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Provide effective treatment with evidence-based natural medicine! Textbook of Natural Medicine, 5th Edition shows how to use natural medicine, Western medicine, or a blend of both to develop scientific treatment plans. Based on a combination of philosophy and clinical studies, this text explains how to diagnose the underlying causes of disease and provide therapeutic interventions that support the body's own healing processes. Written by noted educators Joseph Pizzorno and Michael Murray, this text summarizes the pharmacology of herbal supplements, and emphasizes preventive, non-invasive, and natural treatments.

• UNIQUE! Practical diagnostic and therapeutic guidance is designed specifically for practicing clinicians, and includes key diagnostic criteria, pathophysiology of diseases, and therapeutic rationales.
• UNIQUE! In-depth coverage of science-based natural medicine makes this the most comprehensive textbook in this field.
• UNIQUE! Six separate sections on every aspect of natural/integrative medicine include philosophy, diagnosis, therapeutics, pharmacology, and specific disorders and diseases.
• UNIQUE! Detailed coverage of the most common medical conditions includes not just the recommended interventions but also an in-depth discussion of their fundamental causes.
• Content on the philosophy of natural medicine includes its history and background, with discussions of toxicity, detoxification, and scientific documentation of the healing actions of natural substances.
• Internationally known authors Joseph Pizzorno and Michael Murray lead a team of expert, practicing contributors in providing authoritative information on natural medicine.

• NEW tables, charts, graphs, and other visuals depict important data and summarize key points.
• NEW! Thirty new chapters cover even more disease and therapeutic agents than were covered in the previous edition.
• NEW! Full-color design and illustrations enhance reading and understanding.
• NEW! 50 new images have been added.
5th Edition
Churchill Livingstone Elsevier
ISBN 10:
ISBN 13:
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Joseph E. Pizzorno, ND

Editor in Chief, Integrative Medicine: A Clinician’s Journal, Eagan, Minnesota;
President Emeritus, Bastyr University, Kenmore, Washington;
Chair, Science Board, Bioclinical Naturals, Burnaby, British Columbia

Michael T. Murray, ND

President and CEO, Dr. Murray Natural Living, Inc., Scottsdale, Arizona;
Chief Science Officer, Enzymedica, Venice, Florida

3251 Riverport Lane
St. Louis, Missouri 63043
Copyright © 2021 by Elsevier, Inc. All rights reserved.

ISBN: 978-0-323-52342-4
Volume 1: 978-0-323-52326-4
Volume 2: 978-0-323-52325-7

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
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Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website:
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors
or contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Previous editions copyrighted 2013, 200; 6, 1999, and 1993.
International Standard Book Number: 978-0-323-52342-4

Senior Content Strategist: Linda Woodard
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Publishing Services Manager: Julie Eddy
Book Production Specialist: Clay S. Broeker
Design Direction: Margaret Reid
Printed in China
Last digit is the print number:










To Dr. John Bastyr and all the natural healers of the past and future who
bring the “healing power of nature” to all the people of the world.
Dr. Bastyr, the namesake for Bastyr University, exemplified the ideal
physician/healer/teacher we endeavor to become in our
professional lives.
We pass on a few of his words of wisdom to all who strive to provide the
best of health care and healing: “Always touch your patients—let them
know you care,” and “Always read at least one research article or learn
a new remedy before you retire at night.”

Kathy Abascal, BS, JD, RH(AHG)

Warren M. Brown, ND

Terry M. Elder, DC

Vashon, Washington

Clinical Science Liaison
Medical Affairs
Genova Diagnostics
Asheville, North Carolina

Clinical Sciences
National University of Health Sciences
Lombard, Illinois

Michael J. Chapman, ND

Geovanni Espinosa, ND, LAc, IFMCP,

Yaser Abdelhamid, ND, LAc, MS, BS, BA
Licensed Acupuncturist
Center for Integrative and Lifestyle
Cleveland Clinic
Cleveland, Ohio

Zemphira Alavidze, PhD

Medical Education Specialist
Medical Affairs
Genova Diagnostics
Asheville, North Carolina

Lise Alschuler, ND

Alan G. Christianson, NMD

Professor of Clinical Medicine Assistant
Director, and Fellowship in Integrative
Program of Integrative Medicine
University of Arizona
Tucson, Arizona

President and Executive
Integrative Health
Scottsdale, Arizona

Anthony J. Cichoke Jr., BS, BS, MA, MA,
Portland, Oregon

Sidney MacDonald Baker, MD
Independent Retirement Home
Sag Harbor, New York

George W. Cody, JD, MA
Consulting Historian
Edmonds, Washington

Stephen Barrie, ND, PhD
Senior Executive
Bellevue, Washington

David Barry, BS, BAppSci (Hons), DC, ND
Clinical Research Coordinator
Emeritus Research
Camberwell, Victoria, Australia
Senior Lecturer, Naturopathy
Endeavour College of Natural Health
Melbourne, Victoria, Australia

Kevin L. Conroy, ND
Private Practice
Port Angeles Natural Health
Port Angeles, West Virginia

Peter J. D’Adamo, ND, MIFHI
Professor Clinical Sciences
University of Bridgeport College of
Naturopathic Medicine
Coder/Developer Opus 23 & SWAMI

Peter W. Bennett, ND

Jade Dandy, ND, MSiMR

Clinic Director
Patient Care
Meditrine Naturopathic Medical Clinic
Langley, British Columbia, Canada

The Healing Hut Clinic
Eagle, Idaho
National University of Natural
Portland, Oregon

Faculty Clinical Assistant Professor
NYU Langone Health, Urology
Institute for Functional Medicine
New York, New York

Ralph Esposito, ND, LAc
Adjunct Faculty
New York University
New York, New York

Susan Ann Gaylord, PhD
Director, Program on Integrative Medicine
Physical Medicine and Rehabilitation
University of North Carolina (UNC)
Chapel Hill, North Carolina
Associate Professor
Physical Medicine and Rehabilitation
UNC School of Medicine
Chapel Hill, North Carolina

Alan Goldhamer, DC
Residential Health Education Program
TrueNorth Health Center
Santa Rosa, California
Chairman of the Board
TrueNorth Health Foundation
Santa Rosa, California

Andrea Gruszecki, ND
Science Support Specialist
Meridian Valley Laboratory
Tukwilla, Washington

Bob G. Blasdel, PhD
Research Director
Vésale Pharma
Noville-sur-Mehaigne, Belgium

Patricia M. Devers, DO

Jason A. Hawrelak, ND, BNat(Hons), PhD

Medical Education Specialist
Department of Medical Affairs
Genova Diagnostics, Inc.

Senior Lecturer in Complementary and
Alternative Medicines
College of Health & Medicine
University of Tasmania
Hobart, Tasmania, Australia
Visiting Research Fellow
Australian Research Centre for
Complementary and Integrative
University of Technology Sydney
Sydney, New South Wales, Australia

Peter B. Bongiorno, ND, MSAc, LAc
Co-Medical Director
Naturopathic Medicine
Inner Source Health
New York, New York

Jamie Doughty, BSc, ND
Medical Director
Naturopathic Medicine
Tummy Temple
Olympia, Washington

Rachelle S. Bradley, ND
Private Practice
Heartland Naturopathic Clinic
Omaha, Nebraska


William Eisner, BSc
Duke University
Durham, North Carolina


Bethany Montgomery Hays, MD

Robert Kachko, ND, LAc

Pina LoGiudice, ND, LAc

Assistant Clinical Professor
Maine Medical Center Dept Ob/Gyn
Tufts University School of Medicine
Portland, Maine

Naturopathic Medicine
Inner Source Health
New York, New York
Chief Executive Officer
New York, New York

Innersource Natural Health and
Acupuncture, PC
Huntington, New York

Leah Hechtman, MSci (RHHG),
BHSc (Nat), ND
PhD Candidate
Department of Obstetrics, Gynaecology and
Neonatology | Faculty of Medicine
University of Sydney
Sydney, New South Wales, Australia
National Herbalists Association of Australia
Sydney, New South Wales, Australia
Director and Clinician
The Natural Health and Fertility Centre
Sydney, New South Wales, Australia

Joseph Katzinger, ND
Science Director
Seattle, Washington

Naomi Hoyle, MD
Eliava Phage Therapy Center
Phage Therapy
Eliava Foundation
Tbilisi, Georgia

Corene Humphreys, ND, BHSc, Dip Med
Herb, Dip Hom, QTA
Nutritional Medicine

Mary James, ND
Medical Editor
Naturopathic Doctor News & Review
Scottsdale, Arizona
Expert Panel Member
Women’s Health Network
Portland, Maine

Chief Science Officer and Director of
BrainMD Health
Amen Clinics
Costa Mesa, California

Richard J. Kitaeff, MA, ND,
Dip Ac, LAc
Doctor and Clinic Director
New Health Medical Center
Edmonds, Washington
Staff Acupuncturist
Northwest Hospital
Seattle, Washington
Clinical Affiliate Faculty
Acupuncture and Oriental Medicine
Bastyr University
Seattle, Washington

Cheryl Kos, ND
Personalized Medicine Lifestyle
Bainbridge Island, Washington

Executive Director of Medical
Medical Education
Institute for Functional Medicine
Federal Way, Washington

Independent Researcher
Kenmore, Washington

Helen (Verhesen) Messier
Founder & Chief Medical Officer
Medical Intelligence Learning Labs, Inc.
San Jose, California

Steven C. Milkis, ND
Green Lake Natural Medicine
Seattle, Washington

Gaetano Morello, ND
Clinician, Complex Chronic Disease Program
BC Women’s Hospital
Vancouver, Canada

Gerard E. Mullin, MD
Associate Professor of Medicine
Gastroenterology and Hepatology
Johns Hopkins School of Medicine
Baltimore, Maryland

Stephen P. Myers, ND, BMed PhD

Thomas A. Kruzel, MT, ND

Professor and Director NatMed Research
Southern Cross University
New South Wales, Australia

Rockwood Natural Medicine Clinic
Scottsdale, Arizona

Toshia R. Myers, BS, MA, MPhil, PhD

Sarah Kuhl, MD, PhD

Ordained Minister
United Church of Christ

VA Northern California
Martinez, California

Wayne Jonas, MD

Elizabeth Kutter, BS, PhD

Executive Director
Samueli Integrative Health Programs
H&S Ventures
Alexandria, Virginia

