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Informed Consent and CAM: Truth Not Optional

In three recent posts, Drs. Novella, Gorski and Atwood took the Bravewell Collaborative to task over a report on its recent survey of U.S. “integrative medicine” centers. As Dr. Novella noted,

So what is integrative medicine? When you strip away the rebranding and co-opting of features and treatments of mainstream medicine, you are left with the usual list of pseudoscientific practices that have been trying to insert themselves into mainstream medicine for decades through a series of marketing and propaganda strategies. Bravewell has positioned itself at the forefront of that effort.

Among these pseudoscientific practices listed in a chart from the report included by Dr. Gorski in his post were acupuncture, TCM, reiki, therapeutic touch, naturopathy, homeopathy and reflexology.
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Posted in: Acupuncture, Chiropractic, Energy Medicine, Homeopathy, Legal, Medical Ethics, Naturopathy, Science and Medicine

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IgG Food Intolerance Tests: What does the science say?

I spend a lot of time as a pharmacist discussing side effects and allergies to drugs. For your own safety, I won’t recommend or dispense a drug until I know your allergy status. I don’t limit the history to drugs—I want to know anything you’re allergic to, be it environmental, food, insects, or anything else. Allergies can create true therapeutic challenges: We can’t dismiss any allergy claim, but as I’ve blogged before, there’s a big gap between what many perceive as an allergy and what is clinically considered a true allergy. My concern is not only avoiding the harm of an allergic reaction, but also avoiding the potential consequences from selecting a suboptimal therapy that may in fact be appropriate. You may need a specific drug someday, so  I encourage patients to discuss vague drug allergies with their physician, and request allergist testing as required.

Food allergies can be as real as drug allergies, and are arguably much harder to prevent. We can usually control when we get penicillin. But what about peanuts, eggs, or milk, all of which can also cause life-threatening anaphylaxis?  Food allergies seems to be growing: not only anaphylaxis, but more people believe they have some sort of allergy to food.  Allergy is sometimes confused with the term “intolerance”, which seems more common, possibly as the availability of “food intolerance testing” grows. Food intolerance testing and screening is particularly popular among alternative practitioners. Testing can take different forms, but generally the consumer is screened against hundreds of food products and food additives. They are then provided with a list of foods they are “intolerant” to. I’ve spoken with consumers who are struggling to overhaul their diet, having been advised that they are actually intolerant to many of their favourite foods. These reports are taken seriously by patients who believe that they’ll feel better if they eliminate these products. In the pharmacy, I’ve been asked to verify the absence of trace amounts of different fillers in medications because of a perceived intolerance.  Children may be tested, too, and parents may be given a long list of foods they are told their child is intolerant of. I’ve seen the effects in the community, too. Think going “peanut free” is tough? A public school in my area sent home a list of forbidden food products: dairy, eggs, bananas, tree nuts, peanuts, soy, sesame, flax seed, kiwi, chicken, and bacon. Were these all true allergies? It’s not disclosed. Anaphylactic or not, the parents had informed the school, and the school had banned the food product.

But can a simple blood test actually identify and eliminate food intolerance? That’s the question I wanted to answer.

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Posted in: Basic Science, Diagnostic tests & procedures, Health Fraud, Herbs & Supplements, Naturopathy, Science and Medicine

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Night of the living naturopaths

Colorado’s “degreed” naturopaths (NDs) are nothing if not persistent. Starting in 1994 they have tried seven times to convince legislators that the Colorado’s public needs protection from what “traditional” naturopaths (traditionals) do, and that the best way of providing that protection, they claim, is to bestow licensure on the guys with the college degrees. The irony in this is that the NDs could well be the more dangerous practitioners.

Legislators have been largely sympathetic to the concerns of the more numerous traditionals who fear the loss of their right to work as naturopaths. The NDs have tried neutralize these opponents by reassuring them they could continue to practice naturopathy, but the traditionals don’t buy that. And they won’t easily forfeit the title of “naturopath” to which they believe to have more claim.

So what we have here in Colorado is near 20-year turf war between two types of naturopaths: the NDs who seek legislation to transform naturopathy into a protected guild, and the traditionals who are happy with the status quo. There is no love lost between these groups. Legislators repeatedly advise them to resolve their differences before asking for licensure again, but they haven’t gotten close to détente.

Colorado NDs have made no secret of their economic motivations. Before the 2011 legislative session, the Colorado Association of Naturopathic Doctors (CAND) was reinvigorated by the passage of the Patient Protection and Affordable Care Act which has this “non-discrimination” provision:

(a) Providers- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures. [Sec. 2706]

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Posted in: Naturopathy, Politics and Regulation, Public Health

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Legislative alchemy (briefly) revisited: Naturopathy in Vermont and colloidal silver

A couple of weeks ago, Jann Bellamy wrote about “legislative alchemy” in the new year, in which CAM mischief works its way into state legislatures. Specifically, she mentioned the case of legislators in Vermont trying to declare in law that naturopaths are primary care physicians, who can serve as a patient’s medical home without supervision by real doctors.

