Herbal_supplements_used_to_treat_common.pdf

26 The Nurse Practitioner • Vol. 41, No. 11 www.tnpj.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

ore than half of the adults in the United States have
at least one chronic condition, and one-quarter
of adults have two or more chronic conditions.1
According to the National Health Interview Survey, the fol-
lowing chronic conditions were found to be most prevalent
in adults age 18 and older: hypertension (23.9%), arthritis
(20.6%), heart disease (10.8%), diabetes mellitus (8.6%),
and cancer (8.1%).2
Chronic conditions in adults age 57
and older were reported in the National Social Life, Health,
and Aging Project. The most prevalent conditions found in
this age group included hypertension (59.9%),incontinence
(45.8%),arthritis (34.9%),cardiac conditions (29.9%),can-
cer (27.8%), and diabetes (22.1%).3
The five chronic conditions shared by these two major
national data sets are hypertension, other cardiac condi-
tions, arthritis, cancer, and diabetes mellitus. To manage
these chronic conditions, adults often use herbal products
in addition to conventional treatments,such as prescription
pharmaceuticals. Herbal supplements commonly used for
these conditions and the efficacy of these supplements is
discussed in the following sections.
This article focuses on studies of human subjects, rath-
er than animal or lab studies. Multiple PubMed searches
were performed to identify systematic reviews and meta-
analyses, with single randomized controlled trials (RCTs)
utilized if higher-level evidence was not identified. The
By Saun-Joo Yoon, PhD, RN; Susan D. Schaffer, PhD, ARNP; and Kim Curry, PhD, ARNP
M
Abstract: This is part 2 of a three-part series designed to provide clinicians with a
working knowledge of the use of herbal supplements for health and disease states.
Part 2 of the series focuses on the efficacy of herbal supplements used in the
treatment of common chronic conditions.
Herbal supplements
used to treat common
chronic conditions
Keywords: chronic conditions, complementary and alternative medicine, evidence-based practice,
health promotion, herbal medicine, herbal supplements
part 2
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Photo
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iStock
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www.tnpj.com The Nurse Practitioner • November 2016 27

Herbal supplements used to treat common chronic conditions
Cochrane Database of Systematic Reviews and the Na-
tional Center for Complementary and Integrative Health
were also consulted for all herbs considered for inclusion.
Levels of evidence as described by the Oxford Centre for
Evidence-Based Medicine 2011 working group were used
to appraise the evidence with particular attention to po-
tential harms or risks.
In this rating scale, systematic reviews of RCTs are
considered to be Level 1 evidence, while a Level 2 des-
ignation is used for individual RCTs. Nonrandomized
controlled cohort/follow-up studies are considered to be
Level 3. Case-series, case-controlled studies, or historically
controlled studies are categorized into Level 4, whereas
mechanism-based reasoning work is Level 5.4
However,
levels of evidence do not constitute a recommendation for
treatment. Clinicians must utilize their knowledge of indi-
vidual patients before recommending for or against using
these herbals for any of the chronic conditions discussed
in this article.
■ Hypertension
A number of different herbal preparations have been studied
for hypertension, but not all of them are supported by cur-
rent clinical evidence.
