Before we start to formulate an answer to this question I want to ask you to check your biases and beliefs at the door and consider that such constructs may be misguiding. If you aren’t willing to do that, then there is no point in wasting your time reading what I have to say.
The central thesis of this paper is that the individual bias for natural versus synthetic, supplement versus pharmaceutical treatment is grounded in the environment one grew up in (familial and societal) and the media algorithm one is engrossed in; If optimization of health is to be achieved, these biases must be exposed and contrasted with what is known to be objectively (to the extent that it can be) true. The perception that there is free will or choice is an illusion until one is aware of such bias.
What is the difference between a “natural” supplement and a pharmaceutical “drug”? It seems to me that such a question is a superficial form of a deeper question, rooted in subconscious processes. Clinically, whenever I offer an intervention to address an issue or optimize an aspect of health, I am almost always asked, “is that something that’s natural or is that like, a prescription?” What is the deeper question they are really asking? Are they curious what makes a drug or supplement beneficial? About its binding affinity? Its degree of inhibition or activation? Its specificity or pleiotropy? These are a few of the domains that come into consideration when I choose between potential interventions – but how does a patient, client, or consumer think?
From my limited understanding, the thought process seems to be grounded in trust, or rather mistrust. My clientele are a mixed demographic – some come from the completely conventional backgrounds, some from the opposite, alternative end of the spectrum and many who reside between the two poles. Everyone is influenced by their media, often a collective “group-think” that echoes held beliefs while blocking oppositional perspectives. On the other hand, it is the environment that shapes the subconscious and the transgenerational epigenetic modifications that ‘guide’ gene expression and therefore behavior. So, a new question arises – what is the relative influence of the bias-confirming aspects of media and of the individual environmental and meta-environmental factors when it comes to our attitude toward alternative and conventional medicine? Or, more broadly, when it comes to what we know and what we don’t?
Don't be a marionette - know why you believe what you believe.
With this section, I hope to illuminate how the developmental environment influences bias and belief.
Sometimes the answer is blunt. For example, I started my journey in the healing arts with chiropractic. Prior to that, my exposure to the medical system was purely as a consumer – I went to the physician if I got sick, needed to get cleared for a physical, etc. I (rather my parents) sought help when there was a problem that interrupted my mode of being and introduced otherwise unnecessary chaos into the system. In the interim, I did what I was told in regard to what ‘healthy’ was, but also in regard to how I wanted to function as an athlete. Additionally, my father dabbled in bodybuilding during my childhood and was a fireman, where physical fitness was greatly admired. That influenced me from an early age in regard to what I thought it meant to be healthy, and also shaped the development of many beliefs and biases about what was unhealthy, undesirable, or just ridiculous. In other words, I merely imitated what I could shortsightedly categorize as my ideal. Fast forward to my chiropractic studies and the situation changed. Hypothetically, I soon would be in the business of accruing healthcare consumers rather than being on the side of the accrued. Does this change the perspective? Vastly. Healthy people are complex systems. Unhealthy people are complex systems that have an element of dysfunction somewhere, usually for an unspecified amount of time, that is likely manifesting in ways that grossly mislead us on its origin. Patient’s perception of such a chaotic situation gives rise to endless doubt, questioning, and hope that someone will be able to introduce some order. The whole world of human dysfunction is opened, and with it, thousands of years of potential remedies and treatments. So how is that can of worms constrained? It is constrained with philosophy.
In chiropractic school, despite the academic difficulty of the courses, the philosophy of the practice was painfully simple – all disease is a result of interference of ascending and descending nerve transmission due to vertebral subluxations. This philosophy-turned-belief system massively constrained, as it was supposed to, the treatment choices available [obviously there are massive problems with such a simplification, but for the sake of this example I will leave it be]. But, if this was all there was to do – where does that leave the rest of the healing arts? This is where my long-winded example comes to fruition - the students are led to adopt an ideology around all things ‘un-natural’. Medications? Surgery? Injections? Unnecessary and wrong – if only the individuals ‘needing’ such services had been adjusted in earlier years and maintained their spine such interventions would not be needed. Interestingly enough the philosophy had to bend eventually to allow herbal and Eastern remedies/therapies as valid support in the aim. The profession still has internal arguments and problems about the chiropractic scope of practice. As a result, one can never really know what they will get upon visiting a Chiropractor. I was left for wanting.
