An evidence based overview of naturopathic practice in Australia

Abstract

Naturopaths are consulted by 6.2% of the Australian
adult population, which is comparable to the rates of
consultations with acupuncturists (7.9%) and osteopaths
(5.4%)1.
The Review of the Australian Government Rebate on
Natural Therapies for Private Health Insurance2 (‘the
Natural Therapies Review’) found there is evidence to
suggest whole-system naturopathic practice is effective
in improving patient health for a range of chronic health
conditions. However, the Natural Therapies Review noted
the unregulated nature of the workforce made it difficult
to apply in the Australian context, particularly as most of
the identified research was conducted in North America.
Yet, Australian naturopathic education is comparable in
both length and breadth to North American courses.
The Australian naturopathic profession has been calling
for registration for many years3 and every government
report in the last 20 years examining the need for
registration of naturopathy has recommended this should
occur4. Despite the continued exclusion of naturopaths
from the prevailing Australian regulatory mode, the
profession has grown in size, strength and professional
status at a national and international level. For example,
the regulatory model developed by the naturopathic
profession in lieu of government registration5 is held up
as a best-practice model for self-regulation that could
be adopted by other unregistered health professions.
Alongside this, Australian naturopathic education is
recognised by the international peak body — the World
Naturopathic Federation (WNF) — as aligning with the
highest tier of professional qualification internationally6
and Australian naturopathic researchers attract more
government research funding than other registered
complementary medicine professions.
Even so, since the Natural Therapies Review in 2013
the evidence for whole-system naturopathic practice
has continued to increase: Whereas the Natural
Therapies Review found only one systematic review
for naturopathy containing 6 RCTs with 692 patients, a
more recent review has identified 31 RCTs comprising
9,798 patients, which provide evidence for an increased
number of chronic conditions improved by naturopathic
care7.

Full text

Australian Journal of Herbal and Naturopathic Medicine 2019 31(1)
9© NHAA 2019
Article
An evidence-based overview of naturopathic
practice in Australia
Executive summary
Naturopaths are consulted by 6.2% of the Australian
adult population, which is comparable to the rates of
consultations with acupuncturists (7.9%) and osteopaths
(5.4%)1.
The Review of the Australian Government Rebate on
Natural Therapies for Private Health Insurance2 (‘the
Natural Therapies Review’) found there is evidence to
suggest whole-system naturopathic practice is effective
in improving patient health for a range of chronic health
conditions. However, the Natural Therapies Review noted
the unregulated nature of the workforce made it difcult
to apply in the Australian context, particularly as most of
the identied research was conducted in North America.
Yet, Australian naturopathic education is comparable in
both length and breadth to North American courses.
The Australian naturopathic profession has been calling
for registration for many years3 and every government
report in the last 20 years examining the need for
registration of naturopathy has recommended this should
occur4. Despite the continued exclusion of naturopaths
from the prevailing Australian regulatory mode, the
profession has grown in size, strength and professional
status at a national and international level. For example,
the regulatory model developed by the naturopathic
profession in lieu of government registration5 is held up
as a best-practice model for self-regulation that could
be adopted by other unregistered health professions.
Alongside this, Australian naturopathic education is
recognised by the international peak body — the World
Naturopathic Federation (WNF) — as aligning with the
highest tier of professional qualication internationally6
and Australian naturopathic researchers attract more
government research funding than other registered
complementary medicine professions.
Even so, since the Natural Therapies Review in 2013
the evidence for whole-system naturopathic practice
has continued to increase: Whereas the Natural
Therapies Review found only one systematic review
for naturopathy containing 6 RCTs with 692 patients, a
more recent review has identied 31 RCTs comprising
9,798 patients, which provide evidence for an increased
number of chronic conditions improved by naturopathic
care7.
Jon Wardle1, Amie Steel1,2, David Casteleijn1,3 and Diana Bowman1,3
1 Discipline of Public Health, Faculty of Health, University of Technology of Sydney, NSW, Australia
2 Australian Register of Naturopaths and Herbalists (ARONAH)
PO Box 711, Fortitude Valley, Qld 4006
3 Naturopaths and Herbalists Association of Australia (NHAA) PO Box 696, Ashfield NSW 1800 Australia
doi.org/10.33235/ajhnm.31.1.9-13
Role of naturopathy in the Australian
health system
Approximately 6.2% of Australians have consulted with
a naturopath in the previous 12 months1 and 75% of these
users have a chronic illness8. Furthermore, approximately
1 in 10 Australians with chronic diseases such as sleep
disorders (13.6%), type 1 and 2 diabetes (11.9%), mental
health disorders (9.0%) and asthma (8.7%) consult with a
naturopath (Table 1)9. Based on unpublished data collected
through the Practitioner Research and Collaboration
Initiative (PRACI) — a world-rst, practice-based
research network for complementary medicine
professions including naturopathy10 — Australian
naturopaths also report frequently treating patients
with diagnosed illness of national importance such as
insomnia, depression/anxiety, menstrual disorders, and
arthritis (among others). Half of naturopathic patients
visit their naturopath for most of their health issues and
59.6% use their naturopath as their primary provider,
with 22.2% as their sole primary care provider and
37.1% as the primary provider in conjunction with other
health providers (for example, GPs) used in a secondary
capacity11.
Table 1: Prevalence of consultations with a naturopath
based on diagnosis with nationally important chronic
diseases
Disorder diagnosis % of population who
visited naturopath
Sleep disorder 13.6
Diabetes (type 1 and 2) 11.9
Mental health disorder 9.0
Asthma 8.7
Respiratory disorder 8.5
Cancer 8.3
Gastrointestinal disorder 7.2
Musculoskeletal disorder 6.6
Osteoarthritis 6.0
Cardiovascular disease 5.8
Any chronic disease diagnosis 7.2

