Whole Systems: Chinese Medicine and Acupuncture

The law of yin and yang is the natural order of the universe, the foundation of all things, mother of all changes, the root of life and death. 

–The Yellow Emperor’s Classic of Medicine

Chinese medicine has existed for thousands of years, and in the last few decades, various Chinese therapies have become increasingly popular in the West.  This is particularly true for acupuncture.  Chinese medicine has contributed more to complementary and integrative health (CIH) approaches used in VA than any other Whole Medical system, but it has not been adopted in its entirety.  Two of its components, acupuncture and tai chi/qi gong are part of the VA Integrative Health Coordinating Center’s (IHCC) List One, which means all VA sites are mandated to offer them in some form.  Other elements of Chinese medicine are not approved, including moxibustion, Chinese herbal medicine, and wet cupping. 

Chinese medicine looks at a person as a whole, not only in terms of who they are as an individual but also in terms of how they are connected with the natural world.  It emphasizes preventing an illness from ever occurring, as opposed to living with it after it has occurred.  This is something Whole Health and Chinese medicine have in common.

According to the National Health Interview Survey of 2012, 1.5% of Americans used acupuncture, up from 1.4% in 2007.^[1089]  Use in the U.S. tripled between 1997 and 2007.^[1090]  A 2015 survey of nearly 28,000 American adults found that about 7% of them had used acupuncture in their lifetimes.  In the VA, 91% of facilities now offer either meridian or auricular (Battlefield) acupuncture, as described later in this chapter.  As of 2018, there were nearly 38,000 licensed acupuncturists in the U.S.^[1091]  Acupuncture is a popular option within the U.S. Military Healthcare System.^[1092]  The VA now has qualifications standards for licensed acupuncturists.^[1093]

There are many training programs available for learning Chinese medicine.  In the U.S., there are over 60 colleges of acupuncture and Oriental Medicine.^[1094]  A Master’s in Acupuncture (MAc) takes three years, and a certification as a Master of Oriental Medicine (MOM) typically takes three years as well. 

Over 6,000 physicians in the U.S. have done additional acupuncture training and integrate acupuncture into their medical practices.  Most of these clinicians (often said to provide “medical acupuncture”) work in primary care, but anesthesiologists and pain management specialists also make up a significant number.^[1095]  Non-MD acupuncturists can practice in over 25 states.  In most states, physicians are permitted to practice acupuncture as part of their scope of practice.^[1096]

Chinese philosophy is woven into Chinese medicine at a deep level.  Brief introductions to yin-yang theory, five-element theory, and other Chinese perspectives on health and healing are included on the following pages, and for more information, go to the Resources section at the end of this chapter.  In addition to taking a history, diagnosis is done using all the senses, including through inspection, smell, listening, and palpation (including taking pulses and noting an elaborate array of details). 

Chinese medicine includes a variety of therapeutic approaches.  These are tailored to each person’s individual needs, as well as to the skill sets of the practitioner.  They include the following^[1097]:

• Chinese herbal medicine.  As of 1977, nearly 5,800 different herbs were used in China.^[1098]  Herbal remedies are not prescribed according to a pattern of “one herb for one condition,” as many Western herbalists use.  Rather, most Chinese remedies are combinations of herbs.  How the herbs are mixed is informed by an elaborate process.  Formulas usually have a chief ingredient (treats the pattern of the illness), as well as deputy ingredient (helps the chief), an assistant (synergizes or counterbalances with the chief as needed), and an envoy (synergizes with the other ingredients and focuses the remedy on a given area of the body or meridian).  In early 2014, the Cleveland Clinic opened a Chinese herbal clinic, which has drawn a great deal of attention to the use of this therapeutic approach.^[1099]
• Tui na is a form of Chinese massage.  It can be quite intense, with a number of various movements being used, including pushing, rolling, kneading, rubbing, and raking the skin with the fingers.
• Qi gong involves the cultivation of energy.  It is discussed in Chapter 5, “Moving the Body,” along with tai chi.  Note that there are many types of qi gong beyond the movement therapies that are gaining popularity in the West.  Qi gong is used by some practitioners as a type of energy healing.  (Chapter 17 features more on energy medicine approaches.)
• Chinese dietary therapy.  This involves preparing meals that balance the various forces of nature in the body.  Many food preparers in China know which foods are held to be helpful for which conditions.
• Acupuncture (zhen), moxibustion, gua sha, and cupping.^[1100]  These are actually seen as one therapy, despite their differences.  Moxibustion involves burning the herb mugwort (Artemisia vulgaris) on acupuncture needles that have been inserted into specific points.  It may also be placed directly over the skin.  Gua sha is a technique that involves rubbing or scraping the skin.  Cupping involves creating negative pressure over an acupuncture point and adhering a cup to the skin using the suction.  It gained international attention during the 2016 Summer Olympic Games.  Acupuncture is described in more detail in the Whole Health tool below.

Yin-yang theory.  For Chinese medicine (and all schools of thought influenced by Taoism), everything arises through the interplay of two opposite components—yin and yang.  Yang is more “masculine” and represents activity, motion, ascending, outside/external, bright, and hot.  Yin, in contrast, is said to be “feminine,” as well as stillness, descending, cold, dark, and receptive.  When people are healthy, their yin and yang are in balance.  Various organs and biological functions are said to have different mixes of yin and yang aspects (Figure 18-1).  Note that each part of the yin-yang symbol contains a small amount of the other (the small circles).  The two components do not simply oppose each other; rather, they flow in and out of predominance when a system is balanced. Chinese medicine associates some diseases with one or the other.  Menopause is considered a yin deficiency syndrome.  Hypothyroidism, in contrast, is classed as a yang deficiency illness.^[1101]

Five element theory.  In Chinese medicine, there is a dynamic interplay of five elements: Earth, Fire, Metal, Water, and Wood.  These are related to each other in multiple ways.  Each of the elements generates another.  For example, fire creates ash (earth) as it burns. Each of them also destroys/controls another.  Fire destroys wood, for example, and water destroys fire.  These elements and their interactions are said to govern different organs and different acupuncture meridians. 

