Naturopathy

Naturopathy, or naturopathic medicine, is a form of alternative medicine based on a belief in vitalism, which posits that a special energy called vital energy or vital force guides bodily processes such as metabolism, reproduction, growth, and adaptation. Naturopathy favors a holistic approach with non-invasive treatment and, similar to conventional medicine, encourages minimal use of surgery and drugs.

The term "naturopathy" is derived from Greek and Latin, and literally translates as "nature disease". Modern naturopathy grew out of the Natural Cure movement of Europe. The term was coined in 1895 by John Scheel and popularized by Benedict Lust, the "father of U.S. naturopathy". Beginning in the 1970s, there was a revival of interest in the United States and Canada in conjunction with the holistic health movement. Today, naturopathy is primarily practiced in the United States and Canada. The scope of practice varies widely between jurisdictions, and naturopaths in unregulated jurisdictions may use the Naturopathic Doctor designation or other titles regardless of level of education.

Naturopathic practitioners are split into two groups, traditional naturopaths and naturopathic physicians. Naturopathic physicians employ the principles of naturopathy within the context of conventional medical practices. Naturopathy comprises many different treatment modalities of varying degrees of acceptance by the conventional medical community; these treatments range from standard evidence-based treatments, to homeopathy and other pseudoscientific practices.

Some of the ideology and methodological underpinnings of naturopathy are in conflict with the paradigm of evidence-based medicine (EBM). Many naturopaths have opposed vaccination based in part on the early views that shaped the profession. According to the American Cancer Society, "scientific evidence does not support claims that naturopathic medicine can cure cancer or any other disease, since virtually no studies on naturopathy as a whole have been published".

History
Some see the ancient Greek "Father of Medicine", Hippocrates, as the first advocate of naturopathic medicine, before the term existed. The modern practice of naturopathy has its roots in the Nature Cure movement of Europe during the 19th century. In Scotland, Thomas Allinson started advocating his "Hygienic Medicine" in the 1880s, promoting a natural diet and exercise with avoidance of tobacco and overwork. The term sanipractor has sometimes been used to refer to naturopaths, particularly in the Pacific Northwest region of the United States.

The term naturopathy was coined in 1895 by John Scheel, and purchased by Benedict Lust, the "father of U.S. naturopathy". Lust had been schooled in hydrotherapy and other natural health practices in Germany by Father Sebastian Kneipp; Kneipp sent Lust to the United States to spread his drugless methods. Lust defined naturopathy as a broad discipline rather than a particular method, and included such techniques as hydrotherapy, herbal medicine, and homeopathy, as well as eliminating overeating, tea, coffee, and alcohol. He described the body in spiritual and vitalistic terms with "absolute reliance upon the cosmic forces of man's nature".

In 1901, Lust founded the American School of Naturopathy in New York. In 1902 the original North American Kneipp Societies were discontinued and renamed "Naturopathic Societies". In September 1919 the Naturopathic Society of America was dissolved and Benedict Lust founded the American Naturopathic Association to supplant it. Naturopaths became licensed under naturopathic or drugless practitioner laws in 25 states in the first three decades of the twentieth century. Naturopathy was adopted by many chiropractors, and several schools offered both Doctor of Naturopathy (ND) and Doctor of Chiropractic (DC) degrees. Estimates of the number of naturopathic schools active in the United States during this period vary from about one to two dozen.

