Introduction

Triphala, also known as “triphala churna,” is one of the most popular formulas in Ayurveda. Proponents tout that it has health benefits for all three of Ayurveda’s dosha* constitutions. Triphala is most commonly known as a gentle bowel tonic, being helpful in digestion, and supporting regular bowel movements.

The combination of the three fruits purportedly has a synergistic effect to bolster many other systems as well: to support healthy respiratory, cardiovascular, urinary, reproductive, and nervous systems. It’s been used in the treatment of diabetes and to promote oral health. It has also been suggested as a natural cancer treatment and protectant.

Is there any scientific proof to validate these claims? Let’s take a look at the literature.

*In Ayurveda there are Three Doshas: Vata, Pitta, and Kapha. The doshas are biological energies found throughout the human body and mind. They govern all physical and mental processes and provide every living being with an individual blueprint for health and fulfillment.

What Is Triphala?

Literally meaning “three fruits,” Triphala is a traditional Ayurvedic herbal formulation consisting of equal parts of three fruits native to the Indian subcontinent: Amalaki (Emblica officinalis), also known as Amla or Indian Gooseberry, Bibhitaki, (Terminalia belerica) and Haritaki (Terminalia chebula).

It has been used in India for over 1000 years. According to the great physician Charak in his foundational text Charaka Samhita, taking the Triphala Rasayana (Triphala with honey and ghee) each day has the “potential to make a person live for one hundred years devoid of old age and diseases.”[1] Sushut, in the book Sushruta Samhita, claims that the “formula is useful for treating ulcers and wounds.”[1]

Phenolic acids, flavonoids and tannins are the most commonly found polyphenolic compounds in the plant extracts. It contains about 38% polyphenols and 35% tannins.[2] The polyphenolic acids include gallic acid, ellagic acid, and chebulinic acid. These are all considered antioxidants and may contribute to the proposed medicinal effects of Triphala. Other bioactive compounds include the flavonoids quercetin and luteolin, saponins, anthraquinones, amino acids, fatty acids, and various carbohydrates.[1]

The rasa (taste) of Triphala is considered sweet, sour, pungent, bitter, and astringent. It does not contain a salty flavor.

Traditionally, Triphala is used in a number of forms: churna (fine powder), kwatha (decoction), mashi (ash), taila (oil) and gritha (Triphala cooked with clarified butter or Ghee)[3]. It is also currently available for sale in liquid, tablet, and powdered forms.

Is There Any Research?

A search of PubMed using the term “triphala” revealed 151 articles. Of these, 9 studies were considered “clinical trials.” Of these nine, most are related to triphlala’s use as a mouthwash for oral health. The first paper was written in 1963 and is entitled, “A Study on the Purgative Activity of Triphala.”[4]  On clinicaltrials.gov, there are three clinical trials. Two concern the use of Triphala in mouthwash form.

The other, which is in the recruiting phase is a “Pilot Study of Triphala and Rubia Cordifolia on Gut Microbiome and Skin.” BTW: Rubia Cordifolia, also known as Indian madder, is a flowering plant in the coffee family. It is an important source of red pigment in many regions of Asia and its roots are used in Ayurvedic medicine for treatment of disorders of the blood and lymph.

In comparison, a PubMed search of rifaximin, a drug used to treat a variety of gastrointestinal disorders such as irritable bowel disease, brings up 1136 entries. One hundred and fifty-five of them are clinical trials. There are 94 trials on the clinicaltrials.gov site.

Does Triphala Protect Against Heartburn and Acid Reflux?

I found only two preclinical papers that studied the any gastroprotective effect of Triphala. The first, in 2009, by Nair et al [5] used a polyherbal formulation called NR-ANX-C. It is composed of the extracts from Withania somnifera, Camellia sinensis, Ocimum sanctum, shilajith and Triphala.

Rats were subjected to one of two ulcer-producing scenarios: either induction of ulcers with aspirin or by ligation (tying off) the part of the stomach called the pylorus.  Aside from a control group who were untreated, other groups received NR-ANX-C in one of three doses or with the reflux medications ranitidine (Zantac) or omeprazole (Prilosec).

Each group was “evaluated in terms of antioxidant potential as assessed in terms of protection from lipid peroxidation and the antiulcer activity as seen by the area of gastric lesions, gastric juice volume, gastric pH, total acidity and total adherent gastric mucus content.”

They found that NR-ANX-C was as effective (or more effective) than omeprazole or ranitidine, respectively. There were dose-dependent decreases in gastric juice volume and acidity, gastric pH and lipid peroxidation. The main problem with this study is, of course, that they are using a polyherbal formulation, so we don’t really know what role Triphala plays in all this.

