Naturopathy: Science-based or not?

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(Photo by monkeywing.)

Pictured: An actual homeopathic remedy. I am not kidding.

The College of Physicians and Surgeons of Ontario (CPSO) has drawn criticism recently for their bizarrely-worded policy proposal regarding alternative medicine, most notably from the Canadian Medical Association (general organization feedback here). Common concerns were that the policy is insufficiently objective and science-based, does not adequately address patient protection and physician liability/COI (conflicts of interest), and unjustifiably undermines science-based medical practices for the sake of incorporating modalities that are popular, yet functionally ineffective. This if of great concern to public safety, especially considering an apparent lack of ethical priorities (blank since at least October 2009) and the risk of alternative product manufacturers not adhering to established health and safety rules (for example, see this story from Australia).

A letter to the editor recently published in Allergy, Asthma, & Clinical Immunology further justifies recent concern over alternative medicine practices. In their review of 53 Alberta and BC naturopathic clinic websites for science-based health modalities, authors Timothy Caulfield and Christen Rachul found that the most popularized treatments are not scientifically-defensible, as they have not been objectively and consistently demonstrated to work beyond placebo. Their conclusion:

“A review of the therapies advertised on the websites of clinics offering naturopathic treatments does not support the proposition that naturopathic medicine is a science and evidence-based practice.”

The survey showed that among the top promoted interventions were questionable modalities like homeopathy, chelation, acupuncture, hydrotherapy, and chiropractic and among the top ailments treated were allergies, subjective issues such as pain and fatigue, women’s health issues such as menopause and fertility, digestive issues, etc (see Table 1). Also on the list were progressive conditions such as autoimmune diseases and cancer. Clinical nutrition was on the list of top offered interventions, however this is not alternative when based on good science. Lifestyle counseling was also on the intervention list, which may or may not be alternative depending on what is counseled and, based on naturopaths’ interaction with the scientific community, there is good reason to believe that people who see naturopaths may not be receiving good counsel.

For example, we have seen in the Skeptic North comments (most recently here) that at least some promoters of naturopathy do not appear to possess basic knowledge of the scientific method or the skill of critical appraisal of scientific literature. Looking through the comments, one can see anecdotes confused for evidence (no word on who counts the negative outcomes or who measures against placebo and regression to the mean), cherry picking of evidence among claims of scientific insufficiency to study naturopathic modalities (one comment even implied that naturopathy studies are merely used to appease those who do value science), accusations of bias at the same time as painting the scientific community as bigots who push toxic drugs on an unsuspecting public, equating helpful intent with actual valuable help, likening scientific consensus to “opinion”, anti-immunization sentiments, etc.

Absent from the comments: A professional response to a basic level of criticism that is fundamental to all scientific fields, with adequately appraised evidence of the treatments that were under criticism in the original post.

This is not to single out naturopaths as scientifically-illiterate, as plenty of people are unfortunately not skilled in critical appraisal, no matter what health field they are in. This is a concern among all health professions, but science-based health professions have a scientific framework to help steer them in the right direction. This framework is apparently absent from naturopathy if, for example, homeopathy is still a primary remedy.

Naturopaths’ understanding of science is of particular concern because recent provincial legislation has allowed them to position themselves as primary care practitioners. However, kind ears and unproven modalities do not a health field make, no matter what appeals are made to popularity. Without some objective reasoning to justify treatments and “advice” (such as delaying or abstaining from immunizations), patients are at risk of harm regardless of what benefit was intended.

Naturopaths can be quick to point out shortcomings in standard medical care when criticized, rather than directly and adequately addressing the criticism. The authors explain why this is a significant issue:

There is no doubt that other healthcare professionals, including physicians, provide therapies that are not supported by solid empirical evidence. And a wide range of social forces, including a pervasive industry bias, often distorts the evidence that is used [18]. These are serious problems, for sure. But the evidence issues of the medical profession cannot, obviously, stand as a justification for not using evidence in the context of naturopaths. All healthcare options should, as much as possible, be informed by good science [19]. To this end, the medical profession has a stated commitment to evidence-based practice and is taking steps to deal with the deficits in the production and use of evidence. As evidence improves, new practices are adopted and those shown to be ineffective are dropped.

In other words, two wrongs don’t make a right.

