I glanced at my pharmacy license recently, and noticed I became a licensed pharmacist almost exactly twenty years ago. Two decades seems like a long time to do pretty much anything, yet I can still vividly recall some of the patients I encountered early in my career, working evenings in a retail pharmacy that drew heavily on the alternative medicine crowd. It was the first pharmacy I’d ever seen that sold products like homeopathy, detox kits, salt lamps, ear candles, and magnetic foot pads. And the customers were just as unorthodox. There were some that told me they manipulated their own pH, and others that insisted any prescription drug was designed to kill. And there was a huge clientele that relied on the pharmacy for their “bioidentical” hormones. It was an instructive learning experience, as it was as far from the science of pharmacy school as you could expect to find in a place that still called itself a pharmacy. One of the really interesting aspects of that pharmacy was the enormous supply of vitamins and supplements for sale. It stretched over multiple aisles and even back into the dispensary, where there were some brands kept behind the counter. This wasn’t for any regulatory reason – it was because these were the “naturopathic” supply, the brands often recommended by naturopaths. In order for this pharmacy to sell them they had to keep the products behind the counter, presumably to grant these supplements a veneer of medical legitimacy. These were “special”, and they had the prices to prove it.
It was in this setting that I began to understand the practice of the naturopath. Toronto is home to one of the handful of naturopathy schools in North America, so there are a lot of naturopaths in Toronto. At the time I didn’t know much about naturopathy other than it was some sort of alternative-to-medicine, and their recommendations tended to involve a lot of supplements – and when I say a lot, I mean hundreds-of-dollars-per-month habits for some customers. All of this was good for sales, and for the pharmacy, but it left me perplexed about the medical merits of these products and of naturopaths, especially since I’d never heard of diagnoses like candida overgrowth, detox, adrenal “fatigue”, hormone “depletion”, and widespread nutritional depletion in my pharmacy education.
I started researching naturopathy, and what I learned concerned me. Regular readers to this blog, or to Science-Based Medicine, will be familiar with naturopathy. Depending on where you live, the likelihood that you may encounter a naturopath (or someone that consults one) will vary. Naturopathy has been described as a chimera, something that’s imagined, but in reality is illusory or impossible to achieve. That’s an apt description for naturopathy, as the practice is a strange assortment of unorthodox, discarded, and disparate alternative health practices, linked by a philosophy based on pre-scientific ideas of medicine. The central belief, vitalism, posits that living beings have a “life force” not found in inanimate objects. Vitalism as a hypothesis in medicine was reasonable 200 years ago, but despite being disproved by Wöhler in 1828, it continues to thrive in naturopathy. Naturopathic treatment ideas are grounded in the idea of restoring this “energy”, rather than being based on objective science. It is perhaps unsurprising that disparate practices like homeopathy, acupuncture and herbalism are all part of naturopathy, yet don’t cause any cognitive dissonance for its practitioners. Given there’s no need to justify or rationalize practices in scientific terms, pretty much anything goes, as long as it aligns with this belief system. To be fair, not all naturopath advice is bunk. Some can be sound. Unfortunately this isn’t because there is good scientific evidence to support that practice, but rather that the beliefs and philosophy of naturopathy happen to align with science:
I love being able to look at new approaches that may come along and to ask myself, “Is this within the bounds of the philosophy I so embrace?” And if not, to let it go.
With philosophy rather than objective evidence guiding what a naturopath decides to promote, it should not be surprising that there are serious concerns about the standard of care offered. A letter published a few years ago in Allergy, Asthma, & Clinical Immunology documents the concerns about naturopathy in Canada and any naturopathic alignment to science-based methodologies. Timothy Caulfield and Christen Rachul found that the most widely advertised practices in Alberta and British Columbia lacked a sound evidence base. They concluded:
A review of the therapies advertised on the websites of clinics offering naturopathic treatments does not support the proposition that naturopathic medicine is a science and evidence-based practice.
