By Val Allen, PNMC Director & Naturopath – Many patients are perplexed by recent changes to the ancillary health fund rebates for Naturopaths and Herbalists. The following article by Marla Cunningham gives an excellent explanation of this debacle.
Australian Government, Department of Health Update: 16 July 2018.[i]
In announcing the removal of the private health insurance rebate for the majority of natural therapies, the recent Department of Health statement (see below) reports that “…a review chaired by the former Commonwealth Chief Medical Officer found there is no clear evidence demonstrating the efficacy of the listed natural therapies.”[ii]
The conclusion that there is no evidence for the efficacy of Naturopathy is difficult to comprehend for many who are familiar with the wealth of peer-reviewed scientific evidence on natural medicine, including experts in the field of natural medicine research.[iii],[iv] The content and conclusions of this report with regards to Naturopathy and Herbalism, and the evidence which was notably absent from the review, is the subject of this article.
The report in question was submitted to government in 2015 by the National Health and Medical Research Council (NHMRC). [v] It was commissioned to review the evidence behind complementary medicine services provided by unregistered health professions, which include Naturopathy and Herbalism practice. For Naturopathy and Herbalism, rather than evidence of inefficacy, it essentially turned up a lack of publications that met their specific criteria to include in the review.
The reasons for this were multiple. In fact, the report itself acknowledged several limitations including a restrictive evidence search which only encompassed systematic reviews, published in English, within the last five years – potentially missing a significant body of other existing literature.
However, the major reason explaining the insufficient number of studies that surfaced, was that evidence was sought only on the efficacy of Naturopathy and Herbalism as a ‘health service’ – meaning that only papers on Naturopathic practice as a whole were included. Not surprisingly, whilst there is an abundance of evidence substantiating natural medicines, there are few studies analysing the practice of clinical Naturopathy. Hence, this approach failed to turn up much. It was considered ‘not practical’ to evaluate evidence for the relevant medicines themselves due to the extensive amount of remedies available. As a result, no ‘relevant’ systematic reviews were found for Herbalism; and for Naturopathy there was only one unpublished review from North America on the practice by Naturopathic Doctors.
The report concluded that due to the lack of (included) evidence – “no conclusions can be drawn about the effectiveness of Herbalism as a health service”, and that “further evidence is required to estimate the effectiveness of Naturopathic practice, as practised in Australia”. Far from making strong conclusions about a lack of efficacy, the report stressed numerous times that the findings should not be taken to infer that the specific therapy is not effective.[vi] How this translates to a government policy to scrap government support for these therapies seems a great leap.
What is the Evidence for Naturopathy?
The one systematic review on whole practice Naturopathy that was found by the report – a review of six randomised controlled trials in North America – did provide positive evidence for the practice of Naturopathy. In fact, the review concluded that Naturopathy was effective in improving patient health for a range of chronic health conditions, including anxiety, multiple sclerosis, cardiovascular disease and musculoskeletal conditions.[vii]
Outside of examining Naturopathic practice as a health service, there is substantial published scientific evidence on the component parts of Naturopathic practice – namely dietary modification, exercise, stress management, herbal medicines, nutritional supplementation, probiotic therapy, and a variety of other tools utilised. Suffice it to say, there are many highly-esteemed medical journals which dedicate their entire contents to the subject – including the American Journal of Clinical Nutrition, Phytomedicine, and Complementary Therapies in Medicine, amongst many others.
To showcase the breadth of evidence around these therapies would obviously be an extraordinary task – however, one particular area worth highlighting is the role of natural medicines in reducing the burden of disease for those specific health conditions deemed ‘priority’ by the Australian Government.
