Naturopathic medicine is a system of primary health care that emphasizes optimal wellness and health, disease prevention, and patient education. While in practice naturopathic physicians treat acute and chronic conditions, the primary focus of naturopathy is to support the body's inherent healing abilities and empower the patient to make lifestyle changes necessary to maintain optimal health. Through in-depth history taking, physical examination, and clinical and laboratory evaluation, naturopathic physicians diagnose disease, uncover individual and familial risk factors, and strive to understand the patient as the totality of body, mind, and spirit.

Naturopathic medicine traces its philosophical roots back to the Hippocratic school of medicine (circa 400 B.C.). Its modern form derives from several 18th- and 19th-century natural healing systems, in particular hydrotherapy and nature cure, but also including homeopathy, spinal manipulation, hygienic and Thomsonian systems. Hydrotherapy was popularized by Father Sebastian Kneipp (1842-1897) of Germany, and was brought to the United States in 1892 by Dr. Benedict Lust (1872-1945). Lust later combined Kneipp's water cure with principles of nature cure, founded by Dr. Arnold Rickli (1823-1926) of Austria. In nature cure, food, air, light, water, and herbs are used as medicines to treat illness and enhance the resiliency of an individual's constitution (Pizzorno 1996).

Naturopathic medicine flourished in the early 1900s, and many dietary recommendations made then, such as increasing fiber intake and minimizing saturated fats, are being revisited today. Between the mid-1920s and the early 1940s, formalized medical training, a well-organized medical society (namely, the American Medical Association or AMA), and the development of pharmaceutical medicines and new medical technologies came to the fore, contributing to the simultaneous decline of naturopathic medicine and natural healing (Pizzorno 1996). The green movement and counterculture of the 1960s redirected awareness to the importance of nutrition and health for individuals as well as the environment. Natural holistic healing began to regain popularity and naturopathic medicine was revived (Baer 1992). Recently, accredited naturopathic medical education, active research, and the scientific documentation of naturopathic concepts have led to renewed interest in naturopathic medicine and an acknowledgment of its contribution to healthcare (Pizzorno 1996).

Naturopathic medicine is vitalistic in its approach, embracing the beliefs that life is more than the sum of its parts and that living systems have an innate intelligence that constantly strives for health. Botanical medicine, homeopathy, physical medicine, clinical nutrition, and lifestyle counseling are the primary modalities employed by naturopathic physicians. In particular, botanical medicine and clinical nutrition have increasing bodies of scientific studies to justify their use. The way in which these therapies are applied is unique to the principles of naturopathic philosophy.

There are six principles of healing through naturopathic medicine:

• The Healing Power of Nature (vis medicatrix naturae) is the cornerstone of naturopathic medicine. Enhancing the healing wisdom native to all living systems helps to promote, maintain, and restore normal function. Naturopathic physicians support, facilitate, and elicit healing by utilizing methods and modalities in harmony with the natural process (Downey 2000; Pizzorno 1996).

• First Do No Harm (primum non nocere) means using the least invasive, most gentle therapies first, in order to avoid suppression of symptoms, support the patient's own self-healing process, and minimize the chances of side effects. Patients who cannot be safely treated with naturopathic medicine are referred to other healthcare practitioners (Downey 2000; Pizzorno 1996).

• Identify and Treat the Cause (tolle causam) occurs when a disease's conditions—physical, mental, emotional, or spiritual—facilitate the disruption of health. Symptoms are recognized as manifestations of the body's attempt to resist, defend, adapt, or heal itself when faced with challenges. Therefore, identification of these challenges to the organism is of primary importance when seeking to remove obstacles to health (Downey 2000; Pizzorno 1996). There is often more than one cause to be identified and manipulated. 

• Treat the Whole Person (appreciate health and disease as a totality) reflects the multidimensional aspects of the individual and the environment. The uniqueness of each patient and the multifactorial nature of disease require a comprehensive, individualized approach to diagnosis and treatment. Naturopathic physicians encourage patients to engage both their internal resources (e.g., spiritual beliefs, digestion) and external support (e.g., family and friends, dietary intake) to provide a solid foundation from which to move forward into a greater state of health (Downey 2000; Pizzorno 1996).

• Wellness and Prevention (the ideal "cures") mean more than the simple absence of disease. Assessing risk factors and genetic predisposition helps naturopathic physicians make appropriate interventions and guide patients to establish balance and optimal health. In addition, through education and the promotion of good lifestyle habits, patients learn ways to avoid disease and optimize health (Downey 2000; Pizzorno 1996).

• Doctor as Teacher (docere) illustrates the methods by which naturopathic physicians strive to establish a cooperative doctor-patient relationship, in order to educate patients about their health, and to encourage patients' self-responsibility in their treatment (Downey 2000; Pizzorno 1996).