Other factors that influence health.  The following are also important to Chinese medicine practice13^,[1102]:

• Chi or qi is life force, or vital energy.  The acupuncture meridians are held to be channels for chi.  The chi can be “unblocked” or otherwise maneuvered through the use of acupuncture needles.  There are multiple names for types of chi, based on their location and function.
• Blood is said to be generated from chi as food essence is generated from food being absorbed by the digestive tract.
• Shen is overall vitality or spirit.  If it is found to be doing well, prognosis will be good.
• Jing are acupuncture points described in more detail in the next section.
• Six external factors that can influence health include wind, cold, fire, dryness, summer heat, and dampness.  They harm health if they are excessive or when the body’s defensive chi is inadequate.
• Internal factors include seven emotions: fear, fright, worry, grief, anger, melancholy, and joy.  Excess of any given emotion can also cause illness.
• Interconnectedness is also referred to as “correlative thinking.”  Chinese medicine has many therapies that are based on the idea that each part of the body can offer information about the body as a whole.  This principle is the basis for reflexology, which involves the stimulation of various places on the foot that correlate with various other parts of the body.  For example, some reflexologists hold that sinusitis can be addressed by firmly squeezing the fourth toes, which represent the sinuses.  In auricular acupuncture, it is held that the ear contains a “map” of the rest of the body.  Placing needles in certain parts of the ear, then, will affect the body parts associated with those points.  Battlefield acupuncture, popular for pain management in the military, uses auricular points.^[1103]

 Whole Health Tool: Incorporating Acupuncture

What is Acupuncture?

There are two distinct systems of acupuncture with very different theoretical bases:

1.  Meridian or Body Acupuncture.

Body acupuncture, the most familiar Chinese medicine approach to Westerners, involves the placement of needles in the meridian points.^[1104]  Needles are not hollow like injection or IV needles.  They are usually 0.22-0.25 mm in diameter (much smaller than needles used in Western medicine) and of variable lengths.  A typical acupuncture session may include the insertion of anywhere from a few needles to dozens of them.  Practitioners are taught very specific ways to locate each point based on various anatomical markers.  For example, Pericardium 6 (the 6^th point on the pericardium meridian) is two finger widths up the arm away from wrist crease between two of the forearm tendons.^[1105]  This point is stimulated by motion-sickness bracelets, which have become increasingly popular in recent years and have shown benefit in some studies.^[1106]

Acupuncture points, or jing, are located along chi pathways, which are also known as meridians.  Meridians follow paths longitudinally, or sometimes internally-externally, in the body.  There are also collaterals (luo), which follow horizontal patterns.  Jing-luo regulate the flow of chi and the balance of yin and yang in a person.  Illness arises when flow through them becomes blocked or imbalanced.  There are 361 acupuncture points along 20 meridians (numbers may vary slightly, depending on the acupuncture tradition).  Photos of each meridian, with detailed descriptions, can be viewed at chiro.org or acumedico.com.  All of these factors come into play when an acupuncturist is trying to determine where to insert needles.  Different meridians are named after different organs, but more than just the organs themselves, these energy pathways are governed by the properties or functions that given organs are said to represent.  Points often have evocative names, such as “Supreme Spring” and “Woodworm Ditch.”17

Key degrees and certifications incorporating Chinese medicine include the following:

• DAc—Diplomate of Acupuncture
• DOM—Doctor of Oriental Medicine
• LAc or LicAc—Licensed Acupuncturist
• MAc—Master of Acupuncture
• MOM—Master of Oriental Medicine
• OMD—Oriental Medical Doctor
• RAc—Registered Acupuncturist
• CAc—Certified Acupuncturist (usually a physician trained in acupuncture)

Licensed acupuncturists can now be hired in the VA, and all VA sites are expected to offer acupuncture, either onsite, or in the community.

2.  Microsystem Acupuncture. 

Microsystem acupuncture works very differently as compared to body (or meridian) acupuncture.  The term “microsystem acupuncture” was introduced by Dr. Ralph Alan Dale at the 1974 Third World Symposium on Acupuncture and Chinese Medicine to distinguish it from the traditional body or macro-acupuncture system.

Microsystem acupuncture is based on particular somatotopic fields comprising specific points of correspondence.  That is, a specific part of the body—such as the ear, scalp, foot, hand, or tongue—has a microsystem of points that is mapped out to be used to treat the entire body.  That map is called a somatotopic map.  It is similar to the somatotopic homunculus, the map of the cerebral hemispheres that shows which parts of the body are connected with which parts of the brain.  Each of the microsystem points has a clearly defined correlation to a particular organ or function and may be used for diagnosis as well as treatment.^{[1107],[1108]}  Several theoretical models have been proposed to explain the microsystems, including the holographic model.^{[1109],[1110]}

Battlefield Acupuncture is a 5-point protocol derived from the auricular microsystem, a map of acupuncture points on the ear that are held to be connected to other parts of the body.  Many sites have begun to offer Battlefield Acupuncture (BFA).  Battlefield acupuncture was developed by Dr. Richard Niemtzow in 2001 as a way of relieving pain that could even be used in wartime.^[1111]  It is involves the insertion of extremely small, gold-plated needles into five specific acupoints.^[1112]  These are left in until they fall out by themselves, usually after a period of 2-7 days.15  It works well to have Veterans receive the needles during group visits.^[1113]  BFA is being taught more frequently to VA clinicians.  It has been taught in conjunction with the Whole Health for Pain and Suffering course.

National Acupuncture Detoxification Association (NADA) Protocol is another 5-point ear acupuncture protocol used for stress, emotional trauma, and adjunctive addiction treatment.^[1114]  This protocol involves gentle placement of up to five sterilized needles into specific sites on each ear.  The recipients sit quietly in a group setting for 30 to 45 minutes allowing the treatment to take effect.  A variety of health care practitioners can get trained in this protocol and certified as Auricular Detoxification Specialists.  These trainings are conducted all over the country by NADA-certified trainers through public and private agencies, acupuncture schools and individual practitioners.  State laws vary when it comes to non-acupuncturists practicing “acudetox.”

How Acupuncture Works

There are many theories about how acupuncture works from a physics/biochemistry perspective.^[1115]  Traditionally, the Chinese hold that health is related to the flow of qi (energy) and acupuncture allows it to flow.^[1116]  Western researchers have proposed many theories based on our current scientific understanding, including that acupuncture may stimulate release of certain neurotransmitters, that it causes cells to release chemicals that bind to opioid receptors and block pain, and/or that it alters hormone levels and white blood cell activity.^[1117]  Purine-based signaling,^[1118] nitric oxide release,^[1119] and stimulation of multiple biochemical mechanisms that promote homeostasis^[1120] have also been suggested as potential mechanisms of action.^[1121]  Acupuncture points have a slightly warmer temperature than other points on the body.^[1122]  A 2020 study on mice found that after about 3 minutes of foot acupuncture, blood flow to a mouse’s eyes significantly increased when specific acupuncture points were used.^[1123]

Several theories about how acupuncture works relate to the central nervous system.  Functional MRI studies have shown that needling specific acupuncture points (actual ones only, not sham ones) does indeed stimulate certain parts of the brain to change activity.^{[1124],[1125]}  Inhibition of the microglia in the central nervous system may also play a role.^[1126]  In vitro studies indicate that acupuncture prevents apoptosis (cell death) in a variety of neurological diseases.^[1127]  Manual and electroacupuncture seem to stimulate different parts of the brain.^[1128]  Acupuncture increases body production of neurotrophic factors which can stimulate the creation of new nervous system pathways.^[1129]  In animal studies, it also dilates blood vessels in the cerebral cortex^[1130] and promotes neuroplasticity.^[1131]  A 2018 review of 44 fMRI studies of different parts of the brain found that “true” acupuncture alters the activity of functional networks in the brain relative to sham acupuncture, where random points are used.^[1132]

Who Can Use Acupuncture?

