Herbal support for Influenza

By popular demand, here is a copy of some notes on the upcoming flu season. Looking at the flu trend reports from Google, it seems we're already seeing a national spike in H1N1 cases - and it's not (quite) even October yet! Not to be alarmist, but herbalists can play an important role now and in the future, given the issues with vaccination and the relatively ineffectual drugs like Tamiflu.

Influenza is an acute respiratory illness caused by an RNA virus from the Orthrosynovitic family, of which three serotypes are known (A, B and C). Influenza causes an acute febrile illness with myalgia, headache and cough. Uncomplicated influenza generally resolves over a two to five day period. However, in a significant minority, symptoms of weakness and malaise may persist for several weeks, particularly in the elderly. Complications of influenza include otitis media, pneumonia, exacerbation of chronic respiratory disease, croup and bronchiolitis. Additionally, influenza can cause a range
of non-respiratory complications including febrile convulsions, Reyes’s syndrome and myocarditis. The influenza virus is transmitted primarily via virus-laden large droplets from sneezing, coughing or talking. Transmission may also occur by direct
(for example, person-to-person) or indirect (person-to-person) contact and accounts for 30,000 deaths per annum, US.

H1N1 flu (“swine flu”) is an A subtype, generally affecting the upper respiratory passages and the lungs less so, though can be characterized by a spasmodic, dry cough esp. in the initial stages. Those over 65 appear to be at lower risk because of exposure to the H1N1 type, which is the same as the 1918 flu. This serotype has been largely absent for some time. Most at risk are pregnant mothers and infants under 6 months. H1N1’s most troubling characteristic seems that it spreads 2-3x more readily that most seasonal influenzas.

H5N1 flu (“bird flu”) is also an A subtype, but appears to be much more focused on the lungs for invasion, replication, and symptoms. This serotype has been implicated with the “cytokine storm” (see below), making it more dangerous to those with health immune systems.

H1N1, which caused Spanish flu in 1918, and the 2009 flu pandemic

H2N2, which caused Asian Flu in 1957

H3N2, which caused Hong Kong Flu in 1968

H5N1, a current pandemic threat

Serotypes are determined by the Hemagglutin and Neuraminidase surface markers on the viral capsule. These markers also serve to trigger immune reactions in respiratory epithelial cells.

The symptoms of 2009 H1N1 flu virus in people include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. Some people may have vomiting and diarrhea. People may be infected with the flu, including 2009 H1N1 and have respiratory symptoms without a fever.

In children, emergency warning signs that need urgent medical attention include:

• Fast breathing or trouble breathing
• Bluish or gray skin color
• Not drinking enough fluids
• Severe or persistent vomiting
• Not waking up or not interacting
• Being so irritable that the child does not want to be held
• Flu-like symptoms improve but then return with fever and worse cough

In adults, emergency warning signs that need urgent medical attention include:

• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Flu-like symptoms improve but then return with fever and worse cough

• 104 °F: up per range at which most bodily functions are not altered.
• 106 °F: threshold for possible seizure activity. Normally human body temperature does not rise above this.
• 108 °F: brain damage may occur due to protein destruction.
• 110 °F: human cells begin to die.
In infants aged 1 month, 101.4 °F may be a critical temperature. This rises to 102 °F at 2 months of age.

Clinically, this H1N1 strain seems to require management in 3 general phases:

1. Cool, clammy skin with weak (relatively) pulse requires warming herbs that are also immunomodulants. Ginger, Turmeric, Garlic. Avoid foods.
2. Warm, dry skin and perhaps facial flushing with strong pulse and development of spasmodic cough. Cooling diaphoretics like Peppermint, Bonest are traditionally indicated, along with respiratory antispasmodics. Cooling bitters, esp. Andrographis, can play a role here too.
3. Demulcents and restoratives are important for the final period which can last 2-3 weeks. Consider Licorice, Slippery Elm, Pleurisy Root.

Prevention is, of course, the best medicine. Consistently use Astragalus and Garlic, as well as assessing Vitamin D levels and supplementing as necessary. Modest, plant-rich diet and abundant sleep are also crucial. Finally, limit spread through hygiene and limited contact.

The cytokine storm does not seem to be a crucial component to the 2009 H1N1 flu, but remains a concern nonetheless. This is a severe inflammatory reaction which usually occurs in the bronchiopulmonary system and causes excessive destruction of healthy tissue. It may have been a contributing factor in the deaths related to H5N1 bird flu, as well as the US epidemics of 1957 and 1968.

This inflammatory reaction is set in motion by the immune system and involves cellular players such as helper T-cells, as well as chemicals (“cytokines”) such as interleukin-6 (IL-6), tumor-necrosis-factor-alpha (TNF), and mitogen-activated protein kinases (MAPK, specifically of the p38 variety. This latter agent seems to be a major initiating player and is overexpressed as part of the reaction to certain flu strains). Additionally, if exposed to strains that show evidence of initiating a cytokine storm, virus-infected cells seem to exhibit increased resistance to the inflammatory chemicals that would normally hurt them.