Naturopathic medicine is not defined by its modalities. Practitioners utilize a wide variety of therapies and techniques, from the "nature cure" tradition (i.e., health through diet, hydrotherapy, lifestyle modification, detoxification), to the application of nutritional supplements and herbal extracts in order to manipulate the body's biochemistry and physiology. Some naturopaths are specialists who have additional expertise and training in homeopathy, acupuncture, Ayurveda, or natural childbirth. The majority of naturopaths, however, use an eclectic approach (Bradley 1999). In addition, some state laws have provisions that allow naturopaths to administer immunizations, perform minor outpatient surgery, and prescribe some pharmaceuticals.

In the initial visit, which typically lasts an hour or more, a thorough history is taken. This includes an exploration of diet, lifestyle, stress, and environmental factors. Following the history, an appropriate physical examination and/or laboratory evaluation may be performed. An important component of the visit is to assess the patient's "toxic load." Many factors by themselves may not be sufficient to initiate frank pathologies, but together they may overwhelm the body's ability to respond appropriately. Patients are seen as partners in their care, and a treatment plan usually includes lifestyle modifications (e.g., sufficient sleep, moderate exercise, relaxation practices), dietary recommendations, and a supportive therapy such as a homeopathic remedy, an herbal formula, a physical modality (e.g., hydrotherapy, naturopathic manipulation, therapeutic ultrasound), and/or nutritional supplements (Pizzorno 1996).

In addition to conventional laboratory testing, naturopathic physicians may use innovative diagnostic techniques. The Comprehensive Digestive Stool Analysis (CDSA) is one such tool. This technique allows naturopaths to assess the digestive process, specific nutrient absorption, gut ecology, pathogenic processes, gastrointestinal immunology (fecal sIgA), and metabolic markers, some of which may be used to assess cancer risk (Barrie 1999). An evaluation of hepatic function uncovers a patient's altered metabolic detoxification capacity allowing for better treatment strategies to correct deficiencies and minimize total toxic load (Luckazer 1999).

The principles of naturopathic medicine may be applied to almost any health concern, acute or chronic; the practice may be particularly useful for chronic conditions because of their connection to diet and lifestyle behaviors. Primary research on natural therapies has focused on diet, nutritional supplements, and botanical medicine, and on specific conditions such as HIV (Pizzorno 1996), cancer, and issues regarding women's health (Downey 2000).

A brief discussion of naturopathic medicine's ability to minimize risk factors, reduce symptomatology, prevent and/or reverse disease progression, and treat frank pathologies follows:

Dietary and supplemental nutrients may be useful in reducing risk factors for disease. A prospective study of 578 men with prostate cancer and 1,294 matched controls were evaluated for plasma concentrations of selected antioxidants and risk of prostate cancer. The most significant finding was an association between high concentrations of lycopene (a carotenoid) and reductions in the development of prostate cancer, particularly aggressive cancer in men not consuming beta-carotene supplements. In men with low levels of lycopene, beta-carotene supplements were associated with reductions in risk comparable to those of the high lycopene group (Gann et al. 1999). A randomized, controlled trial in 283 pregnant women at increased risk of pre-eclampsia showed an association between vitamin C (1,000 mg per day) and vitamin E (400 IU per day) supplementation and a 21% decrease in plasma markers of endothelial and placental oxidative stress. Pre-eclampsia occurred in 24 (17%) of 142 women in the placebo group and in 11 (8%) of 141 women in the supplement group (Chappell et al. 1999).

Naturopathic modalities may help relieve symptoms (including pain) and reduce inflammation without causing secondary tissue injury. Gamma-linolenic acid (GLA) has been found to suppress inflammation and joint tissue injury in animals. Two randomized, placebo-controlled trials evaluated treatment of active rheumatoid arthritis patients with GLA versus placebo. The first study evaluated 37 patients randomized to receive placebo (cotton seed oil) or GLA (1.4 g per day of GLA in borage seed oil) for 6 months. The trial realized significant improvements in four measures, with reduction in signs and symptoms and no adverse reactions in the GLA group. There was no improvement in the placebo group (Leventhal et al. 1993). Similarly, the second study evaluated 56 patients randomized to placebo (sunflower seed oil) or GLA (2.8 g free GLA per day) for 6 months, followed by a 6-month, single-blind trial during which all 56 patients received GLA. The GLA group improved by approximately 25% in four measures the first 6 months, and all patients improved during the second 6 months (Zurier et al. 1996).

