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4 Herb Formula by Stacy Kluck

In recent years, Western science has demonstrated increasing interest in researching the pharmacologic effects of traditional Chinese herbs.  Many studies have been done on individual herbs, evidencing a wide array of therapeutic effects including but not limited to: lowering blood pressure, decreasing serum cholesterol and lipid levels, reducing blood sugar, decreasing inflammation, enhancing immunity, reducing and preventing tumor formation and metastasis, and promoting repair and generation of healthy cells.

It is not traditional practice for Chinese herbalists to select herbs based on Western pharmaceutical properties, nor to designate specific herbs for specific Western diseases, as is the method of biomedical pharmacology.  However, with the increasing integration between Eastern and Western medical systems, more and more TCM practitioners are taking these properties into consideration when writing herbal formulas. 

Dr. John Chen, practitioner and author of Chinese Medical Herbology and Pharmacology (2003, AOM Press) and Chinese Herbal Formulas and Applications (2008, AOM Press), for example, has developed a number of formulas that are considered herbal “equivalents” to common Western pharmaceuticals.  At the 2010 Pacific Symposium, he described a simple four-herb formula – comprised of Dan Shen, Ze Xie, Jue Ming Zi, and Shan Zha – that has been found to effectively lower cholesterol levels.  Due to this effect, the formula might be likened to a Statin.  However, despite sharing the single cholesterol-lowering commonality, the formula is in no way similar to a Statin.  It operates via a completely different mechanism of action, and should be considered not as an “equivalent” but rather, a “replacement”.

Before diving into the herbal/pharmaceutical comparison, it is necessary to address the concept of cholesterol itself.  In biomedicine, the discussion surrounding cholesterol is grossly misguided.  The Western medical community claims that high cholesterol levels lead to the clogging of arteries and heart disease.  Despite associations with these conditions, high cholesterol has not been found to be a causative factor.  It never will be.  Cholesterol is not the problem.  Inflammation is.  

Cholesterol is a sterol lipid synthesized primarily within the liver.  It plays a crucial role in the building, integrity, and flexibility of cell wall structure.  It is necessary for the production of several hormones (including cortisol, aldosterone, testosterone, estrogen, and progesterone) and is a precursor to the synthesis of vitamin D.  Additionally, it makes bile acids, which aid in fat digestion.   Some research has shown that it may act as an anti-oxidant.  Cholesterol levels are estimated to be at least 85% genetically determined, and eating cholesterol-rich foods has not been shown to significantly increase serum levels. 

When arteries get clogged, it is true that cholesterol is found (amidst MANY other products, including fatty substances, cellular debris, calcium, fibrin, macrophages and other blood cells, etc...) as a component of the obstructing plaque.  But the plaque did not form because the system had an excess of cholesterol (or any of these other components).  The plaque formed in response to damage.  The plaque then, is not the real problem either.  The core culprit is inflammation of the arterial walls.  The cholesterol, macrophages, fibrin and other agents are actually called in to the damaged arteries as part of a repair process.  If there was no inflammation, these agents would not be signaled to collect at the site; buildup and obstruction would not occur, and systemic levels would be of no concern.

An illustrating analogy would be a road.  Over time, especially with excess traffic and harsh weather conditions, a road gets damaged and cracked (inflammation).  If the governing body does not put funds into regular maintenance (preventative care/routine check-ups), the road will worsen to more extreme levels, and eventually, become nearly unusable.  At that point, a major construction intervention becomes necessary, involving large road crews (cholesterol and other repair agents) and decreased lanes.  This greatly impedes traffic flow and circulation (clogged arteries) and poses a potentially deadly problem.

The answer to this problem is not to stop production/involvement of road workers/construction companies.  Though they compose the overt physical blockage causing immediate distress, they in themselves are not the problem.  Quite the opposite, these repair teams are inherently necessary for the maintenance and proper function of a wide variety of structures throughout the entire system.  They have only collected locally in an attempt to repair a deeper problem.  They would not have collected and impeded flow if the road hadn’t been severely damaged.  

This is where Western medicine misses the mark.  First of all, it is mistaken in claiming that cholesterol itself is a problem.  Secondly, when it is necessary to clear excess, the best method is not to stop overall production of cholesterol or any of the other collecting agents.  Yet this is precisely the mechanism behind the leading cholesterol-lowering pharmaceuticals generically referred to as Statins. 

Statins work to eliminate cholesterol by impeding its production.  They achieve this by inhibiting the enzyme HMG CoA Reductase, which plays a central role in the production of cholesterol in the liver.   Statins basically stop the production of repair teams so that they may not be numerous enough to collect and block traffic.  Unfortunately, Statins do nothing to address the inflammation which signaled for such repair teams to be called in the first place.  Moreover, by cutting production of vital building and repair components, other structures and systems are bound to suffer.  Cholesterol accounts for roughly 50% of the composition of the cell’s plasma membrane.  It is a necessary component for cellular integrity and life functioning overall.  Stopping its production is not at all wise.  It is no surprise that Statins come with a large stack of side effects, including liver and kidney failure. 

