RESEARCH IN NATUROPATHY
There is a substantial body of scientific research relevant to naturopathy. Much work still needs to be done to digest the findings to facilitate evidence based practice. This brief outline is intended as an introductory guide for practitioners (1) interested in finding evidence to support practice and management of individual patients; or (2) wishing to carry out research and (3) provides an outline of the naturopathic evidence-base.1. FINDING EVIDENCE TO SUPPORT PRACTICE
There are two sources of evidence: text-books and the internet. Do not use newspapers' reports of research, which are usually unreliable, often biased and over-state the benefits.
Modern textbooks which refer to scientific evidence include those by Michael Murray and Leon Chaitow. Both authors cite many references, but it is difficult to judge how systematic or objective they have been in assessing the totality of evidence.
The web is a gold-mine and a mine-field! The minefield is Google and other search engines, which are fine for finding bargains but for scientific truth you can assume that 90% of web sites are rubbish. Be similarly suspicious of commercial companies - they are trying to profit from you!
The gold-mine is the web's huge free database of medical research called PUBMED. It has a powerful search facility, and gives you a list of titles of papers that fit your search. Most papers have a short abstract (summary) as well, and some journals offer free access to the whole paper. Try it!
For example, suppose you want to recommend a change in diet for a patient with arthritis, put arthritis AND diet in the Search Box, and you will find some good papers!
Other free databases include the Cochrane Library, the NHS National Library for Health (NLH), the USA governments NCCAM site, and the archive of British Naturopathic Journals (BNJ) on the BNA web site.
2. CONDUCTING YOUR OWN RESEARCH
Conducting research in health and disease is strictly controlled to ensure that the research is ethical, and respects patient confidentiality and human rights. Most types of research require formal ethical approval, and need to be done in collaboration with a college or hospital which are set up to conduct research properly. Another advantage of collaboration is the opportunity for training in research methods. Many UK universities with a Health Science Faculty run postgraduate training modules in Research Methods which are open to practitioners at fairly modest tuition fees.
A good introduction to Research has been published by BNA member Mark Kane who lectures at University of Westminster. His book is Research Made Easy in Complementary and Alternative Medicine (pub. Churchill Livingstone).
There are two kinds of research which are feasible and ethical in your own practice: (1) audit of patient characteristics and progress and (2) case studies of one or a few similar patients.
Audit makes use of the patient case-notes, from which data collected routinely (and accurately!) in practice can be extracted to explore the age, gender and presenting symptoms of patients, and number of visits. If you monitor progress using, say, pain scales or MYMOP (see below), then you can explore progress. An example of audit can be found on Pubmed by searching on "audit AND naturopathic", the whole paper is free to view on the internet:
Wilson K, Busse JW, Gilchrist A, Vohra S, Boon H, Mills E.
Characteristics of pediatric and adolescent patients attending a naturopathic college clinic in Canada. Pediatrics. 2005 Mar;115(3):e338-43.
Case studies are interesting for other practitioners and allow an unusual case or a novel treatment to be described. Publishing a case study requires the explicit permission of the patent because, even if you do not reveal their name, their story may well be recognisable. An example of a case study using a naturopathic approach can be found in BNJ in 2009:
Leach J . Naturopathy can improve quality of life after gastric cancer. Br Naturopathic J (2009); 26.
3. THE NATUROPATHIC EVIDENCE BASE
There are over 900 naturopathic-related papers on PubMEd and over 250 specifically about naturopathy. There are many more on specific topics such as fasting, vegetarian and other dietary interventions, relaxation and mindfulness, exercise and health, and hydrotherapy.
Certain journals such as Nature and The Lancet are the most prestigious, only publishing what they deem to be rigorous and ground-breaking findings. Here are two prestigious, naturopathically relevant studies.
Diet and Arthritis
Lancet. 1991 Oct 12;338(8772):899-902.
Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis.
Kjeldsen-Kragh J, Haugen M, Borchgrevink CF, Laerum E, Eek M, Mowinkel P, Hovi K, Førre O.
ABSTRACT
Fasting is an effective treatment for rheumatoid arthritis, but most patients relapse on reintroduction of food. The effect of fasting followed by one year of a vegetarian diet was assessed in a randomised, single-blind controlled trial. 27 patients were allocated to a four-week stay at a health farm. After an initial 7-10 day subtotal fast, they were put on an individually adjusted gluten-free vegan diet for 3.5 months. The food was then gradually changed to a lacto-vegetarian diet for the remainder of the study. A control group of 26 patients stayed for four weeks at a convalescent home, but ate an ordinary diet throughout the whole study period. After four weeks at the health farm the diet group showed a significant improvement in number of tender joints, Ritchie's articular index, number of swollen joints, pain score, duration of morning stiffness, grip strength, erythrocyte sedimentation rate, C-reactive protein, white blood cell count, and a health assessment questionnaire score. In the control group, only pain score improved score. In the control group, only pain score improved significantly. The benefits in the diet group were still present after one year, and evaluation of the whole course showed significant advantages for the diet group in all measured indices. This dietary regimen seems to be a useful supplement to conventional medical treatment of rheumatoid arthritis.
