Professional Documents
Culture Documents
Ebook Advanced Clinical Naturopathic Medicine PDF Full Chapter PDF
Ebook Advanced Clinical Naturopathic Medicine PDF Full Chapter PDF
Ebook Advanced Clinical Naturopathic Medicine PDF Full Chapter PDF
Cover image
Title Page
Copyright
Acknowledgments
Preface
List of Contributors
References
2 Environmental medicine
History-taking
Who is susceptible?
Toxicants
Electromagnetic fields
Allergens
References
3 Chelation
Description
History
Chelating agents
Chelatable toxicants
Challenge testing
Side effects
References
4 Detoxification
Introduction/overview
Toxins/toxicants
Assessment of toxins/toxicants
Detoxification strategies
References
5 Naturopathic hydrotherapy
Introduction
Acknowledgments
References
6 The microbiome
Overview
References
7 Methylation
Introduction
Protein synthesis
Metabolic pathways
Altered methylation patterns: hypomethylation and hypermethylation
Key nutrients
Special topics
References
References
9 Mind–body medicine
Introduction
Biomedicine
Mind–body medicine
Mind–body therapeutics
References
10 Sports naturopathy
Introduction
Exercise physiology
Energy requirements
Carbohydrates
Protein
Fats
Drugs in sport
Evidence-based supplements
References
Epidemiology
Classification
References
Appendix 11.6 WHO Guidelines for Semen Analysis (2010, 5th edition)
12 Miscarriage
Statistics
Aetiology of miscarriages
Treatment approaches
References
Introduction
Epidemiology
Modes of delivery
Nutritional assessment
Weight in pregnancy
Trimester 1
Trimester 2
Third trimester
References
14 Breastfeeding
Introduction
The World Health Organization recommendations for breastfeeding
Historical context
Functions of breastfeeding
Breastfeeding initiation
Breastfeeding support
Conclusion
References
15 Infancy
Introduction
Arrival
Introduction of solids
Introduction
Dosage calculations
Specific conditions
References
17 Geriatrics
Introduction
Epidemiology
Ageing
Assessment
Geriatric syndromes
References
Epidemiology
Overview
Classification
Contributing factors
Diagnosis
References
19 Down syndrome
Introduction
Prenatal diagnosis
Family
Infant care
Childhood–school-age years
Adolescence
Adulthood
End-of-life care
Therapeutic considerations
Therapeutic application
References
Appendix 19.1 Sexual health resources for parents, carers and health professionals working
with people with Down syndrome and other learning disabilities
Appendix 19.2 Sexual health resources for people with Down syndrome and other learning
disabilities, with the support of carers or family members
Introduction
Evolution of the endocannabinoid system
References
21 Cancer – Advanced I
References
22 Cancer – Advanced II
Part A
Part B
References
HIV statistics (World Health Organization [WHO] HIV/AIDS statistics and data)
AIDS statistics,
Classification
AIDS definition
Aetiology
HIV overview
Differential diagnosis
Naturopathic diagnosis
Naturopathic perspective
Stages of treatment
Herbal medicine
Lifestyle recommendations
References
Introduction
Conclusion
References
Index
Interactions table
References
Copyright
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ISBN: 978-0-7295-4265-4
Notice
Practitioners and researchers must always rely on their own experience and knowledge in
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Because of rapid advances in the medical sciences, in particular, independent verification of
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March 2020
About the Author
MSciMed(RHHG), BHSc(Naturopathy), ND, FNHAA
Leah is an experienced and respected clinician and has been in private practice for over 20 years.
She specialises in fertility, pregnancy and reproductive healthcare for men and women and holds
fellowships and memberships with a number of International organisations.
She has completed extensive advanced training and is currently completing her PhD through the
School of Women's and Children's Health (Faculty of Medicine [UNSW]).
Leah is the Director of The Natural Health and Fertility Centre in Sydney, Australia, where she
maintains her clinical practice.
She is a keynote speaker at conferences locally and internationally to both the functional and the
complementary medicine communities as well as the wider fertility and gynaecological areas of
medicine. She is the author of multiple seminal naturopathic textbooks and is a contributor to
journals and other texts within the naturopathic and functional medicine areas, as well as general
gynaecology, fertility and infertility.
Most importantly, she is a mother to two gorgeous boys who keep her grounded, humbled and
consciously aware. They have helped and continue to help her be a beTer version of herself and
provide insight and direction for her spiritual practice.
List of Contributors
Nicole Bijlsma ND, BHScAc(HONS), Grad Dip OHS, Adv Dip Building Biology
RMIT researcher
Vice President of Australasian Society of Building Biologists, Australia
Liesl BloC PGradDip(MM), BPharm, BHSc(Herbal Med), AdvDip(Nat), Cert IV Assessment &
Workplace Training, Adjunct Senior Lecturer, School of Pharmacy and Biomedical Sciences,
Curtin University, Perth, Western Australia, Australia
Lisa Costa Bir BAppSc(Nat), GradDip(Nat), MATMS, Lecturer and Supervisor, Nutrition and
Naturopathy, Endeavour College of Natural Health, Sydney, New South Wales, Australia
Rhona Creegan PhD, MSc Clinical Biochemistry, MSc Nutrition Medicine, BSc Biomedical
Sciences, Owner Omega Nutrition Health, Perth, Western Australia, Australia
Joanna HarneC PhD, MHSc, BHSc(Complementary Medicine), Grad Dip Clin Nutrition, Grad
Cert Educational Studies, Adv Dip Naturopathy
Lecturer Complementary Medicines, The University of Sydney School of Pharmacy, Faculty of
Medicine and Health, New South Wales, Australia
Fellow of the Australian Research Centre in Complementary and Integrative Medicine, Ultimo,
New South Wales, Australia
Leah Hechtman MSciMed(RHHG), BHSc(Nat), ND, FNHAA, Director, The Natural Health and
Fertility Centre, Sydney, New South Wales, Australia
Brad S. Lichtenstein ND, BCB, BCB-HRV, Associate and Clinical Professor, Bastyr University,
Kenmore, WA
Helen Padarin BHSc(Nat), ND, DN, DBM, DRM, Clinical Naturopath, Nutritionist and
Herbalist, Sydney, New South Wales, Australia
Janet Schloss PhD(medicine), PGC-Clin Nut, AdvDip-HS(Nat), DipNut, Dip HM, BARM
Endeavour College of Natural Health, 269 Wickham St, Fortitude Valley Qld 4006
Fellow at ARCCIM University of Technology Sydney, Ultimo NSW
Naturopathic medicine draws on a rich history of practice that extends many thousands of years. Humans have long needed to rely on the resources
of nature for health and healing, and the use of plants as therapeutic agents is well documented through the history of human civilisation. Using
plants as a source of medicine as well as for their nutritional value has consistently been observed in cultures over time. Other therapies, including the
use of water, heat and cold, and other therapeutic regimens have also variously been used to harness the healing power of nature or vis medicatrix
naturae. Naturopathy grew from these traditions around the turn of the 20th century and is today practised in over 80 countries around the world.
Modern naturopathy combines the best of traditional medicine with contemporary science as a practice that is steeped in tradition while incorporating
modern clinical advances. The manner in which the profession is recognised and regulated varies around the world; however, consistency in core
beliefs as well as commitment to high standards in education, practice and codes of conduct bind the profession together as a system of medicine that
makes a positive contribution to global health.
