Naturopathy

Naturopathy or naturopathic medicine is a form of alternative medicine employing a wide array of "natural" modalities, including homeopathy, herbalism, and acupuncture, as well as diet (nutrition) and lifestyle counseling. Naturopaths favor a holistic approach with non-invasive treatment and generally avoid the use of surgery and drugs. Naturopathic medicine contains many pseudoscientific concepts and is considered ineffective and can be harmful, which raises ethical issues.[1][2][3] Naturopaths have repeatedly been accused of being charlatans and practicing quackery.[1][4][5][6][7][8]

Much of the ideology and methodological underpinnings of naturopathy are based on vitalism and self-healing, rather than evidence-based medicine.[9] Naturopathic education contains little of the established clinical training and curriculum completed by primary care doctors, as naturopaths mostly train by studying unscientific notions and practicing unproven interventions and diagnoses.[1][10] Naturopaths tend to oppose vaccines and teach their students anti- and alternative vaccine practices, resulting in lower vaccination rates.[11][12][13][14] According to the American Cancer Society, "scientific evidence does not support claims that naturopathic medicine can cure cancer or any other disease."[15]

The term "naturopathy" was created from "natura" (Latin root for birth) and "pathos" (the Greek root for suffering) to suggest "natural healing".[16] Modern naturopathy grew out of the Natural Cure movement of Europe. According to the Merriam-Webster Dictionary, the first use in print that can be found is from 1901.[17] The term was coined in 1895 by John Scheel and popularized by Benedict Lust, the "father of U.S. naturopathy".[18] Beginning in the 1970s, there was a revival of interest in the United States and Canada, in conjunction with the "holistic health" movement.

History

Monsignor Sebastian Kneipp, 1821–1897
Benedict Lust, 1872–1945

Naturopaths claim the ancient Greek "Father of Medicine", Hippocrates, as the first advocate of naturopathic medicine, before the term existed.[16][19] Naturopathy has its roots in the 19th century Nature Cure movement of Europe.[20][21] In Scotland, Thomas Allinson started advocating his "Hygienic Medicine" in the 1880s, promoting a natural diet and exercise with avoidance of tobacco and overwork.[22][23]

The term naturopathy was coined in 1895 by John Scheel,[24] and purchased by Benedict Lust, the "father of U.S. naturopathy".[18] Lust had been schooled in hydrotherapy and other natural health practices in Germany by Father Sebastian Kneipp; Kneipp sent Lust to the United States to spread his drugless methods.[5] Lust defined naturopathy as a broad discipline rather than a particular method, and included such techniques as hydrotherapy, herbal medicine, and homeopathy, as well as eliminating overeating, tea, coffee, and alcohol.[25] He described the body in spiritual and vitalistic terms with "absolute reliance upon the cosmic forces of man's nature".[26]

In 1901, Lust founded the American School of Naturopathy in New York. In 1902 the original North American Kneipp Societies were discontinued and renamed "Naturopathic Societies". In September 1919 the Naturopathic Society of America was dissolved and Benedict Lust founded the American Naturopathic Association to supplant it.[18][27] Naturopaths became licensed under naturopathic or drugless practitioner laws in 25 states in the first three decades of the twentieth century.[18] Naturopathy was adopted by many chiropractors, and several schools offered both Doctor of Naturopathy (ND) and Doctor of Chiropractic (DC) degrees.[18] Estimates of the number of naturopathic schools active in the United States during this period vary from about one to two dozen.[15][18][24]

After a period of rapid growth, naturopathy went into decline for several decades after the 1930s. In 1910 the Carnegie Foundation for the Advancement of Teaching published the Flexner Report, which criticized many aspects of medical education, especially quality and lack of scientific rigour. The advent of penicillin and other "miracle drugs" and the consequent popularity of modern medicine also contributed to naturopathy's decline. In the 1940s and 1950s, a broadening in scope of practice laws led many chiropractic schools to drop their ND degrees, though many chiropractors continued to practice naturopathy. From 1940 to 1963, the American Medical Association campaigned against heterodox medical systems. By 1958 practice of naturopathy was licensed in only five states.[18] In 1968 the United States Department of Health, Education, and Welfare issued a report on naturopathy concluding that naturopathy was not grounded in medical science and that naturopathic education was inadequate to prepare graduates to make appropriate diagnosis and provide treatment; the report recommends against expanding Medicare coverage to include naturopathic treatments.[15][28] In 1977 an Australian committee of inquiry reached similar conclusions; it did not recommend licensure for naturopaths.[29] As of 2009, fifteen U.S. states, Puerto Rico, the US Virgin Islands and the District of Columbia licensed naturopathic doctors,[30] and the state of Washington requires insurance companies to offer reimbursement for services provided by naturopathic physicians.[31][32] South Carolina and Tennessee prohibit the practice of naturopathy.[33][34][35]