Rosemary Jacobs, whose life was altered irrevocably when she developed agyria due to colloidal silver noticed another aspect of this new proposed law:

I recently learned that Vermont licenses naturopaths, NDs, as physicians and that they have a state sanctioned formulary, a list of drugs they can prescribe and administer to patients. To my horror, the 2009 formulary includes “colloidal silver preparations” to treat eye infections and “silver” which they can administer intravenously.
http://www.vtprofessionals.org/opr1/naturopaths/info/Naturopathic Physician Formulary 20091211.pdf [pdf download]

I was horrified because of the danger this poses to patients, the incredible ignorance it shows on the part of naturopaths, and because NDs had, without my knowledge, been licensed in Vermont to administer prescription drugs and other strange substances like silver and tin, do physical exams and order the same diagnostic tests that MDs order.

How had this happened without my knowledge? I have been following alternative medicine for 15 years and warning people about the danger of ingesting silver, an alternative “remedy”, because I don’t want anyone else disfigured by it like I was over 50 years ago.

Silver drugs were used by medical doctors before the advent of antibiotics. Although they didn’t work, they permanently turned many people blue and gray. The condition is called argyria. It was formerly common, and is well documented and understood by scientists.

If NDs had known as much about medicine as I, an educated consumer, do, they would have searched the medical literature before including anything in their formulary. If they had done that, they would have seen that: there are no studies showing that ingesting silver in any form or amount offers benefits; colloidal silver does not treat eye infections; taking silver internally or putting it in your eye can result in permanent discoloration.

Colloidal silver is nonsense. There’s no evidence that it is good for anything. Rosemary also revealed to me something I didn’t know before, namely that there’s another woo-friendly Senator that I didn’t really know about: Bernie Sanders, who, according to her, helped naturopaths become players in the medical marketplace.

Posted in: Legal, Naturopathy

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Legislative Alchemy: The New Year

A new year brings new opportunities for practicing the magic of legislative alchemy, the process by which state legislatures transform implausible and unproven diagnostic methods and treatments into perfectly legal health care practices, such as naturopathy, chiropractic and acupuncture. Different states have different legislative calendars, but many begin a new session soon after the first of the year. This gives “complementary and alternative medicine” providers a fresh opportunity to increase their scope of practice, insurance coverage and influence.

The state house doors have barely opened but CAM-friendly bills are already being docketed and sent on to health care and other committees for analysis. Unfortunately, legislators seem less than adept at critical thinking when it comes to perusing CAM legislation. To this point, I’ll start with an example from 2011: “Vertebral Subluxation Awareness Month” in Pennsylvania.

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Posted in: Chiropractic, Legal, Naturopathy, Politics and Regulation

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Iridology

There are many medical pseudosciences that persist despite a utter lack of either plausibility or evidence for efficacy. Some practices emerged out of their culture of origin, or out of the prevailing ideas of a pre-scientific age, while others were manufactured out of the imagination of perhaps well-meaning but highly misguided individual practitioners. They were just made up – homeopathy, for example, or subluxation theory.

Iridology belongs to this latter category – a system of diagnosis that was invented entirely by Ignatz Peczely, a Hungarian physician who first published his ideas in 1893. The story goes that Peczely as a boy found an owl with a broken leg. At the time he noticed a prominent black stripe in the iris of one eye of the owl. He nursed the bird back to health and then noticed that the black line was gone, replaced by ragged white lines. From this single observation Peczely developed the notion of iridology.

Peczely’s idea was that the iris maps to the rest of the body in some way, and therefore the flecks of color in the iris reflect the state of health of the various body parts. This basic approach to diagnosis or treatment is called the homunculus approach – the idea that one part of the body maps to the rest of the body, including the organ systems. Reflexology, auricular acupuncture, and even straight chiropractic follow this approach.

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Posted in: Naturopathy, Science and Medicine

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Alas poor Craniosacral. A SCAM of infinite jest, of most excellent fancy.

It is hard to Sokalize alternative medicine. The closest has been buttock reflexology/acupuncture, but that is a tame example.  Given the propensity for projections of the human body to appear on the iris, hand, foot, tongue, and ear, postulating a similar pattern on the buttocks are simple variations on a common SCAM (Supplements, Complementary and Alternative Medicine) theme. The buttocks?  Not really different from any of the other focal acupunctures.  Most of SCAM does not concern itself with application of reality  and physiology, anatomy, biochemistry, etc can all be expected to be ignored with virtually all SCAM modalities.

Every time I think the heights (or depths) of absurdity has been reached, I discover a Braco the Starer or Himalayan Salt Inhalers. This blog is not affiliated with the British Medical Journal in any way, and although this is being published near Christmas, I want no one think that what follows is a hoax.  I am not, I repeat not,  making up what follows. It is not fiction. Well, it is fiction, but not written by me and believed and practiced by some who really should know better.

Craniosacral Therapy
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Posted in: Chiropractic, Energy Medicine, Humor, Naturopathy, Science and Medicine

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Pediatrics & “CAM” I: the wrong solution

Oh no!  Not again! The venerable medical journal Pediatrics devotes an entire supplement this month to Pediatric Use of Complementary and Alternative Medicine: Legal, Ethical, and Clinical Issues in Decision-Making.