Australian Journal of Herbal and Naturopathic Medicine 2019 31(1)
10 © NHAA 2019
The total rate of naturopathic consultations in the
general population is comparable to other registered
health professions, such as acupuncturists (7.9%) and
osteopaths (5.4%)1 and demonstrates a 5% increase
over 10 years12. Australian naturopaths see an average
of 13 to 14 patients per week and 20 to 21 new patients
per month13, often practising in rural and remote areas
where there are shortages of other health services14.
Australian naturopaths are also relatively integrated into
the Australian health system, with one-quarter (25.8%)
of GPs referring to a naturopath at least a few times per
year15.
This same research also indicates the focus naturopaths
place on factors important to population health and
prevention of chronic illness such as sleep, dietary
habits, substance use, and physical activity (Table 2).
The naturopaths’ self-reported practice behaviours align
with national data collected from patients of naturopaths,
indicating they were prescribed dietary changes (96.3%),
lifestyle changes (mainly exercise) (92.6%) and self-care
techniques (such as stress-reduction and pain-reduction
techniques) (70.4%), many of which directly support the
national Australian guidelines for health promotion and
disease prevention11.
Table 2: Self-reported prescriptions of naturopathic
practitioners in Australia (source: PRACI)
Self-reported practice
behaviours
% of practitioners
prescribing
Lifestyle recommendations 98
Dietary modification 90
Herbal medicine 90
Meditation 88
Exercise prescription 83
Yoga 75
Nutritional supplementation 65
Homoeopathy 36
The naturopathic education and research
landscape
Australian education for naturopaths is considered by the
WNF to be in the top tier of education globally (along with
Canada, India, South Africa and the United States)6. The
professional standard for graduation as a naturopath in
Australia is a four-year bachelor degree program (though
lack of regulation means that untrained practitioners
have historically co-opted the title). A comparison of the
leading Australian four-year program and the leading
accredited Canadian four-year program can be found in
Figure 1. It shows the Australian and Canadian courses
being of comparable breadth, with the Australian courses
containing signicantly more nutrition, herbal medicine
and physical medicine content, while the Canadian
course contains more content on homeopathy and more
student clinic training hours.
The commitment to professionalism in education and
training in the naturopathic community can also be
demonstrated through other initiatives of the Australian
naturopathic profession. The Australian Journal of
Herbal and Naturopathic Medicine (the ofcial journal
of the Naturopaths and Herbalists Association of
Australia — NHAA), for example, is Australia’s highest-
ranked complementary medicine profession journal in
the Scopus database*.
The Australian naturopathic education sector has also
embraced research-led teaching more than any other
complementary medicine (CM) profession. Southern
Cross University developed the rst CM research
higher degree program (in naturopathy) in 1996 and the
Endeavour College of Natural Health (ECNH) developed
Australia’s rst research higher degree program in a
private CM college in 2016, by offering an honours
program in naturopathy. In only two years, graduates
of Endeavour’s honours program have produced 15
publications in international peer-reviewed journals from
their original research projects16.
ECNH also leads research initiatives such as the
International Research Consortium of Naturopathic
Course area Australian
college (ECNH)
Canadian
college
(CCNM)
Biosciences (e.g.
Anatomy, Physiology,
Pathology, Pharmacology)
468 463
Social Science (e.g.
Psychology, Public Health,
Critical Research Skills)
312 260
Naturopathic Theory (e.g.
Naturopathic Principles
and Philosophies)
78 24
Naturopathic Clinic (e.g.
student clinic hours)
624 1280
Homoeopathy 0* 119
Physical Medicine (e.g.
massage, manipulation,
hydrotherapy)
156 48
Electives (e.g. sports
specialisation, community
education, advanced
physical skills)
195 24
Herbal Medicine (e.g.
herbal medicine practice,
integrated pharmacology)
390 147
Nutrition and dietetics
(e.g. clinical nutrition,
dietary planning)
429 182
TOTAL HOURS 2496 2537
Figure 1: Course hours in the leading Australian program
versus the leading Canadian naturopathic program
(note: course hours have been converted into Australian
course hours). Homoeopathy is available as an elective in
Australian courses.
Article

