Fraser Smith, MATD, ND

Naturopathic medicine, and more broadly, an integrative medicine approach, has the distinct attribute of placing importance on increasing resilience. Although there are many very effective, natural medicine treatments for specific acute ailments, the fundamental focus in naturopathic medicine is to increase a patient’s resilience. According to the National Institutes of Health, “Resilience encompasses the capacity to resist, adapt to, recover, or grow from a challenge.”¹ This starts with reestablishing the basis of health. But that is just the beginning. Many patients come to us with years, decades of chronic issues. We diagnose the disease(s) that they suffer from, and per our training, act accordingly with intervention and/or referral.

In a new textbook, Naturopathic Medicine: A Comprehensive Guide, I’ve tried to look at where and how our therapies interact with the patient, based on their levels of dysfunction.² While it is entirely appropriate to look at randomized controlled trials using a natural agent for a given named medical condition, this alone does not always help us support a particular patient’s resilience. I work with naturopathic medical students, a group of doctors-to-be who are highly committed to helping patients recover their health. One question that they ask and that we should be able to answer is: what is different or unique about a patient who has symptoms arising from one part of the body? Aside from the patient’s personality and lifestyle factors, is there anything specific to consider?

There is value in considering the level of dysfunction occurring in a patient, particularly with regards to their symptoms. This is not a new thought. Classical Chinese medicine has a concept of internal versus external diseases, and the nature of the organ/meridian where an imbalance exists. In homeopathy, we see examples of “Levels of Health,” which George Vithoulkas has taught.³ The field of homotoxicology, while not a major focus in naturopathic training, alludes to this concept with its six-phase table or “disease evolution table,” which looks at toxin deposition and the body’s reactions.⁴

In naturopathic medicine, we are looking at the state of affairs of the person and their body, not a particular lesion or agent such as toxins (which can be the issue in many cases). The levels of dysfunction that matter in naturopathic medicine often start with some disturbance to the determining factors of health. This is well outlined by Zeff, Snider, et al.⁵ But sometimes an aggressive etiologic agent such as physical trauma, virulent disease factors, or acute chemical poisoning can disrupt balance in the body.

Hypofunction

The first indicator that something is wrong is simply what I refer to as “hypofunction.” A gradual loss of function is often a subtle phenomenon, but it precedes more obvious pathology.  The aforementioned lack of or disturbance to some precondition of health (such as hydration, sleep, sunlight, movement etc.) will impact the duration of the lack of function, and whether it remains a sub-acute problem.  An example in the textbook, which I’ll repeat here, is that of mild dehydration, which can impact cognition, lung function, urinary tract clearance of salts, etc. More severe dehydration can lead to confusion, agitation, and cardiac arrhythmias.

Impaired Communication and Circulation

A situation of hypofunction that is not resolved will eventually progress to some localized or systemic failure of communication and circulation.  This is often quite reversible, but it will make itself known in more acute symptoms.  Non-alcoholic fatty liver disease has become very common, and some patients start to develop less efficient movement of triglycerides in and out of the liver, and even impaired biliary flow. They may not meet the criteria for being diagnosis with “hepatitis,” but their liver is now exhibiting some serious shortcomings.  Communication and circulation are hallmarks of organized and adaptive organs and systems.  When these functions are degraded, an organ may not perform well, even though the actual cells are still replete.

Inflammation

In Naturopathic Medicine, A Comprehensive Guide, there is a distinction between inflammation and deeper inflammation with extensive immune system involvement.  The state of having impaired circulation and communication with the nearby extracellular matrix, and with the circulatory system can predispose an organ or tissue to some forms of damage. This can be ischemia, poor repair from wear and tear/traumatic damage, or somewhat more susceptibility to infection.  Under these conditions, cellular damage begins to accrue. Inflammation is a normal response to injury, so up to a point, it is a troublesome, but not alarming manifestation of injury and disturbance. It does alert a practitioner to the fact that some underlying functions and some conditions of health are disturbed.

When inflammation persists, it often progresses in intensity. Normally, inflammation should resolve when the initial damage is over, some remodeling can occur locally, and it has time to completely heal. When inflammation rolls on, it leads to an accrual of damaged cells and molecular patterns that signal to the immune system that something is wrong. This calls in, via molecular signaling, more intrusive action by a wider array of white blood cells. This leads to more intense inflammation, and if this is not resolved, yet more molecular patterns that provoke immune intrusion.

An all-too-common example used in the textbook is the growth of an atheroma. This is the central lesion of atherosclerosis. Earlier in this condition, oxidative stress and the accumulation of oxidized LDL particles within the inner lining of arteries cause a change. The artery becomes ever more susceptible to this accumulation of oxidized LDL, and the immune system mounts responses that might be appropriate to remove any foreign body. But in this case, these efforts are unsuccessful.  White blood cells release substances such as myeloperoxidase and more white blood cells, and more oxidative stress, leading to further damage to the artery.

When initial inflammation can’t be resolved and healing with remodeling cannot occur, a chronic inflammation sets in. White blood cells that under normal circumstances would create a natural event of cellular turnover and removal of foreign pathogens or cellular debris now begin to destroy local tissue. An open wound of sorts becomes a constant feature, which releases more signaling for further immune involvement.

