting drug discovery, the rich traditions of herbal medicine developed by trial and error on human subjects over thousands of years contain invaluable biomedical information just waiting to be uncovered using modern scientific approaches. Here we provide an evolutionary and historical perspective on why plants are of particular significance as medicines for humans. We highlight several plant natural products that are either in the clinic or currently under active research and clinical development, with particular emphasis on their mechanisms of action. Recent efforts in developing modern multi-herb prescriptions through rigorous molecular-level investigations and standardized clinical trials are also discussed. Emerging technologies, such as genomics and synthetic biology, are enabling new ways for discovering and utilizing the medicinal properties of plants. We are entering an exciting era where the ancient wisdom distilled into the world's traditional herbal medicines can be reinterpreted and exploited through the lens of modern science.

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Fu-Shuang Li & Jing-Ke Weng

Department of Biology, Massachusetts Institute of Technology, Cambridge, 02139, Massachusetts, USA

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Li, FS., Weng, JK. Demystifying traditional herbal medicine with modern approach. Nature Plants 3 , 17109 (2017). https://doi.org/10.1038/nplants.2017.109

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Received : 11 January 2017

Accepted : 08 June 2017

Published : 31 July 2017

DOI : https://doi.org/10.1038/nplants.2017.109

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Medicinal herbs for the treatment of anxiety: A systematic review and network meta-analysis

Affiliations.

1 Beijing Research Institute of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China; Key Laboratory of Famous Doctors and Famous Prescriptions, National Administration of Traditional Chinese Medicine, Beijing, China; Key Laboratory for Research and Evaluation of Traditional Chinese Medicine, National Medical Products Administration, Beijing, China.
2 Beijing Research Institute of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China; Key Laboratory of Famous Doctors and Famous Prescriptions, National Administration of Traditional Chinese Medicine, Beijing, China; Key Laboratory for Research and Evaluation of Traditional Chinese Medicine, National Medical Products Administration, Beijing, China. Electronic address: [email protected].
3 Beijing Research Institute of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China; Key Laboratory of Famous Doctors and Famous Prescriptions, National Administration of Traditional Chinese Medicine, Beijing, China; Key Laboratory for Research and Evaluation of Traditional Chinese Medicine, National Medical Products Administration, Beijing, China. Electronic address: [email protected].
4 Beijing Research Institute of Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China; Key Laboratory of Famous Doctors and Famous Prescriptions, National Administration of Traditional Chinese Medicine, Beijing, China; Key Laboratory for Research and Evaluation of Traditional Chinese Medicine, National Medical Products Administration, Beijing, China. Electronic address: [email protected].
PMID: 35378276
DOI: 10.1016/j.phrs.2022.106204

Background: Anxiety disorder is a common psychiatric illness. Medicinal herbs have become a field of interest in the treatment of anxiety. This study aimed to evaluate and compare the efficacy and acceptability of all possible medicinal herbs for the treatment of anxiety.

Methods: A Bayesian network meta-analysis was conducted for adults with diagnosed or subthreshold anxiety in randomized controlled trials identified in PubMed, EMBASE, the Cochrane Library, and Web of Science, searched between Jan 1, 1987, and Dec 31, 2021. The outcomes included efficacy (measured by endpoint Hamilton Anxiety Scale [HAMA] Scores) and acceptability (discontinuation by ineffectiveness, worsening of the symptoms, or adverse events).

Results: A total of 29 trials were reviewed, comparing 12 medicinal herbs. Silexan (mean difference [MD]: -3.84, 95% credible interval [CrI]: -6.31 to -1.34) displayed a significant effect on anxiety, and possibly benefitted the treatment of depression (standard mean difference [SMD]: -0.37, 95% confidence interval [CI]: -0.53 to -0.20) and insomnia (SMD: -0.48, 95% CI: -0.76 to -0.21). Kava was found to be an effective anxiolytic (MD: -2.46, 95% CrI: -4.47 to -0.32) but possibly ineffective in patients with generalized anxiety disorder (MD: -0.17, 95% CrI: -2.55 to -1.97). Ginkgo biloba (MD: -4.63, 95% CrI: -9.01 to -0.23) and Withania somnifera (MD: -4.90, 95% CrI: -9.70 to -0.17) were efficacious, as measured by HAMA scores but the trials were limited by their small sample sizes. Galphimia glauca (MD: -1.23, 95% CrI: -4.68 to 2.23) and Manasamitravn Vataka (MD: -1.35, 95% CrI: -7.39 to 4.68) exhibited the same anxiolytic effect as standard treatments, but both were absent from trials that were rated low risk, highlighting that confidence in their ability to provide an anxiolytic effect requires additional study. Conversely, although Passionflower (MD: -4.20, 95% CrI: -8.82 to 0.16) and Saffron (MD: -2.71, 95% CrI: -6.06 to 0.57) did not reduce HAMA scores significantly in the summary network, both were worthy of further study because of support from separate networks. There was insufficient evidence to confirm the effectiveness of Valerian (MD: 0.95, 95% CrI: -6.57 to 8.42) in standard-controlled estimation or the ineffectiveness of Chamomile (MD: 0.54, 95% CrI: -5.13 to 6.25) compared with a placebo for anxiety. Gamisoyo-san (MD: -0.98, 95% CrI: -6.48 to 4.54) and L-theanine (MD: -0.49, 95% CrI: -6.54 to 5.57) did not outperform a placebo for the treatment of anxiety in terms of statistical certainty. All medicinal herbs were well-tolerated and exhibited a good safety profile compared with control groups. When all herbs were compared, there was no statistical evidence to suggest any comparison significantly reduced HAMA scores except Ginkgo biloba vs Kava (MD: -4.41, 95% CrI: -8.32 to -0.35), although Ginkgo biloba was ranked as worst due to its poor tolerability.

Conclusion: Medicinal herbs may be promising for the treatment of anxiety. However, these results should be considered preliminary because of the unconvincing sample sizes, together with the potential effectiveness of placebos.

Keywords: Acceptability; Anxiety; Efficacy; Medicinal herb; Network meta-analysis.

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Traditional herbal medicine: overview of research indexed in the scopus database

Original Article
Published: 28 October 2022
Volume 23 , pages 1173–1183, ( 2023 )

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Hassan Hussein Musa 1 , 2 ,
Taha Hussein Musa 2 , 3 ,
Olayinka Oderinde ORCID: orcid.org/0000-0002-2050-0948 4 ,
Idris Hussein Musa 5 ,
Omonike Olatokunbo Shonekan 6 ,
Tosin Yinka Akintunde 7 &
Abimbola Kofoworola Onasanya 8

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Traditional herbal medicine has been playing an essential role in primary health care globally. The aim of this work is to present an overview of traditional herbal medicine research productivity over the past years. The data was accessed from the Scopus database ( www.scopus.com ), while VOSviewer.Var1.6.6, Bibliometrix, and R studio were used for further analysis of the obtained data. The results showed that researches on traditional herbal medicine increased annually after 1990, followed by a corresponding increase in global citations during the period, with a total of 22,071 authors contributing to all the publications. Yiling Wang of Shanghai Institute of Drug Control, Shanghai, China was the most productive author (TNP = 303), while Journal of “Evidence-based Complementary and Alternative Medicine”, and “Journal of Ethnopharmacology” were the top ranked journals, respectively. Also, China, Japan, and India were found to be the top Corresponding Author's Countries for researches on traditional herbal medicine, as Beijing University of Chinese Medicine, China Academy of Chinese Medical Sciences and China Medical University were top affiliations. Moreover, National Natural Science Foundation of China, National Key Research and Development Program of China, Ministry of Science and Technology of the People's Republic of China, and Ministry of Science and Technology, Taiwan were top funding agencies, with more than 100 documents. The bibliometric research study has revealed an annual increasing trend in traditional herbal medicine, while also revealing that the topmost ranked authors and funding agencies were from Asia especially China.

Methodological quality of systematic reviews on Chinese herbal medicine: a methodological survey

Insight into the characteristics of research published in traditional, complementary, alternative, and integrative medicine journals: a bibliometric analysis

Avoid common mistakes on your manuscript.

Introduction

Traditional herbal medicine (or alternative herbal medicine) has played an essential role as a source of primary health care for many, globally (Maroyi and Cheikhyoussef 2015 ), as it has maintained the health of majorly Africans and Asians for thousands of years with a unique medical system built based on empirical- and accumulated knowledge. It has been reported that ~ 70–80% of Africa’s emerging urban and rural population rely on traditional herbal medicine for health intervention (Hostettmann et al. 2000 ; Lee et al. 2019 ), and even at the moment, billions of people around the world are taking traditional herbal medicine daily in form of food, drugs or supplements (Aydin et al. 2016 ). Traditional herbal medicine have been reported to have been used to cure or prevent many diseases and ailments including gastroesophageal reflux disease (Dai et al. 2020 ), prevents postoperative recurrence of small hepatocellular carcinoma (Zhai et al. 2018 ), adjuvant for chemo- and radiotherapy for cancer (Qi et al. 2010 ), adjunctive therapy for nasopharyngeal cancer (Kim et al. 2015 ), resectable gastric cancer (Lee et al. 2018 ), treatment of viral infections, stress and anxiety as well as improve mental health during Covid-19 pandemic (Shahrajabian et al. 2021 ; Yu et al. 2020 ), just to mention a few. Therefore, sustainable management towards traditional herbal medicine, the reactions, and challenges in the monitoring and safety of plant resources are essential sources of new drugs development which are used in treating several diseases ranging from general body pain to complicated diseases in humans (Kutalek and Prinz 2005 ; Maroyi and Cheikhyoussef 2015 ).

Bibliometric analysis has been used in many fields including Covid-19 and mental health (Akintunde et al. 2021 ), gum arabic (Musa et al. 2021a ), neem (Onasanya et al. 2022 ) and in diseases such as sickle cell anemia (Musa et al. 2021b ), anticancer research using herbal medicine (Basu et al. 2017 ), herbal medicine for pain (Wang and Meng 2021 ), medical treatment of cardiovascular diseases (Huang et al. 2016 ), and natural products against cancer (Du and Tang 2014 ). The findings from these studies have helped researchers to explore new directions for future research while also playing a fundamental role in decision making regarding policy, in addition to identifying new perspectives on potential collaborations in these fields (Basu et al. 2017 ; Du and Tang 2014 ; Huang et al. 2016 ; Musa et al. 2021a , 2021b ; Wang and Meng 2021 ). However, there is yet any bibliometric analysis reportedly conducted to enhance the understanding of research hotspots, frontiers, and trends in the traditional herbal medicine indexed in the Scopus, as this will initaiate a focus on future researches and identify gaps, hence assist to explore current patterns and trends in literatures (Dol et al. 2021 ). Furthermore, using bibliometric analysis will enable researchers have a good grasp of the basic characteristics of the publications done over the years with empirical evidence on traditional medicine.

