Natural Standard Herb & Supplement Handbook: The Clinical Bottom Line by Ethan M. Basch, MD, MPhil, and Catherine E. Ulbricht, PharmD, eds. St. Louis, MO: Elsevier Mosby; 2005. 963 pages. ISBN 0-323-02993-0. $39.95

Natural Standard Herb & Supplement Reference: Evidence-Based Clinical Reviews by Catherine E. Ulbricht, PharmD, and Ethan M. Basch, MD, MPhil, eds. St. Louis, MO: Elsevier Mosby; 2005. 1012 pages. ISBN 0-323-02994-9. $129.00

Created in 1999, the Natural Standard Research Collaboration is an international effort aimed at becoming a source of scientifically based information on complementary and alternative medicine (CAM). The organization maintains an online database of evidence-based CAM reviews, including coverage of herbs, nutritional supplements, treatment modalities, continuing education, and conditions-based cross-referencing. Perhaps most impressive is the input of over 300 contributors from various fields including conventional medicine, pharmacy, osteopathic medicine, chiropractic, naturopathic medicine, Ayurvedic medicine, and traditional Chinese medicine.

The Natural Standard Herb & Supplement Reference: Evidence-Based Clinical Reviews is designed to be a comprehensive systematic review of selected herbs and nutritional supplements. According to the introduction, the textbook is designed for use by clinicians and researchers. With the dizzying array of choices available for a first-time text of this sort, the editors have based their choice of herbs and nutritional supplements “on utilization data, sales trends, frequency of information requests by institutional/individual users of the Natural Standard database, and safety concerns.” The Natural Standard Herb & Supplement Handbook: The Clinical Bottom Line is a smaller, soft-bound book designed to serve as a companion text that gives the busy clinician more abbreviated versions of the content of the larger textbook. Apparently, the information in this “bottom line” reference can be accessed on-line as well.

Being someone who has been in the thick of the “evidence-based” movement in alternative medicine for the past 20 years, I was immediately drawn to the primary textbook. Each monograph is prepared based on an electronic search of 10 databases, including AMED, CANCERLIT, CINAHL, CISCOM, the Cochrane Library, EMBASE, HerbMed, International Pharmaceutical Abstracts, Medline, and NAPRALERT. Researchers in the CAM field were also consulted for access to additional references or ongoing literature. Interestingly, no mention is made of any interaction with herbal/phytomedicine or nutritional supplement manufacturers. Following selection of references, data analysis is performed by healthcare professionals conducting clinical work and research at academic centers using standardized methods for defining the validated measures of study quality. Following creation of each monograph, blinded review of each monograph is conducted by a multidisciplinary research-clinical faculty at major academic centers with expertise in epidemiology and biostatistics pharmacology, toxicology, CAM research, and clinical practice. In cases of the predictable editorial disagreement, members of the editorial board were convened in an attempt to reach a decision, either with or without the help of outside experts.

Perhaps the most difficult and potentially controversial part of each monograph is an “evidence-based validated grading scale” that is used to evaluate the level of evidence for an herb or nutritional supplement for treating a specific disease/condition. The level of evidence grade ranges from “A” (strong scientific evidence) to “F” (strong negative scientific evidence). According to the authors, the objective criteria are derived from validated instruments from evaluating studies, including the 5-point scale used in some recent meta-analysis of common herbs.¹ Some examples from the book include: an “A” for saw palmetto for benign prostatic hyperplasia; a “B” for valerian for insomnia; and a “C” for ginger for motion sickness/seasickness. Being more of a pass/fail kind of a guy, I found the A to F grading scale to be somewhat arbitrary in some places and have concerns that it may deter a clinician from trying a potentially useful therapy in some instances.

The breadth and depth of information included in each monograph is very impressive. Following a section entitled “Clinical Bottom Line” that includes the grading scale, each monograph exhaustively covers dosing/toxicology, adverse effects/precautions/ contraindications, mechanism of action, history, and review of the clinical evidence. Each monograph ends with a section entitled “Formulary: Brands Used in Clinical Trials” that lists the names (when available) of commercial brands that have been used in statistically significant clinical trials—both European brands and their US equivalents. I was surprised to discover that this last section is omitted from the The Clinical Bottom Line companion textbook. Both books also have Conditions Tables at the end that list specific conditions (as well as related conditions) and list herbal or nutritional treatments by grade using the grading scale mentioned above. Prior to this is another section listing potential interactions based on mechanism of action(s) including cytochrome P450 isoenzyme(s) induction or inhibition.

For persons such as myself who love as much detail as possible, I highly recommend the Natural Standard Herb & Supplement Reference: Evidence-Based Clinical Reviews as an excellent reference for your library. I was most impressed with the detail shown in the adverse facts/precautions/contradictions as well as the interactions section. While it is important to keep many of these listings in perspective, the comprehensive review of the literature in these areas is extremely impressive. The interactions section also includes potential interactions with other supplements as well as foods. A safety summary is offered in the Clinical Bottom Line section of each monograph. The review of evidence section requires a bit of reading and the tables listing the studies for herbal medicines pales in comparison to the ABC Clinical Guide to Herbs and The Handbook of Clinically Tested Herbal Remedies.

While herbs dominate the monograph entries in the first editions of both books, there are monographs on nutritional supplements such as coenzyme Q10, niacin, and fish oil. Controversial supplements such as creatine, DHEA, the now-discredited and unavailable PC-SPES®, and shark cartilage are also included. I was disappointed in the monograph entitled “Acidophilus (Lactobacillus).” With the explosion of research on probiotics over the past decade and the use of proprietary strains that have been researched, a 3-page monograph feels like an oversight compared to the detail shown in many of the herbal monographs as well as the fish oil and coenzyme Q10 monographs. Hopefully, future editions will either dedicate a longer section to probiotics or break this section into individual strains that have sufficient research and safety information to warrant their own monograph.

So, here’s my bottom line. I think the primary textbook, Natural Standard Herb & Supplement Reference: Evidence-Based Clinical Reviews, is a must for any medical library and for those researchers or practitioners interested in exhaustive reviews of the clinical safety and efficacy of herbal and nutritional supplements. It stands shoulder-to-shoulder with other important clinical herbal references such as the ABC Clinical Guide to Herbs, The Handbook of Clinically Tested Herbal Remedies, and the ESCOP monographs. While some practitioners may find the companion guide useful, I think many who are looking for a real quick reference will find it a bit cumbersome.

References such as the Natural Standard Herb & Supplement Reference: Evidence-Based Clinical Reviews are critical to not only the understanding of the safety and efficacy of herbal and nutritional supplements but also to the expanded use of these therapies by healthcare professionals in the United States. Some of the herbal and nutritional supplements covered in this book are best used based on sound medical diagnosis and knowledge of other medications that a patient may be taking. It’s my hope that books like this are the first step toward a true CAM textbook that covers the best of both worlds—conventional pharmaceutical and herbal/phytomedicine/nutritional supplements—to offer patients a greater spectrum of choices in treating disease and maintaining wellness.

—Donald J. Brown, ND

Reference

1. Jahad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Controlled Clinical Trials. 1996;17(1):1–12.