Australian Journal of Herbal and Naturopathic Medicine 2019 31(1)
11© NHAA 2019
Article
Academic Clinics (IRCNAC), a collaboration (based on
homogeneity of education standards) of college clinics
in Australia, Canada, New Zealand and the United
States, which is now being used for multiple projects,
including several funded by the US National Institutes
of Health17.The Australian naturopathic profession is also
the only Australian CM profession conducting research
into critical assessment in education18. Ironically this
internal self-critique — a recognised essential element of
professionalisation but absent in most CM professions —
was used by the NHMRC Review to dismiss the evidence
base for naturopathy19.
Regulation of naturopathic practice in
Australia
Registration focuses on providing several safeguards to
ensure the public are accessing safe and effective health
care from appropriately qualied health practitioners.
Every evaluation under these criteria has recommended
that naturopaths warrant registration20,21.
Naturopathic practitioners have consistently identied
regulation of the profession as the major challenge the
profession faces and support the implementation of
regulation to ensure practice standards and promote
public safety3.
Our concerns are that untrained and unethical practitioners
are also able to practise using the title of ‘naturopath’ —
the professional naturopathic community in Australia
and globally does not consider these practitioners as
part of the profession. For the last 20 years, the industry
standard of naturopathic education has been a 4-year
bachelor degree in Australia. Since 2015, government
legislation and accreditation have mandated requirements
that naturopathic education must be delivered within a
degree model.
The Australian naturopathic profession has demonstrated
an understanding of the need for registration through
the establishment of Australian Register of Naturopaths
and Herbalists (ARONAH) to mirror the regulatory
framework of the National Registration and Accreditation
Scheme (NRAS). ARONAH’s standards were developed
through benchmarking against the Association of
Accredited Naturopathic Medical Colleges (AANMC)†
standards in North America as part of their development
and the ARONAH model is recommended by the WNF to
countries seeking to further professionalise naturopathy
in the absence of government registration. Equally in
Australia, the ARONAH model has been mentioned in
the Australian Health Ministers’ Advisory Council report
on Options for Unregistered Health Practitioners22 as an
ideal model for professions not included in the NRAS.
ARONAH and the NHAA — recognised by the WNF
as the pre-eminent naturopathic association representing
naturopaths in Australia — are actively lobbying for the
inclusion of naturopaths and Western herbalists in the
NRAS.
Evidence for the safety, effectiveness
and cost-effectiveness of naturopathic
treatments
The Natural Therapies Review limited its search
for evidence of the safety, effectiveness and cost-
effectiveness of naturopathy to “whole practice” studies
only (meaning specic treatments commonly used by
naturopaths were not considered). Even with this limited
inclusion criteria, the Review found 6 RCTs (comprising
692 patients) which suggested naturopathy may be
effective for a range of chronic conditions, including
anxiety, multiple sclerosis, cardiovascular disease and
musculoskeletal conditions. Since the Natural Therapies
Review was conducted (in 2013) a more recent review
has identied 31 RCTs with 9798 patients, adding type
2 diabetes, polycystic ovarian syndrome, depression,
anxiety and a range of complex chronic conditions to
the evidence base7. Where economic analyses have been
conducted, naturopathy has also shown cost-benet:
a systematic review of cost-effectiveness studies,
conducted in complementary therapies with research
evidence suggesting cost-effectiveness (specically for
treatment of low-back pain and anxiety)23.
However, a sole focus on “whole practice” research is not
likely to capture the full extent of naturopathic evidence.
There are numerous trials registered as evaluating
naturopathy practice in the Australian and New Zealand
Clinical Trials Registry (ANZCTR), yet none of them
identify “whole-practice” research. Even when trials
explicitly evaluate the intervention of a naturopathic
practitioner, they may identify as other interventions.
For example, an ANZCTR-listed naturopathic trial of
122 women with polycystic ovarian syndrome (which
reported improvements in symptoms and risk factors)
did not report as a “whole-practice” naturopathic
intervention, but rather a “combined lifestyle and herbal
medicine intervention”, even though this intervention
was delivered by naturopathic practitioners24. Where
naturopathic care is integrated into conventional health
settings it may also be obscured. For example, a trial of
naturopathic care for 922 cardiac post-surgical patients
at the Alfred Hospital found naturopathic care improved
post-operative heart function, reduced post-surgical
complications and improved adherence and compliance
to hospital rehabilitation services, yet was reported as a
nutritional wellness intervention rather than a naturopathic
intervention, despite the intervention being developed
and implemented by naturopathic practitioners25.
Australia and Canada are recognised as the two global
centres of naturopathic research by the WNF, which is
currently conducting an audit of global naturopathic
research. This audit has already identied 2150 research
articles published by naturopathic researchers in peer-
reviewed medical journals, of which 623 (28.9%) are by
Australian authors, and 596 (27.7%) are conducted in
Australian settings. Of the 10 most published naturopathic
authors in peer-reviewed medical journals, Australia
is the most represented country with four‡. However,
despite this audit identifying naturopathic researchers