After a period of rapid growth, naturopathy went into decline for several decades after the 1930s. In 1910 the Carnegie Foundation for the Advancement of Teaching published the Flexner Report, which criticized many aspects of medical education, especially quality and lack of scientific rigour. The advent of penicillin and other "miracle drugs" and the consequent popularity of modern medicine also contributed to naturopathy's decline. In the 1940s and 1950s, a broadening in scope of practice laws led many chiropractic schools to drop their ND degrees, though many chiropractors continued to practice naturopathy. From 1940 to 1963, the American Medical Association campaigned against heterodox medical systems. By 1958 practice of naturopathy was licensed in only five states. In 1968 the United States Department of Health, Education, and Welfare issued a report on naturopathy concluding that naturopathy was not grounded in medical science and that naturopathic education was inadequate to prepare graduates to make appropriate diagnosis and provide treatment; the report recommends against expanding Medicare coverage to include naturopathic treatments. In 1977 an Australian committee of inquiry reached similar conclusions; it did not recommend licensure for naturopaths. As of 2009, fifteen of fifty U.S. states, Puerto Rico, the US Virgin Islands and the District of Columbia licensed naturopathic doctors, and two states (WA, VT) require insurance companies to offer reimbursement for services provided by naturopathic physicians.

Naturopathy never completely ceased to exist. Beginning in the 1970s, interest waxed in the United States and Canada in conjunction with the holistic health movement.

Ideology
Naturopathy focuses on naturally occurring substances, minimally invasive methods, and encouragement of natural healing. Naturopaths generally favor an intuitive and vitalistic conception of the body, and complete rejection of biomedicine and modern science is common. Prevention through stress reduction and a healthy diet and lifestyle is emphasized, and pharmaceutical drugs, ionizing radiation, and surgery are generally minimized. The tenet of naturopathic practice is self-described by six core values. Multiple versions exist in the form of the naturopathic doctor's oath, various mission statements published by schools or professional associations, and ethical conduct guidelines published by regulatory bodies:


 * 1) First, do no harm; provide the most effective health care available with the least risk to patients at all times (primum non nocere).
 * 2) Recognize, respect and promote the self-healing power of nature inherent in each individual human being. (Vis medicatrix naturae, a form of vitalism).
 * 3) Identify and remove the causes of illness, rather than eliminate or suppress symptoms (Tolle Causam).
 * 4) Educate, inspire rational hope and encourage self-responsibility for health (Doctor as Teacher).
 * 5) Treat each person by considering all individual health factors and influences. (Treat the Whole Person).
 * 6) Emphasize the condition of health to promote well-being and to prevent diseases for the individual, each community and our world. (Health Promotion, the Best Prevention)

Practice
Naturopaths use a wide variety of treatment modalities, focusing on natural self-healing rather than any specific method. Some methods rely on immaterial "vital energy fields", the existence of which has not been proven, and there is concern that naturopathy as a field tends towards isolation from general scientific discourse. The effectiveness of naturopathy as a whole system has not been systematically evaluated, and efficacy of individual methods used varies.

A consultation typically begins with a lengthy patient interview focusing on lifestyle, medical history, emotional tone, and physical features, as well as physical examination. The traditional naturopath focuses on lifestyle changes and approaches that support the body's innate healing potential. Traditional naturopaths do not undertake to diagnose or treat diseases but concentrate on whole body wellness and facilitating the body healing itself. Practitioners of naturopathic medicine hold themselves to be primary care providers and in addition to various natural approaches seek to prescribe prescription drugs, perform minor surgery and apply other conventional medical approaches to their practice. Naturopaths do not necessarily recommend vaccines and antibiotics, and may provide alternative remedies even in cases where evidence-based medicine has been shown effective. "All forms of naturopathic education include concepts incompatible with basic science, and do not necessarily prepare a practitioner to make appropriate diagnosis or referrals."

Methods
The particular modalities used by an individual naturopath varies with training and scope of practice. The demonstrated efficacy and scientific rationale also varies. These include: Acupuncture, applied kinesiology, botanical medicine, brainwave entrainment, chelation therapy for atherosclerosis, colonic enemas, color therapy, cranial osteopathy, hair analysis, homeopathy, iridology, live blood analysis, nature cures—i.e. a range of therapies based upon exposure to natural elements such as sunshine, fresh air, heat, or cold, nutrition (examples include vegetarian and wholefood diet, fasting, and abstention from alcohol and sugar, —ozone therapy, physical medicine (e.g., naturopathic, osseous, and soft tissue manipulative therapy, sports medicine, exercise, and hydrotherapy), Psychological counseling (e.g., meditation, relaxation, and other methods of stress management ), public health measures and hygiene, reflexology, rolfing, and traditional Chinese medicine.