Faculty Emeritas
Bacteriophage Lab
The Evergreen State College
Olympia, Washington

Maeba Jonas, MDiv

Robert Luby, MD

Tennille Marx, ND, CFS
Parris M. Kidd, BSc, PhD

Wendy Hodsdon, ND
Adjunct Faculty
Department of Graduate Studies
National University of Natural Medicine
Portland, Oregon
Adjunct Faculty
Maryland University of Integrative Health
Laurel, Maryland


Michael Alexander Lane, MD
Assistant Professor
Department of Neurology
Oregon Health and Sciences University
Portland, Oregon

Research Director
TrueNorth Health Foundation
Santa Rosa, California

Tara Nayak, ND
Naturopathic Physician
Philadelphia, Pennsylvania

Mark Harrison Nolting, ND, EAMP
Senior Medical Director
Physical Medicine
Chandler, Arizona
Medical Director
Edmonds Wellness Clinic
Edmonds, Washington



John Nowicki, ND

David Quig, PhD

Michael Scott, ND, MSA

Medical Writer, Research Associate
Medical Research Team
Integrative Medicine Advisors, LLC
Seattle, Washington

Vice President
Scientific Support
Doctor’s Data, Inc.
St. Charles, Illinois

Private Practice
Boulder, Colorado

Brian Orr, BA, BS, ND

John C. Reed, MD, MDiv

Tracey Seipel, FANPA, ABC

Country Doc: Integrative Medical Specialty
Seattle, Washington

Founding VP and Fellow of the American
Academy of Medical Acupuncture
Fellow of the Osteopathic Cranial Academy
Diplomate of the American Board of Family
Diplomate of the American Board of
Integrative Medicine
Founding Member, American Holistic
Medical Association

Fellow of the Australian Naturopathic
Practitioners Association
American Botanical Council
Queensland, Australia

Ron Reichert, BA, ND
Naturopathic Physician
North Vancouver, Canada

Ann Shippy, MD

Kristaps Paddock, ND
Medical Director
Charm City Natural Health
Baltimore, Maryland

William Shaw, PhD
Great Planes Laboratory
Kansas City, Missouri

Cristiana I. Paul, MS Nutrition
Independent Research Consultant
Nutritional Biochemistry Research
Cristiana Paul Consulting
Los Angeles, California

Functional Medicine Physician
Environmental Health Expert
Austin, Texas

Corey Resnick, ND
Nicole Pierce, ND
The Vervain Collective
Garden City, Idaho

Lara Pizzorno, MAR, MA, LMT
Senior Medical Writer and Editor
Writing and Editorial Staff
Integrative Medicine Advisors, LLC
Seattle, Washington
Senior Medical Editor
SaluGenecists, Inc.
Seattle, Washington

Terry Arden Pollock, BS, MS
Medical Education Specialist
Medical Affairs
Genova Diagnostics
Asheville, North Carolina

Dirk W. Powell, BS, ND
Adjunct Professor
Naturopathic Medicine
Bastyr University
Kent, Washington

Integrative Health and Nutrition, Inc.
Lake Oswego, Oregon
Medical Advisory Board
Integrative Therapeutics
Green Bay, Wisconsin


Clinical Assistant Professor
Rusk Rehabilitation
New York University Langone
Medical Center
New York, New York
Adjunct Professor
Health Sciences
Touro College
New York, New York

Elaine Roe, MD

Anna Sitkoff, BS, ND

Physician, Hall Health Center
University of Washington
Seattle, Washington

Naturopathic Medicine
Bastyr University
Seattle, Washington

Sally J. Rockwell, PhD, CCN

Robert A. Ronzio, PhD
Executive Director
Research and Educational Services
Insight Learning Institute
Austin, Texas

Angela Sadlon, ND
All Encompassing Healthcare
Centralia, Washington

Lahnor Powell, ND, MPH

Alexander G. Schauss, PhD

Medical Education Specialist
Department of Medical Affairs
Genova Diagnostics
Duluth, Georgia

Senior Director of Research
Natural and Medicinal Products Research
AIBMR Life Sciences, Inc.
Seattle, Washington
Research Associate
Bio5 Institute
University of Arizona
Tucson, Arizona
Research Associate
University of Arizona
Tucson, Arizona

Matt Pratt-Hyatt, PhD
Associate Lab Director
The Great Plains Laboratory, Inc.
Lenexa, Kansas

Barbara Siminovich-Blok, ND, LAc

Pamela Snider, ND
Executive and Senior Editor
Foundations of Naturopathic Medicine
Foundations of Naturopathic Medicine
Snoqualmie, Washington
Associate Professor
College of Naturopathic Medicine
National University of Natural Medicine
Portland, Oregon
School of Naturopathic Medicine
Bastyr University
Kenmore, Washington
Integrative Health Policy Consortium
Conifer, Washington


Virender Sodhi, MD (Ayurveda), ND

Sherry Torkos, BSc, Phm, RPh

Vijayshree Yadav, MD, MCR, FAAN

Ayurvedic Naturopathic Medical Clinic
Bellevue, Washington
Founder and Chief Executive Officer
Ayush Herbs
Redmond, Washington

Pharmacist and Author
Fort Erie, Ontario, Canada

Associate Professor
Oregon Health & Science University
Portland, Oregon

Nick Soloway, LMT, DC, LAc
Private Practice
Helena, Montana

Jessica Tran, ND, MBA
Private Practice
Environmental Medicine
Wellness Integrative Naturopathic
Center, Inc.
Irvine, California

Michael Traub, ND, DHANP, FABNO
Lindsey Stuart, MS, CNM

Naturopathic Medicine
National University of Natural Medicine
Portland, Oregon

Medical Director
Lokahi Health Center
Kailua Kona, Hawaii
Clinical Professor of Graduate Medical
Postgraduate Education
Bastyr University
Seattle, Washington

Mollie Parker Szybala, ND, MPH

Roy Upton, RH

Naturopathic Medicine
Sun Valley Natural Medicine
Ketchum, Idaho

American Herbal Pharmacopoeia
Scotts Valley, California

Certified Nurse Midwife
Boulder, Colorado

Cory Szybala, ND

Venessa Wahler, ND
Jade Teta, ND
Metabolic Effect Inc.
Greensboro/Winston-Salem, North Carolina

Lead ND
Naturopathic Medicine
Tummy Temple
Seattle, Washington

Keoni Teta, ND

Edward C. Wallace, ND, DC

The Naturopathic Health Clinic of North
Greensboro/Winston-Salem, North Carolina

Medical Education Specialist
Medical Affairs
Genova Diagnostics
Asheville, North Carolina

Brice Thompson, ND, MS

Terry Willard, CIH, PhD

Postdoctoral Scholar
Department of Pharmaceutics
University of Washington
Seattle, Washington

Wild Rose College of Natural Healing
Calgary, Canada


Eric L. Yarnell, ND, RH(AHG)
Botanical Medicine
Bastyr University
Kenmore, Washington
Chief Medical Officer
Northwest Naturopathic Urology
Seattle, Washington

Jared Zeff, ND
Naturopathic Physician
Salmon Creek Clinic
Portland, Oregon

Heather Zwickey, PhD
School of Graduate Studies
National University of Natural Medicine
Portland, Oregon
Adjunct Faculty
Oregon Health and Science University
Portland, Oregon
Human Nutrition and Functional Medicine
University of Western States
Portland, Oregon

This fifth edition of the Textbook of Natural Medicine (which has
now been in publication since 1985) brings several new features and
changes to our structure and format. We are especially excited that we
are in full color for the first time, including images and figures. These
dramatically improve our ability to present, in a more understandable
and visually interesting way, the key concepts of and insights into the
underlying causes of dysfunction and disease. We are also delighted
that with all the new chapters and graphics, Elsevier has moved us back
to the two-volume format. To better fit the content into two logical
volumes, we changed the order (and some of the titles) of the sections.
Syndromes and Special Topics moved to Section V because these fit
better in Volume 2 with Section VI, Diseases. Pharmacology of Natural
Medicines moved to Section IV because this fits better with Volume 1.
As usual, we offer many new chapters, and we think the new chapter
on sarcopenia is of particular importance. In addition to new chapters,
some chapters have been renamed for better consistency, and some
have been moved to sections that we felt were more appropriate. To


facilitate utilization, the sections are now color coded, and we have
provided alphabetical tabs to help readers in searching for specific
diseases. Closely related diseases have been placed in a single chapter―for example, depression, dysthymia, manic phase, and seasonal
affective disorder are all located in the chapter on affective disorders
chapter―so becoming familiar with these groupings is essential for
finding specific diseases. There are now 14 appendices that provide
additional resources for the clinician. We worked with authors to
make their writing more succinct and eliminate unnecessary content.
We also reduced the length of Section VI by removing duplication of
content from Section V in the therapeutics portion of the chapters. We
hope you will be as pleased with the latest edition as we are.
Due to the substantial increase in pages this edition, to keep down
costs we had to move all of the approximately 20,000 references to the
online version.
Joseph E. Pizzorno
Michael T. Murray

We would like to thank Inta Ozols, the original commissioning editor, our executive assistant Lavelle Brown
(who so effectively organized and managed all the authors and chapters), and the dedicated staff at Elsevier
(Kristin Wilhelm, Linda Woodard, Laurie Gower, Becky Leenhouts, Jeff Patterson, Julie Eddy, Clay Broeker,
Margaret Reid, Deanna Sorenson, and Allison Kieffer) for their excellent work in making this the best edition ever.