Therefore, in order to identify and further promote the growth and development of traditional herbal medicine, we used Bibliometric analysis to analyse all the published literatures therein. This technique can draw the primary bibliometric landscapes of the development of topics, highlighting the most active authors, influential countries or regions, topmost research interests in the fields and the hot topics covered over the past years, in addition to the international and national collaboration networks among authors, countries or regions. Hence, this paper aims to establish via analysis, the research productivity on the traditional herbal medicines indexed in the Scopus database, while assessing the research gaps by reviewing the published literatures.

Materials and methods

Sources of data.

A bibliographic data acquisition was carried out using the Scopus database ( https://www.scopus.com/ ) updated to March 2, 2022. Scopus is a world leading scientific database widely known for its extensive database of abstracts and citations which offers researchers the most comprehensive literature (covering all fields of natural sciences, medicine, social sciences and life sciences) retrieval.

Search strategy

We developed our search by examining related publications on traditional herbal medicine using the following query with the corresponding search approach based on:

TITLE ("traditional herbal medicine") OR TITLE ("Herbal medicine") OR TITLE ("herbal drug") OR TITLE ("Traditional Chinese medicine") OR TITLE ("Chinese medicine") OR TITLE ("Persian medicine") OR TITLE ("traditional Iranian medicine") OR TITLE ("Ayurveda") AND (EXCLUDE (PUBYEAR, 2022) OR EXCLUDE (PUBYEAR, english AND limit-to AND doctype)) AND (LIMIT TO (DOCTYPE, "ar")) AND (LIMIT-TO (LANGUAGE, "English")).

To ensure the high quality and academic nature of the literatures, only full research articles published in English were included. Initially, the search query returned 10,163 documents and the authors thereafter screened the titles of these articles for relevance. The total extracted docuemtns were harvested after retrieval and saved as Bib format, CSV format, and RIS format for further analysis using the bibliometric tool to run the frequency and generating, visualizing, and analyzing the maps. Two authors (THM and HHM) used bibliometric techniques to set a protocol to retrieve and collect reliable and relevant publications on traditional herbal medicine, as shown in Fig. 1 . More also, the research category and organisations which enhanced the research productivity over the years were manually retrieved, while the quality of publication was assessed by calculating author’s or journal’s H-index (Fassin and Rousseau 2019 ; Garfield et al. 2006 ). The Journals’ impact factor (IF) for the year 2020 was also considered for visualising analysis results by using two bibliometric visualization tools (Garfield et al. 2006 ).

The inclusion and exclusion process on traditional herbal medicine related-publications

Data analysis analysis

Bibliometric data were presented using descriptive mapping analysis via VOSviewer, while Var1.6.6 was used for developing, constructing and viewing the bibliometric maps analysis by the unit of co-occurrence analysis, co-citation and bibliographic coupling to examine the length (L) or total length strength (TLS) occurrences or reports between authors, keywords in the titles, abstracts, organizations and countries within the distributed clusters (van Eck and Waltman 2010 ). Also, bibliometrix and a R package were used to perform the comprehensive bibliometric science mapping analysis (Dervis 2019 ).

Basic characteristics of global publication analysis

In total, 10,163 articles met the criteria of articles published during year 1909 to 2021. It was observed that there was an annual increase in the number of publications after the year 1990 (Fig. 2 ). Of the 10,163 publications, an average of 15.09 citations per documents were found in 2552 Journals, which involved 22,071 authors with 2.34 Collaboration Index (CI) (Table 1 ).

Year-wise distribution of number of publications, 1905–2021

Analysis of 10 top highly-cited documents

The recognition of a document on traditional herbal medicine can be reflected by the number of times it is cited, as presented in Table 2 , on the descriptive analysis of the top 10 articles that have been published on the domain per citation during the years of investigation. An article titled “TCMSP: a database of systems pharmacology for drug discovery from herbal medicines” which was published in the Journal of Cheminformatics by Ru JL et al. (Ru et al. 2014 ) received the top-ranked cited article with 1346 citations and 149.5556 Total Citations Per Year. This was followed by the article “Some traditional herbal medicines, some mycotoxins, naphthalene and styrene, published with World Health Organization International Agency for Research On Cancer (WHO–IARC 2002 ) which received 774 citations and 36.8571 Total Citations Per Year (Table 2 ).

Journal analysis and quality of the publication

A total of 2552 journals were involved in the publication of traditional herbal medicine researches indexed in the Scopus database. The analysis revealed that the Journal of “Evidence-based Complementary and Alternative Medicine” was the topmost productive journal (h_index = 32, TNP = 401), followed by Journal of Ethnopharmacology (h_index = 57, TNP = 359) and then Chinese Journal of Integrative Medicine (h_index = 18, TNP = 253) as presented in Table 3 .

Evaluation of scientific research by geographical area

In the evaluation of the scientific output based on geographical area, it was found that ninety-four (94) Corresponding Author's Countries contributed to the traditional herbal medicine-based published works, out of which only the top 10 most productive countries were listed in Table 4 . People’s Republic of China was revealed to be the most productive (TNP = 4585), followed by the Japan (TNP = 730), India (TNP = 485), USA (TNP = 479) and Korea (TNP = 339), respectively. Meanwhile, the highly cited countries revealed that China is the topmost with reported 67,287 citations at an average citation of 14.675, followed by Japan with 14,372 citations at an average of 19.688 citations and then United States of America with 13,011 at an average of 27.163 citations, while Germany (3163 citations at an average of 27.991 citations) and Iran (1848 citations at an average of 9.625 citations) are coming from the rear back, on traditional herbal medicine-based researches published during the study period.

Authors productivity and co-authorship analysis

On the authors’ productivity, a total of 22,071 authors have been revealed to have contributed to traditional herbal medicine publications within the study period. The analysis of the top 10 authors shows that Yiling Wang from Shanghai Institute of Drug Control, Shanghai, China has the highest contribution with 303 published articles and an H_index of 39, followed by Zhang Y of Yunan University of Chinese Medicine College with 228 published documents and an H_index of 27, among other reported authors, as given in Table 5 .

Top subject areas and funding sponsors for research on traditional herbal medicine

In order to analyse the key subject areas in relation to traditional herbal medicine, most of published articles were indexed in field of Medicine (6005; 38.0%), Pharmacology, Toxicology and Pharmaceutics (2607; 16.5%), Biochemistry, Genetics and Molecular Biology (1885; 11.9%), Chemistry (1341; 8.5%), Agricultural and Biological Sciences (552; 3.5%), Nursing (343; 2.2%), Immunology and Microbiology (337; 2.1%), Chemical Engineering (320; 2.0%), Environmental Science (277; 1.8%), Health Professions (273; 1.7%), amongst other subject areas (Fig. 3 ). Moreover, majority of research fundings emanated form National Natural Science Foundation of China, National Key Research and Development Program of China, and Ministry of Science and Technology of the People's Republic of China. Furthermore, Beijing University of Chinese Medicine, China Academy of Chinese Medical Sciences, China Medical University, and Shanghai University of Traditional Chinese Medicine were amongst the top listed affiliations (Table 6 ).

Subject area on traditional herbal medicine

Co-occurrence analysis

The network visualization of co-occurrence indicates the frequency number of a keyword that appeared to determine the hot topics, while the color of each point on the map represents the density of the term over the past years, and the color represents the cluster. Also, the lines between the items represent the links. All Keywords (the minimum number of occurrences of keyword with over 300) were selected, as only 81 Keywords met the threshold and were included in the network analyses, which show different occurrences of the topic as organized into three (3) clusters with links and total link strength given between the keywords (L = 3118, TLS = 521,963), as shown in (Fig. 4 A).

A Co-occurrence of Keyword Plus analysis ( A ). B Co-author networks analysis among organizations C Co-author networks analysis among countries

Co-author networks analysis among authors, organizations, and countries or regions

Based on a threshold of 10, the minimum number of documents for an author was selected, yielding a total of 47 organizations (Fig. 4 B), which were thereafter organized into 5 distinct groups/clusters with links and total links strength (L = 77, TLS = 346), while countries were organized into 7 clusters with links and total links strength (L = 420, TLS = 2285), as shown in Fig. 4 C.

Bibliometrics has played a significant role in influencing policymaking as well as presenting a better understanding of scientific fields (Akintunde et al. 2021 ; Onasanya et al. 2022 ). The data for this study were retrieved from Scopus because the database provides different h_index ratings for authors who will need them to track citations and determine the impact of their publications (Musa et al. 2021c ). The total number of traditional herbal medicine related-publications has been increasing annually since the year 1990, as traditional herbal medicine has gained attractive attention due to easy accessibility, affordability, safety, promising efficacy, and being environmentally bening (Musa et al. 2021d ; Shahrajabian et al. 2019 ). Their essential roles in public health have led many people of different nationalities to rely on traditional herbal medicince (Soleymani and Shahrajabian 2018 ), as many herbs and plants included in several traditional systems have promising bioactive compounds for modern drug therapy (Shahrajabian et al. 2020 ) (Fig. 5 ).

Prisma flow diagram of the inclusion and exclusion process of the on traditional herbal medicine related-publications

The recognition of a document on traditional herbal medicine can be reflected by the number of times it is cited as presented in Scopus and other databases. “TCMSP: a database of systems pharmacology for drug discovery from herbal medicines” (Ru et al. 2014 ) and “Some Traditional Herbal Medicines, Some Mycotoxins, Naphthalene and Styrene” (WHO–IARC 2002 ) were reported to have being the most influential documents, with the highest number of total citations, as the research of J. Ru and coworkers (Ru et al. 2014 ) focussed on drug discovery from herbal medicines.

The analysis of journals based on h_index, total citations, number of documents, and Journal impact factors for the year 2021, revealed that Evidence-Based Complementary and Alternative Medicine, Journal of Ethnopharmacology and Chinese Journal of Integrative Medicine were the topmost ranked journals, based on their total number of publications, total citations and h_index, as these journals are more concentrated in traditional herbal medicines.

