Integrative physiology and traditional naturopathic practice: Results of an international observational study.

This study was conducted as a cross sectional study involving a survey design of an international sample. This survey involved naturopathic clinics in 14 countries across the European (Portugal, United Kingdom, Switzerland, Spain), Americas (Canada, United States, Chile, Brazil), Western Pacific (Hong Kong, Australia, New Zealand) and African (South Africa) world regions. The survey was administered through the online software program Survey Gizmo during the period November 2018 to February 2019. In collaboration with the World Naturopathic Federation (WNF), an invitation from the research team was emailed to naturopathic professional associations in each country to forward to their association members for recruitment. Participants were included into the study if they were a member of one of the recognised WNF associations and working in clinical practice as a naturopathic practitioner. Additionally, participants were included if they have been in clinical practice for a minimum five years and have access to a computer and internet in their clinic. Where possible, participants were preferred if they reported an average of 10 or more consultations per week however this was not possible in all countries. Participants were excluded if they identified as naturopath practising within a specialised field of health care (e.g., women's health). Interested participants were provided with a participant information sheet and were required to complete an online consent form and screening instrument to assess their inclusion into the study. A maximum of 20 clinicians were recruited from each country. In countries where less than 20 clinicians agreed to participate, all eligible respondents were included. In countries where more than 20 clinicians expressed interest, participants were purposively sampled to reflect diversity of characteristics (e.g. clinic location, years in practice). Upon successful inclusion into the study, the research team received an automated email directing them to send the included participant the primary survey link for data collection. Included participants were required to complete the survey for up to 20 consecutive patients with whom they consulted in their clinical practice. The survey was designed by the research team in partnership with the WNF to ensure it complied with rigorous survey methods and was applicable to practice in all countries included in this study. The list of treatments and conditions used as a basis for survey items were informed by research reported by the WNF 17 , 18 , 19 and a naturopathic clinical texts used in curriculum internationally. 20 The instrument was tested for face and content validity by representatives of the World Naturopathic Federation (see Supplement 1). Data was collected directly from the consulting naturopathic practices via the online survey platform Survey Gizmo. Due to the multilingual nature of the study, the participant information sheet, consent form, screening instrument and survey were drafted in English and translated to French, Spanish, and Portuguese by native language individuals. All translated documents were then cross referenced and translated back to English by a different group of bilingual individuals to ensure there was no discrepancies in the study's documents and data collection instruments. The survey items recorded patient demographics, the patient's reason for consultation, interprofessional care, and naturopathic approach and interpretation on the presenting health concern. Participants were required to state the patient's age and sex (i.e., male, female, or other). This domain requested data collection on the reason for the patient's visit, the type of consultation (initial or follow up), the primary presenting health concern as reported by the patient and the chronicity of the patient's primary health concern (as perceived by the practitioner). Participants were required to report on the patient's primary health concern by selecting one out of 17 health categories (e.g., autoimmune disease, reproductive, cardiovascular) and then select or state the patient's primary health concern or diagnosed condition. Participants were asked to provide their interpretation on the primary health concern and if they considered any of the other body systems to be important in the case management of the presenting concern. This list was replicated from the reasons for the patient's visit domain, however, participants were able to provide data on multiple areas as relevant to the patient health complaint. Additionally, the survey also requested clarification if a previous patient was missed out of the 20 consecutive patients. If the participants confirmed a missed patient, the participant was requested to state the rationale for not obtaining data collection for that patient. Raw data were exported from Survey Gizmo into Microsoft Excel (2003) 21 for data cleaning. Prior to merging, all non-English collected data was translated including all open text responses. All reported data was cross checked for consistent and accurate reporting. The research team classified all reported conditions by predetermined categories (e.g., gastrointestinal) to ensure consistency due to varied participant classification. All cleaned raw data was numerically coded and imported into Stata 14.2 (StataCorp LLC) 22 for analysis. Bivariate analysis was conducted to examine the relationship between the reported patient characteristics and the health systems reported by the naturopathic participants. Additional bivariate analysis was then conducted to identify the relationship between the patients’ characteristics and the two most reported health systems as identified by the consulting naturopathic practitioner. The findings of the bivariate analysis were further tested utilising a chi square test with effect size as determined by Cramer's V . The effect size was classified as negligible association (.00 and under .10); weak association (.10 and under .20); moderate association (.20 and under .40); relatively strong association (.40 and under .60); strong association (.60 and under .80) and very strong association (.80 and under 1.00), as reported by Rea and Parker (1992). 2 A backwards stepwise Poisson regression model was used to identify patient characteristics most likely associated with the health systems as reported by the naturopath. Additional backwards stepwise regression models were employed to identify the patient's characteristics associated with the two most common specific health systems identified as relevant to the management of the patient's reported primary health concern, the digestive and endocrine systems. Independent variables identified as potential confounders (defined as a p value <0.25) as determined by the bivariate analyses conducted were entered into the backwards stepwise regression models, as relevant. Ethics approval for this study was granted by the Human Research Ethics Committee of the Endeavour College of Natural Health (#20181017).

