Pharmacologic/Biologic Medicine

Licensing, Certifying & Training Standards for Alternate Modalities

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NATUROPATHIC MEDICINE:

Training Standards

• The training program for a naturopathic physician (ND) is similar to that for a medical physician (MD), and takes place through a 4-year post-graduate training program.
• There are currently four naturopathic medical schools in the United States and Canada that are accredited by the Council on Naturopathic Medical Education (CNME), www.cnme.org. Information on accreditation is available on the U.S. Department of Education's official website at http://www.ed.gov/admins/finaid/accred/accreditation_pg7.html#nnm.
• Prerequisites: The prerequisites for admittance to a naturopathic medical school are the same as those for admittance to a traditional medical school.

Licensing Standards

• The general standard for licensure is:
  1. Graduation from an accredited 4-year ND program; and
  2. Successful completion of the state licensing board exam.
• There are currently 12 states that licensure NDs: AK, AZ, CT, HI, ME, MN, NH, OR, UT, VT, and WA. The scope of practice may vary according to state licensure laws. A few NDs still practice where they were licensed under an old law, but no new NDs have been licensed since the 1950s.
• In those states where they are licensed NDs may practice as primary care physicians.
  
  
• Pros and Cons of Licensing: As with many other CAM modalities there is differing opinion about the need for and benefit of licensing. Many feel that there are benefits including: greater opportunity for informed consumer access, greater respect as profession, potential for status as primary care physicians, and increased practice potential through insurance coverage. However, there are many that do not support licensure due to the inherent limitations imposed by regulation. For a few views on this important issue, please see the below links:
  • FOR
    The American Association of Naturopathic Physicians;
    The Coalition for Natural Health;
    The Minnesota Natural Health Coalition; and
  • AGAINST,
    The Minnesota Natural Health Coalition

Training Standards

• The practice of herbal medicine is a diverse field with practitioners from many several medicinal traditions using herbal medicine in many different ways. Each tradition has its own standards and as a result there is no formal standard for training.
• The American Herbalists Guild (AHG), www.americanherbalistsguild.com, was founded in 1989 to recognize competent herbalists specializing in the medicinal use of plants from ALL traditions and backgrounds. The AHG has developed a membership system to this effect. While general membership is open to anyone interested, professional membership is open to those meeting the professional level of knowledge and established standards for any tradition.
  
  
  • The AHG currently has established guidelines for several herbal models, including: Western Biomedical Model, Traditional Chinese Medicine (TCM) Herbalism, Earth-Centered Herbalism, and Ayurvedic Herbalism.
    (A comprehensive package of these guidelines is available from the AHG.)
    
    
  • The AHG membership review process is meant to ensure a high level of training and experience. Admissions are currently handled through a peer-review process. The application requirements include:
    1. Comprehensive application;
    2. Proof of meeting core criteria;
    3. Three case histories; and
    4. Three letters of recommendation from professionals in the field of botanical medicine.
  
  
• The standards set by the AHG are disputed within the field. A more recently founded organization the Botanical Medicine Academy (BCA) is also in the process of developing standards of training. Another organization devoted to herbal research and education is the American Botanical Council (ABC), www.herbalgram.org.

Licensing and Certifying Standards

• Several modalities, including TCM Herbalism and Naturopathic Medicine, have their own certification and licensing processes.
• There is currently no formal licensing or certification process for Western Herbal Medicine. However, the AHG (see above), is in the process of developing a program that would provide a national certification in botanical medicine. This certification would be available to professional AHG members that specialize in Western Herbal Medicine.
• The state of licensure and certification in herbal medicine is currently in a state of flux. There will most likely be some sort of national certification exam relatively soon. However, please note that neither of these organizations supports a movement to license herbalists.
• Benefits of certification: Certification would allow those herbalists without another professional system of certification to become recognized as competent professionals. Certification would therefore bring with it the rewards of greater recognition and acceptance. However, there are those in the herbal community that fear that certification will lead to licensure which will eventually lead to a limitation of herbal medicinal practice.

For information regarding herbal standardization please refer to HERBAL STANDARDS.

Standardization

• Terminology:
  • Standardization: adjusting a solution so as to maintain consistency & repeatability in its composition;
  • Concentration: adjusting a solution so as to increase its strength, density, and/or effectiveness.
• While many people prefer to buy standardized because they believe it implies a more potent product, this is not necessarily true. Standardization is intended to ensure consistency from one batch to the next, but is not directly related to potency.
• Pros of Standardization: ensures consistency.
• Cons of Standardization: "More is better" philosophy may develop, causing manufacturers to focus to heavily on one element of a compound, which could result in a product of lesser overall quality and therapeutic benefit

Legal Issues

• Regulation:
  • Supplements are are required to be manufactured to the same high standards that are required of all foods.
  • Like foods, supplements must provide consumers with nutritional information.
  • Supplements must also state the quantity of each of the contained ingredients, or of the "proprietary blends" that make up a product.
  • All herbal products are required to identify the parts used of each of the plant ingredients, and to label them with their commonly accepted names.
  
