Use of herbal products in Southeast Asian countries.
Herbal products can be beneficial though can also be harmful in several circumstances. The responsibility in ensuring safety, quality, and efficacy lies not only in the hands of producers but also in the hands of consumers, caregivers, healthcare providers, as well as medical authorities. The value of herbal products in medical treatments and research development of new treatment for diseases may be elevated through collective efforts from all parties.
There is an unhealthy trend in consumption of herbal products by consumers. These products are being taken even without the recommendation of healthcare practitioners. The public also believes in the efficacy of these products without substantial data and evidence. What is worse is that some of these herbal products contain impermissible levels of heavy metals, which are known to be able to jeopardize individuals' lives. Due to these reasons, it is important to understand how these products can affect consumers' quality of life. Moreover, recommendations should be made to prevent these issues escalating.
Despite several issues reported with the consumption of herbal products, their usage is still increasing in both developing and developed countries. Research and scientific evidence regarding the intake of herbal products and their impacts on the consumers' quality of life are viewed as inadequate. In view of this, it is vital to study their effects on the quality of life to reduce related problems such as undesirable adverse effects while giving therapeutic effects, subsequently maintaining or enhancing the quality of life of consumers.
This editorial presents the effects of the herbal products on the consumers' quality of life, this editorial also discusses several issues with regards to herbal product.
EFFECTS OF CONSUMPTION OF HERBAL PRODUCTS ON QUALITY OF LIFE
George and Henkel  reported that the consumption of tongkat ali as a herbal medicine has been shown to be safe as an alternative to testosterone replacement therapy. Significant improvement in serum testosterone levels, sexual health, bone health, physical conditions, antihyperglycemic effect, as well as cytotoxicity against prostate cancer, has been demonstrated with the consumption of tongkat ali. Thus, herbal medicine can serve as a remedy for late-onset hypogonadism and idiopathic male infertility. George and Henkel further reported that improvement in vitality, physical activity, general well-being, vigor, and mood, as well as reduced anxiety and antiaging effect, can be observed with the consumption of this herbal medicine. Hence, it can improve patients' quality of life.
Herbal medicine is also used in the treatment of breast cancer in Malaysia. Biswal et al.  reported that Withania somnifera has the potential to improve the quality of life in breast cancer patients. The intervention group recorded significantly higher scores than the control group. In addition, improvement in quality of life is also higher than the control group. Another herb used in the treatment of breast cancer is mistletoe. Marvibaigi et al.  conveyed that the use of mistletoe extracts as herbal medicine can be beneficial in improving the health-related quality of life in breast cancer patients.
Another study carried out in a district in Selangor demonstrated the safe use of herbal medicines in treatment of metabolism syndrome of perimenopausal women.  Nigella sativa was used as herbal medicine in the study. The findings concluded that the herbal medicine is effective in reducing weight gain and improving the blood glucose level, hormonal level, and lipid profile of patients. The study also reported that the severity of menopausal symptoms is reduced and there is significant improvement in the quality of life of patients as opposed to placebo group. The domains of health measured include physical function, role physical, bodily pain, general health, social function, role emotional, vitality, and mental health.
Aside from that, there are several studies on herbal products and quality of life which were carried out in ASEAN countries such as Singapore, Thailand, and Indonesia. Lim et al.  state that conditions such as erectile dysfunction (ED) can largely influence the quality of life of Singaporean men though a low percentage of men experiencing this condition opt to undergo treatment worldwide. One of the important factors why patients attempt treatment of ED is to improve their quality of life. A herbal product that has been proven to be highly effective in treating men with ED is sildenafil citrate (Viagra). It has tolerable side effects. Efficacy is shown in 83% of patients in the study while 13.9% reported experiencing side effects. Therefore, usage of sildenafil citrate in treatment of ED helps patients enhance their quality of life sexually as their intimate relationships with their partners improve.
Herbal medicines are also used to treat ED in Thailand to improve patients' quality of life. Herbal medicine is reported to be effective and well-tolerated for the treatment of mild to moderate ED.  As opposed to the placebo group, the users of herbal medicine recorded a higher improvement score for all domains (erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction) when assessed by using the International Index of Erectile Function. Although there are side effects with the use of such herbal medicine, they are tolerable. The most commonly observed with the use of the herbal medicine was dizziness, face numbness, and tachycardia, with first reported by 13.3% of total users while both the latter two reported by 1.6%. The herbal medicine that was used in the study is known as Cappra [R] which is composed of several herbal constituents.
Based on a study conducted in Singapore, a positive response in quality of life is reported with the use of traditional Chinese herbal medicines in the treatment of chronic cytopenic marrow disease.  Improvement in blood counts was observed in patients with myelofibrosis and aplastic anemia without other treatment options. EORTC-QLQC30 was used in the evaluation of patients' quality of life. Overall, improvements were demonstrated in all the domains measured which include functional scales (73.46%), symptom scales (53.3%), as well as global health status (60%). Moreover, the majority (70%) of the total patients opted to continue the treatment with herbal medicines.
Findings from a study conducted in Thailand found that improvement in the quality of life and decrement of conventional treatment are the most common factors for consumption of herbal medicines by cancer patients in Thailand.  Conventional treatment in the treatment of cancer such as chemotherapy and radiotherapy may cause undesirable symptoms. At Wat Khampramong in Thailand, the cancer patients reported reduced symptoms after undergoing herbal treatment.  The reduced symptoms include decrement in pain, dyspepsia, abdominal pain, fatigue, insomnia, coughing, lack of appetite, bleeding, and constipation. Headache, fever, vomiting, and skin irritation also decreased. The hospice treatment consists of 11 herbs (namely Holly mangrove, Mai Sakhin, Malacca Yam, Dog Fennel, ant plant, lovage, cat's whiskers, Ka Chian, Snake Jasmine, Lolly Vine, and Khao Yen Nuea) possessing anticancer properties. These herbal products are used as self-medication. They may also be prescribed by practitioners of traditional medicines. The reduction in those symptom burdens thus denotes that there is improvement in the quality of life of the cancer patients. Moreover, it is possible that the progression of cancer may also be delayed in some patients though this is only shown by anecdotal evidence.