Philosophy of Natural
One of the key features of the various schools of natural medicine that differentiates them from conventional medicine
is their strong philosophical foundation. The basic philosophical premise of naturopathic medicine, for example, is that
there is an inherent healing power in nature and in every human being. We believe that a primary role of the physician is to
“remove the blocks to cure” and enhance this innate healing power within his or her patients.
In many ways, this was the most difficult section of the textbook to write because, before this textbook, no comprehensive history of the social, political, and philosophical development of naturopathic medicine had ever been written. Even in
the halcyon years of the 1920s and 1930s, the profession was never able to agree upon a concise philosophy. This situation
has now changed.
In this section, we provide well-documented chapters detailing the roots of American natural medicine. After a century
of maturation, the naturopathic profession has now widely agreed to a comprehensive definition, set of principles, and
system of case analysis that provide a systematic guide for the application of these concepts in a clinical setting.
The seven fundamental principles of naturopathic medicine are as follows:
The healing power of nature (vis medicatrix naturae)
First, do no harm (primum non nocere)
Find the cause (tolle causam)
Treat the whole person
Preventive medicine
Doctor as teacher
These principles translate into the following questions the practitioner applies when analyzing a case:
• What is the first cause; what is contributing now?
• How is the body trying to heal itself?
• What is the minimum level of intervention needed to facilitate the self-healing process?
• What are the patient’s underlying functional weaknesses?
• What education does the patient need to understand why he or she is sick and how to become healthier?
• How does the patient’s physical disease relate to his or her psychological and spiritual health?
We have further expanded on the philosophical basis of naturopathic medicine by having these concepts addressed by
several authors whose backgrounds allow each of them a unique and, we believe, complementary insight into some of the
fundamental questions of the goals of health care. Although the dominant school of medicine has essentially ignored these
issues, we believe that the true physician cannot function without a sound philosophical basis to guide his or her actions.
Without more than a superficial understanding of health and disease, the physician is more likely to function as a technician, temporarily alleviating symptoms while allowing the real disease to progress past the point of recovery. The huge
and increasing burden of chronic disease in all age groups clearly validates the predictions of the founders of naturopathic
medicine that primarily treating symptoms, while not addressing causes, results in increased chronic disease.


Functional Medicine: A 21st-Century Model
of Patient Care and Medical Education
Robert Luby, MD, and Leo Galland*, AB, MD
What Is Functional Medicine?, 2
Principles, 2
Lifestyle and Environmental Factors, 4
Fundamental Physiological Processes, 4
Core Clinical Imbalances, 4
Antecedents, Triggers, and Mediators, 5
Antecedents and the Origins of Illness, 5

Triggers and the Provocation of Illness, 5
Mediators and the Formation of Illness, 6
Constructing the Model, 6
Assessment, 6
The Functional Medicine Matrix Model, 6
The Healing Partnership, 8
Integration of Care, 10

In this chapter, the basic principles, constructs, and methodology
of functional medicine are reviewed. It is not the purpose of this
chapter to recapitulate the range and depth of the science underlying
functional medicine; books and monographs covering that material
in great detail are already available for the interested clinician and
for use in health professional schools (see Bibliography at the end of
the chapter). The purpose is to describe how functional medicine is
organized to deliver personalized systems medicine and is equipped
to respond to the challenge of treating complex chronic disease more

has not really produced an efficient method for identifying and assessing changes in basic physiological processes that produce symptoms of
increasing duration, intensity, and frequency, although it is known that
such alterations in function often represent the first signs of conditions
that, at a later stage, become pathophysiologically definable diseases. By
broadening the use of functional to encompass this view, functional medicine becomes the science and art of detecting and reversing alterations
in function that clearly move a patient toward chronic disease over the
course of a lifetime.
One way to conceptualize where functional medicine falls in the
continuum of health and health care is to examine the functional
medicine “tree.” In its approach to complex chronic disease, functional medicine encompasses the whole domain represented by the
graphic shown in Fig. 1.1, but it first addresses the patient’s core
clinical imbalances (found in the functional physiological organizing
systems); the fundamental lifestyle factors that contribute to chronic
disease; and the antecedents, triggers, and mediators that initiate and
maintain the disease state. Diagnosis, of course, is part of the functional medicine model, but the emphasis is on understanding and
improving the functional core of the human being as the starting
point for intervention.
Functional medicine clinicians focus on restoring balance and
improved function in the dysregulated systems by strengthening the
fundamental physiological processes that underlie them and by adjusting the environmental and lifestyle inputs that nurture or impair them.
This approach leads to therapies that focus on restoring health and
function, rather than simply controlling signs and symptoms.

Functional medicine encompasses a dynamic approach to assessing,
preventing, and treating complex chronic disease. It helps clinicians
of all disciplines identify and ameliorate dysfunctions in the physiology and biochemistry of the human body as a primary method
of improving patient health. This model of practice emphasizes that
chronic disease is almost always preceded by a period of declining
function in one or more of the body’s physiological organizing systems. Returning patients to health requires reversing (or substantially improving) the specific dysfunctions that contributed to the
disease state. Those dysfunctions are, for each of us, the result of
lifelong interactions among diet, environment, lifestyle choices, and
genetic predispositions. Each patient, therefore, represents a unique,
complex, and interwoven set of influences on intrinsic functionality that, over time, set the stage for the development of disease or
the maintenance of health. To manage the complexity inherent in
this approach, functional medicine has adopted practical models for
obtaining and evaluating clinical information that leads to individualized patient-centered therapies.
Historically, the word functional was used somewhat pejoratively
in medicine. It implied a disability associated with either a geriatric or
psychiatric problem. The authors suggest, however, that this is a very
limited definition of an extremely useful word. The medical profession

*Previous edition contributor


Seven basic principles characterize the functional medicine paradigm:
•	Acknowledging the biochemical individuality of each human being,
based on the concepts of genetic and environmental uniqueness
•	Incorporating a patient-centered rather than a disease-centered
approach to treatment


Functional Medicine: A 21st-Century Model of Patient Care and Medical Education

The Functional Medicine Tree





Organ System




Signs and

The Fundamental Organizing Systems and Core Clinical Imbalances


Digestion, Absorption, Microbiota/Gl,

Energy regulation, Mitochondrial function

Cardiovascular, Lymphatic systems

Biotransformation and Elimination

Structural Integrity

Defence and Repair

Toxicity, Detoxification

From the subcellular membranes to
the musculoskeletal system

Immune system, Inflammatory
processes, Infection and microbiota



Endocrine, Neurotransmitters, Immune
messengers, Cognition

Antecedents, Triggers, and Mediators
Mental, Emotional,
Spiritual Influences

Genetic Predisposition

Attitudes, Beliefs


Sleep &
Exercise &


Personalizing Lifestyle and Environmental Factors
Version 2

© 2015 The Institute for Functional Medicine

Fig. 1.1 The continuum of health and health care: the functional medicine tree. (Courtesy the Institute for
Functional Medicine.)




Philosophy of Natural Medicine

•	Seeking a dynamic balance among the internal and external factors
in a patient’s body, mind, and spirit
•	Addressing the web-like interconnections of internal physiological
•	Identifying health as a positive vitality—not merely the absence of
disease—and emphasizing those factors that encourage a vigorous
•	Promoting organ, cellular, and subcellular function as the
means of enhancing the health span, not just the life span, of
each patient
•	Staying abreast of emerging research—a science- and evidence-based

The building blocks of life, and the primary influences on them, are
found at the base of the functional medicine tree graphic (see Fig. 1.1).
When we talk about influencing gene expression, we are interested in the
interaction between lifestyle and environment in the broadest sense and
any genetic predispositions with which a person may have been born—
in a word, the epigenome. (Epigenetics is the study of how environmental factors can affect gene expression without altering the actual DNA
sequence and how these changes can be inherited through generations.)
Many environmental factors that affect gene expression are (or appear to
be) a matter of choice (such as diet and exercise), others are very difficult
for the individual patient to alter or escape (air and water quality, toxic
exposures), and still others may be the result of unavoidable accidents
(trauma, exposure to harmful microorganisms). Some factors that may
appear modifiable are heavily influenced by the patient’s economic status—if you are poor, for example, it may be impossible to choose more
nutritious food, decrease stress in the workplace and at home, or take the
time to exercise and rest properly. Existing health status is also a powerful influence on the patient’s ability to alter environmental input. If
you have chronic pain, exercise may be extremely difficult; if you are
depressed, self-activation is a major challenge.
The influence of these lifestyle and environment factors on the
human organism is indisputable,1,2 and they are often powerful agents
in the attempt to restore health. Neglecting to address them in favor
of merely writing a prescription—whether for pharmaceutical agents,
nutraceuticals, or botanicals—means the cause of the underlying dysfunction may itself remain unaddressed and further able to contribute
to the genesis of other disease conditions. In general terms, the following factors should be considered when working to reverse dysfunction
or disease and restore health:
•	Diet (type, quality, and quantity of food; food preparation; calories,
fats, proteins, carbohydrates)
•	Nutrients (both dietary and supplemental)
•	Air and water
•	Microorganisms (and the general condition of the soil in which
food is grown)
•	Physical exercise
•	Trauma
•	Psychosocial and spiritual factors, such as meaning and purpose, relationships, work, community, economic status, stress, and belief systems
•	Xenobiotics
•	Radiation

There are certain physiological processes that are necessary to life.
These are the “upstream” processes that can go awry and create
“downstream” dysfunctions that eventually become expressed as

disease entities. Functional medicine requires that clinicians consider
these in evaluating patients so that interventions can target the most
fundamental level possible. These processes are as follows:
1.	Communication
•	Intracellular
•	Intercellular
•	Extracellular
2.	Bioenergetics/energy transformation
3.	Assimilation
4.	Structural integrity
5.	Biotransformation/elimination
6.	Defense and repair
7.	Transport/circulation
These fundamental physiological processes are usually taught early
in health professions curricula, where they are appropriately presented
as the foundation of modern, scientific patient care. Unfortunately,
subsequent training in the clinical sciences often fails to fully integrate knowledge of the functional mechanisms of disease with therapeutics and prevention, emphasizing organ system diagnosis instead.3
Focusing predominantly on organ-system diagnosis without examining the underlying physiology that produced the patient’s signs, symptoms, and disease often leads to managing patient care by matching
diagnosis to pharmacology. The job of the health care provider then
becomes a technical exercise in finding the drug or procedure that best
fits the diagnosis (not necessarily the patient or the underlying physiological dysfunction), leading to a significant curtailment of critical
thinking pathways: “Medicine, it seems, has little regard for a complete
description of how myriad pathways result in any clinical state.”4
Even more important, pharmacological treatments (and even natural remedies) are often prescribed without careful consideration of
their physiological effects across all organ systems, physiological processes, and genetic variations.5 This was notably exemplified by the
cyclooxygenase-2 inhibitor drugs that were so wildly successful on
their introduction, only to be subsequently withdrawn or substantially
narrowed in use because of collateral damage.6,7

The functional medicine approach to assessment, both before and after
diagnosis, charts a course using different navigational assumptions.
Every health condition instigates a quest for information centered on
understanding when and how the specific biological system(s) under
examination became dysregulated and began manifesting dysfunction
and/or disease. Analyzing all the elements of the patient’s story, the
signs and symptoms, and the laboratory assessment through a matrix
focused on functionality requires analytical thinking and a willingness on the part of the clinician to reflect deeply on the underlying
biochemistry and physiology. The foundational principles of how the
human organism functions—and how its systems communicate and
interact—are essential to the process of linking ideas about multifactorial causation with the perceptible effects called disease or dysfunction.
To assist clinicians in this process, functional medicine identified
and organized a set of core clinical imbalances that are linked to the
fundamental physiological processes (organizing systems). These serve
to marry the mechanisms of disease with the manifestations and diagnoses of disease. Many common underlying pathways of disease are
reflected in these clinical imbalances. The following list of imbalanced
systems and processes is not definitive, but some of the most common
examples are provided. We recommend that the organizing systems be
considered in the order as shown in the following list:
•	Digestion
•	Absorption


Functional Medicine: A 21st-Century Model of Patient Care and Medical Education


One Condition – Many Imbalances


Genetics and epigenetics

Diet and exercise

Mood disorders

One Imbalance – Many Conditions

Heart disease Depression
Fig. 1.2 Core clinical imbalances—multiple influences. (Courtesy the Institute for Functional Medicine.)

