Modern shamanism—naturopathy for hypertension

I’m a primary care physician. What I, other internists, pediatricians, and family medicine docs do is prevent and treat common diseases. When we get to diseases that require more specialized care, we refer to our specialist colleagues. There is a movement afoot to broaden the role of naturopaths to make them primary care doctors. The big difference between naturopaths and real primary care physicians (PCPs) is that naturopaths haven’t gone to medical school, completed a post-graduate residency program, and taken their specialty boards. Why is this important? If a naturopath wants to be a PCP, then they must provide the same services as other PCPs. They do not. What, you don’t believe me? The thing is, naturopaths have an incorrect understanding of human biology and do not understand how this is applied in a science-based fashion to prevent and treat human disease.

Naturopathic “physicians” claim that “the human body has an innate healing ability” and that they “teach their patients to use diet, exercise, lifestyle changes and cutting edge natural therapies to enhance their bodies’ ability to ward off and combat disease.”

I must admit that I don’t get it. As a primary care physician (the real kind) I talk to my patients every day about diet, exercise, and lifestyle changes. I’m not sure what “natural therapies” are—all of the medications that I prescribe are “natural”. What is the opposite of natural? Unnatural? Supernatural?

As a primary care physician, I see a lot of common, serious problems, like diabetes and hypertension, and coronary heart disease. Coronary heart disease (CHD) is the biggest killer of Americans, and hypertension (high blood pressure) and diabetes are two of the primary causes of CHD. The next most common killer of Americans is cancer. If naturopaths want to be allowed to practice primary care medicine, they better be prepared to diagnose and treat these conditions in a way that is proven to help patients.

Let’s take a look at the website of their main professional organization, and see what they recommend for, for instance, hypertension. I’m choosing hypertension because their website doesn’t have a section on diabetes or on disease prevention.

First I’ll tell you a little bit about how doctors approach hypertension. High blood pressure leads to heart attacks, strokes, kidney failure, and blindness. Untreated hypertension is one of the biggest health problems in North America. Because hypertension is so common and has so many disabling and deadly consequences, it has been studied quite well. We have learned over the years which type of patients benefit from which blood pressure goals and from which interventions. For example, the ALLHAT trial was released a few years ago. This study followed tens of thousands of people with hypertension and found that a simple and inexpensive intervention (a thiazide-type diuretic pill) was very effective at preventing serious coronary heart disease.

When I tell a patient that they should start a blood pressure medication, they are often hesitant. They often ask if there is another way to lower blood pressure. This has been studied as well. For example the DASH diet has been found to lower blood pressure significantly (from about 4-7 mmHg for the systolic pressure). If I have a patient with mild hypertension, this may do it, if they can stick to the diet. However, most of my patients don’t have stage I hypertension (a systolic BP from 140-159), and even in those who do, the gains from following the DASH diet are minimal. If I get a patient to really stick to it, maybe I can get their BP from 158 down to 152. That’s not very good. Most practicing PCPs know that diet and exercise will achieve good blood pressure goals in a minority of patients. Still, when it’s safe, and the needed goals are modest, we recommend it as first line therapy, especially for pre-hypertension.

In summary, the evidence tells us that we must lower blood pressures to save lives, and that diet and exercise are good enough in a small percentage of patients. We screen for hypertension and its complications, and then prescribe diet, exercise, and/or medications to lower our patients’ risk of becoming ill.

What do naturopaths have to offer? It’s not clear to me from reading their literature how they approach screening, but let’s say they have identified a patient with hypertension.

The website of their national organization gives some good information about what hypertension is and why we should care. What it doesn’t do is explain how they will effectively treat it.

To treat hypertension, naturopaths might counsel patients on eating a healthier diet. Following the DASH (Dietary Approaches to Stop Hypertension) diet includes lowering sodium intake and eating nutrient-rich foods like fresh fruits and vegetables, low-fat dairy, and eating a diet rich in potassium, magnesium, calcium, and fiber. Again, prominent national studies have shown the DASH diet has been shown to be as effective as drugs at reducing blood pressure.

Well, real doctors make those same recommendations. The last sentence is simply false. DASH is not as effective as medication for many hypertensive patients. For some, sure, for others, not at all.

Supplements are also a low-cost and effective way to reduce high blood pressure. Natural diuretics, dandelion and parsley can be used to control blood pressure, although evidence suggests they must be taken in high doses to be effective, (Alternative Medicine Review, 2002). Increasing potassium consumption has shown to reduce the risk of stroke in patients with hypertension by 41 percent (Journal of the American Nutraceutical Association, Houston study, 2002).

Let’s review our goal here. Our goal is to treat hypertension in such a way as to reduce the risk of cardiovascular disease and death. This needs to be done in a way that is proven to work, and is tolerable to the patient. Here, rather than recommend medications that have been proven in large, randomized controlled trials to not only lower blood pressure to to actually achieve these goals, they recommend “natural diruetics”. I also reviewed the article that is (barely) cited. The article is a review of hypertension and the naturopathic approach to its treatment. It is frankly quite frightening. It reviews the biology, and then makes fantastical claims. For example, it ironically compares various nutrients in their ability to “mimic” various classes of blood pressure medication. Then, rather than comparing the efficacy of the supplement to the known efficacy of the drug, it simply recommends using the supplement. If a real doctor did this it would be called “malpractice”.

I can find no naturopathic references that explain what the “doctor” should do when the unproven concoctions fail to control blood pressure. Does this mean that their potions work on everyone, that they have no failures? More likely, they have nothing to offer. Perhaps the good ones refer to a real doctor at this point.

This brings up an important question. If a naturopath wants to be a primary care physician, and yet must refer patients to a real doctor for common problems, what’s the point? A PCP must be able to effectively treat common conditions such as diabetes and hypertension. If they can’t, they’re in the wrong field.

There is no justification for allowing naturopaths to be primary care physicians, and if what they print is accurate, there is no justification for them to treat any patient for any condition. Naturopathy is modern shamanism, and should be banned.