THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 17, Number 12, 2011, pp. 1175–1180

ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2010.0572

Detoxification in Naturopathic Medicine:

A Survey

Jason Allen, ND, MPH,1,2 Melissa Montalto, MS,1 Jennifer Lovejoy, PhD,3 and Wendy Weber, ND, PhD, MPH4

Abstract

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.

Introduction ethers. Comprehensive indices of chemical–disease associa-

tions are available online from advocacy groups,6 indepen-
dent research organizations/networks,7 and the federal
D uring global industrialization over the past cen-
tury, the manufacture, use, and release of xenobiotics,
including synthetic chemicals and metals, into the environ-
government.8 Over 80,000 chemicals are registered for use
today in the United States, with an estimated 2000 new ones
ment has increased exponentially. As a result, exposure to coming to market annually, many of which have not been
persistent bioaccumulative toxicants (PBTs) by humans has studied for adverse health effects.9
increased. Exposure to certain PBTs has been associated with Human biomonitoring is the process of measuring the
adverse health effects, including endocrine disruption,1 neu- amount of chemicals that exist within the body (blood, urine,
rological2 and reproductive effects,3 as well as cancers4 and adipose, cord blood, breast milk, etc.) coming from various
cardiovascular diseases.5 Examples of chemicals associated environmental sources, such as soil, air, water, dust, or food.10
with diseases and disorders include organochlorine pesti- The concentration of these chemicals, assessed by biomoni-
cides, phthalates, bisphenol A, and polybrominated diphenyl toring, is commonly referred to as the ‘‘body burden.’’ Studies

1
Bastyr University Research Institute, Seattle, WA.
2
School of Public Health, University of Washington, Seattle, WA.
3
Free & Clear, Inc., Seattle, WA.
4
Bastyr University Research Institute, Seattle, WA.
Wendy Weber is currently at the National Center for Complementary and Alternative Medicine, National Institutes of Health, Bethesda,
MD.

1175
1176 ALLEN ET AL.