A 2004 survey determined the most commonly prescribed naturopathic therapeutics in Washington State and Connecticut were botanical medicines, vitamins, minerals, homeopathy, and allergy treatments.

Vaccination
Many forms of alternative medicine, including naturopathy, homeopathy, and chiropractic are based on beliefs opposed to vaccination and have practitioners who voice their opposition. This includes non-medically trained naturopaths. The reasons for this negative vaccination view are complicated and rest, at least in part, on the early views which shape the foundation of these professions. A survey of a cross section of students of a major complementary and alternative medicine college in Canada reported that students in the later years of the program opposed vaccination more strongly than newer students.

A University of Washington study investigated insurance claim histories for alternative medicine use in relation to the receipt of vaccinations against preventable illnesses, grouped into children aged 1–2 years and 1–17 years. Both groups were significantly less likely to receive a number of their vaccinations if they visited a naturopath. The study found a significant association between visits to naturopaths with a reduced receipt of pediatric vaccinations and with increased infection by vaccine-preventable illnesses.

Practitioners
A consultation with a naturopathic practitioner typically begins with a lengthy patient interview focusing on lifestyle, medical history, emotional tone, and physical features, as well as physical examination. Naturopathic practitioners can be split into two groups, naturopathic physicians and traditional naturopaths.

Doctors of Naturopathic Medicine
Naturopathic Medicine is represented in the United States by the American Association of Naturopathic Physicians (AANP), which was founded in 1985 and has 2,000 student, physicians, supporting, and corporate members. Many naturopaths present themselves as primary care providers. Doctor of Naturopathy (ND) training includes basic medical diagnostic tests and procedures such as medical imaging and blood tests, as well as vitalism and pseudoscientific modalities such as homeopathy. The Council on Naturopathic Medical Education (CNME) also provides for the inclusion of optional modalities including minor surgery, natural childbirth, and intravenous therapy, though they are not generally licensed to perform these functions; these modalities require additional training and may not be within the scope of practice in all jurisdictions. This training includes naturopathic manipulation, psychological counseling and homeopathy.

The core set of interventions defined by the Council on Naturopathic Medical Education and taught at all six accredited schools in North America includes: acupuncture and traditional Chinese medicine, botanical medicine, homeopathy, nature cure (a range of therapies based upon exposure to natural elements), nutrition, physical medicine, and psychological counseling.

Naturopathic medical license in most areas of North America requires graduation from one of the schools accredited by the Association of Accredited Naturopathic Medical Colleges.

Naturopathic Medicine is represented with seven accredited naturopathic medical schools. In 1956, Charles Stone, Frank Spaulding, and W. Martin Bleything established the National College of Natural Medicine (NCNM) in Porltand, Oregon, in response to plans by the Western States Chiropractic College to drop its ND program. In 1978, Sheila Quinn, Joseph Pizzorno, William Mitchell, and Les Griffith established John Bastyr College of Naturopathic Medicine (now Bastyr University) in Seattle, Washington. That same year, the Canadian College of Naturopathic Medicine was founded in Toronto, Canada. More recently founded schools include the Southwest College of Naturopathic Medicine in Tempe, Arizona, founded in 1992, and Boucher Institute of Naturopathic Medicine in New Westminster, British Columbia, also founded in 1992. The University of Bridgeport in Bridgeport, Connecticut grants ND degrees through the College of Naturopathic Medicine, and the National University of Health Sciences in Lombard, Illinois offers a naturopathic program that is fully accredited by the Council on Naturopathic Medical Education (CNME).

