Sage, also known as common sage or garden sage, is a perennial that grows to a height of 3 feet with blue-violet blooms in summer.^1,2 Salvia officinalis originated in Southeastern Europe in the area that is now known as Albania and Bosnia.³ Today, although cultivated in some European countries (e.g., Albania, Bulgaria, Croatia, Germany, Poland, Romania, Serbia and Montenegro, and Spain) and the United States, more than half of the world’s supply is still wild-collected (mainly in Albania, Bosnia and Herzegovina, Croatia, Serbia and Montenegro), with increasing amounts being wild-collected under organic certification.^4-10

Sage leaves are chewed whole; dried and ground into a powder; prepared as a fluid extract, tincture, or essential oil; or pressed fresh for the juice.³ The genus Salvia is fairly large, containing hundreds of species not addressed in this profile, which are employed for a wide variety of applications in traditional medicine in the regions to which they are native.¹¹ Aside from S. officinalis, the most notable of these are Chinese sage root (dan shen; S. miltiorrhiza) and S. divinorum leaves, the reputed hallucinogen from Mexico.¹¹

History and Cultural Significance

The genus name Salvia derives from the Latin salvere, meaning “to save,” perhaps referring the healing properties of plants in this genus.^3,12 Salvia officinalis was used medicinally by ancient societies in Greece, Egypt, and Rome.³ Traditionally, it was employed to increase fertility, stop bleeding, heal minor skin wounds, treat hoarseness or cough, and improve memory function.³ The English herbalist John Gerard (1545-1607) claimed that sage (usually a tea made from the leaves) was good for the head, brain, and memory,¹³ and the physician/herbalist Nicholas Culpeper (1616-1654) also thought that it improved memory.¹⁴

In India, sage leaves were also used to treat intestinal gas, upset stomach, and infections of the mouth, nose, and throat.³ Historically, sage has been used to promote regularity in a woman’s menstrual cycle and to decrease breast milk production to facilitate weaning.^1,2 Since ancient times in most Mediterranean countries, sage has been popular as a culinary herb for its powerful and intense flavor, especially in meat and poultry dishes.¹²

Current uses of sage include the following: indigestion, treatment of inflammation of the mouth and throat, and excessive sweating, including that associated with peri-menopause; relief of pressure spots that result from the use of a prosthesis; and as a flavoring for food.^1-3,11-12,15 Sage oil has also been employed as a fragrance in soaps and perfumes.^1,3

In 1985, the German Commission E approved the use of sage internally for dyspepsia (upset stomach or indigestion) and excessive perspiration, and externally for inflammation of the nose and throat.³ One of the constituents of sage, salvin (a phenolic acid), has antimicrobial effects against Staphylococcus aureus,¹ a common bacteria responsible for skin and upper-respiratory tract infections. Sage has also shown strong antioxidant properties.^1,2 The German Standard License for sage leaf infusion indicates its use for inflammation of the gums and the mucous membranes of the mouth and throat, for pressure spots caused by prostheses, and in supportive treatment of gastrointestinal catarrh (inflammation of the mucous membranes).²

In 2009, the European Medicines Agency (EMA) published a final monograph which supersedes monographs of EU national authorities (including the German monographs) for the registration of traditional herbal medicinal products in the European Community that contain sage as an active ingredient.¹⁶ Traditional uses approved for sage leaf (dry extract, herbal tea, liquid extract and tincture) are (a) for symptomatic treatment of mild dyspeptic complaints such as heartburn and bloating; (b) for relief of excessive sweating; (c) for the symptomatic treatment of inflammations in the mouth and throat; and (d) for relief of minor skin inflammations.¹⁰ A prerequisite of registration is that the quality complies with the corresponding quality standards monographs of the European Pharmacopoeia (e.g., Sage Leaf PhEur or Sage Tincture PhEur). Concerning sage essential oil, the EMA has concluded that the risks do not outweigh the benefits; thus, a European Community herbal monograph will not be developed until new evidence of clinical safety and efficacy become available.¹⁷

