Detoxification in Naturopathic Medicine:
Jason Allen, ND, MPH,1,2Melissa Montalto, MS,1Jennifer Lovejoy, PhD,3and Wendy Weber, ND, PhD, MPH4
Objectives: This study sought to assess the use of clinical detoxification therapies used by licensed naturopathic
doctors (NDs) in the United States.
Design: This was a qualitative, descriptive, online survey of a convenience sample of NDs.
Methods: An online survey was conducted of NDs who were licensed in the United States. Responses were
analyzed descriptively regarding the use of clinical detoxification therapies. Respondents were recruited from a
membership list provided by the American Association of Naturopathic Physicians, and from alumni e-mail lists
of Council of Naturopathic Medical Education accredited naturopathic medical schools.
Results: Surveys were sent out to 1442 e-mail addresses (261 were returned to sender); a total of 196 respondents
completed the survey (16.6%). Ninety-two percent (92%) of respondents reported using clinical detoxification
therapies. Over 75% of respondents utilized detoxification therapies primarily to treat patients for environmental
exposures, general cleansing/preventive medicine, gastrointestinal disorders, and autoimmune disease. Re-
garding methods used, >75% reported using dietary measures, reducing environmental exposures, and using
botanicals as detoxification therapies. Eighty-three percent (83%) of NDs surveyed reported using follow-up
measurements to determine efficacy of detoxification therapies. The most common were patient symptom
questionnaires (66%), patient medical histories (54%), and urinary provocative challenge testing (53%).
Conclusions: The majority of NDs responding to this survey reported routine use of clinical detoxification
therapies to treat a range of medical conditions utilizing multiple therapeutic approaches. Although the majority
of NDs reported using some follow-up measurements after detoxification therapy, few of these are an objective
means to determine treatment efficacy. Further research is needed in the field of complementary and alternative
medicine clinical detoxification to determine the safety and efficacy of these approaches.
including synthetic chemicals and metals, into the environ-
ment has increased exponentially. As a result, exposure to
persistent bioaccumulative toxicants (PBTs) by humans has
increased. Exposure to certain PBTs has been associated with
adverse health effects, including endocrine disruption,1neu-
rological2and reproductive effects,3as well as cancers4and
cardiovascular diseases.5Examples of chemicals associated
with diseases and disorders include organochlorine pesti-
cides, phthalates, bisphenol A, and polybrominated diphenyl
uring global industrialization over the past cen-
tury, the manufacture, use, and release of xenobiotics,
ethers. Comprehensive indices of chemical–disease associa-
tions are available online from advocacy groups,6indepen-
dent research organizations/networks,7and the federal
government.8Over 80,000 chemicals are registered for use
today in the United States, with an estimated 2000 new ones
coming to market annually, many of which have not been
studied for adverse health effects.9
Human biomonitoring is the process of measuring the
amount of chemicals that exist within the body (blood, urine,
adipose, cord blood, breast milk, etc.) coming from various
The concentration of these chemicals, assessed by biomoni-
toring, is commonly referred to as the ‘‘body burden.’’ Studies
1Bastyr University Research Institute, Seattle, WA.
2School of Public Health, University of Washington, Seattle, WA.
3Free & Clear, Inc., Seattle, WA.
4Bastyr University Research Institute, Seattle, WA.
Wendy Weber is currently at the National Center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda,
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 17, Number 12, 2011, pp. 1175–1180
ª Mary Ann Liebert, Inc.
increasingly suggest that the human body burden of several
chemicals, at physiologically relevant levels, is a real threat to
human health, including fetal and neonatal health.11–15
The term ‘‘detoxification’’ has become common in today’s
society, generally referring to weight loss, addiction recovery,
detoxification are highly variable, nonstandardized, and often
controversial. The clinical definition of detoxification is less
vague. The Centers for Disease Control and Prevention’s
Agency for Toxic Substances & Disease Registry defines de-
books define detoxification as conversion of ‘‘toxic parent
catalyzed or not, that consume toxic metabolites without pro-
ducing injury.’’17,18There are virtually no standardized clinical
practice guidelines or textbooks in the field of detoxification.
