Clinical Naturopathic Medicine Rev Hechtman 9780729541510

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Clinical Naturopathic Medicine

Leah Hechtman MSci Med [RHHG] (USYD), BHSc (UNE), ND (NCC) MACNEM, MASRM, MATMS, MESHRE, MFSA, MNHAA President, The National Herbalists’ Association of Australia (NHAA) Lecturer – UG and PG, School of Biomedical and Health Science, University of Western Sydney, NSW Faculty Member and Lecturer, Green Medicine Institute (GMI) Director, The Natural Health and Fertility Centre, Natural Health and Fertility Pty Ltd Private Practitioner, Sydney, NSW

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© 2012 Elsevier Australia This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher. Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation. This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication. National Library of Australia Cataloguing-in-Publication Data ___________________________________________________________________ Hechtman, Leah. Clinical naturopathic medicine / Leah Hechtman. Revised ed. 9780729541510 (pbk.) Includes index. Naturopathy. Clinical medicine. Integrative medicine. 615.535 ___________________________________________________________________ Publisher: Sophie Kaliniecki Developmental Editor: Neli Bryant Publishing Services Manager: Helena Klijn Project Coordinators: Natalie Hamad and Stalin Viswanathan Edited by Stephanie Pickering, Sylvia Sullivan, Julie Gorman & Harriet Stewart-Jones Proofread by Sandra Slater and Annette Musker Cover design by Modern Art Production Group Illustrated by Rod McClean Index by Jan Ross Typeset by TNQ Books & Journals Pvt. Ltd. Printed by CTPS, China

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Foreword

One of the greatest problems limiting the reemergence of naturopathic medicine has been the lack of modern textbooks, especially ones based on science. When I was a student in the early 1970s, the most current textbook in the US had been published the year I was born! For almost a century the mantra of conventional medicine has been that naturopathic medicine is not only not scientific, it is misguided, giving patients ‘false hope’ at best and, at worst, delaying needed medical interventions. I still remember a debate I had with an MD while I was working as a research associate at a medical school before I decided to enter naturopathic school. I had become a vegetarian and noticed many changes in my body and health. I asked one of my fellow researchers what these changes meant and was told, ‘These are errors in your observations, diet does not affect you.’! The problem for me in the debate, however, was that I did not have any research to refute him, only my experiences. Interestingly, when I asked a naturopathic doctor the same question, he took Guyton’s Medical Physiology – then a standard textbook for medical schools – off his bookshelf and showed me what was happening. I was very impressed that the naturopathic doctor knew physiology better than those I was working with in medical research. I asked him if I could spend a few days with him, watching him see patients. After seeing ‘incurable’ patient after ‘incurable’ patient get better with his care, I was convinced that there was something special here. Clearly diet and natural therapies – though discounted by conventional medicine – were indeed effective. But when I asked my mentor for research supporting his therapies, or modern books on naturopathic medicine to read, he had nothing to offer. Happily, this problem is being addressed, albeit slowly. The first modern textbook of naturopathic medicine was co-authored in 1985 by Michael Murray, ND, and me. The Textbook of Natural Medicine broke an almost four decade hiatus. Now in its third edition, the Textbook’s major contribution was beginning the documentation of the research support for natural medicine. The 2000 page text cites over 10,000 references documenting the efficacy of natural therapies. Another important contribution was that we brought together for the first time naturopaths as the experts for a scholarly publication.

And finally, we developed and documented protocols for the use of natural therapies in the treatment of a wide range of diseases. Unfortunately, it has for far too long been the lone standard for the profession. Finally, this has changed with the emergence of Hechtman’s Clinical Naturopathic Medicine. The major contribution of Clinical Naturopathic Medicine (CNM) that differentiates it from the Textbook of Natural Medicine (TNM) is that it is unabashedly focused entirely on naturopathic medicine. Hechtman and her colleagues expertly look at the historic origins of naturopathic concepts and therapies and then integrate these with scientific research to provide a strong foundation for modern clinical naturopathy. While there is plenty of science, I especially appreciate how the authors carefully considered traditional naturopathic approaches and therapies in the context of modern science to provide students and practitioners guidance on how to think about and treat patients. This is key strength of CNM: practical guidance. As appropriate, almost every chapter covers not only what to do, but how to do it and optimize for the uniqueness of each patient. Nutrient dosages, herbal combinations, potential adverse interactions with conventional drugs, laboratory tests and clinical criteria identifying patient characteristics that require modification of the intervention, etc. are all covered. It is truly, a remarkable compilation of how to practice naturopathic medicine conscientiously, effectively and safely. Another very interesting aspect of CNM is that it is systems, rather than disease, oriented. This means that most of the content is oriented towards physiological systems and what goes wrong rather than the disease the person has and how to treat it. While there is plenty of guidance on how to treat diseases, there is far more attention paid to understanding the function of the system, why it goes wrong and what to do about it. Included also is some very sophisticated guidance on understanding the adverse effects of the drugs used by conventional medicine for each disease and how to mitigate their effects without impairing their efficacy. This latter guidance is extremely important as few realise the prevalence of adverse drug reactions. Research has shown that 25% of patients suffer

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FOREWORD

an adverse event as a result of medical care.1 Worse, in the US adverse reaction to properly prescribed drugs is the fourth leading cause of death.2 Fortunately, many of these adverse events can be prevented by the expert use of natural therapies or alternative to the drugs – both fully described in CNM. Don’t get me wrong here, as this is not a book about alternatives to conventional medicine but rather of naturopathic medicine as an integral part of the healthcare system. While there are plenty of examples of naturopathic therapies as alternatives to conventional medicine,

there are also many examples of how these medicines can collaborate for the very best patient outcomes. I am extremely impressed with this work and wish it had been available when I was a student. Conscientious clinicians will use the great resource every day. My congratulations go to Leah Hechtman and her expert colleagues. This outstanding book will have a profound impact on improving the clinical quality and efficacy of our profession.

Dr. Joseph Pizzorno, ND Editor-in-Chief, Integrative Medicine, a Clinician’s Journal Founder, Bastyr University Commissioner, U.S. White House Commission on Complementary and Alternative Medicine Policy Licensed naturopathic physician with prescriptive rights, State of Washington

1

Gandhi TK, et al. Adverse drug events in ambulatory care. NEJM 2003; 348:1556-64.

2

Lazaraou J, et al. Incidence of drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998;279:1200-5.

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Contents

Foreword, v Contents, vii Preface, xi Acknowledgements, xii Contributors, xiii About the Author, Special Contribution, Reviewers, xiv

Why do We Need to know about Herb/Nutrient–Drug Interactions?, 44 About the Herb/Nutrient–Drug Interaction Tables in this Text, 45 Considerations when Using the Herb/Nutrient–Drug Interaction Tables, 45

Part 1: Principles of Naturopathic Medicine, 1

Part 2: Naturopathic Treatments, 47

Chapter 1 Naturopathic Philosophy, 2 An Ancient Tradition, 2 Nature Cure – Europe, 2 Naturopathy – North America, 3 Naturopathy in Australia, 4 The Principles of Naturopathy (the Six Maxims), 8 The Naturopathic Approach, 9

Chapter 5 Nutritional Medicine, 48 Introduction to Nutritional Medicine, 48 The Vitamins, 50 Minerals, 72 Essential Fatty Acids, 95

Chapter 2 Principles of Nutritional Medicine, 14 Naturopathic Nutrition, 14 Bio-Individuality, 14 The Functional Practitioner, 15 Naturopathic Nutritional Assessment, 15 Clinical Picture Assessment (CPA), 15 Dietary Analysis Methods, 16 Specific Nutritional Testing, 17 Naturopathic Nutritional Treatment, 18 The Future of Naturopathic Nutrition, 19 Chapter 3 Principles of Herbal Medicine, 21 A Brief History of Western Herbal Medicine, 21 Current Western Herbal Medicine – Philosophical Principles, 24 Herbal Actions and Constituents, 25 Safety and Interactions, 28 Principles of Herbal Treatment, 29 Formulating a Herbal Prescription, 29 Constructing a Herbal Formula, 32 Preparation of Herbal Medicines, 33 Posology – Herbal Medicine Dosage, 34

Chapter 6 Herbal Medicine, 103 Introduction, 103 Herbal Medicine Classification, 103 Gastrointestinal System, 106 Hepatobiliary System, 110 Immune System, 112 Respiratory System, 117 Musculoskeletal System, 122 Integumentary System, 123 Urinary and Renal System, 125 Female Reproductive System, 128 Male Reproductive System, 131 Cardiovascular and Haematological System, 132 Endocrine System, 140 Neurological System, 143 Psychological System, 147 Part 3: The Body Systems, 151

Chapter 4 Herb/Nutrient–Drug Interactions, 43 What is a Herb/Nutrient–Drug Interaction?, 43 Types of Interactions, 43 Factors Affecting Metabolism of Drugs, 43 Pharmacokinetic Interactions, 43 Pharmacodynamic Interactions, 44 The Complexity of Herb/Nutrient–Drug Interactions, 44

Chapter 7 The Gastrointestinal System, 152 Overview of The Gastrointestinal System, 152 Role of the Naturopath, 154 Investigations, 156 Potential Interactions, 158 Food Allergy and Hypersensitivity, 170 Irritable Bowel Syndrome, 178 Ulcerative Colitis, 183 Crohn’s Disease, 189 Diverticular Disease, 194 Gastro-Oesophageal Reflux Disorder, 197 Peptic Ulcer Disease, 200

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CONTENTS

Chapter 8 The Hepatobiliary System, 210 Overview of the Hepatobiliary System, 210 Role of the Naturopath, 212 Investigations, 217 Potential Interactions, 218 Cholelithiasis, 221 Cholecystitis, 230 Non-Alcoholic Fatty Liver Disease (NAFLD), 238 Viral Hepatitis, 248 Cirrhosis, 258

Leg Ulcerations, 672 Urticaria, 678 Chapter 13 The Urinary and Renal Systems, 689 Overview of the Urinary and Renal System, 689 Role of the Naturopath, 693 Investigations, 694 Potential Interactions, 701 Urinary Tract Infections (Cystitis), 708 Enuresis, 721 Renal Failure, 727

Chapter 9 The Immune System, 280 Overview of the Immune System, 280 Role of the Naturopath, 289 Investigations, 289 Naturopathic Treatment, 294 Potential Interactions, 299 Autoimmune Disease, 337 HIV (Human Immunodeficiency Virus), 354 Cancer, 385 Chapter 10 The Respiratory System, 418 Overview of the Respiratory System, 418 Role of the Naturopath, 421 Investigations, 425 Potential interactions, 432 Conjunctivitis, 448 Sinusitis and Allergic Rhinitis, 454 Acute Rhinopharyngitis and Influenza, 462 Pharyngitis and Tonsillitis, 469 Asthma, 476 Pneumonia, 485 Bronchitis, 491 Chronic Obstructive Pulmonary Disease (COPD), 498 Chapter 11 The Musculoskeletal System, 508 Overview of the Musculoskeletal System, 508 Role of the Naturopath, 511 Investigations, 512 Potential Interactions, 512 Osteoarthritis, 537 Gout, 551 Fibromyalgia, 561 Osteoporosis, 575 Rheumatoid Arthritis, 586 Systemic Lupus Erythematosus (SLE), 602 Chapter 12 The Dermatological System, 631 Overview of the Dermatological System, 631 Role of the Naturopath, 631 Potential Interactions, 635 Dermatitis/Eczema, 645 Investigations, 646 Psoriasis, 652 Acne Vulgaris, 660 Skin Infections, 665

Chapter 14 The Female Reproductive System, 734 Overview of the Female Reproductive System, 734 Role of the Naturopath, 736 Potential Interactions, 737 The Menstrual Cycle, 761 Premenstrual Syndrome (PMS), 768 Polycystic Ovarian Syndrome, 780 Uterine Fibroids, 794 Endometriosis, 805 Pelvic Inflammatory Disease, 829 Menopause, 842 Chapter 15 The Male Reproductive System, 872 Overview of the Male Reproductive System, 872 Role of the Naturopath, 873 Investigations, 874 Potential Interactions, 876 Benign Prostatic Hyperplasia, 882 Prostatitis, 894 Erectile Dysfunction, 904 Andropause, 918 Chapter 16 The Cardiovascular System, 936 Overview of the Cardiovascular System, 936 Role of the Naturopath, 938 Investigations, 943 Potential Interactions, 944 Hypertension, 963 Coronary Artery Disease (Atherosclerosis, Dyslipidaemia), 977 Cardiovascular Ischaemia (Angina), 993 Coronary Heart Failure, 1005 Chapter 17 The Endocrine System, 1025 Overview of the Endocrine System, 1025 Role of the Naturopath, 1030 Investigations, 1031 Potential Interactions, 1040 Hypothyroidism, 1052 Hyperthyroidism, 1068 Diabetes Mellitus, 1083 Hypoglycaemia, 1108 Stress, 1111 Addison’s Disease, 1124 Cushing’s Syndrome/Disease, 1126

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CO N T E N T S

Chapter 18 The Nervous System, 1138 Principles of the Naturopathic Approach to the Nervous System, 1138 Role of the Naturopath – Neurological System, 1141 Role of the Naturopath – Psychological System, 1171 Potential Interactions, 1174 Investigations, 1180 Sleep Disorders, 1200 Headaches and Migraines, 1214 Multiple Sclerosis, 1232 Depression, 1248 Part 4: The Lifecycle, 1291 Chapter 19 Fertility, 1292 Epidemiology, 1292 Classification, 1294 Aetiology, 1296 Complications, 1304 Investigations, 1305 Therapeutic Considerations, 1313 Therapeutic Application, 1313

Growth and Development, 1422 Colic, 1428 Teething, 1430 Cradle Cap, 1430 Nappy Rash, 1431 Constipation, 1431 Diarrhoea, 1433 Fever, 1435 Recurrent and Chronic Infections, 1435 Otitis Media, 1438 Warts, 1441 Autism and Autism Spectrum Disorders (ASD), 1441 Attention Deficit (Hyperactivity) Disorder – AD(H)D, 1454 Immunisation, 1459 Special Diets, 1460 Appendices

Chapter 20 Pregnancy and Breastfeeding, 1367 Pregnancy, 1367 Introduction, 1367 First Trimester, 1377 Second Trimester, 1383 Third Trimester, 1390 Labour, 1393 Post Partum, 1395 Breastfeeding, 1397

Appendix 1: Herbal Medicine Dosage Chart, 1475 Appendix 2: Herbal Medicines During Pregnancy and Lactation, 1487 Appendix 3: Nutrients: Lifespan Requirements and Pharmacological Dosage, 1491 Appendix 4: Dietary Nutrient Sources, 1508 Appendix 5: Nutritional Assessments and Physical Examination, 1510 Appendix 6: Symbols and Abbreviations, 1515 Appendix 7: Laboratory Reference Values, 1529 Appendix 8: Herbal Medicines and Laboratory Investigation Interactions, 1540 Index, 1545

Chapter 21 Paediatrics, 1411 Dosage Calculations, 1411

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Preface

In Naturopathy, a clinician emerges whose sole intention is to find the cause of a patient’s complaint, to educate and empower them to understand their health manifestation, and to support their presentation with a natural means of treatment. This treatment has evolved over time to be both clinically effective but also rigorously researched and assessed. It is an essential part of the changing face of modern medicine. The practice of Naturopathy currently finds itself in a unique position of change. Within Australia, our current status is the one that is moving towards greater integration within the healthcare system and closer to registration. As such, our treatments require greater responsibility and specificity and a willingness to share this information amongst our colleagues. Without this, our treatments and wisdom risk being lost to other disciplines. As naturopaths, we offer a unique perspective of health care and provide significant support and relief for patients. Our treatments encourage self-responsibility and involvement in the healing process. They foster gentle, restorative and ameliorating approaches to medical conditions. Their validity is time-tested and long-standing. The structure of the text was crucial to the design of the project. It was important that the content was easily accessible, logical and articulate. The textbook has been divided into five sections: Part 1 – Principles of Naturopathic Medicine – providing an overview to our main treatment approaches; Part 2 – Naturopathic Treatments – a specific overview of the two main treatments, nutrition and herbal medicine; Part 3 – Body Systems – each system of the body and relevant major conditions;

Part 4 – The Lifecycles – a naturopathic perspective to the major lifecycle events; and Part 5 – Appendices Relevant for the Student and Clinician. Each section of this book has been arranged in a systematic manner; each chapter pertaining to a specific system of the body or unique topic; and each condition organised according to specified pedagogy that ensures that the content is comprehensively covered. Within each condition, the reader can view the content as an overview for quick access or as a detailed discussion that may provoke critical thought, reflection and consideration. The traditional approach to the topic has been incorporated and integrated into the carefully researched content that has followed. Each reference that was included was not solely as it supported a statement, but was considered and reflected to ensure that the content delivered was sound and accurate. At the conclusion of each condition, the reader is provided with a comprehensive case study. This ensures that each contributor’s unique clinical perspective enriches the content and translates the theory into realistic clinical practice. At the heart of Naturopathy, we must lean on our elders whose traditional system knew that the essence of our treatment relied on the relationship that was formed between the patient and the clinician. Evidence-based medicine forms a component of our system of knowledge. It provides us with a lens to explain the efficacy of our treatment but can never replace the healing relationship. The consultation room continues to be the greatest environment for growth and understanding and ultimately the platform for change and healing.