In the United States, sage leaf is regulated as a food ingredient and as a dietary supplement component. Sage leaf is listed as GRAS (Generally Recognized as Safe) for use as a spice, seasoning, or natural flavor,¹⁸ while sage essential oil is a GRAS flavoring agent.¹⁹ For use of the essential oil as a flavoring, a quality standards monograph for “Dalmatian Type Sage Oil” is published by the United States Pharmacopeia Convention in the Food Chemicals Codex.²⁰ For therapeutic use, as part of the US Food and Drug Administration's (FDA) ongoing review of over-thecounter (OTC) drug products, the Dental Plaque Subcommittee of the Nonprescription Drugs Advisory Committee recently evaluated the safety and efficacy of sage oil combined with peppermint oil (Mentha x piperita, Lamiaceae). While the Subcommittee concluded that sage oil is safe for the intended use, they also concluded that there are insufficient data from controlled studies to permit final classification of the effectiveness of combined peppermint and sage oils as OTC active ingredients for the reduction of plaque and gingivitis.²¹

Modern Research

Note: Some of the studies mentioned below address S. lavandulifolia (lavandulaefolia), which is now recognized as a subspecies of S. officinalis, e.g., Salvia officinalis subsp. lavandulifolia (Vahl) Gams.²² (Unless specified otherwise, the species studied was S. officinalis.)

Based on sage’s traditional use as an aid to memory, preliminary pharmacological investigations were conducted into its bioactivity (S. officinalis and S. lavandulifolia) that led to more detailed in vitro studies which investigated the chemical constituents that might be responsible for aiding failing memory.¹¹ Results suggested that cyclic monoterpenes 1,8-cineole and alpha-pinene, as well as camphor, were responsible for the cholinesterase inhibition witnessed. Additionally, 1,8-cineole, alpha- and beta-pinene appeared partially responsible for the antioxidant effect of sage. Because Alzheimer’s Disease (AD) is thought to be due, in part, to inflammation and damage caused by pro-oxidant compounds that act on the brain cells, and since cholinesterase inhibitors are a standard treatment for AD patients, clinical studies on sage were needed to determine if it might be an appropriate treatment for AD patients.

A 2010 clinical study investigated the effect of the essential oils of S. officinalis and other species on cognition and mood in 135 healthy adults (45 in each group of S. officinalis, S. lavandulifolia, [5 drops of each essential oil in 5 ml water, NHR Organic Essential Oils, Brighton, UK] and no aroma).²³ The S. officinalis group performed significantly better than the S. lavandulifolia and control groups on the quality of memory, specifically long-term or secondary memory with no impact on working memory performance. The authors state that they would not have predicted the non-significant difference between the S. lavandulifolia and no aroma based on previous research, but that one possible explanation could be the lack of standardization of the sage preparations. The S. officinalis findings compared favorably with those reported earlier following oral administration of sage in healthy young participants.

A randomized, placebo-controlled, double-blind, balanced, 5-period crossover study in 2008 investigated the acute effects on cognitive performance of a standardized extract of sage (either 167 or 333 mg of a 70% dried ethanolic extract, Essential Nutrition, Brough, East Yorkshire, UK) in healthy adults (n=20) between 65-90 years of age.²⁴ The study found that administration of a standardized sage extract can improve cognitive function in healthy older people. Specifically, the authors saw dose-specific improvement in secondary memory performance for the 333 mg dose. Results corresponded to those found in earlier studies on younger populations and suggested that further investigations were warranted in larger numbers, other populations, and with different dosing regimens.

In a 2006, a double-blind, placebo-controlled, crossover study, 30 healthy participants received—on 3 separate days, 7 days apart—either 600 mg or 300 mg dried sage leaf or placebo.²⁵ Mood was assessed predose and at 1 and 4 hours post-dose, with each mood assessment being done before and after 20 minute performance of the Defined Intensity Stress Simulator (DISS) computerized multitasking battery. Improved ratings of mood in the absence of the stressor (pre-DISS) occurred with both doses, with the 300 mg dose reducing anxiety and the 600 mg dose leading to alertness, calmness, and contentedness. Reduced anxiety disappeared upon performance of the DISS. Results corresponded to those in other dose-dependent studies, and the authors suggested that further research was warranted into the potential use of sage in treating AD and natural aging, and the mechanisms responsible for the beneficial effects.

