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

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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 )

Cite this article

• 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.

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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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Hassan Hussein Musa & Taha Hussein Musa

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

Department of Chemical Sciences (Chemistry Unit), Faculty of Natural and Applied Sciences, Lead City University, Ibadan, Nigeria

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

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Musa, H.H., Musa, T.H., Oderinde, O. et al. Traditional herbal medicine: overview of research indexed in the scopus database. ADV TRADIT MED (ADTM) 23 , 1173–1183 (2023). https://doi.org/10.1007/s13596-022-00670-2

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Cure and prevention of cardiovascular diseases: herbs for heart

• Suman Ray   ORCID: orcid.org/0000-0002-9293-7591 1 &
• Mahesh Kumar Saini 1  

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Herbs contribute to more than 60-70% in development of modern medicines in the world market either directly or indirectly. The herbal treatments for congestive heart failure, systolic hypertension, angina, atherosclerosis, cerebral insufficiency and venous insufficiency etc. has been known since ancient times. Unlike allopathic medicines, Ayurveda medicines are considered safe, however, the adverse reactions of herbal drugs is also reported. In this paper, we have compiled 128 herbs and their parts that have medicinal value to prevent, alleviate or cure heart disease related disorders. Jaccard Neighbour-joining cluster analysis using Free Tree software was used to assess the relative importance of plants in context with its healing potential for heart related disease. Based on the medicinal value in context with the heart, five major clusters of the selected 128 herbs were made. Correlation of the distance between herbs revealed that most of these herbs were found to have more than one medicinal property. The distance in dendogram depicted closeness of properties curing heart disease; as less the distance between two medicinal plants or two groups they will more close to cure particular heart disease. During drug development, a medicinal plant can be replaced by another plant of same group or by another plant of its neighbour group but from same pedigree. Thus, in case of non-availability of herbs or if it belongs to the category of rare, threatened, and endangered species, such method may add to new ways of drug development.

Introduction

According to WHO, cardiovascular diseases (CVDs) kill 17.9 million people per year, accounting for 31% of all global deaths. Heart attacks and strokes account for 80% of CVD deaths [ 1 ]. Populations in low and middle income countries (LMICs) contribute 75% of the CVD deaths [ 2 ]. It is predicted that by 2030 more than 22.2 million people will die annually from CVDs. Due to high prevalence of CVD among older adults in LMIC, population with CVD has increased and become a major challenge in future for the health care system. The therapeutic potential of herbs in healthcare system is well known in all over the world whether it is for diseased state or proper maintenance of health [ 3 , 4 ]. Since Ayurvedic medicines belong to natural sources, they are considered safe compared with allopathic medicines. However, many adverse reactions of herbal drugs is also reported [ 5 , 6 ]. Ayurvedic medicines can cause adverse effect if the patients continue to take medicines with no monitoring. Prolonged use or overdose of herbal medications lead to side effects e.g. high risk of cardiovascular events. A major drawback is the lack of information on the social and economic benefits on the industrial utilization of medicinal plants [ 7 , 8 ]. The standard pharmacovigilance techniques (WHO guidelines) when applied presents challenges such as the ways in which herbal medicines are regulated, used, named, and perceived [ 9 ]. Very often patient undergo medication with Allopathic and Ayurvedic medicines simultaneously and dose-related responses are rarely measured and reported. Conventional pharmacovigilance tools, such as prescription-event monitoring and the use of computerized health record databases, for evaluating the safety of herbal medicines has limitations too. Reporting of adverse events possibly caused by herbal and traditional medicines in an extensive manner is needed for the systematic and rational use of drugs [ 9 ].

Since herbal medications do not require proof of efficacy and safety and there is lack of enough clinical data on herbal medication although, most of the herbs demonstrate an effect on biological mechanisms [ 10 ]. Clinical studies so far on herbal medications are limited in sample size and its impact on relevant clinical outcomes is not much studied. There is increased risk of side effects as it is not tested in pregnant women and children. Sometimes there is even contamination with other conventional medications and there also exists risk of drug interactions. Even substitution with alternative plant species is also reported. Enough and improved knowledge herbal medications is essential. Also, there should be transparency between patient- physician and possible benefits, side effects should be discussed. Thus, herbal drug development is possible only if there is development of standardized herbal products.

The present study was conducted to assess the relative importance of herbs that has medicinal potential to regulate heart and cure related disease. This may add to enhance drug discovery approaches for its promotion and development i.e. to generate safety data-either before or after marketing of the formulation.

Materials and methods

Plants having medicinal properties for treatment of various heart diseases were extracted from secondary database search e.g. Google Scholar, PubMed and published research articles. Based on this, dataset of 128 different medicinal plants were further grouped and assessed for its relative medicinal potential to regulate and treat heart disease (Table 1 [12-27] http://www.nmpb.nic.in/ , https://en.wikipedia.org/wiki/Scutellaria#Traditional_use ). The percentage of plant parts used for the treatment of heart disease were further assessed (Fig. 1 ). Heart disease and the Plant uses were categorised in three parts: Plants used in only one diseases of heart, two disease of heart, three diseases of heart were grouped together (Table 2 [ 27 ]). Jaccard Neighbour-joining dendrogram were obtained through collected dataset of 128 different plants useful for heart disease ailment, computed performed with the help of Free Tree software version 0.9.1.50 and FigTree version 1.2.2. And mathematical consensus tree so obtained after 1000 replicates of bootstrap. Herbs were recorded as ‘1’ for present or ‘0’ for absent of a particular medicinal property related to heart. The objective of the cluster analysis was to develop sub grouping of plants on the basis of their properties to treat heart disease. This method of clustering not only clusters sample, but also it clusters various clusters that were formed earlier in the clustering process. In this method, each sample or variable was treated as a cluster of 1 and the closest two clusters are joined to form a new cluster [ 28 ].

The percentage of plant parts used for the treatment of Heart Disease

In this paper we have listed 128 plants, its habit and parts used for treatment of heart disease (Table 1 ). Comparative analysis of parts used of percentage of total plants showed that root and rhizome is the most frequently used plant parts followed by leaves, while gum being the least frequently used plant parts in context with ailment of heart disease (Fig. 1 ). The order (maximum to minimum) of plant parts used for heart disease ailment is root and rhizome-leaf-stem-flower-fruit and seed-other parts-gum (Fig. 1 ). Analysis of plants used for various types of heart diseases showed that only one plant i.e. Crocus sativus L. has the potential to cure five types of heart disease-hypertension, heart attack and reduction in blood fat, anti-oxidant and cardiac tonic thus indicating its relevancy in context with cardiovascular diseases (Table 2 ). Similarly, plants having medicinal property to cure four heart disease category were also few (Table 2 ). Maximum number of plants were found to be in category of curing only one heart disease type. Very few plants were observed to have medicinal property capable of treating multiple heart disease type (Table 2 ).

Cluster analysis based on Jaccard Neighbour-joining dendrogram using collected dataset of 128 herbs useful for heart with the help of Free Tree software version 0.9.1.50 and FigTree version 1.2.2. and mathematical consensus tree was obtained after 1000 replicates of bootstrap (Fig. 2 ). Five major clusters of the selected 128 herbs were observed on the basis of their medicinal value in context with heart. Within a cluster most of herbs showing similar properties and medicinal similarity negatively correlated with the cluster distance. Correlation of the distance between herbs also revealed that most of these herbs were found to have more than one medicinal property (Fig. 2 ).

The dendogram depicts 128 different medicinal plants having property to cure some type of heart disease/ailment. The medicinal plants in one group shows that they have similar properties to cure same heart disease. The distance in dendogram depicts closeness of properties curing heart disease; as less the distance between two medicinal plants or two groups they will more close to cure particular heart disease

A variety of modern medicines have been developed from herbs that are being used by native people [ 29 ]. Herb serve as both preventive and therapeutic purposes of many diseases. Use of herbs for cardiovascular diseases such as congestive heart failure, systolic hypertension, angina pectoris, atherosclerosis, cerebral insufficiency, and arryhythmia is prevalent since ancient time [ 30 ]. Herbs has been a continuing source for medicine e.g. antineoplastic drug paclitaxel derived from Taxus brevifolia, digitoxin from Digitalis purpurea, reserpine from Rauwolfia serpentina etc [ 1 ]. These herbs are used for treatment of cardiovascular diseases. Use of herbal medicine though exist since past decade, this system of medicine has several lacunae. For example, herbal medicine lack scientific evidence or assessment. Many of the herbal medicines have toxic effects and major drug-drug interactions too. Therefore, in-depth research is needed to understand the pharmacological activity of the herbs. In this paper, cluster analysis of the potential herbs for heart with its ability to treat various heart related diseases was done to understand the possible combination of the herbs that may help in the development of more effective drug formulation that the existing one. As mentioned in the results section, almost every part of the herb has a medicinal property, although root and rhizome is most frequently used plant parts.