For those concerned with preventing arteriosclerosis and other diseases associated with high cholesterol, Chinese herbal medicine offers a much smarter, more effective approach.  Many formulas, like Dr. Chen’s four-herb formula, work on multiple levels within the body.  In an elegant operation, the herbs simultaneously repair the road (reduce inflammation) --so that fewer repair crew members are needed on site -- and help to clear away excess in instances where the repair effort got a bit overzealous.  They also function to reduce these components overall if there is more floating around than is absolutely necessary.  At no point however, do they stop the necessary crews from being produced.

In TCM terminology, the concept of inflammation is best described as a combination of heat and dampness.  The non-blood cell repair components (ie: cholesterol, fatty substances, cellular debris, fibrin, etc) would be considered more congealed forms of dampness, or phlegm.   And the red and white blood cell components in the repair meshwork would be considered blood stagnation/stasis.   If all of these components congeal to be substantial and thick, this is referred to as an accumulation, or mass. 

In order to eliminate this problem from a TCM standpoint, it is important to address all of these components and mechanisms, and that is exactly what Dr. Chen’s formula does.   By combining four specific and focused herbs, this formula effectively clears heat, drains dampness, resolves phlegm, breaks accumulations, invigorates the blood, and dispels blood stasis.  The end result is a decreased level of serum cholesterol due not to the inhibition of cholesterol production, but rather, to a decreased level of inflammation and an increased quality of blood flow.  

Below are the specific contributions each single herb makes to the formula. (Note: all come in equal dosages in the formula, so no one herb has any more or less functional importance than any other.  The order in which they are listed is arbitrary.)

I.  Ze Xie (Rhizoma Alismatis)


Western research has shown it to have the following properties:

(1) lowers blood lipids & total cholesterol

(2) diuretic

(3) prevents fatty liver

(4) anti-pyretic (lowering fever)

(5) anti-bacterial (inhibits mycobacterium tuberculosis)

(6) hypoglycemic

(7) hypotensive

(8) galactagogue (promote milk secretion)

(9) anti tumor

(10) induces interferon

(11) anti-allergic

(12) anti-lithic

(13) anti-inflammatory

(14) inhibits blood platelet aggregation and thrombosis

(15) dilates coronary artery; inhibits hardening of main artery

According to TCM principles, Ze Xie is sweet, bland, and cold.  It primarily targets the Kidney and Urinary Bladder meridians.  Its primary actions are to promote urination and leach out dampness, to settle/reduce ministerial fire in the Kidney by draining damp-heat from the lower jiao (aka: clear ‘empty’ fire), and to clear qi level heat.

The hallmarks of inflammation are heat and fluid accumulation (swelling).  Ze Xie both clears heat and drains fluid, thus making it anti-inflammatory.  However, in that its heat-clearing mechanism is rooted in the deficiency-type, its signature role in this formula lies in its damp-draining capabilities. 

In addition to decreasing inflammation, this damp-draining power can also help to clear and move out the more fluid-based components involved in cases of obstructing buildup.  In TCM, substances like lipids and cholesterol are considered accumulations of damp/phelgm.  By draining damp and clearing heat, Ze Xie both reduces and prevents such accumulations.  When fluids are moving efficiently, they are less likely to accumulate. 

II.  Dan Shen (Salvia Miltiorrhizae)

Western science has found it to have the following properties:

(1) improves micro-circulation and peripheral circulation, and increases capillary vascular net

(2) dilates and increases blood flow to the coronary artery

(3) increases anoxia tolerance under normal and low pressure

(4) improves myocardial contraction and adjusts heart rate

(5) inhibits blood coagulation and activates fibrinolysis

(6) increases metabolism

(7) strengthens immune system

(8) has sedative effects on CNS

(9) lowers blood cholesterol

(10) hypoglycemic

(11) anti-bacterial

According to TCM, Dan Shen is bitter and slightly cold, and specifically influences the Heart, Pericardium, and Liver meridians.  Its primary actions are to invigorate blood circulation and eliminate blood stasis, to clear heat and relieve irritability, to cool the blood and reduce abscesses, and to nourish the blood and calm the spirit.  