Caution may be advisable with herbal agents such as Echinacea and Elderberry which may stimulate TNF and other cytokines. However, this danger is unclear. More important is the addition of herbs that down-regulate dangerous cytokines while also exhibiting antiviral effects (for instance, St. John’s wort, Baikal Scullcap, Salvia milthiorrhiza, Ginger, Turmeric).

The role of vitamin D in the seasonal nature of the flu bears mention. It has been postulated (Bergner et.al.) that the crucial role of D in promoting healthy immunity.

The crucial role of vitamin D in the innate immune system was discovered only very recently. Both epithelial cells and macrophages increase expression of the antimicrobial cathelicidin upon exposure to microbes, an expression that is dependent upon the presence of vitamin D. Pathogenic microbes stimulate the production of an enzyme that converts 25(OH)D to 1,25(OH)2D, a seco-steroid hormone. This in turn rapidly activates a suite of genes involved in pulmonary defense. In the macrophage, the presence of vitamin D also appears to suppress the pro-inflammatory cytokines. Thus, vitamin D appears to both enhance the local capacity of the epithelium to produce endogenous antibiotics and at the same time dampen certain destructive arms of the immune response, especially those responsible for the signs and symptoms of acute inflammation, such as the cytokine storms operative when influenza kills quickly.

While it is unlikely that the increased deaths in healthy, young adults in the 1918 flu pandemic were entirely due to D deficiency, it is important to ensure adequate immunity esp. in the at-risk populations through testing (if necessary) and supplementation.

Herbal support and supplementation notes:

· Preventative health:

Vitamin D

The only supplement I recommend adding if your diet is adequately plant based. Recommended blood test levels are around 35 ng/mL, but that’s just for adequate calcium metabolism. For immune function, required levels are closer to 50 ng/mL. Supplementation with 5,000 IU daily is necessary.

Astragalus

As a preventative, it should be withdrawn once symptoms begin. Take 3-5 grams of root daily in capsule, or simmer 2-3 TBS in a pint of water and drink through the day. Tinctures are taken at 1 tsp doses once or twice daily.

Garlic

Directly antiviral, ameliorates influenza symptoms, and its pungent compounds have been found to reduce cytokine storm. 3-4 cloves daily is ideal, as close to freshly cut as possible (chop first).

· Herbs that are directly anti-influenza:

Note: for most antiviral herbs, frequent dosing is relatively important in order to maintain physiological levels of herbal medicine ahead of the viral replication curves. Viral populations can easily more than double in an 8 hour period, so it is beneficial to work with antiviral and anti-inflammatory herbs on a 6-8 dose/day schedule. This is a dose roughly every 3-4 hours.

Boneset

Infusion, 1 TBS per pint along with other herbs, sipped every hour or so. Tinctures can also be used, 45-60 drops in warm water every hour or so.

Elderberry

Amazing clinical results against most influenza strains. Safe for H1N1, perhaps caution in H5N1 or other cytokine-storm-inducing strains due to potential TNF stimulation.

Use syrups (1TBS 3-5 times daily) or a fresh preserved succus / juice at the rate of 1tsp every 2-3 hours.

Elder flower tea is useful also, as a cooling way to induce sweating in the latter phases.

Echinacea

There is evidence of activity against influenza viruses, especially when combined with Thuja and Wild Indigo (Esberitox). It is potentially contraindicated in cytokine-storm influenza. Use Esberitox, or a good fresh tincture at doses of 1tsp. every 3-4 hours. Usually best at the first signs of imbalance – fatigue, sore throat, headache.

· Herbs that reduce cytokine storm activity and buffer “hot” influenza symptoms:

Baikal Scullcap root

Reduces cytokine storm and acts as an inhibitor of influenza symptoms. Take 60-90 drops three times a day of a good tincture. Avoid in cases of diarrhea.

Salvia milthiorrhiza root

Immunomodulant for cytokine storm, esp. with a constricted, wiry pulse. Take ½ tsp. of a good tincture three times daily.

Ginger and Turmeric

Both rhizomes are anti-inflammatory and inhibit inflammatory cytokines. This protects respiratory tissue as well as relieving symptoms. Most indicated in the initial phases of the flu as warming agents. Add fresh ginger to teas, or use powders of both at doses of 1-3 grams 2-3 times daily (about ¼ to ½ tsp.).

St. John’s wort

This is a potent antiviral herb, prized as a restorative in deficient, depleted constitutions. Modern evidence points not only to its pharmacological effect on dampening the cytokine storm by suppressing IL-6 and MAPK, but also to its targeted and specific antiviral effect against the H5N1 strains of bird flu, both in the petri dish and in infected poultry. The dose of tincture is 90-120 drops three times daily.

Cannabis?

This herb is potentially a down-regulator of TNF in certain situations, and may have a role to play in especially “hot” influenza strains. It is also an activator of the endogenous cannabinoid system, which stimulates immunoglobulin production in the respiratory epithelium. Not for smoking – low doses of oil-based preparations are best.