The scale of naturopathic medicine can be beder appreciated by considering this summary of key figures, which are likely conservative estimates as
the global profession continues to be beder understood[3]:
Global impact
It is difficult to quantify the impact of naturopathy globally. Arguably, a focus on preventive health and a reduction in reliance on mainstream health
systems would suggest that naturopathy could play a significant role in global health goals. Indicators that can be measured in support of this notion
include the degree to which traditional medicine is used, particularly in developing countries. The economic value of the herbal and supplement
industries is also relevant in considering impact, as naturopathy is a system of health that often prescribes the use of herbal and nutritional
supplements. Additionally, as naturopathic practice takes a proactive stance in relation to disease prevention and patient education, it aligns naturally
with local and global public health goals.[4]
In a number of countries (such as some African nations), traditional medicine practitioners outnumber medical doctors by a factor of 80 : 1. In these
circumstances, traditional medicine is the only viable medical choice for many people.[5] Additionally, where traditional medicine has a strong
historical basis and cultural influence, such as in developed countries including Singapore or Korea, it is often preferred even when contemporary
medicine services are available.[5]
Herbal medicine sales may be difficult to measure, as regulations differ around the world and definitions of plants as foods or medicines may also
vary. As an indication of scale, Chinese herbal medicine sales were worth an estimated US$83.1 billion globally in 2012.[5] In the US, expenditure on
natural products was US$14.8 billion in 2008.[5] Market research analysing the worldwide market for herbal supplements estimates this to grow to
US$115 billion by 2020.[6]
Traditional medicines, of proven quality, safety, and efficacy, contribute to the goal of ensuring that all people have access to care. For many millions of people,
herbal medicines, traditional treatments, and traditional practitioners are the main source of health care, and sometimes the only source of care. This is care that
is close to homes, accessible and affordable. It is also culturally acceptable and trusted by large numbers of people. The affordability of most traditional
medicines makes them all the more attractive at a time of soaring health-care costs and nearly universal austerity. Traditional medicine also stands out as a way
of coping with the relentless rise of chronic non-communicable diseases.
WHO Director-General (2013), Dr Margaret Chan[5] p. 16
It is important to context naturopathy within WHO policy. Traditional medicine is differentiated from Complementary and Alternative Medicine
(CAM), with the former term applied to health systems indigenous to different cultures ‘used in the maintenance of health as well as in the
prevention, diagnosis, improvement or treatment of physical and mental illness.’[5] While in many cases the terms are used interchangeably, the WHO
defines CAM as ‘a broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health
care system’.[5] Given this distinction, and for the purposes of considering global recognition, naturopathy is considered as CAM, although much of
the WHO guidelines and policy relate to both without differentiation.
1 harnessing the potential contribution of T&CM to health, wellness and people-centred healthcare
2 promoting the safe and effective use of T&CM by regulating, researching and integrating TM products, practitioners and practice into health
systems, where appropriate.
WHO traditional and complementary medicine objectives
T&CM represents many different health professions globally. Some are steeped in long history of use, while others such as naturopathy have a more
recent history. Recognising this diversity both across countries and within countries, yet across modalities, the WHO strives for consistency in policy,
safety access and usage:
1 Policy – integrate T&CM within national healthcare systems, where feasible, by developing and implementing national T&CM policies and
programs.
2 Safety, efficacy and quality – promote the safety, efficacy and quality of T&CM by expanding the knowledge base, and providing guidance on
regulatory and quality assurance standards.
3 Access – increase the availability and affordability of T&CM, with an emphasis on access for poor populations.
4 Rational use – promote therapeutically sound use of appropriate T&CM by practitioners and consumers.
1 build the knowledge base that will allow T&CM to be managed actively through appropriate national policies that understand and recognise
the role and potential of T&CM.
2 strengthen the quality assurance, safety, proper use and effectiveness of T&CM by regulating products, practices and practitioners through
T&CM education and training, skills development, services and therapies.
3 promote universal health coverage by integrating T&CM services into health service delivery and self-healthcare by capitalising on their
potential contribution to improve health services and health outcomes, and by ensuring users are able to make informed choices about self-
healthcare.
Regulatory systems
Countries are responsible for establishing their own medicines regulatory authorities (MRAs), and the WHO stipulates these should have a ‘solid
legal basis … sustainable financing, access to up-to-date evidence based information (and) capacity to exert effective market control’.[8] In Australia,
this agency is the Therapeutic Goods Authority (TGA); in the United States, it is the US Food and Drug Administration (FDA). Often, however, these
agencies do not have sufficient knowledge of T&CM. One area of confusion is due to the fact that a plant may be considered as a food, a supplement
or a herbal medicine in different countries. The WHO recommendations only extend to the therapeutic substances, not the practice of T&CM.[9]
History
The WNF was officially incorporated as a not-for-profit organisation in Canada in November 2014. This followed a number of years of work by a
small group of dedicated naturopathic practitioners to ensure the naturopathic profession was represented in a way that befits the significant numbers
of practitioners positively contributing to healthcare around the world. This was preceded by several key events including the 1st International
Congress on Naturopathic Medicine (ICNM) held in Paris in 2013, at which discussions were held about forming a formal world naturopathic
organisation. At the 2nd ICNM conference in Paris in July 2014, a meeting of over 30 naturopaths/naturopathic doctors from 20 countries agreed that
the WNF would be established. An interim commidee was formed consisting of representatives from Australia, Belgium, Canada, France, India, New
Zealand, Spain and the US. The inaugural meeting of the WNF was hosted at the Canadian Association of Naturopathic Doctors (CAND) Health
Fusion conference in Calgary in June 2015. The initial executive of the WNF was formed by four practitioners from around the world who had been
involved in various aspects of the formation of the WNF: Dr Iva Lloyd, ND from Canada (President of the WNF), Dr Tina Hausser, HP, ND from
Spain (Vice President of the WNF), Ysu Umbalo, ND from DR Congo (Secretary of the WNF) and Michael Cronin from the US (Treasurer of the WNF).
Additionally, Dr Jon Wardle, PhD from Australia, and Dr Tabatha Parker, ND from the US, who founded Naturopathic Doctors International, were
appointed Co-Secretaries General.[2,12]
Naturopathic principles
Naturopathy is a traditional system of medicine practised in many countries. A system of medicine is defined by integrated principles, philosophies,
theories and practice of health and disease,[14] and although naturopathic practitioners use an eclectic array of treatment disciplines, there is a
consistent core of philosophy and practice around the world.
The philosophical approach to naturopathy is reflected in six key principles that, although based on traditional values, were formalised in relatively
recent times (1989) by the two North American national naturopathic associations (the American Association of Naturopathic Physicians [AANP] and
the Canadian Association of Naturopathic Doctors [CAND]).[15]
The six naturopathic principles are:
There is a high degree of agreement around the world that these principles reflect the basis of naturopathic practice, indicating that despite other
differences in education, specific modes of practice or regulation, the profession is based on strong common principles.[2]
This alignment of principles not only informs educational curriculum but is also influenced by the prevailing theories that are taught. The role of
education institutions in maintaining naturopathic principles and high standards of education is paramount in the ongoing sustainability of the
profession.
TABLE 1.1
The genesis of naturopathic teaching institutions starts in 1902 with the formation of the American School of Naturopathy in New York by Benedict
Lust. A number of European naturopathic schools also started in the 1920s, such as the Heilpraktiker-Fachschule founded by Josef Angerer (1907–
1987) in Munich, Germany, which remains in operation today as the Joseph Angerer Schule. A number of students from Lust's American School of
Naturopathy transferred their knowledge and skills to other parts of the world including Spain, by José Castro Blanco (1890–1981), and South
America, by Professor Juan Estève Dulin in Argentina, Rosendo Arguello Ramirez in Nicaragua and Juan Antigas y Escobar in Cuba.[1,13] This process
of migration from a central point over the past 100 years helps explain the relatively high degree of alignment between naturopathic educational
institutions as to what is taught.