Licensure
In jurisdictions where Naturopathic doctor (ND or NMD) or a similar term is a protected designation, naturopathic doctors must pass board exams set by the North American Board of Naturopathic Examiners (NABNE) after completing academic and clinical training at a college certified by the Council on Naturopathic Medical Education (CNME). Residency programs are offered at Bastyr University, National College of Natural Medicine, Southwest College of Naturopathic Medicine, and University of Bridgeport. NDs are not required to engage in residency training.

In 2005, the Massachusetts Medical Society opposed licensure in that commonwealth based on concerns that NDs are not required to participate in residency, and are trained in inappropriate or harmful treatments. The Massachusetts Special Commission on Complementary and Alternative Medical Practitioners rejected their concerns and recommended licensure.

In the state of Washington, where naturopathic doctors are licensed comparably to primary care physicians, many naturopathic doctors also accept insurance, with some plans offering the option of designating a naturopath as a primary care provider. In Connecticut and Washington, state law requires insurance providers to provide some coverage of naturopathic services, while Oregon, another state with significant numbers of naturopathic doctors, does not.

Traditional naturopaths
Traditional naturopaths are those who have not graduated from accredited naturopathic medical colleges and are not eligible to obtain a license to practice naturopathic medicine. In licensed states they are not permitted to refer to themselves as NDs or NMDs. They are represented in the United States by two national organizations, the American Naturopathic Association (ANA) founded in 1919 by Benedict Lust, representing about 5,000 practitioners,  and the American Naturopathic Medical Association (ANMA), founded in 1981 and representing about 4,000 practitioners, with several levels of certification. The ANMA also recognizes MDs, DOs, and other medical professionals who have integrated naturopathy into their practices.

The level of naturopathic training varies among traditional naturopaths in the United States. Traditional naturopaths may complete non-degree certificate programs or undergraduate degree programs and can certify at a practitioner level with the American Naturopathic Medical Certification Board (ANMCB) and generally refer to themselves as Naturopathic Consultants. These programs are often online "degrees" and offer no biomedical education as well as no clinical training. Those completing a Doctor of Naturopathy (ND) degree from an ANMCB approved school can become a Board Certified Naturopathic Doctor. Physicians with supplemental training in Naturopathy can become National Board Certified Naturopathic Physicians through the ANMCAB. This board certification is in no way the same as holding an ND license and holds no weight in states that regulate the practice of naturopathic medicine.

Traditional naturopathy as defined by the profession and the U.S. Congress in the early twentieth century does not require a license in the United States. Traditional naturopaths, because they have not received comprehensive naturopathic medical training, as defined by the Council on Naturopathic Medical Education, are not permitted to practice as NDs or NMDs in the 17 licensed states where naturopathic medicine is regulated.

Other health care professionals
According to a 1998 task force report, some physicians are choosing to add naturopathic modalities to their practice, and states such as Texas have begun to establish practice guidelines for MDs who integrate alternative and complementary medicine into their practice. Continuing education in naturopathic modalities for health care professionals varies greatly but includes offerings for many professions, including physicians, physical therapists, chiropractors, acupuncturists, dentists, researchers, veterinarians, physician assistants, and nurses. These professionals usually retain their original designation but may use terms such as "holistic", "natural", or "integrative" to describe their practice. The American Naturopathic Medical Association (ANMA) and American Naturopathic Medical Certification and Accreditation Board (ANMCAB) has recognition and certification programs for Doctors of Medicine (M.D.) and Doctors of Osteopathic Medicine (D.O.) who have supplemented their education with naturopathic studies and integrate naturopathy into their practice.

Regulation
Naturopathy is practiced in many countries, primarily the United States and Canada, and is subject to different standards of regulation and levels of acceptance. The scope of practice varies widely between jurisdictions, and naturopaths in some unregulated jurisdictions may use the Naturopathic Doctor designation or other titles regardless of level of education.

North America
In five Canadian provinces, seventeen U.S. states, and the District of Columbia, naturopathic doctors who are trained at an accredited school of naturopathic medicine in North America, are entitled to use the designation ND or NMD. Elsewhere, the designations "naturopath", "naturopathic doctor", and "doctor of natural medicine" are generally unprotected.