Allium sativum (garlic). Level 1 evidence supports the use
of certain garlic preparations as a complementary therapy
for hypertension.One of the mechanisms of action of garlic
in lowering BP seems to involve endothelium-dependent
vasodilation and relaxation of the vascular smooth muscle
cells.5
Recently, a meta-analysis of nine RCTs with 482 pa-
tients was conducted by Rohner and colleagues. The dura-
tion of the study periods was from 8 to 26 weeks.6
The types of garlic preparation used among the trials
were dried garlic powder (Kwai), time-released garlic pow-
der (Allicor), aged garlic extract, or crushed garlic. Dosages
ranged from 240 to 2,400 mg daily. The authors concluded
that garlic preparations showed some evidence of lowering
the BP, lowering systolic BP by 9.1 mm Hg and diastolic BP
by 3.8 mm Hg; however,more research is needed to confirm
these findings.6
Studies using aged garlic preparations dem-
onstrated greater efficacy.6
Level 2 evidence was provided by a dose response study
involving the use of garlic in doses of 240 mg, 480 mg, or
960 mg daily to treat hypertension. Ried and colleagues
conducted an RCT of 79 patients with uncontrolled systolic
hypertension.7
Aged garlic extract was found to be effective
and well tolerated in patients with uncontrolled hyperten-
sion. Mean systolic BP was significantly reduced in patients
consuming 480 mg of garlic per day for 12 weeks.Garlic was
found to be a safe complementary therapy.7
However, garlic may prolong bleeding and therefore
should be stopped at least 2 weeks before a scheduled sur-
gery.In addition,garlic may reduce the amount of isoniazid
absorbed by the body and may decrease the effectiveness
of antiviral medications used for HIV,
such as nevirapine, delavirdine, and
efavirenz.8
Adverse reactions related
to garlic preparations include gastro-
intestinal symptoms such as bloating,
flatulence, reflux, and mild abdominal
discomfort.6
It is recommended to use
garlic preparations with caution if an
individual is taking any antiplatelet, anticoagulant, anti-
diabetic,antiretroviral,or anti-inflammatory medications.5
Ginseng (Korean red ginseng). Level 2 evidence was sup-
plied by Rhee and colleagues in a study of the effects of Ko-
rean red ginseng on arterial stiffness in 80 individuals with
hypertension who were taking traditional antihypertensive
medications.9
No significant differences in BP changes or
arterial stiffness were noted after 3 months of interven-
tion between the group treated with 3 g/day of Korean
red ginseng and the placebo group, which remained on
their prescribed traditional antihypertensive medication.9
Patients should be advised that there is no good evidence
supporting the use of ginseng for hypertension.
Hibiscus sabdariffa L. (Sudan tea, sour tea). A tropical
plant, H. sabdariffa L. has been used as a food, beverage,
and medicinal herb, particularly for hypertension.A recent
systematic review and meta-analysis of five RCTs with a total
of 390 subjects provided Level 1 evidence that H.sabdariffa L.
significantly lowers both systolic and diastolic BP.10
Doses
and durations included in this analysis varied greatly and
ranged from 3.75 g/day to 100 mg of aqueous H. sabdariffa L.
extract for 15 days to 6 weeks (depending on the clinical
trial). The authors concluded that H. sabdariffa L. showed
promise in managing hypertension safely, but further in-
vestigation is needed to determine potential interactions
with other conventional medications and optimal dose of
H. sabdariffa L.
■ Hyperlipidemia
Allium sativum (garlic). Level 1 evidence supports the ef-
ficacy of garlic for lowering lipid levels. A meta-analysis
of 39 trials including 2,298 participants found that garlic
Level 1 evidence supports the use of certain
garlic preparations as a complementary
therapy for hypertension.

There is some Level 2 evidence of
effectiveness of curcumin for the
management of OA.
reduced total serum cholesterol by 17 ± 6 mg/dL and low-
density lipoprotein (LDL) cholesterol by 9 ± 6 mg/dL in
individuals with elevated cholesterol who used it for more
than 2 months.11
Studied daily doses were as follows: garlic
powder (600 to 5,600 mg/day), garlic oil (9 to 18 mg/day),
aged garlic extract (1,000 to 7,200 mg/day), and raw garlic
(4 to 10 mg/day [one clove equals approximately 1 g]).11
Ad-
verse reactions reported were consisted with those reported
in studies of garlic for hypertension.
An earlier systematic review of 10 RCTs found that 6 of
the studies reported efficacy, with an average drop in total
cholesterol of 24.8 mg/dL.12
Garlic supplements may be
considered for patients with mild hyperlipidemia, although
adverse reactions may limit adherence and potential drug
interactions must be considered.