Australian Journal of Herbal and Naturopathic Medicine 2019 31(1)
12 © NHAA 2019
Figure 2: Cumulative NHMRC grants secured by CAM professional faculties within the university sector. TCM =
traditional Chinese medicine. *Naturopathy no longer has a university-based faculty, 2007–2017
conducting research into naturopathic treatments or
topics, only 157 articles (7.3%) explicitly acknowledge
naturopathy as a whole-practice system of medicine. This
is primarily because research in specic naturopathic
modalities (for example, herbal medicine, hydrotherapy)
or approaches (for example, dietary or lifestyle care
recommended by naturopaths) may be rebadged under
these specic categories. Even in the absence of having
specic university departments, naturopaths are the
most active CM profession involved in research in
Australia, with more naturopaths undertaking research
higher degree programs at Australian universities than
any other CM profession26. Naturopathic researchers
have successfully secured more National Health and
Medical Research Council grants than all other CM
professions (TCM, chiropractors, osteopaths, massage
— Figure 2)27. However, as noted earlier, it is unlikely
that naturopathic research funded by the NHMRC would
be captured as “whole-practice” naturopathic research.
Funding for Australian naturopathic research can also
be seen through PhD scholarships. For example, every
naturopath graduating from the Endeavour honours
program has not only continued on to enrol in a PhD at
a leading Australian university but has also been offered
competitive PhD scholarships — such as the Australian
Government Research Training Program Scholarship —
to support them during their research degree.
Acknowledgements
We are grateful to Endeavour College of Natural Health
and the Practitioner Research and Collaboration Initiative
(PRACI) for providing unpublished data for inclusion in
this document.
Notes
* The Scopus database is the pre-eminent database and quality
metric for peer-reviewed journals. The AJHNM has a score of
0.27, the Journal of the Australian Traditional Medicine Society
a score of 0.09, the Chiropractic Journal of Australia a score
of 0.07 and the Australian Journal of Acupuncture and Chinese
Medicine a score of 0.04. For reference, the median score for
general medical journals is 0.26, which places AJHNM in the top
50% of peer-reviewed medical journals internationally.
† The AANMC regulates the educational standards and delivery of
naturopathic education in Canada and the United States.
‡ Three authors from the top 10 are from the United States, two
from Canada and one from Germany.
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0
2
4
6
8
10
12
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
NHMRCGrants(cumulative)byCMprofession
Naturopathy TCM Chiropractic Osteopathy
Figure 2: Cumulative NHMRC grants secured by CAM professional faculties within the university sector. TCM
= traditional Chinese medicine. *Naturopathy no longer has a university-based faculty, 2007-2017
Article

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