Diabetes Mellitus
Does naturopathy offer something special or uniquely effective for the treatment of diabetes? Naturopaths are alternative medicine practitioners who claim to provide primary care, like medical doctors. Among naturopaths and their supporters, it’s regularly claimed that naturopathy offers something that “conventional” medicine does not: Naturopaths are described as “doctors plus”, using unconventional approaches to coax the body to “heal itself” with methods that are claimed to be safer and more effective than conventional drugs and medical interventions. The superiority of naturopathy over conventional medicine is an argument that showed up in the comments to my last post, when I pointed out that this year’s Nobel Prize in Physiology or Medicine failed to validate either naturopathy or herbalism. Here’s one example:

Someone diagnosed with pre-Type 2 diabetes could visit a Naturopathic Doctor and stop the disease in its tracks. The doctor would recommended a simple diet change to a high-fat, low-carb, zero refined sugar diet, maybe some supplements, and exercise. Bye, bye, Type 2 diabetes. The same person could visit an MD, and before you know it would be taking insulin and Metformin (and other horrible drugs) for the rest of his or her life. An added bonus with the insulin is weight gain. Notice that the diabetes commercials feature overweight actors and actresses? Yes, there are natural cures. Is this is a site promoting good health, or is it a front for the pharmaceutical companies?

You can follow the comment thread for the discussion that followed. The same commenter continued in Mark Crislip’s post on Friday about the difference between naturopathy and conventional medicine:

Allopath – you will be taking insulin, Metformin and other drugs for the rest of your life. Your diabetes will be managed, but there will be a slow deterioration in the quality of your life.

Naturopath – we can reverse this with a change in your diet, along with exercise.

Naturopath wins.

Now this individual never claimed to be a naturopath – but testimonials like these are not surprising. I’ve written several posts in the past about the claims made by naturopaths, and how they stack up against the scientific evidence. Naturopaths offer an array of disparate health practices like homeopathy, acupuncture and herbalism that are linked by the (now discarded) belief in vitalism – the idea we have a “life force”. From this philosophy can sometimes emerge sensible health advice, but not because naturopaths are following the evidence. As long as a treatment is viewed as being congruent with the naturopathic belief system, it’s acceptably “naturopathic”. In past posts I’ve looked at the naturopathic perspectives on fake diseases, infertility, autism, prenatal vitamins, vaccinations, allergies, and even scientific facts themselves. Britt Hermes is a former naturopath and has written extensively about naturopathy from the perspective of an insider, and her evaluation is scathing: There are no naturopathic standards of care, naturopathic training is much different than what naturopaths purport, and the accreditation of naturopathic schools is questionable. Now, diabetes is a widely prevalent chronic disease. It causes a huge burden of illness on society. And while we have a fair understanding of its causes and how to treat it, there are still far too many people suffering from complications of the disease. Diabetes already requires care from multiple medical professionals, including physicians, nurses, dietitians, and pharmacists. Should naturopathy be included? Is there any evidence that demonstrates that naturopathy can “stop” diabetes? And how does advice from a naturopath differ from “conventional” medical advice?

Diabetes: The facts

We have accumulated fairly good evidence about the causes of diabetes mellitus. Every cell in your body needs sugar for energy, and sugar enters the cells through the action of insulin. When sugar can’t enter cells, it accumulates in the blood. Type 1 diabetes usually appears in childhood, and is caused by the body’s inability to produce insulin. Type 2 diabetes is different. Either the cells are insensitive to insulin, or the body does not make enough to lower blood sugar – or it may be a combination of both effects. Type 2 diabetes is predominantly a disease of older adults.

I’m not going to focus on Type 1 diabetes. The discovery (and production) of insulin transformed type 1 diabetes from a death sentence to a chronic illness. I’m also going to ignore the other forms of diabetes (e.g., gestational diabetes). I want to focus on Type 2 diabetes, the most common form (>90% of cases) of the disease, and the type of diabetes that many naturopaths claim to treat.
Type 2 diabetes is a chronic illness that is managed with a specific goal – reducing the complications of the disease. Diabetes can lead to cardiovascular disease (e.g., heart attacks), cerebrovascular disease (e.g., strokes), eye disease causing blindness, kidney disease leading to kidney failure and dialysis, and nerve disease leading to problems like foot ulcers that can eventually lead to amputations. The risks of these outcomes are reduced by managing blood sugar levels. Evidence shows that those with diabetes can have fewer complications if they can control blood sugars effectively. (How intensely blood sugar must be managed is a continued source of debate.)
There are three main lifestyle components to managing diabetes before turning to medication, and they are the cornerstones of treatment: (This detailed 1-page summary from RxFiles covers it all.):

  • dietary changes
  • regular exercise
  • weight control

What does the evidence say?

