Traditional products to avoid

Practical note

Graded moderate: the core evidence is a cross-sectional analysis of a random sample of 193 products (the appropriate design for a prevalence question), consistent with NCCIH and CDC reports; downgraded one level because the sample is from 2005 and limited to internet sales, so current market prevalence is uncertain.

Vegan note

Ayurvedic preparations can include animal-derived ingredients as well as plant, metal and mineral ones, according to NCCIH.

Sources

• Supports“The prevalence of metal-containing products was 20.7% (95% confidence interval [CI], 15.2%-27.1%).” (Abstract) Saper RB, Phillips RS, Sehgal A, Khouri N, Davis RB, Paquin J, Thuppil V, Kales SN. 2008. JAMA. Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet. publisher copyright; metadata and short quotes only; Courtesy of the U.S. National Library of Medicine
• Supports“Some Ayurvedic preparations may contain lead, mercury, or arsenic in amounts that can be toxic.” (Key points) National Center for Complementary and Integrative Health. 2019. NCCIH. Ayurvedic Medicine: In Depth. public domain; credit NCCIH
• Context“All metal-containing products exceeded 1 or more standards for acceptable daily intake of toxic metals.” (Abstract) Saper RB, Phillips RS, Sehgal A, Khouri N, Davis RB, Paquin J, Thuppil V, Kales SN. 2008. JAMA. Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet. publisher copyright; metadata and short quotes only; Courtesy of the U.S. National Library of Medicine
• Context“The U.S. Food and Drug Administration warns that the presence of metals in some Ayurvedic products makes them potentially harmful.” (What the Science Says About the Safety of Ayurvedic Medicine) National Center for Complementary and Integrative Health. 2019. NCCIH. Ayurvedic Medicine: In Depth. public domain; credit NCCIH

Practical note

Graded low: the evidence is case series and a survey, which show the association consistently but cannot give population incidence; the direct link between measured product contamination and measured blood lead supports the direction of harm.

Sources

• Supports“of lead poisoning associated with the use of 10 oral Ayurvedic medications made in India.” (Summary) Hore P, Ahmed M, Ehrlich J, Ng C, Steffen L, Sedlar S, Curry-Johnson P, Graber N, Nagin D, Clark N, Saper R, Scalia Sucosky M. 2012. MMWR Morbidity and Mortality Weekly Report. Lead Poisoning in Pregnant Women Who Used Ayurvedic Medications from India — New York City, 2011–2012. public domain (CDC MMWR); credit CDC
• Supports“A 2015 published survey of people who use Ayurvedic preparations showed that 40 percent had elevated blood levels of lead and some had elevated blood levels of mercury.” (What the Science Says About the Safety of Ayurvedic Medicine) National Center for Complementary and Integrative Health. 2019. NCCIH. Ayurvedic Medicine: In Depth. public domain; credit NCCIH
• Context“Lead concentrations of the medications were as high as 2.4%;” (Summary) Hore P, Ahmed M, Ehrlich J, Ng C, Steffen L, Sedlar S, Curry-Johnson P, Graber N, Nagin D, Clark N, Saper R, Scalia Sucosky M. 2012. MMWR Morbidity and Mortality Weekly Report. Lead Poisoning in Pregnant Women Who Used Ayurvedic Medications from India — New York City, 2011–2012. public domain (CDC MMWR); credit CDC

Practical note

Graded moderate: the evidence is observational, but the association is strong, consistent across several independent exposure settings, and corroborated by aristolochic-acid-specific DNA adducts in tumour tissue, which supports upgrading from low.

Sources

• Supports“This review summarizes major epidemiologic evidence to argue for the causal association between AA exposure and urothelial carcinoma as well as nephropathy.” (Abstract) Yang HY, Chen PC, Wang JD. 2014. BioMed Research International. Chinese herbs containing aristolochic acid associated with renal failure and urothelial carcinoma: a review from epidemiologic observations to causal inference. CC BY 3.0; credit Yang et al., BioMed Research International 2014
• Supports“Cancers of the upper urinary tract (renal pelvis and ureter) and bladder have been reported among individuals who had kidney damage caused by the consumption of herbal products containing aristolochic acids .” (Which cancers are associated with exposure to aristolochic acids?) National Cancer Institute. 2022. National Cancer Institute (cancer.gov). Aristolochic Acids. NCI content; credit the National Cancer Institute as the source
• Context“Herbal remedies containing aristolochic acid (AA) have been designated to be a strong carcinogen.” (Abstract) Yang HY, Chen PC, Wang JD. 2014. BioMed Research International. Chinese herbs containing aristolochic acid associated with renal failure and urothelial carcinoma: a review from epidemiologic observations to causal inference. CC BY 3.0; credit Yang et al., BioMed Research International 2014
• Context“These products have not been approved by the U.S. Food and Drug Administration (FDA) and are often marketed as dietary supplements or “traditional medicines.”” (How are aristolochic acids used?) National Cancer Institute. 2022. National Cancer Institute (cancer.gov). Aristolochic Acids. NCI content; credit the National Cancer Institute as the source