Herbs have more than one medicinal property i.e. it has the potential to prevent or cure more than one disease as demonstrated in our results. For example, only one herb Crocus sativus L. was found to have medicinal property with the potential to treat five heart disease type-hypertension, heart attack, reduction in blood fat, anti- oxidant, and cardiac tonic. Role of this herb against cardiovascular diseases is related to their antioxidant and anti-inflammation effects [ 31 ]. Crocus sativus is found to have antihypertensive and normalizing effect on blood pressure [ 32 ]. It is known to possess a potent inhibitory effect on heart rate and contractility of guinea pig heart via calcium channel-blocking effect [ 33 ]. Other studies also support cardiovascular effects of saffron and its components [ 34 ].

Three herbs- Citrus medica L., Crataegus monogyna, Elettaria cardamom possess medicinal property with the potential to treat four heart disease type. Citrus medica L. “Otroj” (Brain citron), is a member of Rutaceae family. Evidence supports its cardioprotective potential due to its potent antioxidant and free radical scavenging activity [ 35 ]. Crataegus species is shown to represent a safe, effective, nontoxic agent in the treatment of cardiovascular disease and ischemic heart disease (IHD) [ 36 ]. Its mechanism of action include direct scavenging of reactive oxygen species, enhanced superoxide dismutase, and catalase activities, antioxidant activity, down regulation of caspase 3 gene etc. [ 36 ]. Crataegus monogyna are rich in polyphenols and both of its leaves and flowers or alternatively the fruit are used medicinally [ 37 ]. It helps to regulate both high and low blood pressure, in addition to slowly breaking down cholesterol and fat deposits in the body [ 37 ]. It increases conversion rates of LDL or “bad” cholesterol into HDL or “good” cholesterol in the liver and improves blood and oxygen supply to the heart muscle. In cases of congestive heart failure and circulatory disorders, Hawthorns is prominently being used in a holistic approach to heal the body itself [ 37 ]. It plays a role in alleviating irritation and swelling of the blood vessels. Study has shown that small cardamom Elettaria cardamom effectively lowers blood pressure, increases fibrinolysis, and boosts antioxidant status in stage 1 hypertensive patients without affecting blood lipids or fibrinogen levels [ 38 ]. A rat study has also demonstrated the ability of cardamom oil to restore lipid homeostasis in the presence of hypercholesterolemia [ 39 ]. This study has shown reduction in atherogenicity index by dietary intervention with cardamom powder and cardamom oil hence, the cardioprotective potential of cardamom [ 39 ]. The bark of Terminalia arjuna has been demonstrated to show cardioprotective effects against doxorubicin induced cardiotoxicity by increased coronary artery flow and protection of myocardium against ischemic damage [ 40 ]. Terminalia chebula pericap has also been reported to have cardioprotective activity [ 41 ].

The dendogram obtained for 128 medicinal plants by Jaccard Neighbour joining dendogram method depicts 128 different medicinal plants having property to cure some type of heart disease/ailment. The medicinal plants in one group showed to have similar properties to cure same heart disease. The distance in dendogram depicts closeness of the properties curing the heart disease; less the distance between two medicinal plants or two groups, the more it is closer to cure particular heart disease. During drug development, a medicinal plant can be replaced by another plant of same group or by another plant of its neighbour group but from same pedigree (like garlic, turmeric and safflower) on the basis of their similar properties of curing that particular heart disease. Thus, in case of non-availability of the herbs or if it belongs to the category of rare, threatened, and endangered species, such method may add to new ways of drug development. During drug development, if any medicinal plant shows adverse effect, it can be replaced by a plant with similar medicinal potential, suitable for the same drug composition based on cluster analysis.

Generally, herbal medicines is considered harmless as it is derived from natural sources, however, adverse reaction of herbal medicines is also reported. For example, bleeding is the adverse effect of the herbal drug, Ginko biloba. Similarly, gastrointestinal disturbances, allergic reactions, fatigue, dizziness, confusion, dry mouth, photosensitivity are the adverse effect of the herbal drug St. John’s wort. Lack of information on the social and economic benefits on the industrial utilization of medicinal plants is the major drawback in development of the medicinal plant-based industries in developing countries [ 7 , 8 ].

Medicinal plants are the oldest known health-care products and its importance in the primary health care of individuals and communities in both developed as well as developing countries is increasing. However, further research is needed to find compounds of interest in these plants that can be used as safe and effective medicines to treat heart disease.

More scientific research on these plants is needed in order to find new drugs for the treatment of cardiovascular diseases that have no or few side effects.

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Authors sincerely thank Director, CSIR-NISTADS (Pusa, New Delhi) for providing constant support and encouragement in completing this manuscript.

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Ray, S., Saini, M.K. Cure and prevention of cardiovascular diseases: herbs for heart. Clin Phytosci 7 , 64 (2021). https://doi.org/10.1186/s40816-021-00294-0

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Herbal nanomedicines: Recent advancements, challenges, opportunities and regulatory overview

Affiliations.

• 1 National Institute of Pharmaceutical Education and Research-Ahmedabad (NIPER-A), An Institute of National Importance, Government of India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Opp. Air Force Station, Palaj, Gandhinagar, 382355, Gujarat, India.
• 2 National Institute of Pharmaceutical Education and Research-Ahmedabad (NIPER-A), An Institute of National Importance, Government of India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Opp. Air Force Station, Palaj, Gandhinagar, 382355, Gujarat, India.. Electronic address: [email protected].
• 3 National Institute of Pharmaceutical Education and Research-Ahmedabad (NIPER-A), An Institute of National Importance, Government of India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Opp. Air Force Station, Palaj, Gandhinagar, 382355, Gujarat, India.. Electronic address: [email protected].
• PMID: 35026510
• DOI: 10.1016/j.phymed.2021.153890

Background: Herbal Nano Medicines (HNMs) are nano-sized medicine containing herbal drugs as extracts, enriched fractions or biomarker constituents. HNMs have certain advantages because of their increased bioavailability and reduced toxicities. There are very few literature reports that address the common challenges of herbal nanoformulations, such as selecting the type/class of nanoformulation for an extract or a phytochemical, selection and optimisation of preparation method and physicochemical parameters. Although researchers have shown more interest in this field in the last decade, there is still an urgent need for systematic analysis of HNMs.

Purpose: This review aims to provide the recent advancement in various herbal nanomedicines like polymeric herbal nanoparticles, solid lipid nanoparticles, phytosomes, nano-micelles, self-nano emulsifying drug delivery system, nanofibers, liposomes, dendrimers, ethosomes, nanoemulsion, nanosuspension, and carbon nanotube; their evaluation parameters, challenges, and opportunities. Additionally, regulatory aspects and future perspectives of herbal nanomedicines are also being covered to some extent.

Methods: The scientific data provided in this review article are retrieved by a thorough analysis of numerous research and review articles, textbooks, and patents searched using the electronic search tools like Sci-Finder, ScienceDirect, PubMed, Elsevier, Google Scholar, ACS, Medline Plus and Web of Science.

Results: In this review, the authors suggested the suitability of nanoformulation for a particular type of extracts or enriched fraction of phytoconstituents based on their solubility and permeability profile (similar to the BCS class of drugs). This review focuses on different strategies for optimising preparation methods for various HNMs to ensure reproducibility in context with all the physicochemical parameters like particle size, surface area, zeta potential, polydispersity index, entrapment efficiency, drug loading, and drug release, along with the consistent therapeutic index.

Conclusion: A combination of herbal medicine with nanotechnology can be an essential tool for the advancement of herbal medicine research with enhanced bioavailability and fewer toxicities. Despite the challenges related to traditional medicine's safe and effective use, there is huge scope for nanotechnology-based herbal medicines. Overall, it is well stabilized that herbal nanomedicines are safer, have higher bioavailability, and have enhanced therapeutic value than conventional herbal and synthetic drugs.

Keywords: Herbal drugs; Herbal nano medicine (HNMs); Marker constituents; and Ayurveda.

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Herbal Medicines’ Safety and Clinical Application: New Strategies for Overcoming Therapeutic Challenges