Red yeast rice (RYR). This product has become popular
for treatment of dyslipidemia,particularly in those who have
experienced myopathies from HMG CoA reductase inhibi-
tor (statin) drugs or in those who believe they are a safer
alternative to statins. The recommended dosage is 1,200 to
2,400 mg once or twice daily.8
The use of RYR grew nearly
80% from 2005 to 2008 in the United States,with sales of $20
million reported in 2008.8
A meta-analysis of 93 random-
ized trials (primarily published in Chinese),including 9,625
participants, assessed the effectiveness and safety of three
proprietary RYR preparations on primary hyperlipidemia.13
The duration of the interventions in these trials ranged
from 4 to 24 weeks, and designs varied. Although some
of the trials compared RYR with placebo, 37 trials com-
pared xuezhikang 1.2 g and zhibituo 3.15 g variously with
simvastatin, pravastatin, lovastatin, or other statins and
found they were equivalent in lipid-lowering efficacy,
lowering total cholesterol by about 10%.13
Incidence of
adverse reactions ranged from 1.3% to 36% and included
dizziness, anorexia, nausea, and abdominal distension. A
reportedly “small” number of participants experienced
increased serum blood urea nitrogen and alanine ami-
notransferase levels. This trial concluded that long-term
effects and safety should be explored before RYR prepara-
tions were recommended as an alternative treatment for
primary hyperlipidemia.13
A more recent meta-analysis of 13 RCTs (804 par-
ticipants) with duration of at least 4 weeks demonstrated
significant lowering of total cholesterol, LDL cholesterol,
and triglyceride compared with placebo. High-density li-
poprotein levels were unaffected. RYR doses in these trials
ranged from 200 to 3,600 mg/day, and all but four trials
utilized combination products, including garlic, soybean,
niacin,or artichoke leaf extract.No serious adverse reactions
on hepatic function, kidney function, muscle (as measured
by creatine kinase), or fasting blood glucose were reported
in the analyses.14
Although RYR has generally been found to be effective
in treating dyslipidemia,patients need to be aware that RYR
products contain the naturally occurring form of lovastatin
in inconsistent amounts,may potentially be adulterated with
citrinin, a hepatotoxin, and nephrotoxin, and should not
be combined with other statins or other medications that
increase the risk of adverse reactions when combined with
statins.15,16
These medications include the antidepressant
nefazodone, anticoagulants, certain antibiotics, and drugs
used to treat fungal and HIV infections.
■ Arthritis
Although there are several different types of arthritis, the
focus of most herbal therapy has been on osteoarthritis
(OA) and age-related joint disease. Since there is no known
cure for OA, symptom management focuses on reducing
pain with pharmacologic therapies alone or in combina-
tion with nonpharmacologic methods, according to the
OA Research Society International Treatment Guidelines
Committee.17
Harpagophytum procumbens (Devil’s claw). Iridoid gly-
cosides and phenylpropanoid glycosides of Devil’s claw have
shown anti-inflammatory as well as an-
algesic properties biologically and have
long been used for various ailments in
South African regions.18
However,there
is little clinical evidence supporting use
of Devil’s claw for the treatment of OA
pain. Brien and colleagues conducted a
systematic review of relevant trials over
a 10-year period.Fourteen studies were reviewed,including
four RCTs; methodological quality was poor. The authors
concluded that while the evidence showed some support
for the use of Devil’s claw, it was insufficient to recommend
benefit for OA.19
In an open-label study of 42 patients with degenerative
joint disease, investigators studied a marketed mixture of
Devil’s claw, turmeric, and bromelain. Results in this small
sample revealed a significant reduction in pain as measured
with a visual analogue scale,thus providing Level 3 evidence
of some effectiveness when combined with select other plant
products.20
Further investigation is warranted to ensure that

RCTs support the use of this herb. The most commonly
reported adverse reactions of Devil’s claw is gastrointestinal
discomfort.21
Salix alba (willow bark). Willow bark, from the white
willow, contains the active ingredient salicin, which is a
precursor to aspirin.22
Known to be an antipyretic agent,
salicin has Level 1 evidence to support its use for muscu-
loskeletal pain management, such as low back pain and
arthritis pain. A systematic review of seven clinical trials
related to the use of willow bark for musculoskeletal pain
indicated that willow bark extract inhibited COX-2,showed
an antioxidant effect in animal models,and reduced inflam-
mation and pain.23
An open-label observational study with willow bark
extract STW33-I provided Level 3 evidence of the effective-
ness of willow bark. The authors used a willow bark dose
equivalent to 240 mg salicylic alcohol in 436 outpatients.
Patients received two tablets a day for 6 months to manage
arthritis pain. Results of the study indicated steady and
significant reduction of pain throughout the study with
mild adverse reactions, such as gastro-
intestinal discomfort, fatigue, flulike
symptoms, and arthralgia.24
Curcuma longa (turmeric [curcum-
in]). Curcumin is the active ingredient
of the turmeric plant. There is some
Level 2 evidence of effectiveness of
curcumin for the management of OA.
