The latest event sponsored by “integrative medicine” proponents on my medical school campus featured the naturopath “Dr.” PB, a 2003 graduate and valedictorian from Bastyr University. Advertisements all over campus billed the lecture as “Stress, nutrition, and the GI tract,” which seemed innocuous enough. However, the lecture title as written on PB’s slide show was “Naturopathic apologetics for treating the gut.” He explained “treating the gut” to mean that for a wide variety of symptoms the naturopath’s diagnosis inevitibly focuses on the intestine and interventions nearly always involve dietary changes or supplements. Apparently some critics find this preoccupation to be excessive; hence “apologetics,” a word that connotes rational defense of articles of faith. This word choice was appropriate, as the lecturer wove snippets of basic physiology, but never any direct evidence, into a just-so story about how nearly all disease is caused by the modern lifestyle and can be ameliorate with dietary intervention.
PB started the lecture with a brief description of naturopathy, which he said includes a focus on lifestyle, nutrition, exercise, spirit, ”natural medicines” like herbs and also practices such as homeopathy, acupuncture, and hydrotherapy. (These latter techniques were not discussed or even mentioned for the rest of the lecture, although they are prominent on PB’s website.) He described naturopathic education as similar in scope and rigor to medical school, with particular emphasis on physiology and primary care. His words: “we have a very different philosophy [from medicine]: we look for the underlying cause of disease, and we treat with the most natural way possible.” PB ended the introduction with a plea for support in his efforts to get naturopaths licensed in local states as primary care physicians, which would hopefully allow them to prescribe drugs just like residency-trained, board-certified MDs.
Essentially, PB’s model for disease is: chronic psychological stress causes chronic intestinal ischemia (because the sympathetic fight-or-flight response diverts blood from gut); which causes chronic intestinal inflammation; which causes decreased nutrient absoption and increased intestinal permeability; which causes leakage of “toxins, microbes, and undigested food macromolecules” into the blood; which overloads the liver’s detoxification capacity; which leads to chemicals and toxins in the systemic circulation that are responsible for diverse diseases and symptoms. Processed foods and “chemicals” in the average American diet contribute to the “leaky gut” problem. I would not argue that inflammed or ischemic bowels are not serious medical issues with systemic consequences. However, one got the impression from PB’s presentation that most Americans suffer from this pathology simply because we are stressed out at work and we eat fast food!
What kind of disease? Inflammation in the gut can affect cancer, cardiovascular disease, autoimmune disease, and diabetes…I guess because those diseases also have an immune component? Poor nutrition, he claims, not only causes increased blood pressure but also is responsible for symptoms musculoskeletal, neurologic, dermatological, you name it. Furthermore, since 95% of serotonin is found in the gut, then clearly diet is important for depression and mental health, too. I wish I was exaggerating how broad and unsubstantiated the claims were.
PB cited several references in the middle of the presentation, and I scribbled down the citations to share them with you, dear readers, missing only one about psychiatric patients and diet. He referred to (but did not give citation for) a British study correlating heart disease with poor interpersonal relationships, presented as proof that psychological stress can lead to pathology. He cited a Czech report of a technique to monitor gut permeability in celiac patients. He cited a 10-year-old review with an abstract that said “One of the most significant extraintestinal manifestations of gastrointestinal diseases is rheumatologic disorders,” although bizarrely PB immediately admitted that he has “never heard of any other doc” who believes this. (I saw this exact presentation two years in a row, and last year he also said this reference was unusual.) He cited a case report of a single teenage girl whose chronic fatigue syndrome symptoms improved following dietary intervention. He cited a Hepatology study of a particular type of liver disease in pregnant women that seemed associated with “leaky gut.” The haphazard structure of this paragraph represents the rapid display of unconnected abstracts that I experienced. Is this the evidence base that informs naturopathy, or a collection of random references that seem to lend it credence? I was unimpressed by the scholarship on display.
I found myself getting annoyed at PB because despite his fuss over naturopaths’ supposed expertise in intestinal physiology and immunology he seemed curiously imprecise at times. I wrote in my notes at one point “he seems to conflate food allergies with intolerances,” a mistake I have come to expect from laypersons but not from physicians. As an example, he spoke a lot about celiac disease, I suppose because its intestinal pathology causes systemic symptoms that respond to dietary intervention, a pattern he would apply broadly to many other diseases. I transcribed with disbelief as he said “celiac is a frank allergy to wheat.” I don’t think so. Even if it were a slip of the tongue, such sloppiness would not be excusible from someone claiming to be a gut expert on a medical school campus.
In hindsight, I wish I had challenged him on the celiac point, to see if it was a mistake or a alternate theory of the disease. My first problem was that I felt moved to challenge points made on nearly every slide, to challenge his logic and very premises. Then a highly respected faculty member in the audience meekly asked the naturopath for more lifestyle advice, and I got so flustered that I lost the ability to say anything articulate or insightful. Challenging a sectarian in front of a sympathetic audience is difficult!
How can we protect our gut from the ravages of anxiety-induced ischemia and processed food? Here is PB’s eight-step plan for fixing what ails you:
1. De-stress. Find joy in your work, have hobbies, take deep breaths often, sit with your legs uncrossed to “help the chi flow better.”
2. Chew food. Each mouthful should be chewed 20 times “for best health.” A related pearl: everyone should drink at least 50 ouces of water each day.
3. Digestive enzymes. Many Americans need to take such supplements because processed food “lacks natural enzymes.”
4. Healthy food and nutrition. Things to avoid: “fried foods, preservatives, sugar, chemicals, allergenic foods [because they] cause inflammation.”
5. Remove offending foods. If you are allergic or sensitive to a particular food, then avoid it.
6. Take probiotics. He was thrilled to report that there is now evidence for this naturopathic practice acknowledged from medical researchers! He did not give citations supporting his claim for routine use.
7. Sleep at least 8 hours a day.
Banal at best. Even to the extent that some of the advice is good, did we need to invite someone who practices all this woo to tell us that? We have a great Family Medicine department with physicians who would be happy to talk about diet, exercise, sleep, and stress management. Given our local patient population (a lot of diabetes and hypertension), our faculty drill us from day one to talk lifestyle with every patient! No chi belief required.
I hope a more compelling case than what I saw is required before PB’s state allows naturopaths to prescribe pharmaceuticals and practice as primary care physicians. If not, then why should I waste all that time with residency and CME?