Adjuvant herbs (beyond the virus and inflammation):

Dry, spasmodic cough:

A very intense and painful cough can accompany H1N1 2009 influenza. It usually appears after the first 24 hours or so, and affects the beginning of the bronchial tree causing violent coughing with whole-body spasms. The warm drying expectorants (such as Elecampane, Mullein, and Aster) are probably best avoided in favor of the soothing, demulcent expectorants listed below.

Licorice

Its antiviral action may be due in part to the inhibition of virulence factors such as the hemagglutin proteins on the viral capsule. While it is still unclear if it has specific inhibitory effect on H1N1 or H5N1 strains, it remains an excellent demulcent for people of all ages and reliably loosens the dry cough within a day or at most two. This is especially important to help with disturbed sleep. Tincture, 2 droppers in a little water every 2-4 hours. Infusion, 1 TBS of root per cup. 1-2 TBS of infusion every 2-4 hours.

Pleurisy root, Butterfly weed

This demulcent expectorant is particularly indicated if the re is a burning sensation in the chest wall that accompanies the cough. Any spitting of blood, while perhaps a clear sign of cytokine storm and certainly of the need for immediate treatment, was traditionally an indication for this herb. It is also relaxing and mildly diaphoretic. Take 30-60 drops of the tincture 3 times a day.

Lobelia

Strongly antispasmodic, it relieves the whole-body paroxysms associated with the dry bronchial cough and is also a gentle expectorant. Use 10-30 drops of tincture every 3 hours or so, depending on tolerance because it is quite nauseating if given in excess.

Wild Cherry, Peach pit

These herbs contain glycosides of hydrogen cyanide (HCN), which in small doses is calmative and strongly antispasmodic to the lungs. They are valuable as part of a comprehensive protocol that also includes expectorants and antiviral herbs. Cold-infusion is best. Heating dissipates HCN readily tincture is dosed 5-30 drops bid. Wild Cherry bark syrup: 1 pint overnight cold infusion of 1 oz bark; strain, add 2 lbs honey.

Diaphoretic herbs not previously mentioned:

Honeysuckle flower

This remedy from the Chinese pharmacopoeia helps to cool and break a fever. Best during the first and early second stages of the flu to release internal heat and bring warmth to the surface. Usually infused, along with Platycodon for the lungs, Catnip as another antiviral diaphoretic, peach pit as a pulmonary antispasmodic, and Licorice.

Catnip herb

Especially useful as a mildly calmative antiviral diaphoretic for kids. Usually added to tea blends, perhaps with a little Ginger and/or Licorice.

Peppermint

Has some mild antiviral quality, and certainly is cooling and helps break a fever, as well as improve the flavor of herbs such as Boneset. A classic formula: equal parts of Peppermint, Boneset, Elderflower, and Yarrow in the late first / early second stage of the flu, when heat is manifest but the skin still dry and the body still achy, with a tense, tight pulse.

Bitter tonic herbs with antiviral / mucosal tonic effect:

Goldenseal

Not antiviral, but astringent and tonifying to the upper respiratory mucosa. Can alleviate congestion and improve appetite in the second or third stages of the flu.

Andrographis

Also called the “king of bitters”, this herb has shown excellent results when combined with Siberian Ginseng in large trials for the flu. It has antiviral effect and also improves GI tract function and may help regulate cytokine activity and prevent the cytokine storm.

dried herb - 1.5- 5 g/day; tea- 1/2- 1 teasp. steeped in 8 oz water, drink 4oz 3 X day
tincture- 20-60 drops 3 X day. standardized tablets- 100mg. w/ 5mg andrographolide and deoxyandrographolide, take 4 tablets 3Xday

Adaptogenic herbs not previously listed:

Panax quinquefolium

This is the American ginseng root, and while most of the evidence in humans pertains to the cold rather than the flu, it has good immune-enhancing (modulating) effect. It is especially indicated if there is severe stress and/or recurrent infections of all types related to deficient immunity. Take ½ tsp. of tincture 3 times daily, or 2-7 grams daily as whole root or capsule.

Siberian ginseng, though a very different plant, can be used similarly.

Specific pulmonary anti-inflammatory herbs not previously listed:

Platycodon

The balloonflower is used in Chinese medicine to clear heat from the lungs. As such, it seems more specific for the dry, painful and recurrent bronchitis than for moist, low-grade symptoms. It makes a good addition to tincture formulas for those who always have “every cold go to the lungs”. 30-90 drops of tincture 2-3 times daily.

Hyssop

Yet another effective antiviral herb that is gaining more attention in modern times, it is an excellent herb for lung afflictions of the more moist / hot variety. As such, it perhaps has a role to play in the later phases of influenza and to help with recovery. Infusion is excellent, about 1 TBS / cup steeped with a lid 3 times a day.

Top 200 drugs in the US - 2008

Jón T. Njarðarson's team at the University of Cornell has put together an interesting poster listing the top 200 pharmaceuticals used last year, ranked in order of sales dollars. Ostensibly there to "educate students about how chemistry positively impacts our lives" (debatable, I guess), it is a useful list because it gives the brand names, chemical structures, and general uses of these drugs we so commonly run in to in practice. A useful quick-reference (and an alarming amount of money spent).

