Naturopathy: A Critical Appraisal

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Naturopathy: A Critical Appraisal

Postby patoco » Sun Jun 11, 2006 3:14 pm

Naturopathy: A Critical Appraisal

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From Medscape General Medicine™

Special Article

Naturopathy: A Critical Appraisal

Part One

Posted 12/30/2003

Kimball C. Atwood IV, MD

Kimball C. Atwood IV, MD, Anesthesiologist, Newton-Wellesley Hospital, Newton, Massachusetts; Assistant Clinical Professor, Tufts University School of Medicine; Contributing Editor, Scientific Review of Alternative Medicine; Chairman, Committee on the Quality of Medical Practice, Massachusetts Medical Society; email: katwood@partners.org

Disclosure: Dr. Atwood has no financial interests to disclose

Abstract and Introduction

Abstract

Naturopathic medicine" is a recent manifestation of the field of naturopathy, a 19th-century health movement espousing "the healing power of nature." "Naturopathic physicians" now claim to be primary care physicians proficient in the practice of both "conventional" and "natural" medicine. Their training, however, amounts to a small fraction of that of medical doctors who practice primary care. An examination of their literature, moreover, reveals that it is replete with pseudoscientific, ineffective, unethical, and potentially dangerous practices. Despite this, naturopaths have achieved legal and political recognition, including licensure in 13 states and appointments to the US Medicare Coverage Advisory Committee. This dichotomy can be explained in part by erroneous representations of naturopathy offered by academic medical centers and popular medical Web sites.

Introduction

Two naturopaths were recently appointed to the US Medicare Coverage Advisory Committee (MCAC).[1] This contradicts the conclusions of an inquiry made by the US Department of Health, Education, and Welfare (HEW; now the Department of Health and Human Services), the department that houses Medicare itself.

In 1968, naturopaths asked HEW to consider Medicare reimbursement for their practices. The department conducted an investigation and chose not to do so. Its report concluded:

Naturopathic theory and practice are not based on the body of basic knowledge related to health, disease, and health care that has been widely accepted by the scientific community. Moreover, irrespective of its theory, the scope and quality of naturopathic education do not prepare the practitioner to make an adequate diagnosis and provide appropriate treatment.[2]

These conclusions are still valid. Thirty-five years later investigators from Simon Fraser University in British Columbia reported similar findings:

In our research for this chapter, we provided naturopaths and their professional associations ample opportunity to refute the conclusions of several major commissions of inquiry over the years that deemed their therapeutic rationale lacking in scientific credibility. None of our informants was able to convince us that the field had taken these earlier critiques to heart; in fact, precious few seemed to recognize that a problem still exists. [O]ur own bibliographic searches failed to discover any properly controlled clinical trials that supported claims of the profession, except in a few limited areas where naturopaths' advice concurs with that of orthodox medical science. Where naturopathy and biomedicine disagree, the evidence is uniformly to the detriment of the former.

We therefore conclude that clients drawn to naturopaths are either unaware of the well-established scientific deficiencies of naturopathic practice or choose willfully to disregard them on ideological grounds.[3]

What follows is a summary of the current state of "naturopathic medicine." Much of it comes from the position papers and other articles on the Web site of the American Association of Naturopathic Physicians (AANP); from the Textbook of Natural Medicine, the only general textbook of the field, coedited and largely coauthored by one of the Medicare appointees[4,5]; and from the most visible naturopathic school, Bastyr University in Kenmore, Washington, where the coeditor of the Textbook was founder and president and where the other new MCAC appointee is associate dean. Thus, it reflects the health beliefs of these 2 appointees and of the uppermost levels of "naturopathic medicine."

Brief History and Current Status

"Naturopathic physicians" are a recent manifestation of the field known as naturopathy, the origins of which were in the 19th-century German "natural living" movement. Early naturopaths objected to contemporary medical advances, such as the germ theory and vaccinations, but espoused the "water cure," fasting, herbs, homeopathy, colonic "detoxification," and other popular methods of the era.

