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Former naturopath Britt Hermes awarded John Maddox prize for championing science

Nov 182018

This is excellent – Britt Hermes, of Naturopathic Diaries fame, has been awarded the John Maddox Prize.

Hermes said her own professional journey had come at a personal cost and she was being sued for defamation by an American naturopath in a case due to be heard in a German court.

“I was a naturopath, until I looked at the evidence and decided to speak up about the dangerous therapies used in naturopathy, especially those to treat cancer,” she said. “Walking away cost me my friends. I am harassed and being sued for defamation. I am honoured to be recognised by the scientific community for changing my mind.”

Hermes deserves all the accolades she’s getting. As a former naturopath, she’s effectively pointed out that naturopathy is a pseuoscientific practice that is based on vitalistic thinking – and has no place in a modern, science-based health system.

Congratulations, Britt!

See the full story at The Guardian.

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Naturopathy’s fiercest and most-knowledgeable critic is being sued by a naturopath

Naturopathy

Jan 142018

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Britt Marie Hermes is an ex-naturopath who has come clean about her time as a naturopath. This video explains her transition from naturopathy to science and evidence, and is well worth watching:

Britt is being sued by a naturopath who believes you can treat cancer with vitamins and baking soda. From Britt’s post:

Colleen Huber is a naturopathic cancer crusader and owner of Nature Works Best (NWB) naturopathic cancer clinic in Tempe, Arizona. She is not a medical doctor and, to the best of my knowledge, has no formal training in cancer research. Yet, Huber promotes herself as a cancer expert (here, here, and here) and is an outspoken critic of standard-of-care treatments for cancer. She wrote that “conventional treatments (chemo, radiation, etc.) sicken and weaken you and ultimately strengthen the disease.”

Huber treats cancer using alternative therapies, including intravenous injections of vitamins and baking soda. She staunchly advocates that her cancer patients should follow a strict sugar-free diet. She advertises that a sugar-free diet increases a cancer patient’s overall survival, regardless of cancer stage or type.

Naturopathy is based on the idea of vitalism, a pre-scientific belief that some type of magical “energy” is a part of all living things. The idea of vitalism was disproved by Wöhler in 1828, yet the idea remains central to naturopathic ideas about medicine. Naturopaths believe their treatments restore this “vital force”. The practice of naturopathy has evolved over time into a mix of disproven or unproven health practices that includes homeopathy, acupuncture, “detoxification” and herbalism, along with the occasional science-based belief repackaged as “alternative”. (For more information, see my series of naturopathy vs. science posts at Science-Based Medicine.)

If you support science-based medicine you’ll recognize the importance of helping Britt defend herself. See her post here. If you can’t donate, please amplify her post by sharing it widely on social media.

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Should you try a “natural alternative” before medication?

Naturopathy

Jul 172016

Natural remedies are popular. But are they an appropriate substitute for medication?

The idea of taking medication can be frightening. And as consumers and patients that want to make our own informed health decisions, it’s understandable and even appropriate to question our physicians when they recommend drug treatments. We need to understand the rationale for any medication that’s recommended or prescribed, the benefits of therapy, the side effects, and if there are any other approaches that might be more appropriate. Dietary supplements and natural health products are widely marketed as being safe and effective, and are occupying more and more shelf space in pharmacies, usually right beside the pharmacy counter. Many of my patient encounters in the pharmacy have included a discussion on the merits of drug therapy, versus the supplements that may have flashy packaging and impressive claims of effectiveness.

One encounter from my time working at a local pharmacy still sticks with me. I met a new patient who was anxious and eager to get my advice. He’d been cautioned by his family doctor that he was on the borderline of being diagnosed with diabetes. He had come to the pharmacy seeking a supplement that could help him avoid diabetes and medication. Rather than recommend any supplement, I suggested that the best approach he could probably take would be to lose some weight and get some exercise – it could be more effective than any supplement or drug, and would definitely help his health. He agreed, and then asked me what supplement he could take that could help him with some weight loss.

This type of discussion occurs all the time, and seems more common when there’s a lack of trust in the physician, or when the goals of treatment aren’t understood. The patient, reluctant to accept the physician’s recommendation, heads to the pharmacy for what they believe is a second opinion. In some cases, the patient may question the physician’s advice: “All my physician wants to do is prescribe drugs,” is a statement I’ve heard more than once. In those that are reluctant to accept medical treatment, there’s often a willingness to consider anything that’s available without a prescription – particularly if it’s perceived as “natural.” Natural products and dietary supplements are thought to be gentle, safe, and effective, while medicine may be felt to be unnatural, harsh, and potentially dangerous. Yet when I explain to patients that there’s actually little evidence to suggest most supplements offer any meaningful health benefits, I am sometimes met with puzzled or dismissive looks. The supplement industry’s marketing has been remarkably effective, glossing over the fact that the research done on dietary supplements is overall unconvincing and largely negative when it comes to having anything useful to offer for health.

Given I want to ensure patients are making informed health decisions based on good scientific evidence, I was eager to read a post that naturopath Reuben Dinsmore recently posted on the website of the British Columbia Naturopaths Association (BCNA). Entitled “The Top Five Medications You Shouldn’t Take Without Trying a Natural Alternative First,” Dinsmore states that supplements can offer all the benefits yet none of the side effects of prescription drugs:

Natural supplements, or nutraceuticals, have been given a bad rap lately—which, in some cases, has been absolutely warranted. But natural formulas that actually contain what they claim on the label, and that are formulated to have maximal efficacy, can be equal to their pharmaceutical counterparts. Better yet, they can be just as effective without the laundry list of side effects.

I approached the article with curiosity. Are supplements an appropriate therapy before medication? I have no bias against supplements, but I do have a bias against unsubstantiated claims. I want to know what works, supplement, drug or otherwise. I looked at each recommendation as if it was given to me by a patient in the pharmacy, and evaluate it against the scientific evidence.

Understanding the naturopathic approach

I’ve written multiple posts in the past about treatment claims by naturopaths, and how they stack up against the scientific evidence. Naturopaths offer an array of unconventional health practices like homeopathy, acupuncture and herbalism that are linked philosophically by a belief in vitalism – the prescientific idea we have a “life force”. From this philosophy can sometimes emerge sensible health advice, but it can also be illogical and even potentially harmful. In past posts I’ve looked at the naturopathic perspectives on fake diseases, infertility, autism, prenatal vitamins, vaccinations, allergies, and even scientific facts themselves. As long as a treatment is viewed as being congruent with the naturopathic belief system, it’s acceptably “naturopathic” – no matter what the scientific evidence says. Despite this obvious disconnect from science-based medicine, naturopaths present themselves as primary care providers, just like medical doctors. The BCNA’s own marketing campaign describes naturopaths as “medically trained”:

Britt Hermes is a former naturopath and has written extensively about naturopathy, and her perspective is clear: There are no naturopathic standards of care and naturopathic training is very different than what naturopaths claim. She argues is that naturopathy has too much quackery and that what actually makes naturopathy unique is its embrace of pseudoscience.

So let’s examine the five categories of drugs that Dinsmore says have equally effective natural remedies. He lists statins, antacids, SSRIs (selective serotonin reuptake inhibitors), antihypertensives, and benzodiazepines.

Statins for high cholesterol

Why do we treat it?

High cholesterol has no symptoms. We treat high cholesterol to lower the risk of heart disease: heart attacks, strokes, and death. One’s risk of heart disease goes up with the LDL cholesterol level, along with the total number of heart disease risk factors.

When is drug treatment appropriate?

High cholesterol doesn’t mean that drug treatment is mandatory. An assessment will include age, family history, and other health conditions such as diabetes, heart disease, or a prior heart attack or stroke. Lifestyle changes are important: A healthy diet, an appropriate weight, regular physical exercise, and quitting smoking can also reduce your risk of heart disease. In those at low risk, drug therapy many not be necessary. “Statins” are a class of drugs that reduce LDL cholesterol. In those with a prior heart attack or stroke, the benefits of treatment with drugs like statins are well documented.

What benefits have drugs been shown to offer?

There’s two general uses for statin therapy: primary prevention (avoiding a first heart attack or stroke), and secondary prevention (using a statin in someone that has already had a heart attack or stroke) to reduce the risk of another cardiovascular event. There is good evidence that statins reduce the risk of heart attacks and strokes, when used for both primary and secondary prevention. Much of the debate on the usefulness of statins has focused on the net benefit when used in lower-risk groups. This is a fair question, and one that I’ve discussed at length previously. But what is not in question is that statins have been proven to reduce the risk of heart attacks, stroke, and death.

What does naturopathy suggest?

As per Dinsmore:

High cholesterol is blamed for heart attacks and strokes via formation of arterial plaques. But the real culprit is inflammation, without which the plaques wouldn’t form in the first place. Bottom line: You can lower cholesterol all you want, but as long as there is inflammation present, plaques can still form.

Some common side effects of statins include muscle pain, cognitive impairment, sexual dysfunction, and increased risk of cancer and diabetes.

Nutraceuticals are an alternative to statins. These include: Omega-3 fatty acids (best sourced from wild-caught fish oils) and curcumin (the active component in turmeric). Both are excellent supplements to lower inflammation. Garlic extracts have been proven to improve cholesterol levels as well. Another option I discuss with patients is red rice yeast extract, which is the natural compound statins were derived from in the first place, and works in a similar manner. This product may have side effects; I find that it can be beneficial for some patients, but not all, something I deal with on a patient by patient basis.

What evidence supports the use of naturopathic treatments?

The reason we use drug therapy to treat high cholesterol is to lower the risk of heart attacks, stroke, and death. Consequently, that’s the benefit we want to see when we consider taking any treatment – naturopathic or drug. Statins are proven effective, so that’s the effectiveness we should be looking for if we’re going to use supplements as an alternative. There is no published evidence to demonstrate that garlic extracts or curcurmin supplements can prevent heart attacks and stroke, or reduce the risk of death. The data are a bit more encouraging with omega-3 fatty acids (which, incidentally, exist as both a drug and a supplement with different regulatory standards for each), but whether or not these products actually produce a real survival advantage is not clear. There is a Cochrane review on dietary modifications for the treatment of high cholesterol, in which the authors conclude:

No conclusions can be made about the effectiveness of a cholesterol-lowering diet, or any of the other dietary interventions suggested for familial hypercholesterolaemia, for the primary outcomes: evidence and incidence of ischaemic heart disease, number of deaths and age at death, due to the lack of data on these. Large, parallel, randomised controlled trials are needed to investigate the effectiveness of a cholesterol-lowering diet and the addition of omega-3 fatty acids, plant sterols or stanols, soya protein, dietary fibers to a cholesterol-lowering diet.

Red rice yeast extract is effectively a natural but crude source of the statin drug lovastatin (the active molecules are identical). There are questions about its safety that are exclusive to red yeast rice, but not present with prescription drugs. Why red rice yeast extract would be preferred over a drug product is unclear, unless one puts a priority on something “natural” over something that’s standardized, predictable, and demonstrated to be effective.

What approach has the best evidence?

Statins provide proven benefits, reducing heart attacks, strokes, and the risk of death. Even if a supplement reduces cholesterol levels, real benefits haven’t been established. There’s no obvious reason to use supplements for high cholesterol.

“Antacids” (anti-ulcer medications for gastro-esophageal reflux)

Why do we treat it?

The reflux of stomach contents, often called “heartburn” requires medical attention when there is damage to the esophagus, or there are unpleasant symptoms. The objective of treatment is to repair any tissue damage and/or to reduce the symptoms of heartburn.

When is drug treatment appropriate?

So called “lifestyle” modifications are usually recommended first, and they aren’t always effective. Weight loss (if appropriate) can provide relief, as can elevating the head of the bed for those with heartburn at night. Minimizing specific foods or “triggers” is usually not necessary, but some find this approach helpful. Drug treatment with medications like proton pump inhibitors (PPIs), which suppress stomach acid production, are usually appropriate when symptoms are severe, or where there’s esophageal damage.

What benefits have drugs been shown to offer?

PPIs are among the most effective drugs to treat heartburn and heal esophagitis. PPIs are well tolerated over the short term. When acid production is suppressed for long-term periods (months to years), there are concerns this may predispose people to infections and malabsorption conditions. Whether or not PPIs raise the risk of osteoporosis or hip fractures isn’t clear. Many people find these medications highly effective, but some stay on therapy far longer than necessary. Current guidance suggests the lowest dose should be used for the shortest duration possible to minimize these risks.

What does naturopathy suggest?

As per Dinsmore:

It’s said that five million Canadians suffer from heartburn symptoms weekly. Prescriptions for the acid-blocking drugs PPIs (proton pump inhibitors) accounted for $24 million in BC alone in 2013. Risks of taking these mostly involve nutrient deficiencies from poor absorption DUE TO LOW STOMACH ACID (see the problem here?). Examples include bone fractures from poor calcium absorption or anemia from decreased levels of vitamin B12 or iron. B12 deficiency can also cause dementia and neurological damage. There has also been a correlation shown between PPI use and C. difficile infection, which causes life-threatening diarrhea.

Nutraceuticals: Long story short, most people don’t have too much stomach acid. The problem is the acid they have is getting into the wrong place (the lower esophagus) where it burns. This can be from the muscle between the esophagus and the stomach not closing properly, either from poor tone or insufficient stomach acid, which is the signal for the sphincter to close. Limonene (an extract from citrus peel) helps strengthen this muscle and promotes movement of food downward to the stomach. DGL (an extract from licorice root) stimulates mucus production in the stomach, which acts to coat and protect the sensitive lining of the esophagus.

What evidence supports the use of naturopathic treatments?