New advances in understanding the effects of fasting and control of appetite
Nature. 1998 Aug 27;394(6696):897-901.
Leptin modulates the T-cell immune response and reverses starvation-induced
immunosuppression.
Lord GM, Matarese G, Howard JK, Baker RJ, Bloom SR, Lechler RI.
Nutritional deprivation suppresses immune function. The cloning of the obese gene and identification of its protein product leptin has provided fundamental insight into the hypothalamic regulation of body weight. Circulating levels of this adipocyte-derived hormone are proportional to fat mass but maybe lowered rapidly by fasting or increased by inflammatory mediators. The impaired T-cell immunity of mice now known to be defective in leptin (ob/ob) or its receptor (db/db), has never been explained. Impaired cell-mediated immunity and reduced levels of leptin are both features of low body weight in humans. Indeed, malnutrition predisposes to death from infectious diseases. We report here that leptin has a specific effect on T-lymphocyte responses, differentially regulating the proliferation of naive and memory T cells. Leptin increased Th1 and suppressed Th2 cytokine production. Administration of leptin to mice reversed the immunosuppressive effects of acute starvation. Our findings suggest a new role for leptin in linking nutritional status to cognate cellular immune function, and provide a molecular mechanism to account for the immune dysfunction observed in starvation.
THE UK GOVERNMENT PUBLIC HEALTH STRATEGIES
These provide a wealth of information and evidence for naturopaths. In 2004 the UK Government's White Paper "Choosing Health: making healthy choices easier was heralded as setting out "an ambitious agenda of new thinking and practical action to tackle inequalities in health and engage people in looking after their own health" through plans to support changes in tobacco use, alcohol, nutrition, physical activity and more. They introduced action plans such as "5 a day" , Food in Schools and Healthy Living to tackle priority disease groups of cancer, coronary heart disease, diabetes, mental health, the elderly and child health. These action plans set very specific and evidence-based targets. Nutrition policy (Nat Heart Forum) aims to increase fruit and vegetables to at least 5 portions (400g) per day; restrict saturated fats and sugar to less than 10% and 20% of dietary energy respectively, lower salt limited to 2g a day for babies aged 1-3 rising to 6g a day for adults; adequate hydration through drinking at least 1.2 litres (6-8 glasses) of fluids (FSA 2006) ; and reducing high calorie snacks, fast foods, convenience foods and alcohol to control body weight. "Traffic Light" food labelling is being introduced to help consumers. Funding and policy for improving school dinners and snacks has been initiated, largely through public pressure following a televised pilot scheme by a celebrity chef, Jamie Oliver. The changes are based on guidelines from the Caroline Walker Trust.
The policy for physical activity aims to encourage a more active lifestyle - walking or cycling instead of using the car to get to work or school- as well as participation in sports or active leisure pursuits. The target for adults is 30 minutes of moderately intense activity on at least five days in a week. For those at risk of obesity and diabetes, 45-60 minutes is recommended. For children and young people, the recommendation is for 60 minutes each day (B H F 2006). From 2006, general practitioners in the UK are expected to encourage inactive adults to exercise, using goals setting and information-giving; referral to exercise schemes is restricted to programmes being researched for effectiveness (NICE 2006).
RESOURCES
The Health Improvement section of the Public Health page on the Department of Health web site contains their reports on healthy eating, 5 a day, exercise and other major factors that improve health. The latest report is "Be Active, Be Healthy: A Plan for Getting the Nation Moving" (2009)
http://www.dh.gov.uk/en/Publichealth/Healthimprovement/index.htm
The government's policies are supported by evidence from NICE (the National Institute for Health and Clinical Excellence). The guideline for tackling obesity, for example
NICE clinical guideline 43
Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children (2006)
http://www.nice.org.uk/guidance/index.jsp?action=download&o=30361
THE WORLD HEALTH ORGANISATION
The WHO recognises the value of low technology medicine for many world problems. Their Traditional Medicine strategy 2002-2005 identifies the potential of traditional, complementary and alternative medicines to provide care which is affordable, locally available, and acceptable to the population. As evidence for effectiveness, they cite the clinical trials which support the use of acupuncture for pain and nausea, yoga for asthma, tai chi for balance, and herbs in malaria and AIDS.
