Soy and blood lipids

Historical perspective and future directions

The evolution of soy

Soy has been a staple food in the diets of Asian populations for many centuries. In the latter half of the 20th century, North Americans began consuming soy foods on a larger scale, embracing this high-quality protein source as an alternative to animal products high in saturated fats (Messina 2010).

Soy continued to grow in popularity through the 1980’s and 1990’s as evidence of its health benefits began to mount. Research on soy’s active constituents continues to the present day.

A 1995 meta-analysis of the impact of soy foods on cholesterol levels seemed certain to cement soy’s place in a health-promoting diet. This synthesis of published trials reported that consuming an average of 47 grams of soy protein per day could reduce total cholesterol (TC) by 0.60mmol/L (9.3%), low-density lipoprotein (LDL) by 0.56mmol/L (12.9%) and triglycerides (TG) by 0.15mmol/L (10.5%) in hypercholesteremic individuals. At this dose, a non-significant increase in high-density lipoprotein (HDL) of 0.03mmol/L (2.4%) was also observed (Anderson 1995).

FDA and AHA endorsements of soy protein In 1999, the US Food and Drug Administration (FDA) added its voice to the growing acclaim for this humble legume. Soy protein was approved for a health claim to reduce the risk of cardiovascular disease at a daily dose of >25g (Food and Drug Administration 1999). The American Heart Association (AHA) soon followed suit, encouraging the use of soy protein in cholesterol-lowering diets (Erdman 2000), and suggesting that a decrease of 4-8% in LDL levels could be expected with a daily dose of 25-50g. Populationbased studies also indicated a role for soy in the management of lipid levels (Ho 2000).

A period of intense scrutiny has followed in the decade since the FDA approval of the health claim for soy. Subsequent reviews have produced inconsistent results a far smaller magnitude of benefit than that reported in Anderson’s meta-analysis (Weggemans 2003, Zhan 2005). Given this incongruence, the AHA re-evaluated its position on the matter tempering its endorsement of soy, and calling its benefits “minimal at best” in a later statement (Sacks 2006).

An appraisal of meta-analyses published after 1995 reveals that while the benefit of soy consumption may not be as dramatic as originally reported, some positive effect on blood lipids can still be expected from this intervention (Table 1).

Amplification of past results

Although these studies suggest a trend towards improved lipid profiles, the findings are inconsistent. Some studies show benefit for all parameters (Reynolds 2006, Weggemans 2003, Zhan 2005) while others demonstrate no significant effects (Yeung 2003, Taku 2008). Still others indicate a positive response in some measures, namely LDL and TC (Hooper 2008, Taku 2007, Zhuo 2004). None of the studies were able to replicate the results reported by the original meta-analysis (Anderson 1995).

A survey of the disparities between studies of the past and present reveals some important confounding factors. These issues may be responsible for both an amplification of earlier results, and for a comparative reduction in effect of later research. They include:

• Control diets: Treatment diets in some earlier studies were hypocaloric in comparison to controls, resulting in weight loss (Sacks 2006). Others were not matched to controls in terms of dietary fat, fibre and cholesterol content (Weggemans 2003). Recent studies equalize treatment and control diets more carefully (Taku 2008, Zhuo 2004). As weight loss (Dutheil 2010), fibre (Bruckert 2011) and decreased cholesterol intake (Stalenhoef 1997) may independently improve lipid levels, the benefits of soy may have been overestimated as a result of additive effects from these other variables in the treatment diet.

• Participants: Study subjects in early studies were primarily men and pre-menopausal women (Dewell 2006), while more recent studies have included many more post-menopausal women (Zhan 2005, Zhuo 2004). Recent RCTs have failed to show benefit in post-menopausal women (Beavers 2010, Campbell 2010). Reported associations between menopausal status and lipid levels suggest that hormonal factors contribute to dyslipidemia in post-menopausal women (Agrinier 2009). Hormonallyinfluenced dyslipidemia could theoretically be resistant to soy treatment, possibly contributing to the more modest results of recent studies.