Limonene is an ingredient in citrus oils, and is considered “possibly safe” as a supplement by the Natural Medicines database. I could locate no published evidence in PubMed it has been studied for heartburn or GERD. I did find a reference to clinical trials in Alternative Medicine Review, but there’s not a lot of information to review: one trial had 19 adults and had no control group. The other had just 13 participants but was randomized and blinded, noting improvements in heartburn symptoms with limonene. There’s not much safety information on limonene, and it appears to have multiple interactions with drugs. How limonene might work isn’t clear. Long-term effects haven’t been reported.

Deglycyrrhizinated licorice (DGL) is licorice processed to remove the glycyrrhizic acid, which can cause steroid-like side effects when consumed in excess. Short term use of licorice as a supplement is considered “possibly safe” and long-term use is considered “possibly unsafe”. Some branded supplements combining licorice with other herbal ingredients have been studied for the treatment of acid reflux, stomach pain and cramping. How DGL might work isn’t clear. There’s a lack of evidence to suggest DGL is effective.

What approach has the best evidence?

There’s good evidence to show PPIs work, and they work quickly. There are some concerns when used for long-term purposes. The effectiveness of the remedies suggested by Dinsmore is unclear, as is their long-term safety. Given the lack of good evidence showing they work, I wouldn’t recommend the products, but if someone wanted to try them for mild heartburn, they appear to be low risk when used for short-term use.

SSRIs (selective serotonin reuptake inhibitors) for depression

Why do we treat it?

Depression is the most common psychiatric disorder and a major public health issue. It is associated with functional disability and greater risk of death. It frequently recurs.

When is drug treatment appropriate?

We treat depression to put symptoms into remission and to restore baseline (pre-depression) levels of function. The usual initial treatment of depression can include drug therapy or psychotherapy. Psychotherapy alone appears to be just as effective as drug therapy alone. There’s some evidence the combination may be more effective than either approach alone.

What benefits have drugs been shown to offer?

Antidepressants can help with depression, but the magnitude of that benefit has been questioned. The overall advantage of antidepressants over placebo can be modest for mild-to-moderate depression. Selective publication of trials may have led to an overestimate of the efficacy of antidepressants. SSRI’s or selective serotonin reuptake inhibitors are a popular class of antidepressant medications. No particular SSRI is dramatically and consistently superior to any other antidepressant drug in terms of effectiveness, but the side effects can vary. In severe cases of depression, drug therapy is combined with psychotherapy.

What does naturopathy suggest?

As per Dinsmore:

SSRIs (selective serotonin reuptake inhibitors) are the most common class of anti-depressant drugs. One in twelve Canadians will experience major depression in their lifetime, but it’s still one of the most misunderstood conditions. Standard treatment protocols typically target neurotransmitter activity (most commonly serotonin). However, new research indicates the underlying cause may actually be inflammation. Either way, natural medicine has you covered.

Some nutraceuticals to consider are 5-HTP, which is used to make serotonin, with the help of vitamin B6. The herb St. John’s Wort has been studied extensively and appears to work in the same way as SSRIs. Both 5-HTP and St. John’s wort have shown similar efficacy to SSRIs when given for mild to moderate depression. And as I mentioned earlier, omega-3 fatty acids and curcumin decrease inflammation throughout the body, including the brain.

Side effects of SSRIs include sexual dysfunction, weight gain, and worsened/chronic depression. St. John’s wort also has a side effect which should be considered if taking other medications—it impacts liver function, which can result in either higher or lower blood medication levels.

What evidence supports the use of naturopathic treatments?

5-HTP is considered “possibly effective” for the treatment of depression by the Natural Medicines database. It notes:

Overall, despite the preliminary beneficial effects shown in clinical research, the trials to date are generally small and have methodological problems or a lack of generalizability to mixed populations of depressed people. More higher-quality studies in larger patient populations are needed to confirm these result.

St. John’s Wort is considered to be “likely effective” for the treatment of depression by the Natural Medicines database. It’s an interesting natural product that is used widely for antidepressant effects. Trials have many limitations, but the data suggest that SJW may be as effective as SSRIs, but the evidence is less consistent. However, it’s not recommended in most treatment guidelines for many of the reasons discussed before at this blog: preparations of the product are often not standardized, supplement manufacturing quality is not clear, and the dosing may consequently not be predictable. Moreover, St. John’s Wort causes a wide array of drug interactions with other medications, making it difficult to use safely.

What approach has the best evidence?

Overall, there’s better evidence with the SSRIs compared to 5-HTP and St. John’s Wort. However, a decision to use St. John’s Wort is effectively a decision to use medicine, so unsupervised, unmonitored use, when treating depression, should be avoided.

Anti-hypertensives for the treatment of high blood pressure

Why do we treat it?

Untreated high blood pressure, or hypertension, can increase your risk of heart attack, stroke, heart failure, and kidney disease. We treat hypertension to reduce these risks.

When is drug treatment appropriate?

Non-drug treatments are usually considered before drug therapy, and can reduce the need for medication. Weight reduction (when necessary), quitting smoking, avoiding excessive alcohol, a healthy, reduced-salt diet, and regular exercise are all low-risk strategies that can be beneficial. Drug therapy can have side effects. People are usually unwilling to tolerate side effects for a symptomless condition, unless there is a good reason to take medication. There is good evidence that drug therapy provides real benefits to those with hypertension that can’t be controlled by lifestyle changes.

What benefits have drugs been shown to offer?

When drug treatment is considered appropriate (usually when blood pressure exceeds 140/90), there are multiple treatment options that may be appropriate. From Up-to-Date:

In large-scale randomized trials, antihypertensive therapy produces a nearly 50 percent relative risk reduction in the incidence of heart failure, a 30 to 40 percent relative risk reduction in stroke, and a 20 to 25 percent relative risk reduction in myocardial infarction.

The absolute benefit is less impressive, but still real: There’s an approximate 2% reduction in heart attacks and strokes. The benefits of medical treatment are not as clear in those with mild hypertension, those with few risk factors, or the frail elderly.

What does naturopathy suggest?

As per Dinsmore:

Hypertension (i.e., high blood pressure) affects 6 million Canadians, and is responsible for approximately 13 per cent of all deaths. Various classes of anti-hypertensives include diuretics, ACE inhibitors, angiotensin II receptor blockers (ARBs). Diuretics increase urine output, which can negatively affect sodium and potassium levels, which can cause muscle cramps. ACEIs and ARBs may both cause a chronic dry cough. All anti-hypertensives can cause dizziness, headache and low blood pressure.

Again, there are many nutraceutical options for patients to consider, such as CoQ10, magnesium, garlic extracts, omega-3 fatty acids, L-arginine and vitamin C. All of these have all been shown to lower high blood pressure by various means. Dandelion leaf is an effective diuretic that doesn’t lower potassium levels.

What evidence supports the use of naturopathic treatments?

I could find no published evidence that coenzyme-q10, magnesium, garlic, omega-3 fatty acids, l-arginine, or vitamin C supplements reduce the risk of heart attacks, stroke, heart failure, or kidney disease. There is some evidence to show that eating fatty fish (a source of omega-3 fatty acids) can reduce the risk of heart disease or stroke. Omega-3 supplements (also discussed above for hypercholesterolemia) may modestly reduce blood pressure. None of the products listed are considered both safe and effective for treatment of hypertension by the Natural Medicines database. I could find no published evidence that demonstrates dandelion leaf is an effective hypertension treatment.

What approach has the best evidence?

The only reason to treat hypertension with a drug or supplement is to reduce the risk of a future catastrophic event. If medicine is necessary, there’s little reason to choose a “natural” remedy first, as the real-world benefits of supplements have not been proven.

Benzodiazepines for anxiety and insomnia

Why do we treat it?

The term “anxiety” describes worries and fears that are difficult to control and can cause debilitating effects. Insomnia describes difficulty falling asleep or staying asleep. We treat both to reduce the consequences of these conditions, and to restore normal functioning.

When is drug treatment appropriate?

After a workup for underlying causes of anxiety or insomnia, drug therapy might be considered after options like lifestyle changes and cognitive behavioral therapy have been attempted. Benzodiazepines are a class of drugs that can be useful treatments for anxiety and insomnia, though they are usually not the first choice for either condition. There are justified concerns about dependence and tolerance with benzodiazepines, reinforcing the importance of using these medications cautiously and when the benefits are expected to outweigh the risks.

What benefits have drugs been shown to offer?

Benzodiazepines can work quickly and can be effective in anxiety where there’s a poor response to other medications. They are also effective insomnia treatments, with some taking effect within minutes.

What does naturopathy suggest?

As per Dinsmore:

Benzodiazepines are a class of drugs most often prescribed for anxiety disorders and insomnia. They work by binding to receptors for GABA, a neurotransmitter in the brain that calms activity of the nervous system. Interestingly, this is the same mechanism by which alcohol acts in the brain. One obvious effect of benzodiazepines is sedation—great when the treatment target is insomnia. Not so great when you just want to decrease your anxiety but still function. Other side effects include dizziness, loss of balance, and even cognitive impairment at higher doses. They also have a significant risk of developing physical or psychological dependence and rebound anxiety when discontinued.

This is an area where you should have a thorough workup with your naturopathic doctor and consider the options that are right for you. You can take GABA as an alternative (but there’s mixed evidence on whether or not it actually gets into the brain), or herbs such as passionflower (which has the same mechanism of action as benzodiazepines). Other herbs include valerian, chamomile, kava, and many others.

What evidence supports the use of naturopathic treatments?

Up-to-Date has a nice summary:

A variety of herbal products are purported to be useful for insomnia. There is little evidence from randomized controlled trials about the efficacy of many herbals, however, and for those that have been well studied (eg, valerian), there is little evidence of benefit. A meta-analysis that included 14 randomized trials in over 1600 patients found no significant difference between any herbal medicine and placebo on any of 13 clinical efficacy measures of insomnia [94]. The majority of the trials (11 out of 14) studied valerian; chamomile, kava, and wuling were studied in one trial each. Unlike the other herbals studied, valerian was associated with a greater number of adverse events per person compared with placebo. Valerian may also produce hepatotoxic effects [1]. Contamination with undesirable substances poses a problem for many such natural remedies.

And for natural treatments of anxiety, Up-to-Date notes:

None of the herbal remedies described here been shown in clinical trials to be clearly effective or ineffective for anxiety symptoms or disorders. Trials suggest that kava and chamomile may reduce anxiety in some people with generalized anxiety disorder (GAD). Findings from trials of valerian, passion flower, and St. John’s wort are either mixed or negative. Patients may wrongly equate “herbal” with terms such as “good,” “weak,” or “healthy” in evaluating these remedies. These perspectives underestimate their potential risks; some herbs can be potent, poisonous, or addictive. Potentially serious adverse effects of herbal remedies discussed here include hepatotoxicity with kava and anticoagulation with chamomile. It is not known if these remedies are safe or unsafe during pregnancy.

What approach has the best evidence?

It’s understandable to want to avoid benzodiazepines, but they can provide real and demonstrated benefit in select circumstances with close monitoring from a physician. There’s a lack of evidence to demonstrate the efficacy and safety of any of the herbal remedies recommended for the treatment of anxiety or insomnia.

Conclusion: The evidence simply doesn’t support these natural treatments

Naturopaths claim that they can effectively manage medical conditions with “natural” approaches, but the evidence supporting these recommendations has been consistently shown to be absent or weak. It may be that the treatment goals are not understood, which may explain why therapies without any demonstrated benefit are being recommended before proven therapies. In some cases, avoiding drug therapy and using natural remedies may be harmful. In light of the recommendations above, it seems prudent to discuss any naturopathic advice with a health professional like a pharmacist or physician before making any decision to delay medically-recommended drug therapy, or substitute a natural remedy or dietary supplement.

This is a cross-post from Science-Based Medicine. Comments are open there.

Photo from flickr user Ryan Somma used under a CC licence.

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What’s the best detox or cleanse?

Naturopathy

Jan 012016

juice-getty

With 2016 upon us, it’s finally time get serious about your health. You’re resolving to eat better and exercise more. But first, you need to reset your body – and purge yourself of all of your lifestyle and dietary overindulgences. But how? The options seem limitless, and everyone has advice: There’s Dr. Oz, Gwyneth, and even your favourite Kardashian has advice: They’re all telling you how it’s essential to “detox”, “cleanse” and “flush” away all of your toxins. Your local pharmacy has an ever-growing section of products promising a newer, more pure you: supplements, homeopathy, ear candles, and an entire aisle of “detox kits” all promise to suck toxins out of your body. Don’t forget your local naturopath who sells IV vitamin drips as the detoxification solution to your problems. The approaches may differ but all the advocates are completely convinced of one fact: Detoxing will deliver a renewed body and better health. Not only will you look better, you’ll feel better. It is a new year. Wouldn’t a purification from last year’s habits (dietary and otherwise) of last year be the best way to start? Well before you pull out your credit card, there is one fact that “detox” advocates are reluctant to tell you.

“Detox” is a marketing term used to sell you products

“Detox” is a legitimate medical term that has been co-opted to sell useless products and services. It is a fake treatment for a fake condition. Real detoxification isn’t ordered from a menu at a juice bar, or assembled from supplies in your pantry. Real detoxification is provided in hospitals under life-threatening circumstances — usually when there are dangerous levels of drugs, alcohol, or other poisons in the body. Drugs used for real detoxification are not ingredients in a smoothie. What’s being promoted today as “detox” is little different than eons-old religious rituals of cleansing and purification. Framing detoxification in religious terms won’t have the appeal in a world that values science. So use the word “toxin”, not sin, and call the ritual a “detox” – and suddenly you’ve given your treatment a veneer of what sounds scientific. Fake detox is marketed based on three easily-debunked ideas. Once you can spot the flaws, it’s easy to spot the spin and misinformation, and to make smarter, healthier decisions.