Leah Hechtman, MSci Med [RHHG] (USYD), BHSc (UNE), ND (NCC) MACNEM, MASRM, MATMS, MESHRE, MFSA, MNHAA President, The National Herbalists’ Association of Australia (NHAA) Lecturer – UG and PG, School of Biomedical and Health Science, University of Western Sydney, NSW Faculty Member and Lecturer, Green Medicine Institute (GMI) Director, The Natural Health and Fertility Centre, Natural Health and Fertility Pty Ltd Private Practitioner, Sydney, NSW

W

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Acknowledgements

As we near the end of this project, I continue to be inspired at what a group of individuals can achieve. A book of this magnitude is near impossible without the support, dedication and commitment of everyone involved in the project. I have had the honour of working with some esteemed professionals throughout this journey. In the order of their contribution, my appreciation to Kylie Seaton, Rachel Arthur, Ondine Spitzer, Dr Hanni Gennat, David Kirk, Justin Sinclair, Jane Daley, Ses Salmond, Kathy Harris, Karen Bridgeman, Michael Thomsen, Lisa Costa-Bir, Dr Matthew Leach, Kathleen Murphy, Dr Tini Gruner, Dr Suman Naik, Emily Bradley and Helen Padarin. A special note of gratitude goes to Dr Hanni Gennat for her contribution of both Chapter 4 and each of the interaction tables within each system or lifecycle chapter. I have learnt much from working with you all. Your dedication to the project and commitment to sharing your knowledge, experience and insight has been inspiring. Additionally, my thanks to Dr Joseph Pizzorno. I am honoured and privileged to include your foreword is the text. Due to the size of this text and the time involved in its production, those involved have had their share of life experiences. I can safely say that the team has experienced almost all major life changes and I sincerely appreciate each contributor’s integrity to the project. Heartfelt gratitude goes to Ruth Kendon whose contribution unfortunately had to be omitted due to time restrictions. Ruth – your humility and grace made the process much easier – thank you. The text was reviewed by a number of individuals in the industry. Due to the review process, I was not aware of their identity but sincerely appreciated their thoroughness, feedback and enthusiasm to release the best text possible. To Jane Daley, your efforts as technical advisor were supportive, valuable, informative and knowledgeable. I am humbled to consider you a colleague and value your place in my life. My sincere appreciation goes to the team at Elsevier publishers. Their support, direction and dedication to the project have been impeccable. Many thanks to Luisa Cecotti, Neli Bryant, Sunalie Silva, Natalie Hamad, Helena Klijn and everyone else who assisted with the

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project. I have utmost respect and gratitude to Sophie Kaliniecki. Without her patience, support, motivation and vision, this text would have been impossible. Thank you to Marianne Trees and Nadine Campbell for their contributions as research assistants. Your passion, thirst for knowledge and enthusiasm is inspirational. A special thank you to Lisa Costa-Bir as without her research prowess I would have not been able to persevere in the latter parts of the journey. She embodies one whose passion for knowledge is the foundation of her strength as a clinician. It has been a blessing to see her potential unravel over the years and my gratitude is immense. To my assistant and colleague Annmarie Cannone, your support and friendship especially when deadlines were tight, has helped beyond words. My colleagues on the board of NHAA educate, inspire and challenge me in positive ways. Thank you all for your unrelenting passion to drive our profession towards excellence. To my colleagues at the University of Western Sydney, Sydney University, fellow clinicians and other colleagues, my past lecturers, teachers and mentors – you each hold a place in my lineage and have provided me with inspiration and guidance and have helped me become the person and clinician that I am today. To each patient who I have been fortunate enough to treat, you are my greatest teachers. Theory holds limited place in the consultation room and you have each reminded me to respect the innate healing ability of the body, the wisdom and gifts from nature and the tenderness and humility of the human spirit. Special thanks to Marie-Pierre Cleret whose supervision provided grounding, stability and comfort; my friends and family for their encouragement, patience and understanding; my cats for their company when writing into the night and above all my husband, Justin Denes, without whom none of this would have been possible. Your insight that this journey has been bigger than anticipated and your continual love and respect helps me be the person that I am and achieve all that I do. Finally, my gratitude to all herbalists and naturopaths both past and present that continue the tradition – the knowledge is not lost.

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Contributors

Rachel Arthur, BHSc, BNat(Hons) (SCU), MACNEM, MNSA, MNHAA, MANTA Lecturer, School of Health and Human Sciences, Southern Cross University, NSW Professional and corporate educator Private Practitioner, NSW Chapter 2, Principles of Nutritional Medicine Emily Bradley, ND (SSNT), MHSc, NMed (RMIT), MANTA Lecturer, Faculty of Naturopathy, Southern School of Natural Therapies and Endeavour College of Natural Health, VIC Private Practitioner, VIC Chapter 20, Pregnancy and Breastfeeding Karen E Bridgman, PhD M Sci (Hons), M Ed (Higher Ed), M App Sci, ND, DBM, Dip Hom Part-time Lecturer, Faculty of Pharmacy, University of Sydney, NSW, Australia Director, Starflower Pty Ltd and Starflower Herbals Chapter 9, The Immune System Lisa Costa Bir, B App Sc (Naturopathy), Grad Dip (Naturopathy), Certificate IV in Ayurvedic Lifestyle Consultation, MATMS Private Practice, Caringbah, NSW Chapter 11, The Musculoskeletal System Jane Daley BHSc(CSU), MClinSc(SCU), DBM (NCC), GradCertAppSc(Swinburne University), MNHAA Senior Lecturer Southern School of Natural Therapies, Victoria Private Practitioner, Victoria Chapter 7, The Gastrointestinal System Dr Hanni Gennat Dip App Sc (UNE), BSc (UWA), PhD (UWA) Medical Director, Global Natural Medicine Pty Ltd Health Consultant, Private Practice, Australia Chapter 4, Herb/Nutrient-Drug Interactions

Dr Tini Gruner, Dip.Teach, Dip.Psych.Ther, ND, MSc, RNutr, AdjProf(SPCNT), MANPA, MNSA, MNHCA, MISCMR, MNorphCAM Course Coordinator Bachelor of Clinical Sciences, Lecturer in Nutrition and Naturopathy, Clinic Supervisor School of Health & Human Sciences, Southern Cross University Private Practitioner, NSW Chapter 17, The Endocrine System Kathy Harris, MHScHMed (UNE), ND, BEd, MNHAA Lecturer, School of Biomedical and Health Science, University of Western Sydney, NSW Lecturer, Nature Care College, St Leonards, NSW Private Practitioner, NSW Chapter 9, The Immune System David A Kirk, Adv.Dip.Nat. Writer, researcher, educator and consultant to the Complementary Medicines industry Technical Support and Education Manager with Nutrition Care Pharmaceuticals, Victoria, Australia Chapter 5, Naturopathic Treatments Nutritional Medicine Dr Matthew J Leach, RN, DipAppSci (Nat), DipClinNutr, BN (Hons), PhD Research fellow, Health economics and social policy group, University of South Australia Chapter 12, The Dermatological System Kathleen Murphy, ND (ACNM) BA (UQ) Private practitioner, QLD Clinical tutor, Endeavour College of Natural Health, Brisbane, QLD Chapter 16, The Cardiovascular System

Helen Padarin, BHSc(Nat), ND, DN, DBM, DRM, MATMS Private Practitioner, Sydney Australia and Wellington NZ Chapter 21, Paediatrics Ses Salmond, BA (MU), ND, DBotMed, DHom, DNutr (NCC), FNHAA Senior Lecturer, Western Herbal Medicine Department, Nature Care College, Sydney, NSW Private Practitioner, NSW Chapter 8, The Hepatobiliary System Kylie Seaton, BA (GU) GradDip (QUT) BHSc (UNE), MNHAA, Adv Dip Nat, Adv Dip WHM, Adv Dip Hom, Dip Nut (ACNT) Naturopath & Homeopath, Potts Point, NSW Chapter 1, Naturopathic Philosophy Justin Sinclair, ND (ACNT), BHSc (UNE), MHerbMed (USyd), MNHAA, MATMS Sessional Lecturer, Endeavour College of Natural Health, QLD Private Practitioner, QLD Chapter 6, Naturopathic Treatments - Herbal Medicine Ondine Spitzer, MSocH (UM), BHSci (SSNT), BA (LTU), MNHAA Project Officer, Department of Physiotherapy, University of Melbourne, VIC Research Assistant, Department of Surgery, Alfred Hospital/Monash University, VIC Chapter 3, Principles of Herbal Medicine Michael Thomsen, ND (NCC), MSc (Swinburne) MNHAA Medical Director, Global Natural Medicine, Tasmania Private Practitioner, Hobart, Tasmania Chapter 10, The Respiratory System

Dr Suman Naik, MS [Ophth.][India], MBBS [India], Adv.Dip. of Naturopathy/Herbal Medicine/Homoeopathy, Dip. of Nutrition Lecturer, Australasian College of Natural Therapies, NSW Naturopathic practitioner, NSW Chapter 18, The Nervous System

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ABOUT THE AUTHOR Leah Hechtman is Director of The Natural Health and Fertility Centre in Sydney where she specialises in fertility support and mental health. In addition, she is President of the National Herbalists’ Association of Australia, lectures at the University of Western Sydney to

both undergraduate and postgraduate students. Leah is also a contributor to various professional texts and journals, a presenter at conferences and seminars, and is a media spokesperson for the industry.

SPECIAL CONTRIBUTIONS Interactions Tables for each System/Lifecycle chapter, researched and compiled by Dr Hanni Gennat, Dip App Sc (UNE), BSc (UWA), PhD (UWA) Medical Director, Global Natural Medicine Pty Ltd Health Consultant, Private Practice, Australia

Technical Review of Clinical Naturopathic Medicine by Jane Daley (BHSc (CSU), MClinSc (SCU), DBM (NCC), GradCertAppSc (Swinburne University), MNHAA Senior Lecturer, Southern School of Natural Therapies, Victoria

REVIEWERS Anne Cowper, BHSc (CompMed) ND DBM FNHAA Practitioner, Morisset NSW, Lecturer WEA Newcastle Stepanka Dumas, ND Dip.herb Clinic supervisor/lecturer, Australian Institute of Holistic Medicine Karen Martin, ND (SACBM), BTeach (Adults) (UniSA), MDEd (Deakin) Private Practitioner, SA Brad McEwen, MHlthSc (Hum. Nutr.), BHlthSc, Grad. Cert. HlthSc (Hum. Nutr.), ND (Adv.), DBM, DNutr, DSM, DRM, MATMS and MNHAA PhD candidate (University of Sydney) Lecturer in Nutrition (Nature Care College), seminar presenter and researcher

Christine Sullivan, B.Soc.Wk (UQ), ND(ACNM), DHM (ACNM), BN (ACNM), PGD H Sc Nutrition Medicine (UNE) MNHAA, MANPA, AssMACNEM Private Practitioner, QLD Caroline van der Mey, Ad Dip Naturopathy, Dip Hom, Post Graduate Diploma in Phytotherapy Lecturer, AIHM (Australian Institute of Holistic Medicine), Perth, WA Private Practitioner - Naturopathy, WA Louise Zylan, ND (ACNM), MAIMA, MNHAA Lecturer, Southern School of Natural Therapies, VIC Lecturer, Endeavour College of Natural Health Private Practitioner, VIC

Nicole Quaife, B.H.Sci.(Naturo) Clinic Supervisor and Lecturer in Clinical Nutrition, Southern School of Natural Therapies, Melbourne Private Practitioner, Hampton, VIC

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PA R T

1 PRINCIPLES OF NATUROPATHIC MEDICINE

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Naturopathic Philosophy Kylie Seaton

CHAPTER OUTLINE An Ancient Tradition Nature Cure – Europe Naturopathy – North America

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AN ANCIENT TRADITION Naturopathy is a term of recent origin; however, its philosophical basis is steeped in history. Its basic principles are thousands of years old and retain a characteristic resonance today. The ancient Egyptian Ebers Papyrus dates back to the 16th century BC. Historians suggest much of the material it contained was orally transmitted from perhaps as much as five centuries before this. This 40-page document contains the earliest written record of healing practices. The Egyptians were well known for their holistic approach to treatment through the therapeutic use of herbs and food, massage, invocations and rituals.[1] The Greek universe was ordered and understood according to four elements: fire, water, earth and air. On the same principle, Hippocrates (460–377 BC) understood that the body was governed by four corresponding humours: sanguine, melancholic, phlegmatic and choleric. He viewed health and disease in terms of fluid balance and classified herbs and food by their ability to affect this balance. The fundamental principle of the Hippocratic approach to healing was that the cure should be affected by nature and that the physician should only endeavour to facilitate and assist this natural healing process.[2] Galen of Pergamum (AD 130–200) adopted the humoral approach favoured by Hippocrates and in his most famous work, On the Natural Faculties, furthered the understanding of the development, nature and composition of the humours in man and introduced the qualities of warmth, cold, dry and moist to the humoral doctrines. Much of Galen’s work underpinned Western knowledge of medicine throughout the Middle Ages.[3]

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In AD 55 the Greek physician Dioscorides wrote a series of botanical volumes entitled De Materia Medica, which classified drugs according to categories of action; herbs came to be recognised for their warming, bitter, astringent,

Naturopathy in Australia The Principles of Naturopathy (the Six Maxims) The Naturopathic Approach

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diuretic or tonifying characteristics. This work became the most authoritative source of information on therapeutic substances and remained so through most of the Christian era until modern times.[4] Ibn Sina (AD 980–1037), or Avicenna as he became known in the West, was a Persian physician who lived during the late 900s and early 1000s. Avicenna wrote the most complex medical encyclopaedia of the time, the Kitah al Qanun (Canon of Medicine), which was the summation of the medical knowledge of the time and influenced medical education for more than 600 years. Developed from the Galenic medical tradition, the Kitah al Qanun was translated into Latin in the 12th century and was used as medical text in French universities until the 18th century.[5] Hippocrates, Galen, Avicenna and Dioscorides all acknowledged the need for internal and external balance for health to prevail. Underpinning much of ancient healing was recognition of the vital force that has been variously understood in terms of chi, prana, the temperaments, the humours and the elements. Regardless of semantics, the body’s energetics have always been considered important and the healing power of nature has been a unifying thread woven through all traditional healing practices.

NATURE CURE – EUROPE Whilst there are a number of key players in the development of the European hydrotherapy and nature cure movement, the two most influential figures include Vincenz Priessnitz (1799–1852) and Sebastian Kneipp (1824–97). Their pioneering work in hydrotherapy was the subject of provincial rivalry and unrelenting professional jealousy from the medical community, yet laid the foundation for the practice of hydrotherapy and the nature cure movement throughout Europe.

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Chapter 1 Naturopathic Philosophy

Born into a peasant family in Austrian Silesia, Priessnitz received no official medical training. He began treating injuries from local farmyard accidents with cold water applications, wet bandages and compresses. From these early beginnings, Priessnitz experienced overwhelming clinical success as he developed his art of water cure, with Chopin and Napoleon III among those who sought his clinical expertise.[6] His fame soon spread far beyond the confines of Austria and patients from Britain, France, Italy, Constantinople, Philadelphia and Berlin soon sought his guidance.[7] Like Priessnitz, Kneipp came from humble beginnings. Too poor to afford medical help, he cured himself from debilitating tuberculosis with cold water therapy; nightly dips in the icy waters of the Danube during winter were the key to his success.[6] Word of his successful water cures spread and he combined this therapy with the judicious use of herbs to effect cure. Kneipp’s popularity soon crossed the Atlantic and American institutions began treating patients and teaching students the basis of his healing system.[8]

NATUROPATHY – NORTH AMERICA Naturopathy evolved from the European hydrotherapy and nature cure tradition using the principles of nature cure in combination with other modalities like massage, homeopathy and spinal manipulation.

THOMSONIANISM, PHYSIOMEDICALISM AND THE ECLECTICS Samuel Thomson (1769–1843) developed a method of healing that was heavily based on the use of Native American herbal remedies and sweat baths. His approach was labelled heroic but was considered less harmful than the orthodox medicines being used at the time. Thomsonianism developed from the over-enthusiastic use of bleeding, mercury and arsenic by medical practitioners of the time which left patients debilitated and often in a worse state than they were before treatment. Thomson’s simple healing system was based around the concepts of heat and cold; heat was considered life-supporting and cold was considered life-threatening. Substances that stimulated heat in the body, such as diaphoretics, were accepted while substances that introduced cold into the body, such as like mercury, aconite and opium, were avoided.[9] Thomson had a strong belief in an individual’s ability and right to self-treat and firmly believed that the practice of healing should remain with lay people. Underpinning his adamant belief that his system of healing should be only practised by householders was his strong aversion to medical education. He sold franchises to his healing method which he called ‘friendly botanic societies’ up until the time of his death, in 1843.[10] The physiomedicalist movement was initiated by one of Thomson’s assistants in reaction to Thomson’s rejection of educational progression. In 1835, Thomson enlisted the support of Alva Curtis, a young and popular practitioner from Ohio who claimed to have lost only one out of 200 patients. Curtis used this position bestowed upon him by Thomson to gather support for his own system

of healing and led a breakaway movement in 1838 with the establishment of his Independent Thomsonian Botanic Society.[11] In contrast to Thomson’s aversion to furthering medical knowledge, Curtis established medical schools to teach and develop his system of healing which was largely based on the use of herbal medicine. The physiomedicalist movement also initiated the use of an energetic diagnostic system. Patients in deficient states were regarded as ‘asthenic’ and those in excessive states were regarded as ‘sthenic’. Diagnostic procedures such as tongue analysis and pulse diagnosis were also employed so that the most appropriate herbal remedies could be selected. Although physiomedicalism did not flourish in the United States,[12] the system of healing was exported to Britain and was taught at the British School of Phytotherapy until the 1970s. After initial work by Curtis and Cook, the physiomedicalist movement was further refined by Thurston[13] in 1900 as a: medical philosophy founded on the Theorem of a vital force or energy, inherent in living matter of tissue-units, whose aggregate expression in health and disease is the functional activities of the organism and whose inherent tendency is integrative and constructive; resistive, eliminative, and reconstructive to inimical invasion, or disease-causations.