Change, when appropriate as determined by evidence, is important for progress. To that end, the authors ask:

If the naturopathic medicine were truly “science based”, as so often claimed by the advocates of the field, would they still be providing homeopathy as one of their core treatments? Would chelation and colon cleanses be marketed on so many of the clinics’ websites?

Excellent questions.

If naturopathy is to be taken seriously in the health community, proponents must do more than merely pay lip service to science, wielding low-quality studies like shields. Participating in science is more than using the words of science to bolster legitimacy, it is participating in the peer review process and adequately addressing criticism so the field can progress with the evidence. Currently, naturopathy appears rooted in ineffective modalities that are long in tooth and short on benefit with so far no indication that this attitude intends to change.

16 Responses to “Naturopathy: Science-based or not?”

  1. Abber says:

    Kim, thanks for keeping the spotlight on naturopathy. Too many people see it as a credible form of healthcare and you deftly highlight many of the reasons why they should re-evaluate their opinions.

  2. Bill says:

    Great article. I particularly like the conclusion:

    “Participating in science is more than using the words of science to bolster legitimacy, it is participating in the peer review process and adequately addressing criticism so the field can progress with the evidence.”

  3. daijiyobu says:

    re: “science-based health professions have a scientific framework to help steer them in the right direction.”

    Yes, and naturopathy DOES have a framework steering it, if you look at the trunk of the naturo. tree, NCNM, closely.

    I’d argue after more than 15 years of research on naturo. that the framework is to absurdly equate what legitimately is science [not just in fact but also in method / ethos] and what hugely isn’t.

    How else can NCNM state (see http://www.ncnm.edu/academic-programs/school-of-naturopathic-medicine/about-naturopathic-medicine.php ):

    “[our defining] principles [contents and methods!] are based on the objective observation of the nature of health and disease and are examined continually in light of scientific analysis.”

    Very low hanging fruit for us skeptics to analyze, but their irrationality marches on.

    And I should mention, true professions ARE NOT ABSURD.

    -r.c.

  4. In a recent discussion with two skeptics (Steve and Diane), the discussion came around to Naturopaths with prescribing rights.

    We were wondering what criteria a Naturopath would use to determine which medication to prescribe for a given condition. Antibiotics are fairly straightforward, but since they don’t use science based medicine in the first place, how could they judge appropriate use of other medication?

  5. Composer99 says:

    With regards to the caption under the dinosaur picture:

    “Pictured: An actual homeopathic remedy. I am not kidding”

    The great Dave Barry would surely have written: “I am not making this up”.

  6. gmcevoy says:

    not

  7. paul says:

    http://www.huffingtonpost.com/dana-ullman/disinformation-homeopathy_b_969627.html

    This was actually quite well written, with a number of references. Something is foul in the state of sceptic!

    • Scott Gavura says:

      Orac cataloged the ad hominems today. And the long list of references? Kim’s covered this habit from homeopaths before:

      In the view of homeopathy supporters, it seems that any literature or personal testimonial supporting the use of homeopathy is evidence of efficacy. However, the scientific view is that there are several factors that need be taken into account. Even if we set aside prior plausibility, the treatment has to be demonstrably and repeatedly effective in objective contexts with high quality research. A high-quality, objective study reduces as much bias as possible by employing certain standard methodologies and appropriate statistical analyses. It is important to sort out objective change from personal perception, because feeling better is not the same as affecting the course of an illness and the patient’s condition could worsen while they subjectively feel better.

      In evidence-based practice, research (supporting and non-supporting) must be evaluated for both content and quality. Not to consider literature in context is colloquially called “cherry picking” and is undesirable because it gives a skewed representation of the data — any trial could be an outlier. A high quality approach to review a lot of data in a short time is to examine systematic reviews, such as Cochrane Reviews, that comprehensively summarize research on a particular topic.

      • Mike says:

        If Orac wanted to critique Dana Ullman’s article and have people take him seriously, starting off his blog entry by referring to the Huffington Post as a “wretched hive of scum” is not the way to do it. Whether or not his critique of the Ullman article is valid, it’s hard to take anything he says seriously when he starts off with a blast like that.

  8. Steve Thoms says:

    Mike: you said, “If Orac wanted to critique Dana Ullman’s article and have people take him seriously, starting off his blog entry by referring to the Huffington Post as a “wretched hive of scum” is not the way to do it.

    It was a Star Wars reference. Deal with it.

