The Complementary and Alternative Medicine (CAM) marketincluding everything from yoga and meditation to acupuncture and naturopathyis projected to be worth $210.12 billion by 2026, according to Grand View Research.

CAM practitioners often order the same clinical laboratory tests as traditional physicians, and with blood drawn by laboratories like Quest, LabCorp, and some hospitals, said Jaquel Patterson, ND, president of the American Association of Naturopathic Physicians (AANP) and owner of Fairfield Family Health in Fairfield, Connecticut. She mentioned specialized rheumatology assays from reference labs as an example of how she uses clinical laboratory testing.

But some specialty tests that naturopathic practitioners order are not available from local clinical laboratories, which she hopes will change. Its hard to get in relationships with a lab to do courtesy draws, she said.

The challenge for naturopaths? Many clinical laboratory professionals are wary of playing a role in what many see as an unregulated, belief-based system of medicine.

Twenty-two states, plus Washington D.C., Puerto Rico, and the U.S. Virgin Islands regulate naturopathic practitioners. According to the AANP, naturopathic practitioners in these states must fulfill state-mandated continuing education requirements annually and have a specific scope of practice as defined by their states law.

A study published in Annals of Clinical Biochemistry looked at how laboratory tests are commonly used in CAM in the U.S., U.K., and Australia (Ann Clin Biochem 2019 May;56:310-25). Little to no data have been published about which tests are ordered most often, according to the lead author of this paper, Stuart Jones, MSc, FRCPath, consultant clinical biochemist in the department of clinical biochemistry at King Georges Hospital in London. But the most widely available that he has come across in his work include IgG antibodies for food intolerance, nutritional or metabolic profiles, and tests for heavy metal toxicity.

Often, laboratories specializing in CAM perform these tests. To meet the growing demand for CAM testing, a number of small reference laboratories around the world now offer specialty testing specifically marketed to naturopathic providers. Some operate entirely outside of any recognized accreditation program while others are accredited to the standard of established clinical laboratories, said Jones. Some CAM practitioners also offer some of their own tests directly to the public.

There are some CAM practitioners that will use established, validated tests in an appropriate way, but what we have found is that there seems to be a preference in this community for using unvalidated or even discredited tests, often to justify potentially unnecessary treatments and therapies, he said.

This isnt surprising, said Britt Marie Hermes, a PhD student at the University of Kiel in Germany and a former naturopathic doctor who writes about the industry at naturopathicdiaries.com. There is a large degree of variability with regard to how licensed naturopaths practice, she said. Some naturopaths may order and interpret lab tests according to established medical standards, but, based on having worked as a naturopath for several years and having practiced alongside many naturopaths, I can say from personal experience that naturopaths do not use lab tests like medical doctors.

Hermes said this is important for clinical laboratorians to know, and that they should be aware that naturopaths are providing patients with information that conflicts with information put out by medical professionals, she said. She gave as an example the issue that naturopaths will use different criteria to diagnose disease and make medical treatment recommendations.

In their study of CAM laboratories and testing, Jones and his co-authors also note that in the U.S., surveyors from the Centers for Medicare and Medicaid Services no longer routinely inspect CLIA-waived laboratories, which represent thousands of small testing sites.

The authors also point out that CLIA certification requires laboratories to meet standards in a variety of areas including staff qualifications, proficiency testing and test accuracy, reliability, and timeliness. It does not require demonstration of clinical validity and utility. Thus, CAM laboratories in the U.S. can be CLIA certified while offering tests that are neither clinically valid nor clinically useful.

Michael Astion, MD, PhD, medical director in the department of laboratories at Seattle Childrens Hospital and a clinical professor of laboratory medicine at the University of Washington, said he encounters CAM often, usually through parents who consult naturopaths or other CAM practitioners in addition to seeking medical treatment for their children. I think they have a role in the healthcare system, he said. There is some fraud and abuse there, but its not that common in laboratory services. He mostly sees CAMs using traditional laboratory tests, and not over-ordering.

Hes more concerned about tests that go beyond the scope of traditional medicine and how those tests are interpreted. Thats especially true with tests that are done at specialty laboratories. In general the problem with those labs is that tests tend to come back positive because the thresholds for positivity are very low, he said.

One example: hair analysis. Hair is not very good [as an analyte] for anything except maybe arsenic, and thats only good in the hands of some very excellent labs, Astion said. Its a very difficult specimen but CAM labs will do all kinds of toxicity testing on hair that come back with fairly alarming reports. Two other concerning tests are for allergies and food sensitivity. These are tests that youd never see a normal allergist or board-certified gastroenterologist order, he said.

His second concern is the overuse of screening tests and the ordering of very large panels. When you apply the wellness movement to laboratory medicine, you make everybody sick, he said, which is followed by treatments for diseases that arent there.

Requests for urinalysis for heavy metals is also a problem. Everyone is going to have some metals in their urine if they receive a heavy metal chelator, Astion said, but this doesnt mean that theyre sick. That doesnt mean you can eat a bag of fertilizer or drink a can of Raid, but it does mean you can probably use Raid in your house occasionally, and you can fertilize your lawn and, you can paint your house, he said.

Astion doesnt think that CAM practitioners are bad people or trying to make their patients sick, but that many are operating outside the scope of their knowledge. He likens it to the popularity of total body computed tomography scanning businesses in the early 2000s. If I image you from the top of your head to the bottom of your toes, youll have a lot of anomalies. That doesnt mean that theyre disease causingmost of them are not, he said. Thats why all those places closed. They were telling all these people they were sick, which led them to having unnecessary procedures. Thats exactly what happens when you get outside of the scope of your practice.

When patients bring in requests to have blood drawn for CAM testing, Astion said his institution typically refuses and gives parents an information sheet that says we do patient-centered testing. We do not do patient directed testing, he said. We dont judge them. We treat them just like if you came into my Italian restaurant and ordered Japanese food, he said. You can have Japanese food, but you cant have it here.

He will also ask CAM practitioners to stop requesting those kinds of blood draws from his hospital and give them information for a reference laboratory that might work with them. The message to CAM practitioners is, that order doesnt make sense to us. We practice conventional medicine, Astion said. Im not criticizing you, but I dont want to be party to it. Use another lab.

Jen A. Miller is a freelance journalist who lives in Audubon, New Jersey.+TWITTER:@byJenMiller

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Alternative Medicine and Clinical Laboratory Practice - American Association for Clinical Chemistry (AACC)