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The use of herbal medicines is one of the oldest health practices, typically involving plants, fungi, their metabolites, and minerals with the traditions passed on orally or in written records. Dietary and complementary/alternative medicine has become an important element in healthcare. In many regions of East Asia, these approaches are integrated into formal medical treatments. In the United States, surveys indicate that more than 50% of adults use herbal medicines. Historically, herbal medicines have often not been classified as "medicines/drugs" but as "foods," leading to a general perception of them as harmless. Studies show that patients often do not inform their doctors about their use of herbal medicines, which may result in potential drug interactions and adverse events. This is concerning as improper use of herbal medicines is associated with risks such as liver injury and cardiovascular diseases. Due to their complex composition and multi-target properties, various herbal medicines can cause multiple adverse reactions. Drug-induced liver injury is a recognized clinical problem, and herb-induced liver injury has received increasing attention. Studies indicate that the use of drugs and herbal medicines accounts for a significant proportion of acute liver failure cases. Although improper use of herbal medicines can lead to various health problems, the underlying mechanisms are often not fully understood. With technological advances, the application of multi-omics (including genomics, transcriptomics, metabolomics, etc.) and the use of artificial intelligence present new opportunities for understanding such risks of herbal medicines. These technologies aid in understanding the complex nature of herbal medicines and their biological effects. We encourage the submission of different types of contributions including original research, reviews, clinical trials, and detailed case reports. We are particularly encouraging contributions that utilize advanced technologies in this field, such as multi-omics research, artificial intelligence-assisted technologies, clinical big data analysis, and reports on rare cases. All studies must be driven by empirical data and purely in silico studies are outside of the journal’s scope. These studies should focus on the following areas: • Pharmacological studies assessing the treatment of drug-induced liver injury caused by herbal medicines. • Novel research approaches and methods for assessing herb-drug interactions • Cardiovascular risks caused by herbal medicines, including arrhythmias, heart failure, atherosclerosis, and vascular inflammation. • Neurological damage caused by herbal medicines, including behavioral abnormalities. • Respiratory injuries caused by herbal medicines, such as pulmonary fibrosis. • Mechanisms of drug interactions caused by herbal medicines and developments of evidence-based applications of modified treatments in clinical practice, particularly in the elderly and children. Overall, by leveraging advanced methods and pharmacological strategies, we aim to deepen our understanding of the safety and clinical application of herbal medicines. Please note : 1) Please self-assess your MS using the ConPhyMP tool (https://ga-online.org/best-practice/), and follow the standards established in the ConPhyMP statement Front. Pharmacol. 13:953205. All the manuscripts need to fully comply with the Four Pillars of Best Practice in Ethnopharmacology (you can freely download the full version here ). Importantly, please ascertain that the ethnopharmacological context is clearly described (pillar 3d) and that the material investigated is characterized in detail ( pillars 2 a and b ). 2) Clinical trial articles will be accepted for review only if they are randomized, double-blinded, and placebo controlled. Statistical power analysis or a justification of the sample size is mandatory as is a detailed chemical characterization of the study medication (see the ConPhyMP statement). 3) In silico studies like network analyses or docking studies are generally not accepted unless they are combined with detailed in vitro or in vivo analysis of the material (extract) under investigation.

Keywords : Herbal medicines, drug safety, drug-induced liver injury, drug interactions, clinical application of drugs

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The prevalence of herbal medicine among Sudanese adults: a cross-sectional study 2021

• Raheeg Mohamed 1 ,
• Reham Mohamed 1 ,
• Rana Dafalla 1 ,
• Aya Ahmed 1 &
• Abdulrahman Abdeldaim 1  

BMC Complementary Medicine and Therapies volume  24 , Article number:  308 ( 2024 ) Cite this article

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The use of herbal medicine has a long history in Sudan and is widely practiced among the general population. However, there is a lack of studies examining the prevalence, patterns, and predictors of herbal medicine usage in Sudan. Thus, this study was conducted to bridge this gap.

This descriptive cross-sectional study was conducted between January and February 2021. It included Sudanese adults residing in Omdurman, Sudan, using systematic and simple random sampling methods. Data were collected using a structured, adapted questionnaire comprising: the socio-demographic characteristics and the knowledge of herbal medicine and its usage. Moreover, it investigated the commonly used herbal remedies and the participants’ sources of information and procurement of such products. Additionally, we examined the correlation between socio-demographic factors, cultural beliefs, and the use of herbal medicine. Data were analyzed using SPSS, and categorical data were presented as frequencies and percentages. Associations were assessed using chi-square, Fisher’s exact tests, and binary logistic regression ( p  < 0.05).

This study included 381 participants, of which 48.1% were females and 31.4% were aged 20-30. The majority of participants were aware of the practice of herbal medicine and the prevalence of its usage was 85.9%. Peppermint, acacia, hibiscus, ginger, and fenugreek were the most commonly used remedies. Chi-square and Fisher’s exact testing revealed that the participants’ gender and beliefs in the safety and effectiveness of herbal medicines were significantly associated with herbal medicine usage ( p  < 0.05). Binary logistic regression analysis showed that only the perception of herbal medicine’s safety was an independent predictor of its usage (p-value 0.038).

This study reported a very high prevalence of herbal medicine usage, highlighting the acceptability of Sudanese adults towards herbal medicine usage. This prompts further studies to explore their safety, efficacy, and the possibility of their integration into mainstream healthcare practices and policies.

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Traditional medicine refers to the use of knowledge, skills, and practices that rely on the theories and beliefs of various cultures to maintain, prevent, diagnose, promote, and treat both physical and mental health [ 1 , 2 ]. This age-old tradition finds its origin in countries with ancient civilizations such as China, India, Egypt, and South America [ 3 ]. Before the advent of modern medicine, traditional medicine held a prominent position as the primary healthcare system accessible to millions of individuals residing in African rural and urban areas [ 4 ]. In fact, it served as the sole healthcare option for a significant portion of the population. As per the 2019 WHO Global Report on Traditional and Complementary Medicine, different traditional medicine systems involve a range of practices such as acupuncture, herbal remedies, indigenous traditional medicine, homeopathy, traditional Chinese medicine, naturopathy, chiropractic, osteopathy, ayurvedic medicine, and Unani medicine [ 5 ]. Herbal medicine is an essential part of traditional medicine that relates to herbs, herbal materials, and herbal preparations, which are collectively referred to as herbal medicines. These products are made of different plant materials, like seeds, berries, roots, leaves, bark, or flowers, which contain active ingredients. Essentially, herbal medicines are natural products derived from plants that are used for medicinal purposes [ 6 , 7 ].

Herbal medicines continue to be popular in developing countries because of the common belief in their safety, availability, affordability, and cultural acceptability. They are used as over-the-counter medications or recommended by a doctor or a pharmacist [ 8 ]. In Sudan herbal medicines are widely recognized for their role in preventing and treating various diseases. Numerous plant substances are used both as dietary components and for medicinal purposes. Sudan’s natural habitat and ecological characteristics provide an ideal environment for the growth of diverse herbs [ 9 ]. Traditional medicine remains the mainstay of healthcare for 90% of Sudanese population due to limited access to hospitals and conventional drugs especially in rural areas [ 10 , 11 ].

It is important to note that while herbal medicines are generally considered safe, they can still carry risks and side effects. Reported adverse effects listed in previous studies range from relatively mild effects such as nausea, vomiting, diarrhea, constipation, and skin rash to more serious adverse effects such as elevated liver enzymes, hypokalemia, and reactions with cellular macromolecules, including DNA, causing cellular toxicity and/or genotoxicity [ 12 , 13 ]. Understanding patterns, frequencies, and predictors of herbal medicine use can help healthcare providers identify individuals who may need extra guidance on using these remedies safely [ 14 ].

In light of this, there appears to be a need to conduct more cross-sectional research on the use of herbal medicine to gain a comprehensive understanding of the current prevalence, patterns, and predictors of herbal medicine usage within the Sudanese general population. This offers valuable insights into the characteristics and behaviors of Sudanese individuals who utilize herbal remedies. The findings can be used by healthcare providers and policymakers to identify emerging trends, associations, and potential risks associated with herbal medicine usage. This can lead to strict government regulations to promote the safe and responsible use of herbal remedies and raise public awareness regarding their use.

Previous studies on herbal medicine use were conducted across different counties including Turkey, Morrocco, Sierra Leone, Bangladesh, Nigeria, Palestine, Jordan, and Malaysia [ 6 , 11 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. However, there is a lack of studies among the Sudanese population regarding the use of herbal medicine. Literature is scanty in estimating the frequency, patterns, and predictors of herbal medicine usage among the Sudanese general population. This study aims to examine the prevalence of herbal medicine usage among Sudanese adults in a residential district in Omdurman city, Khartoum, Sudan. The objectives include identifying the most commonly used Sudanese herbal remedies and their usage patterns for different medical conditions, evaluating the availability and accessibility of these remedies, and exploring the relationship between cultural beliefs and socio-demographic characteristics of Sudanese adults with the use of herbal medicines.

Study design

This is a descriptive, non-interventional, community-based, cross-sectional study aiming to investigate the prevalence and patterns of herbal medicine usage among Sudanese adults in a residential district in Omdurman city, Khartoum state. The study was conducted between January 2021 and February 2021.

Study setting

The study was conducted in Omdurman City, which is located in the north-western region of Khartoum, Sudan. Omdurman has a population of approximately 2.5 million within an area of 614.9 km2.

Study population

Households’ adults of the selected residential district in Omdurman city, Khartoum, during the period of the study were included in the study population.

Inclusion and exclusion criteria

Both males and females who resided within the selected residential district during the period of the study were included in the study. Individuals who expressed a lack of interest and willingness to participate were excluded from the study.

Sample size and sampling technique

The following formula was used to calculate the sample size [ 11 ]:

Using an estimated prevalence of 50%, the sample size was estimated to be a minimum of 384. A total of 381 were enrolled in the study. The minimal sample size was not achieved.

The study used a two-stage sampling approach:

Systematic random sampling of houses:

The authors had a list of all the residential houses in the target area of Omdurman City, which served as the sampling frame.

They then used a systematic random sampling technique to select every 4th house from the list, ensuring a random selection of houses across the residential district.

Simple random sampling of individuals within the selected houses:

Within each of the selected houses, the authors had a list of the individuals residing there.