Also, the total number of traditional herbal medicine-focused publications generated 94 countries, with China, Japan, India and the USA being the topmost ranked countries in that order. This is in addition to the top 10 most productive authors coming only from China. This is of no coincidence as China is a reservoir of various high-valued medicinal plants, which have been used in the cosmetics, nutraceutical and pharmaceutical industries (Sun and Shahrajabian 2020 ). Increasing the research productivity in China is an indicator of the previous published reports that highlighted that herbal medicine is an essential part of traditional medicine which is part of Chinese culture. Moreso, traditional herbal medicine has been in practise in China for thousands of years (Fabricant and Farnsworth 2001 ). Due to the importance of traditional chinese herbal medicine in Chinese culture, Beijing University of Chinese Medicine and the Chinese Academy of Chinese Medical Sciences were the highest ranked in Organizations-enhanced traditional herbal medicine researches, as the top ten affiliations based on traditional herbal medicines were mainly Chinese domiciled, while the other developing countries are still lagging in conventional herbal medicine research productivity, although most developing countries depend on conventional herbal medicine to treat many diseases (Sen and Chakraborty 2017 ). The lagging in traditional herbal medicine-based researches in most developing countries could be attributed to fewer funding agencies that support scientific researches with grants. The results further revealed that the top ranking authors were Yiling Wang, Zhang Y, Yan-Da Li and Jong-Jing Wang, while Beijing University of Chinese Medicine, Chinese Academy of Chinese Medical Science, China Medical University and Shanghai University of Traditional Chinese Medicine, all based in China, were top ranking organizations. Furthermore, the cooperation networks facilitated by the creation of a database for storing a large portion of the data and their transformation into valuable information , has effectively contributed to the progress of the traditional medicine information system (Noraziah et al. 2011 ). Noteworthy, China’s Comprehensive Herbal Medicine Information System for Cancer has served as an appropriate information resource for traditional medicine researchers (Fang et al. 2005 ), while Web-based Decision Support System for Prescription in Herbal Medicine could play a significant role in controlling the quality of the herbal drugs prescriptions. Also, developed for consulting with the patients in the e-health system, e-health Record System in Australia has successfully assisted traditional medicine practitioners in the treatment management (Bjering et al. 2011 ). Although, there are some limitations as we have only included documents published in English language, while only one database, Scopus was used even though other databases such as Web of Sciences (WoS), Embase, PubMed, and Google scholar have also contributed extensively in the coverage of traditional herbal medicine researches.

Conclusions

The current study is the first bibliometric analysis of traditional herbal medicine scientific researches and publications. The study has shown an increasing publishing trend in recent years, in addition to identifying the global patterns of research, which serves as a tool in supporting the decisions and policies in traditional medicine. However, there is a need to increase research activities and international collaborations, particularly in developing countries as the present world system has been pushing for green and natural products rather than the synthetic ones.

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Acknowledgements

The authors acknowledge the support of the Biomedical Research Institute, Darfur College, Nyala, Sudan, while also appreciating the research innovation of The Organization of African Academic Doctors (OAAD), Nairobi, Kenya for enhancing research collaboration and innovations in Africa.

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Hassan Hussein Musa

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Key Laboratory of Environmental Medicine Engineering, Department of Epidemiology and Health Statistics, School of Public Health, Ministry of Education, Southeast University, Nanjing, 210009, China

Taha Hussein Musa

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Olayinka Oderinde

School of Medicine, Darfur University College, Nyala, Sudan

Idris Hussein Musa

Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Lagos, Lagos, Nigeria

Omonike Olatokunbo Shonekan

Department of Sociology, School of Public Administration, Hohai University, Nanjing, China

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Published: 15 March 2018

Why people use herbal medicine: insights from a focus-group study in Germany

Alexandra N. Welz 1 ,
Agnes Emberger-Klein 1 &
Klaus Menrad 1

BMC Complementary and Alternative Medicine volume 18 , Article number: 92 ( 2018 ) Cite this article

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The use of herbal medicine, as one element of complementary and alternative medicine, is increasing worldwide. Little is known about the reasons for and factors associated with its use. This study derives insights for the use of herbal medicine in Germany regarding the usage aims, role played by the type of illness, reasons for preferred usage and sources of information.

Using a qualitative methodological approach, six focus groups ( n = 46) were conducted. Two groups with young, middle-aged and elderly participants, respectively. After audiotaping and verbatim transcription, the data were analysed with a qualitative content analysis.

We found that treating illnesses was the most frequently discussed aim for using herbal medicine over all age groups. Preventing illnesses and promoting health were less frequently mentioned overall, but were important for elderly people. Discussions on herbal medicine were associated with either mild/moderate diseases or using herbal medicine as a starting treatment before applying conventional medicine. In this context, participants emphasized the limits of herbal medicine for severe illnesses. Dissatisfaction with conventional treatment, past good experiences, positive aspects associated with herbal medicine, as well as family traditions were the most commonly-mentioned reasons why herbal medicine was preferred as treatment. Concerning information sources, independent reading and family traditions were found to be equally or even more important than consulting medicinal experts.

Conclusions

Although herbal medicine is used mostly for treating mild to moderate illnesses and participants were aware of its limits, the combination of self-medication, non-expert consultation and missing risk awareness of herbal medicine is potentially harmful. This is particularly relevant for elderly users as, even though they appeared to be more aware of health-related issues, they generally use more medicine compared to younger ones. In light of our finding that dissatisfaction with conventional medicine was the most important reason for a preferred use of herbal medicine, government bodies, doctors, and pharmaceutical companies need to be aware of this problem and should aim to establish a certain level of awareness among users concerning this issue.

Peer Review reports

The use of complementary and alternative medicine (CAM) has continuously increased over the past decades. In their seminal paper from the late 90s, Eisenberg et al. benchmarked prevalence rates for the use of CAM-based therapy in the US [ 1 ]. They found that the use of CAM increased from 34% in 1990 to 42% in 1997 [ 1 ]. To understand this growing interest in CAM and related forms of therapies, a number of follow-up studies examined prevalence rates and use-related factors of alternative medicine [ 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 ]. From these studies, some common characteristics of the user of CAM can be identified. Typical users are female [ 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 ], middle-aged [ 2 , 3 , 5 , 7 , 8 , 10 ], and well-educated [ 2 , 3 , 4 , 5 , 6 , 7 , 10 ].

However, with respect to the ethnicity of users, their health status, reasons for use, and medical conditions for which CAM was consumed, as well as for prevalence rates within and between countries, reviews in the literature show a less consistent picture [ 12 , 13 , 14 ]. As cautioned by Eardley et al. [ 12 ], this could be related to an insufficiently accurate terminology, i.e. a methodology heterogeneity when including different types and numbers of therapies collectively under the ‘CAM umbrella’. Indeed, the use of different forms of alternative therapies, such as acupuncture, chiropractic or herbal medicine (HM) might be associated with different use-related factors, such as socio-demographics or health status [ 4 , 6 , 13 , 15 , 16 ] and different reasons [ 6 , 16 , 17 ]. Moreover, CAM prevalence rates and use-related factors are expected to vary strongly for specific countries owing to different legal and health-insurance regulations as well as cultural differences [ 18 ]. Both issues, the literature inconsistencies due to including many treatment types collectively under the term ‘CAM’, and the large country-specific differences, call for the study of usage patterns of alternative medicine per country and per treatment on the basis of a clear, well-defined terminology.

Within this article, the focus lies on studying the factors related to the use of a specific subcategory of CAM, herbal medicine (HM), in Germany. HM was often found to be among the most popular and strongest growing forms of CAM [ 1 , 2 , 3 , 4 , 5 , 10 , 11 , 12 ]. To name just one example, in 2007 Gardiner et al. reported a prevalence of 19% of respondents (US adult population) having used HM in the past 12 months [ 19 ]. However, as with CAM, the prevalence rates in EU countries vary significantly (6% - 48%), due to similar reasons, i.e. the unclear terminology and definition of HM used in different studies and country-specific variations [ 12 , 16 ]. Indeed, previous work often considered HM combined with other treatments (e.g. as part of CAM [ 8 , 13 , 20 , 21 ], together with further ‘natural health products’, or dietary supplements, such as mega-vitamins, etc. [ 22 , 23 , 24 , 25 , 26 ]. Moreover, previous studies solely analysing HM often focused on a specific part of the population (e.g. cancer patients, surgical patients, pregnant women, the elderly, etc. [ 27 , 28 , 29 , 30 , 31 , 32 ]). However, it is very difficult to generalise use-related factors and reasons related to, e.g. cancer patients, to the general population. Werneke et al. [ 33 ], for example asked cancer patients for their reasons for taking HM or dietary supplements and were told to ‘fight cancer’ or ‘boost immune system’. These are, of course, relevant reasons for this specific target group but may also provide a limited insight for the general population. This is an important issue, because the aims for HM use were shown to go beyond the mere treatment of an illness, and included preventing it and maintaining/promoting health [ 34 , 35 ], i.e. many users who currently do not even have a specific condition still use HM.

In our work, we examine the factors and reasons relevant for the use of HM, applying an explorative focus group (FG) study in Germany. Furthermore, the aims of and reasons for preferred HM use, the role of the type of illness, and sources of information for different age groups (see also results on HM prevalence rates in refs. [ 19 , 22 , 36 , 37 ]) are explored. In view of the terminology issues mentioned above, HM is defined as all plant-derived products including their natural form, as well as pills derived from extracts. The FG approach is ideal to explore complex human behaviour, attitudes, and motivation [ 38 , 39 , 40 , 41 , 42 ]. In using it, the aim is not to address a statistically-representative pool of opinions. Rather, our goal is to generate a set of deep data and peoples’ insights from the group discussions. We therefore argue that our results can complement more quantitative results on reasons and factors relevant for the use of HM.

Research methodology and data collection method

To examine the factors and reasons associated with the use of HM, we followed a qualitative descriptive method [ 43 ], and focus groups were used for data collection. The optimum number of focus groups and participants per group is not strictly defined a priori and debated in the literature [ 40 , 44 , 45 , 46 ]. In our study, we had a total of six focus groups with six to nine members each, and followed the recommendations given by Krüger & Casey [ 46 ].

Recruitment and participants

To recruit the participants of the focus groups, articles in local and regional newspapers were published in July 2016. Furthermore, flyers were distributed at different places of interest, including the local hospital, the authors’ scientific institute, and specific online communities. The target group of our focus groups was the general population, but specifically people with a general interest in and/or experiences with HM that were 18 years or older and German-speaking. The selection of participants in line with these criteria provided focus groups of participants who were aligned, as regards a general interest in the use of HM, to our core questions. At the same time, the focus groups chosen this way offered a bandwidth of different user experiences. On the basis of their age, the recruited participants (46 in total) were allocated to an age-specific focus group discussion. Thus, we conducted two focus group discussions each for people who were 18–35 years (defined as ‘young’), 36–59 years (‘middle-aged’), and > 60 years (‘elderly’).

