Herb Seed (种子 zhǒng zǐ / 子 zǐ / 仁 rén)

Hei Zhi Ma

Black sesame seeds · 黑芝麻

Sesamum indicum L. · Semen Sesami Nigrum

Also known as: Hu Ma (胡麻), Hu Ma Ren (胡麻仁), Zhi Ma (芝麻),

Hei Zhi Ma (Black sesame seeds) plant

Images shown are for educational purposes only

Black sesame seeds are a mild, food-grade tonic widely used in Chinese medicine to nourish the Liver and Kidneys, strengthen the essence and Blood, and gently moisten the intestines. They are commonly taken for premature greying of hair, dizziness, tinnitus, and dry constipation, especially in older adults or those recovering from prolonged illness. Because of their neutral temperature and pleasant flavour, they are one of the most approachable tonics and are easily incorporated into everyday cooking.

Category Tonifying herbs (补虚药) Yin-tonifying herbs (补阴药)
Therapeutic focus Hair Health Digestive Regularity Healthy Aging Bone and Joint Health

TCM Properties

Temperature

Neutral

Taste

Sweet (甘 gān)

Channels entered

Liver, Kidneys, Large Intestine

Parts used

Seed (种子 zhǒng zǐ / 子 zǐ / 仁 rén)

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Educational content • Consult qualified TCM practitioners for diagnosis and treatment

What This Herb Does

Every herb has a specific set of actions — here's what Hei Zhi Ma does in the body, explained in both everyday and TCM terms

Therapeutic focus

In practical terms, Hei Zhi Ma is primarily used to support these areas of health:

Hair Health Digestive Regularity Healthy Aging Bone and Joint Health

TCM Actions

In TCM terminology, these are the specific therapeutic actions that Hei Zhi Ma performs to restore balance in the body:

Nourishes Liver and Kidney Yin Nourishes Essence and Blood Moistens the Intestines and Unblocks the Bowels Blackens the hair and benefits the eyes

How these actions work

'Tonifies the Liver and Kidneys' means Hei Zhi Ma replenishes the essence (Jing) stored in the Kidneys and the Blood stored in the Liver. In TCM, the Kidneys govern the bones, marrow, and hair, while the Liver opens to the eyes and governs the sinews. When Liver and Kidney essence and Blood become depleted, a person may experience dizziness, tinnitus, blurred vision, weak and sore lower back and knees, or premature greying. Hei Zhi Ma is sweet and neutral, making it a gentle, food-grade tonic that nourishes these organ systems without being too heating or too cooling.

'Nourishes essence and Blood' refers to the herb's ability to replenish the fundamental substances that maintain the body's vitality. In TCM theory, black-coloured foods are understood to have a special affinity for the Kidneys. Hei Zhi Ma's rich, oily nature allows it to deeply moisten and nourish, making it particularly useful for conditions of depletion such as premature greying of hair, hair loss after illness, and general weakness in older adults.

'Moistens the intestines and unblocks the bowels' describes the herb's lubricating effect on the digestive tract. Because Hei Zhi Ma is rich in oils, it can soften and lubricate dry stools. This is especially relevant for elderly individuals or those recovering from illness whose constipation stems from insufficient Blood and body fluids rather than from excess heat. It gently promotes bowel movements without harsh purgation.

Patterns Addressed

In TCM, symptoms cluster into recognizable patterns of disharmony. Hei Zhi Ma is used to help correct these specific patterns.

Why Hei Zhi Ma addresses this pattern

When the Liver and Kidneys lack sufficient Yin and essence, a person may develop dizziness, tinnitus, blurred vision, premature greying, and weakness in the lower back and knees. Hei Zhi Ma directly addresses this pattern through its sweet flavour, which tonifies and nourishes, combined with its specific affinity for the Liver and Kidney channels. Its neutral temperature means it replenishes Yin without introducing excess cold, making it suitable for long-term use. In TCM, black-coloured substances are understood to have a particular connection to the Kidneys, further supporting Hei Zhi Ma's role as a Kidney essence tonic.

