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Herbalism A Tradition of Healing Linda Diane Feldt RPP, NCTMB, NC, RPE Holistic Health Practitioner and Herbalist Outline of this presentation Why herbology matters to conventional practitioners Certification of Developing studies and evidence Nourishing Medicinal The plants Problems in design and standardizing plants Parts of the plant, Harvesting, Preparations Effects of herbs Herbs Practitioners Popular Local Case Studies Herbology and Conventional Medicine Herbs are one of the most popular forms of CAM Consumers both self treat and don’t report use to medical professionals Big money marketing is becoming a larger influence The history of herbal use is greater than 10,000 years - we have a lot to learn from experience Certification Confusing to everyone Certification of Herbs Contents are unadulterated and properly labeled Manufacturing process is acceptable Does not address potency, preparation, or if the active plant part is harvested in the right season. Standards vary, may be random, samples may be submitted, most agencies charge for certification Herbal certification The bad Prone to consumer confusion Does not ensure potency Does not address processing or preparation Does not address safety of the herb Expense may prohibit good companies from using certification The good Helpful to ensure WYSIWYG Raising awareness of importance of herbal quality Important to ensure Good Manufacturing Practices (GMP) are used Can address the real problem of contamination Reputable companies Harvest ethically Employ herbalists and support professional associations Provide access to information on where plants are harvested - avoid non US unless using TCM company philosophy - focus on herbs or marketing? control of product - don’t just repackage or rebottle from suppliers Multi-level marketing deserves special scrutiny Certification is helpful, but is only part of the whole picture. Smaller companies will not be able to afford the process, less popular herbs are less likely to be certified. Examples of companies HerbPharm Frontier Pacific Botanicals Trout Lake Botanicals Scientific Botanicals Phytopharmica Naturopathic Formulary Thorne Research Eclectic Institute MediHerb Bezweken Women's Transition Wise Women Herbals And ?? Certification of Herbalists Traditional Healers Native American, Ayurvedic, Tibb, Unani, Tibetan, etc Traditional Chinese Western Folkloric Western Scientific Earth-centered Ethno-botanical example categories from the American Herbalist Guild Herbalism Training and Education College and University courses Electives within schools that teach wellness, holistic health, bodywork or somatic practices Apprenticeship programs both formal and informal Correspondence courses Herbalism Training and Education (cont.) Traditional initiation and training often combined with religious/spiritual practices Self taught Promotional material and workshops provided by manufacturers Multi level marketing materials Certification provided by herb manufacturers Western Folkloric Tradition Promotes ethical harvesting of plants Uses whole parts of plant, in season Encourages consumer involvement Western Folkloric Tradition Emphasis is on nutritive value of herbs Priority given to local plants, and what is readily available Uses a holistic approach to support the individual and systems of the body Western Folkloric Tradition Encourages sharing of information, stories, experiences, and methods Can easily work in a supportive role with conventional Western Medicine The Big Questions Dangers, concerns, and evidence Are Herbs Dangerous? Adulteration and contamination Misuse, use in place of more effective therapies Ineffective preparations Self medication, misinformation, Drug, surgery and therapy interactions Minimal reporting of adverse events from herbs Misdirection of resources esp. time and money Poisonous plants Combination herbal formulas difficult to track, learn what is effective, what may create reactions Long term use may mask disease serious illness Common Concerns Dose and strength may vary with plant and preparation method No government control/approval Anecdotal evidence lack of studies Significant focus on using herbs for cleansing and purifying, often based on faulty information and myths Research Research on herbs is different than typical drug research The most extensively used herbs and formulas are not patentable Standardization can be difficult with many preparations Blinding is difficult when herbs have strong tastes or odors When used holistically, different herbs might be suggested for