Focus group procedure

All the participants were informed about the content and purpose of the study prior to the FG and joined voluntarily, i.e. they gave informed consent. Our six focus group discussions were held at the authors’ scientific institute between 5 th July 2016 and 22 nd July 2016. Each focus group discussion lasted approximately two hours and was moderated by two of the authors (ANW and KM) using a semi-structured guideline. Both moderators were experienced in moderating group discussions. Furthermore, a research assistant joined each session and operated a digital voice recorder and also took notes on facial expressions/behaviour that could not be audio-taped. Each focus group discussion began with an introduction round, in which the participants, the moderators, as well as the research assistant, introduced themselves. The moderators guided the discussion following a questioning route, encouraging the participants to speak freely and to openly share their views [ 46 , 47 ]. They also answered questions regarding the definition of HM and, with this, a common understanding of HM for all participants of the FG discussions was established. The key topics of our questioning route considered personal experiences in the use of HM, the reasons for using HM, and sources of information about the use. At the end of each focus group discussion, each participant provided socio-demographic and health-related data in a questionnaire. Each participant was given €25 as an incentive.

Data analysis

The recordings of the six discussions were transcribed verbatim. After cross-checking the transcripts against the records by the first author twice, and several readings of the transcripts and memos, the transcripts were analysed using the ‘MaxQDA’ [ 48 ] qualitative data analysis software. It offered the option to structure, systemise, and compare the contents of transcripts from focus group discussions [ 49 ]. To analyse our data, qualitative content analysis was used [ 50 ], following the deductive-inductive technique of coding the data and building categories to describe and explain it (for further details of this approach, the reader is referred to ref. [ 51 ]). In an initial step, the coding system, with relevant reasons and attitudes concerning the use of HM, was developed by ANW, based on a literature review (deductive). In a second step, the coding system was refined inductively based on relevant text passages, relating to the key questions of our study. Specifically, we adapted the coding system by analysing the transcripts of three of the focus group discussions, repeating this procedure until no more changes in the coding system were noted. Then, we adapted the coding system further by analysing the transcripts of all the discussions, repeating this again until no more changes were noted. The entire coding process was accompanied by discussions off all authors, and the completed coding system was reviewed separately by a second member of our team (AEK).

Trustworthiness

Following the guidelines suggested by Lincoln and Guba [ 52 ], in this study the following techniques were employed to maintain the trustworthiness of our findings. Well-established data collection and analysis methods were used to enhance credibility . During the entire research process, more than one researcher was involved, as described in detail above. All involved researchers were experienced in the moderation of group discussions. In particular, the FG discussions were all audio taped and also protocolled. Moreover, the FG participants joined the discussions voluntarily, and therefore the basis for the participants to be honest and open was established. Dependability of our research was ensured by using a consistent approach for the data collection and methodology, as described in detail above. To maintain confirmability and reduce the influence of subjective bias, during the entire data collection and analysis period the researchers held frequent meetings, reflexive and critical discussions, and debriefings. This ensured that every step during the data analysis procedure was well-documented. Also, explicit quotations of different participants of the FGs are cited below to enhance confirmability of the findings of this study. For providing transferability , the research procedure, including data collection and analysis, was described as detailed as possible to enhance the transparency of the research design used. Additionally, important contextual information such as the period of time of the data collection sessions, their number and length, and the restrictions which have been used to recruit people was provided. Finally, the questioning route of the FG discussions can be found in the Additional file 1 .

In this section, first details of the participants of the FGs are briefly reported; secondly, results of the key themes of the questioning route are reported, namely a description of the area of application of HM, reasons for its use, as well as information sources. The quotations which will be subsequently presented were carefully selected to be representative for the topic. Note that certain passages in the quotations had to be anonymised. For each quote, we specify the focus group no. according to Table 1 .

Participants

A total of 46 people responded to our above-described announcement and participated in the six focus groups. These participants have an average age of 51.8 years and were predominantly women, i.e. 60.8%, see below for discussion. Table 1 provides an overview of the focus groups, including their classification according to age including the age range of the participants, the number of participants and gender distribution per group. Additionally, the mean values of the age of the participants per age group are noted: 24.0 (standard deviation, SD = 3.9), 53.6 (SD = 4.8), and 72.3 (SD = 8.1) for young, middle-aged, and elderly, respectively.

Aims of use

In the FG discussions, three major aims of the use of HM (see Table 2 ) were revealed, namely to promote health, to prevent chronic or acute illness, and to treat them, which was the most important aim. There were specific differences by age group: Promoting health with HM was solely important for elderly participants, who mentioned this aspect four times, but it was not mentioned in the other groups. Prevention of chronic or acute illness with HM was especially important for middle-aged and elderly participants, but not for younger ones. For the latter, with the exception of a threat of a serious disease, preventative medication was clearly not relevant:

I try to eat healthily, but I do not take herbal medicine as a preventative care, for not becoming ill later. (FG No. 1).

Important for all age groups, and the most common aim for using HM, was treating an illness. This applied to treatments of both acute and chronic illnesses (Table 2 ).

Role of type of illness

Another important aspect that influences participants´ choice of treatment with HM was the specific disease per se. In this context, participants mentioned a variety of illnesses for which they use HM as a preferred treatment method – these are summarised in Table 3 .

As shown in Table 3 , head and chest colds, flu infection, sleeping disturbances and musculoskeletal issues are the most frequently mentioned illnesses treated with HM. Notably, several participants also mentioned giving HM to their children. Furthermore, HM is seen as a starting treatment before resorting to treatment with conventional medicine (CM):

In my family of six everyone is ill from time to time and, for this I always use plant medicine as a first treatment. (FG No. 3)

Summarising the aspects in the discussions related to the limits of HM and border to CM, the participants mentioned serious diseases (diseases such as cancer, asthma, attention deficit hyperactivity disorder), receiving treatment during and after operations, severe pain, and a fast recovery as important factors:

One of my sons is also ill (attention deficit hyperactivity disorder – Ed. note) and I have tried to use globules, plant remedies and many other things, because I refused synthetic drugs – this showed me that without synthetic drugs it actually does not work. However, if he has a cold or gastro-intestinal disease, he still gets something from my plant medicine chest. However, in the one specific case (of the chronic disease – Ed. note) it just did not work with anything that was tried, and then there is no other way. That is how it is, but it also convinced me of the synthetic route compared to plant medicine. It clearly showed me – stop, there is a limit. For this specific case, there is no way out. (FG No. 3)

So, I have two severe chronic illnesses, and for these two I believe there is no herb. For these you have to use real (medicine – Ed. note), whether one likes it or not. I already use teas, (…) for example to treat a bladder infection. (…) However, for real (heavy – Ed. note) diseases, I do not believe this to be so efficient. (FG No. 5)

Reasons for preferred use

Dissatisfaction with CM, and looking for alternative treatment methods as a consequence, was the most commonly-mentioned reason for using HM among the FG participants. Several participants provided detailed accounts of long-term illness histories, including failed conventional treatment efforts, frustration, and disappointments. Too many side-effects of CM, a lack of treatment effect, as well as dissatisfaction with the conventional doctor were issues mentioned in this context:

I have suffered from neurodermatitis for several decades . Yes, the dermatologists prescribed cortisone for applying it to the skin. Cortisone, this makes the skin thinner, and the dermatologists, they provided me with a very bad prognosis, namely my skin will get thinner and the neurodermatitis will get worse and worse, and they felt sorry for me. During the holidays, one of my relatives gave me a book about folk medicine and there I read it, namely, that there is a plant for the skin, sarsaparilla was the name. I bought a special ointment in the pharmacy. I paid for it myself and used it for a while. It did me good. (..) and, for a long time, I have not had any problems. For decades now, I have not needed a dermatologist. This is, I believe, due to plant remedies. (FG No. 3)

(…) and I realised that, after taking all those pills, I had very strong side-effects, and that these were even worse than the symptoms I had before. (FG No. 6)

The second most important reason for the use of HM provided in the FG discussions was a positive experience with using HM in the past, including treatment successes and a positive impact on health. This lead people to access HM again when needed, and to maintain this specific treatment approach:

In the past, I have always suffered from a cold. I tried a lot, nothing helped, but then I read about plant saps. When using a specific plant sap, for maybe two weeks or a month, then one can prevent such issues. I did it, and lo and behold, all my cold symptoms, which I had regularly four or five times each winter, with a heavy flu, suddenly became less pronounced! I only had these once a year instead. The next winter, I used preventative care again and passed the whole winter without having a single cold. It really helped fabulously and since then I am convinced. I have now used plant sap for six years whenever necessary and I can regulate my entire physical health, like blood-sugar and cholesterol or similar things. When a doctor checks my blood, then I immediately realise that it works. (FG No. 6)

Beyond the above-mentioned dissatisfaction with CM and positive experiences with HM in the past, in discussing reasons for the use of HM, participants mentioned several positive (‘healthy’) aspects and beliefs they associated with using HM: participants evaluated HM as being healthier, more natural, providing a higher tolerability, having few or no side-effects, showing an easier absorption of the ingredients by the body, and a better degradation. In addition to all these aspects, an apparent knowledge of the detailed contents of the HM played an important role for many participants. Being familiar with a plant, either because of knowing the name, or even because of cultivating the plant in the own garden, was said to provide a basis of trust for the users of HM. In contrast, when using chemically-synthesised drugs, participants discussed the issue that not knowing the contents lead them to distrust the treatment:

Between a drug that is made from a plant, or one which is synthetic, I would always decide for the herbal one, simply because one always knows where one stands. If one reads the package of different medicines, I know only very few of the ingredients. (..) I personally would still always prefer to try this (HM) first before taking any other remedy which I do not exactly know what it is. I would just trust more that it could help. Maybe it is also a placebo effect, but I prefer to take this into account rather than putting something into my body when I really do not know what it is and that it is chemically-made. (FG No. 2)

The FG discussion also clearly demonstrated the important influence of tradition and family history on the motivation for using HM: long-standing traditions in families and knowledge regarding “what helps” were discussed as being handed-down generation by generation. After dissatisfaction with CM, positive experiences with HM and the positive aspects/beliefs, the traditional feature, i.e. “it has always been done this way” was the fourth most important reason for preferring HM as a treatment method:

Well, I mean this actually started when we were still kids. If you were ill, then you just got your elderflower juice or lime-blossom tea and I mean they also just have an effect; this is something you take along with you when you get older, and for your own small children, before one always gives them strong medicine, one also tries the things learned from one’s own parents. (FG No. 3)

As a child, I learned from my grandmother what she learned from her grandmother. It started with the fact that even as a child, I also drank lime-blossom tea and mint tea. My grandmother always said that these are for the stomach and cough. During summer, the cold lime-blossom tea, then you will not get a cough and, during winter, a hot one, then the flu disappears. From this, I started to investigate further and now I just take everything (herbal – Eds. Note). (FG No. 4)

Sources of information

The aforementioned influence of family traditions on the use of HM can also be examined from a different viewpoint, namely when considering the sources of information about HM summarised in Table 4 . Thereby, medicinal experts were mentioned only seven times over all the FGs and have about the same importance as information originating from within the family. In addition to this, a significant source of knowledge for users is provided by independent reading. Note that the potential side-effects and/or harm due to HM use were not mentioned.