Beginning in the 1970s, interest waxed in the United States and Canada in conjunction with the holistic health movement.[18][25]

Practice

Naturopathic practice is based on a belief in the body's ability to heal itself through a special vital energy or force guiding bodily processes internally.[1] Diagnosis and treatment concern primarily alternative therapies and "natural" methods that naturopaths claim promote the body's natural ability to heal.[25][36] Naturopaths focus on a holistic approach, often completely avoiding the use of surgery and drugs.[15][37] Naturopaths aim to prevent illness through stress reduction and changes to diet and lifestyle, often rejecting the methods of evidence-based medicine.[9][38]

A consultation typically begins with a lengthy patient interview focusing on lifestyle, medical history, emotional tone, and physical features, as well as physical examination.[25] Many naturopaths present themselves as primary care providers, and some naturopathic physicians may prescribe drugs, perform minor surgery, and integrate other conventional medical approaches such as diet and lifestyle counselling with their naturopathic practice.[25][39] Traditional naturopaths deal exclusively with lifestyle changes, not diagnosing or treating disease. Naturopaths do not generally recommend vaccines and antibiotics, based in part on the early views that shaped the profession, and they may provide alternative remedies even in cases where evidence-based medicine has been shown effective.[3]

Methods

A 2004 survey determined the most commonly prescribed naturopathic therapeutics in Washington State and Connecticut were botanical medicines, vitamins, minerals, homeopathy, and allergy treatments.[40]

The particular modalities used by a naturopath vary with training and scope of practice. These may include herbalism, homeopathy,[40] acupuncture, nature cures, physical medicine, applied kinesiology,[41] colonic enemas,[5] chelation therapy,[4] color therapy,[41] cranial osteopathy, hair analysis, iridology[41] live blood analysis, ozone therapy,[15] psychotherapy, public health measures and hygiene,[38] reflexology,[41] rolfing,[27] massage therapy, and traditional Chinese medicine. Nature cures include a range of therapies based on exposure to natural elements such as sunshine, fresh air, or heat or cold, as well as nutrition advice such as following a vegetarian and whole food diet, fasting, or abstention from alcohol and sugar.[42] Physical medicine includes naturopathic, osseous, or soft tissue manipulative therapy, sports medicine, exercise, and hydrotherapy. Psychological counseling includes meditation, relaxation, and other methods of stress management.[42]

Practitioners

Naturopathic practitioners in Switzerland can be divided into three groups: those with federal diploma, those recognized by health insurances, and those with neither federal diploma nor recognition by health insurances. Naturopaths with federal diploma can be divided into four categories: European traditional medicine, Chinese traditional medicine, ayurvedic medicine and homeopathy.[43][44] The number of listed naturopaths (including traditional healers) in Switzerland rose from 223 in 1970 to 1835 in 2000.[45]

Naturopathic practitioners in the United States can be divided into three groups: naturopathic physicians, traditional naturopaths, and other health care providers who offer naturopathic services.[15][46][47][48][49]

Licensure

Naturopathic doctors are licensed in 17 US states and 5 Canadian provinces.[50] In jurisdictions where naturopathic doctor (ND or NMD) or a similar term is a protected designation, naturopathic doctors must pass the Naturopathic Physicians Licensing Examinations administered by the North American Board of Naturopathic Examiners (NABNE)[51] after graduating from a college accredited by the Council on Naturopathic Medical Education (CNME).[39]

Naturopathic doctors are not eligible for medical residencies, which are available exclusively for medical doctors and doctors of osteopathic medicine. There are limited post-graduate "residency" positions available to naturopathic doctors offered through naturopathic schools and naturopathic clinics approved by the Council on Naturopathic Medical Education.[52] Most naturopathic doctors do not complete such a residency,[40] and naturopathic doctors are not mandated to complete one for licensure,[15] except in the state of Utah.[53]

In 2005, the Massachusetts Medical Society opposed licensure based on concerns that NDs are not required to participate in residency and concerns that the "practices" of naturopaths included many "erroneous and potentially dangerous claims."[54] The Massachusetts Special Commission on Complementary and Alternative Medical Practitioners rejected their concerns and recommended licensure.[55]

Many naturopaths present themselves as primary care providers.[25][39] Doctor of Naturopathy training includes basic medical diagnostic tests and procedures such as medical imaging and blood tests, as well as vitalism and pseudoscientific modalities such as homeopathy.[1][4][5][25]

Continuing education in naturopathic modalities for health care professionals varies greatly.[41]

Traditional naturopaths

Traditional naturopaths are represented in the United States by the American Naturopathic Association (ANA), representing about 1,800 practitioners [56] and the American Naturopathic Medical Association (ANMA).[18]