Most people can use acupuncture.  Children may do better with acupressure, as may others who tend to dislike needles.  Remind people that the needles are a much smaller diameter than IV or injection needles, and they are not hollow; most people find that this makes them much less painful.  Some acupuncturists will, in lieu of needles, use a small amount tape to attach small seeds to acupuncture points to stimulate them that way instead.  One advantage of acupuncture is that needles can be inserted at a distance from a particularly painful, tender, or inflamed area and still have potential benefit.

When to Use Acupuncture: Efficacy

Because acupuncture is used much more widely in the U.S. (and in the VA) than any other aspect of Chinese medicine, and because it has been researched much more thoroughly, it has received the most attention when it comes to research on efficacy and safety.  Acupuncture research is challenging to do.  Having a placebo group is tricky and having “sham” acupuncture—using needles in non-points—sometimes proves superior to no treatment at all and equivalent in effect to “real” acupuncture.  In addition, like so many complementary and integrative health (CIH) approaches, acupuncture therapy is individualized, so two people with the same Western medical diagnosis may be treated in very different ways. 

In January 2014, the Department of Veterans Affairs Evidence-Based Synthesis Program (ESP) Center, created an Evidence Map of Acupuncture.^[1133]  This “review of reviews” created visual overviews of the distribution of evidence for acupuncture and created summaries that could be used to “inform policy and clinical decision making.”  183 systematic reviews met inclusion criteria.  Three main domains were given attention: pain (65 studies), mental health (20 studies), and wellness (48 studies), and the evidence maps below were created. 

The bubble plots show three key pieces of information:

1. The volume of the research—that is, how many studies were found and how many subjects they include.  This is represented by the position of the bubbles on the y-axis. 
2. How effective—or not—acupuncture was as an intervention.  This is represented by how far along the circles are on the x-axis. 
3. How confident one could be that the effects that were found were real.  Confidence is represented by a bubble’s size. 

In these summaries, the evidence is most supportive for the diagnoses that have the biggest circles that are the farthest out on the x- and y-axes (toward the upper right of the diagram).

As of the time of the creation of the evidence maps in 2014, research was most favorable for acupuncture as a treatment for the following45:

In the past few years, there has been a huge increase in the number of available reviews and meta-analyses focused on acupuncture.  While almost all conclude that more research is needed, studies have shown favorable results for all of the following conditions (and the list is by no means exhaustive):

Recent reviews have not shown benefit for acupuncture for dry mouth,^[1174] hip osteoarthritis,^[1175] alcohol withdrawal,^[1176] carpal tunnel syndrome,^[1177] rheumatoid arthritis,^[1178] hypertension,^[1179] or cancer-related pain.^{[1180],[1181]}  Evidence is insufficient (as of May 2020) to know if there is a benefit for neuropathic pain93^,[1182] neck pain,^[1183] obesity,^[1184] glaucoma,^[1185] polycystic ovarian syndrome (PCOS),^[1186] gastroparesis,^[1187] xerostomia (dry mouth),86 general insomnia,^{[1188],[1189]} overactive bladder,^[1190] in vitro fertilization success,^[1191] or cardiovascular disease.^[1192]  There is promise for acupuncture in treating PTSD, benign prostatic hyperplasia,^[1193] chronic prostatitis/chronic pelvic pain syndrome,^[1194] acute stroke, insulin resistance,^[1195] congestive heart failure,^[1196] chronic fatigue syndrome,^{[1197],[1198]} sleep disorders,^[1199] stroke (rehabilitation), and tinnitus as well,^[1200] but more studies are needed.^[1201]

Battlefield Acupuncture research.  In many recipients, BFA is reported to reduce pain for hours to months.  A study of 112 Veterans who attended group clinics reported a decrease in various types of pain by 88% on post-treatment day 0; 81% at day 1; 52% at day 7; and 51% at post-treatment day 40.^[1202]  A 2017 review noted that more research is needed before BFA can be considered an evidence-based approach,^[1203] though a 2017 review of 10 studies found a small benefit and noted that adverse effects were “minor and transient.”^[1204]

What to Watch Out for (Harms)

A 2017 overview of 17 systematic reviews noted that serious adverse events, such as deaths, infections, and local reactions are possible but rarely occur.^[1205]  A 2014 review concluded that acupuncture appears to be safe in anticoagulated patients when done at the appropriate depth in the appropriate locations.^[1206]  The 2014 VA review of reviews on acupuncture, referenced above, also looked at adverse effects.45

• In the “Pain” studies, 12 reviews addressed adverse events, and all of these were minor—for example, bruising, temporary pain, faintness, and discomfort.  They were comparable to adverse effects for control groups.
• Of the “Mental Health” reviews, 6 addressed adverse events.  Most studies found no or minimal events.  Adverse events from acupuncture were lower in number than those for antidepressants (10.2% versus 40.4%).
• In reviews of acupuncture for overall “Wellness,” 13 reviews noted adverse events.  Again, reporting rates were rare.  There was one report of a patient dropping out of a study because of pain. 

A search through four Chinese journals found 1,038 total adverse event case reports up through 2010.  Of these, 35 were cases where fatalities resulted, primarily because acupuncture was performed by someone who was not appropriately trained.  Overly aggressive needling in the chest cavity can potentially cause pneumothorax; a 2019 study of over 411,000 patients in Taiwan found that the rate of this was 0.87 per 100,000 treatments.^[1207]  Risk increased for people with chronic bronchitis, emphysema, pneumonia, lung cancer, and tuberculosis.  Poor sterile technique can lead to transmission of infection; in the U.S., nearly all practitioners use disposable needles, so this is less of a concern.  In the U.S., hospital-related adverse events occur at a much higher rate.^[1208]  Caution should also be used if someone is on blood-thinning medications or has uncontrolled seizures. 