Premise one: Our bodies are accumulating toxins, so we need to detoxify

There’s a reason we fall for the marketing of detoxification — we seem hardwired to believe we need it, perhaps related to our susceptibility to ideas of sympathetic magic. Purification rituals date back to the earliest reaches of recorded history. The idea that we’re somehow poisoning ourselves and we need to atone for our sins seems to be a part of human nature, which may explain why it’s still a part of most of the world’s religions. It’s not miasmas or sin that we’re as worried about today, however. As our knowledge of biology grew, these fears manifested as “autointoxication.” Clean out the bowels, went the theory, and you could cure any illness. Science discarded autointoxication by the 1900’s as we gained a better understanding of anatomy, physiology, and the true cause of disease. Yet the term persists today – but now it’s marketing slogan. Today’s version of autointoxication argues that our environment is increasingly toxic, and it’s making us ill. Depending on who you ask, some combination of food additives, salt, meat, fluoride, prescription drugs, smog, vaccine ingredients, GMOs, not “eating clean”, or perhaps not “eating paleo” are causing a buildup of “toxins” in the body. And don’t forget gluten. Gluten is evil and therefore it is a toxin. (Never mind the science.) So what is the actual “toxin” that is causing you vague but apparently real harm? Detox kits and treatments never name the toxins that they remove, because they’ve never been shown to remove toxins. Picking one common drug store detox kit, Renew Life says:

Did you know that we come into contact with toxins every day—from the environment, our food, and even within our own digestive tract? While the body was built to process these toxins, today’s world places increased stress on our elimination channels. Renew Life Advanced Cleansing Programs are powerfully formulated to promote regular elimination and support the body’s natural detoxification process.* They provide targeted support to the body’s pathways of elimination: liver, lungs, lymphatic system, kidneys, skin, blood, and bowel.*

Note the vague language, which is universal with detox kits and treatments. Toxins are alluded to — but not named. It sounds somewhat plausible, but is non-specific.

The colon remains ground zero for detox advocates. Advertisements may argue that some sort of toxic sludge (sometimes called a mucoid plaque) is accumulating in the colon, making it a breeding ground for parasites, Candida (yeast) and other nastiness. Fortunately, science tells us otherwise: mucoid plaques and toxic sludge simply do not exist. It’s a made-up idea to sell detoxification treatments. Ask any gastroenterologist (who look inside colons for a living) if they’ve ever seen one. There isn’t a single case of mucoid plaque that’s been documented in the medical literature. Not one. The same can be said for rope worms. They do not exist.

Premise two: Illness is the result of chemical toxins

Marketing materials for detox treatments typically describe an array of symptoms and diseases linked to toxin buildup: A few that are general enough to apply to anyone (e.g., headache, fatigue, insomnia, hunger) with a few specifics to frighten you (cancer, etc.) Which toxins cause which disease is left out, and how the toxins cause the symptoms is never actually explained. Here again we see the contrast with real science. To establish that even a single chemical can cause disease requires a significant amount of research. Despite the variety of toxins that are claimed to be causing your illness, marketing claims for detox treatments always fail to link specific toxins to specific symptoms or illnesses. That’s because they can’t — there is no scientific evidence to show that detox treatments have any useful medical effects.

The reality is that our bodies are constantly being exposed to a huge variety of natural and synthetic chemicals. Air is chemicals. Food is chemicals. Drugs are chemicals. Herbs are chemicals. The presence of any chemical in the body, (natural or synthetic) does not mean that it is doing harm. Many naturally-derived substances can be exceptionally toxic, and consequently the human body has evolved a remarkable system of defenses and mechanisms to defend against, and remove unwanted substances. The skin, kidneys, lymphatic system, gastrointestinal system, and most importantly, the liver make up our astoundingly complex and sophisticated intrinsic detoxification system.

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Advocates for detox typically describe the liver and kidney as acting like filters, where toxins are physically captured and retained. It’s argued that these organs need to be cleaned out periodically, like you’d squeeze out a sponge, or change the air filter in your car. But the reality is that the kidney and liver don’t work this way. The liver performs a series of chemical reactions to convert toxic substances into ones that can be eliminated in bile or urine. The liver is self-cleansing — toxins don’t accumulate in it, and unless you have documented liver disease, it generally functions without any problem. The kidney excretes waste products into the urine — otherwise the substance stays in the blood. Anyone that suggests these organs need a “cleanse” is demonstrating that they don’t understand basic anatomy or physiology.

Premise three: Detox diets and treatments remove toxins

A recent review of detox diets in the Journal of Human Nutrition and Dietetics provides the best summary of the evidence supporting detox diets:

To the best of our knowledge, no rigorous clinical investigations of detox diets have been conducted. The handful of studies that have been published suffer from significant methodological limitations including small sample sizes, sampling bias, lack of control groups, reliance on self-report and qualitative rather than quantitative measurements.

The authors could find only a single detox product has been evaluated in the literature. Ultra Clear is a supplement that is claimed to detoxify the liver. The “evaluation” of Ultra Clear, was not blinded, and lacked any controls. The research subjects were 25 naturopathy students. Perhaps not surprisingly, the students reported improvements on a number of measures – but without a properly designed trial, the results don’t provide any evidence that the product is effective.

In general, there was no credible evidence to demonstrate that detox kits do anything at all. While they can be very unpleasant, they have not been shown to remove “toxins” or offer any health benefits. Coffee enemas are commonly promoted as toxin-removers. Coffee enemas offer no medical benefits. Vitamin injections are a popular naturopathic offering that has not been shown to provide meaningful benefits to consumers, as it has no beneficial effect on the ability of your liver or kidneys to work effectively. Chelation injections are touted as a cure-all for all kinds of illnesses, but unlike real chelation that is administered in hospitals for real cases of poisoning, naturopath chelation is not science-based and doesn’t seem to do much of anything (except enrich its proponents).

There is just as little evidence for detox programs. The only one to have been evaluated is via L. Ron Hubbard and the Church of Scientology, called the Hubbard Purification Rundown. It involves niacin supplements, saunas, exercise, polyunsaturated oil consumption, and vitamins, minerals and electrolytes. The protocol was used on a small group of firefighters after 9/11. With small sample sizes and no control groups, any critical evaluation of the results is impossible. Another evaluation with firefighters was equally limited by a lack of proper randomization and blinding. The same protocol was also used in healthy volunteers. Owing to a lack of blinding and placebo, the results are not credible, which is probably why the paper ended up published in Medical Hypotheses.

The bottom line? The onus is on promoters of detox to show their kits and protocols and methods actually deliver as promised — but they don’t, because they don’t have the evidence and they haven’t done the studies. If someone tells you that a detox kit or procedure is effective, ask for evidence.

Detox treatments can be harmful

If they provide no benefit, can detox treatments harm?

When it comes to simple dietary changes, there’s little evidence of harm. Eating more quinoa and kale, and less processed and refined foods is reasonable dietary advice for everyone. Homeopathic “detox” is also likely safe — with no active ingredients, homeopathy is an elaborate placebo system. As you get into more unorthodox detox treatments that actually contain active ingredients, there is the potential for harm. Coffee enemas are a detoxification process that has a real risk of harm. From a medical perspective, coffee enemas are considered unsafe. Rare but serious adverse events like septicemia (bacteria in the bloodstream), rectal perforation, and electrolyte abnormalities have been caused by coffee enemas. Deaths from the administration of coffee enemas have also been reported.

Vitamin injections won’t provide you with any medical benefits but don’t seem as risky, as long as you trust the sterile technique of your alternative provider. However, given some naturopaths seem to be willing to inject products intended for oral use, you might want to think carefully about taking a vitamin injection or chelation treatment, especially when there’s no evidence they do anything meaningful. Glutathione injections, while often touted as a “hangover cure” (among other uses) actually has very little published safety information available to support its use.

What about the detox kits found in pharmacies? Contents vary, but typically contain two categories of ingredients:

A liver “booster” — typically milk thistle (Silybum marianum). If the liver can’t be wrung out and rejuvenated, can it be boosted to do a better job? Milk thistle is the most popular product purported to “boost” the liver’s effectiveness. Milk thistle has been studied in patients with alcoholic liver disease, and in patients with hepatitis B or C, and it has not been found to exhibit any meaningful effects. There is conflicting evidence on the use of silymarin, a milk thistle constituent, for acute toxic liver damage, but there is no published evidence to suggest that consuming milk thistle will cleanse you of unnamed, non-specific “toxins”.
A laxative — Typically magnesium hydroxide, senna, rhubarb, cascara, etc. Laxatives are the ingredients in detox kits that give you the effect you can see (and feel). However, these ingredients can cause dehydration and electrolyte imbalances if not used carefully. Regular use of stimulant laxatives, like senna and cascara, are ill-advised for most healthy adults due to the risk of dependence and electrolyte depletion. They’re among the most potent laxatives, usually used for short periods to alleviate significant constipation or to clear out your bowels before a medical procedure. With regular use, your bowel can grow accustomed to the effects of laxatives which may result in constipation once you stop using them. It’s a perfect case of the treatment causing the illness: After the detox, you get could conceivably become constipated – just in time for another “detox”.

Side effects can continue once a detox ends. Some people experience post-detox effects like nausea and diarrhea. Advocate call these “cleansing reactions” and will assure you it’s “toxins leaving the body”. A more plausible, science-based explanation is that this is a consequence of restarting the digestive process after a period of catharsis, where, depending on the extent and duration of fasting, little to no digestion occurred, and the normal gastrointestinal colonies of bacteria may have been severely disrupted. It’s the same effect seen in hospitalized patients who have difficulty initially digesting food after being fed intravenously. The detox ingredients, and resulting catharsis, may irritate the colon to such an extent that it may take time for digestion to return to normal.

Immediate weight loss is not uncommon after a detox, especially one that involves a laxative. Unfortunately this is usually due to losses in water and possibly muscle tissue, depending on the how disruptive the detox was to normal body function. Regardless of the weight loss, the body will move back to its pre-detox weight over time if diet and activity levels remain the same.

Image via @statsguyUK

There are no quick fixes

Any product or service advertised with the words “detox” or “cleanse” in the name is only truly effective at cleansing your wallet – of cash. Alternative medicine’s ideas of detoxification and cleansing have no basis in reality. There’s no published evidence to suggest that detox treatments, kits or rituals have any effect on our body’s ability to eliminate waste products effectively. They do have the ability to harm however — not only direct effects, like coffee enemas and purgatives, but they also distract and confuse people about how the body actually works and what we need to do to keep it healthy. “Detox” focuses attention on irrelevant issues, giving the impression that you can undo lifestyle decisions with quick fixes. Improved health isn’t found in a box of herbs, a bottle of homeopathy, or a bag of coffee flushed into your rectum. The lifestyle implications of a poor diet, lack of exercise, smoking, lack of sleep, and alcohol or drug use cannot simply be flushed or purged away. Our kidneys and liver don’t need a detox treatment. If anyone suggests a detox or cleanse to you, remember that you’re hearing a marketing pitch for an imaginary condition.

Comments are open over at Science-Based Medicine!

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Review of 17 “alternative” therapies finds no evidence of effectiveness

Naturopathy

Dec 192015

Reiki is as science-based as The Force

Health care systems around the world are being pressured to “do more and spend less”, to make healthcare more cost effective. Owing to aging populations and the growing cost of providing health services, there’s more scrutiny than ever on the value of different health treatments, with the goal of reducing the use of treatments that don’t help. The Choosing Wisely initiative was establishing expressly for this purpose. Regrettably, while well-intentioned, Choosing Wisely hasn’t had as much of an effect as you might expect. Medicine can be slow to change, as David Gorski discussed in a post over at Science-Based Medicine. Unless we ruthlessly scrutinize what we do for effectiveness, and are willing to act on what we learn, self-driven change is unlikely. One way that governments (and insurers) can dramatically reduce the use of a health service or treatment is to simply stop offering it, or paying for it. Yet stopping funding is something that is relatively uncommon in health care. It seems to be much more difficult to stop a practice, possibly owing to inertia, a reluctance to change, and the sometimes-vociferous protests that can emerge from patients or physicians that may feel that their preferred therapy is effective. The formidable challenge of stopping health care funding, once it has started, is one reason why this blog has been very critical of the expanding scope of practice being granted to alternative medicine purveyors – the legislative alchemy that is the first step towards insurance coverage. Because once that’s in place, it will be far more difficult to stop it. So it’s essential to understand the evidence.

Yet sometimes, which the evidence is so stark, insurers and governments face facts and start cutting benefits. Economic circumstances can strengthen that resolve. The most politically-acceptable approach, not surprisingly, is to conduct ruthlessly rigorous scientific reviews. When done effectively, these reviews can lead to solid, science-based decision making. Consider the slow death we are witnessing of homeopathy on the UK’s National Health Service (NHS). The NHS is a comprehensive public insurance system that maintains a “blacklist” of services that won’t be reimbursed if prescribed by a physician. It would seem self-evident that sugar pills should fall into this category, and that’s exactly what we may soon see.

Australia is another country with a fairly comprehensive public healthcare system that is also facing economic challenges and the desire to use its resources more efficiently. It also has a complex system in which the public insurance program (Medicare) is supplemented by private insurance which covers the cost of treatments and service that are not publicly funded. The risk to good care (and choosing wisely) is that there are often fewer incentives to reduce inappropriate costs from private plans, because those costs can be passed right back to the insured, typically in the form of higher premiums.

The Australian government recently undertook a review of natural products covered by private health insurance. It did this for two main reasons: The first was to ensure that private insurance plans were paying for “clinically proven” treatment. The second was based on concerns about tax dollars being used to subsidize ineffective treatments. The government provides a rebate on private insurance, and questions were raised about the extent to which the government was effectively subsidizing “natural” therapies that were not supported by good evidence yet were still being paid for through insurance. So in 2012 the government announced a review of natural treatments to determine if these therapies were effective, safe, and provided good value for money. Perhaps not surprisingly, the report has concluded:

The Private Health Insurance Rebate will be paid for insurance products that cover natural therapy services only where the Chief Medical Officer finds there is clear evidence they are clinically effective.

Such clear evidence has not been found.