Nursing school offered a different philosophy, one geared more heavily toward allopathy and conventional medicine, while also maintaining ‘holistic’ care as a central tenant. Furthermore, nurse practitioner training offered even more tweaks to the philosophy due to certain constraints being lifted, the main one being real medical responsibility and liability for treatment decisions. No longer did I have shelter between my recommendations and a patient’s life. I am the maker of decisions. If I don’t abide by guidelines then I must have the ‘why’ to validate disembarkment from the standard of care for the respective board of licensure and for the patient. Parroting ideology won’t work, especially if it is the ideology held by the minority. As my personal philosophy kept molding I became more fluid in my cognitive set, but also more stringent on what signals I paid attention to in all of the noise. A particular quote by John Wheeler comes to mind:
"As your island of knowledge grows so does the shoreline of ignorance."
The point of these stories is that philosophy dictates practice - it plugs into the default mode network and everything is filtered through that philosophical lens. If you don’t have a philosophy of practice, then you are likely a puppet for someone else’s. In the end, it seemed to me that the dogmatic adherence to any philosophy was a paradoxical and toxic relationship. A core part of the philosophy must be predicated on the pursuit of truth and its application within the healing arts. Epistemology is key on such a shoreline.
OPTIMAL EXPRESSION - DO YOU WANT LESS?
With this section, I hope to elucidate the premise of optimizing the human system without bias.
Let’s start with a question that every person who wants to enhance their health will have to ask themselves – where do you want to be? Physically, cognitively, socially, metabolically, etc.? If you imagine your ideal self, what does that look like? And, more importantly, what are you willing to sacrifice to become that?
In my conceptualization there are three modes through which we perceive the objective world:
The mission is unidimensional: to achieve the goal. The strategies to get there are many, and the tactics are essentially infinite. If you accept the premise that, in order to realize your ideal self, sacrifices must be made, a new question arises: what to sacrifice? Time and effort seem to be the only acceptable tribute. The sacrifice of time is a major one, especially with immediate gratification so abundantly conditioned. It is no wonder that the average individual seeks to stay in Neverland and rejects the premise of personal responsibility necessary for achieving their true ideal. Still, the necessary element of time is not sufficient for the attainment of the end goal.
Here enter what I like to call ‘rare candies’. The concept of rare candies comes from the Pokémon universe, where they are used to impart an entire level’s experience to one little monster. Real-world rare candies are those interventions that narrow the gap between where an individual is and where they want to be. The real kicker with rare candies, though, is that they only really work to reduce the time cost if the individual’s effort is maintained. For example, in Pokémon if you were to give a monster 99 rare candies to max out its level at 100, but did not engage in any battles, it would not reach its full potential and would be inferior to another identical monster who reached level 100 by experience in battle. However, if used concomitantly – rare candy and battle experience, full potential can and will be realized in far less time. So why would anyone prefer to spend, hypothetically, the same time and effort on a certain outcome, when rare candies can be used concomitantly to have an augmented outcome? They likely wouldn’t, which is why the supplement industry is projected to be a 350-billion-dollar industry by 2026. Most health-conscious people, from gym rats and health bloggers to professional athletes and celebrities, are already trying to be their best. So, what is the rationale for remaining “natty*”? This question is taking risk mitigation for granted, but that brings the next point in our aim to understand the natural vs. pharmaceutical ethos – is supplementation with “natural” substances (rare candies) somehow more effective or less risky than synthetic or pharmaceutical means? *gym speak for not using performance enhancing compounds
Firstly, every person needs to define what they deem to be natural because the devil is in the details. Are standardized extracts natural? Surely not as natural as pounding kilograms of turmeric and black pepper to get a decent amount of curcuminoids. No, instead we have, if it’s any good, a 95% standardized curcuminoid extract product that delivers, arguably, pharmaceutical-level supplementation – perhaps nutraceutical would be a better descriptor. In my purview, it seems no more natural than the synthesis of biguanides from the French lilac to make metformin. Translation and distillation of herbal and microbial remedies into their unique constituents is how many of the pharmaceuticals were made, even one so demonized as the statin family. But again, it is crucial for each individual to sit down and define for themselves what they believe ‘natural’ to mean. Once more, I am attempting to push the conversation forward to performance-enhancing compounds. These questions need to be asked before they are half-wittedly answered by someone driven by an agenda (on either side). With that said, can whole foods make a difference in performance and well-being? I believe that to be true, I’ve certainly seen it be fruitful in practice. I dare say the literature also supports eating whole foods for achieving, although what is contained in such recommendations may not align with my personal recommendations. Will whole foods continue to take performance and well-being to the next level once they’ve been integrated? It doesn’t seem to, which is why performance-based supplementing came to be in the first place.