The level of naturopathic training varies among traditional naturopaths in the United States. Traditional naturopaths may complete non-degree certificate programs or undergraduate degree programs and generally refer to themselves as Naturopathic Consultants. These programs often offer online unaccredited degrees, but do not offer proper biomedical education or clinical training. Those completing a Doctor of Naturopathy (ND) degree from an ANMCB approved school can become a Board Certified Naturopathic Doctor.[57]

Traditional naturopathic practitioners surveyed in Australia perceive evidence-based medicine to be an ideologic assault on their beliefs in vitalistic and holistic principles.[9] They advocate the integrity of natural medicine practice.[9] Some naturopaths have begun to adapt modern scientific principles into clinical practice.[58]

Evidence basis

Naturopathy lacks an adequate scientific basis,[9] and it is rejected by the medical community.[9] Some methods rely on immaterial "vital energy fields", the existence of which has not been proven, and there is concern that naturopathy as a field tends towards isolation from general scientific discourse.[16][59][60] Naturopathy is criticized for its reliance on and its association with unproven, disproven, and other controversial alternative medical treatments, and for its vitalistic underpinnings.[3][15] Natural substances known as nutraceuticals show little promise in treating diseases, especially cancer, as laboratory experiments have shown limited therapeutic effect on biochemical pathways, while clinical trials demonstrate poor bioavailability.[61] According to the American Cancer Society, "scientific evidence does not support claims that naturopathic medicine can cure cancer or any other disease.[15]

In 2015 the Australian Government's Department of Health published the results of a review of alternative therapies that sought to determine if any were suitable for being covered by health insurance; Naturopathy was one of 17 therapies evaluated for which no clear evidence of effectiveness was found.[62]

Kimball C. Atwood IV writes, in the journal Medscape General Medicine,

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.[1]

In another article, Atwood writes that "Physicians who consider naturopaths to be their colleagues thus find themselves in opposition to one of the fundamental ethical precepts of modern medicine. If naturopaths are not to be judged "nonscientific practitioners", the term has no useful meaning".[4]

Treatments and practices

Naturopaths are often opposed to mainstream medicine and take an antivaccinationist stance.[3]

According to Arnold S. Relman, the Textbook of Natural Medicine is inadequate as a teaching tool, as it omits to mention or treat in detail many common ailments, improperly emphasizes treatments "not likely to be effective" over those that are, and promotes unproven herbal remedies at the expense of pharmaceuticals. He concludes that "the risks to many sick patients seeking care from the average naturopathic practitioner would far outweigh any possible benefits".[63]

The Massachusetts Medical Society states,

Naturopathic practices are unchanged by research and remain a large assortment of erroneous and potentially dangerous claims mixed with a sprinkling of non-controversial dietary and lifestyle advice.[64]

In terms of education, The Massachusetts Medical Society states:

Naturopathic medical school is not a medical school in anything but the appropriation of the word medical. Naturopathy is not a branch of medicine. It is a hodge podge of nutritional advice, home remedies and discredited treatments...Naturopathic colleges claim accreditation but follow a true “alternative” accreditation method that is virtually meaningless. They are not accredited by the same bodies that accredit real medical schools and while some courses have similar titles to the curricula of legitimate medical schools the content is completely different.[64]

Certain naturopathic treatments offered by naturopaths, such as homeopathy, rolfing, and iridology, are widely considered pseudoscience or quackery.[65][66][67] Stephen Barrett of QuackWatch and the National Council Against Health Fraud has stated that naturopathy is "simplistic and that its practices are riddled with quackery".[5] "Non-scientific health care practitioners, including naturopaths, use unscientific methods and deception on a public who, lacking in-depth health care knowledge, must rely upon the assurance of providers. Quackery not only harms people, it undermines the ability to conduct scientific research and should be opposed by scientists", says William T. Jarvis.[68]

Safety of natural treatments

Naturopaths often recommend exposure to naturally occurring substances, such as sunshine, herbs and certain foods, as well as activities they describe as natural, such as exercise, meditation and relaxation. Naturopaths claim that these natural treatments help restore the body's innate ability to heal itself without the adverse effects of conventional medicine. However, "natural" methods and chemicals are not necessarily safer or more effective than "artificial" or "synthetic" ones, and any treatment capable of eliciting an effect may also have deleterious side effects.[5][15][69][70]

Vaccination

Naturopathy is based on beliefs opposed to vaccination and have practitioners who voice their opposition. The reasons for this opposition are based, in part, on the early views which shaped the foundation of this profession.[71] In general, evidence about associations between naturopathy and pediatric vaccination is sparse, but "published reports suggest that only a minority of naturopathic physicians actively support full vaccination".[72][73]