The content of the field has changed little since then, but the trappings have become modern. A subset of naturopaths now seeks to distinguish itself from "traditional naturopaths": it professes to practice "a distinct form of primary health care," according to the official definition on the Web site of its national organization, the AANP.[6] At the National College of Naturopathic Medicine in Portland, Oregon, "naturopathic physicians" are described as

...primary care physicians, most of whom are in general private practice [and] trained to be the doctor first seen by the patient for general healthcare, for advice on keeping healthy, and for the diagnosis and treatment of acute and chronic conditions.[7]

"Naturopathic doctors" (NDs), as they also call themselves, state that they have received training appropriate to the practice of medicine, including a basic science curriculum equivalent to that taught in medical schools. This training occurs at 1 of 4 schools in the United States or 1 in Canada, each of which offers a 4-year, on-campus curriculum but no significant hospital or residency experience. Four of the schools are not attached to larger universities; the fifth, the University of Bridgeport College of Naturopathic Medicine in Connecticut, is owned by Reverend Sun Myung Moon's Unification Church.

These naturopaths are now licensed in 13 states (Alaska, Arizona, California, Connecticut, Hawaii, Kansas, Maine, Montana, New Hampshire, Oregon, Utah, Vermont, and Washington) and the District of Columbia. Their scope of practice is typically limited only by prohibitions against performing major surgery and prescribing controlled substances. In all of these states they are free to make broad claims of medical expertise. In Washington, an "every category of provider" law forces private insurers to reimburse naturopaths.[9]

The Naturopathic Belief System

Naturopathic beliefs -- including those of "naturopathic physicians" -- are rooted in vitalism, the pre-20th-century assertion that biological processes do not conform to universal physical and chemical principles. Naturopaths describe a "healing power of nature," which is compromised by modern medicine.[10] They state that they "treat the cause of a problem, rather than to merely eliminate or suppress the symptoms."[6] They state that they treat "the whole person." They state that they can "boost the immune system" with herbs and homeopathic preparations. They profess knowledge about preventive medicine that is, implicitly, unknown to medical doctors, public health experts, nurses, nutritionists, and others. They profess special expertise in nutrition and in the use of "natural remedies" made from animal, vegetable, and mineral sources.

Naturopaths invoke a few simplistic theories to explain the causes of disease. These include the actions of ubiquitous "toxins" (including most pharmaceuticals); widespread food allergies; dietary sugar, fat, and gluten; inadequate vitamin and mineral intake; epidemic candidiasis; vertebral misalignments; intestinal "dysbiosis"; imbalances of Qi; and a few others. To diagnose these entities, naturopaths use an assortment of nonstandard methods, among which are iridology or iris diagnosis, which holds that the entire body is represented on the iris of the eye[11]; applied kinesiology, by which an allergy to a food is detected by placing the food particle in one hand of a patient and observing a resulting weakness in the other; hair analysis for alleged toxins and vitamin and mineral deficiencies; electrodiagnosis, which can purportedly detect parasites and other problems by measuring the skin's resistance to a tiny electric current; "live cell analysis"; "pulse" and "tongue" diagnosis; and others.[12,13]

Naturopathic Treatments

Naturopathic treatments include colonic irrigation (enemas) and fasting for "detoxification," hydrotherapy (wrapping part or all of the body in wet towels), homeopathy, acupuncture, chiropractic manipulation, aromatherapy, arduous dietary regimens, intravenous vitamin C, hydrogen peroxide and ozone, whole enzyme pills, herbs, desiccated animal organs, and other "natural remedies." Naturopaths sell these preparations to their clients at a profit, a practice that is both formally approved and joined by the AANP.[14-16]

How does this translate into the practice of naturopathic medicine? The following recommendations and practices are representative:

The repudiation of standard treatments of streptococcal pharyngitis,[17] acute otitis media,[18] and other childhood infectious diseases, offering instead homeopathy, hydrotherapy, and "natural antibiotics" (eg, herbs such as Goldenseal).

Affiliation with the antivaccination movement.[10]

The repudiation of standard treatments of asthma, offering instead, for example, a hydrogen peroxide bath to "bring extra oxygen to the entire surface of the skin, thus making the lungs somewhat less oxygen hungry" or "gems and minerals ... worn as jewelry, or placed around the home in special places."[19] This quotation is from "Articles written by Naturopathic Physicians for the general public" (on the AANP Web site). The author is listed as a "senior editor of the Journal of Naturopathic Medicine, the official publication of the AANP."