Participants ( n  = 56) were based in 14 countries and were more often female (62.5%), aged between 36 and 45 years (37.5%), in practice for 5–10 years (44.6%), and, on average, providing care to between 11 and 20 patients per week (35.7%) (see Table 1 ). The mean number of reported cases (representing individual patients) per participants was 15.1, equating to 854 patient cases in total. Table 1 Participant Characteristics ( n  = 56) Table 1 Characteristic n (%) Country Australia 6 (10.7) Brazil 4 (7.1) Canada 6 (10.7) Chile 4 (7.1) Hong Kong 3 (5.4) India 7 (12.5) Nepal 2 (3.6) New Zealand 3 (5.4) Portugal 4 (7.1) South Africa 2 (3.6) Spain 4 (7.1) Switzerland 2 (3.6) United Kingdom 3 (5.4) United States 6 (10.7) 

 Gender Female 35 (62.5) Male 21 (37.5) 

 Age 26–35 years 11 (19.6) 36–45 years 21 (37.5) 46–55 years 11 (19.6) 56–65 years 11 (19.6) 66 years or more 2 (3.6) 

 Years in clinical practice 5–10 years 25 (44.6) 11–15 years 14 (25.0) 16–20 years 5 (8.9) 21–25 years 6 (10.7) 26 years 6 (10.7) 

 Average number of patients per week Less than 10 9 (16.1) 11–20 20 (35.7) 21–30 12 (21.4) 31–40 8 (14.3) 41–50 4 (7.1) 51 or more 3 (5.4) 

 Mean (SD; Min, Max) Average number of responses per participant 15.1 (7.6; 1, 20) Participant Characteristics ( n  = 56) The majority of the patients described by participants were female (72.6%), working age (81.2%), and visiting the naturopath for a follow up consultation (67.0%) with a chronic health complaint (75.0%) (see Table 2 ). The chi square test identified a negligible association between the number of systems identified as important in the management of the patient's health and the patient's sex ( V  = 0.1058, p  = 0.049), age ( V  = 0.1009, p  = 0.005), and chronicity of the condition ( V  = .1512, p  < .001). Negligible associations were also identified for presenting musculoskeletal ( V  = .1170, p  = .019), endocrine ( V  = .1293, p  = .006), and cancer-related (.1214, p  = .013) complaints. The association between cotreatment by general practitioner ( V  = .1372, p  = .003) and specialist doctor ( V  = .1538, p  < .001), as known by the participant, or by no other health professional ( V  = .1294, p  = .006) was also negligible. Table 2 also reports the outcomes of the backwards stepwise logistic regression of patient characteristics based on the number of systems identified by participants to be relevant to patients. The incidence of a greater number of physiological systems being identified by participants was higher among patients of working age (18–65 years) (IRR 1.3, p  = .042) or elderly (65 years and over) (IRR 1.4, p  = .046). Patients also had a higher incidence of a greater number of physiological systems important to their health if participants considered the patient to have a chronic health condition (IRR 1.2, p  = .003). Table 2 Characteristics of Patients Compared with Number of Physiological Systems Considered by the Participants to be Important in Management of the Patient's Health ( n  = 854) Table 2 All patients ( n  = 852) None ( n  = 36) One ( n  = 292) Two ( n  = 174) Three ( n  = 162) Four or more ( n  = 186) Cramer's V p IRR 95% CI p Sex ( n  = 851) Female 618 (72.6) 26 (70.3) 198 (67.8) 136 (78.2) 113 (69.8) 145 (78.0) .1058 .049 – Male 233 (27.4) 11 (29.7) 94 (32.2) 38 (21.8) 49 (30.3) 41 (22.0) 