From this list of individuals, they used a simple random sampling technique to select the participants for the study.

Data collection methods and tools

Data were collected using a structured, adapted, both open-and-close-ended, paper-and-pencil questionnaire over a period of one month (January 2021-February 2021). The questionnaire used in this study was adapted from previously validated instruments in the literature [ 11 , 19 ]. To scrutinize the content validity of the adapted questionnaire, we had it reviewed by a panel of university professors with expertise in the research area. The professors provided feedback on the relevance, clarity, and comprehensiveness of the items. Based on their input, we refined the questionnaire items to improve the overall content validity of the instrument.

Before filling the questionnaire, subjects were asked to give an informed consent for participation by answering the question: I agree to participate in the study.

The questionnaire was structured into five sections:

Section one contained questions considering the sociodemographic characteristics of the participants, including age, gender, marital status, level of education, occupation, and monthly family income.

Section two contained questions regarding the knowledge of the participants about herbal medicines and their usage patterns.

Section three explored the types of commonly used Sudanese herbal remedies, the forms in which they are used, and the medical conditions associated with their use.

Section four contained questions related to sources of information about herbal medicines and sources for obtaining these products.

Sections five focused on cultural beliefs and their association with the use of herbal medicine.

The questionnaire used in this study is available as Supplementary File 1 .

Data management and analysis

Questionnaires were refined and managed carefully before data entry. Data were tabulated, entered into a Microsoft Excel database, and analyzed using the statistical package for social sciences program version 21 (SPSS). Categorical data were expressed as frequencies and percentages. Numerical data were presented as the mean  ±  standard deviation. The association between the use of herbal medicine and the characteristics of the participants was tested using the chi-square test, Fisher’s exact test and binary logistic regression model with a statistically significant p-value of < 0.05.

Sociodemographic characteristics

One-third of the participants (33.4%) were between 20 and 30 years old. More than one-third (46.3%) were married and had an income less than 10,000 SDG per month (42.8%). More than half of the subjects had university education (55.4%) (Table  1 ).

We observed a statistically significant association between the participants’ gender and their usage of herbal medicines (Table  4 ).

Knowledge and patterns of use of herbal medicines

The majority of the participants (91.6%) were aware of using natural health products. Most of them knew “what herbal medicine is” (89.4%) and reported using herbal medicines (85.9%). More than half of the participants (56.7%) declared using herbal medicines “when sick.” The most common way to use herbal remedies is by preparing them in the form of tea (69%) (Table 2 ).

Types of herbal remedies used

Table  3 illustrates the frequencies of the most commonly used Sudanese herbal remedies. The top five herbal remedies used were peppermint (73.8%), acacia nilotica (71.4%), hibiscus (79.9%), ginger (69.8%), and fenugreek (66.9%).

Common medical conditions for which herbal remedies are widely used

As Fig.  1 shows, herbal remedies are used for treating various medical conditions. The top three were coughs and colds (75.3%), gastrointestinal disturbances (60.1%), and joint pains (41.2%).

Sources of information about how to obtain herbal remedies

Figure  2 shows that the main sources of information about how to obtain herbal medicines are families and neighbors (29%), the internet (19%), followed by friends and colleagues (17%).

Sources for obtaining herbal remedies among the participants

The two most prevalent sources to obtain herbal remedies, as Fig.  3 displays, were herbal product stores and supermarkets.

Beliefs about herbal medicines among the participants

Most of the participants believed that herbal medicines have fewer side effects, are safer, and are more effective in treating various diseases (Table  5 ).

We found a statistically significant association between the beliefs of the participants about the safety of herbal medicines and their usage of herbal medicine (Table  5 ).

We also observed a statistically significant association between the beliefs of the participants about the effectiveness of herbal medicines and their usage of herbal medicine (Table  5 ).

Binary logistic regression analysis for factors associated with herbal medicine usage

Factors demonstrating significant association with herbal medicine usage in the univariate analysis were included in a binary logistic regression model; only perception of herbal medicine’s safety was an independent predictor of their use (p-value 0.038, odds ratio 9.65 (Table  6 ).

Several studies have documented the use of herbal medicine in specific health subpopulations and various locations and settings [ 15 , 16 , 18 , 20 ]. The use of herbal medicine by the general population has been reported in Nigeria, Jordan, and Malaysia [ 6 , 11 , 13 ]. However, there is limited information available on the prevalence of herbal medicine usage in the general population within Sudan.

This study examined the prevalence of herbal medicine usage among Sudanese adults in a residential district in Omdurman city, Khartoum. A high prevalence of 85.9% was observed in our study. This is close to a similar rate observed in another study from Jordan [ 13 ], but is considered a higher rate compared to findings presented in other studies from Nigeria, and Malaysia [ 6 , 13 ]. This can be attributed to the cultural and traditional acceptability of herbal remedies and the availability of diverse herbal resources. Sudan’s geographical location and climate provide a rich environment for a diverse range of medicinal plants and herbs, making them easily accessible to the population.

The study identified the most commonly used Sudanese herbal remedies, including peppermint, acacia nilotica, hibiscus, ginger, and fenugreek. This highlights that these herbal remedies hold cultural significance and are perceived as effective in managing various health conditions within the Sudanese population. Further research and exploration of these herbal remedies can provide valuable insights into their safety, efficacy, and potential integration into mainstream healthcare practices.

A significant proportion of the participants (56.7%) reported using herbal medicines, primarily when sick. The most common method of using herbal remedies was preparing them in the form of tea, which aligns with traditional practices in the region. Herbal remedies were found to be commonly used for treating coughs and colds, gastrointestinal disturbances, and joint pains, in contrast to a study in Nigeria where they were frequently used for treating malaria and reducing blood sugar levels. Another study done in Morocco showed that they were more frequently used for gastrointestinal disorders, which aligns with our findings [ 15 ]. This suggests that herbal medicines are perceived as effective remedies for these medical conditions among the participants. Further research is needed to explore the specific mechanisms and potential benefits of these herbal remedies for the mentioned conditions. Understanding the active compounds, pharmacological properties, and potential interactions with conventional treatments can provide valuable insights into their effectiveness and safety. Clinical trials and rigorous scientific studies are necessary to evaluate their efficacy and establish evidence-based guidelines for the use of these herbal remedies in the management of these medical conditions.

The main sources for obtaining herbal remedies were herbal product stores and supermarkets. This finding highlights the accessibility and availability of herbal medicines through commercial channels. Additional studies are need to ensure the quality and safety of herbal products obtained from these sources. The main sources of information on how to obtain herbal remedies were families, neighbors, and the internet which is consistent with the findings of some previous studies [ 12 , 15 ]. This highlights the influence of social networks and the growing role of online platforms in shaping the use of herbal medicines in the Sudanese population.

This study revealed a statistically significant association between the participants’ gender and the use of herbal medicine, with a p-value of 0.004, indicating that women were more likely to use these remedies than men, which is consistent with the findings of various previous studies [ 14 , 21 , 22 , 23 ]. This could be due to multiple factors. One possible explanation is that women often play a central role in family healthcare and are more likely to seek alternative remedies for themselves and their families. Women may also have specific health concerns or conditions for which they find herbal remedies more suitable or effective. This discrepancy may also be due to the differences in how females and males perceive and define herbal medicines, which can contribute to variations in how these remedies are recognized and valued. These gender-based variations can help explain the differences observed in the use of herbal medicine. Attitudes towards overall health can also contribute to explain this gender difference [ 14 ]. However, further research is needed to explore the specific reasons behind the gender disparity in herbal medicine usage.

The participants’ beliefs about herbal medicines were found to be significantly associated with their actual usage. The belief that herbal medicines are safer and more effective in treating various diseases appeared to influence the decision to use herbal remedies, with p-values of 0.006 and 0.027, respectively. These beliefs reflect the perception of herbal medicines as a natural and holistic approach to healthcare, aligning with traditional Sudanese healing practices. It could also be explained by the historical context of herbal medicines in Islamic culture, which established a strong acceptance of these products among users, enhancing their credibility and popularity [ 12 ]. The perception of herbal medicine’s safety was the only independent predictor of their use (p-value = 0.038, OR = 9.65). This finding suggests that the participants’ beliefs about the safety of herbal remedies played a crucial role in determining whether they chose to use these products, even after accounting for other potential factors. This highlights the importance of addressing concerns about the safety of herbal products and promoting their credibility as a means of encouraging their uptake among the study population. Strategies to enhance the perceived safety of herbal medicines, such as increased regulation, quality control, and public education, may be particularly effective in driving their usage in the Sudanese context, where traditional healing practices remain deeply embedded in the cultural fabric.

This study has several limitations that warrant acknowledgement. While the study aimed to have a robust sample size, the minimal sample size required for the analysis was ultimately not achieved. The use of a general prevalence of 50% for herbal medicine usage among Sudanese adults, rather than relying on prevalence data from other studies, may have also introduced some uncertainty or bias in the estimation of the true prevalence within the target population. To address these limitations, future research would benefit from conducting a comprehensive systematic review or meta-analysis of studies on herbal medicine usage in the Sudanese context. This could provide more reliable and context-specific prevalence data to inform the design and analysis of subsequent studies with an adequately powered sample size. The study was conducted in only one residential district in Omdurman city, Khartoum. Therefore, the findings may not be representative of the entire population or other residential districts and rural areas. Generalizing the results to a broader population or different geographic localities should be done with caution. In order to ensure that the findings are applicable to a wider population, future research should cover multiple districts and diverse areas.

