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The Intersection of Integrative
Medicine and Preventive Medicine
Dr. Ather Ali, ND, MPH, MHS
Associate Research Scientist, Department of Pediatrics
Integrative Medicine Specialist, Yale Stress Center
Director, Integrative Medicine at Yale
Atatürk Üniversitesi – Entegre Tip Sempozyumu
May 2015
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Outline
• Definitions, Framework, and Rationale
• The task: Infusing Integrative Medicine into Preventive
Medicine
• The opportunity (U.S): Better infusing Preventive
Medicine principles into Integrative Medicine
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Context
• 2012-2015 Grant from Health Resources and Services
Administration (HRSA)
– U.S. federal agency for improving access to health care
• “Integrative Medicine in Preventive Medicine Residency
Education”
– To expose residents in Preventive Medicine residency programs
to Integrative Medicine
• National steering committee
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Curriculum Competencies (summary)
•
Integrative Medicine patient assessment including
– prevention- oriented, patient-centered, and lifestyle-focused history
– behavioral, psycho-emotional, social, cultural determinants and environmental
factors.
•
Demonstrate familiarity with integrative medicine
–
–
–
–
•
•
•
theories and approaches
epidemiology and cost
safety and efficacy
training and certification
Self-care /self-management principles in individual and community
settings
Demonstrate familiarity with cultural perspectives held by patients,
clinicians, families, and communities
Interprofessional collaboration
Jani AA, Trask J. Ali A.. American Journal of Preventive Medicine; 2015 (under review).
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Operational Definitions
Preventive Medicine
Integrative Medicine
“Preventive Medicine focuses on
the health of individuals,
communities, and defined
populations.
“…reaffirms the importance of the
relationship between practitioner
and patient, focuses on the whole
person, is informed by evidence,
and makes use of all appropriate
therapeutic approaches,
healthcare professionals and
disciplines to achieve optimal
health and healing.”
Its goal is to protect, promote,
and maintain health and wellbeing and to prevent disease,
disability, and death.”
Academic Consortium of
Integrative Medicine and Health
American College of Preventive
Medicine
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Theoretical vs. Prevalent Practice (United States)
As Defined
•
•
•
•
Natural Products
Mind and Body Medicine
Manipulative and BodyBased Practices
Other
– Movement therapies
– Energy therapies
– Whole systems
Prevalent Practice
•
CAM therapies +/-
•
Lifestyle interventions
– nutrition
– physical activity
– stress reduction
•
Alternatives
– Dietary regimens
– Diagnoses
– Diagnostic methods and tools
•
Off-label/ emerging /
speculative
NCCAM Publication No. D347 (2012)
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ons can be used if necessary.
M therapy otherwise divert the child from imminently necessary conventional treatment?
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d” trial of the proposed approach may be appropriate, provided that the child can be monitored conventiona
tinued as appropriate.
ies that have been selected known to be unsafe or ineffective?
ce can be categorized as follows,
with increasing
risk States
of liability:
The Intersection
– United
ce supports efficacy and safety.
ce supports safety, but evidence regarding efficacy is inconclusive.
ce supports efficacy, but evidence regarding safety is inconclusive.
ce indicates either serious risk or inefficacy.
g for the patient should continue toCAM
monitor the patient and the literature for new information that would ch
Conventional IM
PM
(U.S.)
Mainstream Medicine
rties consented to the use of the CAM therapy?
s particularly important when informing the patient about CAM therapies that may affect the patient’s choice
tio of the proposed CAM therapy acceptable to a reasonable, similarly situated clinician, and does the therap
ort in the medical literature?
ohen MH, Kemper KJ. Complementary therapies in pediatrics: a legal perspective. Pediatrics. 2005;115:774-780.
Treatment Recommendations
Is the therapy
recommended?
EFFICACY
Yes
No
Yes
Recommended
Tolerate
No
Monitor closely
Discouror discourage
age
SAFETY
f State Medical Boards
n addition to the stanry, physical examinast results, and reports
the medical record
umented information
e 14-6). The weighing
Table
14-5. Commonsense Guide to CAM
Ethical
Framework
Is the therapy safe?
iatrician toward cliniresponsible, ethically
legally defensible. A
n of options for the
mmending, tolerating,
actively prescribing
patients is based on an
-benefit assessment107
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Source: Kemper K, Cohen M. Ethics meet complementary and alternative medicine: new light on old
principles. Contemp Pediatr. 2004;21:61-72.
Contemp Pediatr 2004;21:61-72.
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‘Evidence-based Integrative Medicine’
Safety
Efficacy
Science
Other
therapeutic
options
Patient preference
Cost /
Accessibility
High
High
Decisive
None that is
superior
Not a concern
Probable
Possible
Unclear
None / few
Low
Low
Absent /
opposed
Many that are
superior
Prefers
recommended
approach
Anything that will
work
Anything that will
work
Needs
consideration
Prohibitive
Utilization
frequency of
treatment in
question
Always
Often
Never
!
Ali A, Katz DL. American Journal of Preventive Medicine; 2015 (under review).