On the basis of a focus group methodology, our study explored the factors and reasons for consumers using HM in the general population. The first important finding of our study is that the FG participants were predominantly (60.8%) female. When recruiting the FG participants, one important inclusion criterion was a general interest in and/or experiences with HM. The fact that this criterion predominantly attracted female participants is seen as an indication that the user of HM is primarily female, similar to previous results [ 19 , 36 , 37 , 53 , 54 ].

Regarding the aims when using HM that were discussed in the FGs, participants explained that treating an illness was the most common aim for using HM. Preventing an illness and promoting health were less important. It is possible that the latter two aspects are covered more by the use of dietary supplements or other forms of CAM therapies [ 22 , 25 ] and not by HM. It may also reflect the idea that health-orientated behaviour (such as drug use for preventing illness or promoting health) becomes relevant for people only when they are confronted with a substantial health-threat, and not as long as they are healthy. Indeed, participants of the young, middle-aged and elderly FGs discussed different aims for the use of HM, which indicates that health awareness and maintenance become increasingly important with people’s growing age. These were the only differences found in the discussions of the studied age groups.

With respect to most common diseases for which participants discussed the use of HM, we can confirm literature results. Gardiner et al. [ 19 ], and Kennedy [ 23 ] arrived at similar conclusions in their studies, i.e. that head and chest colds are the most common diseases for the use of HM. We also note similarities between previous findings on CAM usage and results from our FG discussions on HM, such as the use of HM/CAM as a treatment before resorting to CM [ 55 ].

As regards the reasons why HM is preferred as a treatment method, in our FGs the most commonly-mentioned ones were dissatisfaction with CM, positive experiences with HM in the past, and positive aspects and beliefs associated with HM. As discussed in the literature on CAM, the first reason can be categorised as a ‘push’ factor (negative aspects/beliefs regarding CM), and the latter two as so-called ‘pull’ factors (positive aspects/beliefs regarding HM) [ 56 ]. In line with previous findings [ 21 , 56 ], in our FG discussions, ‘push’ factors were associated more closely with initially using HM, whereas ‘pull’ factors were discussed more for the motivation to maintain the use of HM behaviour. Thus, different reasons vary in their degree of contributing to the initial and maintained use of HM.

Another specific aspect was the importance of family traditions in the discussions about HM. This became clear in the discussions about the reasons for the use of HM (“it was always done this way”) and family members are also one of the most important sources of information concerning HM.

In our FG discussions, HM often appeared as a form of self-medicated treatment for which many users aim to become experts themselves by, e.g. consulting books or family members. Such sources of information are often considered to be even more important than recommendations by a doctor/practitioner or other experts – this is in line with previous results concerning information sources of HM [ 28 , 36 , 57 , 58 ], CAM [ 7 , 59 ] and on natural health products [ 22 ]. Note that Bardia et al. found that only one-third of the study participants used a majority of HM treatments in accordance with evidence-based indications [ 37 ]. In this context, it is also relevant that FG participants hardly discussed the possible side-effects of HM or negative interactions with other drugs. Quite on the contrary, HM was discussed as being harmless and having many advantages in the FGs. Many herbal products have evidence-based good efficiencies and safety profiles [ 60 , 61 ], but one must be aware of various adverse effects, such as toxicity, over-dosage, herb contamination, and especially herb-herb or herb-drug interactions [ 62 , 63 , 64 , 65 , 66 ]. Studies have shown an apparent lack of risk awareness of HM users, as the majority (82%) believes that there are no interactions of HM with other types of medicine [ 36 ].

Even though the FG methodology has various positive aspects, such as ensuring a clear terminology and mutual understanding of what constitutes HM for all participants of the study, we also note the limitations of our approach. First of all, results from FG studies are difficult to quantify [ 39 ], although a high standard of research (see methods section) was followed to achieve reliability and validity, the qualitative analysis of the FG transcripts may still be influenced by the authors. Furthermore, results from descriptive qualitative research cannot be generalized easily, as the aim is to provide deep data and insight from the discussions rather than addressing a statistically relevant data pool. Moreover, we expect that our results are not easily transferable to other countries because of the vast differences in healthcare systems, regulations, and cultural beliefs. It is also noted that our study does not consider the general population in Germany because all of the FGs were conducted in the same regional area and participants were selected based on a general interest in HM.

We conclude that HM was found to be used predominately for treating mild to moderate diseases (all age groups) and to prevent illnesses/promote health (only elderly participants), and that participants were aware of its limits. Nevertheless, the combination of self-medication, non-expert consultation and missing risk awareness reported here is potentially harmful, especially if people do not report the HM use to their doctor, which is a phenomenon frequently discussed in literature [ 8 , 19 , 23 , 36 , 58 , 67 , 68 ]. This issue is problematic, especially for elderly users, who appeared to be more aware of health-related issues, but also use more prescribed and non-prescribed medicine compared to younger ones [ 67 , 68 , 69 , 70 ]. It is therefore necessary that government bodies, doctors, and pharmaceutical companies aim to establish a certain minimum level of consumer awareness regarding the side and interaction effects of HM. It is equally important that these health-related decision-makers are aware of the dissatisfaction with CM, this being the most important reason for a preferred use of HM. Looking ahead, a consistent terminology and common set of CAM definitions, for example, what exactly constitutes HM as a form of treatment and whether, or to what extent, it is part of CAM, would be an important step towards more validity and comparability in this field [ 32 ]. Building on this, further well-designed research is necessary to obtain a detailed picture of prevalence rates, use-related factors, and reasons for the usage of HM.

Abbreviations

Complementary and alternative medicine

Conventional medicine

Focus group

Herbal medicine

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see http://www.soziologie.de/de/die-dgs/ethik/ethik-kodex.html . (Accessed 1st March 2018).

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Acknowledgements

We would like to thank all the participants in our focus groups. We also acknowledge Ludwig Aschenbrenner and Nikola Mucanov for helping with the organisational issues of the focus groups and for writing the transcripts. We also thank the funding institutions for the financial support. Finally, we thank the reviewers for their helpful comments which contributed to improve our manuscript.

The presented work is part of the ‘Extraktionsverfahren bioaktiver Naturstoffe aus Hopfen’ Project and is funded by the Federal Ministry of Education and Research ( BMBF ). This work was supported by the DFG and the Technische Universität München within the funding programme Open Access Publishing.

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All the authors contributed to the development of the ideas and the design of the study. KM and ANW moderated the focus groups. ANW and AEK performed the data analysis. ANW wrote the manuscript, which was revised by AEK and KM. All authors read and approved the final manuscript.

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Correspondence to Klaus Menrad .

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Ethics approval was not applicable for the type of human data presented in this study, as detailed in official documents by the German Research Foundation (DFG) and the German Society for Sociology (DGS) [ 71 , 72 ]. We additionally followed the ethical principles of the Helsinki declaration, the DFG and DGS. Accordingly participants of the focus groups gave informed consent.

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Welz, A.N., Emberger-Klein, A. & Menrad, K. Why people use herbal medicine: insights from a focus-group study in Germany. BMC Complement Altern Med 18 , 92 (2018). https://doi.org/10.1186/s12906-018-2160-6

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Researcher’s journey turns to forests’ understory

27 Aug 2024

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Shannon Bell at Hardings Ginseng Farm, posing with growing ginseng.

Beneath the Central Appalachian Forest canopy lies a rich, biodiverse world of native plants helping to fill North America's medicinal herb cabinet.

Yet, the benefits and beauty of this rich ecosystem are often overshadowed by a lingering cloud of coal.

“This region is often referred to as the coalfields, but I've found through my research that people living in these communities usually talk about their attachment to the region in relation to their deep love for the mountains and forests, not coal,” said Shannon Bell, professor in the Department of Sociology . “Many different Appalachian people, stretching from pre-colonization to today, have tended, harvested, sold, and used a vast number of forest botanicals like American ginseng, ramps, black cohosh, and goldenseal. These plants have long been integral to many Appalachians’ livelihoods and traditions.”

For years, Bell’s research has centered on environmental injustices in fossil fuel extraction communities, particularly the impacts of mountaintop removal coal mining in these areas. She has written two award-winning books about this research: "Our Roots Run Deep as Ironweed: Appalachian Women and the Fight for Environmental Justice" and "Fighting King Coal: The Challenges to Micromobilization in Central Appalachia ."

But since the COVID-19 pandemic and with support from the Institute for Society, Culture, and Environment , her focus has expanded to investigating inequities in the wild-harvested herbal supply chain and working with local communities to protect and increase populations of at-risk forest botanicals. This has led to multiple grants and projects related to Central Appalachia and its residents, including working with the Appalachian Regional Commission and the creation of the Forest Botanicals Region Living Monument in Wise County, Virginia, which was celebrated on Aug. 18.

“The importance of medicinal plants and forest foods to many Appalachian families’ traditions and strategies for making ends meet has been a thread running through many of the interviews I’ve conducted over the past 20 years, but this was something I had never explored in depth,” Bell said.

Fifty percent of the medicinal herbs, roots, and barks in the North American herbal supply chain are native to the Appalachian Mountains, and the bulk of these species are harvested or grown in Central Appalachia, which includes southern West Virginia, eastern Kentucky, far-Southwest Virginia, and east Tennessee. The United Plant Savers , a nonprofit with a focus on native medicinal plants and their habitats, has identified many of the most popular forest medicinals as species of concern due to their declining populations.