To understand the “conventional” approach to diabetes, I looked to the major sources that one would turn for a summary or overview – treatment guidelines. While guidelines are admittedly inferior to actually understanding all of the primary evidence itself, credible treatment guidelines provide a useful summary of what might be called the “standard of care” in medicine. It’s not mandatory to treat a patient according to guidelines, and guidelines can definitely have biases. However, credible guidelines can provide a useful benchmark upon which we can measure the approaches taken by health professionals. Keeping my focus on North America, I found two major guidelines (Canadian & American) that summarize what could fairly be called the “conventional” approach to type 2 diabetes. Given one of the claims made about science-based medicine is that it prioritizes drug treatments over non-medical approaches, I’ve pulled a few passages that describe the role of lifestyle and diet, areas where naturopaths claim to have a unique role and perspective:

Canadian Diabetes Association – Clinical Practice Guidelines

On reducing the risk of diabetes:

Intensive and structured lifestyle modification that results in loss of approximately 5% of initial body weight can reduce the risk of progression from impaired fasting glucose or impaired glucose tolerance to type 2 diabetes by almost 60%.

On exercise:

Moderate to high levels of physical activity and cardiorespiratory fitness are associated with substantially lower morbidity and mortality in men and women with and without diabetes. A structured program of lifestyle modification that includes moderate weight loss and regular physical activity should be implemented to reduce the risk of type 2 diabetes in individuals with [impaired glucose tolerance].

On diet:

Reduced caloric intake to achieve and maintain a healthier body weight should be a treatment goal for people with diabetes who are overweight or obese. The macronutrient distribution is flexible within recommended ranges and will depend on individual treatment goals and preferences.

The guidelines do not prescribe any particular diet. They point out that there is no single diet that is ideal for everyone:

As evidence is limited for the rigid adherence to any single dietary prescription, nutrition therapy and meal planning should be individualized to accommodate the individual’s age, type and duration of diabetes, concurrent medical therapies, treatment goals, values, preferences, needs, culture, lifestyle, economic status, activity level, readiness to change and abilities.

The Canadian guidelines emphasize the key role of diet and exercise. They are very patient-centred, cautioning that treatment plans must be designed with the patient as a full partner in their care.

American Diabetes Association: Clinical Practice Recommendations

On reducing the risk of diabetes:

Randomized controlled trials have shown that individuals at high risk for developing type 2 diabetes can significantly decrease the rate of diabetes onset with particular interventions. These include intensive lifestyle modification programs that have been shown to be very effective (58% reduction after 3 years).

On exercise:

Exercise is an important part of the diabetes management plan. Regular exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being. Furthermore, regular exercise may prevent type 2 diabetes in high-risk individuals.

On diet:

It is the position of the ADA that there is not a one-size-fits-all eating pattern for individuals with diabetes. The ADA also recognizes the integral role of nutrition therapy in overall diabetes management and recommends that each person with diabetes be actively engaged in self-management, education, and treatment planning with his or her health care provider, which includes the collaborative development of an individualized eating plan.

And:

Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.

On when to start drug therapy:

Most patients should begin with lifestyle changes (lifestyle counseling, weight-loss education, exercise, etc.).When lifestyle efforts alone have not achieved or maintained glycemic goals, metformin monotherapy should be added at, or soon after, diagnosis, unless there are contraindications or intolerance. Metformin has a long-standing evidence base for efficacy and safety, is inexpensive, and may reduce risk of cardiovascular events.

The Canadian and American guidelines deliver the same messages: Lifestyle changes are essential and highly effective. Nutritional planning is essential, but there is no “one diet fits all” approach that works. And medication if necessary (and it usually is), but not necessarily medication.

Diabetes and naturopathy: the good, the bad, the useless

Now let’s turn to the advice provided by naturopaths. In contrast with science-based medicine, there is no clear standard of care with naturopathy – owing to the fact that naturopathy is not based on science or evidence. It is a belief system, or philosophy. Understanding this makes naturopathy a little less baffling – otherwise how could disparate and scientifically-contradictory practices like homeopathy, acupuncture and herbalism all be considered acceptably “naturopathic”? Given there is no requirement to rationalize naturopathy in scientific terms, pretty much anything goes. I’ve used this quote before, but it accurately reflects how naturopaths appear to assess evidence and decide what is “naturopathic” and which will be ignored:

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

In the case of diabetes, however, there have been attempts to compare naturopathic approaches against guidelines – in one case, the American Diabetes Association. A chart audit by naturopaths at a naturopathic clinic concluded the following:

The average audit score was 55.5/90. The most common interventions being used are diet and aerobic exercise, followed by supplements (omega-3 fatty acids) and botanicals. These data suggest that the American Diabetes Association standards of care for type 2 diabetes mellitus are not followed stringently. Education and creation of a naturopathic standard of care may improve audit performance and patient outcomes.

