Translating Herbal Supplement Research for Patient Education Dr. Rosanne Pruitt, PhD,FNP - Adam Carroll - Ashley Lemanski


Herbal supplements are plant based, and they are usually added to the diet for health purposes. Jordan, Cunningham, and Marles (2010) state that the general public often views herbs as a safer alternative to pharmaceutically manufactured drugs because herbal ingredients are naturally occurring in the environment. Therefore, herbal supplements have gained increasing popularity in the United States. According to Aschwanden (2001), over 1,500 medicinal herbs are sold annually, constituting the fastest growing sector in the US pharmaceutical market and a significant source of alternative medicines among patients. Although herbal supplements may be generally safer than pharmaceutically synthesized medications, each herb should be evaluated according to its own significance in promoting health (Cohen & Ernst, 2010).

Herbal supplement purchases are oftentimes made without consulting a primary health care provider or seeking professional advice. Although herbs are not considered to be drugs, herbal supplements can act the same way as drugs in the human body. Because of this, both harmful and helpful effects have been observed through the consumption of herbal supplements. The Food and Drug Administration (FDA) does not regulate herbal supplements the same way as drugs because herbs are considered a food product (Aschwanden, 2001). As a result, herbal supplements do not have to satisfy the strict FDA standards required for prescription medication. Without a reliable, comprehensive resource, few healthcare providers will take the time to research individual herbs to stay up-to-date with the current literature. This can lead to patients making usage decisions without professional advice.

It is important that patients who are taking medications consult with their healthcare provider before beginning to take an herbal supplement in order to avoid medication interactions. In addition, some of the herbal supplements lack adequate research with human subjects. It is important to be aware that some results were observed in animal models and are noted as such in this paper. Also, research concerning the long-term effects of a particular supplement may be lacking.


The purpose of this research is to compile information about herbal supplements and to organize this information into a chart that can be easily referenced by healthcare professionals in clinical settings. This chart will specifically address information pertaining to herbal supplements such as: uses, the quality of evidence related to the efficacy of herbal supplements, and precautions for individuals between the ages of 18-65. A literature review was conducted examining recent research related to the use of commonly used herbal supplements in the general public. Human clinical trials and meta-analyses were preferred while research with animal models were included if human trials were not available. Each herb researched was ranked on a safety scale: green meaning generally safe, yellow meaning use caution, and red meaning avoid use. The completed chart will include research on popular herbal supplements (figure 1).

Figure 1

Several of these herbs from each safety category will be outlined below (figures 2-7).

Two commonly used herbs that are categorized under generally safe are Milk Thistle and Ginseng, two herbal supplements labeled as cautionary are St. John’s Wart and Ginkgo, and two commonly used herbs that are not recommended for patient use are Goldenseal and Ephedra.

Milk Thistle

Generally Safe

Milk thistle is used to treat chronic liver disease, decrease nephrotoxicity, decrease cholesterol and atherosclerotic plaques, decrease blood glucose. Milk thistle is also renal protective. While, much of the research done on milk thistle has been done on animals, few-to-no adverse reactions have been observed in animal studies or in people using the supplement (Haddad, Vallerand, Brault, Haddad, 2011; Ninsontia, Pongjit, Chaotham, Chanvorachote, 2011; Radjabian, Huseini, 2010; Sheela, Jose, Sathyamurthy, Kumar, 2013; Tsai et al., 2008).

Figure 2


Generally Safe

Ginseng has been tested in both clinical trials and animal studies. It is useful in increasing peripheral dilation and in preventing obesity and metabolic syndrome when used over a short period of time. It should be avoided when using many anticoagulants (Bauer, 2013; Li et al., 2014; Park et al., 2014).

Figure 3

St. Johns Wart

Use with Caution

St. John’s Wart has been promoted for the treatment of depression, smoking cessation, cancer, premenstrual symptoms, and ADHD. Current research only definitively supports its efficacy in randomized human clinical trials for the treatment of depression. There is not enough substantial research supporting its other uses. Caution should be advised when taking St. John’s Wart due to the potential for serious adverse drug interactions. Limited research has been conducted on the long term effects of this drug, so research recommends use for less than 3 months at a time (Apaydin et. al,2016; Lind et al.,1996; Yarnell. E, 2015). It is advised that ginkgo be used with caution, especially when being used over extended periods of time (Bauer, 2013).

Figure 4


Use with Caution

Ginkgo is effective in reducing periodontal pathogens, treating ADHD, and it has a protective effect on cerebral ischemia (Bo, Yang, Ruili, & Benyan, 2014; Cheng et al., 2014; Shakibaei, Radmanesh, Salari, & Mahaki, 2015). However, ginkgo can interact with other drugs including anticlotting medications (aspirin) and thiazide diuretics (Bauer, 2103).