Recommendations, by the Bastyr University AIDS Research Center, for treatment of HIV-positive patients with St. John's wort and garlic (both of which have been shown to reduce blood levels of highly active antiretroviral therapy agents), "acupuncture detoxification auricular program," whole-body hyperthermia, "adrenal glandular," homeopathy, "cranioelectrical stimulation," digestive enzymes, colloidal silver, and nearly 100 other dubious methods.[20,21]

Warnings against proven medical and surgical treatments for hypertension, hyperlipidemia, and atherosclerosis, while instead recommending herbs and EDTA chelation.[22]

The insertion of endonasal balloons, followed by their inflation in the nasopharynx, to "release tensions stored in the connective tissue and return the body to its original design," thus curing learning disorders and a host of other problems.[23,24]

Treatment of the acute stroke patient for at least 20 minutes with an "ice-cold compress ... over the carotid arteries under the jaw bone on the neck" (which "may even abort the stroke") and subtle energy medicine.[25] The author of these recommendations is listed as a "senior editor of the Journal of Naturopathic Medicine, the official publication of the American Association of Naturopathic Physicians."

The early detection of multiple sclerosis by "pulse" and "tongue" diagnosis, such as to effect a cure by hydrotherapy, homeopathy, acupuncture, diet, and other methods.[26] The author of these claims is Chief Medical Officer of the Southwest College of Naturopathic Medicine.

The prevention and cure of breast cancer by an assortment of nonstandard tests and "supplements."[27] The author of these claims "has lectured regularly at the Canadian College of Naturopathic Medicine on breast health and stress management."

The treatment of cancer of the prostate with "electrical current in the form of positive galvanism, applied transrectally."[28] This recommendation is from "Articles written by Naturopathic Physicians for the general public" (on the AANP Web site). The author is Chief Medical Officer of the Southwest College of Naturopathic Medicine.

Ubiquitous "toxin" claims, including antifluoridation statements, warnings against most proven pharmaceuticals, and the assertion that "25% of Americans suffer from heavy metal toxicity."[29]

"Natural childbirth care in an out-of-hospital setting" using a "naturopathic approach [that] strengthens healthy body functions so that complications associated with pregnancy may be prevented."[7]

Nearly 100 nonstandard uses for vitamin C recommended by the Textbook of Natural Medicine.[4]

The promotion and sale of "dietary supplements" for virtually all complaints.

Naturopaths have not subjected their basic tenets to critical scrutiny, apparently because they are already convinced that they are correct. For example, the AANP position paper on treatment of streptococcal pharyngitis, offering no supporting evidence, makes this claim: "naturopathic physicians ... have been successfully treating Strep pharyngitis with very low incidence of poststreptococcal sequelae, using various natural antibiotics, and natural immune enhancing therapies, for close to one hundred years ..."[17]

A 1999 survey of the small number of NDs in Massachusetts, performed by 2 investigators from Children's Hospital in Boston, is consistent with these findings. They reported that only 20% of those surveyed would recommend that parents have their children vaccinated and that only 40% would refer a 2-week-old infant with a temperature of 101° F for definitive medical care.[30]

From Medscape General Medicine™

Special Article

Naturopathy: A Critical Appraisal

Part Two

Posted 12/30/2003

Kimball C. Atwood IV, MD

Kimball C. Atwood IV, MD, Anesthesiologist, Newton-Wellesley Hospital, Newton, Massachusetts; Assistant Clinical Professor, Tufts University School of Medicine; Contributing Editor, Scientific Review of Alternative Medicine; Chairman, Committee on the Quality of Medical Practice, Massachusetts Medical Society; email: katwood@partners.org

Disclosure: Dr. Atwood has no financial interests to disclose

........

Implications for Medicare

In an interview for the Seattle Times, one of the new MCAC appointees offered examples of how he might affect the process of selecting therapies for Medicare coverage:

[The new appointee] said he plans to push for more emphasis on prevention and health promotion. He also wants well-proven and cost-effective alternative techniques to be covered by Medicare.