the same symptoms, or combined in different ways on a case by case basis Potency is affected by preparation, harvesting, and other factors researchers may not be aware of Herbal Basics What to use when and how Herbal Basics - what part to use Roots - alkaloids concentrated, more toxic (esp. perennials) Leaves - nutrient rich, less toxic Bark - nutrient rich, less toxic Seeds - often toxic, (annuals and biennials less so), varied components Flowers - rarely toxic, often used topically --Please note these are guidelines only, there are always exceptions. Herbal Basics - when to harvest Roots - spring and fall when alkaloids are concentrated in root Leaves - best before flowering begins Bark - spring, fall harvest may damage tree Seeds - when fully developed Flowers - when fully developed --Please note these are guidelines only, there are always exceptions. Herbal Basics - the preparations Capsules and pills are most common, and least effective unless made with extracts Infusion and decoction especially for nourishing effects Tincture, vinegar, and oil Poultice, compress Salve, bolis, Inhaled by smoking, smudge, vapor, essential oil Nourishing and Medicinal Herbs Two different ways herbs can be used Medicine or Food? In traditional herbalism plants are used for both Substantial healing can occur by nourishing the body or systems of the body Many herbs occupy both roles The nourishing herbs are far less likely to have unwanted side effects Weeds in Michigan are often higher in available nutrients than conventional foods Nourishing herbs Nutrient rich Bio-available Generally considered safe, side effects uncommon Dosage and strength less important Tend to be local, whole, and common Large amounts used, in contrast to medicinal plants Includes tonics Supportive to body systems Long term use is usually beneficial Nourishing Herbs cont. Infusions provide readily absorbable nutrients, vary with herb used. Nettle urtica provides protein, calcium and iron. Esp. helpful for anemia, pregnancy (3rd trimester) Red Clover mineral rich Oatstraw appears to provide trace minerals helpful for endocrine system, some evidence affects fertility Anecdotal information is very positive for using specific infusions to help with allergies, infertility, poor nutrition, blood sugaring balancing, and many other problems. Nourishing Herbs cont. Internal use Infusions Whole plant Water based Vinegar based Cooked Raw (salad) External use Compress Poultice Salve Oils - essential oils and infused oils Medicinal Herbs Dosage and strength important or critical Tend to utilize more toxic parts of plant Stimulate or sedate More likely to have side effects Are often plants that are less common, or rare Long term use is generally discouraged More extensive knowledge is needed to use safely and effectively Medicinal Herbs cont. Internal Use Tinctures Extracts provided in capsules or other Standardized components of plants Drug preparations derived from plants Injections of extracts Capsules (not necessarily effective) External Use Poultice, compress, bolis Salves Oils Popular Herbs The Herbs Ginkgo biloba St. John’s wort Garlic Echinacea Goldenseal Saw palmetto Milk thistle Black cohosh Ginger Valerian Ginkgo biloba Powdered leaves Tincture or infusion Most ancient tree known Uses: cerebral insufficiency, Alzheimer’s Ds, intermittent claudication, tinnitis Ginkgo Increases vascular flow diabetic peripheral vascular disease Raynauds syndrome Other circulatory benefits fro varicose veins, hemorrhoids, eye disorders Affinity for cerebral circulation Inhibits platelet activity factor Ginkgo Used to relieve tension, anxiety, elevate mood Contains flavanoids, terpene lactones, ginkgolides A, B, and C, bilobalide, quercetin, and kaempferol. ginkgolides control allergic inflammation, anaphylactic shock and asthma antioxidant What to watch for Can increase blood flow Discontinue before surgery Do not use with menstrual flooding Do not use with other bleeding problems (ulcer, bruising, etc.) Not suggested with blood thinners, aspirin, etc. Gingko biloba & Dementia 52 week RCT, double blind, multi-center Outcomes in 309 pts (ITT): Pt cognition: tx no change, placebo worse (p=0.04) Caregiver assess: tx slight improve, placebo worse (p=.004) Dose: 120 mg/d of EGb 761 Safety: side effects equal Problems: high dropout rate (50% tx, 62% placebo) Ginkgo & Claudication Meta-analysis of Egb 761 5 placebo controlled trials Moderate to large effect (0.75 Cohen’s d) on pain-free treadmill walking distance Schneider B. Arzneimforsch 1992;42(4):428-436 Ginkgo - Toxicology Adverse events GI complaints bruising & spontaneous bleeding Avoid if taking warfarin, heparin, or NSAIDs Can increase insulin levels May increase sedation with trazodone St. John’s Wort Hypericum Perforatum Used as tincture, extract in pill form, topically as oil or salve Popular as anti-depressant. Also used for muscle aches, nerve pain, nerve regeneration, for herpes outbreaks, bruising St. John’s Wort Utilizes P450 Cytochrome system Can interfere with effectiveness of other medications Possible rash from exposure to sun (sheep and cows) Use with other mood altering drugs of concern Use by people with manic depressive and other psychological conditions of concern St. John’s Wort & Depression Meta-analysis: 23 studies, 1757 pts Mild-mod depression Superior to placebo, rrr =2.67 (1.78-4.01) As effective as TCA’s , rrr=1.10 (0.93-1.31) Fewer side effects than TCA’s Dose: 0.4-2.7 mg Hypericin (standardized extract) Multi-center trial vs. SSRI’s at Duke Linde K, et al. BMJ 1996;313:253-8 St. John’s Wort - Toxicology Side effects Theoretical risk - sunburn Herb-drug interactions Studies - digoxin, protease inhibitors, TCAs Case reports - cyclosporine, warfarin, oral contraceptives, theophylline, SSRIs Theoretical - iron Facts & Comparisons Review of Natural Products, Dec 2000. Garlic (Allium sativum) Uses Lower cholesterol anti-thrombotic lower blood pressure anti-microbial agent Strengthen heart muscle Reduce platelet clumping and clotting Stabilize blood sugar levels Garlic Some caution about use if bleeding is of concern Odor Large amounts can great gas Potential decreased platelet aggregation Garlic Contains alliin in intact garlic bulb Alliin allicin (crushed) 600 – 900 mg of dried powder (1.3% allicin) Garlic - Evidence German Commission E elevated blood lipids prevention of age-related vascular changes 25 studies between 1979-1998 with 2,920 people Mixed results highly dependent on type of garlic preparation Garlic - Evidence 2 Meta-analyses Meta-analysis garlic lowered total cholesterol between 9-12% Anti-hypertensive - 10% reduction Double blind RCT - 152 subjects for 4 years garlic reduced development of atherosclerosis Echinacea spp. E. pallida purpurea angustifolia Use: prevention and treatment of colds, flu,immune system support One of most popular herbs in US German Commission E supportive for colds, chronic URI, UTI UK - GSL Echinacea Stimulating dose not advised with autoimmune and some systemic diseases Can interfere with immune suppression during chemotherapy treatment Stimulating dose should be short term (3-4 days) only No known side effects Concern with steroid treatment - depends on use Echinacea - Human Evidence 26 controlled trials (many open label) 3 blinded RCT’s on URI 1 showed dose dependent decrease in symptoms and duration of “flu” 2 showed 13-20% relative risk reduction of acquiring URI Dose: 30-60 gtts 1:5 (g/ml) tincture TID Species, method of preparation and dose of concern with recent trials Echinacea Systematic Review 16 randomized or quasi randomized trials Echinacea preparation vs. no treatment or placebo 8 trials on prevention, 8 trials on treatment 3396 patients involved Majority with positive results Cannot say which preparation is best Melchart, D. et al. Cochrane Database Syst Rev 2000;2. Goldenseal (Hydrastis canadensis) Used in Native American medicine Taken up by European immigrants Deep forest dweller, endangered species Part used is the root Colds, flu, bacterial diarrhea, intestinal parasites, and ocular trachoma infections Goldenseal Endangered herb Internal use has antibiotic effect Dose, duration, and strength important concern for contributing to antibiotic resistant bacteria Can be difficult to self-administer Overused and misused by general public Present in tooth paste, lip balm, herbal mixtures Goldenseal - Evidence Antimicrobial activity vs. bacteria, viruses, fungi, protozoans, helminths, and chlamydia Active components: berberine (anticholinergic, antisecretory, and antimicrobial) beta-hydrastine (astringent) In rats, Goldenseal increases IgM antibodies Saw Palmetto (Serenoa repens) Used for benign prostatic hypertrophy Hexane extract of dried berries Spasmolytic activity Inhibition of androgen Anti-inflammatory Not an inhibitor of 5reductase Saw Palmetto - Evidence 18 RCT’s, 16/18 double-blinded 2939 men, duration 4-48 weeks Decreased nocturia, improved symptom scores vs. placebo Improved symptom score, improved peak urine flow vs. finasteride Dose: 400 mg dry extract BID Wilt TJ, et al. JAMA 1998; 280:1604-1609. Saw Palmetto - Toxicology Rats: 80x human dose for 6 months Human trials, German Commission E No negative