•	Microbiome/gastrointestinal
•	Respiration
•	Immune system
•	Inflammatory processes
•	Infection and microbiome
•	Energy regulation
•	Mitochondrial function
•	Toxicity
•	Detoxification
•	Endocrine
•	Neurotransmitter
•	Immune messengers
•	Cognition
•	From the subcellular membranes
•	To the musculoskeletal system
Using this construct, it becomes much clearer that one disease and/
or condition may have multiple causes (i.e., multiple clinical imbalances), just as one fundamental imbalance may be at the root of many
seemingly disparate conditions (Fig. 1.2).
The most important precept to remember about functional medicine is that restoring balance—in the patient’s lifestyle and/or environment and in the body’s fundamental physiological processes—is the
key to restoring health.

to acute or chronic illness. For a person who is ill, antecedents form
the illness diathesis. From the perspective of prevention, they are risk
factors. Knowledge of antecedents provides a rational structure for the
organization of preventive medicine and public health.
Medical genomics seeks to better understand disease by identifying the phenotypic expression of disease-related genes and their products. The application of genomic science to clinical medicine requires
the integration of antecedents (genes and the factors controlling their
expression) with mediators (the downstream products of gene activation). Mediators, triggers, and antecedents are not only key biomedical concepts; they are also important psychosocial concepts. In
person-centered diagnosis, the mediators, triggers, and antecedents for
each person’s illness form the focus of the clinical investigation.

Antecedents and the Origins of Illness
Understanding the antecedents of illness helps the physician understand the unique characteristics of each patient as they relate to his or
her current health status. Antecedents may be thought of as congenital or developmental. The most important congenital factor is gender:
women and men differ sharply in susceptibility to many disorders. The
most important developmental factor is age; what ails children is rarely
the same as what ails the elderly. Beyond these obvious factors lies a
diversity as complex as the genetic differences and separate life experiences that distinguish one person from another.


Triggers and the Provocation of Illness

What modern science has taught us about the genesis of disease can
be represented by three words: triggers, mediators, and antecedents.
Triggers are discrete entities or events that provoke disease or its symptoms. Microbes are an example. The greatest scientific discovery of the
19th century was the microbial etiology of the major epidemic diseases.
Triggers are usually insufficient in and of themselves for disease formation; however, host response is an essential component.
It is, therefore, the functional medicine practitioner’s job to know
not just the patient’s ailments or diagnoses but also the physical and
social environment in which illness occurs, the dietary habits of the
person (present diet and preillness diet), his or her beliefs about the
illness, the effect of illness on social and psychological function, factors
that aggravate or ameliorate symptoms, and factors that predispose to
illness or facilitate recovery. This information is necessary for establishing a functional medicine treatment plan.
Identifying the biochemical mediators that underlie host responses
was the most productive field of biomedical research during the second
half of the 20th century. Mediators, as the word implies, do not cause
disease. They are intermediaries that contribute to the manifestation
and/or continuation of disease. Antecedents are factors that predispose

A trigger is anything that initiates an acute illness or the emergence of
symptoms. The distinction between a trigger and a precipitating event
is relative, not absolute; the distinction helps organize the patient’s
story. As a general rule, triggers only provoke illness as long as the
person is exposed to them (or for a short while afterward), whereas a
precipitating event initiates a change in health status that persists long
after the exposure ends.
Common triggers include physical or psychic trauma, microbes,
drugs, allergens, foods (or even the act of eating or drinking), environmental toxins, temperature change, stressful life events, adverse social
interactions, and powerful memories. For some conditions, the trigger is such an essential part of our concept of the disease that the two
cannot be separated; the disease is either named after the trigger (e.g.,
strep throat) or the absence of the trigger negates the diagnosis (e.g.,
concussion cannot occur without head trauma). For chronic ailments
like asthma, arthritis, or migraine headaches, multiple interacting triggers may be present. All triggers, however, exert their effects through
the activation of host-derived mediators. In closed-head trauma, for
example, activation of N-methyl-d-aspartic acid receptors, induction
of nitric oxide synthase, and liberation of free intraneuronal calcium



Philosophy of Natural Medicine

BOX 1.1 Common Illness Mediators
Biochemical Hormones
Free radicals
Transcription factors
Electrical and magnetic fields
Fear of pain or loss
Feelings or personal beliefs about illness
Poor self-esteem, low perceived self-efficacy
Learned helplessness
Lack of relevant health information
Reinforcement for staying sick
Behavioral conditioning
Lack of resources because of social isolation or poverty
The nature of the sick role and the doctor–patient relationship

determine the late effects. Intravenous magnesium at the time of
trauma attenuates the severity by altering the mediator response.9,10
Sensitivity to different triggers often varies among persons with similar
ailments. A prime task of the functional practitioner is to help patients
identify important triggers for their ailments and develop strategies for
eliminating them or diminishing their virulence.

Mediators and the Formation of Illness
A mediator is anything that produces or perpetuates symptoms or
damages tissues of the body, including certain behaviors. Mediators
vary in form and substance. They may be biochemical (e.g., prostanoids and cytokines), ionic (e.g., hydrogen ions), social (e.g., reinforcement for staying ill), psychological (e.g., fear), or cultural (e.g.,
beliefs about the nature of illness). A list of common mediators is presented in Box 1.1. Illness in any single person usually involves multiple
interacting mediators. Biochemical, psychosocial, and cultural mediators interact continuously in the formation of illness.

Combining the principles, lifestyle and environment factors, fundamental physiological processes, antecedents, triggers, mediators, and
core clinical imbalances demands a new architecture for gathering
and sorting information for clinical practice—in effect, a new heuristic to serve the practice of functional medicine. (Heuristics are rules
of thumb—ways of thinking or acting—that develop through experimentation and enable more efficient and effective processing of data.)
This new model includes an explicit emphasis on principles and mechanisms that infuse meaning into the diagnosis and deepen the clinician’s understanding of the multivalent contributors to physiological
dysfunction. Any methodology for constructing a coherent story and
an effective therapeutic plan in the context of complex chronic illness
must be flexible and adaptive. Like an accordion file that compresses

and expands upon demand, the amount and kind of data collected will
necessarily change in accordance with the patient’s situation and the
clinician’s time and ability to piece together the underlying threads of
The conventional assessment process involving the chief complaint,
history of present illness, and past medical history sections must be
expanded (Fig. 1.3) to include a thorough investigation of antecedents,
triggers, and mediators and a systematic evaluation of any imbalances
within the fundamental organizing systems. Personalized medical care
without this expanded investigation falls short.

The Functional Medicine Matrix Model
Distilling the data from the expanded history, physical examination, and laboratory findings into a narrative storyline that includes
antecedents, triggers, and mediators can be challenging. Key to developing a thorough narrative is organizing the story using the Functional
Medicine Matrix Model form (Fig. 1.4).
The matrix form helps organize and prioritize information and also
clarifies the level of present understanding, thus illuminating where
further investigation is needed. For example:
•	Indicators of inflammation on the matrix might lead the clinician
to request tests for specific inflammatory markers (such as highly
sensitive C-reactive protein, interleukin levels, and/or homocysteine).
•	Essential fatty acid levels, methylation pathway abnormalities, and
organic acid metabolites help determine the adequacy of dietary
and nutrient intakes.
•	Markers of detoxification (glucuronidation and sulfation, cytochrome P450 enzyme heterogeneity) can determine the functional
capacity for molecular biotransformation.
•	Neurotransmitters and their metabolites (vanilmandelate, homovanillate, 5-hydroxyindoleacetate, quinolinate) and hormone
cascades (gonadal and adrenal) have obvious utility in exploring
messenger molecule balance.
•	Computed tomographic scans, magnetic resonance imaging (MRI),
or plain radiographs extend the view of the patient’s structural dysfunctions. The use of bone scans, dual-energy x-ray absorptiometry scans, or bone resorption markers11,12 can be useful in further
exploring the web-like interactions of the matrix.
•	Newer, useful technologies such as functional MRIs, single-photon
emission computed tomography, and positron emission tomographic scans offer a more comprehensive assessment of metabolic
function within organ systems.
It is the process of completing a comprehensive history and physical using the expanded functional medicine heuristic and then charting
these findings on the matrix that best directs the choice of diagnostic
evaluations and successful treatment.
Therapies should be chosen for their potential effect on the most
significant imbalances of the particular patient. A completed matrix
form facilitates review of common pathways, mechanisms, and
mediators of disease and helps clinicians select points of leverage for
treatment strategies. However, even with the matrix as an aid to synthesizing and prioritizing information, it can be very useful to consider
the effect of each variable at five different levels:
1.	Whole-body interventions: Because the human organism is a complex adaptive system, with countless points of access, interventions
at one level will affect points of activity in other areas as well. For
example, improving the patient’s sleep beneficially influences the
immune response, melatonin levels, and T-cell lymphocyte levels and helps decrease oxidative stress. Exercise reduces stress,
improves insulin sensitivity, and improves detoxification. Reducing stress (and/or improving stress management) reduces cortisol