A 2005 placebo-controlled, double-blind, balanced, crossover study investigated the effect of S. lavandulifolia on mood and cognition in healthy young volunteers (n=24, 16 female, 8 male, 18-37 years old).²⁶ Single doses of placebo, 25 ml, and 50 ml of a standardized essential oil (Baldwins, London, UK) were given 4 times, 7 days apart. Participants were tested pre-dose and at 1, 2.5, 4, and 6 hours after dosing. Results showed consistent improvement for both doses on speed of memory, alertness, calmness, and contentedness.

In a 4-month, parallel group, placebo-controlled clinical trial in 2003 where 42 patients with mild to moderate AD were randomized to placebo or fixed dose of S. officinalis extract (1:1 in 45% alcohol, Institute of Medicinal Plants, Halejerd, Iran), the patients taking the sage extract showed a significantly better outcome on cognitive functions than placebo.²⁷ Additionally, agitation appeared to remain more frequent in the placebo group.

Human clinical studies on other aspects of sage have also been conducted. In 2009, a trial assessed the relative efficacy of a sage/ echinacea (SE) spray and a chlorhexidine/lidocaine (CL) spray in the treatment of acute sore throat.²⁸ The SE treatment was a little better at reducing sore throat symptoms than the CL treatment during the first 3 days (63.8% vs. 57.8% at 3 days). No differences were noticed in secondary parameters and both were well-tolerated.

A 2007 prospective, randomized, double-blind, placebo-controlled study investigated the anti-inflammatory effects of a sage extract using the ultraviolet erythema test.²⁹ Test areas on the backs of 40 healthy volunteers were irradiated with the minimal erythema dose, then treated with 2% w/w of a commercially available sage extract (Flavex GmbH; Rehlingen, Germany), a 1% hydrocortisone control, 0.1% betamethasone control, placebo ointment, or no treatment. The sage extract significantly reduced the UV-induced erythema compared to placebo, and to a similar extent as the hydrocortisone.

A clinical study from 2001 has documented the benefits of a sage-rhubarb cream to decrease the duration of external lip eruptions caused by Herpes simplex (H. labialis).³⁰ The same study showed that the sage-rhubarb cream was also effective at relieving the pain and swelling that patients experience with herpetic flares.

Future Outlook

There is little specific information concerning the current market statistics for sustainable harvesting of sage. There are certified operators marketing organic wild-collected sage from European countries which requires implementation and inspection of sustainable wild-resource management plans. The European Herb Growers Association (EUROPAM) 2010 update on production of medicinal and aromatic plants (MAPs) in Europe, although not specific, indicates that commercial cultivation increased in Bulgaria while wild collection decreased; that sage remains one of the main medicinal herbs produced in Germany; and that it is still cultivated in Romania and in Greece in cooperatives.³¹

According to one source, Albania has traditionally been one of the world’s leading sage producers.³² It is one of Albania’s most important MAPS exports and, in 2001, 1500 tons were exported with a market value of about $2.5 million (USD).

The US imports sage leaf tracked under the 10-digit Harmonized System Tariff Code (HS Code: 1211.9091.50). In 2009, the US imported 2,294.5 metric tons (MT), down 21% from 2008 imports of 2,909.¹ MT, over 55% of which is exported by Albania.³³ After Albania, the second-largest supplier of sage leaf to the US is Germany. Although Germany is a producer of sage leaf, much of the German exports are likely re-exports of sage leaf originally from southeastern European countries (J. Brinckmann, e-mail, January 17, 2011).

Previous records indicate that worldwide production equaled 35 tons of sage essential oil in 1993, which was valued at $1,800,000.00.³⁴ Morocco produced 124.5 tons of dried leaves for export in 1993, but only 81.4 tons in 1996.³⁵

Turkey is one of the most important sage-producing countries of the world. Due to overcollection of the herb in the wild that was posing a risk to native populations, a 2-year field study was undertaken to determine which of a number of methods would produce the best seedling quality for commercial cultivation of the plant.³⁶ The greenhouse seedbed method proved best because it resulted in the most vigorous seedling development and highest total fresh- and dry-weight herb production. A modified float system produced superior root development and less lateral root damage during transplantation. The authors stated that this was only preliminary data and that further studies were required to elucidate cultural requirements of S. officinalis.

—Gayle Engels

References

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