• Baseline lipid measurements: Although the results of the Anderson meta-analysis are widely quoted as they appear above, only participants with moderate hypercholesterolemia (6.70 to 8.61 mmol/L) at baseline experienced this degree of change (Anderson 1995). Recent meta-analyses have confirmed this association between baseline cholesterol levels and the magnitude of effect (Reynolds 2006, Zhan 2005), although others have found no such relationship (Weggemans 2003, Zhuo 2004). The impressive results from the Anderson study continue to be quoted with no mention of baseline cholesterol status (Campbell 2010, Thorp 2008), resulting in an inaccurate description of effect.

Divergent conclusions from current soy trials (Borodin 2009, Shidfar 2009; Beavers 2010) suggest that other confounding factors have yet to be identified. Variations in soy isoflavone content, equol producer status and manufacturing standards may be partly responsible for these contraditory results.

Soy protein and soy isoflavones

Public statements by both the FDA (1999) and the AHA (Erdman 2000) indicate that soy protein is the agent responsible for lipidlowering, rather than any of the plant’s native isoflavones, which include genistein and daidzein. Studies have tended to show that isoflavones given in isolation have little impact on lipid fractions (Hooper 2008, Taku 2008, Weggemans 2003, Yeung 2003). While this may be true, a case can be made for a synergistic effect between soy protein and soy isoflavones.

The four meta-analyses presented in Table 1 that examined soy isoflavones given in combination with soy protein found benefit from these interventions (Reynolds 2006, Taku 2007, Zhan 2005, Zhuo 2004). Each team further concluded that lipid-lowering is enhanced when doses of isoflavones are highest, although no consistent minimum intake was established.

A hypolipidemic effect has yet to be attributed to any one isoflavone. Older studies on soy provide limited information about specific isoflavone content (Weggemans 2003), creating an opportunity for future research.

Equol producer/non-producer status

Should isoflavones prove to play a role in lipid metabolism in the presence of soy protein, the question of equol status must be addressed. Equol is the active metabolite of daidzein, and can be produced by approximately 30% of the adult population in Western countries (Setchell 2010).

In studies of isoflavones for the management of menopausal symptoms, equol producers tend to show greater response to the intervention (Jou 2008). The same may be true of isoflavones and lipid levels (Cassidy 2006, Taku 2007, Weggemans 2003, Zhuo 2004), although isolated RCTs have yet to demonstrate increased effect in equol producers (Thorp 2008).

Manufacturing concerns

Future studies may conclude that a soy-based storage protein, 7S globulin, is responsible for the hypocholesteremic effect of soy. 7S globulin has been shown to upregulate LDL uptake and degradation in vitro (Lovati 2000).

In comparisons of high- and low-isoflavone soy proteins, ethanol is used to remove isoflavones from soy product (Zhuo 2004). Studies of ethanol-processed soy reveal a marked reduction of 7S globulin and other molecules (Gianazza 2003), which could explain the decreased effect of isoflavone-poor soy protein on blood lipids (Zhan 2005).

Denaturing soy protein through ethanol or heat exposure may even have deleterious effects, as evidenced by a recent study using ultra-heat-treated (UHT) soymilk and control preparations (Hoie 2006). After 4 weeks of supplementation, LDL levels in all subjects increased by an astounding 17-19%.

Dramatically different results were reported when the same investigators evaluated a nondenatured soy protein supplement (Hoie 2007). At the conclusion of the 8-week study, the treatment group experience a decrease in LDL levels of 12.0% (p=0.002), suggesting that manufacturing methods can significantly alter the effect of soy interventions.

Future directions

As our understanding of the mechanisms of soy metabolism evolves, so does our ability to use this intervention in a clinically relevant manner. At present, the evidence supports combining isoflavone-rich, soy protein with other dietary agents such as plant sterols, viscous fibre and nuts to achieve a lipid-lowering effect (Jenkins 2010).

Recent studies suggest reductions in LDL levels of approximately 3-5% may be expected from nondenatured soy protein in doses ranging from 20-60g per day. Studies suggest that an isoflavone content of at least 80mg is associated with benefit (Zhan 2005). Additional reductions of up to 6% may occur if soy protein displaces animal protein in the diet (Jenkins 2010). An increase in HDL of 3% and a decrease in TC of 2-4% may also be associated with soy consumption (Reynolds 2006, Taku 2007, Weggemans 2003, Zhan 2005).