  
• In 1994 the Dietary and Supplement Health and Education Act (DSHEA), http://vm.cfsan.fda.gov/~dms/dietsupp.html, put several guidelines concerning supplements, in addition to the guidelines cited above, into effect. Several informative inclusions are that:
  
  
  1. "Dietary supplements" were separated from foods and drugs and defined as herbals and other "natural medicines" (vitamins, minerals, amino acids, etc.);
  2. Manufacturers of dietary supplements do not need FDA approval before production begins, the proof of safety lies with the FDA;
  3. The FDA may pull any product from the market that it deems an imminent threat;
  4. Therapeutic claims may not be printed in the label, but claims regarding the effect on the "structure and function" of the body are allowed. However, in order to use these claims the labels must include the wording, "This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease;"
  5. A manufacturer must notify the FDA if it plans to manufacture a product containing a "new dietary ingredient;"
  6. General Manufacturing Practices (GMPs): Authority was granted to the FDA to impose GMPs to ensure the safety of products produced.
  
  
• In addition the FDA monitors adverse events (negative side effects) for dietary supplements as part of the Special Nutritionals Adverse Event Monitoring System (SN/AEMS) program. They keep a database of reports and, as result of the DSHEA, have the power to remove any substance they deem as potentially harmful from the shelves.
• The FDA maintains a website devoted to dietary supplements. For more detailed information go to, http://www.cfsan.fda.gov/~dms/supplmnt.html.
• Several dozen states have developed laws to regulate dietary supplements.

Training Standards

• While no global standard exists for the education requirements for dietitians/nutritionists, there are general standards required by individual licensing, certifying and registering bodies.
• In order to meet regulatory standards, educational programs must either be registered by the State Education Department as qualifying for certification, or be accredited by the Commission on Accreditation for Dietetics Education, depending upon state statutes.
• Generally a licensed, certified or registered dietitian must have completed:
  • A state approved or nationally accredited program in dietetics-nutrition leading to the baccalaureate degree or higher academic credential;
  • A substantial amount of time, generally 800-900 hours, of planned work experience.
    Note: (An associate's degree may be adequate, but generally requires more extensive work experience)

Licensing, Certification and Registration Standards

• There are currently 46 states that regulate dietitians or nutritionists through licensure, certification or registration. For information on a particular state please refer to the complete listing of state agencies provided by the Commission on Dietetic Registration.
• While regulation statutes vary by state there are several national organizations that provide certification and registration programs to qualified dietitians/nutritionists:
  
  
  1. The Commission on Dietetic Registration (CDR) is the credentialing agency for the American Dietetic Association (ADA). The CDR awards five distinct credentials, the most general of which are the Registered Dietitian (RD) and the Registered Dietetic Technician (DTR). Both of these certifications require an exam that establishes entry-level knowledge. The RD exam is accepted by many states for licensure.
     (These programs are accredited by the National Commission of Certifying Agencies.)
     
     
  2. The Certification Board for Nutrition Specialists (CBNS) is the certifying arm of the American College of Nutrition (CAN). The CBNS provides certification program for those nutrition specialists with a higher level of educational training. Certification requires: an advanced degree, professional experience and a passing score on the CBNS exam. The specific requirements vary depending upon type on advanced degree obtained. Those who meet the requirements are awarded the title of Certified Nutritional Specialist (CNS).
     The CNS exam is accepted by many states for licensure.
     
     
  3. The Clinical Nutrition Certification Board (CNCB) is non-profit certifying agency which provides a certification program awarding of the title Certified Clinical Nutritionist (CCN). The core requirements include: a baccalaureate degree including core science and nutrition hours, completion of the CNCB Postgraduate Studies in Clinical Nutrition Program, a 900 hour internship, and successful completion of the CCN exam. There are specific exceptions, please see the website for full details.
     State regulation boards do not readily accept the CNCB exam. However, the International and American Associations of Clinical Nutritionists recognize and recommend this exam.
     
     
  4. The American Association of Nutritional Consultants (AANC) offers a certification program as a service to its members. Candidates must successfully complete a series of examinations. Successful candidates may use the initials C.N.C. (Certified Nutritional Consultant) after their names.
     This exam is not used to meet the requirements of state regulatory bodies.