We sense from the very first sentence that we are in familiar territory:

Rapid increases the use of complementary and alternative medicine (CAM) raise important legal, ethical, clinical, and policy issues. (S150)

“Rapid increases”? And evidence of these “rapid increases?” None cited.

We do, however, see the same shopworn reference to popularity deconstructed elsewhere on SBM. What we learned by actually examining “the large 2007 US survey” which purportedly “revealed that ~4 in 10 adults and 1 in 9 children and youth used CAM products or therapies within the previous year”(S150) is that

…most hard-core CAM modalities are used by a very small percentage of the population. Most are less than five percent. Only massage and manipulation are greater than 10 percent. These numbers are also not significantly different from 10 or 20 years ago — belying the claim that CAM use is increasing.

We also find this definition of “CAM”:

a broad domain of healing resources …other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. (S150)

I’m not sure what it takes to become “intrinsic” to the “politically dominant” healthcare system. If it includes being legal, licensed or covered by public and/or private insurance, that would appear to disqualify dietary supplements, chiropractic, acupuncture, homeopathy, homeopathic products and naturopathy as “CAM” in some, or in some cases all, of the American states.

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Posted in: Acupuncture, Chiropractic, Herbs & Supplements, Homeopathy, Legal, Medical Ethics, Naturopathy, Politics and Regulation, Science and Medicine, Vaccines

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Defining what a “physician” is

The very concepts of “complementary and alternative medicine” (CAM) and “integrative medicine” (IM), the former of which “complements” science-based medicine with quackery and the latter of which “integrates” pseudoscience-based with science-based medicine are all about slapping a veneer of scientific legitimacy onto something that has failed to achieve such legitimacy through actual basic, translational, and clinical science. The reason I start out by saying this is to emphasize that CAM/IM is all about using language to persuade that pseudoscience is actually science-based. It’s far more about marketing than accurately communicating concepts. In CAM, everything is “holistic,” and doctors “care for the whole patient,” while “Western medicine” is “reductionistic” and “allopathic.” At the very heart of this language is a false dichotomy: That you must either embrace pseudoscience or that you somehow can’t provide care as compassionate and caring as what the quacks supposedly provide, nor are you able to provide for the emotional needs of your patients. There are two false dichotomies, actually, in that there is also the not-so-subtle implication in CAM that you can’t be truly “holistic” without—you guessed it—embracing the pseudoscience that is at the heart of many CAM/IM modalities.

This use and abuse of language for propagandistic purposes in CAM/IM is not limited to just these examples. In fact, the misuse of language infuses the whole enterprise of CAM/IM to the point that its adherents, not content with being mere “practitioners,” are trying to claim the very title of “physician” for themselves. I learned this from John Weeks, the main force behind the Integrator Blog, a blog dedicated to issues of CAM and IM. He’s the one who first let me know about Andrew Weil’s attempt to put together a board certification in IM. In particular, his reporting on the reaction of CAM/IM practitioners, both physicians and non-physicians, to this initiative by Andrew Weil was most illuminating to me. What was most telling was how further propagandistic use of the language focused on “dominance” by MDs, which in this case struck me as actually being closer to the truth than the usual CAM-speak is. In any case, Dr. Weil’s initiative does indeed appear to be more about taking control of CAM for physicians, his high-minded language about “establishing standards” notwithstanding.

This time around, Weeks has provided me with an education about how alternative/CAM/integrative practitioners now covet the title of “physician”. In the process, he also uses and abuses language in the same way that Andrew Weil and CAM/IM advocates do. This time around, it’s all about co-opting the title of “physician” for non-physician CAM practitioners. It’s bad enough to me when actual physicians are seduced by the pseudoscience of CAM, but this effort appears to be an intentional strategy designed to confuse the public by proclaiming as physicians practitioners who lack the essential skills to be a physician, such as acupuncturists, chiropractors, homeopaths, and naturopaths.
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Posted in: Chiropractic, Homeopathy, Naturopathy, Politics and Regulation

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The Cure

Legislative Alchemy

In Legislative Alchemy I: Naturopathy, II: Chiropractic and III: Acupuncture, we learned how state legislatures transform scientifically implausible and unproven diagnostic methods and treatments into legal health care practices. Examples typical of the sheer nonsense found in both proposed and actual legislation include:

Naturopathic health care [is] a system of health care practices for the prevention, diagnosis, evaluation and treatment of illnesses, injuries and conditions of the human body through the use of education, nutrition, natural medicines and therapies and other modalities which are designed to support, stimulate or supplement the human body’s own natural self-healing processes.

[Chiropractic is] the science of adjustment, manipulation and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that may interfere with the normal generation, transmission and expression of nerve impulse between the brain, organs and tissue cells of the body, which may be a cause of the disease, are adjusted, manipulated or treated.

[Acupuncture is] a form of health care that is based on a theory of energetic physiology that describes and explains the interrelationship of bodily organs or functions with an associated acupuncture point or combination of points that are stimulated in order to restore the normal function of the bodily organ or function.

This is gobbledygook, tarted up with a few scientific-sounding terms — “physiology,” “tissue cells,” “diagnosis.”

 

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