Many clinically important questions remain regarding the role of soy in the management of cardiovascular disease. Is equol producer status a determinant of effect? Can soy use impact the incidence of cardiovascular accidents or coronary heart disease? Can specific populations including post-menopausal women and individuals with Type 2 diabetes benefit from this intervention? These queries represent essential areas for future research.

References:

Agrinier N, Cournot M, Ferrières J. [Dyslipidemia in women after 50: age, menopause or both?]. Ann Cardiol Angeiol (Paris). 2009 Jun;58(3):159-64. Epub 2008 Oct 14. [Article in French] (abstract only)

Anderson JW, Johnstone BM, Cook-Newell ME. Meta-analysis of the effects of soy protein intake on serum lipids. N Engl J Med. 1995 Aug 3;333(5):276-82.

Beavers KM, Serra MC, Beavers DP, Hudson GM, Willoughby DS. The lipid-lowering effects of 4 weeks of daily soymilk or dairy milk ingestion in a postmenopausal female population. J Med Food. 2010 Jun;13(3):650-6.

Borodin EA, Menshikova IG, Dorovskikh VA, Feoktistova NA, Shtarberg MA, Yamamoto T, Takamatsu K, Mori H, Yamamoto S. Effects of two-month consumption of 30 g a day of soy protein isolate or skimmed curd protein on blood lipid concentration in Russian adults with hyperlipidemia. J Nutr Sci Vitaminol (Tokyo). 2009 Dec;55(6):492-7.

Bruckert E, Rosenbaum D. Lowering LDL-cholesterol through diet: potential role in the statin era. Curr Opin Lipidol. 2011 Feb;22(1):43-8.

Campbell SC, Khalil DA, Payton ME, Arjmandi BH. One-year soy protein supplementation does not improve lipid profile in postmenopausal women. Menopause. 2010 May-Jun;17(3):587- 93.

Cassidy A, Brown JE, Hawdon A, Faughnan MS, King LJ, Millward J, Zimmer-Nechemias L, Wolfe B, Setchell KD. Factors affecting the bioavailability of soy isoflavones in humans after ingestion of physiologically relevant levels from different soy foods. J Nutr. 2006 Jan;136(1):45- 51.

Dewell A, Hollenbeck PL, Hollenbeck CB. Clinical review: a critical evaluation of the role of soy protein and isoflavone supplementation in the control of plasma cholesterol concentrations. J Clin Endocrinol Metab. 2006 Mar;91(3):772-80.

Dutheil F, Lesourd B, Courteix D, Chapier R, Dore E, Lac G. Blood lipids and adipokines concentrations during a 6 months nutritional and physical activity intervention for metabolic syndrome treatment. Lipids Health Dis. 2010 Dec 31;9(1):148.

Erdman JW Jr. AHA Science Advisory: Soy protein and cardiovascular disease: A statement for healthcare professionals from the Nutrition Committee of the AHA. Circulation. 2000 Nov 14;102(20):2555-9.

Food and Drug Administration. Food labelling: health claims; soy protein and coronary heart disease. Fed Regist. 1999; 64:577000-33.

Gianazza E, Eberini I, Arnoldi A, Wait R, Sirtori CR. A proteomic investigation of isolated soy proteins with variable effects in experimental and clinical studies. J Nutr. 2003 Jan;133(1):9-14.

Ho SC, Woo JL, Leung SS, Sham AL, Lam TH, Janus ED. Intake of soy products is associated with better plasma lipid profiles in the Hong Kong Chinese population. J Nutr. 2000 Oct;130(10):2590-3.

Hoie LH, Guldstrand M, Sjoholm A, Graubaum HJ, Gruenwald J, Zunft HJ, Lueder W. Cholesterol-lowering effects of a new isolated soy protein with high levels of nondenaturated protein in hypercholesterolemic patients. Adv Ther. 2007 Mar-Apr;24(2):439-47.

Hoie LH, Sjoholm A, Guldstrand M, Zunft HJ, Lueder W, Graubaum HJ, Gruenwald J. Ultra heat treatment destroys cholesterol-lowering effect of soy protein. Int J Food Sci Nutr. 2006 Nov-Dec;57(7-8):512-9.