The detailed and comprehensive work of Thurston provided the physiomedicalist movement with a philosophical basis. In his 400-page document, Thurston provided a rational outline of the failure of regular medicine and went on to set out the theorems of physiomedicalism, the principles of the physiomedicalist movement, and a comprehensive manifesto on medical education, medical terminology, body systems, pathology, disease states, symptoms, diagnosis, food, immunity and the role of the physician. Wooster Beach (1794–1868), established the ‘reformed botanic movement’ which drew on the professionalism of medicine and the heritage of indigenous herbal medicine and European and American healing traditions.[14] As the numbers of practitioners and the popularity of this new movement increased, Beach’s influence diminished and the practice of this system of healing came to be known as the ‘eclectic’ movement. Beach is widely considered to be the founder of eclectic medicine.[15] This movement allowed practitioners to incorporate modalities of other healing systems into their repertoire. Free to experiment with a range of healing modalities, the numbers of eclectic practitioners soared. At its peak, eclecticism claimed over 20,000 practitioners in the United States; these numbers presented serious competition for the practice of orthodox medicine.[16]

THE RISE AND FALL OF AMERICAN NATUROPATHY Naturopathy was formalised as a professional healing modality in the United States of America under the guidance of Benedict Lust in the early 20th century. Lust was a disciple of Kneipp and introduced the practice of Kneipp’s hydrotherapy to the United States. Trained in osteopathy

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and chiropractic, he opened the first health food shop in America and founded massage and chiropractic schools in New York. Lust purchased the rights to the term ‘Naturopathy’ from Dr John Scheel in 1902.[17,18] In the United States, the popularity of naturopathy continued to increase during the 1920s and 1930s, a period often referred to as the ‘halcyon years’. Medicine had offered the public little up until this time and the general public were taken with this new healing art: when naturopathic conventions were held throughout the country, both professionals and the public flocked to them. In 1924, a naturopathic convention in Los Angeles drew a crowd of 10,000 people, naturopathic journals educated the public on disease prevention and health promotion and were widely read. Naturopaths began linking diet and chemical exposure with chronic disease; this thinking was revolutionary for the time.[18] The 1940s and 1950s, however, brought revolutions in modern medicine and several definitive moments in modern medicine crippled the holistic approach to health. Penicillin was introduced in 1941[19] and by the end of 1945, treatment for pneumonia, syphilis, gonorrhoea and scarlet fever had become available. Streptomycin was used to cure the first case of tuberculosis in 1950[20] and any notion of preventative health care took a back seat with the introduction of the intensive care unit[21] and new methods of treatment for the polio epidemic.[22] The first heart lung bypass was conducted in 1953[23] and the drug chlorpromazine was used to treat schizophrenia in the early 1960s.[24] Within 30 years, modern medicine had become seemingly invincible. Such revolutionary developments transformed the public’s perceptions about the value and possibilities of medicine. Augmenting the impact of new technology, naturopathy faced an impossible battle against the might of the American Medical Association (AMA). Under the guidance of George H. Simmons and Morris Fishbein, the AMA transformed itself into a powerful hegemony from advertising revenue derived primarily from drug companies and the tobacco industry. The AMA established a propaganda department in 1913 headed up by Morris Fishbein; the media was used to discredit, ridicule, suppress and quash any form of healing not condoned by either Fishbein or Simmons.[25] The Flexner Report, published in 1910, also severely impacted the practice of both homeopathy and naturopathy in the United States. Although it has been praised for unifying the training of medical practitioners at the time,[26] the Flexner Report ensured that only schools endorsed by the AMA survived.[27] Allopathic, naturopathic, eclectic and homeopathic institutions alike folded; only one eclectic school and one homeopathic school survived. The Flexner Report saw the demise of eclectic, naturopathic and homeopathic medicine in the United States and determined the future path for medical education. The popularity of miracle medicine, the rise in power and influence of the AMA, the Flexner Report, the death of Benedict Lust in 1945 and an un-unified naturopathic community plagued by inner conflict saw naturopathy in America decline and virtually disappear.

NATUROPATHY IN AUSTRALIA EARLY INFLUENCES, 1788–1861 The successful introduction of naturopathy into Australia would not have been possible without the acknowledgment of medicine’s limitations since European colonisation. The prohibitive cost of medicines in the colonies encouraged the practice of self-prescription as a necessary form of primary health care; herbal cures for headaches, venereal disease and rheumatism that were either known as family recipes or found in English medical handbooks were popular. The influence of women as healers during the 1800s reveals a secret and hidden history of healing in Australia kept within the walls of the family home; the art of disease prevention, a tenet of naturopathy, was regarded as women’s work.[28] The migration of hydrotherapy from Europe to America is well documented and early beginnings of naturopathy in Australia can also be traced back to a pamphlet that was published in Launceston, Tasmania, in 1846 detailing Priessnitzian hydrotherapy.[29] The Victoria Hydropathic Establishment opened for business in Malvern Hill in 1861 under the direction of Monsieur and Madame La Moile and offered overnight or daily hydrotherapy treatments. Turkish baths were also popular in central Melbourne and were promoted for their ability to cure illness.[28] Australian naturopathy also has its traditions in the practice of herbalism and homeopathy as the first reported natural therapists in Australia were homeopaths and herbalists.[30] A growing community of Chinese gold prospectors saw Chinese herbalism introduced to the goldfields; by the late 1850s, numerous Chinese herbal shops had opened in central Melbourne. By 1867 it is estimated that 50 Chinese medical practitioners were operating on the Victorian goldfields alongside 25 legally registered doctors.[31] Perhaps one of the most famous European herbal practitioners in Victoria during the 19th century was John Broadbent. Broadbent, the author of two publications, The Australian Botanical Guide (1887) and Botanic Multim in Parvo (1899),[32] established a herbal practice which thrived until the 1930s. His clinical practice at 109 Bourke Street, Melbourne, was famous for its shingle: Botanic Laboratory: All Herbs Guaranteed Pure, Fresh, and True to Nature. Importers of Medical Herbs from Every Part of the Globe: Herbs, Roots, Barks, Seeds, Blossoms. Herbal remedies for all diseases: No Family Should Be Without Them. Deeds Not Words.[33]

THE EMERGENCE OF AUSTRALIAN NATUROPATHY, 1910–40 The period of emergence is marked by the presence of Chinese herbalists on the Victorian goldfields; it has been suggested that Chinese herbalists were the largest group of practitioners using herbal medicines in Australia in the early 1900s.[34] Although naturopathy was only in its early incarnation, the popularity of herbalism at the time was reflected in the formation of Australia’s oldest

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medical association, the National Herbalists Association of Australia (NHAA), in 1920. In 1925, the Victorian parliament attempted to introduce a bill outlawing the practising of herbalism by anyone but pharmacists; Chinese herbalists in Victoria reportedly launched a publicity campaign and using petitions managed to gather 6000 signatures from a supportive general public. The bill was withdrawn.[31] The herbal community in Sydney in the early 1900s was influenced heavily by the Newton and Wheeler families. Gilbert Wheeler was an early practitioner of herbalism in Sydney and came from a family who had practised herbal medicine in Australia from the days of early settlement. Edward James Newton, the grandson of Edward Allen Newton, was another popular herbalist and ran his clinical practice from an office in Pitt Street. Newton became a major importer and supplier of herbs and the herbal formulas handed down by his father were very popular with the local community.[35] Australian naturopathy as we know it today would not have been able to develop without the insight, dedication and benevolence demonstrated by Frederick Roberts and Maurice Blackmore. Roberts (1892–1976) played a key role in the development of osteopathy, chiropractic and naturopathy in Australia. He trained at the London School of Natural Therapies and in 1929 he established the Robert’s Naturopathic Institute in Melbourne.[34] Roberts set up health clinics in Ballarat, Geelong, Brisbane, Ipswich, Newcastle, Toowoomba, Maryborough, Bundaberg, Mackay, Adelaide, Perth and Fremantle, effectively bringing naturopathy to regional Australia. Maurice Blackmore graduated from the British Naturopathic College and immigrated to Australia in 1923. Blackmore was another pioneer of naturopathy in Australia and opened both a naturopathic clinic and Australia’s first health food shop, in Brisbane in 1934.[36]

THE POST-WAR PERIOD The practice of naturopathy in North America was profoundly affected by the development of pharmaceutical drugs and technological advances attributed to World War II; the American naturopathic professional fell into decline as great advances in technology dominated during this period. In Australia, the growing pharmaceutical industry began to dominate and dictate orthodoxy and the practice of Chinese herbalism in Victoria suffered with the continuing impact of the white Australia policy following Federation. Although the impact of these changes on naturopathy has not been specifically researched, natural therapies practitioners in Australia entered a difficult time. A herbal teaching hospital was established in Francis Street near Hyde Park in Sydney in the early 1950s by the NHAA. The teaching hospital was used to train herbalists and free herbal treatment was offered to patients who queued for hours to receive treatment; those who could afford to left donations so that the rent on the premises could be paid. The herbal teaching hospital kept its doors open for 10 years, herbalists worked relentlessly for free to serve the community and all medicines were dispensed at no cost. Despite the success of the clinic and

its increasing popularity with the local community, the NHAA was forced to close the hospital in the early 1960s as making repayments on the premises had become an impossibility.[35] Despite the closure of the herbal hospital in Sydney, and difficult times faced in North America, naturopathy in Australia continued to grow through the 1960s as early pioneers like Maurice Blackmore and Cyril Flowers began to train other practitioners. Alf Jacka established naturopathic clinics in Melbourne and in regional Victorian towns during the 1950s, 1960s and 1970s and, with Blackmore’s encouragement, he established a naturopathic college in Melbourne in 1961.[34]

NATUROPATHY – BOOM FROM THE 1970s ONWARDS Naturopathy experienced a resurgence in the late 1960s and early 1970s as the public became increasingly disillusioned with orthodox medicine. The tragic repercussions of thalidomide treatment in pregnancy became apparent and for the first time, the reductionist approach of medicine was being challenged. In 1962, Rachel Carson published Silent Spring and as a result became an eminent figure in the modern environmental movement. For the first time, the general public were warned about the indiscriminate use of pesticides and fertilisers and the book’s impact was not limited to North America. The 1960s and 1970s saw a worldwide interest in health and the evolution of human consciousness; the general public turned to alternative medicine for answers. Jacka[34] estimates that during the mid-1970s, the student intake at the Southern School of Natural Therapies increased by 400%, reflecting this worldwide trend. The development of naturopathy in Australia has been heavily influenced by the practice of herbal medicine in particular. Denis Stewart established the Southern Cross Herbal School and in 1978, the school awarded Diplomas of Medical Herbalism to its first graduates. Since the original Friday night lectures at the Glebe Town Hall in Sydney, Stewart has been involved with the training of hundreds of students and some of Australia’s finest and most influential practitioners, with Nick Burgess, Andrew Pengelly, Anne Cowper and Christina Scalone all training under Stewart. Stewart is well respected for his system of dosing which evolved from what he considered to be a lack of discipline in existing dosing regimes. Stewart was impressed by the dosing stipulations outlined in the British Herbal Pharmacopoeia of 1983 and began to use those doses in his formulations. Stewart has always maintained that unless a herb is prescribed within the stipulated dose range, maximum benefit from that benefit cannot be achieved. He has been a great exponent of the use of the 1:1 fluid extracts which were the basis of British and Commonwealth Herbal Medicine practitioner’s formulations (personal communication from D. Stewart, herbalist, 29 June 2009). Denis Stewart and Dorothy Hall have been two key players who have helped shape the clinical practice and training of herbalists and naturopaths in Australia. Despite the

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opposing dosage principles that underpin the philosophy of their individual styles of clinical practice, their dedication to naturopathic training established precedents for the movement of naturopathic training into the domain of private colleges and eventually, the university system.

disorders (biography of H. Osiecki supplied by Bioconcepts, Brisbane (QLD), May 2009).

Australian naturopathy has also been heavily influenced by the successes of several other individual practitioners. Robyn Kirby (b. 1936) was a practising herbalist for 26 years and ran successful clinics on the central coast and in Sydney. She was a student of Denis Stewart and the first female president of the National Herbalists Association of Australia. Kirby is widely respected for her Sinus Tonic, which is still manufactured and sold today. Kirby authored several books during her career which added valuable information to the practice of naturopathy in Australia (personal communication from R. Kirby, herbalist, 15 June 2009).

The practice of naturopathy in Australia is evolving. From its early beginnings with the practice of herbal medicine in early settlements and on the goldfields to the more formalised practice of herbal medicine within clinical situations through the 1900s, the use of herbal medicine has always been a key naturopathic modality. With the influence of the European hydrotherapy movement and the new interest in nature cure which was booming in the United States, naturopathy in Australia came to represent the practice of herbal medicine and nutrition with the flexibility of other modalities such as massage, flower remedies, iridology, tissue salts and celloids.

The presence of naturopathy in Australia can also be accredited to ongoing support provided by professional associations such as the National Herbalists Association of Australia. The success and popularity of the conferences organized by Anne Cowper and the quality of research published in the Australian Journal of Medical Herbalism, edited by Cowper, has allowed naturopathy in Australia to survive and grow underpinned by relentless and professional support. Cowper herself has also made significant contributions to the practice of herbal medicine in Australia, writing several publications on herbal manufacturing, running a successful private clinical practice since 1988 and teaching students at naturopathic colleges (personal communication from A. Cowper, herbalist, 18 June 2009).

The formalised teaching of naturopathy programmes in private colleges and universities has predominantly influenced the practice of naturopaths in Australia. With increasing emphasis on herbal medicine and clinical nutrition, underpinned with sound knowledge in the health sciences (anatomy and physiology, pathology, pharmacology), naturopathy is becoming less of an umbrella term for an array of modalities and is streamlining into a practice heavily driven by herbal medicine and clinical nutrition. Naturopathy is taught at the advanced diploma and Bachelor level at private colleges (accredited through the Vocational Education and Training Accreditation Board (VETAB)) and in line with current health training package requirements. A full time naturopathy programme is also taught at undergraduate level at university in Australia. Postgraduate qualifications are available through universities which recognise students’ undergraduate qualifications. This enables access to higher education opportunities including Masters level training for herbal medicine and nutrition and various PhD pathways.

In recent times, Kerry Bone has perhaps been one of the most influential contributors to the practice of naturopathy in Australia. Bone trained at the School of Herbal Medicine in the United Kingdom from 1980 to 1984 and was heavily influenced by Simon Mills and Hein Zeylstra. Over the last 20 years, Bone has relentlessly promoted the value of herbal research to inform clinical practice, but not at the expense of traditional knowledge, and his dedication to research has provided the naturopathic profession with six textbooks that illustrate this approach. He established a masters course in clinical herbal medicine at the University of New England, which was the first of its kind in the world (personal communication from K. Bone, herbalist, 27 May 2009). Augmenting the very ‘herbal’ influence on naturopathy is the nutritional approach to naturopathy. Henry Osiecki has been one of the key contributors to both the national and international naturopathic nutritional knowledge base over the past 25 years. Osiecki was professionally trained as a biochemist, dietitian and nutritionist and has been heavily involved in research and product development during his career. He has written a number of textbooks and his Physician’s Handbook of Clinical Nutrition has become a key undergraduate text and an important clinical reference. More recently, Osiecki has brought together medical models and traditional therapies to form a comprehensive understanding of the biochemical processes involved in cancer development and mood

WHAT IS MODERN AUSTRALIAN NATUROPATHY?

The eclectic and inclusive nature of the art of naturopathic healing, has seen the foundational modalities of herbal medicine, nutritional medicine and nutritional supplementation combined in clinical practice with optional modalities including iridology, flower essences, massage, chiropractic, osteopathy and homeopathy. This integration and practice of several modalities is a definite strength, allowing for flexibility in practice and multiple treatment options that can be chosen and tailored to suit the individual case presentation. More recently, the term naturopathic medicine has emerged and embraces the original European concept of nature cure and the modalities of naturopathy and has placed them within the framework of modern science and medicine. Such placement has resulted in considerable focus on herbal medicine, nutrition and nutritional supplementation as key naturopathic modalities, with other modalities available as treatment electives. Such flexibility means that the practice of naturopathy can, however, be hard to quantify at times. Smith[37] regards the practice of naturopathy as a unique system of primary health care that is not limited to a single modality of healing that combines the art and science of medicine using

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traditional forms of healing and modern scientific knowledge to prevent and treat illness. Notwithstanding the ability of the modern naturopath to don any cap required is significant not only for the current practice of naturopathic medicine but also for the development of the profession. With recognition of and respect for the limitations of practice, the naturopathic practitioner has the flexibility to direct and manage cases with the most appropriate therapeutic techniques. Lifestyle modifications are essential, and it could be argued that they often underpin the degree of clinical success in a case. Change strategies are important, but more important are the techniques that the naturopath uses so that longterm and life-altering change can be made by the client. Motivational support is essential. For effective clinical practice and results, there is increasing demand on the practitioner to understand patient motivation and attitudes to health and success and to be able to fathom the patient’s physical, emotional, spiritual, familial, social, occupational and financial stressors. As such, it is important that the practitioner engage in the mindful practice of self-awareness. Once an understanding of self begins to develop, the practitioner then develops an ability to be able to see a case presentation more objectively and with greater clarity. The lived experience of the naturopath is an essential therapeutic tool; any work done on the self will directly benefit the type of patient who presents and the outcome for that patient. The ability to give and the extent of what is offered in a therapeutic situation is directly related to the amount that the clinician invests in his or her own health and self-awareness.