Panahi and colleagues conducted a single RCT including 40
patients with knee OA. Patients in the study arm received
500 mg of curcuminoid capsules three times per day. Cur-
cumin demonstrated measurable antioxidant effects and
provided symptom relief.25
In a prospective clinical trial
involving a more bioavailable form of curcumin,50 patients
with osteoarthritis of the knee were administered 180 mg/
day of a proprietary curcumin compound. After 8 weeks of
treatment, knee pain was significantly lower as measured
with a visual analogue scale. The investigators concluded
that curcumin displayed modest potential for treating knee
OA.26
This provides additional Level 2 evidence that this
herb may be effective.
Boswellia serrata. This gummy tree resin has long been
used in Ayurvedic medicine. Level 1 evidence was provided
by a systematic review of multiple studies of patients who
took enriched B. serrata 100 mg/day for osteoarthritis.27
Overall results indicated that pain was lowered 17/100
points on a pain scale of 0 to 100 (lower scores indicat-
ing reduced pain). Physical function was improved by
8 points (on a scale of 0 to 100 with lower scores indicat-
ing improved function) after 90 days of herbal therapy.
The authors concluded that there is high-quality evidence
that use of B. serrata reduced pain and slightly improved
physical function.27
■ Cancer
Many oncology experts advise against taking any type of
supplement,including herbal supplements and antioxidants,
during cancer treatment—particularly during chemothera-
py or radiation therapy due to lack of scientific evidence.28
There is also a theoretical concern that antioxidants may
repair the damage to cancer cells caused by cancer treat-
ments, rendering these treatments less effective.28
Despite this, many patients with cancer make use of
supplements. While the American Cancer Society recom-
mends against the use of herbal supplements, the Society
of Integrative Oncology (SIO) proposed a list of potentially
beneficial dietary supplements.Among the list the SIO sug-
gested were curcumin, Maitake mushrooms, green tea, and
Astragalus.29
Curcuma longa (turmeric [curcumin]). Curcumin has
shown radioprotective and chemoprotective functions in
preventing toxicity from chemotherapy or radiotherapy
in some studies.30
No Level 1 or Level 2 studies docu-
menting the effectiveness of curcumin in the treatment
of cancer in humans were located. Use of curcumin may
increase the risk of bleeding when it is used with anticoagu-
lants, antiplatelet drugs, nonsteroidal anti-inflammatory
drugs, herbs (such as ginkgo biloba and garlic), and saw
palmetto.29
Maitake mushrooms. These mushrooms have been
used in Asia to promote health for many years. Maitake
mushrooms contain a polysaccharide, D fraction, that has
been studied for its effectiveness in treating several forms
of cancer, including breast and lung cancers. The D fraction
compound appears to induce apoptosis,or programmed cell
death, in cancer cells, among other mechanisms of action.31
No systematic reviews or RCTs were found that demonstrat-
ed specific efficacy of maitake mushrooms in the treatment
of tumors in patients.
Camellia sinensis (green tea). Green tea leaves have been
used widely and known to have an antioxidant and pro-
apoptotic effect.29
Green tea has largely been studied for
cancer prevention rather than treatment.Even with regard to
prevention, results have been inconsistent and conflicting.32
Green tea leaves have been used widely
and known to have an antioxidant and
proapoptotic effect.

No high-level evidence was found supporting the use of
green tea in cancer treatment.
Astragalus root (milk vetch or huang qi). This herb has
shown immunomodulatory properties and may be used
along with chemotherapy.29
There is Level 1 evidence to
support the use of astragalus root for advanced non–small
cell carcinoma of the lung. McCulloch and colleagues con-
ducted a meta-analysis in 2006 of 34 studies representing
2,815 patients.33
All patients were taking platinum-based
chemotherapy.