Education standards
The WHO describes type I training programs as a minimum standard for naturopathic training, ‘aimed at those who have no prior medical or other
health-care training or experience. They are designed to produce naturopathic practitioners who are qualified to practise as primary-contact and
primary-care practitioners’.[8] A minimum of 1500 hours of study is required with at least 400 hours of supervised clinical training over a two-year full
time study period (or longer as equivalent). In practice, there is quite a degree of variation in naturopathic training around the world. A 2015 WNF
survey of 85 naturopathic education institutions from 49 different countries identified course duration variation from as low as 1200 hours to some
courses requiring over 4000 hours of study. Those at the higher end of the scale tend to align with those courses where the resultant qualification is
one of naturopathic doctor such as in North America. The majority of naturopathic courses around the world comprise 3000 hours of study for the
course.[2,13] There also tends to be a correlation between the level of course accreditation and the length of the course as shown in Fig. 1.2.
Fig. 1.2 categorises courses as government-accredited, self- or voluntary-accredited, and non-accredited programs. In some instances, the same body
accredits education providers as well as course content, which is the situation in the US and Canada. In other regions, such as Australia, separate
bodies regulate training providers and professional course content requirements. In some countries, courses may not be subject to either government
or voluntary accreditation at all.[2,13]
Entry requirements to study naturopathy vary around the world, mostly in direct relation to the level of government accreditation requirements of
the education institutions; that is, those in jurisdictions where the professional and education standards are government accredited tend to have more
stringent requirements. In countries such as the US and Canada, where this is the case, an undergraduate degree is required to enrol in naturopathy
and standardised exit exams are also part of adaining a qualification in these countries. The US, Canada and South Africa all also have government-
approved independent accreditation agencies to maintain these standards of education and graduation. Elsewhere in the world, such as in Australia,
where the qualification for all enrolments after 2016 is a bachelor's degree, previous undergraduate qualifications are not required and exit exams vary
between education providers.[2,13]
Areas of study
Naturopathy courses tend to focus on health sciences, with the sciences forming the core or backbone of the course and naturopathic areas of study
built around these foundational requirements. The areas of study common to naturopathic education programs are as follows[2,8]:
While these areas of study are ubiquitous, the time spent within a course on a given study area varies according to where educational institutions
are located. For example, those in Europe spend the most time on naturopathic history and philosophy, while Asian schools on average spend a
greater percentage of time on the sciences.[2,13]
The high level of agreement internationally in regards to the naturopathic principles is reflected in the consistency with which these areas are
incorporated into naturopathic education. A common element of naturopathic courses is teaching students to treat the whole person as well as a focus
on disease prevention and health promotion. The remaining four principles likewise are incorporated into virtually all curricula – First, Do No Harm;
Healing Power of Nature; Treat the Cause; and Doctor as Teacher.[13] The importance of naturopathic philosophies and theories in course content may
be summarised in the following quote:
Naturopathic medicine is a philosophical system of medicine defined by its principles and theories and supported by research. Ensuring that naturopathic
programs have a strong focus on naturopathic principles and theories is key to maintaining the essence of naturopathy from generation to generation.[3]
Naturopathic philosophies, theories and modalities are subject to cultural and historical influences and show variability as to what is taught around
the world in naturopathic courses. The philosophy of vitalism, or vital force, for instance, is taught universally, as are naturopathic cures. The
treatment modalities that may be taught under the umbrella of naturopathic cures, however, are quite variable, as evidenced by the range of
modalities practised (see the section ‘Naturopathic practice’). Naturopathic philosophies and theories taught at the majority (over 70%) of
naturopathic institutions globally in order of prevalence include[13]:
1 Vital Force*
2 Integration of the Individual*
3 Naturopathic Cures*
4 Value of Fever
5 Therapeutic Order
6 Triad of Health
7 Unity of Disease
8 Hering's Law of Cure
9 Theory of Toxaemia
10 Humoral Theory
Naturopathic practice
There is no ‘one size fits all’ for naturopaths. The range of treatment modalities that may be considered ‘naturopathic’ and how prevalent these are in
practice is influenced by history, culture, professional regulation and any type of practice employed by the practitioner. The following lists the most
common naturopathic modalities around the world[13]:
• Clinical Nutrition
• Botanical Medicine (Herbalism)
• Physical Medicine
• Homeopathic Medicine
• Hydrotherapy – Water Cure
• Prevention and Lifestyle Counselling
• Hygiene Therapy
• Nature Cure.
Additionally, practitioners may be trained in other areas, some of which are clearly influenced by history and culture. For example, naturopaths
practising in India incorporate Ayurvedic medicine, commonly as part of a qualification that also includes yoga training Bachelor of Naturopathy and
Yogic Sciences (BNYS). In other jurisdictions, such as North America, education and practice regulations allow for naturopathic doctors to administer
intravenous treatments and perform minor surgery as part of their scope of practice. Other areas that may be included in training and practice
additionally include: acupuncture, prescription rights, chelation therapy and colon therapy.[2,13]
The environment in which a practitioner completed their naturopathic education and training also varies and may influence not only the modalities
practised, but also the application of them. The majority of naturopaths work in private practice, either as a solo practitioner or as part of a multi-
practitioner clinic. Additionally, an estimated 10% of naturopaths are engaged in research and education or work in the complementary medicine
industry.[3] It is possible for naturopaths or naturopathic doctors to work in hospital sedings, depending on the jurisdiction, but this is not common,
except in India, where it is much more prevalent due to a more traditional focus on nature care in an in-clinic seding.[2,13]
Private practice consultations tend to be, on average, significantly longer than those of medical doctors. They tend to be consumed with detailed
case taking and clinical assessment of the patient as well as generating prescriptions that may include diet and lifestyle recommendations and herbal
and nutritional supplements that may be pre-formulated, extemporaneously formulated or compounded and dispensed on a case-by-case basis. The
majority of initial consultations are at least an hour and follow-up visits are commonly 45 minutes in duration.[2,13]
Naturopathic regulation
Professional recognition and systems of regulation are perhaps the areas of greatest difference in naturopathic practice around the world. In some
regions, the profession is subject to a national regulatory environment and registration; in others this may vary within a country on a state by state
basis, while in other parts of the world various models of self regulation exist. At the minimum, regulation of a health profession provides codes of
professional conduct that must be adhered to. Scope of practice and protection of title may also form part of the regulatory process. What is consistent
is that where statutory regulation through registration does not exist, there is a strong current of sentiment within the profession to be beder
recognised and endorsed as part of the primary healthcare system.
Regulatory models
Naturopathic medicine is regulated in approximately 50% of the world. A third of practising countries are unregulated; however, it is not illegal to
practise naturopathy in those areas. Regulation takes a number of forms; for example, in the US and Canada practitioners must study at a
government-accredited institution and sit a board exam to gain ‘licensure’ to practise as a naturopathic doctor in the states and territories where
licensing laws exist. Other non-accredited education institutions exist and practitioners who graduate from these may practise as naturopaths.[2]
In Australia, the profession of naturopathy lacks government regulation through a centralised registration body, and instead operates under a less
formal third-party regulation of the profession. The professional associations maintain their own codes of conduct, and professional indemnity
(malpractice) insurance is only available for practitioners who meet the associations’ membership requirements. This includes an appropriate level of
education as well as maintaining annual professional development requirements and first aid certification. Additionally, private health insurers will
only provide rebates for consultations with practitioners who are verified members of a professional association.[2]
Scope of practice
The acts that a naturopathic practitioner can perform are generally limited by the scope of education received, which in turn tends to inform
professional insurance coverage. Some acts may be frankly prohibited. The regions with the highest levels of recognition tend to have the greatest
access to a range of practice options including internal gynaecological examinations, intravenous therapies, minor surgery and laboratory testing. The
most common modalities practised as part of naturopathy can be seen in Table 1.2.