“Finding ways to expand these populations through protecting forest habitat and by promoting sustainable economic opportunities, like forest farming, is important for the well-being of the human and more than human communities in Central Appalachia,” Bell said.

Bell’s shift in research focus began while being quarantined at home with a 4-year-old and 8-year-old during the spring of 2020. She began reflecting on her interviewees’ stories of ginseng digging, berry picking, and pawpaw gathering.

“My family and I spent a lot of time in the woods behind our house during quarantine,” Bell said. “We observed the emergence of all the spring ephemerals in the forest understory – hepatica, spring beauty, bloodroot, trillium, mayapple. My son and I documented mayapples in all their different stages, from first emergence to fruiting. I came to appreciate the importance of the region’s botanical biodiversity more than ever, and realized I wanted to incorporate this new part of my life into my research.”

Through support from the Institute for Society, Culture, and Environment's COVID-19 Reset Program — now known as PREP — Bell expanded her research focus to native herbs seamlessly.

“Although not funded, the proposal I was working on during the COVID Reset program allowed me to be ready to apply for several other grant opportunities,” Bell said.

During the program, Bell applied for and received an Appalachian Collegiate Research Initiative grant from the Appalachian Regional Commission, which funds community-based research projects undertaken with students at colleges and universities in the region. During fall 2022, Bell taught a community research class in the Appalachian studies program and led her students on an investigation of inequities in the wild-harvested herbal supply chain . They found that there is a large discrepancy between the pay that wild harvesters receive for the medicinal plant material they collect from the forests and what these processed roots, herbs, and barks sell for on the shelves of natural food stores and pharmacies.

“We discovered that one of the core problems is that most of the processing of herbal plant material happens far away from Central Appalachia, so most of the profits are leaving the region,” Bell said.

The interviews and participant observation data that Bell and her students collected during the class set the stage for her to apply for ISCE’s signature Scholars Program in 2023.

With co-investigator John Munsell, professor and forest management Extension specialist in the College of Natural Resources and Environment , Bell’s scholars project sought to identify ways that Central Appalachian communities could retain more of the profits from the herbal industry while simultaneously ensuring that populations of at-risk forest botanicals not only survive, but thrive and expand in the region.

Bell conducted participant observation and interviews with wild harvesters and is currently working on a mail survey with local herb buyers. She also piloted a ginseng seed distribution program with wild harvesters and helped a wild harvester write a grant proposal to start a forest farm.

“I am particularly interested in helping wild harvesters acquire the resources they need to begin cultivating forest botanicals themselves,” Bell said. “Economic development in post-coal communities often focuses on other types of energy development, like fracking and natural gas pipelines, or on building prisons and landfills. Central Appalachia is one of the most biodiverse places on the planet. I think that placing a greater value on this biodiversity is key to promoting a more sustainable future for the region.”

Bell is currently engaged in multiple projects with university and community partners to benefit people throughout Central Appalachia.

One of these projects is a $490,647 Appalachian Regional Commission Appalachian Regional Initiative for Stronger Economies (ARISE) planning grant, led by Professor John Munsell. Partners from across Central Appalachia are currently in the midst of a year-long planning process that will ultimately lead to a multimillion dollar ARISE implementation grant proposal focused on strengthening forest farming initiatives in Central Appalachia.

Bell is also working to draw attention to the value of Central Appalachia’s biodiversity by leading the creation of the Forest Botanicals Region Living Monument in Wise County.

With funding from Monuments Across Appalachian Virginia , Bell is collaborating with partners at the nonprofit organization Appalachian Sustainable Development, Virginia Tech, the City of Norton, a sculpture artist team, and forest botanicals practitioners to create a monument celebrating the cultural, historical, ecological, and economic significance of Central Appalachia’s abundance of medicinal herbs and forest foods.

Bell said one of the monument's purposes is to challenge narratives about what is valued in the region. “Referring to Central Appalachia as the coalfields overlook the wealth of biodiversity above the coal,” Bell said. “The Central Appalachian forests are a treasure that should be protected and celebrated.”

Many academic and public-facing publications and exhibits are planned as part of these projects, including a book project. Bell also hopes to continue collaborating with Appalachian Sustainable Development and other community partners to create new opportunities for people to deepen their connections to the Appalachian forest understory.

“Shannon has a contagious enthusiasm for both the forest botanicals of Appalachia and people who work with them,” said Robin Suggs, procurement manager at Appalachia Sustainable Development. “She has keen insight into the struggles of formerly coal-dependent communities and how the sustainable production of forest botanicals can positively affect those communities.”

The Forest Botanicals Region Living Monument will include a Storywalk Trail of 10 interpretive signs placed along a wooded trail at Flag Rock Recreation Area, a sculpture, and an online exhibit . An opening celebration for the storywalk trail component of the monument was held on Aug. 18, with the sculpture installation planned for spring 2025.

Lindsey Haugh

Center for Refugee, Migrant, and Displacement Studies
College of Liberal Arts and Human Sciences
College of Natural Resources and Environment
Fralin Life Sciences Institute
Global Change Center
Institute for Society, Culture and Environment
Monuments Across Appalachian Virginia
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Opportunities for Health Promotion: Highlighting Herbs and Spices to Improve Immune Support and Well-being

Consuming a balanced and varied diet is beneficial for health, especially when individuals feel stressed, scared, insecure, unequipped, or disempowered from maintaining their health during the COVID-19 pandemic. Nutrient deficiencies from inadequate intake of healthful foods can contribute to a weakened immune system and greater susceptibility to infection. Including herbs and spices in a balanced and diverse diet is one of the highlights of nutritious eating that supports health and immunity.

The review intended to examine ways to integrate specific herbs and spices into people’s diets and to use them therapeutically in holistic, integrated health promotion.

The research team performed a narrative review by searching PubMed Central and Google Scholar databases. The team developed a search strategy focused on specific common names of spices and herbs in combination with other terms, such as health benefits, health promotion, immunity, inflammation.

This review was conducted in Muncie and Columbus, Indiana.

This review uncovered studies documenting the many therapeutic properties of herbs within the lamiaceae family, particularly basil and spearmint, and spices, including cloves, ginger, and turmeric. Substantial evidence suggests that consumption of a healthful diet, inclusive of herbs and spices, may strengthen the body’s immune system against diseases including highly contagious viruses.

Conclusions

With respect to herbs and spices, the current review’s findings can help to inform and support future recommendations for a standard within the professions of health to provide an improved, healthier, and well-educated dietary guidance for individuals. More studies are needed on the consumption of herbs and spices in human trials to elicit evidence beyond preclinical and animal studies.

Introduction

The COVID-19 pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that began in December 2019, has created a shared global concern for health and well-being, with opportunities for health promotion across all cultures and nations. In response, healthcare professionals have been urgently tasked with providing clear and concise messaging around optimal immune function.

The immune system is vitally important to human health. Throughout the spectrum of global public health, many messages of guidance are being given regularly to promote and improve the health and safety of people around the world. Such health promotion messages include guidance related to proper sanitation and hygiene, wearing of masks, physical distancing, regular physical activity, and the importance of healthy food intake. 1 , 2

The respiratory symptoms associated with the novel coronavirus COVID-19 occur as a result of a cytokine storm3 that overwhelms the host’s immune system with a surging inflammatory response in a very short time. This immune surge sparks a reaction much like that of autoimmune conditions, in which the innate defense systems of the body begin working overtime, damaging internal structures in the attempt to defend against the virus. This results in chronic inflammation3 and progressive health decline.

The inflammatory cytokine reaction is only one molecular response signal and trackable biomarker to determine the health of the body’s immune system, and many other factors of relevance to the body’s immune response are outside of this review’s scope and have been published elsewhere. 4-6 Furthermore, healthcare professionals and emerging research have emphasized the changes to diet and lifestyle behaviors that are related to COVID-19 and to the severity of its symptoms. 7-11

Many people have been inclined to consume more comfort foods and follow unhealthy dietary practices during these extraordinary times of stress and high uncertainty. 12-15 Generally, these foods are highly processed and have large amounts of added fat, sugar, and sodium. 16 , 17 Furthermore, stressful experiences during the pandemic may lead to irregular eating patterns, 18 , 19 increased snacking, and decreased consumption of nutritious foods 20 and beverages, which exacerbate health risks associated with overweight and obesity. 21 Environments of food scarcity, financial insecurity, lockdown, social distancing, and subsequent lack of sleep can further aggravate stress and anxiety, weakening the immune system and compromising the body’s natural healing processes and innate recovery potential.

Greater susceptibility to COVID-19 and a poor immune response and recovery have been observed in people with a variety of lifestyle-related, chronic health problems, such as type 2 diabetes, cardiovascular disease, lung disease, certain types of cancer, and weight issues, such as being overweight or obese. 8 , 21 , 22 Therefore, maintaining nutritional standards through healthful eating is an important step toward active health promotion in the integrated treatment of health conditions and can help prevent potential future diseases. Supporting the immune system using nutrition, including the herbs and spices identified in this review, should be considered to be a healthy dietary practice that may reduce the predisposition to risk and support overall health and recovery. 16

Consuming a balanced and varied diet is beneficial for health, especially when individuals feel stressed, scared, insecure, unequipped, or disempowered from maintaining their health during these vulnerable times. 13 , 15 , 23 Nutrition can play a vital role in both physical and mental health and may be critically important in immunology. 24 , 25 Nutrient deficiencies from inadequate intake of healthful foods can contribute to a weakened immune system and greater susceptibility to infection.

As such, the World Health Organization (WHO) encourages the public to consume a variety of fresh and unprocessed foods daily to maximize nutrition and support healthy immunity. 17 They also suggest avoiding excess added sugar, fat, and sodium to lower the risk of health problems and chronic diseases. 26 By following their recommendations many improvements to health and wellbeing can be easily achieved.

As part of a healthy diet, many plants provide a powerful source of nutrition through antioxidants, polyphenols, phytochemicals and other bioactive compounds, together with needed vitamins and minerals. Because the public may continue to choose and consume highly-processed, packaged foods that often lack nutrient density, 27 working nutrition into a well-developed, integrated model of care is important. All clinicians must work collaboratively to implement healthful guidance to help shape and improve the public’s overall eating patterns and health status during this COVID-19 pandemic.

