http://www.intjnm.org/admin/article/A_Survey_of_Remedies.pdf

This project was supported by grants from the Group Health Foundation, Grants #HS09565 and #HS08194 from the Agency for Health Care Policy and Research and Grant #AR43441-04S1 from the National Institute of Health. In kind support was provided by the Centers for Disease Control and Prevention.

Abstract

Background: Although use of complementary and alternative medicine is growing in the US, little is known about the practice of CAM providers, including naturopathic physicians. In this study, the remedies recommended by naturopathic physicians in Connecticut and Washington were described and compared.

Methods: A secondary analysis of data describing treatments provided at consecutive patient visits from a random sample of licensed naturopathic physicians. Frequencies of recommended remedies (i.e., recommended vitamins and minerals, botanical substances, food-based therapies, and homeopathic interventions) were examined and compared between states.

Results: Ninety-nine practitioners recorded treatment recommendations on a total of 1817 patient visits. Vitamins, minerals, botanicals, therapeutic diets, therapeutic foods and homeopathic remedies were the major remedy categories. Naturopathic physicians in Washington and Connecticut prescribed vitamins, minerals, and therapeutic foods in a similar manner, whereas remedy recommendations for botanicals and homeopathics were highly individualized.

Discussion: This study provides a baseline to which future data can be compared to identify changes in remedy recommendation patterns of naturopathic medicine practitioners.

Introduction

Naturopathy, established in the United States by Benedict Lust in1902 as a lifestyle as well as a system of medicine, is based on the application of six powerful philosophical principles to achieve health and wellness(1). Over time, specific therapeutic treatments associated with those principles have evolved. In this era of increasing public access to alternative approaches to health care(2), we need accurate information reflecting the current practice of naturopathy, also known as naturopathic medicine. 

Relatively little has been published regarding the practice of contemporary naturopathic medicine, especially prescribing patterns. Lee(3) and Cherkin(4,5) describe general practice characteristics of naturopathic doctors in Massachusetts, Connecticut and Washington. Boon(6) further describes the details of practice of NDs in the Cherkin study. She notes that most visits were made by women between 15 and 64 years of age for chronic conditions. Several studies of naturopathic prescribing patterns for specific conditions (i.e., multiple sclerosis(7), breast cancer (8)) have been published. However, detailed information on the major treatments used by NDs for a general patient population has not been published previously. The goal of this paper is to redress this gap by presenting data on the most common remedy recommendations (i.e., vitamins and minerals, botanical substances, food-based therapies, and homeopathic interventions) made by NDs in Connecticut and Washington states. 

Methods

The data presented in this paper are part of a larger study of descriptive characteristics of 4 CAM professions (acupuncturists, chiropractors, massage therapists and naturopathic physicians) in two states in 1997 and 1998 (3,4). This study included information on personal, professional and practice characteristics as well as characteristics of consecutive visits (e.g., reasons for visits, diagnostic and therapeutic services) to a subset of these practitioners. In the first phase of the study, random samples of licensed naturopathic physicians (NDs) from Washington and Connecticut were interviewed by telephone to collect information on their sociodemographic factors, training, and practice characteristics. A sub-set of those interviewed were recruited for the second phase, collection of detailed information describing 20 consecutive patient visits, including supplements and medications recommended, on a two-page form. The visit data collection form included detailed information on specific remedy recommendations (i.e., amino acids, botanicals, immunizations, prescription or over-the-counter medications, Chinese medicines, diet, homeopathics, therapeutic foods, glandular supplements, minerals, vitamins, and miscellaneous treatments).

Contact information for all licensed NDs with addresses in Washington and Connecticut was provided by licensing boards. Our goal was to interview enough randomly selected practitioners to identify a sample of at least 50 practitioners willing to collect data on 20 consecutive patient visits. No financial incentives were provided for participation in the study. The protocol was approved by the Group Health Human Subjects Review Committee and the Beth Israel – Deaconness Institutional Review Board prior to collection of data.