A 2012 review of all known complications related to acupuncture reported to the British National Health Service noted 325 incidents that met inclusion criteria.  They concluded that “Adverse events reported include retained needles (31%), dizziness (30%), loss of consciousness/ becoming unresponsive (19%), falls (4%), bruising or soreness at needle site (2%), pneumothorax (1%), and other adverse reactions (12%).  The majority (95%) of the incidents were categorized as low or no harm.”^[1209]

Because acupuncture has a relaxing effect, it is important that people be careful they are not too drowsy to operate machinery after treatment.  Discretion should be exercised as far as tolerability in people with severe needle phobias or severe mental health concerns.  As a side note, there are reports of imported herbal supplements from China, which may be used in association with acupuncture, being adulterated with toxic compounds.^[1210]

Tips from Your Whole Health Colleagues

• Acupuncturists often say that how long one needs to receive acupuncture (i.e., the number of sessions) is proportional to time a person has had a disorder; that is, if a problem is chronic, it will take longer to respond to acupuncture.  Many therapists will suggest one to three sessions a week for the first few weeks and then scale back.  Acute conditions may heal with just one session.  A 2017 meta-analysis of 20 trials including nearly 6,400 chronic pain patients found that “...approximately 90% of the benefit of acupuncture relative to controls would be sustained at 12 months.”^[1211] 
• Chinese medicine takes an entirely different perspective on the origins of illness.  When a complex person seemingly has multiple unrelated complaints/concerns from a Western perspective, it may be that acupuncture will actually have an explanatory model that can account for them all.
• Researchers have called for more formal clinical practice guidelines, now that acupuncture has been gaining more of a foothold in conventional medical settings.^[1212]

Whole Systems: Naturopathy

The term “naturopathy” was coined in 1895 by John Scheel and later purchased by Benedict Lust, the “Father of Naturopathy.”  As of 2018, there are approximately 6,000 licensed Naturopathic Doctors (NDs) in the United States.^[1213]  ND licensing is done by the states, and currently 22 states and Washington, D.C. require NDs to be licensed to practice.^[1214]  Most NDs are trained in primary care.  They can write prescriptions and order diagnostic testing.^[1215]  There are also many other practitioners, often billed as “Naturopathic Consultants” or simply “naturopaths,” who tend to be credentialed through less rigorous means.

According to the 2012 National Health Interview Survey, 0.4% of those surveyed had sought care from a naturopathic practitioner in the past year, up from 0.3% in 2007.²  This represents roughly 957,000 visits.  The VA Healthcare Analysis & Information Group (HAIG) survey of 2015 found that two or fewer VA facilities currently offer naturopathy.142  Nevertheless, naturopathy is increasingly popular, and it is important for people who work with Veterans to be able to discuss this healing system with them if a Veteran has questions or is seeing someone outside of the VA. 

Like Chinese medicine, naturopathy is often classed as whole medical system, rather than as a specific therapy.  It has a unique overall philosophy of care—an approach that incorporates many different therapies based on how well they resonate with naturopathy’s seven key principles.  These principles tie in nicely the concepts of personalized, proactive, patient-driven care and the Whole Health approach.  They include the following127^,[1216]:

• Respect the healing power of nature (vis medicatrix naturae).  The body’s power to heal itself is key.  The clinician’s role is to support and enhance that process.
• First, do no harm.  Naturopathy begins with the simplest and least invasive approaches and scales up only as necessary.
• Find the cause (versus merely treating symptoms).  Naturopathic physicians seek out the underlying cause of a disease; simply suppressing symptoms is strongly discouraged.
• Treat the whole person.  Physical, mental, emotional, spiritual, and social factors are all taken into account.
• Focus on prevention.  This is highly valued.  Patient education and lifestyle choice counseling are fundamental.
• Keep the focus on optimal health and balance.  This even goes beyond prevention. It can mean focusing on reaching greater wellness, regardless of the severity of a disease or one’s mortality risk.
• The clinician is a teacher.  The word “doctor” is tied to the word “docere,” which means teacher.  The clinician engages the patient as a respected member of his or her team. 

 

Naturopathy encompasses many modalities.  ND students have the option to focus on certain areas as they move through their training.  These include the following^[1217]:

• Diet and clinical nutrition
• Behavioral change, including working with mindful awareness techniques
• Hydrotherapy, the internal and/or external use of water in various forms (ice, liquid water, or steam)
• Homeopathy
• Botanical medicine
• Detoxification.  Go to Chapter 6, “Surroundings,” for more information on “detox” approaches
• Naturopathic physical medicine, the therapeutic use of exercise, physiotherapy, energy work, manipulation, and other approaches
• Acupuncture

Efficacy of Naturopathy

Most research on CIH approaches focuses on separate interventions.  It is more difficult to study a system like naturopathy, which uses combinations of therapeutic approaches.  Some of these approaches may synergize with each other.  Since NDs tailor their health plans to individuals and their specific needs, it is difficult to keep the intervention consistent for a randomized controlled trial format.^[1218]  However, a 2019 review of “whole-system, multi-modality naturopathic medicine” concluded that 33 studies including nearly 10,000 people showed benefit for naturopathy in treating cardiovascular disease, type 2 diabetes, PCOS, anxiety, depression, musculoskeletal pain, and a range of other chronic conditions.^[1219]

A 2009 study of 75 people with anxiety were followed for 8 or more weeks as they received either naturopathic care, which was tailored for each individual, or psychotherapy.^[1220]  Both groups had equivalent, and statistically significant improvements, and average symptom inventory scores decreased by 30.5% in the naturopathy group.  A 2013 Canadian study of postal workers with increased cardiovascular disease risk who received either “enhanced usual care” or “individual care” from an ND markedly reduced their 10-year cardiovascular risk relative to the control group.^[1221]  Another study found that naturopathy was superior to physical exercise over 12 weeks for the treatment of rotator cuff tendonitis.127  Studies on the effects of naturopathic care for type 2 diabetes, gum disease, and breast cancer prevention are ongoing.

Ultimately, understanding the efficacy of naturopathy requires a familiarity with the efficacy of the various complementary approaches encompassed by it.  For instance, hydrotherapy, one of several tools in the naturopathic toolbox, has favorable immunomodulatory effects, and rheumatoid arthritis, osteoarthritis, wound healing, hemorrhoids, heart failure, and varicose veins seem to improve with its use (according to multiple studies).  However, all of these studies have been criticized for having methodological problems.^[1222]  Other approaches, such as the use of specific herbal remedies, have much more evidence-based support. (Chapter 15 has more information on dietary supplements.)

Safety of Naturopathy

Reports of adverse effects of naturopathy are rare, but safety is contingent to some degree on the skill and knowledge of a given practitioner.  Patients should be clear about a practitioners’ qualifications before they go for a visit.  In general, the methods used preferentially by naturopaths are much less invasive or harmful than many conventional medicine interventions.  NDs are preferable to other types of self-proclaimed naturopaths, who have variable levels of training.  It is important to be certain that naturopaths are aware of all the medications a person is taking, and naturopaths should communicate with the medical team regarding any treatment recommendations they make.  A 2020 survey of 277 patient of a naturopathic clinic in Canada found that 46% of them were taking medications and 42% were not disclosing information about what natural health produces they were taking to their physician.^[1223]  Keep in mind that visits typically cost between $100-$400 and may not be covered by insurers (depending on which state a practitioner is in and its licensing regulations).

