Little Alice fell
d
o
w
n
the hole,
bumped her head
and bruised her soul
― Lewis Carroll, Alice in Wonderland
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America spends more money on drugs than any other nation in the world. It's no wonder the health care debate has been so heated and contentious, perhaps reflecting the fact we take more antipsychotics than any other nation as well. Does this mean everyone – tinker, tailor, politician, spy – is operating under the influence? Exactly how many Americans take prescription medications?
Go Ask Alice
The truth is, it’s impossible to answer that question. Invasion of privacy is a modern epidemic – but our personal medical records and health history are still protected by law, on paper at least. Researchers looking to find an exact number of those who can be counted among “the medicated public” run into a privacy wall restricting their access to that information. They can only make an educated guess.
In 2013, researchers at the Mayo Clinic came up with a whopping 70% of Americans who take one or more prescription drug: half take at least two; and 20% take five or more prescription drugs.
Canada’s Centre for Research on Globalization has a slightly different take on it: it claims that the number of prescriptions written by American doctors in 2013 was nearly 13 times larger than the total US population, but that only 48.5% of Americans were taking prescription medications in December, 2013; that 20% took three or more prescription drugs; and that only 10% took five or more.
So, which is it? Is it more or less accurate to say that half of us are in a medicated state of homeostasis?
Age and gender matter as well in describing who takes what medications. The Mayo Clinic presents some fascinating data:
Overall, women and older adults receive more prescriptions. Vaccines, antibiotics and anti-asthma drugs are most commonly prescribed in people younger than 19. Antidepressants and opioids are most common among young and middle-aged adults. Cardiovascular drugs are most commonly prescribed in older adults. Women receive more prescriptions than men across several drug groups, especially antidepressants: Nearly 1 in 4 women ages 50-64 are on an antidepressant.
How sad is that?
These numbers don’t account for over-the-counter (OTC) medications. According to the Consumer Health Care Products Association, 81% of American adults use OTC medications as a first response to minor ailments, while nearly 7 in 10 parents have given their child an OTC medicine late at night to help treat a sudden medical symptom.
But what about herbal medicine? How many people are also taking herbal remedies on top of prescription drugs and OTCs, and how many take herbs exclusively? Do some Americans take no medications or remedies at all? And if so, what about the health benefits of specific foods? Aren’t herbs “foods?” How does “herbal medicine” fit into this equation?
Go down the rabbit hole below the fold to find out more.
Herbs, Foods, and “Nutraceuticals”
For many people who take herbs, it is still a matter of popping pills. Americans have become accustomed to convenience and expect rapid results. It can be hopelessly unrealistic of us and a bit annoying. But to the credit of American herbalists, chemists and pharmacists, food scientists, and the American herbal products industry at large, a variety of fast-acting and effective herbal remedies are finding their way onto shelves in mainstream grocery and drug stores nationwide, sold as OTC products – or at least, these products attract loyal, repeat customers who have concluded on their own that the products are effective. Analysts from inside the industry say that an aging population, a better educated young adult population, and high prices in health care combined with a rising cost of living are driving more customers toward the herbal remedies market. They predict the global market for herbal supplements and remedies will reach over $100 billion by 2017.
Another market sector that uses a significant amount of botanical ingredients and borrows heavily from traditional herbal medicine and its recipes is the cosmetics and beauty products industry. Facial skin care products top sales in this more than $52 billion US market. Like prescription drugs, OTCs, and some herbal remedies, these products – including make-up, hair care, skin care, perfumes, shaving products, tooth paste, mouthwash, deodorants, and so on – are all regulated by the FDA under the provisions of the Federal Food, Drug, and Cosmetic Act of 1938 (FD&C Act).
The industry thrives on a mystique of “beauty secrets” with an almost alchemical air, combining the scientific with the “natural” and “organic.” The range of products in this sector is remarkably diverse. They may be “pure,” single ingredients or simple compounds, or they often blend dozens of botanical, mineral and petroleum-based ingredients, including natural and artificial dyes and fragrances, while increasingly making use of so-called “nutraceutical” vitamins and other nutrients.
This all seems a far cry from herbal medicine – almost as far as the “nutraceutical” market itself, which includes herbal supplements along with vitamins, minerals, and a variety of “functional foods and beverages.” Depending on the product, regulation may fall under the FD&C Act or under a significant amendment to that law, the Dietary Supplement Health and Education Act of 1994.