Fibrosis and Extracellular Matrix Degeneration

What happens with a prolonged and unresolved inflammation following a disruption to normal communication and circulation? Such tissue will undergo a more drastic response to unrelenting damage–a fibrotic reaction.  Tissues that are stressed and then have a normal resolution to inflammation and normal remodeling will eventually respond by fibrin deposition. This deposition of scar tissue is observable with the eye or relatively low-power microscopy. But another concurrent degradation is happening at the same time–the dissolution of an extracellular matrix.

The extracellular matrix is the specialized substrate that is in between cells. Once believed to be some simple “ground substance” that provides a nest for cells, it is now understood to be a specialized communication and transport zone. Proteins and glycoproteins, fibroblastic nerve endings, and some immune cells create a way for cells to communicate, receive nutrients, and expel wastes and toxins. One example is the later stages of ongoing damage to the liver.

When liver cells die because of toxins (alcohol, acetaldehyde, oxidized cholesterol, excessive free fatty acids), they release Damage Associated Patterns (DAMPs). This activates special collagen-producing cells in the liver, known as hepatic stellate cells, which are able to elicit a massive fibrotic reaction. This creates what is effectively scar tissue and that leads to an overall strangulation of the many channels of circulation in the liver (blood must mix with liver cells in order to be filtered; bile must flow from millions of small chambers to larger collecting ducts). DAMPs can also activate macrophages and lymphocytes. Things get worse, and the liver is no longer like the organ it used to be. There is some function, but it is only a matter of time before cirrhosis of the liver ensues.

Decline of Function

As in our liver example, an organ with extracellular matrix breakdown is on its way to no longer carrying out its functions – sometimes called organ failure. What is distinct in this situation is not just an extreme deviation from normal function, but a degradation of the organ at the macroscopic level and, importantly, at the level of the extracellular matrix. Examination of cells in this situation shows changes such as mitochondrial fission.

Relevance to Naturopathic Therapy

Understanding the levels of dysfunction is an opportunity to create more precise treatment approaches that are best suited to the situation at hand. The choice of therapies is yet another set of considerations, which we’ll discuss in an upcoming article. But even at the dysfunction stage of our clinical reasoning, many things are clear. Reversable situations such as hypofunction ought to be easily resolved with correction of disturbances to determining factors of health. Inflammation, even if chronic, may yet be at a stage where resolution of inflammation can still presage a return to mostly normal structure and function.

Deeper inflammation can still be reversed, but the organ and cellular milieu is no longer natural. Therefore, simply removing the original inciting cause of the inflammation will not be enough. A circular pattern of injury and response, a dreaded positive feedback loop, has set in. More pointed therapies to attenuate inflammation and rehabilitate, to whatever degree possible, local/organ level conditions will definitely be needed.

True degeneration and fibrosis tell us that some substitution or major assistance in moment-to-moment function are needed. Maybe that assistance will not be for life. We see remarkable healing progressions in patients, but at least at some early part of this journey, massive support of an organ has to be given. In decline of function, we continue to pay attention to and support normal circulation and communication, the needs for health function, etc; but we must acknowledge that such as patient is at great risk. This is where allopathic therapies, which can maintain a patient in allostasis (unnatural, energetically expensive, but viable states of adaptation), and keep them alive, can be most useful.

Sir William Osler, a hugely influential allopathic physician, and founding dean of Johns Hopkins, emphasized treating the patient, as well as studying the disease.⁶ The ancient Greek medical school of Asclepias influenced Hippocrates and emphasized the patient—not solely the disease category.⁷ We can think of levels of dysfunction as one important dimension in that individualized approach (there are others, such as the patient’s psychological state). In the next installment in this series, we’ll examine a dynamic approach to therapy that complements an individualized analysis of the patient.

References

1. Trans-NIH Resilience Working Group: https://ods.od.nih.gov/Research/resilience.aspx#defining  Accessed March 23, 2023.
2. Smith, F. Naturopathic Medicine, A Comprehensive Guide. Chapter 2, Theory of Disease. Springer, Bern: 2022. Pp. 17 – 38.
3. https://hpathy.com/organon-philosophy/levels-health/. Accessed March 23, 2023.
4. https://www.biologicalmedicineinstitute.com/disease-evolution-table
5. Snider P, Zeff J. Unifying Principles of Naturopathic Medicine Origins and Definitions. Integr Med (Encinitas). 2019 Aug;18(4):36–9.
6. 1903 January 10, Medical News: A Weekly Journal of Medical Science, Volume 82, Number 2, Special Articles: On the Need of a Radical Reform in Our Methods of Teaching Senior Students by William Osler M.D. (Professor of Medicine, Johns Hopkins University), Start Page 49, Quote Page 52, Column 2, Lea Brothers and Company, New York. (ProQuest American Periodicals)
7. Kleisiaris CF, Sfakianakis C, Papathanasiou IV. Health care practices in ancient Greece: The Hippocratic ideal. J Med Ethics Hist Med. 2014;7:6. Published 2014 Mar 15.

Published June 17, 2023

About the Author

Fraser Smith, MATD, ND, is Assistant Dean of Naturopathic Medicine and an associate professor at National University of Health Sciences (NUHS; Lombard, Illinois).

Dr. Smith was the founding academic leader of the ND program at NUHS, which joined NUHS’ family of programs in 2006. He is the author of several books on wellness and nutrition for the public and author of the textbook Introduction to the Principles and Practice of Naturopathic Medicine. In addition to being an educator and licensed naturopathic physician, Dr. Smith is a licensed dietician nutritionist and cardiovascular health researcher.