Integrative medicine and naturopathic medicine share some similarities, but integrative medicine makes use of a broader array of complementary approaches.  NDs tend to have much more intensive training in the use of remedies that might be classed as “natural.”  In many ways the two overlap, and both overlap to a significant degree with the Whole Health approach as well. When all is said and done, all three are geared toward personalizing care, focusing on prevention and self-care, and drawing from the power of nature—both internal and external to the body—to enhance healing.  Bringing naturopathy into a health care system can lead to a “disruptive innovation” much as introducing Whole Health can do.^[1224]

Whole Systems: Homeopathy

“Homeopathy” is a combination of the Greek words for “similar” and “suffering.”  It is a system of healing based on the Law of Similars, the idea that like cures like.  Homeopathy was created in 1796 by German physician Samuel Hahnemann.  Hahnemann experimented with taking cinchona bark and noted that it caused the same symptoms as the disease (remitting fevers) that it was being used to treat.  Through additional experiments involving himself, his students, and other healthy volunteers, he detailed the symptoms associated with taking over 90 different remedies in his Materia Medica.  The process of identifying potential remedies in this fashion is referred to as a “proving,” and new provings continue to be done routinely by modern homeopaths.  Over 5,800 remedies have now had provings.^[1225]

With over 500 million people using it worldwide, homeopathy is the second most used health care system in the world.^[1226]  It is widely accepted in India, Europe, and Latin America.  68% of French physicians consider homeopathic remedies effective.  20% of German physicians use homeopathy, and 42% of British physicians refer patients to homeopaths.^[1227]  It is used less frequently in the U.S.  According to the 2012 National Health Information Surveys, an estimated 2.2% of the U.S. population (over 5 million people) used homeopathy over the past year, up from 1.8% in 2006.2^,[1228]  The primary use is for respiratory and ear/nose/throat complaints.^[1229]  The 2015 VA Healthcare Analysis & Information Group (HAIG) study found that “up to 2” of the 141 VA systems nationwide made homeopathic remedies available to patients.^[1230]

Homeopathy is regulated at the state level.  In most states (but not all), people who are licensed to practice any other health care profession can legally practice homeopathy.  In other states, no license is needed.  Three states (Arizona, Connecticut, and Nevada) require MDs and DOs (Doctor of Osteopathy) to meet specific homeopathy licensing board requirements.^[1231]

The Food and Drug Administration regulates homeopathic remedies as drugs, but it does not evaluate for safety or effectiveness; the focus is on good manufacturing practices. Remedies may only be sold over the counter if they claim to treat minor (not major) health problems, such as vomiting or a viral respiratory infection.139  If they are to be used for a more serious illness (e.g., cancer), they must be prescribed.^[1232]

For many conventional practitioners, the idea of incorporating homeopathy into practice causes discomfort, because suggested homeopathic principles and mechanisms of action do not jive well with what we currently know about chemistry, physics, and biology, although it has recently been argued in homeopathy literature that this is changing.^{[1233],[1234]}  Since the 19th century, there has been a contentious relationship between homeopathic physicians and practitioners of “allopathic” medicine.  (Note that it is perhaps best to use a different descriptor, such as “conventional” medicine, because “allopath” has negative connotations; the term was originally coined to be the opposite of “homeopath.”)139  Many experienced practitioners, particularly outside the U.S. and Europe, believe strongly that homeopathy can produce positive results.  Many physicians take issue with this.^{[1235],[1236],[1237]}  It is up to each clinician to discern for him or herself whether this therapy fits into Whole Health care.  Either way, many patients feel this usually benign therapy does make a difference, and they have strong opinions about continuing to take their remedies. 

Homeopathic Principles

Patient Intakes.  In a classical homeopathy visit, care is highly individualized.  The homeopath begins with an initial intake that can last as long as 2 to 4 hours.  He or she asks multiple open-ended questions to get descriptions of the patient’s symptoms down to the minutest detail.  The homeopath then consults a Materia Medica to find the remedy with a proving that caused symptoms most similar to the ones the patient is experiencing.

Law of Minimum Dose.  Another key principle of homeopathy is the “law of minimum dose.”  Perhaps counterintuitively, it is held that a remedy is more potent—more effective—the lower the dose that is given.  Substances used in homeopathic remedies undergo a process of potentization; that is, a remedy is diluted and then shaken (homeopaths refer to the shaking process as “succussion”).  Dilution and succussion are often done repeatedly.

It is possible to tell how to dilute a homeopathic remedy by looking at the combination of the number and letter printed on the remedy’s label.  If one part of a substance is diluted in 99 parts of the solvent, the final mixture is labeled “1C.”  That is, it has been diluted by 100 (Roman numeral C) one time.  If one part of that 1C solution is diluted a second time with 99 parts of solvent, it is then referred to as “2C.”  A 3C label means that the substance has been diluted down below one part per million.  If the letter is an “X” or a “D” rather than a “C,” the remedy has been diluted by tenfold instead of a hundredfold, respectively.  If something is insoluble, it is triturated; that is, it is ground up and then serially mixed in with lactose powder to dilute the dose.

Mechanism of action.  Below a dose of 23X or 11C, odds are that there are no more molecules of the original homeopathic remedy remaining in the solvent.  It is often asked how such diluted remedies can possibly have any physiological effects.  This is one reason why homeopathy is highly controversial; if it works, it does so through a mechanism of action that is not well understood by modern chemistry and physics. 

Some proponents of homeopathy argue that the hormesis model may apply.  This is described in toxicology and attempts to account for the phenomenon where very low exposures to pollutants or toxins can actually cause favorable biological responses (a response to a vaccine is a useful metaphor).  Some homeopaths argue that homeopathy is effective because the solvent somehow carries a memory, or imprint, of the original substance.^[1238]  As Carlston describes it, “Hahnemann described his process of preparing remedies…as liberating the essence of the remedy from its material aspects and thereby increasing its potency.”^[1239]

Homeopathic products can be made from practically anything.  Many are made of minerals, such as potassium, arsenic (again, at minuscule doses), and sodium.  Others might contain plants, like arnica, a common remedy for acute trauma.  Still others may contain animal materials such as snake venom, falcon blood, ground-up insects (there is a remedy made of honeybees), or duck liver and heart.  The last, duck liver and heart, is the basis for the remedy, Oscillococcinum, which is a popular but not clearly effective over-the-counter influenza remedy. 

Most homeopathic remedies are packaged as small white lactose pellets, and a person typically takes a few of these (between 2 and 5) daily.