Integrative mental health - an herbalist's ideas

Just a quick note for those interested in the outline for some general approaches / suggestions for the herbalist seeking to provide support in the management of mental health issues. This document includes suggestions on assessment process, goal-setting, general tonification approaches, and specific herbs for mental health symptom profiles.
My feeling is that disease labels are not helpful in approaching this aspect of health. Rather, I like to focus on symptoms - highs, lows, fluctuations - and the constitution in which they are presenting. Herbal suggestions are presented from this point of view.

Integrative student clinic at Johns Hopkins

Allegra Hamman has just been hired as a clinical herbalist to complement the care provider team at Johns Hopkins' Student Health and Wellness Center. She is a nurse practitioner (advanced training, similar to that received by a physician's assistant) with years of experience in the conventional medicine field. This June she received her Master's Degree in herbal sciences from Tai Sophia Institute, making her eminently qualified for her new position.
Though I don't know Allegra or her professional style, I am encouraged to see prestigious institutions such as Johns Hopkins responding to the demand they see in their clinics. As Alan Joffe, clinic director, put it: "There is clearly a group of students at Hopkins who prefer approaching health from a perspective other than what traditional Western medicine has to offer; I want to provide those students with some of those services."
Finally, I believe herbalists, as "generalists" well-equipped to handle a variety of complaints commonly seen in the "family practice" setting, can do a lot meet the needs created by a nationwide physician shortage. We represent an effective treatment modality, with a long historical record and excellent safety. Of course, there will always be those at institutions such as Hopkins who have to push back hard against these changes - largely, I might add, out of ignorance of the herbalists' skills and qualifications.

The benefits of Nature for children with ADD / ADHD

File this one under the "let's spend grant money to research the obvious" category: it seems that walking for about 20 minutes in a park, surrounded by trees and Nature, is as effective as Ritalin for managing some of the symptoms commonly classified under the "attention deficit" umbrella.
Researchers recruited 15 boys and 2 girls and walked them for 20 minutes in one of three settings, on different days: an urban park, a residential neighborhood, and a downtown area. Those who walked in the park showed significant, powerful improvements in their ability to concentrate and perform after their walk. The others did not. While these results may seem obvious to us, we can at least gain some measure of comfort in knowing that the mainstream medical community feels like "doses of nature might serve as a safe, inexpensive, widely accessible new tool in the tool kit for managing ADHD symptoms" as Dr. Andrea Taylor, head researcher for the study, wisely commented.
Now, I might feel that a walk in the Vermont woods, as they turn from green to fiery red, might give an even better experience to nurture biophilia, provide renewal and inspiration, and calm a scattered mind. But even a manicured park can do the trick! So finding time to spend outside, away from television, houses, and buildings, is a good idea for our kids. And "nature deficit disorder" might soon be recognized as a legitimate concern. Imagine that...

Bacterial resistance update

Triclosan, a chlorinated polyphenolic compound found in a range of consumer products, has been touted as "antibacterial" and somehow linked, by extension, to providing safety and reducing infection in hospitals and homes. Thus, it's found its way over the last twenty years into soaps and cleansers, and more recently toothpaste (scary).
Scientist at the University of Michigan in Ann Arbor reviewed relevant research on this chemical and the products that contain it, and came to the inevitable conclusion: it doesn't really work at reducing infection rates in hospitals, nor is it any better than regular soap at reducing bacterial levels on hands. And, of course, they tracked and documented cross-resistance amongst bacteria exposed to Triclosan and those who've never tasted the stuff: these ubiquitous antibacterial preparations are contributing to bacterial adaptation and resistance. Our environment is awash in these types of substances already, and bacterial resistance is increasing. Antibiotics, which can be lifesavers in emergency situations, are one thing (overused, granted). But no one should be purchasing these Triclosan-containing products which are ineffective and dangerous to the environmental balance.

Spring in Italy - pt. 1

We returned to Italy in the last two weeks in April (mud season up here in Vermont), and got an amazing jump on Spring. For me it was a chance to see all my family again - it had been way too long! - and reconnect with old friends. Along the way, of course, we found many old friends of a different sort, like this flowering pink peony (Paeonia spp.)



Wild Clary Sage (Salvia sclarea)





















Flowering Hawthorn (Crategus spp.)
























Figs (Ficus carica)























Flowering Rosemary (Rosmarinus officinalis)

Hawthorn for a failing heart

Hawthorn (various Crategus species) received an endorsement in another Ernst-and-friends metareview. The review included 14 trials, and focused on hawthorn's ability to improve the maximum workload of the heart, and improve various cardiovascular markers during exercise-induced strain. The bottom line: hawthorn leaf and flower extract helps. A lot. Even if added to existing medication regimens.
Just to be clear, no new clinical research is coming out of this review. Rather, it attempts to collate existing studies and compare them using a common denominator. Further details on the data are below, but for now my opinion continues to be that hawthorn, either as a berry, a tasty jam, or as a leaf-and-flower extract (or tea), should always be considered as part of the protocol for cardiovascular weakness or imbalance. In fact, I might go further to say that most colorful berries would accomplish similar effects and that, in fact, a nice cocktail of all sorts of berry fruits is probably the best way to go for managing blood pressure, improving capillary integrity, and increasing the efficiency of the heart muscle. Eat well!