In the scope of this formula, this herb plays the important role of keeping the circulation flowing smoothly.  In cases where the repair matrix has caused a blockage, Dan Shen helps reduce the blockage by breaking down static, accumulated blood that has congealed along with the cholesterol and other components (damp/phlegm).   Dan Shen also makes sure that blood continues to circulate effectively by maximizing the flow capacity through the available spaces.  If blood is flowing efficiently, it is more difficult for things to collect and build up.  Because it also clears heat and nourishes the blood, it further decreases the inflammation, and assists the repair process by the generation of healthy, new blood.

III.  Shan Zha (Crataegi Fructus) 

Its properties have been found by Western research to be as follows:

(1) Dilates blood vessels and increases blood flow to the coronary artery

(2) Lowers blood pressure

(3) Lowers serum cholesterol and increase the lethicin/cholesterol ratio

(4) Decreases the deposition of cholesterol in internal organs

(5) Acts as a digestive

(6) Increases the contraction of the uterus

(7) Cardiotonic

(8) Anti-bacterial

Shan Zha, according to TCM, is sour, sweet, and slightly warm, and primarily targets the Spleen, Stomach, and Liver meridians.  Its primary actions are: to reduce food stagnation and transform accumulation, to transform blood stasis and dissipate clumps, and to stop diarrhea.

In the scope of this formula, this herb has the primary task of breaking down the congestion formed by the repair effort.  It excels at breaking down clumps and accumulations of all sorts of materials, including food, phlegm, and static blood.  Additionally, it can work to prevent clumps and future depositions by breaking down any excess components (cholesterol/other lipids/debris) that may floating free in the system.  It reinforces this preventative aspect by assisting Dan Shen in moving the blood. 

Furthermore, its ability to reduce and transform accumulation makes it an aid to digestion.  By assisting the Spleen and Stomach in this process, there will less phlegm and damp created overall, thus decreasing chances of excess within the system.

IV.  Jue Ming Zi (Cassia Semen) 

Western research has determined it to have the following properties:

(1) Anti-hypertensive

(2) Anti-bacterial and anti-fungal

(3) Lowers concentration of serum cholesterol

(4) Emollient

(5) Anti-spasmodic

(6) Diuretic

In TCM theory, Jue Ming Zi is considered to be bitter, sweet, salty, and slightly cold.  It primarily targets the Liver, Large Intestine, and Kidney meridians.   Its main actions are: to clear the Liver and the eyes, to calm the Liver and anchor ascending yang, and to moisten the intestines and unblock the bowels. 

In the scope of this formula, this herb has the primary task of clearing the heat/fire involved in the inflammation.  As opposed to Ze Xie, which primarily clears deficient heat, this herb clears the excess or ‘substantial’ type of heat/ fire.  By clearing fire and anchoring ascendant yang, Jue Ming Zi not only reduces existing inflammation, but also prevents further damage to the vessels.   The intense heat and speed of fire and flaring yang throw extreme force against the vessels.  By leading to the reckless movement of hot blood, and/or wind, these factors quickly and easily damage the vessel walls, resulting in inflammation.  By strongly clearing heat/fire, Jue Ming Zi works to both reduce and prevent the inflammatory process.

To summarize: this four-herb formula is simple, yet elegant.  Ze Xie drains the damp, Dan Shen moves the blood, Shan Zha breaks apart the accumulation, and Jue Ming Zi clears the heat.  In this way, it effectively addresses every aspect of inflammation and the secondary problems that arise from this inflammation.  Though it effectively reduces cholesterol levels, it is nothing like a Statin, and cholesterol reduction alone is not its primary agenda.

Though all of the herbs in the formula have their own long lists of biomedical effects, the power behind the herbs does not lie in the properties as named by Western research.  There are many, many herbs, for example, that have been found to “lower serum cholesterol”.  Yet each individual herb achieves this result through a different mechanism.  To effectively resolve a problem such as the reduction/maintenance of arteriosclerosis, heart disease and other diseases associated with high cholesterol, as this four-herb formula does, the ingredients are still best chosen by considering their known TCM functions. 

If a practitioner randomly selects five herbs to make a “lower cholesterol” formula based solely on the fact that Western research has labeled each of those herbs as a “cholesterol-lowering”agent, it is a toss-up as to whether it will be effective or not.  If the five selected are nicely balanced, as are the herbs in Dr. Chen’s four-herb formula, then it may indeed prove effective.  If the herbs selected are not balanced – perhaps all five are working solely via the drain damp aspect, for instance – it may not work so well at all.

This is why integration should be just that integration…utilizing helpful information from both systems in a way that will best benefit the patient.  For Chinese herbalists, there is no problem in considering the Western research and using that as an aid in herbal selection.   The key is to always consider the traditional Chinese properties that describe the functionality of how and why the herbs elicit the effects that they do.  If this is done, then sophisticated, powerful medicinals such as Dr. Chen’s four-herb formula may be created and find success in both the languages of TCM and Western medicine.