 Age category (n   =   835) Young child (0–4 years) 21 (2.5) 3 (8.3) 10 (3.5) 4 (2.3) 3 (1.9) 1 (0.6) .1009 .005 Ref – – Child (5–11 years) 21 (2.5) 1 (2.8) 16 (5.6) 2 (1.2) 1 (0.6) 1 (0.6) .95 .65–1.40 .794 Adolescent (12-17 years) 10 (1.2) 0 (0.0) 6 (2.1) 1 (0.6) 2 (1.3) 1 (0.6) 1.2 .8–2.0 .455 Working age (18–65 years) 678 (81.2) 31 (86.1) 218 (76.0) 143 (83.6) 132 (83.0) 154 (84.6) 1.3 1.0–1.8 .042 Elderly (65 years and older) 105 (12.6) 1 (2.8) 21 (12.3) 21 (12.3) 21 (13.2) 25 (13.7) 1.4 1.0–1.8 .046 

 Visit (n   =   852) First 281 (33.0) 11 (29.7) 110 (37.4) 52 (30.2) 44 (27.5) 64 (33.9) .0812 .229 – Follow up 571 (67.0) 26 (70.3) 184 (62.6) 120 (70.0) 116 (72.5) 125 (66.1) 

 Chronicity (n   =   844) Acute 165 (19.5) 8 (22.9) 82 (28.4) 36 (20.7) 21 (13.2) 18 (9.6) .1512 <.001 Ref – – Chronic 633 (75.0) 26 (74.3) 186 (64.4) 128 (73.6) 129 (81.1) 164 (87.7) 1.2 1.1–1.3 .003 Unsure 46 (5.5) 1 (2.9) 21 (7.3) 10 (5.8) 9 (5.7) 5 (2.7) 1.0 .8–1.3 .767 

 Primary reason for visit (n   =   854) Musculoskeletal condition 158 (18.4) 13 (33.3) 56 (19.0) 37 (21.3) 29 (17.8) 23 (12.2) .1170 .019 .90 .8–1.0 .051 Gastrointestinal condition 104 (12.1) 6 (15.4) 37 (12.6) 23 (13.2) 15 (9.2) 23 (12.2) .0477 .745 – – – Mental health condition 93 (10.8) 3 (7.7) 38 (12.9) 23 (13.2) 18 (11.0) 11 (5.8) .0946 .104 – – – Wellness and condition 57 (6.6) 1 (2.6) 27 (9.2) 7 (4.0) 12 (7.4) 10 (5.3) .0885 .151 – – – Female reproductive condition 51 (5.9) 1 (2.6) 17 (5.8) 6 (3.5) 12 (7.4) 15 (7.9) .0738 .321 – – – Skin condition 44 (5.1) 3 (7.7) 9 (3.1) 13 (7.5) 9 (5.5) 10 (5.3) .0774 .273 – – – Respiratory condition 43 (5.0) 0 (0.0) 22 (7.5) 8 (4.6) 5 (3.1) 8 (4.2) .0930 .115 – – – Fertility condition 43 (5.0) 0 (0.0) 11 (3.7) 12 (6.9) 9 (5.5) 11 (5.8) .074 .319 – – – Neurological condition 43 (5.0) 1 (2.6) 16 (5.5) 10 (5.8) 5 (3.1) 11 (5.8) .5024 .670 – – – Endocrine condition 40 (4.7) 0 (0.0) 6 (2.0) 7 (4.0) 14 (8.6) 13 (6.9) .1293 .006 – – – Cancer-related condition 39 (4.5) 1 (2.6) 13 (4.4) 4 (2.3) 4 (2.5) 17 (9.0) .1214 .013 – – – Cardiovascular condition 36 (4.2) 2 (5.1) 11 (3.7) 5 (2.9) 4 (2.5) 14 (7.4) .0908 .132 – – – Weight management 34 (4.0) 2 (5.1) 11 (3.7) 6 (3.5) 6 (3.7) 9 (4.8) .0275 .957 – – – Autoimmune condition 31 (3.6) 2 (5.1) 7 (2.4) 7 (4.0) 9 (5.5) 6 (3.2) .0632 .488 – – – Urogenital condition 21 (2.4) 0 (0.0) 7 (2.4) 4 (2.3) 6 (3.7) 4 (2.1) .0498 .712 – – – Ageing or cognition condition 10 (1.2) 0 (0.0) 3 (1.0) 1 (0.6) 4 (2.5) 2 (1.0) .0630 .491 – – – Infectious condition 7 (0.8) 0 (0.0) 2 (0.7) 1 (0.6) 2 (1.2) 2 (1.0) .034 .911 – – – 