The second paper, by Nariya et al [6] looked at the gastroprotective effect of Triphala in rats. Gastric ulcers were induced by water immersion for a period of 14 hours. Treated rats received either: Triphala equal (equal amounts of all 3 components), Triphala unequal (1-part chebula, 2 parts T. belerica, and 4 parts E. officinalis), Chinnhodbhavadi kwath (equal portions of T. chebula, T. belerica, E. officinalis, T. cordifolia, A. indica and T. dioica), or omeprazole.

According to the authors, “Rats pretreated with Triphala unequal formulation (P<0.05) and Chinnodbhavadi kwath (P<0.05) showed significant reduction in ulcer index when compared with the stress control group. Triphala equal formulation exhibited a moderate non-significant decrease in ulcer index.” The findings are not dramatic, and once again, in one preparation, Triphala is mixed with other herbal ingredients.

Bottom line

There are no human studies to support the claim that Triphala protects against acid reflux and heartburn. Animal studies have not shown dramatic improvement and are plagued by using polyherbal formulations.

Can It Treat Cancer?

There are no human trials that examine whether Triphala can be used in the treatment of cancer. There are several in vitro studies (a process performed in a test tube, culture dish, or elsewhere outside a living organism) that look at Triphala’s effect on various cancer cell lines such as human breast [7], colon [8], prostate and pancreas[9].

The data show that Triphala reacts differently with cancer cells than normal ones. It can induce cytotoxicity (cell death) in cancer cells by increasing reactive oxygen species (ROS)* inside those cells, while being nontoxic in normal breast cancer and pancreatic ductal epithelial cell lines. [9] The cytotoxic effects may be mediated through the ERK and p53 pathways [10].

*Reactive oxygen species are a type of unstable molecules that contains oxygen and that easily reacts with other molecules in a cell. A buildup of reactive oxygen species in cells may cause damage to DNA, RNA, and proteins, and may cause cell death. Reactive oxygen species are free radicals.

Shi et al [9] also did an in vivo study of Triphala in nude mice, a strain with a genetic mutation which results in a disabled immune system.. A small amount of pancreatic tumor cells was injected under the skin in both flanks of female mice.

They were divided into three groups: Group 1: Control. Group 2: Received 50mg/kg Triphala five times a week. Group 3: Received 110mg/kg five times a week. Treatment started on the day the tumor cells were injected. Tumors which resulted were measured three times a week and the mice were weighed twice a week. “Our results demonstrate that the growth of tumor was significantly inhibited in the mice that were treated with Triphala as compared with the growth of tumors in control mice.”

The tumor volume in treated mice was approximately half the size of untreated mice. Tumor material from treated and untreated mice were further examined by immunohistochemistry* and western blotting**. They found significantly higher amounts of apoptotic bodies (a sign of cell death) in treated tumor. They also observed getting staining for ERK and p53, suggesting an activation of those systems.

*Immunohistochemistry involves the process of selectively imaging antigens (proteins) in cells of a tissue section by exploiting the principle of antibodies binding specifically to antigens in biological tissues.

**The western blot is a widely used analytical technique used in molecular biology, immunogenetics and other molecular biology disciplines to detect specific proteins in a sample of tissue homogenate or extract.

There is one other aspect that relates Triphala to cancer is that Triphala may help prevent DNA damage induced by radiation. In theory, this could be useful for patients undergoing radiation therapy. As above, studies have only been done in test tubes and in lab animals.

Takauji et al [11] found that Triphala eliminated reactive oxygen species (ROS) in HeLa cells (cervical cancer cells) exposed to ionizing X-radiation. Naik et al [12] found that Triphala inhibited radiation-induced lipid peroxidation in rat liver microsomes and demonstrated the ability to scavenge free radicals such as superoxide.

In animal models, another paper by Sandhya [13] showed that treatment of mice with Triphala prior to whole-body gamma-irradiation reduced radiation-induced mortality by 60%. Yoon et al [14] demonstrated that rats treated with 5 or 10 days of Triphala prior to receiving ionizing radiation showed significantly reduced signs of intestinal damage.

Two papers by Jagetia et al [15] [16] showed that feeding Triphala before irradiation decreased radiation sickness and mortality in mice, and they concluded that the antioxidant and free radical scavenging activities of Triphala contribute to its protective effect.

Bottom line

Although there are some promising resulting in vitro and in animal studies, there are no clinical trial to show the efficacy of Triphala as a treatment or radioactivity protector in humans. Large scale placebo controlled double blind studies are needed.

