How Did the Australian Government Conclude - ‘There’s No Evidence for Naturopathy’?
A recent email by one of Australia's main nutritional supplements suppliers, Metagenics, explained how we find ourselves in this conundrum. I have copied the email in full for your information:
Australian Government, Department of Health Update: 16 July 2018.
In announcing the removal of the private health insurance rebate for the majority of natural therapies, the recent Department of Health statement above reports that “…a review chaired by the former Commonwealth Chief Medical Officer found there is no clear evidence demonstrating the efficacy of the listed natural therapies.”
The conclusion that there is no evidence for the efficacy of Naturopathy is difficult to comprehend for many who are familiar with the wealth of peer-reviewed scientific evidence on natural medicine, including experts in the field of natural medicine research. [3,4] The content and conclusions of this report with regards to Naturopathy and Herbalism, and the evidence which was notably absent from the review, is the subject of this article.
The report in question was submitted to government in 2015 by the National Health and Medical Research Council (NHMRC). It was commissioned to review the evidence behind complementary medicine services provided by unregistered health professions, which include Naturopathy and Herbalism practice. For Naturopathy and Herbalism, rather than evidence of inefficacy, it essentially turned up a lack of publications that met their specific criteria to include in the review.
The report concluded that due to the lack of (included) evidence – “no conclusions can be drawn about the effectiveness of Herbalism as a health service”, and that “further evidence is required to estimate the effectiveness of Naturopathic practice, as practised in Australia”.
The reasons for this were multiple. In fact, the report itself acknowledged several limitations including a restrictive evidence search which only encompassed systematic reviews, published in English, within the last five years – potentially missing a significant body of other existing literature.
However, the major reason explaining the insufficient number of studies that surfaced, was that evidence was sought only on the efficacy of Naturopathy and Herbalism as a ‘health service’ – meaning that only papers on Naturopathic practice as a whole were included. Not surprisingly, whilst there is an abundance of evidence substantiating natural medicines, there are few studies analysing the practice of clinical Naturopathy. Hence, this approach failed to turn up much. It was considered ‘not practical’ to evaluate evidence for the relevant medicines themselves due to the extensive amount of remedies available. As a result, no ‘relevant’ systematic reviews were found for Herbalism; and for Naturopathy there was only one unpublished review from North America on the practice by Naturopathic Doctors.
The report concluded that due to the lack of (included) evidence – “no conclusions can be drawn about the effectiveness of Herbalism as a health service”, and that “further evidence is required to estimate the effectiveness of Naturopathic practice, as practised in Australia”. Far from making strong conclusions about a lack of efficacy, the report stressed numerous times that the findings should not be taken to infer that the specific therapy is not effective. How this translates to a government policy to scrap government support for these therapies seems a great leap.
Some Points of Opposition to the Changes
The changes limit the rights of patients to choose healthcare which they feel is most appropriate for them. Thousands of people find relief and improved wellbeing through their use of natural therapies every week in Australia. These changes will impact their ability to access these services. Over 70% of Australian adults use over-the-counter complementary medicine products, one-third of Australians use complementary medicine therapies including Naturopathy. Furthermore, 42% of complementary medicine users take these medicines to address national priority health conditions.
The natural medicine industry is built on 25,000 small businesses, which contributes $4.2bn to the Australia economy and employs 36,441 people. Thousands more tax-payers are employed in the wider education, manufacturing, wholesale, supply and retail network. This includes 82 TGA approved manufacturing sites and 13,600 high-skilled jobs. If the proposal goes ahead demand will be affected. Natural medicine small businesses, educators and manufacturers could lose business, or even shut down, which would impact local jobs.
Natural medicine is a preventative long-term strategy that will reduce the financial burden on the Australian economy. Natural therapies are crucial to the preventative health strategy of Australia and will significantly reduce the burden on the public health system, especially as our population gets older and larger. Rather than opting for more expensive medical procedures up-front, planned wellness strategies, which natural health Practitioners espouse, can potentially save the healthcare system on hospital and medical costs in the long run.
Far from marginalising an established and highly frequented network of healthcare Practitioners, the government should respond to any perceived lack of evidence by supporting continued research into complementary medicine. Such an approach would continue to have both the individual’s and the nation’s physical and financial health in mind.
Head of Clinical Innovation
Published in the Metagenics Update Aug/Sep Edition
What is the evidence for Naturopathy
Continuing on from the above artice regarding Private Health Insurance Reforms:
The one systematic review on whole practice Naturopathy that was found by the report – a review of six randomised controlled trials in North America – did provide positive evidence for the practice of Naturopathy. In fact, the review concluded that Naturopathy was effective in improving patient health for a range of chronic health conditions, including anxiety, multiple sclerosis, cardiovascular disease and musculoskeletal conditions.7 Outside of examining Naturopathic practice as a health service, there is substantial published scientific evidence on the component parts of Naturopathic practice – namely dietary modification,
exercise, stress management, herbal medicines, nutritional supplementation, probiotic therapy, and a variety of other tools utilised. Suffice it to say, there are many highly-esteemed medical journals which dedicate their entire contents to the subject – including the American Journal of Clinical Nutrition, Phytomedicine, and Complementary Therapies in Medicine, amongst many others. To showcase the breadth of evidence around these therapies would obviously be an extraordinary task – however, one particular area worth highlighting is the role of natural medicines in reducing the burden of disease for those specific health conditions deemed ‘priority’ by the Australian Government.