Globally, nutritional guidelines focus more on food groups—fruits, vegetables, grains, dairy, meats— rather than herbs and spices—derivatives of plants. Many vital nutrients—such as vitamins A, C, and E; minerals like zinc28; selenium; and iron 5 , 29 ; and other emerging bioactive compounds—such as antioxidants, 30 , 31 phytochemicals, 32 , 33 polyphenols, and flavonoids 34 , 35 —have been explored for their effects in promoting immunity.

Herbs and spices have been used for centuries36 in various parts of the world for food coloring, flavoring, and preserving as well as many for applications in nutrition and medicine. They have been sought after for their many innate health promoting properties, with applications in anti-inflammatory, 37 antiviral, 38-41 antimicrobial, antibacterial, antifungal, wound-healing, 42 antimutagenic, and even anticancer 43 , 44 treatments.

Generally, herbs and spices comprise many plant parts, including leaves, roots, stems, seeds, berries, buds, bark, or flowers. Variations of these common natural ingredients have been used in cooking 45 and in medicine. 36 , 46 Although the prevalence of herbs and spices is extensive globally, only in recent years have preclinical and clinical research elaborated on their effectiveness in health promotion. 43

Also important to note, the Food and Drug Administration (FDA) has recognized herbs and spices as generally recognized as safe (GRAS) for human consumption. 47 Including herbs and spices in a balanced and diverse diet is one of the highlights of nutritious eating that supports health and immunity. They are generally low in calories, sodium, and fat and are devoid of cholesterol.

Although food ingredients contain many of the prophylactic compounds for immunity that are found in herbs and spices, it’s interesting to note that many of contemporary, pharmaceutically produced and broadly prescribed medicines have been engineered through scientific findings about natural plant parts. 48 , 49 One such example is the commonly prescribed medication to lower blood pressure known as coumadin, which is named after coumarin present in cinnamon. 50

Naturally, many herbs and spices contain greater levels of bioactive compounds than their synthetic counterparts. 51 Another common spice, ginger, has long been recognized for aiding digestion 52 and has been employed by both the food industry and medicine alike. 53-55 Traditionally, many other herbs and spices have been pursued for their medicinal properties and therapeutic effects including basil, rosemary, cilantro, mint, and turmeric. 56

Currently, individuals with contemporary eating patterns may remain deficient in the essential nutrients needed for optimal health, 27 and herbs and spices can provide substantial benefits to overall nutrition due to their high concentration of phytonutrients 32 , 33 and other bioactive compounds.

It has been observed that a large majority of the US population is unaware of the vast health benefits of herbs and spices. 57 The general public and healthcare professionals alike now report a growing interest and desire to learn more about the use of herbs and spices in health promotion. 57-59 Strengthening immune defenses through the regular intake of these ingredients may lead to decreased health risks and could potentially elicit a shortened recovery time. In fact, recent reports have even focused on the use of herbs and spices to reduce the effects of the cytokine cascades of inflammation in the body—similar to those seen in COVID-19 cases—with respect to individuals who are overweight, with metabolic syndrome and obesity. 60 , 61

This review intended to examine ways to integrate specific herbs and spices into people’s diets and to use them therapeutically in holistic, integrated health promotion. The review addresses ways in which individuals can improve their health and support their immunity. It includes common herbs with a potential impact on immune support, forms of herbs and spices, their influence on overall health status, the prevalence of bioactive compounds, and evidence of supporting research. Lastly, the review discusses the role of clinicians working collaboratively to promote well-being and educate the community about the health benefits of herbs and spices.

Sparked by collaborative interest in providing tangible insights for nutritional health promotion during the current pandemic, the research team completed a literature search using two databases, PubMed Central and Google Scholar. The team developed a search strategy focused on specific common names of spices—cinnamon, ginger, cloves, turmeric, cumin, chili pepper, paprika, black pepper, garlic, and onions—and herbs—basil, rosemary, sage, thyme, oregano, coriander, spearmint, peppermint, and fenugreek—in combination with other terms such as health benefits, health promotion, immunity, and inflammation. The team also hand-searched and found relevant articles to gain further insight.

Articles met inclusion criteria if they were published in English and were available in both abstract and full-text form, and if the primary focus of the article was herb-and-spice use for medical- or nutritional-health promotion or the implications of herbs and spices within the context of inflammation and immune function.

Articles were excluded if the full text wasn’t available or available in English, or if article’s focus was on herb-and-spice use in the context of production, processing, harvest, or horticulture.

In addition, reputable information and guidance on the events surrounding COVID-19 were sought by searching presentations, publications, and recommendations put forth by national and global authorities via a search of worldwide websites.

After screening articles, 247 abstracts were reviewed, and 126 articles were deemed relevant and screened using inclusion and exclusion criteria. Of them, 103 articles were included in the review. Due to the heterogeneity of literature reviewed in this report for the diverse herbs and spices covered, the research team further attempted to include the most relevant articles for each herb and spice. The team found notable differences in the previously published literature for specific herbs and spices, such as a large number of studies for cloves and turmeric compared to thyme and cumin.

The reviewed literature revealed that many questions have been asked about herbs and spices, such as how do these natural ingredients provide therapeutic effects, what bioactive compounds exist within them, and what applications may they provide for the future of health and medicine.

The interest about natural ingredient formularies for prevention and treatment for contagious disease is shared globally due to growing antibiotic resistance and other harmful pathogens endangering human health. Furthermore, hundreds, if not thousands, of species of herbs, spices, and medicinal plants have research interest, with a similarly high number of biological compounds and activities expected to be found with effects in human health.

The current review found many investigations for herbs within the lamiaceae family, especially basil 62-67 and spearmint 68-74 as well as spices, including cloves, 75-80 ginger, 81-98 and turmeric. 56 , 85 , 99-106 The majority of investigations have focused on the antibacterial, antiviral, anti-inflammatory, and antioxidant potential of herbs and spices. Many other herbs and spices may be of research interest for human health but exist outside of those most commonly consumed ones that this review includes.

The findings of this review underscore the importance of the diet and lifestyle choices needed to promote health and immune support 107 as well as future preventive measures. Maintaining the immune system’s healthy functions of regulating environmental factors and responding appropriately through recovery, requires a sufficient supply of essential nutrients for optimal health. As presented in the tables in the review, substantial evidence suggests that consumption of a healthful diet, inclusive of herbs and spices, can strengthen the body’s abilities to defend, respond, and recover from diseases such as highly contagious viruses.

Consumption of herbs of spices may be considered to be important to healthy individuals for health promotion across their lifespans. It’s important to recognize that the literature reviewed suggests that regular intake of such herbs and spices supports overall immunity and may help prevent illness; the investigation as to whether herbs and spices cure illness is beyond the scope of this review.

Complementary health benefits in the use of herbs and spices for immune support may include a reduction in acute and chronic inflammation, 33 , 108-110 blood pressure, cholesterol, 111 free-radical damage, and even pain. 112 Mechanisms elucidating these benefits result from the positive impact of directly using herbs and spices and replacing and/or reducing the use of less healthy ingredients in standard cooking, such as high levels of sodium, sugar, saturated fat, and processed oils. 46 , 113 In particular, herbs and spices have been used to help reduce sodium consumption and lower blood pressure, 114 reducing risks for cardiovascular disease 115 and stroke. 116 Tables 1 and and2 2 detail these studies as well as additional ones. 117-164

Common Herbs Used With Potential Impact for Immune Support. Special attention can be given to the lamiaceae family because these botanical plants are closely related, with similar bioactive compounds; therefore, they should have similar benefits. One of the principle and potent compounds, rosmarinic acid, is shared among this family of herbs. The table highlights the countless potential benefits from antioxidants, polyphenols, phytochemicals, and other constituents of all plant parts. The table doesn’t differentiate between method of consumption, cooking, and preparation, but rather spotlights the substantial understanding for the health promoting benefits of eating more herbs and spices. The table also includes garlic and onion because they are commonly used similarity to herbs and spices as well as various teas because they are primarily curated from a mixture of herbs and spices.

Common Name	Binomial Name	Family (botanical)	Herb/Spice; Plant Used	Bioactive Compound(s)	Research to Support: (Author / year)
Sweet Basil, Holy Basil, Tulsi	Ocimum basilicum L, Ocimum tenuiflorum	Lamiaceae	Herb; fresh and dried leaves and shoots	D-Linalool, methyl chavicol, eugenol cineole, apigenin, catechins, quercetin, rutin, kaempferol, anthocyanins, limonene, terpinene, carvacrol, geraniol, menthol, safrole, tannins, ursolic, p-coumaric, rosmarinic acids
Rosemary	Rosmarinus officinalis L	Lamiaceae	Herb; fresh and dried leaves and shoots	Cineole, borneol, linalool, eucalyptol, camphor, bornyl acetate, α-pinene, camphene, sabinene, phellandrene, α-terpinene, rosmarinic acid, ditarpenes, carnosic acid, carnosol, caffeic acid, limonene rosmanol
Sage	Salvia officinalis	Lamiaceae	Herb; fresh and dried leaves and shoots	Thujone, borneol, cineole, bornylesters, α-pinene, camphene, sabinene, limonene, geraniol saponin, catechins, apigenin, luteolin, phellandrene, α-terpinene, rosmarinic acid, caffeic acid, flavonoids
Thyme	Thymus vulgaris L	Lamiaceae	Herb; fresh and dried leaves and shoots	Thymol, carvacol, linalool, L-borneol, geraniol, amyl alcohol, β-pinene, camphene, p-cymene, caryophyllene, 1,8 cineole
Oregano	Origamum vulgare L	Lamiaceae	Herb; fresh and dried leaves, shoots, and flowers	Thymol, carvacrol, α-pinene, cineole, linalyl acetate, linalool, dipentene, p-cymene, β-caryophyllene, carnosic acid, carnosol, caffeic acid, rosmarinic acid, flavonoids, apigegnin, diosmin, luteolin, tannins, camphor, pinene, cineole, quercetin, -coumaric, protocatechuic acid Diosmetin, myricetin	Santoyo et al, 2014
Coriander (Cilantro)	Coriandrum sativum	Apiaceae	Herb; fresh and dried leaves, and fruits	D-LinaloolD-α-pinene, β-pinene, α and γ-terpinene, gerciniol, borneol, p-cymene, linalool, carvone, limonene, borneol, geraniol, camphor, and elemol, apigenin, rhamnetin, keampferol, quercetin, vanillic acids, rutin, tocopherols, pyrogallol, terpineol, cumene
Spearmint, Peppermint	Mentha spicata, Mentha X piperita	Lamiaceae	Herb; fresh and dried leaves and shoots	Menthol, menthone, menthyl acetate, β-pinene, α-pinene, sabinene acetate; L-Carvone, terpene, carveol, dihydrocarveol acetate, thujone isomenthone, eriocitrin, hesperidin, apigenin, luteolin, rutin, carotenes, tocopherols, caffeic, rosmarinic, chlorogenic acid
Fenugreek	Trigonella foemum graecum	Fabaceae	Spice, Herb; fresh and dried seeds and leaves	apigenin, kaempferol, quercetin, vitexin, tricin, naringenin, Sesquiterpenes, aromatic aldehydes, terpenes, saponins