Twelve studies reported reduced risk of death at 12
months, while 30 studies reported improved tumor re-
sponse data, over chemotherapy alone. Doses of astraga-
lus root varied, and it was administered as a mixture with
other Chinese herbs. McCulloch and colleagues concluded
that astralagus-based herbal therapy may increase the ef-
fectiveness of traditional chemotherapy but further closely
controlled studies are warranted.33
■ Diabetes mellitus
Many herbal products have been studied in the treatment
of diabetes mellitus, including bitter melon, cinnamon,
dandelion, fenugreek, burdock, and onion. Although most
of these herbs lack any recent well-documented clinical tri-
als, there is some evidence in the literature that can provide
guidance on the use of cinnamon and fenugreek.
Cinnamomum cassia or Cinnamomum verum (cinnamon
bark). Clinical evidence does not support the use of cinna-
mon bark to treat diabetes mellitus. This popular treatment
has been said to improve glycemic control, but has not been
shown to differ from placebo in one meta-analysis of 10
RCTs.34
A total of 577 patients received cinnamon (pre-
dominantly C. cassia) orally at an average dose of 2 g per
day for up to 16 weeks.
Cinnamon was compared with placebo, no medication,
or another medication and did not change glycemic control
in any of the three circumstances.The included studies were
judged to lack quality, and none of the studies investigated
morbidity, mortality, cost of care, or quality of life. The
authors concluded that cinnamon was not effective but that
further rigorous studies are needed.34
In an earlier systematic review of eight clinical trials
(five with patients with type 2 diabetes mellitus and three
with nondiabetic patients) with a total of 311 subjects, five
of the eight trials demonstrated a reduction in fasting blood
glucose; however, only two of those demonstrated a statisti-
cally significant difference when compared with placebo.35
Three studies demonstrated no significant difference.
All three of the studies that failed to demonstrate sig-
nificance were conducted with patients
with diabetes. Doses of cinnamon (us-
ing C. cassia or C. verum) used in the
studies varied. The authors concluded
that definitive conclusions could not
be drawn concerning cinnamon as
therapy for diabetes mellitus.35
Further
trials are needed to determine the ben-
efits and risks of using cinnamon for diabetes mellitus.34
Trigonella foenum-graecum (fenugreek). This fiber-rich
plant is popular in many regions of the world including
Egypt, India, and Middle Eastern countries for glycemic
control.36,37
There is Level 1 evidence supporting the use
of fenugreek for glycemic control in patients with diabetes
mellitus. Neelakantan and colleagues conducted a meta-
analysis of 10 clinical trials that demonstrated significantly
lowered fasting glucose, 2-hour postprandial glucose load,
and hemoglobin A1C compared with controls.37
Fenugreek
preparations ranged from seeds to gum isolate to leaves,and
dosages ranged from 1 g (seeds) to 100 g (leaves) per day.
The authors concluded that a beneficial effect was demon-
strated but that further trials were needed with a consistent
preparation of the herb.37
■ Implications for NPs
Although many studies have been conducted to test the
effectiveness of various types of herbal supplements for
treating chronic conditions,more studies are warranted with
rigorous designs,large sample sizes,consistent preparations
and dosages, and specific outcome measures. Particularly,
clinical studies need to provide information about safety
and tolerability. Potential drug-herb interactions should
be taken into consideration if adults take multiple medica-
tions or complex treatments such as chemotherapies with
multiple agents.
It is imperative to have open communication with
patients to prevent adverse outcomes, maintain safety of
treatments, and improve quality of life. The use of any
oral herbal supplements to treat chronic diseases, with or
without the use of prescription pharmaceuticals, should
be managed on an individual case-by-case basis with each
patient. Providers should expect patients with chronic con-
ditions to use,or at least consider,herbal adjunctive therapy,
and they should be prepared to initiate a discussion of the
benefits and risks.
Many herbal products confer significant
pharmacologic effects and may interact with
prescription and nonprescription drugs.

■ Conclusion
The use of herbal supplements to treat chronic conditions is
a long-standing practice. Patients suffering from a chronic
condition are motivated to try a variety of traditional and
nontraditional methods to relieve symptoms and reverse
the disease course. Clinicians should keep in mind that
many herbal products confer significant pharmacologic
effects, and may exhibit interactions with prescription and
nonprescription drugs.
The final part of this three-part series will focus on
existing clinical guidelines for the use of herbal products.
REFERENCES
1. Ward BW, Schiller JS. Prevalence of multiple chronic conditions among
US adults: estimates from the National Health Interview Survey, 2010.