A practitioner would look for one or more of these signs

Premature Greying of Hair

A hallmark sign of Liver-Kidney Yin and essence depletion

Dizziness

From insufficient essence failing to nourish the brain and marrow

Tinnitus

The Kidneys open to the ears; depleted essence causes ringing

Blurry Vision

The Liver opens to the eyes; insufficient Liver Blood dims vision

Commonly Used For

These are conditions where Hei Zhi Ma is frequently used — but only when they arise from the specific patterns it addresses, not in all cases

Arises from: Heart and Kidney Yin Deficiency

TCM Interpretation

In TCM, the colour and lustre of hair depend on the health of two organ systems: the Kidneys, which govern hair growth and colour through their stored essence (Jing), and the Liver, which nourishes hair through its stored Blood. When Kidney essence declines prematurely or Liver Blood becomes depleted, the hair loses its pigmentation and turns grey or white before its time. This is why TCM calls hair 'the surplus of Blood' and 'the outer manifestation of the Kidneys.' Stress, overwork, chronic illness, and natural aging can all deplete these vital substances.

Why Hei Zhi Ma Helps

Hei Zhi Ma directly targets the Liver and Kidney channels, replenishing the essence and Blood that give hair its colour. Its sweet, neutral nature makes it safe for the prolonged use needed to gradually restore depleted stores. In TCM tradition, black-coloured foods are thought to have a particular affinity for the Kidneys. The classical formula Sang Ma Wan (桑麻丸) pairs Hei Zhi Ma with mulberry leaf specifically for premature greying and hair loss, illustrating the herb's central role in this application.

Also commonly used for

Hair Loss

Especially post-illness alopecia from Blood and essence depletion

Dizziness

From Liver-Kidney Yin deficiency

Tinnitus

Associated with Kidney essence insufficiency

Blurry Vision

From Liver Blood and Kidney Yin depletion

Osteoporosis

Traditional use for strengthening bones via Kidney tonification

Insufficient Lactation

Traditional use for Blood deficiency causing low milk supply

Dark Skin

From Blood deficiency failing to moisten the skin

Herb Properties

Every herb has an inherent temperature, taste, and affinity for specific channels — these properties determine how it interacts with the body

Temperature

Neutral

Taste

Sweet (甘 gān)

Channels Entered

Liver Kidneys Large Intestine

Parts Used

Seed (种子 zhǒng zǐ / 子 zǐ / 仁 rén)

Dosage & Preparation

These are general dosage guidelines for Hei Zhi Ma — always follow your practitioner's recommendation, as dosages vary based on the formula and your individual condition

Standard dosage

9-15g

Maximum dosage

Up to 30g per day in decoction for severe constipation or significant Blood and Essence deficiency, under practitioner guidance.

Dosage notes

Standard dose of 9-15g is used for general Liver-Kidney supplementation and nourishing Blood and Essence. For intestinal dryness and constipation, the higher end of the range (12-15g, or up to 30g) may be used. Should always be crushed or ground before decocting or ingesting, as the intact seed coat prevents proper absorption of nutrients and active compounds. The traditional 'nine steamings and nine sun-dryings' processing method enhances digestibility, reduces the greasy nature of the oils, and is preferred for long-term tonic use. Due to its high oil content, daily intake should generally not exceed 15g as a food supplement to avoid digestive burden and excessive caloric intake.

Preparation

Should be crushed or ground before use (用时捣碎). Whole seeds will pass through the digestive tract largely unabsorbed due to the hard seed coat. When used in decoctions, crush first and add with the other herbs. For pills and powders, dry-roast until fragrant and lightly popping, then grind to a fine powder.

Processing Methods

In TCM, the same herb can be prepared in different ways to change its effects — here's how processing alters what Hei Zhi Ma does

Processing method

Clean black sesame seeds are dry-fried over gentle heat until they begin to pop and release a fragrant aroma. They are then removed from heat and crushed before use.

How it changes properties

Dry-frying enhances the aromatic, nutty flavour and makes the oils more available for absorption. The temperature remains Neutral, but the tonic action on the Liver and Kidneys is enhanced, and the intestinal moistening effect becomes more pronounced. Raw sesame seeds are harder for the body to digest due to their intact seed coat; frying cracks the coating and improves bioavailability.

When to use this form

This is the standard clinical form used in most prescriptions and is recommended over the raw form for all therapeutic applications. It should be crushed before decocting or taking as powder to ensure the oils and nutrients are released.