Telephone interviews were conducted by research assistants with randomly selected providers in Washington State in 1998 and in Connecticut in 1999. Information about practice characteristics was obtained from each practitioner who agreed to be interviewed. Of these practitioners, those seeing 10 or more patients per week were asked to complete encounter forms detailing treatment modalities for 20 consecutive patient visits. Those who agreed were mailed visit data forms modeled after those used by the National Ambulatory Medical Care Survey (NAMCS). The forms collected information on a number of visit characteristics including patient demographics, reason for visit, the types of therapeutic services provided, and specific remedy recommendations. Practitioners were instructed to return the completed visit data forms by mail to the study center. If forms were not returned as expected, the provider received a reminder call from study staff.

Because the study used a two-stage sampling design, each visit in the sample was weighted by the inverse of the sampling probability, reflecting both the chance that the particular provider was selected and the proportion of that provider’s annual visits sampled. Accordingly, the frequencies presented in this paper are actually weighted estimates of frequency derived from all visits reported. To examine state differences in the pattern of prescribing some remedies, Spearman rank correlations were used, while differences in proportions were evaluated using a Chi- square test.

Results

Participation Rates

For Washington and Connecticut, 78% and 94% of eligible practitioners, respectively, agreed to be interviewed. Seventy percent (n=65) and 62% (n=34), respectively, of the interviewed practitioners who saw 20 or more patients per week agreed to provide visit data. Data were collected on 1,186 visits in Washington and 631 visits in Connecticut, for a total of 1,817 patient visits reported. 

Remedy categories

The major remedy categories, in order from most to least often prescribed, were vitamins, minerals, botanicals, diet, therapeutic foods and homeopathics. In Connecticut, all types of commonly used remedies were prescribed in 6 to 13% more visits than in Washington (Table 1). Vitamins were the most frequently prescribed remedies (42 – 52% of visits), followed fairly closely by minerals, botanicals (35 – 47% of visits) and therapeutic diets. Recommendation of therapeutic foods and homeopathic remedies were somewhat less common although they were still suggested in 22 – 35% of patient visits. All other categories (i.e., amino acids, immunizations, prescription or over-the-counter medications, Chinese medicines, glandular supplements, and miscellaneous treatments) were used in less than 7% of the visits in either state with the exception of glandulars, which were used in 13% of visits in Washington.

Vitamins

Recommendations for single or multiple vitamins were made in 42% of patient visits in Washington and 52% of patient visits in Connecticut, with formulations containing multivitamins being more commonly prescribed than single vitamins. The pattern of vitamin recommendations was similar in both states (rs=0.61, p=0.063) and apart from vitamin B12, each of the 10 most commonly recommended vitamins were prescribed more often in Connecticut than in Washington State. The most commonly prescribed vitamin form was a multivitamin (Connecticut) or multivitamin/mineral combination (Washington), followed by vitamin C and vitamin E (Table 2). The percent of patient visits in which multivitamins were recommended in Connecticut (21.1%) was almost four times higher than in Washington (5.7%)(p<0.00001).

Minerals

Recommendations for single or multiple minerals were made in 38% of patient visits in Washington and 46% of patient visits in Connecticut with formulations containing multiple minerals being more common than single mineral formulations. Minerals are prescribed by NDs at about 5% fewer visits than vitamins, with similarity in the pattern of prescribing in both states (rs =0.85; p=0.0033). In both states, formulations containing multiple minerals were more often prescribed as a combination including vitamins and minerals than as a multi-mineral (Connecticut: 11.3% combination vs. 4.6% multi-mineral, p< 0.0001; Washington: 8.7% combination vs. 3.5% multi-mineral, p < 0.0001). The most commonly prescribed mineral supplements were calcium, magnesium and a combination of minerals, with or without vitamins (Table 3), with other single minerals substantially less commonly prescribed.

Botanicals

Botanical therapy of some type, either standardized extracts or various types of whole herb preparations, was recommended by NDs in 35% – 47% of patient visits. The pattern of usage of specific botanical forms (i.e., standardized extract, tincture, dry herb, fluid extract, solid extract) was similar in both states (rs=0.93; p=0.003), with wide variation in selection of the herbs themselves. Extracts standardized to a pre-determined level of a single marker substance (standardized extracts), were recommended in 32% of all patient visits, usually in the form of capsules (Table 4). Tinctures (botanical constituents preserved in alcohol) were recommended nearly as often as standardized extracts. Solid extracts were least commonly prescribed.