The study was done during the COVID-19 pandemic period; therefore, due to health restrictions, a paper-and-pencil questionnaire was adopted instead of one-to-one direct interviews with the participants. Using a paper-and-pencil questionnaire as the data collection method in this study has two limitations: the potential for missing data due to skipped or omitted questions and the possibility of inaccurate responses influenced by social desirability bias, memory recall limitations, or question misunderstanding. These limitations may have affected the completeness, accuracy, and generalizability of the data. To mitigate these limitations, future research should explore strategies to minimize missing data, consider alternative data collection methods, and enhance participants’ understanding of the questionnaire. In addition, although the content validity of the adapted questionnaire was established through the review and feedback from university professors, the reliability and construct validity of the instrument were not formally tested in this study. Future research should consider evaluating the psychometric properties of the adapted questionnaire to further strengthen the validity and reliability of the measurement tool.

This study focused on the use of herbal medicines for a limited number of medical conditions, such as coughs and colds, gastrointestinal disturbances, and joint pains. Other medical conditions were not evaluated, which may limit the generalizability of the findings to a broader range of health conditions. It is possible that herbal medicines may be used differently or have varying efficacy for other medical conditions not assessed in this study. Therefore, further research is needed to explore the use of herbal medicines for a wider spectrum of health conditions to provide a more comprehensive understanding of their potential benefits and limitations.

Another limitation of the study is the lack of a clear link between the use of specific herbal remedies for treatment of specific medical conditions. This absence of specificity hinders accurate conclusions regarding the effectiveness and appropriateness of herbal remedies for specific conditions. Consequently, the study’s findings may have limited practical implications for healthcare providers and individuals seeking evidence-based guidance on herbal medicine usage. Future research should aim to establish clearer connections between specific herbal remedies and their corresponding medical indications to enhance understanding of their therapeutic potential. In addition to this, the study did not evaluate the effect of concurrent use of conventional medicine with herbal medicines, which may have influenced the participants’ perceptions of effectiveness, safety, outcomes, and satisfaction levels. Another limitation is that the data collected in the study provide a snapshot of the participants’ experiences with herbal medicines at a specific point in time. It is unable to capture any changes or developments in their experiences over time.

The study revealed a high prevalence rate of herbal medicine use among Sudanese adults (85.9%), which reflects the cultural acceptability and availability of diverse herbal resources in Sudan. The most commonly used herbal remedies are peppermint (73.8%), acacia nilotica (71.4%), hibiscus (79.9%), ginger (69.8%), and fenugreek (66.9%). The findings also highlight that herbal medicines are commonly used for treating coughs and colds (75.3%), gastrointestinal disturbances (60.1%), and joint pains (41.2%). The preferred method of using herbal remedies is preparing them as tea (69%), which aligns with traditional practices in the region. The study also revealed that women were more likely to use herbal remedies than men (p-value 0.004). The beliefs about herbal medicines, particularly their perceived safety (p-value 0.006) and effectiveness in treating various diseases (p-value 0.027), may influence the decision on their usage. The perception of herbal medicine’s safety was the only independent predictor of their use ( p  = 0.038, OR = 9.65). Further research is needed to explore the safety, efficacy, and potential integration of these remedies into mainstream healthcare practices. It is essential to ensure the quality of herbal products obtained from commercial sources while also considering the influence of social networks and online platforms in shaping herbal medicine usage. By gaining a deeper understanding of these aspects, evidence-based guidelines can be established to promote the safe and effective use of these remedies in managing various medical conditions.

Data availability

The corresponding author can provide the datasets used and analyzed in this study upon reasonable request.

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Acknowledgements

We express our sincere gratitude to the participants for their exceptional cooperation in this study. We extend our heartfelt appreciation to the community medicine department at the Faculty of Medicine, University of Khartoum, for their invaluable guidance and support throughout this study.

The study was conducted without any financial support or funding provided to the authors.

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Raheeg Mohamed, Reham Mohamed , Rana Dafalla, Aya Ahmed & Abdulrahman Abdeldaim

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R.M. contributed to the idea, study design, questionnaire design, data collection, data analysis, data interpretation and manuscript drafting.R.M. contributed to the study design, questionnaire design, data analysis, manuscript drafting.R.D. contributed to the data collection, analysis, and manuscript drafting.A.A. contributed to the data collection and manuscript drafting.A.A. contributed to manuscript drafting.All authors revised the manuscript and approved it for publication.

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Mohamed, R., Mohamed , R., Dafalla, R. et al. The prevalence of herbal medicine among Sudanese adults: a cross-sectional study 2021. BMC Complement Med Ther 24 , 308 (2024). https://doi.org/10.1186/s12906-024-04584-1

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Herbal medicines: a cross-sectional study to evaluate the prevalence and predictors of use among Jordanian adults

• Faris El-Dahiyat   ORCID: orcid.org/0000-0002-5264-8699 1 ,
• Mohamed Rashrash 2 ,
• Sawsan Abuhamdah 3 , 4 ,
• Rana Abu Farha 5 &
• Zaheer-Ud-Din Babar 6  

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Introduction

Understanding why adults resort to herbal medicine can help in planning interventions aimed at increasing awareness regarding herbal use. This study sought to investigate the prevalence and to determine factors for predicting the use of herbal medicine among Jordanian adults.

A cross-sectional study was conducted involving 378 older adults who were randomly selected from two different areas of Jordan. A questionnaire was used to gather data and validation criteria for validity and reliability of the content were tested by content and face validity in a panel of experts.

From a total of 500 invited participants, 378 completed the questionnaire. The prevalence of the use of of herbal products in this study was high at 80.2%. Herbal medicines use was not associated with any demographic factors other than age ( p  < 0.05). Moreover, the only associated health-related characteristic was the patient’s disease state including, notably, hypertension ( p  < 0.05). Reasons for not using herbal medicines as reported by nonusers included mainly a lack of belief in their efficacy (52.2%). Another two important reasons were that the individuals believed themselves to healthy and have no need for their use (31.3%) and the unavailability of enough information about the herbal medicines (29.7%). Finally, the most common side effects as reported by patients in this study were nausea and vomiting (9.3%), and, to a lesser extent, skin rash (2.1%).

There is a high rate of use of herbal medicines in Jordan, especially among hypertensive patients. Therefore, there is a need to establish effective herbal medicine policies and health education programs to discuss the benefits and risks of herbal medicine use, with the aim of maximizing patient-desired therapeutic outcomes.

Herbal medicines are substances one can eat or drink and may be vitamins, minerals, or herbs or parts of these substances. They can be defined as ‘plants or plant parts used for their scent, flavour, or therapeutic properties’ [ 1 ]. Herbal medicines are distinct from drugs wherein they are exempted from needing to meet premarketing safety and efficacy standards required for conventional drugs to adhere to [ 2 ]. The use of herbal medicines has increased remarkably throughout the world, with many people now using these products for the treatment of many health problems in health care practice across different countries [ 3 ].

People report using herbal medicine to meet a variety of health care needs, including disease prevention and to cure chronic illnesses such as dyslipidemia, hypertension, diabetes, cancer, and inflammatory bowel diseases [ 4 , 5 ].

The usage of herbal medicines in the world varies depending on location and the prevalence has increased recently. In the Arab world, similar rates have been found. About 80% of the population in Arab societies relies on herbal medicines for the prevention and treatment of illness [ 6 ]. For instance, in Egypt, 37% of the population reported using herbal medicines [ 7 ], while, in Saudi Arabia, a higher proportion of the population (73%) have used herbal medicines [ 8 ]. In Jordan, herbal medicine has maintained popularity as a result of historical, cultural, and psychosocial factors [ 9 ]. The most common reasons for using traditional herbal medicine are that it is inexpensive, more closely corresponds with the patient’s beliefs, avoids concerns about the adverse effects of chemical (synthetic) medicines, satisfies a need for more personalised health care, and allows for a greater public approach to health information [ 10 ].

It is hypothesised that as the use of herbal medicine increases among Jordanian adult populations so too do the occurrence of adverse effects and herbal drug interactions. Knowledge of the predictors of herbal use may help health care providers to identify patients at high risk who would be candidates for receiving additional guidance on the safe use of herbal medicines [ 11 ]. Such could further provide pathways for facilitating positive social changes by developing stricter governmental policies to ensure consumer safety and promote high-quality products and by driving the development of public awareness interventions about herbal use and related health risks.

The present study aimed to examine the prevalence and to identify factors predicting the use of herbal medicine among adults in Jordan. Understanding why adults resort to herbal medicine can help with planning interventions to increase awareness about herbal use. Such could also shed light on the importance of setting frameworks to regulate the entry into, distribution, and use of herbal medicine in the Jordanian market.

