“Bak Kut Teh” a-day books your future THR at bay?

Goh B.H. Goh B.B

Department of Orthopedics and Traumatology Sri Rampai Mediviron Clinic
University Malaya Medical Centre Jalan Sri Rampai
Jalan Lembah Pantai 59100 Setapak Malaysia
Kuala Lumpur

Bak Kut Teh is the Hokkien dish literally translates to Pork Rib Tea, a rich herbal
soup containing dong quai (Angelica Sinensis), known for its warming properties
along side many other herbs. For this reason, it is popularly eaten as breakfast, supper
or late night meal in Malaysia and Singapore. Overall, there are not many herbs which
steroidal activities are well established; among these – most cases were based on
preclinical studies.

Pic 1: Bak Kut Teh – Pork ribs tea

Pic 2: (a) examples of active ingredients of the dish (b) common extra ingredients of Bak Kut
Teh. (BKT varies in ingredients depending on regions)

Steroid-induced osteonecrosis of the femoral head has been one of the common
cause for osteonecrosis hip after trauma ending up with arthroplasty of hip. Numerous
hypotheses for the pathogenesis of this disease have been proposed but the exact
mechanism of steroid-induced osteonecrosis of the femoral head is still remains
unclear. The pathophysiology remains controversial and different mechanism are
proposed including:
 Abnormality of bone marrow stem cells pool
  Hyperlipidemia
 Fat emboli
 Hypercoagulability
 Vascular endothelial dysfunction
 Apoptosis of bone tissue

Figure 1: Pathophysiology of steroid associated osteonecrosis with different pathway

and causes. BMSC (bone marrow stem cells); VEGF (Vascular endothelial growth
factor )

Among all the risk factors reported, oxidative stress disorders may be one of the
most common one participated, which may benefit more when intervened. These
steroidal components which are told to be found in these traditional medications in
long term usage are said to contribute to osteoarthritis, osteonecrosis and
osteoporosis.
Based on the currently minimal available evidence, very few herbs used in TCM
have clinically relevant steroidal activities but questionable in long term contribution
to significant osteonecrosis, especially the hip. Few studies on Ginseng, Dong Quai
and Epimedium have shown an absence of clinically detectable estrogenic activities,
despite the presence of estrogenic compounds in these herbs. Case reports published
had shown that liquorice exerts mineralocorticoid effects, while deer musk contains
androgenic compounds. The present evidence on the steroidal activity of many other
herbs is generally limited to animal studies, which have yet to be collaborated by
clinical studies for their clinical relevance. Relatable herbs to Bak kut Teh are “Dong-
Quai” (Angelica Sinensis), Star Anise, Ginseng and Cordyceps Sinensis which are the
active and popular ingredients in the dish.
Dang Quai also known as “Angelica Sinensis” is the main herbal ingredient of
BKT, often used in gynaecological conditions like peri-menopausal and menstrual
disorders. Its constituent which is Ferulic acid, exhibits oestrogenic activity – working
via several mechanism:
  Stimulates growth breast cancer cells in vitro
 Induces transcription activity in oestrogen responsive cell in vitro
 Suppresses luteinizing hormones (LH secretions)
 Influencing uterine growth and vaginal cytology
Few studies had shown despite the oestrogenic activities in humans, it did not reflect
on the blood oestrodiol level in comparison with placebo – neither did it promotes
gynaecological cellular changes.
Ginseng are generally use for wellness in individuals with fatique. Its constituents
are mainly Panaxynol and Ginsenosides. This had been specifically isolated and were
found to be functional ligands to glucocorticoid receptors in vitro. Animal studies had
shown different mechanism of its effect on steroid synthesis with contradictory
conclusions. To date no clinical report had reported that ginseng consumptions leads
to Cushing syndrome. Ginseng however had shown oestrogenic activities via
stimulation of biosynthesis of estrogen in circulation via increasing estrogen receptor
(ER) in target organs. Studies had seen its benefit on improvement on menopausal
symptoms but nothing conclusive in increased steroidal activities leading to
osteonecrosis of the hip.
Cordyceps Sinensis, a herb of fungal/mushrooms base – are most of the time used
in the ingredient of BKT. In Traditional medicine practice – they are regarded as a
prized tonic that is indicated for people with poor respiratory health and weakness.
Animal studies reported that the extract of this herb has a stimulatory effect on the
adrenal glands and increases the cortisone level. However no clinical reports on its
corticosteroidal activities. However its constituent Cordycepin had found to had
stimulated testosterone secretions as well and testis volume in rats, otherwise
corresponding clinical reports on these effects are still lacking.
Based on current data, Ginseng, Anglican sinensis mainly had shown absence of
clinically detectable oestrogenic activities despites its oestrogenic compound but more
significant steroidal pathway activities. Of all the very few herbs with reported
steroidal effect, Liquorice is one that exerts mineralocorticoid activities, while deer
musk contains androgenic compunds. However this 2 herbs are not active ingredients
in BKT. Summary of the popular herbs reviewed:

Table 1: A summary of the herbs reviewed.

Herb Active compound Steroidal activity Highest level of evidence found*

Liquorice root (Radix glycyrrhizae, Gan Cao 甘草) Glycyrrhizin Mineralocorticoid Level 4
Level 5
Glucocorticoid
Ginseng (Radix Panax ginseng, Ren Shen 人参) Ginsenoside Level 2: absence of clinical
Oestrogenic
oestrogenic effect
Cordyceps (Cordyceps sinensis, Dong Chong Xia Cao Corticosteroidal
Cordycepin Level 5 Level 5
冬虫夏草) Androgenic
Testosterone, epitestosterone,
Deer musk (Moschus, She Xiang 麝香) Androgenic Level 4
androsterone, epiandrosterone, DHEA
Deer antler (Cornu cervi pantotrichum, Lu Rong 鹿茸) Testosterone, androsterone Androgenic Level 5
Level 2: absence of clinical
Epimedium (Herba epimedii, Yin Yang Huo 淫羊藿) Icariin, icaritin, icariside Oestrogenic
oestrogenic effect
Chinese angelica (Radix Angelicae sinensis, Dang Gui Level 2: absence of clinical
Ferulic acid Oestrogenic
当归) oestrogenic effect

*Level 1: systematic review of randomised trials; Level 2: randomised controlled trials; Level 3: cohort studies; Level 4: case series/reports; Level
5: animal or in vitro studies

The present evidence on steroidal activity of many herbs is generally limited to in

vitro and animal studies, which is yet to collaborate by clinical studies and relevance.
Increased steroid in circulation had proven to cause steroid induced boney diseases,
mostly osteonecrosis, osteoporosis and osteoarthritis. These herbs in BKT already had
shown steroidal activities in its compound despite not detectable yet in circulation.
Question is when the consumption of BKT as a cultural and staple norms, likes of the
city of Klang, Selangor in Malaysia. In such community, some people takes it as an
everyday staple breakfast or meal. Large community primary long term food habit,
contributes to steroid induced osteonecrosis? No recent study had demonstrated these
herbs to be adversely affecting the bone. Pathogenesis through disruption to
steroidogenesis pathway causing osteonecrosis is hypothesized but cant be proven at
this moment . Consumption of Chinese herbal ingredients in moderation is adviced.

Key words: Herbs, Osteonecrosis, steroid-induced

Reference:

 Roti & Rice: Bak Kut The – The detailed herbs guide. January 4 2014.
https://www.rotinrice.com/bak-kut-teh-pork-ribs-tea/
 Foon YF et Yeh CL. Steroid in traditional Chinese medicine: whats the
evidence? Singapore Med J 2017; 58(3): 115-120
 Goh SY, Loh KC. Gynaecomastia and the herbal tonic “Dong Quai”.
Singapore Med J 2001; 42: 115-116
 Xu , Ding J. treatment of Panax ginseng antagonizing oestrogen decline in
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