Should naturopaths sell dietary supplements to patients?

Should naturopaths sell dietary supplements to patients?

No, of course not. In my opinion, no one needs to go to a naturopath in the first place. Anything they do that's useful can be just as easily accessed from science-based health care professionals. No need to put yourself through all the quackery for some valid health tips. (Not convinced? Two must reads from "Naturopathic Medicine Week" over on Respectful Insolence: here and here.)

Legal and ethical considerations aside (we'll get to those in a minute), one would be well advised not to take any dietary supplement unless there is sufficient evidence for doing so. Because little evidence exists that dietary supplements are necessary to health or benefit a particular condition, it is likely that most people will never need to take a supplement. Besides that, even in the rare case of a particular dietary supplement being beneficial, there is absolutely no way to guarantee that it's safe because there is no pre-market regulation. That's not just me talking - the FDA itself will tell you this. So will the NIH Office of Dietary Supplements.  The FDA is charged by law with regulating supplements, but then hog-tied by Congress so that it can only play catch-up after something goes wrong.  

This lack of regulation has predictable consequences.  Independent testing of dietary supplements regularly turns up contamination with real drugs and other stuff that isn't supposed to be in there, like lead and mercury.   This is true for both the garden variety tablet, capsule or powdered form and the more "earthy" dried herbs and spices. (Think Spice Islands herbs and spices on your grocer's shelf, but in much bigger quantities.)

Naturopaths have turned these uncertainties about dietary supplements into a marketing strategy for their practices.  Since they eschew evidence-based medicinedietary supplements are a staple of their "natural" armamentarium and their supposed expertise in supplements is advertised to the public. This claimed expertise has never been convincingly demonstrated by any objective, third-party evaluation.  But, putting two and two together, since the health benefits of dietary supplements remain largely unproven, or disproven, and their safety is unknown, the fact that supplements are so often prescribed by naturopaths indicates that they are most certainly not experts.  And it shows.  (Also, here, here and here.)

Safety concerns are supposedly addressed by the naturopaths having a relationship with a "reliable" supplier.  Sometimes the naturopath will have her own, in-office, dispensary and sometimes her website will connect to the website of an on-line supplement retailer.  

The ethics of this practice are questionable.  To be fair, some MDs sell supplements to patients too. (I imagine the numbers are few, although I have no way of knowing that.)  The AMA Code of Medical Ethics doesn't completely forbid it, but "Opinion 8.063 - Sale of Health-Related Products from Physicians' Offices," definitely discourages the practice:

In-office sale of health-related products by physicians presents a financial conflict of interest, risks placing undue pressure on the patient, and threatens to erode patient trust and undermine the primary obligation of physicians to serve the interests of their patients before their own.

As well:

Physicians who choose to sell health-related products from their offices should not sell any health-related products whose claims of benefit lack scientific validity. When judging the efficacy of a product, physicians should rely on peer-reviewed literature and other unbiased scientific sources that review evidence in a sound, systematic, and reliable fashion.

That alone would pretty much eliminate most dietary supplement sales by physicians. Additional restrictions apply, listed in both Opinion 8.063 and other ethical rules to which it refers. 

The American Association of Naturopathic Physicians Code of Ethics doesn't have much to say on the subject.  In fact, it doesn't have much to say on anything. The entire Code is barely over two pages long.  In an oblique way, the Code actually supports the sale of supplements by stating that 

A naturopathic physician shall at all times seek to employ methods of diagnosis and therapy that are consistent with naturopathic medical philosophy and principles of practice, scientific principles and evidence . . .

Note which comes first: "naturopathic medical philosophy and principles of practice." And why just "seek to employ?"  What's wrong with "rely on peer-reviewed literature and other unbiased scientific sources that review evidence in a sound, systematic, and reliable fashion?" 

As part of the obligation to provide care, a naturopathic physician shall use his or her best efforts to facilitate a patient's access to high quality, safe and reliable . . . supplements.  A naturopathic physician shall offer alternative sources for obtaining [supplements] as long as those alternative sources do not compromise safety or clinical effectiveness. 

What a perfect cover. The naturopath can claim that she is simply "facilitating" patient access to good quality supplements and preventing the patient from those other sources that might "compromise" safety or effectiveness.

If a naturopathic physician is faced with a conflict of interest, the conflict shall be resolved in the best interest of the patient. . .  If a naturopathic physician has any financial interests that may conflict with appropriate medical care, the naturopathic physician shall disclose those interests to the patient. 

But wait.  If the naturopath has a duty to ensure access to safe and effective supplements, and selling supplements supposedly accomplishes this, there is no "conflict" in the first place, right? And if there is a conflict, just disclose it.  Job done!

Finally,

A naturopathic physician who makes written or oral public statements concerning specific products sold by a company from which the naturopathic physician receives compensation, or in which the naturopathic physician holds an ownership interest, shall disclose this financial relationship in those public statements.

 Actually, if the "compensation" is based on patient referals, that's  that's illegal in some states.  

Most dietary supplement prescriptions by naturopaths are not supported by sufficient evidence of safety and effectiveness when held to an evidence-based medicine standard.  Selling uneccesary supplements to the patient just simply adds financial insult to injury.

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

Points of Interest 10/12/2014
Points of Interest 10/08/2014