Study design, subjects, and setting

This was a cross-sectional study that was carried out in Jordan. Data collection period was from 10 March to 19 April 2017. During the study period, 500 Jordanian individuals were invited to participate in this study and to fill out an anonymous questionnaire designed to evaluate the nature of their herbal medicine use and to identify factors predicting their use of herbal medicine. Participants were Universities students and their family members. Universities staff and their family. The students were approached while participating in different classes. The study objectives were explained to them and they were informed that the study was to assess the knowledge and beliefs about the use of herbal medicine in Jordan.

Questionnaire deployment and data collection

Data collection was carried out using self-administered questionnaires that were developed by the researchers based on questions extracted from previous studies [ 12 , 13 ].

Content validity and face validity of the items questionnaire was evaluated in a panel of experts. Qualitative face validity was evaluated by asking the opinion of experts including a sample of the target group and 5 faculty members, assessed the questionnaire for appropriateness, complexity, attractiveness and relevance for the items. The items were edited and reworded based on their statements. Content validity was also evaluated by qualitative and quantitative methods. In the qualitative phase, we invited two expert panel to evaluate and discuss the essentiality of the questionnaire items, its wording and scaling, and its relevance. In quantitative method, content validity ratio (CVR) and content validity index (CVI) were tested for each item. If CVR was greater than the criterion of the Lawshe’s table [ 14 ] for each item, the item was weighed as essential; if not, it was omitted. According to the Lawshe table [ 14 ], an acceptable CVR value for 5 experts is 0.99.

The questionnaire was divided into four sections. The first section dealt with respondents’ acquisition, recommendations, and trust of currently available information on herbal medicines. The second part inquired about respondents’ attitudes towards herbal medicines The third part requested the health-related characteristics of study participants. The final section characterised the respondents’ demographics. The methods for response were organised differently, including using single-answer, multiple-answer (participants were allowed to choose more than one answer), and four-point Likert scale (i.e., 1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree) schemes.

Ethical considerations

This study was conducted following the guidelines outlined in the World Medical Association’s Declaration of Helsinki [ 15 ]. Ethical approval for conducting this study was obtained from the Institutional Review Board Committee at Applied Science Private University.

The participation of members of the Jordanian public was strictly voluntary. Informed consent of the participants was obtained prior to study inclusion and no personal data of the participants are reported. The anonymity of respondents was preserved in the study, as the names of participants were not included.

Sample-size calculation and sampling technique

A sample size calculation was performed using the following formula:

Where P is the anticipated prevalence of students’ knowledge, d is the desired precision, and z is the appropriate value from the normal distribution for the desired confidence.

Using a 95% confidence level (CI), 10% precision level, and 50% anticipated prevalence of inappropriate knowledge, a minimum sample size of 96 people was considered as accurately representative for the purpose of this study. In this study, we tried to approach 500 subjects to increase the generalizability of the study. A convenience sampling technique was employed to approach students based on their accessibility and proximity to the researcher.

Statistical analysis

All data were entered and analysed using SPSS© version 22 (IBM Corp., Armonk, NY, USA). Categorical variables were expressed as frequencies and percentages, while continuous variables were presented as means ± standard deviations (SDs). The chi-squared test was used to evaluate demographic and health-related characteristics associated with herbal medicines.

Multiple logistic regression analysis was used to identify attitude-related factors that best predicted the use of herbal medicines in the study population, using odds ratio (OR) values as a measure of association. A p -value of less than 0.05 was considered to be statistically significant.

The first draft of the questionnaire was formed through a grounded theory study and extensive literature review. The questionnaire was divided into four sections. The first section dealt with respondents’ acquisition, recommendations, and trust of currently available information on herbal medicines. The second part inquired about respondents’ attitudes towards herbal medicines. The third part requested the health-related characteristics of study participants. The final section characterised the respondents’ demographics.

In qualitative face validity, by consideration of the expert panel, four items were deleted due to content overlap. One item was also omitted due to complexity. In qualitative content validity, we changed two items according to the experts’ recommendations. In the quantitative stage, CVR of all the items was between 0.99, except for 4-items that had a CVR < 0.62 and therefore were deleted.

The CVI for each item scale was the proportion of experts who rated an item as 3 or 4 on a 4-point scale [ 16 ]. Clarity, simplicity, and relevancy of each item were scored in a four-point Likert scale (from 1: not relevant, not simple, and not clear to 4: very relevant, very simple, and very clear). Items with scores less than 0.7 were omitted. CVI of other items were between 0.8–1.

Construct validity of this questionnaire was evaluated by 378 respondents with mean age of 26.7 ± 5.60 years. Detailed demographic data of the study participants are as shown in Table  1 . A total of 378 respondents responded to the questionnaire and the majority of them reported using herbal medicine (80.8%). The main reason for the nonparticipation of the remaining students ( n  = 122) was a lack of interest in the subject of the study. About two-thirds of respondents were female (69.6%). The majority had either bachelor or college degrees of education (62.9%) and had an annual income of less than 1000 (68.3%).

Table  2 shows responses pertaining to health-related characteristics and the use of herbal medicines. More than three-quarters of the study sample admitted using herbal medicines. The majority of participants rated their health as either excellent or very good (71.4%) but no significant association between the provided health rating and the usage of herbal medicines was observed. About 80% of the study population did not report the presence of any chronic disease, and there was no association between the presence of chronic illness and the use of herbal medicine found. The most prevalent chronic diseases among the study subjects were hypertension followed by diabetes (9.5 and 5.6%, respectively), and there was a statistically significant association between the type of chronic illness and the admitted use of herbal medicines. More than half of the respondents were somewhat unfamiliar with herbal medicines (52.6%). Among those who used herbs, about one-third were using them only during certain seasons, and approximately half of them reported used herbal remedies followed by vitamins and minerals, respectively (48.9 and 21.7%). The main reasons for using the products were to treat disease and maintain health (44.8%). Approximately 22% of consumers experienced side effects from using herbal medicines including, most commonly, vomiting and nausea (9.3%).

Table  3 indicates that the majority of consumers obtained herbal medicines from herbalists followed by from a pharmacy (37.8 and 23.0%, respectively). Herbal medicine use was mainly recommended by family and friends (39.7%) followed by pharmacists (17.7%) and mass media (12.4%). Pharmacists and medical doctors were the individuals most trusted to provide accurate information on herbal medicines (24.6 and 23.3%, correspondingly).

Reported attitudes towards herbal medicines, as presented in Table  4 , revealed that the majority of respondents agreed with six statements and disagreed with two statements. The reported disagreements were with the statements if a herbal medicines is for sale to the public, I am confident that it is safe and herbal medicines are better for me than conventional medicines. The strongest agreement was with the statement herbal medicines can maintain and promote health followed by that the respondents desired to know more about the safety and efficacy of herbal medicines and about the possibility of the use of herbal medicines to treat illnesses (83.3, 79.6, and 77.8%, respectively).

Multivariate logistic regression analysis outcomes comparing who agreed and disagreed about certain statements regarding herbal medicine use are shown in Table  5 . The highest odds were found among people who agreed about the use of herbs to maintain health (OR: 3.9, 95% CI: 0.12–0.57), while the least significant odds were found among those who agreed with the statement a lot of the health claims made by the manufacturers of herbal medicines are unproven (OR: 0.515, 95% CI: 1.05–3.60). Other significant predictors were herbal medicines can be used to treat illness and if a herbal medicineis for sale to the public , I am confident that it is safe ( p  < 0.05).

The nonusers’ reasons for not using herbal medicines are shown in Table  6 . The highest percentage explained that they feel they are healthy and have no need for herbal medicines or they do not have enough information about herbal medicines. There was a significant association between the nonuse of herbal medicines and the mentioned reasons ( p  < 0.05).

The prevalence of herbal use in this study (80.2%) was the highest when compared with findings presented in other studies from Middle Eastern areas [ 5 , 17 , 18 ] and the United States [ 19 ]. The majority of previous studies reported a higher rate of use of herbal medicines among hypertensive patients [ 20 , 21 , 22 ]. In this study, the use of herbal medicines was not associated with any of the recorded demographic factors but age. Moreover, the only associated health-related characteristic was the patient’s disease state, including specifically hypertension. On the contrary, other studies showed an association with some demographic variables such as educational level or marital status as reported by Ibrahim et al. [ 17 ]. Another survey in Turkey showed a significant association with almost all demographic variables considered [ 21 ].

Our study’s findings were consistent with those of other studies, which reported a degree of independence between sociodemographic factors and the use of herbal medicines [ 23 ]. Any discrepancy might be attributed to different perspectives and definitions of herbal medicines among different populations due to variations in the recognition and valuation of herbal medicines as well as attitudes towards herbal medicines among different cultures.

An assortment of herbal medicines is known to be applicable in managing high blood pressure, which is supported by the findings of this study and other studies conducted in developing countries [ 21 , 24 ]. The low cost and acceptability of traditional herbal medicines in different cultures made users confident with adopting these products for both therapeutic and prevention reasons. Moreover, the use of herbal medicines has a historical context and is well-accepted in Islamic culture, further strengthening users’ acceptance of these products.