Natural Medicines Reduce the Burden of Disease
There are a number of health conditions which have been identified as national health priority areas by the Australian Government based on their contribution to the burden of disease in Australia – dementia, obesity, arthritis and musculoskeletal conditions, asthma, diabetes, mental health, injuries, cardiovascular disease, and cancer.[viii]
A comprehensive review which looked at the nature of complementary medicine usage within Australia, found it to be commonly utilised by patients with these diseases,[ix] a trend that is supported by a wealth of evidence on the effectiveness of natural medicines for these conditions. For example, in the priority area of mental health, Professor Jerome Sarris’s January 2018 systematic review highlights high quality (scientifically rigorous) evidence for several herbs in the treatment of anxiety (including passionflower) and depressive disorders (including saffron). For arthritis, the British Medical Journal published a state of the art review in 2017 that included meta-analyses with positive outcomes for both omega-3 fatty acids and turmeric in the reduction of pain and disease activity.[x] For cardiovascular disease and diabetes, magnesium supplementation has consistently demonstrated significant improvements in numerous markers including insulin, glucose, lipids, blood pressure, as well as improved heart function and survival in heart disease patients – all in placebo-controlled trials and meta-analyses.[xi]
A 2014 Frost and Sullivan report predicted the potential healthcare savings if at-risk Australians utilised just a handful of natural medicines for the prevention or treatment of key conditions – B vitamins and omega-3 for cardiovascular health; magnesium, calcium and vitamin D for bone health; lutein and zeaxanthin for eye health; and St John’s wort for depression. Utilisation of these therapies by affected segments of the population was projected to result in a $3 billion net economic benefit annually.[xii]
Beyond the prescribing of natural medicines, Naturopaths are key proponents of the comprehensive lifestyle interventions needed to mitigate chronic conditions. Dietary change, stress reduction and exercise are key therapies recommended by Naturopaths, all backed by a large body of evidence, and essential for the prevention and treatment of lifestyle-related conditions such as cardiovascular disease, obesity, diabetes and dementia.[xiii],[xiv],[xv],[xvi]
Unfortunately in Australia, where approximately 63% of the population are overweight or obese, It has been shown that, only one third or less of these and/or hypertensive patients receive lifestyle advice from their General Practitioner.[xvii] The medical system needs complementary healthcare Practitioners who are experts in the implementation of lifestyle medicine, and who have the capacity and time to engage with and counsel their patients.
Naturopathic Practitioners Promote Patient Empowerment
In order to understand the patient’s perception of care provided by complementary medicine Practitioners, Hope Foley and Dr Amie Steel of the Endeavour Office of Research, published a systematic review last year. They found that patients felt higher levels of empathy and empowerment from complementary medicine consultations than from conventional medicine. Further, this empowerment is associated with a shift towards behavioural change and a more positive way of thinking.[xviii]
Chronic diseases require a significant amount of self‐management on the patients behalf, therefore empowering them can be key to effective management.[xix],[xx] In doing so, patients develop a greater understanding of the impact of their behaviours on their health, make informed choices and decisions to achieve their health goals, and stay committed when challenges arise.[xxi] Higher levels of empowerment in diabetes management have been associated with better patient knowledge, improved medication adherence, and positive lifestyle behaviours.[xxii]
While some studies reported that all complementary medicine consultations created empowerment, this has been more consistently reported with Naturopaths and Herbalists than with acupuncture, massage and homeopathy.[xxiii]This may be due to typical Naturopathic and Herbalist consultations involving a large advice component, compared to the focus in other modalities being on the selection and administration of the treatment by the Practitioner.
Australians are Voting With Their Feet
The high utilisation of complementary medicine in Australia demonstrates that it is considered by many to be a legitimate and important component of healthcare.[xxiv] Complementary medicine is extensively utilised by people with chronic conditions and low quality of life.[xxv],[xxvi] In the CAMELOT study of 2915 Australians with cardiovascular disease or diabetes, 43% had used complementary medicine in the last 12 months.[xxvii] Naturopaths are one of the top four most commonly consulted healthcare Practitioners in Australia, alongside massage therapists, chiropractors and acupuncturists.[xxviii]
For those seeking out complementary medicine, key reasons provided include unsatisfactory results as well as side effects from conventional therapy. Patients also report choosing natural medicine due to its ability to be used as preventative medicine, providing a sense of self-control and self-determination over their own health, and the comprehensive approach to their individual health considerations. [xxix],[xxx]
In a time when most countries of the world are heading towards a chronic disease healthcare crisis (a crisis from both a budgetary and morbidity perspective), individuals who are proactively seeking and engaging with preventative healthcare Practitioners need to be supported in their choices and efforts.
