Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 4

The “Science” and Ethics of “Natural Medicines” (and Nutrition) cont.

This is the continuation of a discussion concerning the explicit claim of “naturopathic physicians”* to being experts in the use of “natural medicines,” defined as “medicines of mineral, animal and botanical origin.” Last week’s post established that the cult has chosen to profit from the “retail selling of medications,” as evidenced by the relevant Position Paper of the American Association of Naturopathic Physicians (AANP) and by that organization’s having made a deal with a drug company to make profits for both itself and its members.

The Position Paper observes that such selling “could be construed as a conflict of interest on the part of the physician.” That is true, if embarrassingly understated: anyone representing himself as a physician, who both recommends and sells the same medications for a profit, has conflicting interests. The conflict undermines his claim to offering responsible advice regarding those medications, and as such is a breach of medical ethics.

The AANP’s deal with MotherNature.com was even worse: by promoting such peddling in a formal, institutional fashion, NDs and their national organization went beyond the already widespread problem of practitioners hawking drugs. It is unclear whether the deal still exists, by the way: MotherNature.com was a victim of the “dot com” bust of a few years ago. It has since been resurrected, but a quick perusal of its new website fails to reveal the old AANP relationship. Nevertheless, I have seen no evidence to suggest that the AANP has changed its view of that sort of deal.

Are NDs Truly “Learned Intermediaries” in the Use of “Natural Medicines?”

This entry discusses the other part of the claim of expertise: that, aside from their conflicting interests, NDs have real knowledge of “natural medicines.” It will become clear during the discussion that the purported naturopathic expertise in nutrition—another standard claim—is also under review. I will include or cite abundant evidence for my assertions, because I’ve found that a predictable response of representatives of the highest levels of “naturopathic medicine” is to flatly deny them. I apologize again for including excerpts from previously published material.

The AANP Position Paper

All by itself, the previously-mentioned AANP Position Paper on Sale of Medications by Physicians provides substantial evidence against a claim of expertise:

II. There are numerous references in the medical literature that document the existence of subclinical disease and the fact that the chances of anyone consuming a diet that meets the RDA for all nutrients is extremely unlikely.

III. There are numerous citations in the medical literature about the efficacy of homeopathic, botanical and other natural substances as medications to be used in the treatment of disease. It is common knowledge that many of the medications prescribed by Naturopathic Physicians (such as homeopathic and botanical medications as well as certain nutrient supplements) are not available elsewhere.

“Subclinical disease” certainly exists, but it is not those that are trumpeted by NDs: “chronic candidiasis,” bogus “food allergies,”  “leaky gut syndrome,” “toxin overload,” “weak immune system,” bogus “vitamin deficiencies,” “subclinical thryoid dysfunction” such as “Wilson’s Temperature Syndrome,” and more. It is categorically untrue that “the chances of anyone consuming a diet that meets the RDA for all nutrients is [sic] extremely unlikely.”

Although there may be “numerous citations in the medical literature about the efficacy of homeopathic, botanical and other natural substances as medications to be used in the treatment of disease,” (italics added), there are none that establish such efficacy for homeopathy (and never will be), and precious few that support the other substances in their “raw” states.

“Identifying Best Practices”: the Textbook of Natural Medicine

The Textbook of Natural Medicine (TNM), now in its 3rd edition, is co-edited by NDs Joseph Pizzorno and Michael Murray. Pizzorno is “Co-founder and past president of Bastyr University,” and is probably the most conspicuous ND in the public domain. Murray is a member of Bastyr’s board of trustees and presides over what appears to be an impressive conglomerate of on-line emporia selling snake oil and medical mis-information. A pitch on the Bastyr website for the 2nd edition of the TNM,[1] the one discussed here, proclaimed:

The 2nd edition of the Textbook of Natural Medicine … is the most comprehensive and widely-referenced text available on natural medicine. It covers a wide range of approaches for managing and treating over 100 conditions and health problems.

The first edition was reviewed in The Journal of Alternative Medicine as “the ultimate book on naturopathic medicine.”

The TNM itself asserts that

This Textbook, with some 10,000 research literature citations, provides well-documented standards of practice for natural medicine.