Among the interventions promoted by naturopaths were (no surprise) homeopathy, chelation, acupuncture and hydrotherapy. And among the top conditions naturopaths claimed to treat were allergies. People suffering with allergies are a target market for naturopaths – which is concerning, because potentially life-threatening conditions are no place for pseudoscience. About five years ago, a coalition of seven Canadian allergy organizations wrote a letter (PDF) to the British Columbia Minister of Health, protesting the plan to allow naturopaths to perform allergy testing and treatment. They identified multiple concerns about the ability of naturopaths to treat allergies, given their diagnostic and treatment methods are not based on scientific standards. Since that letter was written, some of their cautions have already come to pass. I’ve already described how Canadian naturopaths (working with pharmacies, sadly) have turned unvalidated IgG blood testing into a lucrative market to diagnose fake food “intolerances” with the secondary market of selling supplements to correct for all the new dietary restrictions that are recommended.
I was reminded of allergies again this week when a colleague passed on a post from a naturopath about seasonal allergies. Before we go into that post, it’s worth reviewing the scientific evidence on seasonal allergies. The medical term is allergic rhinitis and you’re probably familiar with the symptoms: itchy watery eyes, sneezing, runny nose and nasal congestion, cough, and fatigue are all typical. It’s common, affecting 10-30% of the population, and while it’s not life threatening, can be quite debilitating. Seasonal allergies are usually caused by pollen, and you can often tell what you’re allergic to by checking the pollen counts. Trees, grasses and weeds can all cause seasonal allergies. Pollen exposure causes reactive individual to product antibodies, which bind to mast cells in the nasal mucosa and basophils in the blood. Subsequent exposure to the same allergen causes mast cell activation and the typical cascade of symptoms. The diagnosis is based on a clinical examination, but many people diagnose themselves – they take an antihistamine and see if they feel better. (Not a strategy I recommend.) The ideal treatment is avoidance, but that’s difficult, so many rely on drug therapy. The main categories of treatments are the inhaled steroids (e.g., Flonase) which reduce the allergy cascade by direct action in the nasal passages, and the oral antihistamines, which centrally reduce histamine activity. For most, these products are effective and well-tolerated. Medical consultation is always advisable to ensure the diagnosis is clear, and referrals to allergists are warranted for complex cases. There are several other forms of treatments, with allergy shots generally reserved for the most refractory situations.
Naturopaths consider themselves to be primary care providers comparable to medical doctors, so their advice can justifiably be compared against the same standard. Naturopath Shawna Darou’s bio notes she “graduated from the Canadian College of Naturopathic Medicine (www.ccnm.edu ) at the top of her class and was the recipient of the prestigious Governor’s Medal of Excellence” so presumably her advice is representative of what you should expect from a naturopath. Here’s what she advises to “prepare your immune system” in her column on seasonal allergies [webcitation]:
A liver-focused cleanse before the start of your allergy season. This often makes a great impact on your allergy susceptibility. If you have severe allergies all summer, then a second cleanse mid-summer is also recommended. Most people schedule a 10-20 day cleanse in late March or early April.
Not a good start. Cleansing is pure pseudoscientific quackery, and there is no evidence that “cleansing” even occurs, or that has any effect on seasonal allergies. Your liver doesn’t need any cleansing, allergies or not, and your susceptibility to an allergen has nothing to do with a fictitious treatment. Allergies can wax and wane season to season based on pollen levels and even individual responses, and that variation can occur regardless of any “cleanse”.
Testing for food sensitivities. Chronic, long-term food sensitivities cause significant stress on the immune system and prime your body to react to seasonal allergens. If you reduce overall immune system stress by removing food intolerances from your diet, seasonal allergy symptoms will be minimized. If you haven’t already had a food intolerance test, please ask about one.
Naturopaths regularly promote unvalidated and clinically useless IgG blood testing to diagnose imagined food intolerances, in part because it’s a primer to sell unnecessary supplements. What’s never disclosed is the fact that IgG blood testing hasn’t been clinically validated to diagnose intolerance to a single food product, yet naturopaths claim to test for hundreds of these food “sensitivities”. Allergy organizations explicitly warn against this testing:
The Canadian Society of Allergy and Clinical Immunology (CSACI) is very concerned about the increased marketing of food-specific immunoglobulin G (IgG) testing towards the general public over the past few years, supposedly as a simple means by which to identify “food sensitivity”, food intolerance or food allergies. In the past, this unvalidated form of testing was usually offered by alternative or complementary health providers, but has now become more widely available with direct-to-consumer marketing through a nationwide chain of pharmacies. There is no body of research that supports the use of this test to diagnose adverse reactions to food or to predict future adverse reactions.