NATUROPATHY WITHIN THE AUSTRALIAN HEALTHCARE SYSTEM There are three forms of regulation available to health practitioners in Australia. These include self-regulation, statutory registration and co-regulation. Naturopathy in Australia is self-regulated and is practised under common law, which allows for the practice of naturopathy without any training whatsoever. However, because of the strict educational and professional registration requirements imposed by health insurance companies, although in theory it is possible to set up and practise as a naturopath without qualifications, it is much more difficult in practice. Such unqualified practice also detracts from the professionalism and legitimisation that naturopathy practitioners seek from the health care system and public perception. Although there is no official recognition for naturopaths within the Australian healthcare system, naturopathic practitioners are already working within a primary and allied healthcare network. Despite strong lobbying campaigns, naturopaths in Australia to this point have failed to obtain statutory registration even though naturopathy is taught at both a college and university level; chiropractors and osteopaths have managed to gain registration in all states and territories and Traditional Chinese Medicine practitioners have gained registration in Victoria. As such, naturopaths in Australia continue to take a back seat and are often relegated to being the ‘last port of call’ for

patients with chronic or unresolvable conditions or for patients who suffer life-threatening illness and want to make sure all treatment bases are covered. At present, there is a prevalence of complementary and alternative medicine use in Australia and research indicates that in 2006, 1.9 million naturopathic consultations were conducted.[38] Australia is experiencing a quick evolution towards naturopathic professionalism, and, more and more, naturopathy is being accepted as mainstream. However, despite the progress in public awareness, a definite split within the profession is apparent. One sector of the profession is rallying to retain the traditional principles of a healing art that has been viewed as a fringe modality, a cottage industry of sorts, that has prevailed throughout various political agendas of recent decades because of its underground nature. The other sector is striving for professional legitimisation of naturopathy and is pushing for statutory registration, giving naturopaths recognition that has until now been reserved for allied health professionals such as physiotherapists, podiatrists and osteopaths. Such division within the profession leaves the practice of naturopathy undefined; a lack of cohesion within the profession provides an environment where therapeutic imperialism can thrive. The existence of a multitude of professional associations has stifled the voice of a unified profession and it is this lack of unity that has made government negotiation difficult. The push towards registration surely provides a framework which will ensure the survival of naturopathic practice. The movement towards registration has already begun; rather than question whether registration is in fact a necessity, the professional should be asking whether they want to drive the process, or whether they are satisfied to be mere passengers. A cohesive movement into the future is required to not only preserve traditional practices but also to legitimise current practice. At present, increased interest in complementary medicine has been attributed to a decline in faith in the previously unquestioned power of modern medicine. Rather than being pushed away from orthodox medicine, however, studies have reported that the general public is pulled towards complementary medicine.[39,40] The very foundations of naturopathy, once dismissed and ridiculed, are now being accepted. The importance of fresh food, fresh air, exercise, good quality sleep and rest are now accepted as is the need to limit the body’s toxic overload. Integrative medicine conferences now refer to the six maxims of naturopathy as fundamental principles of medicine. They may be the principles of healing in the future, but they certainly have not been the principles of medicine in the past. The failure of modern medicine explains the increased popularity of integrative medicine. At present, integrative medicine at its worst relies on cherry picking evidencebased medicines that can be used in conjunction with or in place of pharmaceuticals. Its scope is overwhelmingly limited, but in effect still provides solutions to both general practitioners and patients. At this point, orthodox and integrative medicine cannot offer what naturopathy

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can. Integrative practitioners are for the most part still dictated to by evidence-based research limited by the current scientific paradigm. Time constraints and strict medico-legal guidelines augment this. Naturopaths, on the other hand, are freer to explore both empirical and evidence-based knowledge from several healing modalities. The flexibility of naturopathic practice means that the naturopath’s toolkit can assume a Tardis-like status and naturopathic solutions to health problems far exceed what the few evidence-based herbs or supplements can offer. We are perhaps, at this point, in the process of accumulating the research, ideas and concepts that will eventually instigate a shift in consciousness and a more evolved understanding of human health. Until that point, those players restricted by the paradigm within which they work must continue to further their understanding of health and disease. Those players not trapped by the paradigm of modern medicine must also continue to seek answers to questions that are so central to the human condition but relegated to the ‘fringe’. Each player must keep with them an appreciation of the limits of modern medicine and an understanding of the infinite possibilities of healing which have been demonstrated in the past, and which are still to be experienced. Each healer, whether orthodox or complementary, brings a unique set of experiences and values to their work, and consequently will attract patients who resonate with that experience.

THE PRINCIPLES OF NATUROPATHY (THE SIX MAXIMS) THE HEALING POWER OF NATURE (VIS MEDICATRIX NATURAE) An understanding of the first tenet of naturopathy necessitates both an acceptance and an appreciation of the power of nature. This power exerts influence by dictating how the body responds to internal mechanisms that direct cure and external influences that support and encourage cure. Naturopathy recognises that nature is both perfectly balanced and organised intelligently to create, maintain, repair and destroy matter synchronistically. The body also has its own intuitive and sophisticated mechanism of healing that operates in congruence with the laws of nature. As nature regenerates itself without the need for human intervention so too does the human body. The use of nature’s healing agents (air, earth, water and sun) in combination with a clean diet, exercise, good sleep, relaxation, meditation and an optimistic outlook are examples of external factors that can influence and support the body’s innate ability to heal. The naturopath’s role is to support and facilitate the body’s natural ability to heal.

IDENTIFY AND TREAT THE CAUSE (TOLLE CAUSAM) Underpinning this principle is the basic understanding that all illness must have a cause and for health to be restored and optimised the cause or causes of the

disease state must be identified and removed. In this sense, symptoms are regarded as indicators of disharmony. They can be viewed as direct indicators of the cause of disease or as gross indicators of the intense homeostatic effort required to adapt and repair. A mechanic would never remove a warning light from a car’s dashboard to correct a mechanical problem detected during a service; in the same way symptoms should never be removed or suppressed from the body in order to restore health.

TREAT THE WHOLE PERSON (TOLLE TOTUM) Health and disease are the results of an intricate and intimate interplay of physical, emotional, mental, spiritual, social, familial and occupational factors. Failure to address all aspects relevant to a patient’s pattern of health and disease fundamentally ignores the complexity of the human being. By its very nature, such ignorance motivates healing interventions that are reductionist, short-sighted and founded in the disease rather than a health-focused treatment model.

FIRST DO NO HARM (PRIMUM NON NOCERE) The principle of inflicting no harm on patients is a naturopathic reaction to the heroic medical procedures of the past that saw the use of mercury, arsenic and the practice of bloodletting. An understanding of this principle necessitates an acknowledgement of the healing power of nature. The naturopath’s role is to facilitate the body’s natural ability to heal and if this approach underpins practice, then harmless practice will be a direct result. Naturopathic practice that respects the principle of harmfree treatment is traditionally non-invasive, and avoids the suppression of symptoms and the prescription of harmful doses of medicine.

DOCTOR AS TEACHER (DOCERE) The word doctor has a Latin origin and originally meant ‘teacher’. The maxim doctor as teacher reiterates the principle that as part of nature, the body can heal without human intervention. The power to eliminate disease and optimise health lies with the body itself not with the naturopath, and in this sense the naturopath assumes the role of teacher so that the body’s natural healing mechanisms are supported. In this teaching role, the naturopath seeks to educate the patient and encourage self-education. The naturopath must be able to inspire and motivate the patient and encourage self-motivation. Ultimately, naturopathy seeks to empower the patient and encourage self-empowerment.

PREVENTION (PREVENTARE) Seeing a naturopath to facilitate disease prevention is a concept that is becoming increasingly difficult to promote in a sickness-focused healthcare system. As a result of this, the principle of disease prevention is more readily applied once a person is already under the care of a naturopath. Treatment of the primary complaint can begin and through a process of risk factor analysis, constitutional

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susceptibility and genetic tendency, naturopathy can be employed to prevent both the sequelae of disease states and the development of new states.

THE NATUROPATHIC APPROACH The naturopathic approach to health and disease focuses on the restoration of health where health has deteriorated, the optimisation of health where good health prevails, and the prevention or slowing of health deterioration. Naturopathy, in its basic form, is a celebration of simplicity with the promotion of fresh air, clean water, adequate rest, nutritious food and the use of herbal remedies and nutrition to assist with the body’s self-healing processes. Despite the complexities of modern disease pathogenesis, astounding improvements in the patient’s quality of life can be achieved by adhering to simple yet effective techniques to encourage self-healing. As a key feature of naturopathic practice, simplicity does not necessitate that the naturopathic approach is in any way unintelligent. The brilliance of this system of healing is the intelligence behind the simplicity. Comprehensive case taking plays a fundamental role in naturopathic practice as practitioners strive to find answers in the many causes of health deterioration rather than rely on a single diagnosis. Naturopathic clinicians are often presented with numerous therapeutic challenges; informed clinical reasoning and case management will ensure optimal client care. Modern medicine treats symptoms and often suppresses disease states. This method of approach does little to identify and understand the dynamic causal interplay of symptoms that can only be elicited with comprehensive care taking. Integral to treatment and optimal patient care is the naturopath’s understanding of their role. This reveals a comprehension of the extent to which naturopathy can be used for patient benefit as well as an understanding of the limits of treatment. In any case, successful case management requires that the naturopathic practitioner draws on a network of qualified and experienced practitioners from other modalities (counsellors, acupuncturists, homeopaths, osteopaths), so that the patient is offered the best care. A key strength of naturopathic practice is the ability to offer consultations (between 30 minutes and 1 hour) that enable and facilitate a longer comprehensive case taking process. The ability to offer appointments allows the practitioner and the patient to establish a rapport and provides a base where key issues (often not what the patient presents with) can be identified and discussed. This consultation time is what many patients seek, and fail to find, in the current healthcare system. Notwithstanding, naturopathy offers much more than just lending an ear to patients, but it is this ear that opens dialogue and can unfold issues that block healing. An initial visit to a naturopath would usually begin with a complete health history. If necessary, physical examination or inspection will take place and the patient will be referred to a general practitioner if necessary.

After the initial case has been taken, the naturopath may order pathology tests through private laboratories; these can be general, functional or specialised. Other specific diagnostic tests can be requested, for example: comprehensive diagnostic stool analysis (CDSA), gastrointestinal tract tests, functional liver detoxification profile (FLDP), Helicobacter pylori stool antigen (HpSA), intestinal permeability (IP), 3-day parasitology (3DP), genetic diagnostic testing, salivary hormone profiles, adrenal hormone profile, baseline hormone profiles, metabolic profiles, nutritional profiles, hair tissue mineral analysis (HTMA) and food sensitivity profiles. Some naturopaths choose to work with fewer laboratory investigations and rely on laboratory tests ordered through the patient’s doctor and good case taking to identify problems. Augmenting the conventional medical history, the naturopathic assessment will also spend considerable time assessing dietary, lifestyle, occupational, social, environmental and emotional influences and the impact these have on patient health and illness. The naturopath will then formulate a treatment plan which addresses both symptomatic relief and the cause of the illness or disease the patient presents with. Herbal medicine, nutritional supplementation, nutritional advice and counselling are key practice components with homeopathy, with flower essences and massage being introduced where necessary. Follow-up appointments allow for treatments to be adapted, modified and tailored to suit ongoing or differing demands. The second or third appointment can often introduce the naturopath to many of the patient’s underlying drives that influence health. Follow-up appointments also allow for an approach to healing that is shared by both the patient and the practitioner as these appointments allow the patient to report progress, setback, insights and experiences – all components are essential to healing. At all times the naturopath must remain cognisant of the need to do no harm. Often, patients will present with debilitation from conventional treatments, so the practitioner’s job is to first restore then optimise health with as much care for patient safety and well-being as possible. Mills and Bone[41] refer to the need to balance physiological enhancement with physiological compensation. In this instance, physiological enhancement aims to create a state of robustness by raising vitality and physiological compensation attempts to compensate for organs or organ systems that are over- or under-functioning.

THERAPEUTIC ORDER The therapeutic order is the cornerstone of naturopathic treatment; it recognises the principles of naturopathic medicine and prioritises treatment according to these principles. This order fundamentally acknowledges the use of non-invasive and restorative agents as the first line of treatment. Treatments should then build in intensity as necessary. The therapeutic order is generally consistent for each patient; however, individual treatments should always be prescribed within the context of this therapeutic order. An Australian specific therapeutic order (after

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the original US order authored by Zeff and Snyder) is generally understood to be as shown below: 1. Restore the basis of health by understanding and minimising the obstacles to cure and promoting opportunities for healing. 2. Identify potential obstacles to health and support/treat accordingly: a. Hereditary/genetic influences – including parental preconception health, inborn errors, epigenetics b. Lifestyle considerations – hygiene, environmental, spiritual, social, relaxation, exercise, socioeconomic, interrelationships, stress c. Previous medical history and treatment d. Dietary intake and assimilation. 3. Stimulate the body’s natural ability to heal by addressing the cause of the disease. 4. Modulate body systems – strengthen weakened organs and tonify overactive organs. The focus includes: a. Strengthening the immune system b. Eliminating toxins c. Reducing inflammation d. Tonifying the nervous system e. Balancing metabolic and hormonal activity f. Strengthening and toning other body systems as necessary. 5. Address structural disturbances – referral to a massage therapist or osteopath may be necessary. 6. Address specific pathology or conditions and prescribe accordingly once the cause has been identified and treated. 7. Refer for suppression or surgical intervention if required. Adapted from A Hierarchy of Healing: The Therapeutic Order. The Unifying Theory of Naturopathic Medicine, Jared Zeff, ND, LacPamela Snider, ND, Stephen P. Myers, ND, BMed, PhD, in Textbook of Natural Medicine. This was originally adapted from Zeff J, Snyder P. Course syllabus: NM51 71, Naturopathic clinical theory. Seattle: Bastyr University, 1997–2005.

Although the therapeutic order in the Unites States continues and suggests diagnosis and treatment with drugs and the inclusion of surgery, in Australia the therapeutic order cannot progress unless the practitioner is qualified in conventional medicine or surgery. Referral at any necessary point during the therapeutic order is essential.

THE HOLISTIC PRACTITIONER The holistic practitioner can be defined by the way that practitioner handles cases and relates to patients and family members of the patient, and by how other support is sourced, introduced and managed. Effective case taking and case management are imperative to holistic treatment and perhaps the ability to restore a patient’s health rests heavily on the quality of the case history that is taken. The tradition of follow-up consultations is also important in holistic treatment. Trust between the patient and practitioner develops over time as the therapeutic relationship develops and deepens, thus treatment can often address concerns that would have otherwise gone unnoticed without this relationship. The importance of follow-up consultations is imperative to this deepening therapeutic relationship. Holistic treatment must also endeavour to ascertain what a practitioner can bring to a therapeutic arrangement. Qualities such as confidence, certainty, presence (or the ability to hold a space) and gratitude to the patient for

sharing their healing journey are key components of a holistic approach to healing. An area of holistic treatment that is often overlooked, either ignorantly or unashamedly, is the health of the practitioner. With such emphasis on the optimisation of patient health, practitioner health is often overlooked and without investing in self-care, the practitioner will fail to deliver the qualities necessary for a truly holistic treatment approach. The first tenet of naturopathy introduces the concept first do no harm. Traditionally this has been interpreted to explain the necessity of harmless practice and the importance of patient safety. A more holistic interpretation can see this tenet expanded to include the need for the naturopath to encourage the patient to do no harm to him/ herself and for the naturopath to likewise do no harm to him/herself. This brings with it the notion of practitioner self-care. An understanding of the principle doctor as teacher would not be complete without an understanding of disease as teacher. This transcendental view may not be appropriate at all times; however, patients facing terminal illness may address this topic in consultation without being prompted. In this teaching role, the naturopath also becomes a listener and a confidant. The ability to hold the space is a prerequisite; advice and opinion are far less powerful than open ears, an open mind and an open heart. An understanding of the principle doctor as teacher would not be complete without acknowledgement of the patient as teacher role in naturopathic practice. The ability of a patient to continually teach is reliant on the practitioner’s ability to continually learn from patients. Such an organic relationship is truly symbiotic and holistic.

MIND–BODY MEDICINE – ANCIENT TRADITIONS All ancient cultures acknowledge a role for the spirit within. It has only been with the superimposition of allopathic medicine that this spirit has been dismissed and ridiculed as being unscientific. A Western understanding of health is founded in mechanistic biomedical theory. Founded in reductionism and rationalism, this understanding provides little framework within which non-dichotomous concepts of healing can exist. With the emergence of modern allopathic medicine, the holistic patient-specific model of healing was replaced by a disease-specific model with little room for mind–body understanding, acceptance or investigation, and also with allopathic medicine came a shift from the art of healing to the science of disease. The interconnectedness of the body and mind is paramount to all ancient and indigenous systems of healing. Healing temples in Ancient Greece provided healing in the form of cleansing baths and fasts and the use of imagery and prayer, and hands-on healing was common practice.[42,43] Paracelsus maintained a fundamental belief in the mind–body connection; he believed that faith and imagination were the true vehicles of healing and that physicians were only able to heal by tapping into the power of God.[44] Australian aboriginal concepts of health have also traditionally been holistic and based heavily on

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Chapter 1 Naturopathic Philosophy

relationships between the people, the land and spiritual belief. Traditional Chinese Medicine relies on the force of chi, as Ayurveda relies on prana; the notion of universal energy connecting mind, body and spirit and generating each individual’s life force is fundamental to these healing traditions.

Early Research Questions the Mind–Body Dichotomy The learned German abbess and mystic Hildegard of Bingen (1098–1179) practised mind–body medicine through her belief in the elements; the accumulation of black bile, for instance, was regarded not only as an imbalance in the natural humours but also as a build up of suppressed emotion.[45] The dichotomous view can be traced back to the concept of dualism, which has largely been attributed to Descartes (1596–1650), who proposed that the mind and body are different substances.[46] Newton presented a departure from Descartes’s approach and the accepted notion of Cartesian duality at the time. In his student notebooks he showed an early interest in the causal interdependence of the mind and body and expressed a particular interest in the connection between memory and physiology.[47] In 1905 Darwin alluded to the as yet undiscovered concept of mind–body medicine when he linked emotions with the potential of physical strength. He stated ‘a man or animal driven through terror is endowed with wonderful strength, and is notoriously dangerous in the highest degree’.[48] The first scientific understanding of the mind– body connection was documented in the literature 6 years later by Walter Cannon. Cannon pioneered understanding of the emotional influence on disease states and the influence of hormonal and nerve transmission on bodily functions. In 1911 he published research[49] that correlated emotional disturbance with digestion dysfunction in animals. In 1914, he documented[50] the interaction between fear, rage, stress and asphyxia on bodily function, and in revolutionary work in 1928 he suggested that emotion could be transported either to the hypothalamus to influence peripheral movement, or to the neo-cortex where higher brain activity was stimulated.[51] In 1936[52] he published more extensive research on the role of emotion in disease formation. Cannon was the first investigator of this emerging field of psychosomatic medicine that attempted to link and explain emotional influences on disease states. In groundbreaking work in 1949, MacLean identified and named the limbic system and suggested that psychosomatic disorders were the result of disrupted communication between the limbic system and the neo-cortex.[53] In fact, the term psychosomatic was first introduced by MacLean; he described psychosomatics as the pursuit of knowledge that attempts to explain how and why psychological processes were expressed through physiological body changes.[54] In the 1950s, Alexander[55] suggested that psychological disorder and conflict contributed to the development and pathogenesis of medical conditions; his work was criticised as it failed to link psychological function to the majority of disease states present

at that time. The failings of such early models provoked more research and in the 1970s Engel[56] presented a biopsychosocial model of illness that identified interrelationships among biological, psychological, and social systems that influence health and disease processes. In 1980, the Nobel laureate and physicist David Bohm detailed the presence of energy that permeated and connected every subatomic particle, atom and molecule in the universe. Bohm argued that mind and matter could not be separated – he considered them two aspects of an indivisible reality and proposed that meaning which can be both mental and physical links but is not separate from them.[57] Central to this theory is the concept of interconnectedness; the universe simply cannot be separated into material (body) or non-material (mind/spirit) components. Furthermore, the sense of interconnectedness does not imply superimposition of one state onto the other; the two forms are inseparable and form part of the whole. Isolating either the physical or the mental is as useless as attributing the power of a magnet to only one of its poles. Psychoneuroimmunology is the study of the interactions between behaviour, neural and endocrine function, and immune system processes. This new field was introduced to the scientific community in 1981 by Ader,[58] who revealed that immunoregulatory processes were influenced by the brain and that neural function, endocrine function and behaviour are in turn influenced by the immune system. Further insights into the power of mind–body medicine were revealed as studies on the ancient traditions of transcendental meditation,[59] prayer[60] and yoga,[61] as well as more Westernized concepts of imagery,[62] relaxation[63] and stress reduction[64] were published. There is an abundance of evidence in the scientific literature which documents the power of mind–body healing. So the question remains, why has modern medicine not overwhelmingly embraced this research? The problem herein perhaps lies not so much with the cohort of people who identify as mind–body medicine deniers, but with the inability of the reductionist, mechanistic paradigm of both Western medicine and current scientific research to effectively facilitate mind–body enquiry and practice.