Within complementary and alternative medicine (CAM), there
may be a large variation between CAM practitioners’ use of
detoxification therapies, depending on schooling, subsequent
methods are used by CAM practitioners on a regular basis for
the purpose of detoxification (for diagnosis or treatment).
To the authors’ knowledge, no comprehensive assessment
of clinical detoxification practice in the United States has ever
been conducted. However, limited data on specific detoxifi-
cation protocols are available in the literature. For example,
detoxification using a medical food supplement (UltraClearª
and UltraClear SUSTAINª) in combination with a modified
elimination diet was found to improve Metabolic Screening
Questionnaire scores, and increase Phase I and II metabolism
markers, although not all findings were statistically signifi-
cant.19,20A review by Crinnion summarizing a case series
spanning over 10 years of practice with patients undergoing a
detoxification protocol indicated that 83% of people who had
undergone these treatments self-rated their results as ‘‘good’’
or ‘‘great.’’ These questionnaires were filled out by patients
0–10 years after completion of the protocols, and therefore
serve as a subjective means of rating efficacy.21One of the
most frequently cited programs, the Hubbard Purification
Program,22is currently being used at a high-profile clinic in
Manhattan to treat World Trade Center rescue workers. The
multicomponent program is centered on graduating doses of
niacin, as well as sauna, exercise, nutrient supplementation,
and electrolytes. While methodological descriptions of the
program lack specificity, particularly regarding rationale,
medical monitoring, and poor characterization of endpoints,
it has been shown to decrease serum and adipose levels of
lipophilic chemicals, including polycholorinated biphenyls
and 1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane.23–25In ad-
dition, its strong association with L. Ron Hubbard and the
Church of Scientology has drawn some criticism.
The few previous studies on detoxification, while provid-
ing promising data, have had important methodological
limitations, including lack of peer-review, lack of randomi-
zation, lack of control groups, poorly characterized method-
ology, and small sample sizes. With the body burden
research suggesting possible or probable adverse human
health effects from these exposures, there exists an urgent
public health and clinical need for research on methods of
decreasing body burden (detoxification). Before rigorous
clinical trials can be conducted, there is need for a better de-
scription of the current detoxification treatments used by
CAM clinicians. Naturopathic doctors are an excellent re-
source for this information because they are provided clinical
training indetoxification methods, althoughthis trainingmay
be more based on biochemical rationale and anecdote than
evidence based. The purpose of this survey was to obtain
information from licensed naturopathic doctors (NDs) prac-
ticing in the United States on the use of detoxification treat-
ments and outcome measures assessed in their practices.
This was a qualitative, descriptive, electronic survey of
NDs licensed in the United States. The survey, its mainte-
nance, and responses were conducted using the online ser-
vice Survey Monkey (Portland, OR). Participants were
notified in the first page of the survey of the approximate
time required to complete the survey, data storage measures,
and confidentiality. Participants were not compensated for
completing the survey. Participants gave their consent by an
electronic signature and the study and consent form was
approved by the Institutional Review Board of Bastyr Uni-
versity in Kenmore, WA.
Subjects for this survey were NDs licensed to practice
medicine in the United States. Subjects were recruited via
e-mail; addresses were obtained from the American Associa-
tion of Naturopathic Physicians (AANP) website. In addition,
attempts were made to contact alumni representatives of the
four U.S. naturopathic medicine schools accredited by the
Council on Naturopathic Medical Education: Bastyr Uni-
versity, National College of Natural Medicine, Southwest
College of Naturopathic Medicine & Health Sciences, and
order to recruit alumni for the survey via e-mail. Of those
Medicine sent e-mails to their alumni with information about
this survey. The e-mails sent to both AANP e-mail addresses
and alumni contained a short paragraph regarding the exis-
tence and purpose of the study along with a link to the survey
website. Information provided by the AANP suggested that
there are over 2100 licensed NDs in the United States.