 Health care team (n   =   854) General practitioner 369 (43.2) 14 (40.0) 101 (34.5) 78 (44.8) 81 (47.0) 95 (50.3) .1372 .003 1.1 1.0–1.2 .020 Specialist doctor 237 (27.8) 9 (25.7) 55 (18.8) 52 (29.9) 54 (33.1) 67 (35.5) .1538 <.001 1.1 1.0–1.2 .034 Allied health practitioner 106 (12.7) 2 (5.7) 31 (10.6) 26 (14.9) 23 (14.1) 24 (12.7) .0669 .431 – – – Other complementary medicine practitioner 93 (10.9) 3 (8.6) 23 (7.9) 20 (11.5) 23 (14.1) 24 (12.7) .0797 .246 – – – No other health practitioner 282 (33.0) 14 (40.0) 119 (40.6) 53 (30.5) 43 (26.4) 53 (28.0) .1294 .006 – – – 

 Specific systems considered Gastrointestinal system 348 (40.8) 0 (0.0) 48 (16.4) 63 (36.2) 99 (60.7) 138 (73.0) .4912 <.001 Endocrine system 203 (23.8) 0 (0.0) 21 (7.2) 41 (23.6) 46 (28.2) 95 (50.3) .3909 <.001 Musculoskeletal system 151 (17.7) 0 (0.0) 21 (7.2) 26 (14.9) 36 (22.1) 68 (36.0) .2989 <.001 Female reproductive system 134 (15.7) 0 (0.0) 11 (3.8) 30 (17.2) 29 (17.8) 64 (33.9) .3175 <.001 Mental health 132 (15.5) 0 (0.0) 29 (9.9) 30 (17.2) 27 (16.6) 46 (24.3) .1722 <.001 Cardiovascular system 108 (12.7) 0 (0.0) 12 (4.1) 11 (6.3) 27 (16.6) 58 (30.7) .3223 <.001 Integumentary system 79 (9.3) 0 (0.0) 9 (3.1) 6 (3.5) 15 (9.2) 49 (25.9) .3182 <.001 Autoimmune condition 74 (8.7) 0 (0.0) 3 (1.0) 5 (2.9) 18 (11.0) 48 (25.4) .3428 <.001 Respiratory system 71 (7.3) 0 (0.0) 7 (2.4) 5 (2.9) 15 (9.2) 44 (23.3) .3044 <.001 Ageing and cognition 69 (8.1) 0 (0.0) 9 (3.1) 10 (5.8) 13 (8.0) 37 (19.6) .2368 <.001 Neurological system 67 (14.3) 0 (0.0) 13 (4.4) 12 (6.9) 15 (9.2) 27 (14.3) .1498 .001 Urogenital system 41 (4.8) 0 (0.0) 4 (1.4) 1 (0.6) 12 (7.4) 24 (12.7) .2277 <.001 Cancer 29 (3.4) 0 (0.0) 7 (2.4) 3 (1.7) 0 (0.0) 19 (10.1) .2021 <.001 Characteristics of Patients Compared with Number of Physiological Systems Considered by the Participants to be Important in Management of the Patient's Health ( n  = 854) Table 3 presents the analysis of patient characteristics based on whether the participant considered the gastrointestinal system or endocrine system to be an important consideration in the management of the patient's health. These two physiological systems were selected as they were identified most frequently by participants. Based on bivariate analysis, the digestive system was weakly associated with patients based on chronicity of their health complaint ( V  = .1149, p  = .004), or having a musculoskeletal complaint ( V  = .1067, p  = .002) and was found to have negligible association with the patient presenting with an endocrine complaint ( V  = .0981, p  = .004). The analysis also indicated a weak association between the participant considering the digestive system important for the patient's case and other systems also being viewed as relevant, including respiratory ( V  = .1042, p  = .002), endocrine ( V  = .1023, p  = .003), female reproductive ( V  = .1009, p  = .003), and integumentary ( V  = .1382, p  < .001) systems. Autoimmune pathophysiology was also found to have a weak association ( V  = .1681, p  < .001) with the digestive system in the context of the factors considered important by participants for an individual patient's health management. Consideration of both the cardiovascular system ( V  = .0931, p  = .006) and general wellness and prevention ( V  = .0799, p  = .020) were identified through the analysis as having a negligible association with practitioners considering the digestive system as an important factor in the management of the patient's health. Co-treatment by a specialist doctor ( V  = .1140, p  = .001) or a general practitioner ( V  = .0800, p  = .019) had a weak and negligible association respectively. Table 3 Characteristics of Patients that Participants have Considered the Digestive System ( n  = 348) or Endocrine System ( n  = 204) as an Additional Factor to Consider in Management of the Patient's Health Table 3 All participants ( n  = 854) Digestive system ( n  = 348) V p IRR a 95%CI p Endocrine system ( n  = 203) V p IRR 95%CI p Sex Female 618 (72.6) 145 (28.7) .0401 .243 – – – 160 (80.0) .0904 .009 – – – Male 233 (27.4) 86 (25.1) – – – 40 (20.0) – – – 