Far from marginalising an established and highly frequented network of healthcare Practitioners, the government should respond to any perceived lack of evidence by supporting continued research into complementary medicine.[xxxi] Such an approach would continue to have both the individual’s and the nation’s physical and financial health in mind.
Author: Marla Cunningham
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[i]Australian Government. Department of Health [Internet]. Canberra ACT: Department of Health; 2018 [updated 2018 July 16; cited 2018 Aug 3]. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/private-health-insurance-reforms-fact-sheet-removing-coverage-for-some-natural-therapies.
[ii]Australian Government. Department of Health [Internet]. Canberra ACT: Department of Health; 2018 [updated 2018 July 16; cited 2018 Aug 3]. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/private-health-insurance-reforms-fact-sheet-removing-coverage-for-some-natural-therapies.
[iii] Leach MJ, Steel A. The potential downstream effects of proposed changes in Australian private health insurance policy: The case for naturopathy. Advances in Integrative Medicine. 2018 Apr 4. https://doi.org/10.1016/j.aimed.2018.04.001.Art
[iv] Wardle J. The Australian government review of natural therapies for private health insurance rebates: what does it say and what does it mean? Advances in Integrative Medicine. 2016 Apr 1;3(1):3-10.
[v] Australian Government. Department of Health [Internet]. Canberra ACT: Department of Health; 2017 [updated 2017 June 29; cited 2018 Aug 3]. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/phi-natural-therapies
[vi] Australian Government. Department of Health [Internet]. Canberra ACT: Department of Health; 2017 [updated 2017 June 29; cited 2018 Aug 3]. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/phi-natural-therapies
[vii] Australian Government. Department of Health [Internet]. Canberra ACT: Department of Health; 2017 [updated 2017 June 29; cited 2018 Aug 3]. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/phi-natural-therapies
[viii]Australian Government. National Health and Medical Research Council [Internet]. Canberra ACT: National Health and Medical Research Council; 2016 [updated 2016 Aug 31; cited 2018 Aug 3]. Available from: https://www.nhmrc.gov.au/book/nhmrc-corporate-plan-2016-2017/nhmrc-s-strategic-direction/major-health-issues
[ix]Reid R, Steel A, Wardle J, Trubody A, Adams J. Complementary medicine use by the Australian population: a critical mixed studies systematic review of utilisation, perceptions and factors associated with use. BMC Complementary and Alternative Medicine. 2016 Dec;16(1):176.
[x] Chen L, Michalsen A. Management of chronic pain using complementary and integrative medicine. BMJ. 2017 Apr 24;357:j1284. PMID: 28438745.
[xi] Gröber U, Schmidt J, Kisters K. Magnesium in Prevention and Therapy. Nutrients. 2015 Sep 23;7(9):8199-226. PMID: 26404370.
[xii] Shanahan C, Lorimier R. Targeted use of complementary medicines: potential health outcomes and cost savings in Australia. Frost & Sullivan (Australia) Pty. Ltd., Sydney. 2014 Oct;116.
[xiii] Dietz WH, Solomon LS, Pronk N, Ziegenhorn SK, Standish M, Longjohn MM, et al. An integrated framework for the prevention and treatment of obesity and its related chronic diseases. Health Aff (Millwood). 2015 Sep;34(9):1456-63. PMID: 26355046.
[xiv] Bredesen DE. Reversal of cognitive decline: a novel therapeutic program. Aging (Albany NY). 2014 Sep;6(9):707-17. PMID: 25324467.
[xv] Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, et al. 2016 European guidelines on cardiovascular disease prevention in clinical practice. Kardiol Pol. 2016;74(9):821-936. PMID: 27654471.