Common Spices Used With Potential Impact for Immune Support

Common Name	Binomial Name	Family (Botanical)	Herb, Spice; Part of Plant Used	Bioactive Compound(s)
Cinnamon, Ceylon, Cassia, Saigon	Cinnamomum verum, cassia, loureiroi	Lauraceae	Spice; derived from bark of plant	Hydroxycoumarins cinnamaldehyde, cinnamate, cinnamic acid, Eugenol, limonene, terpineol, catechins, proanthocyanidins, tannins, linalool, safrole, pinene, methyleugenol, benzaldehyde
Ginger	Zingiber officinale Roscoe	Zingiberaceae	Spice; rhizome fresh and dried spice	Gingerol, paradol, shogaols, zingerone, hydoxyphenylpropenes, vallinoids, geraniol, geranial, borneol, linalool, camphene, zingerol, zingiberon
Cloves	Syzygium aromaticum	Myrtaceae	Spice; flower bud	Eugenol, dehydroeugenol sesquiterpenes, caryophyllene, tannins, isoeugenol acetyleugenol pinene, vanillin, gallic acid, flavonoids, phenolic acids
Turmeric		Zingiberaceae	Spice; rhizome fresh and dried spice	Curcuminoids, demethoxycurcumin, bisdemethoxycurcumin, tetrahydrocurcumin, eugenol, carotene, ascorbic acid, caffeic, -coumaric, protocatechuic, syringic, vanillic acid
Cumin, black cumin, black seed	Cuminum cyminum L. Nigella sativa L.	Apiaceae	Spice; seeds	Coumarins, cumin aldehyde, cuminal, β-pinene, γ-terpinene, safranal, quercetin, p-coumaric, rosmarinic, trans-2-dihydrocinnamic acids flavanoids
Chili pepper, paprika	Capsicum annuum, Capsicum frutescens	Solanaceae	Spice; seed and fruit	Capsaicin, tocopherol, lutein, carotene, capsanthin, quercetin, ascorbic acid, rutin
Black pepper	Piper nigrum L	Piperaceae	Spice; Dried fruit berries	β-pinene, piperine, oleoresins, piperolein, β-caryophyllene, limonene, lignans, alkaloids, flavonoids, myristic acid, myristicin, citral, palmitic acid, piperine, terpinen-4-ol and ubiquinone, lauric acid
Garlic	Allium sativum	Amaryllida-ceae	Fresh and Dried; fruit, bulb	D-Linalool, Methyl chavicol, eugenol cineole, Allyl sulfides, allicin, ajoene, S-allyl-L-cysteine (SAC)
Onion	Allium cepa	Amaryllida-ceae	Fresh and Dried; fruit, bulb	Quercetin, kaempferol, myricetin, and catechin, apigenin, dipyridyl disulfide, rutin, quercetin-4-glucoside
Various teas	Camellia sinensis	Theaceae	Fresh and Dried; leaves, stems, shoots, flowers	Quercetin, kaempferol, catechin, gallocatechin, epicatechin, epigallocatechin gallate theaflavins, myricetin

Additional citations to note that provide comprehensive reports on multiple herbs/spies include:

Peter, 2012 165
Kaefer & Milner, 2008 166
Shahidi and Ambigaipalan, 2015 167
Kaefer & Milner, 2011 168
Yashin et al, 2017 169
Shan, et al, 2005 170
Lampe, 2003 171
Jassim & Naji, 2003 172

Guidance for the relationship between nutrition and health can act as primary prevention and help reduce some of the more significant risk factors for viral infections, such as COVID-19. Those at increased risk of infection include the elderly and those with underlying comorbidities 10 , 12 related to diet and lifestyle. With the goal of improving human defenses against viral susceptibility and promoting overall healthy living, reducing obesity and diabetes, 61-175 and supporting the immune system, the current review examined a series of herbs and spices that healthcare professionals can advise and inspire individuals to include in their regular eating patterns.

Supporting the role of nutrition in disease prevention, the Centers for Disease Control and Prevention (CDC), WHO, and the Academy of Nutrition and Dietetics have further published information on ways to promote optimal immune function and overall good health by following nutritional recommendations, staying active, having fun in the kitchen, and prioritizing mental health. 1 , 2 , 175

For consumers to benefit from the opportunity to incorporate integrative and inclusive support for diet and lifestyle recommendations, the role of education and expertise in the jobs of healthcare professionals is key. Interest is growing in understanding intricate and accurate nutritional-health aspects regarding which herbs and spices can offer benefits to immunity, and the knowledge is important for all medical and allied health care professionals, such as registered nurses, primary care physicians, psychologists, osteopaths, mental health counselors, registered dietitian nutritionists, and social workers. The effort of working collaboratively through complementary care models to provide comprehensive care for individuals and families is crucial, especially during the pandemic. 176

Integrative healthcare prioritizes the use of a patient-centered approach in which the whole person is treated comprehensively by a well-coordinated care team. A central part of patient-centered care is listening to the patient’s perspective and amplifying his or her voice versus prescribing care in an authoritative manner. 176

In recent years, the focus has increasingly been on complementary, alternative, and integrative medicine approaches. During the current pandemic, the public is continuously seeking information related to prevention and treatment from all sources. It’s then advantageous for healthcare professionals to communicate effectively and share knowledge and understanding related to the use of herbs and spices to support immunity, regardless of whether the scope of their practice falls more within the conventional versus complementary and alternative spectrums.

If healthcare professionals are able to share the many health benefits of herbs and spices and the methods by which they can be routinely incorporated, clients and patients can feel encouraged and empowered in their understanding of which herbs and spices they can include in their diets and why.

Tables 1 and and2 2 can be used as a resource for nutrition and healthcare professionals at large, who can familiarize themselves with many of the common herbs and spices and can instruct individuals on divergence from typical eating patterns, with opportunities to highlight regular intake to promote good health and boost immunity. A wide variety of advances in food and nutrition insight are readily available in collaborative and complementary, health promotional practice as well as inclusive communication strategies for professionals. All of these suggestions may help strengthen confidence and competence for individuals interested in improving their health through food and nutrition. From regular consumption to specific medical applications, herbs and spices deserve a place on the plates of all eaters.

As the future of nutrition science continues to evolve with rapidly advancing technology and research, the current research team expects further incorporation of beneficial herbs and spices to be included in general nutrition guidance. It’s anticipated that future research will focus on identification of genetic expressions known to provide greater defense or greater risk for viral infections. 38

The future will also likely see more interest in investigations for natural-medicine modalities and opportunities to discover even more bioactive compounds and plant properties that are important for promoting optimal health and longevity. 49 , 172 Similarly, the future will see a high desire on the part of the public and of particular population groups to alter their eating patterns across their lifespans, toward improvement of potential health defenses and disease prevention post-COVID-19, in expectation of future infectious diseases.

Observational data and epidemiological trends will demonstrate just how important healthy eating patterns are for human health and well-being. The particular expertise of a complementary healthcare team is warranted during this extraordinary time in history.

It’s clear that the role of food and nutrition in reducing the risk of infection and promoting health and recovery shouldn’t be overlooked. The power to prevent infection and promote optimal immune function is available. Additionally, providing accessible, supplementary guidance may help to lessen fears and panic and improve overall mental and emotional health while providing physical-health benefits.

Consequently, future guidance may include regular and routine use of particular food ingredients, such as distinctive herbs and spices, known to promote their excellent prophylactic effects. 38-40 , 172 Nutritional guidance for optimal immune function can help improve global prevention of infection as well as act to help treat and reverse a wide range of common comorbidities that tend to make individuals more susceptible to infectious disease.

This review has several limitations that should be considered, such as the absence of substantial previous research on the topics of nutritional science that focused on herbs and spices with special attention to immune function. Likewise, little is known about the specific novel coronavirus, COVID-19, at this time, although health professionals continue to understand more each day. Therefore, this review can’t speak to specificity of prevention or treatment for SARS-CoV-2, but it does substantiate the need for investigations.

In addition to using herbs and spices to boost immunity and prevent disease, emerging research from around the globe highlights many natural compounds found in herbs and spices as potential therapeutic options to complement medical treatment for the novel coronavirus SARS-CoV-2 as they have been explored for their effects on mitigating COVID-19 177-181 and similar coronaviruses. 182-186

Another limitation of the study is the general lack of funding for natural and complementary medicine modalities, such as the potential reason for the lack of inclusion of herbs and spices in generic, public health nutritional guidance. Lastly, due to the sheer number of botanical plants with theorized or validated, previously investigated or yet to be discovered benefits, the authors couldn’t include a high volume of the different herbs and spices known in different regions and cultures around the world. Thus, it would be wise to work with local experts in nutritional science, botanical medicine, and functional foods to learn more about the health benefits of specific herbs and spices beyond the context of this review. Collaborative communication to the public can provide encouragement and confidence to consumers for simple strategies to support optimal health and immunity.

Biographies

Jonathan Isbill , MS, RDN, Nutrition and Dietetics Registered Dietitian Nutritionist, Columbus, IN, USA.

Jayanthi Kandiah , PhD, RDN, CD, Associate Dean, College of Health; Interim Chair, Department of Nutrition and Health Science; and Professor of Nutrition and Dietetics, Department of Nutrition and Health Science, Ball State University, Muncie, IN, USA.

Natalie Kružliaková , PhD, RDN, LD, Assistant Professor of Nutrition and Dietetics, Department of Nutrition and Health Science, Ball State University, Muncie, IN, USA.

Medical Disclaimer

The authors don’t suggest the use of any food ingredients, botanicals, herbs, spices, or otherwise as replaceable treatment options to any standard medical care but offer this review as complementary guidance with integrated support with qualified medical professionals and health educators, who are highly trained and experienced in health promotion and disease prevention.

Authors’ disclosure Statement

Authors declare that they have no conflicts of interest related to this review.

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Why people use herbal medicine: insights from a focus-group study in Germany

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