The Review of the Australian Government Rebate on Natural Therapies for Private Health Insurance

The reality with many “natural” remedies is that there is often a lack of good evidence with which to evaluate them. Consequently, we’re often left with an “absence of evidence” rather than evidence that points clearly in one direction or another. (This gets to the distinction of evidence-based medicine from science-based medicine). In this review, the authors did not consider plausibility (a problem I will come back to), but looked only for direct evidence, drawing a very strict definition:

The data set was limited to systematic reviews (i.e., reviews of trials) published in the last 5 years. However, the authors noted that most reviews searched for all potentially relevant primary studies, without date limitations. They also considered literature submitted by stakeholders. Upon examination, both were felt to be low-quality evidence.
Searches were limited to the English language (which might limit the evidence base for some therapies).

The major problem with this approach was summarized by the authors as part of the quality assessment, and they noted the following:

A lack of randomized controlled trials. Even trials reported as RCTs didn’t contain enough information to demonstrate that they were truly randomized.
Poor comparators. Often trials were designed to make the assessment of a particular “natural therapy” impossible.
Lack of power. Studies were underpowered and not designed to actually answer the question being asked.
Lack of blinding. With most trials measuring subjective effects, blinding the investigator and the patient was critical. This was rarely observed. It was also observed that some therapies are very difficult, if not impossible, to truly blind (e.g., massage).

What was reviewed?

In three cases, the review had to modify its approach. Multi-modality therapies, like herbalism or naturopathy, needed to be studied differently. One topic, Ayurveda (natural medicine with Indian roots) was dropped owing to the diversity of the treatments and the requirement to translate data. Four others (hypnotherapy, biochemistry, nutrition and psychotherapy) were also dropped as it wasn’t clear which aspects of these therapies were “natural therapies”.

I’ve been blogging for years, but some of these therapies were new to me:

The evidence

Alexander technique

Alexander technique is a type of physical therapy that aims to improve movement and correct posture, with the goal of improving health and reducing pain. Invented by Frederick Matthias Alexander, the process seems to encompass elements of mindfulness in the practice. Nine systematic reviews were identified, but the overall evidence base was poor. The reviewers concluded that the Alexander technique may be effective in improving pain and disability of low back pain in the short term (up to 3 months) but the long-term effectiveness of Alexander technique was unclear. There was insufficient evidence for other conditions to draw any conclusions.

Aromatherapy

Aromatherapy uses essential oils with the intent of delivering a medicinal effect. It’s used as part of massage therapy, but also on its own. The main uses are to treat stress and anxiety, but the oils are also thought to help reduce pain and nausea. Proponents make very wild claims about the effectiveness of aromatherapy of essential oils, but the actual evidence is lacking. There was limited, low-quality evidence to suggest aromatherapy may be effective in reducing anxiety and agitation in patients with dementia, and possibly in reducing generalised anxiety in some other situations, such as before health-care procedures. However, this observation emerged from data that was judged to be of poor quality. The overall effectiveness and relevance of aromatherapy for these uses felt to be unclear. The effect of aromatherapy on health outcomes with other conditions remains uncertain.

Bowen therapy

Bowen therapy is a form of physical manipulation/massage/bodywork that is described as a soft-tissue remedial therapy or a form of bodywork that primarily focuses on the myofascia. Therapists use their fingers and thumbs to apply gentle rolling movements over muscles, tendons, and connective tissues. Invented by Australian Thomas Ambrose Bowen which he described as a “gift from god”, you can learn to offer Bowen therapy over a weekend. When the limited data were considered, it was concluded that there was insufficient evidence to make any conclusions about the safety or efficacy of Bowen therapy.

Buteyko

Buteyko (the Buteyko method) is a breathing technique developed in Russia for the treatment of asthma. It involves shallow breathing, through the nose, with breath-holding at the end of the exhalation. It is promoted as a treatment for respiratory disorders. It was invented by Konstantin Buteyko in a moment of inspiration when he was dazzled by a bright light (I’m starting to see a pattern here). The quality of the evidence for Buteyko is low. None of the evidence reviewed demonstrated that the Buteyko breathing technique improves pulmonary function, asthma symptoms or quality of life in adults. There is weak evidence that it may decrease bronchodilator use compared with inactive controls, however.

Feldenkrais

The Feldenkrais method was invented by Moshe Feldenkrais. It is a gentle form physical therapy that focuses on breath, posture, and movement. What the Feldenkrais technique promises is vague and seems to revolve around nonspecific “wellness” rather than any objective effects. While several systematic reviews were found, few contained any RCTs. Data quality, again, was poor. Overall, the effectiveness of Feldenkrais for the improvement of health outcomes in people with any clinical condition was felt to be uncertain.

Herbalism/western herbalism

Herbalism was the basis of modern pharmacology and involves the use of plants and plant-derived substances as medicine. The report identified three main types of herbalism: Chinese, Ayurvedic and “western”. Herbals treatments can be administered in many ways – not just orally. This review looked at the overall effectiveness of herbalism – not just herbal remedies, as the question facing the review was the funding of herbalists as an insured service. Chinese and Ayurvedic medicine were excluded from the review as they were determined to be out of scope. No systematic reviews were found. While there is considerable research on individual plants and products, there was no data on the overall effects of herbalism, and the process of “individualized” treatments as provided by herbalists. Given herbalism is effectively the provision of impure drugs and chemical combinations, the authors noted the significant potential for adverse events with herbalism, particularly when herbal remedies are combined with drug products.

Homeopathy

Homeopathy is an elaborate system of placebos where most homeopathic “remedies” contain no active ingredients at all, invented 200 years ago by German physician Samuel Hahnemann. Based on the idea that “like cures like” (which is a form of sympathetic magic) and the belief that sequentially diluting a substance will increase its effect (because the water has a “memory” of the substance), most remedies are inert. The authors looked at the National Health and Medical Research Council report as part of this review. They noted that there is little high-quality evidence, the available evidence is not compelling, and overall fails to demonstrate that homeopathy is an effective treatment for any condition.

Iridology

Iridology is an alternative health practice that is based on the belief that medical conditions manifest in the iris. Examining the iris is thought to bring insights about overall health as well as specific organs and body functions. Iridology is prescientific pseudoscience, yet is used by iridologists, naturopaths and homeopaths for diagnostic purposes. No systematic reviews were identified that have studied iridology, signaling there is a lack of evidence to demonstrate any effectiveness for the practice.

Kinesiology

Kinesiology is the study of body movement that identifies factors that block the body’s “natural healing process”. It is more commonly referred to as “applied kinesiology (AK) or specialized kinesiology, which should be distinguished from the science-based use of the term kinesiology, which refers to studies of mechanics and anatomy. (This portion of the review was poorly done and confusing to parse, as it did not distinguish clearly between the different practices that may be called kinesiology.) AK was invented by chiropractor George Goodheart and is a combination of chiropractic, acupuncture and western biomechanics. Applied kinesiology is pure pseudoscience. Dysfunctions found in AK are addressed by focusing on acupressure points and other specific body movements. The literature search found only a single systematic review on the topic of applied or specialised kinesiology. Not surprisingly, it was observed that there is a lack of evidence showing AK is effective for any condition.

Massage therapy

The term massage therapy or myotherapy encompasses a number of different manual therapies, and this review included remedial massage, sports therapy massage, deep tissue massage, myofascial release, therapeutic massage, myotherapy, lymphatic drainage, traditional Thai massage and Swedish massage. Systematic reviews were sought for any form of massage therapy. This was an extensive review and the data search results for each type of massage therapy are outlined in detail. Overall, the data was found to be of low quality. It’s important to acknowledge that like other manual therapies, blinding for providers and patients is difficult, as is data collection, as most outcomes are patient-reported, subjective measures.

The reviewers noted that there is a lack of good-quality evidence that examines the effectiveness of massage therapy for many conditions, and is actually inconclusive/uncertain for 29 clinical conditions it assessed. There is mixed but promising evidence for low back pain, and for reducing the length of stay in pre-term infants. There were some specific recommendations made about future research which I think are worth noting, as they point to the number of variables that may affect the effectiveness of massage therapy, and our ability to assess it:

In practice, massage therapists often combine various treatment modalities or techniques within a single session, and may also treat patients over longer periods of time than those assessed in an RCT. To allow for more firm and conclusive statements about the effectiveness of massage therapy for a particular clinical condition, more rigorous, multicentre, and well-designed clinical studies assessing the effectiveness of massage therapy for a particular patient population are required. RCTs need to combine treatment approaches so as to properly reflect the way that massage therapy is applied in practice. Also, there is little data about what constitutes an effective massage therapy session. Further research is required regarding optimal treatment parameters such as number of sessions or duration of sessions required, combined with longer-term follow-up of patients to assess the long-term effectiveness of massage therapy. Similarly, further high-quality research is required that reflects the way that myotherapists use various touch and equipment-based interventions in practice, to enable the effectiveness of this therapy to be assessed.

Naturopathy

As has been noted many times on this blog, naturopathy is an alternative medicine practice that encompasses a variety of modalities including homeopathy, herbal medicine, and Traditional Chinese Medicine. “Vitalism” is the belief that living beings have a “life force” not found in inanimate objects; as a concept vitalism was disproved by Wöhler in 1828. Despite this, the idea remains the central dogma of naturopathy and informs much of its practice. Naturopathic treatment ideas are all grounded in the idea of restoring this “energy”, rather than being based on objective science. Naturopaths can use conventional medicine as part of their practice, but this tends to occur only when its use aligns with the naturopathic belief system. This review focused on the overall effectiveness of naturopathy and naturopathic practitioners, rather than individual remedies or treatments, some of which are covered separately in the report (e.g., homeopathy, which is a “clinical science” in naturopathy). The reviewers found a single systematic review as an unpublished abstract. Conditions studied included cardiovascular disease, multiple sclerosis, anxiety and various types of musculoskeletal pain. There was no data on acute conditions. The overall quality of the evidence was rated as low. It wasn’t clear if this data was generalizable, as the studies were North American, where many states (and Canadian provinces) licence naturopaths. Naturopathy is unregulated in Australia. While the reviewers concluded that there is some evidence to suggest that naturopathy as a service is effective in improving patient health for a range of chronic conditions, there were numerous limitations noted with that data. And as regular readers to the blog will know, the evidence demonstrating that naturopathy is effective is lacking.

Pilates

Pilates is an exercise practice that is said to benefit health through improvements in strength, coordination, balance, flexibility, proprioception, range of motion, body definition, and muscle symmetry. It focuses on the body’s core muscles, as well as posture. Invented by Joe Pilates, there are over 500 exercises that may be done on the floor or using specialized equipment. Despite the popularity of Pilates, there is little published evidence that examines its efficacy. A search found 10 systematic reviews that included 18 unique RCTs. Conditions studied included obesity, breast cancer, strength/balance and falls prevention, low back pain, and stress urinary incontinence. Overall the data was quite limited, even for the conditions studied. The authors concluded that the effectiveness of Pilates for the conditions studied was uncertain. The most favourable interpretation was that Pilates may offer some benefit for low back pain, but even this tentative conclusion was limited by poor data quality.

Reflexology

Reflexology is the practice of applying pressure to the feet in the belief that points on the soles correspond to different organs and locations in the body overall. This type of massage is believed to release “blockages” and stimulate healing. Reflexology is another alternative medicine practice that is pure pseudoscience. Like iridology above, reflexology is a homonculus, or mapping-based system. Not surprisingly, this review found a lack of data and concluded that the effectiveness of reflexology was uncertain for all conditions that were assessed.

Rolfing

Rolfing is another form of manual therapy (sometimes referred to as structural integration) that is used to treat different health conditions, both musculoskeletal and non-musculoskeletal in nature. It seems to have elements of massage, yet focuses on the fascia and seems to veer more into beliefs about “energy medicine”. Rolfing was invented in the 1950s by Ida Pauline Rolf who claimed to identify a correlation between muscular tension and emotions. While anecdotal claims of effectiveness exist, there is a lack of published evidence that has critically examined Rolfing. The review concluded that there is a lack of evidence effectiveness of Rolfing for any clinical condition. Consequently, the safety, quality and/or cost-effectiveness of Rolfing could not be determined.

Shiatsu

Shiatsu is a form of massage therapy that incorporates acupressure, with origins in Japan. Shiatsu is considered a gentle massage (unlike Rolfing) where pressure is applied to over 150 pressure points on the body. Its aim is to restore and “balance” “energy flows” in the body. Practitioners may also use other treatments, such as moxibustion, cupping, food as medicine and judo therapy/tai chi/qi gong. The researchers found no systematic reviews for shiatsu for any condition, so were unable to draw any conclusions about its effectiveness or safety. They noted that the lack of evidence makes it difficult for consumers and others to make informed assessments of this therapy.

Tai chi

Tai chi, taiji or taijiquan is a mind/body exercise that involves slow, flowing movements. It has origins in China as a martial art and is based on Confucian and Buddhist philosophies. It is thought that tai chi can balance the body’s yin and yang and the overall “life force” or “qi”. While there are several variants of tai chi, all use slow movements and focused breathing techniques. There is a substantial evidence base for tai chi: The authors found 37 systematic reviews that included 117 unique RCTs, and almost 9,000 participants across 16 clinical conditions. Overall, the quality of the evidence was not good however. The reviewers concluded that there was low-quality evidence to suggest that tai chi may have some beneficial health effects compared to control for some conditions. However, owing to the dearth of good data, the magnitude of any benefit was not clear. Tai chi is well tolerated, and the reviewers concluded it could be considered a safe treatment in the populations studied.