Hooper L, Kroon PA, Rimm EB, Cohn JS, Harvey I, Le Cornu KA, Ryder JJ, Hall WL, Cassidy A. Flavonoids, flavonoid-rich foods, and cardiovascular risk: a meta-analysis of randomized controlled trials. Am J Clin Nutr. 2008 Jul;88(1):38-50.

Jenkins DJ, Mirrahimi A, Srichaikul K, Berryman CE, Wang L, Carleton A, Abdulnour S, Sievenpiper JL, Kendall CW, Kris-Etherton PM. Soy protein reduces serum cholesterol by both intrinsic and food displacement mechanisms. J Nutr. 2010 Dec;140(12):2302S-2311S.

Jou HJ, Wu SC, Chang FW, Ling PY, Chu KS, Wu WH. Effect of intestinal production of equol on menopausal symptoms in women treated with soy isoflavones. Int J Gynaecol Obstet. 2008 Jul;102(1):44-9.

Lovati MR, Manzoni C, Gianazza E, Arnoldi A, Kurowska E, Carroll KK, Sirtori CR. Soy protein peptides regulate cholesterol homeostasis in Hep G2 cells. J Nutr. 2000 Oct;130(10):2543-9.

Messina M. A brief historical overview of the past two decades of soy and isoflavone research. J Nutr. 2010 Jul;140(7):1350S-4S.

Reynolds K, Chin A, Lees KA, Nguyen A, Bujnowski D, He J. A meta-analysis of the effect of soy protein supplementation on serum lipids. Am J Cardiol. 2006 Sep 1;98(5):633-40.

Sacks FM, Lichtenstein A, Van Horn L, Harris W, Kris-Etherton P, Winston M; American Heart Association Nutrition Committee. Soy protein, isoflavones, and cardiovascular health: an American Heart Association Science Advisory for professionals from the Nutrition Committee. Circulation. 2006 Feb 21;113(7):1034-44.

Setchell KD, Clerici C. Equol: history, chemistry, and formation. J Nutr. 2010 Jul;140(7):1355S-62S. Epub 2010 Jun 2.

Shidfar F, Ehramphosh E, Heydari I, Haghighi L, Hosseini S, Shidfar S. Effects of soy bean on serum paraoxonase 1 activity and lipoproteins in hyperlipidemic postmenopausal women. Int J Food Sci Nutr. 2009 May;60(3):195-205.

Stalenhoef AF. [Cholesterol reducing food certainly is useful]. Ned Tijdschr Geneeskd. 1997 Dec 27;141(52):2543-5.(abstract)

Taku K, Umegaki K, Ishimi Y, Watanabe S. Effects of extracted soy isoflavones alone on blood total and LDL cholesterol: Meta-analysis of randomized controlled trials. Ther Clin Risk Manag. 2008 Oct;4(5):1097-103.

Taku K, Umegaki K, Sato Y, Taki Y, Endoh K, Watanabe S. Soy isoflavones lower serum total and LDL cholesterol in humans: a meta-analysis of 11 randomized controlled trials. Am J Clin Nutr. 2007 Apr;85(4):1148-56.

Thorp AA, Howe PR, Mori TA, Coates AM, Buckley JD, Hodgson J, Mansour J, Meyer BJ. Soy food consumption does not lower LDL cholesterol in either equol or nonequol producers. Am J Clin Nutr. 2008 Aug;88(2):298-304.

Weggemans RM, Trautwein EA. Relation between soy-associated isoflavones and LDL and HDL cholesterol concentrations in humans: a meta-analysis. Eur J Clin Nutr. 2003 Aug;57(8):940-6.

Yeung J, Yu TF. Effects of isoflavones (soy phyto-estrogens) on serum lipids: a meta-analysis of randomized controlled trials. Nutr J. 2003 Nov 19;2:15.

Zhan S, Ho SC. Meta-analysis of the effects of soy protein containing isoflavones on the lipid profile. Am J Clin Nutr. 2005 Feb;81(2):397-408.

Zhuo XG, Melby MK, Watanabe S. Soy isoflavone intake lowers serum LDL cholesterol: a meta-analysis of 8 randomized controlled trials in humans. J Nutr. 2004 Sep;134(9):2395-400.