Canadian herbal product regulation

There's a somewhat alarming development afoot in Canada relating to the sale, use and dispensation of herbal medicines and "natural" supplements. We've been following the discussion on herbal product regulation here in the United States, and looked briefly at the impact that Canadian legislation passed in 2004 (very similar to the FDA's current rules) and the impact it's had on herbalists.
Now, the Canadian Ministry of Health is attempting to pass a bill that would radically step up enforcement of the new, stringent rules. These regulations are largely based on the framework of the Codex Alimentarius, a global agreement designed to 'harmonize' the preparation and dosing of various medicinal substances, from vitamins to herbs. Therefore, herbal products would have to be of ineffective potency and completely divorced from any health claims to be able to skirt this new legislation. No longer interested in regulating only drugs, the Canadian government wants to broaden its scope of oversight to all 'therapeutic substances' with this new law. Oh, and it steps up resources for enforcement and lowers the requirements for search and seizure (beware the herb police).
Many are showing righteous concern (here's a good legal summary from a concerned perspective). If the trends continue, we could see this coming in the United States soon.

Echinacea as a common cold preventative - again

We've been over in Italy for the last few weeks, and updates here are difficult. I'll be posting some photos of wild springtime herbs soon, but for now a little tidbit that will surely make news (because it shows a negative result for an herbal intervention): another study tells us that Echinacea doesn't prevent the common cold.
90 volunteers received 3 caps pf Echinacea purpurea tops twice a day for 8 weeks, and reported 8 sick days vs. 12 for placebo. This is an 'insignificant' result. I'm not sure when the research community will figure out that this is a) an inappropriate dose and delivery system and that b) it is an inappropriate application of the herbal remedy.
Perhaps that's not the point. Perhaps media articles that say "Echinacea fails" are more enticing than actual helpful research. I just wish someone would send me the funding that researchers get for conducting these trials so I could buy more compost for my garden...

Devil's Claw and rheumatic inflammation

Devil's Claw (Harpagophytum procumbens) is native to South Africa, lives in dry soils, and produces large underground tubers that are a source of both food and medicine.
The tubers are rich in flavonoids, phytosterols, and a particular type of bitter iridoids (one of which, extensively researched, is known as harpagoside and usually serves as the 'marker compound'). It is traditionally used as a tonic for the digestion, helping to improve appetite and assimilation while also being very nourishing. It has also served as a general depurative and diuretic.
More recently interest has focused on its analgesic and anti-inflammatory qualities, with a range of human trials in the literature that expand on lots of pharmacological data (Doloteffin, the standardized aqueous extract of the whole tuber used in many trials, yields about 50mg of harpagoside per dose). Seems best for back pain, osteoarthitis, and muscular pain -- or generally, most chronic conditions involving structural inflammation.
A new study for the first time looks at Devil's Claw in chronic inflammation of autoimmune origin. It's not placebo-controlled, but rather focuses on qualitative impressions from the clinicians and the patients regarding long-term rheumatic inflammation of the knee, hip, and various other joints. Over 200 people were included in the study, though folks taking H2 and proton-pump inhibitors (two varieties of heartburn drugs) were turned away because of the potential for herb-drug interactions. Patients were followed for 8 weeks (with a mid-course checkup at week 4) and, with an eye to safety, were also evaluated through a blood analysis that looked at comprehensive blood counts and liver enzyme levels.
Bottom line: the only adverse events reported weer occasional mild GI upset. Over 50% of participants rated the results as "good" or "excellent", with assessment criteria showing a reduction in pain and stiffness, and improved joint function across the board. Additionally, no changes were seen in any blood values, showing that Devil's Claw is well-tolerated, has no liver toxicity, and works quite well for rheumatic joint pain.
A final note: the authors recorded that a majority of NSAID (aspirin, ibuprofen) users scaled back or eliminated the use of these painkillers during the study, because they no longer were necessary. They go on to point out that, since rheumatic complaints are chronic but have 'flare-ups', the Devil's Claw could be used for long-term management and the NSAIDs added only as needed. This would reduce the chance of side-effects from the medication, and improve patient well-being overall.

Late winter lichens

Yes, the Equinox has passed, but here in the mountains of Vermont we still have two feet of snow in the fields. I've been jealous lately looking at the pictures of spring greens everyone is starting to harvest!
Well, short of digging for goldthread and wintergreen, we decided to visit with the thriving local lichen population. The first stones to emerge from the feet and feet of snow we had this winter were in the graveyard.

Sage improves memory and attention

'He that would live for aye,
Must eat Sage in May.'