Information was collected in a descriptive manner in order
to gain a general understanding of naturopathic medical
detoxification practices. Data are presented mostly in per-
centage form. Data regarding numerical values, such as
years in practice, are reported as means with standard de-
viations. Data summaries were calculated by survey soft-
ware on Survey Monkey. Means and standard deviations
were computed with Microsoft Excel (2002).
E-mails were sent to 1181 potential respondents, and 196
licensed NDs provided electronic signatures voluntarily
1176 ALLEN ET AL.
consenting to participate in the online survey (16.6% re-
sponse rate). Participants had been in practice from 0 to 32
years, with a mean of 7.3 years. The majority of respondents
were female (72.1%), practicing in Washington State (34%)
or ‘‘Other’’ (i.e. unlicensed states for naturopathic medi-
cine; 26%), and were either graduates of Bastyr University
(54.8%) or National College of Natural Medicine (31.7%). See
Table 1 for detailed information on survey respondent
Use of detoxification therapies by naturopathic doctors
Ninety-two percent (92%) of respondents reported using
detoxification therapies in their practices. On average, 28
patients per month were seen specifically for detoxification
therapy. Reported use of detoxification therapies in specific
age groups was as follows: 13% of respondents treated
children from birth to 6 years of age, 23% treated children
and adolescents 7–17 years of age, 98% treated adults 18–55
years of age, and 63% treated patients 55 years of age and
Respondents reported treating a wide variety of patient
populations and medical conditions with detoxification
therapies, with over 75% treating environmental exposure
(82%), general cleansing/preventive medicine (81%), gas-
trointestinal disorders (80%), and autoimmune disease (76%;
Types of detoxification therapies utilized
by naturopathic doctors
When asked about detoxification therapies utilized in their
practice, respondents reported using multiple therapies, with
over 75% reporting the use of dietary measures such as
‘‘cleansing foods,’’ increased fruit/vegetable intake, vitamin/
mineral supplementation, organic foods, elimination diet,
probiotics, and stool bulking agents/fiber, as well as reduc-
ing environmental exposure and liver, gallbladder, or lym-
photrophic botanicals, such as cholegogues (herbs that
promote the excretion of bile), and lymphogogues (herbs that
promote lymphatic flow; Table 3).
Measurements to determine the need for
and efficacy of detoxification
Respondents were asked what diagnostic techniques they
employed to determine the need for detoxification therapies.
Thirteen percent (13%) of respondents stated that they did
not use diagnostic techniques. The three most common di-
agnostic techniques reported by respondents were medical
history (81%), environmental exposure history (62%), and
comprehensive metabolic panel (55%). (It should be noted
that a routine medical history does not often include a
spondents reported that detoxification therapy lasted a mean
of 37 days, and ranged from 3 to 365 days.
Table 1. Demographics of Respondents
Licensure status (N=201)
Not licensed/don’t know
Currently practicing (N=98)
Average years in practice (N=196)
Average number of patients seen
per week (N=167)
Average number of patients seen
per month (N=167)
School where ND degree was granted (N=199)
Boucher College of Naturopathic
Canadian College of Naturopathic
National College of Natural Medicine
Southwest College of Naturopathic
Medicine & Health Sciences
University of Bridgeport College
of Naturopathic Medicine
aOther, student at National College of Natural Medicine.
ND, naturopathic doctor.
Table 2. Naturopathic Doctors Reporting Treatment
of Patient Populations/Medical Conditions
With Detoxification Therapies
General cleansing/preventive medicine
Chronic fatigue syndrome
Multiple chemical sensitivity
Mercury amalgam removal
Recovery from chemotherapy/radiation
Other psychologic disorders
PMS, premenstrual syndrome.
DETOXIFICATION IN NATUROPATHIC MEDICINE1177
Eighty-three percent (83%) of respondents stated that they
used follow-up measurements to determine efficacy of de-
toxification therapies. Subjects who reported using follow-up
measurements indicated that they did so after an average of
23 days, with a range from 0 to 360 days. The three primary
follow-up measurements reported were patient symptom
questionnaire, patient medical history, and urinary provoc-
ative challenge testing.