British Columbia

Naturopathic Association Landmark Advancements in Health Care

In the fall of 2010 British Columbia’s healthcare services took a profound leap forward: Licensed naturopathic physicians, who chose to obtain prescribing authority, were granted access to a wide range of therapeutics previously limited by prescription. is enhanced the existing care NDs currently provide while improving primary care options for patients across the province.

It was a pivotal moment for the profession and by extension provincial healthcare in general. While recent decisions by the ministry of health have put more value on and better recognized the legitimate scope of naturopathic practice, they have been a long time coming in British Columbia. Although licensed as doctors in the province since 1923, originally in an omnibus bill encompassing “allopaths, naturopaths and osteopaths,” it was 1936 when distinct legislation for naturopathic physicians was formally passed. Since then, however, many traditional medicines previously available to NDs, as well as the ability to compound and prescribe, have gradually and increasingly become limited. It was 1958 when the provincial government established a legislative mandate to enact a defi ned schedule of preparations for licensed NDs. But that commitment lagged in legislative limbo for many years, despite a formal “materia medica” being completed in 1979 and a tentative commitment to act on the mandate at the start of the 1990s.

It took decades to weather these many setbacks, along with the focussed determination and dedication of a huge number of physicians, and the support of many others through letters, meetings, presentations, solicitation and eventually even public outcry, to bring the issue to the fore.

Despite a tentative commitment to move forward as mentioned, a major stumbling block occurred in the 1990s when the NDP government initiated a legislative and scope of practice review process for all heath professions. is stalled all scope issues for six years. And, despite years of negotiation and volumes of correspondence, as well as a forward-leaning preliminary report, the end result was a huge setback. e fi nal report in 2001 nearly derailed the profession with stagnant, uninformed views on integrative care with no substantive reasoning for its regressive tone. We were fortunate that with the support of our patients, and with the extensive research collated during the review years, we had a strong case to move forward on scope issues and to question the review process and outcome. An independent health audit was commissioned by the ministry to more fully examine these outstanding issues and, in late 2004, the Naturopathic Scope of Practice Gap Analysis was completed. Ultimately, the initial scope review of naturopathic medicine was found lacking; once that was clearly established, we were able to meet with ministry offi cials, outline the historical and contemporary practice of naturopathic physicians, and work cooperatively to achieve a practice status commensurate with the education, training and expertise of our members. At the same time the existing Liberal government also began holding its “Conversation on Health Care” meetings across the province. Overwhelmingly British Columbians expressed their desire for choice and meaningful access to complementary and preventive health care. is culminated in a rone Speech commitment in 2008 whereby the government made clear its support and committed to steps to recognize the value of naturopathic medicine in the province and bring resolution to what had been in limbo for decades.

It would be impossible to individually thank the people who collectively brought us to this significant turning point: The doctors who so tirelessly campaigned during the 1970-80s when the profession was but a few dozen strong; those who contributed to research, writing, meeting and speaking before ministers, panels and bureaucrats; and the many directors over the years who built on the efforts of those before them. It is most important, however, to note that without the concerted and combined efforts of both our professional and regulatory associations to advance the profession, our efforts would have been in vain.

From the BCNA perspective, it was unfortunate we had to argue so persuasively to obtain access to many botanical medicines, natural therapeutics and other traditional items which, over time, had become scheduled and therefore inaccessible to NDs. However, most positively, this protracted negotiation gave opportunity and allowed for the significant enlightenment and education of politicians, staff and other health professionals on the education and training of NDs and the substantial contribution NDs make to health care in the province. Underscoring how prevention and treatment of physical and mental disease, disorders and conditions is at the heart of primary care, and of course the extensive nature of naturopathic care was actually a revelation to many! It was also a complex issue to explain that NDs would be offering prescriptions when appropriate, that access to drugs wasn’t about a departure from current practice but more a reflection of the expertise of naturopathic physicians and streamlining their delivery of primary care. Most importantly, an appropriately certified naturopathic physician may now have full access to the natural medicines previously held behind locked doors but used so safely and effectively for so many years in the past. Now, delivery of healthcare is also made simpler for any patient who may require a so-called drug medication but seeks primary care from an ND because they do not have to make additional trips to other providers. For patients seeking non-drug alternatives, the ND can legitimately adjust, if appropriate, drug regimens while introducing non-drug therapies. In a sense, the ability to prescribe legitimizes the decision not to prescribe.