 Age category Young child (0–4 years) 21 (2.5) 10 (3.0) .0531 .673 – – – 2 (1.0) .1022 .069 – – – Child (5–11 years) 21 (2.5) 8 (2.4) – – – 1 (0.5) – – – Adolescent (12-17 years) 10 (1.2) 2 (0.6) – – – 2 (1.0) – – – Working age (18–65 years) 678 (81.2) 275 (81.9) – – – 170 (87.2) – – – Elderly (65 years and older) 1 (2.8) 41 (12.2) – – – 20 (10.3) – – – 

 Visit First 281 (33.0) 104 (33.1) .0519 .130 – – – 70 (34.7) .0185 .590 – – – Follow up 571 (67.0) 241 (66.9) – – – 132 (65.4) – – – Chronicity – – – – – – Acute 165 (19.5) 50 (14.5) .1149 .004 – – – 26 (13.1) .0900 .033 – – – Chronic 633 (75.0) 279 (80.9) – – – 160 (80.8) – – – Unsure 46 (5.5) 16 (4.6) – – – 12 (6.1) – – – 

 Primary reason for visit Gastrointestinal condition 104 (12.1) 35 (10.1) .0538 .116 – – – 21 (10.3) .0313 .360 – – – Respiratory condition 43 (5.0) 18 (5.2) .0052 .879 – – – 3 (1.5) .0908 .008 0.3 0.1–0.9 .035 Cardiovascular condition 36 (4.2) 14 (4.0) .0079 .816 – – – 15 (7.4) .0882 .010 4.0 2.0–8.3 <.001 Endocrine condition 40 (4.7) 25 (7.2) .0981 .004 2.3 1.1–4.5 .020 16 (7.9) .0845 .014 – – – Female reproductive condition 51 (5.9) 20 (5.8) .0079 .818 – – – 25 (12.3) .1495 <.001 3.7 2.0–6.9 <.001 Musculoskeletal condition 158 (18.4) 47 (13.5) .1067 .002 – – – 21 (10.3) .1173 .001 – – – Skin condition 44 (5.1) 26 (7.5) .0870 .011 2.1 1.1–5.0 .022 8 (3.9) .0306 .371 – – – Urogenital condition 21 (2.4) 6 (1.7) .0394 .250 – – – 2 (1.0) .0531 .120 – – – Autoimmune condition 31 (3.6) 19 (5.5) .0811 .018 2.3 1.0–5.0 .035 9 (4.4) .0240 .483 – – – Cancer-related condition 39 (4.5) 21 (6.0) .0583 .088 – – – 11 (5.4) .0228 .505 – – – Fertility condition 43 (5.0) 13 (3.7) .0493 .150 – – – 21 (10.3) .1356 <.001 3.3 1.7–6.5 .001 Ageing or cognition condition 10 (1.2) 5 (1.5) .0205 .549 – – – 0 (0.0) .0608 .076 – – – Infectious condition 7 (0.8) 3 (0.9) .0039 .909 – – – 2 (1.0) .0103 .764 – – – Wellness and prevention 57 (6.6) 25 (7.2) .0169 .621 – – – 9 (4.4) .0501 .143 – – – Weight management 34 (4.0) 16 (4.6) .0261 .445 – – – 12 (5.9) .0551 .107 – – – Mental health condition 93 (10.8) 41 (11.8) .0237 .488 – – – 15 (7.4) .0628 .067 – – – Neurological condition 43 (5.0) 14 (4.0) .0384 .262 – – – 13 (6.4) .0350 .307 – – – 

 Health care team General practitioner 369 (43.2) 167 (48.0) .0800 .019 – – – 88 (43.4) .0016 .963 – – – Specialist doctor 237 (27.8) 118 (33.9) .1140 .001 1.5 1.1–2.1 .016 65 (32.0) .0532 .120 – – – Allied health practitioner 106 (12.7) 50 (14.4) .0492 .151 – – – 26 (12.8) .0067 .845 – – – Other complementary medicine practitioner 93 (10.9) 40 (11.5) .0161 .638 – – – 26 (12.8) .0344 .315 – – – No other health practitioner 282 (33.0) 104 (29.9) .0553 .106 – – – 60 (29.6) .0411 .229 – – – 