Yoga

Yoga is a traditional Indian mind and body practice that involves a combination of physical postures, breathing techniques and meditation or relaxation. Depending on the form of yoga, there may be elements of stretching, strengthening and mediation. While spiritual elements are important components of traditional yoga, it is more popular as a form of exercise that ignores many of these elements. The reviewers found 67 reviews, 59 of which contained a total of 111 unique RCTs of yoga. The evidence base is limited by small, poor-quality studies that were poorly reported, making interpretation difficult. Consequently, the reviewers could only identify that there is weak evidence that yoga improves symptoms in people with depression compared with control. There was insufficient information available for other conditions.

Conclusion: Absence of evidence and plausibility

A comprehensive Australian review has found that there is a uniform lack of good quality clinical evidence to support the use of 17 different “natural” treatments. While absence of evidence is not the same as evidence of absence, the lack of good data to demonstrate efficacy suggests that these practices cannot be considered evidence-based. While this report gives a comprehensive summary of the current evidence, it is not without its problems. These therapies vary widely in their plausibility. On one end, iridology and homeopathy are pure pseudoscience. Pilates, yoga, and tai chi, however, are physical exercise which are admittedly difficult to evaluate in RCTs, yet are much more likely to have the potential to be beneficial. It’s here that a more clear science-based medicine filter would have been useful, something that the authors seem to acknowledge in their comments on the report, where plausibility is mentioned as a potential guide for future research. Given the very rigorous evidence bar it established, it is likely that insurance subsidies for these 17 treatments may end as a consequence of this review.

This is a cross-post from Science-Based Medicine. Comments are open there.

Photo via flickr user James Deacon used under a CC licence.

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A disturbing case of “naturopathic medicine” for whooping cough

Naturopathy

Nov 082015

Whooping cough does this to children. It can even kill them. And it's preventable. Antvaccinationists oppose this.

Whooping cough does this to children. It can even kill them. And it’s preventable. Yet some prefer the disease over an effective vaccine.

Over at Science-Based Medicine you’ll find my recent post on Heather Dexter, who claims to be a “Board Certified Naturopathic Doctor” in Michigan, and blogs at likemindedmamas.com. She recently used her blog to describe, in astonishing, horrific, gut-wrenching detail, how she let three of her children suffer for months with whooping cough without seeking proper medical attention. She’s pulled the post off her website now, but the internet never forgets, and you’ll find this case discussed over at Naturopathic Diaries, the Skeptical OB, and at Respectful Insolence as well.

In all my blogging about naturopathy I don’t think I’ve ever encountered a case that left me so upset – because Dexter’s belief in the “naturopathic philosophy” meant that three small children endured months of misery (apnea, vomiting, and turning blue), useless remedies (homeopathy, herbal remedies, and even regular enemas) all because of a belief system that prioritizes a philosophy over scientific evidence.

Find the original post over a Science-Based Medicine.

Photo via OneSalientOversight via Reddit.

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How a diet scam was born: The rise and fall of green coffee bean

Naturopathy

Feb 012015

Green Coffee Beans - Fake Cures For Real Conditions
I thought I’d written my final post on the Dr. Oz-fueled green coffee bean extract (GCBE) diet supplement fad. But now there’s another appalling chapter, one that documents just how much contempt The Dr. Oz Show seems to show for its audience, and how little Dr. Mehmet Oz seems to care about providing medical advice that is based on good science. Last week it was revealed that the “naturopath” that Dr. Oz originally featured in his GCBE segment, Lindsey Duncan, didn’t disclose a direct conflict of interest when he spoke. After inaccurately describing the supplement’s effectiveness, he directed consumers, using keywords, to web sites that he owned or operated. The infamous “Dr. Oz Effect” worked, with Duncan selling $50 million in GCBE supplements in the following months and years. It has also been announced that Duncan and his companies have been fined $9 million by the Federal Trade Commission (FTC). The documentation released by the FTC [PDF] gives remarkable insight into how a scam to make millions was launched, and how the Dr. Oz Show is a willing platform for the routine promotion of dubious “experts” and worthless supplements.

The story of GCBE is really the story of Dr. Mehmet Oz, and his eponymous daytime television show. If you’re trying to sell a supplement, yet you don’t have actual scientific evidence to back up your claims, The Dr. Oz Show is your ticket to recognition and sales. No other show on television can top The Dr. Oz Show for the sheer magnitude of bad health advice it consistently offers, all while giving everything a veneer of credibility. Yet, this is a symbiotic relationship. Oz needs products that excite his audience. After all, everything is a “miracle” to Oz (He’s found 16 so far). The story of green coffee bean extract actually began in April, 2012, in a revealing email from the show to Duncan [PDF]:

“We are working on a segment about the weight loss benefits of green coffee bean and I was hoping that Lindsey Duncan might be available to be our expert. Has he studied green coffee bean at all? Would he be able to talk about how it works?” At that time, Duncan had no familiarity with the purported weight-loss benefits of GCBE, nor did Defendants sell GCBE. Nevertheless, within a few hours, a senior member of the Defendants’ public relations team replied: “Awesome! Thanks for reaching out, Dr. Lindsey does have knowledge of the Green Coffee Bean. He loves it!” Later that day, Defendants contacted a manufacturer of GCBE and, on or about the same day, submitted a wholesale order for GCBE raw material.

Note that the topic had already been decided upon before hand-picking the “expert” to profile it. Duncan was known to the producers, having promoted another supplement on the show before. Why Duncan? While he called himself “Dr. Lindsey Duncan”, Duncan has a naturopathy degree from the Clayton College of Natural Health, a school that the State of Texas considers a “fraudulent or substandard degree”, as it’s on a list that Texas maintains called “Institutions Whose Degrees Are Illegal To Use in Texas“. Not only is Duncan’s naturopathic degree shoddy, Texas doesn’t recognize the degree of Naturopathic Doctor at all. Despite this, Duncan lives in Texas and presented himself as “Dr. Lindsay” in the media repeatedly. Aside from the FTC prosecution, Duncan has also been prosecuted by the State of Texas [PDF] for Violations of Texas Education Code and for False, Misleading and Deceptive acts:

In addition to the use of the honorific “Dr.,” Mr. Duncan presents the appearance of a health practitioner, which he has done in television show appearances, media interviews, speaking engagements, and video promotions, by donning lab coats and making references to clinical experience and practice. Mr. Duncan’s acts and practices mislead the public into believing that he is disseminating health advice or knowledge, but such advice or knowledge is based on educational background and training which he does not have and when his underlying motivation is to sell products in which he has a financial interest.

Duncan and his companies have been selling supplements since at least 2010, and the FTC documents note how his marketing strategy has been directed at securing television appearances on programs like The Dr. Oz Show and The View. Duncan and his companies appeared to use a consistent approach:

Find a supplement to sell.
Get Duncan on television, pretending to be a health professional.
Have Duncan promote products in which he has a direct financial interest.
Do not disclose the conflict of interest.
Have Duncan describe how to find product on the internet, suggesting search terms he knows will direct traffic to his own website (e.g., “pure”).
Used pre-arranged search engine optimization (SEO) to drive internet searches to his own website.
Buy Google AdWords advertisements to capture even more traffic.
Profit.

The FTC documentation gives a “behind the scenes” perspective of The Dr. Oz Show. When the show’s producers contacted Duncan about GCBE, they did no work to independently verify he had any credible expertise or education that might suggest he would be an appropriate guest to provide medical advice. They did not appear to ask if he had any conflicts of interest. It seems they simply decided he would be their “expert”. The producers and Duncan then actively collaborated on the segment’s script. Duncan edited the script to ensure he could subtly verbally promote the brands in which he had direct financial interest. To do so, he emphasized that viewers should look for “pure” GCBE online which was a keyword he’d linked with his own brand. He emphasized that consumers should buy 400mg capsules, the type his company sold. Subsequent to the taping, the producers went one further, asking Duncan which web sites he recommended. He recommended his own, without disclosing his relationship with those companies. He then set up several fake websites that all linked to his own sites, with the intention of boosting his Google ranking to the top.

Duncan went even further. He contacted Walmart with “extremely confidential” information, offering to sell them GCBE based on the expected Dr. Oz effect. He also tried to buy up a large supply of the raw GCBE material, apparently with the intention of reselling it after the expected surge in interest.

Normally, I don’t recommend weight loss supplements, especially weight loss supplements that claim “easy weight loss” or “fast weight loss,” but the Green Coffee Bean has truly amazed me.

– Not-a-Doctor Lindsey Duncan on The Dr. Oz Show, broadcast April 26, 2012.

Duncan’s strategy worked. The episode was first broadcast on April 26, 2012. It’s worth watching again. Sales surged.

The real shame of the entire GCBE saga is that the signs it was bogus were always available. After Duncan’s first appearance on Dr. Oz, I reviewed the study itself, and concluded it looked questionable. The trial was small, not properly blinded, poorly written and didn’t pass the sniff test for credible research. The findings were suspicious, with participants losing as much weight on the placebo as the drug. There was no information presented to confirm it was a safe product. Anyone on Oz’s staff that spent an hour actually reading and understanding the paper should have seen there were serious problems with its credibility. The claims and statements made by both Duncan and Oz were outlandish, with the entire episode triggering most of the Federal Trade Commission’s “red flags” in advertisements for worthless products. And all of this was well before the investigation that subsequently determined that the entire study was fraudulent, prosecuted by the FTC, and subsequently, retracted. These investigators were so incompetent, they couldn’t even fake data convincingly. The FTC has now concluded that Duncan ought to have known the trial and its conclusions were questionable:

The defendants’ representations that GCBE would cause rapid and substantial weight loss without diet or exercise had no scientific support. The study the defendants continually referenced in their advertising, even absent Duncan’s mischaracterizations of it, suffered from serious facial flaws that should have been evident to the defendants. Accordingly, our complaint alleges that the defendants’ efficacy claims were false or unsubstantiated, and that their clinical proof claim was false. The proposed order approved by the Commission includes appropriately strong injunctive relief and requires the defendants to pay $9 million in equitable monetary relief.

– FTC statement

It’s worth noting the extent of the hoax that Duncan perpetuated after the show was broadcast. The other spokepeople for Duncan’s products that appeared on television and radio? They were paid, often without disclosing a conflict of interest. The online reviews from “ordinary consumers” on Amazon.com? Also paid for by Duncan and his companies. The video testimonials on his websites? Those were his employees. It was all a carefully-orchestrated facade to drive sales of his own products.

I actually do personally believe in the items I talk about on the show. I passionately study them. I recognize that oftentimes they don’t have the scientific muster to present as fact. Nevertheless, I would give my audience the same advice I give my family, and I have given my family these products.

– Dr. Mehmet Oz Senate subcommittee testimony, June 17, 2014 (Emphasis added)

The green coffee bean extract saga didn’t end there. Each time Dr. Oz revisited the topic, even without Duncan on the show, Duncan’s sales spiked. In 2013, Oz discussed GCBE on his show again. This time, the bad science was all on Oz’s hands. Oz conducted a clinical trial on his audience, without obtaining IRB (research ethics) approval. 50 women were randomized to the supplement or placebo for two weeks. Not surprisingly, there were no substantive effects found: The GCB group lost about 2 pounds, and the control group lost about 1 pound. Without any detailed statistics being presented, it was impossible for anyone to evaluate the Oz “research“.

The next nail in the GCBE coffin came in 2014. Dr. Oz appeared at Senate subcommittee hearing where he was verbally eviscerated for his promotion of GCBE and other weight loss products, in the face of no credible evidence. That same year, the FTC announced it was suing a Florida-based company (Applied Food Sciences) for its promotion of Green Coffee Antioxidant (GCA), a supplement containing GCBE. In September, the FTC announced it had a deal and settlement from Applied Food Sciences (AFS) and it was a bombshell. Not only was the advertising misleading, but the trial itself was fraudulent:

The FTC charges that the study’s lead investigator repeatedly altered the weights and other key measurements of the subjects, changed the length of the trial, and misstated which subjects were taking the placebo or GCA during the trial. When the lead investigator was unable to get the study published, the FTC says that AFS hired researchers Joe Vinson and Bryan Burnham at the University of Scranton to rewrite it. Despite receiving conflicting data, Vinson, Burnham, and AFS never verified the authenticity of the information used in the study, according to the complaint.

Despite the study’s flaws, AFS used it to falsely claim that GCA caused consumers to lose 17.7 pounds, 10.5 percent of body weight, and 16 percent of body fat with or without diet and exercise, in 22 weeks, the complaint alleges.

Although AFS played no part in featuring its study on The Dr. Oz Show, it took advantage of the publicity afterwards by issuing a press release highlighting the show. The release claimed that study subjects lost weight “without diet or exercise,” even though subjects in the study were instructed to restrict their diet and increase their exercise, the FTC contends.

Now, with the Duncan settlement, the GCBE saga seems to be complete.

Conclusion

Green coffee bean extract would be a fringe supplement today if it weren’t for the “Dr. Oz Effect” and a supplement seller that knew exactly how to exploit it. We’ve seen this episode of Dr. Oz before. Shoddy science, a bogus product, a conflicted seller and unrealistic claims of efficacy. This is just one example of the dozens of useless health products and treatments the show has featured. Oz and his show are either oblivious to the facts, or indifferent to them. At no time did Oz appear take his responsibility as a medical doctor seriously. While Duncan and his companies have been fined, it’s clear that the Dr. Oz show played a big part in this enormous, yet avoidable, weight loss scam.

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Naturopathy and “biomedical” treatments for autism

Naturopathy

Nov 202014

For the past several months I’ve been contrasting the advice from naturopaths against the scientific evidence, in a series I’ve been calling “naturopathy versus science”. In past posts I’ve looked at the naturopathic perspectives on fake diseases, infertility, prenatal vitamins, vaccinations, allergies and even scientific facts themselves. From a blogging perspective, naturopathy is a fascinating subject to scrutinize, as there is seemingly no end of conditions for which naturopaths offer advice that is at odds with the scientific evidence. As a health professional, I want to encourage the best use of health resources, and support patient autonomy and decision-making by providing credible, evidence-based information. Given repeated calls for naturopathy to be “integrated” with conventional medicine, I’ve spent a lot of time reading what naturopaths have to say about different medical conditions. What I’ve found is concerning. Naturopaths describe themselves a health professionals capable of providing primary care, just like medical doctors. And they’re increasingly seeking (and obtaining) physician-like privileges from governments. Yet there is a lack of evidence to show that naturopathy offers anything distinctly useful or incrementally superior to science-based medicine.