increasingly suggest that the human body burden of several clinical trials can be conducted, there is need for a better de-
chemicals, at physiologically relevant levels, is a real threat to scription of the current detoxification treatments used by
human health, including fetal and neonatal health.11–15 CAM clinicians. Naturopathic doctors are an excellent re-
The term ‘‘detoxification’’ has become common in today’s source for this information because they are provided clinical
society, generally referring to weight loss, addiction recovery, training in detoxification methods, although this training may
or a panacea for numerous nonspecific ailments. Approaches to be more based on biochemical rationale and anecdote than
detoxification are highly variable, nonstandardized, and often evidence based. The purpose of this survey was to obtain
controversial. The clinical definition of detoxification is less information from licensed naturopathic doctors (NDs) prac-
vague. The Centers for Disease Control and Prevention’s ticing in the United States on the use of detoxification treat-
Agency for Toxic Substances & Disease Registry defines de- ments and outcome measures assessed in their practices.
toxification as ‘‘the process of removing a poison or toxin or the
effect of either from an area or individual.’’16 Clinical toxicology Methods
books define detoxification as conversion of ‘‘toxic parent
Research design
compounds to nontoxic metabolites,’’ or ‘‘all reactions, enzyme-
catalyzed or not, that consume toxic metabolites without pro- This was a qualitative, descriptive, electronic survey of
ducing injury.’’17,18 There are virtually no standardized clinical NDs licensed in the United States. The survey, its mainte-
practice guidelines or textbooks in the field of detoxification. nance, and responses were conducted using the online ser-
Within complementary and alternative medicine (CAM), there vice Survey Monkey (Portland, OR). Participants were
may be a large variation between CAM practitioners’ use of notified in the first page of the survey of the approximate
detoxification therapies, depending on schooling, subsequent time required to complete the survey, data storage measures,
training, or individually developed protocols. It is unclear what and confidentiality. Participants were not compensated for
methods are used by CAM practitioners on a regular basis for completing the survey. Participants gave their consent by an
the purpose of detoxification (for diagnosis or treatment). electronic signature and the study and consent form was
To the authors’ knowledge, no comprehensive assessment approved by the Institutional Review Board of Bastyr Uni-
of clinical detoxification practice in the United States has ever versity in Kenmore, WA.
been conducted. However, limited data on specific detoxifi-
cation protocols are available in the literature. For example, Respondents
detoxification using a medical food supplement (UltraClearª
Subjects for this survey were NDs licensed to practice
and UltraClear SUSTAINª) in combination with a modified
medicine in the United States. Subjects were recruited via
elimination diet was found to improve Metabolic Screening
e-mail; addresses were obtained from the American Associa-
Questionnaire scores, and increase Phase I and II metabolism
tion of Naturopathic Physicians (AANP) website. In addition,
markers, although not all findings were statistically signifi-
attempts were made to contact alumni representatives of the
cant.19,20 A review by Crinnion summarizing a case series
four U.S. naturopathic medicine schools accredited by the
spanning over 10 years of practice with patients undergoing a
Council on Naturopathic Medical Education: Bastyr Uni-
detoxification protocol indicated that 83% of people who had
versity, National College of Natural Medicine, Southwest
undergone these treatments self-rated their results as ‘‘good’’
College of Naturopathic Medicine & Health Sciences, and
or ‘‘great.’’ These questionnaires were filled out by patients
University of Bridgeport College of Naturopathic Medicine, in
0–10 years after completion of the protocols, and therefore
order to recruit alumni for the survey via e-mail. Of those
serve as a subjective means of rating efficacy.21 One of the
schools, Bastyr University and the National College of Natural
most frequently cited programs, the Hubbard Purification
Medicine sent e-mails to their alumni with information about
Program,22 is currently being used at a high-profile clinic in
this survey. The e-mails sent to both AANP e-mail addresses
Manhattan to treat World Trade Center rescue workers. The
and alumni contained a short paragraph regarding the exis-
multicomponent program is centered on graduating doses of
tence and purpose of the study along with a link to the survey
niacin, as well as sauna, exercise, nutrient supplementation,
website. Information provided by the AANP suggested that
and electrolytes. While methodological descriptions of the
there are over 2100 licensed NDs in the United States.
program lack specificity, particularly regarding rationale,
medical monitoring, and poor characterization of endpoints,
Statistical analysis
it has been shown to decrease serum and adipose levels of
lipophilic chemicals, including polycholorinated biphenyls Information was collected in a descriptive manner in order
and 1,1,1-trichloro-2,2-bis( p-chlorophenyl)ethane.23–25 In ad- to gain a general understanding of naturopathic medical
dition, its strong association with L. Ron Hubbard and the detoxification practices. Data are presented mostly in per-
Church of Scientology has drawn some criticism. centage form. Data regarding numerical values, such as
The few previous studies on detoxification, while provid- years in practice, are reported as means with standard de-
ing promising data, have had important methodological viations. Data summaries were calculated by survey soft-
limitations, including lack of peer-review, lack of randomi- ware on Survey Monkey. Means and standard deviations
zation, lack of control groups, poorly characterized method- were computed with Microsoft Excel (2002).
ology, and small sample sizes. With the body burden
increasing for a number of synthetic chemicals, and increasing Results
research suggesting possible or probable adverse human
Survey respondents
health effects from these exposures, there exists an urgent
public health and clinical need for research on methods of E-mails were sent to 1181 potential respondents, and 196
decreasing body burden (detoxification). Before rigorous licensed NDs provided electronic signatures voluntarily
DETOXIFICATION IN NATUROPATHIC MEDICINE 1177