Tables 5 – 7 list the 10 most commonly prescribed standardized extracts, tinctures, and dry herbs, with each percentage in the table referring to the proportion of visits in which a particular type of botanical was prescribed among all visits with any botanical prescribed. Even the most commonly prescribed individual botanical substances of each form were recommended very infrequently.

Therapeutic Diet

Although therapeutic diets were recommended in 37% of visits, recommendations for each specific type of diet varied between 1 and 10% of visits (Table 8). The most often recommended were hypoglycemic, rotation/elimination, dairy elimination and hypoallergenic diets. Somewhat less common were high fiber, liver support/detoxification, high protein and vegetarian diets. Once again, differences between the two states did not reach a statistically significant level (p=.418).

Therapeutic Foods

In both states, foods serving as a source of essential fatty acids were by far the most often recommended therapeutic (15% of patient visits for Washington, and 24% for Connecticut; Table 9). Other specific foods were recommended in fewer than 5% of visits. The pattern of recommendation for therapeutic foods was similar in both states (rs=0.81, p=0.007).

Homeopathic Remedies

Homeopathic remedies were prescribed in 35% of patient visits in Connecticut and 22% of visits in Washington, with about half of the remedies being prescribed for constitutional treatment and most of the rest being prescribed for acute treatment (Table 10). When acute symptoms were the focus of treatment, a single homeopathic substance was recommended about as often as a product combining multiple homeopathic substances. Actual use of homeopathic remedies was very individualized, resulting in even the most “common” homeopathic remedies rarely being prescribed.

Discussion

These data describe the prescribing patterns of naturopathic physicians in two states, Connecticut and Washington. Therapeutic treatments provided by NDs typically included supplementation with vitamins and minerals, use of botanicals and dietary recommendations, including use of specific foods. Homeopathic remedies were prescribed less commonly.

To our knowledge, no other studies of ND prescribing patterns in a general patient sample have been published. However, these patterns can be compared with supplement use by a variety of populations, with sales figures for various dietary supplements and with general medical recommendations. Findings from these studies will be described under each of the subheadings.

Strengths and Weaknesses of the study

This study has a number of strengths including the inclusion of two geographically separated states with generally similar practice laws, random sampling of licensed naturopathic physicians, a relatively high response rate, and large sample sizes. The main limitation of the study is that we collected data in only two states and they have practice laws that are somewhat broad compared with other states that license NDs (5). Furthermore, while there were broad similarities in the way supplement recommendations were made by NDs in these two states, no information is available on the reasons for the recommendations, so we are unable to explore the reason for observed differences.

Vitamins

Vitamins, most often in a multivitamin formulation or in combination with minerals, were the most commonly recommended supplement by naturopaths in both states, followed by vitamins C and E. Our finding are similar to those of the Third National Health and Nutrition Examination Survey reported by Ervin et al. (9) showing that 40% of the US population are taking dietary supplements, most commonly multivitamins (37%), vitamin C (13%) and vitamin E (6%). Retail sales data of vitamins and minerals in the US also corroborate our findings, with 31% of all 31% of all such sales being multivitamin preparations (10). Other commonly sold vitamin and minerals are (in order of decreasing sales) vitamin E, vitamin C, iron, calcium and B vitamins (10). 

Recommendations for prescription of vitamins are changing. In 1976 an article in Postgraduate Medicine stated: “The prescription of vitamin preparations as dietary supplements should be limited to specific instances of need …Specific vitamins in therapeutic amounts should be prescribed only in the presence of vitamin deficiencies or increased requirements.”(11). Recently released recommendations such as the Harvard School of Public Health assertion that a multivitamin provides a “nutritional safety net” for the majority of the population who do not get enough vitamins from their diet to prevent several chronic diseases (12) and the review by Fletcher and Fairfield published in 2002 (13) concluding that “it appears prudent for all adults to take vitamin supplements” have reversed the previously held belief that the diet alone provides sufficient vitamins to support health. Naturopathic vitamin prescription patterns as shown by this study are in line with the recent trend of conventional medical recommendations.