Functional Medicine: A 21st-Century Model of Patient Care and Medical Education


Chief Complaint (CC)
History of Present Illness (HPI)
Past Medical History (PMH)
– Explore antecedents, triggers, and mediators of CC, HPI, and PMH
Family Medical History
– Genetic predispositions?
Review of Organ Systems (ROS)
Medication and Supplement History
Dietary History
Social, Lifestyle, Exercise History
Physical Examination (PE)
Laboratory and Imaging Evaluations
Explore Core Clinical Imbalances:
Assimilation Imbalances
Defense and Repair Imbalances
Immune system
Inflammatory processes
Infection and microbiota
Energy Imbalances
Energy regulation
Mitochondrial function
Biotransformation and Elimination Imbalances
Communication Imbalances
Immune messengers
Structural Integrity Imbalances
From the subcellular membranes to the musculoskeletal system
Initial Assessment:
– Enter data on Matrix form; look for common themes
– Review underlying mechanisms of disease
– Recapitulate patient’s story
– Organ system-based diagnosis
– Functional medicine assessment: underlying mechanisms of disease; genetic and environmental
Treatment Plan:
– Individualized
– Dietary, lifestyle, environmental
– Nutritional, botanical, psychosocial, energetic, spiritual
– May include pharmaceuticals and/or procedures
Fig. 1.3 Expanding the accordion file: the functional medicine assessment heuristic. (Courtesy the Institute
for Functional Medicine.)

levels, improves sleep, improves emotional well-being, and reduces
the risk of heart disease. Changing the diet has myriad effects on
health, from reducing inflammation to reversing coronary artery
2.	Organ-system interventions: These interventions are used more
frequently in the acute presentation of illness. Examples include
splinting; draining lesions; repairing lacerations; reducing fractures, pneumothoraxes, hernias, or obstructions; or removing a
stone to reestablish whole-organ function. There are many interventions that improve organ function. For example, bronchodilators improve air exchange, thereby decreasing hypoxia, reducing
oxidative stress, and improving metabolic function and oxygenation in a patient with reactive airway disease.
3.	Metabolic or cellular interventions: Cellular health can be addressed
by ensuring the adequacy of macronutrients, essential amino acids,

vitamins, and cofactor minerals in the diet (or, if necessary, from
supplementation). An individual’s metabolic enzyme polymorphisms can profoundly affect his or her nutrient requirements.
For example, adding conjugated linoleic acid to the diet can alter
the peroxisome proliferator–activated receptor system, affect body
weight, and modulate the inflammatory response.13–15 However,
in a person who is diabetic or insulin resistant, adding conjugated
linoleic acid may induce hyperproinsulinemia, which is detrimental.16,17 Altering the types and proportions of carbohydrates in the
diet may increase insulin sensitivity, reduce insulin secretion, and
fundamentally alter metabolism in the insulin-resistant patient.
Supporting liver detoxification pathways with supplemental glycine and N-acetylcysteine improves the endogenous production of
adequate glutathione, an essential antioxidant in the central nervous system and gastrointestinal tract.



Philosophy of Natural Medicine

Retelling the
Patient’s Story
(Predisposing Factors—

Triggering Events

Physiology and Function: Organizing the Patient’s Clinical Imbalances

Defense & Repair
(e.g., Immune,

(e.g., Digestion,
Absorption, Microbiota/GI,

(e.g., from Subcellular
Membranes to



e.g., cognitive

e.g., emotional
regulation, grief,
sadness, anger,

(e.g., Energy


e.g., meaning &
relationship with
something greater

(e.g., Endocrine,
Neurotransmitters, Immune

& Elimination
(e.g., Toxicity,

(e.g., Cardiovascular, Lymphatic System)

Modifiable Personal Lifestyle Factors
Sleep & Relaxation


Exercise & Movement






© 2015 Institute for Functional Medicine

Fig. 1.4 The Functional Medicine Matrix Model. (Courtesy the Institute for Functional Medicine.)

4.	Subcellular/mitochondrial interventions: There are many examples of
nutrients that support mitochondrial function.18,19 Inadequate iron
intake causes oxidants to leak from mitochondria, damaging mitochondrial function and mitochondrial DNA. Making sure there is sufficient iron helps alleviate this problem. Inadequate zinc intake (found
in more than 10% of the U.S. population) causes oxidation and DNA
damage in human cells.19 Ensuring the adequacy of antioxidants and
cofactors for the at-risk individual must be considered in each part of
the matrix. Carnitine, for example, is required as a carrier for the transport of fatty acids from the cytosol into the mitochondria, improving
the efficiency of β-oxidation of fatty acids and resultant adenosine triphosphate production. In patients who have lost significant weight,
carnitine undernutrition can result in fatty acids undergoing ωoxidation, a far less efficient form of metabolism.20 Patients with low
carnitine may also respond to riboflavin supplementation.20
Subcellular/gene-expression interventions: Many compounds
interact at the gene level to alter cellular response, thereby affecting
health and healing. Any intervention that alters nuclear factor-κB
entering the nucleus, binding to DNA, and activating genes that
encode inflammatory modulators, such as interleukin-6 (and thus
C-reactive protein), cyclooxygenase-2, interleukin-1, lipoxygenase,
inducible nitric oxide synthase, tumor necrosis factor-α, or a number of adhesion molecules, will affect many disease conditions.21,22
There are many ways to alter the environmental triggers for nuclear
factor-κB, including lowering oxidative stress; altering emotional
stress; and consuming adequate phytonutrients, antioxidants,
alpha-lipoic acid, eicosapentaenoic acid, docosahexaenoic acid,

and γ-linoleic acid.21 Adequate vitamin A allows the appropriate
interaction of vitamin A–retinoic acid with more than 370 genes.23
Vitamin D in its most active form intercalates with a retinol protein
and the DNA exon and modulates many aspects of metabolism,
including cell division in both healthy and cancerous breast, colon,
prostate, and skin tissue.24 Vitamin D has key roles in controlling
inflammation, calcium homeostasis, bone metabolism, cardiovascular and endocrine physiology, and healing.24
Experience using this model, along with improved pattern-recognition skills, will often lessen the need for extensive laboratory assessments. However, there will always be certain clinical conundrums
that simply cannot be assessed without objective data, and for most
patients, there may be an irreducible minimum of laboratory assessments required to accumulate information. For example, in the clinical
workup of autism spectrum disorders in children, heavy-metal exposure and toxicity may play an important role. The heavy-metal body
burden cannot be sensibly assessed without laboratory studies. In most
initial workups, laboratory and imaging technologies can be reserved
for those complex cases in which the initial interventions prove insufficient to the task of functional explication. When clinical acumen and
educated steps in both assessments and therapeutic trials do not yield
expected improvement, laboratory testing often provides rewarding
information. This is frequently the context for focused genomic testing.

The Healing Partnership
No discussion of the functional medicine model would be complete
without mention of the therapeutic relationship. Partnerships are


Functional Medicine: A 21st-Century Model of Patient Care and Medical Education

formed to achieve an objective. For example, a business partnership
forms to engage in commercial transactions for financial gain; a marriage partnership forms to build a caring, supportive, home-centered
environment. A healing partnership forms to heal the patient through
the integrated application of both the art of medicine (insight driven)
and the science of medicine (evidence driven). An effective partnership
requires that trust and rapport be established. Patients must feel comfortable telling their stories and revealing intimate information and
significant events.
In the 20th century, contemporary medicine, traditionally considered a healing profession, evolved away from the role of healing the
sick to that of curing disease through modern science. Research into
this transition revealed that healing was traditionally associated with
themes of wholeness, narrative, and spirituality. Professionals and
patients alike report healing as an intensely personal, subjective experience involving a reconciliation of meaning for an individual and a perception of wholeness. The biomedical model as currently configured
no longer encompasses these characteristics.
Contemporary medicine considers the wholeness of healing to be
beyond its orthodoxy—the domain of the nonscientific and nonmedical.25 We disagree. To grasp the profound importance of the healing
partnership to the creation of a system of medicine adequate to the
demands of the 21st century, an emerging body of relevant research
was reviewed.26–28 As Louise Acheson, MD, MS, associate editor of the
Annals of Family Practice, articulated insightfully in that journal29: “It
is challenging to research this ineffable process called healing.”
Hsu and colleagues asked focus groups of nurses, physicians, medical assistants, and randomly selected patients to define healing and
describe what facilitates or impedes it.30 The groups arrived at surprisingly convergent definitions: “Healing is a dynamic process of recovering from a trauma or illness by working toward realistic goals, restoring
function, and regaining a personal sense of balance and peace.” They
heard from diverse participants that “healing is a journey” and “relationships are essential to healing.”
Research into the role of healing in the medical environment has
generated some thoughtful and robust investigations. Scott et al.’s26
research into the healing relationship found very similar descriptions
to those of Hsu et al.30 The participants in the study27 articulated
aspects of the healing partnership as follows:
1.	Valuing and creating a nonjudgmental emotional bond
2.	Appreciating power and consciously managing clinician power in
ways that would most benefit the patient
3.	Abiding and displaying a commitment to caring for patients over
Three relational outcomes result from these processes: trust,
hope, and a sense of being known. Clinician competencies that facilitate these processes are self-confidence, emotional self-management,
mindfulness, and knowledge.27 In this rich soil, the healing partnership
The characteristics of a conventional therapeutic encounter are
fundamentally different from a healing partnership, and each emerges
from specific emphases in training. In the therapeutic encounter, the
relationship forms to assess and treat a medical problem using (usually) an organ-system structure, a differential diagnosis process, and
a treatment toolbox focused on pharmacology and medical procedures. The therapeutic encounter pares down the information flow
between physician and patient to the minimum needed to identify
the organ-system domain of most probable dysfunction, followed by
a sorting system search (the differential diagnosis heuristic). The purpose of this relationship is to arrive at the most probable diagnosis as
quickly as possible and select an intervention based on probable efficacy. The relationship is a left-brain–guided conversation controlled