The old English proverb, quoted by venerable herbalists from Gerard to Maude Grieve, refers to the virtues of the common garden sage (Salvia officinalis). This gracious aromatic herb, of a dry and warming energy, was long considered to confer immortality, a quickness of wit and eye, and protection from disease.
Previous research has shown evidence for sage's ability to enhance mood, reduce anxiety, and improve performance in healthy young volunteers (lemon balm, too), and the in-vitro research on the herb's ability to exert anti-cholinesterase activity (prolonging the activity of the neurotransmitter acetylcholine) has made it a target for research in aging and dementia. Acetylcholine is involved in transmitting signal in an area of the brain called the basal forebrain (amongst others), and there is evidence that this region of the central nervous system degrades as we age, leading to memory loss and cognitive impairment (as in Alzheimer's, for instance). Acetylcholine also provides the connection between the nervous system and musculature, and deficiencies are associated with conditions such as myasthenia gravis.
In this most recent study, 20 healthy older volunteers aged 65 to 90 were given various doses of a sage extract, and the results indicate an improvement in a variety of cognitive markers, along with a reduction in the score dropoff over the course of the day (the volunteers stayed sharper, longer). Some details:

• the extract was made with 70% alcohol, then concentrated and freeze-dried to a final weight-to-volume ratio of 7.5:1. This is pretty darn concentrated. Researchers were going for the volatile terpenes primarily (well-soluble in alcohol). They found 333mg to be the most effective dose; this is about 2.5 grams of leaf, or about 7.5 ml (1 and 1/2 tsp.) of a 1:3 tincture of sage.
• the extract was compared to placebo, in a variety of categories including word recognition and recall; vigilance; reaction time; spatial and numeric memory; and delayed picture recognition tests. Below are graphs of the changes in (a)secondary memory and (b)accuracy of attention:

So, sage is definitely worth considering in the context of other herbs such as Ginkgo and Rhodiola in helping buffer the effects of aging on otherwise healthy minds. Perhaps there is indeed some wisdom in the old Latin proverb, Cur moriatur homo cui Salvia crescit in horto? ('Why should a man die as long as sage grows in his garden?'). Or at least, why should he (or she) grow old and forgetful?

Herbs regulated as drugs?

Michael McGuffin, President of the American Herbal Products Association wrote an interesting counterpoint in response to an editorial in the journal Clinical Pharmacology and Therapeutics (full text for both should be available for all starting in April 08). J.D. Morrow, a pharmacologist from Vanderbilt University, essentially argued that the FDA has had way too little authority under DSHEA, the act passed in 1994 that classes herbal supplements as 'foods' and regulates them as such. His concerns:
. "A major problem with the DSHEA is that the FDA bears the burden of proof if it decides to assert that a supplement is unsafe".
. "Many supplements contain active ingredients with the potential for serious adverse pharmacological effects if administered in excessive—or, in some cases, even recommended—dosages".
. "The sheer amount of usage and number of products available make adequate oversight of dietary supplements extremely difficult and provide the potential for agents with significant toxicity to enter the marketplace".
Well, thankfully, in order to safeguard us from certain doom, the FDA issued its final rule last summer to help address some of these concerns. Indeed, J.D. Morrow was involved in the commission that pushed for the approval of tighter standards. Nevertheless, he continues:
. "These needed regulations have been a long time in coming but are clearly designed to make more uniform the quality of products sold to the American public".
. "Again of concern, however, is the ability of an understaffed and underfunded FDA to enforce these regulations without additional support".
As I have always suspected, the FDA will require an armed enforcement unit! Only then can we ensure adequate product uniformity.
Morrow concludes that "there is little, if any, evidence that most agents are medically efficacious" (really?) and that therefore "enhanced regulation of the dietary supplement industry (...) must be done immediately".

McGuffin provides some needed clarification in the description of the current regulatory framework. Under DSHEA,
. "a statement for a dietary supplement may be made if…the manufacturer of the dietary supplement has substantiation that such statement is truthful and not misleading".
. "[Starting on] 22 December 2007, all marketers of supplements (and nonprescription drugs) must submit reports of serious adverse events that they receive. The FDA’s role in regulating dietary supplements has thus been expanded significantly".
. "Criticisms of herbal supplements tend to focus on areas in which federal regulatory agencies fail to enforce the current laws. (...) But these are not failures in the law; these are examples of
the need for more active enforcement of existing law".
As for the new GMP (Good Manufacturing Practices) rules in last summer's FDA pronouncement,
. "These regulations are much more extensive than the standard cGMP rules for conventional foods. The FDA acknowledged that some provisions of the new cGMP rule “may be similar to
the existing drug CGMP regulations,” and many sections of this new rule are borrowed directly from the cGMPs for drugs".
. "In addition, the FDA has assigned itself records-inspection powers that greatly exceed its authority in the conventional food sector".
And, McGuffin concludes,
. "An “herbs as drugs” option could only be seriously considered for the United States marketplace if there is also a willingness to allow claims for the use of these products in the treatment, cure, and prevention of disease and if legitimate historical records are accepted to support claims for traditional use".