TABLE 1.2
Prescribing nutritional supplements and herbal formulations is a common tool of trade in naturopathic practice, and maintaining an in-practice
dispensary is usual in Africa, South East Asia, North America and the Western Pacific. In other world regions, this is less usual and is prohibited in
some European and Latin American countries where direct dispensing to patients is not possible.[2]
The ability to order laboratory tests also varies around the globe with some practitioners able to not only order laboratory testing but also to take
the sample in some instances, such as naturopathic doctors taking blood tests. Where licensed as primary care practitioners, this generally also
extends to the ability to order diagnostic imaging such as x-rays. Others may be limited to the ability to order functional pathology tests such as hair,
saliva and stool testing, while some are prohibited from ordering or accessing such testing at all.[2]
Use of title
Protection of title allows for use of certain professional titles to be protected for use by appropriately qualified practitioners. The level of protection is
generally tied to regulatory models and may additionally be covered under regional or national legislation. For example, in the US only graduates of
accredited naturopathic medicine courses who have additionally passed a board examination may be licensed to practise as naturopathic doctors. In
Germany, the title Heilpraktiker may be used only upon passing a state examination process. In countries such as Spain and Australia, which also
have a long history and large numbers of naturopaths, the title of naturopath is not protected, meaning that anyone can call themselves a naturopath
and practise even if not appropriately trained.[2]
Professional representation
Some countries have only one national association, while others have multiple professional associations. These may have differing geographical
jurisdictions, represent different education standards or have other more philosophical differences within the same geographical areas. As a general
rule, those countries more recently establishing associations establish one national body, as is the case in many African nations. In countries with
longer histories of practice in an unregulated professional environment such as in Australia and New Zealand, there are multiple associations, some of
which represent a variety of ‘natural health’ modalities.[2]
The core foundations of naturopathic principles temper the rich diversity in the nuances of naturopathic practice. As a result, what is seen is a
global span of practice that has more similarities than differences and that forms a global profession. While naturopathy is relatively young compared
to some traditional medicines, its historical roots in botanical medicines and other nature-based cures provides practitioners with strong links to
tradition. Combined with contemporary science, naturopathic medicine provides an important element in healthcare provision that is recognised for
its value by the WHO. The future of global naturopathic medicine must be shaped by a commitment to high standards of education and practice and a
united voice for the profession.
TABLE 1.3
South East Asia region (countries where naturopathy is practised): India, Indonesia, Nepal and Thailand.
Traditional medicine practices in South East Asia are represented strongly by Ayurvedic, Unani and Siddha philosophies, with Ayurveda arguably
the best known in Western cultures. These systems of medicine are known by regionally specific names including Jamu in Indonesia, Dhivelhibeys in
the Maldives and Koryo medicine in the Democratic People's Republic of Korea. Several countries, including Bhutan, Myanmar, Nepal and
Bangladesh, recognise traditional medicines as valuable contributors to population healthcare and protect these values under Acts of Parliament.[19]
Countries both large and small in the region have rich histories of traditional medicine. Although small, Bhutan is known as Menjong Gyalkhab,
meaning ‘land of medicinal plants’, alluding to its rich abundance of herbal medicines used as part of the traditional medicine system known as Sowa
Rigpa. This system evolved from Tibetan medicine and developed after the arrival of Shabdrung Rinpoche from Tibet Region of China in the 16th
century.[20]
Ayurvedic, meaning ‘science of life’, medicine was first documented somewhere between 2500 and 500 BC in India and, as such, is one of the
longest continually practised systems of medicine in the world. India's massive population requires significant healthcare resources and it is estimated
that 70% of the poorer, rural populations rely on Ayurvedic medicine for their healthcare needs.[21] Homeopathy is a comparatively recent addition
and was introduced to India in the 1830s during homeopathy founder Samuel Hahnemann's lifetime. The relative cost effectiveness of this modality
has seen its popularity flourish and there are now many homeopathic as well as naturopathic training institutions, practitioners and specialised
hospitals throughout the country.[22] Acharya Puccha Venkata Ramaiah originally brought the practice of naturopathy to India around 1885 after
having trained under the German naturopath Louis Kuhne. Naturopathic practice was then revived in the 1940s thanks to support from Mahatma
Gandhi. In Nepal, naturopathy started in 1968.[2]
In India naturopathic education courses are combined with yoga and known as a Bachelor of Naturopathy and Yogic Sciences (BNYS). This is a five-
and-a-half-year full-time medical degree that is recognised by the Indian government under the Ministry of AYUSH (Ayurveda, Yoga and
Naturopathy, Unani, Siddha, Homoeopathy).[2]
See Table 1.4 for information regarding naturopathy in South East Asia.
TABLE 1.4
Eastern Mediterranean region (countries where naturopathy is practised): Bahrain, Egypt, Kuwait, Morocco, Qatar, Saudi Arabia and United Arab
Emirates.
Traditional Arabic and Islamic medicine developed in the eastern Mediterranean region with its generous natural repository of herbal medicines.
The medical system developed in the Middle Ages as Arab herbalists, pharmacologists, chemists and physicians built on the ancient medicinal
practices of Mesopotamia, Greece, Rome, Persia and India. This legacy is considered an important foundation for contemporary medicine as it
developed in Europe. Most famously, the work of Ibn Sina (Avicena in the West), known as Al-Qanun-fil-Tib (Canon of Medicine), plays an important
role in the history of medicine. This book remained relevant for over 600 years and was published more than 35 times during the 15th and 16th
centuries alone.[23] While the medieval Islamic world was spread broadly, wars, including those with the Odoman Empire, caused the Islamic
civilisation into decline by the end of the 1400s.[24]
Traditional medicine remains important in the region, with 88% of the WHO member states of the region acknowledging its continued use.
Approximately 40% had established a national policy on T&CM as of 2010.[5] As for regulation, the WHO[5] declared that ‘Five Member States
reported that they already had regulations for practitioners, with explicit regulations for different disciplines such as acupuncture, ayurveda,
homeopathy and herbal medicine in four of them’ (p. 64).
The WNF understands that the first legally practising naturopathic doctor in Saudi Arabia was a graduate from the National College of Natural
Medicine (NCNM) in the US who began practice in 2005.[2]
See Table 1.5 for information regarding naturopathy in the Eastern Mediterranean.
TABLE 1.5
European region (countries where naturopathy is practised): Austria, Belgium, Bosnia and Herzegovina, Cyprus, Czech Republic, Denmark,
Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Luxembourg, Netherlands, Norway, Portugal, Romania, Russia, Slovenia,
Spain, Sweden, SwiNerland, Ukraine and United Kingdom.
Contemporary Western herbal medicine is based on the herbal medicine traditions of Europe, and early European medical advances form the basis
of contemporary medical healthcare systems. Germany, in particular, was home to several key practitioners who contributed to the evolution of
contemporary naturopathy (as discussed earlier in this chapter). As may be expected, contemporary Germany has recognised naturopathic
practitioners for some time under the ‘HeilpraktikergeseN’ law of 1939 and there is a high degree of utilisation of natural remedies in the population.
The first college was established in 1936, and although naturopathic education was prohibited during World War II, the Josef Angerer Schule
reopened in 1950 and continues to operate today.[2]
The German situation is, however, not replicated throughout all of Europe. In some countries, such as Spain, naturopathy has been practised
virtually since its inception, with the first naturopathic centre opened in Barcelona in 1925 by José Castro Blanco and Nicolas Capo. Today the
profession is recognised but yet not government regulated, although the national association OCN-FENACO is actively lobbying for this to occur.[2] In
nearby Portugal, naturopathy did not appear until the 1970s. This was followed by naturopathic schools and professional associations and,
subsequently, laws in 2004 that regulated a number of natural therapies including naturopathy. Naturopathy arrived in France in the 1940s, with
Pierre Valentin Marchesseau considered the father of naturopathy in that country.[2] The European Union of Naturopathy (Union Européenne de
Naturopathie – UEN) was formed in 2002 with 17 countries listed as members on its website.[25]
See Table 1.6 for information regarding naturopathy in Europe.
