Elder Berries

You may or may not have noticed that I stepped away from blogging a few months back, though it feels like longer to me. I want to express my appreciation to the David Gorski and Steven Novella for their understanding, and to Dr. Jonathan Howard for stepping in while I was away. I’ve learned a lot from Dr. Howard’s posts, and I hope you’ve appreciated his writing, too. They’ve been saying blogging is dead or dying for over a decade, but I’m thrilled to be back making my modest contribution to SBM’s Sisyphean mission and keeping science and medicine blogging alive.

– Scott

For more than a year, I felt like it was inappropriate or irrelevant to write about anything other than the pandemic, given how quickly the science was emerging and how it totally dominated all aspects of our lives. I wasn’t thinking of much else. But I’m increasingly optimistic that we are on our way out. Notwithstanding new variants, breakthrough infections, and the inevitable antivaxxer tears, it’s the effectiveness of the vaccines and now the emergence of effective antivirals that makes it look like the worst of the pandemic may be behind us.

With that cautious optimism in mind, maybe it’s time to look at some of our recurring topics, such as the popularity of complementary and alternative medicine. Pre-pandemic, I probably would have guessed a global pandemic that kills millions might turn people away from unsubstantiated, unproven supplements that have limited roles in actually promoting health. I would have been terribly wrong. The pandemic created the conditions for a huge surge in demand for herbal remedies, as detailed in the 2020 American Herbal Council annual report. They recently reported that supplements made up of herbal and/or fungal ingredients had sales that exceeded $10 billion in 2020, a 17.3% increase over 2019, crushing the previous record increase of 9.4% in 2018. Let’s take a closer look at some of the highlights.

Elderberries sales surge amidst pandemic

Elderberries make me think of Monty Python, not supplements. But elder berry (or elderberry, if you prefer) was the top selling “mainstream” (food/grocery/pharmacy) supplement in 2020, with a sales surge of a whopping 150% over 2019. This ingredient has been growing in popularity for past few years, moving from 25th top selling herbal ingredient in 2015, to first place in 2020. The fruit of the European or Black elder tree, it has a long history of use in food, beverages and for medicinal purposes, where berries are used as a laxative, diuretic, and to treat respiratory infections. It is an active ingredient in supplements like Sambucol and is manufactured into a variety of lozenges and other products. The Natural Medicines Database rates elder berry as “possibly effective” for influenza but notes that a small clinical trial with adults and children showed it did not reduce the duration of symptoms. Harriet Hall blogged about it in 2019 and was perhaps a bit more optimistic than I am now. In 2020, the largest double-blind, randomized, placebo controlled study of elder berry on influenza (87 patients) was published and found no meaningful effects. The National Center for Complementary and Integrative Health says, “There’s not enough information to show whether elderberry is helpful for any other health purposes”. Perhaps not surprisingly, there is also no published evidence to suggest it is effective to prevent or treat COVD-19 infections. The Herbal Gram report notes:

Google searches for “elderberry” peaked in late March 2020, shortly after the World Health Organization declared the COVID-19 outbreak a pandemic,6 and the fifth most-common search with “elderberry” in 2020 was “elderberry coronavirus.”7 According to the US National Center for Complementary and Integrative Health (NCCIH), there were no published human clinical trials related to elder berry and COVID-19 as of July 2021,8 and the FDA sent warning letters to at least five companies in 2020 for marketing products with unsubstantiated claims involving elder berry and COVID-19.9

It is understandable that “immune health” would be a frequent reason for seeking dietary supplements in 2020, perhaps demonstrating the triumph of marketing over evidence. There are no dietary supplements that can actually boost immunity or improve resistance to, or the consequences of, COVID-19 infections. The report notes that other products that were popular in 2020 for “immune health” included echinacea, garlic, and turmeric, with all of these products experiencing sales increases.