That is, the 'gold standard' of the double-blind, placebo-controlled trial would need to be altered for substances that have a long, substantiated track record of historical use.

It will be interesting to see what eventually happens in the United States, since the regulation of herbal medicine has been in a virtual state of 'limbo' compared to Europe, Australia, and the rest of the world. If we had a crystal ball, we might be able to see how heightened regulations and 'professionalization' of herbalists and herbal products might affect our ability to practice our art in the future. Oh, but wait -- we have Canada (which works almost as well):

So many of us are afraid we’re going to go out business. Some people plan to go underground, some people plan to go defiant and see if they’re actually willing to put us in jail . . . we are like the weeds and will never be eradicated.

So spoke an unidentified Canadian herbalist in response to the new regulations that govern natural health products (NHPs). Here is a brief summary of the historical context:

"Until recently, NHPs in Canada were regulated as either foods or as drugs, as stipulated by the Food and Drugs Act. A major impetus for the creation of new NHP regulations was widespread concern that the Food and Drug regulations were inappropriate for NHPs (...) A new regulatory framework came into law January 1, 2004, with a transition period of 6-year. NHPs, including herbs, vitamins, minerals, essential fatty acids and homeopathics which are used to prevent, diagnose or treat disease, restore or correct function or maintain or promote health are now classified as drugs at the level of the Food and Drugs Act".

Very much like the progression we're seeing folks like Morrow advocate. For Canadian herbalists, these new regulations are much more difficult and may well force many underground. As American herbalists have oft lamented,
"smaller companies tend to be run by people who are herbalists, and herbs are their life, and they are very fussy about the quality of the herb and the manufacturing of the herb (...) They're going to make it very difficult for small manufacturers to continue to operate. I really think that they’re treating NHPs as if the risks associated with them were equal to the risks associated with drugs".

We need to think deeply about the costs and benefits associated with increased regulation in a framework that relies on conventional approaches to research, manufacturing, and delivery of medicines. All the components of such a network are extremely different in American herbalism (and, in fact, a unified framework is very difficult to pin down). But if we can be flexible and examine the effects of substances based on their historical context, modern research, and current folk wisdom, then perhaps we can learn to alter our entire approach to health care. After all, form follows intention, and as long as we advocate abstracted, culturally disconnected research as the only way to 'truth', we will continue to experience increased costs, side effects, adverse events, and chronic disease.

Michael Pollan and Real Food

Food - our basic sustenance, one of our most primal interfaces with the natural world - plays a crucial role in the ongoing creation of ourselves, and in the maintenance of the all-important "internal balance". So, when we begin to lose our balance with the food we consume, it is no wonder that "disease" sets in. And it is no wonder that these "diseases" are slow to progress, leaving us in a state of chronically deteriorating health.
So, to re-enliven the body, mind, and spirit, herbalists have always been strong advocates for an old-time, whole-food, plant-rich diet - with some extra punch now and again in the form of herbs and spices. I've read some excellent thoughts on this subject over at The Herbwife's Kitchen, and have become quite suspicious of any larger company (witness Kashi / General Mills) trying to sell me something in a box.
So it was with great pleasure that I listened for a little while to Michael Pollan, author of The Botany of Desire (one of my favorite modern descriptions of the human/plant bond). Amy Goodman interviewed him on Democracy Now! and his comments clearly articulate the perils of overthinking and overprocessing the food we eat. The wide-ranging interview discusses the history of the food-industrial complex in the USA; 'nutritionism'; chronic disease and its link with food; whole foods, local foods; biotechnology; and more. Some comments:

And, in fact, one of my tips is, don’t eat any food that’s incapable of rotting. If the food can’t rot eventually, there’s something wrong. (...)

And the last premise of nutritionism is that the whole point of eating is to advance your physical health and that that’s what we go to the store for, that’s what we’re buying. And that’s also a very dubious idea. If you go around the world, people eat for a great many reasons besides, you know, the medicinal reason. I mean, they eat for pleasure, they eat for community and family and identity and all these things. But we’ve put that aside with this obsession with nutrition. And I basically think it’s a pernicious ideology. I mean, I don’t think it’s really helping us. If there was a trade-off, if looking at food this way made us so much healthier, great. But in fact, since we’ve been looking at food this way, our health has gotten worse and worse. (...)

Cholesterol in the diet is actually only very mildly related to cholesterol in the blood. It was a—that was a scientific error, basically. We were sold a bill of goods. (...)

We learned how to grow food with lots of synthetic fertilizers made from natural gas, pesticides made from petroleum, and then started moving it around the world. So now we take about ten calories of fossil fuel to produce one calorie of food energy. Very unsustainable system. (...)

and, in conclusion:

Well, the interesting thing is that most traditional cuisines are very healthy, that people—that the human body has done very well on the Mediterranean diet, on the Japanese diet, on the peasant South American diet. It’s really interesting how many different foods we can do well on. The one diet we seem poorly adapted to happens to be the one we’re eating, the Western diet. So whatever traditional diet suits you—you like eating that way—you know, follow it. And that—you know, that’s a good rule of thumb.