The Placebo Effect A placebo is an inert substance that is believed to have therapeutic effects through the mobilisation of the body’s natural healing powers. J. Haygarth reported it in an unusual 1800 publication entitled Of the Imagination, as a Cause and as a Cure of Disorders of the Body: Exemplified by Fictitious Tractors, and Epidemical Convulsions. Early work by Pepper,[65] Osler,[66] Wolf[67] and Beecher[68] laid the foundation for future investigations into the clinical significance of the placebo effect. The placebo effect has been the subject of numerous clinical trials and has sparked extensive clinical[69] and ethical[70] debate. The power of placebo has been demonstrated in the treatment of pain[71] and insomnia[72] and researchers have noted the placebo can increase immunity, alleviate depression, prevent asthma, improve angina

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and hasten the wound healing process.[73] Researchers have also concluded that certain types of placebos work more effectively than others; two placebo pills have more demonstrated efficacy than one, intravenous placebo injections are more powerful than pills, larger pills that are brown or purple in colour are more powerful than smaller pills, and extremely small red or yellow pills demonstrate most therapeutic effect.[74,75] Much less reported than the placebo effect is the concept of the nocebo. The nocebo is a substance with inert properties that increases pain and results in health deterioration. It is estimated that 20–30% of patients receiving placebos experience mild side-effects such as diarrhoea, pain, nausea, skin rashes and heart palpitations.[76] In a 2004 study,[77] patients with Parkinson’s disease underwent a surgical procedure in which human neurons were transplanted into participants’ brain tissue. Half of the study participants received no neurons but were told they had undergone the procedure. The power of placebo was demonstrated when the group who received no surgical intervention showed significant improvements in both brain and body function, leading the researchers to report evidence of a very strong placebo effect. The mind and body cannot be separated; herbal medicines, nutrition and physical adjustments can be used to correct the physical manifestation of disease processes. Remedies and interventions are employed to bring out change in organ systems, organs, tissues and cells. However, they also influence molecules, atoms, subatomic particles and energetic vibrations. Naturopathy, like Ayurveda and Traditional Chinese Medicine, is the embodiment of mind–body medicine; and let us not forget the basic tenets – the body has the power to heal itself.

REFERENCES [1] Chast F. A brief history of drugs: from plant extracts to DNA technology. In: Wermuth CG, editor. The practice of medicinal chemistry. 2nd edn Edinburgh: Elsevier; 2003 p. 3–28. [2] [Anonymous]. What medicine owes to Greek culture. Lancet 1939; 234(6045):90–104. [3] Stelmack RM, Stalikas A. Galen and the humour theory of temperament. Pers Individ Dif 1991;12(3):255–63. [4] Eadie MJ. The antiepileptic materia medica of Pediacus Dioscorides. J Clin Neurosci 2004;11(7):697–701. [5] Sanai M. Avicenna. Lancet 1954;264(6833):329–30. [6] Kirchfield F, Boyle W. Nature doctors pioneers in naturopathic medicine. East Palestine, OH: Buckeye Naturopathic Press; 1994. [7] Scoutetten H. Hydrotherapy in Germany. Graefenberg and Priessnitz. Lancet 1843;40(1029):274–6. [8] Blake E. Naturopathic hydrotherapy. In: Chaitow L, editor. Naturopathic physical medicine: theory and practice for manual therapists and naturopaths. Edinburgh: Elsevier; 2008. [9] Winston D, Dattner AM. American system of medicine. Clin Derm 1999;17:53–6. [10] Willard TL. Textbook of modern herbology. 2nd ed. Calgary: Wild Rose College of Natural Healing; 1993. [11] Griggs B. Green pharmacy: a history of herbal medicine. London: Robert Hale; 1983. [12] Haller JS. Kindly medicine, physio-medicalism in America, 1836–1911. Kent, OH: Kent State University Press; 1997. [13] Thurston JM. The philosophy of physiomedicalism: its theorum, corollary, and laws of application for the cure of disease. Richmond, In: Nicholson Printing; 1901. [14] Haller JS. Medical protestants, the eclectics in American medicine, 1825–1939. Carbondale, IL: Southern Illinois University Press; 1994.

[15] Wood M. Vitalism – the history of herbalism, homeopathy and flower essences. Berkeley: North Atlantic Books; 1992. [16] Ody P. The herb society’s complete medicinal herbal. London: Dorling Kindersley; 1993. [17] Micozzi MS. Historical aspects of complementary medicine. Clin Derm 1998;16:651–8. [18] Pizzorno JE, Snider P. Naturopathic medicine. In: Micozzi MS, editor. Fundamentals of complementary and integrative medicine. 3rd ed. St Louis: Elsevier; 2006. [19] Rosengart MR. Critical care medicine: landmarks and legends. Surg Clin North Am 2006;86(6):1305–21. [20] Rifkind D, Freeman GL. The Nobel prize winning discoveries in infectious diseases. Edinburgh: Elsevier; 2005. [21] Berthelsen PG, Cronqvist M. The first intensive care unit in the world: Copenhagen 1953. Acta Anaesthesiol Scand 2003;47(10):1190–5. [22] Somerson SJ, Sicilia MR. Historical perspectives on the development and use of mechanical ventilation. AANA J 1992;60(1):83–94. [23] Bailey CP, Musser BG, Morse DP. The accomplishments of open heart surgery: the status of 35 patients 18 to 36 months following the operation. Am J Cardiol 1959;4(2):147–54. [24] Mathalone MB. Ocular effects of phenothiazine derivatives and reversibility. Lancet 1965;2:29–35. [25] Ullman D. The homeopathic revolution: why famous people and cultural heroes choose homeopathy. Berkeley: North Atlantic Books; 2007. [26] Banta DH. Abraham Flexner – a reappraisal. Soc Sci Med 1971;5:655–61. [27] Coulter HL. Divided legacy: the conflict between homoeopathy and the American Medical Association. Berkeley: North Atlantic Books; 1973. [28] Martyr P. Paradise of quacks: an alternative history of medicine in Australia. Sydney: Macleay Press; 2002. [29] Claridge RT. Hydropathy: or the system of effecting cures by means of cold water, epitomised from the celebrated work of Captain Claridge, FSA. In: Martyr P, editor. Paradise of quacks: an alternative history of medicine in Australia. Sydney: Macleay Press; 2002. p. 108. [30] Evans S. The story of naturopathic education in Australia. Complement Ther Med 2000;8:234–40. [31] Loh M. Victoria as a catalyst for Western and Chinese medicine. Journal of the Royal Historical Society of Victoria 1985;56(3):38–46. [32] Trickey R. Women, hormones and the menstrual cycle. Sydney: Allen & Unwin; 1995. [33] McGregor P. A history of complementary medicine in Victoria. Diversity 2000;2(2):12–9. [34] Jacka J. The politics and the passion: the development of natural therapies in Australia, a twentieth century phenomenon. Diversity 1997;12:6–9. [35] Kirby RA. herbal heritage. Five generations: biography of Paul Wheeler, herbalist. Sydney: National Herbalists Association of Australia; 1990. [36] Baer H. The drive for legitimation in Australian naturopathy: successes and dilemmas. Soc Sci Med 2006;63:1771–83. [37] Smith MJ, Logan AC. Naturopathy. Complement Alternat Med 2002; 86(1):173–84. [38] Bensoussan A, Myers SP, Wu SM, et al. Naturopathic and Western herbal medicine practice in Australia – a workforce survey. Complement Ther Med 2004;12:17–27. [39] Furnham A, Kirkcaldy B. The health beliefs and behaviours of orthodox and complementarty medicine clients. Br J Clin Psychol 1996;35:49–61. [40] Furnham A, Forey J. The attitudes and beliefs of patients of conventional versus alternative (complementary medicine). J Clin Psychol 1994;50:458–69. [41] Mills S, Bone K. Principles and practice of phytotherapy. Edinburgh: Elsevier; 2000. [42] Caton R. Health temples in Ancient Greece and the work carried on in them. Lancet 1914;183(4715):126–9. [43] Caton R. Hippocrates and the newly discovered health temple of Cos. Lancet 1906;167(4306):695–7. [44] Rodgers D. Mind body matters. In: Micozzi MS, editor. Fundamentals of complementary and integrative medicine. 3rd ed. Edinburgh: Elsevier; 2006. [45] Strehlow W, Hertza G. Hildegard of Bingen’s medicine. New Mexico: Bear 1988. [46] Harré R. Mind–body dualism. In: Smelser NJ, Bates PB, editors. International encyclopedia of the social and behavioral sciences. Edinburgh: Elsevier; 2004. p. 9885–989. [47] Dempsey L. Written in the flesh: Isaac Newton on the mind–body relation. Stud Hist Philos Sci 2006;37:420–41. [48] Darwin C. Expression of emotions in man and animals. New York: D. Appleton; 1905. [49] Cannon WB. Mechanical factors of digestion. New York: Green; 1911. [50] Cannon WB. The emergency function of the adrenal medulla in pain and the major emotions. Am J Physiol 1914;33:356–72.

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Chapter 1 Naturopathic Philosophy [51] Cannon WB. The mechanism of emotional disturbance of bodily functions. N Engl J Med 1928;198:877–84. [52] Cannon WB. 1936 The role of emotions in disease. Ann Intern Med 1936;9:1453–65. [53] MacLean PD. Psychosomatic disease and the visceral brain. Recent developments bearing on the Papez theory of emotion. Psychosom Med 1949;11:338–53. [54] Maclean PD. Contrasting functions of limbic and neocortical systems of the brain and their relevance to psychophysiological aspects of medicine. Am J Med 1958;25(4):611–26. [55] Alexander F. Psychosomatic medicine. New York: Norton; 1958. [56] Engel GL. The need for a new model: a challenge for biomedicine. Science 1977;196(4286):129–36. [57] Bohm D, Factor D. Unfolding meaning: a weekend of dialogue with David Bohm. London: Routledge; 1986. [58] Ader R. Psychoneuroimmunology. New York: Academic Press; 1981. [59] Travis F, Haaga DAF, Hagelin J, et al. Effects of transcendental meditation practice on brain functioning and stress reactivity in college students. Int J Psychophysiol 2009;71(2):170–6. [60] Mao J, Farrar JT, Xie SX, et al. Use of complementary and alternative medicine and prayer among a national sample of cancer survivors compared to other populations without cancer. Complement Ther Med 2007;15(1):21–2. [61] Salmon P, Lush E, Jablonski M, et al. Yoga and mindfulness: clinical aspects of an ancient mind/body practice. Cogn Behav Pract 2009;16(1):59–72. [62] Reed T. Imagery in the clinical setting: a tool for healing. Nurs Clin North Am 2007;42(2):261–77. [63] Kushner K, Marnocha M. Meditation and relaxation. In: O’Donohue WT, Cummings NA, editors. Evidence-based adjunctive treatments. Edinburgh: Elsevier; 2008. p. 177–205. [64] Speca M, Carlson LE, MacKenzie MJ, et al. Mindfulness-based stress reduction (MBSR) as an intervention for cancer patients. In: Baer R, editor. Mindfulness-based treatment approaches. Edinburgh: Elsevier; 2006. p. 239–61.

[65] Pepper OHP. A note on the placebo. Trans Stud Coll Physicians Phila 1945;13(8):81–2. [66] Osler W. Aequanimitas. 3rd ed. New York: Blakiston; 1953. [67] Wolf S. Effects of suggestion and conditioning on the action of chemical agents in human subjects the pharmacology of placebos. J Clin Invest 1950;29(1):100–9. [68] Beecher HK. The powerful placebo. J Am Med Assoc 1955;159(17):1602–6. [69] Hróbjartsson A, Gøtzsche PC. Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment. N Engl J Med 2001;344:1594–602. [70] Polgar S, Ng J. Ethics, methodology and the use of placebo controls in surgical trials. Brain Res Bull 2005;67(4):290–7. [71] Wager TD. The neural bases of placebo effects in anticipation and pain. Seminars in Pain Medicine 2005;3(1):22–30. [72] Perlis ML, McCall WV, Jungquist CR, et al. Placebo effects in primary insomnia. Sleep Med Rev 2005;9(5):381–9. [73] Humphrey N. Great expectations: the evolutionary psychology of faith healing and the placebo effect. In: Humphrey N, editor. The mind made flesh: essays from the frontiers of psychology and evolution. New York: Oxford University Press; 2002. [74] Turner JA, Deyo RA, Loeser JD, et al. The importance of placebo effects in pain treatment and research. JAMA 1994;271(20):1609–14. [75] Arnstein P. The placebo effect. Seminars in Integrative Medicine 2003; 1(3):125–35. [76] Wolf S, Pinsky RH. Effect of placebo administration and occurrence of toxic reactions. JAMA 1954;155:339–41. [77] McRae C, Cherin E, Yamazaki TG, et al. Effects of perceived treatment on quality of life and medical outcomes in a double-blind placebo surgery trial. Arch Gen Psychiatry 2004;61:412–20.

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The Endocrine System

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CHAPTER OUTLINE Overview of the Endocrine System Role of the Naturopath Investigations Potential Interactions Hypothyroidism Hyperthyroidism

1025 1030 1031 1040 1052 1068

SECTION A OVERVIEW OF THE ENDOCRINE SYSTEM See Fig. 17.1 for an overview of the endocrine system.[1] The endocrine system is a complex system of glands and their secretions, known as hormones (a term first used by Starling in 1905).[394] The functions of these hormones have far-reaching implications for our health and wellbeing, as they play a vital role in multiple essential life functions. This includes our ability to reproduce, metabolise food, fight infection, grow and develop. The endocrine system comprises both the endocrine glands and their associated hormone-secreting tissues and organs. The endocrine glands include the pituitary, thyroid, parathyroid, adrenal and pineal glands. The associated tissues and organs (which have the ability to secrete hormones) include adipose tissue, the hypothalamus, ovaries, testes, pancreas, thymus, kidneys, stomach, liver, small intestine, skin, heart and placenta.[93]

GLANDS AND HORMONES OF THE ENDOCRINE SYSTEM Please see Table 17.1 for a summary of the glands and the associated hormones.

GLANDS Pituitary Gland

1083 1108 1111 1124 1126

However, both are regulated by the hypothalamus region of the brain, with the hypothalamic hormones being transported through the hypophyseal portal system. These hormones act on the anterior pituitary to produce numerous hormones, but are released directly from the posterior pituitary (which acts as a storage and releasing conduit rather than a synthesiser of hormones). This direct link between the hypothalamus and pituitary ensures immediate communication between the two, without the hormones being diluted into the general circulatory system. This gland is a key link between the nervous and endocrine systems, as emotional, painful and stressful experiences all affect the secretion of pituitary hormones due to its vital connection with the hypothalamus.

Thyroid Gland The thyroid is a highly vascularised butterfly-shaped gland that weighs approximately 30 g and receives 80–120 mL of blood per minute. It is located below the larynx and straddles the trachea. The thyroid is influenced by the anterior pituitary hormone thyroid stimulating hormone (TSH) and produces thyroxine (T4) triiodothyronine (T3) and calcitonin. It is the only endocrine gland that stores its hormones in large quantities, with a normally functioning thyroid storing approximately a 100day supply of hormones. The control of thyroid hormone secretion is via a negative feedback system, although the level of iodine also contributes to this by influencing the amount of viable thyroid hormones.

Parathyroid Glands

The pituitary gland is a 1–1.5 cm pea-shaped structure that has two anatomically separated lobes, known as the anterior and posterior pituitary. Of these two lobes the anterior pituitary is the larger and it secretes more hormones. © 2012 Elsevier Australia.

Diabetes Mellitus Hypoglycaemia Stress Addison’s Disease Cushing’s Syndrome/Disease

The parathyroid glands are located behind the ‘wings’ of the thyroid, and normally consist of four small round glands (two on each lateral lobe of the thyroid, with one superior and one inferior). Parathyroid hormone (PTH) regulates the concentrations of calcium, magnesium 1025

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Pineal Hypothalamus Pituitary Thyroid Parathyroids

Thymus Adrenals Pancreas

Ovary Testes

FIGURE 17.1 The endocrine system.

and phosphate ions in the blood. The level of calcitonin (from the thyroid) and PTH is directly linked to the blood calcium level via a negative feedback system. PTH has the following functions: it promotes the activity of osteoclasts, it acts on the kidneys to release calcitriol (in order to increase the amount of calcium that is absorbed from foods in the presence of vitamin D), slows the loss of both calcium and magnesium through urine and increases the loss of phosphate through the urine.