 Specific additional systems considered Gastrointestinal system 348 (40.8) 101 (49.8) .1023 .003 1.5 1.1–2.2 .019 Respiratory system 71 (7.3) 41 (11.8) .1042 .002 – – – 18 (8.9) .0112 .744 – – – Cardiovascular system 108 (12.7) 57 (16.4) .0931 .006 1.7 1.1–2.6 .015 31 (15.3) .0441 .198 – – – Endocrine system 203 (23.8) 101 (29.0) .1023 .003 – – – Female reproductive system 134 (15.7) 70 (20.1) .1009 .003 1.6 1.1–2.4 .020 60 (29.6) .2129 <.001 2.9 1.9–4.4 <.001 Musculoskeletal system 151 (17.7) 67 (19.3) .0342 .318 – – – 34 (16.8) .0137 .690 – – – Integumentary system 79 (9.3) 49 (14.1) .1382 <.001 2.0 1.2–3.3 .008 28 (13.8) .0875 .011 – – – Urogenital system 41 (4.8) 22 (6.3) .0590 .085 – – – 14 (6.9) .0547 .110 – – – Autoimmune condition 74 (8.7) 50 (14.4) .1681 <.001 2.7 1.6–4.6 <.001 29 (14.3) .1116 .001 2.4 1.4–4.2 .002 Cancer 29 (3.4) 15 (4.3) .0419 .221 – – – 9 (4.4) .0320 .350 – – – Ageing and cognition 69 (8.1) 30 (8.6) .0165 .630 – – – 16 (7.9) .0041 .906 – – – Wellness and prevention 245 (28.7) 115 (33.0) .0799 .020 1.5 1.1–2.0 .016 48 (23.7) .0623 .069 0.7 0.5–1.0 .042 Mental health 132 (15.5) 51 (14.7) .0184 .591 – – – 19 (9.4) .0942 .006 0.4 0.3–0.7 .002 Neurological system 67 (14.3) 25 (7.2) .204 .551 – – – 17 (8.4) .0110 .748 – – – a IRR – Incident Rate Ratio. Characteristics of Patients that Participants have Considered the Digestive System ( n  = 348) or Endocrine System ( n  = 204) as an Additional Factor to Consider in Management of the Patient's Health IRR – Incident Rate Ratio. Regression analysis found a greater incidence of the digestive system being identified as important for an individual patient's health if the patient visited the participant for management of an endocrine (Incident Rate Ratio [IRR] 2.3, p  = .020), skin (IRR 2.1, p  = .022) or autoimmune (IRR 2.3, p  = .035) condition. Patients for whom participants considered the digestive system important also had a higher incidence of co-treatment by a specialist doctor (IRR 1.5, p  = .016). A greater incidence of participants listing the cardiovascular (IRR 1.7, p  = .015), female reproductive (IRR 1.6, p  = .020), and integumentary (IRR 2.0, p  = .008) systems were also seen among patients for whom the digestive system was considered to be relevant to an individual patient's care. Participant consideration of an autoimmune condition (IRR 2.7, p  < .001) or wellness and prevention (IRR 1.5, p  = .016) as additional factors relevant to a patient's health were also seen more often among patients for whom participants reported the digestive system as important. The analysis related to the endocrine system as a factor considered important in individual patient care plans is also presented in Table 3 . The chi square test found negligible associations between the identification of the endocrine system as relevant and the patient's sex ( V  = .0904, p  = .009) and chronicity of the patient's complaint ( V  = .0900, p  = .033). The bivariate analysis indicated weak associations between the endocrine system being identified as important and the patient's type of presenting complaint, such as female reproductive ( V  = .1495, p  < .001), musculoskeletal ( V  = .1173, p  < .001) and fertility-related conditions ( V  = .1356, p  < .001). Negligible associations were found with other types of presenting complaints including respiratory ( V  = .908, p  = .008), cardiovascular ( V  = .0882, p  = .010), and endocrine ( V  = .0845, p  = .014) conditions. Alongside the endocrine system, associations with other systems considered by participants to be important in the management of their patient's health were identified. A moderate association was found for the female reproductive system ( V  = .2129, p  < .001), a weak association was reported for the gastrointestinal ( V  = .1023, p  = .003) system and autoimmune conditions ( V  = .1116, p  = .001) and the association with the integumentary system ( V  = .0875, p  = .011) and mental health ( V  = .0942, p  = .006) was negligible. Backwards stepwise regression analysis indicated an increased incidence of cardiovascular (IRR 4.0, p  < .001), female reproductive (IRR 3.7, p  < .001) and fertility-related conditions (IRR 3.3, p  = .001) and a reduced incidence of respiratory conditions (IRR 0.3, p  = .035) as primary reasons for the visit, among patient for whom participants identified the endocrine system as important to the management of the patient's health. Participants also indicated the female reproductive system (IRR 2.9, p  < .001), autoimmune conditions (IRR 2.4, p  = .002) and the gastrointestinal system (IRR 1.5, p  = .019) with greater incidence among patients for whom the endocrine system was described as an important additional consideration. In these patients, there was a lower incidence of wellness and prevention (IRR 0.7, p  = .042) and mental health (IRR 0.4, p  = .002) being listed as relevant to the patient's condition.