Efficacy of Homeopathy

A 2010 “meta-review” summarized findings from six Cochrane reviews on homeopathy that were available at that time.^[1240]  Here are some highlights:

• As of 2010, 150 controlled clinical trials of homeopathy have been published.  Some have positive results, others negative.
• A 1997 Lancet review noted that the effects of homeopathy are not entirely due to placebo,^[1241] but a 2005 Lancet review concluded that they are.^[1242] 
• The 6 articles in the Cochrane meta-review focused on cancer, ADHD, asthma, dementia, influenza, and labor induction.  None of them concluded that homeopathy is effective.

A Cochrane review conducted in 2019 found that the homeopathic remedies asafetida and nux vomica have unclear benefit as remedies for irritable bowel syndrome (IBS).^[1243]  A 2012 review did not find good evidence that convincingly showed Oscillococcinum as beneficial in influenza treatment.^[1244]  A 2017 systematic review found that the homeopathic Galphimia glauca or certain homeopathic nasal sprays may have small beneficial effects for allergic rhinitis, but more study is needed.^[1245]  A 2018 review concluded that homeopathic remedies for upper respiratory infections (URIs) had fewer adverse effects and had equivalent benefits to conventional treatments; noting that the quality of studies was poor.^[1246]  A 2014 review of homeopathy for fibromyalgia found 10 case reports, three observational studies, one nonrandomized trial, and four RCTs which were supportive overall of benefit.^[1247]  Conclusions were noted to be preliminary due to lack of data.  A 2018 review concluded homeopathy could be useful from a public health standpoint, particular for URIs and fibromyalgia.^[1248]  Finally, a 2018 review found no indication of benefit for obesity or diabetes.^[1249]  A 2019 trial including 25 patients with spinal cord injury found that adjunctive treatment decreased frequency of urinary tract infections.146

A 2015 RCT randomized 410 patients to receive a full homeopathy intake.^[1250]  The homeopathy group “experienced a significant improvement in physical cognitive, social and emotional functioning” to the point where it was recommended as an adjuvant therapy to standard medical care; results did not indicate it would serve as an alternative to standard care.  In 2016, the same group went back to look at mortality data for the 401 patients and found a statistically significant improvement in survival time for the homeopathy group.^[1251]  A 2019 trial involving 60 people with insomnia found that individualized homeopathic treatment was significantly more effective than placebo.^[1252]

Natural Standard, a website that offers systematic reviews related to integrative medicine, rates the homeopathy literature as being “insufficiently reliable” to draw conclusions for the dozens of different indications that have been studied thus far.^[1253]  In contrast, a 2013 review noted that in order to make general statements that homeopathy is ineffective, 90% of clinical trials were excluded, most of which had favorable results.^[1254]  Reviewers suggested that future reviews focus on specific disorders or remedies for a clearer sense of efficacy.

No homeopathic remedies are listed on the VA formulary.  In a health food store or online, one can purchase generic remedies that claim to be effective for common illnesses.  This is not exactly homeopathy in its truest sense, because these remedies are not precisely matched to individual patients’ symptoms. 

Safety of Homeopathy

A 2016 systematic review and meta-analysis of 41 trials, with 6,055 total participants, noted that 28 of the trials reported adverse effects, but ultimately, this was equivalent to what was reported by members of the control groups.^[1255]  Rarely, certain homeopathic remedies are promoted as substitutes for immunizations, but there is no data to support this indication.

Whole Systems: Ayurveda

Ayurveda is a medical system unto itself, with a long, rich history of academic investigation and professional experience.  Like naturopathy, it draws from a number of different techniques including various forms of meditation and yoga.  Ayurveda means “the science of life” or longevity.  It focuses as much on prevention as it does on cure, if not more. 

Historically, Ayurveda has its roots in ancient Indian Vedic knowledge.  Although it dates back more than 5,000 years, it remains an important source of primary health care in India, with 80% of the Indian population using it.^[1256]  It has gained increasing interest in Western culture in recent decades.  In fact, it is rapidly growing in popularity worldwide. While Ayurveda is not yet widely available in the U.S., there are patients who are trying it out, and it is gaining increased popularity in the media.^[1257]

Ayurveda is usually classed as a “System of Medicine” within the National Center for Complementary and Integrative Health (NCCIH) taxonomy.  It is used by roughly 0.1% of the American population, according to the 2012 National Health Interview Survey, and this is similar to 2007 findings.2  As of 2015, Ayurveda was not being offered within any VA facilities.142  To learn more about specific schools or to check on credentials for someone in the U.S., see the National Ayurvedic Medical Association Member Schools page.

Licensure and Education

Long ago, Ayurvedic knowledge was passed from a guru (a general term for teacher) to a disciple.  Around 2,000 years ago, teachings were formalized in books, and Ayurvedic medical colleges were created.  There are currently over 200 Ayurvedic colleges and schools in India.  Trainees have educations very similar to MDs in the United States, with training in anatomy and physiology and the requirement that they complete an internship. A Bachelors of Ayurvedic Medicine and Surgery (BAMS) requires five years of study and a two-year internship.  BAMS students must write a graduate thesis and complete advanced training to receive a Master of Ayurvedic Science (MASc) degree.  It can take 9-10 years to complete this training process.  In many places, MASc degrees have been renamed as Doctor of Medicine in Ayurveda (MD in Ayurveda) degrees.^[1258]

Because Ayurveda is not widely recognized in the U.S., and because practitioners are rare, there are few American training programs.  There are some schools in the U.S., but they do not have a standardized curriculum.  Sometimes Western clinicians will take a brief course and then label themselves as Ayurvedic practitioners, so it is important to clarify a given practitioner’s credentials.

Philosophy and Principles

Ayurveda has evolved over thousands of years, and there are many different ways it might be practiced.  However, most schools draw from some common overarching themes. Several of these are listed here.

The five elements.  Like Chinese medicine, Ayurveda focuses on five elements.  These elements are not the same ones as for Chinese medicine, however. The Ayurvedic elements are:

• Space/ether.  Linked to communication, hearing, and expansion of consciousness, space’s function is to allow for the existence of matter and the intelligence that exists in every cell.
• Air.  Air is associated with sensation, breathing, touch, and movement (including of thoughts and ideas).
• Fire.  Fire is linked to transformation, particularly of food as it is digested and absorbed.  Understanding, sight, and transformations of thought and emotion are also tied to this element.
• Water.  Water includes all the fluids in the body, as well as the sense of taste and the emotions of love and compassion.
• Earth.  Earth is associated with solidified parts of the body, the sense of smell, and being grounded.

The three doshas.  Doshas might be thought of as types of energy that are present in all things, including the human body.  They are also referred to by some sources as “functional principles.”170  The three doshas are kapha, pitta, and vata.  Table 18-1 describes key aspects of each.  They define a person’s constitution, or prakriti.