Common Herb Pairs

These ingredients are traditionally combined with Hei Zhi Ma for enhanced therapeutic effect

He Shou Wu
He Shou Wu 1:1 (equal parts)

He Shou Wu (Polygonum multiflorum) and Hei Zhi Ma together provide a powerful Liver-Kidney tonic combination. He Shou Wu strongly tonifies Liver Blood and Kidney essence, while Hei Zhi Ma supplements this with gentle Yin nourishment and intestinal lubrication. Together they address the full spectrum of Liver-Kidney depletion symptoms.

When to use: Premature greying of hair, hair loss, weak lower back and knees, and dizziness from Liver-Kidney essence and Blood deficiency.

Sang Ye
Sang Ye Sang Ye 4 : Hei Zhi Ma 1 (in Sang Ma Wan)

Sang Ye (Mulberry leaf) clears Liver heat and calms Liver Yang, while Hei Zhi Ma nourishes Liver and Kidney Yin from below. One clears and one nourishes, creating a balanced approach that addresses both the branch (ascending Liver Yang) and the root (underlying Yin deficiency). This is the classical pairing in the formula Sang Ma Wan.

When to use: Dizziness, blurred vision, dry eyes, premature greying, and hair loss from Liver-Kidney Yin deficiency with mild Liver Yang rising.

Rou Cong Rong
Rou Cong Rong 1:1

Rou Cong Rong (Cistanche) warms the Kidney Yang and moistens the intestines, while Hei Zhi Ma nourishes Kidney Yin and lubricates the bowels with its oils. Together they address constipation from both Yang and Yin deficiency, providing comprehensive intestinal lubrication without being overly warming or cooling.

When to use: Chronic constipation in elderly patients with Kidney deficiency, especially when both Yin and Yang are weak.

Sang Shen
Sang Shen 1:1

Both Sang Shen (Mulberry fruit) and Hei Zhi Ma tonify the Liver and Kidneys, nourish Yin, augment Blood, and moisten the intestines. Sang Shen is slightly cool and enters the Blood level more strongly, while Hei Zhi Ma is neutral and enters the Kidneys to replenish essence and marrow. Together they provide deeper nourishment from two complementary angles.

When to use: Liver-Kidney Yin deficiency with premature greying, dizziness, tinnitus, and dry constipation.

Comparable Ingredients

These ingredients have overlapping uses — here's how to tell them apart

Huo Ma Ren
Hei Zhi Ma vs Huo Ma Ren

Both Huo Ma Ren (hemp seed) and Hei Zhi Ma moisten the intestines and relieve constipation. However, Huo Ma Ren is primarily classified as a moistening laxative with stronger bowel-lubricating action but minimal tonic properties. Hei Zhi Ma is classified as a Yin tonic that also happens to moisten the intestines. Choose Hei Zhi Ma when constipation accompanies Liver-Kidney deficiency with greying hair, dizziness, or tinnitus. Choose Huo Ma Ren when the primary goal is relieving intestinal dryness constipation without the need for Liver-Kidney tonification.

Sang Shen
Hei Zhi Ma vs Sang Shen

Both tonify the Liver and Kidneys, nourish Blood and Yin, and moisten the intestines. Hei Zhi Ma is neutral in temperature and particularly enters the Kidneys to replenish essence and marrow, making it better for premature greying and bone weakness. Sang Shen is slightly cool and enters the Blood level more directly, giving it a stronger Blood-nourishing and mildly cooling effect. Sang Shen is preferred when there is more Blood deficiency or mild heat, while Hei Zhi Ma is better for Kidney essence depletion.

Gou Qi Zi
Hei Zhi Ma vs Gou Qi Zi

Both Gou Qi Zi (Goji berry) and Hei Zhi Ma tonify the Liver and Kidneys, benefit the eyes, and nourish essence. Gou Qi Zi is slightly warm and has a stronger action on benefiting the eyes and brightening vision, and also has some Lung Yin nourishing effect. Hei Zhi Ma is neutral and has stronger intestinal moistening action due to its high oil content. For vision problems from Liver-Kidney deficiency, Gou Qi Zi is often preferred; for constipation with Liver-Kidney deficiency, Hei Zhi Ma is more appropriate.