influences GI disturbances, headache No significant adverse effects Drug interactions Theoretical - Estrogens, oral contraceptives, iron German Commission E reports none Black Cohosh (Cimicifuga racemosa) Fresh root tincture or dried root infusion Remifemin, used in Germany since 1950’s Used for hot flashes and night sweats German Commission E: Premenstrual discomfort Dysmenorrhea Menopausal neurovegetative symptoms Black Cohosh - Mode of action Steroidal terpenes? isoflavones? others? Methanol extracts bind estrogen receptors Inhibits estrogen dependent breast tumor cell lines Lowers LH in rats and women, no effect on FSHa Stimulatory effect on endometriumb,c Actein may be beneficial in hypercholesterolemia and peripheral arterial disease a. Duker 1991; b. Stoll 1987; c. Warnecke 1985 Black Cohosh - Clinical Trials 5 RCTs in literature Randomized, head to head trial 60 pts, < 40 yr. old with hysterectomies Estriol vs. conjugated estrogens vs. estrogen-gestegen sequential vs. black cohosh extract Outcome: Kupperman’s Menopausal Index Black cohosh equal to other treatments Lehmann-Willenbrock, et al. Zentralblatt fur Gynakologie 1998;110:611-8 similar findings: Warnecke, 1985 Black Cohosh Update Recent RCT 85 breast cancer survivors 59 were on tamoxifen 40 mg/d Remifemin vs. placebo x 2 months No benefit for hot flashes Jacobson JS, et al. J. Clin. Oncol 2001;19:2739-45. On-going trial at Columbia Univ RCT, 1 year duration hot flashes, endometrial thickness, bone metab, cognitive effects Black Cohosh - Toxicology Overdose: nausea, dizziness, nervous system disturbance Mice - spread of breast CA Large doses may cause miscarriage. Contraindicated in pregnancy Long term safety unknown Ginger Zingiber officinale Used for nausea Helpful for colds and flu Warming herb Many other folkloric uses Ginger for Nausea & Vomiting of Pregnancy 2 trials show efficacy compared to placebo excess Yang (excess Qi) N not in AM, N worse p eating, N improves p vomiting ginger is too “hot”, use peppermint excess Yin (deficient Qi) N in AM, N better p eating, N worse p vomiting ginger will be helpful Tiran D. Comp Ther Nursing & Midwifery. 2002;8:191-196 How to take ginger Dose 3-9 grams fresh (or dried) peeled ginger root Tea made from grated fresh root (2 inches root, 1 qt water, simmer covered 20 minutes and strain) Commercially available capsules NOT ginger biscuits or ginger beer Tiran D. Comp Ther Nursing & Midwifery. 2002;8:191-196 Ginger Root Safety? Contraindicated in German Commission E 6-gingerol is mutagenic in vitro at high doses Other compounds in ginger are anti-mutagenic Widely used in Traditional Chinese Medicine No contraindication in Pharmacopoeia of the People’s Republic of China (1995) May increase miscarriage Milk Thistle Silybum marianum Protects liver Promotes hepatic cell growth Supports normal liver function Antioxidant Milk thistle Hepatoprotective antioxidant activity toxin blockade at the membrane level enhanced protein synthesis antifibriotic activity possible anti-inflammatory or immunomodulating effects Stimulates action of nucleolar polymerase A causing in ribosomal protein synthesis, stimulating regenerative ability and formation of hepatocytes Milk Thistle: Effects on Liver Disease and Cirrhosis and Clinical Adverse Effects Summary, Evidence Report/Technology Assessment: Number 21 Sept. 2000. Agency for Healthcare Research and Quality, Rockville MD German commission E monographs Milk thistle German Commission E Monographs report No contraindications No known side effects No known interactions with other drugs Valerian Valeriana officinalis Perennial root is used, best as tincture or extract as taste is foul Used to treat nervous system disorders such as anxiety, restlessness, insomnia, back spasms Valerian May increase effects of CNS depressants, avoid concurrent use May negate effects of MAOIs and meds containing Phenytoin, and warfarin Can cause insomnia, headache, restlessness, nausea, vomiting, vision changes, palpitations, and overdose = hepatoxicity May impair ability to drive or similar tasks Mosby’s Handbook of Herbs and Natural Supplements 2001 Herbs Local to Michigan Local Herbs For thousands of years all herbs used were: Local Common Harvested by practitioner or user Prepared at time of use or preserved for off-season Special non-local herbs were available by trade Current Practice This type of use is still relevant today. Advantages Low or no cost No fear of adulteration Know plant part and if picked at best time Fresh Gets you out in nature Personal/spiritual experience with plant(s) Michigan Herbal Allies In Michigan we are