A letter published a few years ago in Allergy, Asthma, & Clinical Immunology was a more general attempt to understand the alignment between naturopathy and scientific standards. Timothy Caulfield and Christen Rachul found that the most widely-advertised practices in Alberta and British Columbia lacked a sound evidence base. They concluded:

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

Among the interventions promoted by naturopaths were homeopathy, chelation, acupuncture and hydrotherapy. Caulfield’s and Rachul’s approach was similar to the one Mark Crislip described last week – an attempt to comprehensively review statements made on naturopathy websites. The challenge, as Mark acknowledged, is the sheer volume of websites – he made it through 30. Being unable to audit naturopath practices, I looked to what appeared to be “authoritative” naturopathic websites for guidance on how diabetes is currently managed from a naturopathic perspective.

NDhealthfacts.org

Last year I wrote about ndhealthfacts, a Wikipedia-like database created and edited only by naturopaths which is an effort to rebut the strong anti-pseudoscience stance against naturopathy taken by Wikipedia. ndhealthfacts has a page dedicated to naturopathic approaches to type 2 diabetes. Some of the advice is aligned with treatment guidelines: Maintain a healthy body weight. Don’t smoke. Exercise regularly. In terms of treatments, however, the website offers a long list of questionable advice that veers from unnecessary (food advice) to unproven (vitamin and supplements) to the demonstrably useless (homeopathy):

Nutritional Foods include:

  • Fruits such as guava, lemon, plum, crab apple.
  • Vegetables, Roots, Nuts & Gourds such as corn silk, kohlrabi, yam, water chestnut.
  • Legumes such as string (green) bean, mung bean.
  • Meats such as beef, pork.

Clinical Nutritional Supplementation includes:

  • Vitamins such as Vitamin C, Vitamin E, Vitamin B12
  • Minerals such as magnesium, chromium, zinc
  • Amino Acids such as taurine, L-Carnitine, Alanine and Histidine.
  • Other supplements such as Alpha lipoic acid essential fatty acids, N-acetyl-cysteine (NAC), antioxidants, bioflavonoids, Coenzyme Q10, Betaine HCL, Brewer’s Yeast, Flax Seed Oil, Lycopene, Psyllium, Quercetin, Spirulina
  • Herbs such as Bilberry (Vaccinium myrtillus), Garlic (Allium sativum), Ginseng (Panax ginseng), Goldenseal (Hydrastis canadensis), Bitter melon (Momordica charantia), Gymnema (Gymnema sylvestra), Fenugreek (Trigonella foenum-graecum), Milk Thistle (Silymarin marianum), Saltbush (Atriplex halimus), East Indian Kino tree (Pterocarpus marsupium), Bilberry (Vaccinum myrtillus), Ginkgo (Ginkgo biloba)[7], Burdock (Arctium lappa), Cinnamon (Cinnamomum), Goat’s Rue (Galega officinalis), Licorice (Glycyrrhiza glabra), Capsicum frutescens, Olive (Olea europaea)

Gemmotherapies such as Acer campestre, Juglans regia, Juniperus communis, Olea europaea, Vaccinium myrtillus

Homeopathy

  • Classical homeopathics: Phosphorus, Uranium nit., Argentum nit., Codeinum, Natrum sulph, and Silica. Sulphur, Calc carb

Traditional Chinese Medicine & Acupuncture In Traditional Chinese Medicine, conditions are diagnosed based on patterns of symptoms. Diabetes is not considered to be caused by the same process in each individual, but several processes are possible and would each be treated uniquely:

  • Lung-Stomach Heat Accumulation & Fluid Damage, Intense & Exuberant Stomach Heat, Qi & Yin Dual Vacuity, Kidney Yin Vacuity, Spleen-Stomach Qi Vacuity, Damp Heat Obstructing the Center, Spleen-Kidney Yang Vacuity.

American Association of Naturopathic Physicians

The AANP also offers advice on diabetes. It attributes other factors to the disease:

The controllable factors include: poor diet, over-eating, nutritional deficiencies, high refined grains and sugars consumption, high saturated fat consumption, lack of exercise, and being overweight/obese. Environmental toxins and hormonal imbalances are also noted for initiating insulin resistance.