There is no question as to how dangerous many pharmaceutical agents can be, as evidenced by the typical page of potential adverse effects that accompany them. However, with such acknowledgement comes the potential of mitigation and/or avoidance with use. Many steps can be taken to reduce the incidence of adverse effects by manipulating dosage, time of administration, taking with/without food, etc. We know this from the research done on the product in question. Additionally, most pharmaceutical products have the benefit of being studied in humans, at particular doses, which simplifies clinical guesswork and potential problems. The problem, really, is that there seems to be a lack of critical thought on the side of the prescriber in regard to individual nuance and the standard of care. Most drugs do not work great, the anti-depressant class being the poster child, and yet are still prescribed as a first line therapy where other, more effective therapies are reserved for once the medications fail. In such an instance something with a better side effect profile and similar efficacy, like St. John’s Wort, SAM-e, and folate may be more appropriate. However, this decision is not based on the label of the product as natural – it is simply a better choice. On the other hand, some drugs work really well. To cast them aside in favor of a weaker product, whether it be a different medication class or a ‘natural’ product, due to ideology is a poor choice.
There is an additional layer of complexity in regard to the perception of safety of pharmaceuticals: the trust a consumer has in the provider. One may question the knowledge and motivations of the practitioner. Are they a puppet to pharmaceutical influence? Is their training myopic? Is their ideology determined by rigid guidelines? Do they make decisions based on critical thought, individual nuance, or personal clinical hypotheses? How does one begin to trust their provider without simply falling victim to the influence of authority? I would argue the solution is spending adequate time to answer questions and dialogue about any concerns the individual has and take time to develop a clinical relationship that is characterized by humble counsel based on current understanding of the relevant literature. Conventional medical professionals are just not as inherently trustworthy as they once were, and I don’t think that is a bad thing. Respect should be earned on an individual basis. In conclusion, the safety argument may be a subconscious substitute for lack of trust in the prescriber. Of course, this may be secondary to other biases, which I will cover next.
I often see fiduciary reasoning behind the mistrust of pharmaceuticals, or Big Pharma, as if all products of the corporate monster are bad (presumably distract from ‘real’ cures or treatments and do more harm than good) solely because they make massive amounts of money off them. Such all-or-nothing thinking is not helpful and serves only to confirm bias. One can acknowledge the limitations and weaknesses of the pharmaceutical industry without the delusion of institutional malevolence. Next, the supplement industry, (Big Supps?) as alluded to before, is not foreign to profit. In fact, the supplement industry and pharmaceutical industries have the same motive: profit. They both troll each other, too. The pharmaceutical industry uses the legion of credentialed supporters to delegitimize the supplement industry and the supplement industry utilizes the public distrust of government agencies and corporate industry (while growing massive itself). So, on the grounds of money and profit this argument has no leg to stand on. Of course, there is a guise of patient care and healing and the very real force of hope that any given product will help those who are suffering, but in the end, it is still about sales and the bottom line for any company. Representatives are often the intermediaries who convey this guise and bridge the gap between patient outcomes and corporate responsibility, along with free food to loosen up the biases.
