Naturopathy, References, Citations, Your Brain on Nature (review)

Curmudgeon’s Corner

Hansel, Gretel, et al

By Jacob Schor, ND, FABNO

Many myths and stories tell us of protagonists who had the foresight to leave a trail behind them that allows them to escape their fate or perhaps find their way home.

Theseus kills the Minotaur of Crete and escapes its maze thanks to a ball of yarn that Ariadne has given him.¹ Hansel and Gretel find their way home with white pebbles that reflect the moonlight. An attempt to use a breadcrumb trail instead proves less effective due to avian consumption.² (We should note that neither story ends quite happily ever after: Theseus abandons Ariadne after discovering she’s already married, and Hansel and Gretel find their way home but are again abandoned in the forest by the woodcutter and his wife the very next day.)

In our modern world and in our pursuit of evidence-based medicine, we also try to leave a trail behind us, not so much to find our way back but to understand how we got to where we are. We do this via citations; we reference the study or source of our assumptions and so leave a link to the ideas that have led us to believe what we do and the conclusions we have reached.

Practicing medicine is itself an odyssey and an exploration; often someone’s life depends on the decisions we make. We must traverse a maze of knowledge that is made more complicated by constantly evolving science. In a way, truth shifts with time. If we were still part of a Greek myth, it would be like sailing an Aegean archipelago of free-floating islands, which drift about shifting positions over time. Citations anchor ideas in time and place while at the same time acknowledging the possibility that these beliefs may change.

Two things have pushed me to ponder all this. First, lab work a patient brought in has left me perplexed how to interpret it, and second, there are several books sitting on my nightstand that I’ve been wanting to write about.

My patient’s report was from a well-known company back East that specializes in cardiac risk assessment. Their panel includes a measurement of myeloperoxidase enzyme, a value that the lab suggests is strongly correlated with risk of cardiac events. My patient’s levels tripled over the past 12 months and are well above what the lab considers acceptable values.

Such an augur of ill health should ethically require me to share the information with the patient’s other health caregivers. My long habit when communicating with other providers is to include citations to justify any ‘facts’ I report. This habit of justifying beliefs is no doubt the result of my practicing naturopathic medicine in Colorado decades before it was legal to do so. When practicing medicine without a license, one needs not just to look smart, or at least not appear to be making stuff up, but also to be somewhat persnickety about being on the EBM side of the line between quacks and legitimate practitioners.

Pubmed.gov quickly provided me with a recent study on myeloperoxidase as a CVD risk factor; Oyenuga et al’s study was just published in October 2018. Abayomi Oyenuga from the University of Minnesota, along with collaborators from Chapel Hill, Johns Hopkins, and the University of Texas, measured myeloperoxidase levels in the Atherosclerosis Risk in Communities (ARIC) cohort that included 1,465 participants and examined the risk of cardiovascular disease, coronary artery disease, heart failure, peripheral artery disease and cardiovascular mortality for a period just less than ten years long. Unfortunately, they found no association between myeloperoxidase measures and any of these conditions.³

The patient was sitting with me watching as I read (and then read again) this information, I was at a loss of what to say. The lab report claims a five-fold increase in risk for individuals with elevated myeloperoxidase enzymes. For obvious reasons I would have liked to compare the Oyenuga study with those upon which the lab based their claim.

The lab report itself cited a 2013 paper by Tang et al to justify their claim, though the citation was incomplete. I had to search for “Tang and myeloperoxidase and 2013,” a search that yielded about 80 citations. The 2013 paper by Tang that I think the lab was alluding to turned out to be W. H. Wilson Tang from the Cleveland Clinic and the paper, I think is, “Usefulness of cardiac biomarker score for risk stratification in stable patients undergoing elective cardiac evaluation across glycemic status.” I found this one near the bottom of my list of PubMed search results.

Tang’s study team asked if B-type natriuretic peptide, myeloperoxidase, and HS C-reactive protein either alone or in combination could be used as prognostic markers for heart disease. They followed 3,635 stable patients who had had angiography for three years. Using a score based on this combination of markers they were able to predict those who were at high risk for major adverse heart events (HR 7.61, p <0.001).⁴

My patient was long gone (as in, she had left the office) before I found this study. I’m still debating how to interpret her lab results. Her other risk markers were normal range. All this would have been simpler if there had been a complete citation that included the study title or one of the simple identifiers such as a PMID number or a doi. If there had been a thread to follow back to where they came up with this idea, my task would have been simpler. Now I need to follow up with the patient and see if we have values for these other possible markers. Perhaps if Ariadne had cut the strand of yarn, Theseus would have figured out that something was wrong with the relationship early on?