Adrenal Glands The adrenal (also called suprarenal) glands are two highly vascularised pyramid-shaped glands lying superior to each kidney. Both weigh approximately 3.5–5 g with a height of 3–5 cm, width of 2–3 cm and thickness of approximately 1 cm, and they double in size from birth. Each gland comprises an adrenal cortex (which accounts for 80–90% of its size) and a centrally located adrenal medulla. The adrenal cortex is subdivided into three zones: the zona glomerulosa (producing the mineralocorticoid aldosterone), the zona fasciculata (producing glucocorticoids cortisol, corticosterone and cortisone) and the zona reticularis (producing androgens). The production of aldosterone is related to increased blood levels of potassium and angiotensin II, while the production of both the glucocorticoids and androgens are linked with the release of adrenocorticotropic hormone (ACTH). The adrenal medulla is a part

of the autonomic nervous system (ANS). Instead of having nerve ganglions and neurotransmitters, the adrenal medulla releases the hormones adrenaline and noradrenaline from chromaffin cells. Eighty percent of the adrenal medulla cells produce adrenaline, with only 20% producing noradrenaline. It is cortisol from the adrenal cortex that induces the production of an enzyme to convert noradrenaline to adrenaline. The secretion of adrenaline and noradrenaline is induced when a person is in a stressful situation. Impulses from the hypothalamus stimulate the preganglionic neurons, which then stimulate the chromaffin cells to produce adrenaline and noradrenaline. These hormones then add to the flight-or-fight response by acting on the autonomic nervous system.

Pancreas The pancreas is located in the curve of the duodenum. It is not only an endocrine gland but also an exocrine gland, due to the release of pancreatic enzymes via the pancreatic and accessory ducts. In this section we are concerned about the function of the endocrine alpha (secrete glucagon), beta (secrete insulin), delta (secrete somatostatin) and F (secrete pancreatic polypeptide) cells of the pancreas. These occur in tiny clusters throughout the pancreas, called pancreatic islets or islets of Langerhans (after Paul Langerhans who discovered these cells in 1869). To date the interactions between these hormones is not fully

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C h a p te r 1 7 Th e E n d o c r i n e Sys te m 1027

TABLE 17.1 Summary of Hormone Function Gland

Hormone

Control Condition

Target

Effect of Secretion

Anterior pituitary

Human growth hormone (hGH) or somatotropin (WS)*

Hypothalamus monitors low blood sugar then secreting growth hormone-releasing hormone (GHRH). A rise in blood sugar causes the secretion of growth hormone-inhibiting hormone (GHIH)

Liver, muscle and connective tissues

Stimulates tissues to synthesise and release insulin-like growth factors (IGFs). These cause a rise in blood glucose and build proteins

Thyroid-stimulating hormone (TSH) or thyrotropin (WS)*

Hypothalamus monitors low blood levels of thyroid hormone and secretes TSH. A rise causes the secretion of GHIH

Thyroid gland

Stimulates the thyroid gland to secrete T3 and T4. The secretion of TSH may also be due to lowering of blood temperature or blood sugar

Follicle-stimulating hormone (FSH) (WS)*

Hypothalamus matures at puberty and begins to secrete gonadotrophin-releasing hormone (GnRH)

Ovaries and testes

In females causes the development of egg cells and the ovarian secretion of oestrogen. In males the production of sperm is increased

Luteinising hormone (LH) (WS)*

Hypothalamus matures at puberty and begins to secrete GnRH

Ovaries and testes

In females causes the ovulation and stimulates the secretion of progesterone. In males the secretion of testosterone

Prolactin (PRL) (WS)*

Fall in sex hormones before menstruation inhibits. Pregnancy and suckling increase secretion

Mammary glands

Initiates and maintains milk secretion in the mammary glands together with oxytocin and sex hormones

Adrenocorticotropic hormone (ACTH) (WS)*

Hypothalamus monitors stress and secretes corticotropin-releasing hormone (CRH). A negative feedback system inhibits

Adrenal cortex

ACTH causes secretion of glucocorticoids, e.g. cortisol

Melanocytestimulating hormone (MSH) (WS)*

Hypothalamus monitors stress and releases CRH secretion of melanocytestimulating hormones (MSH). Dopamine inhibits secretion

Melanocytes in skin

Causes melanocytes to secrete pigment called melanin

Oxytocin (OT) (WS)*

Hypothalamus controls levels after puberty. In birthing the secretion of oxytocin increases

Uterus and breast

Causes smooth muscle contraction in the uterus and release of milk from mammary ducts

Antidiuretic hormone (ADH) (WS)*

In hypothalamus, osmo (water)-receptors stimulate secretion of ADH in response to high blood concentration

Kidneys, sweat glands, arterioles

Decreases volumes of urine and perspiration. Raises blood pressure. The overall affect is to increase movement of nutrients from capillaries

Triiodothyronine (T3), thyroxine (T4) (LS)**

Hypothalamus monitors body temperature and metabolic rate. If either falls TSH is released

All cells of body

Increases oxygen use in cells, cellular metabolism and growth

Calcitonin (CT) (WS)*

High levels of blood calcium increases and low blood calcium decreases calcitonin

Osteoclasts and osteoblasts

Decreases the activity of osteoclasts and increases uptake of calcium and phosphate into the bone matrix

Parathyroid

Parathyroid hormone (PTH) (WS)*

High levels of blood calcium decreases and low blood calcium increases secretion of PTH

Osteoclasts

Increases the activity of osteoclasts, and absorption of calcium from foods. In the presence of vitamin D

Adrenal cortex

Mineralocorticoids, aldosterone (LS)**

Formation of angiotensin or increased blood potassium (K+)

Nephron in kidneys, blood filtration tissues

Increases the reabsorption of Na+ from the kidneys and loss of potassium in the urine. Regulating blood ion concentration

Glucocorticoids, cortisol (LS)**

Homeostasis disrupted, hypothalamus secretes CRH, this along with low levels of blood glucocorticoid stimulate anterior pituitary to secrete ACTH

Muscles, liver, adipose tissue, blood vessels and immune cells

Increases protein breakdown (muscles) and formation of glucose from amino acids and lactate. Increases fat breakdown and use of fatty acids for energy. Depresses inflammatory and immune responses. Overall aim to increase energy availability

Androgens, other and sex hormones (LS)**

Hypothalamus matures and stimulates secretion of androgens

All body cells

Promotes growth particularly, secondary sexual characteristics. Continues to produce oestrogens after menopause in women

Posterior pituitary (secreted by hypothalamus and stored)

Thyroid

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1028 P A R T 3 : T H E B O D Y S Y S T E M S

TABLE 17.1 Summary of Hormone Function—cont’d Gland

Hormone

Control Condition

Target

Effect of Secretion

Adrenal medulla

Adrenaline, noradrenaline (LS)**

Receive direct stimulation from sympathetic division of autonomic nervous system (ANS) to cause secretion when homeostasis disrupted

Heart, circulatory system and lungs

Increase heart output of blood, blood flow to liver/muscles and airway size in lungs. Suppress blood flow to skin and digestive system. Actions of the fight or flight response as neurotransmitters

Pancreatic alpha cells

Glucagon (WS)*

Low blood glucose level causes secretion of glucagon from alpha cells in pancreas

Liver

Increase blood glucose level by formation of glucose from glycogen (glycogenolysis), lactic acid and amino acids (gluconeogenesis)

Pancreatic beta cells

Insulin (WS)*

High blood glucose levels stimulate secretion of insulin from beta cells in the pancreas

Liver, muscle and adipose tissue

Decreases blood glucose level by increasing permeability of glucose to cells. Increases formation of glycogen, proteins and lipids

Pancreatic delta cells

Somatostatin (WS)*

High levels of free glucagon and insulin stimulate secretion. Also suppresses secretion of hGH

Alpha and beta cells. Small intestine

Stabilises levels of glucose, amino acids and lipids in blood. Reduces cell metabolic processes that promote growth

Pancreatic F cells

Pancreatic polypeptide (WS)*

Pancreatis polypeptide is secreted by intake of high protein meal and exercise

Delta cells, pancreatic digestive enzymes and gall bladder

Increases ability of digestive system to absorb proteins (as amino acids) and fats. Increases availability of nutrients for cell growth

Ovaries

Oestrogens and progesterone (LS)**

FSH stimulates the production of oestrogens and progesterone

Female reproductive system, mammary glands

Regulate female reproductive cycle and promote development of feminine secondary sexual characteristics

Relaxin (WS)*

Secreted in later stages of pregnancy

Connective tissues (esp. cartilage)

Increases elastic qualities of pubic symphysis and cervix to facilitate movement of child through the birth canal

Inhibin (WS)*

Stimulated by increased secretion of oestrogens and progesterone

Anterior pituitary

Inhibits secretion of FSH

Testosterone (LS)**

FSH stimulates the production of testosterone

Male reproductive system

Regulates production of sperm cells and promotes development of masculine secondary sexual characteristics

Inhibin (WS)*

Stimulated by increased secretion of testosterone

Anterior pituitary

Inhibits secretion of FSH

Pineal

Melatonin (WS)*

Released in darkened environment

Hypothalamus, possibly reproductive organs

Contributes to setting of body clock and sleeping rhythms. Inhibits activity of reproduction in animals

Thymus

Thymosin, thymopoeitin (WS)*

Production begins in utero and thymus shrinks after puberty

T cell maturation

These hormones control development of T cells into functioning immune cells

Testes

*WS, water soluble, target receptor on cell membrane. **LS, lipid soluble, target receptor in nucleus.

understood. See Fig. 17.2 for more detailed information on the negative feedback between glucagon and insulin.

Ovaries and Testes The ovaries and testes are the vital endocrine glands responsible for sexual maturation and reproduction. They are also referred to as the gonads due to their production of gametes (sperm in males and oocytes in females).

The ovaries are the two female gonads. They are the size and shape of two unshelled almonds and are located on either side of the uterus. They produce two steroid hormones (oestradiol and oestrone, which are both oestrogens), as well as inhibin (a hormone that inhibits the secretion of follicle-stimulating hormone (FSH)) and relaxin (a hormone that increases flexibility and dilates the cervix during the later stages of pregnancy).

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C h a p te r 1 7 Th e E n d o c r i n e Sys te m 1029 Direct effects of insulin Glycogenolysis Gluconeogenesis

Indirect effects of insulin Decrease free fatty acid flux to liver Glucagon secretion

Gluconeogenesis Insulin – Adipose tissue

Glucagon Insulin – – Free + fatty acid Glucose

Glycogen

+ Glucagon Insulin –

Glucose

Islet

FIGURE 17.2 Flow diagram of negative feedback between glucagon and insulin.[4]

The testes are two oval glands measuring approximately 5 cm in length and 2.5 cm in diameter, each weighing approximately 10–15 g. Developing near the kidneys, they descend via the inguinal canals during the seventh month of fetal development, and eventually sit in the scrotum. The testes produce both testosterone and inhibin, which regulate the production of sperm and masculine secondary sexual characteristics via a negative feedback system.

Pineal Gland The pineal gland is located on the midline roof of the third ventricle of the brain, and has a mass of only 0.1–0.2 g. It consists of both neuroglia and pinealocytes, which secrete melatonin. Melatonin is a water-soluble hormone that is derived from serotonin, and is released in higher quantities when a person is away from sunlight (for instance, at night-time). It plays a role in the setting of the ‘body clock’, in the setting of sleeping rhythms, and has been found to inhibit reproductive activity in some animals during non-reproductive seasons.

Thymus The thymus consists of two lobes, located posterior to the sternum and anterior to the aorta. The size of the lobes varies greatly from birth to adulthood, enlarging during childhood to approximately 70 g and atrophying during adolescence to approximately 3 g. The thymus has an important role in immune function, secreting the hormones thymosin, thymic humoral factor (THF), thymic factor (TF) and thymopoietin. These hormones promote the maturation of T cells into functioning immune cells.

HORMONES Hormone Receptors The hormones secreted from these glands, tissues and organs are released into the surrounding interstitial fluid, which then diffuse into capillaries and disperse directly into the bloodstream. This distinguishing feature differentiates them from exocrine glands (such as oil and sweat

glands), which utilise ducts to transport their secretions. These hormones act as signals to their target tissues, and to the system as a whole. While exocrine gland secretions are delivered to their targets via ducts, endocrine hormones circulate freely in the bloodstream. They are only able to promote a response in tissues by ‘fitting’ to the target tissue’s glycoprotein receptors, just as a lock and key fit together to open a door. If a cell does not contain any receptors for that type of hormone, it will not be able to produce an effect on that cell. For example, thyroid cells do not have any receptors for oxytocin, thus oxytocin does not affect the function of the thyroid. This is despite its general presence in the bloodstream. Hormone receptors are constantly being produced and broken down according to their perceived requirement. The perceived requirement is altered if there is too much or too little of a hormone present, with a target cell having anywhere from 2000 to 100,000 receptors. For example, if a patient has a consistently high level of blood insulin the number of insulin receptors in target tissues will reduce. The location of hormone receptors differs according to the type of hormone that binds to it. For lipid-soluble hormones (e.g. steroid and thyroid hormones) the receptors are inside the target cells, and for water-soluble hormones (e.g. thyroid-stimulating hormone (TSH), oxytocin and antidiuretic hormone) they are part of the plasma membrane surrounding cells. A target cell will have a greater response to a hormone depending upon the level of hormone in the bloodstream, the number of receptors and the influence of other hormones. For example, the presence of both FSH and oestrogen has a greater effect on the production of oocytes in the ovaries than either hormone acting alone. In contrast some hormones act antagonistically with one another, for example glucagon and insulin.

Hormone Secretion The secretion of hormones is dependent upon the stimulation of the gland. This is regulated by chemical changes in the blood, the presence of other hormones and signals from the nervous system. Regulatory systems within the endocrine system primarily operate via a negative feedback system. This means that if a level of the hormone is low, more is secreted, and when this level is high again the secretion is inhibited. For example, low blood levels of T3 and T4 stimulate the release of thyrotropinreleasing hormone (TRH) in the hypothalamus, which then causes the anterior pituitary gland to secrete TSH. This then leads the thyroid to release more T3 and T4, but when the hypothalamus and anterior pituitary detect elevated T3 levels, TRH and TSH release is inhibited. As such most hormones are released into the blood stream in short bursts, stopping and starting due to this negative feedback mechanism (Fig. 17.3). In contrast, the release of a hormone in a positive feedback system then stimulates more to be released, with no direct stopping mechanism. An example of a positive feedback system is the production of oxytocin during childbirth. The presence of oxytocin continues to rise with each contraction of the smooth muscle of the uterus, and this rising level

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1030 P A R T 3 : T H E B O D Y S Y S T E M S

DNA damage Growth factors

E2F

DHFR

p53

Cyclin A-cdk2

Replication

p14ARF

DNA Polymerase α Cyclin A Cyclin E

RB-E2F P

p21cip1 p27kip1

Cyclin E-cdk2

p57kip2 E2F-DP

?

P

p16INK4a p15INK4b

RB- P Cyclin D-cdk4/6

Cyclin A-cdk-2 Cyclin E-cdk-2

p18INK4c

E2F- P DP- P

FIGURE 17.3 Flow diagram of negative and positive feedback systems.[5]

leads to more contractions, and so the cycle continues until the delivery of the child. This feedback system has been used traditionally to ensure the prompt delivery of the placenta after the birth of a child, as the stimulation caused by breastfeeding immediately after birth further enhances the release of oxytocin, thus aiding the contraction of the uterus.

ROLE OF THE NATUROPATH TRADITIONAL INTERPRETATION The traditional understanding of the endocrine glands was largely reliant upon symptomatic evidence, as there was no deeper knowledge of the functions of the endocrine system until the mid 19th century. More comprehensive theories were developed in the mid to late twentieth century, but many questions still remain to be answered today. The developmental changes caused by the castration of calves and humans (as evident in eunuchs) caught the attention of many enquiring minds in ancient Egypt and China, and led philosophers of those times to wonder at the mechanism of action of the testes. Similarly goitres were first recognised in China in 2700 BC,[391] and repeatedly noted in numerous cultures since. Avicenna (Abou Ali Sina, 980–1037), in his medicinal and philosophical masterpiece al-Qanun (‘The Cannon of Medicine’), outlined the physical symptoms of both insulin-dependent and non-insulin-dependent diabetes.[392] However, it was many centuries later, in 1869, before the pancreatic insula were discovered by Langerhans. The anatomical discoveries of each of the endocrine glands greatly pre-dated the understanding of their functions. The thymus gland was known to the Alexandrians in the 3rd century BC, and the thyroid, pineal and pituitary glands were anatomically described by Galen.[393] The adrenal glands were not discovered until the 16th century and the pancreatic and parathyroid glands in the latter 19th century. Pre-dating each of these discoveries

was the anatomical observation by the earliest physicians of both the gonads and the liver.[393] Although the functions of individual endocrine ‘hormones’ (a term first used by Starling in 1905)[394] were unknown, symptomatic treatment of endocrine diseases was widespread. For example, goat’s rue (Galega officinalis) was used in medieval Europe for the treatment of diabetes and became the basis of the modern drug metformin. Goat’s rue continues to be used by modern herbalists for its blood sugar regulating actions. Similarly fenugreek (Trigonella foenum-graecum) was used by Avicenna in the treatment of diabetes, and also continues to be used for this condition in modern naturopathic treatment.[395] The treatment of the endocrine system initially centred on the humoral beliefs of Galen. The pituitary was thought to be a sump for phlegm (waste products) from the brain which were then expelled via the nasal passage.[396] Similarly, goitres were thought to be caused from excess phlegm; however, they were treated with empirical treatments of marine sponge and seaweed.[391] These humoral theories were largely believed until 1855, when a number of scientists and physicians disproved them, although they had been anatomically disproved some 200 years previously by anatomists such as Conrad Victor Schneider and Richard Lower.[394]

MODERN INTERPRETATION The modern interpretation of the endocrine system is based on both the traditional use of herbs (for both symptomatic relief and treating the cause) and the scientific understanding of the connection between the nervous and endocrine systems. The scientific experimentation of the mid 19th century saw a radical shift and deeper understanding of the endocrine system, as experiments such as those carried out by A.A. Berthold (in 1849) were able to show that the action of the endocrine glands was not local, but systemic.[397] Berthold castrated four out of six young male chickens. Two of these four had their testes transplanted to the abdominal cavity, while the remaining two had their testes removed completely. The growth of the two uncastrated chickens was normal, and they developed into roosters with fully developed cones, wattles and plumage. The two fully castrated chickens failed to develop any male rooster characteristics, displaying only atrophied combs and wattles. Surprisingly for the scientists of the time, the two chickens with the transplanted testes grew to become fully developed roosters, displaying the same male characteristics as the control roosters. This was among the first evidence that hormones existed, that they were transported throughout the body in the bloodstream, and that they had a decisive role in sexual growth and maturation. Further experiments and observations conducted around this time helped to prove this theory, such as the observations of Thomas Addison (also in 1849) on patients with what he termed ‘melasma suprarenale’ (adrenal disease), a disorder which is now called Addison’s disease in his honour.[393] The understanding of the endocrine system progressed rapidly from this point, as these ‘internal secretions’

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C h a p te r 1 7 Th e E n d o c r i n e Sys te m 1031

were eventually shown to be chemical structures called ‘hormones’.[393] The discovery of each individual hormone quickly ensued at the turn of the 20th century. Following this the role of the hormones on the overall process of metabolism (a term first used by Michael Foster in 1876) and regulation was discovered via the work of Harvey Cushing and Langdon-Brown.[393] Until the mid 20th century the symptomatic approach to treatment remained, with varying results. This is evident in the quote below from Ellingwood (1910)[398] discussing the treatment and prognosis of diabetes mellitus: Treatment:–As yet no specifics have been discovered, either for this disease as a whole, or for any of its attendant conditions. Various measures have been devised but these have usually been ultimately abandoned. While dietary measures are by far the most important. Prognosis:–The prognosis as to cure is always unfavourable.