When it comes to proper nutrition, we love to pop our pills. In one of the fastest growing markets in the world, the VMS industry (Vitamins, Minerals, and Supplements) generated about $32 billion in revenue globally for nutritional supplements alone in 2012. Once considered an obscure fetish of body builders and “health food nuts,” the VMS market is now mainstream, reaching men, women, and children from all walks of life, its products often included in both conventional doctors’ and natural health care practitioners’ recommendations. This attractive growth market is recently seeing participation by “strategic buyers” like Hormel Foods, owner of Skippy Peanut Butter and Spam. That’s hardly “herbal medicine.”
What’s in a Name?
The National Center for Complementary and Alternative Medicine at the National Institutes of Health (NCCAM) lumps all herbal remedies in with “Natural Products” as part of “health care approaches developed outside of mainstream Western, or conventional, medicine.” NCCAM estimates that some 40% of Americans use natural products and other complimentary and alternative medicine, or “CAM.” The Center defines “Natural Products” as “herbs (also known as botanicals), vitamins and minerals, and probiotics.” Other “CAM” therapies include mind and body practices, such as meditation, massage, and yoga.
Although NCCAM is a distinguished lead agency for scientific research on complementary and alternative medicine, its definition of “herbal medicine” (or lack thereof) falls a bit short. Herbal remedies did not, in fact, develop outside of mainstream medicine. It is difficult to think of an herbal remedy used in modern times that did not first pass through the old country doctor’s black bag. Before the advent of synthetic drugs (pre-20th century), conventional “Western” doctors prescribed and used an array of herbal concoctions. Even many plant medicines from China and other nations were well-known to American doctors of the past. Synthetic drug developers in turn took their cues by isolating and studying the active constituents of well-known medicinal plants. To this day, many pharmaceutical products still use botanical raw materials as their primary source ingredients.
Examples of the overlap between herbal and conventional medicine are abundant. To name only a few: For more than two centuries, conventional Western doctors have used Digitalis purpurea, or purple foxglove, a common but deadly European garden flower naturalized in the wild in some parts of the United States, as a potent cardiac drug; Quinine, a crystalized alkaloid that occurs naturally in the bark of the South American Cinchona tree, was the first effective Western treatment for malaria, dating back to the 17th century; Artemisinin, isolated from the Chinese herb Ching-hao or Sweet Annie (Artemesia annua), is part of the first-line treatment for malaria currently recommended by the World Health Organization.
Plants can be and are used as powerful medicines. But many common herbal remedies are also found in the kitchen pantry. Culinary herbs and spices have been carefully selected over the centuries, not just for flavor, but also for specific actions they have on digestion and other body systems. Parsley, sage, rosemary, and thyme all find their place in the herbal “Materia Medica.” Our favorite herbal remedies from the kitchen can be hard to distinguish between “medicine” and “food.” In patient or market surveys of health care preferences, how do you count the number of people who throw some extra garlic into their chicken soup when they catch a cold?
Eating Well? Or Eating Ourselves Sick?
“You are what you eat” is a basic tenet of natural health care, or “CAM.” Our national state of health certainly attests to that. America’s most common, chronic health problems, from heart disease and obesity to diabetes mellitus and even some types of cancer, are to a large degree caused by what and how we eat – and can be prevented, treated and improved by what and how we eat as well.
To put some perspective on the notion that the American medicated public may be eating itself sick, here are some sobering numbers. According to the Centers for Disease Control and Prevention (CDC):
About half of US adults (47%) have at least one of the following major risk factors for heart disease or stroke: uncontrolled high blood pressure, uncontrolled high LDL cholesterol, or are current smokers. Ninety percent [ ! ] of Americans consume too much sodium, increasing their risk of high blood pressure.
The CDC also asserts that “
Obesity is a national epidemic and a major contributor to some of the leading causes of death in the U.S., including heart disease, stroke, diabetes and some types of cancer.” The CDC estimates that more than one third of American children are overweight or obese, while
NIH says more than 2 in 3 adults are overweight or obese.
A good deal of America’s worst, chronic health problems are caused by poor diet (where smoking, alcohol, and drug use are considered part of one’s “diet”) and lack of exercise. They develop over time, as a result of long-term bad habits and excesses. When used to prevent or reverse chronic health problems, herbal remedies are often taken over long periods of time, like a new, good habit to replace the old, with gradual and long term, though not always immediate, health benefits.
A variety of herbal remedies fall into the category of what a traditional herbalist might call “food herbs.” They are incorporated into the diet as fresh, whole foods; added to recipes as spices or condiments; or taken daily as a “tonic” or regular dietary supplement, in tea, capsule, tablet, cordial or tincture form. Herbs like dandelion root and leaf, burdock root, cayenne peppers, mint, and garlic are commonly found at farmers markets and grocery stores. It is not entirely fair or accurate, however, to say that “food is herbal medicine” or that “herbal medicine is food.” Nonetheless, in the United States, herbal remedies are regarded as “dietary supplements,” which, unlike prescription drugs, can be sold without scientific proof that they are or are not safe and effective when used medicinally.