While changes in recommendations for vitamin prescription in conventional medical literature are clear, little has been published on the actual vitamin prescribing patterns of medical doctors. A study by Frank et al. (14) indicates that half of the female physicians in their study took a multivitamin-mineral supplement, and 35.5% did so regularly. A survey of cardiologists with data from 1995 and 1996 found that 44% reported regularly taking antioxidants (vitamin E 39%, Vitamin C 33%, β carotene 19%), while only 37% regularly prescribed antioxidants to their patients (15).

As more is learned about the effect of vitamins in the body, conventional recommendations for vitamin dosages are also changing. The Recommended Dietary Allowance (RDA), based on prevention of vitamin deficiencies, has been the standard for many years. The Food and Nutrition Board of the Institute of Medicine has updated vitamin dosage recommendations with the publication of new Dietary Reference Intakes (DRI).(16) These values are different from the old recommendations, with some recommended dosages increasing and others decreasing. In addition, vitamin dosages designated as “UL” present the upper level considered to be safe for use by adults. Future research on prescribing patterns would ideally include data from all types of primary care medical practitioners and would include information on the dosages recommended and the clinical reasoning underlying the recommendation to supplement with vitamins. 

Minerals

In our study, minerals were prescribed slightly less often than vitamins and were most commonly recommended in combination with other minerals (with or without vitamins), followed by single mineral recommendations for calcium and magnesium. This prescribing pattern mirrors the pattern of total supplement sales in the US, in which supplements containing multiple vitamins and minerals command 30.7% of the total supplement market, with single minerals adding an additional 11.8% (17). 

Contrary to previous beliefs that a normal diet would provide adequate mineral intake (12), recent studies are showing that significant portions of the general population do not consume sufficient minerals to meet current recommendations. For example, an FDA assessment of dietary nutritional elements in 1982-1989 found that, while intake of iodine, selenium, phosphorus and potassium was adequate for the general population, copper intake was low and calcium, magnesium, iron, manganese and zinc were low in specific sub-groups of individuals (18). The elderly appear to be at particular risk for mineral deficits. In a review of nutrition in the elderly, Trip (20) found many studies documented inadequate mineral levels in the elderly, particularly for calcium, magnesium and zinc, and reported that conventional medicine authorities recommended a daily multivitamin-mineral supplement.

The prescribing patterns in our study are consistent with both the documented mineral deficits in the US population and the recently revised recommendations of conventional medical authorities. Few studies exist of mineral prescribing patterns among MD’s. However, Kamel et al (22) found that MDs treating patients in an academic long-term care facility were under-prescribing supplementation with calcium.

Future research on mineral prescribing patterns should include data from all classes of primary care providers and would capture the dosages, the form and the quality of the supplements as well as clinical reasoning for the recommendation.

Botanicals

While there was substantial variation in individual botanicals prescriptions, NDs in both states commonly prescribed botanicals and used similar types of botanical preparations (standardized extracts in 1/3 of patient visits, whole plant preparations in 2/3 of patient visits). Our finding that Echinacea was the single most commonly prescribed botanical is consistent with the results of a recent Canadian survey where Echinacea was the most popular botanical product recommended by both MDs and NDs (23). Sales data from a survey of the US population (24) and from the National Nutritional Foods Association in 1999 and 2000 (17) showed Echinacea to be the most commonly purchased natural product (24), as did facts published by the National Nutritional Foods Association from 1999 and 2000, indicating that Echinacea alone captured 7.93% of the total herbal sales.(17) While several of the most commonly prescribed botanicals by NDs (Echinacea, St. John’s Wort, ginseng, green tea and milk thistle) are also commonly purchased on the open market, most commonly prescribed botanicals are not.