Defining the scope of “naturopathic” treatment is difficult. Naturopaths offer an array of disparate health practices like homeopathy, acupuncture and herbalism that are only linked by the (now discarded) belief in vitalism – the idea we have a “life force”. From this philosophy can sometimes emerge reasonable health advice, but that has little to do with the science or the evidence. As long as it’s congruent with the naturopathic belief system, it’s acceptably “naturopathic”. One of the signs that naturopathy isn’t medicine is that it needs a prefix. Notice how there isn’t a “pharmacy medicine” or “nursing medicine” that’s distinct from science-based medicine. It’s just “medicine” – health professionals base their practices on scientific evidence and principles that reach across professions. Naturopathy doesn’t share the same evidence base as medicine, and in some cases, disagrees with its basic scientific principles. It needs to be qualified as distinct, and hence: “naturopathic medicine”. Notice how Rexall makes it easier to find the non-evidence-based products:

naturopathic and homeopathic

This week an advertisement was passed to me that promoted naturopathy at a Toronto public school:

The Learning Disabilities Association is pleased to present this Workshop for Parents and Professionals:
ADHD and LD Naturally
Guest Speaker: Dr. Joseph Steyr
Do you want to know more about natural treatments for ADHD and Learning Disabilities? Dr. Steyr is a Naturopathic Doctor and also has been diagnosed with a Learning Disability since he was a young child. His talk will start with a short introduction to what is Naturopathic Medicine and continue to a discussion of the biology of ADHD/LD. Using that foundation of understanding we will then go over ideas of how nutrition, herbal and homeopathic medicine is used to help support and treat people living with ADHD or LD.

Naturopaths using homeopathy is nothing new (it’s a “clinical science” within their practice, and hence overlap in the photo above), but this bulletin was distributed by the Toronto District School Board, the largest school board in Canada. As a Toronto resident [full disclosure: I have family members in TDSB schools] I’ve always understood that the TDSB was large enough to manage children with special needs and learning disabilities appropriately. It’s a big board with the capacity to offer specialized, focused care. So I was disappointed to see the school board describing homeopathy as “medicine”, and permitting a naturopath to speak. This is especially concerning given that Toronto Public Health notes that some Toronto public schools have up to 40% of students with “exemptions” from the vaccination schedule. Given naturopathy as a practice is antagonistic to vaccination, I wondered if this naturopath shared the perspective of his peers. What I found was troubling. I’ve been reading far too much this week about how how alternative medicine and its purveyors can harm children, so it’s frustrating to see poor thinking about science promoted by academic and charitable organizations that should know better. What’s even more alarming than naturopathy for ADHD and learning disabilities is the naturopathic approach to autism, a condition that naturopaths claim is caused by vaccines, and can be treated with naturopathy.

Autism is related to vaccination only because of a manufactroversy that the two are related, a link that was never based on any credible evidence. Autism is also the unfortunate target of a cornucopia of quackery, all claiming to offer benefit in areas where science-based medicine may not offer satisfactory answers or treatments. The problems with the “naturopathic” approach to autism become clear with an understanding of the science of the disease. Autism can be described as a spectrum of neurodevelopmental cognitive disorders and delays, with variable effects on communication and socialization. There’s no known single cause, and while the disease seems to be strongly influenced by genetics there are a number of factors that are hypothesized to contribute, which include environmental components. While the scientific understanding of autism continues to grow, there are still maddening gaps in the evidence base. There is no cure for autism, but there are evidence-based approaches that can be effective.

Autism biomed

The lack of a “cure” for autism hasn’t stopped alternative medicine proponents from bringing forward their own (unproven) treatments. “Autism biomed” is short for biomedical, and is the umbrella term for the interventions used to “treat” autism medically. There are countless “biomedical” treatments for autism, and they’re offered by alternative (and sometimes conventional) practitioners. What proponents of “autism biomed” treatments always have in common is that they proclaim a superior understanding of autism over “conventional” medicine. And with this special insight comes the confidence that their particular biomed treatments are effective. Their entire perspective on autism as a disease may be quite different. Because they believe autism has external triggers and causes, they see autism as something “done” to a child that can therefore be “undone” with the right treatment: biomed. Consequently it’s not uncommon to see biomed practitioners claim that autism is either curable or highly treatable with their treatments. Biomed treatments can range from mild interventions (like modest dietary changes) to the truly horrific, like chemical castration or bleach enemas. Joseph Steyr, the naturopath noted above, is a proponent of autism biomed. Taking a closer look at his website, his description of biomedical treatment neatly encapsulates the biomed belief system:

The Biomedical Approach believes that environmental triggers (infectious agents, vaccines, foods, pesticides, pollutants/heavy metals) accumulate to a threshold point where Autism starts. These factors can trigger Autism on their own, or in conjunction with genetic susceptibilities. Once Autism begins, untreated triggers and nutrition deficiencies will lead to a worsening of the condition. Starting Biomedical Approach treatments, along with Behavioural therapies, as early as possible increases the chances that Autistic behaviours can be reduced or possibly eliminated. Naturopathic medicine offers many treatment options, from therapeutic diets, herbal (botanical) medicines, vitamin and mineral supplements, to homeopathic remedies, hydrotherapy (waterbased therapies such as foot baths and low‐heat infrared saunas) and (needle‐free) acupuncture.

To biomed purveyors like Steyr, autism is “triggered” by products like vaccines. Other naturopaths hold these same beliefs. Hilary Andrews, a naturopath in Portland Oregon claims:

While the measles-mumps-rubella or MMR vaccine has been strongly linked to the onset of autism, I believe that prior vaccinations also play a cumulative role in this disease. Current vaccination schedules overload very young, fragile immune systems with a huge number of viruses. The number of vaccinations administered to children has more than doubled during the last decade. Today, a child receives approximately 33 doses of 10 different vaccines before the age of six.

To naturopaths, vaccines are yet another “toxin” triggering autism spectrum as well as conditions like food allergies and “nutrient sensitivities”. To detoxify your autistic child, Steyr offers useless but probably harmless treatments like homeopathy and foot baths. He also offers treatments with greater risk for harm, like herbalism or the quackery of hyperbaric oxygen. But Steyr is no rogue naturopath. There is no shortage of naturopaths offering biomedical treatments for autism. A comprehensive list of treatments would be impossible – but here are some of the common treatments promoted by naturopaths:

CEASE therapy

Anke Zimmerman, a naturopath in Victoria, British Columbia, offers Complete Elimination of Autistic Spectrum Expression (CEASE) therapy which uses homeopathy to allegedly rid the autistic child of vaccine toxins. Homeopathy is an elaborate placebo system, with no medicinal effects. Here it is pseudoscience that’s neatly packaged snake oil and promoted to parents of autistic children.

Autonomic Response Testing

Eugene Quan, a Calgary naturopath claims he can cure autism:

We now know that autism is not a psychological disorder. It is biomedical … viruses, bacteria, candida, parasites, and heavy metals cause the behaviours that lead to an autism diagnosis. Once you remove what is causing the symptoms, you can remove the diagnosis … Dr. Quan at Western Naturopathic in Calgary can help your child become autism-free in 1-2 years. Dr. Quan uses Autonomic Response Testing for clear patient assessments, resulting in successful individualized treatment plans. Dr. Quan guides us through a myriad of options, organ-supportive protocols, the vaccine issues, healing the gut, parasites, mould sensitivity, stemming, seizures, speech issues, tonsils, soul awareness, and biofilm elimination. His approach is making a positive difference in the lives of many children and parents searching for options.

Autonomic Response Testing is a variation of applied kinesiology, where muscles are “tested” to determine “sensitivities” to different products. ART is complete pseudoscience and there’s no scientific evidence that ART or applied kinesiology is anything other than a parlour trick – or in this case, a bogus diagnostic.

Food intolerance testing

Sharon Behrendt, a naturopath in Orleans, Ontario, claims that children with autism are suffering from food allergies:

Many children with ASD have food allergies, due to abnormalities in their digestive and/or immune systems. If food is not broken down and digested, then the partly digested food can pass from the gastrointestinal tract into the bloodstream. The immune system recognizes those foods as foreign to the body, and may launch an immune response to those foods, including brain inflammation. These food allergy reactions are called IgG, or delayed, food reactions, as they can take hours or even a couple of days to occur.

Perhaps not surprisingly, Behrendt wants you to stay away from gluten and milk. She also claims:

Removing allergic foods can result in a wide range of improvements in up to 65% of ASD children, in particular improvements in behavior, focus and concentration.

Citation required. I’ve blogged extensively about how naturopaths do not diagnose or treat allergies according to scientific principles. IgG food testing offered by naturopaths is clinically useless and is not recommended by medical professionals for allergy testing. IgG testing leads to unnecessary and potentially-harmful food restrictions, with no relationship between the IgG test and autism.

Behrendt also recommends juicing (delicious, but medically useless) and B12 injections (useless, unless you’re deficient).

Supplements, supplements, supplements

Marianne Fernance, a naturopath in Brisbane, Australia, recommends detoxification, but also vitamin B12, zinc, and magnesium, as well as essential fatty acids for children with autism. The reality is that many children with autism are placed on (sometimes highly restrictive) diets, which increases the risk of nutritional deficiencies if close attention isn’t paid to nutrient intake. The evidence seems to show that special diets do not work for autism, so unless there is a clear dietary restriction or deficiency, supplementation should not be necessary.

Low-dose naltrexone

Nicola McFadzean Ducharme, a naturopath in San Diego, California, recommends low-dose naltrexone for autism. Steven Novella has a much longer summary of the lack of evidence that supports LDN. In short, LDN is an opiate antagonist, usually used to treat narcotic overdoses by blocking the drug’s action at the cell receptor. When used at very low doses, there’s no convincing evidence it has any established role in the treatment of autism.

Chelation

McFadzean Ducharme also advertises chelation, a common pseudoscientific treatment offered by naturopaths:

Heavy metal toxicity is a key component in many children suffering with autistic-spectrum disorders. Whether through exposure via environmental factors such as contaminated food or water, or vaccinations these toxins are detrimental to your child’s health. The detection of toxicity levels of heavy metals is challenging and sometimes difficult to quantify. Tests such as hair analysis (Great Plains or Doctor’s Data) are a good place to start and can give some useful information with regards to the potential of heavy metal poisoning. However, it is important to realize that hair testing is a screening tool and further diagnostics may be necessary to qualify heavy metal toxicity.

Chelation has legitimate uses when it’s part of a protocol for actual heavy metal poisoning. You don’t diagnose heavy metal poisoning with hair testing, however. The hair testing is simply used to give the provider the impetus to recommend useless treatments. When used by alternative medicine providers, chelation is quackery used to remove fictitious “toxins” in the body. There is no credible evidence that supports the use of chelation in autism. What’s concerning about chelation is that the intravenous infusions are not without risks, and chelating children with autism has caused deaths.

Conclusion

Like the other medical conditions they claim to treat, naturopaths do not look at autism from a science-based perspective. Many appear to place a strong emphasis on environmental factors as causes, regularly calling out out vaccines as contributors. Naturopaths offer an array of pseudoscientific treatments they call “biomedical”, with some practitioners claiming that autism biomed can “cure” autism. The reality of autism biomed is quite different than the vision promoted by practitioners. There are countless autism biomed interventions, but there is one universal feature: There is no convincing evidence that autism biomed treatments have any meaningful therapeutic effects on the features of autism. Autism biomed is anecdote driven experimentation. There is no convincing evidence that naturopathy has anything meaningful to offer for the treatment of autism.

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Naturopathy, Paternalism and Infertility Treatments

Naturopathy

Oct 092014

Pregnancy Test
This is another post in the naturopathy versus science series, where a naturopath’s advice is assessed against the scientific literature.

It’s Naturopathic Medicine Week in the United States, so it’s time for another look at the alternative medicine practice that blogger Orac likes to call the One Quackery to Rule them All. Naturopathy is an oddity among alternative medicine, because it’s a hodgepodge of other practices linked by an underlying belief in vitalism: the pre-scientific notion that living things have a “life force”. Vitalism disappeared from medicine when Wöhler synthesized urea in 1828, yet the belief in vitalism is a central tenet of naturopathic philosophy. Naturopaths liken themselves to be primary care providers akin to family physicians (general practitioners) but their practices are quite different: rather than make decisions based on scientific evidence, naturopaths pick and choose based on what they feel is congruent with their vitalistic philosophy, sometimes despite good scientific evidence that shows they are wrong. For example, homeopathy is an alternative medicine practice that is very popular with naturopaths. It is an elaborate placebo system where “remedies” contain no medicinal ingredients: they are literally sugar pills. There is no demonstrable medical effect from homeopathy, and so it isn’t part of science-based medicine. Yet homeopathy is a “core clinical science” for naturopaths, and the practice of homeopathy is part of their licensing exam.

Naturopathy: Alt-Med Paternalism

According to naturopaths, what they offer is a return to the practice of medicine that’s now been lost:

While the training and approach of ND’s is progressive, they practice in ways reminiscent of old-fashioned family doctors. They take the time and effort to learn about each patient and his/her family. This means seeing fewer patients a day. Naturopathic physicians commonly spend 60 to 90 minutes per patient visit, listening to patient concerns, diagnosing and treating each patient as an individual. This is a practice that benefits both patient and doctor.