This may sound alarming, but it may also be the best, common sense approach to the fact most Americans do not want the government telling us what we can and cannot eat and drink, or declaring that every food on our plate is technically a “drug” that ought to be federally regulated as such. It allows us to buy garlic, ginger, cranberries, lemons, etc. in the produce section without a doctor’s Rx form. If Grandma knew that fresh horseradish root safely opens up the sinus cavities, and proved it by serving it up for every sniffle and sneeze, not all of us need a double-blind clinical trial and government stamp of approval in order to agree with her conclusion.
Research may not be required for product sales, but still a wealth of information exists about the use, safety and efficacy of just about any herb ever used as food or medicine. The scientific literature is by no means complete and in some ways, is still in its infancy. But, especially in light of the growing popularity and widespread availability of herbs and herbal supplements, plant medicines and herbal combinations are under increasing scientific scrutiny. The American Botanical Council, the Natural Medicines Comprehensive Database, and the NCCAM at the National Institutes of Health are among the leading institutions in the US dedicated to providing accurate information to medical professionals, product manufacturers, natural health care practitioners, and to the general public.
Health Food Tastes Like GRAS
Many herbs are also foods, while prescription drugs are simply not. But what about herbs that aren’t really foods at all, used medicinally to treat specific health problems? Most herbal remedies are not actually considered “foods” by the people who use them, even if they are classed as “dietary supplements” by the FDA.
Of the top herbal supplements sold in America, only two would be considered “food herbs” by a traditional herbalist. According to the University of Maryland Medical Center, the most commonly used herbal supplements in the U.S. include Echinacea, St. John's Wort, Ginkgo, Garlic, Saw Palmetto, Ginseng, Goldenseal, Valerian, Chamomile, Feverfew, Ginger, Evening Primrose, and Milk Thistle. None of these are considered a staple food, though Garlic and Ginger are common household spices found in everyday foods – and both are also Generally Recognized As Safe.
The FDA’s listing of Generally Recognized As Safe (GRAS) food substances is more or less a negative-engineered project: substances are on the list if no evidence exists or if there is insufficient proof of public hazard caused by the intended use. In some ways, substances on the list are like sitting ducks, waiting for sharp-shooting researchers to come along and pick them off.
GRAS applications are submitted by product manufacturers seeking FDA approval, or, FDA may review a product’s compliance and/or GRAS status by its own initiative. By law, product labels, websites, and other marketing materials of both GRAS and non-GRAS dietary supplements and “functional foods” can only make health and safety claims that are already well-documented and approved by FDA. Claims like “cures the common cold” or “reduces the risk of AIDS” on the label of these products would simply be fraud, since no herb, food, vitamin or other nutrient can be said to do either. Such claims would require that the product and any marketing materials be pulled from the shelf and/or internet, the substance classed as a “drug,” researched to verify the accuracy of any claims and tested for safety – along with a whole lot of fines and paperwork.
Some product manufacturers hope to nudge certain substances out of GRAS status and into the “drug” category so they can, with due process, make marketing health claims of super-powers their products possess that can’t possibly be reproduced in the kitchen or in any OTC product. Others want the GRAS status to stick so their products do not have to undergo more rigorous regulatory scrutiny and can remain competitive as alternatives to formally-classed “drug” therapies. It’s a bit like scientists trying to dance a waltz while their politicking sales team partners really just want to do the tango – with the FDA as the dance party’s chaperone.
Although the FDA is as good as it gets in terms of verifying public safety and efficacy of commercial food and drugs, cosmetics, and dietary supplements in the US, consumers are often left at the bottom of the totem pole when it comes to the politics of packaging and health-related claims. This is true not only in regard to potentially or outright fraudulent claims, but also when it comes to herbal remedies that work well but are left in a research no-man’s-land of poor profitability. Who pays for research proving dandelion leaves picked in the backyard are as safe and effective a diuretic as Brand X?
Medicated Wellness
This brings us back to the question of how we define and use herbal medicine. If we can assume that most or all Americans are currently, or have been previously, or will be in the future, part of a “medicated public” using multiple prescription drugs and OTC medications, how do GRAS and non-GRAS herbs and other “natural products” blend in to the chemical cocktail of our nation’s “medicated wellness?”
As expressed in the acronym “CAM,” herbs and other natural products can be used either to compliment (along with) prescription drugs, or they can be used as an alternative to (instead of) conventional medicine. It’s really not clear how many Americans use only herbal remedies, or how many are using both herbs and prescription drugs – though we can say with certainty that all Americans eat medicinal plants routinely as food, whether they know it or not.
