Lay out the welcome mat: naturopathy has come in from the cold

Naturopathic teachers, practitioners and companies should ensure that better evidence becomes available. b dd b/Flickr

Use of complementary medicine (CAM) is widespread but often condemned by medical practitioners as being baseless or quackery. But some practices that fall under the umbrella of CAM do have a basis in evidence and may even offer lessons to medical doctors.

What is naturopathy?

Naturopathy is a health practice defined by its principles and philosophies.

This makes it slightly different from the work of other complementary medicine (CAM) professionals, such as herbalists, homoeopaths, acupuncturists and chiropractors, whose work is defined by the tools of their trade.

For this reason, the latter are often called the general practitioners of CAM.

The main principle of naturopathy is that its practitioners work with the body’s natural physiological processes to promote healing. A full list of these principles can be found here.

Nearly one in 10 Australians sees a naturopath, and the profession has garnered a lot of attention recently – often for the wrong reasons – particularly in relation to its ignorance of evidence-based medicine.

So can naturopathy be based on evidence?

Evidence-based naturopathy

Not all naturopathy is completely esoteric. Some naturopathic treatments – such as using the herb St John’s Wort for mild to moderate depression or ginger for treating morning sickness – are well-known examples of CAMs with a good body of evidence behind them.

And although much has been made of the potential risks of other treatments such as Kava, they have been shown to be effective in conditions such as anxiety, while having a lower risk profile than currently used conventional medications.

Naturopathic treatments based on evidence aren’t limited to these therapies: I recently co-edited the first international evidence-based naturopathic desktop clinical text, which contained over 4000 scientific references for naturopathic treatments.

There is also a broad swathe of traditional knowledge, which may not be scientifically validated but shouldn’t necessarily be entirely discarded.

Traditional knowledge can be extremely useful, for example, the malarial drug (artemisinin) was (quite recently) drawn from traditional Chinese medicine.

But it should also be noted that much of this “traditional evidence” is abused to make claims about CAM products that bear little resemblance to their original form. This is particularly problematic for newer “nutraceutical” or “herbal extract” products.

As recently as the early 2000s, major medical journals were dismissive of the suggestion that fish oil could improve cardiovascular health.

Now the Heart Foundation has minimum recommendations and fish oil. It’s also been found to be cost effective and have amongst the lowest number needed to treat (NNT) of any intervention for secondary prevention of further heart disease in patients who have had a heart attack.

Overwhelmingly, the most evidence for pretty much any condition belongs to dietary and lifestyle modifications.

Health promotion counselling on diet, physical activity, and stress management is incorporated into almost every naturopathic encounter.

This forms the backbone of any naturopathic consultation and is reinforced over successive patient visits.

Although some naturopaths have developed reputations as “product pushers” who ignore this component, their practice is in opposition to naturopathic principles, not in tandem with them.

Some other long-standing concepts that have been a part of naturopathic treatment for a long time are also gaining validity.

For example, regulating insulin levels was recommended as a standard treatment in naturopathic texts in women with Polycystic Ovarian Syndrome long before it became convention.

And naturopaths were observing the link between Vitamin D and intestinal health in immunity before it became widely accepted in scientific circles.

So what are the problems?

Of course, there are problems in the naturopathic camp.

Some practitioners do continue to focus on overtly non-evidence based treatments, such as using Vega machines or other questionable or untested diagnostic techniques or advising homoeopathic vaccination.

They sometimes promote these as valid alternatives to conventional methods or obscure and questionable theories of disease.

But, just as many homoeopaths refuse to endorse homoeopathic vaccination, it should be noted that these treatments have little to do with naturopathy, or its underlying principles.

The problem, as some commentators suggest, is some naturopaths have in fact been shaped by their status as a marginal profession. They have therefore assumed oppositional postures irrelevant to the core doctrine or principles of naturopathy.

There certainly is a fringe element that opposes many conventional interventions for no apparent reason than opposition itself.

But in most cases, individual naturopaths, not naturopathy itself, remain the problem.

This is compounded by the fact that since naturopathy is unregulated, anyone can call themselves a naturopath, and the well-known term is often co-opted by individuals with little relationship to the profession.

This was seen with the introduction of GST-free status for naturopathic consults early in the last decade. Lack of protection of title allowed non-naturopathic practitioners of every persuasion to suddenly reclass themselves as naturopaths overnight to gain access to this benefit.

Regulating to ensure minimum standards of practitioner education and accountability can help make the profession more evidence based.

Guaranteeing that practitioners have minimum conventional health science, public health and critical analysis training in their courses will foster a culture respectful of evidence.

It could also help deal with some of the other issues in naturopathy, such as practitioners making unfounded claims (as a rule of thumb if a practitioner makes incredible claims they’d better have incredible evidence), financially exploiting patients, or simply not having the training to recognise serious problems requiring referral.

In fact, following an evidence-based model of naturopathy can actually reinforce naturopathic principles, and help remove the influence of various fringe therapies and commercial interests that are apparent in any profession, including this one.

CAM practitioners have been a magnet for criticism from evidence-based medicine proponents. But it also needs to be remembered that there are problems with the evidence-based medicine movement that exists beyond the CAM sector.

A recent Australian Doctor article called it a house without foundations, which, “at its ‘most absolutist’ … was ‘a form of zealotry’ that failed to recognise real-life patients in all their confounding non-evidence-based complexity”.

David Sackett, co-founder of the modern evidence-based medicine movement, said, “Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough”. 

There is no denying there are problems in the CAM sector. However, it’s also possible that CAM attracts enough critical interest to act as a “canary” to broader issues of evidence in the health sector.

After all, a dearth of evidence isn’t something limited to CAM - we don’t know anything on the effectiveness of over half of all health interventions.

Naturopathy and evidence - no need for contradiction

But even if we do need to be less dogmatic in our approach to evidence-based medicine, there is no doubt that CAM practitioners also need to embrace the principles of evidence-based practice more proactively than they currently do.

In fact, there is no philosophical reason that they shouldn’t.

This does not have to exclude the use traditional therapies that don’t have double-blind placebo controlled trials where appropriate, but it does require clinical justification for choosing treatments.

Protocol or shotgun medicine - usually designed to shift product rather than disease - is unacceptable under such a model, as are unfounded diagnostic techniques.

Naturopaths also shouldn’t wait for pet therapies to work and instead modify treatment or refer when the patient is not getting results.

The lack of modern scientific evidence shouldn’t serve as a call to throw out the naturopathic baby with the bathwater. It should instead serve as a call for research into naturopathy, and CAM more broadly.

This can build on the emerging or traditional evidence which many practitioners currently have to rely - as little else currently exists for many therapies (positive or negative).

Evidence-based practice requires the use of the best available evidence. Naturopathic education providers, practitioners and CAM companies, which now form a multi-billion dollar industry, should all be actively involved in ensuring better evidence becomes available over time.

However, to state that naturopathy in and of itself cannot be evidence-based - as many detractors do - is quite simply false.