Another key point in the process to a change in legislation was emphasizing that the status quo was confusing to the patient and led to unacceptable discrepancies in care. Without access to pharmaceuticals, when necessary, members are often in a position of ambiguity. There can even be an inherent danger to the public and the profession; for example, in a case such as bronchial pneumonia, where the ND deems antibiotics are required in the short term, yet cannot prescribe them, this unreasonably constrains care. It also places the patient at risk due to delays in appropriate care. And, for patients who had seen an ND in US jurisdictions where NDs have long had the authority to prescribe scheduled medicines routinely, it was often discouraging and confusing for them to receive care here.

For many decades BC’s naturopathic physicians have been seeking from government recognition for a scope of practice in keeping with the contemporary and historical practice of licensed NDs. In the 2008 Throne Speech the BC Liberals made a commitment to proceed with two facets of naturopathic medical care: Prescriptive rights and diagnostic facility access. The process leading to this announcement involved many years of negotiation, research, and collaborative assessment. The government’s commitment was based on this lengthy and detailed process; it was a commitment based on sound judgement having reviewed the educational criteria, current and historical practice of NDs, and, most importantly, ensuring the highest levels of patient-centred healthcare are available to all British Columbians. The BCNA believes that this commitment is the right choice for British Columbians: It reduces the existing burden on MDs while ensuring the provision of safe and effective primary healthcare in a measured fashion.

It also came as a surprise to many in government and even other health professionals that in fact not every prescription was a drug. For example, high dose vitamins, some amino acids, hormones, botanicals and herbs (which NDs have used for decades) had slowly become “scheduled” without legal access to non-prescribers. This element of moving forward was emphasizing the evolving art of medicine. Bureaucrats never questioned advances in drug therapy or technology for MDs—but initially questioned the need for such changes with NDs. Addressing this objectionable double-standard was another obstacle on the route to legislative advancements.

Further, it was often a difficult task to explain that changes to scope of practice weren’t about vested interest but about the patient’s interest. The BCNA’s Four Point Plan is based on improving safe, effective, economical preventative healthcare. It was disingenuous for the government to assume that NDs don’t deal with drugs on a daily basis. Primary care by definition involves dealing with patients on a drug regime, considering pharmaceuticals and/or an alternative, drug/non-drug interactions, and myriad other interconnected health issues. Exhaustively detailing and re-emphasizing that NDs don’t practice in a void may seem elementary but was actually critical to moving forward. Further, the ability to prescribe segues with the government model of “shared scopes” of practice. The change also keeps with the long record of safety and effectiveness of naturopathic medicine.

A final key element to moving forward on improvements to scope of practice came in no small part from a government willing to work with us. We have been fortunate in that the Liberal government over the last decade had a commitment to allowing licensed health providers to practice to the full extent of their education and training. That commitment was essential for us to establish dialogue on our Four Point Plan and to improve awareness of the safe, effective, patient-centred health care that is the foundation of naturopathic care. The BCNA’s plan focussed on how NDs can deliver high quality primary health care, reduce duplication and inefficiency and alleviate the shortage of MDs.

Despite this major advancement, the BCNA remains committed to its initial Four Point Plan, three items of which (full diagnostic access, hospital privileges and referrals to specialists) are still to be fully realized. In addition, there is much work to be done with respect to access of federally controlled substances, an issue we are working on with our national association. Still, this landmark in provincial and Canadian healthcare marks a fundamental shift towards better patient options, enhanced choice and true complementary care. We are hopeful this step will lead to improvements in care across the nation.