TABLE 1.6
Latin America and the Caribbean region (countries where naturopathy is practised): Argentina, Bahamas, Barbados, Bermuda, Chile, Colombia,
Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Saint Lucia, Uruguay, Venezuela
and Virgin Islands (US).
Traditional medicine in South and Central America has been maintained largely through use by indigenous tribal groups, rural and lower-income
urban people. Traditional medicine practice includes herbalists, bone-seders and midwives as well as spiritual healers. Several countries have mixed
historical relationships with their traditional healers or ‘curandero’. In Peru, a high proportion of people, particularly in more remote regions, use
curanderos even though the practice was outlawed for a period of time in 1969. Guatemala, Ecuador and Cuba too have had mixed histories of
acceptance since the mid 20th century, yet use prevails, in particular with traditional midwives adending births.[19] Alternatively, in Brazil a national
policy on ‘Integrative and Complementary Practices’ has been implemented in recognition of the economical and cultural benefits of integrating
traditional medicines into healthcare systems.[5]
The predominant trend in the region is that in populations under-served by modern medicine – whether due to remote location, indigenous
populations or lower socioeconomic status – traditional medicine systems, where they exist, invariably fill the gap. This aligns with the WHO goals to
beder utilise T&CM to reduce inequities in population health outcomes.[5]
Naturopathy migrated south from the New York-based American School of Naturopathy. Notable students by country include: Carlos Rosendo
Arguello Ramirez (Nicaragua), Juan Antigas y Escobar (Cuba) and Juan Esteve Dulin (Argentina). Today there are several higher-education
institutions teaching naturopathy in the region. Some of the oldest include HOVINAT, formed in 1986, and Asoeducalt University, formed in 1996,
both in Venezuela. Some of the most recent include UPAV, which introduced a degree course after it was formally incorporated in Mexico in 2012, and
the Autonomous University of Tlaxcala, also in Mexico, which launched a course in late 2013.[2]
See Table 1.7 for information regarding naturopathy in Latin America and the Caribbean.
TABLE 1.7
North American region (countries where naturopathy is practised): Canada and the United States.
While based in European traditions, naturopathy as a contemporary system of medicine was born in the US. The practice grew from its beginnings
in New York in 1901 with a number of additional schools opening in the US and Canada over the next 20 to 30 years. During this time, the number of
naturopathic doctors grew, conferences and professional journals flourished and the profession was regulated in a number of US states and Canadian
provinces. While popularity persisted into the 1930s, the profession experienced a downturn from this time to the 1970s ‘due to the growing political
and social dominance of Western medicine and other economic factors … including (the) impact of wars, the Great Depression, the shifting of funding
and support to allopathic-based medical schools and the birth of pharmaceutical medicine and the promise of “miracle cures”’ (p. 47).[2] When
considering the evolution of naturopathy, the influence of the Native American people and the herbal medicines they introduced to the European
sedlers can be seen in a number of herbal medicines widely utilised today.
The Council on Naturopathic Medical Education (CNME) accredits naturopathic educational institutions in the US and there are currently five such
institutions across the country, including the National University of Natural Medicine (NUNM) in Portland, Oregon, established in 1956, which is the
oldest, and also Bastyr University in Seadle, which opened in 1978. These colleges together with two Canadian schools are also recognised by the
American Association of Naturopathic Medical Colleges (AANMC), an educational consortium. Graduates from these accredited schools are eligible
to sit the Naturopathic Physicians Licensing Examinations (NPLEX), which allows for registration in the states and provinces that have legislation
regulating naturopathic doctors. Most states in the US have state naturopathic associations, while the association representing naturopathic doctors
nationally is the American Association of Naturopathic Physicians (AANP), founded in 1984.[2] Additionally, the American Naturopathic Medical
Association (ANMA) founded in 1981 represents a range of practitioners that practise naturopathy in addition to licensed naturopathic doctors. In
some states, it is not legal to practise as a naturopath.[26]
While the majority of Canadian provinces and territories have local naturopathic associations, one national association was established in 1950. The
Canadian Association of Naturopathic Doctors (CAND) represents practitioners who have graduated from an accredited naturopathic school. Scope
of practice, regulation and protection of title may also vary from province to province, as is the case in the US. The naturopathic profession in both
countries developed largely in tandem and, as a result, they are quite closely aligned.[2,15]
See Table 1.8 for information regarding naturopathy in North America.
TABLE 1.8
Western Pacific region (countries where naturopathy is practised): Australia, China, Hong Kong (China), Japan, Malaysia, New Zealand,
Singapore and Vanuatu.
Many parts of the Western Pacific region have not only a history of traditional medicine, but maintain a connection to that tradition today. The
practice of traditional Chinese medicine in China as well as a number of other countries is an active exemplar of this. This is no doubt related to the
strong level of support for traditional medicine by the Chinese government. The Chinese constitution embeds traditional medicine in the healthcare
system, and modern and traditional Chinese medicine are often practised side by side. Likewise, in countries including Japan, Mongolia, The
Philippines, Singapore and the Republic of Korea (South Korea), government policy actively recognises the contribution and value of traditional
medicine systems.[19]
Australia and New Zealand are differentiated by a more recent Western presence influencing their traditional medicine practices, and while New
Zealand regulates standards for traditional Māori medicine, this is less apparent when considering Indigenous Australian healing practices.[19] Rongoā
is the traditional Māori medicine and is still practised today. It influenced the early western sedlers, including Scodish doctor James Neil, who
incorporated a mix of native and European herbal remedies in his book The New Zealand Family Herb Doctor in 1889.[2]
The presence of naturopathy in the Western Pacific stems from early adoption of the profession in Australia, where records indicate naturopathic
practitioners in Queensland and Victoria as early as 1904. Early practice was strongly influenced by the UK and US until Alfred Jacka opened the first
formal, four-year training college, the Southern School of Natural Therapies (SSNT) in Melbourne in 1961. In 1995, the college went on to introduce
the first government-accredited degree program in naturopathic medicine. Southern Cross University then followed suit with the world's first public
university naturopathic program in 1996.[2] Education standards in Australia and New Zealand currently allow both undergraduate degree and
diploma level programs in naturopathic medicine. However, in Australia the degree program became the minimum education standard for new
graduates at the end of 2018. In Australia and New Zealand, there are a number of national professional associations, and in lieu of government
regulation via statutory registration, the associations perform a pseudo-regulatory function. There have been a number of enquiries into regulatory
requirements and while naturopathy has been assessed against the Australian National Registration and Accreditation Scheme criteria and meets the
criteria for statutory registration, this has not been yet been implemented.[27]
See Table 1.9 for information regarding naturopathy in Western Pacific.
TABLE 1.9
References
[1] Cody GW, Hascall H. The history of naturopathic medicine. Pizzorno J, Murray M. Textbook of natural medicine. 4th ed. Churchill
Livingstone; 2013. E-book. .
[2] World Naturopathic Federation. World Federation Report. [Internet; Available from] hdp://worldnaturopathicfederation.org/wp-
content/uploads/2015/12/World-Federation-Report_June2015.pdf; 2015.
[3] World Naturopathic Federation. 2016 Naturopathic Numbers Report. [Internet; Available from]
hdp://worldnaturopathicfederation.org/wp-content/uploads/2015/12/2016-Naturopathic-Numbers-Report.pdf; 2016.
[4] Wardle J, Oberg EB. The intersecting paradigms of naturopathic medicine and public health: opportunities for naturopathic
medicine. J Altern Complement Med. 2011;17(11):1079–1084.
[5] World Health Organization. WHO Traditional Medicine Strategy: 2014-2023. [Internet; Available from]
hdp://www.who.int/medicines/publications/traditional/trm_strategy14_23/en/; 2013.