This paper presents the first international examination of the characteristics of patients accessing non-specialised naturopathic care. Our analysis identifies a number of key findings that warrant careful consideration. Firstly, more than one physiological system was considered in patient management regardless of the primary reason for the visit in many cases, a pattern that aligns with both traditional and contemporary naturopathic teachings and philosophies. 16 The multisystem approach of naturopaths indicates a holistic approach is referring not only to mind-body-spirit but also suggests the application of an integrated approach to physiology and pathophysiology informs clinical management of patients. This has been documented in contemporary naturopathic texts which highlight the importance of considering multiple organ systems and key systems such as the digestive and nervous systems, regardless of the disease presentation. 16 Furthermore, naturopathic medicine emphasises holism - defined as recognising all aspects of the human that are influenced by internal, external and social factors including psychological, spiritual, functional (physiology) and structural components of the individual in clinical care. 19 Evidence of the multi-system approach of naturopaths can be found in the writings of many 19th and 20th century naturopaths such as Lorenz Gleich (1850), J.E. Cummins (1920), Edward Earle Purinton (1920s) and Benedict Lust (1905). 18 Holistic assessment is considered part of the naturopathic case-taking model where the inherent strengths and weaknesses of physiological systems are assessed on a case-by-case basis alongside mental, social and spiritual factors. 16 The multi-system naturopathic approach reflects the core naturopathic principle–treat the cause ( Tolle Causam ) rather than treating the disease. 23 Holism is the foundation of a core principle of naturopathic philosophy—treat the whole person ( Tolle Totum ). 17 Endocrine and digestive function – or dysfunction – were commonly reported by this cohort of naturopaths as an important underlying factor to be considered in the treatment of their patients’ primary complaint. Nutrition and digestion are essential components of naturopathic clinical practice. Traditional naturopathic texts describe “nutrition as a fundamental core of wellness and naturopathic philosophy” 24 and this continues into the present day with modern textbooks noting the common naturopathic view that many diseases “colloquially all come down to the gut”. 20 Interestingly, emerging contemporary research appears to support this view, specifically as it relates to the association between many of the conditions linked to the digestive system in our study (e.g. autoimmune, skin, and endocrine conditions). For example, it is presumed that in genetically susceptible individuals, there may be a strong gastrointestinal microbiome association with autoimmune conditions such as primary sclerosing cholangitis, primary biliary cirrhosis, and autoimmune hepatitis. 25 Regarding skin conditions, a growing body of evidence is now supporting clinical improvement in dermatological illness by using gastrointestinally modifying interventions such as prebiotics, probiotics, and synbiotics. 26 Pertaining to endocrine disorders, autoimmune linked gastroenterological and endocrine conditions have long been known to be associated (e.g., coeliac disease and autoimmune thyroiditis). 27 In addition, a collection of research is building using diverse study designs that suggest an association between environmental toxicants, specifically endocrine disruptors, and various endocrine disorders including diabetes. 28 The gastrointestinal system plays an important role in such toxin degradation and excretion, primarily via the liver and microbiome-based degradation enzymes, 28 further supporting the rationale of considering the gastrointestinal system in one's clinical approach to some endocrine disorders. The endocrine system was also associated with some specific conditions in our analysis. Particularly noteworthy is the link between the female reproductive system and the endocrine system. One striking example of this link is that of polycystic ovarian syndrome (PCOS), one of the most common endocrine disorders in women. 29 Naturopathic intervention has been found to improve PCOS outcomes via a combination of regulating sex hormones (evidenced in a reduction in androgens), a decrease in body weight and a regulation of cortisol via the hypothalamic-pituitary-adrenal (HPA) axis 29 an example of the integrative physiology approach of naturopathic intervention. Endometriosis, affecting an estimated 10–15% of women of reproductive age, 30 is another common female reproductive condition where naturopathic intervention focuses on hormone regulation (as opposed to conventional treatments which have a predominant focus on hormone replacement). 31 Endometriosis is said to be an oestrogen-dependent disease and is a good example of an ‘inter-systems’ condition where multiple body systems are involved in the pathophysiology including the HPA and hypothalamic-pituitary-ovarian (HPO) axes, inflammatory pathways and the immune system. 30 While hormone levels may be modified with herbal medicine or other naturopathic interventions, 32 these treatments may also upregulate metabolic pathways involved in hormone clearance, such as with oestrogen which is predominantly metabolised by the liver and eventually eliminated through bile and faeces. 33 Therefore, a naturopathic approach to treating female reproductive disorders would include restoring or facilitating gastrointestinal and digestive function, with an emphasis on dietary intake. The trends in association between endocrine, female reproductive and digestive systems in our analysis reflect naturopathic philosophies and approach including naturopathic biological and physiological understanding of the body. Interestingly, mental health conditions only showed a trending association in our analysis, despite women with PCOS reported to be over three and five times more likely to experience depression and anxiety respectively. 34 This study is not without limitations. While this is the only study to date positing naturopathic clinical practice within an integrative physiology paradigm, the findings may not be generalisable to the aggregate international naturopathic profession. However, this study does provide preliminary findings that require larger and more focused studies. The diversity of naturopathic practice in specific geographical areas is likely to be impacted by cultural, social and regulatory influences and this requires consideration within the context of these national and regional settings. The target population was limited to members of professional associations and therefore biases may have been introduced by excluding naturopaths who possibly have lower standards of professional practice, particularly in countries were regulatory mechanisms ensuring consistency in training and practice are absent. As such the generalisability of this data to the overall international naturopathic profession is not clear. Due to the pilot nature of this study, it was decided to have a smaller representation of naturopathic practitioners from a greater number of countries. However, as the Agency for Health Research and Quality describes, a level of representativeness can be afforded by practice-based research conducted in a minimum of five locations and with at least 15 participating clinicians. 35 Additional bias may have been introduced by the self-reported nature of the survey data that required naturopaths to report on patient characteristics. The accuracy of this data was not independently confirmed by the researchers. Regardless of these limitations, this study provides an important contribution to the understanding of naturopathic practice at an international level. In conclusion, naturopaths across the world adopt an integrative physiological approach to the diagnosis and treatment strategies of chronic and complex health care complaints. Among multiple body systems reported to be implicated, the digestive system is the most common. This approach of naturopaths is supported by the growing body of scientific literature implicating aberrations in gastrointestinal health and its microbial composition with extraintestinal conditions.