Table 18-1. The Three Ayurvedic Doshas170^{,[1259],[1260]}

Dosha Name	Nature	Purpose	Associated Character Traits
Kapha	The energy of structure; holds the cells together.	Influences tendons and bones; supplies water for body needs.	Associated with being even-keeled, patient, and loving.  When out of balance, tied to attachment and greed.  Tied to congestive disorders, including sinusitis and edema.  Obesity more common.
Pitta	The energy of metabolism and digestion.  Mainly fire and water elements.	Governs digestion, absorption, thinking, and body temperature.	Tied to leadership and intellect or, when imbalanced, to hatred and anger.  Linked to inflammatory problems, skin rashes, and ulcers.
Vata	The energy of movement.  Related to the space and air elements.  Increases with age.	Influences anything in the body that moves—e.g., heart, blinking, muscles, cellular transport.	Creativity and flexibility when balanced. Anxiety and poor planning when not.  Linked to twitches, tics, painful joints, and lung diseases.

Some people have one predominant dosha.  Others have two.  Rarely, people have a balance of all three.  The doshas interweave in a person, just as body, mind, and consciousness are said to do in Vedic philosophy.  Everyone has a unique combination of doshas, and if something moves out of balance, they may shift into a different pattern. 

There are many online quizzes you can take to determine your doshas (while learning more about them along the way).  Two options include: Naturedoc.com and Yogainternational.com.  Patients often enjoy taking such quizzes to see where they are in terms of balance.

Concepts of disease in Ayurveda.  Ayurveda classifies causes of disease in many different ways.  Vaidyas (Ayurvedic practitioners) ask a number of questions to determine what has weakened the body’s defenses.  Questions asked about a given symptom might include whether it is acute or chronic, related to past trauma, linked to habitual behaviors, genetic, tied to diet, related to surroundings, or influenced by psychological, supernatural, or spiritual factors.

Disease is thought to arise as a progression through six steps, including accumulation of a dosha, provocation of dysfunction in local organs, spread to other organs, deposition in weak parts of the body, and manifestation (where it finally becomes possible to make a physical diagnosis because physical damage to tissue is occurring).170

Ayurvedic diagnosis.  Ayurveda uses sources of diagnostic information, including pulse, urine and stool characteristics, appearance of the tongue, how speech and voice sound, palpation, and the appearance of the eyes.  A general physical examination may also be done. 

Ayurvedic treatment.152^,170^,171  There are eight traditional Ayurvedic specialties.  These are strikingly similar to many Western medical specialties.  They include internal medicine, surgery, psychiatry, toxicology, geriatrics, pediatrics, gynecology, and otorhinolaryngology (ENT). Treatments used by each can range from herbal remedies and surgical interventions to marma therapy (much like acupressure) and the use of stones or crystals.  The goal is to balance doshas and re-establish a person’s unique overall balance.  Treating symptoms is insufficient; root causes are sought.

Different Ayurvedic therapeutic interventions include oil massage and sweating therapy, which prepare the body for panchakarma.  Panchakarma (which translates as “five actions”) includes therapeutic vomiting, purgative or laxative use, nasal administration of substances, blood purification, and enemas.  After panchakarma, a personal treatment plan is created based on a person’s dominant dosha or doshas.  Specific herbs are given to oppose dominant dosha qualities and enhance those that are lacking.  Meditation and yoga, as well as dietary modification, are important aspects of therapy.  Doshas are said to be linked to different tastes.  For example, pungent, sour, and salty tastes increase pitta. The diet can be modified according to individual needs to rebalance the doshas.  Treatment may also involve chromotherapy (use of specific colors of light) or palliation, which is used if a person is not felt to be ready for or able to handle panchakarma. 

Many Ayurvedic herbal remedies are now widely available in the United States. Examples you may hear about include^[1261]:

• Ashwagandha—Used to enhance energy and manage fatigue.
• Bacopa, also known as Brahmi—Used to improve cognition.
• Butterbur—For allergic symptoms and headaches.
• Fenugreek—Lowers LDL, raises HDL; helps maintain serum glucose.
• Guggul—Used to treat lipid problems, but data not supportive.
• Gymnema—For blood glucose control. Putting powdered gymnema on the tongue can temporarily remove taste sensation.
• Triphala—A remedy composed of three different fruits; used for constipation.
• Tulsi—Used for inflammation and infection, particularly respiratory infections.
• Turmeric (some would argue it is a Western remedy now, too)—Also for inflammation.

Efficacy of Ayurveda 

There are over 630 reviews related to Ayurveda on the U.S. National Library of Medicine PubMed.gov site and nearly 5,200 studies.  Most systematic reviews focus on Ayurvedic herbal remedies used for specific indications.  Of course, as the saying goes, lack of research is not synonymous with lack of efficacy.  There is something to be said for a healing tradition having been evolved for over five millennia.  Ayurvedic journals, such as the Journal of Ayurveda and Integrative Medicine and the International Journal of Ayurveda Research, have been disseminating research in recent years and encouraging further investigation.

While, as is so often the case, there is “a need for further research,” there are a number of conditions for which Ayurveda has been shown to hold promise.  Of course, the literature notwithstanding, most Ayurvedic practitioners would hold that it can be used in general for most health conditions, just as Western medicine and other “Whole Systems of Medicine” can.

Noting that this is by no means comprehensive of all study findings related to Ayurveda, some examples of related research are listed below:

• A 2011 Cochrane review of Ayurvedic treatment for diabetes concluded that, “Although there were significant glucose-lowering effects with the use of some herbal mixtures, due to methodological deficiencies and small sample sizes we are unable to draw any definite conclusions regarding their efficacy.”^[1262]  Of note, there were no significant adverse events noted in any of the studies.  Many different types of therapy were used by the Ayurvedic providers participating in the study.
• A 2018 study found that Ayurveda was beneficial for knee osteoarthritis based n WOMAC Index in a group of 151 participants.^[1263]  A 2014 review found that two Ayurvedic combinations, Rumalaya and Shunti-Guduchi, seemed to be safe and effective treatments for osteoarthritis.^[1264]  These remedies were noted to be comparable to glucosamine, another popular osteoarthritis treatment, for pain improvement.  No severe adverse events were noted in the 10 randomized and 14 nonrandomized trials that were reviewed.  Other Ayurvedic drugs used for osteoarthritis were not found to be as helpful.
• One review found that the Ayurvedic combination, Triphala, showed promise in preventing and treating cancer and the adverse effects of radiation and chemotherapy.^[1265]
• One review of the literature noted that rasayana Ayurvedic supplements had radioprotective effects for patients undergoing radiation therapy.^[1266]
• A 2007 systematic review concluded that the majority of randomized controlled trials that were found to be of good quality showed benefit for three Ayurvedic supplements—garlic, guggul, and arjuna—for preventing ischemic heart disease.^[1267]
• A 2007 Cochrane Review concluded that Ayurvedic medications may have some positive effects on schizophrenia, but only a few “pioneering” studies have been done and more data is needed.^[1268]
• A 2014 review failed to find enough research to determine Ayurveda’s effectiveness in rheumatoid arthritis.^[1269]

One recent review focusing on the use of Ayurvedic diagnostic methods noted that none of the studies to date had used Ayurvedic diagnostic criteria before using Ayurvedic remedies for treatment, which raised methodological concerns.^[1270]

Safety of Ayurveda 

In general, Ayurvedic approaches seem to be quite safe.  Safety and monitoring for adverse effects has been woven into its use in India for hundreds of years.  Most studies of Ayurvedic interventions have focused on specific herbal remedies.  As with all dietary supplements, these remedies should be approached with appropriate caution regarding the potential for adverse effects or interactions with medications.  Chapter 15, “Dietary Supplements,” has more information.

