Naturopathic Medicine - Let the Evidence Speak

Research in Naturopathic Medicine

Many readers will be aware of an ongoing public debate regarding the validity of naturopathic medicine. The debate often centers on the existence of evidence to support the safety and effectiveness of naturopathic medicine.^[1] In this article, we throw new light on the state of naturopathic medicine research and highlight the oft-overlooked body of evidence that already exists. First, we must distinguish between two types of scientific research in the field of naturopathic medicine. The first is the traditional-style single-intervention study, in which a single therapy, such as omega-3 fatty acids or vitamin D, is administered to a group of people. This therapy is compared with a placebo or other “control substance” and outcomes of interest are assessed over time. An abundance of such evidence exists investigating the effects of individual natural therapies,^[2–5]] however, this is not the focus of this article.

One of the strengths of naturopathic medicine, however, is its ability to combine several types of therapies into a cohesive plan of treatment in order to enhance effectiveness. For instance, nutritional supplementation may be combined with acupuncture in the treatment of pain. Herbal medicine may be combined with nutritional therapy and homeopathy for the treatment of infertility. Lifestyle counseling may be combined with nutritional supplementation for the treatment and prevention of cardiovascular disease and/or diabetes. Therefore, a second type of naturopathic medicine research examines the use of combined therapies used together in a systematic approach to the treatment of a given condition. Such research is termed “whole systems research” because it investigates an entire system of medicine or entire treatment approach taken as a whole, rather than the effects of a single isolated agent.^[6] Whole systems research is more generalizable; that is, it tells us more about how naturopathic medicine works in real-life settings. It assesses treatments as they are usually administered (together), in the context of a doctor-patient relationship, and also allows for better assessments of associated costs. This type of research is an exciting new area within naturopathic medicine. Mental health, chronic pain, and cardiovascular disease are three prominent categories of chronic health conditions which are currently recognized as being both inadequately managed through current conventional strategies, and impose a burden on the resources of the health-care system.. We examine the role of naturopathic medicine in these areas.

Mental Health

Mood disorders such as anxiety and depression affect a large portion of Canadian society. According to the Canadian Mental Health Association (CMHA), up to 20% of Canadians experience mental illness, with up to 8% experiencing depression within their lifetime, and up to 5% suffering from anxiety.^[7] An argument could be made that a much larger percentage experience anxiety, with many simply being unaware or undiagnosed. The costs of mental illness include reduced quality of life, lost productivity, and costs to the health-care system; of these, the latter is estimated to be almost 10 billion dollars.^[7] In addition, there have been concerns about the safety and effectiveness of common pharmaceutical approaches in some instances, such as in patients with mild to moderate depression.^[8]

Research has shown that naturopathic medicine can significantly reduce anxiety and improve mood.^{[9, 10]} In a randomized controlled trial, Cooley et al. administered naturopathic care or a standardized psychotherapy intervention (PT) over a period of 12 weeks to 81 patients suffering from anxiety for at least the last six weeks.^[9] Participants in the naturopathic-care group received dietary counseling, deep-breathing relaxation techniques, a multivitamin, and the herbal medicine ashwagandha (Withania somnifera) (300 mg twice daily, standardized to 1.5% withanolides). The psychotherapy intervention group received psychotherapy, matched deep-breathing relaxation techniques, and a placebo. After eight weeks, patients in both groups experienced significant improvements in their anxiety scores, measured as the Beck Anxiety Index (BAI). BAI scores decreased by 56.5% in the naturopathic care group and by 30.5% in the psychotherapy group. The naturopathic-care group also reported greater improvements in concentration, fatigue, social functioning, vitality, and overall quality of life. This study shows that both naturopathic care and psychotherapy improve anxiety; however, naturopathic care may lead to greater improvement. Naturopathic care also led to improvement in other measures related to quality of life.

Another study evaluated the impact of naturopathic care on mood and quality of life in patients with diabetes.^[10] Forty patients with type 2 diabetes were selected to receive add-on naturopathic care, in addition to their standard care, for one year. Naturopathic care consisted of diet and lifestyle counseling and use of select nutritional supplements. In addition to benefit on areas related to diabetes, the patients receiving naturopathic care reported significant improvements in self-care behaviour, motivation, and mood, compared to patients received standard care only. This study underscores the truly holistic nature of naturopathic medicine; while diabetes was the condition of interest, delivery of naturopathic care led to improved health in other seemingly unrelated areas as well, including mental health.