They also recommend supplements:

Patients will be given various supplements, which are invaluable. They work synergistically with the other aspects of the comprehensive protocol to replace deficient nutrients; help lower their glucose levels and decrease their insulin resistance; reduce inflammation, lipids and blood pressure; and protect them from diabetic induced damage.

There is in fact no evidence that demonstrates that supplements have any meaningful effectiveness for any of these conditions.

The AANP also believes that naturopathic care can reverse damaged nerves and kidneys:

They can at times see their damaged nerves and kidneys to recover full functioning, and those without such damage will have protection from developing it. Naturopathic treatment of diabetes can be incredibly effective and naturopathic physicians should be the first type of doctor a diabetic patient seeks out for long term care.

Canadian College of Naturopathic Medicine

The CCNM makes accurate statements about the importance of diet and exercise in diabetes, but also recommends treatments and supplements that are either unproven, or useless:

Naturopathic doctors are well-trained and are able to provide patients with excellent treatment options for diabetes. They utilize modalities such as nutrition, lifestyle counselling, botanical medicine, traditional Chinese medicine, and homeopathy. Many scientific studies have validated the use of naturopathic treatments for helping achieve optimal health for diabetics.

One example of a nutritional treatment is the supplementation of the element chromium. Chromium supplementation has been shown to improve blood sugar levels in diabetics. Studies have shown chromium to be safe and effective, and generally without any significant side effects. Another example of a therapy used by naturopathic doctors is a herb called gymnema sylvestre. Studies have shown that gymnema has the ability to decrease blood sugar as well. Like chromium, the studies using gymnema have not shown any side effects caused by its use.

Conventional medicine (i.e., the ADA) says that there is “insufficient evidence” to support the use of chromium or herbal supplements. I also consulted the Natural Medicines database which describes chromium as “possibly effective” at reducing some of the markers of diabetes, noting poor quality data and conflicting trial results. The same database says that there is “insufficient evidence” to evaluate the effectiveness of gymnema for the treatment of diabetes.

The Naturopathy

This website recommends a range of treatments, ranging from the odd to the downright dangerous, such as fasting, enemas, an “alkaline diet”, “mud baths”, yoga, sun baths, and “chromo therapy”, (a new one for me), where it’s believed the colours yellow and green have healing properties.

Others

I also looked to naturopath web sites that advertise that they treat diabetes. Some naturopaths are appropriately cautious and suggest that herbs may be beneficial, but also note that cannot replace medicine. Others boldly claim to use unproven and ineffective treatments like hydrotherapy and mud therapy to “detoxify” the body. The Toronto Centre for Naturopathic Medicine says it will treat the underlying lifestyle factors of diabetes but also offers supplements, herbals, acupuncture and homeopathy as treatment. Chelation, which has no demonstrable value in the treatment of diabetes, appears to be frequently offered to persons with diabetes. A British Columbia-based naturopath recommends both chelation and ozone therapy, in addition to recommending supplements. There appears to be no natural limit on the types of treatments offered by naturopaths for the treatment of diabetes.

Is there any published evidence?

Having reviewed the approaches advertised by naturopaths, I looked to the literature: Is there any published evidence naturopathy offers anything beneficial? There is some published evidence, but the results are disappointing. Some studies try to evaluate “naturopathic” counselling.What’s not clear is if there’s anything uniquely naturopathic to this advice.  Diabetes treatment guidelines emphasize that care must include multiple professionals and be patient-centred. Moreover, counseling on diet and exercise is hardly naturopathic – it’s core advice in conventional treatment guidelines. Whether naturopathic management of diabetes has any beneficial effects remains unclear.

The good is not unique, the unique is not good

Naturopaths offer a variety of services to persons with diabetes, ranging from what appears to be sensible and evidence-based, but can also include unproven and even possibly harmful approaches. There is no evidence to suggest that any services that are uniquely “naturopathic” have any established role in the treatment of diabetes: What’s good is not unique, and what is unique is not good. With no clear practice standards, persons with diabetes appear just as likely to be given sensible advice on the management of diabetes as they are to get bad advice, and to be sold products and services with no proven value. In light of the unreliability and inconsistency in the way that naturopaths manage diabetes, it would seem prudent to discuss any advice offered by a naturopath with a health professional, preferably one that specializes in diabetes, before making any decisions based on that advice.


Photo from flickr user Steve Davis used under a CC licence.

Posted by Scott Gavura

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