by the clinician and characterized by algorithmic processing and statistical thinking.31,32
The functional medicine healing partnership forms with a related
but broader purpose: to help the patient heal by identifying the underlying mechanisms and influences that initiated and continue to mediate the patient’s illness(es). This type of relationship emphasizes shared
responsibility for identifying the causes of the patient’s condition and
achieving insight about enduring solutions. The healing partnership is
critical to the delivery of personalized systems of medicine and to managing the uncertainty (choices under risk) inherent in clinical practice.
In the healing partnership, the appropriate utilization and integration
of left-brain and right-brain functions are found.
In language, we have the fullest expression of the integration of leftand right-brain function. Language is so complex that the brain has
to process it in different ways simultaneously—both denotatively and
connotatively. For complexity and nuance to emerge in language, the
left brain needs to see the trees, and the right brain helps us see and
understand the forest.33,34
The starting point for creating a healing partnership is the patient’s
experience. People, not diseases, can heal. Mindful integration of brain
function is at the heart of a healing partnership. Some of the basic steps
for establishing a healing partnership include the following:
1.	Allowing patients to express, without interruption, their story about
why they have come to see you. (Research focused on the therapeutic
encounter has repeatedly found that clinicians interrupt the patient’s
flow of conversation within the first 18 seconds or less, often denying the patient an opportunity to finish.35) The manner in which the
patient frames the initial concerns often presages later insight into the
root causes. Any interruption in this early stage of narrative moves
the patient back into left-brain processing and away from insight.36
2.	After focusing on the chief concerns, encouraging the patient’s
narrative regarding the present illness(es). Clarifications can be
elicited by further open-ended questioning (e.g., “Tell me more
about that”; “What else do you think might be going on?”). During
this portion of the interview, there is a switching back and forth
between right- and left-brain functions.
•	During this conversation, signs and symptoms of the present
illness are distributed by the practitioner into the Functional
Medicine Matrix Model form as previously described.
•	Analysis of the data thus collected proceeds by assessing probable
underlying causes—based on evidence about common underlying
mechanisms of disease—and ongoing mediators of the disease.
Next, conveying to the patient in the simplest terms possible
that to achieve lasting solutions to the problem(s) for which the
patient has come seeking help, a few fundamental questions must
be asked and answered to understand the problem in the context
of the patient’s personal life. This framing of the interview process
moves the endeavor from a left-brain compilation to a narrative
that encourages insight—based on complex pattern recognition—
about the root causes of the problem.
4.	At this stage, control is shared with the patient: “Without your
help, we cannot understand your medical problem in the depth and
breadth you deserve.” Implementing this shared investigation can
be facilitated by certain approaches:

For determining antecedent conditions, the following
questions are useful:
•	When was the last time you felt well? When were you
free of this problem?
•	What were the circumstances surrounding the appearance of the problem?
•	Have similar problems appeared in family members?



Philosophy of Natural Medicine

One Condition, Many Causes

One Cause, Many Conditions




Low Thyroid






Vitamin D





Fig. 1.5 Overview of the functional medicine (FM) model. (Courtesy the Institute for Functional Medicine.)

b.	For triggers, the following question is critical:
•	What conditions, activities, or events seemed to initiate the problem? (Microbes and stressful personal
events are examples but illustrate quite different categories of triggers. Triggers by themselves are usually
insufficient for disease formation, so triggers must be
viewed within the context of the antecedent conditions.)
c.	Mediators of the problem are influences that help perpetuate it.
•	There can be specific mediators of diseases in the
patient’s activities, lifestyle, and environment. Many
diverse factors can affect the host’s response to stressors.
•	Any of the core clinical imbalances, discussed previously and shown on the Functional Medicine Matrix
Model, can transform what might have been a temporary change in homeostasis into a chronic allostatic
It helps at this juncture to emphasize again that the following issues
are elemental in forming a healing partnership:
•	Only the patient can inform the partnership about the conditions
that provided the soil from which the problem(s) under examination emerged. The patient literally owns the keys to the joint
deliberation that can provide insight into the process of achieving a
healing outcome.
•	The professional brings experience, wisdom, tools, and techniques
and works to create the context for a healing insight to emerge.
•	The patient’s information, input, mindful pursuit of insight, and
engagement become “the horse before the cart.” The cart carries
the clinician—the person who guides the journey using evidence,
experience, and judgment and who contributes the potential for
expert insight.

The crux of the healing partnership is an equal investment of focus
by both clinician and patient. They work together to identify the right
places to apply leverage for change. Patients must commit to engage
both their left-brain skills and their right-brain function to inform and
guide the exploration to the next steps in assessment, therapy, understanding, and insight. Clinicians must also engage both the left-brain
computational skills and the right-brain pattern-recognition functions
that, when used together, can generate insight about the patient’s story.
An overview of the functional medicine model is given in Fig. 1.5.

Functional medicine explicitly recognizes that no single profession can cover all the viable therapeutic options. Interventions and
practitioners will differ by training, licensure, specialty focus, and
even by beliefs and ethnic heritage. However, all health care disciplines (and all medical specialties) can—to the degree allowed
by their training and licensure and assuming a good background
in Western medical science—use a functional medicine approach,
including integrating the matrix as a basic template for organizing and coupling knowledge and data. Consequently, functional
medicine can provide a common language, a flexible architecture,
and a unified model to facilitate integrated and integrative care.
Regardless of the discipline in which the clinician has been trained,
developing a network of capable, collaborative practitioners with
whom to comanage challenging patients and to whom referrals can
be made for therapies outside the primary clinician’s own expertise will enrich patient care and strengthen the clinician–patient

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11.	Yu SL, Ho LM, Lim BC, Sim ML. Urinary deoxypyridinoline is a useful
biochemical bone marker for the management of postmenopausal osteoporosis. Ann Acad Med Singapore. 1998;27(4):527–529.
12.	Palomba S, Orio F, Colao A, et al. Effect of estrogen replacement plus
low-dose alendronate treatment on bone density in surgically postmenopausal women with osteoporosis. J Clin Endocrinol Metab. 1002;87(4):
13.	Moya-Camarena SY, Vanden Heuvel JP, Blanchard SG, et al. Conjugated
linoleic acid is a potent naturally occurring ligand and activator of PPARa.
J Lipid Res. 1999;40:1426–1433.
14.	Gaullier JM, Halse J, Hoye K, et al. Conjugated linoleic acid supplementation for 1 y reduces body fat mass in healthy overweight humans. Am J
Clin Nutr. 2004;79:1118–1125.
15.	O’Shea M, Bassaganya-Riera J, Mohede IC. Immunomodulatory ­properties
of conjugated linoleic acid. Am J Clin Nutr. 2004;79(S):
16.	Malloney F, Yeow TP, Mullen A, et al. Conjugated linoleic acid supplementation, insulin sensitivity, and lipoprotein metabolism in patients with
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23.	Balmer JE, Blomhoff R. Gene expression regulation by retinoic acid. J Lipid
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27.	Miller WL, Crabtree BF, Duffy MB, et al. Research guidelines for assessing
the impact of healing relationships in clinical medicine. Altern Ther Health
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A Hierarchy of Healing:
The Therapeutic Order

A Unifying Theory of Naturopathic Medicine
Stephen P. Myers, ND, BMed PhD, Pamela Snider, ND, Jared Zeff, ND, and
Zora DeGrandpre*, MS, ND

A Brief History of Naturopathic Medicine, 11
Original Philosophy and Theory, 12
Modern Naturopathic Clinical Theory: the Process of
Development, 13
A Theory of Naturopathic Medicine, 15
Illness and Healing as Process, 16
The Naturopathic Model in Acute Illness, 16
The Naturopathic Model in Chronic Illness, 17
The Determinants of Health, 18
Therapeutic Order and Naturopathic Assessment, 18
The Assessment Order: Components of a Vitalistic Assessment of
Illness, Healing, and Health, 18

Therapeutic Order, 20
Acute and Chronic Concerns, 21
Establish the Conditions for Health, 21
Stimulate the Self-Healing Mechanisms, 22
Support Weakened or Damaged Systems or Organs, 23
Address Structural Integrity, 23
Address Pathology: Use Specific Natural Substances, Modalities,
or Interventions, 23
Address Pathology: Use Specific Pharmacological or Synthetic
Substances, 24
Suppress Pathology, 24
Theory in Naturopathic Medicine, 24


The profession went through a period of decline, marked with
internal disunity and paralleled by the rise of biomedicine and the
promise of wonder drugs. By 1957, there was only one naturopathic college left. By 1975, only eight states still licensed naturopathic physicians, and by 1979, there were only six. A survey
conducted in 1980 revealed that there were only about 175 naturopathic practitioners still licensed and practicing in the United
States and Canada.6 In contrast, in 1951, the number was approximately 3000.7
The decline of naturopathic medicine after a rapid rise was due to
several factors. By the 1930s, a significant tension developed within
the profession regarding clinical naturopathic practice based on traditional principles; the development of unified standards; and the
role of experimental, reductionist science as an element of professional development.8,9 Many naturopathic doctors questioned the
capacity for the reductionist scientific paradigm to research naturopathic medicine objectively in its full scope.8,10,11 This tension
split the profession of naturopathic physicians from within after the
death of Lust in the late 1940s, at a time when the profession was
subject to both significant external forces and internal leadership
This perception created a mistrust of science and research. Science
was also frequently used as a bludgeon against naturopathic medicine,
and the biases inherent in what became the dominant paradigm of scientific reductionism made a culture of scientific progress in the profession challenging. The discovery of effective antibiotics elevated the
standard medical profession to dominant and unquestioned ­stature by

In 1900 Benedict Lust “invented” naturopathy, as an eclectic practice
that combined many natural therapies and therapeutic systems under
the umbrella of a comprehensive philosophy and system of practice
based on the European nature cure movement that flourished in the
1800s. At the core of this philosophy was the vis medicatrix naturae
(healing power of nature) and the naturalistic concept of vitalism. As
such, naturopathic medicine has deep historical roots and represents
a lineage of Western natural medicine that can be traced back to the
Roman, Greek, Egyptian, and Mesopotamian cultures and, conceptually, to many traditional and indigenous world medicines.
The modern naturopathic profession originated with Lust, and it
grew under his tireless efforts. He crisscrossed the United States, lecturing and lobbying for legislation to license naturopathy, testifying
for naturopaths indicted for practicing medicine without a license, and
traveling to many events and conferences to help build the profession.
He also wrote extensively, including two monthly newspapers (The
Naturopath and Herald of Health) for nearly 40 years, to foster and
popularize the profession, and through his efforts, the naturopathic
profession grew rapidly.2–4 By the 1940s, naturopathic medicine had
developed a number of 4-year medical schools and had achieved licensure in about one third of the United States, the District of Columbia,
four Canadian provinces, and a number of other countries.3,5
*Previous edition contributor