Figure 5


Not Recommended

Goldenseal is often used for the treatment of sore throats, GI disease, and wounds. However, it is not recommended because studies have revealed that it can increase the incidence and size of liver tumors and cause DNA damage. As a result, goldenseal should be avoided (Chen et al., 2013; Dunnick et al., 2011; Harris, Grace, & Eddey, 2015).

Figure 6


Not Recommended

Ephedra is commonly used as a weight loss supplement and an energy booster. Research supports its efficacy in weight loss and increasing energy but strongly recommends that ephedra be avoided due to its serious adverse effects. Side effects of ephedra observed in human clinical trials have been linked with hypertension, stroke, myocardial infarction, and death. The risks of the herbal supplement clearly outweigh any benefit it may have on an individual’s health (Abourashed et al., 2003; Boozer et al., 2002; Haller & Benowitz, 2000; Shekelle et al., 2003).

Figure 7


We surveyed 30 patients in the Joseph F. Sullivan Center about their supplement use and dialogue concerning supplement use with their healthcare providers. Out of the 30 participants, 47% of patients surveyed reported that their healthcare provider had not asked about their use of herbal supplements. This is especially significant because providers at this clinic strive to discuss alternative therapies with their patients (fig. 8). 27% of the patients surveyed reported that they regularly used herbal supplements without telling their healthcare provider (fig. 9). Avocado, Cinnamon, Garlic, Ginger, and Green Tea were reported as the most commonly used herbal supplements by participants (fig. 10).

Figure 8
Figure 9
Figure 10


While there is much research concerning the risk-benefit profile of herbal supplements, this information is not compiled in a way that makes it easy for healthcare professionals to offer recommendations to patients. As a result, our ongoing research of milk thistle, ginseng, St. John’s Wart, ginkgo, goldenseal, and ephedra in addition to about 40 other herbs will be used to produce a current user-friendly chart to guide healthcare professionals in advising their patients. This chart will help to improve patient outcomes of clients who consult a healthcare provider before using herbal supplements.

Presentation and Publication

Research concerning herbal supplements and the herbal supplement chart was presented at the Sigma Theta Tau Nursing Research Conference in Dublin, Ireland and a manuscript entitled “Herbal Supplements: Safety and Research Support” has been submitted to the Editorial Manager of The Nurse Practitioner. A resolution was presented in support of increasing advocacy for the addition of a herbal supplement inquiry on health history forms and the article was published about this topic in Imprint.

At the conference center for the oral presentation. From Left to Right: Adam Carroll, Dr. Rosanne Pruitt, and Ashley Lemanski
The Cliffs of Moher, Ireland
Scholarly Journal manuscript was submitted to
First page of Imprint article

We would like to extend a special thanks to the Calhoun Honors College, Clemson Creative Inquiry, and the Clemson University School of Nursing for making this research possible.


Abourashed, E. A., El‐Alfy, A. T., Khan, I. A., & Walker, L. (2003). Ephedra in perspective–a current review. Phytotherapy Research, 17(7), 703-712.

Aschwanden, C. (2001). Herbs for health, but how safe are they? Bulletin of the World Health Organization, 79(7), 691-692. doi.org/10.1590/S0042-96862001000700025

Apaydin, E. A., Maher, A. R., Shanman, R., Booth, M. S., Miles, J. V., Sorbero, M. E., & Hempel, S. (2016). A systematic review of St. John's wort for major depressive disorder. Systematic Reviews, 51-25. doi:10.1186/s13643-016-0325-2

Bauer, B. (2013). Mayo Clinic: Book of Alternative Medicine (2nd ed) Time, Inc. ISBN 13:978- 1-60320-836-9

Boozer, C. N., Daly, P. A., Homel, P., Solomon, J. L., Blanchard, D., Nasser, J. A., ... & Meredith, T. (2002). Herbal ephedra/caffeine for weight loss: a 6-month randomized safety and efficacy trial. International Journal of Obesity & Related Metabolic Disorders, 26(5).

Chen, S., Wan, L., Couch, L., Lin, H., Li, Y., Dobrovolsky, V. N., & ... Guo, L. (2013). Mechanism study of goldenseal-associated DNA damage. Toxicology Letters, 221(1), 64- 72. doi:10.1016/j.toxlet.2013.05.641

Cohen, P. A., & Ernst, E. (2010). Safety of herbal supplements: A guide for cardiologists. Cardiovascular therapeutics, 28(4), 246-253. doi: 10.1111/j.1755-5922.2010.00193.x

Dunnick, J. K., Singh, B., Nyska, A., Peckham, J., Kissling, G. E., & Sanders, J. M. (2011). Investigating the potential for toxicity from long-term use of the herbal products, goldenseal and milk thistle. Toxicologic Pathology, 39(2), 398-409. doi:10.1177/0192623310394211

Haddad, Y., Vallerand, D., Brault, A., & Haddad, P. S. (2011). Antioxidant and hepatoprotective effects of silibinin in a rat model of nonalcoholic steatohepatitis. Evidence-Based Complementary & Alternative Medicine (Ecam), 8(1), 1-10. doi:10.1093/ecam/nep164

Haller, C. A., & Benowitz, N. L. (2000). Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. New England journal of medicine, 343(25), 1833-1838.