Examples could include natural ear-infection treatments for infants and acupuncture treatments for those suffering sports injuries or drug addiction, he said.[1]

Naturopathic literature suggests that by prevention and health promotion this Medicare adviser is referring to "detoxification," "cleansing programs" for "food allergies" and "candidiasis," enemas, "constitutional" homeopathic preparations, and so forth. "Natural ear-infection treatments for infants" are not only unproved but are implausible and dangerous. Acupuncture treatments for sports injuries are unlikely and unproven, and acupuncture for drug addiction has been convincingly disproved.[31]

Elsewhere, the same appointee recommends a flower pollen extract for benign prostatic hypertrophy,[32] an "intranasal douche with hydrastis tea" for bacterial sinusitis,[33] a "general bowel detoxification diet" for autism,[34] and oral bromelain (a protein extracted from pineapples) for the "lumpy skin around varicose veins."[35] For cervical dysplasia and pelvic inflammatory disease, he recommends "vaginal depletion packs," 1 by 3-inch cotton tampons containing a tar-like mixture of botanical oils, left in place for 24 hours at a time and repeated weekly.[36]

Formal criteria require that appointees to the MCAC be "from among authorities in clinical and administrative medicine, biologic and physical sciences, public health administration, health care data and information management and analysis, the economics of health care, medical ethics, and other related professions."[37] How were the 2 naturopaths selected? On February 18, 2003, I sent a letter to Thomas A. Scully, the Administrator of the Centers for Medicare & Medicaid Services, making points similar to those in this article and implicitly asking that question. There were 30 cosignatories.* Mr. Scully had not replied as of December.

*Lee S. Anderson, Marcia Angell, Seth Asser, Robert Baratz, R. Christopher Barden, Stephen Barrett, Heather Brock, Carl E. Bartecchi, Henry N. Claman, E. Patrick Curry, John E. Dodes, Bruce L. Flamm, Laura J. Fochtmann, Timothy Gorski, Saul Green, Arthur P. Grollman, James J. Kenney, Jeffrey M. Lohr, Janice Lyons, Peter Madras, Frederick L. Merian, Steven Novella, Arnold Relman, John A. Robinson, Barbara Rockett, Francis X. Rockett, Linda Rosa, Wallace Sampson, Sally Satel, Gerald Weissmann

Dissent From the White House Commission on Complementary and Alternative Medicine Policy

Two dissenting members of the recently adjourned White House Commission on Complementary and Alternative Medicine Policy warned, in a letter to Department of Health and Human Services Secretary Tommy Thompson, of the problems introduced by official endorsements of naturopaths and other "complementary and alternative medicine" (CAM) practitioners:

Vulnerable Populations

Patients will often resort to "CAM" practices, modalities and practitioners upon the diagnosis of a debilitating, chronic or terminal condition. Recent Senate hearings have documented the special vulnerability of the elderly [emphasis added] on fixed-incomes to these phenomena.

[CAM practitioners] are not positioned for equivalency with conventional primary care providers. Efforts to equate their degree of training, or the scientific basis of their practice, with that of the designated primary care specialties puts the public at risk of receiving unvalidated and non-evidence based primary care.

... "CAM" "health promotion" and "prevention practices" also include preventing disease by "balancing qi," "eliminating parasites and toxins," "cleansing the liver" and/or by "cleansing the blood" via a multitude of supplements and questionable practices. Our uncritical acceptance of "CAM" wellness and health promotion can be interpreted as an endorsement of these claims. It is absolutely unclear what role, if any, "CAM" practices play in preventing disease and to what extent patients are burdened with useless treatments and products in their pursuit of "wellness."

In sum, generic pronouncements about "CAM" neither serve the public interest nor protect the public health. It is essential to separate the effective from the ineffective, the safe from the unsafe and to contextualize these practices against conventional modalities before [emphasis added] any of them can be recommended for incorporation into the Nation's healthcare system.[38]

Even if Medicare itself successfully resists the efforts of its new advisers, their appointments are already being trumpeted to the public as evidence that the federal government considers naturopathic practices to be valid.[39,40] This will likely help naturopaths in their pursuit of universal state licensure and reimbursement by health insurers. Because licensed health care providers determine their own standards of care,[41] it would be detrimental to the public if naturopaths were successful in this pursuit.[42]

Comment

"Naturopathic medicine" is an eclectic assortment of pseudoscientific, fanciful, and unethical practices. Implausible naturopathic claims are still prevalent and are no more valid now than they were in 1968. The current wave of unexamined CAM fascination, however, appears to have helped naturopaths convince some that they have special abilities and that they are trained to be primary care physicians.