Philosophy of Natural Medicine

a culture that turned to mechanistic science as an unquestioned authority. The dawning of the atomic age reinforced a fundamental place for
science in a society increasingly dominated by scientific discovery. In
this culture, standard medicine, with its growing political and economic strength, was able to force the near elimination of naturopathic
medicine through the repeal or “sunsetting” of licensure acts.2,3,12
In 1956, as the last early doctor of naturopathy (ND) educational
program ended (at the Western States College of Chiropractic), several doctors, including Drs. Ralph Weiss, Charles Stone, W. Martin
Bleything, and Frank Spaulding, created the National College of
Naturopathic Medicine in Portland, Oregon, to keep the profession
alive. However, that school was nearly invisible as the last vestige
of a dying profession and rarely attracted as many as 10 new students a year. The profession was considered dead by its historical
The culture of America, dominated by standard medicine since the
1940s, however, began to change by the late 1960s. The promise of science and antibiotics was beginning to seem less than perfect. Chronic
disease was increasing in prevalence as acute infection was becoming less predominant, and standard medicine had no “penicillin” for
chronic diseases. In the late 1970s, scholars in family medicine proposed
a biopsychosocial model of care in response to a prevailing perception
of a growing crisis in standard medicine.13 The publication of Engel’s
“The Need for a New Medical Model” in April 1977 signaled the founding of the field of family medicine based on a holistic philosophy. This
shifting culture within standard medicine paralleled a broader social
movement in support of alternative health practices and environmental
awareness. Elements of the culture were rebelling against plastics and
cheap synthetics, seeking more natural solutions. The publication of
Rachael Carson’s Silent Spring in 1962, an indictment of chemical pesticides and environmental damage, marked a turning point in cultural
thinking. In Silent Spring, Carson challenged the practices of agricultural scientists and the government and called for a change in the way
humankind viewed the natural world.14 New evidence of the dangers of
radiation, synthetic pesticides, and herbicides and environmental degradation from industrial pollution was creating a new ethic. Organic
farming, natural fibers, and other similar possibilities were starting to
capture attention. A few began seeking natural alternatives in medicine.
By the late 1960s and early 1970s, enrollments at the National College
of Naturopathic Medicine began to reach into the 20s. The 1974 class
numbered 23 students. In 1975 the National College enrolled a class of
63 students.15 The profession was experiencing a resurgence.
In 1978, with a desire to create a college based on science-based natural medicine, Joseph E. Pizzorno, ND, LM, and his colleagues—Les
Griffith, ND, LM; Bill Mitchell, ND; and Sheila Quinn—created the John
Bastyr College of Naturopathic Medicine in Seattle, Washington. With
the creation of Bastyr, named after the eminent naturopathic physician
Dr. John Bartholomew Bastyr (1912–1995), the profession entered a
new phase. Not only did this new college double the profession’s capacity to produce new doctors, but it also firmly placed the profession on
the ground of scientific research and validation. “Science-based natural
medicine,” coined by Dr. Pizzorno, was a major driving force behind
the creation and mission of Bastyr. Both Drs. Bastyr and Pizzorno had
significant influence and leadership in achieving this focus.
One of Dr. Bastyr’s important legacies was to establish a foundation
and a model for reconciling the perceived conflict between science and
the deeply established healing practices and principles of naturopathic
medicine. Kirchfeld and Boyle4 described his landmark contribution
as follows:
Although naturopathic colleges in the early 1900s did include basic
sciences training, it was not until Dr. John Bastyr (1912–1995)
and his firm, efficient and professional leadership that science and

research-based training in natural medicine was inspired to reach
its fullest potential. Dr. Bastyr, whose vision was one of “naturopathy’s empirical successes documented and proven by scientific
methods,” was himself the prototype of the modern naturopathic
doctor, who culls the latest findings from the scientific literature,
applies them in ways consistent with naturopathic principles and
verifies the results with appropriate studies.
Bastyr also saw a tremendous expansion in both allopathic and
naturopathic medical knowledge, and he played a major role in making sure the best of both were integrated into naturopathic medical
Bastyr met Lust on two occasions and was closely tied to the nature
cure tradition of Kneipp through two influential women: his mother,
and his mentor, Dr. Elizabeth Peters, who studied with Father Kneipp.
He effortlessly integrated the clinical theories and practices of naturopathy with the latest scientific studies and helped create a new and truly
original form of modern primary clinical care within naturopathic
medicine. He spent the 20th century preparing the nature cure of the
19th century for entry into the 21st century.2,16 Today’s philosophic
debates within the profession are no longer about science. They now
tend to center on both sides of the earlier debate and include challenges
to the nature cure tradition. A current debate, for instance, is about
the role of “green allopathy” within the profession: the tendency to
use botanical medicine or nutritional supplements as a simple “green
drug” or pharmaceutical replacement therapy. This is in contrast to
implementing the full range of healing practices derived from the
nature cure tradition and within the framework of the therapeutic
order construct to stimulate health restoration as the foundation for
reversing disease, alongside, or instead of, botanical medicine or nutritional supplements. Professional consensus appears strong that the full
range of naturopathic healing practices must be retained, strengthened, and engaged in the process of education and scientific research
and discovery in the 21st century.17–19

Through the initial 50-year period of professional growth and development (1896–1945), naturopathic medicine had no clear and concise
statement of identity. The profession was whatever Lust said it was.
He defined “naturopathy” or “nature cure” as both a way of life and a
concept of healing that used various natural means of treating human
infirmities and disease states. The “natural means” were integrated into
naturopathic medicine by Lust and others based on the emerging naturopathic theory of healing and disease etiology. The earliest therapies
associated with the term involved a combination of American hygienics and Austro-Germanic nature cure and hydrotherapy. Leaders in
this field included Kuhne, Lindlahr, Trall, Kellogg, Holbrook, Tilden,
Graham, McFadden, Rikli, Thomson, and others who wrote foundational naturopathic medical treatises or developed naturopathic clinical theory, philosophy, and texts to enhance, agree with, and diverge
from Lust’s original work.20–28
The bulk of professional theory was found in Lust’s magazines,
Herald of Health and The Naturopath. These publications displayed the
prodigious writings of Lust but did not contain a comprehensive and
definitive statement of either philosophy or clinical theory. Lust often
stated that all natural therapies fell under the purview of naturopathy.
Several texts were considered as somewhat definitive by various aspects
of the profession at different times. These texts included Adolph Just’s
Return to Nature (1896), Louis Kuhne’s The New Science of Healing
(1899), and the seven-volume Natural Therapeutics by Henry Lindlahr,
MD, which was published in the early 1900s. Lindlahr’s Nature Cure
(1913) was considered a seminal work in naturopathic theory, laying


A Hierarchy of Healing: The Therapeutic Order

the groundwork for a systematic approach to naturopathic treatment
and diagnosis. Lindlahr ultimately presented the most coherent naturopathic theory extant, summarized in his Catechism of Nature Cure,
which presented a five-part therapeutic progression:
1.	“Return to nature”—attending to the basics of diet, dress, exercise,
rest, etc.
2.	Elementary remedies—water, air, light, electricity
3.	Chemical remedies—botanicals, homeopathy, etc.
4.	Mechanical remedies—manipulations, massage, etc.
5.	Mental/spiritual remedies—prayer, positive thinking, doing good
works, etc.29
Lindlahr’s five-step therapeutic progression follows the Catechism’s
disease causation model: “The primary cause of disease, barring accidental or surgical injury to the human organism and surroundings
hostile to human life, is violation of Nature’s Laws.” The effects of violation of nature’s laws on the physical human organism are also the
primary causes of disease because they inhibit normal function, lower
vitality, and result in tissue destruction:
Lowered vitality
Abnormal composition of blood and lymph
Accumulation of waste, morbid matter, and poisons in the system
Fevers, inflammation
Mechanical luxations
Weakening and loss of reason, will, etc.29
In 1948 Spitler wrote Basic Naturopathy, a Textbook,10 and in 1951
Wendel wrote Standardized Naturopathy.11 These texts presented
somewhat different approaches; Spitler’s text emphasized theory and
philosophy, whereas Wendel’s text was written, as evidenced by the
title, to emphasize the standard naturopathic practices of the day,
with an eye toward regulatory practice. In contrast, Kuts-Cheraux’s
Naturopathic Materia Medica, written in 1953, was produced to satisfy a statutory demand by the Arizona legislature but persisted as one
of the few extant guides of that era. Practitioners relied on a number
of earlier texts, many of which arose from the German hydrotherapy
practitioners30–35 or the eclectic school of medicine (a refinement
and expansion of the earlier “Thomsonian” system of medicine)36–40
and predated the formal American naturopathic profession (1900).
However, by the late 1950s, publications diminished. The profession
was generally considered on its last gasp, an anachronism of the preantibiotic era.
During the process of winning licensure, naturopathic medicine
was defined formally by the various licensure statutes, but these definitions were legal and scope-of-practice definitions, often in conflict
with each other, reflecting different standards of practice in different
jurisdictions. In 1965 the U.S. Department of Labor’s Dictionary of
Occupational Titles41 presented the most formal and widespread definition. The definition was not without controversy because it reflected
one of the internally competing views of the profession, primarily, the
nature cure perspective:
Diagnoses, treats and cares for patients using a system of practice that bases treatment of physiological function and abnormal
conditions on natural laws governing the human body. Utilizes
physiological, psychological and mechanical methods such as air,
water, light, heat, earth, phytotherapy, food and herbs therapy,
psychotherapy, electrotherapy, physiotherapy, minor and orificial
therapy, mechanotherapy, naturopathic corrections and manipulations, and natural methods or modalities together with natural
medicines, natural processed food and herbs and natural remedies.
Excludes major surgery, therapeutic use of x-ray and radium, and


the use of drugs, except those assimilable substances containing elements or compounds which are components of body tissues and
physiologically compatible to body processes for the maintenance
of life.41
This definition did not list drugs or surgery within the scope of
modalities available to the profession. It defined the profession by therapeutic modality and was more limited than most of the statutes under
which naturopathic physicians practiced,42 even in 1975, when there
were only eight licensing authorities still active.