Practical note

Graded low: evidence comes from case reports, case series, analytical sampling and regulatory warning data, which consistently show adulteration occurs but cannot estimate how common it is across the current market.

Vegan note

Some traditional Chinese medicine products contain animal-derived ingredients such as bear bile; a review describes bear farming for bile as extremely inhumane and links extensive consumption to bears becoming endangered.

Sources

• Supports“From 2007 through 2016, 776 adulterated dietary supplements were identified by the FDA and 146 different dietary supplement companies were implicated.” (Abstract) Tucker J, Fischer T, Upjohn L, Mazzera D, Kumar M. 2018. JAMA Network Open. Unapproved Pharmaceutical Ingredients Included in Dietary Supplements Associated With US Food and Drug Administration Warnings. publisher copyright; metadata and short quotes only; Courtesy of the U.S. National Library of Medicine
• Supports“The list of adulterants contains drugs associated with serious adverse effects like corticosteroids. In several instances, patients were seriously harmed.” (Abstract) Ernst E. 2002. Journal of Internal Medicine. Adulteration of Chinese herbal medicines with synthetic drugs: a systematic review. publisher copyright; metadata and short quotes only; Courtesy of the U.S. National Library of Medicine
• Context“Inadequately regulated herbal medicines may contain toxic plant material, be contaminated with heavy metals, or be adulterated with synthetic drugs.” (Abstract) Ernst E. 2003. European Journal of Pediatrics. Serious adverse effects of unconventional therapies for children and adolescents: a systematic review of recent evidence. publisher copyright; metadata and short quotes only; Courtesy of the U.S. National Library of Medicine
• Context“One report from Taiwan suggests that 24% of all samples were contaminated with at least one conventional pharmacological compound.” (Abstract) Ernst E. 2002. Journal of Internal Medicine. Adulteration of Chinese herbal medicines with synthetic drugs: a systematic review. publisher copyright; metadata and short quotes only; Courtesy of the U.S. National Library of Medicine
• Context“Bear farming is extremely inhumane and many bears died of illness such as chronic infections and liver cancer.” (Abstract) Feng Y, Siu K, Wang N, Ng KM, Tsao SW, Nagamatsu T, Tong Y. 2009. Journal of Ethnobiology and Ethnomedicine. Bear bile: dilemma of traditional medicinal use and animal protection. CC BY 2.0; credit Feng et al., Journal of Ethnobiology and Ethnomedicine 2009

Practical note

Traditional claim: the frame is reported, not graded. The testable part (metal content) is supported by the 2008 product survey and the CDC case series, which describes rasa shastra as intentionally prepared with metal, mineral or gem compounds.

Sources

• Supports“Rasa shastra compared with non-rasa shastra medicines had a greater prevalence of metals (40.6% vs 17.1%; P = .007)” (Abstract) Saper RB, Phillips RS, Sehgal A, Khouri N, Davis RB, Paquin J, Thuppil V, Kales SN. 2008. JAMA. Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet. publisher copyright; metadata and short quotes only; Courtesy of the U.S. National Library of Medicine
• Supports“Rasa shastra is a type of Ayurvedic medication that is intentionally prepared with metal, mineral, or gem compounds” (Discussion) Hore P, Ahmed M, Ehrlich J, Ng C, Steffen L, Sedlar S, Curry-Johnson P, Graber N, Nagin D, Clark N, Saper R, Scalia Sucosky M. 2012. MMWR Morbidity and Mortality Weekly Report. Lead Poisoning in Pregnant Women Who Used Ayurvedic Medications from India — New York City, 2011–2012. public domain (CDC MMWR); credit CDC
• Context“Metals may be present due to the practice of rasa shastra (combining herbs with metals, minerals, and gems).” (Abstract) Saper RB, Phillips RS, Sehgal A, Khouri N, Davis RB, Paquin J, Thuppil V, Kales SN. 2008. JAMA. Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet. publisher copyright; metadata and short quotes only; Courtesy of the U.S. National Library of Medicine