Common Substitutes & Adulterants

Related species and common adulterations to be aware of when sourcing Hei Zhi Ma

The most clinically important distinction is between black sesame (Hei Zhi Ma, the black seeds of Sesamum indicum) and flaxseed/linseed (Ya Ma Zi, Linum usitatissimum), which was historically also called 'Hu Ma Zi' in some texts, creating significant confusion. The two have different botanical sources and somewhat different therapeutic actions: both moisten the intestines, but black sesame uniquely supplements Liver and Kidney and nourishes Blood, while flaxseed focuses more on nourishing Blood and dispelling wind. They can be distinguished by size, shape, and color: flaxseeds are slightly larger, more flattened, and reddish-brown. Black sesame may also be adulterated with cheaper dyed white sesame seeds. Authentic black sesame, when rubbed between wet fingers, will only lightly tint the water; heavily dyed imitations leave strong black color immediately.

Educational content — always consult a qualified healthcare provider or TCM practitioner before using any herb.

Toxicity Classification

Classical Chinese pharmacopoeia toxicity rating for Hei Zhi Ma

Non-toxic

Black sesame is classified as non-toxic in the Chinese Pharmacopoeia and has a long history as both food and medicine. It contains no known toxic alkaloids or harmful compounds at standard doses. The main safety consideration relates to its very high oil content (approximately 50-55% fat by weight): excessive consumption may cause digestive discomfort, oily stools, or exacerbate conditions related to excess sebum production. Sesame oil cake fed to livestock in large quantities has been reported to cause gastrointestinal distress in animals, but this is not a concern at human medicinal doses.

Contraindications

Situations where Hei Zhi Ma should not be used or requires extra caution

Caution

Chronic diarrhea or loose stools (Spleen deficiency with dampness). Black sesame is rich in oils and has a moistening, bowel-lubricating nature. In people with weak digestion and a tendency toward loose stools, it can worsen diarrhea.

Caution

Chronic enteritis or inflammatory bowel conditions with active diarrhea. The high oil content and intestine-moistening action can aggravate these conditions.

Caution

Seborrheic alopecia (oily scalp hair loss). Excessive consumption of black sesame, which contains over 50% fat, may increase sebum production, potentially worsening oily scalp conditions and seborrheic dermatitis.

Caution

Excessive phlegm-dampness or obesity with greasy tongue coating. The rich, oily nature of black sesame can further generate dampness and phlegm in those already burdened with these pathogenic factors.

Special Populations

Important considerations for pregnancy, breastfeeding, and pediatric use

Pregnancy

Generally considered safe at standard dietary and medicinal doses. Black sesame is a common food item and there is no traditional contraindication during pregnancy. Some classical texts actually list it among foods beneficial during pregnancy for nourishing Blood and moistening dryness. However, as with all oily and intestine-lubricating substances, very large doses should be avoided to prevent excessive bowel loosening.

Breastfeeding

Considered safe and traditionally beneficial during breastfeeding. Classical sources such as the Ben Cao Gang Mu specifically record black sesame as a remedy for insufficient breast milk (妇人乳少). Its Blood-nourishing and moistening properties are thought to support lactation. No known concerns about harmful substances transferring through breast milk.

Children

Black sesame is considered safe for children and is widely used as a nutritious food for growing children. It is rich in calcium, iron, zinc, and essential fatty acids beneficial for development. For medicinal use in children, reduce the dose proportionally by age (typically one-third to one-half of the adult dose). Best administered crushed or ground, as whole seeds pass through the digestive tract unabsorbed. Can be given as sesame paste, porridge, or mixed into food. No specific age restrictions are traditionally noted.

Drug Interactions

If you are taking pharmaceutical medications, be aware of these potential interactions with Hei Zhi Ma

No well-documented serious drug interactions have been reported for black sesame at standard medicinal doses. However, the following theoretical considerations apply:

  • Anticoagulant/antiplatelet medications: Black sesame contains vitamin E and unsaturated fatty acids that may have mild blood-thinning effects. While clinically significant interaction is unlikely at standard doses, patients on warfarin or similar medications should be aware of this possibility.
  • Antidiabetic medications: Preclinical and some clinical evidence suggests sesame and its lignan sesamin may lower blood glucose. Patients taking insulin or oral hypoglycemics should monitor blood sugar if consuming large amounts regularly.
  • Antihypertensive medications: Some meta-analyses suggest sesame may modestly reduce blood pressure. An additive effect with antihypertensive drugs is theoretically possible at high doses.