In North America, each jurisdiction that regulates naturopathy defines a local scope of practice for naturopathic doctors that can vary considerably. Some regions permit minor surgery, access to prescription drugs, spinal manipulations, obstetrics and gynecology and other regions exclude these from the naturopathic scope of practice.

Canada
Several Canadian provinces license naturopathic doctors: British Columbia, Alberta, Manitoba, Ontario, and Saskatchewan. British Columbia has regulated naturopathic medicine since 1936 and together with Ontario (since 2009) are the only two Canadian provinces that allow certified NDs to prescribe pharmaceuticals and perform minor surgeries.

United States

 * U.S. jurisdictions that currently regulate or license naturopathy include: Alaska, Arizona, California (see California Bureau of Naturopathic Medicine), Connecticut, Colorado, District of Columbia, Hawaii, Idaho, Kansas, Maine, Minnesota, Montana, New Hampshire, North Dakota, Oregon, Puerto Rico, US Virgin Islands, Utah, Vermont, and Washington. Additionally, Florida and Virginia license the practice of naturopathy under a grandfather clause.
 * U.S. jurisdictions that permit access to prescription drugs: Arizona, California, District of Columbia, Hawaii, Idaho, Kansas, Maine, Montana, New Hampshire, Oregon, Utah, Vermont, and Washington.
 * U.S. jurisdictions that permit minor surgery: Arizona, District of Columbia, Idaho, Kansas, Maine, Montana, Oregon, Utah, Vermont, and Washington.


 * U.S. states which specifically prohibit the practice of naturopathy: South Carolina, and Tennessee.

Naturopathic doctors are not mandated to undergo residency between graduation and commencing practice, except in the state of Utah.

Australia
Currently the industry is self-regulated. There is no protection of title, meaning that technically anyone can practise as a naturopath. The only way to obtain insurance for professional indemnity or public liability is by joining a professional association, which can only be achieved by having completed an accredited course and gaining professional certification. From mid-2013 the Australian Register of Naturopaths and Herbalists is to provide a database of accredited and educated practitioners of Naturopathy.

In 1977 a committee reviewed all colleges of naturopathy in Australia and found that, although the syllabuses of many colleges were reasonable in their coverage of basic biomedical sciences on paper, the actual instruction bore little relationship to the documented course. In no case was any practical work of consequence available. The lectures which were attended by the committee varied from the dictation of textbook material to a slow, but reasonably methodical, exposition of the terminology of medical sciences, at a level of dictionary definitions, without the benefit of depth or the understanding of mechanisms or the broader significance of the concepts. The committee did not see any significant teaching of the various therapeutic approaches favoured by naturopaths. People reported to be particularly interested in homoeopathy, Bach's floral remedies or mineral salts were interviewed, but no systematic courses in the choice and use of these therapies were seen in the various colleges. The committee were left with the impression that the choice of therapeutic regime was based on the general whim of the naturopath and, since the suggested applications in the various textbooks and dispensations overlap to an enormous extent, no specific indications are or can be taught.

India
In India there is a 5½-year degree course offering a "Bachelor of Naturopathy and Yogic Sciences" (BNYS) degree. The first college of naturopathy was started in Hyderabad, Andhra Pradesh by B. Venkatrao which offered a Diploma in Naturopathy (ND) and 3½-year "Diploma in Naturopathic Medicine & Yogic Science" (DNYS) run by Akhil Bhartiya Prakritik Chikitsa Parishad, New Delhi, but now has a full-time residential degree course. There are a total of fifteen naturopathy colleges in India.

Naturopathy and Yoga, as an Indian system of medicine, falls under the Department of AYUSH, Ministry of Health & Family Welfare, Government of India.

The Indian government established the "Central Council for Research in Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy” in 1969 as an autonomous organization under the Ministry of Health and Family Welfare. This organization was tasked to conduct scientific research into those branches of alternative medicine, until 1978. During this period, the development of Naturopathy was looked after by the Ministry of Health & Family Welfare directly. In March 1978 the composite council was dissolved and replaced by four independent research councils, one each for Ayurveda and Siddha, Unani, homoeopathy and yoga and naturopathy.