Chronic Pain

A second area of relevance for naturopathic medicine is the management of chronic pain. This includes pain from arthritis, joint injuries, autoimmune arthritis, as well as chronic migraine and fibromyalgia. According to the Canadian Pain Society (CPS), one in five Canadians suffers from chronic pain.^[11] The CPS also reports that “pain is the most common reason for seeking health care and accounts for up to 78% of emergency room visits”.^[11] Economically, the annual cost of chronic pain in Canada is estimated at around 60 billion dollars. Clearly, this is an area where current management is suboptimal. Several studies demonstrate the effectiveness of naturopathic medicine in managing conditions of chronic pain, including low-back pain, rotator-cuff tendonitis, and temperomandibular joint dysfunction (TMD).^{[12, 13, 14]}

Two studies by Szczurko et al. at the Canadian College of Naturopathic Medicine evaluated the effectiveness of comprehensive naturopathic care in the treatment of low-back pain and rotator-cuff tendonitis.^{[12, 14]} In the first study, a total of 85 patients with rotator-cuff tendonitis were randomized to receive either naturopathic care or standardized physical exercises for 12 weeks. The naturopathic care group received dietary counseling, acupuncture, and a digestive enzyme called Phlogenzym (2 tablets three times per day). The physical-exercise group received passive, active-assisted, and active range of motion exercises and a matched placebo. At the end of 12 weeks, the Shoulder Pain and Disability Index (SPADI) scores decreased significantly in both groups: by 54.5% in the naturopathic care group, and by 18% in the physical exercise group. There were also significant improvements in pain visual analog scale, quality of life, as well the range of shoulder extension, flexion, and abduction, with the naturopathic care group showing superiority in each outcome. In the second study, on low-back pain, a total of 75 patients with low-back pain were randomized to receive naturopathic care or standardized physiotherapy exercises for 12 weeks.^[14] The naturopathic-care group received dietary counseling, deep-breathing relaxation techniques, and acupuncture, while the control group received education and instruction on physiotherapy exercises using an approved education booklet. At the end of 12 weeks, the naturopathic-care group reported significantly lower back pain as measured by the Oswestry disability questionnaire. Quality of life was also significantly improved in the naturopathic-care group. Secondary outcomes including spinal flexion, weight-loss, and body mass index (BMI) also improved in the naturopathic care group. Finally, in a third study by Ritenbaugh et al., naturopathic care was evaluated in the treatment of TMD, which contributes to jaw pain and migraines.^[13] A total of 160 patients were randomized to one of three treatment groups: naturopathic care, traditional Chinese medicine (TCM), or standard care at the TMD specialty clinic where the study was run. Standard care consisted of bite splints and self-care counseling by dentists specializing in TMD. Traditional Chinese medicine utilized acupuncture therapy. Naturopathic care consisted of stress-reduction techniques, nutritional counseling, and use of supplements and herbs. At the end of treatment as well as at three months posttreatment, both TCM and naturopathic medicine demonstrated significantly greater reductions in ratings of “worst facial pain” compared to standard care. Naturopathic care also led to reductions in patient ratings of psychosocial interference from TMD. Collectively, these studies show that naturopathic care can lead to improved management of chronic pain originating from a diverse variety of conditions.

Cardiovascular Disease

Finally, an important area where naturopathic medicine can potentially play a role in disease prevention and management is cardiovascular disease. Cardiovascular disease is the second leading cause of death in Canada, following cancer.^[15] Several factors have been associated with increased risk of cardiovascular disease, including elevated cholesterol, blood pressure, blood glucose, and being overweight. When three or more of these are present at even borderline high values, their combination is called “metabolic syndrome”.^[16] Metabolic syndrome affects approximately 25% of Canadians and is the subject of increasing attention with respect to implementation of preventative strategies for the development of cardiovascular disease. Patients with diabetes are also at elevated risk of cardiovascular disease, including heart attack, stroke, and small-vessel disease that affects end-organs such as kidneys, eyes, and extremities. Both of these groups of patients are ideal candidates for add-on naturopathic care in order to reduce long-term disease risk. A handful of studies have evaluated the role of naturopathic medicine in managing cardiovascular disease risk factors in these patients.^{[10, 17]} In the randomized controlled trial by Seely et al., a total of 246 patients identified as being at increased risk of cardiovascular disease based on their cholesterol level were randomized to receive add-on naturopathic care for 12 months in addition to standard care through their family physician, or standard care alone.^[17] Naturopathic care consisted of health-promotion counseling, diet counseling, and nutritional or herbal supplementation. At the end of one year, patients in the naturopathic group had a significantly reduced 10-year cardiovascular risk estimate compared to control patients. Significantly fewer patients receiving naturopathic had metabolic syndrome after one year, compared to standard care alone. A second study by Bradley et al. (described briefly above) examined naturopathic medicine in the management of type 2 diabetes.^[10] A total of 40 patients with poorly controlled diabetes were selected to receive adjunctive naturopathic care in addition to their standard care for one year. Naturopathic care consisted of dietary counseling, exercise recommendations, stress reduction techniques, and select nutritional supplementation. At the end of one year, patients receiving naturopathic care demonstrated improved blood-glucose control evidenced as a reduction in HbA1C levels, as well as improvements in health-promoting behaviors such as engaging in exercise and motivation to change their lifestyle.

Together, these studies show that comprehensive naturopathic care in addition to standard medical care results in improvements to long-term cardiovascular risk, prevalence of metabolic syndrome, blood-glucose control, and implementation of health-promoting behaviors. As a whole, our analysis of existing naturopathic medicine research shows that wider use of naturopathic medicine may help fill current gaps in health-care and improve the management of several chronic health conditions when added to standard care.