The most recent development in the understanding and subsequent treatment approach to the endocrine system has developed since the 1920s due to the knowledge of the interconnected nature of both the endocrine and nervous systems.[8] Specifically, it is the vast amount of research conducted in the latter part of the 20th century regarding the hypothalamic–pituitary–adrenal (HPA) axis and psychoneuroimmunology (PNI) that has most significantly altered the understanding of the endocrine system.[399] This innate link between the brain, the body and health has given a greater scientific basis to the holistic nature of the naturopathic treatment approach. For example, studies conducted in Russia on Siberian ginseng (Eleutherococcus senticosus) during the great ‘space race’ have helped to establish that the use of single herbs can alter immune function, physical stamina and aid stress adaptation, all via the endocrine system.[283] This holistic treatment of the endocrine system is often a key factor in treatment due to the role stress plays in many patients’ lives. However, the power of what Bellamy and Pfister (1992)[368] term ‘the largest endocrine gland’ (the brain) is yet to be fully realised. They quote Albert Schweizer’s musings to better explain their point:

INVESTIGATIONS Investigations used in endocrine disorders are summarised in Table 17.4.

TESTOSTERONE AND SEX HORMONE BINDING GLOBULIN (SHBG) Normal values of testosterone and sex hormone binding globulin are shown in Table 17.5.

HUMAN CHORIONIC GONADOTROPHIN (HCG) TEST (URINE PREGNANCY TEST) This test is used to diagnose pregnancy, monitor ‘high risk’ pregnancy, and as a tumour marker for certain tumours (Table 17.6). Human chorionic gonadotrophin hormone is normally secreted by the placental tissue after the ovum is fertilised (i.e. from the earliest stages of development). HCG will appear in the blood of pregnant women as early as 10 days after conception.

URINARY HORMONE ASSESSMENT Oestrogen metabolites – an assessment of the urinary levels of oestrogen metabolites 2-hydroxyoestrone (2-OHE1) and 16α-hydroxyoestrone (16α-OHE1) provides information about the way in which oestrogen is being metabolised by the patient. A result showing a low ratio (a reduced 2-hydroxyoestrone) indicates that there is a state of oestrogen excess within the patient. Alternatively a high ratio (increased 2-hydroxyoestrone) indicates an oestrogen deficient state. This test is suitable for males and females and is conducted using the first morning urine sample (the patient must fast from 10 p.m. the evening before). Females taking the test are advised to take it between days 18 and 25 of their menstrual cycle.

URINARY IODINE

The witch doctor succeeds for the same reason all the rest of us succeed. Each patient carries his own doctor inside him. They come to us not knowing that cure. We are at our best when we give the doctor who resides within each patient a chance to go to work. (p. 259)

Excess iodine is excreted via the kidneys, thus providing an accurate measurement of recent iodine usage/requirement (Table 17.7). First morning urine samples provide the most accurate results; 24-hour urine samples are not required for this test. A study conducted in Indonesian children found urinary iodine excretion to be the best method for detecting iodine deficiency when compared with TSH, goitre palpation, ultasonography, intellectual performance and anthropometric indices (Pardede, Hardjowasito et al. 1998).

This concept of the patient’s innate healing ability is central to the naturopathic approach to treatment, and is rapidly being given a scientific basis of evidence via the function of the endocrine system.

Nutritional medicine treatment of endocrine disorders is described in Table 17.2. Some useful herbal medicines are listed in Table 17.3. And Table 17.8 lists some potential herb–drug interactions.

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TABLE 17.2 Nutritional Medicine Requirement

Justification

RDI[350]

Therapeutic Dose

Food Sources

A high strength, sustained release multivitamin/ mineral preparation

The excess production of thyroid hormones that occurs in hyperthyroidism leads to a higher metabolic rate and subsequently nutrients are depleted at a higher rate. Additionally, in hyperthyroidism there is malabsorption. Due to these factors a greater number of nutrients are required by the body. Similarly where there is adrenal exhaustion higher requirements will be required by the body to meet increased demands

–

–

N/A

Vitamin B complex

The B vitamins provide energy and support during physically demanding periods. They are involved in maintaining the health of the hormone-producing glands[351]

Comprehensive complex containing individual B vitamins as per below:

–

Legumes, whole grains, nuts, beans, brewer’s yeast, leafy green vegetables

Thiamin (vitamin B1)

Vitamin B1 is involved with other B vitamins in energy metabolism and the normal functioning of nerves. Vitamin B1 may be needed during periods of increased physical and mental stress and has been clinically proven to protect the adrenal gland from functional exhaustion

Men: 19–30 years 1.2 mg/d 31–50 years 1.2 mg/d 51–70 years 1.2 mg/d > 70 years 1.0–1.2 mg/d Women: 19–30 years 1.1 mg/d 31–50 years 1.1 mg/d 51–70 years 1.1 mg/d > 70 years 1.1 mg/d

5–150 mg/d

Legumes, liver, nuts, whole grains, wheatgerm

Vitamin B2

Vitamin B2 is crucial in the production of energy and may be needed in periods of heightened stress. Along with vitamins B5, B12, folic acid, potassium and sodium it stabilises the activity of the adrenal glands

Men: 19–30 years 1.3 mg/d 31–50 years 1.3 mg/d 51–70 years 1.3 mg/d >70 years 1.6 mg/d Women: 19–30 years 1.1 mg/d 31–50 years 1.1 mg/d 51–70 years 1.1 mg/d >70 years 1.3 mg/d

10–200 mg/d

Avocados, beans, currants, eggs, milk and dairy products, sprouts, whole grains

Vitamin B3

Nicotinamide is converted into the active forms of niacin in the body. Niacin is required for the function of more than 200 enzymes throughout the body and is a component of the glucose tolerance factor, which helps to control blood glucose delaying or preventing the need for insulin by interfering with immune-mediated beta cell destruction. Vitamin B3 has also been found to help slow down the development of nephropathy in diabetes[351]

(As niacin equivalents) Men: 19–30 years 16 mg/d 31–50 years 16 mg/d 51–70 years 16 mg/d >70 years 16 mg/d Women: 19–30 years 14 mg/d 31–50 years 14 mg/d 51–70 years 14 mg/d >70 years 14 mg/d

10–3000 mg/d

Almonds, eggs, chicken, mackerel, meat, peanuts, salmon, sardines, sunflower seeds

Vitamin B5

Vitamin B5 enhances adrenal cortex function. Deficiency leads to a compromised adrenal cortex function. Vitamin B5 down-regulates hypersecretion of cortisol secondary to high stress situations

Men: 19–30 years 6 mg/d 31–50 years 6 mg/d 51–70 years 6 mg/d >70 years 6 mg/d Women: 19–30 years 4 mg/d 31–50 years 4 mg/d 51–70 years 4 mg/d >70 years 4 mg/d

20–500 mg/d

Avocado, beans, egg yolks, green vegetables, milk, mushrooms, oranges, royal jelly, sweet potato, wholegrain cereals

Vitamin B6

Along with the other B vitamins, vitamin B6 is important during periods of stress, providing support to the nervous system and adrenal glands. Vitamin B6 deficiency has been shown to cause symptoms of hypoglycaemia, increased insulin sensitivity and degeneration of beta cells

Men: 19–50 years 1.3 mg/d 51–70 years 1.7 mg/d Women: 19–50 years 1.3 mg/d 51–70 years 1.5 mg/d

10–150 mg/d

Brewer’s yeast, chicken, yolk, legumes, mackerel, oatmeal, salmon, tuna, walnuts

Vitamin B9

Along with vitamins B2, B5, B12, potassium and sodium vitamin B9 stabilises the activity of the adrenal glands

Men: 19–70 years 400 μg/d Women: 19–70 years 400 μg/d

1000–5000 μg/d

Beans, eggs, green leafy vegetables, lentils, yeast

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TABLE 17.2 Nutritional Medicine—cont’d Requirement

Justification

RDI[350]

Therapeutic Dose

Food Sources

Vitamin B12

Along with vitamins B2, B5, folic acid, potassium and sodium, vitamin B12 stabilises the activity of the adrenal glands

Men: 19–70 years 2.4 μg/d Women: 19–70 years 2.4 μg/d

300–800 μg

Bacterial synthesis in the gut Clams, egg yolk, herring, milk, meat, oysters, salmon, sardines

Biotin

Supplementation with biotin has been found to help maintain healthy blood sugar levels in individuals with diabetes as the generation of glucose is dependent on a biotin-containing enzyme

Men: 19–70 years: 30 μg/d Women: 19–70 years: 25 μg/d

0.5–15 mg/d

Bean sprouts, egg yolk, milk, peanuts, soy beans, wholegrain cereals

Vitamin C

Vitamin C is a water soluble antioxidant that protects against oxidative stress associated with thyroid diseases. The adrenal gland is among the organs with the highest concentration of vitamin C in the body. Interestingly, both the adrenal cortex and the medulla accumulate such high levels of ascorbate. Vitamin C is a co-factor required both in catecholamine biosynthesis and in adrenal steroidogenesis. Production of adrenaline and noradrenaline are dependent on vitamin C.[352] Vitamin C can also help to regulate blood glucose

Men: 19–70 years 45 mg/d Women: 19–70 years 45 mg/d

250–10,000 mg/d

Blackcurrant, broccoli, citrus fruits, kiwis, strawberries, rosehips, guava, mangoes, pineapple

Vitamin D

Glucose intolerance and insulin secretion has been observed during vitamin D deficiency, resulting in type 2 diabetes. It is theorised that this is due to vitamin D receptors in several tissues and cells, including the pancreatic beta-cells

Men: 19–50 years 5.0 μg/d 51–70 years 10.0 μg/d >70 years 15.0 μg/d Women: 19–50 years 5.0 μg/d 51–70 years 10.0 μg/d >70 years 15.0 μg/d

400–1600 IU/d

Synthesised by the action of sunlight on skin, fish liver oils–cod, halibut, herring, tuna, egg yolk, milk, sprouted seeds

Vitamin E

Hypothyroidism is accompanied with increased oxidative stress and fat soluble antioxidant vitamin E supplementation exerts beneficial effects on this situation. Vitamin E can enhance insulin sensitivity thus reducing the need for insulin and other hypoglycaemics[351]

Men: 19–70 years 300 mg/d Women: 19–70 years 300 mg/d

100–800 mg/d

Almonds, beef, corn, egg yolks, nuts, safflower, sunflower, wheatgerm

L-tyrosine

L-tyrosine is an essential precursor for the synthesis of the catecholamines adrenaline, noradrenaline and dopamine and the thyroid hormone thyroxine. Supplementation with tyrosine aids adrenal function helping during periods of prolonged stress, to support the body and improve stress adaptation.

1120 mg/d

1120 mg/d

Almonds, beef, cheese, chicken, eggs, fish, soy beans, wild game

Zinc

Zinc is required for healthy thyroid function and the synthesis and metabolism of thyroid hormones. Deficiency of zinc dependent enzymes may result in decreased thyroid hormone levels and resting metabolic rate (RMR). Changes in zinc metabolism are commonly observed in diabetic patients

Men: 19–70 years 14 mg/d Women: 19–50 years 6 mg/d

10–100 mg/d

Beef, baked beans, cashews, egg yolks, ginger, herrings, liver, milk, lamb, oysters, sunflower and pumpkin seeds, whole grains

Selenium

Selenium is essential for the biosynthesis and function of the iodothyronine deiodinase enzymes that are essential for the conversion of T4 to T3. Selenium-dependent glutathione peroxidases protect against oxidative damage to the thyroid gland. Deficiency leads to decreased conversion of T4 to T3, and oxidative stress on the thyroid gland as a result of reduced glutathione peroxidise activity. The thyroid gland contains more selenium per gram than any other tissue in the body. Selenium is also important for healthy blood sugar regulation. Deficiency may reduce insulin secretion

Men: 19–70 years 70 μg/d Women: 19–70 years 60 μg/d

200–600 μg/d

Alfalfa, brazil nuts, cashews, crab, eggs, fish, garlic, kidney, liver, mackerel, oysters, peanuts, tuna, whole grain cereals, broccoli, onions

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1034 P A R T 3 : T H E B O D Y S Y S T E M S

TABLE 17.2 Nutritional Medicine—cont’d Requirement

Justification

RDI[350]

Therapeutic Dose

Food Sources

Magnesium

Magnesium assists in the maintenance of normal healthy blood glucose metabolism. Hypomagnesaemia is frequently present in diabetic patients hence magnesium is often suggested in patients with diabetes mellitus who have proven hypomagnesaemia and the presence of its complications

Men: 19–30 years 410 mg/d 31–70 years 420 mg/d Women: 19–30 years 310 mg/d 31–70 years 320 mg/d

300–1000 mg/d

Eggs, cocoa, almonds, brewer’s yeast, cashews, kelp, wheatbran, wheatgerm, buckwheat

Manganese

Manganese plays a crucial role as part of its role in the glucose tolerance factor and is required for metabolism of carbohydrates as the synthesis of new glucose from puyruvate is necessary on manganese-containing enzymes as well as for normal insulin secretion. Deficiency may contribute to blood sugar abnormalities and reduced pancreatic cell function Manganese is required for thyroid hormone function

Men: 19–70 years 5.5 mg/d Women: 19–70 years 5 mg/d

2–50 mg/d

Almonds, beans, coconuts, corn, kelp, sunflower seeds, legumes, walnuts, whole grains

Alpha lipoic acid

Alpha lipoic acid, also known as thioctic acid, is an antioxidant and decreases the risk of cell damage attributed to free radicals. Alpha lipoic acid is unique in that it is soluble in water as well as fat and is therefore able to scavenge both fat- and water-soluble free radicals. It also has the ability to recycle or regenerate endogenous antioxidants including vitamins C and E, CoQ10 and glutathione. Alpha lipoic acid plays a role in glucose metabolism and is involved in the transport of blood glucose into cells. It may therefore help maintain healthy blood sugar levels and has been used in diabetics to assist with the conversion of sugar to energy and is thought to be beneficial in reducing the effects of oxidative stress[353] which are associated with this condition, as well as decreasing symptoms associated with diabetes such as diabetic polyneuropathy[354]

50–600 mg/d[355]

600 mg/d[353,355]

Typical dietary sources of lipoic acid are muscle meats, heart, kidney, and liver, and to a lesser degree, fruits and vegetables; potatoes

Chromium

Chromium is an essential micronutrient for humans. It plays a role as a co-factor in all insulin-regulated activities including carbohydrate, lipid and protein metabolism and is an essential component of glucose tolerance factor, a compound that helps to regulate blood sugar. Chromium is particularly important for normal carbohydrate metabolism and assists in maintaining healthy blood glucose levels, by aiding the transport of glucose from the blood into the cells Chromium may be used where diets are high in simple sugars and refined carbohydrates, which may have increased chromium requirements

Men: 19–70 years 45 μg/d Women: 19–70 years 35 μg/d

100–400 μg[356,357]

Asparagus, beer, cheese, egg yolk, molasses, nuts, oysters, peanuts, prunes, raisins

Iodine

Iodine is an essential component of the thyroid hormones thyroxine (T4) and triiodothyronine (T3), and deficiency impairs synthesis of these hormones. Approximately 60 μg of iodine is absorbed each day by the thyroid gland; however, it is estimated that 150 μg is required each day for optimum functioning of the thyroid gland[358]

Men: 19–70 years 150 μg/d Women: 19–70 years 150 μg/d

100–1100[356,359]

Seaweed (e.g. wakame), cod, iodised salt, lima beans, mushrooms, oysters

Sources: see end of chapter

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C h a p te r 1 7 Th e E n d o c r i n e Sys te m 1035

TABLE 17.3 Herbal Medicine Class

Example

Justification

Adaptogen

Eleuthrococcus senticosus (Siberian ginseng)

Adaptogens improve non-specific responses to stress by increasing the resistance of the recipient to a variety of physical, chemical, or biological stressors while also promoting recovery and acting as a general regulator in the body. Siberian ginseng has traditionally been used as a prophylactic to build resistance, reduce susceptibility to illness, and promote health and longevity. Its activity appears to be based on whole body effects rather than particular organs or systems, which lends support to the traditional view that ginseng is a tonic that can revitalise the functioning of the organism as a whole. Siberian ginseng increases levels of noradrenaline, serotonin, adrenaline and cortisol (improving positive and negative responses to stress)

Adrenal restorative

Rehmannia glutinosa (rehmannia)

Rehmannia is an adrenal tonic that has been used in Traditional Chinese Medicine to nourish qi (vital energy). Rehmannia works by supporting the adrenal cortex and pituitary gland during prolonged stress and regulates cortisol levels. In trials done on rabbits, rehmannia reversed morphological changes to the pituitary and adrenal cortex, antagonising the suppressive effect of glucocorticoids on the hypothalamus–pituitary–adrenal axis[360]