consenting to participate in the online survey (16.6% re- therapies, with over 75% treating environmental exposure
sponse rate). Participants had been in practice from 0 to 32 (82%), general cleansing/preventive medicine (81%), gas-
years, with a mean of 7.3 years. The majority of respondents trointestinal disorders (80%), and autoimmune disease (76%;
were female (72.1%), practicing in Washington State (34%) Table 2).
or ‘‘Other’’ (i.e. unlicensed states for naturopathic medi-
cine; 26%), and were either graduates of Bastyr University Types of detoxification therapies utilized
(54.8%) or National College of Natural Medicine (31.7%). See by naturopathic doctors
Table 1 for detailed information on survey respondent
When asked about detoxification therapies utilized in their
characteristics.
practice, respondents reported using multiple therapies, with
over 75% reporting the use of dietary measures such as
Use of detoxification therapies by naturopathic doctors
‘‘cleansing foods,’’ increased fruit/vegetable intake, vitamin/
Ninety-two percent (92%) of respondents reported using mineral supplementation, organic foods, elimination diet,
detoxification therapies in their practices. On average, 28 probiotics, and stool bulking agents/fiber, as well as reduc-
patients per month were seen specifically for detoxification ing environmental exposure and liver, gallbladder, or lym-
therapy. Reported use of detoxification therapies in specific photrophic botanicals, such as cholegogues (herbs that
age groups was as follows: 13% of respondents treated promote the excretion of bile), and lymphogogues (herbs that
children from birth to 6 years of age, 23% treated children promote lymphatic flow; Table 3).
and adolescents 7–17 years of age, 98% treated adults 18–55
years of age, and 63% treated patients 55 years of age and Measurements to determine the need for
older. and efficacy of detoxification
Respondents reported treating a wide variety of patient
Respondents were asked what diagnostic techniques they
populations and medical conditions with detoxification
employed to determine the need for detoxification therapies.
Thirteen percent (13%) of respondents stated that they did
Table 1. Demographics of Respondents not use diagnostic techniques. The three most common di-
agnostic techniques reported by respondents were medical
Percent (%) history (81%), environmental exposure history (62%), and
comprehensive metabolic panel (55%). (It should be noted
Licensure status (N = 201) that a routine medical history does not often include a
Licensed ND 97.5
comprehensive environmental exposure history). Re-
Not licensed/don’t know 2.5
Total 100 spondents reported that detoxification therapy lasted a mean
Gender (N = 197) of 37 days, and ranged from 3 to 365 days.
Female 72.1
Male 27.9
Total 100 Table 2. Naturopathic Doctors Reporting Treatment
Age (N = 197) of Patient Populations/Medical Conditions
21–35 years 36 With Detoxification Therapies
36–45 years 33.5
46–55 years 21.3 Percent (%)
56–65 years 9.1 Conditions N = 169
Currently practicing (N = 98)
Yes 98.5 Environmental exposure 82
No 1.5 General cleansing/preventive medicine 81
Total 100 Gastrointestinal disorders 80
Average years in practice (N = 196) 7.3 (SD – 6.5) Autoimmune disease 76
Average number of patients seen 21.5 (SD – 19.0) Inflammation 72
per week (N = 167) Fibromyalgia 71
Average number of patients seen 84.7 (SD – 81.0) Chronic fatigue syndrome 69
per month (N = 167) Weight loss 65
School where ND degree was granted (N = 199) Endocrine disorders 62
Bastyr University 54.8 Multiple chemical sensitivity 59
Boucher College of Naturopathic 0.0 Liver disease 58
Medicine PMS 53
Canadian College of Naturopathic 2.5 Cardiovascular disease 51
Medicine Mercury amalgam removal 49
National College of Natural Medicine 31.7 Neurodegenerative illness 46
Southwest College of Naturopathic 9.5 Cancer 44
Medicine & Health Sciences Depression 43
University of Bridgeport College 1.0 Infertility 41
of Naturopathic Medicine Recovery from chemotherapy/radiation 40
Othera 0.5 Menopause 39
Total 100 Prepregnancy 39
Other psychologic disorders 30
a
Other, student at National College of Natural Medicine.
ND, naturopathic doctor. PMS, premenstrual syndrome.
1178 ALLEN ET AL.

