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CAM on campus: Naturopathy

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.

8. Exercise.

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?

Posted in: Medical Academia, Science and Medicine

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28 thoughts on “CAM on campus: Naturopathy

  1. Tim, your posts are scary examples of the crap that modern medical students will increasingly be exposed to, if we can’t turn the sCAM supertanker around. Keep’em coming.

    Bongiorno is an idiot. New York, I’m sorry to say, will get exactly what it deserves if it licenses NDs: “primary care doctors” who make it up as they go or who go along with BS that others of their ilk have made up.

    There is a correlation between inflammatory bowel disease and rheumatologic disease, but it has nothing to do with “poor interpersonal relationships.” Both are autoimmune diseases, and in some cases there are known, genetic correlations, eg, HLA-B27 (human leukocyte antigen) with both ulcerative colitis and ankylosing spondylitis. Recent innovative drug therapies have similar molecular targets in both IBC and rheumatologic diseases as well. Paradoxically, it could be argued that ‘boosting the immune system’ would worsen both types of disease, although that phrase is so simplistic as to be scientifically useless.

    The Ns’ obsession with celiac disease is everywhere and has begun to make its way into popular culture, ala ‘toxins’ in general: according to Ns, gluten is nearly always one of the “underlying causes of the disease.” Thus you’ll find “gluten-free” aisles in Whole Foods and other such emporia, and increasingly so. A boon for the true sufferer of gluten enteropathy, but cumbersome nonsense for everyone else, especially hapless kids whose parents have been led to believe that every unpleasant behavior or ear infection has gluten (and sugar and multiple ‘food allergies’) to blame.

    Licensing NDs=Idiocracy

  2. Militant Agnostic says:

    In Mark Crislip’s Quackcast Podcast on Probiotics he said that probiotics might cause bowel inflammation. I assume this is because they are not your familiar little buddies. Is there any evidence to support this hypothesis? If there is, it would be some more evidence that the naturopaths are talking out of their colons (again)>

  3. This is a typical method of CAM types to show that their magic is valid and based on real science. Use enough science to appeal to a broad group, which seems convincing. Orthomolecular medicine uses the science that some micronutrients, say niacin, have a beneficial effect, so they conclude that lots of these nutrients will cure everything. Very tiresome.

  4. Skeptico says:

    Just curious – what is the difference between an allergy and an intolerance?

  5. Michelle B says:

    Skeptico, an intolerance pertains to an enzymatic defect (one is defective in some way regarding the digestive enzymes for handling lactose in milk or gluten in wheat) while an allergy involves the exuberant release of IgE antibodies, mistaking a non-noxious substance as a peanut as a problem.

    Good post: Essentially, Bongiorno’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.
    _______

    Thirty years ago, this nonsense was peddled in NYC by a Dr. Markus and later by Dr. Corsello. I fell for it. What a boon for health once a believer lets go of this nonsense. They caused the psychological stress by drumming in that somehow humans can’t take stress in stride in most instances. They never talk about the positive aspects of stress, as what Selye discovered, eustress.

    Many former religious believers have told me, that once they let go of their non-evidential beliefs, they feel so much lighter. I say it is same for believers in alternative medicine–the ridiculous core claims of alternative medicine is a negative stress. Buffoons.

  6. daijiyobu says:

    But, this ND tells us, & I’m being sarcastic, here:

    (see http://www.innersourcehealth.com/more.html )

    “a naturopathic doctor (ND) attends a four-year medical school and is educated in all of the same basic and clinical sciences as a medical doctor [...] a naturopathic doctor takes rigorous professional basic science and clinical board exams.”

    Anyway, at the New York Association of Naturopathic Physicians’ web page of which Bongiorno is the VP [contact him here, vicepresident@nyanp.org ], Andrew Weil himself is up in a short video clip appealing for New York ND licensure, and Weil tells us “naturopathic doctors are very well trained [...&] it really helps improve the general health of the population.”

    I guess that little issue regarding naturopathy’s fraudulent mislabeling of their profoundly science-ejected belief set as science — basically, the destruction of boundaries in terms of what is and what isn’t legitimately science — is not ethically troubling to Weil.

    Also, that clip has an Arizona MD legislator who labels himself an “allopathic physician” tell us that the ND school in Arizona is “science-based”, and the clip then tells us SCNM is a “medical college”.

    Furthermore, NYANP’s president tells us in that clip:

    “licensure will provide protection to the public by creating standards of education”.

    Hands down the best stoned thinking I’ve seen for a while:

    the deception is sophisticated — academic, legislative, clinical…

    -r.c.

  7. Noadi says:

    Michelle beat me to it. I’m lactose intolerant, my body can’t digest it and I suffer some unpleasant side effects when I have milk that make me think very carefully whether I really want icecream but won’t kill me. My brother is allergic to pennecillin, he has any and he goes into anaphylactic shock and would die if he didn’t receive medical attention quickly (since it is derived from mold he has had reaction to bread and cheese molds that were pretty severe). Not all allergies are that severe but many food allergies, especially peanut, are.