Medical philosophy comprises the underlying premises on which
a health care system is based. Once a system is acknowledged, it
is subject to debate. In Naturopathic medicine, the philosophical debates are a valuable, ongoing process which helps the
understanding of health and disease evolve in an orderly and
truth-revealing fashion.
Randall Bradley, ND43
After the profession’s decline in the 1950s and 1960s, a rebirth
was experienced, more grounded in medical sciences and fueled by
a young generation with few teachers. The profession’s roots were
neglected out of ignorance, for the most part, along with a youthful arrogance. By the early 1980s, it was apparent that attempts to
regenerate the progress made by Lust would require the creation
of a unified professional organization and all which that entailed:
accreditation for schools, national standards in education and licensure, clinical research, and the articulation of a coherent definition of
the profession for legislative purposes, as well as for its own internal
development. These accomplishments would be necessary to be able
to demonstrate the uniqueness and validity of the profession, guide
its educational process, and justify its status as a separate and distinct
medical profession.
In 1987 the newly formed (1985) American Association of
Naturopathic Physicians (AANP) began this task of developing a unified professional organization under the leadership of James Sensenig,
ND (president), and Cathy Rogers, ND (vice president). Four tasks
were developed, and committees with specific chairs were delegated.
One task was to pursue accreditation of our schools through governmental accreditation bodies, headed by Joe Pizzorno, ND. Another was
to create a standard, national licensure examination, independent of
the profession, headed by Edwin Smith, ND. A third was to create a
peer-reviewed journal that the profession could use to demonstrate
its rational basis, headed by Peter D’Adamo, ND. The fourth was a
committee to head the creation of a new definition of naturopathic
medicine headed by Pamela Snider, ND, and Jared Zeff ND, LAc. The
“Select Committee on the Definition of Naturopathic Medicine” succeeded in its 3-year project, which culminated in the unanimous adoption by the AANP’s House of Delegates (HOD) of a comprehensive,
consensus definition of naturopathic medicine in 1989 at the annual
convention held at Rippling River, Oregon.44–46 The unique aspect of
this definition was its basis in definitive principles, rather than therapeutic modalities, as the defining characteristics of the profession.
In passing this resolution, the HOD also asserted that the principles
would continue to evolve with the progress of knowledge and should
be formally reexamined by the profession as needed, perhaps every
5 years.44–49
In September 1996 the AANP HOD passed a resolution to review
three proposed principles of practice that had been recommended as



Philosophy of Natural Medicine

additions to the AANP definition of naturopathic medicine originally
passed by the HOD in 1989. These three new proposed principles
were rejected, and the AANP HOD reconfirmed the 1989 AANP definition unanimously in 2000. The results of a profession-wide survey
conducted from 1996 to 1998 on these three new proposed principles
demonstrated that although there was lively input, the profession
agreed strongly that the original definition was accurate and should
remain intact. The HOD recommended that the discussion be moved
to the academic community involved in clinical theory, research, and
practice for pursuit through scholarly dialogue.50–54 This formed the
basis for further efforts to articulate a clinical theory. AANP members
stated in 1987 to 1989 during the definition process: “These principles
are the skeleton, the core of naturopathic theory. There will be more
growth from this foundation.”46 By 1997, this growth in modern clinical theory was evident.
The first statement of such a theory was published in the AANP’s
Journal of Naturopathic Medicine in 1997 in an article titled “The
Process of Healing, a Unifying Theory of Naturopathic Medicine.”55
This article contained three fundamental concepts that were presented
as an organizing theory for the many therapeutic systems and modalities used within the profession and were based on the principles articulated in the consensus AANP definition of naturopathic medicine. The
first of these was the characterization of disease as a process rather than
a pathological entity. The second was the focus on the determinants of
health rather than on pathology. The third was the concept of a therapeutic hierarchy.
This article also signaled the emergence of a growing dialogue
among physicians, faculty, leaders, and scholars of naturopathic
philosophy concerning theory in naturopathic medicine. The hope
and dialogue sparked by this article were the natural next step of a
profession redefining itself both in the light of today’s advances in
health care and with respect to the foundations of philosophy at
the traditional heart of naturopathic medicine. This dialogue naturally followed the discussions of the definition process and created
a vehicle for emerging models and concepts to be built on the bones
of the principles. The essence and inherent concepts of traditional
naturopathic philosophy were carried in the hearts and minds of a
new generation of naturopathic physicians into the 21st century—
these modern naturopathic students and naturopathic physicians
began to gather to articulate, redefine, and reunify the heart of the
This new dialogue was formally launched in 1996, when the AANP
Convention opened with the plenary session “Towards a Unifying
Theory of Naturopathic Medicine,” with four naturopathic physicians presenting facets of emerging modern naturopathic theory.
The session closed with an open microphone. The impassioned and
powerful comments of the naturopathic profession throughout the
United States and Canada engaged in the vital process of deepening
and clarifying its unifying theory. Dr. Zeff presented “The Process of
Healing: The Hierarchy of Therapeutics”; Dr. Mitchell presented “The
Physics of Adjacency, Intention, Naturopathic Medicine, and Gaia”;
Dr. Sensenig presented “Back to the Future: Reintroducing Vitalism as
a New Paradigm”; and Dr. Snider announced the Integration Project,
inviting the profession to engage in it by “sharing a beautiful and
inspiring anguish—the labor pains of naturopathic theory in the twenty-first century. We know what we have done, and we know there is
much more…The foundation is laid. We are ready now for development and integration.”56
Days later, in September 1996, the Consortium of Naturopathic
Medical Colleges (now the American Association of Naturopathic
Medical Colleges [AANMC]) formally adopted and launched the
Integration Project, an initiative to integrate naturopathic theory and

philosophy throughout all divisions of all naturopathic college curricula, from basic sciences to clinical training. A key element of the project engaged the further development and refinement of naturopathic
theory. The project was cochaired by Drs. Snider and Zeff from 1996
to 2003. Steering members from all North American naturopathic colleges participated and contributed.46 Methods included professional
and scholarly research, expert teams, symposiums, and training. The
result was the fostering of systematic inquiry among academicians, clinicians, and researchers concerning the underlying theory of naturopathic medicine, bringing the fruits of this work and inquiry into the
classroom and into scientific discussion.57
The Integration Project sustained both formal and informal dialogue since its inception in 1996, which continues today through
the Foundations of Naturopathic Medicine Institute. The work has
engaged faculty and scholars of naturopathic philosophy in the United
States, Canada, the United Kingdom, Australia, and many other countries where naturopathy is established or is professionalizing. It has
also engaged institutional leaders and practicing doctors and faculty in
all areas of the profession. Why? Naturopathic philosophy is deeply felt
as the “commons” of naturopathic medicine: a place where the profession meets—one that is owned by all naturopathic physicians—that
reflects, holds, and deepens the heart of naturopathic medicine. The
philosophy of naturopathic medicine is the foundation and heart of
naturopathic medicine and consists of its heritage, knowledge base,
concepts, and knowledge codification; its clinical decision making;
its integration and initiation of scientific research; and its public
policy positions. The philosophy remains valid by evolving with the
progress of knowledge, the progress of science, and the progress of
the human spirit. It is for this reason medicine is seen as an art and
a science. Because naturopathic philosophy engages the intuitively
felt mission of nature doctors, it is vital that the profession periodically gathers to renew and revitalize progress regarding its unifying
The Integration Project sparked a wide range of activities in all six
ND colleges at that time, resulting in all-college retreats to share tools,
retreats for training of non-ND faculty in naturopathic philosophy,
integration of a basic sciences curriculum, expert-team revision of
core competencies across departments ranging from nutrition to case
management and counseling, development of clinical tools and seminars for clinic faculty, creation of new courses, and the integration of
important research questions derived from naturopathic philosophy
into research studies and initiatives.58 The latest effort, the Foundations
of Naturopathic Medicine Institute and Project (textbook codification
and symposia series; see includes its
development and presentation of the founding educational module on
emunctorology, an essentially naturopathic science, during 2009 and
2010. This is a joint effort of faculty from several of our schools, led by
Drs. Thom Kruzel, Rita Bettenberg and Stephen Myers.
North American core competencies for naturopathic philosophy and clinical theory were developed by faculty representing all
accredited ND colleges in a landmark AANMC retreat in 2000. The
AANMC’s Dean’s Council formally adopted these competencies in
2000 and recommended that they be integrated throughout curricula
in all ND colleges. These national core competencies included the process of healing theory, Lindlahr’s model, and the hierarchy of therapeutics (the therapeutic order).59,60
Finally, many meetings with scholars and teachers of naturopathic
theory and other faculty and leaders—formal and informal—resulted
in the further development and refinement of the hierarchy of therapeutics developed by Dr. Zeff in 1997.
Drs. Snider and Zeff and worked closely with each other and then
with other naturopathic theory faculty from AANMC colleges in a


A Hierarchy of Healing: The Therapeutic Order

BOX 2.1 Working Definition of Naturopathic


Consensus Statement from Naturopathic Nutrition Faculty Retreat, Naturopathy
and Nutrition Panel and Southern Cross University, June 2003, Preamble
Naturopathic medicine is a distinct system of primary health care—an art,
science, philosophy and practice of diagnosis, as well as treatment and prevention of illness. Naturopathic medicine is distinguished by the principles
that underlie and determine its practice. These principles include the healing
power of nature (vis medicatrix naturae), identification and treatment of the
causes (tolle causam), the promise to first do no harm (primum non nocere),
doctor as teacher (docere), treatment of the whole person, and emphasis on
prevention. These principles give rise to a practice that emphasizes the individual and empowers him or her to greater responsibility in personal health
care and maintenance.
Naturopathic nutrition is the practice of nutrition in the context of naturopathic
Naturopathic nutrition integrates both scientific nutrition and the principles
of naturopathic medicine into a distinct approach to nutritional practice.
Core components of naturopathic nutrition are:
Respect for the traditional and empirical naturopathic approach to nutritional
The value of food as medicine
An understanding that whole foods are greater than the sum of their parts
and recognition that they have vitality (properties beyond physiochemical
Individuals have unique interactions with their nutritional environments
In the context of the definition, and with respect to the therapeutic order, the practice of naturopathic nutrition may include the appropriate use of the following:
Behavioral and lifestyle counseling
Diet therapy (including health maintenance, therapeutic diets, and dietary
Food selection, preparation, and medicinal cooking