More on “integrating” pseudoscience with science

Naturopathy is at least 99% woo. That has to be said at the outset. Naturopaths might brag about all the science they take in naturopathy school, claiming that it’s as much as MDs take. Even if that were true, the question is not how many hours of basic science naturopaths take, but rather what’s taught in those hours and, more importantly, what’s taught in the clinical hours. For instance, given that you can’t have naturopathy without homeopathy, it implies that what’s taught in basic science classes in naturopathy school allows room for the incredible magical quackery that is homeopathy to be not just plausible but a standard of naturopathic care. As long as that is true, naturopaths are deluding themselves (and deceiving the public) when they claim that naturopathy is based on science. Indeed, the only complaint I’ve ever heard from naturopaths about homeopathy is that it’s either too complicated or that naturopathy schools teach it wrong, not that homeopathy is superstitious thinking based on ancient principals of sympathetic magic.

Of course, it’s not just homeopathy that makes naturopathy by and large a hodge-podge of beliefs and treatments that range from the mundane science-based, such as recommending the same things that “conventional doctors” recommend, such as losing weight and exercising, to the questionable, such as as recommending all manner of supplements, to hokum like traditional Chinese medicine, acupuncture, and various forms of “energy healing,” to pure quackery, like homeopathy. When taken as a whole, naturopathy is a system of medicine that fetishizes anything it views as “natural” and as a result is heavily weighted towards pseudoscience and quackery.

All of this is why one of the more disturbing developments in quackery lately is the move for naturopaths to market themselves as primary care practitioners. It is a role for whyc they are woefully untrained., their delusions otherwise notwithstanding. Unfortunately, they are having some success legislatively, not only gaining licensure in a number of states but gaining prescribing privileges and the right to do primary care in some. They do through a combination of savvy marketing, appeals to “health freedom,” and, of course, the co-opting of science.

Once again, when it comes to trying to convince people that naturopathy is good medicine and that, contrary to reality, “integrative medicine” doesn’t represent “integrating” quackery with real medicine, that wretched hive of scum and quackery, The Huffington Post, excels. So does our old friend John Weeks, propagandist for pseudoscientific medicine of all stripes and, above all, “integrating” quackery into science-based medicine. This time around, he’s done it in an article, How Naturopathic Doctors Are Proving the Value of Integrative Medicine. In it, Weeks tries to argue that not only isn’t naturopathy science-based, but that integrating naturopathy with science-based medicine improves outcomes.

I’m not impressed.

I’ll show you what I mean. Weeks starts by seemingly magnanimously thanking conventional medicine for providing the scientific basis for the Textbook of Natural Medicine the consumer-focused counterpart the Encyclopedia of Natural Medicine , because many of the studies they referenced were “gleaned from conventional medical literature.” No doubt. Of course, it’s how such bodies of studies are interpreted where naturopaths fail, inevitably ascribing near magical powers any positive evidence they could cherry pick in support of their favored woo. However, I suppose that, in a way, it is rather chivalrous of Weeks to give credit where credit is due in doing the research they could not and that they could use for their own propagandistic purposes.

Unfortunately, it’s only a prelude to patting oneself on the back for “paying conventional medicine back”:

Now it looks like present day naturopathic researchers may be paying back this debt — at least as far as their medical doctor colleagues in integrative medicine are concerned.

A recently-published study of naturopathic treatment for diabetes and a review of 13 outcomes studies of “whole practice” naturopathic treatment each support the value in the multiple modality, individualized approach that is also favored by integrative M.D.s.

The study Weeks is touting is this one, Adjunctive naturopathic care for type 2 diabetes: patient-reported and clinical outcomes after one year. I am underwhelmed. First, it’s a small study, only 40 patients with type 2 diabetes, a hemoglobin A1c level between 7.5% adn 9.5%, and at least one other cardiovascular risk factor, such as hyptertension. Second, and more importantly, it’s for all intents and purposes uncontrolled. Yes, there is a control group, but it’s a more or less useless control group. Basically, it’s a control group (the “usual care cohort”) constructed from the medical records of patients who, we are told, were potentially eligible to join the “adjunctive naturopathic care” (ANC) cohort but were not invited. Although the study was prospective, there was no randomization, and the groups were not treated as close to identically as possible. Basically, this was an observational cohort study in which one cohort was never seen by the investigators. Thus, the ANC group got a letter, came to see the naturopath several times, and knew they were taking part in a study.