[6] Global Industry Analysts, Inc. The global herbal supplements and remedies market trends, drivers and projections. [Available from]
hdp://www.strategyr.com/MarketResearch/Herbal_Supplements_and_Remedies_Market_Trends.asp; 2015.
[7] United Nations. Sustainable Development Goals. [Available from] hdp://www.un.org/sustainabledevelopment/health/; 2015.
[8] World Health Organization. Benchmarks for Training in Naturopathy. [Internet; Available from]
hdp://apps.who.int/medicinedocs/en/d/Js17553en/; 2010.
[9] World Health Organization. Essential medicines and health products. [Nd; Available from]
hdp://www.who.int/medicines/areas/quality_safety/regulation_legislation/assesment/en/.
[10] WHO. Resolution WHA69.24 ‘Strengthening integrated people-centred health services’. [Available from]
hdp://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_R24-en.pdf; 2016.
[11] Wardle J, Cook N, Steel A, et al. The World Naturopathic Federation: global opportunities for the Australian profession. Aust J Herb
Med. 2016;28(1):3.
[12] World Naturopathic Federation. About WNF. [Internet; Available from] hdp://worldnaturopathicfederation.org/about-wnf/.
[13] World Naturopathic Federation. Naturopathic Roots Report. [Internet; Available from] hdp://worldnaturopathicfederation.org/wp-
content/uploads/2015/12/Naturopathic-Roots_final-1.pdf; 2016.
[14] Rosenzweig S. Whole medical systems. The Merck Manual, consumer edition. 2016 [Available from]
hdp://www.merckmanuals.com/home/special-subjects/complementary-and-alternative-medicine-cam/whole-medical-systems
[Internet].
[15] Lloyd I. The history of naturopathic medicine, a Canadian perspective. McArthur & Company: Toronto, Canada; 2009.
[16] Mhame PP, Busia K, Kasilo OM. Clinical practices of African traditional medicine. African Health Monitor. [Internet; Available from:]
hdps://www.aho.afro.who.int/en/ahm/issue/13/reports/clinical-practices-african-traditional-medicine; 2010.
[17] University of Western Cape. About us. [Internet; Available from] hdps://www.uwc.ac.za/Faculties/CHS/SoNM/Pages/About-Us.aspx.
[18] The Allied Health Professions Council of South Africa. [Internet; Available from] hdp://ahpcsa.co.za/.
[19] Bodeker G, Ong CK, Grundy C, et al. WHO global atlas of traditional, complementary and alternative medicine. World Health
Organization: Kobe, Japan; 2005. World Health Organization. .
[20] World Health Organization. Review of traditional medicine in the South-East Asia region. [Internet; Available from]
hdp://apps.searo.who.int/PDS_DOCS/B0514.pdf?ua=1; 2004.
[21] Pandey MM, Rastogi S, Rawat AKS. Indian traditional Ayurvedic system of medicine and nutritional supplementation. Evid Based
Complement Alternat Med. 2013;2013:e376327.
[22] Ministry of AYUSH. Summary of infrastructure facilities under Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and
Homoeopathy. [Internet; Available from] hdp://ayush.gov.in/infrastructure/summary-infrastructure-facilities-under-ayush.
[23] Azaizeh H, Saad B, Cooper E, et al. Traditional Arabic and Islamic medicine, a re-emerging health aid. Evid Based Complement Alternat
Med. 2010;7(4):419–424.
[24] Majeed A. How Islam changed medicine. BMJ. 2005;331(7531):1486–1487.
[25] Union Européenne de Naturopathie – European Union of Naturopathy. Historical. [Internet; Available from]
hdp://www.naturopathy-union.eu/en/presentation-eun/historical/.
[26] American Naturopathic Medical Association. [Internet; Available from] hdp://www.anma.org/home.html.
[27] Wardle J. The National Registration and Accreditation Scheme: what would inclusion mean for naturopathy and Western herbal
medicine? Part I – the Legislation. Aust J Med Herb. 2010;22(4):113.
2
Environmental medicine
Nicole Bijlsma
Environmental medicine is the evaluation, management and study of detectable human disease or adverse
health outcomes arising from exposure to external physical, chemical and biological factors in the general
environment.[1,2] Environmental medicine is a speciality field that has been adopted by occupational and
environmental doctors, but largely ignored in patient-centred general practice despite the fact that toxicants
alone have been implicated in many chronic diseases typically seen in routine medical practice.[3] There are
several reasons why this may be so:
• Most chronic diseases arise from a complex interaction between genes and the
environment and, until recently, this relationship has been hampered by limited
knowledge of the human genome and the inclination of scientists to study disease using
models that consider exposure to single agents at high doses[4]
• Very liIle of the vast amount of literature on environmental exposure is published in
general medical journals[5]
• It takes years to translate scientific discovery to clinical practice[6]
• Clinicians do not undertake house and workplace visits to identify obvious triggers
• There is competition from other disciplines in crowded medical curricula
• There are limitations in adopting a reductionist approach to compartmentalise the
body into separate systems
• The need to provide evidence-based medicine that is conclusive and leaves no room
for doubt has delayed action on environmental toxicants.
Widespread exposure to toxicants occurs in the human population from the womb to the tomb at levels
known to cause adverse health effects.[7–10] This is largely because the burden of proof is not on industry to
prove that its products or technologies are safe, and the inadequacies of chemical risk assessment fail to
consider multiple routes of exposure, mixture effects, transgenerational epigenetic effects, the impact of
endocrine-disrupting chemicals (EDCs) during critical windows of human development and individual
susceptibility,[5] although some countries are aIempting to address this (for example, the REACH directive in
Europe and the Toxic Substance Control Act in the US). Consequently the history of medicine is liIered with
numerous examples of missed opportunities, wasted resources and counterproductive policies due to an
inability to act on available evidence.[11] In 1857, the father of epidemiology, Dr John Snow, was able to
demonstrate that ‘contagions’ in water were responsible for a cholera epidemic[12]; in 1950 Dr Richard Doll
published his findings correlating smoking with lung cancer[14]; and in 1956 Dr Alice Stewart was able to prove
that one fetal x-ray doubled the incidence of childhood leukaemia.[13] These clinicians were ostracised from
their peers and the medical establishment at the time of their findings and it took decades for their work to be
validated. There are many environmental hazards that have had devastating consequences on human health,
such as lead, mercury, asbestos, benzene, organochlorine pesticides and polychlorinated biphenyls (PCBs).[15]
The question we as clinicians need to ask ourselves is, ‘When is there sufficient evidence to act?’[5]
Despite calls from numerous organisations[16–19] to provide clinicians with more training and awareness in
environmental health, there are multiple barriers to the clinical assessment of toxic environmental exposure.
Clinicians are limited in their capacity to test for environmental exposure as many of the tests available have
not been validated (e.g. provocation testing, lymphocyte sensitivity tests, DNA-adduct and mitochondrial
testing, visual contrast sensitivity tests), are inconsistent or controversial (hair mineral analysis, detoxification
profiles), only assess short-term exposure (blood, stool and urine), may not be predictive of adverse health
outcomes (genomic profiling), are costly or are not available. In addition, there may be no reliable biomarkers,
such as those involved with electromagnetic field exposure. While emerging technologies in the field of
metabolomics are predicted to have a profound impact on medical practice in years to come,[20] in the interim
clinicians can do many things to address environmental exposure. This starts with taking a thorough history of
the patient's health symptoms and environmental exposure, establishing the patient's inherent susceptibility to
environmental toxicants and educating the patient on how they can reduce their exposure to toxicants: these
topics are the focus of this chapter.