surrounded by herbal helpers. When you begin to learn them, it changes the experience of being outside and your ability to interact with nature. Help is all around you. It is a very powerful thing to experience regularly. Finding and making you own medicine creates independence, and provides other options to the conventional insurance/medical systems. Just a few of the hundreds In your yard: plaintain, dandelion, motherwort, lamb’s quarters, echinacea, Groundsel, shepherd’s purse, chickweed, mallow, self heal Coming in from the woods: stinging nettle, cleavers, garlic mustard, poke, red raspberry From the surrounding countryside: mullein, yellow dock, burdock, chicory, red clover, St. John’s wort, yarrow Plantain Plantago Used in salads, for bites and skin irritations, soothes oral cuts and radiation burns Leaves chewed, poultice, juiced or salve. Seeds of some species ground and used internally for diarrhea and constipation Plantain (cont.) Externally speeds healing, stops bleeding, draws out foreign matter, kills bacteria, decreases itching, decreases pain. Grows in driveways, paths, near sidewalks, lawns. Dandelion Taraxacum officinalis Famous for liver support and nourishment, rich in vit. A, diuretic Relieves gas and heartburn (20 drops tincture before meals) All parts are edible Dandelion (cont.) Grows in lawns, fields, and where it is needed. Used as tincture (leaves and root), eaten as green, steeped in vinegar, bitter infusion Echinacea A plains flower perennial, Ech. purpuria grows easily in Michigan gardens Roots are harvested in fall of third or fourth year and tinctured fresh Echinacea Echinacea angusifolia harder to grow, roots can be dried. Uses are commonly known, note that Echinacea can be used to stimulate or nourish the immune system. Anti-viral. Echinacea stimulate Two Actions nourish useful for a limited time useful when a fast result is required can have possible side effects useful for an unlimited time useful when a long term result is required especially indicated for recovery from long term or chronic illness side effects are unlikely Lamb’s Quarter Chenopodium Eaten for high calcium and carotenes Available early spring through fall (if picked regularly) Can be blanched and frozen for winter nourishment Lamb’s Quarter (cont.) Excellent green for making calcium rich vinegar Grows in disturbed ground Easy to identify by “chalky” appearance Use in place of lettuce for salad base Nettle Urtica Leaves eaten for calcium, iron, protein, micronutrient content. Can also be made into infusion. Tincture or infusion aids kidneys, adrenals Salve or tea used for burns Nettle (cont.) May decrease insulin resistance Infusions, soups, vinegars maximize nettle’s rich nutritional value that nourishes many body systems. Grows near water and high nitrogen sources Garlic Mustard Allaria petiolata Seriously invasive plant. You are encouraged to pick it (roots and all) nearly anywhere you find it. Save the top 1/3 and compost the rest. Garlic Mustard (cont.) Use fresh in salads, blanch and freeze as pot green, great in sauces and soups, use in place of garlic in many recipes. Medicinal benefit unknown, but as nutritious as most greens. Mullein Verbasci Traditional use to stop smoking (substitute) Leaves, infusion, and tincture nourishing for lungs Oil from flowers used for earaches Mullein (cont.) Leaves used to help effectiveness of coughs, to reduce asthma, to calm lung inflammation Found by roadsides, meadows, beginnings of paths and in gardens. A startling plant in the second year, can grow 6-9 feet. Yellow Dock Rumex crispus Root used as tincture to promote iron absorption, nourish liver. Root used as oil as wound healer (bruises, tissue damage, trauma) Yellow Dock (cont.) Leaves used as food (great as pesto) contain high amounts of easily absorbable iron. Great plant for treating anemia (tincture of roots) Will only grow in iron rich soil, fields and open land Burdock Arctium lappa Tincture of the root is used for skin diseases, antitumor, as a deep alterative The root can be eaten (first year and spring of second year only). Used raw, in stir fries, or pickled Found in pour quality disturbed ground, open fields Burdock (cont.) Root contains high levels of inulin, may help blood sugar stabilization and calcium absorption Leaves as poultice or compress used to heal burns (including from hot pepper oil) Leaves as poultice quickly heal skin abrasions Other ideas Learn 1-2 plants per year Learn each plant thoroughly - were it grows, why it grows there, what parts are used, when are they harvested, what it tastes like, and how to prepare it