Reasons for not using herbal medicines are different as reported by nonusers, and no significant single reason for non usage was stated. However, the highest percentage of nonusers reported they did not believe in the efficacy of herbal medicines. Other important reasons were that the individuals felt healthy and had no need for its use and there was unavailability of adequate information about the herbal medicines. These findings might prompt manufacturers of these herbal products to disseminate more information and perform more outreach and education regarding their products.

The highest adopted products were herbal remedies, as about of half of our sample used these products, followed to a lesser extent by vitamins and minerals, and the total percentage represents less than one-quarter of our population. Our results indicated that older patients were the most frequent users of herbs, vitamins, and minerals. This can be explained by the fact that the older population has more ailments and health issues as compared with their younger counterparts and hence are likely looking for additional health and wellness support.

The reasons for the use of herbs as reported by the study population were mainly to treat diseases and to maintain health followed by preventing illness, which are logical findings in relation to the use of such herbal products. The use of herbal medicines was recommended by family and friends to the greatest extent and secondly by pharmacists, while physician recommendations were the most infrequent recommendations received. Consistently, other studies found nearly the same pattern where seekers do not ask medical advice and instead depend upon friends and family members for guidance [ 25 , 26 ].

The most common side effects as reported by patients in this study were nausea and vomiting and, to a lesser extent, skin rash, which is inconsistent with the findings of other studies that found other multiple side effects including mainly skin rash as the primary unwanted effect of traditional therapy [ 25 , 27 ]. Side effects and drug interactions are common among users of these herbal products, as they are users of other medications such as antihypertensive drugs; hence, health care professionals should be vigilant and educate patients regarding these issues. In addition, the lack of accurate or regulated dosing of these products is another major concern. All of these aspects represent potential sources of debate among health professionals about the risk–benefit ratio and effectiveness of these products.

Limitations

Study participant recruitment was done inside universities, so most of the study sample was from specific age groups spanning students’ ages. Another limitation was the convenience sampling method used in this study. Our findings may not be extrapolated to the broader population of Jordan or to those of other countries.

We found that the use of herbal medicines is common among the study population, including specifically hypertensive patients, in Jordan, and the same is true among other Middle East populations. Demographic characteristics are not significantly related to the use of herbal medicines. The only determinant of the use of these products is the presence of elevated blood pressure. Nausea and vomiting were the most common side effects reported by consumers of herbal medicines. It is worth knowing that herbal products are not risk-free and the risk of drug interactions is not currently well-studied, so further research in this area is warranted and health care professionals should suggest caution to patients where appropriate.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors are extremely grateful to the survey participants who took the time to participate in the study. Without their participation and feedback, this study would not have been possible.

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El-Dahiyat, F., Rashrash, M., Abuhamdah, S. et al. Herbal medicines: a cross-sectional study to evaluate the prevalence and predictors of use among Jordanian adults. J of Pharm Policy and Pract 13 , 2 (2020). https://doi.org/10.1186/s40545-019-0200-3

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Current Status of Herbal Drugs in India: An Overview

Ashok d.b. vaidya.

1 Bharatiya Vidya Bhavan’s Swami Prakashananda Ayurveda Research Centre, University of Mumbai, 13th North-South Road, Vithalnagar, Juhu Scheme, Mumbai 400 049, India

2 Medicinal Plants Committee, PHARMEXCIL, Hyderabad, India

Thomas P.A. Devasagayam

3 Radiation Biology and Health Sciences Division, Bhabha Atomic Research Centre, Mumbai 400 085, India

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Herbal drugs constitute a major share of all the officially recognised systems of health in India viz . Ayurveda, Yoga, Unani, Siddha, Homeopathy and Naturopathy, except Allopathy. More than 70% of India’s 1.1 billion population still use these non-allopathic systems of medicine. Currently, there is no separate category of herbal drugs or dietary supplements, as per the Indian Drugs Act. However, there is a vast experiential-evidence base for many of the natural drugs. This offers immense opportunities for Observational Therapeutics and Reverse Pharmacology. Evidence-based herbals are widely used in the diverse systems and manufactured, as per the pharmacopoeial guidelines, by a well-organised industry. Significant basic and clinical research has been carried out on the medicinal plants and their formulations, with the state-of-the-art methods in a number of Institutes/Universities. There are some good examples. Indian medicinal plants also provide a rich source for antioxidants that are known to prevent/delay different diseased states. The antioxidant protection is observed at different levels. The medicinal plants also contain other beneficial compounds like ingredients for functional foods. Hence, the global knowledge about Ayurveda and Indian herbals will hopefully be enhanced by information on the evidence-base of these plants. This will yield rich dividends in the coming years.

Introduction

India has a very long, safe and continuous usage of many herbal drugs in the officially recognized alternative systems of health viz . Ayurveda, Yoga, Unani, Siddha, Homeopathy and Naturopathy. These systems have rightfully existed side-by-side with Allopathy and are not in ‘the domain of obscurity’, as stated by Venkat Subramanian [ 1 ]. Millions of Indians use herbal drugs regularly, as spices, home-remedies, health foods as well as over-the-counter (OTC) as self-medication or also as drugs prescribed in the non-allopathic systems [ 2 ]. The more than 500,000 non-allopathic practitioners are trained in the medical colleges (>400) of their respective systems of health and are registered with the official councils which monitor professionalism. Hence, these systems are not folklore or traditional herbal practices. There are basic axioms of these systems leading to a logical and systematic structure of pathogenesis and diagnosis, which serves also as a determinant for therapy [ 3 ].

The developer of a potent natural product penicillin, Nobel-laureate Ernst Boris Chain wrote an inspiring article entitled “The quest for new biodynamic substances”. In 1967, he wrote, “In China and India there has been an extensive drive aimed at the systemic study of medicinal plants traditionally used in these countries in folklore medicine; this has failed, so far, to bring to light new classes of compounds with interesting pharmacologic activities. As far as drug research is concerned, therefore, we cannot expect many major surprises to come from the study of plant constituents” [ 4 ]. The current overview would disprove the infallibility of this Nobel laureate, by giving examples of novel activities of Indian medicinal plants.

Observational Therapeutics and Reverse Pharmacology

India, having a pluralistic healthcare system, offers an unfettered choice for the quest for new clinical effects of traditionally used medicinal plants [ 5 ]. Roy Chaudhary coined a neologism for such a discipline—Observational Therapeutics [ 6 ]. He expressed his hope that further research directed at a few of the chronic diseases against which more drugs are needed, such as diabetes, bronchial asthma, could lead to the discovery of new drugs for these conditions. Observational Therapeutics is an antecedent of the path of Reverse Pharmacology for new natural drug development. Reverse Pharmacology was proposed and initiated by Vaidya [ 7 ]. Reverse Pharmacology is possible only in those countries with pluralistic healthcare and where robust clinical and laboratory documentation of novel human, pharmacodynamic effects are possible by inter-system collaborative teamwork [ 8 ]. India, at the national level, has adopted this approach of Reverse Pharmacology and also the golden triangular research for correlating the three fields by R & D network viz. modern medicine, Indian systems of medicine, and life and pharmaceutical sciences [ 9 ]. Reverse Pharmacology is defined as the science of integrating documented clinical/experiential hits, into leads by transdisciplinary exploratory studies and further developing these into drug candidates by experimental and clinical research. The identification of structures with novel biodynamic effects can also lead to new chemical entity path for drug development.

The scope of Reverse Pharmacology is to understand the mechanisms of action at multiple levels of biological organization and to optimise safety, efficacy and acceptability of the leads in natural products, based on relevant science.

Research Approach to Herbal Products

The path of Reverse Pharmacology, arising from Observational Therapeutics is complementary to other approaches for natural drug development (Fig.  1 ).

Research Approach to herbal products (R & D Path for Natural Products)

The diversity of medical uses of plant is at times daunting for a new entrant to the field. But for a multidisciplinary research and a development network the options of research approach provide deep motivation for identification of new pharmacophores. Besides expanding the herbal therapeutic and preventive armamentarium, new pharmacophores may help to evolve new targets of drug action as well as a possibility for combinatorial chemistry on the novel pharmacophores. For example, curcumin has been a target molecule for a significant endeavour for a large number of combinatorial compounds. The Council of Scientific and Industrial Research (CSIR), in India has initiated sizeable and meaningful efforts for the development of herbal-based formulations for diabetes, arthritis and hepatitis by a national network programme [ 8 ]. The industry, the academia and the government research laboratories work in close collaboration. Interesting and novel activities have been detected with the selected plants and some of the active ingredients of therapeutically demonstrable effects e.g. glycaemic control and inhibition of HbA1c (glycosylated haemoglobin) level coupled with a reduction in in vitro formation of Amadori products.

The diverse approaches to herbal drugs have led to interesting hits and novel activities, which need further in depth drug development efforts, both as herbal as well as new single molecule drugs. Table  1 lists the activity of ten of the interesting Ayurvedic drugs [ 10 – 19 ].

