I read with interest the research article in CMAJ by Seely and colleagues1 regarding the reduction of calculated coronary heart disease risk. The goal of their investigation was to test the hypothesis that naturopathic care is superior to usual care. Although the authors have shown that a generous investment in counselling is effective at reducing calculated risk of coronary heart disease, they have not shown any effect specifically attributable to naturopathic care. For example, dietary counselling appears to be effective regardless of the provider.2 As a practising cardiologist, I routinely “deliver diet and health promotion advice” to my patients and “emphasize this form of self-directed care.” In response to a statement in the accompanying CMAJ editorial by Stanbrook,3 I would welcome the opportunity to spend an additional 4 hours in consultation with my patients who are at high risk for coronary heart disease, and I suggest such an intervention would have been the appropriate control comparator.
Furthermore, I have concern about the evidence base used to determine lifestyle interventions. Appendix 1 in the article by Seely and colleagues1 suggests that coffee intake should be reduced or eliminated. Literature published before the trial registration, however, showed an association between moderate coffee intake and both a reduced risk of diabetes4 and no increase in risk of coronary heart disease.5 Conversely, the evidence showed little clinical benefit from some of the recommended supplements, or showed no evidence that supports a clinical benefit (i.e., from cinnamon, pomegranate juice, lutein).