Dietary Advice

Foods and dietary considerations when taking Hei Zhi Ma

Avoid eating large amounts of cold, raw, or greasy foods alongside black sesame, especially if the goal is to nourish the Spleen and Stomach. Since black sesame is already very oily, combining it with other high-fat foods may cause indigestion, nausea, or loose stools. Pairing it with easily digestible foods like congee (rice porridge) or warm soups supports absorption. People using black sesame to address premature graying or hair loss should also ensure adequate protein intake from other sources. Reduce intake if experiencing loose stools or abdominal bloating.

Botanical Description

Physical characteristics and morphology of the Hei Zhi Ma source plant

Sesamum indicum L. (Pedaliaceae family) is an erect annual herbaceous plant that grows 60 to 150 cm tall. The stem is upright and distinctly four-angled (quadrangular), sometimes branching depending on the cultivar. Leaves are opposite, varying from ovate to lanceolate, 3 to 10 cm long, with a green upper surface and paler underside.

Tubular flowers, white to pale pink or purple, appear one to three at a time in the leaf axils during summer. The fruit is an erect, pubescent capsule approximately 2 to 8 cm long, rectangular in cross-section, containing numerous small seeds arranged in compartments. When ripe, the capsules split open (dehisce) to release the seeds. The medicinal product consists of the small, flattened oval seeds (about 3 mm long, 2 mm wide) with a distinctive black seed coat. The plant thrives in warm climates with well-drained soils, tolerates drought well, and is widely cultivated across tropical and subtropical regions.

Sourcing & Harvesting

Where Hei Zhi Ma is sourced, when it's harvested or collected, and how to assess quality

Harvesting season

Autumn (August to September), when the fruit capsules turn yellowish-black and begin to ripen.

Primary growing regions

Widely cultivated throughout China except the Tibetan Plateau. Major production areas include Henan (especially Zhumadian and Pingyu County, considered the premier terroir for sesame), Shandong, Hubei, Anhui, Jiangxi, Hebei, and Sichuan provinces. Pingyu County in Henan is historically regarded as the optimal growing region, earning the title 'Sesame King of the Central Plains' due to its ideal sandy-black soils, warm climate, and abundant sunlight. Globally, black sesame is also produced in India, Sudan, and Myanmar.

Quality indicators

Good quality black sesame seeds are uniformly black with a smooth, glossy surface or fine reticulate (net-like) wrinkles. Seeds should be plump, full, and roughly uniform in size (about 3 mm long, 2 mm wide), with an intact flattened oval shape. When the thin black seed coat is broken, the interior cotyledons should be white, oily, and rich-looking. The seeds should have a mild, pleasant, slightly sweet and nutty aroma with a distinctly oily taste. Avoid seeds that are shriveled, dusty, dull in color, broken, or have a rancid smell indicating oxidized oils. Seeds from Henan (especially Pingyu County) are traditionally considered the highest quality, with higher anthocyanin content and richer oil composition.

Classical Texts

Key passages from the classical Chinese medical texts that describe Hei Zhi Ma and its therapeutic uses

Shen Nong Ben Cao Jing (《神农本草经》)

Original: 胡麻，味甘平无毒。主伤中虚羸，补五内，益气力，长肌肉，填脑髓。久服，轻身不老。

Translation: Sesame (Hu Ma). Sweet in flavor, neutral in nature, non-toxic. It treats damage to the interior and wasting, supplements the five organs, boosts strength, grows muscle flesh, and fills the brain marrow. With prolonged use, it lightens the body and prevents aging.

Ben Cao Gang Mu (《本草纲目》, Li Shizhen)

Original: 胡麻取油以白者为胜，服食以黑者为良。

Translation: For pressing oil, white sesame is superior; for medicinal consumption, black sesame is best.

Shen Nong Ben Cao Jing Shu (《神农本草经疏》, Miao Xiyong)

Original: 胡麻，益脾胃，补肝肾之佳谷也。

Translation: Sesame is an excellent grain that benefits the Spleen and Stomach and supplements the Liver and Kidney.

Ben Cao Bei Yao (《本草备要》)

Original: 补肝肾，润五脏，滑肠。明耳目，乌须发，利大小肠，逐风湿气。

Translation: Supplements Liver and Kidney, moistens the five organs, lubricates the intestines. Brightens the ears and eyes, blackens the beard and hair, benefits the large and small intestines, and expels wind-dampness.