The National Institute of Naturopathy in Pune was established on 22 December 1986. It encourages facilities for standardization and propagation of the existing knowledge and its application through research in naturopathy throughout India. This institute has a governing body, with the Union Minister for Health as its president.

United Kingdom
Naturopathy is not regulated in the United Kingdom. The largest registering body, the General Council & Register of Naturopaths, recognises only two courses in the UK, being taught at osteopathic schools: the British College of Osteopathic Medicine and The College of Osteopaths Educational Trust. In 2012, publicly funded universities in the United Kingdom dropped their alternative medicine programs, including naturopathy.

There are also the Association of Naturopathic Practitioners, The British Naturopathic Association, and Incorporated Society of Registered Naturopaths.

Evidence basis
Naturopathy lacks an adequate scientific basis under the methodology of evidence-based medicine (EBM). Members of the medical community show a critical or rejecting view of naturopathy. Traditional naturopathic practitioners surveyed in Australia perceive EBM as an ideologic assault on their beliefs in vitalistic and holistic principles. They advocate the integrity of natural medicine practice. Traditional natural medicine practitioners surveyed in Australia could have problems in understanding and applying the concept of EBM. If naturopathy offers verifiable results for specific conditions, greater scientific knowledge of the mechanisms of those naturopathic protocols could result in improved therapy models. Some naturopathic physicians have begun to contribute to research and adapt modern scientific principles into clinical practice.

There are growing collaborative efforts between naturopaths and medical doctors to evaluate the safety and efficacy of naturopathic medicine in prevention and management of a broad range of common ailments, and to decide whether accessibility of naturopathic services will enhance patient health in a cost-effective way.

Naturopathy is criticized for its reliance on and its association with unproven, disproven, and other controversial alternative medical treatments, and for its vitalistic underpinnings. As with any medical care, there is a risk of misdiagnosis; this risk may be lower depending on level of training. Certain naturopathic treatments offered by traditional naturopaths, such as homeopathy, rolfing, and iridology, are widely considered pseudoscience or quackery.

"Natural" methods and chemicals are not necessarily safer or more effective than "artificial" or "synthetic" ones; any treatment capable of eliciting an effect may also have deleterious side effects.

Stephen Barrett of Quackwatch and the National Council Against Health Fraud has stated that Naturopathy is "simplistic and that its practices are riddled with quackery". "Non-scientific health care practitioners, including naturopaths, use unscientific methods and deception on a public who, lacking in-depth health care knowledge, must rely upon the assurance of providers. Quackery not only harms people, it undermines the ability to conduct scientific research and should be opposed by scientists", says William T. Jarvis.

K. C. Atwood writes, in the journal Medscape General Medicine, "Naturopathic physicians now claim to be primary care physicians proficient in the practice of both "conventional" and "natural" medicine. Their training, however, amounts to a small fraction of that of medical doctors who practice primary care. An examination of their literature, moreover, reveals that it is replete with pseudoscientific, ineffective, unethical, and potentially dangerous practices". In another article, Atwood writes that "Physicians who consider naturopaths to be their colleagues thus find themselves in opposition to one of the fundamental ethical precepts of modern medicine. If naturopaths are not to be judged "nonscientific practitioners", the term has no useful meaning. An article by a physician exposing quackery, moreover, does not identify its author as "biased", but simply as fulfilling one of his ethical obligations as a physician.

According to Arnold S. Relman, the Textbook of Natural Medicine is inadequate as a teaching tool, as it omits to mention or treat in detail many common ailments, improperly emphasizes treatments "not likely to be effective" over those that are, and promotes unproven herbal remedies at the expense of pharmaceuticals. He concludes that "the risks to many sick patients seeking care from the average naturopathic practitioner would far outweigh any possible benefits".