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The Intersection of Integrative Medicine and Preventive Medicine

Dr. Ather Ali, ND, MPH, MHS (c)Associate Research Scientist, Department of PediatricsIntegrative Medicine Specialist, Yale Stress CenterDirector, Integrative Medicine at Yale

Atatürk ÜniversitesiMay 2014

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Outline

• Definitions, Framework, and Rationale• The task: Infusing IM into PM• The opportunity (U.S): Better infusing PM into IM

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Operational Definitions

Preventive Medicine (ACPM)“PM focuses on the health of individuals, communities, and defined populations. Its goal is to protect, promote, and maintain health and well-being and to prevent disease, disability, and death.”

Integrative Medicine (CAHCIM)“…that 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.”

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IM therapies vs. IM in practice

NCCAM (Current) • Natural Products• Mind and Body Medicine• Manipulative and Body-

Based Practices• Other

– Movement therapies– Energy therapies– Whole systems

In practice• CAM therapies +/-• Lifestyle interventions

– nutrition– physical activity– stress reduction

• Alternatives– Dietary regimens– Diagnostic methods

and tools• “Off label” or

“speculative” therapies

NCCAM Publication No. D347 (2012)

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The Intersection

CAM (U.S.)

Conventional - Mainstream Medicine

PMIM

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Assumptions

• Rationale for IM– depends largely on CAM

• U.S. health care system– closely allied to conventional practices– reimbursement

• ‘More blue’

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Framework: Public Health/General PM

• Population-based public health skills• 1°, 2°, and 3°prevention-oriented clinical

practice in a wide variety of settings• 4° prevention – of interest

– “to avoid patient overdiagnosis and overtreatment”

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IM Patients – Prevention Oriented

• N=4,182 (Bravewell PBRN)– 85% white; 73% college educated; 73% female

• Why IM? – "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%)– Whether for wellness, acute care, or chronic illness

Explore (NY). 2012 Nov;8(6):348-52.

S L I D E 9BMC Public Health. 2007 Aug 27;7:217.

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Primary Prevention

• Largest impact (PAR) – EPIC-Potsdam data (1)

• “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– CVD and T2DM

• 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 CAM/IM approaches– pain management– symptom control– stress relief– disease management

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Tertiary Prevention – Areas of Promise

• Pain syndromes – Inpatient settings – Dusek data (1)

• Symptom control—even when disease etiology and pathophysiology unknown– medically unexplained symptoms– fibromyalgia, irritable bowel syndrome, chronic fatigue

syndrome– Often complicated by psychological comorbidities

J Patient Saf. 2010 Mar;6(1):48-51

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Practices and Practitioners

• At all levels, the judicious integration of healthcare professionals and approaches can provide benefits generally unavailable in conventional settings

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Bottom Line

• Integrative Medicine offers knowledgeable guidance to tailored therapies across the full spectrum of both conventional and CAM practice

• Providing any given patient more options—and more opportunities for success—in the pursuit of personal health

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Safety

• There are inherent risks in therapeutic practices where the scientific evidence base is often at best incomplete

Pediatrics. 2005;116(4):e568-75.

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Take home messages

• Much potential in 1°, 2°, and 3° prevention arenas

• Integrative Medicine professionals already part of the healthcare system

• Collaborative vs. contradictory care• Primum no nocere

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An opportune moment

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PM – 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 vaccination

Pediatrics. 2006 May;117(5):1532-41.

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Vaccine attitudes / CAM

• Canada: Partial or nonvaccination associated with (1)– Pressure to vaccinate (OR=3.07) – Parent endorsing CAM provider as most trusted source

(OR=3.57)• Students: mistrust in public health

institutions/anti-vaccine attitudes increase by class year (2)

• Less data about practices– Delayed / selective schedules

(1) PLoS ONE 6(8): 2011 e22737 (2) Vaccine 26 (2008) 6237–6243

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Intentional nonvaccination sequeale

• Measles– UK 2013 (1)

• NE; 100 cases, 29 hospitalizations• Most in unvaccinated children, adolescents

– San Diego 2008 (2)• unvaccinated 7 YO boy returned from Switzerland

– 839 exposures; 11 additional cases (all in unvaccinated)– hospitalization of infant too young to be vaccinated

• Pertussis– WA state 2012 (3)

• 2,500+ cases by mid-2012—a rate unseen since 1942 – 1,300% increase in pertussis; two infant deaths

• Highest rate of vaccine refusal (6.2 %)

(1) BMJ 2013;346:f662 (2) Pediatrics 2010;125;747 (3) MMWR 61(28);517-522

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This work was supported by a grant from

National Center for Complementary and Alternative MedicineNational Institutes of HealthU.S. Department of Health and Human Serviceswww.nccam.nih.gov