Ben Cao Xin Bian (《本草新编》)

Original: 芝麻性润而汁乌，乌自入肾，既入肾，自能润髭矣，况又通任督之脉乎。

Translation: Sesame is moistening in nature and its juice is dark. Darkness naturally enters the Kidney; once it enters the Kidney, it naturally moistens the beard. Moreover, it also opens the Ren and Du vessels.

Historical Context

The history and evolution of Hei Zhi Ma's use in Chinese medicine over the centuries

Black sesame has one of the longest documented histories of any medicinal food in Chinese medicine. It was first recorded in the Shen Nong Ben Cao Jing (circa 1st-2nd century CE) under the name 'Hu Ma' (胡麻, literally 'barbarian hemp'), listed as an upper-grade (上品) herb. The name 'Hu Ma' reveals its origin story: according to the Qi Min Yao Shu, Zhang Qian brought sesame seeds back to China from the Western Regions (modern-day Uzbekistan) during the Han Dynasty (around 2nd century BCE). The prefix 'Hu' (胡) designated goods from Central Asian lands. The Southern Dynasties physician Tao Hongjing praised it as the finest of all grains, declaring it 'foremost among the eight grains' (八谷之冠).

Considerable confusion arose in classical literature about whether 'Hu Ma' and 'Ju Sheng' (巨胜) were the same plant. Tao Hongjing's Ben Cao Jing Ji Zhu distinguished them by seed color, while the Tang dynasty pharmacist Su Jing differentiated them by capsule shape. Eventually, Song dynasty scholars such as Su Song and Kou Zongshi concluded that the two names referred to the same plant. Li Shizhen's Ben Cao Gang Mu agreed, settling the debate.

A famous traditional processing method, 'nine steamings and nine sun-dryings' (九蒸九晒), was described in Ge Hong's Bao Pu Zi (4th century CE). This labor-intensive technique was believed to make the seeds more digestible and enhance their tonic properties. The Song dynasty pediatrician Qian Yi used sesame in his Bai Xiang Wan formula for childhood diseases, and countless classical formulas for premature graying pair black sesame with He Shou Wu for nourishing Liver and Kidney.

Modern Research

4 published studies investigating the pharmacological effects or clinical outcomes of Hei Zhi Ma

1

Systematic review and meta-analysis of sesame on glycemic control (2022)

Sohouli MH, Haghshenas N, Hernandez-Ruiz A, Shidfar F. Journal of Food Biochemistry. 2022;46(3):e13897.

A meta-analysis of 8 controlled clinical trials found that sesame consumption significantly reduced fasting blood glucose (by about 21 mg/dl) and HbA1c levels, though it did not significantly affect insulin resistance. The interventions included sesame oil, sesamin supplements, and tahini over periods of 45 days to 9 weeks.

PubMed
2

Meta-analysis of sesamin supplementation on blood pressure and lipid profile (2022)

Sun Y, Ren J, et al. Frontiers in Endocrinology. 2022;13:842152.

A systematic review and meta-analysis of 7 randomized controlled trials (212 participants) examined sesamin's effects on cardiovascular risk factors. Results showed potential benefits for lowering total cholesterol and LDL-cholesterol, though findings across trials were not fully consistent. Sesamin lignans were identified as the key bioactive compounds.

3

Meta-analysis of sesame on cardiovascular risk factors (2021)

Khosravi-Boroujeni H, et al. Complementary Therapies in Medicine. 2021;59:102743.

An updated meta-analysis of randomized controlled trials found that sesame intake significantly decreased total cholesterol, triglycerides, systolic and diastolic blood pressure, body weight, and BMI compared to control groups. The authors concluded sesame consumption may reduce cardiovascular disease risk.

PubMed
4

Meta-analysis of sesame on inflammatory biomarkers (2021)

Rezaei S, et al. Journal of Inflammation Research. 2021;14:5643-5660.

This meta-analysis of 7 RCTs (310 participants) found that sesame consumption significantly reduced serum interleukin-6 (IL-6) levels. Effects on CRP and TNF-alpha were not significant overall, though subgroup analyses suggested benefits with sesamin capsules, larger sample sizes, and female participants.

Research on individual TCM herbs is growing but still limited by Western clinical trial standards. These studies provide emerging evidence and should be considered alongside practitioner expertise.