Mad Honey as an Alternative Treatment in Turkey’s Black Sea Region: What Ugur et al. (2019) Found

Documentation of how deli bal is used in Turkey’s Black Sea communities runs parallel to the clinical literature on grayanotoxin poisoning, but it is much thinner, and the most direct evidence comes from a questionnaire survey of hospital patients rather than from ethnographic fieldwork. Emergency medicine case series have characterised the adverse effects of mad honey, and poisoning has followed ordinary use as food, such as on bread or in tea, as well as use as a remedy (EFSA 2023). Claims for its health benefits are centuries old (Jansen et al. 2012).

The main source for this page is Ugur et al. (2019), who surveyed 353 patients attending a pulmonary disease clinic in Ordu province between December 2014 and February 2015. An ethnobotanical study of 165 informants in Güce district, Giresun, carried out between 2018 and 2021, also recorded local views on mad honey (Karaköse 2022). Ugur and colleagues interviewed participants face to face with a 17-question form covering whether they used mad honey, why, how often, how much per use, and whether they had ever been poisoned by it. Neither study set out to interview traditional healers.

Key Takeaways

• Among 157 mad honey users in the Ordu survey, the stated purposes were nutrition (49.7%), asthma (28.7%), gastrointestinal disorders (12.1%), cough (6.4%) and hypertension (3.2%) (Ugur et al. 2019). Local beekeepers in another study ranked sexual performance as the most common reason for therapeutic use among men aged 41 to 60 (Demircan et al. 2009).
• Of those users, 22.9% said they had been poisoned by mad honey; dizziness was the symptom most often recalled, and 16.7% of those poisoned saw a doctor (Ugur et al. 2019).
• None of these uses is supported by controlled clinical trials; scientific evidence for the medicinal properties of grayanotoxin-containing preparations is scarce (Jansen et al. 2012).
• The survey evidence is limited: the Ordu sample was clinic patients who agreed to take part, answers were self-reported, and the honeys were not analysed for grayanotoxin (Ugur et al. 2019).
• Poisoning cases reported in Europe in recent decades are mainly linked to honey imported from Turkey or Nepal, and none has been reported from honey of EU origin (EFSA 2023).

Contents

1. Reported Uses
2. Amounts Reported and Adverse Effects
3. Limitations of the Evidence
4. Relevance to Current Research and Practice
5. Sources

Reported Uses

Hypertension is among the uses most often named in reviews of Black Sea mad honey (EFSA 2023; Silici and Atayoglu 2015), and the Güce ethnobotanical study recorded that mad honey is regarded locally as dangerous but is eaten in small amounts to reduce blood pressure (Karaköse 2022). In the Ordu survey, however, only 3.2% of users named hypertension as their reason (Ugur et al. 2019). In the Ordu survey, 53.5% of users took mad honey daily, 16.6% once a week, 9.6% once a month and 20.4% once a year, for whatever purpose (Ugur et al. 2019). Hypotension and bradycardia are among the most common signs of mad honey poisoning (Jansen et al. 2012), so a fall in blood pressure is an expected effect, but it is the same effect that brings poisoned users to hospital. Whether mad honey as used in folk practice produces clinically meaningful blood pressure change has not been tested in controlled trials.

Gastrointestinal complaints are also commonly cited: 12.1% of users in the Ordu survey took mad honey for gastrointestinal disorders (Ugur et al. 2019). Deli bal is reported to have been used for peptic ulcers, gastritis, stomach pain and indigestion (Ullah et al. 2018; Ugur et al. 2019). No controlled clinical data exists to support or refute these traditional GI indications.

Sexual performance is a further reason, and among middle-aged men it may be the main one: ten local beekeepers surveyed by Demircan et al. (2009) ranked sexual performance enhancement as the most common reason for therapeutic use in men aged 41 to 60, and 18 of the 21 poisoning patients in that study were men. Patients may be reluctant to report this use (Eroglu et al. 2013). The aphrodisiac claims associated with deli bal lack clinical evidence (Jansen et al. 2012). They should be understood as folk tradition rather than evidence-based indication.

Reviews also list diabetes, heart failure, asthma, cough, colds and arthritis among its folk uses (EFSA 2023; Ullah et al. 2018; Ugur et al. 2019). Which use dominates depends on who is asked: among patients at a pulmonary clinic, the most common reason other than nutrition was asthma, which the authors say may reflect the setting (Ugur et al. 2019), while beekeepers pointed to sexual performance in middle-aged men (Demircan et al. 2009).