The second thing that has me obsessing about references today is that I’ve been working my way through The Oxford Textbook of Nature and Public Health: the role of nature in improving the health of a population.⁵ Edited by Matilda van den Bosch and William Bird, this is probably the most significant scholarly treatise written yet about nature and medicine. Its target audience is MPH students or perhaps more advanced sorts: it probably should be required reading for every naturopathic doctor in practice. It is heavily referenced, long sentenced, filled with long strings of multisyllabic word, a true textbook printed in an impressively small font. In other words, it’s not easy reading.

Yet, much of the information is brilliant and the words (recall that phenomenon where you hit one tuning fork and another nearby fork of the same frequency begins to vibrate, a phenomenon called resonance.) resonate in my naturopathic soul. Here is the opening paragraph from the forward:

For virtually all our development, humans have been totally dependent on nature. With increasing industrialization and urbanization, human beings have become partly disconnected from natural environments, both physically and mentally. The disconnection is now being viewed as a threat to health and this book explains how this disconnection displays through several pathways and eventually defined health outcomes. Equally, contact with natural environments may serve as a remedy for many contemporary health issues.

It’s not just slow reading. Like many textbooks it is a collaborative effort of multiple contributors, and each chapter has been written by a different committee. The resultant text can feel choppy, an ad hoc choir made up of multiple voices attempting to sing the same song. But that’s often the nature of textbooks.

This would be a perfect textbook for a naturopathic school class learning how to employ nature to promote health. I would suggest it as required reading except that few students will have the time or attention span to get through it. They will complain about the price (The softcover version is $75 on Amazon). For doctors in practice, reading it would be an even bigger stretch. Who will make the time?

It’s the sort of book you think you should read and wish you had read and but likely never will.

So, is there an easier way? I picked up a copy of Your Brain on Nature by Eva Selhub, MD, and Alan Logan, ND.⁶ The book’s website refers to Dr Logan as a biophilosopher, which I’ll assume is a cool new euphemism for naturopath. The book nicely reviews the scientific studies that have demonstrated the beneficial effects that exposure to nature has on many aspects of health, in particular mental health. It’s a comprehensive review and more important a fast and easy read. I would be writing a glowing review here, telling all of you to go out and buy this book and read it this weekend, except for one thing. There are no citations, no bibliography, no way to find the way back to any study the authors summarize, and pretty much the entire book reviews the scientific literature. It’s that Theseus problem again… you need that ball of yarn before entering this maze.

Let me open the book randomly:

In a 2011 study of over 4,500 adults followed for several years, total screen time was associated with a higher risk of death. And the risk increase was not small: it was 52 percent higher versus those with the least screen time. Surprisingly, exercise or lack thereof wasn’t the mediating factor. Among those who logged the highest amount of screen time, being physically active reduced their risk of dying from any cause by a mere 4 percent (to 48 percent higher risk of dying!) compared with those who exercised and had the least screen time.

This sounds like incredible information. This is the sort of stuff you might want to quote to a patient. The book is packed with interesting data summaries all put into context by an excellent narrative. Yet never is there enough clarifying information on any study being described to allow the reader to actually locate it. It feels as if the book was originally written with endnotes ending each paragraph but that some editor along the way did a copy and paste selecting the “text only” tab, deleting all the little footnote superscripts.

The Oxford textbook on the one hand is almost too thick with citations as there is a lot of theory and debate about mechanisms of action and heady subjects I had little interest in. The Logan – Selhub entry lacks references altogether. It’s like in the Goldilocks story. “This chair is too big and this chair is too small….. This book is too referenced, and this book not referenced at all.”

I contacted Dr. Logan about this and he responded with an interesting explanation: he tells me that I was correct; it was the publisher, Wiley & Co, who did not want to include the references. Doing so, they insisted, would increase the weight of the book and so increase the cost to consumers. Unhappy with this Dr. Logan went ahead and posted all of the citations online:

http://www.yourbrainonnature.com/references-from-the-book.html.

That’s far better than no citations, and perhaps it is the solution for Goldilocks; you can read the text without the clutter of footnotes, but you can still find the source of the information when and if you have the need.

It’s a compromise, of course, but it’s better than nothing. It’s essential for NDs to be publishing books. This is a good book. The world should recognize NDs as experts on natural health. At the same time, we do not want to be unprofessional about it; our books need to be referenced. The old method of using unidentifiable anecdotal stories about individual patients to prove the efficacy of a treatment, is just that, old, out of date, and should be unacceptable in modern naturopathic medicine.