One of the major concerns with Ayurvedic dietary supplements is heavy metal contamination.  A 2008 study in the Journal of the American Medical Association conducted testing for heavy metals on 230 different medicines.  Over one-fifth of them contained detectable levels of arsenic, mercury, or lead.  This included products manufactured in both the U.S. and abroad.^[1271]  Be sure to check out product safety using reliable sources, such as Consumer Lab.

Conclusion

With hundreds—or even thousands of years—of accumulated information related to diagnosis, prevention, self-care, and treatment, Whole Medical Systems have great potential to inform personal health planning.  Get to know the various practitioners of Chinese medicine, naturopathy, homeopathy, Ayurveda, and other practitioners working in other Whole Medical Systems in your area.  Consider experiencing these therapies yourself.  It can be quite informative to enlist an entirely different philosophy and perspective for patients, especially if they have a complex health history.  It is not uncommon for a Chinese medicine practitioner, vaidya, naturopath, or homeopath to see a complex patient from a perspective that makes sense of an array of symptoms that are not readily explained by Western medicine diagnoses.

Whole Medical Systems Resources

Websites

VA Whole Health and Related Sites

Integrative Health Coordinating Center SharePoint of Acupuncture and Battlefield Acupuncture

.

https://dvagov.sharepoint.com/sites/VHAOPCC/IHCC/SitePages/Acupuncture.aspx
• Evidence Map of Acupuncture.  Compilation of systematic review data by VA Health Services Research and Development (HSR&D). https://www.hsrd.research.va.gov/publications/esp/acupuncture.cfm
• CIH Listservs. To be added, contact:
• Acupuncture listserv: vhava-bfa-community@DVAGOV.onmicrosoft.com
• Other listservs: Lana Frankenfield. Lana.Frankenfield@va.gov
• National CIH Subject Matter Experts, as of FY 2020.
• Acupuncture: Juli Olson.  Juli.Olson@va.gov
• Battlefield Acupuncture: Juli Olson. Juli.Olson@va.gov

Whole Health Library Website

• Whole Health for Pain and Suffering.
• https://wholehealth.wisc.edu/courses/whole-health-for-pain-and-suffering/

Other Websites

• Ayurveda.
• Ayurvedic Body Type Quiz.  Online quiz to determine dosha. http://www.naturdoctor.com/Chapters/Quiz/AyurvedicQuiz.html
• Ayurvedic Medicine: In Depth.  National Center for Complementary and
• Integrative Health. https://nccih.nih.gov/health/ayurveda/introduction.htm
• Dosha Quiz.  Yoga International.  https://yogainternational.com/article/view/dosha-quiz
• International Society for Ayurveda and Health.
• http://www.ayurvedahealth.org
• National Ayurvedic Medical Association.  http://www.ayurvedanama.org
• Find an Ayurvedic Professional.  https://ayurvedanama.site-ym.com/search/custom.asp?id=945
• Ayurvedic nutrition.
• How to Eat for Your Dosha.  Goop.com. https://goop.com/food/recipes/ayurveda-how-to-eat-for-your-dosha/  
• Recipes at the Ayurvedic Institute. https://www.ayurveda.com/resource/recipes/
• Chinese Medicine.
• Qi Journal of Traditional Eastern Health & Fitness.
• https://www.qi-journal.com
• Traditional Chinese Medicine: What You Need to Know.  National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/traditional-chinese-medicine-what-you-need-to-know
• Yin-Yang House.  Introduction to Chinese medicine and has a comprehensive set of acupuncture meridian diagrams.  http://www.yinyanghouse.com/
• Homeopathy.
• American Institute of Homeopathy.  https://homeopathyusa.org
• Guide to Homeopathic Research.  http://homeopathyusa.org/guide-to-research.html
• Homeopathy.  National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/homeopathy
• Naturopathy.
• American Association of Naturopathic Physicians.  Find local naturopathic physicians and offers answers to patient FAQ’s. http://www.naturopathic.org/
• Others.
• Consumer Lab. https://www.consumerlab.com/
• PubMed.gov.  U.S. National Library of Medicine.  https://pubmed.ncbi.nlm.nih.gov

Books

• Acupressure’s Potent Points: A Guide to Self-Care for Common Ailments, Michael Gach (1990)
• Ayurveda Beginner’s Guide: Essential Ayurvedic Principles and Practices to Balance and Health Naturally, Susan Weis-Bohlen (2018)
• Ayurveda: Life, Health and Longevity, Robert Svoboda (1992)
• Ayurveda Lifestyle Wisdom: A Complete Prescription to Optimize Your Health, Prevent Disease, and Live with Vitality and Joy, Acharya Shunya (2017)
• Ayurveda: The Ancient Indian Healing Art, Scott Gerson (1997)
• Ayurvedic Cooking for Westerners: Familiar Western Food Prepared with Ayurvedic Principles, Amadea Morningstar (1995)
• Between Heaven and Earth: A Guide to Chinese Medicine, Harriet Beinfield (1992)
• Chinese Self Massage Therapy: The Easy Way to Health, Ya-Li Fan (1999)
• Clinical Naturopathy: An Evidence-Based Guide for Practice, Jerome Sarris (2014)
• Textbook of Ayurveda I: Fundamental Principles, Vasant Lad (2001)
• Textbook of Ayurveda II: Complete Guide to Clinical Assessment, Vasant Lad (2007)
• Textbook of Ayurveda III: General Principles of Management, Vasant Lad (2012)
• Textbook of Natural Medicine, Joseph Pizzorno (2012).
• The Web That Has No Weaver: Understanding Chinese Medicine, Ted Kaptchuk (2000)
• Voices of Qi, Alex Holland (2000)

Special thanks to Aysha Saeed for providing additional information for the Chinese Medicine portion of this chapter.