Amounts Reported and Adverse Effects

Asked how much they took each time, 36.3% of users in the Ordu survey said one teaspoon, 34.4% one dessert spoon and 29.3% one tablespoon (Ugur et al. 2019). These are reported habits, not safe amounts: the same paper cites case reports in which a single teaspoon was enough to cause poisoning, and the grayanotoxin in a spoonful depends on the honey.

People in the eastern Black Sea region are familiar with the symptoms of mad honey poisoning (EFSA 2023, citing Gunduz et al. 2006, 2007, 2008). Among Ordu users who had been poisoned, the symptoms recalled were dizziness (33.3%), nausea and vomiting (22.2%), weakness (13.9%), blackouts (13.9%) and fainting (8.3%). Half waited at home for the symptoms to pass, a third drank buttermilk, a traditional remedy, and 16.7% saw a doctor (Ugur et al. 2019). Clinical treatment is saline infusion and atropine (Gunduz et al. 2008). Among the users surveyed in Ordu, 22.9% reported at least one episode of mad honey poisoning (Ugur et al. 2019).

Limitations of the Evidence

The published documentation of deli bal use is subject to several important limitations. The Ordu survey used no sampling method, recruited only patients attending one pulmonary clinic between December 2014 and February 2015, and relied on self-report (Ugur et al. 2019). Spoon sizes are approximate and the honeys were not analysed, so the same spoonful can carry very different amounts of grayanotoxin: Turkish mad honeys measured by Aygun et al. (2018) ranged from 0.17 to 20.22 µg/g grayanotoxin I and from 0.00 to 75.46 µg/g grayanotoxin III.

The evidence on generational change is mixed. In Güce, traditional knowledge of medicinal plants was found to be declining among younger people (Karaköse 2022), but in the Ordu survey mad honey users and non-users had almost the same mean age, 56.8 and 57.2 years (Ugur et al. 2019).

Relevance to Current Research and Practice

The survey literature serves several functions for current researchers and practitioners. It shows that mad honey use is common in at least one Black Sea province: 44.5% of the Ordu patients had used it, and about half of those users took it for a health reason rather than as food (Ugur et al. 2019). It also shows that poisoning is common enough among local users for the authors to recommend that health professionals counsel people on its risks (Ugur et al. 2019).

Sources

• Aygun A, et al. (2018), Grayanotoxin levels in blood, urine and honey and their association with clinical status in patients with mad honey intoxication. Turkish Journal of Emergency Medicine 18(1):29-33.
• Demircan A, et al. (2009), Mad Honey Sex: Therapeutic Misadventures From an Ancient Biological Weapon. Annals of Emergency Medicine 54(6):824-829.
• EFSA CONTAM Panel (2023), Risks for human health related to the presence of grayanotoxins in certain honey. EFSA Journal 21(3):7866.
• Eroglu SE, et al. (2013), Grayanotoxin (Mad Honey) – Ongoing Consumption After Poisoning. Balkan Medical Journal 30(3):293-295.
• Gunduz A, et al. (2006), Mad honey poisoning. The American Journal of Emergency Medicine 24(5):595-598.
• Gunduz A, et al. (2008), Clinical review of grayanotoxin/mad honey poisoning past and present. Clinical Toxicology 46(5):437-442.
• Jansen SA, et al. (2012), Grayanotoxin Poisoning: ‘Mad Honey Disease’ and Beyond. Cardiovascular Toxicology 12(3):208-215.
• Karaköse M (2022), An ethnobotanical study of medicinal plants in Güce district, north-eastern Turkey. Plant Diversity 44(6):577-597.
• Silici S, Atayoglu AT (2015), Mad honey intoxication: A systematic review on the 1199 cases. Food and Chemical Toxicology 86:282-290.
• Ugur HG, et al. (2019), Investigation of mad honey use as an alternative treatment in patients admitted to the pulmonary clinic: Ordu, Turkey example. Brazilian Archives of Biology and Technology 62:e19180488.
• Ullah S, et al. (2018), Mad honey: uses, intoxicating/poisoning effects, diagnosis, and treatment. RSC Advances 8(33):18635-18646.