Herbal and nutritional therapies may be beneficial in improving physiologic function and minimizing disease severity. A review of 15 clinical trials examining the effects of at least 600 mg per day of alpha-lipoic acid on diabetic neuropathy indicates long-term improvements in symptoms, motor and sensory nerve conduction in the lower limbs, and cardiac autonomic neuropathy (Ziegler et al. 1999). A multicenter, double-blind, placebo-controlled, randomized trial of Ginkgo biloba administered to patients with mild to severe dementia (Alzheimer's or multi-infarct dementia) revealed consistent improvement in cognitive performance and social function over a period of 6 months to 1 year (Le Bars et al. 1997). In a multicenter, placebo-controlled, double-blind study evaluating the efficacy of an extract of Crataegus (hawthorn) in the treatment of NYHA stage II cardiac insufficiency, significant improvements in cardiac performance were achieved in the Crataegus group versus placebo during the 8-week trial (Weikl et al. 1442).

When nutrients and herbs are used at doses high enough to achieve a pharmacological effect, side effects and adverse events may occur. Of particular concern are interactions that result from overlapping metabolic pathways. The cytochrome P450 system, through which numerous drugs, vitamins, and herbal constituents are metabolized, has been associated with such interactions. St. John's wort (Hypericum perforatum) has been shown to inhibit cytochrome P450 enzyme activities (Obach 2000). A single-blind, placebo-controlled, parallel study of the interaction between St. John's wort and digoxin found reduced trough concentrations and maximum concentrations of 33% and 26%, respectively (Johne et al. 1999). More recent research suggests possible interaction of St. John's wort with protease inhibitors, such as indinavir and cyclosporin, through a similar mechanism (Breidenbach et al. 2000; FDA 2000). Herbs used to modulate liver function, such as milk thistle (Silybum marianum), turmeric (Curcuma longa), or even dandelion root (Taraxacum officinalis) may alter hepatic clearance of medications. In addition, herbs high in water-soluble hydrocolloidal fiber may delay gastric emptying and interfere with absorption of orally administered medications. These herbs include marshmallow root (Althaea officinalis), slippery elm (Ulmus fulva), and aloe (Aloe vera) (Brinker 1997). Certain combinations of foods, nutrients, and drugs may also yield unforeseen complications. Beta-carotene, considered safer than vitamin A in high doses, has been found to be hepatotoxic when combined with ethanol (Leo and Lieber 1999).

Pharmacological doses of nutrients and herbs should be administered only by experienced practitioners, due to the possibility of toxicities and drug-herb interactions. Please see the monographs on individual herbs and supplements for detailed information regarding specific substances.

Because naturopaths treat the patient and not the disease, studies allowing for individualized treatments may provide a more realistic evaluation of the effectiveness of naturopathic medicine. For example, a randomized, double-blind, placebo-controlled trial of 126 children with acute diarrhea treated with individualized homeopathic remedies found decreased duration of diarrhea and frequency of stools (Jacobs et al. 2000).

Finding a reliable means by which to evaluate naturopathic medicine is complicated by several factors. Because naturopathic practice varies widely, there is a lack of standardized treatment protocols—i.e., the gold standard of randomized, controlled studies. Distilling what heals into an isolated mechanism is a challenge for an individualized, whole-person system such as naturopathic medicine. Some naturopathic principles, such as the belief in the inherent healing abilities of the body, have been partially illuminated through scientific inquiry. Molecular-biological research has shown that cellular autoprotective mechanisms are mediated by heat-shock proteins (stress-response proteins) that stabilize cellular structures and/or functions for extended periods (Lohff et al. 1998). This finding may open the door to a greater understanding of health, disease, and the mechanisms behind the innate wisdom of the body.

Naturopathic physicians complete a four-year, postgraduate, accredited program in naturopathic medicine, receiving a Doctorate in Naturopathy (ND) upon graduation. The program is similar to conventional medical education. The first two years consist of academic training in the basic sciences, laboratory assessment, and physical examination. The last two years focus on academic training in physiological systems and therapeutic modalities, in addition to supervised clinical training. Naturopathic students may choose to specialize in one or more modalities. Graduates must pass a national board examination in naturopathic medicine and fulfill individual state requirements before receiving a valid license. Naturopathic physicians complete ongoing continuing education in naturopathic medicine and their specialty (Downey 2000).

It is important to differentiate between license-eligible naturopathic physicians and those practitioners who have completed mail-order or correspondence school programs that award the Doctorate in Naturopathy. The latter do not meet the educational standards of accredited naturopathic medical schools, nor have their graduates received the extensive, supervised clinical training that graduates of accredited schools receive (Downey 2000).

Currently, there are four accredited naturopathic medical programs in North America: Bastyr University in Bothell, Washington; National College of Naturopathic Medicine in Portland, Oregon; Southwest College of Naturopathic Medicine and Health Sciences in Tempe, Arizona; and Canadian College of Naturopathic Medicine in Toronto, Ontario. There are 11 states that license naturopathic physicians, and more states are currently pressing for licensure legislation (Downey 2000).