Naturopathy is a traditional healthcare system based on philosophical principles codified during the 19th and 20th centuries. 1 These principles were drawn from the philosophy and practice of ancient Grecian medicine, European traditional medicine (including both European herbal medicine and Germany's Nature Cure movement) and the Eclectic physicians of the late 19th and early 20th centuries. 1 Naturopathy is a distinct profession that is recognised as one of the major global traditional medical systems by the World Health Organization. 2 Naturopaths are widely consulted by patients in Australia, 3 Europe, and North America. 4 Two of the key philosophical tenets of naturopathy are an emphasis on Tolle Causam (treat the cause) and Tolle Totum (treat the whole person). 5 These core concepts have been repeatedly emphasised by both traditional 6 and contemporary 1 , 5 naturopathic texts. Research exploring naturopathic clinical care often reflects these points of focus. For example, naturopaths often address the gastrointestinal system (specifically intestinal hyperpermeability) in their approach to rheumatoid arthritis. 7 As another example, a randomised, controlled trial of naturopathic care in anxiety utilised an intervention composed of a multivitamin, breathing exercises, and lifestyle and nutrition counselling, in addition to a herbal medicine that specifically targeted the anxiety. 8 Health and medical researchers have recently begun to delve more deeply into the interrelationships between physiological systems, such as the gastrointestinal and endocrine systems, within the context of disease occurring in other systems. For instance, research has now found the composition of the gastrointestinal microbiota to influence mood and behaviour, 9 as well as a potential role for gut microbiota-derived bacterial endotoxins and intestinal hyperpermeability in the pathophysiology of depression. 10 Other research has found a putative role of gut microbiota-derived endotoxins in the pathophysiology of endometriosis, 11 type 2 diabetes, 12 and cardiovascular disease. 13 Such studies, and the results of interventional trials, 14 , 15 suggest that treatments aimed at altering the functionality of one body system, such as the gastrointestinal tract, can have substantial impacts upon other body systems. Naturopathic texts suggest that clinicians should focus on a number of body systems both when case-taking and when designing treatment. 16 However, there is no known research that has explored how naturopathic practitioners are applying their philosophical tenets and principles within routine clinical care. With this in mind, this study aimed to characterise naturopathic practice as it relates to the identification of multiple physiological systems in the diagnosis and treatment of patients.