Herb Garden at Bastyr University

The American Association of Naturopathic Physicians website explains what naturopathy is and has a webpage with FAQs. Number 15 addresses How do naturopathic doctors prevent and treat heart disease? It provides a lot of insight into how naturopaths think and what they do. It is worrisome.

NDs excel?

It starts with the claim that NDs “excel at preventing and treating cardiovascular disease because they focus on identifying the underlying causes of disease and empowering patients to make enduring lifestyle changes to restore and maintain their health.” They don’t provide any evidence that NDs understand the underlying causes of cardiovascular disease better than MDs, or that they “excel” at either preventing or treating cardiovascular disease, or that they have better patient outcomes than good mainstream MD clinicians.

Treating the whole person

They review all the body systems, and address genetic, environmental, and lifestyle factors. How is this different from what any good clinician does? The standard medical history includes a review of systems, family history, and social history. The biopsychosocial model of disease is what is taught in medical schools.

Time with patients

It says NDs typically spend 1-2 hours with a patient to take a detailed history and to identify all possible sources of inflammation that might contribute to heart disease. That sounds laudable, and MDs are often frustrated by the time constraints of their practice. Spending that much time is likely to impress and reassure patients, but does it really improve outcomes?

In medical school, when student doctors first learn to take a patient’s medical history, they spend an hour or more with each patient, asking about everything. At each step in the learning process, the interview becomes more streamlined, more focused. Doctors learn to spend their time on the most pertinent questions and omit others. If you are treating a woman with heart disease, you don’t really need to know that she broke her arm when she was seven, or that she was breast-fed, or when she got her first period, or that her mother’s brother had prostate cancer.

There is some evidence that the extra time NDs spend with patients is not put to good use. Despite their vaunted emphasis on prevention, patients of naturopaths are less likely to have been vaccinated and more likely to have vaccine-preventable diseases.

Individualized treatment

“Treatment approaches are individualized to each patient…” Again, this is what any good clinician does. Even if they start with a “cookbook” approach, they modify the recipe according to the needs of each patient. For instance, the published guidelines for statins specify that clinicians are expected to rule out secondary causes of hyperlipidemia, to take other individual patient factors into consideration, and to discuss risks/benefits and patient preferences before starting therapy.

All too often, NDs base their individualization of treatment on factors that are speculative, not evidence-based. “Your doctor will individualize treatment with an emphasis on natural agents, such as clinical nutrition, botanical medicine and counseling.” Wouldn’t it be better to individualize treatment with an emphasis on what works rather than what is “natural”? There is little evidence for the effectiveness of botanical remedies in treating cardiovascular disease. Do they have some special knowledge about how to individualize treatments, knowledge that MDs are not privy to? When they individualize treatment, they are often merely choosing what they think is best for the individual based on their own speculations rather than on any evidence. And nutrition and counselling are mainstream, not the special province of NDs.

Targeted labs

They say they individualize laboratory testing. They order a lot of non-standard tests such as “Comprehensive neurotransmitter profile.” Is there any evidence that getting those tests guides treatment in a rational manner or improves outcomes in cardiovascular disease?

“Management of vital signs with medications as needed”

They prioritize natural and minimally invasive treatments that allow the body to heal itself. “If their state license permits, NDs can prescribe medications such as diuretics, beta-blockers, and ACE inhibitors as a bridge to manage symptoms of chronic inflammation or cardiovascular disease (e.g. hypertension), until the body repairs itself.” They offer natural protocols to manage the side effects of medications, and their stated goal is to reduce or eliminate the use of medications. Did you notice the words “to manage symptoms”? Yet they claim they are not treating symptoms but addressing the underlying causes of illness. Sometimes managing symptoms is the best we can hope to do, but when MDs do that, NDs criticize them.

Optimizing gastrointestinal function

They say they optimize gastrointestinal function by “restoring proper PH, balancing flora, correcting leaky gut and constipation.” They apparently subscribe to the nonsensical acid/alkaline theory of disease. They apparently think science has advanced to the point where we know how to balance gut flora; we don’t. While intestinal permeability is a real phenomenon, the “leaky gut syndrome” is a medically unrecognized entity hypothesized by practitioners of alternative medicine. And while constipation has been correlated with cardiovascular mortality, causation has not been established and there is no evidence that treating constipation will prevent heart disease or improve outcomes.

Addressing endothelial dysfunction

They say endothelial dysfunction is caused by lifestyle factors including tobacco use, obesity, age, hypertension, hyperlipidemia, physical inactivity, and poor diet. Yes, these are recognized risk factors for cardiovascular disease. They offer to restore normal endothelial function by “empowering” patients to make lifestyle modifications, and with botanical medicine and clinical nutrients. There is some preliminary evidence for certain herbs and nutrients, but not enough to persuade evidence-based clinicians to incorporate them into mainstream medical practice. As for “empowering” patients, we would all like to do that. They don’t explain how they go about it, and how they know their methods improve outcomes.

Motivating physical activity

“Naturopathic doctors believe it is their duty to inspire patients to exercise, rather than just give them guidelines. Because of the extra time they spend getting to know your lifestyle and support systems, they are often able to give you creative and personalized recommendations for physical activity that you can not only implement, but also sustain.” That sounds good. But are NDs actually successful in getting patients to sustain exercise? And do their efforts actually improve outcomes? Where’s the data? Should MDs be doing this, or might it be more efficient to refer patients to exercise experts and coaches?

What’s missing?

Conspicuous by its absence is one of the most essential arrows in the cardiologist’s quiver: statins. They really do what NDs only claim to do. They have been proven to reduce the rate of cardiovascular events and deaths. They have been proven to improve endothelial dysfunction and to reduce inflammation. They address the underlying causes of disease. Apparently NDs are content to deprive their patients of the life-saving benefits of statins simply because they are not “natural.”

Conclusion: what’s good is not special; what’s special is not good

Much of what NDs do is indistinguishable from what all good clinicians do. Most of the things they do differently are not evidence-based. And they omit proven evidence-based treatments that MDs routinely use.

It’s hard to take NDs seriously in the absence of convincing evidence that their patient outcomes are better than those of good mainstream clinicians.

Last week I reviewed Jim Alcock’s book How We Believe. In it, he says there are three types of healing: natural healing (the body heals itself), technological healing (drugs, surgery) and interpersonal healing that depends on context and personal interactions and that leads to improvements in illnessbut not in disease. NDs may be good at the third type, and mainstream medicine might be able to learn a thing or two about interpersonal healing from them. But NDs clearly have much to learn from science-based medicine.

Posted by Harriet Hall

Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about pseudoscience and questionable medical practices. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so),  and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel.  In 2008 she published her memoirs, Women Aren't Supposed to Fly.