Continuing on through the advice:
Purchase a neti pot or a saline nasal spray, which are methods for clearing out the sinuses. Using this daily (1-2x) during allergy season will flush the allergenic pollens out of your nasal passages which will also help to minimize your symptoms.
Irrigating the nasal passages with saline or a neti pot is reasonable advice, is incorporated into conventional treatment guidelines, and is widely recommended by family physicians. It’s an example of where the naturopathic philosophy happens to align with the actual evidence. Neti pots and nasal rinses are generally low risk, but users must ensure they use distilled or previously-boiled water, as plain tap water may have a brain-eating amoeba that can kill.
Watch your stress levels: high stress hormones (cortisol especially) can worsen allergies or make you more susceptible to them. Find methods to lower your stress such as: yoga, exercise, breathing exercises, guided imagery or meditation. If you need further support to lower stress hormones, certain supplements can help to lower cortisol while you work on the external factors.
Neuroimmunology is a real science examining the relationships between the nervous system and the immune system. This advice, however, is unproven speculation. There is no published evidence to suggest you can meaningfully manipulate your allergy symptoms by will alone. Having said that, none of this is likely to be harmful – with the possible exception of supplements, which are unnecessary. With the exception of real medical conditions like adrenal insufficiency, your cortisol levels are not something you need to concern yourself with.
Mold alert: In the past few summers, there were high counts of mold spores circulating. Symptoms most commonly observed are around the eyes – swelling, itching, watering, rashes. In general, people who are sensitive to external molds often have an internal yeast imbalance which makes the immune system more sensitive to external moulds [sic]. If this applies to you, please ask about a ‘yeast-cleanse’ to prevent mold allergies this summer.
Molds can cause allergic rhinitis, so this is an opportunity to promote a made-up disease – candida (yeast) overgrowth. Yeast cleanses are just another variation of the detoxification myth that naturopaths believe, despite the lack of any scientific justification or evidence of effectiveness. People with seasonal allergies don’t have a yeast imbalance, and they don’t need a yeast cleanse: they need to prevent and control histamine release. There’s no fake disease that needs to be invoked.
If you are still getting allergies, even after these recommendations, there are also some natural alternatives to antihistamines that can be used that have no side-effects. Examples include: vitamin C, quercitin, various herbal combinations, homeopathic nasal sprays and specific homeopathic remedies.
Instead of recommending demonstrably effective treatments, like antihistamines, there’s the recommendation for unproven and ineffective treatments. There’s no persuasive evidence that vitamin C, quercitin or any herbal medicines have any meaningful effects comparable to drug therapies, or are backed by adequate scientific evidence to support their use. And herbal remedies are not innocuous. Some, like echinacea, feverfew, and chamomile are members of same plant family that includes ragweed, and could potentially aggravate, rather than relieve, allergies.
Homeopathic nasal sprays are simply saline nasal sprays – there are no active ingredients, yet you’re charged even more for the memory of some substance that was diluted out of existence. Homeopathy is a placebo system, and the “remedies” are usually pure sugar pills – completely inert and without medicinal effects. There’s no scientific justification for homeopathy in the management of seasonal allergies – or for any medical condition, for that matter.
Naturopaths purport to be science-based primary care providers and claim to have the training equivalent to medical doctors. Surveys of naturopathic practices suggest naturopaths do not offer treatments that are science-based, a finding that is consistent with the recommendations examined from a Canadian naturopath. While they claim to treat the “root cause” of disease, their recommendations suggest they lack (or reject) objective evidence about the scientific nature of conditions like seasonal allergies. With a practice that prioritizes philosophy over science, naturopaths are tilting at medical windmills.