- History of elderberry in medicine
- Era of modern medicine
- What the science says
- Sambucol vs. Sambucus
- Clinical studies to date
- What’s the verdict?
- Best elderberry syrup brand?
Supplement companies know this, which is why they’re all too happy to oblige by offering a purported boost for immunity, weight loss, enhanced energy, or whatever else it is that ails you.
And more often than not, you’re paying a hefty price tag for it.
But what are you paying for? Is there any scientific evidence to back their claims?
Other times it’s not the supplement companies to blame, but rather myths circulating among the public. For example, the Wuhan coronovirus outbreak of 2020 has elicited a lot of panicked suggestions for prevention – like using garlic or elderberry – but what does the science say?
The truth may surprise you.
Let’s review Sambucol for colds and similar products like Nature’s Way original Sambucus (many people confuse these two brands, they’re not the same thing).
The Sambucol original black elderberry syrup is probably the most popular, though in recent years they’ve also came out with a version for kids, gummies, effervescent tablets, and something they call pastilles, which are basically cough drops. All of these products contain the berry extract.
History of elderberry in medicine
Its use in medicine is definitely not new.
As far back as the 4th century before Christ, it has been claimed that the famous physician Hippocrates called this berry his “medicine chest” (1). In the 17th century, the famous English writer and gardener John Evelyn had wrote:
“If the medicinal properties of its leaves, bark and berries were fully known, I cannot tell what our countryman could ail for which he might not fetch a remedy from every hedge, either for sickness, or wounds.”
In other words, he believed the elder tree was a remedy for many things.
As an herbal remedy for colds, it’s also reportedly been used for centuries. The Pharmacopoeia – published by the London College of Physicians – was first published in 1618 as an instruction manual for making prescription formulations (prior to that, there was lack of consistency because the apothecaries and grocers would make their own). Numerous editions were published throughout the two centuries which followed, reportedly containing at least 6 recipes for black elderberry syrup. Most added sugar.
The National Druggist was a St. Louis based journal for pharmacists. Published in 1918, volume 48 discussed the current opinion as well as the history of elderberry treatment for colds, citing earlier literature:
“…as a ‘saponaceous resolvent’ promoting the ‘natural secretions by stool, urine, and sweat,’ and diluted with water for common colds”
Era of modern medicine
In academia and elsewhere, the occasional research done about the antiviral properties of elderberry had never ceased. Though it wasn’t until the 90’s and 00’s when intriguing clinical studies and reviews on elderberry syrup were published. That’s when it began to garner more attention.
The inventor of Sambucol was Dr. Madeleine Mumcuoglu, a viralogist who developed the formulation in Israel. First sold in 1991, it wasn’t available in the U.S. until 1996.
According to an advertisement published that same year, it was “the result of nearly twenty years of research and exhaustive testing in hospital laboratories.” That would peg the development as beginning in the 70’s.
They claim it to be the most researched black elderberry extract in the world and indeed, it appears most human studies have used this brand.
Compounds in this fruit have been studied for:
- influenza A and B viruses (the causes during winter flu season)
- common colds
- H1N1 virus (swine flu)
- sinus infections
To be clear, it has not yet been studied for the strain of coronavirus responsible for the Chinese outbreak in 2020.
However, it has been studied in the lab for other types, like human coronavirus NL63 (HCoV-NL63).
In that lab 2019 study, Taiwanese scientists reported that the caffeic acid, chlorogenic acid, and coumaric acid found in the extract “significantly inhibited the replication of HCoV-NL63 in a cell-type independent manner, and specifically blocked virus attachment.” (10)
Contrary to what some may say, remember that was in the lab only. Just because it may work in a Petri dish, that does not mean it works in a living body.
What the science says
Does elderberry syrup really work? That depends on what your definition of “work” is. To be clear and avoid confusion, there is no such thing as a cure for colds. No berry, food, supplement, or medicine has been proven to do that.
That being said, there has been research involving the European elder (Sambucus nigra L.) and how it might help with respiratory illnesses.
Preliminary studies have suggested that it might shorten the duration of the flu by up to 3 days and help with cold symptom relief.
Officially this berry extract ingredient – whether as Sambucol or another brand – is sold as a dietary supplement only. It is not a medicine for treating, preventing, or curing any disease. Much more research needs to be done for there to even be a chance of that status ever changing. As of today, it is considered unproven.
With those caveats said, here is a review of the research so far.
Sambucol vs. Sambucus
Before diving into the studies, it’s important to make sure we’re all on the same page.
What is the the difference between Sambucus and Sambucol? These terms may actually refer to not just two, but three different things…
Sambucus the plant
This is the scientific name for the genus of flowering plants which includes the European black elderberry (Sambucus nigra). There are about 3 dozen plants which have the “sambucus” word in their name; Sambucus chinensis (Chinese red elder), Sambucus ebulus (European dwarf elder), and Sambucus pubens (American red elder) just to name a few.