Does It Help Cleanse the Colon?

The term “cleanse the colon” is one that is often used, but seldom used in a medically appropriate way. According to Dr. Michael Picco of The Mayo Clinic: “Colon cleansing is normally used as preparation for medical procedures such as a colonoscopy. However, some alternative medicine practitioners offer colon cleansing for other purposes, such as detoxification.

But colon cleansing — also called a colonic or a colonic irrigation — for such purposes isn’t necessary. That’s because your digestive system and bowel already eliminate waste material and bacteria from your body.”

Nevertheless, as Triphala has been used for centuries as a digestive aid in Aryuvedic medicine, there have been a few studies to look at the effect of Triphala on the colon, often with mixed results. Mehmood et al [17] focused on the P. emblica component of Triphala. Their in vivo studies on guinea pigs and rabbits showed that P. emblica stimulated bowel motility at lower doses but caused relaxation of the bowel at higher doses.

Rayudu and Raju [18] studied the effect of Triphala as a treatment for colitis induced in the oral administration of 3% dextran sulfate sodium (DSS) in rats.

They found that “The colitis rats treated with higher dose of Triphala (300 mg/kg) exhibited normal parameters similar to normal control group animals, which is on par with standard drug mesalzine effect.” They believed that flavonoids in Triphala have anti-oxidant and anti-inflammatory actions which lead to these findings.

Westfall, Lomis and Prakash [19] looked at a pre- and probiotic formulation which consisted of Lactobacillus plantarum, Lactobacillus fermentum and Bifidobacteria infantis along with Triphala as a prebiotic. They studied the effect of formulation on the gut microbiota of Drosophila melanogaster (fruitfly).  You can read a quick primer on microbiomes in the digestive section of my article on Cranberry. They found that Triphala supported growth of beneficial bacterial while inhibiting pathogenic species. They also noted enhanced gut motility.

Have any research studies been done with human subjects? Very few. Munshi et al. [20] enrolled 31 otherwise healthy individuals with functional constipation. They were followed using two scales, a visual analogue scale to assess subjective measurements such as degree of straining with bowel movements, sensation of incomplete evacuation, sensation of blockage toilet and associated symptoms like acidity, belching flatulence and bloating.

Measurable scores included number of bowel movements/week, time spent on the toilet, and the “Bristol Stool Form Scale” (see image). All subjects were treated with 14 days of Triphala along with Isabgol husk (psyllium) and Senna extract, and assessed at the start, 7 days, 14 days, and 21 days after the baseline visit.

The results showed that treatment with the polyherbal formulation significantly increased (P>0.05) the mean weekly bowel frequency by 65% after one week and almost 80% by two weeks. Stool form was significantly improved and there was also significant improvement in straining, sensation of incomplete evacuation, sensation of blockage, time spent on toilet and associated.

At 21 days, improvement scores decreased but remained above the baseline level. It’s hard to decide what to make of these results as there are no controls, and the study is not double blind. Also, might I point out the obvious that psyllium and senna are both components of many laxatives such as Metamucil® and Senekot®.

Mukherhjee et al [21] studied 160 patients between 16 and 52 years of age. They were divided into 4 groups of 40. Group one was a control group. Group II and III (M1 and M2) received Triphala readily available in the market from two different companies, Group IV (IH) received Triphala made in house by the researchers.

They received treatment for 45 days. Mixed responses were observed with different preparations of Triphala on bowel movement and wellbeing.

There was significant improvement in the amount, frequency, and consistency of stool in all triphala treated groups compared to controls. There was also improvement in the amount or presence of mucus in stool and flatulence in Groups II, III, and IV compared to controls, but no significant changes were found in other parameters.

Most recently, Tarasiuk et al [22] did a review of the literature focused on the components of Triphala’s effectiveness and therapeutic value for improving lower GI symptoms in functional GI disorders, especially irritable bowel disease (IBS).

They postulate that since Triphala is rich in polyphenols, vitamin C and flavonoids, it provides antioxidant and anti-inflammatory effects. Likewise, the acids in it- gallic, chebulagic and chebulinic acids may possess cytoprotective and antifungal properties.

They conclude that Triphala “holds potential in improving lower GI symptoms and may be a valuable and effective addition to standard treatment of IBS. Supplementation of TLP herbal formulations alone or along with other probiotics can be recommended in ongoing clinical studies.”

Bottom Line

Although Triphala has been traditionally used for the relief of gastrointestinal ailments, there is limited, and sometimes contradictory scientific evidence to support the claims. As there is some preclinic work to support it, large scale double blind placebo controlled human studies should be undertaken.