    About the gluten thing, I actually responded on twitter to someone who was wondering if everyone is intolerant to gluten because he’s seen so much hype about it. Since it seemed a legit question I answered nicely that most people are not being diagnosed by a doctor and that self-diagnosis is not a good idea.

  8. Joe says:

    Tim, thanks for that, thoroughly depressing, account. I always had the impression that the unifying aspect of naturopathy was “detoxification” (well, and opposition to criticism); yet that guy seems to have skipped it. Perhaps I was wrong, or he was smart enough to skip that particular idiocy.

    Apropos daijiyobu’s comments, I also thought they held themselves above medical doctors. Again, was I wrong- or are they changing their stance concerning the “medical” designation?

    Also, how does this guy work in NY (or anyone, anywhere they are not licensed) without getting in trouble for practicing without a license? As I recall, in 2002 K Atwood counted 32 Ns in MA. I live in the most rural area of the state and there are two within walking distance of my place (I feel blessed). It seems one has a license in a neighboring state (CT, NH and VT all offer it) and lures MA residents to an out-of-state office. The other seems to practice here, while claiming to be licensed (with the implication that it is an MA license, rather than acknowledging it is out-of-state). I repeat, how do they get away with it?

  9. David Gorski says:

    Time or length of study doesn’t matter if what is being studied during that time is pseudoscientific nonsense. In fact, increasing the length of study of such material could be a bad thing, because then naturopaths know a lot more about a lot more B.S.–and believe that B.S. more strongly. This makes the deprogramming much more difficult.

  10. Joe says:

    May I add a corollary to D Gorski’s comment- licensing ,and allowing quacks to regulate themselves, doesn’t make them less quacks. It does, however, shield them from certain criminal prosecutions. Thus, licensing protects the quacks, not the public.

  11. Dr Benway says:

    I haz an angry.

  12. The Blind Watchmaker says:

    Why does he need all the Woo? He makes some good points (if not obvious ones) about eating healthy foods, exercising and getting enough sleep. Why can’t he just stop there?

    Why does he need to bring SCAM products into this. Could it be that he has something to sell? Hmmmm.

    Great post.

  13. Tim Kreider says:

    Re: comment by watchmaker

    Near the end of the talk, Bongiorno questioned the ethics of any practitioner who both prescribes and sells natural medicines, which I thought was quite admirable. I am not sure how to square this comment, however, with the commerce page of his website: http://www.innersourcehealth.com/store.aspx

  14. Dr Benway says:

    I am not sure how to square this comment , however, with the commerce page of his website…

    He had a cognitive dissonencectomy?

  15. “He makes some good points (if not obvious ones) about eating healthy foods, exercising and getting enough sleep. Why can’t he just stop there?”

    A: Because everyone already knows those things, or could easily learn them by reading a milk carton. Besides, they are part of the camouflage. Read Dr. B’s ‘tampon essay’ at:

    http://tuftedtitmouse.blogspot.com/2009/03/why-nccam-reminds-us-of-tampons.html

    “I am not sure how to square this comment , however, with the commerce page of his website…”

    One thing I’ve noticed about Ns is that they’ve become very good at playing to the audience at hand. I’ve seen numerous examples of dishonest statements by them, some of which I mentioned in the “Atwood’s response” link in Tim’s essay. We can’t tell from Bongiorno’s website if he profits from his “store,” but there is nothing to suggest that he doesn’t.

    Interested readers might want to peruse that website at some length. It is the typical assortment of quack treatments, fluff testimonials (all by women; I shudder with vicarious embarrassment for the fairer sex), dissing of real doctors, ‘anti-aging’ (through acupuncture!), and other nonsense that is the bread and butter of the practice of “naturopathic medicine.” He warns potential patients not to stop medicines that have been prescribed by a medical doctor, but only because “under New York Education Law 8211, we advise each patient as to the importance of consulting with a licensed physician regarding your condition.” In other words, that will end as soon as the coveted licensure becomes a reality.

    How he and his partner can get away with ‘practicing medicine’ without licenses, by the way, is likely expained by their acupuncture licenses. This is fairly standard for NDs hanging shingles in states without ND licensure. Other common loopholes are chiropractic licenses, PA licenses, or being in group practices with (cynical or moronic) MDs. The Ns are still breaking the law, of course, but like Colorado and Massachusetts and probably many other states, NY is too busy with other things or too stunned by the societal move toward idiocracy to do anything about it. Bongiorno also has bona fides in the medical-schools-selling-out-to-quackery department: he is

    “an adjunct faculty member at New York University, where he teaches classes on Holistic Healing, and…regularly teaches medical students at Mount Sinai school of Medicine.”

    Wouldn’t that make it awkward for the Man to bust him now? Yet another reason that medical schools shouldn’t give these pretenders even the time of day.