[xvi] Dunkley AJ, Bodicoat DH, Greaves CJ, Russell C, Yates T, Davies MJ, et al. Diabetes prevention in the real world: effectiveness of pragmatic lifestyle interventions for the prevention of type 2 diabetes and of the impact of adherence to guideline recommendations: a systematic review and meta-analysis. Diabetes Care. 2014 Apr;37(4):922-33. PMID: 24652723.
[xvii] Booth AO, Nowson CA. Patient recall of receiving lifestyle advice for overweight and hypertension from their general practitioner. BMC Fam Pract. 2010 Feb 1;11:8. PMID: 20113530.
[xviii] Foley H, Steel A. Patient perceptions of clinical care in complementary medicine: A systematic review of the consultation experience. Patient Educ Couns. 2017 Feb;100(2):212-223. PMID: 27693375.
[xix] Ouschan R, Sweeney J, Johnson L. Customer empowerment and relationship outcomes in healthcare consultations. European Journal of Marketing. 2006 Sep 1;40(9/10):1068-86.
[xx] Hernandez-Tejada MA, Campbell JA, Walker RJ, Smalls BL, Davis KS, Egede LE. Diabetes empowerment, medication adherence and self-care behaviors in adults with type 2 diabetes. Diabetes Technol Ther. 2012 Jul;14(7):630-4. PMID: 22524548.
[xxi] McAllister M, Dunn G, Payne K, Davies L, Todd C. Patient empowerment: the need to consider it as a measurable patient-reported outcome for chronic conditions. BMC Health Serv Res. 2012 Jun 13;12:157. PMID: 22694747.
[xxii] Hernandez-Tejada MA, Campbell JA, Walker RJ, Smalls BL, Davis KS, Egede LE. Diabetes empowerment, medication adherence and self-care behaviors in adults with type 2 diabetes. Diabetes Technol Ther. 2012 Jul;14(7):630-4. PMID: 22524548.
[xxiii] Foley H, Steel A. Patient perceptions of clinical care in complementary medicine: A systematic review of the consultation experience. Patient Educ Couns. 2017 Feb;100(2):212-223. PMID: 27693375.
[xxiv] Spinks J, Hollingsworth B. Policy implications of complementary and alternative medicine use in Australia: data from the National Health Survey. J Altern Complement Med. 2012 Apr;18(4):371-8. PMID: 22515796.
[xxv] Lin V, Canaway R, Carter B. Interface, interaction and integration: how people with chronic disease in Australia manage CAM and conventional medical services. Health Expect. 2015 Dec;18(6):2651-65. PMID: 25069626.
[xxvi]Reid R, Steel A, Wardle J, Trubody A, Adams J. Complementary medicine use by the Australian population: a critical mixed studies systematic review of utilisation, perceptions and factors associated with use. BMC Complement Altern Med. 2016 Jun 11;16:176. PMID: 27289517.
[xxvii] Manderson L, Oldenburg B, Lin V, Hollingsworth B, de Courten M, Canaway R, et al. Care seeking, complementary therapy and herbal medicine use among people with type 2 diabetes and cardiovascular disease CAMELOT phase II: surveying for diversity. Australian Journal of Herbal Medicine. 2012;24(2):46.
[xxviii] Reid R, Steel A, Wardle J, Trubody A, Adams J. Complementary medicine use by the Australian population: a critical mixed studies systematic review of utilisation, perceptions and factors associated with use. BMC Complement Altern Med. 2016 Jun 11;16:176. PMID: 27289517.
[xxix] Reid R, Steel A, Wardle J, Trubody A, Adams J. Complementary medicine use by the Australian population: a critical mixed studies systematic review of utilisation, perceptions and factors associated with use. BMC Complement Altern Med. 2016 Jun 11;16:176. PMID: 27289517.
[xxx] Warren N, Canaway R, Unantenne N, Manderson L. Taking control: Complementary and alternative medicine in diabetes and cardiovascular disease management. Health (London). 2013 Jul;17(4):323-39. PMID: 23014892.
[xxxi] Bensoussan A, Lewith GT. Complementary medicine research in Australia: a strategy for the future. Med J Aust. 2004 Sep 20;181(6):331-3. PMID: 15377248.
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