Does It Help Reduce Cholesterol?

I was able to find only three scientific papers related to the effect of Triphala on cholesterol. The first, by Saravanan et al [23] looked at the effect of Triphala on the cholesterol levels in normal and experimentally induced hypercholesteremic rats. Rats were divided into 4 groups- 1. Normal rats, 2. Normal rats treated with triphala for 48 days, 3. Rats fed a high cholesterol diet, and 4. Rats on high cholesterol diet treated with Triphala for 48 days.

Triphala-fed mice had significantly lower triglyceride and VLDL levels vs. normal control animals. Total cholesterol, HDL, and LDL levels were not significantly changed. In hypercholesterolemic rats (all of whom had abnormal lipid parameters), those treated with Triphala had significant decreases in total cholesterol, triglycerides, LDL, and VLDL levels.

The second, by Tanaka et al [24] looked only at the Terminalia billirica component of Triphala. They looked at the effect of Terminalia billirica extract (TBE) on LDL oxidation and inflammation in macrophages.

A microphage is a type of white blood cell, of the immune system, that engulfs and digests cellular debris, foreign substances, microbes, cancer cells, and anything else that does not have the type of proteins specific to healthy body cells on its surface. They found radical scavenging activity and lipoxygenase inhibitory activity, which they suggest that it might “inhibit atherosclerosis plaque progression.”

Lastly, there is a paper by Auti et al [25]. I have a hard time knowing what to think about this paper. It compares the effect on hypercholesterolemia of two formulations- Lekhana Basti vs.Triphala. Lekhana Basti is an ayurvedic preparation which contains honey, rock salt, Triphaladya Taila, Putoyavanyadi Kalka (a paste of herbs), Triphala Kwath, Gomutra (cow’s urine), 6 other ingredients. In this study, Triphala is used as the control formulation! Nineteen patients were given either Lekhana Basti (LB) or Triphala (TP) for 21 days.

Cholesterol profiles were obtained before and after the trial, and the patients were also measured for body weight, body mass index, body fat and body circumferences of the chest, abdomen, hip, pelvis, and thighs as well as skin fold thickness.  Those treated with LB had a 5% decrease in serum cholesterol and 9% decrease in LDL compared to those receiving Triphala. “Significant effect on body weight, BMI, BMR, body fat %, skinfold thickness, and body organ measurement was seen” in LB compared to TP patients, on the order of about 3%.

Bottom Line

There is insufficient evidence to support the use of triphala in the treatment of elevated cholesterol.

Does It Help Weight Loss?

There were three papers that looked at the effect of Triphala on weight loss (not including Auti’s paper above [25] where Triphala is used in both the test and control groups). Banjare et al [26] did an in vitro study of a adipose cell tissue line (3T3-L1). They used a mixture of dexamethasone, isobutylmethylxanthine and insulin to induce adipogenesis (growth of fat cells).

Some of the induced cells were also treated with varying concentrations of an aqueous extract of Triphala.  They then measured the amount of fat present. 3T3-L1 cells treated with Triphala had a decrease in the amount of fat in the cells compared to induced controls. They also assessed the amount of mRNA for four genes known to be involved in adipogenesis. They found treatment with Triphala decreased mRNA for these genes in a dose dependent manner. They conclude that Triphala “regulated lipid accumulation by down regulating expression of adipogenesis.”

Gurjar, Pal and Kapur [27] looked at the effect of Triphala as well as each of its three individual components (amalaka, haritaki and bibhitaki) on diet-induced obesity in mice. All mice (except for those in a control group- normal diet ND) were fed a high fat diet (HFD)for 10 weeks, beginning at 7 weeks of age.

Of these mice, one was left untreated (HFD), while the others received Triphala (HFD + T) or one of its three components (HFD + A, HFD+ H or HFD+ B). The researchers found that mice fed a HFD treated with Triphala or any of its components had a significant reduction in body weight (P<.0001), energy intake, and percentage body fat (P<.001) compared to those only on a HFD.

Kamali et al [28] is the only study done with human subjects. They used “Itrifal Saghir” an Iranian preparation of Triphala. Sixty-two obese subjects (ages 16-60) were divided into two groups for a 12-week, double-blind, randomized, placebo-controlled trial. Subjects either took 5 grams/day of Itrifal Saghir or placebo.

They found that the treatment group had a mean difference of effective weight loss of 4.82kg (10.6 lbs) compared to controls. The mean decrease in waist circumference was 4.01 cm (1.58 inches) and hip circumference was 3.21 cm (1.26 inches).