Table 1

Activity of interesting Ayurvedic drugs

*A = Widespread and safe usage, B = Dietary supplements, C = Evidence based, D = IND-NDA (Investigate New Drug—Natural Drug Application)

Literature on Indian medicinal plants

There is vast literature on Ayurveda in Sanskrit, Hindi and regional languages that is often not accessible to the other language groups. The monographs and books in English are also available. But sometimes there are errors in translating the technical Sanskrit and Indian words into English. It is desirable that prior to embarking on developing any Indian herbal drug, the original Sanskrit textbooks or the experts and scholars of Ayurveda are properly consulted. There have been many scientific reviews on Indian medicinal plants too. Table  2 lists some of the highly recommended books, monographs and reviews that can be used as per the needs of the reader [ 20 – 45 ]. There has been an ongoing major CSIR effort of digitizing the traditional Ayurvedic knowledge library (TKDL).

Table 2

Recommended literature on Indian medicinal plants

Institutions/Centres Working on Indian Medicinal Plants

A large number of academic, industrial and government institutes are conducting research on the medicinal plants of India. There has been no systematic review of the massive work that is available from this nation. Many international data-bases and web-sites do not cover even the work published in the Indian Journals. Hence, there is a global lack of awareness of the mass and nature of work carried out on diverse aspects viz. ethnobotany, phytochemistry, pharmacognosy, pharmacology, clinical trials, safety studies and formulation-research. Table  3 provides a short list of some of the eminent institutes which are active in research on medicinal plants and in Ayurveda.

Table 3

Herbal Research institute/centres in India

Use and Potential of Selected Indian Plants

Since ancient times a number of Indian medicinal plants have been used globally. There are many references to Indian medicinal plants and trade in spices in a number of historical documents. For instance, Indian aloe is very widely used in India for cosmetic, medicinal and nutraceutical purposes [ 46 ]. But the antiaging effects of the pickled preparations are unique [ 47 , 48 ]. Despite the global reputation of aloe in dermato-cosmetics, the potential as antiaging is still untapped. Similarly, the plant Adhatoda vasica has been extensively studied for cough and the active principles have been known [ 49 ]. However, the potential for use in bleeding disorders and tuberculosis is untapped. Table  4 cites the clinical uses and the therapeutic potential of 14 selected Indian medicinal plants [ 50 – 99 ]. There is a need for an international collaborative effort to explore, on a fast track, the hits provided by clinical observations of astute physicians.

Table 4

Use and potential of selected Indian plants

Reverse Pharmacology on these selected plants may lead not only to new leads and drug candidates but also to novel targets and pharmacodynamic efforts. For example, investigations on Coleus forskohlii , used as pickles in some parts of India, led to isolation of forskolin, with multifaceted effects. The latter were mediated by activation of adenylate cylase and increased concentration of cyclic adenosine monophosphate (cAMP) [ 100 ]. Subsequently, forskolin (Fig.  2 ) has served as a very important tool in molecular pharmacology and endocrinology.

Forskolin (7β-acetoxy-8, 13-epoxy-1, 6β, 9-trihydroxylabd-14-en-11-one)

There are cAMP-independent effects of forskolin viz. through modulation of nicotinic acetylcholine receptor channel desensitization, modulation of voltage-gated potassium channels, reversal of multidrug resistance etc. [ 99 ]. This example suggests the complexity of effects of even simple phytomolecules. Hence, the emphasis has to be primarily on the human effect, as documented in Observational Therapeutics.

Indian Medicinal Plants as a Source of Antioxidants and Radical Scavengers

In recent years, there is a tremendous interest in the possible role of nutrition in prevention of disease. In this context, antioxidants, especially derived from natural sources such as Indian medicinal plants and herbal drugs derived from them, require special attention. Antioxidants neutralize the toxic and ‘volatile’ free radicals. Antioxidants have many potential applications, especially in relation to human health, both in terms of prevention of disease and therapy [ 101 , 102 ]. In biological systems oxygen gives rise to a large number of free radicals and other reactive species collectively known as ‘reactive oxygen species’ (ROS). Another group of reactive species are termed as ‘reactive nitrogen species’ (RNS) [ 103 , 104 ]. In a normal healthy human, the generation of ROS and RNS are effectively kept in check by the various levels of antioxidant defense. However, when the humans get exposed to adverse physiochemical, environmental or pathological agents this delicately maintained balance is shifted in favour of pro-oxidants resulting in oxidative stress [ 101 ]. Cellular damage induced by oxidative stress has been implicated in the etiology of a large number (>100) of human diseases as well as the process of ageing. Various antioxidants may prevent and/or improve diseased states [ 101 , 103 , 105 , 106 ]. These include the intracellular antioxidant enzymes and the dietary or oral supplements in the form of vitamin C, vitamin E, β-carotene, zinc and selenium [ 107 , 108 ]. Antioxidants also can act at different levels of protection such as prevention, interception and repair.

Indian medicinal plants provide a rich source of antioxidants. A review of literature shows that there are over 40 Indian medicinal plants showing antioxidant abilities at various levels of protection (Table  5 ). The medicinal plants that show significant antioxidant activity include Acacia catechu , Achyranthes aspera , Aegle marmelos (Bengal quince, Bel), Aglaia roxburghiana (Priyangu), Allium cepa (Onion), Allium sativum , Aloe vera , Amomum subulatum , Andrographis paniculata , Asparagus racemosus , Azadirachta indica , Bacopa monniera , Bauhinia purpurea , Brassica campastris , Butea monosperma , Camellia sinensis , Capparis decidua , Capsicum annum , Centella asiatica , Cinnamomum verum , Commiphora mukul , Crataeva nurvala , Crocus sativus , Curcuma longa , Cymbopogan citrates , Emblica officinalis , Emilia sonchifolia , Garcinia atroviridis , Garcinia kola , Glycyrrhiza glabra , Hemidesmus indicus , Hypericum perforatum , Indigofera tinctoria , Melissa officinalis , Momordica charantia , Morus alba , Murraya koenigii , Nigella sativa , Ocimum sanctum , Picrorrhiza kurroa , Piper beetle , Plumbago zeylanica , Premna tomentosa , Punica granatum , Rubia cordifolia , Sesamum indicum , Sida cordifolia , Swertia decursata , Syzigium cumini , Terminalia arjuna , Terminalia bellarica , Tinospora cordifolia , Trigonella foenum-graecum , Withania somnifera and Zingiber officinalis [ 109 – 111 ]. There are also a number of ayurvedic formulations containing ingredients from medicinal plants that show antioxidant activities. These are Abana, Amrita bindu, C-phycocyanin, Centalaplus, Chapparal, Geriforte, Jigrine, Liv-52, Maharishi formulations, Muthu marunthu, Ophtacare, P55A, Sandhika, Student rasayana and Tamra bhasma. There are still a large number of plants and ayurvedic formulations whose antioxidant activities need to be examined in relation to their potential therapeutic and related beneficial properties. More recent assays also should be included to study the antioxidant properties of medicinal plants or their chemical constituents. This will greatly help in identifying more potent compounds with potential applications in prevention and/or therapy of human ailments. Newer approaches utilizing collaborative research and modern technology in combination with established traditional health principles will yield rich dividends in the near future in improving health, especially among people who do not have access to the use of costlier western systems of medicine.

Table 5

Indian medicinal plants and levels of antioxidant action

Indian Medicinal Plants as a Source of Other Beneficial Compounds

These medicinal plants are also important source of other type of beneficial compounds including the ingredients for functional foods. These functional foods promote better health to prevent chronic illness. Some ingredients that make food functional are dietary fibres, vitamins, minerals, antioxidants, oligosaccharides, essential fatty acids (omega-3), lactic acid bacteria cultures and lignins. Many of these are present in medicinal plants. Indian systems of medicine believe that complex diseases can be treated with complex combination of botanicals unlike in the West, with single drugs. Whole foods are hence used in India as functional foods rather than supplements. Some medicinal plants and dietary constituents having functional attributes are spices such as onion, garlic, mustard, red chilli, turmeric, clove, cinnamon, saffron, curry leaf, fenugreek and ginger. Some herbs such as Bixa orellana and vegetables like amla, wheat grass, soybean and Garcinia cambogia have antitumor effects [ 112 , 113 ]. Other medicinal plants with such functional properties include Aegle marmelos , Allium cepa , Aloe vera , Andrographis paniculata , Azadirachta indica and Brassica juncea [ 111 , 114 ].

Conclusion and Future Prospects

In India more than 70% of the population use herbal drugs for their health. There is a vast experience-based evidence for many of these drugs. There are also a number of Institutes/Universities in India carrying our research on herbal drugs and medicinal plants. Using ‘reverse pharmacological’ approach, several Institutes carry out basic and clinical research on the potential health benefits of herbal drugs. There are many successful examples in this direction. These herbal drugs and Indian medicinal plants are also rich sources of beneficial compounds including antioxidants and components that can be used in functional foods. Newer approaches utilizing collaborative research and modern technology in combination with established traditional health principles will yield rich dividends in the near future in improving health, especially among people who do not have access to the use of costlier western systems of medicine.

Acknowledgments

We thank Dr. Shridhar Anishetty and Mr. Rajkumar Mishra for their help in preparation of the overview.