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“Responsible” Integrative Medicine
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Assumptions
•
Rationale for Integrative Medicine
– depends largely on CAM
•
U.S. health care system
– closely allied to conventional practices
– reimbursement
•
‘More blue’
CAM$(U.S.)$
IM$
PM$
Conven.onal$1$Mainstream$
Medicine$
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Framework: Public Health/General Preventive Medicine
• Population-based public health skills
• 1° prevention – prior to disease occurrence
– Seat belts, immunization, avoiding smoking
• 2° prevention – treating prior to symptomology
– Cancer screening, treating HTN to reduce CVD risk
• 3° prevention – treatment to reduce risk of reoccurrence
– Much of medical care
• 4° prevention
•
– “To avoid patient overdiagnosis and overtreatment”
“Primordial Prevention”
– focuses on the alteration of societal (i.e. environmental, economic, social,
behavioral, cultural) structures that affect disease risk
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Integrative Medicine Patients – Prevention Oriented
• N=4,182 (Bravewell Practice-Based Research Network)
– 85% white; 73% college educated; 73% female
• Why Integrative Medicine?
– "to improve health and wellness now to prevent future
problems" (84%)
– "to try new options for health care" (77%)
– "to maximize my health regardless of whether or not my illness
is curable" (75%)
– For wellness, acute care, or chronic illness
Explore (NY). 2012 Nov;8(6):348-52.
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Integrative Medicine Patients – Healthy Habits
BMC Public Health. 2007 Aug 27;7:217.
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Primary Prevention
• Greatest impact
– EPIC-Potsdam data (1)
– 4 factors prevented 80% of CVD, T2DM, cancers, stoke
– Smoking, BMI <30, healthy eating, physical activity (3.5hr/wk)
• “Integrative” approaches (vs. good medicine)
– Diet/lifestyle guidance
• ‘walking the walk’ – role modeling (2)
• important component of U.S. integrative medicine practice
• ‘culture of wellness’
– stress reduction techniques
– sleep
(1) Arch Intern Med. 2009 Aug 10;169(15):1355-62. (2) Obesity. 2012 May;20(5):999-1005; Prev Cardiol. 2010 Fall;13(4):180-5
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Secondary Prevention
• Lifestyle approaches
– Ornish (1), Jenkins (2), Bradley (3) studies
– Cardiovascular disease and Type 2 diabetes
• Motivated patients and providers
– teachable moments
• High impact area in conditions with strong lifestyle
associations
(1) JAMA. 1998;280(23):2001-2007 (2) JAMA. 2011 Aug 24;306(8):831-9. (3) BMC Complement Altern Med. 2012 Apr 18;12:44.
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Tertiary Prevention
• Full range of Integrative Medicine approaches
–
–
–
–
pain management
symptom control
stress relief
disease management
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Tertiary Prevention – Areas of Promise
• Pain syndromes
– Inpatient settings – Minnesota data (1)
– Acupuncture, massage, mind-body therapies
• Symptom control—even when disease etiology and
pathophysiology unknown
– medically unexplained symptoms
– fibromyalgia, irritable bowel syndrome, chronic fatigue
syndrome
– often complicated by psychological comorbidities
• Mind-body therapies are important
J Patient Saf. 2010 Mar;6(1):48-51
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Primordial and Quaternary Prevention
• Integrative medicine tends to be philosophically aligned
towards environmentalism and social justice
– Interest in social determinants of health
– Accessibility
• Concerned with iatrogenesis (adverse effects of medical
treatment)
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Summary
•
•
•
•
•
Integrative Medicine offers knowledgeable guidance to tailored
therapies across conventional and CAM practice
Giving a patient more therapeutic options gives more opportunities
for success
Much potential in 1°, 2°, and 3° prevention arenas
Collaborative vs. contradictory care
Primum no nocere
CAM$(U.S.)$
IM$
PM$
Conven.onal$1$Mainstream$
Medicine$
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An opportune moment
CAM$(U.S.)$
IM$
PM$
Conven.onal$1$Mainstream
Medicine$
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Preventive Medicine – Core Competencies
• Biostatistics
• Epidemiology
• Research into causes of disease/injury in population
groups
• Practice of prevention in clinical medicine
• Planning and evaluation of health services
• Environmental and occupational medicine
• Management of health care organizations
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Example – CAM and childhood vaccination
Pediatrics. 2006 May;117(5):1532-41.
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Research Principles
•
Some CAM clinicians argue that individualized therapies cannot be
studied using rigorous methods
– Not true
– Requires creativity
•
“Any health claim can be systematically evaluated using rigorous
methodology”
– Conventional or alternative
•
“Alternative therapies, not alternative outcomes”
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Our research
•
Clinical Trials
–
–
–
–
–
–
–
•
Meditation in chronic pain/fibromyalgia in adolescents
Individualized diets in irritable bowel syndrome
Intravenous vitamins in fibromyalgia
Massage for osteoarthritis of the knee
Chromium for the prevention of type 2 diabetes
Cocoa and chocolate for CVD risk reduction
Fermented soy for irritable bowel syndrome / microbiome
Epidemiologic studies
– Vaccine attitudes and practices in CAM students
– Use patterns of unconventional laboratory tests
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International Congress on Integrative Medicine and
Health – May 2016 – United States
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This work was supported by a grant from
National Center for Complementary and Integrative Health
National Institutes of Health
U.S. Department of Health and Human Services
www.nccih.nih.gov
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