Prev Chron Dis. 2013;10:120203.
2. National Center for Health Care Statistics. Data file documentation, National
Health Interview Survey 2012. Hyattsville, MD: National Center for Health
Care Statistics, Centers for Disease Control and Prevention; 2013.
3. Vasilopoulos T, Kotwal A, Huisingh-Scheetz MJ, Waite LJ, McClintock MK,
Dale W. Comorbidity and chronic conditions in the National Social Life,
Health and Aging project (NSHAP), Wave 2. J Gerontol B Psychol Sci Soc Sci.
2014;69(suppl 2):S154-S165.
4. Centre for Evidence-Based Medicine. OECBM levels of evidence. 2011.
www.cebm.net/index.aspx?o=5653.
5. Ried K, Fakler P. Potential of garlic (Allium sativum) in lowering high blood
pressure: mechanisms of action and clinical relevance. Integr Blood Press
Control. 2014;7:71-82.
6. Rohner A, Ried K, Sobenin IA, Bucher HC, Nordmann AJ. A systematic
review and metaanalysis on the effects of garlic preparations on blood
pressure in individuals with hypertension. Am J Hypertens. 2015;28(3):
414-423.
7. Ried K, Frank OR, Stocks NP. Aged garlic extract reduces blood pressure in
hypertensives: a dose-response trial. Eur J Clin Nutr. 2013;67(1):64-70.
8. Natural Medicines Comprehensive Database. Herbs and supplements. 2016.
www.nlm.nih.gov/medlineplus/druginfo/herb_All.html.
9. Rhee MY, Kim YS, Bae JH, et al. Effect of Korean red ginseng on arte-
rial stiffness in subjects with hypertension. J Altern Complement Med.
2011;17(1):45-49.
10. Serban C, Sahebkar A, Ursoniu S, Andrica F, Banach M. Effect of sour tea
(Hibiscus sabdariffa L.) on arterial hypertension: a systematic review and
meta-analysis of randomized controlled trials. J Hypertens. 2015;33(6):
1119-1127.
11. Ried K, Toben C, Fakler P. Effect of garlic on serum lipids: an updated meta-
analysis. Nutr Rev. 2013;71(5):282-299.
12. Alder R, Lookinland S, Berry JA, Williams M. A systematic review of the ef-
fectiveness of garlic as an anti-hyperlipidemic agent. J Am Acad Nurse Pract.
2003;15(3):120-129.
13. Liu J, Zhang J, Shi Y, Grimsgaard S, Alraek T, Fønnebø V. Chinese red yeast
rice (Monascus purpureus) for primary hyperlipidemia: a meta-analysis of
randomized controlled trials. Chin Med. 2006;1:4.
14. Li Y, Jiang L, Jia Z, et al. A meta-analysis of red yeast rice: an effective and
relatively safe alternative approach for dyslipidemia. PLoS One. 2014;9(6):
e98611.
15. Childress L, Gay A, Zargar A, Ito MK. Review of red yeast rice content and
current Food and Drug Administration oversight. J Clin Lipidol. 2013;7(2):
117-122.
16. Gordon RY, Cooperman T, Obermeyer W, Becker DJ. Marked variability of
monacolin levels in commercial red yeast rice products: buyer beware! Arch
Intern Med. 2010;170(19):1722-1727.
17. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the
management of hip and knee osteoarthritis, part I: critical appraisal of exist-
ing treatment guidelines and systematic review of current research evidence.
Osteoarthritis Cartilage. 2007;15(9):981-1000.
18. Mncwangi N, Chen W, Vermaak I, Viljoen AM, Gericke N. Devil’s claw—a
review of the ethnobotany, phytochemistry and biological activity of Harp-
agophytum procumbens. J Ethnopharmacol. 2012;143(3):755-771.
19. Brien S, Lewith GT, McGregor G. Devil’s claw (Harpagophytum procumbens)
as a treatment for osteoarthritis: a review of efficacy and safety. J Altern
Complement Med. 2006;12(10):981-993.
20. Conrozier T, Mathieu P, Bonjean M, Marc JF, Renevier JL, Balblanc JC. A
complex of three natural anti-inflammatory agents provides relief of osteo-
arthritis pain. Altern Ther Health Med. 2014;20(suppl 1):32-37.