There’s an enormous amount of wisdom contained in a cuisine. And, you know, we privilege scientific information and authority in this country, but, of course, there’s cultural authority and information, too. And whoever figured out that olive oil and tomatoes was a really great combination was actually, we’re now learning, onto something scientifically. If you want to use that nutrient vocabulary, the lycopene in the tomato, which we think is the good thing, is basically made available to your body through the olive oil. So there was a wisdom in those combinations. And you see it throughout.

Pharmaceuticals in tap water

An investigation by the Associated Press reveals some disturbing facts about the presence of a variety of medications in the public water supply of at least 41 million Americans. Major metropolitan areas were sampled along with representative rural communities from all 50 states.
The array of pharmaceuticals includes seizure medications, antibiotics, mood stabilizers, steroids and other hormones, and more. While it may be in the best interest (of someone) to over-medicate the American psyche with antidepressants and muscle relaxants, it is of immediate concern to see high levels of antibiotics entering the environment and registering appreciable quantities in water. It is no wonder antibiotic resistance is so prevalent amongst pathogenic bacteria.

Herbal Internet Resources

Some links to excellent free online material for herbal research, historical exploration, or just hours of gazing at full-resolution botanical illustrations...

Current Herbal

Herb Med Pro
www.gaiaherbs.com/herbs.php

Free access to a database of over 200 medicinal herbs with complete links to relevant research, categorized by pharmacological, in-vivo, and human trials. Extensive referencing and links.

WHO Monographs on Selected Medicinal Plants - Volume 1
www.who.int/medicinedocs/index.fcgi?a=d&d=Js2200e

WHO Monographs on Selected Medicinal Plants - Volume 2
www.who.int/medicinedocs/index.fcgi?a=d&d=Js4927e

WHO Monographs on Selected Medicinal Plants - Volume 3

http://www.who.int/medicinedocs/collect/medicinedocs/index/assoc/s14213e/s14213e.pdf

Plants-for-a-future Database Search
www.ibiblio.org/pfaf/D_search.html#NAME

Select from a wide range of plants, based on edible, medicinal, and agricultural uses. Extensively referenced.

Materia Medica Articles Index

www.medherb.com/Materia_Medica/materia_medica.htm

Paul Bergner's searchable online archive of newsletter articles pertaining to specific items in the Materia Medica.

Jim Duke's Phytochemical and Ethnobotanical Databases
www.ars-grin.gov/duke/

A searchable database of plants providing chemical
constituents, cross-linked with the actions of said chemicals. An
interesting exploration of phytochemistry.

PLANTS Database | USDA PLANTS

plants.usda.gov/index.html

Extensive database providing information on plant distribution and taxonomy. Also describes commercial and ecological uses, and reports on endangered status. Extensive links and photos for most plants.

Classic Herbal

Henriette's Herbal Homepage

www.henriettesherbal.com/

Massive online library that includes many older N. American texts, but also an extensive collection of the best of online herbal questions posted to Usenet, and thousands of pictures by Henriette.

Herbal Therapeutics Research Library
www.herbaltherapeutics.net/herbal_therapeutics_lib...

David Winston's Online library

Maude Grieve's "A Modern Herbal"
www.botanical.com/botanical/mgmh/comindx.html

The classic 1931 text that covers a wide array of medicinal plants, includes rudimentary chemical analysis, extensive preparation notes, and medicinal activity for each plant.

Medical Historical Library: Electronic Texts in the History of Medicine
www.med.yale.edu/library/historical/siderits.htm

A variety of classic European texts scanned into images, usually with browsable indexes. Includes a full copy of Fuch's 1544 herbal, extensively illustrated.

MBG Library: Rare Books

www.illustratedgarden.org/mobot/rarebooks/

Over 130 rare and classic herbal and botanical works. Incredible full-resolution pages, many containing stunning botanical illustrations.

Medical Reference

THE MERCK MANUAL MEDICAL LIBRARY: The Merck Manual of Diagnosis and Therapy
www.merck.com/mmpe/index.html

Professional version of the manual of human disease, including mainline conventional treatment and medications used.

eMedicine The Continually Updated Clinical Reference
www.emedicine.com/

Professional reference, most extensive and up-to-date, for conventional medicine, diseases and diagnoses, and medications used.

Nutrition facts, calories in food, labels, nutritional information and analysis – NutritionData.com
www.nutritiondata.com/

Specific nutritional information on almost any food or prepared product. Portion sizes, conversions, and cross-references.

Plant People

A new collection from photographer Hans Silvester documents the incredible plant-based ceremonial and celebratory outfits of he Surma and Mursi tribes of East Africa's Omo Valley. This region, which borders Kenya, Ethiopia, and the Sudan, is certainly not one of the least troubled areas of the globe. Yet people there, as everywhere, find time to continue old traditions that glorify and celebrate humankind's connection to Nature. A rich, beautiful, and heartening display.
Some selections below.