It is also very important to remember that professional scope of practice decides what tools are available to practitioners. It is no wonder a medical doctor is going to primarily depend on pharmaceuticals, surgery, interventional procedures, and so forth while concomitantly down-playing the importance or utility of dietary supplements, even though they have the ability to ‘prescribe’ them (obviously with the shift toward functional and integrative medicine this example has more exceptions but still remains the rule). On the other hand, alternative medicine providers will steer in the opposite direction because, with the exception of some naturopathic physicians, they cannot access the pharmaceutical arsenal. Why would they recommend something that would take the client elsewhere? Additionally, they do not have the education to understand when a particular medical tool would be ideal. Instead, the anti-pharma ethos has its tendrils deeply engaged where health is conflated with naturalism. I am again writing in terms of the general rule, not the exceptions.
There is no better example of this phenomenon than the recent surge of interest in ‘peptides’. Of course, peptide hormones and messengers have been used in medicine for many, many years, for example: insulin, sermorelin, chorionic gonadotropin, oxytocin, vasopressin, thymosin a-1, glucagon-like peptide 1, melanocortin-1, and more, all have pharmaceutical analogues available by prescription. Additionally, there are many small molecule peptide receptor agonists/antagonists (rather than the peptide itself) available that act like peptides but are modified for efficacy purposes. All that said, since many of these peptides are available for purchase without prescription through research laboratories, the alternative and non-licensed communities have come unhinged with excitement for such high potency tools at their disposal – and with good reason. However, it goes without saying that the adoption of peptides and concomitant disdain for pharmaceuticals is incongruous. But, people still lean on these substances being natural as the saving grace for remaining ideologically possessed rather than just updating their internal models. It is the kind of intellectual dishonesty that will prevent the unification of the healing arts.
Another reason that seems common is the perceived permanency of a pharmaceutical intervention – the thought that once you start something you’re on it for life. The underlying prediction is false, but if it is replaced with curiosity instead there yields a productive question: what is the expected treatment course with this intervention? Every patient/client should ask this question for everything they take, regardless of its categorical belonging, because in the end the goal is to take as few things as possible, right? To become resilient enough to manage with lifestyle changes only? Of course, some may choose to repeat an intervention that improves their wellbeing. I always tell the people I work with that we only ‘date’ interventions to start off with, we do not ‘marry’ them. We establish a time course to project out when and what we should observe should the interventions be beneficial, and then reassess once that point rolls around. The trajectory of improvement then dictates the reduction in dose or complete withdrawal of an intervention to see how the system maintains itself in absence of the intervention(s). Once more, this core question should be asked despite belief around natural and pharmaceutical tools. Patients are very poorly educated on why they take certain medications. This never fails to astound me. However, it also extremely common for someone to walk into my office with a list of 20 supplements they’ve taken for god-knows how long, and with no subjective or objective inkling as to how they are helping. People need to be educated on why they take something, what should be changing, how to monitor the expected change, and how long they’ll likely need it.
Now, back to the original questions from the previous section – in the pursuit of one’s ideal self, what is desired? How can that ideal be realized? What are the costs – opportunity, physiologic, financial, etc. that need to be considered? These are the questions that matter, and depending on the answer the recommended course of interventions will differ. But nowhere in the conversation is the dichotomy discussed herein introduced – the conversation is simply guided by sacrificial demand of the individual’s goal, i.e the time frame in which they would like to achieve it. All non-nutritional, non-sleep, non-exercise, and non-social/personal stress management interventions are, in my opinion, not natural by definition. If I give someone melatonin at bedtime, that doesn’t mean its natural simply because the same compound exists in the human body. No, it is precisely the opposite of natural, as an exogenous formulation is being introduced in a manner foreign to the system. Once these questions are asked and an individual can get down to the root of why they think they know something to be true, the perceived understanding can be re-examined in a way that is not threatening to the ego. It’s okay to be wrong about something and to change one’s mind after assimilating new information or shedding old assumptions. I hope that this article has raised questions and created more intellectual openness – here’s to progress and meeting goals!
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