History-taking
According to Bijlsma and Cohen,[5] history-taking should encompass the following:
– A detailed symptom history that includes a timeline from the prenatal period
– A family history that includes previous generations
– An obstetric, paediatric, dietary, environmental and occupational exposure history (links to
questionnaires developed for chemical, electromagnetic field and mould exposure are provided
in this chapter)
– A history of pharmaceutical and recreational drug use
– A detailed place history that includes places of residence, school and work across the lifespan
including primary modes of transportation, with a focus on proximity to toxicants (mining,
industry, traffic and other sources of air and water pollution), allergens and electromagnetic fields
– Use of external data sources, geographical information systems and apps to assess exposure to
electromagnetic fields (real time) and exposure maps (mining, radon, traffic, pollen), as well as
government or non-government environmental pollution reporting regarding ambient air
monitoring and drinking water quality
– A physical examination to look for physical signs of metabolic, neurological, reproductive or other
disease and comorbidities
– Assessing current toxic load by performing various biomonitoring tests including assessment of
biomarkers in various body tissues to evaluate long-term accumulation of toxicants
– Networking with other professionals who can assess the patient's home and/or workplace to
establish sources of exposure.
Who is susceptible?
Why is it that a person may work in a department store spraying perfumes day by day, year by year, and be
completely unaffected by the environment while a person walking past the same area develops a headache that
makes them unwell for the rest of the day? Why do people react differently to pharmaceutical drugs? Why can
one person smoke heavily all of their life with no apparent symptoms, while another dies from smoking-
related disease in middle age? Establishing a patient's inherent susceptibility to environmental toxicants
requires an assessment of their genetic predisposition, age and timing of exposure, gender, gut microbiome,
nutrition, drug use and disease states.
Genetic predisposition
Genetics loads the gun, but the environment pulls the trigger. Professor Judith Stern
Environmental exposure and individual susceptibility go hand-in-hand. Simply put, you cannot address one
without the other. Until recently, clinicians were limited in their scope to assess individual susceptibility to
eliciting the patient's race/ethnicity status and taking a thorough family and personal history, as alterations in
highly penetrant genes (mutations) explain only a small fraction of complex diseases. Completion of the
human genome in 2003, however, shifted aIention to explore the impact of gene variants or SNPs (single-
nucleotide polymorphisms) in the aetiology of chronic disease as the direction and magnitude of the exposure-
response effect can vary with different genetic polymorphisms.[4,21,22] For example, there is a higher incidence
of asbestos-induced respiratory disease in carpenters with a homozygous deletion of the glutathione-S-
transferase Mu 1 (GSTM-1) gene, which plays an important role in phase II liver detoxification.[23] Human
variability in phase I and II detoxification can vary more than ten-fold depending on genetic polymorphisms in
metabolic enzymes.[24,25]
Studies that explore polymorphisms in the aetiology of chronic disease are frequently inconsistent,
inconclusive and contradictory. They often fail to demonstrate cause and effect because multiple genes are
involved, polymorphisms in some genes may be compensated by other genes and few studies consider these
SNPs within the context of the patient's lifestyle and/or environment. Taking breast cancer as an example,
although well-established risk factors have been identified for breast cancer (including age,
menarche/parity/menopause, family history, being overweight, drug use, smoking, high penetrance gene
mutations [BRCA1, BRCA2, TP53 and PTEN] and gene variants in detoxification and DNA repair pathways),
individually they confer only a small or negligible risk.[3,26] When polymorphisms are combined or considered
within the context of relevant environmental and lifestyle exposure, such as being overweight, smoking, using
alcohol or drugs, or following toxicant exposure, especially during the prenatal and pubertal periods, the
statistical power becomes significant in some[27–31] but not all studies,[32,33] depending on which polymorphisms
and environmental factors are investigated. This gene–environment interaction may explain why US-born
Asian women have an almost two-fold higher incidence of invasive breast cancer than native Asian women.[34]
Like most complex chronic diseases, determining the aetiology and pathogenesis of breast cancer requires big
data resources[32] involving large-scale multicentre studies that include detailed individual data, environmental
background and gene–gene and gene–environment interactions.[35] The synergistic relationship between genes
and the environment in the aetiology of chronic diseases like autoimmune diseases, metabolic disorders,
neurodevelopmental disorders such as autism, neurodegenerative disorders such as Parkinson's disease and
various cancers has been confirmed by numerous studies.[26,36–39]
While the cost of gene testing has become more affordable, few clinicians implement it because of the time
involved, a lack of training, ethical considerations and the fact that very few of the one million-plus SNPs have
clear functional implications and actionable outcomes that are relevant to mechanisms of disease.[3,40]
Furthermore, current aIempts to predict a person's reaction to drugs and toxicants based on their genetic
predisposition alone have not met the anticipated success.[41] In addition, the implications for clinical practice
have been limited[42] because other compounding factors such as age, gender, gut microbiome, nutrition and
lifestyle factors have been shown to influence the way in which toxicants are metabolised in the body.
Gender
Gender differences in toxicant exposure are well documented. For example, women have higher peak blood
alcohol levels than men when given the same dose because they metabolise alcohol more slowly than men,[71]
have a smaller volume of distribution for alcohol and a higher percentage of body fat.[72] Similarly, multiple
chemical sensitivity is significantly higher in women than in men,[73,74] which is suspected to be due to
women's higher body fat-to-muscle ratio resulting in a higher body burden of toxicants and because women
are often the primary consumers of personal care and cleaning products that contain solvents and EDCs.[7,75] In
contrast, autism is four to five times more common in males than in females[76] and has been correlated with
exposure to EDCs such as pesticides, phthalates, PCBs, solvents, toxic waste sites, air pollutants and heavy
metals.[38] Most of these toxicants are anti-androgens and xeno-oestrogens, which have been shown in animal
models to affect both brain and genital development in male progeny[77] and coincides with the sharp rise in
the number of male reproductive abnormalities over the past 50 years.[78]
Gut microbiome
The metabolic activity of the gut microbiome is comparable to that of the liver,[79] with 850 bacterial genera
involved in the metabolism of xenobiotics[63] and drugs.[79] A study conducted by the Pfizer pharmaceutical
group discovered ‘accidentally’ individual variances in drug metabolism arising from the patient's gut
microbiome.[80] The metabolic profile of a patient's urine was tested before and after ingestion of paracetamol
and it was found that the presence of p-cresol sulfate (a metabolite from Clostridium difficile bacteria found in
the gut) significantly altered the ratio of paracetamol-sulfate and paracetamol-glucuronide metabolites in the
urine. It was deduced that in patients with a gut microbiome excreting large amounts of p-cresol, the p-cresol
competes for the same enzyme-binding sites and takes up a large part of the rate-limiting phase II sulfation
pathway, such that paracetamol is forced to undergo phase II glucuronidation instead of sulfation.[80] In these
patients, paracetamol-induced hepatotoxicity is increased, because depletion of glutathione levels causes the
reactive metabolites to bind to macromolecules in hepatocytes.[81] Competitive inhibition (between toxicants
and metabolites originating from the gut microbiome), resulting in higher blood levels of each chemical, is a
phenomenon observed with increasing mixture complexity.[82]
This may explain why many mould-affected patients with associated gut dysbiosis appear to become
chemically sensitive. Why is this significant? Many drugs, environmental toxicants and their metabolites,
catecholamine neurotransmiIers such as dopamine, adrenaline and noradrenaline, and hormones undergo
phase II sulfation, so this has wide-reaching ramifications for human health. Interestingly, autistic children
have been shown to have higher levels of Clostridia[83] and low sulfation capacity, which could cause a cerebral
increase of catecholamines and subsequent changes in behaviour, especially when they eat foods high in
phenolic amines (chocolate, wheat, corn sugar, apples and bananas).[84] Furthermore, Clostridia are present in
higher numbers in many chronic illnesses such as Alzheimer's, Parkinson's disease and type 2 diabetes,[85]
which coincidentally are also diseases commonly associated with various toxicant exposure to pesticides and
heavy metals – both of which have been shown to alter gut flora. Depletion of glutathione stores may result in
increased oxidative stress levels, especially in neurons and glial cells,[86] as well as many other downstream
effects because of glutathione's involvement in iron metabolism, phase II glutathione conjugation, DNA
synthesis and repair, protein synthesis, prostaglandin synthesis, amino acid transport and enzyme activation.