Likening naturopathy to “old fashioned” medicine is apt. On the positive side, naturopath consultations are much longer than medical doctors. But that’s where the positives end. Like old-fashioned medicine, naturopaths don’t practice according to what the scientific evidence says. Without a scientific basis for decision-making, “treating each patient as an individual” is justification for making treatment decisions on the fly, without any standard of care, or even an expectation that naturopaths must defend or explain their decisions from an evidence perspective. And despite all the claims that naturopaths do “individualize” their treatments, what naturopaths offer for virtually every condition tends to be based around the same pseudoscientific beliefs: You’re toxic. You’re acidic. You’re filled with yeast. Your adrenals are tired. And lately, gluten is poison. And the solutions offered are strikingly similar: homeopathy, acupuncture, and lots and lots of supplements.

The era of paternalism in modern, science-based medicine largely disappeared with the “old time family doctor” too. Today’s medical model is based on principles of patient autonomy and informed consent. Health professionals are responsible for providing objective information on treatments to support informed decision-making by patients. This advice must be defensible and is judged by what is considered that profession’s standards of practice — which are scientific standards. Patients, as partners, take information provided by health professionals and make care decisions based on a consideration of their own values and preferences. In an informed consent model, lying to patients about a treatment’s efficacy, or withholding information about the evidence, is not only unethical, it could put a health professional’s license at risk.

Naturopathy, like other alternative medicine practices, appears to be highly paternalistic, and consequently may be compromising patient autonomy and choice. It does this by first promoting the idea that science and evidence is relative, poisoning the well for what comes next — the erosion of an objective standard of care. Second, providers fail to offer full disclosure on the efficacy of their treatments. Naturopaths do not offer treatments based on good evidence (as I’ve described in my series of posts and as documented in the literature). While naturopaths can offer science-based advice, they can also promote practices that are are either not proven to work, or are proven not to work. Third, vitalistic beliefs push naturopaths to shift responsibility for illness on to the patient, a tactic which has been described as “Your disease, your fault”, implying that many illnesses are preventable — confusing patients about the scientific facts of their own health conditions. Finally, naturopathy creates fake diseases like adrenal fatigue out of whole cloth, and conveniently offers the treatments for them as well. True patient-focused, autonomous care requires discussions that are grounded in honest disclosures between provider and patient, which seem incompatible with the philosophy and practices of naturopathy. An illustrative example of naturopathic paternalism can be found in today’s case study: naturopathic treatments for infertility.

The Facts of Infertility

Infertility is formally defined a failure to conceive after 12 months of regular intercourse without use of contraception (in women under 35 years of age) or after 6 months of regular intercourse without contraception (women 35 or older). The number of couples that are infertile isn’t clear. Current estimates from the CDC [PDF], suggest around 6.0% of America women are affected, which is over 1.5 million women between the ages of 15-44. Infertility isn’t rare, and many women (and couples) seek medical advice for what’s perceived as impaired fertility.

It’s important to note that failure to conceive isn’t an issue for an individual — it’s an issue for a couple, and should not be assumed to be due to the female. Infertility is a disease of physiology, not psychology. Causes include a lack of sperm, tubal obstruction, or a failure to have regular periods. Often it may not clearly be an identifiable cause, and it can be difficult to sort out probable from possible causes. But medical science has made significant progress in identifying the (true) root causes of infertility, and addressing them. Treatments either target reversible causes, or the attempt to circumvent causes that can’t be reversed. Lifestyle factors that are usually suggested include smoking cessation, minimizing caffeine and alcohol, and ensuring coitus is attempted regularly around the appropriate time in the ovulatory cycle.

Medical therapies for infertility include drug treatments with fertility drugs. Other treatments can include surgery and procedures like intrauterine insemination or in-vitro fertilization. Medical advances have brought significant advances in treating infertility, and up to 50% of infertility cases can be addressed with medical interventions.

Naturopathy and Fertility: Where Anything Goes

Fertility is big business for naturopaths. An Alberta survey of naturopath websites found that 45% advertised that they could treat fertility issues. And it’s not surprising that there would be a search for alternative options. “Medicalizing” what usually occurs naturally can be quite distressing. If only there were a “natural” approach to infertility that could eliminate the poking, the prodding, and all the drugs. So is there? Here are the themes from among the 251,000 sites featuring naturopathy+infertility. Perhaps not surprisingly, most naturopaths offer similar lists of causes (and treatments):

Toxins, toxins, toxins: According to naturopath Iva Keen, you’re not pregnant because you’re toxic:

Most chemicals used in everyday life do not go through the same checks medicines do. Consequently; poisonous chemicals end up circulating in our environment, food supply, air and water. … Unfortunately, our waterways are constantly being polluted by industrial waste and by products, pharmaceutical drugs, pesticides and herbicides and commercial cleaning products. Heavy metals are the most common of the reprotoxins reaching our water supply through industrial waste, jet fuel exhaust residue and a variety of other sources.

Keen suggests drinking filtered water — an unnecessary recommendation, as there’s no evidence that municipal water supplies are causing infertility.

You need to detox: According to naturopath Shawna Darou:

In many cases, treatment may start with a 10-14 day detoxification program with the aim to reset hormone levels, remove toxins as much as possible and remove inflammatory foods. Toxins may be an impediment to fertility and before the body can conceive it needs to detox various toxins that have built up in fat cells over many years of living in polluted environment and consuming unhealthy foods that contain fertility inhibitors.

As has been pointed out many times, “detox” as advertised by naturopaths is a delusion. Genuine detoxification treatments are medical procedures that are not casually selected from a naturopath’s menu of services. Yet the term has been co-opted to give a veneer of medical legitimacy to what is effectively a catharsis, with no objective medical benefits — and zero impact on infertility.

You need homeopathy: Darou continues:

Homeopathy is a powerful aid in stimulating fertility. In 50% of our clinical case we observed a dramatic positive change in fertility directly related to homeopathic treatment. Each case will undergo a thorough homeopathic assessment and constitutional remedy recommendation.

How magic beans stimulate fertility isn’t clear — you’d think with a 50% effect, that a clinical trial would be easy to perform. The one trial I could find showed no effect.

You need herbs: Naturopath Nicola McFadzean Ducharme is a strong proponent of herbal medicine for infertility, listing dozens of herbal remedies she recommends for infertility:

For many natural therapists, herbal remedies form the foundation of naturopathic treatment of infertility.

and

Given that hormonal balance is dependent on the hypothalamic-pituitary-reproductive axis, as well as the pineal gland, remedies to support this should be given, such as Avena, Passiflora and Pulsatilla. These herbs also act as nervines, strengthening and supporting the nervous system. Rehmania, Peony and Licorice may also strengthen pituitary function.There are particular herbs that have estrogenic, progesterogenic or adaptogenic effects. Estrogenic herbs include Alfalfa, Licorice, Fennel, Hops and Clover. Progesterogenic herbs include Wild Yam, Birth Root, Sarsaparilla and Stargrass; while Chaste Tree, Saw Palmetto and Blue Cohosh are adaptogenic, meaning they regulate either way depending on the need.

Prolactin excess can be treated with Chaste Tree or Rehmania; Bugleweed and Hops will help high levels of LH; FSH levels can be raised through use of Black Cohosh, which also lowers raised LH and increases estrogen. Chaste Tree lowers elevated FSH, testosterone, prolactin and raises low levels of LH and progesterone.

Emmenagogues are herbs used to promote circulation and menstruation, and therefore are indicated if amenorrhea is present. Such herbs include Mugwort, Pennyroyal, Tansy, Rue and Southernwood. These should be used with the herbs that promote normal ovarian function. If excessive bleeding is the problem, hemostatic and astringent herbs such as Shepherd’s Purse, Beth Root, Lady’s Mantle, Cranesbill, Raspberry and Black Haw may help.

This advice goes on for several more paragraphs. Perhaps not surprisingly, there is no established role for herbal remedies to treat infertility. No products have been demonstrated to have meaningful effects. Then there’s the teratogen (birth defect) risk of herbal medicines. Combined with the unclear quality control of herbal products in North America, herbal products bring risk, with no established benefit.

You need vitamins: Prenatal vitamins are a science-based treatment during the pre-conception period, but there’s no good evidence that prenatal vitamins provide a fertility benefit. Naturopath Pamela Frank who claims that “We only recommend science based treatments” makes the following recommendations:

As a naturopathic doctor, my 4 years of post-graduate nutrition training and 14 years of experience makes me one of the most highly qualified diet and nutrition experts in health care. Naturopathic doctor training in nutrition is unbiased by political interests such as the Canada Food Guide, the dairy marketing board or the wheat marketing board, based instead on what is scientifically proven to help balance hormones and improve fertility. Diet can either cause or contribute to infertility. Likewise correcting your diet can help your body to reverse infertility. Special individually customized diets will be recommended, and treatment may include nutritional supplements such as vitamins, minerals, enzymes, and other natural supplements.

i.e., Your body, your fault. She continues:

Certain vitamins and minerals can help balance hormones, nourish the endocrine glands like the adrenals, thyroid, ovaries and pituitary and support liver detoxification. Most are safe to use along with fertility treatments and to continue throughout pregnancy. Multivitamins in our experience do not work to fix a deficiency. Why? Because they contain too many different vitamins and minerals, often at too low a dose, that are all competing to be absorbed. We find it far more effective and efficient to target the specific vitamins and minerals that our individual patients need. Vitamins and minerals can also have a significant impact on the health of your future child. Conditions like ADHD and autism have been linked to deficiencies of B vitamins and minerals like magnesium, environmental toxins and hormone imbalances in the mom.

Again, no references, and no basis in reality.

You need acupuncture: Acupuncture is widely touted as an effective treatment for infertility, particularly in combination with in-vitro fertilization. According to naturopath Fiona McCulloch,

We also provide acupuncture, using research driven protocols that have been proven to increase fertility by a substantial margin (40-60% increase in success rates for IVF cycles). Acupuncture provides you with the time and space to feel completely relaxed while physically enhancing blood flow to your pelvic organs and developing follicles as you go through natural cycles, or prepare for your IVF or IUI cycles. Overall, the program will substantially improve follicle health, enhance implantation, and restore hormonal and emotional balance.

Naturopath Shawna Darou claims the following:

Acupuncture is a non-invasive, all-natural way to improve your chances of becoming pregnant with assisted reproductive procedures by up to 65%¹.

To her credit, Darou at least lists references. Unfortunately the facts (when you don’t cherry pick) are less impressive than the claims. The evidence for the effectiveness of acupuncture on infertility is less than established. In fact, there’s no good evidence that acupuncture has medical effects for any condition, including infertility. And why would it? Infertility has a physiologic cause. Acupuncture is a theatrical placebo which lacks any objective effects. It is a belief system that’s also based on vitalistic thinking except with acupuncture, ‘Qi’ is the life force.

Stop eating gluten: Naturopaths are proponent of clinically useless IgG food intolerance tests. They recommend these tests as part of fertility evaluations, and also recommend avoiding gluten, linking it to infertility.

Naturopathy reduces stress, which improves fertility: Naturopath Jen Newell claims:

Research into Naturopathic Medicine has found that seeing a Naturopath reduces stress for patients by 15-20%. Patients feel listened to and are able to discuss aspects of their care and lives to reduce perceived stress. Managing stress increases chances of successful conception. Naturopathic care is also helpful at reducing anxiety associated with fertility treatments.

No evidence or citations are provided. I could find no data in medical literature to substantiate this point, though I can see how a 90 minute consultation where unrealistic promises are made to patients could in fact reduce stress. However the link between stress and infertility is not clear, and while stress reduction is probably beneficial for its own reasons, there’s no established evidence that stress reduction will increase fertility rates.

Conclusion

Naturopaths claim to be primary care providers, like medical doctors, but practicing with an older model of medicine. Given the paternalism and disregard for scientific evidence displayed in this evaluation of naturopathic infertility treatments, one wonders if naturopaths realize just how accurate this statement is. Naturopaths were identified to routinely and consistently offer treatments that are either not proven effective, or are proven to be ineffective. They uniformly failed to disclose on their websites that their treatments lack good scientific support, which may leave consumers with a misleading impression about the effectiveness of naturopathic treatments. Given there is no evidence that these treatments have any meaningful effects, there is no demonstrated role for naturopathy in the treatment of infertility.

Photo from flickr user TipsTimesAdmin used under a CC licence.

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The truthiness of naturopathic “facts”

Naturopathy

Sep 212014

LaLaLaLa

This is another post in the naturopathy versus science series, where a naturopath’s advice is assessed against the scientific literature. It’s a cross post from Science-Based Medicine, where the original post has (at last count) 436 comments:

When you think medicine, your first thought may be “physician”. But the practice of medicine today is a collaboration, as few health professionals, even physicians, can deliver health care completely independently. As a pharmacist I’ve worked closely with physicians, nurses, and other health professionals my entire career. Collaboration starts early, and the setting is usually the teaching or academic hospital, which is always crawling with students, interns, and residents from all professions. Teamwork and trust are essential. In order for different professions to work effectively together, there has to be a common foundation. For medicine, that foundation is science. From basic science principles through a common understanding of fields like biochemistry and physiology, health professionals all work from the same basic understanding about how the body works and what the principles of medicine actually are. If I give a recommendation to a physician or a nurse, I’m basing that assessment on an evidence base that we both rely on. It’s not “pharmacist evidence” versus “physician evidence”, it’s “medical evidence”. This is reality-based healthcare.