A naturopathy textbook recommends "a return to nature in regulating the diet, breathing, exercising, bathing and the employment of various forces" in lieu of the smallpox vaccine.[74] The British Columbia Naturopathic Association lists several major concerns regarding the pediatric vaccine schedule and vaccines in general.[75] The Oregon Association of Naturopathic Physicians reports that many naturopaths "customize" the pediatric vaccine schedule.[76]

Regulation

Naturopathy is practiced in many countries and is subject to different standards of regulation and levels of acceptance. The scope of practice varies widely between jurisdictions, and naturopaths in some unregulated jurisdictions may use the Naturopathic Doctor designation or other titles regardless of level of education.[47] The practice of naturopathy is illegal in two USA states.[33][34][35]

Australia

In 1977 a committee reviewed all colleges of naturopathy in Australia and found that, although the syllabuses of many colleges were reasonable in their coverage of basic biomedical sciences on paper, the actual instruction bore little relationship to the documented course. In no case was any practical work of consequence available. The lectures which were attended by the committee varied from the dictation of textbook material to a slow, but reasonably methodical, exposition of the terminology of medical sciences, at a level of dictionary definitions, without the benefit of depth or the understanding of mechanisms or the broader significance of the concepts. The committee did not see any significant teaching of the various therapeutic approaches favoured by naturopaths. People reported to be particularly interested in homoeopathy, Bach's floral remedies or mineral salts were interviewed, but no systematic courses in the choice and use of these therapies were seen in the various colleges. The committee were left with the impression that the choice of therapeutic regime was based on the general whim of the naturopath and, since the suggested applications in the various textbooks and dispensations overlapped to an enormous extent, no specific indications were or could be taught.[29]

The position of the Australian Medical Association is that "evidence-based aspects of complementary medicine can be part of patient care by a medical practitioner", but it has concerns that there is "limited efficacy evidence regarding most complementary medicine. Unproven complementary medicines and therapies can pose a risk to patient health either directly through misuse or indirectly if a patient defers seeking medical advice." The AMA's position on regulation is that "there should be appropriate regulation of complementary medicine practitioners and their activities."[77]

India

In India, naturopathy is overseen by the Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH); there is a 5½-year degree in "Bachelor of Naturopathy and Yogic Sciences" (BNYS) degree that was offered by twelve colleges in India as of August 2010.[78] The National Institute of Naturopathy in Pune that operates under AYUSH, which was established on December 22, 1986 and encourages facilities for standardization and propagation of the existing knowledge and its application through research in naturopathy throughout India.[79][80]

North America

In five Canadian provinces, seventeen U.S. states, and the District of Columbia, naturopathic doctors who are trained at an accredited school of naturopathic medicine in North America, are entitled to use the designation ND or NMD. Elsewhere, the designations "naturopath", "naturopathic doctor", and "doctor of natural medicine" are generally unprotected or prohibited.[35][47]

In North America, each jurisdiction that regulates naturopathy defines a local scope of practice for naturopathic doctors that can vary considerably. Some regions permit minor surgery, access to prescription drugs, spinal manipulations, midwifery (natural childbirth), and gynecology; other regions exclude these from the naturopathic scope of practice or prohibit the practice of naturopathy entirely.[35][81]

Canada

Four Canadian provinces license naturopathic doctors: British Columbia, Alberta, Ontario, and Saskatchewan.[82] British Columbia has regulated naturopathic medicine since 1936 and together with Ontario (since 2009) are the only two Canadian provinces that allow certified NDs to prescribe pharmaceuticals and perform minor surgeries.[83]

The province of Quebec does not directly regulate naturopathy. The Quebec Ministry of Education has prohibited schools from offering doctoral programs in the subject, and there are no universities with a naturopath program. Therefore, studies must be done out of province. Furthermore, in Quebec, the Collège des médecins du Québec (CMQ) has exclusive rights to perform certain activities including but not limited to ordering diagnostic examinations, prescribing medication and other substances and clinically monitoring the condition of patients whose state of health presents risks. This severely restrains the scope of practice.[84]

United States

United Kingdom

Naturopathy is not regulated in the United Kingdom. In 2012, publicly funded universities in the United Kingdom dropped their alternative medicine programs, including naturopathy.[86]

Switzerland

The Swiss Federal Constitution seizes the Swiss Confederation and the Cantons of Switzerland within the scope of their powers to oversee complementary medicine.[87] In particular, the Federal authorities must set up diplomas for the practice of non-scientific medicine. The first of such diplomas has been validated in April 2015 for the practice of naturopathy.[43] There is a long tradition for naturopathy and traditional medicine in Switzerland. The Cantons of Switzerland make their own public health regulations. Although the law in certain cantons is typically monopolistic, the authorities are relatively tolerant with regard to alternative practitioners.[44]

See also

References

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