Tonic

Withania somnifera (ashwagandha)

Withania somnifera is a gentle tonic that is considered to be the pre-eminent adaptogen from the Ayurvedic medical system. Withania improves responses to stress, possibly via an action on the adrenal glands, and also has anti-inflammatory and sedative effects. Withania is used to treat nervous exhaustion, convalescence and debility associated with chronic inflammatory conditions

Aldose reductase inhibitor

Glycyrrhiza glabra (liquorice)

Aldose reductase is an enzyme in carbohydrate metabolism that converts glucose to sorbitol. Its activity increases as the glucose concentration rises in diabetes particularly in the lens of the eyes, the peripheral nerves and glomerulus, leading to retinopathy and neuropathy. Liquorice in its role as an aldose reductase inhibitor helps to prevent eye and nerve damage in people with diabetes

Antiobesity

Coleus forskohlii (coleus)

The exact mechanism of Coleus forskohlii in weight loss is unknown; however, based on in vitro data it is hypothesised that Coleus forskohlii may cause an increase in cyclic adenosine phosphate (cAMP) which in turn leads to an activation of protein kinase which activates lipase (an enzyme involved in the breakdown of triglycerides, fatty substances in the blood and components of LDL cholesterol). This results in thermogenesis, loss of body fat and the maintenance of lean body mass.[361] Coleus forskohlii may have a thyroid stimulating action, thus possibly increasing metabolic rate and thermogenesis and may regulate insulin secretion thus positively affecting fat and protein metabolism

Appetite inhibiting

Gymnema sylvestre (gymnema)

Gymnema is an Ayurvedic herb with the ability to inhibit the taste of sweetness, hence its nickname ‘sugar destroyer’. Gymnema reduces desire for food, particularly those that are sweet in taste, leading to its action as an appetite inhibitor. This action also means it is a useful addition to any weight-loss programme

Hypoglycaemic

Galega officinalis (goat’s rue)

Galegine in goat’s rue has been associated with marked reductions in blood sugar levels. Studies in the 1970s demonstrated that the alkaloid galegine within goat’s rue is responsible for reducing blood sugar levels.[362] The British Herbal Pharmacopeia confirms the action of galega as a hypoglycaemic agent with anti-diabetic activity and indicates its use for diabetes[363]

Hepatic, hepatoprotective, hepatotrophorestorative

Bupleurum falcatum (bupleurum)

The liver plays an important role in the effective metabolism of the thyroid hormones as well as the regulation of their systemic endocrine effects. Suboptimal liver function can affect thyroid hormone metabolism hence the application of hepatics in the management of thyroid conditions. Bupleurum falcatum is a Traditional Chinese Medicine which displays hepatoprotective activity. It is highly indicated where there is poor liver function

Pancreatic trophorestorative (endocrine functions)

Gymnema sylvestre (gymnema)

The exact mode of action by which gymnema exerts its pancreatic trophorestorative action is unknown. It appears that gymnema helps to support healthy pancreatic function via a wide array of actions rather than just one; these include the inhibition of intestinal absorption of glucose and promotion of glucose homeostasis, and also increasing the number of cells in the pancreas responsible for insulin production

Thyroid stimulant

Fucus vesiculosus (bladderwrack)

Fucus vesiculosus is a valuable source of iodine, a trace element necessary for regulating the body’s metabolism and normal production of thyroid hormones. Organic iodine, such as that found in bladderwrack, is likely to be better utilised by the body in terms of bioavailability and less likely to be excreted than potassium iodide[364]

Thyroid suppressant/ regulator

Lycopus spp. (bugleweed)

Lycopus is a perennial herb containing phenolic acids. In the 19th century Lycopus was given to calm the nerves. Today Lycopus is primarily used to help manage hyperthyroid conditions as well as the associated cardiac symptoms. High doses of Lycopus cause a reduction of thyroid stimulating hormone in animal experiments; conversely in hyperthyroid patients treated with low doses of Lycopus improvement of cardiac symptoms was reported[365]

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TABLE 17.8 Potential Interactions Drug Classes Commonly Used

Herb/Supplement

Potential Outcome

Recommendation

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (glipizide, glibenclamide, glimepiride) Insulin analogue (lispro, aspart, isophane, lente, ultralente, detemir, glargine)

Alpha lipoic acid (ALA)

Possible additive or synergistic effect; hypoglycaemia may result; however, clinical significance uncertain ALA may protect insulin action under oxidative stress

Consider co-administration: the use of ALA as an adjunctive to other diabetic treatment may act as in a preventative mode, particularly in dysglycaemic patients Monitor patient closely in conjunction with other health professionals

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (glibenclamide, glimepiride)

Coenzyme Q10

Possible beneficial effect; some hypoglycaemic drugs inhibit the CoQ10 enzyme NADH-oxidase, which may exert further adverse effects on insulin biosynthesis in individuals with diabetes mellitus

Consider co-administration: monitor glucose levels closely

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (glipizide, glibenclamide, glimepiride) Oral hypoglycaemic agents/Insulin sensitisers/α-glucosidase inhibitors (acarbose) Oral hypoglycaemic agents/insulin secretagogues/glitinides (repaglinide) Oral hypoglycaemic agents/insulin sensitisers/ glitazones/thiazolidinediones (rosiglitazone, troglitazone, pioglitazone) Insulin analogue (lispro, aspart, isophane, lente, ultralente, detemir, glargine)

Conjugated linoleic acid (CLA)

Interaction inconclusive; CLA has been shown to improve glucose tolerance, but also to increase fasting plasma glucose concentrations

Low risk: monitor patient closely in conjunction with other health professionals

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (glipizide, glibenclamide, glimepiride) Insulin analogue (lispro, aspart, isophane, lente, ultralente, detemir, glargine)

Omega-3 fatty acids

Interaction uncertain; adverse effects of fish oil on glucose control medications are unlikely, possibly short-lived, and may vary according to the patient

Low risk: clinical implications of interaction will depend on a variety of factors: monitor patient Lifestyle interventions also recommended to moderate possible adverse effects of omega-3 fatty acid therapy

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (glipizide, glibenclamide, glimepiride) Oral hypoglycaemic agents/insulin sensitisers/α-glucosidase inhibitors (acarbose) Oral hypoglycaemic agents/insulin secretagogues/glitinides (repaglinide) Oral hypoglycaemic agents/insulin sensitisers/ glitazones/thiazolidinediones (rosiglitazone, troglitazone, pioglitazone)

Acetyl-L-carnitine

Possible additive effect; L-carnitine significantly lowers fasting plasma glucose in type 2 diabetic patients. However, fasting triglyceride levels are increased

Low risk: consider co-administration in patients with healthy lipid profile. Monitor lipid levels in conjunction with other health professionals

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (glipizide, glibenclamide, glimepiride) Oral hypoglycaemic agents/insulin sensitisers/α-glucosidase inhibitors (acarbose) Oral hypoglycaemic agents/insulin secretagogues/glitinides (repaglinide) Oral hypoglycaemic agents/insulin sensitisers/ glitazones/thiazolidinediones (rosiglitazone, troglitazone, pioglitazone) Insulin analogue (lispro, aspart, isophane, lente, ultralente, detemir, glargine)

Chromium

Possible additive effect; chromium potentiates insulin activity through multiple mechanisms and has hypoglycaemic activity in some individuals Possible beneficial effect; compromised chromium status may contribute to insulin resistance, dysglycaemia and onset of diabetes

Caution: monitor drug and nutrient requirements, and patient glucose levels closely Consider co-administration if deficiency is indicated. Monitor patient in conjunction with other health professionals

Diabetes mellitus

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TABLE 17.8 Potential Interactions—cont’d Drug Classes Commonly Used

Herb/Supplement

Potential Outcome

Recommendation

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (glipizide, glibenclamide, glimepiride)

Magnesium

Possible beneficial interaction; magnesium intake may improve insulin sensitivity and secretion, thus increasing drug activity on glucose. Enhanced drug response may cause hypoglycaemia or facilitate therapeutic strategy

Consider co-administration: Monitor patient closely and titrate drug dose

Insulin analogue (lispro, aspart, isophane, lente, ultralente, detemir, glargine)

Magnesium

Possible beneficial effect; magnesium can improve insulin sensitivity and secretion

Consider co-administration: monitor patient closely

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin)

Vitamin B1

Possible adverse effect; taken together, thiamine and metformin may increase the risk of lactic acidosis, and reduce thiamine activity

Low risk: co-administer if indicated. Separate doses by 2–4 hours

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin sensitisers/ glitazones/thiazolidinediones (rosiglitazone, troglitazone, pioglitazone) Oral hypoglycaemic agents/insulin sensitisers/α-glucosidase inhibitors (acarbose) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (gliclazide, glipizide, glibenclamide, glimepiride) Oral hypoglycaemic agents/insulin secretagogues/glitinides (repaglinide) Insulin analogue (lispro, aspart, isophane, lente, ultralente, detemir, glargine)

Vitamin B3

Possible adverse effect: high-dose niacin administration could interfere with the therapeutic activity of glucose control medications, resulting in hyperglycaemia Possible beneficial effect: niacinamide may enhance secretion and increase insulin sensitivity, and may be beneficial in preventing and/or delaying type 1 diabetes. Niacinamide does not appear to interfere with insulin or hypoglycaemic medications

Moderate risk: consider coadministration of low-dose niacin or niacinamide in deficient patients. Monitor patient closely and regularly in conjunction with other health professionals (plasma glucose and liver enzymes) Lifestyle interventions also recommended

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin)

Vitamin B9 (folate)

Possible adverse effect: metformin may reduce folate levels in diabetics by reducing folic acid absorption

Low risk: consider coadministration. Diabetic patients may need folic acid supplements to reduce hyperhomocysteinaemia and their risk of cardiovascular disease

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin)

Vitamin B12

Beneficial nutritional effect: metformin therapy causes reduced vitamin B12 absorption and low serum total vitamin B12 by depressing intrinsic factor (IF) secretion and uptake of B12-IF complex. May also reduce folate

Low risk: consider co-administration. Supplement also with folic acid and calcium Monitor folate and cobalamin status

Insulin analogue (lispro, aspart, isophane, lente, ultralente, detemir, glargine)

Vitamin E

Interaction uncertain; vitamin E may improve glucose tolerance in diabetics

Low risk: caution is warranted against high doses of vitamin E in obese patients. Monitor patient in conjunction with other health professionals

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin sensitisers/ glitazones/thiazolidinediones (rosiglitazone, troglitazone, pioglitazone) Oral hypoglycaemic agents/Insulin sensitisers/α-glucosidase inhibitors (acarbose) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (gliclazide, glipizide, glibenclamide, glimepiride) Oral hypoglycaemic agents/insulin secretagogues/glitinides (repaglinide) Insulin analogue (lispro, aspart, isophane, lente, ultralente, detemir, glargine)

Zinc

Possible additive effect; zinc may improve both insulin secretion and insulin sensitivity and may exert insulin-like effects

Low risk: use cautiously with diabetes medications. Monitor patient closely

Continued

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TABLE 17.8 Potential Interactions—cont’d Drug Classes Commonly Used

Herb/Supplement

Potential Outcome

Recommendation

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (gliclazide, glipizide, glibenclamide, glimepiride) Insulin analogue (lispro, aspart, isophane, lente, ultralente, detemir, glargine)

Allium cepa Allium sativum

Possible additive effect; significant hypoglycaemic effects of garlic and onion are preliminary Garlic extracts may provide other, beneficial and cardioprotective effects

Low risk: consider coadministration in some patients, but not as a strategy for reducing blood glucose levels

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (gliclazide, glipizide, glibenclamide, glimepiride)

Cinnamomum zeylanicum

Possible additive effects; cinnamon has been shown to potentiate insulin activity and increase glucose metabolism May produce synergistic, beneficial effect under professional supervision

Low risk: consider coadministration. Monitor patient and drug levels closely

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin sensitisers/ glitazones/thiazolidinediones (rosiglitazone, troglitazone, pioglitazone) Oral hypoglycaemic agents/insulin sensitisers/α-glucosidase inhibitors (acarbose) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (gliclazide, glipizide, glibenclamide, glimepiride) Oral hypoglycaemic agents/insulin secretagogues/glitinides (repaglinide) Insulin analogue (lispro, aspart, isophane, lente, ultralente, detemir, glargine)

Coleus forskohlii

Possible additive effect; coleus stimulates insulin release and may enhance the effect of hypoglycaemic agents or exogenous insulin

Moderate risk: use with caution. Monitor serum glucose levels in conjunction with other health professionals. Drug dose may require adjustment

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin sensitisers/ glitazones/thiazolidinediones (rosiglitazone, troglitazone, pioglitazone) Oral hypoglycaemic agents/insulin sensitisers/α-glucosidase inhibitors (acarbose) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (gliclazide, glipizide, glibenclamide, glimepiride) Oral hypoglycaemic agents/insulin secretagogues/glitinides (repaglinide) Insulin analogue (lispro, aspart, isophane, lente, ultralente, detemir, glargine)

Gymnema sylvestre

Possible additive effect; the hypoglycaemic effects of gymnema may potentiate the effects of hypoglycaemic drugs in diabetic patients May produce synergistic, beneficial effect under professional supervision

Moderate risk: monitor serum glucose levels in conjunction with other health professionals. Drug dose may require adjustment

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (gliclazide, glipizide, glibenclamide, glimepiride)

Momordica charantia

Possible additive effects; Bitter melon has been shown to produce hypoglycaemic activity May produce beneficial effect under professional supervision

Moderate risk: monitor patient and drug requirements closely in conjunction with other health professionals

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (gliclazide, glipizide, glibenclamide, glimepiride) Insulin analogue (lispro, aspart, isophane, lente, ultralente, detemir, glargine)

Panax quinquefolius

Possible adverse effect; American ginseng can induce lowering of postprandial glucose levels in humans

Moderate risk: prescription for glycaemic control is not indicated for this herb, particularly in conjunction with antidiabetic drugs

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (gliclazide, glipizide, glibenclamide, glimepiride) Insulin analogue (lispro, aspart, isophane, lente, ultralente, detemir, glargine)

Panax ginseng

Interaction uncertain; theoretical adverse interaction is based on established property of American ginseng to induce lowering of postprandial glucose levels

Low risk: prescription for glycaemic control is not indicated for this herb

Oral hypoglycaemic agents/insulin sensitisers/biguanides (metformin) Oral hypoglycaemic agents/insulin secretagogues/sulfonylureas (gliclazide, glipizide, glibenclamide, glimepiride)

Trigonella foenum-graecum

Possible additive effects; fenugreek exerts hypoglycaemic activity by delaying glucose absorption and enhancing its utilisation May produce beneficial effect under professional supervision

Moderate risk: monitor blood sugar levels closely

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TABLE 17.8 Potential Interactions—cont’d Drug Classes Commonly Used

Herb/Supplement

Potential Outcome

Recommendation

Analgesic/acetylsalicylic acid (aspirin)

Omega-3 fatty acids

Inconclusive; the combination of omega-3 fatty acids and aspirin may be beneficial under certain circumstances (e.g. heart disease due to improved blood flow characteristics, relaxation of endothelial cells, etc.) but problematic in other conditions (e.g. warfarin therapy due to increased risk of bleeding complications)

Risk variable: closely monitor patients at risk for excessive bleeding

Analgesic/acetylsalicylic acid (aspirin)

Chromium

Possible adverse effects; interaction inconclusive. Aspirin may theoretically increase chromium levels, which could increase the risk and magnitude of side-effects

Low risk: monitor patient closely. Check chromium levels in patients on longterm chromium therapy

Analgesic/acetylsalicylic acid (aspirin)

Vitamin B2

Interaction uncertain; concurrent intake of aspirin and riboflavin has been reported to cause gastric intolerance in some patients

Low risk: monitor patient closely

Analgesic/acetylsalicylic acid (aspirin)

Vitamin B3

Possible beneficial effect; aspirin can moderate niacin-induced cutaneous flushing and other niacin-induced effects

Low risk: consider co-administration Caution: closely monitor patients at risk for bleeding. Monitor liver enzymes

Analgesic/acetylsalicylic acid (aspirin)

Vitamin C

Possible beneficial effect; aspirin increases urinary excretion of ascorbic acid and decreases its metabolic availability. Vitamin C can reduce aspirininduced gastric mucosal damage and toxicity, and enhance its activity. However, vitamin C may increase blood levels and adverse effects of aspirin

Consider co-administration, especially with potential ascorbic acid depletion. Promote nutritional diet in patients on long-term aspirin therapy

Analgesic/acetylsalicylic acid (aspirin)

Vitamin E

Possible additive effect; vitamin E may reduce platelet aggregation and hence cardiovascular risk

Low risk: consider co-administration with multiple antioxidants, including mixed tocopherols and coenzyme Q10

Analgesic/acetylsalicylic acid (aspirin)

Zinc

Interaction uncertain

Regular monitoring is essential if aspirin and zinc are used concomitantly. Separate doses by at least 2 hours

Analgesic/acetylsalicylic acid (aspirin)

Allium sativum

Possible additive effect; may provide additional antiplatelet activity, increasing the risk of bleeding. Coadministration in antithrombotic protocols may enable lower doses of the drugs, and reduce adverse drug effects

Moderate risk Avoid or adopt and monitor bleed times

Anticoagulants/antiplatelet drugs (aspirin, warfarin)

Codonopsis pilosula

Possible additive effect; Codonopsis may inhibit platelet aggregation, enhancing drug effect

Low risk: monitor patient bleeding times in conjunction with other health professionals

Analgesics/acetylsalicylic acid (aspirin)

Coleus forskohlii

Possible adverse effect; coleus may increase the risk of bleeding associated with some pain relievers

Moderate risk: use with caution

Analgesic/acetylsalicylic acid (aspirin)

Glycyrrhiza glabra

Possible beneficial effect; liquorice helps reduce gastroirritant adverse effects of aspirin

Consider co-administration using deglycyrrhizinated liquorice (DGL)

Lipid-lowering therapies (statins)

Chromium

Interaction uncertain; chromium may increase HDL levels

Low risk: monitor patient closely. Check HDL levels in patients on long-term chromium therapy

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