  16. wertys says:

    At my rehabilitation hospital we have a regular Thursday lunchtime CPD meeting, and last year the doctor organizing it took it into his head to arrange a series of talks by ‘specialists’ in ‘alternative disciplines’ ostensibly so we could at least hear what they were telling our pts who tend to be very vulnerable to woo. I was incredibly restrained at the acupuncture one until the guy giving the talk (sadly a general practitioner who has drunk the kool-aid) asked me specifically as a pain specialist what I thought about his form of treatment. I received a formal dressing-down afterwards from the organizer for having the lack of grace to lie about what I thought about what he was presenting. The next week we had a myotherapist/Bowen therapy meister who was so wacky that no satire was required, and my colleague at least had the sense to cancel the talk planned for the next week on energy healing !

    Motto, hold everyone to the same level of rigor and the rubbish will be apparent to everyone. Medical students benefit from seeing quacks get picked to pieces in public fora as long as it is done without ad hominem bias and preferably as long as they can see it being done to real scientists as well. They can then develop an appreciation for this essential part of the scienific process. Political correctness and politeness should not prevent one pointing out the thiness of the emperor’s apparel !

  17. Versus says:

    Re: “licensure will provide protection to the public by creating standards of education”.
    This “protecting the public through licensing” rationale for licensing alt med practitioners always drives me crazy. All licensing does is give them an undeserved veneer of respectability. Now they can say they are a “licensed and regulated heath care profession.” Of course, who are on the regulatory boards? Other alt med practitioners! And how is thier scope of practice defined in the statutes? It incorporates their nonsense “theories” thereby legalizing their fraud.
    As to how they get away with practicing when there is no licensing for their, um, specialty in a particular state, maybe they shouldn’t. You can always turn them in for unlicensed practice. In my state (Florida) you can do this anonymously, and I have. (Someone was calling himself an “N.D.” even though Florida stopped licensing them in 1959 and the Department of Health website clearly states you can’t say you’re an N.D. unless you are one of the presumably rapidly dwindling number licensed in 1959.) Last year the Florida legislature declined the opportunity to start licensing N.D.s again, I am proud to say.

  18. Joe says:

    K Atwood wrote “Read Dr. B’s ‘tampon essay’ at: http://tuftedtitmouse.blogspot.com/2009/03/why-nccam-reminds-us-of-tampons.html

    The same story pertains to condoms. There was a time when a man would go to a pharmacy and order a six-pack of beer, a carton of cigarettes, and (whisper) and a box of rubbers.

    Sometimes, in the past, men would offer banter to deflect embarrassment: “Is there tax on them rubbers?” The pharmacist would reply “No, they stay on by themselves.”

    Today, a guy can boldly order a box of prophylastics, and then whisper the request for cigs.

  19. ImperfectlyInformed says:

    That does sound a heckuvalotta nonsense, and it must have been rather awkard to sit and listen to it. However, it’s important to note that food intolerances aside from celiac disease and lactose intolerance are probably not just mythological quack-frauds and probably matter in IBS (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1774223&tool=pmcentrez) and eosinophilic esophagitis (http://www.metapress.com.proxy.lib.pdx.edu/content/u1k260jg01071126/).

    For a more sophisticated and well-referenced altmed review of food intolerance and disease, see: http://www.thorne.com/altmedrev/.fulltext/3/2/90.pdf

  20. MBoaz says:

    Tim,

    First, I just want to thank you for writing. It’s nice to hear from an appropriately skeptical medical student.

    I’m curious to know what your sense is of your fellow med. student’s opinions regarding CAM. Do you find that your peers largely share your skepticism, or is there widespread “openness” to CAM?

    I’m actually a reformed and fully rehabilitated acupuncturist (though I’m still haunted at night by vivid recollections of the stupid). I’m applying to medical schools this year, and am finishing up some undergrad. prerequisites. I’m pretty frequently disturbed (though not really surprised)by my fellow premedical students’ total lack of skepticism regarding CAM whenever it comes up in conversation. What do you think? Are we totally screwed?

  21. Tim Kreider says:

    MBoaz,

    I may expound on this topic in a future post, but briefly I think that most med students are shruggies who couldn’t be bothered with CAM. They don’t quite get why either the CAM boosters or I care so much about the issue.

    I think it’s fair to say that neither general intelligence nor a good undergraduate education will prevent people from falling for compelling but fallacious ideas. I have an unusual pre-med background (math major), as do you it sounds, but many pre-meds are bio majors stressing out about the MCAT. The students are smart and competent and learn the concepts inside and out, but those courses and that test do not necessarily groom skeptical thinking. Ditto for first- and second-year med students, perhaps to a greater degree. It’s hard enough to learn all the facts and dogma without worrying about which ones might not be true! I trust that third year and beyond involves more training in searching the literature and evaluating evidence, since textbooks are then no longer sufficient.

    Good luck with your application! In some ways, it’s the hardest part.

    Tim

  22. Mojo says:

    4. Healthy food and nutrition. Things to avoid: “fried foods, preservatives, sugar, chemicals…”

    Actually, the chemical-free diet appears to have certain drawbacks:

    http://www.darwinawards.com/darwin/darwin1999-58.html

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