Table 3. Use of Detoxification Therapies vironmental exposures.28,29 For example, some fruits and
in General Therapy vegetables that contain antioxidants and phytonutrients en-
hance detoxification. Research demonstrates that green leafy
Percent (%)
vegetables have large amounts of antioxidants and enhance
N = 169
phase II detoxification in the liver.30,31 Consuming Brassica
Cleansing foods (i.e., Brassica family, beet root, 91 vegetables enhances Phase II detoxification by inducing the
dandelion, etc). glutathione/glutathione S-transferase (GST) system.32 Or-
Increased fruit/vegetable intake 88 ganosulfur components of garlic oil, diallyl disulfide, and
Vitamin/mineral/antioxidant supplementation 85 diallyl trisulfide have also been shown to increase hepatic
Organic foods 85 detoxification in rat models through enhancement of phase II
Elimination diet 84 metabolism via GST.33 In addition, certain organically grown
Probiotics 83 produce may have higher antioxidant and bioactive com-
Reduce environmental exposure 81
pound levels, as well as lower pesticide/herbicide/fungicide
Stool bulking agents/fiber 79
Cholagogue herbs 75 levels.34,35
Sauna 66 As the interest in complementary and alternative medicine
Chelating agents 60 grows in the United States and ND licensure increases,27 the
Skin brushing 56 public may have increased exposure to detoxification thera-
Lymphagogue herbs 51 pies under the care of a licensed ND (or other health care
Avoidance of animal products 47 provider) to address the potential adverse effects of an in-
Constitutional hydrotherapy 40 creasing body burden of synthetic chemicals.
Unmonitored cardiovascular exercise 39 Respondents to this survey indicated that they treat a
Increased protein intake 35 wide variety of patient populations and medical conditions
Colonic irrigation/colon hydrotherapy 33
using detoxification therapies. Due to the format of this
Combination homeopathic remedies 33
Fasting 31 survey, it was not possible to determine why or how NDs
Constitutional homeopathic remedies 27 treated these patient populations/conditions, only that they
Laxative herbs 27 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-
Eighty-three percent (83%) of respondents stated that they
tive medicine, gastrointestinal disorders, and autoimmune
used follow-up measurements to determine efficacy of de-
diseases.
toxification therapies. Subjects who reported using follow-up
Detoxification therapies reported in this survey varied
measurements indicated that they did so after an average of
widely, with 22 of 30 specific therapies used by over 25% of
23 days, with a range from 0 to 360 days. The three primary
respondents. Detoxification therapies reportedly used by
follow-up measurements reported were patient symptom
more than 75% of NDs included dietary measures (cleansing
questionnaire, patient medical history, and urinary provoc-
foods, increased fruit/vegetable intake, vitamin/mineral/
ative challenge testing.
antioxidant supplementation, organic foods, elimination
diet, stool bulking agents/fiber), probiotics, reducing envi-
Discussion ronmental exposure, and cholagogue herbs (herbs that pro-
mote the excretion of bile). The data seem to indicate that
Use of detoxification therapies by naturopathic doctors
more general detoxification therapies reported are frequently
Methods of detoxification have existed in different cul- used for a number of conditions, whereas more specific
tures for thousands of years, ranging from sweat lodges in therapies may be utilized less frequently by NDs or only for
Native American traditions to Panchakarma of Ayurvedic specific conditions.
medicine. Today, naturopathic medical students are trained
in detoxification principles through coursework in bio-
Strengths and limitations
chemistry, nutrition, gastroenterology, environmental medi-
cine and clinical rotations (personal communication, John This survey presents data for the first time on detoxifica-
Hibbs, ND, Bastyr University 2010; Dr. Walter Crinnion, ND, tion therapies used by naturopathic physicians. Due to the
Southwest College of Naturopathic Medicine [SCNM]). format of the survey, it was not possible to assess which
Dr. Crinnion now directs an Environmental Medicine De- therapies were used for conditions treated, except for those
partment at SCNM, specifically to educate health care pro- specifically asked about.
viders and conduct research on environmental toxicants and Selection bias may have occurred, since the recruitment
their health effects.26,27 Furthermore, a small group of NDs process was via e-mail and it is possible that not all licensed
specializing in environmental medicine and detoxification NDs have e-mail accounts, or perhaps more likely that ad-
are in the process of forming the Naturopathic Association of dresses were mistyped, filtered as junk mail, or were old
Environmental Medicine (bylaws approved by the House of e-mail accounts. Another source of selection bias was the use
Delegates of the AANP, 2008), for promoting research, of AANP-listed e-mail addresses, since there is a cost for
education, and standards of practice. membership and NDs are not required to be members of this
Research supports the role of medical nutrition in the organization for licensure purposes. Furthermore, only two
prevention and treatment of disease, inflammation, allergies, of the four United States naturopathic colleges sent the sur-
and asthma, as well as protecting against and treating en- vey e-mails to their alumni. Thus, the results of this survey
DETOXIFICATION IN NATUROPATHIC MEDICINE 1179

may not be generalizable to the whole population of NDs why specific detoxification interventions are used, and how
practicing in the United States. effective they are is needed. Public health, CAM practition-
E-mails were sent to 1442 people (261 e-mails were re- ers, and conventional medicine may benefit from more de-
turned to sender), and 196 individuals provided an electronic tailed surveys, formal quantitative assessments, such as
signature, resulting in a 16.6% response rate. Numbers for practice-based research networks, and detoxification-specific
e-mails sent through alumni organizations were not avail- clinical trial research.
able. This response rate is lower than previously published
surveys of NDs regarding breast cancer treatment, which Acknowledgments
was 47%, and multiple sclerosis treatment, which was
This study was supported, in part, by grants 5 F32
44.2%.36,37 Studies comparing electronic versus mail surveys
AT003366-03 and 5K99AT004711-01 from the National
of medical residents and faculty, and Canadian physicians,
Center for Complementary and Alternative Medicine, Na-
support the theory that response rates of electronic surveys
tional Institutes of Health, and by the Bastyr University Re-
are lower, but result in a shorter response time, and that
search Institute. Its contents are solely the responsibility of
quality of data is either equivalent, or open e-mail responses
the authors and do not necessarily represent the official
tend to be longer than mail responses.38,39 Information could
views of the National Center for Complementary and Al-
not be gathered on nonrespondents, so it was not possible to
ternative Medicine, or Bastyr University.
assess for the degree of response bias in this survey. It is
possible that those who utilized detoxification therapies in
Disclosure Statement
their practice were more likely to respond. Still, valuable
information was gathered on the detoxification therapies No competing financial interests exist.
used by NDs in their practices, which has not previously
been presented in the literature. References
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