Ashwagandha sales had a large increase (185%) in mainstream channels with $31 million in sales, putting it as the 12th best selling herb in 2020. Popularity has grown quickly over the past few years as more consumers in North America have become familiar with this product. Ashwagandha is used in the Ayurveda medical system and is touted to be an “adaptogen”, a product said to help one resist or adapt to stress. The name of the plant is Withania somnifera, which is a small shrubbery from which the roots are dried and used for medicinal purposes. Oral consumption of ashwagandha seems to be safe, and there is evidence that it does have medicinal effects. The Natural Medicines Database rates it as “possibly effective” to reduce stress and stress-related weight gain. Harriet Hall discussed ashwagandha in March 2021, and noted The Medical Letter‘s warning about the risk serious adverse events:

There is no convincing evidence that ashwagandha supplements are effective or safe for any indication; patients should be advised not to take them. FDA-approved drugs are available for treatment of all the conditions for which these herbal supplements are being promoted.

The paper quotes a survey conduced by the “Council for Responsible Nutrition” which represents dietary supplement manufacturers, with some insight into how and why consumers changed their supplement habits:

According to CRN’s 2020 COVID-19 Consumer Survey, 43% of supplement users changed their supplement routines since the beginning of the pandemic, and of those, 91% increased their supplement intake. When asked why these consumers increased their supplement intake, nearly a quarter cited mental health reasons, including stress and anxiety.

There’s no question that the pandemic has affected mental health. It’s not surprising that people sought out therapies and tried to self-medicate with supplements, particularly when health professionals may have been harder to access.

Apple cider vinegar

This supplement has admittedly always puzzled me. It’s vinegar, not magic! Yet the pandemic was the backdrop to a 100% surge in mainstream market sales over 2019, leading to an amazing $80 million in sales. ACV has been recommended as a cure-all for decades, for everything from weight loss to digestive issues (especially the ubiquitous “detox”) to the belief that it can affect blood sugars and insulin sensitivity. New to me, you can apparently get ACV in tablets, capsules and even “gummies” now. Personally, I use ACV occasionally in a salad dressing. For that purpose, it seems to be highly effective. For any medicinal or health-oriented use, research and evidence is lacking.

On the decline

Harriet Hall discussed garcinia back in 2013 when it was featured on The Dr. Oz Show. Sales through mainstream channels skyrocketed through 2015, hitting $54 million, based on his promotion of the fruit as a “magic weight loss cure”. Following multiple lawsuits, Senate hearings, and an FTC settlement with a garcinia manufacturer, sales have been steadily declining.

Another product which probably deserves its own blog post is ivy leaf supplement, which is manufactured into cold and influenza remedies. Sales of these products dropped significantly in 2020, possibly owning to the dramatic decrease in colds and influenza due the public health measures enacted to control the spread of the novel coronavirus.

Finally, another product with significant decline in sales is CBD oil, down from a peak in 2019. While it was the top selling product in the “natural” sales channel (meaning specialty supplement retailers, like GNC), sales dropped 36% over 2019, to $57 million. The report speculates on possible factors for the decline, ranging from isolation at home, the prioritization of immune health, and the quality issues with CBD in the United States market place, where many products advertised as containing CBD actually have no CBD in them. (If you’re looking for regulated, quality-controlled CBD then I invite you to come to Canada when cannabis products are not only legal, the number of retail shops seemingly has no upper limit. Just don’t try crossing the border with it.)

The pandemic affected everything, even supplement buying behavior

The pandemic disrupted industries and forced businesses to adapt – and the herbal supplement industry is no exception. What surprised me was how much the pandemic has turned out to be a net positive for this industry. Clearly, the decades of marketing herbal remedies and dietary supplements as safe and effective has paid off, driving sales increases and demand for products with little to no evidence of efficacy. But given what we’ve seen in the pandemic in terms of demand for products like hydroxychloroquine and later ivermectin, a lack of effectiveness is no barrier to sales success.



Posted by Scott Gavura