Integrative Therapeutics

Commitment to advancing the naturopathic profession

Integrative Therapeutics Inc (ITI) has been serving integrative healthcare practitioners for over 35 years. A well-developed array of product off erings has allowed Integrative to operate as a one- stop shop for physicians wishing to stock a dispensary of evidence-based, quality natural health products. Some of the company’s best known products include the innovative Ubiquanol QH (a reduced form of CoEnzyme Q10), IVY-calm (cough syrup made from an ivy leaf extract), a series of probiotic pearls covering a broad spectrum of researched probiotic strains, and Cortisol Manager, a combination of several ingredients including ashwagandha, theanine, and magnolia for improving abnormal cortisol patterns.

The US- based company manufactures the Integrative Therapeutics line in an FDA-registered drug establishment. Standards established for pharmaceutical manufacture are met and exceeded daily. Reproducibility across batches of product is key to maintaining excellence in quality control.

Integrative Therapeutics takes tremendous pride in providing evidence-based offerings. Novel ingredients subjected to the rigors of randomized, placebo- controlled clinical research are incorporated into the line, keeping the company on the cusp of novel medicines generated in the realm of integrative medicine. e company differentiates the level of clinical evidence of product offerings based on label colour; a green label denotes on- point human clinical research for the product in question. A silver label typically denotes a novel delivery system of a particular ingredient, and the ingredient in question has been validated in human clinical trials. A blue label denotes products formulated on a combination of traditional use and clinical research.

The foundation of Integrative Therapeutics was established in servicing the community of naturopathic physicians. Among many initiatives of the company to advance the profession, the creation of a partnership with the American Association of Naturopathic Physicians (AANP) is perhaps the most exciting of them all.

The ITI-AANP STAIR residency program is designed to provide exceptional new ND graduates a rare residency opportunity. Successful naturopathic clinics demonstrating direct integration with medical doctors are invited to accept a resident through the ITI-AANP STAIR program. e resident is compensated through the ITI-AANP STAIR program, and the accepting physician is gifted the services of a distinguished new graduate. e new graduate is afforded a unique residency experience, gaining insight into patient management strategies in fully integrative environments, as well as hands- on training in operations management, dispensary management, and all other facets that comprise operations of a successful integrative medical clinic. The first placement of graduates in the ITI-AANP STAIR program occurred in 2007. Each year the program places two ND graduates in facilities that have demonstrated excellence in integration.

The Integrative team felt it imperative to offer the line to the rapidly- growing segment of the profession representing Canadian naturopathic doctors. e regulatory obstacles deterring many US-based companies were welcomed by the team. Already complying with pharmaceutical as opposed to natural health product standards of manufacture made for an easy process of satisfying Health Canada expectations of quality control, safety, and efficacy.

Integrative Therapeutics Inc remains a pillar among companies healthcare providers have come to rely on. Dedication to quality control and evidence-based interventions has resulted in maintained success through the decades. Their commitment to advancing the profession of naturopathic medicine demonstrates loyalty to the professionals who helped the company grow to the level of achievement attained today.

The Patient Whisperer

Finding patients that fit

There’s a fundamental numbers problem facing practitioners in integrative medicine: most people aren’t buying what you’re selling.

Take naturopathic medicine. Good stats are hard to come by, but it’s not unreasonable to assume that less than 10% of the people in your area use an ND with any regularity. It’s probably closer to 3%.

at’s a pretty small slice of the pie.

e good thing about that slice, though, is that it’s tasty. It’s made up of people who already understand what you do and want what you have to off er. ey’re already on board. ey love you. ey need less educating, less convincing.

The downside of that small slice of the pie, though, is that it isn’t always enough to feed everyone. Most of us need to wade out into the vast blue ocean of opportunity that is the other 90% or more of the population. And that’s where the trouble begins: it turns out that the ocean is a big place, and not everyone in it is friendly.

The Problem With Skeptics

That unexplored area on the map represents the opportunity to grow your practice. It’s a vast, untapped mass of people who have often never heard of you or what you do, never mind actually considered trying it.

But strange territory has a way of changing how we behave. Faced with uncertainty and skepticism, we change our stance. We become less confi dent. We compromise more. In an eff ort to win over skeptics we cut fees, stay late, open early, and make a host of other concessions that impact our lives and the quality of the care we deliver.

In short, trying to win people over is when we become the Jackass Whisperer. We spend money trying to reach them. We give them time, and more time, and still more time. And worst of all, we let our confi dence hang on whether or not they’ll fi nally agree with us.