Our study findings suggest that botanicals are a more important part of ND care (35 to 47% of visits) than of “over the counter” use by the general population. Although 40% of the US population reported taking some type of dietary supplement in NHANES III(9), herbs made up only 7% of the supplements taken and the general public in 2002 spent only 16.8% of their supplement budget on herbs (17). 

Future research on botanical prescribing patterns for primary care physicians should include information about dosage and details of herbal preparation in addition to which substances were recommended.

Homeopathic remedies

Homeopathic remedies are prescribed in one fifth to one third of patient visits. By contrast, a survey by Barnes et al. (24) found that only 3.6% of adults in the US have ever used a homeopathic remedy and only 1.7% had used one in the past 12 months. Consistent with these findings, homeopathic remedies constituted 3.4% of the total dietary supplement sales in the US in 1999 and 2000. As with botanicals, it appears that an individual visiting an ND would be more likely to receive a recommendation for a homeopathic remedy than they would be to try it on their own.

While there is a growing body of research investigating the efficacy of homeopathic remedies for treating specific conditions as well as comparing homeopathic treatment with conventional treatment, we could find no other research regarding prescribing patterns by primary care providers. 

Comparison of practice patterns in Washington and Connecticut

The pattern of use for remedy categories was remarkably similar in both states studied, particularly in the areas of vitamins, minerals, and therapeutic foods. In the botanical and homeopathic categories, any single substance was recommended in relatively few patient visits, although the remedy categories are clearly central to naturopathic practice. In spite of this individualization in specific remedies selected, the form of both botanicals (standardized extract, tincture, dry herb, etc.) and homeopathics (constitutional vs. acute, single vs. combination) recommended was again strikingly similar across states.

Differences in the way naturopathic medicine is practiced between the two states may result from differences in professional regulatory environments (such as the legal definition of scope of practice or the structure of third party reimbursement), patient characteristics, regional differences in physician education, or the impact of local or regional sources of information for practicing physicians. In nearly all instances, remedy recommendations were made in a higher percentage of patient visits in Connecticut than in Washington. Selections of individual substances for botanical and most dramatically, homeopathic treatment differed in the two states. It may be that the population served in these two states differs in dietary choices, use of self-prescribed supplements and/or preferred treatment approaches. It is also possible that practitioners educated before or after a certain date prescribe differently, and that distribution of practitioners from different eras is not similar in the two states. It may be that the location of professional training is an influential element in prescribing practices. Once again, differences in reimbursement policies or practice regulation may play a role. Recognizing that differences exist is the first step toward asking questions about what underlying factors promote those differences. A deeper understanding of those factors may help improve the match between practice and patient needs, help modify the curricula of professional training programs, and raise awareness about the patterns of information dissemination as the professional knowledge base changes.

Conclusions

When remedy recommendations are part of the treatment plan, NDs rely heavily on vitamins, minerals, botanicals and therapeutic diets, with individual therapeutic foods and homeopathic remedies being prescribed somewhat less often. Both vitamins and minerals are most often prescribed in combination as opposed to individually. The use of botanicals as a class is important to naturopathic medicine, although no individual substances dominate the treatment picture. Homeopathic remedies are recommended on a regular basis, and once again are used in a highly individualized manner, with no single remedy dominating usage. Data such as these can help define naturopathic medicine as it is being practiced in the United States and provide important information about current prescribing practices as well as a baseline against which future data can be compared to identify changes in practice.

References

1. Pizzorno JEJ, Snider P. Naturopathic Medicine. In: Micozzi MS, editor.  Fundamentals of Complementary and Alternative Medicine. Philadelphia,  Pennsylvania: Churchill Livingstone; 2001. p. 159-192.

2. Eisenberg D, Davis R, Ettner S, Appel S, Wilkey S, Van Rompay V, et al. Trends in alternative medicine use in the United States, 1990-1997. Journal of the American Medical Association 1998;280(18):1569-75.

3. Lee, AC, Kemper KJ. Homeopathy and naturopathy practice characteristics and pediatric care. Arch Pediatr Adolesc Med. Jan 2000;154:75-80.

4. Cherkin DC, Deyo RA, Sherman KJ, Hart GL, Street JH, Hrbek A, et al. Characteristics of licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. Journal of the American Board of Family Practice 2002;15:378-90.