for maximum benefit. Case Studies Highlighting The Different Ways Herbs are Used Herbs can be used for: Acute conditions Chronic problems Prevention Nutrition System strengthening Easing transitions Repair Substitutes for drugs Psychiatric care A complement to conventional treatment Case Study: Prophylactic Use of Echinacea angustifolia and purpurea Tincture for Management of a Recurrent Staphylococcus Infection Staph Case Study con’t. 46 yo female CHF Heart cath age 53, followed by staph infection Broad spec. antibiotics no effect Echinacea ang. 30-40 drops every 3 hours Symptom improvement within 2 hours Two days both, stopped Ech. Symptoms returned within 4 hours Ech and Antibiotic together, no symptoms Staph Case Study con’t. MD stopped antibiotics, pt. stopped Ech. Symptoms returned Ech. as before - symptoms gone One day without Ech, some symptoms Ech 10 drops day no symptoms For next 7 years, until death, two skipped days symptoms return -proven at least five times Significant points Echinacea fought an antibiotic resistant infection Low dose (nourishing) as effective as high dose (stimulating) Low dose safe to use long term Long term use was necessary Mechanism of action for effect of low dose unknown Preventative 5 year old girl, 38 year old female Both have daily exposure to kids at day care and are frequently ill with colds, ear infections, and pink eye. Low dose of Echinacea used long term: 2-3 drops for the 5 year old and 10 drops for adult. Both experience marked decrease in frequency and severity of illnesses. Severe Anemia Male health professional with symptoms of severe fatigue, depression, digestive disturbances History revealed no obvious reason for fatigue Symptoms consistent with anemia, home test kit showed Hemoglobin 6.5, pale gums, eyelids, etc. Client then revealed rectal bleeding and hemorrhoids Suggested immediate follow up with MD - confirmed 6.3 hemoglobin Severe Anemia con’t. For blood loss: nettle infusion, yellow dock tincture, other diet additions of high iron food Counseling on diet that may have contributed to the problem, possible needed changes (client eliminated red meat) For hemorrhoids: use of witch hazel sitz baths, witch hazel applied topically Two days of use reported improvement of hemorrhoids Four weeks later, significant improvement of energy levels, hemoglobin above 9, no rectal bleeding, no noticeable hemorrhoids Transition 42 year old female post surgery complete hysterectomy Removed from hormone therapy after cancer is found Trouble sleeping, hot flashes, and mood swings for over 3 months Uses 10 drops motherwort tincture at night, all symptoms resolved within one week. Repair/pain relief 42 year old female experiencing significant nerve pain following needle biopsy on lung, lasting more than 4 months. Difficult to tolerate any touch and even clothing contact St. John’s Wort oil applied topically Pain decreased within days, continued to progress with continued use Had a pain free mammogram a few months later See related article on nerve regeneration www.holisticwisdom.org/articles Complementary to Conventional Treatment 23 year old female with ALL treated with chemotherapy drugs Used milk thistle extract during each treatment, as well as 2 x a day 20 drops in water Liver tests consistently came back normal Nursing staff questioned her about her high energy levels and unexpectedly good liver profiles My later conversations with her medical team confirmed their initial surprise, and their belief that the milk thistle was a significant factor. To Learn More Free monthly herb classes sponsored by People’s Food Coo-op (fourth Thurs.) Free monthly herb classes sponsored by Whole Foods Index to studies - www.herbmed.org Good source for traditional use and recent evidence www.naturalstandard.com (access through taubman library database) Michael Moore’s database www.medherb.com/1herb.htm listing research, ethnobotany, constituents, traditional use, and more. To learn more Mosby’s Handbook of Herbs and Natural Supplements For local identification and research Peterson’s A Field Guide to Medicinal Plants and Herbs, Steven Foster and James Duke The Complete German Commission E Monographs (buy book or online with American Botanical Council membership) Through the Taubman library CAM databases: Dr. Duke’s Phytochemical and Ethnobotanical Database Contact Information Linda Diane Feldt P.O. Box 3218 Ann Arbor MI 48106-3218 734-662-4902 [email protected] www.holisticwisdom.org Slide credit # 32-66 based on material prepared with Sara L. Warber, MD Suzanne Zick, ND, MPH Leslie Shimp, PharmD Dogs harvesting herbs