The medicinal research is focused on the Sambucus nigra, not the other species.
When research says “sambucus” you can assume they are referencing the Sambucus nigra/European black elderberry.
Sambucol Original Formula
Evidence suggests that it was Sambucol who was the first brand to market. Reportedly, Dr. Mumcuoglu founded the Israeli company Razei Bar to sell the syrup under the Sambucol name and Nature’s Way was or soon became the distributor of that product.
Purportedly there was a dispute/breakup between the companies early on and that’s when Nature’s Way Sambucus was sold as a different product. Being in the 90’s, online records of this are limited and neither company currently addresses the history on their websites.
Nature’s Way Original Sambucus
This references the brand which is marketed under the name Original Sambucus. What type of elderberry is used in Nature’s Way Sambucus? The same European black variety. To make things even more confusing, when people say “sambucus” they may be referencing the shortened Latin name for the berry rather than this brand name.
In short, both Sambucol and Sambucus label their products as original in some regard, but the evidence seems to suggest Sambucol was first to market and for the clinical studies which do cite a brand name, it is Sambucol we have seen. However they both use the same primary active ingredient.
Sambucol vs. Sambucus
|Nutrition Facts (Supplement Facts)|
|Sambucol Original Formula||Nature’s Way Original Sambucus|
|Manufacturer/Owner:||PharmaCare US, Inc.||Schwabe North America, Inc.|
|Where It’s Made||Product of France||Not Disclosed|
|Serving Size||2 teaspoons (10ml)||2 teaspoons (10ml)|
|Main Ingredient||3.8g black elderberry extract||100mg black elderberry (Extract standardized to BioActives® from 6.4g of cultivar elderberries)|
|Other Ingredients||Glucose Syrup, Purified Water, Citric Acid, Potassium Sorbate (To Retard Spoilage)||Fructose, Purified Water, Vegetable-source Glycerin, Malic Acid, Natural Raspberry Flavor With Other Natural Flavors|
|Dairy Free||yes (Cold & Flu formula is not vegan because it contains dairy derived lactose)||unknown (labeled as vegetarian, does not specify if “other natural flavors” are plant or animal derived)|
|Soy Free||yes||unknown (but appears likely)|
|Nut Free||yes||unknown (but appears likely)|
|Free of Artificial Colors||yes||yes|
|Free of Artificial Flavors||yes||yes|
|Free of Artificial Preservatives||unknown (potassium sorbate can be naturally derived or synthetically produced)||yes|
|Kosher Certified||yes (but their homeopathic Cold & Flu Relief products are not kosher)||yes|
|Manufacturer Product Claims||“Sambucol is the Original Black Elderberry Extract that has been on sale for the past 20 years. Not all black elderberry extracts are the same. Only Sambucol uses the proprietary elderberry extract that was used in published clinical studies. Other products use a concentrated, standardised elderberry extract that does not have the natural balance of the elderberry extract used in Sambucol. This is a fundamentally different ingredient and so cannot be considered to be equivalent.”||“Made from a unique cultivar of black elderberries with a higher level of naturally-occurring flavonoids. Full-spectrum black elderberry extract standardized to anthocyanins, which are potent flavonoid BioActives®. Gentle, solvent-free extraction method ensures maximum flavonoid potency. Our elderberry extract has been tested for bioavailability and activity within the body”|
In addition to the two aforementioned names, there are other brands of elderberry syrup/liquid concentrate on the market such as:
- Gaia Herbs, 5.4 oz (organic)
- Honey Garden, 8 oz (organic)
- Nature’s Answer Alcohol-Free, 8 oz
- Now Foods, 8 oz
- Natural Sources, 16 oz
While the complete ingredients list of these 5 other brands does vary, what they have in common is that all contain at least some amount of black elderberry (Sambucus nigra).
As far as personal reviews of Nature’s Answer, Now Foods, Honey Garden, or Natural Sources, we do not have any to share. However, one of us at Superfoodly has used the organic elderberry syrup from Gaia Herbs while sick and his opinion was positive.
Clinical studies to date
The European Medicines agency lists over 70 references “supporting the assessment” of the purported health benefits of elderberry (2). These are not just for the cold, but research ranging from colitis in rats, to the amount anthocyanins and proanthocyanidins (antioxidants) in the fruit.
Outside of the human body (in vitro) it has been found to inhibit several strains of the influenza virus. But just because it works in a laboratory Petri dish, that does not mean it will work in your body.
Since we’re only reviewing it for the common cold and influenza, we’re going to zero in on clinical studies which have been accepted by the U.S. National Library of Medicine for inclusion into their PubMed database.