Also, contrary to what was claimed in the abstract, the ANC and usual care cohorts had a number of notable differences. The ANC cohort was younger, had a higher A1c (and thus more room for improvement), and lower blood pressure. Interestingly, more of the ANC group used metformin (80% versus 20%), which suggested that they had more severe diabetes and, therefore, more room for improvement:

Use of oral medications and insulin increased in the ANC cohort during the 12-month observation period, with three patients starting on sulfonylureas, three patients starting on metformin and six patients starting on basal insulin. The total number of prescription refills also increased in the ANC cohort on average during the observation period from 4.7 ± 2.2 per year during the year prior to baseline compared to 5.9 ± 2.7 per year during the ANC observation period, whereas refills did not change in the usual care cohort (i.e., 4.2 ± 3.0 refills/year during the prior year compared to 4.0 ± 3.2 refills during the ANC observation period).

Did these patients get worse and require more medication or was their compliance improved? Who knows? If it was improved compliance, did it have anything to do with naturopathy? Given that the control group wasn’t treated the same way or observed in any way other than by reviewing medical records, improvements observed in the ANC group could well be due to the study effect, also sometimes called the Hawthorne effect. This is a well-known confounder of clinical trials in which subjects improve or modify an aspect of their behavior that’s being experimentally measured simply because they know they are being studied, not because the experimental manipulation worked. In fact, if I were intentionally trying to maximize the Hawthorne effect, I would be hard-pressed to come up with a better study design than this one. Consistent with this, although there were a lot of statistically significant improvements in hard clinical parameters (such as HbA1c) at six months, by twelve months the observed improvements were no longer significant while the subjective measures remained improved.

In other words, this study shows little. Interestingly, there were also adverse events reported in the ANC group, nearly all due to adverse reactions to supplements.

Next up on the quackademic medicine hit parade directed by weeks is a poster presentation. I kid you not. He’s referencing a poster presentation:

The poster presentation was entitled “Systematic Review of Outcomes Studies of Outcomes Studies of Whole Practice Naturopathic Medicine.” The poster team, led by Erica Oberg, N.D., MPH and Carlo Calabrese, N.D., MPH, acknowledged that “formal whole practice studies in naturopathic medicine are a recent phenomenon.”*

All of the naturopathic studies were on chronic conditions. “Some degree of clinical benefit” was found in each, “sometimes quite strong.” Eight of the 13 used quality of life measures with all showing improvements. While noting many “methodological weaknesses,” the team concluded that the review “provides evidence of effectiveness and cost savings in chronic diseases in the observed or validly-modeled practice of trained and licensed naturopathic doctors.”

Here’s a description of the study. You know what they say about meta-analyses: Garbage in, garbage out. Oddly enough Weeks didn’t link to the actual poster; so I will. It’s right here. It’s even more underwhelming than the first study. It pools twelve studies of widely varying conditions. Given how many different conditions were examined (tendonitis, temporomandibular joint problems, low back pain, hypertension, multiple sclerosis, and menopausal symptoms, among others) I find it hard to believe how one could legitimately pool the results in any meaningful way, much less to conclude that naturopathic interventions are beneficial and cost-effective. This is particularly true given that only six of the studies were actually randomized clinical trials; the rest were observational or retrospective.

None of this stops Weeks from exulting:

Such research is of most value to real world decision makers. The aim is not to show that X therapy caused Y response under controlled conditions. Rather, these help stakeholders — whether employers, individuals, hospitals, or accountable care organization leaders — understand what may happen if a given population of patients is cared for by a set of integrative practitioners. These specifically help answer whether naturopathic doctors will be helpful if included in care teams or benefit plans.

Evidence like this will answer no such question. It’s too low quality to answer much of any question. But this is the sort of evidence what Weeks and the naturopaths whose “integration” with science-based medicine he promotes use to make their case, which makes his claim that soon doctors will be soon borrowing the results of research carried out by naturopaths for anything.

Naturopaths and their apologists trumpet that naturopathic care should be “integrated” into conventional medicine because their nostrums add something unique and valuable. In reality, anything science-based that they add is nothing that physicians don’t know already anyway (eat a good diet, get enough sleep, and exercise). What they add that is unique is something that shouldn’t be “integrated” with conventional medicine: magical thinking, pseudoscience, and quackery. To paraphrase Mark Crislip, “integrating” feces with ice cream doesn’t make the ice cream better; it just contaminates it with feces.