21. Warnock M, McBean D, Suter A, Tan J, Whittaker P. Effectiveness and safety
of Devil’s claw tablets in patients with general rheumatic disorders. Phyto-
ther Res. 2007;21(12):1228-1233.
22. Sego S. Willow bark relieves pain and inflammation. Clin Advisor. 2011;
14(6):129.
23. Vlachojannis JE, Cameron M, Chrubasik S. A systematic review on the effec-
tiveness of willow bark for musculoskeletal pain. Phytother Res. 2009;23(7):
897-900.
24. Uehleke B, Müller J, Stange R, Kelber O, Melzer J. Willow bark extract STW
33-I in the long-term treatment of outpatients with rheumatic pain mainly
osteoarthritis or back pain. Phytomedicine. 2013;20(11):980-984.
25. Panahi Y, Alishiri GH, Parvin S, Sahebkar A. Mitigation of systemic oxida-
tive stress by curcuminoids in osteoarthritis: results of a randomized
controlled trial. J Diet Suppl. 2016;13(2):209-220.
26. Nakagawa Y, Mukai S, Yamada S, et al. Short-term effects of highlybioavail-
able curcumin for treating knee osteoarthritis: a randomized, double-blind,
placebo-controlled prospective study. J Orthop Sci. 2014;19(6):933-939.
27. Cameron M, Chrubasik S. Oral herbal therapies for treating osteoarthritis. The
Cochrane Collaboration. 2014. www.cochrane.org/CD002947/MUSKEL_oral-
herbal-therapies-for-treating-osteoarthritis.
28. Rock CL, Doyle C, Demark-Wahnefried W, et al. Nutrition and physical ac-
tivity guidelines for cancer survivors. CA Cancer J Clin. 2012;62(4):242-274.
29. Frenkel M, Abrams DI, Ladas EJ, et al. Integrating dietary supplements into
cancer care. Integr Cancer Ther. 2013;12(5):369-384.
30. Goel A, Aggarwal BB. Curcumin, the golden spice from Indian saffron, is a
chemosensitizer and radiosensitizer for tumors and chemoprotector and
radioprotector for normal organs. Nutr Cancer. 2010;62(7):919-930.
31. Soares R, Meireles M, Rocha A, et al. Maitake (D fraction) mushroom
extract induces apoptosis in breast cancer cells by BAK-1 gene activation.
J Med Food. 2011;14(6):563-572.
32. Boehm K, Borrelli F, Ernst E, et al. Green tea (Camellia sinensis) for the
prevention of cancer. Cochrane Database Syst Rev. 2009;(3):CD005004.
33. McCulloch M, See C, Shu XJ, et al. Astragalus-based Chinese herbs and
platinum-based chemotherapy for advanced non-small-cell lung cancer:
meta-analysis of randomized trials. J Clin Oncol. 2006;24(3):419-430.
34. Leach MJ, Kumar S. Cinnamon for diabetes mellitus. The Cochrane Col-
laboration. 2012. www.cochrane.org/CD007170/ENDOC_cinnamon-for-
diabetes-mellitus.
35. Kirkham S, Akilen R, Sharma S, Tsiami A. The potential of cinnamon to
reduce blood glucose levels in patients with type 2 diabetes and insulin
resistance. Diabetes Obes Metab. 2009;11(12):1100-1113.
36. National Center for Complementary and Integrative Health. Fenugreek.
2012. https://nccih.nih.gov/sites/nccam.nih.gov/files/Herbs_At_A_Glance_
Fenugreek_06-15-2012_0.pdf.
37. Neelakantan N, Narayanan M, de Souza RJ, van Dam RM. Effect of fenu-
greek (Trigonella foenum-graecum L.) intake on glycemia: a meta-analysis of
clinical trials. Nutr J. 2014;13:7.
Saun-Joo Yoon is an associate professor at the University of Florida, College of
Nursing, Gainesville, Fla.
Susan D. Schaffer is a clinical associate professor at the University of Florida,
College of Nursing, Gainesville, Fla.
Kim Curry is a clinical associate professor at the University of Florida, College
of Nursing, Gainesville, Fla.
The authors have disclosed that they have no financial relationships related to
this article.
DOI-10.1097/01.NPR.0000502793.50737.2f

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