1995 – Panama flu outbreak
This is the earliest. It was a placebo-controlled and double blind study. It took place at a kibbutz in Panama while an outbreak of the flu (type B) was happening (3).
- To be eligible, a participant must have exhibited at least 3 qualifying flu symptoms of less than 24 hours in duration. If so, they received either the elderberry treatment or a placebo.
- 40 people participated; 20 received Sambucol and 20 received a placebo.
- They ranged from 5 to 56 years of age.
- After it began, some participants were not counted due to inconsistent treatment, other medications being used, or because they ended up testing negative for a virus.
- Ultimately there were 15 people counted who had received the elderberry (all had influenza type B) and 12 who had placebo (2 had influenza type A, 10 had type B)
- 93.3% of the treatment group showed “significant improvement of the symptoms, including fever” within 2 days.
- 91.7% of the of the placebo group showed improvement but it took 6 days.
Many alternative medicine enthusiasts have compared the results of the elderberry extract vs. Tamiflu (oseltamivir phosphate), since the latter is a prescription medication that is known to shorten how long you’re sick for.
However it is very premature to compare those two. This is a tiny study involving a couple dozen people, while Tamiflu is a medication which has undergone regulatory scrutiny and extensive (as well as very large) clinical trials throughout the world.
So while the results of Sambucol may look promising here, keep in mind this is a very preliminary study.
2001 – side effect on cytokines
If elderberry juice does work for colds and other viruses, why does it work? Yes, the ORAC value of elderberries, which is a laboratory measurement of its antioxidant content, is about 300% that of blueberries. But how much antioxidant activity it may have has nothing to do with antiviral activity.
Some speculate it may be the effect elderberries have on cytokines.
What are cytokines? In Greek, “cyto” means cell and “kinos” means movement… cell movement. That’s exactly what they do.
Cytokines are types of proteins which are released by cells of our immune system. Think of these cytokines as a chemical messenger. They go and tell other immune system cells to “move” and do things – like fight an infection.
In a nutshell, some theorize that having higher amounts of cytokines might boost immunity function.
This study is not specific to any type of viral infection. It looked at the effect of black elderberry on the immune system of healthy people (4).
12 participants who were “young and healthy” students were given a non-proprietary standard black elderberry extract as well as branded Sambucol products.
- Echinacea for colds is a popular herbal remedy. However the researchers claim that studies similar to this one had shown that Echinacea does not increase cytokine production.
- Using black elderberry extracts, a 2 to 45 fold increase in the production of inflammatory cytokines was observed.
- A standardized extract of the black elderberry had the highest increase. Second place went to the Sambucol original syrup. Third place went to Sambucol Immune System Formula. Last place went to Sambucol Kids, which makes sense; it has the lowest amount of elderberry because it’s a smaller dosage.
Exciting to hear, but again we stress this too is a tiny study. Even if this berry might increase cytokine production, it is only a theory that such an effect might benefit the immune system in fighting the flu or another viral infection.
A similar study by the same researchers was published a year later in 2002. It pitted the same three Sambucol products against two other products claiming to be immune enhancers; Protec and Chizukit N (which contains Echinacea and propolis). The Sambucol products increased the measured cytokines by a higher amount (5).
2004 – Norway’s flu season
This was a randomized, double-blind, placebo-controlled study that took place during a flu season a few years before being published (’99 to ’00) (6).
- Total of 60 patients who were suffering flu-like symptoms for less than 48 hours were enrolled.
- Ages ranged from 18 to 54 years old (around 30 on average).
- After excluding those who were not eligible, there were 26 people who were given elderberry syrup and 28 were given a placebo.
- The elderberry extract dosage was 15 ml taken 4x per day, for a total of 5 days.
On average, those receiving the Sambucol dosage had symptom relief 4 days earlier versus the placebo. This was according to their “Visual Analogue Scale Score” which was based on:
- frequency of coughing
- mucus discharge
- nasal congestion
- aches and pains
- quality of sleep
- global evaluation
How to take elderberry syrup… with or without food? In this study they were instructed to take Sambucol with food. The other study was silent on how to use it.
Also, their need for nasal sprays and painkillers during the illness was “significantly less” than what the placebo patients required.
|Type of medication||How many in placebo group needed it||How many in elderberry group needed it|
As far as bad side effects from Sambucol, the worst reported was that one of the patients hated the taste. No other adverse reactions were reported.
2016 – air travel and catching colds
Don’t you hate it when that guy or gal next you on the plane is coughing and sneezing up a storm. Currently you are healthy, but you may not be after that flight!
This study didn’t look at whether nearby passengers might be safer, but it did look at whether black elderberry might help prevent catching a cold (7).
If they did catch one, they then wanted to see if the supplement might reduce cold symptoms (if they’re coughing and sneezing less, in theory that might help those nearby, right?).