The gut microbiome is a major player in the pathogenesis of chronic metabolic and central nervous system
diseases.[85,87] Gut microbes can influence the fate of neurons in various regions of the brain,[88] as well as the
development and maturation of the microglia; produce neurotransmiIers like GABA,[89,90] nitric oxide,[91]
serotonin, noradrenaline and dopamine[92]; and influence anxiety and depression,[93] autism spectrum disorder,
[88,94]
Parkinson's disease[95] and psychiatric disorders in patients with intestinal dysbiosis.[96] Gut microbes
produce short-chain faIy acids (SCFAs) from non-digestible carbohydrates, which have many biological
actions including: being an important energy source for colonic epithelial cells[97]; regulating gene expression
by binding to G-protein-coupled receptors found in a wide variety of tissues and cells (adipocytes, immune
and endocrine cells)[98,99]; modulating intestinal gluconeogenesis and appetite[100]; regulating inflammation by
acting on T regulatory cells[101,102]; and regulating the production of leptin.[103–105] This host–microbial
relationship is bidirectional and is the end product of a billion years of permanent interaction with our
environment.[106] Gut microbial diversity and composition are profoundly influenced by host diet, lifestyle,
drugs, disease, the presence of pathogens, genetic background and environmental factors.[100,107–109]
Nutrition
Nutrition plays an important role in both the onset and the prevention of many chronic diseases associated
with toxicant exposure. Complex interactions of multiple polymorphisms play a key role in how individuals
respond to dietary interventions (nutrigenetics) and how some nutrients may affect gene expression
(nutrigenomics),[110] which may inadvertently affect the way individuals deal with environmental toxicants.
About 25 tonnes of food passes through a person's gut in their lifetime, making food the primary source of
exposure to microbes and toxicants. The past 20 years have shown that diet and nutrients not only contribute
to shaping the gut microbiota composition, but they also affect many genes related to inflammation and
oxidative stress and provide key nutrients for a large number of biological processes vital for detoxification,
the immune response (including gene expression), protein synthesis, modification and degradation,
metabolism, signal transduction, and cellular proliferation and survival.[111,112] Numerous constituents in
nutraceuticals (foods that provide health benefits) have been identified, including antioxidant flavonoids,
proanthocyanidins, carotenoids, dietary fibre, phyto-oestrogens, glucosinolates, catechins, saponins and
lignans,[113] which may explain the effectiveness of health-promoting diets like the traditional Mediterranean
diet in lowering the risk of chronic diseases.[114,115]
Recent longitudinal studies investigating dietary intake in human centenarians have shown that
micronutrients (zinc, copper, selenium) and polyphenolic antioxidants in fruits and vegetables play a pivotal
role in maintaining and reinforcing the performance of the immune and antioxidant systems, as well as in
affecting the complex network of genes.[112,116] Similarly, many foods have been implicated in the development
of disease. A high-fat diet has been shown to disrupt Gram-negative intestinal populations of animals,
liberating lipopolysaccharide and resulting in low-grade chronic inflammation.[79] Alcohol induces CYP2E1
enzyme (which is involved in phase I detoxification, activates various carcinogens and is responsible for
metabolising many volatile organic compounds) and simultaneously depletes glutathione levels in the liver,
thereby reducing the ability to detoxify other chemicals.[82] It is well established that a Western diet produces
chronic inflammation due to excessive levels of omega-6 oils, saturated fat, sugars and starches, as well as a
deficiency in micronutrients and antioxidants.[117,118]
Ethnicity
Ethnicity is an important marker for susceptibility to environmental toxicants and is the outcome of the
interaction between genetics, diet and geography, as family members who share a family history of heart
disease are also more likely to share other risk factors such as diet, activity and place history.[119]
Polymorphisms in key detoxification pathways and gut microbiota with distinct xenobiotic metabolising
capacities also vary with ethnicity.[63]
Toxicants
The chemicals humans are exposed to, through their diet, home, workplace or environment, can have a
profound effect on their health[121]: 27% of global chronic disease mortality is aIributed to exposure to radon,
ozone, lead, workplace chemicals, cigareIe smoke, wood smoke (from cooking fires) and air pollution.[122]
There are more than 124 million chemicals registered for use on the world's largest database, the Chemical
Abstract Service,[123] and most of the artificial portions of these chemicals have never been tested for their
impact on human health. Large population biomonitoring studies have revealed widespread exposure to
toxicants at levels in humans known to cause adverse health effects.[7–10] While chemical exposure is ubiquitous
in the general population, environmental hazards are inequitably distributed according to class, race, location
and lifestyle factors.
Air
• Homes, workplaces and schools should be located away from known sources of air
pollutants such as industrial zones, shipping ports, mining areas, flight paths, military
bases, sewage sites, municipal tips and waste sites, bus/truck/taxi depots, carparks and
heavy traffic
• New buildings and renovations should consider the microclimate and topography of
the site to maximise the use of natural light, promote passive ventilation and good
drainage, and reduce the need for artificial heating and cooling. They should also use
natural, unadulterated, sustainable and hygroscopic building materials that are low in
volatile organic compounds, are not radioactive and do not adversely impact the
electroclimate of the space or the health of the occupants
• Homes located near known sources of air pollutants should be sealed and retrofiIed
with a whole house filtration system that includes HEPA and carbon filters
• Homes built prior to the 1980s should be tested for lead paint and asbestos by a
licensed professional prior to conducting any renovations
• Air-conditioning and heating systems and natural gas appliances should be well
maintained and serviced in accordance with the manufacturer's guidelines. The air
intake for an air-conditioning system should not be located near food outlets or vehicle
exhaust (i.e. garage, carpark)
• Heating and cooking sources that use wood, coal or dung as a fuel source (e.g. open
fireplace, wood combustion stove) should be avoided
• Cars should not be left to idle in enclosed garages
• Exhaust fans in the kitchen, bathroom and laundry should be regularly cleaned and
vented to the outside
• Environmental tobacco smoke, air fresheners, scented candles, incense, and perfume
and fragrances in cleaning and personal care products should be avoided
• Furnishings should be made from natural fibres and materials (timber, glass, metal,
bamboo, wool, organic coIon) that have been sourced and made locally
• An integrated pest management plan that avoids the use of chemical pesticides should
be implemented
• Occupational exposure should implement the hierarchy of control in accordance with
legislative requirements.
Food
• Pesticides, fungicides and herbicides used on fruits, vegetables, legumes, grains and
nuts
• Food additives in processed foods such as food colouring, flavours, preservatives,
acidity regulators, antioxidants, emulsifiers, stabilisers, thickeners, anticaking agents and
sweeteners
• Eating top predators (fish) that are likely to contain heavy metals and persistent
organic pollutants
• Antibiotics, agrochemicals and antiparasitic drugs used in livestock
• Radioactive nuclides occurring naturally in soil and water or arising from nuclear
accidents
• Heavy metals in plants and animals (arising from artificial and natural sources)
• Food packaging made from plastic (phthalates, bisphenol-A) and tins (BPA lining, lead
solder)
• Cooking utensils: copper or aluminium pots and pans, eroding non-stick cookware,
plastic bakeware
• Plastic wraps and containers (numbers 1, 3, 6 and 7), lead- or cadmium-containing
glazed ceramics or containers with leaded crystal or radioactive glazes
• Freezing or heating food in plastic.