Bottom line

There is some preclinical studies which point to Triphala as being useful for weight loss.  The single clinical trial seems to support this. It would be nice to see additional clinical trials confirm this.

Does It Help Arthritis Sufferers?

“Arthritis” means joint inflammation. Although joint inflammation is a symptom or sign rather than a specific diagnosis, the term arthritis is often used to refer to any disorder that affects the joints. There are many types of arthritis, including ankylosing spondylitis, gout, juvenile arthritis, osteoarthritis, psoriatic arthritis, reactive arthritis, and rheumatoid arthritis.

Many of these causes have an autoimmune basis, while others (such as osteoarthritis) may be due to physical factors. Because there are many types and causes of arthritis, researchers have looked at several ways to assess whether Triphala can help arthritis sufferers.

Kalaiselvan and Rasool [29] looked at the effect of Triphala on bone and cartilage degradation in arthritic rats. Arthritis was induced in the paw pads of rats by injecting a solution called Freund’s adjuvant.  Eleven through twenty days later, the rats were injected in the abdomen with Triphala. The subjects were monitored for inflammatory marker enzymes and after the trial the paw tissue was examined radiologically (by x-ray) and histopathologically (under a microscope).

As expected, they noted a decrease in bone collagen and increased inflammatory markers in the arthritic rats. However, treatment with Triphala significantly inhibited the inflammatory enzyme markers (even compared to the anti-inflammatory indomethacin) and analysis of the radiological and histopathological specimens showed significant improvement as well.

Sumantran et al [30] did in vitro testing of the effect of Triphala on two enzymes: hyaluronidase and collagenase. These enzymes are thought to contribute to cartilage degradation. An assay utilizing gel electrophoresis* was used to measure the levels of these enzymes. Triphala and some of its individual components (particularly T. chebula) was found to significantly inhibit these two enzymes. They propose that Triphala can have chondro-protective properties.

*Gel electrophoresis:Gel electrophoresis is a laboratory method used to separate mixtures of DNA, RNA, or proteins according to molecular size. In gel electrophoresis, the molecules to be separated are pushed by an electrical field through a gel that contains small pores.

Other research groups (Ingale et al [31], Kalasiselvan and Rasool [29, 32]) looked at the  immunomodulatory effects of Triphala as a model for treatment of arthritis. Ingale used a cell line of rabbit synoviocytes (specialized cells in the lining of joints which normally produce lubricin, a crucial protein for joint lubrication).

They measured the effect of Triphala on the activity of collagenase type II, levels of the free radical nitric oxide (NO), and levels of lipid peroxidase. These mediators play a role in the break down and inflammatory processes which take place in osteoarthritis.

Treatment with Triphala (as well as three other Aryrvedic formulations) improved the levels of these mediators. They conclude from this that all the selected Ayureda formulations “were found to be effective in controlling synovitis, to reduce oxidative stress and to arrest cartilage-loss; three pivotal pathologies associated with OA.” It seems to me to be a bit of a leap to go from results in a test tube to a pronouncement of clinical efficacy.

Kalasiselvan , using the same technique to induce arthritis in rats as he did in the previous study, also looked at the effect of Triphala on lipid peroxidation, antioxidant levels and lysosomal enzymes. As in Ingale’s study, the addition of Triphala reduced abnormal levels of the above mediators to control levels, similar to the results obtained with indomethacin.

Bottom line

The small number of in vitro and in vivo studies show that Triphala appears to modify the effect of mediators that are involved in the inflammation and joint destruction found in arthritis. Unfortunately there are no human studies and so I can’t recommend it at this time.

Is Triphala Safe?

Overall, Triphala has a good safety profile. The most common side effect may be loose stools or gastrointestinal upset.

Kamili’s trial [28] of Itrifal Saghir in the treatment of obesity followed liver and kidney function during their 12 week trial. They found no adverse effects or significant changes. Likewise, Munshi’s study of Triphala in patients with functional constipation [20] none of the patients reported any adverse events during the entire study duration.

Conclusion

Triphala is a formulation of three fruits used for centuries in Ayurvedic medicine. It has been used as a bowel tonic as well as a booster for the respiratory, cardiovascular and nervous systems. Although in vitro and animal studies have shown some promising results, there are very few clinical trials and most are not large scale nor are they double-blind, random, or placebo controlled studies. These need to be done before we can say that research supports the medicinal claims.

Fortunately, Triphala has a good safety profile, so if you wish to try Triphala, it is probably safe to do so. It is always best to speak to your healthcare provider before beginning any new supplements.