It’s for this reason that I’m baffled by the suggestion that medicine needs to “integrate” alternatives-to-medicine treatments. I understand the principles of homeopathy, acupuncture, and naturopathy. And those principles are antagonistic to science-based medicine. Imagine working with someone calling themselves a health professional that believes that they can restore a patient’s “vital force” by giving remedies that are pure water. Or stick needles in the skin to stimulate nonexistent “meridians”. Or even decide what scientific evidence they’re going to accept and use – not based on the strength of the evidence, but on a pre-scientific belief system. That’s naturopathy in a nutshell, which is one of the oddest alternative health practices out there. It’s not just homeopathy, or herbalism, or acupuncture. It’s all the above, and more. The central belief, “vitalism”, posits that living beings have a “life force” not found in inanimate objects. Vitalism as a concept was disproved by Wöhler in 1828, yet the idea continues to thrive in naturopathy. Naturopathic treatment ideas are all grounded in the idea of restoring this “energy”, rather than being based on objective science. It is perhaps unsurprising that naturopathy has evolved to include disparate practices like homeopathy, acupuncture and herbalism. Given there’s no requirement to justify or rationalize practices in scientific terms, pretty much anything goes, as long as it aligns with the underlying philosophy. Not all naturopathic advice is bunk – some can be evidence-based. However, that’s not because it’s grounded in evidence, but rather despite it: sometimes medical advice happens to align with the naturopathic philosophy. I’ve used this naturopath’s quote before, but from my perspective it concisely sums up how naturopathy likes to pick its own facts.

I love being able to look at new approaches that may come along and to ask myself, “Is this within the bounds of the philosophy I so embrace?” And if not, to let it go.

– Amy Rothenberg, Naturopath

Perhaps not surprisingly, there are numerous criticisms of naturopathy in the literature, and surveys of the services offered by naturopaths confirm that naturopathy as it is actually practiced does not appear to be science-based nor evidence-based. This type of data isn’t helpful to naturopaths that are pressing to be treated as medical professionals akin to medical doctors. Naturopaths have been fighting for “integration” as health professionals for some time, and they believe themselves to be capable of providing primary care like family physicians. And despite the fact that naturopathy is grounded in an unscientific belief system, naturopaths claim repeatedly that their practices are science-based, recognizing that legislators (and the public) generally places a high value on science. Naturopaths even describe naturopathy as “science-based natural medicine“. The AANMC claims:

Because today’s naturopathic doctors (NDs) believe in understanding patients from the cellular level up, they actively pursue the latest biochemical findings relating to the workings of the body and the dynamics of botanical medicines, nutrition, homeopathy and other natural therapies. Their diagnoses and therapeutics are science based and increasingly evidence based. While the training and approach of naturopathic physicians is progressive, naturopathic physicians practice in ways reminiscent of old-fashioned family doctors. They take the time and make the effort to learn about each patient and his/her family.

For some reason I keep returning to blog about naturopathy because it’s the one alternative-to-medicine practice that seems to genuinely confuse the public. Even those that might be a bit wary of an acupuncturist or herbalist might be willing to give a naturopath a try – after all, many states are granting them health professional privileges. So the marketing is working. But criticisms of naturopathy are not hard to find, either. One place that alternative medicine practices get a fairly rough ride is Wikipedia. I have mixed feelings about Wikipedia. It can be inaccurate. But I use it, and you probably do too. As a starting point to research, rather than the final word, Wikipedia can often be quite useful. And there is no denying its popularity. Given Wikipedia’s popularity and search ranking, it should not come as no surprise that alternative medicine providers and advocates want Wikipedia to support their own practices. But Wikipedia’s contributors are generally quite critical of alternative medicine, given it lacks scientific support. Earlier this year an alternative medicine group started a change.org petition asking Wikipedia’s founder Jimmy Wales to create and enforce new policies that “allow for true scientific discourse about holistic approaches to healing.” It seems they didn’t like the nasty editors who “used the narrowest possible understanding of science to inhibit ‘open discussion'”. Wales responded in a way that made advocates of science-based medicine smile:

Every single person who signed this petition needs to go back to check their premises and think harder about what it means to be honest, factual, truthful. Wikipedia’s policies around this kind of thing are exactly spot-on and correct. If you can get your work published in respectable scientific journals – that is to say, if you can produce evidence through replicable scientific experiments, then Wikipedia will cover it appropriately. What we won’t do is pretend that the work of lunatic charlatans is the equivalent of “true scientific discourse”. It isn’t.

If you don’t like the facts, invent your own

All of this leads me back to a naturopathic resource I stumbled onto a few weeks ago. Created by naturopaths (and edited by naturopaths only), ndhealthfacts.org is intended as a resource for naturopaths and their patients, so naturopaths can provide information that is presumably more oriented towards naturopathic practices (without all those nasty skeptics). While anyone can create a wiki, this one is notable for its ownership. It is edited by one of the “leaders” in naturopathic circles, Iva Lloyd. According to her bio,

Dr. Lloyd founded Naturopathic Foundations Health Clinic in 2002 after graduating from the Canadian College of Naturopathic Medicine (CCNM). She is editor of the Vital Link, the professional journal of the Canadian Association of Naturpathic [sic] Doctors (CAND), and she is on the editorial board of other professional journals. She teaches part-time at the CCNM and she presents internationally on naturopathic assessments, the energetics of health and the role of the mind in healing.

As the editor of a journal published by Canada’s national naturopathic organization, Lloyd’s participation should mean that ndhealthfacts provides information that accurately describes the naturopathic philosophy and treatment system. Given that only naturopaths are allowed to edit ndhealthfacts, yet the wiki is written for the public, the entries can reasonably be assumed to illustrate the current naturopathic consensus, as well as give insight into a world without criticism. With that in mind, let’s look at some of the entries, contrasting it with other resources. I’ve pulled excerpts, with links so you can do your own evaluation. Post any other notable entries you find in the comments:

Naturopathy (ndhealthfacts):

Naturopathic medicine is a distinct system of primary health care derived from a strong philosophical belief about life, health, and disease. Its principles and philosophies are an integral component of naturopathic assessment, diagnosis, and treatment. Naturopathic medicine promotes wellness and prevention. It blends modern scientific knowledge with traditional and natural forms of medicine and it emphasizes disease as a process rather than as an entity.Naturopathic medicine is defined by principles rather than by methods or modalities. Above all, it honors the body’s innate wisdom to heal. The emphasis of naturopathic therapies is to treat the causes of disease and to stimulate the healing power of body by using natural techniques and therapies. Naturopathic doctors diagnose and treat both acute and chronic conditions and treat patients of all ages.

Naturopathy (Wikipedia):

Naturopathy or naturopathic medicine is a form of alternative medicine employing a wide array of “natural” treatments, including homeopathy, herbalism, and acupuncture, as well as diet and lifestyle counseling. Naturopaths favor a holistic approach with non-invasive treatment and generally avoid the use of surgery and drugs. Naturopathic philosophy is based on a belief in vitalism and self-healing, and practitioners often prefer methods of treatment that are not compatible with evidence-based medicine. Naturopathic medicine is replete with pseudoscientific, ineffective, unethical, and possibly dangerous practices.

Vis medicatrix naturae (Healing Power of Nature) (ndhealthfacts):

The term vis medicatrix naturae which means the healing power of nature was established by Hippocrates to denote the body’s ability to heal itself or innate healing. This healing power is an inherent self-organizing, ordered healing process of living systems which establishes, maintains and restores health. The Vis Medicatrix Naturae is the power of nature to heal, an extension of creator consciousness or cosmic consciousness. While everything on the planet has become somewhat disharmonious, this energetic template or spiritual blueprint is held, inviolable, within our nature and is made avilable [sic] as a [sic] exemplar during the process of healing.

Vis medicatrix naturae (Healing Power of Nature) (Wikipedia):

In the nineteenth-century, vis medicatrix naturae came to be interpreted as vitalism, and in this form it came to underlie the philosophical framework of homeopathy, chiropractic, hydropathy, osteopathy and naturopathy.^[5] As Bynum notes, “Search the Internet for vis medicatrix naturae and you will find yourself in the land of what we now politely call ‘alternative’ or ‘complementary’ medicine”.

Homeopathy (ndhealthfacts.org):

Homeopathy is an energy medicine system. The challenge with most current research techniques are that they are not designed to evaluate this form of medicine. Yet even still, there is a growing body of research that supports the use of homeopathy.

Homeopathy (Wikipedia):

Homeopathy is a system of alternative medicine created in 1796 by Samuel Hahnemann based on his doctrine of like cures like: a substance that causes the symptoms of a disease in healthy people will cure similar symptoms in sick people. Homeopathy is considered a pseudoscience, and its remedies have been found to be no more effective than placebos.

Adrenal fatigue is a fake disease commonly diagnosed by naturopaths.

Adrenal fatigue (ndhealthfacts.org):

Adrenal fatigue is a term used to describe “hypo” functioning adrenal glands. Excess physical, emotional, and psychological stressors can deplete the adrenal glands causing a decrease in output of adrenal hormones, especially cortisol. This can have a profound effect on the body.

Adrenal fatigue (Wikipedia):

Adrenal fatigue or hypoadrenia are terms used in alternative medicine to describe the unproven belief that the adrenal glands are exhausted and unable to produce adequate quantities of hormones, primarily the glucocorticoid cortisol. Adrenal fatigue should not be confused with recognized forms of adrenal dysfunction such as adrenal insufficiency or Addison’s Disease. The term “adrenal fatigue”, which was coined in 1998 by James M. Wilson, may be applied to a collection of mostly nonspecific symptoms. There is no scientific evidence supporting the concept of adrenal fatigue and it is not recognized as an actual diagnosis by the medical community.

Another fake disease is candidiasis, when diagnosed by a naturopath:
Candidiasis (ndhealthfacts):

Candidiasis, or Candida albicans is the most prominent fungal infection and it is commonly associated with both acute and chronic diseases. All fungal infections grow better when the immune system is weaker. Aging individuals tend to have weaker immune systems, accounting for the higher rate of fungal infections with increased age. Candida is a yeast infestation that begins in the digestive system. It is a strong, invasive fungus that attaches to the intestinal wall and can spread to other areas of the body (sinuses, ears, reproductive tract). Candida overgrowth has been shown to cause symptoms in nearly every body system with the most noted symptoms arising from the gastrointestinal, genitourinary, endocrine, nervous, and immune systems.

Candidiasis (Alternative medicine) (Wikipedia):

What has been described as “a large pseudoscientific cult” has developed around the topic of Candida, with claims up to one in three people are affected by conditions with terms such as systemic candidiasis, “candidiasis hypersensitivity”, fungal type dysbiosis, Candida-related complex, the yeast syndrome, yeast allergy, yeast overgrowth, or simply “Candida” or “yeast problem”. Some practitioners of alternative medicine have promoted these purported conditions and sold dietary supplements as supposed cures; a number of them have been prosecuted.

You can see the impact of a little skepticism. While Wikipedia may not be 100% accurate in its articles, overall it summarizes the scientific evidence and consensus much more accurately. There are also dozens of supplement monographs. Here where the risk of harms becomes even more apparent:

Black Cohosh (ndhealthfacts): Claimed to be useful for whooping cough. Also notes, “Very effective for menopause if used for 2-6 months as alternative to HRT (hormone replacement therapy)”. Makes no mention of treatment risks.

Black Cohosh (UptoDate): Black Cohosh “does not appear to be more effective than placebo for reduction of vasomotor symptoms”. The reference also mentions a possible estrogenic effect of black cohosh, and cautions against use in women with breast cancer.

The most telling statement on ndhealthfacts, and about naturopathy in general, may be the entry on naturopathic research:

There are many ways in which the scientific method is used and applied appropriately to naturopathic medicine, but there are also many ways in which this method is neither appropriate not applicable.

Conclusion

Naturopaths claim that they practice based on scientific principles. Yet examinations of naturopathic literature, practices and statements suggest a more ambivalent attitude. NDhealthfacts.org neatly illustrates the problem with naturopathy itself: Open antagonism to science-based medicine, and the risk of harm from “integrating” these practices into the practice of medicine. Unfortunately, the trend towards “integrating” naturopathy into medicine is both real and frightening. Because good medicine isn’t based on invented facts and pre-scientific beliefs – it must be grounded in science. And naturopathy, despite the claims, is anything but scientific.

Photo from flickr user hebe used under a CC licence.

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Understanding the naturopathic approach

Statins for high cholesterol

Why do we treat it?

When is drug treatment appropriate?

What benefits have drugs been shown to offer?

What does naturopathy suggest?

What evidence supports the use of naturopathic treatments?

What approach has the best evidence?

“Antacids” (anti-ulcer medications for gastro-esophageal reflux)

Why do we treat it?

When is drug treatment appropriate?

What benefits have drugs been shown to offer?

What does naturopathy suggest?

What evidence supports the use of naturopathic treatments?

What approach has the best evidence?

SSRIs (selective serotonin reuptake inhibitors) for depression

Why do we treat it?

When is drug treatment appropriate?

What benefits have drugs been shown to offer?

What does naturopathy suggest?

What evidence supports the use of naturopathic treatments?

What approach has the best evidence?

Anti-hypertensives for the treatment of high blood pressure

Why do we treat it?

When is drug treatment appropriate?

What benefits have drugs been shown to offer?

What does naturopathy suggest?

What evidence supports the use of naturopathic treatments?

What approach has the best evidence?

Benzodiazepines for anxiety and insomnia

Why do we treat it?

When is drug treatment appropriate?

What benefits have drugs been shown to offer?

What does naturopathy suggest?

What evidence supports the use of naturopathic treatments?

What approach has the best evidence?

Conclusion: The evidence simply doesn’t support these natural treatments

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“Detox” is a marketing term used to sell you products

Premise one: Our bodies are accumulating toxins, so we need to detoxify

Premise two: Illness is the result of chemical toxins

Premise three: Detox diets and treatments remove toxins

Detox treatments can be harmful

There are no quick fixes

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The Review of the Australian Government Rebate on Natural Therapies for Private Health Insurance

What was reviewed?

The evidence

Alexander technique

Aromatherapy

Bowen therapy

Buteyko

Feldenkrais

Herbalism/western herbalism

Homeopathy

Iridology

Kinesiology

Massage therapy

Naturopathy

Pilates

Reflexology

Rolfing

Shiatsu

Tai chi

Yoga

Conclusion: Absence of evidence and plausibility

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Conclusion

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Autism biomed