Other than that, findings from a study conducted in Bali, Indonesia, displayed that conditions such as fecal incontinence in older people will affect their quality of life.  Reduction in quality of life was reported with increased embarrassment, increased awareness in location of toilets, plan according to bowels, and staying at home more often than those without fecal incidence. In contrary with the previous studies in Malaysia, Singapore, and Thailand, herbal medicines were stated as ineffective in treating fecal incontinence in older people and thus unable to improve the quality of life of the patients.
In the Philippines, herbal medicines are also used to treat diseases. Strokes pose a burden in the Philippines, affecting the quality of life of patients as well as their families.  Thus, herbal medicines are used as an approach to reduce strokes. As there is no specific herb that can be used to prevent strokes, several herbs have been used by the locals to treat hypertension, diabetes, and hypercholesterolemia which are the risk factors contributing to a stroke. It is further conveyed that an herbal medicine called NeuroAid[R] is popularly used in the prevention of strokes. However, the study on its efficacy in improving patients' functional outcome and thus quality of life is still ongoing.
ISSUES REGARDING HERBAL PRODUCTS
One of the rising issues faced in regards to herbal products is the perceived effectiveness of these products. In 2012, a study done in Penang, Malaysia, showed that 43.3% of respondents agreed that traditional medicines used for aphrodisiacs would cause an increase in their sexual libido.  The perceived effectiveness of herbal medicines may increase the usage of herbal medicines without concrete knowledge of the products' efficacy. The consumption of herbal medicines without prior knowledge of the product is also risky. Kim Sooi and Lean Keng  discovered that 89.8% of a total of 460 patients consumed herbal medicines with low or no knowledge about the herbs.
The use of these drugs is also perceived as safe and harmless. About 38.2% of the respondents stated that traditional aphrodisiacs are safer than current conventional drugs.  This perception is probably based on the fact that the active ingredients of the products are extracted from natural sources as well as positive response from past experiences. Nevertheless, the hazardous contents of some of these products have been discovered in a study where the herbal products containing tongkat ali were found to be contaminated with excessive level of heavy metals such as mercury, which are considered as off limits.
Aside from the hazardous contents that can be found in herbal plants, there are also other factors that can cause herbal drug-induced health problems. Lack of good manufacturing practice and pollution are the factors that attribute to the adverse effects as stated by Ismail and Mohd Mokhtar  Furthermore, the growing consumption of herbal products may elevate the incident risk of adverse effects. Herbal medicine consumption should always be reported to the healthcare providers. Generally, this is to avoid risks of adverse effects as there may be interactions between the herbal medicines and conventional medicines, interactions with food, and/or interactions between herbal medicines taken. Problems arise as most consumers take this matter lightly and do not inform their respective healthcare providers of the use of herbal medicines. Kim Sooi and Lean Keng  conveyed that the respondents did not report the use of herbal medicines in pregnancy to their pregnancy care providers.
The matter becomes more of a concern as the products are perceived to be cheaper than prescription medicines. From the study, 46.9% of the participants perceive traditional and complementary medicines as cheaper than prescription medicines.  According to Ismail and Mohd Mokhtar,  the cheaper costs of herbal products as compared to conventional medicines will promote the actual buying of the products and thus, lead to the growing usage of the products. The accessibility of herbal products can also promote the use of these products. In Malaysia, Hassali et al.  noted that 46.9% of respondents agreed that herbal drugs are easily accessible.
Another problem which is relevant to this topic is the incidents in which the consumption of these products occurs without healthcare providers' recommendation. However, in another study in Malaysia, Hassali et al.  reported that 49.2% of the respondents stated that they would consult healthcare providers before using traditional and complementary medicines as aphrodisiacs.
Besides that, consumers are generally required to be monitored by practitioners or healthcare providers after consumption of herbal medicines. However, this is not usually the case as they are rarely or largely unsupervised after taking herbal medicines. In a study of 460 patients, Kim Sooi and Lean Keng  reported that the majority of pregnant Malay women (81%) in the study used herbal products without the supervision of healthcare providers. Similarly, Poonthananiwatkul et al.  stated that the usage of traditional medicines by cancer patients in Thailand is rarely monitored. Hence, this uncontrolled use of traditional medicines, especially those of unknown composition, may worsen the issue of concern.
Herbal medicines have been used to treat various diseases. However, the studies on efficacy and effects of herbal products found mixed results. Some studies' findings contradict with other studies in relation to herbal products. Moreover, studies on herbal products and quality of life in the Southeast Asia region are currently lacking. Thus, further studies should be done to gain more information in this area.
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
Nurul'Afifah Sulaiman (1), Long Chiau Ming (1,2)
(1) Faculty of Pharmacy, Vector-borne Diseases Research Group (VERDI), Pharmaceutical and Life Sciences CoRe, Universiti Teknologi MARA, Selangor, Malaysia, (2) Unit for Medication Outcomes Research and Education, Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia
Address for correspondence: Dr. Long Chiau Ming, Unit for Medication Outcomes Research and Education, Pharmacy, School of Medicine, University of Tasmania, Private Bag 26, Hobart, Tasmania 7001, Australia.
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|Author:||Sulaiman, Nurul'Afifah; Ming, Long Chiau|
|Publication:||Archives of Pharmacy Practice|
|Date:||Jan 1, 2016|
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