Use of detoxification therapies by naturopathic doctors
Methods of detoxification have existed in different cul-
tures for thousands of years, ranging from sweat lodges in
Native American traditions to Panchakarma of Ayurvedic
medicine. Today, naturopathic medical students are trained
in detoxification principles through coursework in bio-
chemistry, nutrition, gastroenterology, environmental medi-
cine and clinical rotations (personal communication, John
Hibbs, ND, Bastyr University 2010; Dr. Walter Crinnion, ND,
Southwest College of Naturopathic Medicine [SCNM]).
Dr. Crinnion now directs an Environmental Medicine De-
partment at SCNM, specifically to educate health care pro-
viders and conduct research on environmental toxicants and
their health effects.26,27Furthermore, a small group of NDs
specializing in environmental medicine and detoxification
are in the process of forming the Naturopathic Association of
Environmental Medicine (bylaws approved by the House of
Delegates of the AANP, 2008), for promoting research,
education, and standards of practice.
Research supports the role of medical nutrition in the
prevention and treatment of disease, inflammation, allergies,
and asthma, as well as protecting against and treating en-
vironmental exposures.28,29For example, some fruits and
vegetables that contain antioxidants and phytonutrients en-
hance detoxification. Research demonstrates that green leafy
vegetables have large amounts of antioxidants and enhance
phase II detoxification in the liver.30,31Consuming Brassica
vegetables enhances Phase II detoxification by inducing the
glutathione/glutathione S-transferase (GST) system.32Or-
ganosulfur components of garlic oil, diallyl disulfide, and
diallyl trisulfide have also been shown to increase hepatic
detoxification in rat models through enhancement of phase II
metabolism via GST.33In addition, certain organically grown
produce may have higher antioxidant and bioactive com-
pound levels, as well as lower pesticide/herbicide/fungicide
As the interest in complementary and alternative medicine
grows in the United States and ND licensure increases,27the
public may have increased exposure to detoxification thera-
pies under the care of a licensed ND (or other health care
provider) to address the potential adverse effects of an in-
creasing body burden of synthetic chemicals.
Respondents to this survey indicated that they treat a
wide variety of patient populations and medical conditions
using detoxification therapies. Due to the format of this
survey, it was not possible to determine why or how NDs
treated these patient populations/conditions, only that they
were being treated with detoxification. However, it was
possible to gather data on the most common conditions for
which NDs used detoxification therapies (>75%), which in-
cluded environmental exposure, general cleansing/preven-
tive medicine, gastrointestinal disorders, and autoimmune
Detoxification therapies reported in this survey varied
widely, with 22 of 30 specific therapies used by over 25% of
respondents. Detoxification therapies reportedly used by
more than 75% of NDs included dietary measures (cleansing
foods, increased fruit/vegetable intake, vitamin/mineral/
antioxidant supplementation, organic foods, elimination
diet, stool bulking agents/fiber), probiotics, reducing envi-
ronmental exposure, and cholagogue herbs (herbs that pro-
mote the excretion of bile). The data seem to indicate that
more general detoxification therapies reported are frequently
used for a number of conditions, whereas more specific
therapies may be utilized less frequently by NDs or only for
Strengths and limitations
This survey presents data for the first time on detoxifica-
tion therapies used by naturopathic physicians. Due to the
format of the survey, it was not possible to assess which
therapies were used for conditions treated, except for those
specifically asked about.