    (Though I’ll note that you left out the “…and quackery” part of the Orac quote)

    • Mike says:

      Just because its from a movie doesn’t make it acceptable. I’m a Scarface fan, but had he referred to Dana Ullman as a cockroach I would have been equally unimpressed. But if the folks at skeptic north want to condone and encourage that type of stuff, that’s their choice.

      • Kim Hebert says:

        Mike, do you have anything relevant to say about the actual content of the post?

      • Mike says:

        Hi Kim,

        Well, since you asked, your post is mostly just a summary of the aaci letter to the editor, with a few digs thrown in at previous commenters. To a certain extent I’m generalizing here, but when you look at the most common conditions for which people are seeking the advice of a naturopath, (i.e. “allergies, subjective issues such as pain and fatigue, women’s health issues such as menopause and fertility, digestive issues, etc”) you’ll find areas where many people are generally not satisfied with what they’re getting from their MD.

        I would be willing to bet that the majority of people seeking the advice of a naturopath are well-educated and with decent jobs. I would also be willing to bet that these people are well aware that the process of becoming an MD is much much more difficult and stringent than that involved in becoming an ND. I would also be willing to bet that these people also understand that the advice and recommendations being provided by their ND would be dismissed by their MD as not having sufficient ‘proof’ of efficacy.

        As to whether or not naturopathy is science-based, I would say that it is science-“based”. It’s science”ish”. There’s a science “component” to it. If someone wants to define what it means to be science-based in the purest form (and I’m sure that to a skeptic, that’s the only way to define it), then even mainstream medicine is not 100% science-based. Cigarettes have always been deadly despite the medical community’s insistence for a long time that there was no evidence to prove it. Drugs are frequently taken off the market when it’s determined that they’re not as safe as the medical community’s ‘evidence’ had previously indicated. Scientific consensus may not be an “opinion”, but it can certainly be wrong.

        In my view, the notion of ‘science-based’ is a spectrum. I would wholeheartedly agree that mainstream medicine is more ‘science-based’ and way more ‘evidence-based’ than alternative medicine. And I would guess that the majority of people who go to their naturopath would agree with that as well. As much as it pains skeptics to see this happening, educated people are making an informed decision to seek the advice of naturopaths in spite of the fact that the recommendations being doled out by naturopaths do not have the same breadth of ‘evidence’ to support them as most of the recommendations being doled out by MDs.

        The aaci letter does point out what it sees as “serious problems” with the way evidence is distorted by the pervasive industry bias of mainstream medicine. Your response to that is that two wrongs don’t make a right. Perhaps that is true, but I think the more relevant question to be asking is which of the two wrongs is truly a bigger threat to public health.

  9. gmcevoy says:

    No need to spread disinfo aboot homeoquackery when the facts are laughably absurd

    That naturoquackery builds on this makes it farce

    Moxibustion, really? Waving burning mugwort aboot will align your chakras?

    Party like it’s 1399.

  10. Tim McDowell says:

    The biggest problem with Naturopathy as opposed to some other more outlandish forms of woo, is that at least some of it seems quite reasonable and common sensical. Eat healthy, get lots of rest, exercise, don’t overindulge etc. Nobody argues with that. The problem starts when they claim such basic health advice as unique to Naturopaths, as if physicians don’t talk to people about diet and exercise.

    This ties in nicely with their naturalistic fallacy (natural=better) and becomes part of the come on that gets otherwise intelligent people in the door. The bait and switch happens after that. Naturopaths apparently are equal opportunity woo-meisters. Homeopathy? Sure. Acupuncure? Yep, they do that too. Biofeedback gizmos and the machine that goes “ping”. You bet !

    I really don’t understand why Naturopaths even wanted the power to prescribe, as it violates their basic principles. I can only assume it is because they realize most of what they do is useless, and they do a lot of “there there” while waiting for self limited diseases to run their course. Yes, there’s a lot of that in general medicine as well, but at least we are honest about it.

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  • Kim Hebert

    Kim Hébert is an occupational therapist. She is interested in the promotion of science and reason, particularly regarding therapeutic health interventions. She blogs occasionally about occupational therapy and other health topics at Science-Based Therapy. Her hobbies are art and astronomy. **All views expressed by Kim are her personal views alone, and do not necessarily reflect the opinions of current or former employers, associations, or other affiliations. All information is provided for discussion purposes only, and should not be used as a replacement for consultation with a licensed and accredited health professional.