Most treatises on naturopathy that physicians and the public are likely to read are uncritical promotions that simply restate what naturopaths claim. Yet these views are found on the Web sites of academic medical centers and the large commercial sites for the general public. For several years, the Caregroup/Harvard Medical School Web site urged readers, without further comment, to "please consult your local telephone yellow pages" for "naturopathic physicians" and other CAM practitioners.[43] The Web site of the University of Washington School of Medicine portrays "naturopathic physicians" as well trained to practice "primary care integrative natural medicine," with a "scope of practice [that] includes all aspects of family and primary care, from pediatrics to geriatrics, and all natural medicine modalities." It further asserts that "naturopathic diagnosis and therapeutics are supported by scientific research drawn from peer-reviewed journals from many disciplines."[44] None of these statements can withstand rigorous scrutiny.

InteliHealth, a joint venture between Harvard Medical School and Aetna, promises to "[provide] credible information from the most trusted sources."[45] As recently as the spring of 2002 InteliHealth stated, "NDs are trained as family physicians"; they "treat the whole patient, not just the disease symptoms"; they "successfully combine so many therapies"; "Naturopathic doctors throughout the country are becoming increasingly recognized as primary care providers." The article suggested that if the reader were already consulting an ND, she might reasonably choose not to see an MD.[46] When InteliHealth replaced this article with a new one, it did so without explanation, failing to warn readers of the dangers of having trusted the previous information. The replacement article, moreover, approvingly describes naturopaths as "[concentrating] on principles of holistic health (pertaining to body, mind and soul), prevention and self-care." It does not address the serious shortcomings of the field.[47]

WebMD, the parent corporation of Medscape, offers this:

A naturopathic doctor often combines many different complementary therapies to enhance the body's natural vital force.

A licensed naturopathic physician (ND) attends a 4-year, graduate-level naturopathic medical school and is educated in the same basic sciences as a medical doctor (MD).[48]

Naturopathic medicine is used for health promotion, the prevention of disease, and treatment of illness. Most naturopaths can treat earaches, allergies, and other common medical problems. Naturopathic medicine tries to find the underlying cause of the person's condition rather than focusing solely on symptomatic treatment.[49]
The WebMD treatise also advises, "Naturopathy should not replace conventional methods of treatment for certain conditions,"[49] but how is the patient to know? The assumption is that naturopaths will act responsibly, but they have neither the medical training nor the requisite scientific skepticism to do so. On the contrary, they portray themselves as primary care physicians. The unwary reader might conclude that naturopaths are trained to provide "conventional methods" when appropriate, but NDs have had only a small fraction of the training of primary care MDs. Instead they have been steeped in homeopathy and other highly implausible, ineffective practices. It is unlikely that readers of WebMD and the other sources mentioned here will appreciate this dichotomy.

The National Center for Complementary and Alternative Medicine (NCCAM) has had 3 naturopaths on its advisory council in the past 3 years.[50] It proposes to conduct research into CAM methods advocated by "licensed/certified CAM practitioners (Doctors of chiropractic, naturopathy, [etc.])."[51] The NCCAM advises citizens who consult CAM practitioners to ask about licensure or certification early in the process.[52]

Like the NCCAM, WebMD also admonishes readers to seek only licensed naturopaths: "without licensing standards, individuals with little or no formal education may proclaim themselves naturopathic physicians without medical school education or board testing."[48] The clear message is that such licensing implies competence. There is, however, no evidence that "educated" naturopaths -- the most prominent of whom provided the clinical examples for this article -- are more competent than others.[9] If anything, "traditional naturopaths" (ie, those who did not attend the "approved" schools) may be less of a threat to public health because they do not pretend to be primary care physicians.

Graduates of campus-based, 4-year naturopathic programs who have passed a standardized examination may demonstrate consistency from one practitioner to the next. But that says nothing about the validity of what they do -- which can be determined only by reference to the facts of nature and by rigorous testing of biologically plausible claims. At least one leading CAM researcher has acknowledged this fact:

Those who believe that regulation is a substitute for evidence will find that even the most meticulous regulation of nonsense must still result in nonsense.[53]

Conclusion

This is the first article in a mainstream medical journal that critically summarizes the field of "naturopathic medicine." If physicians continue to consider naturopaths and other "alternative" practitioners as inconsequential -- or, if the only articles on CAM that most physicians read are uncritical -- pseudoscience will continue to make inroads into patient care and health policy. The information presented herein illustrates why official sanctioning of naturopaths as health care providers, including their appointments to the MCAC, should be considered unwise.
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