Harris., Grace & Eddey (2015). Adverse events from complementary therapies: An update from the natural therapies workforce survey part 2. Journal Of The Australian Traditional- Medicine Society, 21(3), 162-167.

Jordan, S. A., Cunningham, D. G., & Marles, R. J. (2010). Assessment of herbal medicinal products: challenges, and opportunities to increase the knowledge base for safety assessment. Toxicology And Applied Pharmacology, 243(2), 198-216. doi:10.1016/j.taap.2009.12.005

Li, X., Luo, J., Anandh Babu, P. V., Zhang, W., Gilbert, E., Cline, M., & ... Liu, D. (2014). Dietary Supplementation of Chinese Ginseng Prevents Obesity and Metabolic Syndrome in High-Fat Diet-Fed Mice. Journal Of Medicinal Food, 17(12), 1287-1297. doi:10.1089/jmf.2014.0016

Linde, K., Ramirez, G., Mulrow, C. D., Pauls, A., Weidenhammer, W., & Melchart, D. (1996). St John's wort for depression-An overview and meta-analysis of randomised clinical trials. Bmj, 313(7052), 253-258. doi:10.1136/bmj.313.7052.253

Ninsontia, C., Pongjit, K., Chaotham, C., & Chanvorachote, P. (2011). Silymarin selectively protects human renal cells from cisplatin-induced cell death. Pharmaceutical Biology, 49(10), 1082-1090. doi:10.3109/13880209.2011.568506M

Park, K., Park, K., Kim, J., Yun, Y., Kim, S., Lee, C., & ... Lee, J. (2014). Efficacy and safety of Korean red ginseng for cold hypersensitivity in the hands and feet: A randomized, double-blind, placebo-controlled trial. Journal Of Ethnopharmacology, 15825-32. doi:10.1016/j.jep.2014.09.028

Radjabian, T., & Huseini, H. F. (2010). Anti-hyperlipidemic and anti-atherosclerotic activities of silymarins from cultivated and wild plants of Silybum marianum L. with different content of flavonolignans. Iranian Journal Of Pharmacology & Therapeutics, 9(2), 63-67.

Sheela, N., Jose, M. A., Sathyamurthy, D., & Kumar, B. N. (2013). Effect of silymarin on streptozotocin-nicotinamide - Induced type 2 diabetic nephropathy in rats. Iranian Journal Of Kidney Diseases, 7(2), 117-123.

Shekelle, P. G., Hardy, M. L., Morton, S. C., Maglione, M., Mojica, W. A., Suttorp, M. J., ... & Gagné, J. (2003). Efficacy and safety of ephedra and ephedrine for weight loss and athletic performance: a meta-analysis. Jama,289(12), 1537-1545.

Tsai, J. H., Liu, J. Y., Wu, T. T., Ho, P. C., Huang, C. Y., Shyu, J. C., & ... Liu, Y. C. (2008). Effects of silymarin on the resolution of liver fibrosis induced by carbon tetrachloride in rats. Journal Of Viral Hepatitis, 15(7), 508-514. doi:10.1111/j.1365-2893.2008.00971.x

Yarnell, E. (2015). Herbal Adjuncts to Antidepressants. Alternative & Complementary Therapies, 21(3), 131-137. doi:10.1089/act.2015.29003.ey

Video: https://www.youtube.com/watch?v=y6_-dtVCCKs

Picture Credit: Created with images by The Ken Cook - "Milk thistle flower" • thuantri_hoangde - "ginseng yellow grass" • leesamlong - "A hybrid?" • ivoxis - "gingko ginkgo biloba sheet" • cricketsblog - "Goldenseal" • Ashley Basil - "Ephedra fragilis"


Created with images by The Ken Cook - "Milk thistle flower" • thuantri_hoangde - "ginseng yellow grass" • leesamlong - "A hybrid?" • ivoxis - "gingko ginkgo biloba sheet" • cricketsblog - "Goldenseal" • Ashley Basil - "Ephedra fragilis"

Report Abuse

If you feel that this video content violates the Adobe Terms of Use, you may report this content by filling out this quick form.

To report a Copyright Violation, please follow Section 17 in the Terms of Use.