5. Cherkin DC, Deyo RA, Sherman KJ, Hart GL, Street JH, Hrbek A, et al. Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. Journal of the American Board of Family Practice 2002;15:463-72.

6. Boon HS, Cherkin DC, Erro J, Sherman KJ, Milliman B, Booker J, et al. Practice  patterns of naturopathic physicians: results from a random survey of licensed practitioners in two US States. BMC Complement Altern Med 2004;4(1):14.

7. Shinto L, Calabrese C, Morris C, Sinsheimer S, Bourdette, D. Complementary and alternative medicine in multiple sclerosis: Survey of licensed naturopaths. J Altern Complement Med. 2004 Oct;10(5):891-7.

8. Standish LJ, Greene K, Greenlee H, Kim JG, Grosshans C. Complementary and alternative medical treatment of breast cancer: a survey of licensed north american naturopathic physicians. Altern Ther Health Med. 2002 Sep-Oct;8(5):68-70;72-5.

9. Ervin RB, Wright JD, Reed-Gillette D. Prevalence of leading types of dietary suppplements used in the third national health and nutrition examination survey, 1988-94. Advance Data from Vital and Health Statistics. No 349. Hyattsville, Maryland: National Center for Health Statistics. 2004.

10 US Department of Health and Human Services (HHS). Commission on Dietary Supplement Labels, Final Report. Transmitted Nov 24th, 1997. Available at: http://www.health.gov/diesupp/ch2.htm.

11 White PL. Vitamin preparations: proper use in medical practice. Postgrad Med. 1976 Oct;60(4):204-9.

12 President and Fellows of Harvard College. Vitamins. Harvard School of Public Health. Available at: http://www.hsph.harvard.edu/nutritionsource/vitamins.html. Accessed May 21st, 2005. 

13 Fletcher RH, Fairfield KM. Vitamins for chronic disease prevention in adults: clinical applications. JAMA. 2002 Jun 19;287(23):3127-9.

14 Frank E, Bendich A, Denniston M. Use of vitamin-mineral supplements by female physicians in the United States. Am J Clin Nutr. 2000;72:969-75.

15 Mehta J. Intake of Antioxidants among American cardiologists. Am J of cardiol. 79…

16 Council for Responsible Nutrition. About Supplements > General Information > Vitamins and Minerals. Available at: http://www.crnusa.org/about_recs.html. Accessed May 14th, 2005.

17 The National Nutritional Foods Association. Facts about the natural products industry > Sales by Product Category. Available at: http://www.nnfa- northwest.com/facts.htm. Accesses May 21st, 2005.

18 Lukaski HC. Vitamin and mineral status: effects on physical performance. Nutrition. 2004 Jul-Aug;20(7-8):632-44. 

19 Zive MM, Nicklas TA, Busch EC, Myers L, Berenson GS. Marginal vitamin and mineral intakes of young adults: the Bogalusa Heart Study. J Adolesc Health. 1996 Jul;19(1):39-47.

20 Trip F. The use of dietary supplements in the elderly: current issues and recommendations. J Am Diet Assoc. 1997 Oct;97(10 Suppl 2):S181-3.

21 McCarron DA. Role of adequate dietary calcium intake in the prevention and management of salt-sensitive hypertension. Am J Clin Nutr. 1997 Feb;65(2 Suppl):712S-716S.

22 Kamel HK. Underutilization of calcium and vitamin D supplements in an academic long-term care facility. J Am Med Dir Assoc. 2005 Mar-Apr;5(2):98-100.

23 Einarson A, Lawrimore T, Brand P, Gallo M, Rotatone C, Koren G. Attitudes and practices of physicians and naturopaths toward herbal products, including use during pregnancy and lactation. Can J Clin Pharmacol. 2000 Spring:7(1):45-9.

24 Barnes PM, Powell-Griner E, McFann K, Nahin RL . Complementary and alternative medicine use among adults: United States, 2002. Advance data from vital and health statistics; no 343. Hyattsville, Maryland: National Center for Health Statistics. 2004.