Selection bias may have occurred, since the recruitment
process was via e-mail and it is possible that not all licensed
NDs have e-mail accounts, or perhaps more likely that ad-
dresses were mistyped, filtered as junk mail, or were old
e-mail accounts. Another source of selection bias was the use
of AANP-listed e-mail addresses, since there is a cost for
membership and NDs are not required to be members of this
organization for licensure purposes. Furthermore, only two
of the four United States naturopathic colleges sent the sur-
vey e-mails to their alumni. Thus, the results of this survey
Table 3. Use of Detoxification Therapies
in General Therapy
Cleansing foods (i.e., Brassica family, beet root,
Increased fruit/vegetable intake
Reduce environmental exposure
Stool bulking agents/fiber
Avoidance of animal products
Unmonitored cardiovascular exercise
Increased protein intake
Colonic irrigation/colon hydrotherapy
Combination homeopathic remedies
Constitutional homeopathic remedies
1178 ALLEN ET AL.
may not be generalizable to the whole population of NDs
practicing in the United States.
E-mails were sent to 1442 people (261 e-mails were re-
turned to sender), and 196 individuals provided an electronic
signature, resulting in a 16.6% response rate. Numbers for
e-mails sent through alumni organizations were not avail-
able. This response rate is lower than previously published
surveys of NDs regarding breast cancer treatment, which
was 47%, and multiple sclerosis treatment, which was
44.2%.36,37Studies comparing electronic versus mail surveys
of medical residents and faculty, and Canadian physicians,
support the theory that response rates of electronic surveys
are lower, but result in a shorter response time, and that
quality of data is either equivalent, or open e-mail responses
tend to be longer than mail responses.38,39Information could
not be gathered on nonrespondents, so it was not possible to
assess for the degree of response bias in this survey. It is
possible that those who utilized detoxification therapies in
their practice were more likely to respond. Still, valuable
information was gathered on the detoxification therapies
used by NDs in their practices, which has not previously
been presented in the literature.
This is the first survey conducted of NDs regarding the
use of detoxification therapies in clinical practice. The wide
variety in responses regarding age, patient populations/
conditions, and therapies may reflect the philosophy of
‘‘comprehensive, multidisciplinary, and individualized in-
terventions,’’ typical of the naturopathic profession.40It was
possible to ascertain information regarding primary detoxi-
fication therapies utilized by NDs for several specific con-
ditions. The high frequency of use of dietary interventions
for detoxification is supported, in part, by the scientific lit-
erature. Important in future research would be the inclusion
of controlled clinical trials of both specific detoxification
therapies and comprehensive protocols, where biochemical
tests in addition to clinical outcomes are used to determine
the effect of treatment. To this end, further research is needed
to determine the validity and reliability of laboratory mea-
sures or patient-reported outcomes to assess the efficacy of
As increasing evidence of the relationship between body
burden and adverse health effects of synthetic chemicals
emerges, safe and effective methods of reducing body bur-
den levels will be a vital component of naturopathic medi-
medicine in general. Detoxification therapies used by NDs
may serve as an adequate means to reduce the body burden
of synthetic chemicals found today in humans; however,
scientifically rigorous research is needed to determine the
safety and efficacy of these therapies. The authors’ observa-
tion that only approximately 50% of surveyed NDs reported
use of laboratory measures to assess toxicant exposure, or to
determine the efficacy of treatment is surprising and could be
a result of the survey design (the validity of certain types of
toxicant testing is highly controversial, and beyond the scope
of this survey). Nevertheless, it is clear that further research
and practice standards are needed. This survey provides an
important step into examining the general use of detoxifi-
cation therapies by NDs. Further elaboration of how and
why specific detoxification interventions are used, and how
effective they are is needed. Public health, CAM practition-
ers, and conventional medicine may benefit from more de-
tailed surveys, formal quantitative assessments, such as
practice-based research networks, and detoxification-specific
clinical trial research.
This study was supported, in part, by grants 5 F32
AT003366-03 and 5K99AT004711-01 from the National
Center for Complementary and Alternative Medicine, Na-
tional Institutes of Health, and by the Bastyr University Re-
search Institute. Its contents are solely the responsibility of
the authors and do not necessarily represent the official
views of the National Center for Complementary and Al-
ternative Medicine, or Bastyr University.
No competing financial interests exist.
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Address correspondence to:
Jason Allen, ND, MPH
School of Public Health
University of Washington
4225 Roosevelt Way NE
Seattle, WA 98195
1180 ALLEN ET AL.