On its back cover is an endorsement by homeopath Wayne Jonas, the former Director of the NIH Office of Alternative Medicine:

The Textbook of Natural Medicine is the most comprehensive summary available of the actual practices and recommendations of naturopaths and complementary practitioners.

In a presentation to the Institute of Medicine in 2003, Timothy Birdsall, ND, representing the AANP, presented a slide with the heading “How do you identify best practices and communicate those practices to the field?” Immediately underneath was the first answer:

• Text and Reference Books

–Textbook of Natural Medicine, by Pizzorno & Murray

I’ve made a point of demonstrating that the TNM is representative of the tenets and practices of “naturopathic medicine” because, as mentioned above, each time I’ve quoted it or other representative treatises, I’ve been accused of misrepresenting what NDs really do. Well excuse me, but that will just not do. Such accusations, coming as they have from the highest levels of the cult, indicate a systematic dishonesty.

A Quasi-Scientific Study by Me

The 2nd edition of the TNM comprises about 1600 pages; about 500 are devoted to “Pharmacology of [~60] Natural Medicines,” and additional assertions about those and more are scattered generously throughout the book, including in each of the approximately 80 chapters devoted to “Specific Health Problems.” Having established the TNM as exemplary of the best practices of “educated naturopaths,” it is reasonable to examine what it has to say about those substances. When I was on the Massachusetts Special Commission, I compared the TNM’s assertions of safety and efficacy to those found in a source that bases its findings on peer-reviewed literature: the Natural Medicines Comprehensive Database (NMCD). This was the best source that I could find, even though it skims over problems inherent to “raw” botanicals, as does “herbal medicine” in general, and even though it ignores prior probability, as is the norm for Evidence-Based Medicine.

The NMCD ranks medicines for safety and efficacy, and discusses possible mechanisms of action, contraindications, and interactions with other drugs and disease states. Only the “effective” category suggests efficacy equivalent to FDA-approved drugs. The “likely effective” category suggests that the substance shows some promise. The “possibly effective” category suggests only that the substance might work. To continue the analogy with FDA-approved drugs, consider that the vast majority of “possibly effective” drugs would never win FDA approval.

The following table shows the results of comparing the two sources’ evaluations of 13 substances. All page numbers refer to the TNM, 2nd edition. [1] I chose a cross-section of “natural medicines”: a few based on general familiarity, others based on naturopathic claims for common medical problems, and still others reflecting the less-familiar categories of “animal and mineral origins.” I did not include every purported use for each substance. I chose the examples before making the comparisons (the reader will have to trust me about that), thus avoiding a bias for substances and uses with particularly large discrepancies between the two sources of evaluation. Nevertheless, the “study” cannot claim to have escaped the possibility of significant sampling error—although the subsequent discussion ought to convince readers that this is unlikely. A further limitation of this comparison is that it was made in 2001; subsequent information must alter some of its implications—to the further detriment, I suspect (because I haven’t looked at the 3rd, 2005 edition), of the claims of the TNM. The results:

Comparison of NDs’ “Best Practice” Claims for “Natural Medicines” with a Rigorous Standard (The Natural Medicines Comprehensive Database)

The comparisons are not favorable to naturopathic claims. Only a few agents and indications that are highly touted by the Textbook of Natural Medicine received even a “possibly effective” rating by the NMCD. Some received a “likely ineffective” rating. For the vast majority, there was “insufficient reliable information” to come to any conclusion. An example is vitamin C. It is recommended for nearly one hundred non-standard indications in the TNM, but according to the NMCD is “possibly effective” for only one: modestly reducing the duration of the common cold. For the rest it is either “likely ineffective” or there is “insufficient reliable information” upon which to base any conclusion.

Most of the claims in the Textbook of Natural Medicine are grossly exaggerated and based not on human studies but on simplistic speculations occasionally supported by in vitro (“test tube”) studies or animal studies. Frequently, claims for vitamins are extrapolations from their role in reversing the classic vitamin deficiency states, but these aren’t applicable to patients who are not vitamin deficient. An example, in the Textbook’s discussion of glaucoma, is on p. 1250:

Of foremost importance in achieving collagen integrity are optimal tissue concentrations of ascorbic acid [vitamin C].