By themselves, herbal remedies have remarkably few side effects or reported cases of toxicity. Prescription drugs of all kinds, on the other hand, have a remarkably large amount of side effects and incidents of poisoning or overdose. The amount of known side effects is, in part, a result of more, and required, scientific research into safety and efficacy. But according to the CDC and the FDA, prescription drug abuse is an epidemic. Painkillers (analgesics) were the number one substance most frequently involved in all human exposure cases reported to Poison Control Centers in the US in 2011, while analgesic exposures as a class increased more rapidly than any other substance over the past 11 years, according to the American Association of Poison Control Centers’ National Poison Data System.
In combination with one or more prescription drug and/or OTC medication, herb/drug interactions may be known and well-researched, or may be unknown, and are often a real health risk. Herbs can mimic or magnify the actions of drugs; they can increase or decrease metabolism and thus effect the rate of drug absorption; or they can antagonize or counteract a drug’s intended action. There’s no real “rule of thumb” for how specific herbs will interact with specific prescription drugs, since each individual’s state of health and personal drug profile will be different. Herb/drug interactions must be determined on a case-by-case basis, preferably in advance of ingestion, which can require a good bit of research on the part of consumers and health care professionals.
Vitamins, minerals, and even our foods can also interact with and affect the actions and efficacy of prescriptions drugs. Anyone who takes Warfarin or other prescription blood thinners (anticoagulants) is warned not to take any vitamin K, available in drug and grocery stores as a dietary supplement and found naturally in dark, leafy greens.
For people taking multiple prescriptions and supplements, eating breakfast, lunch, and dinner become major research projects.
The internet certainly makes all that research much easier. The NIH’s National Library of Medicine maintains current information on dozens of commonly ingested herbs, vitamins, and minerals, including safety concerns and possible interactions. Of the top herbal supplements most commonly taken by the American public, all have some safety concerns and potential interactions, whether they are GRAS “food herbs” or not.
Garlic, a time-tested “tonic” herb for the blood and heart, can interact with blood thinners and increase the rate at which the body metabolizes certain drugs, especially AIDS medications, which can reduce their effectiveness. Millions of Americans rush for the Echinacea at the first sign of a cold or flu in themselves or anyone around them. It can slow down the rate at which the body breaks down caffeine, causing unintended jitters, and can interfere with the actions of immunosuppressant drugs, used by organ transplant patients and to treat a wide variety of auto-immune disorders. St. John’s Wort, a well-reputed herbal “nervine” and anti-depressant, can antagonize or accelerate the actions of conventional psycho-active drugs, increase the rate of estrogen break-down and thus interfere with some birth control methods, and might cause severe reactions to sun exposure. Saw Palmetto, most commonly used to decrease the symptoms of enlarged prostate in men, acts something like a hormone and decreases estrogen levels in the body while also slowing down blood clotting. Pregnant and nursing mothers, people preparing to undergo surgery, and those who take estrogen, birth control, or anticoagulant prescription drugs should probably avoid taking Saw Palmetto.
Herbal Medicine as a Lifestyle Choice
For these and other reasons, some Americans who use herbal remedies opt to avoid the prescription drugs instead – whether they simply “believe” in natural health care or have carefully researched and scientifically confirmed that choice. Some may simply be lucky, blessed with good health and a strong mind and body from birth through old age. Those who choose herbal medicine as a lifestyle choice, however, have a strong suspicion it has little to do with luck: By using herbal medicine they prevent disease and achieve and maintain an optimal state of physical and mental health.
Conventional medicine has its advantages, and in some situations, it clearly surpasses the ability of herbs, vitamins, minerals, and foods to treat physical and mental illness and to save lives. “Western” or “modern” medicine is especially good at emergency and critical, intensive care. What’s more, herbalists and other natural health care practitioners, RNs, LPNs, product manufacturers, store clerks, teachers, plumbers, accountants, and tax attorneys are forbidden by law to diagnose illness and prescribe treatment, unless they possess a medical degree (MD). The mother who gives her child a warm oatmeal-water bath, the grandmother who makes “fire cider” every winter and nags everyone in the house to gulp it down, the chef who keeps an Aloe plant near the stove, are all simply using common sense. But self-diagnosis and self-medication are always to some degree, a risk – and can be fatal.
Nevertheless, herbal medicine and natural health care have proven themselves safe and effective to millions of Americans. As a matter of freedom of medical choice and in good taste, the conventional medical community and FDA will have to pry our garlic from our cold, dead fingers – even if it does interact with Warfarin.