Part Three: Trends in the Americas
Part Three: Trends in the Americas
by Eric Brand
Practitioners in the Americas use a diverse blend of methods and dosage forms. Korean extractors exist on the market and are prominent in Korean clinics, but they are rarely seen outside of the Korean community. Many Western practitioners use granules, and raw herbs are generally available. While most patients in Asia as well as the West abhor the taste of Chinese herbal medicine, one of the most striking aspects of the Western market is the variety of approaches used to reduce or mask the taste of Chinese herbal medicine. Gelcaps, tablets, syrups, liquors, and pastes are seen throughout the global world of Chinese medicine, but it is only in the West that these forms constitute a large portion of the practitioner-prescribed herbal medicine.
One of the most distinctive features of Chinese herbal medicine in the Americas is the widespread use of alcohol/water liquid concentrates and tinctures. Tinctures are traditional preparations that use a combination of soaking and maceration in alcohol, while the liquid concentrates are generally made by slow-cooking the herbs in an alcohol/water medium and reducing the liquid under low heat. These liquid concentrates and tinctures are not really seen on the marketplace in Asia, so in a sense they can be considered to be a distinctive feature of the practice of Chinese medicine by Western practitioners.
In Western herbal medicine, many substances are made into alcohol tinctures, which are the taken by the dropper. However, the Western-style tincture typically utilizes lower doses of plant product than the prescriptions of clinical Chinese medicine, and most historical Chinese formulas used only water rather than alcohol to extract the medicinals. Chinese medicine definitely has a rich tradition of making herbal liquors, but alcohol is only used for certain situations. Alcohol is considered to have a warming and freeing action that helps to quicken the blood. Because of this, medicinal liquors are commonly used in the treatment of impediment disease as well as in supplementing wines.
Alcohol is regarded as a distinct medicinal substance in Chinese medicine, and it is found in classical formulas such as gua lou xie bai bai jiu tang (Trichosanthes, Chinese Chive, and White Alcohol Decoction) from the Jin Gui Yao Lue (“Essentials from the Golden Coffer”). Most traditional practitioners believe that the warm, acrid nature of alcohol must be taken into account when using it in formulas, so it is often considered to be a less-than-ideal medium for heat-clearing formulas, such as yin qiao san (Lonicera and Forsythia Powder). Furthermore, while traditional Chinese herbal liquors are highly effective for gradual, long-term supplementation or slow, enduring treatment of impediment disease, liquors and tinctures are generally inadequate for delivering the doses required when decoction formulas are indicated.
Many Western patients are new to Chinese medicine, and strong-tasting herbs with unfamiliar delivery forms are not always easily accepted by Western patients. Consequently, many practitioners attempt to adapt the familiar Western tincture-bottle delivery form when using Chinese medicine. The harsh taste and comparatively low concentration of a traditional tincture has led some innovating companies to create water/alcohol extracts, which are concentrated at low heat to form a liquid concentrate. Glycerin may be added during this process to sweeten the flavor and strengthen the natural preservative effect of the alcohol. While this delivery method is often very acceptable to Western patients, it is difficult to concentrate a liquid extract beyond 1 gram of crude herb per milliliter of extract. Consequently, practitioners must either prescribe liquids at a dose that is significantly lower than the dosage used in a standard decoction, or else they must recommend quantities of liquid extracts that greatly exceed the standard few droppers used in Western herbal medicine.
Additionally, the use of alcohol as a solvent introduces unknown variables because most Chinese herbal formulas were historically only used as a water-based decoction. Alcohol is a very effective solvent, and undoubtedly some Chinese herbs are highly suited to alcohol extraction. Yet while increased beneficial effects may be achieved with some herbs by using alcohol as a solvent, other herbs may have alcohol-soluble constituents that have undesirable or even harmful effects that are not present when the herb is used in a traditional decoction. Because of this unknown confounding variable, many practitioners and researchers choose to emphasize only water-based extracts for formulas that were traditionally administered by decoction.
In an effort to find products that can achieve standard Chinese medical dosage levels while avoiding the strong herbal taste, many practitioners in the Americas choose to use concentrated extracts in a gelcap form. While this method is generally regarded as the best solution to the problems of dosage, convenience, and flavor, it has the disadvantage of being labor-intensive for a practitioner who gives customized formulas to each patient. For practitioners that can effectively use classical formulas on their own or in combination with other formulas on the market, capsules are often the best solution for patients that cannot accept the taste of raw herbs or granules. Capsules made from concentrated extracts can be purchased for a fraction of the cost of liquid extracts and compare favorably to granules and raw herbs in terms of value.
A key consideration with encapsulated products is the concentration ratio of the extract used. Because each gelcap holds only about 500mg, encapsulated products should be made with highly concentrated extracts that lack fillers. Generally speaking, capsules or tablets are only able to approximate the daily doses used in Chinese medicine if patients either consume large numbers of capsules or if practitioners prescribe concentrates that are at least 7:1 to 10:1. A single 10:1 gelcap provides the equivalent of about five grams of raw herbs, so patients can achieve decoction-strength doses with only 9—12 capsules per day. A high concentration is preferred because raw herbal formulas typically require 50 grams of crude drug per day or more, and patient compliance is much higher with 10 capsules of a 10:1 extract than with 20 capsules of a 5:1 or even 40 capsules of a 2.5:1 extract.
It could be said that the greatest overall differences in Chinese herbal medicine between the US and Asia relate to dosage. In Asia, raw herbs are generally taken by decoction at a dose of one pack per day, whereas in the Americas, one pack of raw herbs is often taken for two days. Despite the fact that North American patients tend to have a higher body weight than their Asian counterparts, they often consume Chinese herbs at a dosage that is essentially half of the traditional dose.
In a similar paradox, Taiwanese granules are often prescribed at doses that are a fraction of the doses used in Taiwan. Part of the confusion seems to lie with the labeling information, which is required by US law to state a specific dose. Given the litigious nature of American society, most companies are understandably cautious in their dosage recommendation, so the dosage listed on the label is often well-below the dosage that is regularly used by a trained practitioner. Furthermore, most loose granules have the Asian labeling on concentration ratios removed for the US market, so practitioners are often at a loss to know how the powder corresponds to the raw herbal weight.
Taiwanese granules are generally used at a dose of around 18g/day in Taiwan, but many practitioners in the US use doses as low as 4—6 g/day. Perhaps the majority of Western practitioners prescribe granules in a dose range of around 6—12g/day, but many practitioners remain uncertain about how proper granule dosing is determined. Additionally, many instructors in American schools come from China but teach in schools that stock Taiwanese granules, which are more prominent on the American market. The granule product is different than what they used in their training in China, and teachers cannot effectively educate students on granule dosage because the standard raw dose equivalent is absent from the label. Consequently, practitioners often rely on the label information, which is essentially just an overly cautious (read: “please don’t sue me”) guideline that is required by FDA laws.
Truly we live in a diverse time. Everywhere around the world, cultures are interacting at a pace that has never been seen before. This cultural exchange allows us to really learn about what’s going on in the global world of Chinese medicine, and it is surprising to see how many differences there are between the West and the East. Certainly within East Asia alone there is an incredible diversity of medical approaches, and as Chinese medicine continues to globalize, the scope of these fascinating cultural encounters will only continue to increase. I wonder how they’ll start dosing granules in Africa, I really do.
Copyright Blue Poppy Ent. Inc., 2009. All rights reserved.
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