Natural Medicines Reduce the Burden of Disease
There are a number of health conditions which have been identified as national health priority areas by the Australian Government based on their contribution to the burden of disease in Australia – dementia, obesity, arthritis and musculoskeletal conditions, asthma, diabetes, mental health, injuries, cardiovascular disease, and cancer.8 A comprehensive review which looked at the nature of complementary medicine usage within Australia, found it to be commonly utilised by patients with these diseases,9 a trend that is supported by a wealth of evidence on the effectiveness of natural medicines for these conditions. For example, in the priority area of mental health, Professor Jerome Sarris’s January 2018 systematic review highlights high quality (scientifically rigorous) evidence for several herbs in the treatment of anxiety (including passionflower) and depressive disorders (including saffron). For arthritis, the British Medical Journal published a positive meta-analysis in 2017, for both omega-3 fatty acids and turmeric in the reduction of pain and disease activity.10 For cardiovascular disease and diabetes, magnesium supplementation has consistently demonstrated significant improvements in numerous markers including insulin, glucose, lipids, blood pressure, as well as improved heart function and survival in heart disease patients – all in placebo-controlled trials and meta-analyses.11
A 2014 Frost and Sullivan report predicted the potential healthcare savings if at-risk Australians utilised just a handful of natural medicines for the prevention or treatment of key conditions – B vitamins and omega-3 for cardiovascular health; magnesium, calcium and vitamin D for bone health; lutein and zeaxanthin for eye health; and St John’s wort for depression. Utilisation of these therapies by affected segments of the population was projected to result in a $3 billion net economic benefit annually.12
Beyond the prescribing of natural medicines, Naturopaths are key proponents of the comprehensive lifestyle interventions needed to mitigate chronic conditions. Dietary change, stress reduction and exercise are key therapies recommended by Naturopaths, all backed by a large body of evidence, and essential for the prevention and treatment of lifestyle-related conditions such as cardiovascular disease, obesity, diabetes and dementia.13,14,15,16
Unfortunately in Australia, where approximately 63% of the population are overweight or obese, It has been shown that, only one third or less of these and/or hypertensive patients receive lifestyle advice from their General Practitioner.17
The medical system needs complementary healthcare Practitioners who are experts in the implementation of lifestyle medicine, and who have the capacity and time to engage with and counsel their patients.
In order to understand the patient’s perception of care provided by complementary medicine Practitioners, Hope Foley and Dr Amie Steel of the Endeavour Office of Research, published a systematic review last year. They found that patients felt higher levels of empathy and empowerment from complementary medicine consultations than from conventional medicine. Further, this empowerment is associated with a shift towards behavioural change and a more positive way of thinking.18
Chronic diseases require a significant amount of self ‐ management on the patients behalf, therefore empowering them can be key to effective management.19,20 In doing so, patients develop a greater understanding of the impact of their behaviours on their health, make informed choices and decisions to achieve their health goals, and stay committed when challenges arise.21
Higher levels of empowerment in diabetes management have been associated with better patient knowledge, improved medication adherence, and positive lifestyle behaviours.22 While some studies reported that all complementary medicine consultations created empowerment, this has been more consistently reported with Naturopaths and Herbalists than with acupuncture, massage and homeopathy.23 This may be due to typical Naturopathic and Herbalist consultations involving a large advice component, compared to the focus in other modalities being on the selection and administration of the treatment by the Practitioner.
Australians are Voting With Their Feet
The high utilisation of complementary medicine in Australia demonstrates that it is considered by many to be a legitimate and important component of healthcare.24 Complementary medicine is extensively utilised by people with chronic conditions and low quality of life.25,26
In the CAMELOT study of 2915 Australians with cardiovascular disease or diabetes, 43% had used complementary medicine in the last 12 months.27 Naturopaths are one of the top four most commonly consulted healthcare Practitioners in Australia, alongside massage therapists, chiropractors and acupuncturists.28
For those seeking out complementary medicine, key reasons provided include unsatisfactory results as well as side effects from conventional therapy. Patients also report choosing natural medicine due to its ability to be used as preventative medicine, providing a sense of self-control and self-determination over their own health, and the comprehensive approach to their individual health considerations.29,30
In a time when most countries of the world are heading towards a chronic disease healthcare crisis (a crisis from both a budgetary and morbidity perspective), individuals who are proactively seeking and engaging with preventative healthcare Practitioners need to be supported in their choices and efforts. Far from marginalising an established and highly frequented network of healthcare Practitioners, the government should respond to any perceived lack of evidence by supporting continued research into complementary medicine.31 Such an approach would continue to have both the individual’s and the nation’s physical and financial health in mind.
Author: Marla Cunningham, Metagenics Head of Clinical Innovation