But the worse part of all of this is that chasing skeptics doesn’t work. It turns out that after all your eff ort, expense and agony, the skeptics are still the same way they were when you started: skeptical. And in the meantime, they’ve drained time and energy away from the people you love to help.

Worse still, it’s not even their fault. It’s yours. e problem with skeptics, it turns out, is not that they’re skeptical. It’s that we keep pouring energy into them. But that leaves us with a dilemma. Your fans currently aren’t enough to feed you. But the people that aren’t your fans can be an enormous drain of resources to market to. So how do you grow?

1. Understand the Cost of a Lost Skeptic…is Almost Nothing Before you can truly let go of the people that don’t fi t, you need to understand how little you’re actually giving up. ere’s often a little voice in your head that speaks up when you start pandering to skeptics. It’s a voice that says, “ is person isn’t a great fi t. Let them go.” en, of course, another voice speaks up that says, “Who do you think you are? You can’t aff ord to be so picky.”

That second voice is often the squeaky wheel – it gets all the attention. But the problem with that voice is that it’s terrible at math. It’s the voice of fear, and it believes that every lost opportunity is also lost income.

It turns out, though, that patients who don’t fi t simply don’t have that much value to your practice. ey often can’t be pleased. ey consume resources. ey don’t refer. ey don’t comply, and then they complain to others.

Let them go.

2. Define Who Fits Once you know what you don’t want more of, it’s important to defi ne the patients you do want.

In our clinic, the people who need our help the most and make the best patients have one or more of these three things in common:

• A health complaint that no one else could help resolve

• An intolerance to conventional options, or the need to reduce or eliminate a conventional care dependency

• A desire for better health care service. Th ings like more time, accessibility, no waiting, respect and informed consent.

That’s it. If someone meets one or more of those criteria, we can help. It’s that simple. Your criteria might be far more specifi c – what’s important is that you have criteria. Your criteria help strain that big, unwashed slice of pie, fi ltering out who doesn’t fi t, and leaving behind the people that we can best help.

3. Start Fan Whispering ose rules also serve an even more important purpose: they help other people understand who we can help. at’s critical, because even when you defi ne who you do want, there’s still a barrier to be surmounted: the people you want don’t know you. You may have what they want, but you may not have the credibility to bring them in.

But who does have the clout? e people connected to them – their friends, family, colleagues, service providers and more. And guess where they are? In your practice.

Tapping into new patients, then, begins not by trying to fi nd the people you want to be your fans, but by speaking to the ones who already are. ey’re your levers to help shift others. ey’ re the ones with the infl uence and the reach to step out into that big ocean and attract the people you’re looking for.

But how do you do it? What does it mean to focus on your fans?

Delight them:

You’re not really competing with the ND down the street – unless you want to keep squabbling over that same small slice of pie. What you’re really competing with is the idea in our minds that health care should be free. To justify your fee-for-service existence, you need to thrill your fans, every time. Do that, and they’ll do the hard work of convincing their friends and family that you’re worth every penny.

Eliminate barriers to entry:

Your fans are already out their singing your praises. But occasionally they’re stumbling across the same roadblock you are: the cost of what you do. We hear stories all the time of people desperately trying to convince their friends and family to visit a naturopath, but the person in question can’t seem to get over the cost issue.

Why not just remove it? Just for one visit?

Empower your fans to remove that barrier. Selectively give out certifi cates for a complete fi rst visit to your best patients, and ask them to off er it to someone. ey’ll know who needs it most. And once that person sees what you’re really about, the money may be far less of a barrier than it once was.

Find e Fans With Reach:

In terms of their ability to deliver patients to you, not all fans are created equally. And not all fans are patients. Who can you partner with in your community that can reach the people you’re seeking? One fan with reach can go a long way to fi lling your practice. We’ve met more than one practitioner whose practice was built almost entirely on referrals from another provider who was a true fan.

Patient Whispering Pays Off

Over time, the best quality and quantity of patients will come from inside your practice. ey’ll be delivered by the people who love you most, and fi t you best. Where they won’t come from is from people who don’t fi t. Spend your time speaking to the people who love what you do. When you meet a jackass – and you will – move on.