The American Association of Naturopathic Physicians (AANP) in Seattle, Washington hosts annual conventions, publishes the Journal of Naturopathic Medicine, develops practice guidelines, provides referral and licensing information, and offers books and tapes authored by NDs. Contact the association at 206-298-0126, or on the web at www.naturopathic.org.

Baer HA. The potential rejuvenation of American naturopathy as a consequence of the holistic health movement. Med Anthropol. 1992;13(4):369-383.

Barrie S. Comprehensive digestive stool analysis. In: Murray MT, Pizzorno JE, eds. Textbook of Natural Medicine. 2nd ed. New York, NY: Churchill Livingstone; 1999:107-116.

Bradley RS. Philosophy of naturopathic medicine. In: Murray MT, Pizzorno JE, eds. Textbook of Natural Medicine. 2nd ed. New York, NY: Churchill Livingstone; 1999:41-49.

Breidenbach T, Kliem V, Burg M, Radermacher J, Hoffman MW, Klempnauer J. Profound drop of cyclosporin A whole blood trough levels caused by St. John's wort (Hypericum performatum) [letter]. Transplantation. 2000;69(10):2229-2230.

Brinker FJ. Interactions of pharmaceutical and botanical medicines. J Naturopathic Med. 1997;7(2):14-20.

Chappell LC, Seed PT, Briley AL, et al. Effect of antioxidants on the occurrence of pre-eclampsia in women at increased risk: a randomised trial. Lancet. 1999;354(9181):810-816.

Downey C. Naturopathic medicine. In: Novey DW, ed. Clinician's Complete Reference to Complementary/Alternative Medicine. Philadelphia, Pa: Mosby; 2000:274-282.

Food and Drug Administration. Risk of Drug Interactions with St. John's Wort and Indinavir and Other Drugs. Rockville, Md: National Press Office; February 10, 2000. Public Health Advisory.

Gann PH, Ma J, Giovannucci E, et al. Lower prostate cancer risk in men with elevated plasma lycopene levels: results of a prospective analysis. Cancer Res. 1999;59(6):1225-1230.

Jacobs J, Jimenez LM, Malthouse S, et al. Homeopathic treatment of acute childhood diarrhea: results from a clinical trial in Nepal. J Altern Complement Med. 2000;6(2):131-139.

Johne A, Brockmoller J, Bauer S, Maurer A, Langheinrich M, Roots I. Pharmacokinetic interaction of digoxin with an herbal extract from St. John's wort (Hypericum perforatum). Clin Pharmacol Ther. 1999;66(4):338-345.

Le Bars PL, Katz MM, Berman N, Itil TM, Freedman AM, Schatzberg AF. A placebo-controlled, double-blind, randomized trial of an extract of Ginkgo biloba for dementia. North American EGb Study Group. JAMA. 1997;278(16):1327-1332.

Leo MA, Lieber CS. Alcohol, vitamin A, and beta-carotene: adverse interactions, including hepatotoxicity and carcinogenicity. Am J Clin Nutr. 1999;69(6):1071-1085.

Leventhal LJ, Boyce EG, Zurier RB. Treatment of rheumatoid arthritis with gammalinolenic acid. Ann Intern Med. 1993;119(9):867-873.

Lohff B, Schaefer J, Nierhaus KH, Peters T, Schaefer T, Vos R. Natural defenses and autoprotection: naturotherapy, an old concept of healing in a new perspective. Med Hypotheses. 1998;51(2):147-151.

Luckazer D. Functional assessment of liver phase I and II detoxification. In: Murray MT, Pizzorno JE, eds. Textbook of Natural Medicine. 2nd ed. New York, NY: Churchill Livingstone; 1999:153-158.

Obach RS. Inhibition of human cytochrome P450 enzymes by constituents of St. John's wort, an herbal preparation used in the treatment of depression. J Pharmacol Exp Ther. 2000;294(1):88-95.

Pizzorno JE. Naturopathic Medicine. In: Micozzi MS, ed. Fundamentals of Complementary and Alternative Medicine. New York, NY: Churchill Livingstone; 1996:163-181.

Weikl A, Assmus KD, Neukum-Schmidt A, et al. Crataegus Special Extract WS 1442. Assessment of objective effectiveness in patients with heart failure [article in German]. Fortschr Med. 1996;114(24):291-296.

Ziegler D, Reljanovic M, Mehnert H, Gries FA. Alpha-lipoic acid in the treatment of diabetic polyneuropathy in Germany: current evidence from clinical trials. Exp Clin Endocrinol Diabetes. 1999;107(7):421-430.

Zurier RB, Rossetti RG, Jacobson EW, et al. Gamma-linolenic acid treatment of rheumatoid arthritis. A randomized, placebo-controlled trial. Arthritis Rheum. 1996;39(11):1808-1817.