- 312 passengers who were not sick, flying from Australia to an international destination
- Average age was 51 and about two-thirds were women. Hardly any smoked (only 13 out of 312). Average BMI was 25.
- 158 were given an elderberry supplement (capsules) and 154 were given a placebo.
- The brand BerryPharma was used, which appears to only be sold in Europe and other countries outside of North America. Its formula contains Sambucus nigra grown in Austria. Each capsule contained 300 mg of the berry extract (which was 22% polyphenols, i.e. quercetin and its glycosides, rutin) and 15% anthocyanins (i.e. cyanidin and pelargonidin glycosides).
- Unlike the other studies, this evaluated elderberry for cold prevention since dosage began before being sick. Participants took 2 capsules daily for 10 days before travel, 3 capsules per day while traveling and during the four days which followed (total treatment time of 15 to 16 days).
Among all 312 participants, 29 of them (about 9%) got a cold.
Of those who got sick, 17 were on placebo and 12 were on elderberry supplements. Even though the latter got sick less, the difference was not statistically significant.
However the length of time they were sick was significantly lower in the elderberry group versus placebo.
When adding up the total number of sick days among all those who caught a cold, the placebo group had a total of 117 sick days and the elderberry group had 57.
2018 – meta-analysis of trials
To be clear this is not another trial. The one from 2016 remains the most recent.
This is a meta-analysis of all the randomized, controlled clinical trials. (11)
What that means is the researchers pooled the results of all the trials together and evaluated them together.
Here are the trials they included:
For any math geeks out there, what follows are the statistics of the results. You know, how many standard deviations and all that good stuff…
For a translation to plain English, here’s an excerpt from their conclusion:
“This meta-analysis provides evidence that elderberry supplementation at the onset of upper respiratory symptoms substantially reduces overall symptom duration as compared to a control group, with an effect size of 1.717. Flu vaccination status does not significantly alter the effects of elderberry supplementation (ES: 1.721; ES: 1.749). Elderberry supplementation appears to reduce symptoms caused by influenza virus (ES:2.074) substantially more effectively than upper respiratory symptoms caused by the common cold (ES: 0.662).”
What’s the verdict?
Several years ago, the FDA confiscated elderberry juice concentrate from a company in Kansas. Why? Because even after previously being warned, they were allegedly claiming it could treat or prevent the flu and other illnesses (8).
“Products with unapproved disease claims are dangerous because they may cause consumers to delay or avoid legitimate treatments.”
That was quote in the FDA’s news release about the incident. It’s good advice.
Using a Sambucol cold and flu relief dosage might not harm you, but postponing medical treatment can be dangerous for many people, especially the elderly and those who have compromised immune systems (like HIV/AIDs).
With that said, it is understandable why many people are intrigued by the research and studies so far about using black elderberry for the hope of flu prevention, or the hope of shortening how long you are sick with a cold. But the research for those claims is very limited.
There are many customer reviews you can read online which rave about Sambucol brand, Nature’s Answer, Gaia Herbs, and Nature’s Way Sambucus syrup, elderberry capsules and gummies (as well as other brands). But remember a good review is not proof that a product really works.
It might work, but it needs to go through an adequate number of well designed clinical trials to find out for sure.
A 2017 paper which reviewed the data so far summed up nicely where the science currently stands (9):
“While the extent of black elder’s antiviral effects are not well known, antiviral and antimicrobial properties have been demonstrated in these extracts, and the safety of black elder is reflected by the United States Food and Drug Administration approval as generally recognized as safe. A deficit of studies comparing these S. nigra products and standard antiviral medications makes informed and detailed recommendations for use of S. nigra extracts in medical applications currently impractical.”
Someday, hopefully we will know whether or not using elderberry extract helps the common cold or seasonal flu. However as of today, it is unproven for those uses, so please keep that in mind if you choose to use it as a dietary supplement.
Best elderberry syrup brand?
Even though Sambucol appears to be the most studied, we feel there are not enough studies out there in order to decide what the best brand is (or the worst, for that matter). Plus since this ingredient is not yet proven to work for anything, a “good” or “bad” brand is largely a subjective opinion.
That being said, some people prefer organic elderberry supplements. There are a few which are USDA certified organic such as:
If you want the most studied brand though, where can you buy Sambucol? From our experiences, finding these products might involve traveling to multiple pharmacies/grocery stores. What’s for sale at Walmart may be different than Walgreens and Rite Aid pharmacy. Worse yet, some locations may have it while others do not.
Some Whole Foods sell Gaia but aside from that, it can be difficult to find a diverse selection of brands and sizes.
In the product photos featured at the start of this review, we actually had to visit 2 different stores in the Los Angeles area (CVS and Ralphs/Kroger) because one sold Sambucol while the other sold Nature’s Way Sambucus. Neither sold both brands!
Examples of Sambucol brand products for sale:
These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.