This is not strictly false, but is irrelevant unless the patient is suffering from scurvy, and it has nothing to do with the pathogenesis of glaucoma. To illustrate the point, consider that water is also “of foremost importance in achieving collagen integrity,” but more of it than usual will neither prevent nor treat glaucoma. Notice the implications of this, and of my comment in the table about how vitamins work, for naturopathic pretensions to expertise in nutrition.

Here is an instructive correspondence that I had at the time with one of the editors of the Natural Medicines Comprehensive Database:

From: “Kimball Atwood”
To:
Subject: hydrastis canadensis
Date: Mon, Jan 29, 2001, 8:54 AM

According to the Textbook of Natural Medicine (Pizzorno and Murray, Churchill Livingstone, 1999), “Goldenseal is one of the most effective of the herbal antimicrobial agents. Its long history of use by herbalists and naturopathic physicians for the treatment of infections is well documented in the scientific literature.” Your monograph mentions only a suggestion of this in the “people use for” field, and nothing at all about it in the “effectiveness” field. Is the statement in the Textbook incorrect?

Thanks,
Kimball Atwood, M.D.

Hello Dr. Atwood,

We often find that our standards for suggesting a given natural product is effective or not are much higher than that typically found in the “naturopathic” literature. Often with the Textbook of Natural Medicine and other similar references, it is implied that products work for certain conditions based on in vitro or animal data. This is the case with goldenseal (Hydrastis canadensis). In some cases, studies with an isolated and purified constituent of goldenseal (berberine) have also been used to imply that goldenseal is effective.

Goldenseal is promoted for everything from viral infections to bacterial to fungal infections. Unfortunately, there is almost no clinical evidence that it works for any of these conditions. We do not make the leap from animal data and in vitro data to say that natural products work for a given condition. Furthermore, as you will see in our Mechanism of Action section, there is some evidence that the active constituent of goldenseal probably doesn’t reach serum levels adequate to have a clinically significant effect.

Take care,

Philip J. Gregory, Pharm.D.
Assistant Editor
Natural Medicines Comprehensive Database

The Natural Medicines Comprehensive Database also appears to use a “much higher” set of standards in discussing safety. Just as efficacy is exaggerated in the TNM, dangers are minimized. This is especially true for uses of agents in pregnant or breast-feeding women, which are rarely mentioned by the TNM but frequently cautioned by the NMCD.

The major safety issue having to do with largely ineffective “natural medicines,” of course, is their being substituted for other, truly effective, medicines. When this is done for patients with serious illness, disastrous outcomes can occur. The Textbook of Natural Medicine and other naturopathic treatises recommend such substitutions repeatedly, as exemplified in the links below.

More Examples and Expert Opinion

Can be found here. A review of the TNM by Arnold Relman, the emeritus editor of the New England Journal of Medicine, can be found here. More examples from the AANP Position Papers and the TNM, including language that would certainly lead to a recrudescence of now-rare rheumatic heart disease and a comprehensive look at the level of “evidence” that the TNM brings to bear for its claims about omega-3 fatty acids, can be found here. More discussion of the “research” collaboration between the NCCAM and Bastyr University, which includes several absurd and dangerous “natural medicines” studies, can be found here.

Conclusion

The common claim, made by “naturopathic physicians” and their apologists, that they are trustworthy experts in the use of “natural medicines” and “therapeutic nutrition,” is without basis in either medical ethics or science.

1. Pizzorno JE and Murray MT (eds.) Textbook of Natural Medicine (TNM), Churchill Livingstone, Edinburgh, 1999

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*The Naturopathy Series:

1. “CAL”: a Medico-Legal Parable
2. Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 1
3. Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 2
4. Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 3
5. Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 4
6. Colorado is Nearer to Promoting Naturopathic Pseudomedicine—Aided by the Colorado Medical Society
7. Naturopathy and Liberal Politics: Strange Bedfellows
8. Open Letter to Dr. Josephine Briggs
9. Smallpox and Pseudomedicine